INTRODUCTION

Stroke is a “rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (Aho K Harmsen 1980). Stroke is a disease of developed nation and it’s the third leading cause of death and long term disability all over the world with an incidence rate of 10 million per year (Sudlow and Warlow 1996). Stroke occurs at any age but it is more common in elderly between 55 to 85 years of age (Boudewejn Kollen and Gert Kwakkel 2006).

Stroke is classified into two types based on the pathology and cause, Ischemic stroke, occurs when the blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. The ischemia results when there is Thrombosis, Embolism, Systemic hypoperfusion and venous thrombosis. Hemorrhagic stroke occurs when there is accumulation of blood anywhere within the skull vault. These hemorrhage results when there is microaneurism, arterio venous malformation and inflammatory vasculitis (Capildeo and Habermann 1977).

Normal cerebral blood flow is approximately 50 to 60 ml/100g/ Minutes and varies in different parts of the brain. When there is ischemia, the cerebral auto-regulatory mechanism will compensate for the reduction in the cerebral blood flow by local vasodilatation and increase the extraction of oxygen and glucose from the blood. When the Cerebral Blood Flow is reduced to below 20 ml/100g/min, an electrical silence occurs and synaptic activity is greatly diminished in an attempt to preserve energy stored. Cerebral blood flow of less than 10ml/100g/min results in irreversible neuronal injury. These neuronal injuries occurs when there is formation of microscopic thrombi, these microscopic thrombi are triggered by ischemia induced activation of destructive vasoactive enzymes that are released by endothelium, platelets and neuronal cells. These result in the development of hypoxic ischemic neuronal injury which is primarily induced by overreaction of some neurotransmitters like glutamate and aspirate. Within an hour of hypoxic-ischemic insult there will be ischemiec penumbra where auto- regulation is ineffective. This stage of ischemia is called window of opportunity, where the neurological deficit created by ischemia can be partly or completely reversed. After this stage is a stage of neuronal death, in which the deficit is irreversible (Heros 1994).

Functional restrictions resulting from stroke are paralysis of upper limb & lower limb function, cognitive deficit, visual disturbances, disturbance of gait and mobility, spasticity of muscle, loss of co-ordination and speech problems. The loss of upper extremity control is common after stroke with 88% of survivors having some level of upper extremity dysfunction. Basic Activities of Daily Living (ADL) skills are compromised in acute stroke, with 67% to 88% of patients demonstrating partial or complete independence (Amit Kumar Mandall 2009). Muscle weakness, or the inability to generate normal levels of force, has clinically been recognized as one of the limiting factors in the motor rehabilitation of patients with stroke. Following stroke, some patients lose independent control over select muscle groups, resulting in coupled joint movements that are often inappropriate for the desired task. These coupled movements are known as synergies and, for the upper limb flexor synergy: shoulder flexion, adduction, internal rotation, elbow flexion, wrist flexion and finger flexion. Upper limb extensor synergy: shoulder, elbow, wrist and finger extension.

The rehabilitation of upper extremity is quite challenging. Many therapeutic approaches are currently available in the rehabilitation of upper extremity function. Most commonly used treatment approaches are ROODs approach, Sensory motor approach, PNF, Brunnstroms movement therapy, Bobaths technique and neuro developmental therapy. In this Proprioceptive Neuromuscular Facilitation (PNF) is widely used in the rehabilitation of upper extremity function in stroke patients. (Amit Kumar Mandall 2009).

PNF is a therapeutic intervention used in rehabilitation which was originally developed to facilitate performance in patients with movement deficits. PNF exercises are based on the stretch reflex which is caused by stimulation of the Golgi tendon and muscle spindles. This stimulation results in impulses being sent to the brain, which leads to the contraction and relaxation of muscles. When a body part is injured, there is a delay in the stimulation of the muscle spindles and Golgi tendons resulting in weakness of the muscle. PNF exercises help to re-educate the motor units which are lost due to the injury. A variety of methods fall under the rubric of PNF, including the exploitation of postural reflexes, the use of gravity to facilitate movement in weak muscles, the use of eccentric contractions to facilitate agonist muscle activity, hold relax, contract relax, rhythmic stabilization, rhythmic initiation and the use of diagonal movement patterns to facilitate the activation of bi-articular muscles (Etnyre & Abraham L D, 1987; Hardy & Jones, 1986 Osternig, Robertson, Troxel, & Hansen, 1987).

Tomasz Wolny, Edward Saulicz and RafaÅ‚ Gnat in 2009 conducted a randomized control study on the efficacy of proprioceptive neuro-muscular facilitation in rehabilitation for activities of daily living in late post-stroke patients. In this study sixty four stroke patients were recruited from the neurological rehabilitation centre Subjects for this study were recruited based on some inclusion criteria. The patients with loss of sphincter control, loss of mobility, locomotion and communication were included in this study and patients with grade 5 or 6 ‘Repty’ Functional lndex scale were included in this study. After the recruitment of patients, all the 64 patients were randomly divided into two groups, group A (control group) and group B (experimental group). Group A will receive conventional treatment like strengthening, gait training etc. Group B will receive PNF based exercise. A pre and post assessment of the functional status of the stroke patients was done using ‘Repty’ Functional lndex scale. The treatment will be continued for 21 days for both the groups in the neurological rehabilitation centre. . The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. ANOVA was used to compare the average changes among the two groups. The result of this study showed that PNF-based rehabilitation exercise of late post-stroke patients significantly improved in their ADL functional performance and in locomotion when compared to the control group treated with conventional therapy.

Kuniyoshi Shimura.A, Tatsuya Kasai. B in 2002 conducted a study on Effects of proprioceptive neuromuscular facilitation on the initiation of voluntary movement and motor evoked potentials in upper limb muscles activity. In this study author investigated the effect of PNF limb positions and neutral limb positions on the initiation of voluntary limb movement and motor evoked potentials in upper limb muscles. In this experimental study the patients were divided into two groups, in experimental group 1 they investigated the effectiveness of PNF by considering the effects of limb position changes on the initiation of voluntary movement in terms of electromyographic reaction times. In experimental group 2 they investigated the effectiveness of no (neutral limb position) movement by considering the effect of limb position changes on the initiation of voluntary movement with electromyographic reaction times. After signing the consent the experiment was conducted on the patients. Two upper arm positions used in this study, a neutral position (N) and a position facilitating activity of the upper extensor muscles (PNF). The effects of these positions are observed in the EMG. The subject could passively adopt the two upper arm positions using his right (affected) arm by means of especially made arm holders. For each arm position, six blocks of 10 trials were performed. All trials of the first

block and the first trial of each of the following blocks were excluded from the analysis to eliminate start-up effects. In addition, a few trials were discarded because of obvious mistakes in the recording. EMGs were recorded simultaneously from three muscles (Brachioradialis, triceps brachii and deltoid) using 3 cm diameter, bipolar, silver surface electrodes connected to an EMG-unit.

The result of this study showed that the EMG discharge order differed between the two positions. PNF position improves movement efficiency of the joint by inducing changes in the sequence in which the muscles are activated. Hence PNF has an effective role in the initiation of voluntary movement and motor evoked potential in upper limb muscle activity.

Pamela Duncan and Lorie Richards et al., in 1998 conducted a study on the effect of Home-Based Exercise Program for Individuals with Mild and Moderate Stroke. In this randomized controlled pilot study, 20 individuals with mild to moderate stroke who had completed acute rehabilitation program and those who were 30 to 90 days after onset of stroke were randomized to a 12-week (first 8-week will be therapist-supervised program and the next 4-week will be independent program) rehabilitation program. After signing the consent form, patients were selected based on some inclusion criteria like (1) 30 to 90 days after stroke; (2) minimal or moderately impaired sensorimotor function (3) ambulatory with supervision and/or assistive device; (4) living at home; and (5) living within 50 miles of the University. The exclusion criteria for this study are (1) a medical condition that interfered with outcome assessments or limited participation in sub maximal exercise program, (2) a Mini-Mental State score <18 and (3) receptive aphasia that interfered with the ability to follow a 3-step command.

The participants for this study were selected and evaluated by a therapist based on the inclusion and exclusion criteria. If the subjects agreed to participate in this study, then the basic assessment is done after getting the informed consent. The severity of the stroke were assessed using Orpington Prognostic Scale (Sue-Min Lai and Pamela W. Duncan 1998) and Fugl-Meyer Motor Score (Pamela W Duncan 1982) that includes assessment of motor function of the arm, upper extremity proprioception, coordination, balance, and 10 cognitive questions. The functional assessments are performed using Barthel Index Activities of Daily Living (Fricke and Unsworth 1997) Lawton Instrumental Activities of Daily Living and Medical Outcomes Study-36 Health Status Measurement (Colleen and John 1992).

Functional assessments of balance and gait of the participants were assessed using 10-Meter Walk, 6-Minute Walk (Kosak and Smith 2005) and Berg Balance Scale (Berg, Wood-Dauphinee and Williams 1995). Upper extremity hand function was evaluated with the Jebsen Test of Hand Function.The Jebsen is a standardized assessment to measure the time taken to perform hand activities. These includes: writing a short sentence, turning over 3×5 cards, picking up small objects, stacking checkers, simulated eating, moving empty large cans, and moving weighted cans(Jebsen, Taylor, Trieschmann 1969).

After baseline assessment the subjects were randomly assigned into two groups, experimental group and control group. In experimental groups the PNF exercise were taught to the patients on day one as an home exercise and they were asked to continue the same exercise as an home program for eight weeks with three visits to the physical therapy department every week. The exercise includes assistive and resistive exercises using Proprioceptive Neuromuscular Facilitation Patterns and Theraband exercise to the major muscle groups of the upper and lower extremities. Subjects in the control group received usual care as prescribed by the physicians. The subjects of this group were assessed by the research assistant.

The demographic data of both the groups were statistically compared using Wilcoxon rank sum tests. The results of this study showed that there is no difference in the pre and post exercise treatment. There is no change in the upper extremity function and the functional health status in both the experimental group as well as in control group after the treatment interventions.

Ruth Dickstein, Shraga Hochman, Thomas Pillar, and Rachel Shaham in 1992 conducted a study on Stroke Rehabilitation with Three Exercise Therapy Approaches. One hundred and ninety-six hemiplegic patients were randomly selected for this study. All subjects were referred to the physical therapy department of a geriatric-rehabilitation hospital over a period of 18 months were admitted to the study. All patients had a recent cerebrovascular accident and came for a rehabilitation program after an average stay of 16 days in a general hospital. Sex distribution was equal with a mean age of 70.5 years. Thirteen physiotherapists were enrolled in the study for exercise administration and the subjects were assigned randomly to each therapist. The data were collected in a separate form, which has two parts; first part was used to collect the basic information like age, gender, side affected and location of the damaged artery. The second part was used to record the variable data. Each therapist treated their first five patients with conventional method, next five with PNF method and the last five with Bobath method. All patients were treated for five days a week for six weeks, and each treatment sessions were last for 30 to 45 minutes.

The outcomes of each patient are measured before the treatment and every week thereafter. The functional independence is measured with Barthal index. Muscle tone of the involved extremities

was checked by passive movements of the extremities with the patients in supine position. Muscle tone was graded using an ordinal scale composed of five points: a) flaccid, b) low, c) normal, d) high, and e) spastic. Ambulatory status of the patient was assessed and classified with a nominal four category scale: a) patient does not walk, b) patient walks with an assistive device and person’s help, c) patient walks with an assistive device, and d) patient walks independently. The treatment was continued for 6weeks in both the groups. The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. The Kruskal-Wallis one-way analysis of variance (ANOVA) was used to compare the average changes among the three groups.

The results of this study showed that there is no significant difference in the improvement of activities of daily living and in the walking ability. But there is significant difference in the improvement of muscle tone in PNF group and in Bobath group when compared to the conventional treatment group.

CONCLUSION:

The poor quality of the trials reviewed severely limits the conclusions that can be drawn. However, it seems that currently there is no evidence, that interventions based on the Proprioceptive Neuro-muscular Facilitation (PNF) are more effective than other approaches. One Study done by Ruth Dickstein on PNF vs. Bobath concluded that PNF exercise given in conjunction with Bobath technique are more effective in improving wrist strength and upper limb function than giving PNF alone. But the outcomes used in these studies are ordinal rating scales, which may not be sensitive enough to differentiate the effect of the two techniques. The number of subjects recruited for these studies is very less. We cannot come to conclusion on the effect of PNF in upper limb function with these less number of studies.

Stroke patients may vary widely on factors such as physical impairments, speech impairments, severity of impairments, cognitive impairments, and also in the individual personality and learning styles. So, we cannot assume that this PNF technique is superior to all other techniques, because we cannot say this technique can be used in individuals with stroke and at every stage of recovery. For example one approach may be effective in initial stage of stroke, but the same approach may not be effective for chronic stroke patients. Factors such as depression, spatial awareness, cognition, comprehension and sensory loss could also have an impact on the response of a technique.

In most of the studies there is no exact clinical finding about the problem, size of lesion and the site of lesion. Characteristics of the lesion may explain the variability in responsiveness to the intervention. There is no ideal timing of the interventions, whether the technique should be given in the initial stage or late stage of stroke.

In this review on the effect of PNF in upper limb function in stroke, evidence on the current practice is lacking. Because of the lack of evidence on current practice it is very difficult to make a conclusion. Evidence of support and treatment used in these articles is not standard to use in today’s health care practice. It is suggested that further studies comparing the effect of PNF with other approaches using sensitive, reliable outcome measures and with homogenous sample size should be done. Therefore it is important that future studies clarify the analysis and interventions used within the PNF technique to enable accurate evaluation of the study. No studies on this review assessed the efficacy and the effectiveness adequately, so further studies should be done to get an effective and optimal approach in the rehabilitation of upper limb function in stroke patients.

Introduction

The purpose of this study is to discuss why nurses should show sympathy for NHS partnerships and values. It also explains how nurses ensure that people care and sympathize by establishing therapeutic relationships with patient care users. As a nurse, why it is necessary to consider the legal and ethical issues related to compassionate care, please do not start work until the client notifies (Boyle, 2011). Sympathy is an important part of caring. In addition, nurses are required to show compassion, lack of presence can encourage patients to feel depressed and sick from enthusiasm. Despite the fact that the media are considering it, fundamental research on patient experiences and compassionate practices and achievements in the field of care is still difficult to obtain (Smith, Dewar, Pullin, and Tocher 2010).

Discussion

Compassion is described in this exam, because the nurse cares about the patient as a person and is approaching their touch in a balanced relationship. It is difficult to calm and leave a few minutes in single patients. There is also a nurse attitude. In particular, this particular event, corresponding to their needs, and the necessary part of being sympathetic to the patient, can be ignored or not considered by the other party (Jarrell et al., 2014).

The introduction of patient experience, patient information, and empowerment of patients to maintain their autonomy was described as moral moderation, reported ethical care measures, and what nurses simply expect to do (Firth and Cornwell, 2009). Scientist Watson called these moral humanitarian exchanges “care arrangements / care time”, which is a major part of her withdrawal hypothesis. These results also found what Watson calls “excellent special areas” that rely entirely on one nurse and patient experience (Burnell & Agan, 2013) compared to the male reference system.

Task A: As A Nurse Why Is It Important To Ensure Compassionate Care In Nursing In Relation To Partnership And The NHS Values

Compassion is an institution that establishes interpersonal relationships and promotes physical and mental health. In Great Britain, the importance of compassion in care is reflected in various advanced medical reports, and nurses believe that nurses should provide compassionate care to patients. In any case, a global focus is growing, and despite the growing potential and level of development of the healthcare system, there is disappointment and compassion at the central level (Cornwell & Goodrich, 2009).

It is necessary to consider and evaluate how sympathy becomes the main concern within the group, and attention to a culture of compassion should be expanded at all levels of nurse leadership, training and registration (Dewar et al., 2010). Planning and implementation of the guidance system is to solve the complexity of providing compassionate care that is necessary. Despite this, the practice of promoting and implementing evidence base can be a cumbersome task, especially in the absence of such confirmation, and when different evidence extends to validation (Dewar et al., 2014).

Ask if there is sympathy for care, especially patient attention (Dewar et al., 2010). This article is based on studying the patient’s experience in compassion in care and understanding how they see the apparent lack of compassion in nursing. The implications of this survey were proposed for outline education and compassionate teaching aids to illustrate the practice of demonstrating the capabilities of physicians in the UK at the University of the National Health Service (NHS).

Task B: When Forming A Therapeutic Relationship With Your Patients Service Users How Would The Nurse Ensure That People Are Treated With Care And Compassion

Compassion is an intricate miracle that is difficult to portray. So far, there has been very little confirmation of the entire definition, and many of the descriptions of the work mentioned in the writing are full of Aristotle’s suffering and kindness, as described Dewar et al., (2010)deeply aware of the pain of another person, but also hope to reduce the suffering of others.

Although this is useful, the definition itself does not fully use the terminology in care. For example, words such as compassion, sensitivity and care often use mutual sympathy. Although nurses are certainly not the pain of outsiders, compassionate care is not only a calming pain, but also getting into patients, and giving them freedom and pride (Dewar et al., 2014).

This part of compassion was portrayed as moral superiority, something that nurses can easily foresee. It also talks about the moral dimension of moral concern and is described as the essence of care, the essence of care in this way. Perhaps the most effective definition comes from Dewar’s speech (2014) at the 2010 International Conference at the Royal College of Nursing (RCN):

… We agree with how people are. It can be maintained and maintained. This includes the observation of the helplessness of people, met with a warm response to it and acting on them in some way, which is important for a person. It is characterized by the fact that the population gives and acquires it, so the process of seizing relations between the populations is an important part of its progress.

This definition follows from the work between NHS Lothian and Napier University and, apparently, reflects the essence of charity, as it is experienced by single patients and nurses. This definition recognizes complex concepts of compassion and helps us remember their subjectivity in health care from the point of view of nursing and the patient.

In the UK, this type of measurement of humane care has significantly improved in health care. Rankin (2013) called for the care of all patients in the next phase of the NHS audit, treating all patients with balance, compassion and respect. The Prime Minister’s Committee sympathetically takes care of its report, and recently the British and the Director of the Welsh Nursing Affairs distributed “compassion in practice”, and compassion is an integral part of her caring vision (Bramley & Matiti, 2014).

However, in terms of the complexity of coordination, the Patients Association specifies the experience of patients with insufficient basic services, and the Health Protection and Compassion Report of the Health Ombudsman describes the unsatisfactory truth in health care (Mills, Wand & Fraser, 2015). These problems have recently been mentioned in the famous report of Francis, which causes compassionate concern for a larger topic. These records show photographs of the NHS, ignoring the sympathetic response to the needs of patients (Adam & Taylor, 2014).

In order to strengthen the practice of nursing, it is important to distinguish the compassion of patients. Understanding the patient’s perception of compassion will greatly contribute to compassionate care in practice. The current work recognized the need for clear reports from the patient’s perspective and calls for assistance in surveillance research to express compassionate and compassionate help (Dewar & Nolan, 2013). After studying the patient’s perception of the characteristics of compassionate nurses, it is believed that additional research will help to better our understanding on how to become a compassionate nurse.

Task C: As A Nurse Why Is It Important To Consider Legal And Ethical Issues In Relation To Compassionate Care.

Initially, enforcement mechanisms were often abolished to prevent harmful behaviour, rather than demand good behaviour (Rankin, 2013). To put it bluntly, the main goal of the law is not to let us become fallen angels, and not make us blessed ambassadors. The Tort law does not expect that we will meet the most famous standards – just a reasonable personal standard. The criminal law (in general) does not imply that we help the needy, and do not hurt people. Thus, the law does not cause curiosity unless it is proved that a person who does not sympathise, causes pain to the patient. Secondly, the law mainly revolves around issues that are easily identified. That is, to a limited extent, why “evil considerations” are not illegal by nature (Wiklund & Wagner, 2013). In legislation, there is no need to try to control specific behaviour, because it is not protected for evidence. Simply put, the court will not make it clear whether the nurse will treat the patient with sympathy. Third, regardless of whether the aforementioned priorities can be achieved, we still have the problem that the idea of ​​empathy is mostly too vague, which makes it impossible to fulfil the need for legal control (Burnell, 2009). As for the expectations of the law that people will take special actions, at the moment the subject has the right to know in advance what the law expects from them. The trouble is that the idea of ​​compassion does not have clear characteristics to give the exact direction. It is released in two different ways (Astbury, 2008). First, the very concept of empathy can lead to a wide range of discussions, and there is no reasonable consensus. Secondly, compassionate people will depend on whether the person is governed. To give a direct explanation, it can be compassionate if the nurse presents to the patient an exciting statement that does not cause sympathy for the treatment of the private patient and does not want to test enthusiasm. Heart method (Burnell, 2009). This expands the problem when artists realize the expectations of the law in their specific circumstances.

Morality respects the standards of good judgment and professional conduct. A nurse has a great responsibility for the patient, the person, the manager and the whole call. They are basically able to understand the various ethical, legal and professional issues they face in their careers. For all patients, nurses have three main obligations, namely, autonomy, confidentiality and care obligations (Astbury, 2008). These obligations are complemented by dominance criteria, which means promotion or prosperity, as well as providing the greatest benefit and non-anger to the patient, which means maintaining a strategic distance from injury. If in practice any laws or policies are violated, these are professional obligations to fulfil legal obligations. In 2001, the inspection found that after the expansion of court cases and disclosure requirements, it was clear that additional recommendations on ethical dilemmas in the calls for health (Rankin, 2013) were needed.

Subsequently, various committees for clinical ethics (CEC) and ethics committees (RECs) were established in the UK to achieve far-reaching ethical support. Constant change in health and the conduct of scientific and social values ​​mean that therapists must understand the new ethical issues in the field of recovery and find out how to respond correctly (Bramley & Matiti, 2014).

Conclusion

The survey shows that patients believe that compassion must be firmly adapted to a broader mind-set of providing assistance in nursing practice. Although this study recognizes that empathy requires the expert to have some serious energy and responsibility, it also has the importance of a short-term component that creates a compassionate relationship between the guardian and the patient (Brumley & Matiotti, 2014). The demand for a nurse’s ability is often considered an obstacle to compassion in a relationship. The data presented here is complex and reminds us that as a nurse the smallest transaction can deliver compassionate activity.

Compassion in caring is still seen as a moral ideal, what nurses simply expect to do, and described as the essence of care, in this respect, are the concerns. The possibility that nurses can be encouraged to compassion is a hostile problem, regardless of the conclusions between the members of the exam, and the current reports of Dewar and Nolan (2013) indicate the need for care. This division of assessment is particularly important for crusades conducted by the chief care officer in the UK, suggests that there is some work to convince the general population that the attitude of caregivers to care can change or progress. In addition, patients admit that there is little change in the place where the healing centre and ward association manage the individual behaviour of employees.

In most cases, guardians increasingly understand the impact of unsympathetic activities, and most people feel the opportunity to change personal and social practices. Although, calls for nursing work are aimed at increasing the importance of compassion, without any changes, this may not improve the overall experience of patients, thereby increasing the importance of sympathetic culture throughout the health association.

References

• Adam, D. and Taylor, R., 2014. Compassionate care: Empowering students through nurse education.
  
  Nurse Education Today
  
  ,
  
  34
  
  (9), pp.1242-1245.
• Astbury G. 2008. Communication. In: Mason T, editor; Mason-Whitehead EBA, editor.
  
  Key Concepts in Nursing. Los Angeles,
  
  CA: Sage; pp. 62–68.
• Boyle, D.A., 2011. Countering compassion fatigue: A requisite nursing agenda.
  
  Online J Issues Nurs
  
  ,
  
  16
  
  (1).
• Bramley, L. and Matiti, M., 2014. How does it really feel to be in my shoes? Patients’ experiences of compassion within nursing care and their perceptions of developing compassionate nurses.
  
  Journal of clinical nursing
  
  ,
  
  23
  
  (19-20), pp.2790-2799.
• Burnell L. 2009;
  
  Compassionate care: a concept analysis.
  
  Home Health Care Management & Practice. 21:319–324.
• Burnell, L. and Agan, D.L., 2013. Compassionate care: Can it be defined and measured? The development of the Compassionate Care Assessment Tool.
  
  International Journal of Caring Sciences
  
  ,
  
  6
  
  (2), pp.180-187.
• Cornwell, J. and Goodrich, J., 2009. Exploring how to ensure compassionate care in hospital to improve patient experience.
  
  Nursing Times
  
  ,
  
  105
  
  (15), pp.14-16.
• Dewar, B. and Nolan, M., 2013. Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting.
  
  International Journal of Nursing Studies
  
  ,
  
  50
  
  (9), pp.1247-1258.
• Dewar, B., Adamson, E., Smith, S., Surfleet, J. and King, L., 2014. Clarifying misconceptions about compassionate care.
  
  Journal of Advanced Nursing
  
  ,
  
  70
  
  (8), pp.1738-1747.
• Dewar, B., Mackay, R., Smith, S., Pullin, S. and Tocher, R., 2010. Use of emotional touchpoints as a method of tapping into the experience of receiving compassionate care in a hospital setting.
  
  Journal of Research in Nursing
  
  ,
  
  15
  
  (1), pp.29-41.
• Firth-Cozens, J. and Cornwell, J., 2009. Enabling compassionate care in acute hospital settings.
  
  London: The King’s Fund
  
  .
• Jarrell, K., Ozymy, J., Gallagher, J., Hagler, D., Corral, C. and Hagler, A., 2014. Constructing the foundations for compassionate care: How service-learning affects nursing students’ attitudes towards the poor.
  
  Nurse education in practice
  
  ,
  
  14
  
  (3), pp.299-303.
• Lown, B.A., Rosen, J. and Marttila, J., 2011. An agenda for improving compassionate care: a survey shows about half of patients say such care is missing.
  
  Health Affairs
  
  ,
  
  30
  
  (9), pp.1772-1778.
• Mills, J., Wand, T. and Fraser, J.A., 2015. On self-compassion and self-care in nursing: Selfish or essential for compassionate care?.
  
  International journal of nursing studies
  
  ,
  
  52
  
  (4), pp.791-793.
• Rankin, B., 2013. Emotional intelligence: enhancing values‐based practice and compassionate care in nursing.
  
  Journal of advanced nursing
  
  ,
  
  69
  
  (12), pp.2717-2725.
• Smith, S., Dewar, B., Pullin, S. and Tocher, R., 2010. Relationship centred outcomes focused on compassionate care for older people within in‐patient care settings.
  
  International Journal of Older People Nursing
  
  ,
  
  5
  
  (2), pp.128-136.
• Wiklund Gustin, L. and Wagner, L., 2013. The butterfly effect of caring–clinical nursing teachers’ understanding of self‐compassion as a source to compassionate care.
  
  Scandinavian Journal of Caring Sciences
  
  ,
  
  27
  
  (1), pp.175-183.

Evidence based practice is a buzzword that appeared in healthcare settings in last decade. Pressure from government agencies on healthcare providers to deliver excellent clinical practice increases importance in implementation of evidence based practice. In order to sustain effective outcome in rehabilitation, is essential for clinician to manifest evidence-based practice into clinical made decision. The aim of essay is to define evidence based practice (EBP) and implementation of paradigm, EBP into occupational therapy process in Peter’s case. In order to understand Peter’s case paper draws information about his condition, multiple sclerosis (MS). Essay will explore evidence-based practice through range of researches in occupational therapy (OT) intervention, identifying possible benefits for Peter’s well-being.

Evidence-based practice is one of most debatable process of last few decades. EBP developed and arouse from evidence-based medicine defined by Professor David Sackett and other scholars, as an attempt to find best evidence to assist healthcare professionals with making best decisions for patients (Bailey et al, 2007). EBP is process where gathered best available evidence and clinical expertise assists clinical decision-making. Decision process is understandable for client, justifiable to other healthcare professionals, where gathered evidence (through research process) allows clinician to assess current practice. Collaboration between patient satisfaction, clinical judgment, and up to date information throve EBP to become powerful toll to underpin clinical intervention (Taylor, 2000). Definition of EBP is based on best evidence, clinical expertise, patient values, and circumstances where clinician takes under consideration all those elements in practice settings. Clinician is expected in EBP process to apply criticism, educational skills and to recognise system of values meaningful for client (Hoffman et al, 2009). When applying evidence into intervention clinician is proved to use skills upon which he or she could judge and recognise best evidence for practice. Hierarchy of evidence to recognise best evidence to underpin intervention guides clinician (Taylor, 2000). Author as the strongest and most valid elevates systematic reviews and meta-analyses from all, through which clinician has access to publish and unpublished evidence. Taylor (2000) recognises ‘gold standard’ evidence in randomize control trials (RTC); they are to be considered by healthcare professionals as effective in intervention. Limited credibility is given to non-experimental studies, non-randomized trials, opinions or experts discussion where level of validity is low.

EBP takes form of several steps to address information to relevant intervention: asking the question, searching for evidence, critically appraising evidence, collaborate evidence with clinical expertise and client personal values and finally evaluate. The form of question could determine information about certain patient. Clinical question includes several components: P – patient and/or problem, I – intervention, C – comparative intervention (optional, include if relevant), O – outcome (PICO). For example, in Peter’s case clinician through formulated clinical question determines valid information about him: P -middle age male with multiple sclerosis, I – occupational therapy, C- physiotherapy, vocational therapy and O- benefit in patient well being (Hoffmann et al, 2009). Evidence research for PICO is a next step for clinician. Valid information gathered through steps of EBP process needs reliable source, where materials and references are found. Key aspect of EBP is for clinician to have access to books, journals, conferences, RCT, systematic reviews, and databases. Clinician is aided by nowadays technology in journey to find best evidence; allied tool is internet where most of databases are placed. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE, The Cochrane Database, and OTseeker are databases that assist and guide evidence based therapist to develop sufficient and explicit evidence in clinical intervention (Hoffmann et al, 2009).

Best evidence is determined by evidence-based clinician on validity of evidence through hierarchy of research (Lin et al, 2010). Critical appraisal of evidence clinician bases on RCT, where RCT could be best choice to underpin treatment options. EBP process is tailored to patient’s needs and beliefs, so client could feel empowered and included in rehabilitation process. For example, in Peter’s case client-centred occupational therapist would concentrate on Peter’s priorities, which are employment and his knowledge about MS. Although clinician in rehabilitation process manifests EBP, implementation of EBP could be a challenge for both parties (Lin et al, 2010). Process can be time consuming due to large amount of researches available. High demand to understand researches for both parties is seen as an obstacle. Therapist could have limited knowledge to conduct particular research or lack of understanding patient’s goals. However evidence based therapist could seek help from current employer in ongoing training, communicate arouse issues with other health professionals and client or collaborate to conduct small group evidence based project (Lin et al, 2010).

Peter diagnosis is relapsing- remitting form of multiple sclerosis. According to National Institute for Clinical Excellence (NICE, 2004) multiple sclerosis is chronic, progressive disease of the central nervous system, which affects young and middle-aged adults. MS causes damage to myelin, which is fatty substance surrounds the brain and spinal cord. Scare tissues within the brain or spinal cord replace myelin. Damage leads to disruption in ability of nerves to conduct electrical impulses. Individuals affected by MS experience functional loss, including weakness, fatigue, spasticity and impairments of cognition, vision, speech, swallowing, bowel, and bladder function. MS occurs with an episode from which individual recover full, after that, disease develops in certain form. NICE (2004) statistics shows that 80% individuals with MS are diagnosed with relapsing- remitting form of disease. Relapsing – remitting disease occurs when patients experience relapse, which can last from 1 day to several months. Relapse occurs in loss of mobility, loss in function of bladder, loss of vision, general paralysis of the voluntary muscles. There is no progression between relapses.

Multiple sclerosis is long-term condition with complex problems, which requires wide range of healthcare professions input: nurses, doctors, physicians, occupational therapists and many more. At the present, there is no cure for disease (NICE, 2004).

Turning now to discuss evidence-based practice occupational therapy interventions, which could be beneficial for Peter.

Peter expresses symptoms of anxiety, he does not know much about his condition, he developed negative stereotype of doctor due to insufficient amount of information about his illness.

Evidence based practitioner could build therapeutic relationship with Peter, for example by effective communicated information about his condition. Evidence based therapist would inform patient about his condition appropriate to his knowledge abilities. Ongoing support, access to information and advice on treatment could have positive influence on patient experience during rehabilitation process (Köpke et al, 2010). Köpke et al (2010) protocol highlights sufficient and adequate information through different channels (leaflets, internet and education programs) allows patient to understand illness, to develop management strategies and to avoid unrealistic expectation from rehabilitation process. Occupational therapist could develop collaborative relationship with Peter through engagement in making decisions, medical interventions, and new technological aids tailored to individual needs. For example, information process is tailored and designed for Peter’s level of understanding, Consequently Peter’s main expectations are reassured by occupational therapist – to be included in rehabilitation process, fell heard and understood. Furthermore, patient can understand complexity of disease has choice in various treatment options and feels empowered (Reynolds, 2005).

MS has impact on many areas on people life, where employment status concern individuals, many may struggle to remain in work role. Sweetland et al (2007) undertook study, where participants were tape recorded to show expectations and implications for patients with MS in vocational market. Paper demonstrated demand in MS workforce population access to vocational rehabilitation, support performance in work place, management of anxiety and fear from discrimination. Peter well-being is influenced by fear, uncertainty about employment status, insufficient money income, and deteriorating health condition. Define employment legislation to patient and employment rights, as a disable person and provide vocational support (Disability Employment Advisers and the Access to Work Scheme), could guide Peter to understand his status in work field (Sweetland et al, 2007). Evidence based practitioner could introduce Peter to legislation act. For example, Disability Discrimination Act (1995) could show Peter his rights as an employee. Information about eligibility to social benefits allows service user to feel reassured about financial aspect of life (Johnson et al, 2004). To help in employment service occupational therapist could liaise with Job Centre and local government authorities (council) to achieve financial grant for adaptation in work environment according to progression of illness. However, therapist has to be mindful about patient condition at work. Peter complains about fatigue (overwhelming tiredness) and muscle spasm. Peter is a forklift truck driver, remain in same working environment could put on risk himself and others. MS exposes individuals to risk of injury because fatigue could lead to nausea, disorientation, and loss of balance. Ongoing assessment of work conditions is important for individuals to present problems as they arise. Management of fatigue symptoms, support from employer and work colleagues, flexible work schedule, knowledge development about social benefits could have positive impact on employment performance. Informing employer about illness would be important due to health and safety issues, furthermore to set up solutions in working environment. Taking into account Peter’s expectations and needs evidence based practice therapist could develop intervention where Peter could sustain effective employment (Johnson et al, 2004).

Young and middle age adults are affected by Peter’s condition (MS). Various aspects of individual life are affected by illness. Disturbance occurs in education, employment, physical functioning or disability and important to many sexual life. Clinically effective therapist applying intervention in sexual life filed should take sensitive approach. Peter’s condition would have impact on his sexual performance, therefore therapist should concentrate on client-centred approach, adapt actions to fulfil patient needs and expectations. Often patients exhibit needs, but they do not express them, where upon that evidence based therapist should apply observation skills and intuition in rehabilitation process (Reynolds, 2005). Insufficiency in therapeutic understanding of biographical disruptions such as relationship breakdown due to poor or absence of sexual activities can be a barrier between patient and therapist. Effective communication has a significant role in active participation into rehabilitation where issues of sexual dysfunction arise. Although, sexual life is meaningful need of many individuals, embarrassing nature of issue for patient and therapist may influence patient’s adherence to long-term treatment (Reynolds 2005). Evidence based practitioner acknowledges complexity of sexual dysfunction advising patient to seek advice in collaborative services like counselling. In Peter’s case, client- centred therapist through sensitive approach could address problems with erectile dysfunction or is prepared for remark from patient side. Evidence based practitioner could address Peter with pharmacological help (Viagra); offer to see specialist in sexual problems and advice how to use sexual aids or adapt sexual position (NICE, 2004).

Multiple sclerosis is long term neurological condition. According to World Health Organization (WHO, 2008), there is no treatment that can cure MS. Evidence shows that cost of medical treatment can be expensive and it is only limited to slow down progression of disease. WHO document (2008) highlights importance of rehabilitation process in MS. For example evidence, based therapist could draw attention to management strategies for illness. Occupational therapist could show Peter how to manage fatigue through keeping daily diary of activities, regular exercise and implement schedule of brakes between activities. Evidence based therapist could liaise with other healthcare professions to promote client centred approach to MS. Result of collaboration between multidisciplinary team could be beneficial for Peter. For example, evidence-based occupational therapist could collaborate with psychologist, where psychology session could help Peter adjust to, and cope with MS. Finally yet importantly, rehabilitation process could improve quality of his life (WHO, 2008).

This overview of studies is focused on efficiency of occupational therapy for Peter, who suffers from MS. Key aspect for evidence based practice therapist is to enable Peter to remain independent and provide him with achievable goals. Occupational therapy for Peter could have problem-solving approach. Critically evaluating their practice evidence based occupational therapist would create opportunities where Peter could enhance his life quality. Evidence based therapist would seek advice from other health care professions and government agencies, local authorities to promote effective and sustainable employment status. Effective communication between occupational therapy and Peter would build profession relationship, which could be a bridge to engage patient in lifetime rehabilitation journey. Empathic, client centred occupational therapy process would be perceive as allied tool to help Peter to understand his difficult and complex illness. However, occupational therapist would not be able to treat his condition, nevertheless evidence-based occupational therapist could help Peter sustain his independence and enable Peter to regain feeling of ‘normality’.

REFERENCES:

Bailey, D., M., Bornstein, J., & Ryan, S. (2007). A case report of evidence-based practice: From academia to clinic. American Journal of Occupational Therapy, 61(1), 85-91.

Disability Discrimination Act 1995. (1995) London: HMSO

Hoffmann, T., Bennett, S., Del Mar, C. (2009). Evidence-Based Practice Across the Health Care Professions. Australia: Elsevier.

Johnson, K., L., Amtmann, D., Yorkston K., M., Klasner, E., R., Kuehn, C., M. (2004). Medical, Psychological, Social, and Programmatic Barriers to Employment for People with Multiple Sclerosis. Journal of Rehabilitation. [Online] Available at: http://proquest.umi.com/pqdweb?Ver=1&Exp=10-27-2015&FMT=7&DID=577472521&RQT=309&cfc=1 [Accessed 28 October 2010]

Köpke, S., Solari, A., Khan, F., Heesen, C., Giordano, A. (2010). Information provision for persons with multiple sclerosis. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD008757. DOI: 10.1002/14651858.CD008757.

Lin, S., H., Murphy, S., L., Robinson, J., C. (2010). Facilitating Evidence-Based Practice: Process, Strategies, and Resources. The American Journal of Occupational Therapy, 64(1), 164-171.

National Institute for Clinical Excellence and the National Collaborating Centre for Chronic Conditions (2004) Multiple Sclerosis: National clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians.

Reynolds, F. (2005). Communication and Clinical Effectiveness in Rehabilitation. London: Elsevier.

Sweetland, J., Riazi, A., Cano, S., J., Playford, E., D. (2007). Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers. Multiple Sclerosis. [Online]Available at: http://proquest.umi.com/pqdweb?Ver=1&Exp=11-09-2015&FMT=7&DID=1370288031&RQT=309[Accessed on 10 November 2010]

Taylor, M., C. (2000). Evidence- based practice for occupational therapists. Oxford: Blackwell Science.

World Health Organisation (2008). Atlas multiple sclerosis resources in the world 2008. [Online] Available at: http://www.who.int/mental_health/neurology/Atlas_MS_WEB.pdf [Accessed on 28 October 2010]

Student number: 1041133

Discuss the strengths and limitations of the educational leaflet that you developed within a small group during HH1103 seminars.

The aim of this essay is evaluation of educational and communicational material in form of leaflet based on Helen case, who suffers from Juvenile Chronic Arthritis (JCA). Essay draws definition of condition and determines how leaflet is presented and why. Moreover, paper demonstrates leaflet limitations and strengths and how well meets it purpose. The purpose of the leaflet was to inform Helen and her parents, in simple form and manner, about her condition-JCA. Furthermore, leaflet is designed to pass message about available services, form of rehabilitation, and management of JCA.

Leaflet main topic is concentrated around solutions in life style and rehabilitation for 14-year-old girl Helen. Leaflet is designed upon Helen personal experience and her illness JCA. JCA is condition, which affects joints in children, age under 16 years old. One in 1000 children in United Kingdom is affected; in relation to gender, females are impacted more than males. Skin rush, joint swelling, fever, change in mood are symptoms associated with JCA. Rehabilitation process has successful rate in majority cases; it enables individual to preserve normal rate of growth and psychological development (Arthritis Care, 2010).

The leaflet is composed in simple form where colourful scheme would attract Helen’s attention. Choice of the colours is not patronizing, it is modern and does not have significant impact on cost of producing the leaflet (Department of Health, 2003). When it comes to graphics, pictures suggest activities in which Helen could engage and introduce to the rest of the family importance of active lifestyle. For example, picture of the family in swimming pool displayed on the front of the leaflet, illustrates meaning to rehabilitation process. Furthermore, it encourages Helen and her family to participate in activity. Swimming sessions could motivate family to spend quality time together and empower Helen in her illness. The National Health Service (NHS) logo could be discouragement for Helen, making leaflet to official. However, it could be invitation point for her parents, where it could be a source of credibility (Department of Health, 2003).

The font size is readable and information flow through the leaflet. Information is arranged in small intersections to make more understandable for children. It was important to implement bullet points where possible so leaflet draws attention and it is not boring, but has patient friendly-text aspect. Identify source of information is distinguished where it proved leaflet to be honest guide to JCA (Department of Health, 2003).

It was priority to locate information about medical treatment. Helen compliance with medication is insufficient. Information introduced in leaflet could persuade her to follow guidelines from GP related to her medical treatment. There is some evidence, where written information about medication has benefits on patients’ outcomes: like knowledge or compliance (Nicolson et al, 2009). Compliance with medication could be beneficial for Helen by reducing level of pain; subsequently medication would reduce swelling of the joints and enable Helen in active participation in physical form of treatment. The area where leaflet informs patient about medication could be less informative. Information about medications could be to formal for Helen by putting her off. However, leaflet could guide Helen into different source of information (internet or other leaflets), where medication is explained in simple language, and details possible side effects (Nicolson et al, 2009).

It is a challenge to develop leaflet for the patient with low readability and those who expect information that is more specific. Determine whether the leaflet language is comprehensible and suitable for majority of population is based on Reading Ease score (Reynolds, 2005). Language used in leaflet is readable to average 13-14 year old child. Simple and plain language could be easy to remember. Verbal information could be easily forgot or misunderstood during patient consultation session. Written information could hence patient participation in rehabilitation (Dixon-Woods, 2001). Medical jargon is reduced to minimum when explaining JCA. Adequate knowledge about condition explained in plain language could be a form of education. Available treatment options for Helen’s condition could empower her parents in decision-making process (Dixon-Woods, 2001). However, if patients who would like to explore condition in more details, leaflet should provide more adequate information in last section of leaflet.

Overall, concept of the leaflet is good. Leaflet is not only about patient information, but has numerous advice and solutions for Helen and her family. Therefore, it seems sensible that leaflet guides reader to seek advice in additional services. Group could implement few improvements in some areas. Where needed team could concentrate on board public and made it leaflet less official. Moreover, would be beneficial if leaflet explore more about occupational therapy and physiotherapy rehabilitation for Helen. Nevertheless, leaflet achieved it main purpose: to communicate information about Helen’s condition to her and family.