Health Promotion in Adult Nursing: Adult Asthma Case Study

This essay will address how to help a 20 year old asthma sufferer bring to an end his recurrent admissions to hospital because of acute exacerbations in his asthma. Asthma is a common and chronic inflammatory disorder of the airways, associated with marked health and economic consequences. It is estimated that approximately 5.2 million people in the United Kingdom (UK) suffer from asthma, making the condition the most common long term illness in this country. Asthma accounts for 1,400 deaths per annum, with a third of these being among individuals under 65 years of age. Similarly, asthma also accounts for about 69,000 hospital admissions a year. It is estimated that more than half of the 5.2 million people with asthma in the UK do not have adequate symptom control. While 500,000 of these have asthma that is difficult to control with available medication, and are thought to be resistant to corticosteroids, asthma is not well controlled in approximately 2.1 million people for reasons such as non-concordance with medication (Asthma UK, 2004, pp3-7).

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As already mentioned asthma is a long-term chronic condition (LTC) and although chronic illness is not a newly-recognised phenomenon, the incidence and prevalence has significantly increased over the second half of the 20th century and continues to rise in the 21st century (Howie, 2005, p318). This is not least because of the aging population and advances in medical science diminishing the impact of infectious diseases. In addition, the emergence of unhealthy lifestyles is arguably the trigger for many non-communicable diseases such as chronic heart disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease to which asthma has similar pathophysiology. (Nissinen et al, 2001, p963). It is estimated that in the UK over 17.5 million people are affected by a LTC and 8.8 million have long term illness that severely limits their day to day ability to cope. It is proposed that those aged over 65 affected by a LTC are more likely to have multiple long term conditions, which makes care particularly complex. Debatably, unhealthy lifestyles and an aging population are the reasons for the high prevalence of LTCs contributing towards the large financial costs in caring for these patients who occupy up to 42 percent of all acute hospital bed days (Department of Health (DH), 2005b, p10). Arguably, these issues indicate that these patients are not receiving the care in ways that meet their needs or the needs of the health system. It is proposed that this is why management of LTCs is of specific importance to current Government health strategies. To this effect, numerous policy documents have been published that define the present philosophies for the management of LTCs.
One particular policy; The National Service Framework (NSF) for Long Term Conditions was published by the DH in March 2005 (DH, 2005b, p24). The NSF predominantly concentrates on individuals’ with long-term neurological conditions. However, it is anticipated that to a great extent the guidance presented could be relevant to all long-term conditions. The document has outlined 11 “quality requirements” and among others there are various ones that are particularly pertinent to Steven Williams’s case. These include the provision of person-centred care and choice, the offering of information and support for the safe and effective use of medicines, the supporting of self care and the consideration of health promotion needs.
It is suggested that in order to meet Steven’s needs he will require support and education so that he can make informed choices. Metcalf (2005, p60) suggests that informed choice for those with LTCs is the key to success and a means of examining issues pertaining to non-concordance, risk taking behaviours and patient choice. As already mentioned, Steven began to smoke when he started attending university. Cigarette smoking is implicated as a health-risk behaviour and there is evidence to suggest that active smoking in adults with asthma increases asthma severity. A study by Siroux et al, (2000, p470) on the relationships of active smoking to asthma and asthma severity, found that current smokers with asthma had more asthma symptoms, more frequent asthma attacks (≥ 1 attack per day) and scored higher on the asthma severity scores, compared to those asthma sufferers who had never smoked and ex-smokers. Other trigger factors that can exacerbate asthma symptoms include house dust mites, pet allergens, pollen, moulds and fungal spores, certain drugs such as asprin and beta blockers, occupational triggers and viral respiratory tract infections (Roberts, 2002, p46).
Arguably, in Steven’s case, alongside his lack of concordance with his asthma medication, it is suggested that his smoking habit is a key factor in his acute asthma exacerbations. Therefore, it is proposed that Steven needs help with smoking cessation and education on the side effects and concordance of his medication.
Numerous approaches are presently being utilised for smoking cessation. These approaches incorporate pharmacological methods, such as nicotine replacement therapy or antidepressants, hypnotherapy, and exercise supported interventions. Behavioural approaches include stage based interventions, which mainly use the transtheoretical model (Prochaska, DiClemente & Norcross, 1992, p1102-14) and this model divides people into five different stages. These are the precontemplation, contemplation, preparation, action, and maintenance stages. The justification behind “staging” people, as such, is to fit the therapy to a person’s need at his or her particular point in the change process. Succession through the stages is in order, although relapses to previous stages can happen. The model also recognises 10 processes of change, the theory being that the effectiveness of the different processes of change will vary according to the patient’s stage. Arguably, however, this has not repeatedly been defended in empirical research (Sutton, 2000, p31).
It is proposed that it would be necessary for health professionals to recognise precisely an individual’s stage of change, or readiness to change. This is so that an intervention based on “stage specific processes” of change can be employed. It is important that the stage of change is re-evaluated regularly, and that the intervention should reflect changes in the individual’s willingness to change. These elements of the intervention can be continual until the person accomplishes and sustains the change in behaviour. In this way, stage based interventions develop and adjust in answer to the individual’s progression through the stages of change. Therefore it is debated that stage based models recommend that interventions that take into account the existing stage of the individual will be much more successful and efficient than “one size fits all” interventions (Prochaska, DiClemente & Norcross, 1992, p1103). Having said this however, the stages of change theory does not take into account any outside influences that might have an impact on a person’s ability to change.
It is proposed that Steven recognises that he has a problem and has asked for help. Therefore, it is suggested that this places him in the contemplation stage. It is suggested therefore, that Steven needs to be given help and advice that will lead him to the preparation for action stage. In doing this, debatably, it will be necessary for Steven to assess his feelings regarding his smoking behaviour. It is important therefore that health professionals who are using behavioural change models for smoking cessation are thoroughly trained in the procedure or at least are aware of the availability of a smoking cessation nurse. Ethically, it is argued that health professionals have a duty of care to help patients like Steven live healthier lifestyles. However, ethically Steven has the right to autonomy in his lifestyle choices (Tschudin, 2003, p151).
It is proposed that inhaled corticosteroids are still the most effective preventer drug for attaining treatment objectives (British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN, 2004, Chapter 4, p2). Steven has voiced concerns about the effects of steroids and this has stopped him taking his preventative inhaler. Similarly, he only uses his reliever inhaler when he becomes extremely wheezy. This is in accordance with Bender’s (2002, p554) suggestion that one of the reasons people do not take their medication is because they are worried about side effects. It is argued that this could be because their initial concerns might have not been fully addressed by health professionals (Carter et al, 2003, p27). It is proposed that nurses are ideally placed to educate patients on the benefits of medication concordance. It is important that a nurse thoroughly explains the necessity of the treatment and any subsequent side effects. Inhaled corticosteroids are the main preventative treatment for asthma sufferers. When taken twice daily at a low dose, corticosteroids are highly effective in reducing asthmatic symptoms, improving lung function, and reducing cellular inflammation. Systemic effects are rare on a low dose and most asthma patients are extremely well controlled on a low dose inhaler. Adverse local effects can include dysphonia and oral candidiasis. These symptoms can be relieved by either gargling or rinsing the mouth with water after inhalation (Roberts, 2002, p48). It is proposed that if Steven regularly takes his preventative inhaler then his asthma will be better controlled and he is much less likely to need systemic corticosteroids that can have adverse side effects such as weight gain and thinning of the skin when taken long-term.
The NSF quality requirements of person-centred care and choice, and the offering of advice on the use of medication are relevant to the case mentioned, as is the consideration of health promotion needs. The patient will require help in giving up smoking as this is a major factor contributing to his repeat admissions to hospital. Help in the correct use of his medication is also required if he is to remain free from episodes of acute asthma. Nurses caring for patients like Steven will need to know what help is available with smoking cessation and the various options that can be offered to individuals who want to cease smoking. The Prochaska and DiClemente model of behaviour change is commonly used in smoking cessation; however, its effectiveness is questionable.
Asthma UK (2004) Where do we stand, (last accessed: June 25th 2007)
Bender BG (2002) Overcoming barriers to nonadherence in asthma treatment, Journal of Allergy and Clinical Immunology, 109 Supplement 6, S554-559
British Thoracic Society, Scottish Intercollegiate Guidelines Network (BTS, SIGN) (2004) British Guideline on the Management of Asthma: A National Clinical Guideline, revised edition, Edinburgh,, chapter4, (last accessed: June 26th 2007)
Carter S, Taylor D & Levenson R (2003) A Question of Choice: Compliance in Medicine Taking, Medicines Partnership, London
Department of Health (2005b) The National Service Framework for Long-term Conditions, (last accessed: June 25th 2007)
Howie K (2005) Long-term conditions, Practice Nursing, 16, 7, 318
Metcalf J (2005) The management of patients with long-term conditions, Nursing Standard, 19, 45, 53-60
Nissinen A, Berrios X & Puska P (2001) Community-based noncommunicable disease intervention: lessons from developed countries for developing ones, Bulletin of the World Health Organisation, 79, 963-970, (last accessed: June 25th 2007)
Prochaska JO, DiClemente CC & Norcross JC (1992) In search of how people change: Applications to addictive behaviors, American Psychologist, 47, 1102-14
Roberts J (2002) The management of poorly controlled asthma, Nursing Standard, 16, 21, 45-51
Tschudin V (2003) Ethics in Nursing: The Caring Relationship, Third edition, Butterworth Heinemann, London
Siroux V, Pin I, Oryszczyn MP, Le Moual N, & Kauffmann F (2000) Relationships of active smoking to asthma and asthma severity in the EGEA study, European Respiratory Journal, 15, 3, 470–477
Sutton S (2000) A critical review of the transtheoretical model applied to smoking cessation. In: Norman P, Abraham C, Conner M, eds. Understanding and changing health behaviour: from health beliefs to self-regulation. Amsterdam: Harwood Academic Press

Case report of Mothercare plc

Case report of Mothercare plc

Introduction to the company- very brief

     Mothercare plc is a retailer, specialized in clothing industry. They predominantly sell products, such as clothing, furniture for children, bedding and toys, for mothers-to-be, babies and young children.

     In recent years, there is a significant change in the ways to purchase goods. Customers prefer online shopping to walking into the stores. According to the statistics of the past 8 years, the flux years were from 2012 to 2015, where performance drastically went down. It is obvious that the company suffered from a huge loss during this period.

Performance in the early years and problem years including causes of problems

     Overall speaking, the performance in these 8 years has rooms for improvement. With reference to the graphs of return of equity (ROE) and operating margin of Mothercare and its competitors— Debenhams plc and M&S, the company’s ratios was below the industry average. The ROE of Mothercare reached its minimum points at -69.14% and -101.8% at 2012 and 2014 respectively, while other companies remained steady at approximately 20%. Moreover, the operating profit of the company plummeted since 2009 and attained its minimum at -12.61% in 2012, with a gradual growth to 1.55% in 2017. One point worths noting is that both ratios of its competitors have a declining trend, so Mothercare had similar figures as them in 2017, meaning that the performance is getting better.

     Performance in the early years— 2010 and 2011— was impressive in terms of profitability and return on investment. The gross margin (12.01%) and operating margin (5.95%), dividend payout ratio (2.73%) and earnings per share (GBP 0.282) reached the peak in 2009. It reveals that stock was being sold at a lower prices and investors had more confidence in the company. It is because the potential return was higher and the investment looked attractive. A high dividend payout shows that a larger proportion of profits is distributed to shareholders in the form of dividends. The whole business was profitable and shareholders could benefit from it.

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     Nevertheless, the company experienced a recession from 2012 to 2015. In terms of profitability, the percentage of operating margin and return on capital employed in this period was negative. The financial statement also reveals that the net loss was at a lowest point of GBP 91.8 million in 2012, meaning that the revenue could not cover the expenses. It was not effective in using the long term financing to generate revenue. The difference between the percentage in gross margin and operating margin should be highlighted. Particularly from 2012 to 2015, the gross margin was positive, but the operating margin was negative. The huge difference symbolized a large amount of operating expenses.

     Regarding the liquidity, the firm was not capable to meet its short term obligations because the current and acid test ratios were lower than the norm. When the ratios are low, the company would have a high risk of facing liquidations. The gap between the 2 ratios illustrates that inventory was tied up in the capital, leading to insufficient liquid funds to meet its short term debts. The figures of inventory in the financial statements was around GBP 100 million over the past years, proving a high level of inventory at the same time. The cash conversion cycle had an increasing trend from 32.21 days in 2009 to 45.03 days in 2017. This 39.8% change matched with the cash figure in financial statements, which was GBP 0 in 2017. It features that it takes a long time to obtain cash from the company.

     The factors behind all these alterations can be classified in to economy wide and industry wide factors. For economy wide changes, first, the labour income, i.e. wages, of households escalated in recent years. (UK pay growth rises to 3.1%, the highest in almost a decade, October 16, 2018) Hence, they can consume more goods for each hour of work. With a high consumption bundle, customers will ask for a wider variety of products and better fashion choices. They may purchase products with higher quality and price and spend money on other goods. As a result, the fall in sales revenues leads to a reduce in profits.

     For industry wide changes, with the advancement of technology, online shopping has become popular, especially in the retail industry. Consumers prefer purchase online as it is much more convenient. The number of customers walking into the stores receded. Yet, the number of physical stores is fixed in short run, meaning that the fixed cost, for example rent, has to be paid. A large amount of sunk cost will make the firm difficult to breakeven and may have decreasing returns of scale. Since people would not buy the physical goods in stores, inventory piles up in the warehouse. It negatively affects the liquidity of the firm.

     In addition, retail industry emphasizes a good customer experience. The attitude of staff, payment methods and layout inside the store may affect one’s impression to the company. If a person is unsatisfied with his/her shopping experience, he/she may not visit the shop again. The firm was less profitable.

     Apparently, investors were pessimistic about the prospect of Mothercare. The share price dropped gradually from 635.50 in 2010 to 14.76 in 2018. (Share price information, accessed January 20, 2019) More and more shareholders sell their shares, leading to a decrease in share price. On top of that, the dividend payout percentage have been 0 since 2013, because the firm did not distribute any dividend throughout these years. The earnings per share was below 0 from 2012 to 2015. Every share an investor bought, it could not generate profits but loss. This investment is no longer attractive to people. They do not have strong confidence in the company.

Road to recovery

     In light of this, the company obtained funds to overcome the problems. The gearing ratio was particularly high in 2014 with 19.74%. It reveals that nearly 20% of long term capital was obtained through debts financing. The company might borrow from banks and fund its long term assets.

     A few strategies were adopted to improve the situation. First, the company plans to reduced its stores to fewer than 80 by April 2019 and the leases of 32 stores will expire within 3 years. (2018 Annual report, 2018) The closures will significantly dwindle the fixed cost, including the rent, equipment in the stores and wages for salesperson. It predicts to save costs by a minimum of GBP 19 million per annum. (2018 Annual report, 2018) As a result, the the gross margin, operating margin and return on capital employed were positive figures in 2016 and 2017. Profits increased due to a drop in costs.

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          Second, the company carried out a Corporate Social Responsibility Plan, including the CR 2020, aiming to support the overall aims of the UN Sustainable Development Goals (CR 2020 targets, accessed January 20, 2019), employee sponsorship matching fund etc. Moreover, the Mothercare Group Foundation aims at helping parents to give the best to the children, no matter education, well-being or health. The charity funds made generous donations of GBP 40,000 to Tommy’s and researched into pregnancy problems and provide health information to mothers-to-be. (Charitable Giving, accessed January 20, 2019) They even cooperated with Bliss, a UK charity providing care and support to premature and sick babies and their families. All these actions show that Mothercare contributes back to society and does not solely focus on profit maximization. People may be impressed by this practice and invest in the company ultimately.

Future problems

     Based on the past statistics, two predictions can be made. First, Mothercare has to be aware of its inventory level. The average inventories holding periods was escalating since 2009 from 47.26 days to 61.1 days in 2017. It means that the inventory usually needs to be held for around 2 months before selling it. A lengthening inventory holding period may increase warehouse costs and build up inventory levels. It may cause loss of inventories due to decay or out of date. Obsolete and expired inventories cannot be sold.

     Second, the company should keep an eye on the management of debtors and creditors. The receivables settlement period spiked from 14.95 days in 2009 to 28.61 days in 2017. It takes a longer time for customers to repay their debts. It implies there is a poor credit control and if the longer a debt is owed, the more likely it will become bad. The payables period also went up from 29.89 days in 2009 to 44.58 days in 2017. The company is less efficient in paying it creditors due to a longer collection period. It implies the firm may have liquidity problems as it needs to delay its payment. They may not have sufficient cash in hand. The payables period is shorter than the receivables period, meaning that when the firm may have a lack of capital after they pay their suppliers, as they haven’t received money from debtors.

     Therefore, the company should pay attention to the inventory level and strategies for debtors and creditors.

Appendix- List of References

Larry E (2018), “UK pay growth rises to 3.1%, the highest in almost a decade”, The Guardian, Tuesday October 16 2018

Mothercare (2018), 2018 Annual Report, Mothercare plc, 2018

Mothercare (2019), CR 2020 targets, Mothercare plc, accessed January 20 2019

Mothercare (2019), Charitable Giving, Mothercare plc, accessed January 20 2019

Mothercare (2019), Share Price Information, Mothercare plc, accessed January 20 2019

Case Study on Adolescent Depression

This case study concerns a teenage service user whom we shall refer to using a pseudo name, Katie, to maintain confidentiality in line with the Nursing & Midwifery Council Code of Conduct (NMC, 2015). Katie suffers from a comorbidity of Type 1 Diabetes (T1D) and depression, and the focus of case study is on thedepression component. Managing and treating depression has proved to be sometimes difficult for both practitioners and patients due to its multi-dimensional aetiology which is attributed to a combination of biological, environmental and personal factors. Its impact is equally challenging as it usually associated with poor disease control, adverse health outcomes and quality of life impairment (Andreoulakis, Hyphantis, Kandylis, & Iacovides, 2012).The case study will explore pathophysiological and psychological perspectives in the aetiology of depression. The objective of the survey is to undertake a systematic enquiry (Holloway, & Wheeler, 2010). Using a real world situation to gain a deeper understanding of the situation to try and solve a problem and improve the current situation (Aitken & Marshall, 2007).The utility of Cognitive Behaviour Therapy (CBT) is discussed as the intervention that was prescribed for Katie. The rationale is that CBT is relevant to the assessment outcomes and the symptoms presented by Katie.

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The GP referral to the Community Mental Health Team states that Katie is a 16-year-old enthusiastic teenager, who is in full-time education and enjoys extramural activities in school and also enjoys socialising. Recently Katie was diagnosed with type 1 diabetes (T1D) and prescribed insulin pump therapy. Following this diagnosis, Katie became remarkably withdrawn from friends and family, with expressions of hopelessness and low self-esteem. She has lost interest in the activities that she has been enjoying in her life. Her GP diagnosed depression. The condition has been getting worse and persistent for three weeks, putting a significant strain on her parents, including two siblings who live with her. The GP concluded the case warranted specialist attention and referred Kate to the Community Mental Health Team.
Katie’s referral notes suggested that her depression should be assessed further due to deterioration in her mental health. The assessment highlighted significant depression symptoms such as poor sleeping patterns, weight loss, burdensomeness, constant feeling of sadness (National Institute for Health and Care Excellence, 2016). Also, self- loathing, insomnia, lack of energy, irritable mood, physical pains and a gloomy outlook on life including diminished pleasure in enjoyable activities were the contemporary (National Institute for Health and Care Excellence, 2016). The symptoms are likely to impact on the ability to cope, personal relationships and the general quality of life (Pryjmachuk, 2011). To determine the severity of Katie’s mental health, the Registered Nursing Practitioner took the lead in completing a Patient Health Questionnaires (PHQ-9) with Katie. Katie scored as having major depression. This self-reporting tool is critical in aiding practitioners to conceptualise depression as it can be used to monitor, diagnose, and measure the severity of depression (Wu, 2014). The risk of harm is critical to the assessment of depression (NICE, 2016). Studies show that mental disorders are present in 90% of suicide cases in the UK, with depression found in 60% of the cases (Centre for Suicide Research, 2012). Hence, Katie was assessed on the risk of self-harm. However, she did not state any thoughts or actions of self-harm or suicide attempts. Due to the severity and the diverse nature of her symptoms an appointment was arranged for Katie to see the team Psychiatrist. Katie agreed to the decision. This led to the intervention discussed later in the essay.
Katie’s symptoms include loss of appetite, and there is substantial evidence that links eating disorders with depression, especially among young females (Allen, Crosby, Oddy, & Byrne, 2013). As pointed out by Allen et al. (2013) Eating disorders can lead to over eating, which contributes to other problems such as obesity and type 2 diabetes, Loss of appetite can lead to malnutrition, Loss of weight and fatigue. Eating problems also lead to stomach aches, cramps and constipation (Allen et al. 2013). Literature also shows that depression is linked to nearly every other physical and mental illness, as according to the joint report (Royal College of Psychiatrists and Royal College of General Practitioners, 2009). Also, there is sufficient of evidence that physical illness disturbs our feelings and thinking, just as social, and personal stress can cause ill health (Royal College of Psychiatrists and Royal College of General Practitioners, 2009). Also, other diseases can trigger stress and onset depression, as is the case with Katie who got depressed after a diagnosis of diabetes. Oladeji & Gureje (2013) suggest that patients can be caught in a vicious circle in which depression contributes to other present conditions and vice versa.
Conceptualising the pathophysiology of depression is made complicated by the fact that while the majority of patients respond to pharmacological treatments such as antidepressants, some patients remain partially or wholly unresponsive to drugs (Cryan, & Leonard, 2010).In these illustrations, there are individual differences in the manifestation of depression that cannot be addressed in current drug regimes. It follows that treatment for depression needs to be observed according to how each patient’s response to treatment(Andersson, & Cuijpers, 2008).And this should provide guidance in formulating Katie’s care plan in this study. However, there is research evidence that links depression for the maintenance of the homoeostasis and stress levels (Leonard, 2005; Cryan, & Leonard, 2010). Stress is often well-defined as a state of real or perceived threat to homoeostasis (Leonard, 2005). The homoeostasis process function is to provide the essential balance and stability in the body systems to enable cells to sustain life (Clancy, & McVicar, 2011).Stress to the homoeostasis will activate stress response to provide the required body function balance (Leonard, 2005). Critically to the depression paradigm, the stress response mechanism is mediated by multiple responses that involve the endocrine, nervous, and immune systems, which are collectively known as the hypothalamic-pituitary-adrenal axis (HPA) (Cryan, & Leonard, 2010). Changes that happen to the HPA and the immune system as a result of chronic stress can trigger anxiety and depression (Leonard, 2005). Depression is also ascribed to imbalances that arise in the brain about serotonin, norepinephrine and dopamine (Charney, Feder & Nestler, 2009).
Evidence suggests that the physiological functions that are mediated by neurotransmitter serotonin include sleep, aggression, eating, sexual behaviour and mood (Nutt, Demyttenaere, Janka, Aarre, Bourin, Canonico, Stahl, 2007). All these symptoms are much dominant in most depression cases, and indeed symptoms such as insomnia, loss of appetite experienced by Katie. Research also suggests that reduced production of serotonergic neurones that make serotonin has an impact on mood states and contributes to depression (Nutt et al. 2007). However, several lines of evidence suggest that neurotransmitter dopamine is involved in motivation that drives to seek reward and pleasure, and it is believed low levels on this transmitter play a role when depressed people cease to enjoy activities that they enjoyed in the past (Charney et al. 2009). Katie had been a vibrant juvenile and lost all the passion for passion when she was diagnosed with depression. Research suggests antidepressants play a role in improving neurotransmitter imbalances (Anderson, 2013). However, in the case of Katie, National Institute for Health and Care Excellence, NICE (2017), recommends that antidepressants should be used in young people and children only after alternative therapies have been considered.
The psychological impact of depression on the patient is concerned with the patient’s concepts of self, how they conceptualise their illness and the world around them (Barlow, 2014). It is quite critical as this impact on behaviour and treatment outcomes (Sanders & Hill, 2014). Above all, an analysis of Katie’s symptoms and assessment suggest there are significant psychological issues. The symptoms that relate to behaviour include lack of motivation as shown by poor school work and lack of interest in social events that she enjoyed before. She is no longer taking responsibility for daily actions and routines. Katie’s care plan and treatment should aim to address this. There are also symptoms that relate to self. She felt continuously sad about her present condition, resulting in emergency visits to her GP. In other words, Katie may have felt a loss of status and purpose, having become remarkably withdrawn from friends and family, she was not able to retain a sense of confidence in her the future. Some of Katie’s psychological concerns can be addressed within the Community Mental Health Team working with other professionals and Katie’s Care-Coordinator, and also with Katie’s family. The support of family and friends could be mobilised to give emotional, spiritual and financial assistance, with her family assuming an influential changing role and responsibilities when one person is ill (Washington & Leaver, 2009). The motivation for Katies to participate in daily activities could be initiated by working with the Occupational Therapy to engage in activities at the community centre.
Sanders and Hill (2014) examined the psychological impact of depression, in so far as it is conceptualised by the patient, as grounded in the concept of self. They assert that the idea of self is concerned with perceptions and awareness of being, the pattern of perceptions, which is also concerned with consequences for personality and change (Sanders & Hill, 2014). Also, a well-functioning self-characterised by assimilation and ability to respond to new experiences. However, a good self-process can become impeded by other impaired person -processes such as intrusive thoughts and any other perceptions that pose a threat and target the self (Sanders & Hill, 2014). Threats to the self, which can be internal or external, can culminate in patterned restrictions on perceptions and response which is configured as depression expressed in symptoms such as pervasive feelings of negativity (Sanders and Hill, 2014). This conceptualisation encapsulates Katie’s perception of herself as Katie could still enjoy her life only if she could change her perception of herself. Katie’s intervention needs to focus on changing her perception of herself.
Specifically, the Nursing process involves identification of priorities as well as the determination of appropriate patient-specific outcomes and arbitration, thus determine the urgency of the identified problem and prioritising the patient’s needs (Ackley, & Ladwig, 2013). In other words, mutual goal setting, along with symptom, pattern, recognition and triggers, will help prioritise interventions and determine which intervention is going to provide the greatest impact (Ackley, & Ladwig, 2013). Heeramun-Aubeeluck, & Luo, (2012) assert that collaborative care, behavioural interventions, and psycho-education are helpful in encouraging patients to maintain treatment and enhance psychological well-being and quality of life. The intervention chosen for Katie in this case study is Cognitive Behaviour Therapy (CBT). CBT can be accessed through referral to Improving Access to Psychological Therapies (IAPT). CBT is supported by NICE (2017), and also various government publications over the years have recommended the use of CBT such as No Health without Mental Health (Department of Health, 2011) and Talking Therapies. CBT is concerned with how people think (cognition), how they feel (emotion) and how they act (behaviour) (Daniels, 2015). CBT is psychoeducational and focused on changing the way people conceptualise illness to influence their behaviour and attitude (Daniels, 2015). The objective of cognitive processing is to examine patients’ thoughts and help them to learn the skills of acknowledging negative thoughts, often referred to as negative automatic thoughts (NATs). They will then be able to re-evaluate these ideas using an objective framework, and this can involve using approach to gathering evidence for the validity of ideas, such as proof against and for, surveys, or asking a trusted other (Grist, 2011). The rationale for CBT in this study is that its characteristics as a therapy would be helpful to address Katie’s symptoms and profile, as mostly the symptoms that impact on her quality of life are of cognitive and behavioural nature.
Equally important, a problem-solving approach will be adopted to structure and organise Katie’s nursing care and treatment. Katie will be involved in the whole process to empower her in her care plan through a person-centred approach and intervention that is evidence-based. Evidence-based interventions are practices or programs that have peer-reviewed, documented empirical evidence of effectiveness. Evidence-based interventions use a continuum of activities, strategies, integrated policies, and services whose effectiveness has been verified or informed by research and evaluation (National Resources Centre for Mental Health Promotion & Youth Violence Prevention, 2017).Gulanick & Myers (2016) contend that intervention is a basis for excellence in nursing practice, which includes correctly identifying existing needs, as well as recognising potential needs or risk, planning, delivering care in own fashion to address actual and prospective needs as well as evaluating the effectiveness care. More importantly, nurses must be able to work autonomously with confidence with significant others, such as families, friends, and carer’s to ensure Katie’s needs are met, including self-care arrangement (Nursing and Midwifery Council, 2015). Besides, as the name suggests, CBT comprises distinct therapy approaches that the address either the cognitive or the behavioural aspects associated with mood disorders, including depression. In CBT cognitive and behavioural approaches can be used in combination or unilaterally (Dobson & Dozois, 2009).
The behavioural perspective in CBT looks at the environment and behaviour of the patient. Depressive symptoms are attributed to a decrease in environmental reward, reinforcement
of depressive reactions and avoiding alternative actions that facilitate good health (Hopko, Lejuez, Lepage, Hopko, & McNeil, 2003). The behavioural perspective to depression underpinned by the works of Lewisohn (1974), who concluded that the pleasure obtained through interaction with one’s environment increases the likelihood of a rewarding behaviour. Further, change in the environment could result in deficient response-contingent positive reinforcement (RCPR) which directly contributes to depression (Dobson & Dozois, 2009). Dobson & Dozois, (2009) highlights Response-Contingent Positive Reinforcement as positive or pleasurable effects deriving from the behaviour of a person within their environment and the likelihood of increasing such conduct. Behavioural Activation therapy has proved to be useful in addressing deficient RCPR and improving mood and thoughts. This treatment focuses on availing activities that support environmental reinforcement (Hopko et al. 2003). Both the cognitive and the behavioural components of treatment would benefit Katie. Sheldon (2011) contends that CBT is a therapeutic approach that involves talks and conferences. In this therapy, the patients are involved in discussions, and they express their feelings, behaviours and thoughts to a CBT professional during the initial assessment (Sheldon, 2011). Kassel (2016)asserts the value of CBT as a therapy that teaches individuals how to think and react to certain stressful situations appropriately and can be used for some across a range of disorders including phobias, schizophrenia, depression, eating disorders, anxiety disorders, and relationship difficulties. When embarking on CBT interventions, the therapist uses information collected from an interview the patient; in this case, it would be with Katie and guides her through a description of the CBT model of depression as it applies to her profile and symptoms (Kassel, 2016). Also, general models of how thoughts, moods, behaviours, and physical sensations interact are discussed, enabling identification of a model as it relates to the patient’s life.
Several lines of evidence suggest that CBT is one of the most effective treatments when anxiety and depression present as the primary symptoms (Royal College of Psychiatrists, 2009). Further, CBT helps to make sense of a profound problem by breaking it down into smaller bits (Kassel, 2016). The National Centre for Biotechnology Information (2012) highlights that a combination therapy consisting of medical drugs and CBT has been establishing to be more efficient when that when medication is used alone in patients with more severe, recurrent or chronic forms of depression in the acute treatment phase. However, as highlighted by RCP (2009) CBT does not a quick fix, and if the patient is feeling depressed, it will be difficult to concentrate on getting them motivated. Further, CBT courses can last for six weeks to sixths months depending on the type of problem, and how motivated the patient is on engaging. CBT offers some significant advantages as an alternative therapy. Given all that has been mentioned so far, it is evident that CBT has considerable influence on the disease burden of depression as the treatment is safe and cheap (RCP, 2009). Also, it can administer as a self-help programme. CBT is now also delivered online, however, the quality of these trails is not always right (Andersson, & Cuijpers, 2008). RCP (2009) notes that some research suggests that CBT may be better than antidepressant at preventing depression relapses. However, it is necessary for the patient to keep practising their CBT skills, even after they are feeling better
The two dominant approaches to conceptualising and treating depression that is the physiological perspective and psychological perspective, offer plausible concepts in understanding the aetiology of depression, yet the patient may attach different conceptualization of the illness, which results from the idea of the self. The idea of the self is quite critical in treatment outcomes in so far as it mediates changes in cognition and behaviour. However, it has not yet been clearly established how the perspectives interact to cause depression symptoms. This case study highlights that when treating depression, it is essential to carefully monitor the response to treatment as some people will not respond to available therapies. Further, as some people don’t respond to treatment, there is a lot of research that needs to be done to understand how antidepressants work in different people entirely. Finally, cognitive behavioural therapy has numerous benefits for patients, including, decreased psychological distress, improved pain management, increasing self-efficacy, execute the sources of action required to manage prospective situations, better quality of life and function.
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Case Study: Fractured Hand

Introduction The reflective framework chosen for this case study is that of Peters (1991). This framework has been used and favourable evaluated within education (Bell and Gillett, 1996). Peters’ (1991) reflective framework incorporates a guideline called DATA comprising four steps;


The first step is the description of an aspect of practice the clinician wants to change. Identification would be made of the context and the reason the clinician wants to change the practice and their feelings about this. Analysis involves identification of the factors that lead to and the assumptions that support the present approach. This includes analysis of beliefs, rules and motives supporting the present approach (Imel, 1992). Theorizing is the next step which looks at the theories for developing a new approach building on the theories that were identified that were supporting the present approach. The final step is the action putting the new theories (if appropriate) into practice to ensure that such cases continue to be managed appropriately in the future. “Success of this process would occur only through additional thought and reflection” (Murray, 2006).
DATA Description
Patient presentation
At 11 am a 64 year old lady presented to the Accident and Emergency Department with a painful right wrist following a fall. We shall call her Betty but, in order to protect confidentiality, that was not her real name. She had been brought to the department by car by her husband.
Patient assessment
Betty was seen by the triage nurse and subsequent upon waiting her turn was allocated a cubicle. I saw her at 11.20 hours.
An understanding of the pathophysiology of fracture is important if important aspects of the patient’s history are not to be missed. Firstly taking an adequate history of the accident, including details of the mechanism of the fall, will help the clinician to decide whether the amount of force applied to the bone would be of the degree that would be expected to cause that particular fracture. Secondly there may be underling osteoporosis leading to fracture with minimal trauma. There may be factors in the history suggestive of osteoporosis e.g. use of systemic steroids (Angeli, 2006) or early menopause without subsequent hormone replacement therapy. A fracture which occurs after only minimal trauma and from a standing height or less, the degree of trauma being that which would not normally be expected to fracture healthy bone, may be what is known as a fragility fracture. This occurs where a bone is weakened by a pathological process , (Majid and Kingsnorth, 1998) such as osteoporosis. In distinction a pathological fracture occurs because of metastatic bone disease. Thirdly not just the mechanism of the fall but the reason for the fall needs to be considered. Betty had slipped on some ice when walking outside to her car. In the absence of such a clear history other factors in the history should be considered; for instance “funny turns,” visual problems, cerebrovascular accidents, or non accidental injury. It is important to directly enquire about that last aspect.
On inspection Betty’s right wrist was swollen. The skin was intact. There was some distortion of the normal contour of the arm typical of a “dinner folk” deformity. The distal part of the radius was angulated dorsally, the wrist supinated and the hand deviated towards the thumb. On palpation the distal radius was markedly tender. There was no crepitus. Betty was unable to use her right arm at all. The radial and ulnar pulses were readily palpable and there was good capillary refill in the hand. Sensation in the radial, ulnar and median nerve dermatomes was normal as were finger and thumb movements. The preliminary diagnosis of Colles fracture was made with some degree of confidence since the patient was a 64 year old female who had fallen on an outstretched and had classic examination findings of such a common injury.
For a completely confident diagnosis a plain X ray was required. For an X ray of a suspected fractured limb the following are requirements (Majid and Kingsnorth, 1998);

The X ray should be in two different planes at right angles.
The X ray should involve the joint above and below the suspected fracture site. In this case the wrist and the elbow.

X ray examination of Betty’s arm revealed a transverse extra articular fracture of the distal radius within one inch of the wrist joint. The distal radial fragment was displaced dorsally. A Colles fracture could now be diagnosed with confidence.
Analgesia was given by intra muscular injections of morphine 10 mg and stemetil 12.5 mg. The arm had been temporarily immobilised with a splint and elevated to prevent further injury and swelling prior to the X ray examination. Arrangements were made for prompt reduction of the fracture. The displaced fracture was reduced and manipulated and then immobilised. Betty chose to have a general anaesthetic for this procedure.

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To disimpact the fracture Betty’s hand was pulled distally whilst her wrist was hyper extended. Once disimpaction had been achieved the wrist was manipulated so that it was flexed with some ulnar deviation and pronation. In this position it was immobilised by a plaster cast which extended from just distal to the elbow to the metacarpophalangeal joints. These joints (and therefore the plaster) were at the site of the transverse skin crease across the palm. When the plaster had been applied Betty could move her elbow joint and her fingers and thumb. A check X ray confirmed the bone ends to be in a satisfactory position.
Post operative instruction Betty was advised to wear her right arm in a sling and to move her shoulder, elbow and her fingers and thumb to prevent stiffness in these joints. Complications of immobilisation in fracture are joint stiffness and tissueand especially muscle, atrophy. An important and serious complication is Sudek’s atrophy which probably occurs due to neurological and microvascular compromise. Better was instructed to contact the hospital if her fingers became painful, swollen, cold or discoloured. This could indicate that the plaster was too tight and impeding the circulation. Rarely carpal tunnel syndrome can occur due to pressure on the median nerve at the wrist. Betty was then discharged once she had recovered fully from the anaesthetic and was able to walk around. Betty asked if she could drive and this was allowed following evidence that driving is safe with a right Colles plaster (Blair, 2002). A further review was arranged for one week. Betty was advised that the fracture would most likely heal in four to six weeks. Once the fracture had healed by six weeks the plaster was removed and physiotherapy was advised.
DATA Analysis
On analysis of the case presentation it is apparent that the well known clinical features of a fracture were present;


as were the five classical features of a Colles fracture, often called the “dinner fork deformity” (GP Notebook, 2006);

Dorsal displacement of distal fragment
Distal fragment dorsally angulated
Hand deviated towards the thumb
Wrist joint supinated
Proximal impaction

The absence of crepitus might be explained by the fact of the fracture being impacted.
A fracture of the distal radius is one of the commonest fractures in adults (Majid and Kingsnorth, 1998). The Colles fracture was first described by Collees in 1814 (GP Notebook 2006) and is a transverse fracture across the distal radius within one inch of the wrist joint with dorsal displacement and angulation of the distal part of the radius.
Sometimes a Colles fracture is associated with a fracture of the ulnar styloid (GP Notebook, 2006) and this must be sought on X ray. A Galeazzi fracture (GP Notebook, 2006) is a distal radial fracture associated with a dislocation of the distal radio-ulnar joint and is important to diagnose (also by means of an X ray) since it requires open fixation to promote adequate healing. Another injury also caused by a fall on the outstretched hand and which it is important not to miss is a fractured scaphoid (Hodgkinson, 1994). This is clinically characterised by tenderness in the “anatomical snuff box” which is that area on the back of the hand found by hyperextension of the thumb. If present this fracture mandates appropriate immobilisation to reduce the risk of subsequent disabling avascular necrosis. Other injuries can occur following a fall on the outstretched hand, such as fractures to the clavicle, humerus and other parts of the radius hence the need for the wide area of view on X ray examination.
Although the presentation was a typical one there was not a mechanism in place to arrange suitable follow up for Betty to see if measures were necessary to protect her from subsequent osteporotic hip fracture. This problem is not an uncommon one in accident and emergency departments as found by a systematic review of 35 studies showing that those individuals with fragility fractures seldom received investigation or treatment of osteoporosis (Giangregorio, 2006). The writer feels that such action would be important since Colless fracture is common and hip fracture a devasting condition. The writer feels that quite simple steps could be put in place to arrange appropriate follow up.
An analysis of why Colles fractures are commoner in women than in men needs to consider the full picture. For instance initially it might be assumed that because postmenopausal women are lacking in oestrogen and therefore predisposed to osteoporosis that is the only reason. However research has shown that women have more falls than men and they are more likely, when they fall, to fall forwards onto the outstretched hand (O’Neill, 1994).
There is an assumption that the risk assessment for likelihood of subsequent hip fracture will be dealt by someone else. The accident and emergency department does need to concentrate on the acute problem. However hip fracture will necessitate subsequent accident and emergency department involvement. Preventative measures may be a neglected but important aspect of the accident and emergency role despite resources being an ever restraining factor.
DATA Theorizing
Fracture healing is affected by general and local factors (Majid and Kingsnorth, 1998). The general factors include the patient’s age, wellbeing, nutritional and endocrinological state. With regard to the local factors a compound fracture (i.e. a fracture which involves breach of the overlying skin) incorporates a risk of infection which will prejudice healing. Local factors affecting healing include the site of the fracture, proximity of bone ends and adequacy of blood supply. The pathophysiology of fracture healing consists of three stages (Majid and Kingsnorth, 1998);

Inflammatory phase
Repair phase
Remodelling phase

In the inflammatory phase haematoma contains osteoclasts which remove dead bone. Over two weeks granulation tissue forms which contains osteoblasts which form new bone. In the reparative phase the granulation tissue becomes fibrocartilagenous callus. The callus gradually turns into bone during the consolidation phase. Remodelling occurs as the bone adapts under the influence of the stresses placed upon it.
Delayed union occurs when healing requires an excessive duration and non union when there is a failure to heal. Factors associated with poor union include a poor blood supply or displaced bone ends. Treatment is aimed at reducing this risk by optimising the position of the fragments and immobilising them.
To develop a new approach to the prophylaxis of hip fracture will require multidisciplinary agreement with the formulation of guideline for information giving to both patient and general practitioner. Ideally an appointment would be generated for the bone mineral density scanning and reporting and advising. A mechanism of patient information will be required in parallel.
DATA Actions proposed
Treatment plan
The aims of the proposed action were to achieve;

Healing of the bone, and
Preservation of function of the arm and wrist joint.

There was more than minimal displacement of the fractured bone therefore manipulation was required. During manipulation it was important to pull the hand in order to disimpact the fracture. Manipulation then involved a reversal of the position that was present making up the dinner fork deformity.
If the fracture is displaced this may, if left untreated, lead to breach of the overlying skin and convert a closed fracture to an open one with the subsequent increased infection risk. An unreduced displaced fracture may compromise the blood supply distally. Correctly to lessen these risks Betty’s fracture was reduced promptly.
The treatment consisted of (GP Note book, 2006);

Rehabilitation in order to preserve function

The aim of immobilisation was to allow the fracture to heal without movement of the bone ends but to facilitate as much movement of the unaffected joints as possible.
An understanding of the pathophysiology of fracture helps to determine what the risk is for subsequent fracture. If this risk is high it will be advantageous to give some prophylactic treatment to lessen this risk. The fractures with greater morbidity are hip fractures and vertebral fractures and a radial fracture may be an “early warning” sign of an unacceptable risk of fracture with a more serious consequence. Bone mineral density measurements may be indicated in the near future. If this is outside the normal range and taken in conjunction with the present fracture there may be a need to consider prophylactic measures against osteoporosis and further fracture.
A Colles fracture is associated with subsequent hip fracture but the association is greater in men than in women according to a metanalysis (Haentjens, 2003). Nonetheless it may be prudent to advise Betty to check with her general practitioner whether she now falls into the category of the local guideline for measuring bone mineral density. Woman with a Colles fracture within ten years of the menopause had an eight fold increase incidence of hip fracture compared with the rest of the population but the increased risk diminished by age 70 in a study by Wigderowitz (2000). In this study bone mineral density was lower in women who had a Colles fracture that in the general population but after age 66 there was no significant difference. The paper concluded women of 65 and under presenting with a Colles fracture should undergo bone mineral density testing. Bone mineral density checking though not an exact predictor of subsequent fracture is a worthwhile measurement in diagnosing osteoporosis (Small, 2005). Treatments are available and might be considered if osteoporosis is confirmed (McCarus, 2006). Guidelines are also available (SIGN, 2003).
Oestrogen does protect bone from osteoporosis but is no longer recommended as first line prophylaxis in view of recent studies showing concern about the association with cardiovascular adverse events (Sicat, 2004). Other options include raloxifene, a selective oestrogen receptor modulator which reduces spinal but not hip fractures and biphsophonates e.g. alendronate which does reduce hip fracture incidence (British National Formulary, 2006).
Action on prophylaxis would likely most easily and consistently be arranged via computerisation of letter of appointment and information to the patient following discharge. This would necessitate no increased time or resources within the department but would cover all at risk patients.
Angeli A Guglielmi G Dovio A et al 2006 High prevalence of asymptomatic vertebral fractures in post-menopausal women receiving chronic glucocorticoid therapy: A cross-sectional outpatient study. Bone. 39(2) 253-9
Bell M and Gillett M 1996 Developing reflective practice in the education of university teachers. Different Approaches: Theory and Practice in Higher Education. Proceedings HERDSA Conference 1996. Perth, Western Australia, 8-12 July. Accessed 23 June 2006
Blair S Chaudhri O Gregori A 2002 Doctor, can I drive with this plaster? An evidence based response. Injury. 33(1) 55-6.
British National Formulary. 2006 British Medical Association London.
Giangregorio L Papaioannou A Cranney A et al 2006 Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 35(5) 293-305
GP Notebook accessed 23 June 2006. Accessed 23 June 2006
Haentjens P Autier P Collins J et al 2003 Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am 85-A(10):1936-43
Hodgkinson DW Kurdy N Nicholson DA et al 1994 ABC of Emergency Radiology: the wrist BMJ 308:464-468
Imel S 1992 Reflective Practice in Adult Education. ERIC Digest No. 122 ED346319 accessed on 23 June 2006
Majid and Kingsnorth 1998 Fundamentals of surgical practice. Greenwich Medical Media. London
McCarus DC 2006 Fracture prevention in postmenopausal osteoporosis: a review of treatment options. Obstet Gynecol Surv. 61(1) 39-50
Murray B Lafrenz LU 2006 The Role of Reflective Practice in Integrating Creativity in a Fashion Design Curriculum accessed 23 June 2006
Accessed 23 June 2006
O’Neill TW Varlow J Silman AJ et al 1994 Age and sex influences on fall characteristics. Ann Rheum Dis 53(11):773-5
Peters JM Jarvis P et al 1991 Adult education: Evolution and achievements in a developing field of study. San Francisco: Jossey-Bass. Quoted by Bell and Gillett 1996
Peters JM 1991 “Strategies for Reflective Practice.” In R. G. Brockett (Ed), Professional Development for Educators of Adults. San Fransisco: Jossey Bass. Quoted by Bell and Gillett 1996
Sicat BL 2004 Should postmenopausal hormone therapy be used to prevent osteoporosis? Consult Pharm. 19(8) 725-35
SIGN 2003 Scottish Intercollegiate Guideline Network 71 management of osteoporsis.
Small RE 2005 Uses and limitations of bone mineral density measurements in the management of osteoporosis. MedGenMed. 2005 May 9;7(2) 3
Wigderowitz CA Rowley DI Mole PA et al 2000 Bone mineral density of the radius in patients with Colles’ fracture. Journal of Bone and Joint Surgery (British) 82B 87-9

Mental Health Case Study: Generalised Anxiety Disorder (GAD)

Mental health, Amir Daud case study

Later in your initial discussions with Amir you think he may be having an anxiety disorder. Identify the character of anxiety disorder Amir is likely to be experiencing and what constituents in his history indicate this type of upset.

Amir is highly likely to be experiencing Generalized Anxiety Disorder (GAD) which results from too much sympathetic activation of the neural system. It makes the person experiencing it gets constant nervousness that leads to a negative impact on both physical and emotional health status. It significantly interferes with the normal behavior path of the individual at its mercy. Amir spent two years in torturous detention in Afghanistan, which was a time of constant uncertainty and anxiety followed by a perilous journey to Australia. While he was in detention, he witnessed many episodes of self-harm by fellow detainees who had lost hope and pessimistic about their future welfare which have contributed to increasing Amir’s trauma and anxiety state. The fact that he felt powerless in his situation aggravated his stress levels because he lacked hope or someone or something that would help secure it in that hopeless state of personal business.
Amir is also battling with mild depression from worrying too much about the family he left behind as he says he feels guilty because he is aware they are still facing persecution. He blames himself for not being able to rescue them from that situation. In addition, Amir is required to secure himself employment, only he feels quite the opposite due to his impatience and poor absorption.

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The major symptoms of this disorder include restlessness, exaggerated startle response, sleep disturbance, difficulty in concentrating, irritability and tremor. The symptoms must have occurred days than not for at least 6months and must cause clinically important distress or impairment in social, occupational or other significant areas of functioning’ (APA, 2000). According to Sigmund Freud, His type falls under Neurotic category of which is defined as the anticipation of negative consequences that activate defensive processes. This is as a consequence of his experience in the detention which he says makes him sleep poorly and development of negative intrusive thoughts during his waking time in the morning.
Possible Treatments that could be administered to Amir include pharmaceutical medication (SSRIs and Benzodiazepines) or herbal extracts made from a relaxant made from the root of the kava plant (Hall, 1998).
Derek Hayes, A. G., Suhaini, M. J., & Kassim, K. K. (2014). Hope and Mental Health Nursing. LinkedIn Corporations.
Hall, R. H. (1998). Anxiety Disorders.
Psychiatryonline. (2014). Neurobiology of Anxiety Disorders. Retrieved March 31st, 2014, from
School, I. S. (2008). Neurobiology of Anxiety Disorders. In I. S. School. Russia: St. Petersburg.

Explain what is meant by the neurobiology of anxiety.

Anxiety is a psychological and a behavioral state commonly characterized by avoidance behavior which affects a patient emotionally and psychologically. Neurobiology of anxiety is the classification of all anxiety disorders that affect the brain emotional states. These emotional states could be anxiety about the future, fear of the present or depression about events that occurred in the past. There are many different categories of the neurobiology of anxiety as listed below.
Generalized anxiety disorder (GAD) which is most common in young adults like Amir. It’s the fear, anxiety and depression associated with reaction to any dangerous situation. (Psychiatryonline, 2014). GAD is more likely than not to be confused with other anxiety disorder types. For one to conclude that a patient has it, they must identify four symptoms from the first rank list and at least one from the second list.
First rank

Inability to relax or restlessness
Exaggerated sudden response
Muscle tension
Poor sleeping habits
Poor concentration
Easily irritable


Nausea or abdominal complaints
A Dry mouth

Stress disorders (Post traumatic stress disorder- PTSD) and Phobias which are divided into specific and social phobia. These are characterized by a general feeling of dissociation from reality.
Panic disorders (With or without agoraphobia) -Attributes are manifested by intense apprehension, terror, fear often associated with feelings of hopelessness and intense physical discomfort. Attacks usually last for a short while and rarely take hours. In case they are accompanied by agoraphobia, there is a fear of being in places or Situations from which escape might be hard or in which help might not be available in the event of a panic attack (Diagnostic and statistical manual of mental health, 2000)
Agoraphobia without history of panic disorder- The (Diagnostic and statistical manual of mental health, 2000) identifies the essential feature of this disorder as fear of being in places or situations from which escape might be difficult or in which help might not be available in the event of suddenly developing a symptom that could be incapacitating or extremely embarrassing.
Obsessive-Compulsive Disorder (OCD) –This is characterized by involuntary recurring thoughts or images that the patient is not able to dispense. The victims feel powerless despite them knowing that it’s irrational behavior. The four general categories are: counting, checking, cleaning and finally avoidance. They happen frequently, which consequently interferes with normal daily activities.
Acute Stress Disorder-It’s an anxiety disorder due to a general medical condition. Symptoms of are judged to be the direct physiological consequence of a general medical condition. They may include prominent generalized anxiety symptoms, panic attacks, or obsessions or compulsions (APA, 2000)
APA. (2000). Diagnostic and statistical manual of mental health (4th Ed.). DSM-IV-TR: American Psychiatric Assocaition press.
Psychiatryonline. (2014). Neurobiology of Anxiety Disorders. Retrieved March 31st, 2014, from
School, I. S. (2008). Neurobiology of Anxiety Disorders. In I. S. School. Russia: St. Petersburg.

Why is hope relevant in mental health nursing practice? How might you incorporate this concept in subsequent therapeutic communication with Amir? What other elements of communication might you employ?

Hope is a vital element in any human’s life and is a pivotal act in any mental health nurse. It helps people with any medical problem get assurance about their situation, whether or not the treatment or recovery is complete. Kylma and Vehvilainen-Julkunen (1997) described it as an experience, emotion or need. The term in nursing is regarded as being dynamic and helps in rebuilding a patient’s self-worth and how they regard themselves which acts as a complementary treatment.
Amir needs to be shown unconditional acceptance, understanding and tolerance to help him overcome his disorder condition. A patient who believes that their situation can change through professional guidance and hard work from their end does find a way out of their situation. The reason the placebo effect is important when dealing with patients like Amir. The nurse-client relationship with Amir’s case needs to be on a personal level, to breed trust and a sense of value. Recognizing that Amir’s case is difficult will be the first step to helping him since for him to feel inspired by the therapeutic communication; he must feel the same energy from the nurse. There are different ways in which one can inspire hope especially in Amir’s case. They include:
Educating Amir of his condition, treatment and assuring him that he can still achieve all his goals and objectives like any normal human being.
Group therapy –This is where the assessor tries to interact with the patient with a group of other patients with more or less similar anxiety disorders with the aid of a leader to help them resolve interpersonal problems. Groups bring a sense of security and trust that they not battling their condition alone. More often, this results in positive outcomes in almost all cases.
Humor-Using humor to help Amir arouse happy thoughts and avoid the negative thoughts he gets during his waking time. Humor results to laughter which has been proven to be therapeutic.
Spiritual aspect-Here one tries to introduce spirituality, faith in the patient, which is a form of faith in all religions.
Psychoanalysis-The main goal will be to reduce his anxiety and guilt through verbal processes.
Conduct Humanistic therapy to help him fulfill his full potential and improve self concept.
Conduct Behavior and cognitive therapy to help him change unwanted abnormal behaviors and acquire desirable ones through revising his thoughts and behavioral training.
Later, Amir can be engaged in the assessment of his hope level to monitor any progress. Use of Herth Hope Index (HHI) rating where higher rate shows a high level of hope and subsequent opposite are an indication of low self-worth and depression.
Amir detachment from the normal world could drive him to commit suicide and thus the nurse need to do a full assessment on his level of hope. Effective communication of the management plan and encouraging self-help strategies will also play a big role during management discussion with Amir.
Derek Hayes, A. G., Suhaini, M. J., & Kassim, K. K. (2014). Hope and Mental Health Nursing. LinkedIn Corporations.
Psychiatryonline. (2014). Neurobiology of Anxiety Disorders. Retrieved March 31st, 2014, from

Define what is meant by ethnicity. Given Amir’s ethnic background explain what cultural assessments you might make in planning his ongoing care.

Ethnicity refers to a state in which an individual belongs to a certain social group which happens to share common national, customs or cultural traditions. Amir is ethnic Hazara. The Hazara people have for a long time been the victim of discrimination in Afghanistan. At the refugee camp the people there are more likely to be of the same ethnicity with Amir. This will make it easier for Amir since he will feel a sense of belonging while interacting with people who share his cultural values and origin.
I would use a cultural assessment tool to help me get all the information about Amir cultural background. Details I would include in the assessment area include: –
The primary language spoken by Amir, how he communicates with other people who speak a different language, whether he requires an interpreter or not, the highest level of education he has attained, whether his condition has ever occurred before, if it did in what manner was it handled, what are his normal ways of coping with stress?
Let Amir describe his family living arrangements, the major decision maker in the family, his religious beliefs and any religious requirements or restrictions that may place limitation to his care, any special belief and practices that may vary from the conventional ways, from whom has the family been seeking help from.
Additionally, the following questions should help in cultural assessment.

Are there any topics that are particularly sensitive or unwilling to discuss (because of cultural taboos)
Are there any activities in which Amir is unwilling to participate (because of cultural customs or taboos)
What are the Amir’s personal feelings regarding touch?
What are his personal feelings regarding eye contact?
What is his personal orientation to time? (Past, present, future)
Any particular illnesses to which the Amir may be bioculturally susceptible?

All the above questions will help gather any possible information regarding the Hazara ethnic group which will help in treatment program recommended to Amir while he is in Australia. It will also help the employer of his religious and ethnic practices to avoid stigmatization.
Mary C.Townsend, D.-B. (2011). Nursing Diagnoses in Psychiatry Nursing (8th Edition Ed.). Philadelphia, 1915 Arch Street: F. A Davis Company.
Psychiatryonline. (2014). Neurobiology of Anxiety Disorders. Retrieved March 31st, 2014, from

Client Based Care Case Study: Elderly with Diabetes

Client Based Care Study
In this essay, the author will explore the care of a single patient, encountered in clinical practice, examining the impact on quality of care, and on the health and wellbeing of the individual, of key aspects of care. Case studies allow nurses to reflect on practice, examine critical elements of case and of clinical decisions made and actions taken, and to examine areas of care in more detail. This essay will explore the care of one patient, who shall be called Molly, an older, community dwelling adult with Type 2 diabetes, who was admitted to a medical admissions ward having been found unconscious at her home by neighbours.

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The essay will examine the aspects of her care that relate to the management of her condition, the assessment and management of her social, care and personal needs, and the planning of her future care and support needs. Reference will be made to governmental guidelines and policies, and to interprofessional working as a fundamental component of meeting patient needs in this case.
Diabetes is a chronic disease which is known to impact significantly on the health, wellbeing and prosperity of individuals, of families, and of society as a whole[1]. More than 1.4 million in the UK are affected by diabetes[2]. Because of the great impact that this disease has on public health and on the use of NHS and social care resources and services, the Department of Health has published a National Service Framework for diabetes, which not only sets standards for management and diagnosis of the disease, but outlines best practice in the light of the latest available evidence on the condition[3].
There are two types of diabetes, Type 1 and Type 2, both of which are signified by a persistent high level of circulating blood glucose, due to a lack of insulin or a significantly impaired response to insulin, or to a combination of both factors[4]. Type 1 diabetes is due to the insulin-producing cells in the pancreas, called the Beta Cells, located in the Islets of Langerhans, failing to produce insulin, because the body’s own immune system has destroyed them[5]. Type 2 diabetes is usually caused by a reduced amount of insulin production by these cells, and by a degree of insulin resistance within the body, wherein the body’s metabolic responses to insulin are not as sensitive[6]. Type 2 Diabetes is the condition which Molly, the patient in this case study, has been affected by.
Molly is a 66 year old woman who has had Type 2 diabetes for 17 years. She is treated by twice daily insulin, and, living independently still in her own home, she is visited once weekly by a district nurse to monitor her glycaemic control and check her insulin stocks and her general wellbeing. Molly has a BMI of 35, and also has a history of hypertension which is controlled by medication. She has her blood pressure checked weekly as well. Molly lives alone, never having married, and has no children. She has an active social life, attending a local book group, taking part in a local history and re-enactment society, and volunteering at a community library. She is known by the district nurses to be competent in administering her own insulin and measuring her own blood sugar, but she does not always adhere to her regimen and her recommended diet, because it can interfere with her social life.
Molly was found unconscious by one of her neighbours at 9 pm, and the ambulance was called. Paramedics attending were told of her history by her neighbour, who waited with her, and suspected either Diabetic Ketoacidosis or hypoglycaemia. Diabetic ketoacidosis is a condition which can be life-threatening, and is usually due to a lack of insulin, which means that the cells of the body are unable to use glucose for energy, and so instead convert fat reserves to energy, which can produce ketone bodies which can adversely affect brain function[7],[8]. Hypoglycaemia can be caused by an overdose of insulin, or inadequate carbohydrate intake in a person who is taking insulin, or by the patient taking too much exercise, thus using up glucose, or by a combination of these
Paramedics found her blood sugar to be 1.1 mmols, and administered glucagon to reverse the hypoglycaemia. She recovered consciousness quickly once her blood sugar improved, but was also given facial oxygen, and had full observations taken. Molly remained confused after insulin administration. She was taken to the medical admissions unit for a full assessment and, if necessary, in-patient admission and review of her diabetes. According to emergency care principles for the diabetic patient, the priorities are to save the patient’s life, alleviate their symptoms, prevent long-term complications of the disease and their current risk factors, and then to implement care that will help to reduce risk factors for their health, such as hypertension obesity, smoking, and hyperlipidemia, along with providing ongoing education and support for self-management of their condition[9].
In Molly’s case, the team evaluated her condition, because although the initial diagnosis was hypoglycaemia, suggested by her self-reported history of missing meals that day and being very busy, the differential diagnosis was diabetic ketoacidosis, which can be precipitated by physical or biological stress, including changes in endocrine function or other diseases, such as myocardial infarction[10]. Molly is pale as well, a finding suggestive of hypoglycaemia, along with her elevated blood pressure and dilated pupils[11]. As Molly was conscious, her Glasgow Coma Score was 13, and she had responded well to glucagon, according to established diabetic protocols, she needed to be stabilised and undergo a range of investigations to determine any other disease or factors precipitating her condition[12].
Blood pressure, temperature, pulse and respiration rate were monitored recorded via continuous telemetry, and an ECG was carried out, which ruled out myocardial infarction. Molly had blood sent for Full Blood Count, Liver Function Tests, Urea and Electrolytes and Glucose, as well as insulin levels, prothrombin time, clotting factors[13]. Prothrombin Time and Clotting Factors may also be tested, due to the risk of disseminated intravascular coagulation. Bloods were also sent to test HbA1c; Fructosamine; Urinary albumin excretion; Creatinine / urea; Proteinurea; and Plasma lipid profile[14]. Urine was dipped with reagent strips to test for glucose, protein (suggestive of kidney problems) and ketones.
Because of her presentation, Molly was put on a continuous IV infusion of insulin, titrated hourly using a syringe driver against blood glucose, with an infusion of 5% glucose running in a different IV port. IV fluid therapy, and fluid balance, were also monitored closely[15]. Diabetes can cause kidney damage and impaired urinary function, so monitoring kidney function was an important part of care[16].
Once Molly was stabilised, ongoing care related to supporting her health and wellbeing, and minimising complications of her diabetes, became an important part of care. Diabetes is a significant public health issue, because it is not only associated with the ‘social’ disease of obesity, but also because as a disorder it is associated with a number of serious health implications[17]. These complications include macrovascular complications, including atherosclerosis and cardiovascular disease[18], [19], [20]; diabetic retinopathy and sight loss due to vascular damage which weakens the walls of the blood vessels in the eyes, causing microaneurysms and leakage of protein into the retina, vascular damage and scar tissue [21], peripheral neuropathy, peripheral vascular disease and gastrointestinal dysfunction, gomerular damage, and kidney failure[22]. The impact of this disease on public health relates to the fact that many people of working age are diabetic, and because the condition is chronic as well as serious, with acute exacerbations and so many complications, it presents a serious drain on health and social care resources. Therefore, it is imperative that individuals with diabetes are identified as early as possible, and are educated and supported in good self-management, and provided with ongoing care to maintain good glycaemic control[23].
Molly’s status as an older adult is also a public health issue, because older adults constitute the largest patient group in the UK, and the ones which consume the biggest proportion of healthcare services[24]. However, it was also important to avoid stereotyping Molly as an older person, and making assumptions about her needs and her health. Although she was obese and hypertensive, and had Type 2 diabetes, she was very active and had a very important social life, and was usually independent and self-caring. It was important to consider the social support that she had, and to ensure that she was aware of any services or support she might be able to access if she felt it necessary. However, some members of the multidisciplinary team, in particular, some of the medical staff, did appear to act in a way that suggested they were stereotyping Molly based on these factors (age, weight, health) and were discussing her case without really making clear reference to her as a whole person. This leads on to the need to evaluate the multidisciplinary input in Molly’s case, and the quality of the interprofessional working that took place, which is discussed below.
As can be seen from the list above, diabetes can affect the individual and the body in complex ways, and so requires an holistic approach to care[25]. Care should also be based on evidence based, collaboratively agreed care pathways[26], as suggested by the NSF for diabetes[27]. Molly may need a comprehensive review of her management and her lifestyle, the patterns of care and the ongoing monitoring of her condition[28]. The National Institute for Clinical Excellence recommends a patient-centred approach to ongoing patient education and management, and also suggests a number of options for patients who might require different forms of insulin administration, such as continuous sub-cutaneous insulin[29], [30]. This, however, was not suitable for Molly, because it is usually for people with Type 1 diabetes.
Health promotion and education is an important part of Molly’s care at this point, which is related to the fact that her current hospital admission is due to mismanagement of her condition herself. It was important to determine what factors about her lifestyle and behaviours had led to the lapse and the serious hypoglycaemia. Ongoing care, health promotion and education involved multi-professional collaboration and integration of care into a complex, detailed care plan. The aim was to provide Molly with the information, support and guidance that would allow her to view her diabetes management as a means of achieving a better quality of life, rather than viewing her diabetes as something which interfered with her quality of life. It was also important to view Molly in terms of supporting her to continue with her normal social activities. Research shows that making changes in lifestyle, and providing good, effective health education, helps to contribute to reducing rates of diabetic complications[31].
However, the kind of health education and support used is important, because different approaches have different levels of effectiveness. Some research examines the differences between health education that tries to persuade patients to be compliant with regimes and activities designed by health professionals, approaches which are usually generic, and health education that is client-centred[32]. Client centred approaches are usually more effective, as they are individualised. Research shows very clearly that patients with diabetes need to understand their disease fully, and be supported and empowered to make the lifestyle and behavioural changes that will enhance their wellbeing whilst enabling them to control their condition[33]. In this case, a diabetic nurse specialist was involved with Molly’s case, and a plan for health education and support drawn up, with clear guidelines and a tailored plan for managing her social life around her diabetes. Diabetes UK recommends a structured, tailored education programme for people with the condition[34].
Interprofessional and multidisciplinary working is a fundamental component of care for a patient with diabetes like Molly[35]. This means that diabetic patients should experience seamless care, addressing all needs, with access to all the professionals necessary to support her care[36]. Specialist involvement, including diabetic nurse specialists, was a feature of this care, and helped with a client centred focus[37]. The literature suggests that it is important for a lead professional to take charge[38], but in Molly’s case, her lead nurse was not present for the majority of her inpatient stay, and there was a lack of effective coordination of the complex number of professionals involved.
In relation to multidisciplinary, interprofessional working Molly was referred to ophthalmic services for a check-up, to ensure that there was no diabetic retinopathy or glaucoma. She was referred to a dietician to support her in managing her dietary intake. She was also referred to a social worker. Diabetic specialist doctors were involved, and a report was sent to the diabetic nurse at her local surgery, as well as to her GP. Molly ended up staying in hospital, however, on a medical ward, for two weeks, even though her condition was stabilised rapidly, and she experienced no further complications. In this case, interprofessional working was not effective, because although the said referrals were made, or were recorded to have been made, Molly was not seen by the dietician or a social worker for over a week, and only when she began to threaten to take a discharge against medical advice did the dietician and social worker arrive and get involved. The doctors in charge of Molly’s case however appeared to make judgements about plans for discharge and ongoing care without involving the nursing team and without considering some aspects of her social situation and Molly’s own preferences and wishes.
It is apparent, from this case, that while Molly’s immediate medical needs were met, the interprofessional working element of her ongoing care failed in some way. There are a complex range of professionals and support workers who provide healthcare[39]. Because of this complexity, interprofessional education has become part of healthcare education programmes[40]. Interprofessional working is supposed to help with the provision of true patient-centred care, and the highest quality of care[41]. However, experience in this case, and some of the literature, cites ongoing problems with interprofessional working in a number of contexts. Some of this is to do with the professional boundaries and hegemonies which persist in healthcare professions, which continue to be defended rigorously by each profession[42]. Some literature shows that elitism, professional isolationism and professional defensiveness can have negative effects on health professionals themselves as well as on the quality of care delivery[43]. Yet there is ample government guidance, particularly from the Department of Health, which aims to improve service provision, and the NSF for Older People[44], identifies the most important elements of care and service provision which must be improved upon. Standard 2 of the NSF, ‘Person-Centred Care’, requires that health and care services are designed around the needs of the older patient (and their carers)[45]. However, this kind of needs-based care then demands
. “an integrated approach to service provision… regardless of professional or organisational boundaries, [which is] delivered by clinical governance, underpinned by professional self regulation and lifelong learning” .”[46]
In Molly’s case, the fundamental role of the nurse in providing leadership and coordination for her care was not acknowledged or supported. Some researchers suggest that this can be due to medical hegemony[47]. Current approaches to offsetting such ingrained hierarchical thinking are very much focused on initial education of healthcare professionals, overcoming historical professional boundaries[48], [49], [50]. The research shows that there is a difference between multiprofessional working, which does not transcend the traditional hierarchies and boundaries , and inter-professional working, which is built on the desire to share care, support each other, and value each others’ expertise[51]. Government drivers continue to underpin strategies for better, ‘joined up working.’[52],[53].
The failures which occurred in Molly’s care were clearly linked to poor communication between the healthcare professionals, a lack of joined up working, and a lack of recognition, perhaps, of the importance of the social aspects of Molly’s case, and the health-education aspects, based on her individual needs. On reflection, the author believes that had there been better, collaborative working, then none of these needs would have been overlooked and they would have been dealt with more speedily. But another aspect of her care that could be improved upon was related to her own involvement in her case. Molly was not fully involved in her case discussions and in the medical decisions made about her care. While this can be a product of the medical hegemony mentioned before[54], it constitutes a serious oversight and is not in line with governmental guidance[55]. Research shows that the patient voice is the most important one in terms of collaborative care planning and management[56].
This case study has identified the case of Molly (a pseudonym), an older patient with Type 2 diabetes who received good quality clinical care in meeting her acute care needs and managing her medical condition and its potential consequences, but for whom interprofessional working failed in relation to ongoing care and multi-discinplinary involvement. Diabetes is a significant public health issue, and a range of governmental guidance and research evidence informs care for patients with the condition. The public health issues surround the serious morbidity and mortality associated with diabetes, and the fact that good management and glycaemic control can minimise these complications. In this case, the patient’s needs were prioritised medically, but interprofessional communication broke down. While the appropriate referrals were made, proper joined up working did not take place. Similarly, Molly was not fully involved in her case, and should have been.
Diabetes is a serious, chronic condition, and one which requires patient-centred assessment, identification of needs, and management. All those involved should adhere to the available guidelines and commit to effective interprofessional working.
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[1] Department of Health (2002)
[2] Hilton, L. & Digner, M. (2006) p 89.
[3] Department of Health (2002).
[4] Department of Health (2002).
[5] Watkins, P.J. (2003).
[6] Watkins (ibid)
[7] DoH (ibid)
[8] Hankin, L.(2005) p 67.
[9] Watkins (ibid).
[10] Turina, M., Christ-Crain, M. & Polk, H.C. (2006) p 291.
[11] Guthrie, R.A. & Guthrie, D.W. (2004) p 113.
[12] Edge, J.A., Swift, P.G.F., Anderson, W. & Turner, B. (2005) p 10005.
[13] Hankin (ibid)
[14] Reinauer, H. (2002)
[15] Guthrie (ibid)
[16] Guthrie (ibid)
[17] DoH (2002); Department of Health, (2001).
[18] Guthrie (ibid)
[19] Bloomgarden, Z.T. (2006)
[20] Soedmah-Muthu, S.S., Fuller, J.H., Mulner, H.E. et al (2006)
[21] Guthrie (ibid)
[22] DoH (2002).
[23] DoH (2002)
[24] Department of Health, (2001)
[25] Collis, S. (2005)
[26] Pollom, R.K. & Pollom, R.D. (2004)
[27] O’Brien, S.V. & Hardy, K.J. (2003)
[28] Snow, T. (2006)
[29] NICE (2003)
[30] Diabetes UK (2006)
[31] Anthony, S., Odgers, T. & Kelly, W. (2004)
[32] Skinner, T.C., Cradocl, S., Arundel, F. & Graham, W. (2003)
[33] Antony (ibid)
[34] Diabetes UK (2006)
[35] DoH (2002)
[36] Keene, J., Swift, L., Bailey, S. & Janacek, G. (2001)
[37] Keen, H. (2005)
[38] Scott, A (2006)
[39] Masterson, A. (2002)
[40] Pollard, K.C., Miers, M.E. & Gilchrist, M. (2004)
[41] Kenny, G. (2002)
[42] Colyer, H.M. (2004)
[43] Price (ibid)

Decision Making Processes in Firm Partnerships: Case Study

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Case Study on Big Pharma’s Marketing Tactics

Case Study On The Big Pharma’s Marketing Tactics In The Pharmaceutical Industry
Facts And Assumptions
The term ‘Big Pharma’ is a terminology used to refer to the pharmaceutical industry. The name relates to people’s strong belief that it has played an active role in the ever increasing complicity and costs of health care. There is a crisis in the health care sector and it is believed that the Pharmaceutical Companies have abandoned science and resorted to salesmanship. No reasonable progress is currently being made in the industry due to the negative perception created by unscrupulous marketing strategies being employed (Archie 2009). Doctors should prescribe drugs to patients but are never expected to do marketing and advertising of their products and services. The other fact in the case study is that unethical business practices such as Pfizer’s off-label marketing practices and undue influence to medicines that should be prescribed by doctors to patient, normally lead to a likely increase in the cost of medical services due to the unfair and unleveled competition. The assumption among most people, which is not the truth, is that all pharmaceutical companies engage in dubious marketing tactics. The other assumption is that the Big Pharma companies sell unethical drugs. However, the truth is that the company sells ethical drugs even though the marketing strategies employed by the company are of questionable standards.

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Major Overriding Issues
There are a number of problems in the case study.  One of the overriding issues is that Pfizer Company illegally did the marketing of Neurontin anti-seizer drug. The fact that pharmaceutical industry has decided to lay a lot of emphasis in the marketing of pills and other related drugs rather than developing new crucial ones is an issue of concern too. Drugs firms have also been accused of marketing drugs for purposes that have not been prescribed by the renowned drug and food administration department. Accusations of off-labeling illegal marketing policies and other related marketing wrongs have also emerged as a major problem in the industry. This is a very serious problem which has compromised the integrity and ethical standards of doctors and the entire pharmaceutical industry.
Sub-issues And Related Issues
The ‘Big Pharma’ companies have been accused of participating in unethical business practices. Medical students have been hired to companies even before they graduate from their medical schools.  This is a likely act of poaching talented skills in the market without following the right recruitment process and laid down procedures and policies in the industry. Furthermore, methods such as offering doctors underserved holiday packages, expensive gifts and other kickbacks, have been used to compromise the integrity of the industry as doctors who are given these favours are expected to recommend the specific company’s drugs thus boosting the performance of the company’s in the competition. The costs of drugs have continued to skyrocket due to lack of control of the market practices.
Analysis And Evaluation
Medical practitioners such as doctors, pharmaceuticals, governments and other law enforcement agencies, pharmaceutical companies, and the entire public that seek medical services are the major stakeholders in the industry. The government’s stake in the case is its responsibility and duty to ensure that their subject receive the right medical services they deserve. People have a right to a healthy life and proper medical services. The government also benefit through the taxes paid by other stakeholders in the pharmaceutical industry.
The doctors’ stake in the industry is based on the fact that for them to grow in their career and attain self fulfillment, they have to ensure that the sick people get proper medical care. Their salaries and duration of being employed would also be determined to a greater extent by the standards they maintain in the market. Expensive medical serviced would lead to a decline in customers due to very costly services hence low income. The pharmaceutical industry, research institutes and shareholders in the company have an interest of maximizing profits and making the highest gains possible in their various investments made in the industry. Unscrupulous and corrupt means being employed by the pharmaceutical companies and some medical practitioners compromises the integrity and ethical standards of the industry. It also leads to decline in the performance of most pharmaceuticals organizations.
CSR Analysis
Pfizer Company has the responsibility of ensuring that it regulates the costs of medical services and products under its line of operation. Good pricing would also make more people to receive better healthcare services since they would be in a position to afford the prescribed drugs. It also has the ethical responsibility of using ethical marketing tactics that would benefit both the company and the community of persons who uses its products. Legally, the company must ensure that it follows the due marketing process, price regulation standards, marketing policies hence fully adhering to the rule of law. Such efforts would lead to fair competition in the marketing thus other pharmaceutical companies (competitors) in the industry would have an opportunity to compete on a fair platform. The government would receive the necessary taxes while doctors would live a more fulfilled life with good salaries and wages being received. Proper CSR would help in facilitating efforts to reach a solution to the health care problem.
The case mainly involves Pfizer Pharmaceutical Company in its use of very questionable marketing tactics. The company used very unscrupulous methods in marketing the Neurontin anti-seizer drugs and doing off label-marketing of the painkiller Bextra and other medicines in order to lure more customers into using their medicines. Rather than employing such unfair and unethical marketing tactics, the company should instead have followed the normal marketing channel of producing medicine and simply alerting the medicine practitioners through various existing hospital departments of the existence of their medicines. It is indeed the discretion of the doctors, upon their tests and knowledge, to choose which medicines to prescribe to the patients without any undue external influence.
Recommendations And Implementations
Various relevant laws and policies need to be put into practice. This would ensure easier market control measures meant to ensure that any unethical practices in the industry are curbed. Guidelines on how marketing by pharmaceutical companies should be carried ought to be clearly stipulated. In order to ensure ethical practices are adhered to, education and public awareness forums should be carried to the stakeholders. Doctors should also be protected against selfish companies that demand, threaten and force them into prescribing certain company drugs. Control mechanisms of the cost of healthcare also need to be put into place in order to ensure that customers are not exploited by selfish and unscrupulous medical practitioners. In addition to that, serious penalties and in some instances, nullification of trade licenses should be enforced to companies and individual persons who use unethical marketing tactics.
Appendix: Stakeholder Map
Work Cited
Archie B.C. Business Ethics: A Brief Readings on Vital Topics, a collection of his columns. Athens Banner-Herald Publishers, 2009

Blake Sports Apparel Case Analysis

Blake Sports Apparel and Switch Activewear was once a small manufacturing company that developed sports apparel and accessories using logos of leagues and brands. Founded by Cameron Barker’s father, Blake Sports Apparel and Switch Activewear changed hands after a decade, placing the company in the management of his son Cameron Barker.  Soon after the change in leadership, Barker was determined to grow the company by expanding his clientele. Barker began a partnership with the mid-size brand Cartlock and after, transitioned to the very large company Howell. However, new challenges and problems arose for Blake Sports because of the rapid growth. Several employees were punished and criticized for expressing pressing issues that needed to be addressed in the company. Some of the issues included lack of leadership, communication barriers, secrecy and mistrust, and lack of involvement and interaction.  With these pressing matters brought to light, Barker intern reflected on his own leadership, or lack thereof, and proposed possible solutions that could benefit and improve his team and the company.

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To me, the most pressing problem within this case study is the poor leadership that has been demonstrated throughout the company. Not only CEO Cameron Barker, but the whole Blake Sports executive team failed to provide examples and demonstrate what proper leadership should look like. When asked about their opinions on the leadership within the company, employees went as far as saying that CEO Barker “was described as inspiring, empowering, and talented, for example, but not as a coach to his team. As a self-identified introvert, he admitted to spending little time engaging socially with colleagues” (Groysberg 9). Personally, if I did not have any intimate connection or social interactions with my boss or mangers, I would find it very difficult to grow and further our relationship. By disclosing personal information, you allow yourself to be vulnerable and create a bond of trust. To me, the personal interaction of managers is part of what makes them a good leader. Companies need good personal mangers that can find a balance of work and play, however still being able to construct a since of production and encourage hard work.. Another problem that employees highlighted was the lack of communication in the workplace. In the article, there are several examples of how poor communication is a major issue within the Blake Sports. In one instance, because of lack of communication, employees felt the company was secretly withholding information from them, and not providing critical information needed between the various departments. Information from the case study stated that “the combination of apparent secrecy and the company’s privately held status led employees to question the company’s financial standing and the degree of its profitability” (Groysberg 6).  By withholding information, the employees assumed that the company was in financial trouble, thus hindering their job performance because of the possible financial distraction. Another example of communication problem would be that there was a lack of communication between personnel regarding important information.  Missing deadlines, unacceptable work environment behavior, and task orientation/ deadlines are all things that should be address via face to face or personal communication. As stated in the case analysis, “the deadlines were habitually ignored, which led to otherwise avoidable issues, such as missing shipping dates to customers and although team members did make the effort to attend the check-in meetings, no one set an agenda, so the meetings often ran for an inadequate length of time”(Groysberg 6-7). Perhaps the biggest issue of all in the Blake Sports company was the level of cooperation. Because individuals in the organization were working against each other rather than together, production and shipping slowed and was complicated. Because the employees did not have any team bonding activities or exterior relationship, they were dividing among themselves because of differences. Thus, hindering production because they would compete against each other rather than working together. In the article employees state that “the executive-team members look at one another as competition, not as collaborators” (Groysberg 9-11).

In one’s own reflection, I feel that one of the reasons the company has so many problems is because of the rapid growth that was unexpected. Transitioning from a small company to a large company comes with challenges and difficulties. For instance, you have more employees, thus meaning very different cultures, backgrounds, and values that all must mesh together to work in harmony. Because the company grew and transitioned so quickly, I feel that if they were to implement more guidelines to follow, they could give direct expectations as to what the employees are expected to act and preform to help ensure a smoother transition. I feel that by also making training and employee bonding mandatory, this would ensure that each employee starts off on a clean slate with the companies’ value and expectations as their foundation.  In many large companies such as Amazon, Google, Apple, and now Blake Sports, you need a strong, determined, and respected leader who can intern be an example of what your company represents.  I feel that a CEO is necessary for the face of a company, however having multiple powers of leadership, like a board of directors, is a good, in-depth way to address issues and get various opinions and ideas on how to handle them. I also think that training for managers on how to handle different problem situations that arise would be beneficial to the company, as the managers can provide feedback to the bosses in regard to performance, employee satisfaction, and production. I feel that this solution would also help with the communication drawbacks. I feel that by having weekly or bi-weekly meeting with the head of the company, the employees would feel more involved and interactive. By doing this, you are creating a bond with the employees that suggests that the executives do care about each person. Supporting my idea, the textbooks states that “if employees trust their leaders, they will buy in more readily” (Nelson 200).  In these meetings there should be a timekeeper and secretary to take notes of the meetings. The company could go a step further and publish the notes and future agendas taken at the meetings for those who could not attend or as a reminder. These meetings would set the tone for open information. By having this since of open communication between departments, this leaves no room for secrecy or miscommunication- especially if it is published in a newsletter.

By using Bruce Tuckman’s five-stage model, Cameron Barker could successfully improve the overall environment of Blake Sports Apparel and Switch Activewear. By using this group model, Barker could make the environment fun, productive, and the place people want to work at. The following is a summarized explanation of how the five-stage model works. Forming (stage one) would allow for team members to get to know each other better and acknowledge each other’s values or “ground rules”. Storming (stage two) is the stage in which they will first experience conflict. However, they will also experience and exercise “trustworthiness, emotional comfort, and evaluative acceptance” per the textbook (Nelson 141-142).  Norming (stage three) is when employees begin to settle into their job, having a clearer understanding of their responsibilities and duties.  Preforming (stage four) is the stage in which members are goal oriented and do not have to rely on the directions from a manager/leader.  Adjourning (stage five) the final stage, is when the employees feel accomplished because they have successfully completed the given task at hand.

 Companies that focus on employee training, group activities, and communication are by far the most successful companies with the happiest employees.  By making it your companies’ mission to value, uphold, and instate these three things, you are creating an environment that will thrive. Remember, people don’t quit companies- they quit managers.

Work Cited

Groysberg, Boris and Baden, Katherine C. “Blake Sports Apparel and Switch Activewear: Bringing the Executive Team Together.” Harvard Business School. (2017) p. 1-12. Print.

Nelson, Debra L., and James C. Quick. ORGB5: Organizational Behavior. Cengage Learning, 2017.


Child Language Development Case Study

This paper explores a case study with one family with a child displaying slower language development, examining the case in the light of well-known theories around child development. These theories, which include scientific approaches, social approaches, and applied approaches to understanding and supporting child development, are evaluated in the light of the existing literature and in relation to health visiting practice.
The Case
Child A is a 2 year old male, the only child of a same sex lesbian couple, living in an ex-council house within a village environment. The area of the village in which they live is predominantly local authority housing, but they bought their house as a private sale from its previous owner. The biological mother, who for the purpose of this essay will be called Mother A, was brought up in this village, and left to attend university and have a career, returning when the child was 3 months old. Mother A works 21 hours a week as a nurse, and also works ad hoc shifts as an agency nurse. Mother B is a university graduate who left full time employment to move in with Mother A, and now works for a local women’s charity part time, as a child support worker.

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Child A displays normal development in most areas, and demonstrates clear cognition and understanding of language and interactions, potentially beyond the standard for his stage of development. However, Child A does not use verbal language himself very much, and at times displays behaviour which suggests he is withdrawn and not interested in socialising. Mother A states that Child A socialises well in the Creche he attends 3 days per week. However, Mother A also states that as a family they are very socially isolated. Mother A’s extended family lives within 3-5 miles of them, but has very limited contact, because of discomfort with their lifestyle. The family attempted to join a mother and toddler group, but were made to feel unwelcome, and both parents state that they are ostracised by their local community, and cannot access social support from a wider lesbian community because they have no childcare other than the crèche. They have been unable to secure a childminder or babysitter because of their alternative family arrangement.
Observations of interactions between parents and child demonstrate good, positive attention from both parents. Mother A is very ‘attuned’ to the child and ‘interprets’ behaviours and expressions, anticipating the child’s needs. Interaction between health visitor and child suggests the child is capable of proper linguistic expression. On one occasion, the child corrected the health visitor, to inform her that a shell in his ‘collection’ was grey, not white. The child also shows some ability to recognise alphanumeric characters. Despite this, verbal communication seems very limited.
This case provides an interesting dilemma in exploring the theories which would explain the apparent linguistic retardation this child displays. Bowlby’s attachment theory, for example, might suggest that the child’s linguistic restriction is due to some element of attachment, and that the primary attachment figure for this child is Mother A. In the absence of what others might describe as a normal social sphere for the child, the attachment between Mother A and Child A may never have been challenged, and this close attachment means that the child feels no motivation to speak, because his needs are being anticipated by his primary caregiver. Discussion with both parents does not indicate that the child undergoes separation distress (Bowlby and Bowlby, 2005)), but this could be anticipated from what might be an overly strong and exclusive attachment to Mother A. However, this author feels that attachment theory does not provide a model to explain what effect this kind of relationship might have on linguistic development. Behavioural theories of child development might also provide some insight, particularly if the child views that his current behaviours are being rewarded and reinforced by one or both of his parents (see, for example, the theories of Skinner, Pavlov and Watson).
Scientific and biological theories of linguistic development may shed some light on the situation. Chomsky (2007), for example argues that the development of language in the individual child depends on a combination of genetic factors, which precipitate language learning in terms of a biological imperative, experience, which relates to the placement of the child as interacting with its social world, and principles of development which are not specific to the faculty of language. What this demonstrates is a move away from Cartesian dualism, and the reintegration of the processes of the mind into the functional and developmental processes of the body (Chomsky, 2007). In this case, therefore, Child A is likely to have biological imperatives precipitating linguistic development, but may not be achieving his potential due to a possible deficit in his interactions with the social world. It may be that this theoretical perspective highlights the single most important feature in this case, the lack of social integration into the wider social world, or into normal society. This is not to say that if a same sex lesbian family were socialising in peer groups or social networks, that this would not be normal – far from it. What is notable about this case is that the family are isolated from both general, “heterosexual” society and from peer-related social groups. If there are, then, elements of linguistic development which are founded on social interactions, a deficit in these areas would likely indicate a potential reason for Child A’s linguistic retardation. The family have attempted to ensure the child is with his own peer group by placing him in a crèche, a group childcare environment, rather than a single carer environment, which is a positive move. However, it could be that even this is not sufficient to precipitate the linguistic development that would be expected of Child A at this point.
Classic theories such as Piaget’s constructivist theory, which posits certain developmental stages, might be useful here. In Piaget’s theory, constructivism is an alternative to simple biological understandings of child development, and the development of children’s thinking and cognition is segemented into four stages, which are viewed as progressive (Dawson-Tunkin et al, 2004). Piaget’s stages suggest that children must all move through these stages, sequentially, in order to develop ‘normally’. It is unsurprising that many theorists argue against the centrality of these sorts of stages, as being too restrictive and rigid and not necessarily universally applicable (Dawson-Tunkin et al, 2004). Piaget posits that equilibration, the process of learning wherein the individual reflects on previous experiences to assimilate new concepts and knowledge into current knowledge, is perhaps the most significant of the features of children’s development (Dawson-Tunkin et al, 2004). So, although Piaget understood that biological maturation may set the timetable and limits of some aspects of child development, but stresses that the environment in which children are placed, and their interactions with that environment, is essential to them developing as they should. “Children who have severely limited interactions with their environments simply will not have the opportunities to develop and organize their cognitive structures so as to achieve mature ways of thinking” (Cook and Cook, 2005). There appears to be an almost inbuilt dissatisfaction with equilibrium, requiring individuals to extend their cognitive structures by seeking out, assimilating and processes new information (Cook and Cook, 2005). This is complemented by reflective abstraction, in which individuals take note of something in their environment, then reflect on it (Cook and Cook, 2005). However, Piaget also argues that “children do not passively absorb structures from the adults and other people around them…[but] actively create their own accommodations and so construct their own understandings” (Cook and Cook, 2005). Feldman (2004) criticises Piaget’s theories because they do not properly allow for the individuality of children, and for differences in development which might be quite marked between children in different circumstances (Feldman, 2004). This author also questions whether there is any need for such rigorous demarcation of stages of development, because if they are still only theories, then labelling children as failing or falling behind might be detrimental to the child and his/her family. However, many theories of development, general and linguistic, do suggest that social environment and/or interactions affects cognitive and linguistic development.
Therefore, it could be that in this case, Child A, through his experiences to date, which have been somewhat limited in wider social interaction, has developed his own understandings of the role and function of language in his life, and has perhaps come to the conclusion that the verbalisation of language, at least for him, is rarely necessary. Cognition is not absent, this is evident from interactions with him. He can speak, or at least, it is evident that he understands language, symbols and complex sentence structures, but he does not have any motivation to speak. If asked to carry out a relatively complex task, such as ‘put the shells back in the truck, and put the truck away”, he can do this, readily, and willingly. But if asked to describe what he is doing or to describe his truck, he uses one word answers, gestures and facial expressions to communicate.
Cole et al (2004) discuss how positive emotions are important in child development, suggesting that “emotions organise attention and activity and facilitate strategic, persistent or powerful actions to overcome obstacles, solve problems and maintain wellbeing (Cole et al (2004). This might suggest that perhaps Child A is not being placed in situations where he is emotionally tested enough, in order to motivate him to utilise language in ways that other children might do.
Bell and Wolfe (2004) also suggest that there is a need to better understand and explore the role of emotions in organizing and regulating a child’s thinking and learning, and also in understanding the role and of thinking, learning and action in the regulation of children’s emotions. Certainly both Piaget and Vygotsky both argue that children working together learn more than children attempting to, for example, solve problems alone (Cole et al, 2004). It would be no great stretch to see the connection between these collaborative or interactive experiences, the emotional responses of children, and their development, and this must include linguistic development, because these interactions would require the use of language, and perhaps, the development of new linguistic capabilities. Callanan (2006) states that children’s cognitive processes are connected to the language they hear around them. In this case, therefore, it could be argued that Child A may be limited linguistically because the language he hears around him is only that of his two main carers, and of course, the language he hears on television. His social isolation may be affecting the ways in which he is thinking about the world, because he is exposed to limited verbiage.
A Freudian analysis of this situation would be both problematic and challenging. If Child A is passing through Freud’s stages of psychosexual development, it could be said that he is perhaps arrested in his oral stage of development, and has not moved out of this stage because of his relationship either with Mother A alone or with both of his female parents. Freudian analysis here is fraught with difficulties, however, because this is not a typical heterosexual relationship, and so the parameters within which Freud’s psychoanalytical theories are framed simply to do not apply. The whole issue of gender here could be a difficult one, because there may be those who believe that a male child needs a gender-similar role model, and his current parenting situation does not provide this. However, contemporary theories on child care and child rearing have veered away from gender-specific behaviours and advocated for gender-neutral child rearing, a reorientation which has followed in the wake of radical and second wave feminist theories (Martin, 2005). These feminist theories have at times rejected concepts such as socialisation in the development of children’s social and personal awareness and in developing gender identity (Martin, 2005). However, this author believes, as does Martin (2005), that socialisation is an important feature in child development, and that while Freudian theories posit primary socialisation as occurring within the home, socialisation also occurs once the child is exposed to new environments. If the child is only exposed to limited social environments, this might also mean the child does not become socialised to as many environments and behavioural codes as it should do. Certainly, this author has met colleagues who have argued that the lack of a male role model, or male role models in the home situation, would constitute a problem. However, it would seem that many would argue that gender neutral parenting would not affect development, particularly if gender and chld development is fixed by biology (Martin, 2005).
Vetegodt and Merrick (2003) suggest that there are five important needs that children have, in relation to formation of their identity and in relation to their cognitive development. These needs are: “the need for acknowledgement, acceptance, awareness, or attentions, respect and care” (Vetegodt and Merrick, 2003). There is a suggestion that if children do not have these needs met, they may then modify their own identities to adjust to their parents and the situation (Vetegodt and Merrick, 2003). While this may not necessarily be true, in the case of Child A and his family, it might be that his needs are met in the home situation, but his needs may be being met in other situations. Certainly, conversations with the parents suggest that they fear his needs, of the nature described above, would not be met outside the family environment because of the nature of his family. There is an ongoing belief that childhood is of primary importance in children forming ‘healthy identities’ (Taylor, 2004).
The Role of the Health Visitor
These theories are mere explorations of potential reasons for an apparent deficit in linguistic development in Child A. Addressing this developmental issue with the parents, in this context, is likely to be somewhat challenging, particularly as the relationship between the health visitor and the parents is of primary importance (Jack et al, 2005). Certainly the child’s home situation is a positive one, and there are no issues in relation to economic or other deprivation. Both parents are intelligent and open to discussion about development and the child’s social needs, but both are also, understandably, sensitive about their continued social exclusion. However, the role of the health visitor is to promote the child’s health and wellbeing (Condon, 2008), and so part of the role in this situation is to assess this wellbeing and ensure the child is offered full participation in all the aspects of health promotion and disease prevention available (Condon, 2008). In this case, as Mother A is a nurse, and Child A has been subject to all necessary health checks, immunisations, and the like. Engaging with the family has allowed the health visitor to identify elements of the home situation which could affect maternal wellbeing, and so affect child development and wellbeing, but there are no signs of postnatal depression or anything else to raise any warning signs (Peckover, 2003)
Here, the role of the health visitor may be to assist the family in identifying ways of extending their social sphere and social life, and integrating their child into social groups and networks which might be more accepting of their alternative family construct. However, there are limits to what a health visitor can advise, and it might be necessary to look at other disciplines, other professionals, and other agencies to support this family. Certainly with changes in the law and social life in recent years, it is becoming less challenging for alternative families to find support and inclusion, but in this case, it would seem that social inclusion may be negatively impacting upon their child’s development.
The public health dimension of the health visitor role is very much vaunted in the literature and in governmental policy, but is less easy to realise in practice (Cameron and Christie, 2007). Yet activities such as those discussed in this essay contribute to the public health dimension of the health visitor’s role, in concrete ways. Perhaps it is most important to view the macrocosm of public health policy in relation to the microcosm of the daily work of the health visitor, although it is not always easy to evaluate the day to day function of this role in relation to wider public health improvements.
It would appear that, whatever the theoretical standpoint, there seem to be a range of ways of defining child development, and many of these relate to the way that children relate to their environment. While there may be a biological imperative to develop cognitively, developing cognitive and, in the case of Child A, linguistic processes, there can be factors which can negatively affect these processes. If these factors are socially mediated, then the social environment that the child finds itself in may be as important as providing good nutrition and health protection. The author deliberately chose a family which was not characterised by typical socio-economic deprivation, or domestic violence, or drug abuse, to demonstrate that child development is fundamentally about the child learning to interact with others, peers and adults alike, in a range of social contexts, and it would seem, from this case, that linguistic development may be more psychologically mediated by such contexts. It may be more than a simple biological/cognitive process, and may require exposure to a range of social settings to fully develop properly, to motivate the child to use language effectively.
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