Depression is regarded as a major global public health problem it affects all types of people in all cultures a cross the world, and is the cause of substantial suffering and disability Worldwide.

Depression is fourth leading cause of disability .Depression is predicted to be the second leading cause of disability in the year (2020) the disability also increases with severity of the depression. The World Health Organization (2006) established that over the past45 years, suicide rates had increased by60% worldwide and that suicide was the third most common cause of death for both men and women between the ages of 15 and 44 years demonstrating a change from earlier figures where older people were the most likely group to commit suicide. The World Health Organization (2006) stated that depression was the cause for approximately 90percentage of all cases of suicide (Hansson, 2010).

Depression

Is a common mental health disorder that often presents with depressed mood, loss of interest or pleasure feeling of guilt or low self worth, disturbed sleep, loose of appetite, low energy and poor concentration. As result, these problems can become chronic or recurrent and lead to substantial impairments in the individual’s ability to take care of his or her everyday responsibilities (WHO, 2011).Genetics and neuroscience research and other research studies have shown that depressive illnesses are disorders of the brain. Yet, the exact causes for these illnesses are not yet clear and are still being studied. Imaging technologies such as magnetic resonance imaging (MRI) scans show that the brains of people with depression look different from those of people without the illness. The scans show that the areas of the brain that control moods, thinking, sleep, appetite and behavior are not functioning properly (National institutes of health, 2007).

There are many causes of depression such as a reaction to life event( i.e.) death of a loved one, breakdown of relationship, financial worries, stressful events in person life and difficult childhood experiences are leading to depression in adulthood (Walsh, 2009).

There are also genetic causes such as family history of disease, there are biochemical causes such as changes in hormones and there are chemical imbalances psychological causes such as social, anxiety, stress. As well as there are serious medical illnesses like, diabetes, cancer, Parkinson’s disease, in addition to the causes there are some medication which are taken for these illnesses may cause side effects that contribute to depression (National institutes of health, 2007).

Types of depressions

There are many types of depressions described.

• 
  Major depressive disorder (MDD) in old age
  

It is associated with increased volumes of visceral fat, which is also known as organ fat is located inside the peritoneal cavity ,packed in between internal organs as opposed to subcutaneous fat which is found underneath the skin and intramuscular fat which is found interspersed in skeletal muscle (Anderson, Anderson, 2006).

As well as a high prevalence of the metabolic syndrome, this is a cluster of metabolic derangements that are associated with primary disturbances in adipose tissue (Potenza, &Mechanic 2009).It is characterized by at least 2 weeks of depressed mood or loose of interest in pleasure consists of a single episode as recurrent major depression at various points in life often it begins between ages 18 and 45 (Major depression,2009).The symptoms can be very sever can also include psychosis, psychosis mean a person has lost the ability to distinguish between what is real and what is not real. A person can experience hallucinations. Moreover, hallucinations are when major depressive disorder person sees things that are not there or hears voices (Kneisal, Wilson&Trigoboff)

• 
  Major depression episode
  

It is mood of disturbance characterized by sadness and grief is resulting from personal loss, tragedy, or loss of interest in activities (Kneisl, Wilson & Trigoboff, 2004).

• 
  Dysthymic disorder
  

It requires a chronically depressed mood for the at least two years symptoms tend to be less severe than in major depressed disorder(Kneisl, Wilson & Trigoboff, 2004).

• 
  Seasonal affective disorder
  

Seasonal affective disorder, it is also called (SAD) that triggered by the season of the year the symptoms begin in the winter and end by summer (Kneisl, Wilson&Trigoboff, 2004).

• 
  Bipolar disorder
  

Are group of mood disorders that include manic episode, hypomanic episodes, depressed episodes and cyclothymiacs disorder. Bipolar disorders tend to be recurrent decreasing in frequenancy as the individual age’s most bipolar 1 disorder clients return to normal functioning (Kneisl, Wilson&Trigoboff, 2004).

• 
  Mood disorder due to other conditions
  

It is manifested by physiological conditions mood disorder due to a general medical condition such as hepatitis it may also induced by substance abuse such as cocaine or prescribed medication like antihypertensive or oral contraceptive (Kneisl, Wilson&Trigoboff, 2004).

• 
  Postpartum mood episodes (PPME)
  

Almost 50% of women experience it is occurs from 2 weeks to 1 year following the birth of the child (Kneisl, Wilson&Trigoboff, 2004).

Diagnosing depression

The (DSM-IV) the diagnostic and statistical manual of mental disorders is probably the most widely consulted classification system in psychiatry. Its provides a system for the classification of all mental disorders, including differential diagnosis, with a coding system for each disorder for record-keeping purposes. The manual is designed to guide diagnosis in clinical practice (Barker, 2009). Moreover, the important step in getting appropriate treatment is visit a doctor or the mental health professional, he or she will exclude the case of the other medical cause of depression by doing the complete physical exam and interview and laboratory tests.

The mental health professional will ask about the history of symptoms, such as when it started and how they have lasted a long time, whether signed before, whether they were treated. Hence, the mental health professional will diagnose depression then the most appropriate treatment will be choose and to be start (National institutes of health, 2007). There are many screening instrument are used in diagnosis of depression such as the Zung self-rating depression scale (WHO, 2011) The GDS- scoring sheets (Walsh, 2009).

Psychiatric unit

Patient who are in need of psychiatric care for depression are often admitted to psychiatric unit for treatment of in-patient who requires psychiatric care (Anderson, Anderson, 2006).

Role of the nurse

According to American Nurses Association psychiatric mental health is specialized area that includes the continues and comprehensive primary mental health care services in promoting of optimal mental health and preventing of mental illness.Hence,self awareness,empathy,emotional support and moral integrity all enable the psychiatric nurse to practice the use of self artfully in therapeutic relationships(Kneisl,Wilson&Trigoboff,2004).

The Depression Nurse Specialist (DNS) plays a key role in initially assessing symptoms of depression, educating and activating patients, providing feedback on patients progress to their primary care clinician, helping to implement treatment plans, and monitoring patients to improve their compliance with their treatment regimen. Moreover, the care is consisting of face -to face patient supervision, and communication (RAND, 2010).A major goal for nursing is to provide the high level of physical care that it currently meet the needs of the patients holistically. Patient who receive holistic care generally do much better than those who do not. It is also well documented that those with a good support group, which provides good emotional, psychological and social, spiritual help do much better than those without it. To integrate the above to provide best practice advice on the care of people with depression and their family and careers (Anderson, et el. 2010).

Jean Watson theory of human caring influenced by Jungian psychology, feminist theory caring healing within Watson framework is based on values like, kindness, love of self and others

A humanistic altruistic value system faith hope and sensitivity of self and others. Therefore, her theory emphasizes sensitivity of self and values clarification regarding personal and cultural beliefs. As a result, she credits much of her thinking on therapeutic relationship and communication to work indentifying congruency, empathy and warmth as foundational to a caring relationship that expression of emotion Watson develops the notion of spiritual environmental and the interconnectedness of all things. (Kneisl, Wilson&Trigoboff, 2004).

Emotional support

Emotional support is regarded as a sensitive under-standing approach that helps patients accept and deal with their illnesses. This includes that the patient have the to communicate their anxieties and fear, drive comfort from a gentle, sympathetic caring person and increase their ability to care for themselves (Anderson, Anderson, 2006).

Nursing management

Nursing management of patients suffering from depression generally includes emotional support. Emotional support involves facing the patients as individuals, increasing their feelings of safety, reducing their anxieties and increasing the patients trust and faith in the future. Patient typically experience painful thoughts and emotional such as fear, grief, confusion, shame embarrassment and guilt. Patients are often afraid of losing control of themselves or of being viewed as weak for expressing their felling (Keltner, Schwecke & Bostrom, 2007).In general most patient desire to have someone to support them emotionally. In fact, many hospital have a counseling service, many patients feel more comfortable with the nurse who provides emotional support and care to them. Thus, the nurse is the most available person to question and to seek support from, so this is a natural desire (Lee, 2009).

Aim

To explore the impact of emotional support given by the nurse to patients with a diagnosis of depression, in a psychiatric unit.

Research questions

How dose emotional support affect the patient outcome?

By giving emotional support to the patient, how does this affect the nurse?

Do all patients with depression in a psychiatric unit need emotional support?

METHOD

A literature review is the method chosen for this study. “A literature review is a critical summary of research on a topic of interest, often prepared to put a research problem in context” (Polit&Beck, 2008).

The authors will analyse between 15-25 articles by reading them and exchanging the articles

Between the authors, and then highlight the similar words, which were like, depression using the following tools during the research for data collection.”Literature review which is critical summary of research on a topic of interest, often prepared to put a research problem in context” (Polit&beck, 2008).

PubMed

During the author searching, we use PubMed, “which is a database that anyone, anywhere in the world with internet access can search for journal articles and permanent resource regardless of your institutional affiliation” (Polit&Beck, 2008).

CINAHL

It is regarded as an important electronic database for nurses its covers references to virtually all English language nursing and allied health journals. In addition to provide, bibliographic information for locating references (i.e. the author, title, journal, year of publication volume and page number). (Polit&Beck, 2008).

Mesh term (key word)

Depression, Depressions type, emotional support.

Data collection

Inclusion criteria and exclusion criteria

The PubMed and CINAHL are used in this study to search for academic article and all in English language. The authors will include the old age 56 and above patient with major depression disorder in the hospital especially in psychiatric unit. The authors will exclude the cases without major depression disorder and young ages under 56.

ETHICALS CONSIDERATIONS

Ethical consideration is known as moral values of the method, procedures, perspective and how to analyze problems and issues (Polit&Beck, 2008).The authors must consider the ethical issues, in the articales, which were approved by the ethical committee. According to(National Institute of Environment Health Sciences,2010) the research ethic are honesty, objectivity, integrity, carefulness,respect,and they used the justices when they did their survey. The authors avoid any misconduct such as fabrication, falsification or plagiarism in reviewing the research (Polit&Beck, 2008).

REFERENCES.

Anderson, I., Pilings., Barres, A., Bayliss, l., Bird., Burbeck,R.,Graham,C.,,C. Clarke., Dyer., Flanagag,E., Harris., Hopkins,S., et el. (2010). Depression the treatment and management of depression in adult. (Update edition). London. The British psychological society and the royal college of psychiatrists.

Anderson, K., N. &Anderson, L., E. (2006) Mosby pocket dictionary of nursing medicine and professions allied to medicine (UK edition).England. International limited.

Barker, P., (2009). Psychiatric and Mental Health Nursing the craft of caring (2th ed.). United Kingdom. Hodder Arnold.

Chiu, E., (2004).Epidemiology of depression in Asia pacific region. Bulletin of Royal Australian and New Zealand College of psychiatrists. 12 suppal: S4-10.

Greggersen, W.,RUDORF,S., Fassbinder,E.,Dibbeh,L.,Stoeckelhuber,BM., Hohagen,F., Oltmans,KM.,KG.,Schwiger,U., et el .(2011).Major depression,bordeline personality disorder ,and visceral fat content in women. European Archives psychiatry and clinic neuroscience

.DOI:10, 1007/ s 00406- 0194-6.

Hansson .M., (2010).Depression in primary care Detection, treatment, and patients own perspectives .Umea University, Sweden.

Kenisal, Carol., Ren. Wilson, Holly., Skodol. Trigoboff, Eileen., (2004).Contemporary psychiatric- mental health nursing (1st ed). New Jersey. Upper Saddle River.

Keltner,N.,L. Schwecke,L.,H. Bostrom,C.,E. (2007).Psychiatric Nursing .( 5th ed ).The United States of America. Mosby Elsevier.

Khandelwal, S., (2001).Conquering depression. South -East Asia .World Health Organization http://whqlibdoc.who.int/searo/2001/SEA_Ment_120.pdf.

Lee, M., L. (2009). Nursing Success in Providing Emotional Support: The Patients‟ Perspective.

Jefferson City. Meredith L. Lee. http://library.cn.edu/HonorsPDFs_2009/Lee_Meredith_L.pdf

Lindstran,A., Bergstorm,S., Rosling, H., Rubenson,B., Stenson,B., Tylleskar,T., et al (2010).Global health : An introductory text book . United state of America. Student litterateur AB Lund, Sweden

Major depression (2009).what is depression. Retrieved on March 9.2011 from http://www.epigee.org/mental_health/depression.html

National Institute of Environmental Health Science (2010).What is Ethics in Research& Why is Important? Retrieved March 15,2010,fromhttp://www.niehs.nih.gov/research/resources/bioethics/whatis.cfm

NIH Senior Health (2007) .Depression .Retrieved on March 4.2011 from http://nihseniorhealth.gov/depression/causesandriskfactors/01.html

Polit, D., F. & Beck, C., T. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice (8th Ed.). Philadelphia: Lippincott Williams & Wilkins.

Potenza, M., V. &Mechanic, J., I. (2009) .The metabolic syndrome definition global impact and pathophysiology.Nutrioin in clinic practice.24 (5): 56-77.

Rand (2010). Objective analysis effective .Retrieved on MARCH 3.2011 fromhttp://www.rand.org/pubs/monograph_reports/MR1198z2.html

Walsh, L., (2009). Depression care across the lifespan. (1st ed). United Kingdom. John Wiley & Sons.

World Health Organization. (2011). Depression. Retrieved on March.4, 2011 from http://www.who.int/mental_health/management/depression/definition/en/

World Health Organization. (2011) Suicide. Retrieved on March.9, 2011 from http://www.who.int/topics/suicide/en

World Health Organization. (2011).The Zungset rating depression.Retrived on March 19, 2011 from http://www.who.int/substance_abuse/research_tools/zungdepressionscale/en/

How does ADHD and/or autism impact on the pupil, other pupils, teachers and the whole school?

Introduction and Overview

First, is to define ADHD and Autism: Attention Deficit Hyperactivity Disorder (ADHD) is a disorder that tampers with major parts of the brain that is related the control of a person’s attention, activity and emotions which make them appear hyper or weird. ADHD can also be considered as the poor functioning and poor communication between different areas of the brain. Autism mainly appears during the first 3 years of the child’s development and growth. It’s in relation to routines and repetition of behaviors which range from mild to severe. It doesn’t mean that autism is a damage or disease.

Jaffe-Gill et al (2008) postulate that the symptoms of ADHD will show if the section of the brain which controls hyperactivity, is not fully developed or not coordinating well with the rest of the brain and therefore it is not that the child is not able to control his behavior. Autism is not purely a genetic disorder which cannot be treated but certain reactions on the genes which are indeed affected by the external environment al factors. Autism is treatable as the important part that should be understood is, if the reactions can be flipped on, they can be as well be flipped off.

Secondly, ADHD and Autism affect children and the signs and symptoms expose themselves in many different forms. The three major areas which most of the symptoms are categorized in are; in attention, hyperactivity and impulsivity. It becomes clinical when the impulsiveness and hyperactivity go beyond the social norms. The child may have difficulty in paying attention, may be fidgety, gets easily distracted, may not be able to sit still, may have difficulty in doing homework, chores around the house, or may be disorganized.

Consequently, the hyperactive-impulsive type AHDH symptoms include; being always ‘on the go’, struggles to wait in line, always fidgeting or squirming, running or climbing in excess, Struggles to remain seated, Blurts out answer before hearing question, talks too much, Struggles with interrupting or intruding and lastly they cannot play quietly. The last of the AHDH types is the combined type. This is the common of the three and it is a combination of the inattentive type and the hyperactive-impulsive type. Before a parent or teacher gets to establish an AHDH case, they may feel that the child is acting out or seeking attention. Without medication or/and behavioural therapy a child struggles to control his or her behaviour.

Other signs of ADHD are shown when the child gets so disruptive or fidgety in class that interferes with the teacher as she tries to teach the other students, the student blurt out answers in class, the student find sit hard to wait for his turn in the line, the child also becomes so hyperactive that he cannot sit through a session for instance, the church service or watching a movie. With autism the three core areas that are involved or show the signs of the disorder include; social-not socially interacting with the environment and just being by themselves, communication which is manifested by the age of 3 when a delay in speech is eminent, and repetitive movements or limited interest.

Fact file on ADHD

There are various facts about Autism and ADHD:

On ADHD, it affects between 5 to 10% of the school going children and affects more boys than girls about 3 to 4 times more, another fact is that 50 to 60 % of the children will continue to experience the symptoms throughout to adulthood, the ones which need pediatric prescriptions are about 78%. Many cases of ADHD are reported worldwide, especially those that affect children below the age of 3 years (Fuller, 2008). This is the year that is said to be when Autism and ADHD manifest and begin to show up prominently.

On Autism; 1 in every 150 children are diagnosed with autism while 1 in every 94 boys has the disorder. It is further evident that each day, about 67 children are diagnosed with the Autism disorder and a new case is reported every 20 minutes. In comparison to AIDS, diabetes, & cancer, it is further true according to statistics that more children will be diagnosed with autism this shows that it is the most rapidly growing acute developmental disability in the U.S. boys are expected to have autism four times more. There is neither cure nor medical detection for autism.

Since ADHD and Autism affect the school going children, and they spend at least eight hours everyday in school, the teachers and students are more likely to observe the change in behaviors in the students and hence a big impact will be felt within the school and its environment. This document will look at the impacts of autism on pupil, on other pupils, on teachers and on the whole school.

Impact of Autism on Pupil

Children with severe speech difficulties finding it difficult to communicate may become very frustrated. They may be reluctant to communicate or may refuse to do so at all. If required to communicate, they may show signs of intense stress or anxiety. The child may have low self esteem and may feel rejected by peers (and may in fact be rejected by some). In such circumstances, it may become difficult to recognize that.

Without support, the child may develop behavioral, emotional and social difficulties. This appears to be supported by evidence of communication problems among population such as children in care and pupils in school.

Because of their dependence on structure, major problems can arise for children with autism outside lesson times. Although breaks from lessons are designed to provide normal children with the opportunities they need to relax and to interact with their peers, for a child with autism such period can be extremely stressful, children who are able to behave quite acceptably when involved in guided and structured activities frequently appear much more ‘odd’ or unusual at times of free play.

Stereotyped and ritualistic behaviors may become more apparent and exposure to teasing or bullying is much more of a risk, especially because staff supervision at such times is greatly reduced. Break times are designed to reduce the pressure from the children not increase and therefore by allowing the children with autism to go for the break will just increase the amount of pressure in them thus it would be good if they are not allowed to go but instead relax in class by themselves without any disturbance.

School meals can be another source of difficulty and it is clear from personal accounts that having to tolerate the noise and smells of meals in a crowded school canteen can be almost akin to torture for individuals with autism. Been forced into close proximity with other students, or made to eat food of particular textures or mixed together on the plate (many individuals cannot bear separate items of food touching each other) can be extremely stressful.

Clare Sainsbury writes: (the potential of making mistakes (and the anxiety caused by fear of making mistakes) is enormous. One of my most vivid memories of secondary schools is been hauled out of the lunch queue by one of the dinner ladies shouting angrily, and made to stand to one side; she refused to tell me why. Only after I had burst into tears was I allowed back….nobody ever explained what I had done wrong….and to this day I still have no idea.)

A quiet corner in which to eat, being allowed to eat slightly earlier or later than other pupils, or being permitted to bring sandwiches are among the simple solutions that can transform a nightmare into a practicable tolerant activity. If the principal problem is lack of knowledge of what to do when the basic rules can be explained simply – and discreetly- beforehand. Games and extracurricular lessons are also frequent causes of stress for pupils with autism, who may lack the motor coordination, the ability to follow rapid instructions or unwritten rules and the social reciprocity required in order to contribute to these activities in any useful way.

Competitive sports are a particular problem and are probably best avoided altogether, both for the sake of the person with autism and the rest of the class. However, physical fitness can be improved by encouraging activities that improve body awareness and coordination such as yoga, swimming, golf, walking or gymnastics if sensitively taught.

Impact of Autism on Other Pupils

The impact of Autism on other pupils can be as a result of the reaction of the children affected by Autism (Autistics). Due to the hyperactivity, in them, the other pupils will develop fear in them as they will seem as a threat to them. For instance, if a child is the kind who throws things around when annoyed, will make his classmates scream, run away, there may be accidents in that a child can be hit by the furniture or the object thrown around.

Autistics are also known to be bright and understand things so fast, besides their self esteem was lowered by other students, they can also lower other pupils self esteem in academics especially. This is so because the weaker ones will be teased by them and feel threatened instead. In many cases, if the teacher does not realize this early enough, she may have ea tendency of rushing through the syllabus since of the assumption that if one or two pupils have understood what is been taught, the rest will learn from them.

For some children this lack of understanding may result in a refreshing acceptance of the child with autism for the person they are. However, some children may be fearful and this may result in ostracizing, bullying, or mocking the children with autism (Kinsley, 2008). These attitudes create a matrix of difficulties for the child with the disorder which exacerbates their already significant impairments in forming peer relationships.

Impact of Autism on Teachers

According to Folin and Lian (2008), a teacher’s attitude towards pupils with Autism is directly related to the knowledge and understanding of the condition. Consequently, there is a need to develop systems and means by which knowledge and understanding about Autism are share with other colleagues. Understandably, we are in competition with multitude of other demands on professionals and, therefore, need to promote information, in an accessible and manageable form which is tailored to the context they are working in. the depth of knowledge required might lie on a continuum from awareness to expertise by the role they perform.

Colleagues whose only contact with pupils with autism is during break times or assemblies will need a different level of understanding to those colleagues who may share the same teaching space. Similarly, these colleagues’ needs will differ again from the people primarily responsible for the teaching of youngsters with Autism. Responding to this continuum of professional development need, the training portfolio may include: Informal approaches, inset days, outreach, accredited courses, and resources.

Each of these depends upon practitioners within the field promoting the cause of pupils with the disorder in a positive and proactive manner.

Impact of Autism on the Whole School

A major impact in the whole school would be loosing children due to parents transferring their children to other schools because of various reasons such bullying. There has been case from various schools of major bullying taking place within the school; educators and society are concerned about the violent attacks in the schools (Schultz, n.d.). It is imperative that there should be a school-wide bullying prevention programs. This program will be specially tailored to address all issues that come along with the ADHD and Autism pupils.

Bullying is pervasive, in the schools and adults ought to be at the forefront in bullying. This is basically because a lot of pupils will lose out especially if they are bullied until it affects their academics. It is further recommended that the right academic modification as well as academic adaptation is incorporated into the school program. The law generally requires that every child should be provided with proper and a safe learning environment. Every school should thus have the facilities for special education of the children with Autism. Compliance to these standards should be ensured on a constant basis.

Conclusion

ADHD and Autism are disorders that affect parts of the brain. They are not purely genetic and can be controlled. Measures should be taken to create a good environment for both the children that need special attention and the other children and also the school environment. ADHD and Autism therefore affects the children’s ability to learn. This in itself means that there are various learning activities that the students with Autism will have to miss out on, thus impacting negatively on their performance in class. Whenever the class performance deeps, the school’s overall performance will also dip in a similar fashion.

To sum it up, the pupil with ADHD and Autism will learn slowly thus impeding their ability to keep up to pace with the rest. Their performance will also be negative with minimal or negative advancement. Similarly, the other pupils will find it difficult to be taught at the same pace as the pupil with ADHD and Autism (Sprinkle, 2004). When their learning is affected, they will have to also exhibit withdraw signs as well as lose interest in the subject being taught. On the other hand, the teachers will find it very strenuous so that they will develop an attitude that will affect their teaching patterns. Eventually this translates into poor school performance and loss of reputation as a result. Therefore, the school will suffer from adverse publicity from the critics. Likewise, the school will be compelled to expend large sums of money in setting up a unit specially meant for the ADHD and Autism pupils.

References

Folin, C., & Lian, M.J. (2008). Reform, inclusion, and teacher education: towards a new era of special education in the Asia-Pacific region. New York: Routledge. Retrieved October 06, 2009 from http://books.google.co.ke/books?id=X0rfLl87vkcC&printsec=frontcover&source=gbs_navlinks_s#v=onepage&q=&f=false

Fuller, J. (2008). How to Use Behavior Modifications to Treat Childhood ADHD. eHow.

Retrieved October 06, 2009 from http://www.ehow.com/how_4607436_behavior-modifications-treat-childhood-adhd.html

Jaffe-Gill, E., Smith, M., Segal, R., & Segal, J. (2008). Behavior Therapy for

ADD/ADHD. Retrieved October 06, 2009 from http://www.vaxa.com/behavioral-treatment-adult.cfm

Kinsley, R.S. (2008). What Is ADHD? KidsHealth.com. Retrieved October 06, 2009 from

http://kidshealth.org/PageManager.jsp?dn=KidsHealth&lic=1&ps=107&cat_id=146&article_set=21612

Schultz, J.J. (n.d.). Behavior Modification Instead of Medication? Retrieved October 06,

2009 from http://school.familyeducation.com/add-and-adhd/medical-treatment/42677.html

Sprinkle, N. (2004). ADHD Behavior Therapy: Promoting Discipline & Focus in Kids.

Additudemag.com. Retrieved October 06, 2009 from http://www.additudemag.com/adhd/article/860.html

Background

Cardiovascular disease (CVD) is one of the main causes of disability and premature mortality worldwide (Lopez et al., 2006) and it significantly affects the costs of healthcare. CVD has been reported to be a leading cause of mortality in Australia with around 29% of deaths attributable to CVD in 2015 (ABS, 2016). In 2008-09, CVD represented 12% of the total health expenditure in Australia and rates of hospital-related patient services for CVD have increased between 2001-08 and is continuing to increase (AIHW, 2014). CVD encompasses a range of conditions including coronary artery disease (includes myocardial infarction), stroke, hypertension or congestive heart failure. In 2014-15, it was estimated that approximately 1 in 5 Australian adults aged 18 and older have been burdened by 1 or more cardiovascular diseases (AIHW, 2018).

There are a number of modifiable health risk factors that contribute to an increased risk of CVD such as hypertension, diabetes, tobacco smoking, high blood lipid and cholesterol profile, obesity, physical inactivity and chronic alcohol consumption (Smith, 2007). Many of these risk factors are inter-related; for instance, obesity and diabetes are connected as one condition can lead to the other. Moreover, physical inactivity and obesity are linked as one does lead to the other and vice versa. Obesity can also lead to a high blood lipid and low-density lipoprotein (LDL) cholesterol profile, but this could also be due to genetic factors with inborn errors in the metabolism of lipids and cholesterol. This is notable in a condition known as familial hypercholesterolaemia where individuals may lack genetic factors involved cholesterol uptake into cells, leading to elevated levels in the blood, and hence atherosclerotic plaque formation, i.e. coronary artery disease (Varghese, 2014).  On top of these, risk factors such as increasing age, family history and ethnicity increase the rate of CVD (Buttar et al., 2005). However, this list comprises risk factors that are non-modifiable. Around the world, it has been found that male gender is a non-modifiable risk factor, however, Australian statistics show that the prevalence of CVD was measured as similar between male and female adults aged 18-54. However, according to graphical data of the National Health Survey, the prevalence is observed to be greater in Australian male adults aged 55-75+, which also supports that age is a cardiovascular risk factor and this is due to physiological changes that occur to arteries over time as well as issues in metabolic processes (AIHW, 2018; Tuomilehto, 2004).

In terms of the modifiable risk factors, it was found that, in 2014-15, 14.5% of Australian adults smoked daily, and this prevalence increased in regional and remote areas of Australia and was also higher in areas containing populations of low socioeconomic status (SES) (National Cancer Control Indicators, 2017). As for diabetes, its prevalence has tripled between 1989-90 and 2014-15 to 4.7% and trends have been increasing and are expected to increase over time. The prevalence of diabetes was found to be similar by geographical location but doubled in low socioeconomic groups (AIHW, 2018). Furthermore, the Australian Bureau of Statistics reported that in 2011-12, approximately one-third of Australian adults ages 18 and older had high total cholesterol. This distribution between male and female gender was similar, however, a higher prevalence was found in Australian residents located in regional and remote areas (ABS, 2012). It has been reported that physical inactivity accounts for more than 1 in 10 (12.2%) of the burden of myocardial infarctions worldwide and interestingly, the prevalence of physical inactivity was greater than smoking (35% and 26% respectively) worldwide (Yusuf et al., 2004; Wen et al., 2014).

It is therefore evident that CVD has a highly deleterious effect on the health of Australian adults and the increasing prevalence of modifiable cardiovascular risk factors is alarming and should be addressed in order to reduce the CVD burden. It is therefore necessary to focus on a number of social determinants that contribute to the increasing prevalence of these risk factors, i.e. to understand the role and relationship of upstream ‘causes of causes’ that promote CVD. These may include social determinants such as low SES which entails low income, unemployment and poor education. Investigating these will address the health disparities seen between different demographics of Australians where there are varying degrees of CVD prevalence based on SES and geographical location as discussed above. This essay will focus on unemployment and education as key social determinants that pertain to CVD.

The social determinants relevant to CVD

Unemployment

People who are living in low socioeconomic areas have many disadvantages such as low income, poor education, low employment rates and poor housing characteristics (ABS, 2016). Although there are some preventive interventions and treatments towards reducing the risk of CVD, such as behavioural risk factors, early detection and multiple treatment options for people who are already exposed to the disease; people in low socioeconomic areas are impacted differently as they do not always have access to these options particularly with regards to limited healthcare access as people in higher socioeconomic areas (Martinez-Garcia et al., 2018). This may be attributed to the cost of healthcare, particularly private health, where low income earners or the unemployed are disadvantaged due to the inability to access these services. As a result, public healthcare systems become flooded and hence patients often will not receive optimal treatment for their condition. It was found that in 2014-15, 20% of Australians that lived in an area of low SES were 1.6 times as likely to have at least two chronic health conditions such as CVD and diabetes, compared to the demographic of people with an SES representing the highest 20% (ABS, 2015). Furthermore, in 2009-11, it was reported that Australian adults residing in areas of the lowest SES have a life expectancy that is approximately 3 years less than those in the highest areas (NHPA, 2013). As outlined above, with CVD being the leading cause of mortality worldwide and having represented nearly a third of deaths in 2015 in Australia, it can be deduced that higher rates of CVD may be a significant contributing factor to the lower life expectancy in these areas. Unemployment rates have decreased over time in Australia, yet despite this, unemployment remains a major problem in the nation (ABS, 2018). Mathers and Schofield (1998) have discussed that people who are unemployed are at a higher risk of death and being ill or disabled than those who are similar age and employed. The stress that comes with being unemployed has a large impact on a person’s physical and mental health and wellbeing (Dooley et al., 1996). Unemployment may be a result of a physical or mental illness, however, for many, it may also be the reason they have health issues. Unemployment can cause several health problems through its psychological consequences and financial issues.

In general, people with no or few qualifications or skills, who have disabilities or poor mental health, who are caregivers, who are in ethnic minority groups or, people who are excluded from groups for different reasons, are at a higher risk of being unemployed (AIHW, 2015). The negative effects that come with unemployment may mostly be the due to the significant change in an individual’s lifestyle. They go from spending time at work for a long time every week to having that time free with the stress they will have from being unemployed. These may include negative changes such as altered dietary habits, increased habitual smoking, alcohol consumption or drug use. These can subsequently compound and lead to other effects such as physical inactivity, financial problems, problems in social life and relationships and depression, which are known to be the cause of serious health problems including obesity, lung conditions such as chronic bronchitis and most importantly, CVD (Weber and Lehnert, 1997).

A study done by Kasl et al. (1980) tracked the cholesterol levels of people who were expecting to be unemployed and subsequently becoming unemployed. It was found that unemployment contributed to higher cholesterol levels through fear of loss of job or unemployment. They had found that once these individuals started working again, their cholesterol levels corrected back to what was deemed a normal level. Furthermore, numerous studies have investigated the relationship between unemployment and blood pressure. While a study done by Schnall and Landsbergis (1992) did not show any significant effects of unemployment on blood pressure levels, Janlert (1992) and Hammarstrom (1994) both showed that unemployment had a negative effect on blood pressure levels, where higher unemployment rates lead to a higher prevalence of hypertension. As discussed, hypertension and a high blood LDL cholesterol are significant risk factors for CVD and as demonstrated, unemployment leads to high blood pressure and high cholesterol levels and once individuals begin working again, these measurements restore to normal levels. It is therefore clear that unemployment may lead to an adverse health profile that are known contributors to CVD, and hence it can be implied there is an inverse association between unemployment and CVD. More specifically, the physiological burden associated with unemployment increases the likelihood that an individual may develop CVD.

Education

Having no or low education may also be an important social determinant that contributes to CVD. Reasons that may explain this include not enough knowledge of the disease to take action for treatment, and similar to unemployment; physical inactivity, stress and increased tobacco smoking and substance use. There are several studies that show the relevance between education and cardiovascular disease. A study performed in Australia by Korda et al. (2017) containing 267,153 men and women aged over 45, showed that Australians that are not educated, who leave school early or do not complete it, have over twice as much risk of having a heart attack than those with a university degree and that improved education is an important factor in reducing the socioeconomic variation in CVD. This study more specifically found that the rates of heart attacks in adults aged 45-64 years who have no education is 150% higher than people with a university degree and 70% higher than those with intermediate levels of education. Similarly, a study done in the United States looking at participants aged 38-47 years found that the risk of having cardiovascular disease was 27.9% lower for people with a college degree than people without a college degree and it was concluded that factors in early life such as education may be important in contributing to CVD risk (Loucks et al., 2012). It is clear that studies conducted in Australia and in other countries support that individuals that have received poor education may be affected by CVD later in life.

The reason unemployment and education lead to a higher CVD rate is because, as demonstrated, many of the risk factors associated with CVD such as, hypertension, high blood LDL cholesterol, physical inactivity and smoking may come with being unemployed or having received no or minimal education. These factors may also affect the individual’s ability to act for prevention, early intervention or treatment. For example, a person who is not educated in the risks of CVD may not know that they need to take preventive actions to minimise their CVD risk, and a person who is unemployed may not be able to afford to pay for their medications such as statins (cholesterol-lowering drugs) or cardiovascular procedures such as coronary artery bypass graft surgeries. Ultimately, it is evident that unemployment and education should not be neglected in Australian adults so that the overall burden caused by CVD can be minimised, therefore leading to better health outcomes in this nation.

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Choosing a nursing career is very challenging; because we take the responsibility of ones life. A nurse has to be competent enough and hard worker, but the critical care nurse should be more skillful and critical thinker, because they directly provide care to critically ill patients. Critical care areas have high tech monitoring, patient status changes continuously. Therefore staff needs to be experienced however for the novice nurse the environment is very new and they don’t acquire enough skills. In critical care areas staff should be quick responder because patient’s condition deteriorates within minutes. Staff needs to respond quickly otherwise the patient may suffer. (Morrison et al. 2001).Critical care areas are designed to give care to especially critically ill patients. Critical care nurses are persons who provide care to those patients who are with life threatening problems and at high risk. The new graduate nurses are not able to provide their excellence of service because they have lack of experience, lack of communication skills, and chances of error increase.

Firstly, they are fresh graduates and have lack of experience. They directly came from school; just after graduation so they have deficit in clinical knowledge and they also don’t know the policies. Their skills are not well developed due to which they are at high risk to make mistakes. They are not practical because they have not encountered critical patients in reality. So if patient have any internal deterioration in condition they are unable to understand or recognize it. According to Ihlenfeld (2005) “When coming directly from nursing school and starting their careers in the critical care area, new nurses are able to start without preconceived ideas about nursing care. However, they bring with them inexperience, lack of personal confidence in their own abilities, and the need for professional reassurance.” I want to share an experience that in unit I was team leader and due to lack of experienced staff I assigned a novice nurse in special care area. I was too busy so, after three hours I got the chance to assess her practice. I entered in the room and I observed that one patient’s heart rate was very high. When I asked her about the patient’s condition that staff said that monitor leads are not well secured, but I had some doubt. I went to the patient and checked manual pulse which was too high. Suddenly, patient developed arrhythmias then I called doctor and we managed the patient. After that event, I realized that novice cannot work in critical care areas. According to Morrison et al. (2001) Seven hundred and thirty five reports covering 1,472 incidents were identified as relating to nurse staff inexperience. “Nurse Staff inexperience can have a negative impact on the quality of care delivered to critically ill patients, as shown by the occurrence and outcome of incidents related to such inexperience Errors are more likely to occur when inexperienced staff is combined with staff shortage, inadequate supervision and high unit activity”.

Secondly, novice nurses don’t have effective communication skills. They did not have worked individually in hospital setup, so their Interpersonal skills are not well developed. They face many problems while communicating with other health care workers, patients and their families properly. According to the critical care nurse “Physicians demand information, co-workers are stressed, families are frightened, and patients feel helpless. Therefore, it is essential for the nurse to practice strong interpersonal dynamics both verbally and nonverbally and to stimulate optimistic health team communications” this lack of impersonal skill decrease nurse’s involvement in patient’s care. Moreover, they are very new so, they try to discuss patients more for their learning purpose and this will break patient’s confidentiality and privacy.

Thirdly, critical care nurses should be competent and manage their work on time. On the other hand novice nurse need much time for a simple task, because of that they get overwhelmed even with very few tasks. Due to workload they get confused, and become anxious, and get frustrated easily and unable to manage their work on time which increases chances of error. Sometime these errors can become sentinel and can put the patient’s life in danger. Furthermore, they have lack of self-confidence due to new working environment. It’s better to first assign them in ward setup to bring competence and build confidence in them. According to Proulx & Bourcier (2008) “Graduate nurses are often overwhelmed with the multiple roles and tasks required in caring for critical care patients. The preceptors at Catholic Medical Center, Manchester, New Hampshire, identified a major concern with graduate nurses: too much time was required for the new nurses to become proficient at completing basic critical care tasks.” I have observed that due to some reasons like increasing nursing workload, and high nursing turnover, absenteeism rates and staff shortages or not having senior staff we assign novice nurses in critical area. Moreover, due to lack of experience and skills practices they cannot make proper decisions, and are unable to manage patients which increase the patient stay in hospital.

According to Morrison et al. (2001) “Nurses in intensive care are continually challenged with monitoring patients, making decisions and responding in a timely manner to make changes in patient condition. The nurse’s ability to make accurate clinical judgments is crucial”. However, inexperienced nurses may be unprepared for the demands of intensive care nursing, requiring extra support and supervision.”

We can take the example of our hospital; our management has taken the decision they don’t hire the novice nurses in critical care area.

Yes, this is very right that novice has lack of experience, not competent, and don’t have communication skills, but they can work in critical care area, for the reason that they are fresh graduates, subsequently can bring new changes with their new knowledge as they are up to date with new information and strategies to management patient . Work in critical care area is very important for their growth, professional development, and their learning. Furthermore, Skills and knowledge come with experience, and experience also make person competent and confidence. They should be allowed to work in critical care areas. In addition, hospital should arrange the sessions and learning programs for them to make them more competent. Unit management needs to assign novice nurse in critical area with an experienced staff for training and make that staff more competent and aware about environment. According to Ihlenfeld (2005) “To provide new graduates with the education and experience that they need to independently practice in critical care, mentors are recommended to be assigned to new nurses. These role models help the graduate nurse to grow into the critical care role.” When I was working as a staff, in our unit we used to assign novice nurse with senior expert staff for six to eight weeks to train them, before assigning them permanently and individually.

This is true that knowledge competency and confidence come with experience. It is necessary for novice professional growth, but we cannot let to put the patient’s life in danger for one person’s learning. We can teach them initially in general wards. They can first get experience in ward setup and then can be transferred to critical care areas. Since they have lack of communication abilities consequently, they cannot communicate effectively with patient, and which hinders repo building between nurses and patient hence cannot help patients. Experienced staff can perform these tasks very accurately.

All in all Novice nurse should not be allowed to work in critical care area, because they have lack of experience, don’t have communication skills, are not competent to work in critical care area and help patients to cope with this uncertain situation. Lastly, I would recommend that they should be first assign in general wards for their professional growth, skill practices, and to increase the knowledge.

Proulx, D. M., & Bourcier, B. J. (2013). GraduateNurses in the Intensive Care Unit: An Orientation Model.