• Anja Bialas
• Jörn Janssen
• Alice Temitope Olude

Table of content

1 Obesity as the major health risk for the population of the Republic of Nauru –Causes and Impact ………………………………………………………………. 3

2 Possibilities and constraints of health protection policies in Nauru …………….. 4

2.1 Assessment of the requirements of adequate health policies in Nauru ……… 4

2.2 Discussion of Financing Options of Social Health Protection in the Case of

Nauru ………………………………………………………………………… 6

3 Conclusions and Recommendation ……………………………………………… 8

1 Obesity as the major health risk for the population of the Republic of Nauru –

Causes and Impact

The world’s smallest independent Republic Nauru, which is located in the South Pacific Ocean, set a distressing record of being one of the countries with the highest obesity rates. About 71.1 % adult of the population are considered to be obese (CIA 2014). Due to the WHO (2014), obesity is defined as “abnormal or excessive fat accumulation that may impair health”. The most important direct results or epiphenomena are cardiovascular diseases (e.g. stroke), which are mentioned by the WHO as the leading cause of death in 2012. Other ailments are diabetes, musculoskeletal disorders (e.g. osteoarthritis) some sort of cancer as well as mental disorders (WHO 2014).

Nowadays, obesity at Nauru may result from the lack of access to a healthy environment, especially lack of access to fresh and healthy food and lack of physical activity. Besides that, other reasons from previous periods have to be discussed shortly, which may also be responsible for the present situation.

After independence in 1968, Nauru used to be one of the richest countries in the world with high rates of GDP per capita due to its rich phosphate deposits. Due to bad governance, for instance the mismanagement of funds, lack of structural, economic and environmental policies, Nauru went bankrupt finally. Today, the republic is a low-income country and can be characterized by the following attributes:

• Lack of established industries
• Deteriorating capital plants
• High unemployment rate of 90% due to estimations by the CIA of 2005 (
  
  CIA 2014
  
  )
• Destroyed landscape (90% of the land are deteriorated due to intensive phosphate mining) (
  
  CIA 2014
  
  )
• High dependency on imports of almost all goods (food and other consumer goods)
• High dependency from aid, especially from the donor Australia

In spite of all these health problems, Nauru lacks a good health care system and it cannot afford to create one because of its weak economic and social state. Now, Nauru lacks the capacities to deal with the most important health risk obesity on the one hand, which affects the majority of the country. On the other hand it can be estimated, that Nauru will not be able to create an environment for the community to prevent further progress of overweight and obesity within the next years. For that reason it can be stated, that the country will not be able to deal with the problem in a proper way in the short and in the intermediate term.

In the light of this, the paper would examine the present situations of Nauru healthcare and why the standard financing options won´t work while also falsifying already tested hypotheses about the effectiveness of standard financing options.

2 Possibilities and constraints of health protection policies in Nauru

2.1 Assessment of the requirements of adequate health policies in Nauru

What are the requirements for an adequate health policy, and how might the situation in Nauru look like, in detail? In the following, this chapter is going to answer the stated questions. Therefore, it uses six basic indicators of good health policies; the focus on lifestyle and needs of population, consideration of other sectors relevant for health, participation of the population, use of locally available resources, integration and coordination of preventive, promotional, curative and rehabilitative measures, and decentralization of services.

With this, the subject of the following chapter is to create an understanding of Nauru´s situation today, while simultaneously trying to present the major problems.

• 
  Focus on lifestyle and needs of population
  

Beginning with lifestyle, we address directly one of the major problems. Before the country became rich, due to phosphate exportation, the population provided themselves through farming, fishing and hunting (20min 2011). The natural food and the gently cooking preparation, through boiling, supported the inhabitants with healthy, organic and substantial food. But with the growing income the eating habits changed towards imported, fat and durable food from the West, especially, meat and chips found their way in the supermarkets and so into stomachs of the population. Together with a low amount of working people, Nauruan grew fatter and unhealthier.

Another problem is that only processed or canned food finds its way on the island, until today, because the transportation of vegetables or fruits would take too long and would be too expensive. Even with an active government, the imported goods are still a problem (20min 2011).

The lifestyle of the population changed over the last decades. Today´s government focuses on the problem and is trying to support the population. Information on measures and programs are discussed in several media but are not published via official channels. Therefore it remains questionable, if the government´s efforts are sufficient and suitable to address the problems.

• 
  Use of locally available resources – considering their scarcity
  

The considerations of the government lead to daily walks of the president, anti-obesity campaigns, with signs and banners, and a support campaign for natural and healthy foods, which seemed to have some success. Especially the small trend towards more healthy food, developed with the growing poverty. Imported food is often more expensive than rural food. Therefore, the people do not have much of a choice and it is hardly to count as a success.

• 
  Participation of the population in search for solutions
  

The participation of the population seems rather small. Even though the average lifespan of a male Nauruan dropped under the age of 50, the support of the population is limited (WHO Nauru 2012). A few people profit from the working benefits, only the youngest go to school or college. The problem, the 95% obese people, are whether neither young nor working. Most of them are out of school and not working. Therefore, they do not see the necessity for change (Nauru Government 2014). Due to this, they are hard to motivate and engage. Participation of the population is critical for the success of all measures to reduce the health risks. It can be stated, that participation is rather low. It should be a major concern of the government to focus on that issue.

• 
  Consideration of other sectors relevant for health
  

With the acceptance and notion of the problem obesity, the government tried to support the population through single activities; additional focus on sport activities in the education system, free aerobic classes, the creation of sport tournaments, the provision of more sport areas and the support of those areas with the needed equipment and a guaranteed time for employees to do fitness. Naturally, because only a few people work, only a few benefit from the walking regulation, which does not support a change efficiently. Additionally, they started an anti-diabetes campaign and inform children in schools about the difficulties coming from an unhealthy lifestyle early on. As a result of this, the president walks every day, visible for everyone, on the landing zone of the airport, to motivate the population (20min 2011).

• 
  Integration and coordination of preventive, promotional, curative and rehabilitative measures
  

The government of Nauru agreed that they could only support the older population through high medicine standards, sufficient medication in case of diabetes, free athletic classes, obesity warnings and specialized medicine treatments (20min 2011). The young generation gets additional education about unhealthy living styles, is supported with more opportunities and motivation to do sports and. The focus of the government therefore lays on trying to change the development of the future generations and alleviation of the present problems for the older generations. Extravagant measures, like the daily walk of the president are one of the things, which were implemented to raise awareness.

• 
  Decentralization of services
  

The decentralization is not relevant because of the very small size of the country.

2.2 Discussion of Financing Options of Social Health Protection in the Case of

Nauru

There are various ways that a social health insurance could be financed. This section of the paper will be explaining the various financing options, the various features of each of the options, how they work and then assess its feasibility in financing social health insurance policies in Nauru.

The various financing options the paper would examine are as follows: User fees, Prepayment scheme, Government budget and Private insurance. Besides that Social insurance and Micro-insurance are further options of financing, which will not be focused in the following discussion.

User Fees

This involves an “out-of-pocket” financing of health services. In other words, the people would have to pay out of their pocket and it is usually on an immediate basis. It has been argued overtime whether this form of financing is effective or not, and also whether it promotes the use of social health insurance. While some argued that it provides a measure to check over utilization of health services, some argued that it doesn’t encourage the poor (who are the most vulnerable to health risks) to use health services as it is usually too expensive for them to manage. Also, it doesn’t really protect people from risks as there is no insurance element.

With all the above mentioned, it is quite clear why this form of financing cannot be used in Nauru. In a country with 90% unemployment according to CIA fact book and with its citizens having no source of income, it will be impossible for them to pay for health services out of their pockets much less immediately.

Prepayment Scheme

Prepayment scheme as the name implies is the payment for a service in advance. This involves a payment of premium before the occurrence of the hazard. It has same features like the user fees except that it has an insurance element in that the users pay ahead of the occurrence of the hazard.

This also cannot work for the citizens of Nauru as most of them are unemployed so there is no way of making payments in installments. Also, most of the employed are working in the informal sector, which makes it even more difficult for pooling of funds.

Government Budget (Taxes)

The government can also get to finance health care policies. This is usually done by allocating a percentage of government budget to the health care sector. Also, it could be done through payment of tax by citizens to government but usually with subsidies. This form of financing acts as a balance between the rich getting health coverage and the poor getting coverage as well. This is so because it is cheaper, provides universal access with low administration costs and most importantly, more coverage at little or no costs.

The Nauru government has an annual budget of $AUD 35.6 million as reported by the UNICEF in 2002, as well as a total expenditure of $AUD 79 million, which brings its deficit to $AUD 49 million. With this huge deficit and 90% of her revenue coming from aid, the health sector remains under funded still even though a higher percentage of her budget goes to providing health services. Making it also almost impossible to singlehandedly provide good health services based on government funding.

Private Insurance

Private health insurance is a form of voluntary insurance taken out by users themselves for various reasons. It has been argued that private health insurance helps cater to needs of the rich which allows the government to focus on catering better to the needs of the poor with limited resources. Also, it helps to provide more choices to the consumers and acts as a catalyst to reforms and efficiency in public health insurance. Despite all of these advantages, it is still really expensive and even widens gap between the rich and poor. Moreover, it is a bit difficult to administrate.

Presently, there is no form of private health insurance in Nauru. This is no surprise as private health insurers usually invest where the profits are higher and also insure people with lowest vulnerability to risks. In Nauru, most of its people suffer from obesity and diabetes; thus, if there were to be any coverage by insurance, these two diseases have to be a main focus but private insurers won’t want to insure them as the probability of the risk occurring is really high.

3 Conclusions and Recommendation

The paper focused mainly on two pillars, which are assessment of the requirements of adequate health policies and financing options. Within the chapters 2.1 and 2.2., we could give evidence for a number of problems, of which inhabitants of Nauru suffers today. Those can be summarized by the following characteristics:

1. Country specific obstacles like the small size, small number of inhabitants, high number of unemployed people, as well as the high number of diseased people and mismanagement in the past.

2. Lack of self-responsibility

3. High dependency burdens

4. Budget constraints

These problems affect the health conditions of the country to large extend and worsen the situation of people who suffer from obesity but also support a large number of obesity incidence.

We must come to the conclusion that for the same reasons / problems, Nauru will not be able to deal with the problem in a proper way in the short and in the intermediate term. Also, it can be estimated, that Nauru will not be able to formulate adequate policies and strategies to address the needs of those people who already suffer from obesity as well as those who are in danger to come down with obesity.

Furthermore it is critical to find sufficient and sustainable sources how to finance the budget and especially a budget for health policies.

Even if the authorities are aware of the problem and have been implementing single strategies to fight against obesity, it lacks of a broad and sustainable implementation of concrete measures to address the problem.

Due to the requirements of adequate health policies, it can be stated, that Nauru is not able to improve the situation remarkably. At the moment, the awareness concerning a responsibility and especially self-responsibility of the Nauruan authorities to address the needs of a healthy population is not obvious. The major argument here is, that there is no transparency because of lack of adequate information.

In terms of financing options, Nauru has to look for other, maybe unconventional financing options e.g. selling the right for an arts project (film, book) because of the countries unique past or Nauru could initiate a crowd funding campaign, which offers adventure vacation for money. Besides that, Nauru should focus on financing options, which makes the country independent from single donor states like Australia, e.g. credit at the World Bank.

Bibliography

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(Accessed 14 August 2014)

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Introduction

Pancreatic cancer is the most lethal and hard to diagnose type of cancer and thus often called the “silent killer”. Currently, no early detection method and no effective treatment are available for pancreatic cancer. Moreover, out of all patients diagnosed with pancreatic cancer, 75% will die within the first year where most within 3-6 months (Klein, 2013). While it is practically impossible to tell what person will develop this type of cancer the essential pathophysiology of cancers can help with understanding the origins and reasons for pancreatic cancer development.

Like most cancers, pancreatic cancer is caused by damage to DNA leading to its mutation. These mutations can be originated from different sources which can be categorized according to the nature of the occurrence. Three main categories of mutations have been universally recognized: inherited mutation, age-related, carcinogen caused or due to human behavior (Klein, 2013). The outcome of the exposure to one or multiple DNA mutation causes may be the formation of the neoplasms in the pancreatic tissue which may progress to actual pancreatic cancer where initial growth of the tumor is silent; therefore, symptoms are usually a sign of advanced disease.

The objective of the present research paper is to highlight the epidemiological facts related to pancreatic cancer (i.e frequency, distribution and determinants of health) and identify the public health authorities’ approaches towards management and control of this devastating health condition.

Frequency, Distribution And Determinants of Health

According to Canadian Cancer Registry age-standardized incidence rated (ASIR) of pancreatic cancer has been declined for men by 0.46% on the course from 1991 to 2007 with 11.2 case per 100,000 population in 1991 and 10.5 cases in 2007 respectively. However, during the same period of time the ASIR of pancreatic cancer for women per 100,000 population remained steady with a slight fluctuation hovering around 8.5 case.

The prevalence rate in United States and Europe has been calculated to be about 99,901 cases before 2012 with an incidence of 37,685 new cases in 2012. Despite the fact that some significant progress in cancer survival rate has been attained the projected 5-year rate of survival remained persistent slightly rising to 5.4% since 1975. Such poor outcomes are mostly due to the fact of the nature of the cancer where more than 80% of the patients presenting with already advanced stage and metastatic aetiology (Klein, 2013).

However, despite the poor prognosis of 5 years that has been shared by researches conducted both in US, Europe and Canada the age-standardized mortality rate (ASMR) in Canadian men has declined substantially by 0.61 percent since 1992 lingering around 8.9 cases per 100,000 in 2009 (95% confidence interval). With regards to women ASMR the data from Statistics Canada claims the decrease of 0.2% for the same period of time which attests to the stability of rates in women (Zaheer & Gallinger, 2013).

Determinant of Health

The most commonly recognized carcinogen related to pancreatic cancer is cigarettes. Smoking remains the most associated risk to cancer development having odds ratio (OR) of 1.74, 95% confidence interval (CI). Thus, the cessation is the main recommendation being disease specific (Zaheer & Gallinger, 2013).

Less putative risks associated with this type of cancer include: body mass index (BMI) over 35 (OR of 1.55 and 95% CI) and alcohol consumption of over 6 beverages a day is seen to be associated (OR 1.46, 95% CI) (Borgida et al., 2011).

Original Epidemiological Studies

Management of pancreatic adenocarcinoma in Ontario, Canada: a population-based study using novel case ascertainment

This uses prospective case-control and cross-sectional survey observational study design. The study population is pancreatic adenocarcinoma (PA) patients in Canada with data sources from diagnosed patients of PA between 2003 and 2006 who were identified using electronic pathology reporting (E-path) of the Pathology Information Management System (PIMS). For more information questionnaires were mailed to patients. The main results showed a low participation rate of 26% (351 out of 1325). Nonresponders were mostly over 70 years old and more likely to have had treatment in non-academic centres. While, 54% of responders had a potentially curative operation with 77% being 70 years or younger (p=0.03). Academic centres had higher resection rates and less frequently aborted resections with curative intent. Low rates showed 43% of responders received chemotherapy and 7% participated in clinical trials (Borgida et al., 2011).

Diagnosis and management of pancreatic cancer

This uses case-control and prospective observational study design. The study population is Canada with data sources from Cochrane for systematic reviews, reference lists from prior studies, Medline, PubMed and Google Scholar using MeSH terms. The main results shows the diagnosis and treatment relevant to the general clinician includes screening via Triphasic abdominal contrast computed tomography is most preferred for diagnosis, smoking cessation as the sole preventative measure, curative potential remains with surgery, adjuvant chemotherapy, and survival benefit from FOLFIRINOX, gemcitabine alone and plus for advanced cases (Zaheer & Gallinger, 2013).

Identifying people at a high risk of developing pancreatic cancer

This uses cohort, case-control and prospective observational study design. The study population is North America with data sources from familial pancreatic cancer registry and other registries (Klein, 2012). The main results was that through relatives of pancreatic cancer patients there has been demonstrated in relation to pancreatic cancer a familial aggregation of 1.5–1.3-fold increased risk, quantified risk of this cancer and other cancers, identification of susceptibility genes in these high risk families and initiation of screening trials (Klein, 2012).

Public Health Approaches

Electronic Pathology Reporting System

Electronic Pathology Reporting System (E-path) is an approach used to identify pancreatic adenocarcinoma (PA) patients across Ontario. It is implemented to provide the fastest source of cancer information. Ontario Cancer Registry uses Pathology Information Management System (PIMS), which relies on E-path. The E-path system is a database used for collecting electronic pathology information from laboratories in Ontario that process tumour specimens. E-path provides reports in a timelier manner than paper-based reports and has shown an increase in report’s completeness. This has great advantage when studying patients that have fast and progressive disease such as PA. In this system, electronic pathology reports come from each laboratory and are queued in a database by health record technicians for on-screen review. This process occur daily in most laboratories and weekly in some low-volume laboratories. If the health record technician see the report findings useful, the report will be coded and consolidated with the OCR database. Reports of particular cancers like PA are filtered and printed by study personnel for review (Borgida et al., 2011).

Educational Events and Symposia

Organizations such as Pancreatic Cancer Canada host some series educational events for Pancreatic Cancer (PC) patients, their families, relatives, and friends in places across Canada. These events give opportunity for patients learn more about the topics related to pancreatic cancer. Also, there are meetings or conferences held by leaders in the PC field to talk about different topics and bring mutual trust and friendship to survivors and those touched by the disease (Pancreatic Cancer Canada, 2011).

Research

Established partnerships with leading research hospitals to raise the profile of the disease. Funding is being provided by organization like PCC to continue the fight for cancer (Pancreatic Cancer Canada, 2011).

References

Borgida, A. E., Ashamalla, S., Wigdan, A-S., Rothenmund, H., Urbach, D., Moore, M., Gallinger, S. (February 2011). Management of pancreatic adenocarcinoma in Ontario, Canada: A population-based study using novel case ascertainment. U.S. National Library of Medicine National Institutes of Health, 54(1), 54-60. doi: 10.1503/cjs.026409

Klein, A. P. (December 6, 2012). Identifying people at a high risk of developing pancreatic cancer. U.S. National Library of Medicine National Institutes of Health, 13(1), 66-74. doi: 10.1038/nrc3420

Pancreatic Cancer Canada. (2011) Educational Events and Symposia. Retrieved from:

http://www.pancreaticcancercanada.ca/site/PageNavigator/facingpancreaticcancer_educational_events.html

Pancreatic Cancer Canada. (2011) Research. Retrieved from:

HOME

site/PageServer?pagename=research_main

Zaheer K. S., & Gallinger, S. (2013). Diagnosis and management of pancreatic cancer. Pancreatic Cancer Canada. Retrieved from:

http://www.pancreaticcancercanada.ca/site/DocServer/Steven_Gallinger_report_April_23_2012.pdf?docID=1361

Workplace violence has emerged as an area of huge interest to both small and large business recently. Some employers are denying that their business is affected by this problem but the fact that workplace violence has strike all businesses including the health sector. Workplace violence is a multifaceted problem that it is so pervasive that the Centers for Disease Control (CDC) have classified it as a national epidemic.

Healthcare workers are surrounded by a wide range of occupational hazards including but not limited to back injuries, needle stick injuries, contact with contagious, stress and violence. (Sullivan, E. & Decker, P. 2005)

Workplace violence includes both physical and non physical violence it could vary from physical assault, homicide to non-physical violence, like verbal abuse, sexual or racial harassment or making threats.

Non-physical type of violence is rarely discussed. It is harassment but not recognized as such because there is no discernible discrimination. When the harasser and targeted person are both members of protected status groups, there is no prohibition, no protection. The offensive, intimidating, threatening work environment is certainly hostile, just not illegally hostile. (Namie, 2005)

The term workplace bullying has been described as an umbrella term that incorporates harassment, intimidation and aggressive or violent behaviors (Hadikin & O’Driscoll, 2000). Einarsen (2000) defines workplace bullying as:

“When one or more individuals, repeatedly over a period of time, are exposed to negative acts (be it sexual harassment, tormenting, social exclusion, offensive remarks, physical abuse or the like) conducted by one or more other individuals. In addition, there must be an imbalance in the power-relationships between parties. The person confronted has to have difficulties defending himself/herself in this situation”. (pp. 383-384). Clearly, a person would not allow themselves to be bullied if they had the ability to defend themselves (Niedl as cited in Einarsen, 2000).

Workplace bullying evolves in harmful effects on healthcare providers, patients the organization and the health system as a whole. It has particular importance to the nursing profession, in view of the growing concern over the poor professional practice environment of nurses in many countries. Such environment leads to problems in retaining and recruiting nurses, contributing to the overall nursing shortage, and ultimately resulting in decline in quality patient care. (ICN) The phenomenon of workplace bullying is quite new and has only been studied for a little over two decades. (Rayner, Hoel, & Cooper, 2002)

“Violence in the workplace is a major source of inequality, discrimination, stigmatization and conflict at the workplace. Increasingly it is becoming a central human rights issue” (WHO). At the same time, workplace violence is increasingly appearing as a serious, sometimes lethal threat to the efficiency and success of organizations. Violence causes immediate and often long-term disruption to interpersonal relationships, the organization of work and the overall working environment (ILO, 2002).

Despite the frequency of workplace violence, studies suggest that most incidents in hospitals and healthcare facilities go unreported. According to the U.S. Department of Justice, Federal Bureau of Investigation, “of great concern is the likely under-reporting of violence and persistent perception within the healthcare industry that assaults are part of the job. Under-reporting may reflect a lack of institutional reporting policies, employee belief that reporting will not benefit them, or employee fears that employers may deem assaults the result of employee negligence or poor job performance”. (www.massnurses.org)

Many nurses do not recognize the multiplicity and the broad definition of workplace violence. Understanding the type and frequency of violent behaviors experienced in the healthcare setting will provide the foundation for early recognition and prevention of violence. Creating an environment that does not accept nor tolerate acts of violence will increase staff satisfaction, reduce medical error and improve clinical outcomes. In this study, workplace bullying will be highlighted as major ethical problem, experienced by nursing personnel but simultaneously overlooked.

Project aim

To determine the prevalence, impact, context, consequences of workplace bullying among nursing personnel, in order to assist in developing legal and programmatic response to improve nurses’ safety and satisfaction.

Specific objective for the study:

In order to determined the incidence, prevalence, impact, context, consequences and prevention strategies of workplace bullying against nursing personnel.

To analyze victims’ reaction to violence and the consequences of workplace violence.

To assist in developing legal and programmatic response to improve providers’ safety, satisfaction and retention.

Problem statement:

Violence and physical assault are recognized as significant occupational hazards for the healthcare providers worldwide. Violence in societies increases and become a second leading cause of death in some societies (Mayer et al 1999). Bulling is on form of violence that has a devastating effect on employee’s life, family and career. To detect the scope and the prevalence of workplace bullying, to increase staff awareness of violence with the objective of identifying the perpetrator characteristics, this study will be conducted. To ensure safe working environment in Salmaniya Medical Complex, managers should provide training for healthcare providers in relation to prevention and responding to bullying and aggression. Healthcare providers should understand that violence result from a number of variables, like stress, pain, fear of unknown, extended waiting time to be seen and treated and unpleasant environment

Research questions:

What is the incidence of bullying of nursing personnel during the past six months?

Did the variables of age, gender and experience as alter the nurse’s experience of bullying?

Dose nurses job satisfaction affected by bullying behavior?

The conceptual framework:

The Psychological Harassment Model will be used. Psychological harassment is a heterogeneous phenomenon. Each bullying action shows a different frequency, has different determinant motivations (e.g. remove someone from the company, competition for tasks, status, advancement, gain a supervisor’s favor, or play a joke on someone), a variety of consequences, and the phenomenon occurs in different circumstances. From this paper’s standpoint, psychological harassment is first a dynamic linear process with four phases, which is illustrated in Figure 1. The interaction of three types of antecedents (phase 1) can develop psychological harassment behavior (phase 2), which creates response from the victim and the organization (phase 3), and produces three types of effects (phase 4). But, it is also a uni-linear process. For instance, the antecedents (phase 1) can directly influence the responses (phase 3) of an individual (e.g. personality) or an organization (e.g., culture). For example, the personality of the victim can influence the nature of the individual response, or the culture of the firm can influence the characteristic of the organizational response. In the same way, the antecedents (phase 1) can directly influence the effects (phase 4). For instance, the personality of the victim can influence the psychological harassment health effects.

Figure 1 The Psychological harassment process phase. (Adapted from Polipot-Rocaboy, G. 2006)

Definition of terminology:

Workplace: Any health care facility, whatever the size, location (urban or rural) and the type of service(s) pro-vided, including major referral hospitals of large cities, regional and district hospitals, health care centers, clinics, community health posts, rehabilitation centers, long-term care facilities, general practitioners offices, other independent health care professionals. In the case of services performed outside the health care facility, such as ambulance services or home care, any place where such services are performed will be considered a workplace. (ILO et al 2002)

Satisfaction: is generally understood to be an individual’s emotive or affective response, either in a positive or in a negative direction, to some experience or situation. There is some debate regarding whether satisfaction is a uni-dimensional concept or a multidimensional one. Some useful reviews of the literature in this connection have been offered by Prichard (1960), Vroom (1964), and Napior (1969) .

Workplace violence: incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. (Adapted from European Commission, ICN 2007)

Bullying:

Bullying is a sub-lethal, non-physical form of violence psychological in both its execution and impact on targeted individuals, bullying is a kind of long-term hostile behavior detected in employees at workplaces. It involves hostile and unethical communication which is directed in a systematic manner by one or more individuals, mainly toward one individual, who, due to mobbing, is pushed into a helpless and defenseless position and held there by means of continuing mobbing activities. These actions occur on a frequent basis (at least once a week) and over a long period of time (at least six months’ duration). (Angeles, M. et al 2006)

Literature review

Through their national work environmental acts Sweden, Finland and Norway support the rights of workers to remain both physically and mentally healthy at work. Yet, in recent years, a work environment problem has been discovered, the existence and extent of which was not known previously. This phenomena has been called “mobbing,” “ganging up on someone” or psychic terror. It occurs as schisms, where the victim is subjected to a systematic stigmatizing through, inter alia, injustices (violation of a person’s rights), which after a few years can mean that the person in question is unable to find employment in his/her specific trade. Those responsible for this tragic destiny can either be co-worker or management. (Leymann, 1990)

Women and men are bullies. Women comprise 58% of the perpetrator pool according to a research done at the Workplace Bullying Institute (WBI). Half of all bullying is woman-on-woman. Overall, women comprise the majority of bullied people (80%). Without laws and none exist in the U.S., employers are reluctant to recognize, let alone correct or prevent destructive behavior, preferring to dismiss bullying as “personality clashes.” (Namie, 2005)

Because of the predominance of women in the nursing profession, subsequent attempts to explain intimidation in nursing focused on gender-based theories of the behavior of oppressed groups. More recently it has been proposed that intimidation may be the result of nurses who feel a lack of control attempting to gain control through bullying others. External pressures are often held responsible, such as health care workers’ need to find a scapegoat for errors. The impact of the reform of the health care industry on staff is another reason cited for the existence of this behavior. The financing and downsizing of hospitals for example, leads to greater levels of acuity in the hospital patient population and hence increased workloads for nurses. Increased stress is often the result, and this is said to contribute to an increased tendency for bullying in the nursing workforce. (Stevens, 2002)

According to ILO/ICN/WHO/PSI they identified workplace violence “Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work involving explicit or implicit challenges to their safety, well being or health”. The Californian Occupational Safety and Health Administration (Cal/OSHA), categorized workplace violence into three types

Type I: the aggressor has no legitimate employment relationship to the worker or the workplace and, usually, the main object of the violence is obtaining cash or valuable prosperity or demonstrating power. Examples are robbery, mugging, and road rage.

Type II: the aggressor is someone who is the recipient of a service provided by the affected workplace or by the worker. Examples are assault or verbal threats by patients, carers or relatives of the patient.

Type III: the aggressor is another employee, a supervisor or manager. Examples are bullying and harassment.

Type I is referred to as “external violence”, Type II as “client initiated” violence and Type III as “internal” violence. The internal violence will be tackled in this study.

Bullying is a sub-lethal, non-physical form of violence psychological in both its execution and impact on targeted individuals, bullying is a kind of long-term hostile behavior detected in employees at workplaces. It involves hostile and unethical communication which is directed in a systematic manner by one or more individuals, mainly toward one individual, who, due to mobbing, is pushed into a helpless and defenseless position and held there by means of continuing mobbing activities. These actions occur on a frequent basis (at least once a week) and over a long period of time (at least six months’ duration). Because of the high frequency and long duration of hostile behavior, this maltreatment results in considerable mental, psychosomatic and social misery”. These hostile behaviors include verbal aggressions, rumors, humiliations, and so on. Three types of bullying can be considered depending on the power of victims and aggressors: horizontal, up-down and down-up bullying. Up-down bullying occurs when a superior harasses one of her subordinates. Down-up bullying occurs when a worker or a group or workers harasses his/their superior. When bullying occurs between co-workers at the same hierarchical level it is called horizontal bullying.

Workplace violence is often considered part of the job in the health sector and therefore been more frequently overlooked than in another sectors until recently.

Workplace violence has an impact on the providers’ health, productivity and dignity. The impact of violence is not just on individual level but extend to organizational and social levels.

The consequences of violence in the workplace are serious for both an organization and the employee. Victims of workplace violence have an increased risk of long-term emotional problems and post-traumatic stress disorder (PTSD), a disorder which is common in combat veterans and victims of terrorism, crime, rape and other violent incidents. Symptoms experienced by victims include self doubt, depression, sleep disturbances, irritability, decreased ability to function at work, increased absenteeism, and disturbances in relationships with family, friends and co-workers (American Federation of State, County and Municipal Employees, n.d). Organizations are significantly affected financially due to low worker morale, increased job stress and turnover, reduced trust of management and coworkers, and hostile work environments (NIOSH, 2002).

A report from the ILO (1998) concluded that workplace violence is becoming increasingly global and crosses boarders; moreover it also reported that women are especially at risk of violence as they work in high risk occupations.

Healthcare workers especially nurses are at high risk of workplace violence. Half of all claims of aggression in the workplace come from the health sectors (bureau of Justice Statistics, 1992-1996). Healthcare workers face 16 times the risk of violence from patient/clients than other service workers (Elliot, P. 1997. Nursing Management, 28, 12, 38-41). The Joint Commission’s survey found that more than 50 percent of nurses have been the target of some form of abuse at work and more than 90 percent report having witnessed abusive behavior. Furthermore, 75 percent of nurses who responded believed that this type of behavior can reduce patient satisfaction and disrupt care.

Despite the severity of the situation, neither the management nor the coworkers are likely to interfere or take action to support the victim. On contrary if the victim complains they often faces disbelief and questioning their own role. (Einarsen, S. et al.2003)

Workplace violence is thought to be heavily underreported, as a result of lack of consensus on taxonomy of violence; cultural acceptance of violence; lack of an appropriate reporting system; lack of employment interest; and fear of blame or reprisal (Daniels C. & Marlow P. 2005).

Although a bullying culture in nursing is not often specifically referred to in large-scale studies of hospitals’ nursing dissatisfaction and retention strategies, it is clear that tackling this issue may be critical. The literature indicates that this sort of nursing culture may be more prevalent than the profession may care to admit.

Methodology:

Organization of the study:

A well known nonprofit secondary care facility in the Kingdom of Bahrain will be selected to conduct this study.

The primary provides for health care in Kingdome of Bahrain is the public health sector; Salmaniya Medical complex (SMC) is the main hospital in the kingdom, meets the secondary and tertiary health care needs of the entire citizens and residents. The majority of the healthcare providers are working in SMC.

Study population:

From the total number of staff nurses working in SMC 300 staff will be selected randomly.

All major discipline in the hospital will be covered (medicine, surgical, emergency, pediatrics etc.)

Study Design:

Quantitative study design will be used to explore the relationship between the workplace bullying and job satisfaction.

Data collection methods:

To assess workplace bullying, the Negative Acts Questionnaire (NAQ) developed by Einarsen and Raknes (1997), will be used.

The Negative Acts Questionnaire comprises 22 items referring to particular behaviors in the workplace that may be perceived as bullying as well as a self-report item on victimization. The behaviors or negative acts are descriptive without labeling the actions as bullying. The behaviors include; being shouted at, being humiliated, having opinions ignored, being excluded, repeated reminders of errors, intimidating behavior, excessive monitoring of work, and persistent criticism of work and effort.

Participants will be requested to complete a 5-point Likert scale on how often they had been subjected to these behaviors over the last six months, with response categories ranging from never (1), now and then (2), monthly (3), weekly (4) and daily (5). To estimate the frequency of exposure to bullying behavior, Leymann’s operational definition of workplace bullying of one incident per week over a period of at least 6 months was employed. The questionnaire is devided into three parts section A. demographic data, section B. the Negative Act Questionnaire and section C. is about the nurses job satisfaction.

Place and time:

The questionnaire will be distributed to the target population with a cover letter ensuring anonymity.

Pilot study:

The questionnaire will be tested in a pilot study of 50 nurses working in SMC to test the validity. The employee in the pilot study will not be included in the actual study. Ethical approval will be obtained for this study.

Data management and analysis plan:

The data will be analyzed using the Statistical Package for the Social Sciences (SPSS).

Plan expected and Agenda

Design research plan

1 month

Pilot study, analyze data and revise

15 days

Implementation of the study

1 month

Data analysis

1month

Obesity is a condition that emanates from malnutrition and presents with serious social and psychological problems. It is present across different ages and affects individuals in the developing and developed countries. Aiko and Sturm (845-856) writes that obesity has turned into one of the most serious global epidemics as it spreads, to many parts of the globe affecting millions of healthy lives each day. The most shocking revelation is that obesity epidemic is not only affecting developed nations. From studies this condition continues to affect even the individuals in the developing world. This essay aims at discussing some of the views of Aiko and Sturm who authored an article dubbed “The obesity epidemic and changes in self-report biases in BMI.” on obesity epidemic and how self-report biases have increased the trends in obesity cases across the globe. This essay will also cite the research gaps that the authors did not include in their study.

According to World Health Organisation (WHO), the obesity epidemic remains one of the ignored public health problems that affect millions of individuals across the globe. In a forecast, WHO predicts that without proper public health initiatives, obesity epidemic will affect many people globally and lead to aggressive health complications. According to WHO, this condition is mainly affecting women as compared to men. Nonetheless, the author notes that many men have higher cases of overweight while women have higher cases of obesity. What the article fails to mention is the cases of obesity among children.

Children who had developed obesity in the US and other major cities tend to place the blame on the food sellers such as McDonald. The author reiterates that while many people blame the eater (children), the blame should be made on the food makers. I agree with the author on the fact that many children who are trying to get affordable foods often end up feeding on unhealthy fast foods. Such foods as stated by Aiko and Sturm (855) should not be taken more than once in a single day. However, the author notes how he had to eat fast foods repeatedly since it was the only option for affordable food.

This article explains that there are many cases of diabetes because the fast food industry has grown ten-fold t offer children as well as adults cheaper and easier alternative to affordable foods. Nevertheless, many people working in the restaurants have not realised the dangers that they expose their customers to. I also agree with the fact that ignorance among individuals has contributed to obesity epidemic. While many people yearn for sumptuous foods sold in McDonald, Taco, and KFC, a few understand the risks of obesity that they are exposed to. The fact that Food and Drug Administration does not cover prepared foods, there is little information concerning the caloric contents of such foods.

Additionally, I also contend with the claim that marketing of hazardous fast foods to children is to blame for the heightened rates of obesity among the children. As many fast food companies continue to grow, many children find access to such foods regularly. This has led to unprecedented levels of risks of developing obesity. In this manner, the claim by the author that food sellers are to be blamed for the obesity epidemic. However, the author did not mention the possible effects of sedentary lifestyle and other risk factors such as family history of obesity and lack of warning labels on high-calorie foods.

On the other hand, there are many initiatives that had been introduced in the US such as funding for new bike trails and sidewalks, restrictive labelling of foods and prohibiting marketing of dangerous foods to children. According to the article, such initiatives have the ability of reducing the cases of obesity among school children. High tax for high-fat foods aimed at reducing the production and sale of foods known to cause obesity among the children. According to Gotay et al. (e64-e68), such initiatives are wrought and irrelevant. Balko (Para.3) objects such moves on the basis that they limit the ownership of one’s control of health. The author says that if such regulations are enforced, then certain individuals are forced to be responsible for other people’s problems.

I contend with the claim that individuals have become irresponsible for their own health. While people are supposed to care about their health, many individuals continue to blame the Federal Government on healthcare management. While many consumers continue to develop bad habits, obesity epidemic continues to rise. I also contend that whatever we eat is our own business. While there are many people who think that public health can resolve the issue of obesity, I concur with the writer that our health is a private issue and should not belong to the public health. For instance, Aiko and Sturm (856-860) note that fighting the obesity epidemic starts by change of lifestyle, nutrition as well as physical exercise. These preventive measures are often done privately and not with the help of the government or the public health. However, I disagree with the author on account that healthcare should be privatized. While the government spends millions of shillings in facilitating preventive projects, Dietz (575-596) acknowledge that many people may not be able to afford such initiatives. The cost of health is very high, as such; public health programs aim at initiating preventive measures that target the reduction of diseases and epidemics.

It is true that the contemporary methods of measuring obesity among various populations. The article dubbed, “The Obesity Epidemics and the changes in the Self-reported biases in BMI,” gives a clear insight of how cases of obesity are not fully discovered among individuals. Idyllically, such cases may remain obscure for a longer period of time without the knowledge of the public health officials. I agree with the author that biases subject to social desirability as well as recall errors have led to poor reporting of obesity cases in many countries. As such, this event has facilitated increased cases of obesity leading to unimaginable obesity epidemic.

The author notes that BMI measurement error leads to underestimation of the BMI that can be used to determine the case of obesity among individuals. I also contend with Aiko and Sturm on the fact that media coverage on the cases of obesity has uncovered the lack of awareness among individuals and their weights. According to Aiko and Sturm (4), poor reporting of BMI is one of the faults that ostensibly cause lack of awareness on obesity and related disorders. However, the media has played an imminent role that has transformed lives of many individuals by exposing the disparities in BMI self-reports and the actual BMI reports.

While the bias in self-reporting has been cited as one of the reasons why obesity is growing rapidly in the US, Aiko and Sturm (3) note that measuring of the BMI should include the detailed analyses that will minimise the errors that occur during measurement of the procedures. While the media has been proactive in raising obesity awareness in the recent times, Aiko and Sturm (5) note that the problem of error in self-reporting has led to poor accuracy in estimating the number of individuals who suffer from obesity. To this end, acknowledge that there are possibilities of the obesity epidemic becoming out of control.

Individuals only continue to gain weight when there are no weight reduction initiatives. As such, it is important to institute proper weight and height measuring techniques that ensure accuracy in reporting the BMIs of individuals. The BMI measurement remains the commonest way of determining whether an individual is obese or not. In this manner, it is imperative as stated by Aiko and Sturm (5) to use techniques that teach individual populations on the obesity epidemic.

On the contrary, I disagree with the claims of the author that the outburst of obesity epidemic is due to errors in measuring the BMI among individuals. Ideally, there are many factors that have changed over time concerning how individuals view healthy choices. Awareness on the obesity issues help in adopting preventive measures that help many individuals in preventing obesity. In this manner, the author should have included lack of information as one of the main facilitators of obesity. A mixture of factors leads to the development of obesity. In this manner, note that erroneous measurement of the BMI can only be counted as a secondary factor in the development of obesity epidemic.

The American Heart Association indicates that many Americans are dealing with complications of obesity in the United States. This is a confirmation that this condition has become a major epidemic. Individuals have chosen unhealthy lifestyles that continue to facilitate the development of the epidemic. With the increased trends in technology, sedentary lifestyles have replaced the manual techniques that ensured physical activities among individuals. On the other side, resisting food cues has been a major problem among many individuals suffering from weight problems. As such, there is a major problem in dealing with nutrition and lifestyle than dealing with BMI measurement errors. However, Aiko and Sturm (4) are also right since raising awareness on obesity can help people in remaining fully aware and capable of regulating risks that can initiate the development of obesity. To this end, it is evident that obesity epidemic is dependent on variant factors that should be considered while preventing the condition.

Works Cited

Dietz, William. “The Response of the US Centers for Disease Control and Prevention to the Obesity Epidemic.”

Annual review of public health

36 (2015): 575-596.

Gotay, Carolyn, et al. “Updating the Canadian obesity maps: an epidemic in progress.”

Can J Public Health

104.1 (2012): e64-e68.

Hattori, Aiko, and Roland Sturm. “The obesity epidemic and changes in self-report biases in BMI.”

Obesity

21.4 (2013): 856-860.

Radley, Balko. “What you Eat is your Business.” Commentary (2004): Para.1-16