Contents

1. Introduction

2. Stress in our life

3. Time-Management

4. Conclusion

Bibliography

1. Introduction

Our everyday life is accompanied by haste and tension. Not only that we live with a watch in hand, we still have to cope with many obligations, to play the role of a good employee, partner, parent, and colleague – all this generates stress. Such a stress can be mobilising, it makes us use our time properly, helps to concentrate and our performance improves (Eustress). But if the dose of stress is getting bigger, many of us can not deal with it. We become nervous, irritable, lose faith in ourselves, and feel like we are in a vicious circle from which it is impossible to get out. Getting tired of everything, we are increasingly dissatisfied with each other (Distress). (Harry Mills,Natalie Reiss, Mark Dombeck, 2018) Therefore, it is worth taking a closer look at your life and appreciate the role of positive stress, and reduce the effects of this excessive one, which has a destructive impact on both – our mind and health.

2. 
   Stress in our life
   

Stress is a phenomenon commonly known and experienced almost by every person. Colloquially, the concept of stress is understood as an unpleasant condition caused by a difficult situation, e.g. illness or negative experiences. It is associated with feelings such as tension, fatigue, a sense of hopelessness, a sense of inability to cope with a given situation and even pain.

It is often said that stress is a sign of our times, that the current conditions in which a person lives are conducive to the creation of stress. However, in fact, the phenomenon of stress has always accompanied human’s life. Humans always had to face and cope with more and less difficult challenges that life had thrown at them and they had to adapt to changing environmental conditions, but the difference is only in its sources. According to contrary and colloquial opinions, stress is something natural in our lives, and the phenomenon of stress is not negative, in a small dose is necessary and can motivate us to act, but in excess it can disorganize our behaviour or even badly affects our health. (Lazarus & Folkman, 1984) Therefore, the problem with stress lies in whether we are able to manage it and how can deal with it – simply speaking, how affectively we can “tame” it.

According to (Lazarus & Folkman, 1984) stress is the relationship between a person and the environment, which is assessed by the person as aggravating or exceeding his or her resources and threatening his or her well-being. Due to the strength and scope of their influence, they distinguished the following categories of stressors:

–          Dramatic disaster events covering whole groups – they include events that happen to several people or to whole communities at the same time. They are usually unpredictable, have a very strong impact and require great efforts to deal with stress. Natural disasters, wars, large scale contamination and technical catastrophes are examples of stressors – cataclysms. They attack the most basic human values, like life, shelter, putting very high demands. (Lazarus & Folkman, 1984)

–          Serious challenges and threats related to individuals or to several people – these are usually events in personal or professional life. They may or may not be unpredictable. The list of this type of stressors, includes events such as death of a spouse, divorce, separation, imprisonment, loss of employment, as well as marriages. The list also included positive events ( for example, a holiday trip). All these events involve the necessity of adjusting themselves to each other. Minor, everyday afflictions these are small but persistent problems, the “nuisance of everyday life”. These include, for example, minor misunderstandings in the family, inability to find the right thing or the difficulty of being on time. Those type of stressors’ strength lies in the universality and high frequency of occurrence. (Lazarus & Folkman, 1984)

When analysing the concept of the stressors the following needs to be taken into account:

a)     Strength and range of influence of stressors (from dramatic events, such as war, natural disasters that affecting whole group, individuals to minor everyday nuisances and troubles, such as to miss the bus, or disagreement with your colleagues) (Lazarus & Folkman, 1984).

b)     Constant changes in life (death of family member, marriage, unemployment, divorce, illness) and the change itself (new job, new place, school, new technology –the fear of the unknown).

c)     Controllability of stressors (what extent their occurrence, course and consequences depend on the intentional action of those involved. The control of the majority of stressful events is limited, they are partially controllable, in some respects, under certain conditions or up to a certain point in time. For example, lack of control over situation in workplace is a reason of stress.

d)     The time characteristics of stressors (short-term stressful situations, such as visit with a doctor, recurrent events that cause chronic stress or a series of stressful activities, such as long-term conflict in workplace or incurable illness) (McLeod, 2009).

The above classification, helps to identify stressors as factors (internal and external) which are very diverse and can be characterised from different points of view, because different people will have different reactions to particular situations. The human body reacts to stressful situation on both physiological (accelerated breathing and rapid heartbeat, excessive sweating, and disturbances in the functioning of the digestive system) and mental level (reduced ability to concentrate and make decisions, defining the situation as a threat, thinking about the situation and yourself in negative categories). These reactions are accompanied by feelings of anxiety. (Lazarus & Folkman, 1984)

The next step in the stress management is to find an effective strategies for coping with challenging situations. Their effectiveness would be determined by type of stressor, the person involved and the situation itself (McLeod, 2009). According to (Lazarus & Folkman, 1984) there are two type of coping responses: emotional focused and problem focused. Emotional focused coping involves many techniques, such as reducing the negative emotions, (anxiety, embarrassment, fear, depression, excitement and frustration) by meditation, relaxation training, praying, eating and drinking more. Emotion-focused coping is not a long term solution because may have negative side effects as it delays the person dealing with the problem. However, any of those methods may be the only realistic option when the source of stress is outside the person’s control. The second type of response is an active behaviour – reaction that helps to change the stressful situation in order to eliminate or reduce the stress. Problem-Focused tactics are: problem-solving, obtaining a social support, setting realistic expectations, a good time management (McLeod, 2009)

3. 
   Time-Management
   

The modern world is moving forward. Hurry became our obsession. People are caught up in competition, crushed by duties they cannot stop. Attempting to perfectly combine home and business matters means that each day is one big race. This race against time – costs us a lot – our health, well-being, happiness. So what is Time, and why it is so important to learn how to manage it?

The Time has different meaning to different people. Fons Trompenaars and Charles Hampden- Tuner (Fons Trompenaars and Charles Hampden – Turner, 1997)explained The Time rightly:

“Time is increasingly viewed as a factor that organisations must manage. There are time-and-motion studies, time-to-market, and just-in-time, along with ideas that products age, or mature, and have a life cycle similar to that of human beings. Uniquely in the animal kingdom, man is aware of time and tries to control it. Man thinks almost universally in categories of past, present and future, but does not give the same importance to each one (…) How we think of time is interwoven with how we plan, strategise and co-ordinate our activities with others. It is an important dimension of how we organise experience and activities.” (Fons Trompenaars and Charles Hampden – Turner, 1997).Their definition of time helps us to believe, that the value of our time is influenced by how we used the time that has passed and how we approach the time that will come. And because we evaluate what has passed and what it will be, we give value to our time ourselves. We give it a value by assessing whether something is worth our time or it is just a waste of it. Therefore, if the Time is important to us we will make sure, we use it efficiently with a great appreciation. For that reason, an effective time management is the key to a better quality of life. Proper time management requires planning and organizing your own actions in such a way as to lead to the fastest achievement of the intended goals. By setting goals and defining our priorities and what is important in our life, we will be able to recognize unproductive activities ‘time stealers’ that we do consciously and unconsciously. This could be anything from many hours watching TV, a mobile device and its endless appeal, multitasking, jumping around from one thing to the next one without a plan , failure to delegate, dealing only with the ‘urgent’ rather than the ‘urgent and important’ items or being disorganised. Having knowledge, of what steals the time it will allow to limit them and gain more time to rest and develop relationships with loved ones (Hutchinson, 2018). One of the other condition when introducing beneficial changes in time management system is to make haste slowly. A careful life is a conscious choice of what we do. Hurrying up slowly does not mean giving up actions or efforts, this means to live more carefully, without excessive haste, closer to nature, celebrating moments, consciously making decisions, creating your own world and following the rhythm to pursue goals or make the dreams come true. By doing something slower, we focus on what we do here and now, without sweating the small stuff and waste energy on unnecessary things. Guided by Sophocles words “

Hurry slowly to avoid mistakes

” stressed person can live slower, in order to gain more time for tackling unfavourable situation or problem, trying to find the best solution for it, and to draw conclusions for the future. Experiencing each day carefully and enjoying the each moment leads to a good, peaceful life, in which it is easier to accept the failure and what is inevitable.

4. 
   Conclusion
   

Regardless of how we look at stress, regardless of whether we have seen that it is nothing bad in itself, we must remember that it is simply a part of our lives. A stress-free life is simply impossible. The only sensible approach to stress is learning to deal with it. The first step to do this is to develop the habit of reflection – “observation” of your own experiences. When we know what causes fear in us, we can take appropriate action. When we know our feelings and reactions, we can learn how to control them. And more importantly, if we gain ability to manage time effectively we not only be able to reduce stress but also prevent it.

Bibliography

• Fons Trompenaars and Charles Hampden – Turner, 1997. How We Manage Time. In:
  
  Riding The Waves of Culture ,Understanding Cultural Diversity in Business.
  
  London: Nicholas Brealey Publishing Ltd, p. 120.
• Hutchinson, H., 2018.
  
  Time Management Slides,
  
  Dublin: Hely Hutchinson Training.
• Lazarus, R. & Folkman, S., 1984. Concept of Stress. In:
  
  Stress,Apraissal and Coping.
  
  1st ed. New York: Springer Publishing Company Inc, pp. 11-14.
• McLeod, S., 2009.
  
  Emotion Focused Coping.
  
  [Online]
  Available at:
  
  https://www.simplypsychology.org/stress-management.html
  

  [Accessed 14 November 2018].

• 
  Ingrid Joy Moreno Castaneda
  

Abstract

This paper presents the different aspects of person-centred approach in the promotion of health to the elderly with dementia and other geriatric health conditions. The principles of individuality, rights, choice, privacy, independence, dignity, respect and autonomy are discussed. Impacts of equality, culture and diversity in the provision of person-centred approach are also presented within the scope of public health, health promotion, attitudes toward health and the demand for healthcare.

The non-person-centred approach namely institution perspective and bio-medical perspective are also reviewed. By gathering information through the internet, other approaches to the provision of healthcare to the elderly are also discussed and presented so as to give us a better view of the different approaches that facilities might be using and help us understand the structure of care available.

Introduction

We are all unique in every way, although we may come from one cultural background and even from the same family, we possess our own set of traits that make up our identity. Similar yet different in many ways.

Regardless where life takes us, I believe that each and every one of us has the right to be respected and as we grow older, we continue to live life with dignity.

Health providers are continuously looking for ways to make the provision of health be of quality. With dementia and elderly care, a number of approaches are being practices in order to make their services suit to the needs of the clients trying to put into account the complexity of each person.

The Task

Person-centred approach puts the elderly with dementia the centre of care. It is a holistic approach where the elderly works in partnership with the care giver and the family in maintaining, promoting, and enhancing a quality of life for the elderly with dementia.

Question 1

Person-Centred Approach is the manner of care that focuses on the person as a whole and as an individual. Its care recognizes the uniqueness of the person, his personality and personal identity which all contributes to the person’s identity. It supports the person with dementia in all aspect of his or her needs and not just on the physical aspect of care. There are a number of principles that are inter-related with each other in this approach. One principle co-exists with the other and the absence of one will make it difficult for this approach to be a success. This approach allows personal growth of the elderly towards self-actualization leading to proper coping with the changes that comes with old age.

• Individuality is what sets a person apart from others. It is that set of qualities or characters that distinguishes a person’s uniqueness. This is an approach that focuses on dealing with the person’s subjective view of life. Basing care from the elderly’s achievements, abilities and desires at the same time treating them with respect and dignity as a person.

• A right is what is due to the person. The approach focuses on the elderly’s right to make his own choices on how to live life. It also supports the person to make his own decisions regarding his care and even allowing him the right to experience “bad decisions.”

• Choice. In person-centred approached the elderly is empowered to make informed choices on how to deal with things and on what they want to do and face the consequences after each decision.

• Privacy is of great importance in this approach. Confidentiality is kept at all times. The elderly’s principles and views of something are not to be discussed with others without the consent of the person involved. This also includes the person’s personal date even past experiences. This is also the reason why when rendering care to residents the doors of the room are kept closed to provide privacy for the client.

• Independence is having the capability to do things on your own. In this approach it supports the person to be on his own and in order to allow this, the care provider safeguards the environment and puts out assistive devices like handrails to allow movement with a level of independence. And if capable the elderly is allowed to go out of the facility provided with proper identification.

• Dignity is being worthy of respect. In here the person with dementia is viewed beyond the disease and his views and principles are honoured. This approach allows the elderly to live according to his moral principles.

• Respect in person-centred approach gives high regard for the elderly putting into consideration the person’s achievements, abilities and qualities. The elderly is allowed to uphold his own beliefs and values without being judged.

• Autonomy is letting the elderly in full control of his care. This principle is possible in a healthcare facility when the elderly is given the right information about his diagnosis and give them the chance to understand fully their health condition in order for them to make informed decisions about their care.

Question 2

• Institution perspective focuses on the set of rules and guidelines by the institution. In here the care providers patterns their plans of care abiding to the set of rules of the facility or institution. Like for instances when the client is still capable of going out, he will not be allowed to do so if it is not allowed in the facility promoting safety for the client. Also in cases when the rule is for residents to have their meals in the dining area, then all clients will have to be there during mealtime and will not have the option to have it in a tray in their room not unless if they are not well enough to do so but their nutritional needs are met by a prepared well balanced meal. Institution perspective puts the laws and rules of the institution and its adherence to it as top priority rather than the desires and needs of the clients but still addressing the health, social, emotional and physical well-being of the elderly.

• Bio-medical perspective deals with the medical aspect of dementia. It starts with setting the medical diagnosis of the disease basing it from the signs and symptoms manifested by the client. Signs and symptoms of dementia vary from one person to another but in order to diagnose it as dementia, it must have at least two impairments from the core elements namely: memory, communication and language, ability to focus, reasoning and judgment and visual perception. This perspective emphasizes that the disease is progressive in nature with minimal hope for the future and intervention is focused of drug treatment.

Question 3

• Reality-Orientation Approach is presenting information to the person with dementia, re-orienting the person with the date, time, his or her current location and the person and the situation to bring him back to reality. For those with dementia, there is a need for constant re orientation and reminder of the now. It is important to ask them if they know where they are, and tell time the date, the day, time of the day and even sharing information about what is happening in the society to keep them up to date to issues. Care providers can all build a conversation by asking the elderly about his family, their whereabouts, and how they are, this can also be a way to assess the extent of memory loss of the elderly and provide updated information should there be a need. Pictures, clocks, calendars and reading materials can also be used to help the client be oriented of important things and be a clear indication of ‘today.’

• Validation approach is acknowledging what the elderly with Alzheimer’s disease is experiencing. Usually this approach is used with people in the late stage of Alzheimer’s. In most cases, when an elderly is on the late stage of the disease they manifest certain gestures or behaviour that may seem abnormal and incomprehensible. These mannerisms are indications of what the elderly is trying to convey. Unlike the reality-orientation approach where there is the reorientation of facts, here the thoughts of the elderly are accepted as it is no matter how bizarre it may be, it is seen as a reality either one belonging in the present or in the past. The care provider empathizes with the elderly by putting oneself in the shoes of the elderly and seeing things with the eyes of the client, at her or his level and stand point. The approach does not deny nor judge the thoughts of the elderly no matter how abnormal it is thus, reducing the elderly’s stress, enhancing dignity, promoting happiness for the elderly and understanding the meaning of the behaviour for the elderly. When the care giver steps into the shoe of the elderly they may get to understand that this abnormal behaviour may be a manifestation of the elderly’s unfinished issues and somehow can help in resolving these issues. Since the elderly’s thoughts are not denied and rejected by the care giver, he or she is able to build trust thus encouraging good communication.

• Assistive technologies are devices or gadgets that are products of technology that are beneficial to the elderly with dementia. These are gadgets that can be used to make the elderly’s life easier and near to normal as can be and live a life with dignity. To name a few of these devices, we have the hearing aids to help those who are experiencing hearing loss to help them in proper oral communication. Even items which have censor like faucets and lamps make it easy for the elderly to use these items. Digital clocks are even of great help for them to tell the time. Radio and television sets make it easy for them to know the currents events through the news. In some instances the elderly can also be track using tracking devices to know their whereabouts should they be out of the vicinity. Phones are also a product of technology which allows constant communication of the elderly with the family no matter the time and distance. There is also what it called telecare, which are gadgets that help the care provide in rendering care, like hoist to help in mechanically moving the elderly. There are also gadgets like digital thermometer and blood pressure to make vital signs monitoring easier and convenient.

• Holistic Approach focuses on four aspect of care for the elderly, the environment, the communication between the recipient of care and the provider, nutrition and the activity of the client. The care provider should make the environment or living space of the elderly free of clutter and with safety features like hand rails so as to allow maximum movement for the client with less anxiety. The environment should also be free of unnecessary noise for sometimes this can make the elderly agitated. The care provider should also nurture a good verbal and non-verbal communication with the elderly. If the elderly is not a native of the country and has limited vocabulary then it is just necessary that someone should stand as an interpreter so as for interactive communication to take place. In cases when the elderly cannot talk but can read and comprehend, then care provider can make use of visual materials for communication like pen and paper. The health of the client is also given importance by establishing a nutritional plan starting with the assessment of the nutritional demands of the client and then structuring the diet of the client according to his or her nutritional needs. The care provider should also organize a series of activities for the client may it be physical or mental in nature. Activity like show and tell is an opportunity for the client to show something and express his or her thoughts about it. Then there are also board games or memory games that will help the client put their thinking capabilities to use. There also a number of activities that require a little physical movement like pin bowling which can also be a source of exercise for the client.

• Alternative therapy: Music and Art Therapies. Music therapy makes use of music to set the mood of the client and to connect emotions and feelings between the client and care provider. Mellow tunes can help soothe the emotion of the client and music of different eras can also evoke feelings from the client by reminiscing past life experiences. Here the client may also be given the option to choose the kind of music he or she wants to listen to. Clapping and dancing are also encouraged to add in the enjoyment. Art therapies should be that which are not too childish to avoid demeaning the clients. Care givers can assist the clients to start their art work and then they can put their feelings and thoughts into the art activity then they are encouraged and asked to tell the stories behind their work. The activity should give clients the ample time to do their art work putting into consideration capabilities of the elderly and that they don’t have to finish everything in one sitting to prevent putting stress and anxiety on the clients.

Question 4

• Public Health and Health Promotion

Public health focuses on the promotion of health and the enhancement of life by taking measures and interventions that will prevent and treat dementia and other geriatric health conditions. This is a combined effort by the private and government health sectors, communities and individuals. In New Zealand, the ministry of health allots a budget for the health promotion of the aging citizens. This benefit is for all New Zealand citizens regardless of culture. The health care providers stand by the principle of equality in rendering care. They give the same kind of care to their clients treating them all as equals. In the provision of person-centred approach to individuals with dementia within public health and health promotion, there might be an issue with regards to cultural diversity. Yes, there is equality in the sense that every citizen of the country is given the right to have access to this health benefits regardless of cultural background and with this in mind, it is safe to say that these services are assumed to be what the general population needs not putting into account that this is a country with a diversity of culture.

• Attitudes to health and demand for healthcare

The attitude we have towards health greatly varies on the cultural background that one has. And thus how we value health will also relate to the demand for healthcare. How we live out life during the younger years will result to the health condition that one will have in the aging years. The family and the cultural preferences play a great role in the choices of food that we eat even in people with dementia or other geriatric health conditions.

According to the Ministry of Health (2003), a significant issue for Pacific households here in New Zealand is the affordability of food. They are most likely to report that they sometimes run out of food due to financial strains compared to the Maori and the Europeans. This would only mean that the elderly will not have the sufficient amount of nutrients in their day to day diet.

Question 5

The different health sector standards and codes of practice basically set the guideline for the person-centred approach in the sense that it covers the entirety of the approach. As what these codes of practice states, every person has the right to be treated with respect. Just like the approach it has it emphasis on the person as an individual who has every right to respect. These codes practice also recognizes the individuality and uniqueness of every one and states that one should not be discriminated for his age, cultural background, religious and political opinion, etc. Just like that in the person-centred approach towards people with dementia and with other geriatric health conditions they should be from discrimination. Privacy and safety are of great importance also as stipulated in the various codes of practice and in the person-centred approach. Although with dementia or other geriatric health conditions, the elderly should viewed as an individual pass his or her health condition that comes with age.

Recommendation:

I highly recommend that for facilities who offer services to the elderly with dementia and with other geriatric health conditions they must try to group their elderly accordingly, those with similar principles, personal backgrounds and traits, in this manner they can somehow establish the necessary routines and activities that would suit the group’s personalities. Even with the distribution of food, they can group this in a way that would give them the right nourishment at the same time giving the clients the opportunity to eat the kind of food that they have grown with for this too is a part of their identity. When healthcare providers try to give a personal level in the provision of their services it somehow shows that they acknowledge the individuality and uniqueness of their clients.

In the provision of health services, I suggest that services should be pattern to the character of the said community, in this way, the needs of the members will be provided with their healthcare needs accordingly. I also suggest that there should be teams who will visit the communities on a regular basis to continuously assess the health needs of the society and make ways to give the people easy access to their services.

Conclusion:

In conclusion, there are a number of approaches that can be used in the provision of healthcare services. These approaches cannot be a success without the dedication of the healthcare providers. There are many aspects to consider when deciding on the kind of approach to practice with people with dementia and other geriatric health conditions but we must not forget that although old and frail they are still individuals with a respective identity who are worth of our respect and should be given the due right to live their remaining days with dignity.

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Research is an essential part for the growth of any profession in today’s world. Nursing research is a systemic inquiry to answer the question or problems encountered in the clinical practice, education and administration (Polit & Beck, 2008). Research studies have great importance in nursing profession because it provide strong evidence that help nurses to make sound clinical decision and judgment in the clinical setting; it helps to give evidence based nursing care to the patient that would be clinically appropriate, cost effective and result in positive outcome of patient. Moreover, it assists to elevate the standard and reputation of nursing profession. In addition, knowledge contribution will be increased in the discipline (Polit & Beck, 2008). Therefore, nurses are expected to understand and conduct research in their field. This paper illustrate the paradigms for nursing research, highlight the epistemological and ontological assumption related to Positivist and Naturalistic paradigms, mention the philosophy of quantitative and qualitative research than narrate the underlying philosophy that will guide my thesis work.

According to Donaldson and Crowley (as cited by Northrup, 1992), “a discipline is characterized by a unique perspective, a distinct way of viewing all phenomena…” (p. 154). Philosophy of a profession serves as a guide for the practice and research. Nursing philosophy can give a direction for nurse’s practice, education, research and scholastic work (Steven & Edwards, 2008). The key components of philosophy include “ontology” and “epistemology”. Ontology deals with nature or involves the philosophy of reality; whereas, the term epistemology comes from the Greek word “episteme” means knowledge. In simple term epistemology is the philosophy of knowledge or how we come to know the reality (Gortner, 1993).

Research philosophical paradigm are sets of beliefs and practices that regulate inquiry within a discipline by providing lenses, frames and processes through which study is carried out (Steven & Edwards, 2008). Research philosophy directs the perspective from which researcher formulate research questions, plan how problem can be investigated, select research design as well as identify what methods are used and how data are collected, analyzed and interpreted (Steven & Edwards, 2008). Therefore, nurse researchers before conducting any study should have clarity about the paradigm because it will enable them to structure inquiry, and select the research approach. According to Polit & Beck, (2008) Nursing research paradigms are broadly classified as Positivist paradigm (also termed as Empiricist) and Naturalistic paradigm (also termed as Post-positivist, Interpretative or Constructivist). The researchers does not always clearly state the philosophical stance on which the study is based; however, one can identify the stance by carefully reading the literature review, identifying the research question, understanding the purpose of the study and examining the researcher’s method (Carr, 1994). Moreover, the researcher’s knowledge of both types of research approach endorse accurate selection of the methodology for the problem identified (Carr, 1994). Research methods are selected that facilitate to plan a study systemically, to collect data and investigate information (Boyd, 2001). Qualitative and Quantitative are the two major research methods or approaches used in nursing studies. “Qualitative is a systematic, interactive and subjective approach used to describe life experiences and give them meaning” (Burns & Grove, 2006, p. 35). This type of research is conducted to describe and promote understanding of human experience such as stress. While, “Quantitative research is a formal, objective, and systematic process in which numerical data are used to obtain information about the world” (Burns & Grove, 2006, p. 35). The example of quantitative research question: what is the prevalence of drug abuse in Pakistan”? Both approaches are needed to provide knowledge in nursing discipline. They are also characterized by ontological and epistemological differences to conceptualize and conduct research.

Philosophy of Qualitative Research

Philosophy of qualitative research is “interpretive, humanistic, and naturalistic” (Creswell, 2007). It places significant importance to the subjectivity. The ontological assumption is that there is no single reality but encompasses multiple realities for any phenomenon (Speziale & Carpenter, 2003). Moreover, every individual perceive, interpret and experience a situation or phenomena of interest from one own point of view, since individual has different experience of reality (Polit & Beck 2008). The epistemological assumption is that knowledge developed from subjective observation, which is at the level of rich description, and in-depth understanding (Speziale & Carpenter, 2003). According to Creswell (2007), qualitative researchers believe that “truth is both complex and dynamic and can be found only by studying persons as they interact with and within their sociohistorical settings” (p. 89). Therefore, qualitative research, phenomena can best understand and sort by embedding researcher in the situation rather than quantifying data that require a construction of a fixed instrument or a set of question (Speziale & Carpenter, 2003). Furthermore, it is context and time bound (Polit & Beck 2008). Qualitative study is generally conducted in the naturalistic setting rather than in the artificial laboratory (Burns & Grove, 2006). Researcher interacts with the participants explore perceptions, feelings, thoughts, beliefs, expectations, and behavior to obtain knowledge about the phenomena of interest so researchers has an active part in the study (Burns & Grove, 2006). This approach encompasses well-planed steps before researcher enters the settings in which observations and inquiries would be made (Speziale & Carpenter, 2003). The focus of qualitative research is usually broad not reductionistic because the intent is to give meaning to the whole (Polit & Beck 2008). In this approach, data is collected through in-depth conversations, diary keeping, extensive interviewing, extended observation, and focus groups interviews to acquire insights regarding these subjective realities, so no attempts are made to control interaction (Polit & Beck 2008). Qualitative data take the form of words so researchers keep a detail notes, and record the interviews than identifies categories that help to sort and organize the data (Creswell, 2007). The intent for the organization of the data is to have individualized interpretation that describes the phenomenon being studied (Creswell, 2007). Moreover, researcher spends substantial time going back and forth through the notes that would help to identify important connections (Polit & Beck 2008).

Quantitative approach is emerged from positivist paradigm. Positivist paradigm places considerable value on “rationality, objectivity, prediction and control” (Burns & Grove, 2006, p. 15). “The ontological assumption is that there is one reality, which exists and can be validated through the senses” (Brink & Wood, 2001, p. 22). Epistemological assumption is that knowledge can be define and explore through careful measurement of the phenomenon of interest. Researchers believe that “all human behavior is objective, purposeful, and measurable” (Brink & Wood, 2001, p. 22). It encompasses the study of research questions or hypotheses that identify prevalence and characteristic of the concept, test the relationship, assess cause and effect relationship between variable and tests for intervention effectiveness (Polit & Beck 2008). The researcher needs to find or develop the instrument or tool to measure the phenomenon of concern while researcher remain detached from the study in order to prevent personal values and biases to influence the study results (Polit & Beck 2008). Research is driven by numerical data collection than it is subjected to statistical analysis. The focus or perspective for quantitative research is usually concise and reductionistic which means whole cannot be studied but it will be broken down into parts so that the parts can be examined (Polit & Beck 2008). Furthermore, “Quantitative research requires control to identify and limit the problem and attend to limit the effect of extraneous or outside variables that are not the focus of the studies” (Burns & Grove, 2006, p. 132). Control, instrument and statistical analyses are used to ensure that the research findings accurately reflect reality and that would help to make the finding generalize (Brink & Wood, 2001). The four quantitative research designs used most often in nursing research are descriptive designs, correlation designs, experimental designs and quasi-experimental designs (Burns & Grove, 2006)

The methodology chosen depend on what one are trying to do; researcher purpose and question to investigate rather than commitment to a particular paradigm (Brink & Wood, 2001). Thus, the methodology must match a particular phenomenon of interest. My thesis topic: Stress and Coping among first year master students at Aga Khan University (AKU). I have selected quantitative approach because I am interested to identify factor that causes stress among first year master student at Aga Khan University and explore the coping strategies used by the students. Moreover, it helps to investigate the stress level among different entities of AKU such as School of Nursing, Medical College and Institute of Education development. The finding from the study recommends possible strategies that would assess future students dealing with the stress so that they are able to cope more effectively. The research design guides the researcher in planning and implementing the study in a way that is most likely to achieve the intended goal (Polit & Beck 2008). Skill in selecting and implementing a research design can improve the quality of the study and thus the usefulness of the findings; therefore, to achieve that purpose Descriptive Cross-sectional design would be selected. It is appropriate for “describing the status of phenomena or for describing associations among phenomena at a fixed point in time” (Polit & Beck, 2008, p.166). The overall aim is to ‘discover new meaning, describe what exists, determine the frequency, and categorize, count, or measure information’ (Burns and Grove, 2006, p. 24). In quantitative descriptive research, data is obtained from many participants under natural conditions, with no attempt to manipulate the situation (Brink & Wood, 2001). To illustrate, a descriptive study, I have formulated following research questions that include “what are the sources of stress among first year master student at AKU”. “What are the difference between stress level among first year master students at School of Nursing, Medical College and Institute of Education development”? “What are the coping strategies use to manage stress by master students of AKU”? In a quantitative study, researcher starts with a theory, framework or conceptual model. I have selected Roy adaptation model. In quantitative study, researcher follows step-by-step process by posing a question to the end by obtaining an answer. All the findings together provide a composite picture related to the number of student suffering from stress, the factors that cause stress among students, stress copying strategies among students and finally comparing the stress level of different entity at AKU. It has been clearly stated in the research topic and question that the study setting would be Aga Khan University. It has School of Nursing, Medical College and Institute for Education development. These entities offers different masters programme which include Master of Science in Nursing, Master in Bioethics, Master in Epidemiology and Biostatistics, Master in Health Policy and Management and Master of Education Programme. The universal sampling would be planned. The information would be obtained from all those who are in the first year Master programme at AKU 2010-2011. Taking the entire study sample reduces the sampling error (Polit & Beck 2008). The major study variables are stress and coping. A tool “student stress and coping inventory” is selected for the study. This tool is develop and tested by Barbara Jaffin Cohen, (2001). This tool is selected because it assesses the major variable of the study. It is also planned that tool would be pilot tested to check its utility and appropriateness in the local context. A pilot study is a crucial element of a good study design, area of concern, lesson learn and refinements needed are identified (Por, 2005). Quantitative information is analyzed through statistical procedure. It covers broad range of techniques; from simple that is use regularly to compute the average through computer to complex and sophisticated method. Researcher use statistical procedure to organize, interpret and communicate numeric information (Polit & Beck 2008). I have plan for descriptive statistic to describe and synthesize data.

Conclusion

According to Clarke (1998), “research methods can be described, considered and classified at different levels, the most basic of which is the philosophical level”. All nursing research is conducted within philosophical paradigm because it help investigator to understand explicitly the philosophical assumptions underlying their methodological choices (Steven & Edwards, 2008). Proctor (1998) considers that consistency between the aim of a research study, the research questions, the chosen methods, and the personal philosophy of the researcher is the essential underpinning and rationale for any research project.

The current worldwide opioid ‘crisis’ has been well described. Deaths from opioid misuse are now the number one cause of unintentional deaths in the US(1). Doctors have been central to the development of the problem through the overprescribing of opioid medications. Post-surgical discharge overprescribing has been identified as a contributor to the opioid ‘crisis’ and to persistent opioid use in individuals(1-3).

Internal hospital programs focused on opioid reduction and multimodal analgesia use for elective surgery such as ‘fast track’ and Enhanced Recovery After Surgery (ERAS) are now commonplace(4). They aim to improve post-operative recovery and reduce hospital length of stay through the protocolization of elective surgical pathways. Day case surgery has also gained in popularity and these initiatives see patients discharged into the community more quickly with acute pain that often requires opioid analgesia(5, 6). There is a tension between managing pain effectively and reducing the risk of opioid harm.

A recent systematic review by Wetzel and colleagues looking at postsurgical opioid prescribing interventions found evidence for organizational level changes and guidelines in reducing prescribed quantities(7). They also identified a study reducing opioid prescribing to children where patient follow up showed poorly controlled pain in 5.4% of patients(7).

Poorly treated acute pain is a risk factor for the development of persistent pain and ongoing opioid use(8). Guidelines to assist with discharge prescribing may support doctors in decision making to balance this tension by improving patient care and safety.

A literature review was undertaken to evaluate evidence on the impact of postsurgical discharge prescribing guidelines for opioid reduction and pain management. Specific focus was given to evaluating the relevance to the New Zealand context given differences in healthcare systems worldwide.

A formal search of the SCOPUS database using the key words ‘discharge analgesia’ and ‘guidelines’ returned 341 references. A further modified search including ‘New Zealand’ returned 27 references. A purposeful search was made of Australasian journals (NZ Medical Journal, Anaesthesia and Intensive Care and ANZ journal of Surgery) to find NZ specific studies since 2009 including the above terms and any reference to ‘opioid’. Abstracts were reviewed to determine relevance. Editorial and commentary pieces were included to evaluate current perspectives on the topic. In addition, articles were retrieved based on citations in articles reviewed and other relevant references as encountered during reading.

Perioperative exposure to opioids is a risk factor for persistent opioid use with up to 6% of opioid naive surgical patients continuing opioid use beyond 90 days after surgery(9). A retrospective cohort study of over half a million opioid naïve patients showed that just one repeat opioid prescription after surgery increases the risk of persistent opioid use by 40%(8). Each additional week of postoperative opioid use increased the risk of persistent opioid use, and discharge with a large opioid supply also increased the duration of opioid use in patients(8). This finding is supported by a phone survey of women post cesarean section by Bateman and colleagues who found women prescribed more opioids at discharge from hospital used more opioids, independent of their pain scores. They discuss that prescribing large quantities may ‘set expectations’ for pain and analgesic use(10). Giving more opioids after surgery does not appear to mean we are giving better care or even managing pain well. Prescribing more does however leave many patients with an unused supply at home that is available for diversion, misuse and potential harm(8, 10, 11). 40-70% of prescribed opioids in the US go unused after surgery according to one review(1). The problem of opioid overprescribing after surgery is now significant and well established.

Clinical stewardship by both anaesthetists and surgeons in providing solutions for opioid overprescribing was a strong theme identified in the literature(1-3). This acknowledges wider ownership of the problem by these specialists as the initiating opioid prescribers of the perioperative period. The most frequently identified prescribers in the literature however were junior doctors in training(11-13). A lack of education and guidance in pain management and opioid use was frequently mentioned as a factor in overprescribing by junior staff(21, 8, 11). Generational patterns of prescribing quantities based on habit and routines rather than evidence were recognized as widespread among surgeons in particular. Characterized by ‘the way I do it’ or ‘what I have always done’(13). In qualitative interviews with surgical residents, Lee and colleagues showed social influences and beliefs strongly influenced their prescribing behaviours(12). Prescribing large quantities of opioids to keep patients from phoning or returning for pain relief was reported. This was motivated in part by a concern for the patient but also not wanting to be bothered or seen by others to have got things wrong. Not wanting to be out of step with what their colleagues were doing was important to junior doctors. Behaviour change education and prescribing guidelines were developed from themes identified at these interviews. The initiatives were effective in reducing prescribed opioids without an increase in repeat prescriptions(14). A criticism of prescribing guidelines over time however was they ‘had no teeth’ as they were not enforceable and behavior change needed to be maintained through ongoing education(15).

The need for repeat opioid prescription often appears as a surrogate for pain measurement in the literature. The assumption that ongoing pain would require more medication, and therefore repeat prescriptions, is made in several studies reviewed evaluating surgery specific opioid requirements as a guide to discharge prescribing(14, 16, 17). Howard and colleagues additionally incorporated pain scores in their survey of patients following laparoscopic cholecystectomy to determine a procedure specific opioid guideline. On average patients were dispensed 50 opioid tablets at discharge but used only 6 tablets. Their guideline revised practice to a recommended 15 tablets with no reported increase in repeat prescriptions(17). Procedure specific guidance on discharge opioid prescribing holds appeal in its simplicity of a specified number of pills to match a surgery. A consensus prescribing guideline from a US multidisciplinary panel at Johns Hopkins University Hospital for 20 common procedures included patients, surgeons and allied health staff on the panel(13). The patients suggested lower numbers of discharge opioid tablets than the surgeons across all procedures. The authors emphasized the importance of including the patient experience when planning discharge prescribing guidelines.

Inclusion of the patient experience, especially through qualitative studies, does not feature prominently in the literature on discharge opioid prescribing.  Criticism of the ‘numbers of tablets for specific procedures’ approach is made in several commentaries as lacking individualization to the patient(21, 18). The nuancing of tapering opioids after discharge is not contained in a number but requires both patient and prescriber education(21, 19). Broader guidance incorporating patient risk assessment, pain scores, inpatient opioid use and patient preferences are advocated for by several authors(21, 19, 20). An example of this type of guideline from Australia is given by Stewart and colleagues. They recommend a range of opioid quantities for discharge based on patient pain scoring and opioid use in the preceding 24 hours. Their intervention also included education for prescribers to improve practice(15). While opioid prescribing reduced, the effectiveness of pain control and patient experience is absent from their data. The tension between opioid risk, pain management and individualization in planning guidelines is discussed but no solutions advanced.

Developing a prescribing guideline for pain management is more complex than a guideline to simply reduce prescribed opioid quantities. Enhanced Recovery After Surgery protocols for elective surgery are frequently focused on opioid minimization perioperatively to speed functional recovery(4). These protocols are effective at reducing length of hospital stay but typically don’t include discharge prescribing guidance. One study specifically reviewed discharge prescribing pre and post the introduction of an ERAS protocol for colorectal surgery and found an increase in opioid prescribing at discharge. Reduced length of stay in hospital was discussed as a key driver of this(5).  The lack of individualization of care within ERAS protocols around pain management has been identified as both a strength and weakness in separate studies.  Brandal and colleagues recognised the absence of a guideline for discharge prescribing led to high rates of opioid prescription without assessment of patient factors. 70% of patients with low pain scores and low opioid use prior to discharge were still discharged with opioids(6). The undoing of opioid sparing ERAS techniques at discharge by doctors ‘habits’ of prescribing seems like a gap in planning. This point is echoed and expanded in a review which identifies the benefits of ERAS as an opioid reducing care pathway(1). The lack of linkage of these protocols to discharge prescribing, and importantly post-discharge repeat prescribing is highlighted as an opportunity to develop guidance.

The current focus on reducing opioid prescriptions without increasing the quality of patient care is criticized in a commentary by Clarke and Ladha from the Toronto Transitional Pain Service(21). In contrast to much of the literature they disagree with the emphasis on individual prescribers and the emerging ‘blame culture’ around opioid prescribing. Rather than just guidelines they advocate for wider health system and policy changes. The gap between primary care and hospital is particularly highlighted as a deficiency in discharge care planning and opioid prescribing(21). Several other review articles advocate for attention to care planning and transition to primary care but specifics in this area are absent from the wider literature. Advice for patients to seek help with their general practitioner after discharge for pain management is often encouraged but guidance for general practitioners is typically not included within guidelines(15, 19, 22). The experience of both general practitioners and patients after discharge is also not well addressed in the literature.

The differences in healthcare systems worldwide accounts for some variation in the literature reviewed as the US in particular is overrepresented as the ‘home’ of the opioid ‘crisis’(7).  Hospital systems interventions such as reducing the default limits on electronic prescribing programs are described as potentially more effective than prescriber education in the US(22). In New Zealand opioid prescriptions must be handwritten on separate specific forms so this type of intervention is not applicable. Equally it may have helped reduce opioid prescribing at baseline in New Zealand due to the additional steps required to prescribe including accessing the forms from locked storage.

In evaluating the literature from a New Zealand perspective there were few specific references found and evidence for New Zealand opioid discharge prescribing guidelines was absent. A recent commentary in the New Zealand Medical Journal discusses similarities and differences between the US opioid ‘crisis’ and New Zealand. The lack of up to date data on opioid use in New Zealand is highlighted as a concern for health care planning(23). Pharmacy data for New Zealand however shows that opioid prescriptions are increasing and are most frequently initiated in hospital, consistent with the wider literature reviewed(24).

Current evidence shows discharge prescribing guidelines appear effective in reducing prescribed opioid amounts, but there is disagreement as to their efficacy in pain management and role in patient centered care. The patient experience is not at forefront in much of the literature and postsurgical prescribing limits may result in poorly controlled pain which is a risk for the development of persistent pain. Repeat prescribing after surgery has been identified as increasing the risk of persistent opioid use but there is little available evidence to guide the transition from hospital discharge to primary care pain management. Further research exploring the transition of patient care after surgery from hospital into primary care within the New Zealand health system could be used to inform opioid prescribing. Qualitative methodologies would enable better understanding of the experiences of both patients and general practitioners in developing guidelines that are patient and clinician focused.

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