According to University of California, School of Medicine (2010), Autonomy is the “personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice.”  Although Mrs. Cheng is a cancer patient with only one month to live, nowhere is mentioned that she could be of unsound mind or suicidal as certified by a doctor so her decision to smoke is then make while in a state of sound mind. Principle of autonomy states that patients are to be allowed to make their own decision without influence or coercion by another. Clearly Mrs. Cheng’s decision was to not to give up smoking. By asking Mrs. Cheng to decide not to go to the garden to smoke because of manpower constraint or any other reason which is not of patient’s own is a violation of her autonomy which is definitely not ethical.

According to Beauchamp (2008), Beneficence is a “moral obligation to act for the benefit of others, helping them to further their important and legitimate interests, often by preventing or removing possible harms”. Smoking is generally bad for health, and more so for people who already have cancer. Smoking is known to increase the size and extent of cancerous cells and metastases. (Zow, Hsu, and Eng, 2004). Thus the nursing staff should advise and encourage Mrs. Cheng to stop or reduce the number of cigarette she smoke as it will worsen her condition by possibly hastening death.

Non-maleficence is defined as not to deliberately cause unnecessary harm or injury to the patient, either through acts of commission or omission, “above all, do no harm” (McCormick, 2008). By restricting Mrs. Cheng to go out to smoke, the nursing staffs are depriving Mrs. Cheng of possibly the only thing that she enjoyed in what thought to be the last one month of her life thus affecting the quality of life Mrs. Cheng has. Mrs. Cheng might then become unhappy and miserable which might gradually caused her to become depressed or even suicidal since there is also no caregiver support for her as the rest of her family died in the tsunami. Thus, the nurse should not ask Mrs. Cheng to refrain from going out to smoke as they will be doing harm to the patient and violating the ethical principle of non-maleficence.

Justice refers to what the general public deems as right and fair (Hawley, G., 1997, p.26). To deprive an elderly patient of what she would like to do in the last one month of her life is simply cruel and unjust. To utilize manpower to accompany a patient just for smoking 5 hours a day when the nurse would be able to do more for other patients in the ward is a waste of manpower as well as tax payers’ money. It is also unfair to the other staffs that have to cover extra duties while this particular staff is away in the garden with Mrs. Cheng. Due to shortage of manpower and unfinished work, the staffs might have to stay back to finish their work, taking up their personal time which could be spend with their own family. Quality and duty of care to the rest of the patients might be in question if the remaining nurses in the ward have to rush to finish their work before the shift ends.

Identify ethical conflicts

Beneficence versus Non-maleficence

Often a healthcare professional’s good intention might not be what is best for the patient. Though to stop smoking has its benefits to health, it seems almost futile to ask a person who only has one month of lifespan to quit smoking. For a smoking cessation program to succeed, it would take more than a month, not to mention Mrs. Cheng has to endure the unpleasant withdrawal effects and unhappiness in the last few weeks of her life of not having to smoke (Zow, Hsu, and Eng, 2004). To resolve the conflict between the two principles of ethics, one needs to weigh the risk and benefits between the two to make a decision (Pantilat, 2008).

Autonomy versus Beneficence

Autonomy requires the staff to respect the patient’s decisions whereas beneficence requires the staff to make decision in the patient’s best interest, to remove harm and to do good. These two principles conflicted as a result when what a patient wants is deemed harmful to her health and as a healthcare worker, the responsibly is to remove the harm. To resolve it, the healthcare worker should respect that the patient decision as long as it is made in a state of sound mind and continue to try to convince the patient otherwise by making sure that patient has all the information she needs to make a correct decision (Pantilat, 2008).

Consider the Law

Duty of care

A nurse owes a duty of care to a patient, where there is a nurse-patient relationship that creates that duty. (Corcoran, 2000) In this case, the staffs of the medical ward owe Mrs. Cheng a duty to see to her needs and wellbeing, ensuring safety by accompanying Mrs. Cheng to the garden being one of it. The nurse accompanying have the option of wearing a N95 mask supplied by the hospital for protection against the organic vapors from the cigarette smoke. (Mask and More, 2010)

Patient advocacy

According to Singapore Nursing Board (SNB), Code of Ethics and Professional Conduct, Value Statement 7(2006), the nurses need to advocate in the best interest of the clients, by “ensuring clients’ interest and needs are recognized and considered by the entire healthcare team” and also protecting the clients from any form of coercion to involuntarily agreed to accept or change their decision. In this scenario when some nurses are advocating for the other patients’ quality of care, it is very important to ensure that the nurses also advocate for Mrs. Cheng’s interest and needs as well so as to ensure fair treatment of all patient irregardless of race or age. (SNB Code of Ethics and Professional Conduct, Value Statement 1, 2006)

Nurses and Midwives Act

Any registered nurse or enrolled nurse found to have been guilty of misconduct or negligence shall either be imposed a fine upon, have their registration suspended or terminated. (Nurses and Midwives Act, Section 19, 2a-d) By breaching the duty of care not abiding by the SNB Code of Ethics and Professional Conducts, the nurses are likely to be guilty of misconduct or even negligence if relations are proven between the breach of duty and the injury caused (Nair, n.d.).

Consent to Medical Treatment & Palliative Act 1995

“Medical Practitioners in the practice of palliative care for patients in the terminal phase of a terminal illness are protected from civil and criminal liability by the Act if they administer treatment only to relieve pain and distress, even though an incidental effect of the treatment is to hasten death, provided they act with consent; in good faith and without negligence; and in accordance with proper professional standards of palliative care”. (Consent to Medical Treatment and Palliative Act 1995, Section 7.1) In this case, Nicotine patch could be a consideration provided that patient consented to using it. It can be administered to relieve the urge to smoke thus preventing patient from suffering from the withdrawal when the staff is unavailable to bring her to the garden to smoke.

Capacity to give consent

According to the Mental Capacity Act 2008, Section 3 (21, 4), a person is assumed to have mental capacity unless proven otherwise, and should not be deemed as incapable of making a decision simply just because he or she made an unwise decision. Thus it is to assume that Mrs. Cheng is capable of making decisions for herself in terms of treatment and among other things. The palliative team should then come together with patient to discuss issues, propose suggestion(s), provide relevant information and allow the patient to make a decision for herself.

Relationship between the clinical-ethical decision and the law

In nursing, decisions made regarding patients’ care and needs are always based on the ethics and standard of practice that the Nursing Board or Council upholds. The Code of Ethics and Professional Conducts, Standard of Practice and Competency Standards are all in turn, written according to the Law in terms of legislation that govern it, e.g. Nurses and Midwives Act.

Making the ethical decision

Ethical decision

The author believes that Mrs. Cheng should be allowed to continue to go to the outside garden to smoke in the company of a nursing staff if she chose to. This decision is justified by balancing the principles of ethics and by following the Australian Nurses and Midwifery Council (ANMC) Code of Ethics and the SNB Code of Ethics and Professional Conducts.

Nurses are to promote and uphold patient’s autonomy by respecting the informed decision made by the patient concerning their own care. (SNB Code of Ethics and Professional Code of Conduct, Value Statement 2, 2006) Thus if Mrs. Cheng’s decision is to continue smoking despite being informed and educated on the hazards of smoking, then the nurses should accept and respect that decision.

According to ANMC, Code of Ethics, Value Statement 2.3, nurses who are indifferent to her colleagues’ plight, manipulative and bullying their colleagues are basically just disrespectful towards others and are ethically intolerable. Thus some of the staff from the ward should not use resignation to coerce the management or the rest of the nurses to agree to a decision that they are in favour of but might not be beneficial to the patient.

Document the decision

Effective documentation provides evidence to show that individualized nursing care and the patient’s response to that care outcome. Proper documentation of the quality care the nurses have given ensure that they would be able to defend themselves in court if they were being subpoenaed (Henderson, 2010).

The documentation would include the date and time, names of the people who are present during the discussion, topics discussed for e.g. no smoking policy, assigning additional staff on each shift, and the understanding of the patient of these topics, comments from various parties including the patients, and the final decision, the plans to follow up and schedule a time for evaluation. The documentation of the decision will be done in a clear manner and according to the organizational guidelines. (ANMC Registered Nurse Competency Standards 6.3 and 10.3) The patient’s mental capacity will also be documented by the team doctor present at the discussion to ensure that patient did not agree to any decision when she is in a vulnerable state of mind (A Guide for Healthcare Professionals, n.d.).

Evaluate the decision

Evaluation must be done throughout the whole process and not just at the end of it as it is a process of gathering data and analyzing it, using the information gathered to determine whether the plan is progressing towards the objectives and planned outcomes set initially (The Importance of Evaluation, 2005). In order for the plan of care to succeed, continuous supervision, evaluation and revise of plan of care in accordance with evaluation data is needed. (ANMC Standard of Practice, Standard 8.1 & 8.2, 2008 and Standard 3 of SNB Standard of Practice, 2006).

Total word count: 2487

Reference List

A Guide for Healthcare Professionals: Consent to Medical Treatment and Palliative Act 1995 (n.d.). Retrieved from http://www.health.sa.gov.au/consent/documents/provisionsexplanation-pir-sahealth-1002.pdf

Australian Nursing & Midwifery Council. (2008). National competency standards for the registered nurse. Retrieved from http://www.anmc.org.au/userfiles/file/RN%20Competency%20Standards%20August%202008%20(new%20format).pdf

Australian Nursing & Midwifery Council. (2008.). Code of professional conduct for nurses in Australia. Retrieved from http://www.anmc.org.au/userfiles/file/New%20Code%20of%20Professional%20Conduct%20for%20Nurses%20August%202008(1).pdf

Australian Nursing & Midwifery Council. (2008). ANMC code of ethics for nurses in Australia. Retrieved from http://www.anmc.org.au/userfiles/file/New%20Code%20of%20Ethics%20for%20Nurses%20August%202008.pdf

Boxing Day Tsunami. (2009). Retrieved from http://www.boxingdaytsunami.com/

Beauchamp, T. (2008). The Principle of Beneficence in Applied Ethics. Retrieved from http://plato.stanford.edu/entries/principle-beneficence/

Cancer Council Australia. (2010). Colorectal Cancer. Retrieved from http://www.cancer.org.au/aboutcancer/cancertypes/colorectalcancer.htm

Corcoran, M. (2000).What is negligence? BJU International, 86(3), 280-285.

Hawley, G. (1997). Ethics workbook for nurses. NSW: Social Science Press.

Henderson, J. G. (2010). Nursing: The importance of documentation and charting. Retrieved from http://www.helium.com/items/1427307-nursing-nurses-documentation-charting-quality-of-care-patients-soapie-litigation

Kerridge, I., Lowe, M. and McPhee, J. (2005). Ethics and law for the health professions (2nd ed.). Sydney: Federation press.

Mask and More, 2010. Retrieved from http://www.masksnmore.com/3mmasks1.html

McCormick, R. T. (2008). Ethics in Medicine: Principles of Bioethics. Retrieved from http://depts.washington.edu/bioethx/tools/princpl.html

Nair, S. (n.d) Medical Negligence: Duty of Care. Retrieved from http://www.sma.org.sg/sma_news/3307/duty_of_care.pdf

Pantilat, S. (2008). Ethics Fast Facts: Autonomy versus Beneficence. Retrieved from http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_auton_bene.htm

Pantilat, S. (2008). Ethics Fast Facts: Beneficence versus Non-maleficence. Retrieved from http://missinglink.ucsf.edu/lm/ethics/Content%20Pages/fast_fact_bene_nonmal.htm

Singapore Nursing board. (2006). Code of ethics and professional conduct. Retrieved from http://www.snb.gov.sg/html/1151900236839.html#II

Singapore Nursing board. (2006). Standards of practice for nurses and midwives. Retrieved from http://www.snb.gov.sg/html/1153709353750.html

Poon, E. (n.d.). Nursing Challenge in Hospice Care. Retrieved from www.hpp.moh.gov.sg/HPP/1250487879924.html

Singapore Cancer Society. (2008). Colorectal Cancer. Retrieved from http://www.singaporecancersociety.org.sg/lac-fcco-colorectal-cancer.shtml

Singapore Ministry of Defence. (2006). Deadly for of Air Pollution. Retrieved from http://www.mindef.gov.sg/imindef/mindef_websites/topics/elifestyle/articles/smoking/deadly_form_of_air.html

The Importance of Evaluation. (2005). Retrieved from http://www2.guidestar.org/rxa/news/articles/2005/importance-of-evaluation.aspx?articleId=767

World Health Organization. (2010). Definition Of Palliative Care. Retrieved from http://www.who.int/cancer/palliative/definition/en/

Zow, H. C., Hsu, A. A. L., & Eng, P. C. T. (2004). Smoking cessation programme: the Singapore General Hospital experience. Singapore Medical Journal (2004), 45(9), 430. Retrieved from http://www.sma.org.sg/smj/4509/4509a4.pdf

According to the World Health Organization, a third of the world’s population is infected with Mycobacterium tuberculosis (World Health Organization). New cases were estimated to number 9.4 million with 1.8 million deaths in 2008 (Thomas). Gary Maartens and Robert J. Wilkinson published a review in the December, 2007 issue of The Lancet that outlines the current condition of tuberculosis(TB) in the world today. Specifically, the authors report on the status of research, diagnostic techniques, treatment options and the epidemic of HIV-associated tuberculosis in Africa.

Mycobacterium tuberculosis is the bacterial causative agent of a disease that has been a leading cause of death for much of earth’s history and still is for many developing countries. Maarten and Wilkinson noted recent regional changes in the incidence of TB with improvements made in many regions while incidence in sub-Saharan Africa has increased. This increase is correlated with the HIV epidemic in Africa and presents complex challenges in the task of controlling TB. In addition to HIV, multidrug-resistant and extensively drug-resistant (XDR) strains of tuberculosis account for increasing numbers of new cases and recurrent disease in previously treated patients. The authors state that 4% of patients worldwide have a multidrug-resistant strain. Included in that percentage are patients with XDR strains. One reported study of a tuberculosis outbreak in HIV-infected individuals showed that 24% of those patients had XDR strains and this resulted in a 98% fatality rate (52 of 53 patients). Genetic analysis of the bacterium indicated that transmission of the TB had been recent and it was noted that two-thirds of the affected patients had been hospitalized in the two years prior. The concern is that they may have acquired the XDR strain of TB while hospitalized, highlighting the need for better treatments and more precaution when treating these patients. Without improvements in rapid diagnosis and treatment, the incidence of drug-resistant strains will continue to rise.

Genomic analysis has become an important tool in understanding microorganisms and Mycobacterium tuberculosis has been extensively studied and its genes have been sequenced. Analysis conducted on 875 different strains of Mycobacterium tuberculosis from 80 countries has resulted in the discovery of six distinct lineages of TB that seem to have adaptations to specific populations of humans. As an example, the east African-Asian strain affects people of Indian origin, regardless of where they currently live. Another strain, W/Beijing, has less specificity, affecting people all over the world, but it also seems to be more virulent. Each of these strains is the result of mutations in the DNA of the bacterium. Different strains of TB have different mechanisms which allow them to modulate or suppress the immune system response. Many of these mechanisms have to do with the molecules that comprise the mycobacterial cell wall such as phenolic glycolipids. Two large studies have identified that membrane-associated proteins, molecular transporters, and ion channels play a vital role in the virulence of TB. These discoveries not only help scientists better understand the pathogenesis of tuberculosis; they also provide new targets for treatment.

In addition to the genetics of the bacteria, the genetic makeup of the host is critical. Specific receptors on human macrophages recognize specific molecules of the cell wall of Mycobacterium tuberculosis and trigger cellular signaling cascades that can result in greater host resistance or increased susceptibility to TB. Two of the receptors involved have a role in vitamin D activation and a deficiency of this vitamin has been noted in some tuberculosis cases, leading the authors to speculate about the possibility of vitamin D supplementation for prevention. Mutations in one of these cellular signaling pathways were shown in a series of studies to predispose individuals to “severe atypical mycobacterial infections.” This line of inquiry, identifying the specific genetic mutations that give rise to virulence factors in the bacteria or greater susceptibility in the host, could lead to huge advancements in the understanding and eventual eradication of TB, but the authors point out that these studies would need to be extensive, which equates to expensive.

Diagnosis and treatment for tuberculosis hasn’t significantly changed in decades. Microscopic analysis and bacterial culturing are the standard protocols used to detect a TB infection, but these techniques have drawbacks, the most obvious being the time and labor involved in culturing. Maarten and Wilkinson state the obvious by expressing a desire for a more sensitive test that is rapid and affordable. A few emerging candidates are discussed, including nucleic-acid amplification tests and enzyme-linked immunospot analysis (ELISpot analysis). Nucleic-acid amplification tests have not proven to be significantly better at identifying TB. They are also expensive and require specialized equipment, making them unsuitable for use in most developing countries with limited resources. The ELISpot analysis, however, has promise in that it shows greater sensitivity and specificity than the tuberculosis skin test (TST), particularly in differentiating between exposure to TB and an active infection. In addition to assessing whether a patient is dealing with a tuberculosis infection, it is critical to know whether the strain of TB is drug-resistant. Current methods of determining drug resistance require 6-8 weeks, but microscopic analysis of liquid culture growth can be done within 10 days and has the advantages of being inexpensive and easily available, even to locations with limited resources. HIV infection further complicates diagnosis of tuberculosis and a determination is frequently made based solely on clinical symptoms and x-rays. This can lead to faster treatment, but could also be a contributing factor in the creation of resistant strains.

Current methods of treatment involve a cocktail of medications taken for at least six months. This protocol typically has good results, even in patients with HIV. The treatment strategy utilized internationally is called “directly observed treatment short course (DOTS).” This method of control has contributed to gains made in prevention, diagnosis, and treatment, but still has many shortcomings. The authors advocate a combined approach and point to very high adherence rates for HIV treatments with a more patient centered approach, which empowers the patient to take care of themselves rather than reporting to a clinic to be observed taking a medication.

The medications used to treat TB have changed very little and new medications are desperately needed, especially in light of the increase in drug-resistant strains. A commonly used medication, rifamycin is proving to be less effective in patients with HIV due to the development of resistance or because of some metabolic process reducing the concentration of the medication in their bodies. Fluoroquinolones have been shown to be effective but seem to be prone to rapid development of resistance and toxicity. The authors report on two new antimycobaterial drugs that have novel mechanisms of action and are in the process of testing.

The complications of treating patients with HIV and TB are many. Most of the symptoms of TB are due to immune response (immunopathological), but the immune systems of HIV patients are already suppressed. The medications to treat TB can further suppress the immune response leading to an increase in viral load and the possibility of more opportunistic infections. In addition, many of these medications have proven to be hepatotoxic, which HIV patients are even less equipped to handle. Complications can also include “paradoxical deterioration” whereby the treatment of HIV results in a worsening of TB symptoms. The important point is that more research is required to understand the immune system functionality in concurrent infections of TB and HIV.

The treatment of latent infections is aimed at preventing these infections from becoming active, particularly in immunocompromised patients. The most common strategy is a 6-12 month course of isoniazid. Although widely used, this treatment carries the same risks of medication resistance and hepatotoxicity as other TB drugs. Additional information on the physiology of latent infections could lead to better drugs and better strategies for treatment.

Vaccination, which is widely available in Europe, but not used in the United States, has shown some efficacy in preventing severe TB infections in children, but the length and strength of protection is in question. Tuberculosis is still transmitted, allowing the continued spread of the bacteria. Novel vaccines are being tested and a few show promise to provide better protection. The authors reiterate the need for large, long term studies.

Sub-Saharan Africa is experiencing an epidemic of HIV-associated tuberculosis. The capacity to manage this epidemic is severely hindered by socioeconomic, medical infrastructure, and political issues. Treating with antiretrovirals has reduced the number of cases of tuberculosis, but HIV patients are still much more likely to develop tuberculosis. The best preventative measure seems to be to reduce the incidence of HIV and the best treatment strategy is to identify and treat active tuberculosis. Treating both HIV and tuberculosis concurrently poses special problems. Many of the drugs have potentially negative interactions, either reducing efficacy or increasing toxicity. In addition, there is the possibility of immune reconstitution inflammatory syndrome. This disorder manifests as a worsening of TB symptoms in a patient that was improving, likely due to an improved immune response resulting from treatment of HIV. In essence, successful treatment of HIV results in an escalation of tuberculosis symptoms. Steroids used to treat the TB have some success, but at the risk of increased complications from HIV. There is a fine line in concurrently treating these diseases and much more to understand about it.

This article serves both as a reminder of the enormity of the problems associated with Mycobacterium tuberculosis and as a call to arms for more research. With a third of the world’s population affected, it is extremely surprising that we don’t have a symbol, a color, a celebrity backed telethon with accompanying song, or a three-day walk to raise awareness and money for research. I suppose part of the problem is that the problem is “over there” and so we in America are less aware. Preventing the spread of the bacteria seems to be the best option for a long term reduction in incidence, and a new vaccine would seem to be the logical next step. In reading the article, it seems the challenges in treating tuberculosis are almost overwhelming. Tuberculosis lives and multiplies in the macrophages of the human immune system, the very cells that would normally play a key role in eradication of a bacterial infection. This uncommon arrangement, in addition to the complexity of the interactions between humans and Mycobacterium tuberculosis, is key to understanding the disease in the hope of finding better solutions. If we could find a way to induce the body’s immune systems to attack the bacteria itself without the formation of tubercles or other negative effects, that would be an ideal solution. If that is not possible, we need to find those mechanisms or characteristics that are unique to the bacterium or its pathogenesis and create a drug to act on those. The challenges are many. The authors repeatedly used the term “political will” and it seems that this may be the key to resolving the problem of tuberculosis. While the article serves the purposes of reminding and rallying, it seems to be written for those already familiar with the disease and is poorly organized. The authors seem to “hopscotch” about with very little in the way of transition, making it difficult for a novice to assimilate the information. It is a good review of the current direction, but without the foundational information required to understand what it means.

Lorna V. Tablazon

Karen Rouleau

Asthma is a chronic (long-term) disease that makes it hard to breathe. Asthma can’t be cured, but it can be managed. With proper treatment, people with asthma can lead normal, active lives (Canadian Lung Association, 2014). There can be many causes for asthma, it may run in the family through genetics or might be from air pollutants in the outside environment. The one point to remember is that even when symptoms are mild, asthma should not be ignored. Untreated or under treated, asthma can lead to severe respiratory distress and in rare cases, sudden death. This paper will be discussing about dealing with a child with asthma. The main focus will be on school-age children, specifically, a 6 year old child.

Pathophysiology

Signs and Symptoms of Asthma

According to Wicks (2006), early signs and symptoms of asthma include stuffy nose with congestion, irritating cough, sneezing bouts, headache, face becoming pale or flushed, and fever (p. 27-28). With mild persistent asthma, symptoms of cough, wheezing, chest tightness, or difficulty breather occur (Rosto, 2009).

Course of Illness

In response to contact with a triggering substance or mechanism, mast cells of the immune system, which are found in loose connective tissue, are responsible for releasing vasoactive (action on vessels) chemical mediators, including histamine, bradykinin, leukotrienes, cytokines and prostaglandins. Chemotactic (produces specific cell movement) chemical mediators released from the mast cells cause neutrophils, lymphocytes and eosinophils to infiltrate the cells of the bronchial lining. These target the respiratory system and cause bronchoconstriction, vascular congestion, vasodilation, increases in capillary permeability, mucosal edema, impaired mucociliary action (removal of mucus and contaminants within the bronchial tree by movement of the cilia inside the bronchioles), and increased mucus production, which leads to an increase in airway resistance. Mucus plugging may also occur in the smaller bronchioles. These pathophysiologic factors produce the typical clinical presentation of asthma, including wheezing and respiratory distress (Limmer et al., 2004)

Prognosis

According to some studies, asthma disappears in 30 to 50 per cent of children at puberty, but often reappears in adult life. Up to two-thirds of children with asthma continue to suffer from the disorder from puberty and adulthood. Moreover, even when asthma has clinically disappeared, the lung function of the patient frequently remains altered, or airway hyper-responsiveness or cough may persist. Children with mild asthma are likely to have good prognosis, but children with moderate or severe persistent asthma probably continue to have some degree of airway hyper-responsiveness and will be at risk of having asthma throughout life (Gupta et al., 2001).

Admission to the Hospital

Safety Concerns

Children with asthma that are hospitalized are vulnerable to pathogens and allergens that are present in the new environment. There are safety concerns that a nurse must be aware of when caring for a child with asthma. First, check for the oxygen saturation of the child. Children with life-threatening asthma or SpO2 <92% should receive high flow oxygen via facemask or nasal cannula (Borton, 2010). Another one is to know what allergens might trigger the child’s asthma attack. The hospital is an open environment where people come and go, therefore, contaminants and allergens from the outside environment may possibly be present in the hospital setting. Lastly, is the child’s risk for falls. Falls account for 35% to 40% of injuries (Warda, 2004).

Age Appropriate Toys

Play activities in the school-age child involves increased physical and intellectual skills and some fantasy (Leifer, 2011). Toys such as construction sets, help develop hand control. School-age children prefer a wide range of art materials, such as sparkles, fine brushes, hole-punchers, and tape dispensers. A wide variety of different artistic mediums also encourage children to be creative and use their imagination. Lastly, choose challenging board games, since children are now able to understand rules and interact with their peers (NYCDS, n.d). Rituals such as collecting items and playing board games are also enjoyable quiet activities for the school-age child (Leifer, 2011).

Impact of Hospitalization

Being hospitalized due to asthma can have a huge impact, not only to the child, but also toward the family. Asthma is a leading cause of absenteeism in school students, which in severe cases can cause them to fall behind in their work (Asthma Australia, n.d.). Another thing to note is that when hospitalized, some children can regress in behavior and become overly dependent on their parents (PICS, n.d). Lastly, if the hospitalized child has siblings, they may get affected too. When one child in a family has to receive medical care, the experience can be upsetting to his/her siblings. Some emotional responses of these siblings may include: feelings of abandonment, rejection and isolation (Children’s Specialized Hospital, 2014).

Communication Techniques

Communicating with a 6 year old does present some challenges. They tend to be bossy, are sometimes rude, and experiment with language, but they are very sensitive to criticism (Leifer, 2011). One method for successful communication with school age children is to start and agreement, not an argument (PBSparents, 2014). This can be done by asking the child something where the final answer would be an agreement. For example, asking the child which arm they would prefer when starting an intravenous line instead of saying that it should only be done in the right arm. The hospitalization of children can have an impact on parents too. To communicate better with the parents, the nurse can provide an advice page, covering topics such as how to explain to kids what will happen in the hospital and how to comfort their children (Blackstone & Pressman, n.d.). Lastly, School-age children can handle more pieces of information at the same time (Gable, 2003). To effectively make the child understand what is happening, the nurse can describe the illness using simple concepts (Goldman, & Mathews, n.d.). For example, explain to the child that he is being admitted to the hospital not because he is being a bad child, but because of his illness.

Baseline Data

To better aid in diagnosing or rendering care for a child with asthma, certain baseline data has to be taken during the child’s assessment. First is to check for known allergies. In many cases, allergy information helps medical personnel discover a cause for problems like swelling or difficulty breathing. Second is to check for pre-existing illnesses or conditions. Pre-existing illnesses or conditions can have a great impact on the kinds of tests or treatments administered during an emergency. Third is to check for immunizations done. Lastly, check for previous hospitalizations and operations. This information may help during and following an emergency situation (Dowshen, 2013).

Conclusion

School-age children, especially the 6 year old, do present challenges when it comes to rendering care. According to Leifer (2011), children may be unable to verbalize their needs (p. 436), therefore the nurse in collaboration with the parents and the rest of the health care team must work together in coming up with techniques and strategies to be able to render the best means of care for a school-age child.

References

Asthma Australia. (n.d.).

Asthma in school-aged children.

Retrieved from

http://www.asthmaaustralia.org.au/asthma_in_school_aged_children.aspx

Blackstone, S., & Pressman, H., (n.d.).

Effective communication in children’s hospitals.

Retrieved from

http://www.patientprovidercommunication.org/pdf/25.pdf

Borton, C. (2010).

Management of childhood asthma.

Retrieved from

http://www.patient.co.uk/doctor/management-of-childhood-asthma

Canadian Lung Association. (2014).

Asthma.

Retrieved from

https://www.lung.ca/diseases-maladies/asthma-asthme/what-quoi/index_e.php

Children’s Specialized Hospital. (2014).

Effects of hospitalization on siblings.

Retrieved from

http://www.childrens-specialized.org/Programs-Services/Specialty-Programs/Recreational-Therapy-and-Child-Life/About-Child-Life/Sibling-Support/Effect-of-Hospitalization-on-Siblings.aspx

Dowshen, S. (2013).

Knowing your child’s medical history.

Retrieved from

https://www.akronchildrens.org/cms/kidshealth/2104a0fe743eca5e/

Goldman, S., & Mathews, M., (n.d.).

Parenting strategies.

Retrieved from

http://www.pbs.org/opb/childrenshospital/parents/pop/pop-ts_communicate.htm?500

Gupta, A., Gupta, R., Kushwaka, KP., & Bansal, H. (2001).

Asthma care and management,


guidelines for doctors.

India: Jaypee Brothers Publisher

Liefer, G. (2011).

Introduction to maternity and pediatric nursing 6



^th



ed.

USA: Elsevier Limmer, D., Mistovich, J.J., Krost, W.S. (2004).

Pathophysiology of asthma.

Retrieved from

http://www.emsworld.com/article/10324789/pathophysiology-of-asthma

NYCDS. (n.d.).

You and your family: childcare and parenting.

Retrieved from

http://www.nebenefit.com/nycds/resource_ctr/index.aspx?thePage=ynyr_family/childcare/play/choose_toys.ascx&subnav=rc&sidenav=rc

PBSparents. (n.d.).

Strategies for working out.

Retrieved from

http://www.pbs.org/parents/talkingwithkids/negotiate_2.html

Pediatric Integrated Cancer Service. (n.d.).

Impact of hospitalization on children and


adolescents.

Retrieved from

http://www.pics.org.au/Impactofhospitalisationonchildre nandadolescents

Rosto, E. (2009).

Pathophysiology made incredibly easy.

USA: Lippincott Williams & Wilkins

Warda, L. (2004).

Is your hospital safe for children? Applying home safetfy principles to the


hospital setting.

Retrieved from

http://www.ncbi.nlm.nih.gov/

pmc/articles/PMC2721182/#

Wicks, S. (2006).

All about asthma: what you need to know.

USA: eFortune US

Section 1 “Professional capabilities”

Domain2: Professional Communication and Collaboration

It is important and essential for health professionals to improve on communication skills with patients in daily medical settings. Diverse cultural backgrounds, various physical and mental conditions of patients also need to be considered seriously and respectfully. According to O’Daniel and Rosenstein (2008), effective communication encourages collaboration and helps prevent medical errors.

There was a good example from my first clinical placement in 2018. The case was related to effective communication with the patient.

J.W is a 43 years old Italian woman who has been referred to the medical imaging centre for X-ray assessments. According to Dauer et al. (2013), the perceptions of patients regarding to the X-ray examination could be affected by the communication approach taken by the radiographer.  In other words. it is suggested that the responsibility of the radiographer to clearly deliver accurate information such as risks, benefits and the whole process of the X-ray examination plays an important role in effective communication with the patient.

Appropriate and effective communication in this case involves various aspect, for example, the respectful attitude towards patients, the display of professional conduct, giving understandable instructions, providing post examination care if necessary. The relationship between radiographers and patients can thus be strengthened if effective communication implemented.  Most patients are actually with little conceptions about the exam they are having. Thus, information given from radiographers in this stage becomes extremely critical to them. Sufficient clinical information obtained from patients assist in determining the most appropriate types of imaging approach and accurate imaging projections for better perform the exam efficiently and safely.

Since J.W. is a non-English-speaking patient, during the communication process, the barriers were encountered because of language difference. The obvious communication barrier between J.W. and us became one of the factors preventing her from cooperating with our instructions, and even ended up avoiding any eye contact with us. We’ve tried implemented multiple strategies to effectively communicate with J.W. Firstly, via simple sentences and words, which might be easier to understand; secondly, speaking every word clearly with gentle voice; thirdly, demonstrated the required positions straight away. Fortunately, the outcome turned out ideal.  The trusting relationship finally established between J.W. and us, and the X-ray examination has done successfully.

Bal (1981) suggested that an overall understanding of the English level of the patient would help medical professionals adapt language accordingly. Aspects listed below are which would be allocable when communicating with non-native English speaking patients:

a. Speak clearly with normal volume.

b. Giving instructions in a clear and logical sequence

c. Do not use medical jargon

d. Longer explanation is usually easier to be accepted thus better not to condense the contents explanation is usually easier to be accepted.

e. Avoid delivering too much information in one session as this may negatively affect the memory while concentrating to understand

f. Ensure patients have full understanding of instructions and given information after each conversation

The lack of English vocabulary required to express the medical symptoms or problems is the obstacle that is very difficult for those who are non-native English speaking patients to overcome (Frank, 2000).

In my future clinical practices, I would take account in all variations of individual patient and adapt specific techniques to achieve the goal of building appropriate interaction with patients, forming effective communications, and professionally performing X-ray examinations. In this special case, I’ve gained valuable experiences from problem solving and adapting specific communicational techniques to successfully conduct the whole examination.

Section 2: “Lead the way”

In medical imaging settings, the role of radiographers is evolving due to globalisation, economic recession, technological advancements, and an increase ageing population (Sithole, 2013). Based on the changing role of radiographers, the concept of leadership must to be emphasized as an essential component which professionals should have to maintain quality and excellence in diagnostic radiography practice. According to Yukl (2002), leadership is the process of facilitating individual and collective efforts to accomplish the shared objectives. ‘’Leader’’ in the medical imaging setting can be defined as the people who have direction, vision, drive and the personal skills that can motivate and lead people in an emotional intelligent manner. A high degree of self-awareness is therefore essential. The leadership of members who at particular position in the medical environments has the required knowledge and skills to lead the department in curricular activity. Furthermore, it is necessary for leaders in DR to assist radiographers to navigate the volatile and complex health care environment. Profession of radiography can thus be ensured by sustainable and effective leadership, which help to face challenges and ongoing changes from the medical environment in the future (Bloom, 2014).

Nerveless, challenges regarding to leadership still encountered in everyday practice within radiography professionals.

An example presented below happened in one of my theatre shifts during my second clinical placement. It associated with the use of leadership power from my clinical supervisor.  In the operating theatre, there was another student who inadvertently touching the surgical equipment which has already been sterilised. The surgical nurse then yowled at the student and rebuked the clinical supervisor. The student was excluded from the whole surgery as the mistake was unacceptable for the whole nursing team. However, at the same time, the supervisor immediately tried to negotiate with the nurse and explained to her that he would take the responsibility of the mistake form the student and ensure everything was well-prepared for the surgery. After the negotiation, the student was allowed to continue the learning process in the theatre. By the end of the day, the supervisor also communicated with the student and let him know what to improve on for the next theatre experience. This example demonstrated the good use of the leadership power from the clinical supervisor to maintain good and open relationship with the student. The supervisor also took the responsibility to properly communicate with the nursing team. Equal relationship between the student, the supervisor, and the nurse was highlighted in this positive leadership example. However, some challenges might be encountered by the leader during the process of achieving successful leadership. This may include having conflicts with other health professionals, students, or patients. Although, the good practical decision-making and effective communication skills was still successfully exhibited in this case.

Section 3: “Reflection time”

A reflective practice activity involves engagement of the practitioners in a continuous cycle of self-observation and self-evaluations in order to critically think and analyse about their own actions and reactions (University College Dublin, n.b.). It’s recognised as a way to learn from our experience as radiographers. The goal of improving on professional practice, observing and refining practice on an ongoing basis can also be accomplishing by participating in reflective practice activities, which allows allied health professionals to identify strengths and weakness accordingly (SARRAH, n.b.).  According to Mantzourani (2019), reflective practice has been linked to distinct characteristics that encourage stimulating evaluation process and hence empower health professionals to achieve better practice.

Keeping a daily reflecting journal can be a good reflecting practice activity for medical imaging professionals. The contents of each journal should be structured into six sections (Gibbs, 1988) :

1. Description:
2. Feelings
3. Evaluations
4. Analysis
5. Conclusion
6. Action plan

For Description and Feelings, the details of the event should be included such as locations, people involved, what activities was proceeding, reasons of happening, contexts of the event, and outcomes. Feelings relating to the process at different stage of the event also need to be specified. It seems similar between the third and fourth part of the journal, which are Evaluation and Analysis. In the section of evaluation, consider both positive and negative parts of the experience. Evaluation and judgement can be made in this section. Proper analysis can be done by breaking the event into smaller components which can be discussed separately and accurately. For conclusion part, try to integrate all the information obtained in previous sections and develop insight into ourselves and other people’s behaviour in terms of how they contributed to the outcome of the event. In the final step of the journal, which is about action plan, it is important to think forward when encounter the similar situation again and to plan what can be done differently or handle the case even better with further knowledge in the future. Reflection and ability to adapt rapid changes in workplace are necessary factors for lifelong learning to occur in medical imaging professions.

To summarise, reflective practice is an essential component in medical practice based on the previous discussion. If reflective practice is performed comprehensively and continuously throughout long term, improved performance and other associated benefits can thus be achieved. Learning from previous experiences and developing own personal skills could be factors leading to a better allied health professional. According to (CAMRT , 2014), successful and continuing professional development can be accompanied via reflective practice. The advantages of reflecting practice are numerous. Enhanced professionalism with greater autonomy and responsibility for future learning. Self-awareness are heightened with the capacity to engage in self-regulation and self-monitoring. The reflective practice activity refers to an ideal approach for medical imaging professionals to work on lifelong objectives or in the future career. The approach facilitates understand and integration of new knowledges, with opportunities to incorporate aptitudes, values, personal beliefs and local professional culture.

References

• Bloom, R. (2014). Leading the Way in Radiography: Radiography Students’ Perceptions of Leadership in the Field, Leadership Opportunities, and Themselves as Future Leaders.
  
  Theses and Dissertations (All)
  
  .
• CAMRT . (2014).
  
  MRTs reflect on their practice to set goals for professional development
  
  . Retrieved from REFLECTIVE PRACTICE: https://camrt-bpg.ca/professionalism/professional-development/reflective-practice/
• Dauer, L., Thornton, R., Hay, J., Balter, R., Williamson, M., & Germain, J. (2011, April).
• Fears, Feelings, and Facts: Interactively Communicating Benefits and Risks of Medical Radiation With Patients. American Journal of Roentgenology, 196, 756-761.
• Desselleb, S., Lec, J., Lonied, J., Lucasc, C., & Mantzourani, E. (2019). The role of reflective practice in healthcare professions: Next steps for pharmacy education and practice.
  
  Research in Social and Administrative Pharmacy
  
  .
• Frank, R. (2000, March). Medical communication: non-native English speaking patients and native English speaking professionals. English for Specific Purposes, 31-62.
• Gibbs, G. (1988).
  
  Learning by doing: a guide to teaching and learning methods
  
  . London: Further Education Unit.
• Lau, L. (2007). Leadership and management in quality radiology.
  
  Biomed Imaging Interv J, 3
  
  (3).
• O’Daniel, M., & Alan H. Rosenstein, A. H. (2008). Professional Communication and Team Collaboration.
  
  Agency for Healthcare Research and Quality (US)
  
  .
• SARRAH. (n.b.).
  
  Reflective Practice
  
  . Retrieved from Services for Australian Rural and Remote Allied Health :
  
  https://sarrah.org.au/content/reflective-practice
  
• University College Dublin. (n.b.).
  
  Defining Reflective Practice
  
  . Retrieved from Open Educational Resources of UCD Teaching and Learning, University College Dublin: http://www.ucdoer.ie/index.php/Defining_Reflective_Practice

• Yielder, J. (2006). Leadership and power in medical imaging.
  
  Radiography
  
  , 305-313.
• Yukl G (2002). Leadership in organisations. Upper Saddle River (NJ): Prentice-Hall.