Emotional Support of Persons with Diabetic Retinopathy

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Emotional support of persons with diabetic retinopathy specifically tailored to point-of-care providers treating patients with diabetes


Introduction

Emotional support can be defined as the expression of empathy and understanding towards an individual living with a problem. In the case of a person living with diabetes, emotional support may allow him or her to communicate fears and anxieties, receive positive feedback from friends and family, and help sustain self-care abilities. Emotional support and encouragement from health care providers are essential for patient’s motivation and management of diabetes which requires lifelong self-care and discipline. Patients self-manage diabetes, a chronic condition, in the absence of any day to day positive feedback. Research has consistently documented the beneficial effects of social support and supportive relationships on physical and mental well-being, particularly for patients living with diabetes. This section is dedicated to ways you can empower your patients by addressing their fears and discussing treatments options in a respectful and meaningful manner.


A 3D View – Distress, Depression, and Diabetes

Self-care is the cornerstone of diabetes management. Living with diabetes means managing and coping with the condition every hour of every day. This constant effort can be exhausting and stressful for patients and often leaves them feeling isolated and alone. It is thus not surprising that people living with diabetes have a higher risk of developing emotional problems than the general population. Despite advances in diabetes care a significant proportion of patients with diabetes still experience diabetes-related distress (44.6%) or clinical depression (13.8%)  (nicolucci a, 2013 Diabetes Med 767-777). Moreover, it has been well documented that the psychological well-being of patients plays a pivotal role in day to day self-management of diabetes. Distress and depression in patients with diabetes can lead to worsening of metabolic control, higher rate of complications, increased health care costs, worsened functional disability and early mortality. Put simply, diabetes-related distress and depression can limit one’s functional ability and coping mechanisms leading to reduced diabetes self-care.

The diagnosis of diabetes related retinopathy can be the source of significant additional emotional stress for patients as noted below:

Fear of going blind

The new diagnosis of diabetes related retinopathy can be distressing for patients as it brings the fear of losing vision and going blind. This anxiety and concern are heightened by the fact that for those living with diabetes are 25 times more likely to experience visual impairment. Patients with a prior history of diabetes with no retinopathy may view this new diagnosis as a setback in their efforts to manage diabetes. Patient’s distress may be heightened further by the plethora of information about diabetes related retinopathy and complications on the internet that may not be relevant to their condition.

Change in lifestyle

For most of us the world is what we see through our eyes. When confronted with the possibility of vision loss, patients worry what that would mean for their quality of life. Patients express fear of losing their means of livelihood and financial earnings. Cost of care, rising insurance premiums and higher copayments may be additional points of stress.

Loss of independence

The prospect of vision loss for patients often means becoming dependent on friends and family for daily tasks that have thus far been routine. Loss of vision may mean having to give up driving privileges, reading, playing sports etc.

As physicians, it is our job acknowledge this concern and reduce risk factors to ensure the best possible visual outcome for our patients. Fortunately, this has become easier with improvements in both systemic and intraocular medications. Coupled with advancements in insulin delivery and glucose monitoring we are now able to arrest and often reverse the stages of diabetes-related retinopathy that if untreated can lead to visual loss. When discussing these treatment modalities it is important to deliver this care in a supportive and understanding manner; often it is not what is said but how it is said that will be remembered. In other sections of this report, we hope to ease some of the concerns and fears related to diabetes-related retinopathy and its treatments. We believe that the goal from an ophthalmologic point of view (aside from preventing visual loss) should be improving self-management skills and reducing diabetes-related distress help people live with diabetes.


Sticks and Stones – The Language of Diabetes

Sticks and stones will break my bones but …. sadly words do hurt and the language we chose often reflects the unspoken opinion that we may be feeling. When talking about diabetes it is important to use language that does not judge but rather informs. Try to avoid language that implies a moral judgment about behaviors and blame. Try to respect and accept that patients have the right to make choices and use language that reflects the understanding that diabetes may not always take priority in one’s life, and that patients have accepted responsibility for their condition. Diabetes is frustrating, challenging and distressing for many people. When we focus on what is perceived as a patients ‘non-adherent’ behavior we can dismiss the efforts that they are making. Remember that wellness and health involve more than just gaining ‘control’ or achieving a number on a lab result. We should enable and educate our patients using appropriate and encouraging language.

The Most Powerful Drug Used by Mankind

It is arguable that the role of a physician is moving in the direction where the patient is at the center of care and physicians are peripheral health advisors. Physicians empower their patients to use the available resources, wanting what is best and practicing under the assumption of “first, do no harm”. Physicians recommend tests or treatments where the potential benefits outweigh the harm. What is often unrecognized and unintentional is that the way the recommendations are delivered can be causing harm. Language is an important part of our identity and we create meaning from the messages that we hear.

The English writer, Rudyard Kipling, once said: “words are, of course, the most powerful drug used by mankind”. Words can shape how a person thinks and feels about themselves as well as their medical conditions. As physicians, we use words to influence a patient to do or feel things that are not normal for them — just as medications would do. Language can empower people when used in a positive way. Words can link people together, spread knowledge, and improve self-image. However, it is important to realize that language can also be used to disempower people by degrading or harming their self-image. Words can completely wipe out a part of someone’s identity and can leave a negative impression causing their emotions to deflate. Language cannot be separated from thought or experience.

Empowering language should be used to educate and motivate people with diabetes. Careful use of language applies equally to the conduct of health services, health professionals, family, friends, and colleagues of people with diabetes, and the media. When people use language to shame and judge others, it can contribute to diabetes distress and ultimately slow progress and hinder diabetes outcomes. Furthermore, people with diabetes may do themselves a disservice if they also use negative language. There are effective ways of communicating about diabetes. When discussing a medical condition such as diabetes we, as physicians, should be using language that encourages positive interactions and positive outcomes.

To expand, the word “diabetic” is often used as an adjective or as a noun. When used as an adjective, diabetic foot, diabetic eye, and diabetic person, the word places focus on the physiology or pathophysiology. It is better to put the person first. Avoid using a disease to describe a person and to avoid describing people as a disease. Suggested replacement language would include foot ulcer, infection on the foot, diabetes-related retinopathy, and a person with diabetes. When the diabetic is used as a noun, “Are you diabetic?”, this labels someone as a disease. There is much more to a person than diabetes. “Do you have diabetes?”, a person living with diabetes, a person with diabetes, a person who has diabetes would be appropriate replacement language. When in doubt, call someone with diabetes by their name and remember person-first language puts the person first. There is much more to a person than his or her diabetes – mindful language is a simple shift that can be powerful in reducing stigma and negativity.

As health care professionals we should be working toward person-centered care that is based on respectful, inclusive, and empowering interactions. We have an opportunity to respect the language used when counseling our patients and should be selecting strength-based, collaborative, and person-centered messages that encourage people to learn about and take action to manage complex diseases.


Management approach to diabetes related retinopathy

Diabetes-related visual loss is a fear that all persons with diabetes will experience at one time or another. When faced with the thought of blindness, individuals often focus on what they stand to lose along with their vision. Patients often express concern over the loss of employment, their independence and privacy, along with the loss of friends and family. These anxieties are normal and as a physician, it’s important for us to acknowledge our patients’ fears, as they are to be expected. It is also our responsibility to help our patients move beyond those fears and help them reclaim a positive outlook about their vision and diabetes management. Losing your vision does not mean you’ve lost your intelligence, knowledge, or skills, but you may need to learn some new ways of doing things to remain independent. With proper training and practice, people with diabetes and visual impairment can manage their diabetes and other daily activities. Your goals to live confidently, independently, and productively can be achieved.

Sadly, it is the concern and fear of going blind that will often lead to patients missing appointments and delaying care which can lead to worsening of their retinopathy and vision. Currently, it is recommended that adult patients with Type 1 diabetes undergo an eye exam 5 years after diagnosis and that adults with Type 2 diabetes have an exam at the time of their diagnosis. Subsequent exams will occur every 1-2 years if no signs of diabetes-related retinopathy are seen. More frequent examinations will be required if there is evidence of diabetes-related retinopathy (Solomon et al Diabetes Care 2017 Mar; 40(3): 412-418

). Unfortunately, in the United States, less than two-thirds of patients are receiving appropriate screening and 90% of diabetes-related visual loss can be avoided with appropriate treatment and follow up. By educating our patients on the importance of eye screenings and addressing their fears we have the ability to prevent visual loss from diabetes.

Eye exam, timing, and experience

There are several parts to an eye exam that is performed by an ophthalmologist (medical doctor) or optometrist. Health care professionals recommend that all people have periodic and thorough eye exams as part of routine primary care, this is especially true for patients with diabetes as they can be asymptotic in the early stages of retinopathy. The typical eye examination will begin with an initial screening room where technician may take a complete medical history including a complete list of medications and allergies. Vision is then checked both at near and distance and with and without eyeglasses. After a careful assessment of pupillary function, a series of eye drops are placed in each eye to dilate the iris and check the intraocular pressure. Dilation will typically take about 15-20 minutes. Once the eye is dilated, the doctor will examine the eye using a microscope called a slit lamp. Further examination of retina may be done with a light source worn on the head called an indirect ophthalmoscope. Both of which allow a view of the ocular structures including the retina. The light from each instrument may appear very intense but will not injure the eye. The doctor may decide to take various photographs of the back portion of the eye. This may or may not include an injection of a dye to better visualize the retinal vessels and ocular circulation. Images of the retina are often displayed on a monitor to help explain the ocular findings. This is meant as a tool to help with the understanding of the diagnosis and not to criticize or frighten the patient. If diabetes-related retinopathy has been detected and requires treatment it may come in the form of an intravitreal injection, laser treatment, or intraocular surgery. The importance of maintaining glycemic control in target range coupled with controlling blood pressure, lipid levels, and avoiding tobacco is also stressed.

Cross my heart, hope to die…(Well You Know the Rest) – The Reversal of Retinopathy

As you have read in other chapters the past decade has seen a dramatic shift in the management of diabetes-related retinopathy. With the appropriate care, we are now able to stabilize retinopathy and ongoing treatments will often lead to improvement in vision (Ref  Wells et al

.



Ophthalmology 2016;123(6):1351-9). The wonderful aspect about treating changes that affect vision is that the eye is an organ that is easily accessed. While the thought of placing medications into the eye is at first frightening the reality is that by treating the eye locally we minimize complications that may occur the medication is given systemically. As a primary care provider, you have the ability to help set the expectations for our patients. This should be hope rather than fear and punishment. All too often we tell our patients if you don’t do this you will have to do that. “If you don’t control your blood sugar you will need to go on insulin. You don’t want a shot do you?” We have created a relationship that has our patients believing that they have failed and the necessary treatment can be seen as a form of punishment. We know that the progression of diabetes is towards the failure of beta cells to produce enough insulin. This happens early for patients with Type 1 diabetes and late for Type 2. We should express to our patients that it is the progression of diabetes, not their failure that leads to the need to take medications to remain healthy. By presenting a positive outlook on how we are able to treat the damage that diabetes causes, and preparing your patients for having an eye exam and possible treatment, we have the ability to dramatically reduce the number of patients that lose their site from diabetes-related retinopathy.

What to Expect From an Intravitreal Injection

Intravitreal injections provide an effective method for the administration of medications in the treatment of many ocular diseases. In fact, the number of intravitreal injections has increased to a point that they are a common ocular treatment. By reducing anxiety and increasing knowledge about a procedure we can help our patients experience less emotional and physical discomfort with intravitreal injections. Chen et al. (2012) reported that diversion methods such as listening to classical music before and during intravitreal injections significantly decreased anxiety in patients.  While there are multiple ways to give an injection the basic principles are as follows:

The patient is placed in a comfortable supine position with the head supported.

Numbing drops or injection will be placed on the eye.

Topical betadine drops will be instilled on the eye.

A small device will help keep he eyelids open and away from the site of injection.

The patient is then asked to look in a given direction, often away from the physician.

Medicine will then be injected into the eye with a small needle. There may be a pressure sensation but typically not painful.

Afterward, the eye may be rinsed with sterile eye wash.

The procedure is done in the providers’ office and takes less than 15 minutes. This may need to be repeated as often as every month until diabetes-related retinopathy stabilizes.


Emotional and Informational support

Patients living with diabetes should be well educated about diabetes, its management, and its consequences.  Knowledge about disease pathophysiology, dietary and lifestyle modifications, treatment regimens and warning signs of possible complications are prudent for patients and their close family and friends. Patients should also have easy access to information about new treatment modalities and technologies. The internet is a useful resource however patients should be educated about reliable websites and information sources. Patients should be cautioned about unfiltered and unsubstantiated perspectives about a disease and its management which may provide disinformation and be the cause of additional anxiety and stress.  A certified diabetes educator can help you set priorities and coach you on seven key areas of diabetes management.

Below are trusted resources for additional information.

AAO Preferred Practice Pattern for DR:


https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2017

AOA Clinical Practice Guideline:


http://aoa.uberflip.com/i/374890-evidence-based-clinical-practice-guideline-diabetes-mellitus

American Diabetes Association: Figures and Tables


http://care.diabetesjournals.org/content/40/3/412.figures-only

AADE7 Self-Care Behaviors for Managing Diabetes Effectively


https://www.diabeteseducator.org/living-with-diabetes/aade7-self-care-behaviors

AADE’s DANA: One-Stop Healthcare Technology Resource for Diabetes Educator


https://www.danatech.org

Visual Impairment and Low Vision support

Despite our best efforts patients may still lose vision and go blind. There is no such thing as being “prepared” for this kind of news. It is important to remember that regardless of the stage of diabetic retinopathy individuals with diabetes should continue to control their risk factors to help preserve the remaining vision as well as minimizing other diabetes-related complications.  Fortunately, professional support is available and far more accessible than most people realize. There are adaptive techniques and remarkable, ever-advancing technology and products to help patients with visual loss continue to maintain visual independence.

During the early stage of diabetes-related retinopathy, no visual aid may be necessary as there is often no visible change or loss in vision. However, as retinopathy progresses, or should macular edema occur, treatment and vision assistive tools may be necessary for utilizing remaining vision. Once visual loss occurs finding devices that provide additional lighting, viewing choices (such as a vertical and horizontal screen), focus adjustment/magnification power, and color contrast options are all great features for visual support. Some visual aids, like an electronic magnifier, can be carried in a pocket or a purse and offer powerful magnification, lighting, and image capture, which is helpful when viewing a menu for individuals with central loss of vision. With a feature like an image capture, the information being viewed can be captured on the screen and displayed like a photograph, allowing the user to move the device displaying the image, to where peripheral sight can gather the magnified information. Larger visual aids such as a desktop magnifier provide more hands-free visual assistance, geared at home and office usage. When deciding upon which visual aid is right, determine what your primary use of the device will be, explore the features available and the ease of use of each aid, seek product feedback, and discuss with your eye-care specialist the available products for visual aids.

LOW VISION AIDS

Patients with diabetes have specific visual needs related to their diabetes self-care. These include being able to test blood sugar level and administer appropriate insulin dose, read food labels and medicine bottles, perform foot care and attention to any wounds. The ability to safely drive and maintain economic self-reliance would have a positive impact on their emotional state. Visual aids may allow patients with visual impairment to maximize the use of their vision and live independently while managing their diabetes.

Optimal Lighting: It’s hard to overstate the importance of good lighting — but too much lighting can also impede vision. The lighting in your home should be evaluated with attention given to directional lighting for near tasks and motion-activated lights to help prevent accidents in dark environments. Filtered lenses can reduce the glare from bright light and improve the ability to discern objects from their surroundings. Because many patients with diabetes experience color vision loss along the yellow-blue axis, they are able to benefit from the contrast enhancement of amber filters with less awareness of the yellow-amber color than those with normal color vision.

Magnification: Magnifiers, strong bifocals, closed-circuit television systems, large print, and computer screen magnification programs are some examples of tools that can provide effective magnification for low vision. Small pocket magnifiers can be used to read labels or menus. Standing magnifiers can be used to read or view items at home or work. Closed Circuit TVs (CCTVs) are cameras that project a magnified image onto a computer or television screen and can help with reading the newspaper, mail, or medicine labels.

Computer adaptations: There are numerous ways to modify a computer to make it usable by a person with visual impairment. Software programs can change the text size, screen background color, or text color. Screen magnifiers work like a magnifying glass for the computer screen. Screen readers speak everything on the screen, including text, graphics, control buttons, and menus in a computerized voice. Some programs are available in basic, free versions and other programs have free trial periods so that users can give the software a try before making a purchase. Some e-readers also have voiceover, and can read the book out loud — no audiobook subscription required.

Writing aids: Use paper with bold lines to help you write in a straight line. If bold lines aren’t enough, plastic guides can be purchased to help you sign documents, write letters, fill out checks, and write addresses on envelopes more easily. Felt-tipped markers create lines that are bolder and easier to see than lines created by ballpoint pens. Black print on yellow or ivory paper reduces glare and improves visibility. Some banks will provide large-print checks, check guides to help fill in the correct spaces, and in addition billing statements can be provided in large print.

Home safety: Falls can be avoided in the home by making some relatively small changes. Place strips of reflective tape or paint on stairs to make each step more visible. Remove throw rugs or use non-skid rubber-backed rugs. Use a rubber mat in the bathtub or shower. Have grab bars professionally installed in the bathroom; towel racks are not strong enough to support you if you slip.

Smart Devices: Voice-activated personal assistants can summon up information on command, lessening the need to read from a screen. And smart home devices can perform hundreds of tasks on your behalf: play music, check the weather, place orders online, make a grocery list, and sync with other smart home devices like thermostats and outlets. Wearables use head-mounted magnification technology to help people see distances, faces, and television.

pediatrician’s office for advice

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pediatrician’s office for advice

She asks the RN in the pediatrician’s office for advice to manage the problem at home. Jorge is excited to go on a Boy Scout camping trip, and the mother is concerned that he will experience embarrassment, because the boys and the leader could find out about this problem.
• What type of enuresis is Jorge experiencing?
• Identify two (2) pieces of assessment data the RN should collect.
• How will this data be used in planning nursing care?
• Describe one (1) physiological, and one (1) psychosocial intervention that could help either Jorge or his mother deal with this problem.
Base your initial post on your readings and research of this topic. Your initial post must contain a minimum of 250 words. References, citations, and repeating the question do not count towards the 250 word minimum.

Ethical Legal Decision-making Dilemma for the Nurse Practitioner

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Honesty versus withholding information

Ethical legal decision-making dilemma for the nurse practitioner

In creating an ethical and legal decision-making dilemma involving an advanced practice nurse in the field of a family nurse practitioner (FNP) I will be choosing the practice dilemma of honesty versus withholding information. I am choosing this dilemma to show the ethical and legal quandary that NPs may face when dealing with patients who have requested physician assisted death (PAD) (Stokes, F., 2017). As a hospice nurse, and soon to be hospice provider I am aware of this request (recently had one) and the ethical and legal ramifications that can become unleashed due to this request. If I choose honesty, and I am practicing in a state that has legalized this practice, I am obligated to facilitate the request; regardless of my personal beliefs and opinions. In contrast, I am not advocating for my patient and their wishes by choosing to withhold information regarding their request for PAD; within my scope as an advanced practice nurse I can listen to them, counsel them, and refer them to a physician that can further assist them.  PAD is also known as death with dignity and it occurs when a physician provides interventions that intentionally assist a patient to die, for example, prescribing lethal medication to hasten death when suffering from an irreversible, excruciatingly painful disease. PAD should not be confused with euthanasia. Euthanasia occurs when a physician administers a lethal dose versus PAD which the patient self-administers the medication prescribed by the physician. Death with dignity is legal in Oregon, Washington, Vermont, Colorado, and California. It is available through court ruling in Montana and most recently New Mexico (Stokes, F., 2017). In Canada, a recent law was passed entitled MAID. MAID is Medical Assistance in Dying and allows NPs to participate in PAD. The law allows an NP to diagnose and prescribe the lethal medications to assist the patient. Situations in which PAD is requested are challenging for physicians and other healthcare practitioners because they raise significant clinical, ethical, and legal issues (AAHPM, 2015).

Code of ethics

The code of ethics for nurses is a vital tool that every nurse must follow. It is regularly updated to reflect changes in health care structure, financial elements, and delivery of care (AMA, 2015). The code of ethics supports nurses in consistently providing respectful, humane, and dignified care. There are nine provisions and interpretive statements which provide a concise statement of ethical values, obligations, and duties of every individual who enters into this profession. These statements serve as the profession’s ethical standards and expresses nurses’ own understanding of our commitment to society. The nine provisions mentioned are as followed: Provisions 1-3 are a clean and concise reminder of the values and commitments of a nurse. Provisions 4-6 describe and identify the boundaries of duty and loyalty.  Provisions 7-9 describe the duties of the nurse that extend beyond individual patient encounters.

The most relevant code of conduct that applies in my practice dilemma of honest versus withholding information in my practice dilemma, in my field of FNP, would be provisions 4-6; the boundaries of duty and loyalty. One ethical principle that could be violated would be the code’s interpretive statements which provide specific guidance for practice (ANA, 2015). The code of ethics for nurse’s interpretive statement 1.4 states: “The nurse should provide interventions to relive pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life” (Stokes, F., 2017). My chosen profession as a FNP promises to provide and advocate for safe, quality care for all patients and communities. These codes bind nurse to support each other and make us accountable to their ethical and professional obligations.

Violation of ethical principle and law

The legal ramifications and violation of law for practicing PAD are as followed; FNP’s cannot legally or ethically make the diagnosis to determine terminal illness, for the purpose of qualification in PAD (Stokes, F., 2017. Federal law states, a NP can make the recommendation of hospice care but, they cannot sign the certificate of terminal illness (CTI). Only two physicians are a to sign; one being the primary care provider, and the other the hospice medical director.   Secondly, not all states have allowed NP’s to practice independently without a collaborative agreement; the role of the NP in PAD should be carefully considered.                Lastly, several states adhere to laws allowing for prosecution of persons who provide assistance in the hastening of one’s death. Nurse can be liable for negligence when they breach the standard of care. Additional consequences include; having restrictions placed on their license by the board of nursing, suspension, or loss of licensure (Stokes, F., 2017).

Decision to prevent violation of ethics and laws

Decisions that demonstrates integrity while preventing violations of ethical principles and prevent laws from being violated; simply avoiding your involvement in the practice of PAD. As a FNP you can choose to provide the patient with information on end of life care or PAD, terminate the NP-patient relationship, and arranges for a consultation. Keeping in mind, making judgements on when to offer full disclosure may serve to undermine the bond of trust between a patient and nurse (To tell or not to tell, 2017)

.

Discussing and exploring other options such as; providing resources, comfort, and support for the patient and family allows you to remain involved in their care. The healthcare provider can reject the patients request for PAD without abandoning the patient and involvement in their care (Taboada, P., 2017). The advance practice nurse will refrain from judgement or bias against the patient based on their request for PAD and anticipate contemplations relating to the standards of care, your personal beliefs, and the law.

Recommendations to resolve moral distress

Three recommendations that will resolve advanced practice nurses’ moral distress in the dilemma would include initially; time spent developing and understanding the patient or families point of view (McCabe, M., Wood, W., and Goldberg, R., 2010). I can offer support to the patient while determining how to exercise their autonomy in regards to their illness. Secondly, I will promote and encourage hospice or palliative care to relieve pain and suffering while enhancing quality of life (AAHPM, 2015). Lastly, I will listen to questions and evaluate concerns during our conversation of PAD while acknowledging, addressing, and thoroughly investigating them.

In conclusion, I find the topic of physician assisted death controversial, even to myself. I see both sides of this dilemma. I empathically relate to the patient who has an irreversible illness/disease process and intractable pain. I relate to the healthcare provider who understands and practices PAD, and those who oppose it based on their own values and beliefs. A recent situation tested my own beliefs and ethical values. As a hospice administrator, working amongst a varied population of residents; independent living, assisted living, and those in memory care. I met a gentlemen living in the independent living section who visited me regularly to talk about hospice as his wife and brother were both receiving hospice cares at their end of life. Two weeks ago, I received a phone call from this resident; he was asking for a visit. When I arrived he asked me if I was still doing hospice to which I replied yes. He then told me he was ready for hospice. I was confused as he looked healthy, thinner than when I had last seen him, but, still living and functioning independently.  He explained he was going to start fasting and that he knew what he was doing and that he had declined to point of not wanting to live like that anymore. He asked me to take care of him. I asked him why he was making this choice, to end his life. He stated he was 89, he had a great life, great marriage, but, didn’t want to continue as his health was declining and he was not feeling as good as he wanted to. I asked him if he spoke to his physician about his plan, he told me no as he didn’t want to involve him. I asked if he was depressed and he said no, as he was in the past, but, he wasn’t now. I explained while I respect his decision his doctor would have to be involved in the process. Not wanting to break his trust in me I proposed he have that discussion and share his thoughts with his doctor. I also elicited the help of our social worker who spoke to him about code status, legal, and ethical considerations. Thankfully, he told me he wouldn’t start fasting until he spoke to his PCP. I found relief from my ethical dilemma by merely talking it out while maintaining trust in our nurse-patient relationship.

References

  • American academy of hospice and palliative medicine (AAHPM) (2015). California medical association removes opposition to physician aid in dying bill. Retrieved from: Google Scholar.

    http://aahpm.org/positions/pad
  • McCabe, M. S., Wood, W. A., & Goldberg, R. M. (2010). When the family requests withholding the diagnosis: who owns the truth?

    Journal of oncology practice

    ,

    6

    (2), 94-6
  • Westrick, Susan, J., (2014). Essential of nursing law and ethics. (2

    nd

    edition). Burlington, MA: Jones & Bartlett learning.

Leadership within a Residential Care Home

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In our society it is rather common for every person of diverse backgrounds and experiences to converge and interact with each other. It is a challenge for a group of heterogeneous nature to act efficiently and to act as an organic whole. Thus, here comes in the challenge of an efficient leadership. This essay will describe a scenario within a UK residential care home, which demonstrates effective transformational leadership via a systems and organisational approach. Before describing the scenario, the difference between management and leadership will be outlined.

Leadership and management are similar concepts, but each comprises unique components that make them distinct (Marquis and Huston, 2006). Primarily, the key purpose of management is to achieve results through the efficient use of people and resources, hence an approach that is usually autocrative. Management is largely concerned with operational issues, such as planning, analysis and problem-solving (Bennis & O’Toole, 2005).

Leadership, on the other hand, is more participative, one definition of clinical leadership being: ‘Leadership is a dynamic process of pursuing a vision for change in which the leader is supported by two main

groups: followers within the leader’s own organization, and influential players and other organizations in the leader’s wider, external environment’ (Goodwin,2006, p. 22). The integration of leadership skills into management approaches shows that although there is a difference between managers and leaders, there is an overlap whereby both are needed for an organisation to be successful.

The integration of distinct leadership and management skills were demonstrated in the following scenario:

A Filipino carer was promoted to a higher position, as a lead carer within a residential care home, which caters to approximately 40 service users diagnosed with dementia. From the start, he exudes potential to be a leader. Unlike others, he does less talking and does more work that produces very productive output. He is well respected because of his ability to inspire his colleagues to do better by setting himself as a good example. Prior to his promotion, the care home was subjected to be inspected by the Care Quality Commission (CQC), an independent working body which aims and works to regulate all the care homes, hospitals and other sectors to warrant that they rightfully comply and adhere to the specific standards to ensure that optimum care and safety of the service users/ patients are justly given, due the home’s inadequacies. Poor management, lack of sanitation, and inadequate staffing were among the observed shortfalls, along with the absence of a holistic, person-centered approach to care. As a newly assigned leader of the home and a novice in this position, the said Filipino carer is faced with an arduous challenge not only to help improve the quality of service the care home has to cater to its service users but most especially to be able to shepherd its subordinates to the best of his ability for the success of its whole organization.

The lead carer, in his new position, adopted a transformational leadership style, the focus being on achieving change through teamwork. Transformational leadership moves away from the superior/inferior dyad towards an emphasis on the importance of relationships in the achievement of long-term goals (McGee, 2007). This style places emphasis on the importance of communication and team-building (Whitlock, 2009), which supports the Creating Capable Teams Approach (CCTA) of encouraging teamwork and staff involvement in decision-making and action-planning (Hollingsworth, 2009).

The lead carer demonstrated good communication skills, which are fundamental to effective leadership (Barrett, 2006). Assessing the problem encountered, he demonstrated the ability to prioritise necessary action and delegate tasks to those capable of achieving the desired goals. Then, rather than take an autocratic approach and merely instructing staff as to their given task, he encouraged participation in the decision-making process. This strategy was used to enhance staff commitment by allowing a certain level of bureaucratic leadership, where regulations and policies were adhered to, without being autocratic. Similarly, this approach encouraged staff participation without being laissez faire, a leadership style that allows employees to deal with the situation entirely on their own regardless of skill and capability (Shaw, 2009). Whilst the latter can be an effective learning tool, it is also highly risky within the clinical setting where patient safety is paramount.

Recognising that staff would require a strong role model in order to achieve such drastic changes, the lead carer provided a learning environment for the staff, as well as a senior model from whom to learn. This was beneficial in terms of continued professional development. Indeed, taking advantage of teachable moments is another skill demonstrative of effective leadership (Scott & Mouza, 2007).

By taking into consideration the needs and capabilities of individual staff members, a sense of teamwork was harnessed, which in turn acted to motivate and empower staff. Using this leadership style also buffered any stress of the working environment because staff needs were being supported (Newton & Maierhofer, 2006). The lead carer also buffered the stress of a demanding workload and a changing working environment by being consistent in his manner, providing praise where it was due and, where necessary, suggesting alternative courses of action in an understanding manner. Such high levels of support and feedback from supervisors has been found to increase staff well-being (Newton & Maierhofer, 2006).

Of particular inspiration was the leader’s ability to adapt to an ever-changing situation, succeeding to maintain service user safety whilst also providing ample learning opportunities from which all staff could gain knowledge and hone their skills. Flexibility has been reported to be essential for effective leadership, as is the ability to adopt different styles of leadership under different circumstances (Sims, Faraj, & Yun, 2009). In this scenario, the lead carer was flexible enough to teach by example, being fully involved in the changes being made.

The effective implementation of the changes highlighted within this scenario was largely dependent on the leadership skills of the lead carer. Indeed, transformational leadership has been found to be positively associated with higher employee satisfaction and performance, as well as higher service user satisfaction. These, in turn, correlate positively with less adverse events within an organisation (Wong & Cummings, 2009).

The charisma of the lead carer reflects characteristics described by trait theory (Zaccaro, Heinen, & Shuffler, M. 2007), which proposes that leaders are born with inherited personality and behavioural traits that are suitable for leadership. This indicates that this leadership role might have come naturally to the lead carer within this scenario thus clearly supported by the fact his charms and wits managed to provide a positive output both for his colleagues and the entire organization. Interestingly, Filipino leaders do show a preference for relationship-orientated as opposed to task-orientated approaches (Mujtaba and Balboa, 2009). It is their innate characteristic and instilled value to give importance and utmost respect to the people they are around with, regardless of their social status, beliefs ,opinions. On the other hand, the leader also demonstrated problem-solving skills that suggested he was continuing to utilise circumstances in order to strengthen his leadership skills, learning from the present experience. This supports the theory that leadership skills can be taught (Parks, 2005). Covey (2000) purports that principle-centred leaders are continually learning from their experiences. Principle-centred leaders are also synergistic ‘ they can work with change and improve almost any situation they are. They emanate a positive energy and optimistic attitude, which also manifests in a belief in others. Along with his transformational style of leadership, the lead carer within this scenario also demonstrated characteristics of a principle-centred leader.

In terms of management skills, the lead carer acted according to the three independent roles that Mintzberg, Ahlstrand and Lampel (2010) propose for managers: interpersonal; informational; and decisional. By taking into consideration individual staff needs and providing information to encourage active involvement in decisions, the leader chose to use influence rather than authority to manage inadequacies within the home. This strategy has been recommended by Crevani, Lindgren and Packendorff (2007) who also advocate moving the focus away from the manager and towards the team as a whole. This is demonstrative of the system approach to management.

The system approach to management was first introduced by Bertalanffy (1968) as ‘general system theory.’ Such an approach endorses organisational theory, whereby the organisation (in this case, the residential care home) is viewed holistically ‘ as a whole system comprising many subsystems, and within the context of the larger external environment. Madara (2008) defines a system as ‘a composition of several components working together to accomplish a set number of objectives’ (p.1). The lead carer, using the system approach, sought to resolve issues around poor management, lack of sanitation, and staffing problems, by working on the organisation as a whole and not merely targeting these three subsystems. Indeed, system theory purports that the activity of any subsystem of an organisation affects, in varying degrees, the activity of every other subsystem. In this case, improving staffing was likely to positively impact staff output, such as the provision of adequate sanitation. Furthermore, using a holistic approach to leadership and management, whilst also acting as a role model, was likely to enhance the presence of a holistic approach to care within the home.

The basic components of any system or organisation are: Input, Process, Output, Controls and Feedback loop. The input within this residential care home comprise care standards, scheduling of care, individual care needs, staff recruitment, staff supervision, staff abilities, and absenteeism and turnover. The process comprises the strategies used to determine issues such as required staffing levels and training needs, or limits in the number of service users who care can be accommodated. The output comprises these processes being put into action somehow, such as, for example, developing a care schedule for each service user. Controls are procedures put in place to ensure the planned input and output is achieved, such as the development of policies, procedures, and contracts. The feedback loop then enables the achievement of goals, such as improving sanitation and thus service user satisfaction, which can feed back positive input and output into the system.

System theory enabled the lead carer, using a transformational leadership style, to look at the organisation as a whole for achieving overall effectiveness, to provide staff with a shared focus to strive towards, and to consider the environment in which an organisation works. In this sense, the lead carer demonstrated an ability to analyse a situation, action plan, and motivate people to achieve organisational goals.

However, the leader might have benefitted further from a consideration of how different environmental and cultural dimensions relate to the type of leadership style adopted. The cultural dimension most often researched in terms of leadership is individualism-collectivism (Gelfand, Nishi, & Raver, 2007). This dimension is related to the integration of individuals into primary groups as well as the degree to which individuals look after themselves or remain integrated in groups. The leader within this scenario used a collective management practice, but needs to be mindful of staff from individualistic cultures, who value autonomy and personal needs above group needs. The importance of such considerations is highlighted by Kwantes and Boglarsky (2007), who found that organisational culture is strongly perceived as being related to both leadership effectiveness and personal effectiveness.

In terms of transformational leadership, as used within this scenario, Ergeneli, Gohar and Temirbekova (2007) provide cultural insight into this. By examining transformational leadership in Pakistani, Kazakh and Turkish business students they found that some aspects of transformational leadership are culture-specific, especially the aspects of inspiring a shared vision and being a role model.

The effectiveness of a chosen leadership approach is also influenced by gender. For example, Paris, Howell, Dorfman, & Hanges (2009) have demonstrated that preferred leadership styles differ between genders and across countries, cultures, and industries. In general, female managers showed greater preference for participative, team-oriented, and charismatic leadership styles than did males. On the other hand, both males and females valued humane-oriented leadership.

This scenario provided valuable insight into the importance of self-development and continued professional development in terms of leadership skills. Key factors described as effective in nurturing transformational leaders include provision and access to effective role models, as well as mechanisms for mentoring and clinical supervision (Davidson, Elliott & Daly, 2006). It is clear that an understanding of one’s own personal values and goals through personal insight and a willingness to reflect carefully on working relationships with others are necessary for developing the transformational leadership approach.

Gained from this scenario is a better understanding of leadership and the fact that it comprises a complex range of factors reflective of skills, characteristics, context and people. Furthermore, leadership is not merely a series of skills or tasks, but more so an attitude that entails adequate innate or maybe acquired leadership behaviour and dedication. The leadership skills currently possessed include good communication skills, effective team working, and strong problem-solving skills. The characteristics currently possessed that contribute to effective leadership include motivation, goal-focus, and a passion for continual learning. It is anticipated that these skills and characteristics, along with a working environment comprising people with a shared vision will facilitate the development of those skills and characteristics that require further nurturing.

It is clear that dynamic leaders and supportive environments are essential in the development and achievement of best practice models. The discussed scenario has provided further insight into the importance of this. It has also highlighted how the systems framework is fundamental to the organisational theory of leadership and management, since organisations are complex goal-oriented processes. In addition, cultural factors that might influence leadership effectiveness have been acknowledged and integrated into the learning experience. Effective leaders manage through a balance of both task and relationship focused behaviours, and thus it is important that the relationship-orientated approach that comes so naturally to this leader does not prevent task-orientation where necessary Huang and Mujtaba, (2009). This new insight and understanding can be harnessed for future leadership practice.

The author also firmly believes that all leaders are confronted to make their own personal choices of their leadership style to meet the needs of the many situations with respect to their organizations. Though there is no absolute uniform style to lead one situation or scenario from the other, effective and efficient leaders, based on their own discretion opt for a certain style which they think would work best for the entire organization.

10 Discussion Questions Regarding Substance Abuse

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10 discussion questions. 1 paragraph per question

 

Discussion 1
Describe the major causes for concern regarding cocaine use and compare them with various causes for concern regarding amphetamine use, showing evidence of your understanding of their similarities and dissimilarities.

 

Discussion 2
Explain the basic rationale and theoretical foundations for the extensive use of amphetamine in the treatment of ADHD (attention-deficit hyperactivity disorder).

 

Discussion 3
Discuss the feasibility of controlled drinking as a realistic goal for those who are dependent on alcohol, citing evidence of support for as well as of opposition to this controversial concept of treatment.

 

Discussion 4
Discuss the rationales for and against viewing alcohol dependence as a disease.

 

Discussion 5
Present the pharmacology of opioids, including chemical changes and mechanism of action.

 

Discussion 6
Describe the potential adverse effects and possible health risks associated with anabolic steroid use by males and females, including psychological manifestations of use that have been observed in many athletes who have used these substances indiscriminately.

 

Discussion 7
Describe the acute behavioral and acute physiological effects of marijuana. What are the behavioral or physiological effects of long-term marijuana use?

 

Discussion 8
Summarize the major causes for concern associated with the effects of THC and/or marijuana use.

 

Discussion 9
List and briefly describe the major characteristics of the following treatments for substance dependence: total abstinence (Alcoholics Anonymous), motivational enhancement therapy, contingency management, relapse prevention, and the detoxification and maintenance phase of pharmacotherapies, making certain to explain the differentiating features of each.

 

 

 

Discussion 10
Develop an outline of your own suggestions for a multifaceted, comprehensive approach to drug abuse prevention in your community or local school district. 

How Can Socialization and Mentoring Be Used For Career Advancement?”CAREER CONNECTION: This assignment builds socialization skills and establishes the importance of mentoring to aid in career advancement.

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How Can Socialization and Mentoring Be Used For Career Advancement?”CAREER CONNECTION: This assignment builds socialization skills and establishes the importance of mentoring to aid in career advancement.

The team has been invited to present at a conference before top executives of Fortune 500 companies. The topic the team is presenting on is “How Can Socialization and Mentoring Be Used For Career Advancement?”

Create a 10- to 15-slide Microsoft® PowerPoint® presentation in which you address the following as they relate to the topic:

How can socialization and mentoring be used to advance a career?
How can socialization and mentoring help minimize resistance to change using the contingency approach?
How can socialization and mentoring help people embrace these changes as a part of career advancement?
Include Feldman’s three-phase model of socialization and the six socialization tactics as part of the discussion.
Include speaker notes at the bottom.

Cite a minimum of two quality sources. You may use the textbook as one.

Format the references according to APA guidelines and include as a reference slide at the end of the presentation.

Learning Experience 3 Observe several different exercise classes at clubs- sports teams to identify if any coaches or instructors are asking students to do bio-mechanically incorrect activities.Then l

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Learning Experience 3

Observe several different exercise classes at clubs, sports teams to identify if any coaches or instructors are asking students to do bio-mechanically incorrect activities.Then list the contraindicated exercises and explain the benefits to risk ratio, i.e.: why they were wrong, what could be the long term effects of those exercises, and what exercises would be safer.

Communication With Family Members Of Critically Ill Patients

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Critical Care Unit (CCU) or Intensive Care Unit (ICU) is designed to meet the special needs of acutely and critically ill patients in a hospital setting. In many acute care setting, the concept of ICU care has expended from delivering care in a standard unit to bringing ICU care to patients wherever they might be. The electronic or virtual ICU is designed to augment the bedside ICU team to monitoring the patient from a remote location. The ICU staff includes critical care physician, respiratory therapist team, critical care nurses, and advanced practice nurses (APN). The capability exists to continuously monitor ECG, blood pressure, oxygenation saturation, mechanical ventilation, cardiac output, intracranial pressure, and temperature. More advanced monitoring devices allow for the measurement of cardiac index, stroke volume, ejection fraction, end-tidal carbon dioxide (CO2), and tissue oxygen consumption (Lewis et al., 2007).

Intensive care settings are designed to assist and care for patients with complex, multiple or life threatening heath problems. Many of the patients are ventilated and/or chemically paralyzed and sedated. The emphasis in ICUs is on technology and short stays. The environment is often noisy, technical and fear inducing to many patients (Usher& Monkley, 2001).

The intensive car unit (ICU) is a place where technology is used to save or enhance the lives of patients and is staffed with clinicians who are skilled at managing physiology and responding to the rapidly changing status of their patients. The clinicians who work in the ICU are able to multitask, set priorities, and constantly assess and manipulate an array of medical machines and vital signs to help improve the patient’s functional status. These clinicians are focused on helping patients get their life back to how it was before the injury or illness landed them in the ICU. Patients are transferred to the ICU to receive an aggressive level of treatment that is not available on other units in a hospital (Treece, 2007).

Communication

Communication refers to an organized, patterned system of behavior that may be verbal or nonverbal. Verbal communication includes not only the language or dialect, but also the voice tone, volume, timing, and one’s ability to share thoughts and feelings. Nonverbal communication may take a form of writing, gestures, body movements, posture, and facial expressions. Nonverbal communication also includes eye contact, use of touch, body language, and style of greeting. Other variables to consider include the role of gender, age, acculturation, status, or position on what is considered to be appropriate eye contact. For example, Muslim Arab women exhibit modesty when avoiding eye contact with men other than their husbands and when in public situations (Lewis et al., 2007).

Communication regarding end-of-life issues with patients and families has long been recognized as complex and not always done well as judged from all those involved. From the perspective of families, they have indicated that when involved in making decisions at end of life, they feel a sense of comfort and support when they might otherwise feel helpless. A number of studi

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es have identified what families report to be helpful when making end of life decisions for their loved ones. These factors included communicating timely, emotionally supporting families in making decisions, having an advanced directive that provides honor, and having access to the patient before and after death (Liaschenko.J., O’Conner-Von. S., Peden-McAlpine. C, 2009).

The importance of effective communication in intensive care settings is well established. However, anecdotal and research evidence suggests that many patients recover from episodes of critical illness that necessitated admission to an intensive care unit (ICU) with a less than favorable view of the nurses’ ability to communicate effectively. Patients often describe how they felt frustrated and alienated by the apparent lack of communication in these settings. Further, just because patients are unconscious, we can never assume they do not perceive attempts to communicate with them (Usher& Monkley, 2001).

With increasing focus on improving care in the ICU, the author runs the risk of forgetting the family of patients who survive their ICU stay. There are several reasons to focus on communication with the families of all critically ill patients. First, it is generally not clear whether critically ill patients will survive at time when clinician-family communication should be occurring. Second, although the patient’s death in the ICU is a risk factor for psychological symptoms among family members, even family of patient who survive are at increased risk of these symptoms compared to the general population. Finally, there is evidence that family members of patients who survive are actually less satisfied with communication from ICU clinicians than family of patients who die. If we are to be truly effective in improving clinician-family communication, we must attempt to improve this communication for the family of all critically ill patients (Curtis & white, 2008).

Role of the ICU nurse

The nurses who work in critical care units are responsible for providing care to patients who are experiencing or at risk for experiencing life threatening conditions. Patients typically cared for in a critical care unit include patients that have had major invasive surgery, accident and trauma patients, or patients with multiple organ failure. Nurses who work in critical care units must assess and monitor the patient closely in order to identify subtle changes in a patient’s condition that warrant immediate intervention. Patients who admitted to a critical care unit need intensive care in order to maintain their condition, monitoring, and continuous adjustment of treatment, such as changing in doses of multiple intravenous medications, and changes in ventilator support. Critical care nurses must be able to interpret, integrate and respond to a wide array of clinical information because of the critical nature of patients’ conditions (Kozier, Erb, &Berman, 2008).

The critical care nurse cares for patients and the families of patients with acute and unstable physiological problems in an environment equipped for technically advanced methods of assessing and managing patient problems. The American Association of Critical Care Nurses (AACN) defines critical care nursing as that specially dealing with human responses to life-threatening problems (Lewis et al., 2007).

Nursing staff in ICUs are important facilitators of communication because they provide a link between the patient and the outside world. Nurses are said to provide a conduit for

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initiating and maintaining a modicum of normality in an otherwise alien environment. This is important when many of the patients are unconscious, as is the case in these settings (Usher& Monkley, 2001).

Critically ill patient

A patient is generally admitted in ICU for one of three reasons. First, the patient may be physiologically unstable, requiring advanced clinical judgments by the nurse or physician. Second, the patient may be at risk serious complications and required frequent and often intensive assessment. Third, the patient may require intensive and complicated nursing support related to the use of intravenous (IV) polypharmacy such as sedation and thrombolytics drugs. The patient who admitted to ICU are due to a serious conditions such as respiratory distress, major cardiac surgeries, and myocardial ischemic or infarction (Lewis et al., 2007).

Severe sepsis with associated multisystem organ dysfunction is a leading cause of death in patients hospitalized in intensive care units (ICU). The gastrointestinal tract plays an important role in the pathogenesis of multiorgan dysfunction owing to breakdown of intestinal barrier function and increased translocation of bacteria and bacterial components into the systemic circulation and all those factors lead the patient to become critically ill ( Jacobi, C. A., Schulz. C., Malfertheiner. P, 2011).

For many patients, a stay in an intensive care unit can be very frightening and confusing. Some patient may have been prepared for such an eventuality, while others may have been admitted there unexpectedly. In either case, the intensity of the environment and the level of staffing required can be very daunting. In these settings, many patients will have a period of being either intubated or requiring the formation of a tracheostomy, leading to them being unable to talk and therefore asking questions about their health, their care or their prognosis. The lack of control of their own environment can have a significant number of counter effects on the individual’s cognitive and psychological status and potentially can result in misunderstandings. Many studies have demonstrated that the promotion of a suitable means of communication for an individual can improve well being, which may therefore increase compliance with rehabilitation therapies and reduce length of stay (Batty. S, 2009).

Ninety percent of deaths in the ICU involve withdrawing or withholding care, but less than five percent of critically ill patients are able to participate in the decision making process leading to treatment limitation (LeClaire, Oakes, & Weinert, 2005).

Most of the critically ill patients do not have decision making capacity, family members frequently become involved with clinicians in discussions about the goals of care and often must represent patients’ values and treatment preferences in these discussions. Therefore, clinician family communication is

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a central component of good medical decision making in the ICU. Prior studies suggest that family members view clinicians’ communication skills as more important than our clinical skills (Curtis & white, 2008).

Family

The family is a basic unit of society. It consists of those individuals, male or female, youth or adult, legally or not legally related, genetically or not genetically related, who are considered by the others to represent their significant persons. Family consists of persons (structure) and their responsibilities within the family roles (Kozier, Erb, &Berman, 2008). The definition of family member is the direct family person or significant one who identified as “close relative” (Henderson & Knapp, 2005).

Family members of patients in the ICU are exposed to considerable stress. To better help relatives in this situation it is important to gather information about how they experience the information provided by and support from the medical staff. The staff may underestimate relatives’ needs (Myhern, Ekeberg, Langen& Stokland, 2004).

Communication between families and providers in the intensive care unit includes sharing information about illness and prognosis, engaging families in treatment decision making, and offering support. Treatment decisions are complex, and communication is essential for designing treatments that incorporate patient values. Communication also affects patient and family outcomes (Scheunemann, McDevitt, Carson, & Hanson, 2010).

However, communication is complicated by time constraints, lack of communication skills training, unclear goals and processes, and challenging family dynamics. Nurses must possess good communication skills in order to provide humane, complete and comprehensive care. Such abilities imply: listening well, honesty, avoiding a conspiracy of silence, fake cheerfulness, never dismissing hope and providing relief of pain. The guidelines of the American Association of Colleges of Nursing State that a nurse must have certain skills to be able to provide a high quality assistance to for example dying patients and their families, such as an effective and compassionate communication ability, when death issues are concerned, among other skills (Trovo de Araujo, M. M., & Paes da Silva, M. J, 2004).

Family members are becoming an increasing part of care giving for seriously ill patients, whether this is informal support and care in the home or surrogate decision making in the ICU. Informal care and decision making provided by family, partners, and friends constitute a growing portion of the health care provided to seriously ill patients. Furthermore, approximately 20% of deaths in the United States occur in the ICU, and most of these deaths involve family members acting as surrogates for the patient. In the ICU setting, there is an additional reason to focus on the needs of the family. Since family members are often serving as surrogate decision makers, decisions about the care of the patient depend in part on the family. To the extent that family members; distress affect their ability to provide substituted judgment, these burdens of family members can interfere with patient care. Therefore, effective communication with family members that minimizes stress on the family and provides support for the family will improve not only family outcomes but also medical decision making for the critically ill patient (Curtis & white, 2008).

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AIM:

To describe nurse’s experiences of communicating with family members of critically ill patients in an ICU setting.

METHOD:

The authors used a literature review method design in their research topic.

Literature review

This study is a literature review of 15 academic original articles. A literature review discusses published information in a particular subject area within a certain time period. A literature review can be just a simple summary of the sources, but it has an organizational pattern and combines both summary and synthesis of entails information (Polit & Beck, 2008).

Data collection

PubMed and CINAHL

In a general way the MEDLINE Database was developed by U.S. National Library of Medicine (NLM), and is widely recognized as the premier source for bibliographic coverage of the biomedical literature. MEDLINE cover about 5000 medical, nursing, and health journals published in about 70 countries and contain more than 15 million records dating back to the mid-1960s (Polit & Beck, 2008).

MeSH

Medical Subject Headings is to index articles. MeSH terminology provides a consistent way to retrieve information that may use different terminology for the same concepts (Polit & Beck, 2008). The authors searched for scientific articles by using PubMed database. By using MeSH box search to found our key word as follow:

“Communication”[Mesh]) AND “Family”[Mesh]) AND “Nursing Methodology Research”[Mesh], ((“Patients”[Mesh]) AND “Critical Illness”[Mesh]) AND “Intensive Care Units”[Mesh].

Search process in PubMed

Search word PubMed

Numbers of hits

Read abstract

Read article

Chosen articles

Date Time

Patients, Critical illness, Intensive Care Unit.

17

17

10

6

10-15/3/2011

Communication, Family, Nursing experience.

129

20

6

2

10-19/3/2011

Inclusion criteria and limits: PubMed and CINAHL are used in this study to search for the academic articles. PubMed comprises biomedical literature and CINAHL database the cumulative index to nursing and allied health literature, is a resource for nursing and allied health literature. The inclusion criteria for articles will be English language, nursing specialty, original scientific articles, setting Critical Care Unit (CCU) or Intensive Care Unit (ICU). And articles which was published between 2000-2010. It is concerned about human being studies in addition, only primary sources have been taken. The main concern was applied to nursing attitudes and experiences and any study includes other professions besides nursing was considered.

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Data analysis

The articles are all read and are analyzed manually and documented on word office program in the computer. The main concepts were highlights with different colors and are documented in different files. All different aspects are taken in the consideration, and are scheduled according to information correspondence and differences. The studies’ conclusions are read by the authors and included as supportive points in the conclusion of the study.

Quality of the study

In this study the classification and evaluation of the articles scientific quality is based on Sophiahemmet University College criteria.

ETHICAL CONSIDERATIONS:

The author are concern to deal with the results in an honest way and no changes to be made to the facts and finding. The articles which are used all ethically approved. The result will include both information that will support author’s thoughts and those which are not (Polit & Beck, 2008).

formal- in-depth case analysis requires you to utilize the entire strategic-management process. Assume your group is a consulting team asked by Nintendo to analyze its external/internal environment an

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formal, in-depth case analysis requires you to utilize the entire strategic-management process. Assume your group is a consulting team asked by Nintendo to analyze its external/internal environment and make strategic recommendations. You will be required to make exhibits/matrices to support your analysis and recommendations. The case analysis must encompass  pages plus the exhibits/matrices, cover page, and reference page. The cover page must include the company name, your group name, and the date of submission. The matrices must not be part of the analysis body but exhibits.

The completed case must include:

  • Executive summary;
  • Existing vision, mission, objectives, and strategies;
  • SWOT analysis;
  • Porter’s 5 Forces;
  • Value Chain Analysis;
  • Financial Ratio Analysis;
  • Balance Score Card;
  • Intellectual Assets: Human Capital, Social Capital, Technology;
  • Organizational Design;
  • A list of alternative strategies, giving advantages and disadvantages for each;
  • A recommendation of specific strategies and long term objectives;
  • An action timetable/agenda.

Have your group leader place the results of the case analysis in a single document and post it to

Group Assignments>Week 8: Group Case Analysis 2 (Module/Week 8)

in your Group Discussion. Be sure that the assignment is in a business-professional format; include current APA citing and referencing.

Submit this assignment by 11:59 p.m. (ET) on

Friday

.

Note: Your assignment will be checked for originality via the SafeAssign plagiarism tool.

How would you, as the nurse, apply the “Art of Nursing” to the following situations?

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How would you, as the nurse, apply the “Art of Nursing” to the following situations?

How would you, as the nurse, apply the “Art of Nursing” to the following situations? Write a paragraph for each scenario.

a. A mother who has delivered a stillborn child

b. A patient who has just been told he has cancer

c. A family who is unsure whether or not to place a loved one in

How would you, as the nurse, apply the “Art of Nursing” to the following situations? Write a paragraph for each scenario.

a. A mother who has delivered a stillborn child

b. A patient who has just been told he has cancer

c. A family who is unsure whether or not to place a loved one in