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investigation the effectiveness of a brief / a low burden intervention in reducing hypnotic prescribing

Order Description

Please be aware that this will be a protocol of my research. I will give you a brief explanation the I will provide you my colleague work that I will do the same thing. I am going to implementing the intervention then looking in depth may be then interviewing the GPs (general practitioners) or patients who come to or did not come the office (doing it in structured manner). please have a look to these work down as I am going to select 2 practices to work with. I am providing my colleagues’ work just to give you an Idea about what can been done.
Hypnotic Audit & Review 2014/15 X Surgery

Practice prescribing of hypnotics & benzodiazepines is measured and compared at a local (prescribing performance) and a national (QIPP indicator) level.

Why Audit?

* Continuing concern over long term use (1)

* Taking a benzodiazepine and/or hypnotic was associated with double the risk of death from any cause compared with no prescription for these drugs. Dose-response associations were found and there were approximately 4 excess deaths linked to these drugs per 100 people followed for an average of 7.6 years after their first prescription. (2)

* Driving whilst under the influence of drugs is a significant cause of injuries and deaths on the road. (3)

* Patients are not always given appropriate information and advice on the risks associated with long term use (4):

* Tolerance & addiction

* Drowsiness, clumsiness, forgetfulness, confusion, impaired judgement

* Falls & fractures – in people older than 60 years, these drugs are associated with an increased risk of falling of between 50-70% in relative terms. (5)

* Association with increased risk of dementia and increased cancer incidence in those prescribed high doses (6)

How is usage measured? Hypnotic ADQ per STAR PU – This is a measure of the total quantity of Benzodiazepines and Z-drugs prescribed, weighted for age and sex of a practice’s population.

At the start of the project x Surgery was the 4th highest prescriber out of 50 East Berkshire practices. x Surgery Q2 (Oct-Nov 13) 2013/14 ADQ 461

What action was taken in X Surgery?

1. Practice meeting to agree course of action with all prescribers. A consistent message is vital for success and helps to prevent patients pressurising or singling out a particular GP.

2. Search – patients prescribed these drugs during April – July 2013.

* Exclusion criteria: Housebound, care/nursing home (reviewed separately by care home pharmacist & responsible GP) and palliative care patients; one off supplies e.g. for back spasm, fear of flying and for epilepsy treatment.

3. Analysis consistently shows that a simple letter intervention reduces benzodiazepine use in patients who have been using them long-term (7). Letter sent to remaining patients to:

* Explain concern over the patient’s long-term use of named hypnotic/s

* Highlight potential side effects when taken over a prolonged period.

* Ask the patient to consider a reduction in their use. – Include advice on how to gradually reduce or cease use in a manner that is feasible and will decrease the likelihood of withdrawal symptoms.

* Invite the patient to discuss the issue further with own GP or by booking into pharmacist led clinic.

4. For those receiving a letter, these drugs were moved from repeat to acute and limited to 56 days supply.

5. A 2nd short reminder letter sent to non responders 3 months after the initial letter, also informing the patient that the maximum length of supply was now 30 days in line with CD regulations (June 2014).

6. Posters advertising clinics and detailing risks of long term use put up in waiting rooms

7. Agree initiation & prescribing policy for new prescribing – support leaflet supplied

8. Full range of support leaflets and reduction schedules available in all consulting rooms.

9. Monthly pharmacist (independent prescriber) led clinics offering 20 minute appointments. Scope of practice demonstrated by Benzodiazepines learning module via MHRA Training and Continuing Professional Development (CPD) and personal CPD records.

10. Reception staff / prescription clerks’ informed.

11. Raised awareness with local community pharmacies by providing self help leaflets & posters

Main audit observations

o 196 patients prescribed hypnotics, 95 patients prescribed benzodiazepine, 25 prescribed both.

o Included 37 patients care home residents

o 4 RIP during project

o Age range 5 – 101 years

o Length of supply range 1 day – 100 days

o 99% on repeat

o 107 patients with fall/fell in consultation, recording total of 238 falls, often leading to GP appointments, OOH/MIU/A&E attendances & hospital admissions. This included 14 fractures, 54 A&E/admitted and at least 3 road traffic accidents.

o There was occasional documentation of addiction & tolerance discussions.

Clinic Protocol

o Identify & address any underlying cause of insomnia, anxiety & depression

o Promote non drug therapies such as sleep hygiene methods and relaxation techniques using diaries & self help leaflets.

o Involve patient support network

o Guided by patient, negotiate flexible, gradual withdrawal schedule

o Convert to diazepam if appropriate

o Rebook for review, ongoing support and encouragement as appropriate

o Continue dose reduction at pace comfortable to patient

o Monitor withdrawal effects until stopped completely or at lowest dose to control effects of withdrawal. Where complete withdrawal may not be an achievable goal there is still benefit to be gained in reducing use to the minimum effective dose. (Ref BNF).

o Revisit benefits of stopping at every contact

o Highlight risks for drivers, including details of the proposed 2015 drug driving offence for those affected.

o Link patient into support services (Talking Therapies, SMART/T2, age concern, Community Veterans Mental Health Service)

What were the potential barriers to success?

* Not perceived to be a problem

* Cheap drugs – budget not affected

* Time & impact required

* More commonly used Z drugs are perceived to be safer than temazepam

* Patient resistance

* Limited support programmes available within mental health services

Results

Number of patients seen/telephoned by GPs was not measured. Number of pharmacist led clinic sessions 14 (First clinic January 2014: Last clinic January 2015)

> Number of patients seen 45

> Number of patient appointments attended 97

> Number of DNA 2

X Surgery Q2 (Oct-Dec 13) 2013/14 ADQ 461

X Surgery Q2 (Oct-Dec 14) 2014/15 ADQ 263

After the conclusion of the project, X surgery (Q2 2014/15) moved from 4th highest hypnotic ADQ per STAR PU prescribers to 29th out of 50 practices and below England average.

The inclusion of this prescribing performance indicator meant that all 50 practices received a consistent message regarding harms of long term use together with the offer of additional support material. A decrease can be seen by a large number of practices.

No other practice achieved the same magnitude of reduction as X surgery (as seen in Graph 1 below), who had received a higher level of support in terms of education, letters sent to patients and pharmacist led clinics over this time period. (Latest epact data available Q2 14/15)

Graph 1 – highlighting X Surgery

Medication Results: [12 month time period Oct12 – Nov13 vs Oct13 – Nov 14 (ePACT)]

The number of items dispensed decreased by 572, despite changing prescriptions to 30 days supply and thereby potentially increasing the number of items ordered.

The annual cost of hypnotic and benzodiazepine prescriptions reduced by £8,744.35, despite temazepam price fluctuations.

January 2013: Temazepam 10mg £4.23/28,

August 2013: Temazepam 10mg £27.08/28,

November 2014: Temazepam 10mg £19.77/28,

Table 1. Change in X SURGERY prescribing of hypnotics

X Surgery Previous 12 Months Current 12 Months

Chemical Substance Items Cost Items Cost

Temazepam 415 £13,186.81 205 £6,554.73

Zopiclone 1,023 £1,894.21 842 £1,232.56

Lorazepam 230 £1,096.01 209 £787.14

Oxazepam 147 £545.84 98 £238.27

Nitrazepam 93 £500.10 46 £138.81

Zolpidem Tartrate 175 £457.69 153 £279.15

Lormetazepam 6 £397.92 4 £234.14

Clonazepam 84 £239.44 44 £108.87

TOTAL 2173 £18,318.02 1601 £9,573.67

Melatonin prescribing remained stable, indicating patients had not been switched to melatonin as a non hypnotic alternative.

OUTCOMES – Benefit to individual, practice and wider public health agenda

* Keeping patients from harm by reducing exposure to side effects

* Patient in control, involved in own healthcare decisions & empowered to manage their medicines

* Prescriber education promotes consistent patient experience and raised awareness of potential serious side effects for patient and prescriber.

* Improved patient access to healthcare in convenient location with choice of provider

* Vulnerable or complex patients linked into other support agencies

* Opportunity to discuss other medication, helping patients to get the most from their medicines.

The final word – What particularly went well and what was hard?

Practice engagement over the course of the project was superb. It was well supported from the outset with the delivery of a consistent message, and patients actively encouraged to attend the pharmacist led clinic. GPs held steadfast regarding keeping supply on acute rather than repeat, at least until the patient had received the relevant support information. Initially, pressure on GPs time was high. Inevitably, this quickly decreased, but was time consuming on top of the usual high work load.

References

(1) As long ago as 1988, the Committee on Safety of Medicines advised that benzodiazepine hypnotics should be used only if insomnia is severe, disabling or causing the patient extreme distress. The lowest dose that controls symptoms should be used, for a maximum of 4 weeks and intermittently if possible. NICE guidance also recommends that when, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications. NICE also confirms that there is no compelling evidence of a clinically useful difference between ‘Z drugs’ and benzodiazepine hypnotics from the point of view of their effectiveness, adverse effects, or potential for dependence or abuse. There is no evidence to suggest that if patients do not respond to one of these hypnotic drugs, they are likely to respond to another. Despite these national safety warnings and guidance, overall prescribing of hypnotics is not decreasing.

(2) BMJ 2014;348:g1996(published 19 March 2014)Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. After an average of 7.6 years, prescription of an anxiolytic, a hypnotic or both was associated with double the risk of death from any cause compared with no prescription for these drugs, after accounting for pre-existing psychiatric disorders, other diseases and other prescribed drugs.

(3) Report of the Review of Drink and Drug Driving Law, Sir Peter North, June 2010; Department for Transport, Impact Assessment for the new offence of driving with a specified controlled drug Impairment by drugs was recorded as a contributory factor in about 3% of fatal road accidents in Great Britain in 2011, with 54 deaths resulting from these incidents. Some evidence suggests drug driving is a much bigger road safety and may be a factor in 200 road deaths per year. A large study of drivers prescribed sleeping tablets in the previous 7 days had double the risk of road traffic accidents compared with those who did not take them.

(4) PMID:15203405 Aging Ment Health. 2004 May;8(3):242-8.Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers.

5) Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. 2009;169(21):1952-1960. doi:10.1001/archinternmed.2009.357.

(6) BMJ 2014;349:g5205 doi: 10.1136/bmj.g5205 (Published 9 September 2014) Benzodiazepine use and risk of Alzheimer’s disease:case-control study

(7) Vicens C, Bejarano F, Sempere E, et al. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Br J Psychiatry. 2014 Feb 13 and Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593857.

There is a graph has been sent to me showing the prescribing rate in some practices .The practices in question are the 2nd highest and 4th highest prescribers on the graph above

Indigenous Health

Order Description

SUMMARY/CASE STUDY – 1000 words:
The Case-Study (Russell Nelly, Workshop 10 – Week 12) is central to the summary. Summarise your knowledge and
understanding of the unit’s key concepts through the life story of Russell Nelly.
Validate your position with evidence from the unit’s text book (Eckermann et al, 2010) and peer-reviewed academic
articles, as well as other sources.
Consider your engagement and interaction with Aboriginal people as a future health professional
· A minimum of 5 academic references for Summary/Case Study
· APA 6th referencing style required.
The only authoritative version of this Unit Outline is to be found online in OASIS
· Connect aspects of the course to your own experience and/or understanding.
· Explore and identify similarities and differences between your culture and that of Indigenous people.
· Relate the knowledge and content to how this might be relevant or applicable to your future professional role
Submission: Assessments are to be submitted electronically to Turinitin on Blackboard via the submission point under the
‘Assessments’ menu. Please keep your Tii receipt for proof of submission.

Sources:

Eckermann, A-K., Dowd, T., Chong, E., Nixon, L., Gray, R, and Johnson, S.(2010) (3rd Ed) Binan Goonj: Bridging Cultures in Aboriginal Health (3rd ed., pp. 1-42). Marrickville, NSW: Elsevier. [Chapter 1.]

https://www.abc.net.au/news/2013-10-21/bellear-indigenous-sovereignty/5032294?WT.mc_id=newsmail

Crawford, F., Dudgeon, P., Garvey, D., & Pickett, H. (2000). Interacting with Aboriginal communities. In P. Dudgeon, D. Garvey, & H. Pickett (Eds.), Working with Indigenous Australians: A handbook for Psychologists (pp. 185-201): Gunada Press.

Durey, A. (2010). Reducing racism in Aboriginal health care in Australia: Where does cultural education fit? Australian and New Zealand Journal of Public Health, 34(1), S87-S92.

Aboriginal Services Branch in Consultation with the Aboriginal Reference Group. (2009). Working with Aboriginal People and Communities: A practice resource. Ashfield, NSW: NSW Department of Community Services.

Nursing Council of New Zealand. (2011). Guidelines for cultural safety, the Treaty of Waitangi and Maori health in nursing education and practice. Wellington, New Zealand: Author.

GHS5841 Research and Evidence for Practice/Workbook: Supplementary Assessment

Name:
Student ID:
Instructions
Type your answer in the space provided. You may wish to use a different font or text colour to make your answers stand out. Note that the space is not indicative of the appropriate length of your answer; the text below will move down as you type. Do not delete any of the text already in this template. The marks allocated to each question are an indication of the amount of detail required. You are not required to write an essay in response to any questions; an outline of the pertinent information is all that is required (but the marker must be able to make sense of it). If you use any sources to help answer the questions these must be correctly referenced; inappropriate references will not be accepted.
Answers should be as precise as possible and should answer the question that is actually asked. For questions requiring calculations, you are advised to show how you arrived at the answer.

Incorrect or inappropriate information supplied in addition to correct information for any individual question will result in a loss of marks for that question. (Eg the answer will be deemed to be half right and half the available marks will be allotted. The actual percentage will vary depending on the amount of incorrect information relative to the correct information and the number of marks available.)

Up to 5 marks will be deducted for incorrect or inappropriate referencing, depending on the magnitude of the errors and the relative percentage of accurate and inaccurate references. No marks will be deducted for poor grammar, spelling etc. providing the answer is intelligible.

Save your file as a Word document with your Student ID in the filename. Upload the completed file to Moodle as usual.

This paper consists of 104 marks and constitutes 20% of your grade for this unit.
REFERENCES should be between 2010- 2015

QUESTION 1     (3marks)
a) Locate, and give the reference for,one article that represents the highest evidence available relating to the changing of intravenous administration sets.
b)According to the JBI evidence hierarchy (effectiveness domain), what level of evidence is this article?
c) What is the evidence regarding the frequency of administration set changes?

QUESTION 2     (10 marks)
a) Identify the appropriate measurement scale for the following:
Variable    Measurement Scale
Length
Body temperature
Time of day (Night, Dawn, Noon, Afternoon, Evening)
pH
Hair Colour
Ranking of journals in a category according to impact factor
Presence or absence of infection
Height

b) You construct a survey and create categories for age – what scale is this? Identify one advantage and one disadvantage of measuring the variable in this way.

QUESTION 3     (2 marks)
The lifespan of light bulbsis normally distributed, with a mean life of 850 hours, and a standard deviation of 20 hours.
a) What would be the expected lifespan of approximately 99% of the light bulbs?
b) What percentage of light bulbs should last for at least830 hours?

QUESTION 4     (8 marks)
Nursing staff in a surgical ward are interested in acupressure in treating postoperative nausea and vomiting. They decide to carry out a study comparing its effectiveness with that of standard treatment. Patients must consent to the study to be included.
a) Explain the difference between internal and external validity in studies such as this[2 marks]
b) Identify 3 threats to internal validity in this study and suggest strategies by which they could be prevented or reduced [6 marks]

QUESTION 5     (6 marks)
A class of 30 students received the following marks (expressed as percentages) for their overall assessment.
Student    Mark        Student    Mark        Student    Mark
Grace    50        Sunil    62        Ahmed    67
Jianxia    76        Louisa    90        Tracey     72
Mark    82        David    72        Lian    62
Herlina    52        Jennifer    54        Abdul    20
James    64        Matilda    69        Melanie    65
Bianca    77        Elise    43        James    59
Mishal    35        Ramon    75        Jehan    67
Nawal    85        Caroline    62        Diana    58
Chris    78        Zara    70        Peter    68
Simon    60        Sunit    56        Rebecca    53

a) Calculate: [3 marks]
i) The mean
ii) The median
iii) The mode
b) You wish to know whether there is a difference between the marks obtained by male and female students. How would you examine the association between these two variables?[1 mark]
c) What statistical test would you perform to examine the significance of this association? [1 mark]
d) You are also interested to know whether there is an association between the marks obtained for this subject, and those obtained for another unit which all of the students have taken. To compare the marks you calculate Pearson’s correlation coefficient, and obtain a result of -0.334. What can you conclude about the relationship between the two sets of marks? [1 mark]

QUESTION 6 (3 marks)
The graph below indicates the distribution of the memory test scores of 123 people. What inference can you make about the distribution of scores? [1 mark]
c) For this dataset, what would be the most appropriate measure of: [2 marks]
i) central tendency
ii) dispersion

QUESTION 7     (15 marks)
Julia works in a general medical ward where the majority of patients have intravenous infusions. She is concerned about the incidence of phlebitis around the cannulation site and wonders whether it is related to the type of dressing used to secure the cannula. Currently all cannulae are secured with adhesive tape. After examining a variety of available products, Julia and her team decide to try a transparent, non-occlusive dressing to see if the incidence of phlebitis is affected.
a) Generate a null hypothesis and an alternate (non-directional) hypothesis for Julia’sstudy[2 marks]
Null:
Alternate:
Julia and her team commence a study to test this hypothesis.For the first 6 months of the study, all enrolled patients have their IV cannulae managed with the standard dressing. The incidence of phlebitis is documented and all other relevant data is collected. For the next six months, all enrolled patients have their cannulae managed with the new dressing. The same data is collected as previously.
b) What is the name of this research design? What level of evidence (according to the JBI hierarchy) will it generate? [2 marks]
c) What design could be used to provide a higher level of evidence? Why is this second design considered superior? [2 marks]
d) Give three (3) reasons why Julia’s team might have chosen the first design over the second [3 marks]
e) For this study, identify [2 marks]:
i) the independent variable
ii) the dependent variable
f) How will Julia’s team examine the association between the independent and dependent variables? [1 mark]
g) What statistical test would be appropriate to test the hypothesis? [1 mark]
h) The test is performed and the result generated is p=0.004. Interpret the p-value. [1 mark]
i) What decision would you expect the researchers to make with respect to the null hypothesis? [1 mark]

QUESTION 8    (7marks)
Researchers are interested in comparing the effectiveness of a non-pharmacological method of managing pain compared with pharmacological management in patients with arthritis. They decide to conduct a systematic review.
They perform the systematic review and find 4 studies have been conducted. All have measured patients’ self-reported pain using a visual analog scale (1-10), and have compared the mean pain score for the experimental and control groups. The researchers are able to combine the findings from these studies in a meta-analysis, testing the null hypothesis that there will be no difference in the pain scores between the two treatments. These findings are displayed graphically in the Figure in Appendix 1.
a) What does the figure indicate about the outcomes of the 4 individual studies?   [2 marks]
b). Comment on the width of the confidence intervals for the various studies. What is the likeliest reason for the difference?[2 marks]
c) When the findings from the 4 studies are combined, the difference between the mean pain scores is 0.4, with 95% confidence intervals of -0.4 and 1.2. Interpret these confidence intervals [2 marks]
d) What conclusion will the researchers make regarding the null hypothesis? [1 mark]

QUESTION 9     (21 marks)
Jane is a new graduate coordinator at a hospital where she manages the transition to practice of new graduates employed at the hospital. She has introduced a mentorship program on two of the wards where she provides primary mentorship to 10 graduates and wishes to conduct qualitative research to explore the new graduates’ perspectives on their transition experience in these wards, and compare it toother support programs in the hospital.
a) Identify an appropriate methodology for this study and provide a rationale for its use.Include at least one reference specific to the methodology. Identify the paradigm with which this methodology is aligned. [6 marks]
b) Identify and provide the rationale for a suitable sampling strategy for this methodology. [3 marks]
c) What data collection strategy/strategies would be most appropriate for this methodology? Give reasons. [3 marks]
d) Describe, and provide a rationale for, an appropriate method of data analysis for this methodology. [3 marks]
e) Identify three (3) elements of research rigour relevant to this methodology and provide a specific example of how each could be achieved in this study. [6 marks]

QUESTION 10    (16marks)
a) With respect to the study in the Question9, identify specific ethical problems which this study raises, and the ethical principle which is threatened in each case. What specific strategies couldJane adopt in her research procedures to overcome these ethical problems?  [6 marks]
b) Provide an example of each of the following ethical review categories, and give reasons why the type of study would be categorised in this way [8 marks]
i) a type of study requiring approval by the full Human Research Ethics Committee (HREC)
ii) a type of study that could be approved by the Chair of the HREC alone
iii) a type of project that could be exempted from ethical review
iv) a type of study that would not require approval by any external body or committee
c) In the study in Question 9, what type of consent would you expect participants to provide? Why? [2 marks]
QUESTION 11    (13 marks)
In the appendix at the end of this document you will find extracts from interview transcripts from a study examining the experiences of lecturers at a UK university. “Rachel” and “Fern” are pseudonyms for two of the study participants. The specific question addressed in these extracts is “What are lecturers’ experiences of teaching various types of students?”
a) What type of interview are these examples of? [1 mark]
b) Written transcripts contain only the words spoken by the participants. What other data is available during the actual interview, and is important to take into account when considering their answers to the questions? As a researcher, how would you collect this type of data? [4 marks]
c) From the data, identify two (2) themes that could contribute to answering the research question. Provide 3 examples of data (ie, quotes from the interviews) that would contribute to each theme. [8 marks]

REFERENCES

REFERENCES should be between 2010- 2015

APPENDIX I

Figure: Findings of 4 studies, showing the difference between the mean pain score (central square) for the experimental (non-pharmacologic management) and control (pharmacologic management) groups. 95% confidence intervals are shown by the lines. The final diamond shows the combined difference between mean scores (mean score for experimental group minus mean score for control group) and 95% confidence intervals (ie meta-analysis of the 4 individual studies).

APPENDIX II
Extract 1: Fern
Interviewer: Okay, we are now going to focus on students. A question about the attendance and motivation of students.
Fern: I think that’s difficult, I think now we’re treating the preliminary degree as a career grade it’s becoming a bit like school. In a sense you’ve got some kids who love to be there and other kids who can’t be bothered because they’re just going through the motions. And there used to be about 5–10% of people went to university so I imagine you were effectively teaching that minority who really want to be there. But now you have some who are not too bothered; they’re here to get a qualification and get on with their lives, and they’re quite instrumental with that. But people don’t attend because they’re working, they don’t come in because as soon as they know what the assessment is they go to do it and don’t want to learn. They’re not particularly interested in learning they just want to get the assessment and that’s it. So I think to a certain extent that I understand that’s instrumental to students doing reasonably well. They don’t have a breadth of education but they can technically get though the assignment. So I just let them get on with it and concentrate on those who really want to do it, you know. So really it’s like the old university group inside the mass really, so you know I just focus – that’s not true, I don’t just focus on those who are interested. But if a minority, like lectures aren’t compulsory, we don’t take down registers so there might be people not there. But we do take registers in seminars so we have more people there. If I find some people haven’t turned up to class I don’t worry about it because I teach those that are there and those who are there by definition are the most interested. So attendance is a problem, that cynicism of ‘oh let’s get through this’, ‘oh we’ve got to do this degree, let’s get through it’. There’s still loads of interested students but, if they’re not there, then they’re either working or not interested.
Interviewer: Okay, what is your experience of teaching mature students?
Fern: Oh it used to be fabulous, in the good old days when there were grants we had loads and loads of mature students and sometimes up to a third of a course were made up of mature students. And there would be all sorts of people, we had vicars, we had retired miners – all sorts of people coming in. And lots of women who had returned to work after having children. And several of them struggled with it but some of them were really fabulous. In fact we had a couple of mature students just recently on the course; I wouldn’t say more so than other students, but they were here because they wanted to be here. And they were desperate to learn and desperate to know, some of the brightest students we had were the mature students. And I thought it was marvellous taking somebody who had no chance of education and suddenly had the confidence to realise that they could come to learn and I think it’s fabulous. I really, really enjoyed that, you don’t have that now because of course they can’t afford to take the loans out, mature students, they have to work. You know, no government grants, there’s no support for them so they’ve all gone, nearly all gone.
Interviewer: Have you noticed this change since it became a university or just the whole…
Fern: It’s the loss of the grant. I don’t think it’s got anything to do with turning into a university; I suppose there’s also the whole strict admissions and this kind of thing. But I don’t think that’s got to do with being a university because I think traditional universities used to take in more mature students all the time so I don’t think it’s got anything to do with being a university. I think that it’s just to do with increased bureaucracy and the loss of grants.
Interviewer: Have you noticed any differences between the way that students like to be taught? Like more traditional students liking it one way and mature students a different way or?
Fern: I don’t know…
Interviewer: A difference in methods of teaching?
Fern: I don’t think there’s a difference in methods of teaching. I think all students now need the information, they want to know what the assessment is; they want to know what they need to do because they want to know how to get the marks. They really are quite instrumental, whereas the mature students never were here just to get the qualification – that was the icing on the cake. They were here to learn and to enjoy the process. I’m not sure that students enjoy the process any more; I don’t know if students get a kick out of learning anymore, they do it because they have to do it otherwise they won’t get the jobs they want. So whether it’s to do with style of teaching, it’s got to do with the content and the seminars, the attitude is just very, very different – take the information.
Interviewer: What is your experience of overseas students?
Fern: Loads of it through the years. Again, it’s about the same; there was a stage where the international students were quite exceptional: they had quite a struggle to get here and wanted to learn as much as possible. Whereas now we get loads of international students being sent by their government to get trained up, to get qualifications, and therefore they haven’t got a hunger to learn. Well, that’s not true, some of them do. But their priority is to get that qualification in the time scale because otherwise they’ll have to pay the money back or lose their job so people are under that very instrumental pressure, so not doing it for the love of it. I think it’s much the same; I don’t think it’s to do with being an international student but I think it’s to do with being put through the grinder to get the qualifications. And I think that makes it difficult, but many of them are a delight to teach, very interesting, obviously they bring new experiences and different perspectives.
Interviewer: And what about language barriers?
Fern: That’s very difficult because, if people just aren’t experienced, they may not understand what you’re saying. I have quite a fast delivery so I don’t probably teach in a style that students would find useful. I work with PowerPoint but then I explain things and I think that I do that quite quickly, and therefore, if the language isn’t there, I think that to pick up the meaning of what I am saying may be quite difficult. So I do try to repeat things rather than say it slowly, I try to say things two or three times. But yes, I think people seem to learn quite quickly when they get here and have to learn another language. But I know students who can barely speak and still manage to get through it somehow. I think a combination of low motivation, not really being very on top of a subject and not being able to speak – when you’ve got that combination it’s pretty difficult, but I haven’t often seen those combinations all together. For instance I have very able, very polite international students who barely speak English but, as I say, they can still get over it. It’s a mixture really.
Extract 2: Rachel
Interviewer: Okay, we’re going to move on now to student diversity. What is your experience of teaching mature students?
Rachel: I taught a lot of mature students in my previous job, but in this post at the moment I’m teaching predominately undergraduates.
Interviewer: And have you noticed any differences between traditional and mature students?
Rachel: No, nothing huge.
Interviewer: What about in terms of preferred teaching methods?
Rachel: With mature students you can probably be a bit more flexible with your teaching methods and you can also expect them to read. They’ll probably take it quite seriously so, for instance, when I was teaching some mature students in my last job, if you asked them to read something, they would come back having made notes. So I think they tend to take studying more seriously while traditional undergraduates are less likely to read. So you have to rely on different teaching methods so in that respect, yes there is a difference. Mature students are also more likely to bring their work to you for guidance. This may be just a lack of confidence because they haven’t been in higher education before or for a long time or just because they feel more committed to the course they’re doing.
Interviewer: And do you get more satisfaction from teaching mature students as opposed to traditional students or vice versa?
Rachel: I like to teach them all: it’s different and there’s great satisfaction if you have a good traditional student sitting there and they’ve read something because they’re interested in it after you’ve given the lecture about it. If they hadn’t thought about something before, but now they are reading about it, then the satisfaction is immense. On the other hand, it’s quite demoralising when you feel that you’ve given your heart and soul to a lecture and then the students come along to a seminar and are just not interested – it’s quite demoralising. It’s also frustrating because you can’t actually make people do work for seminars.
Interviewer: Okay, have you got any experience of teaching overseas students?
Rachel: No, not really, no.
Interviewer: We’re going to look at teaching now. What’s your experience of teaching using lectures?
Rachel: In the terms of the response you get or how you feel about it?
Interviewer: Both.
Rachel: I don’t mind big lectures now; I used to be terrified and used to find it really hard to stand up in front of lots of people. But now I think I feel a bit more confident about that. I think it’s frustrating when you write a lecture and you know people are talking and I think it happens more these days; it’s hard to keep good order in your lecture theatres because there are lots of students. I think some of the two-hour lectures are too long but I still think it’s a really good way of imparting knowledge – providing a structure to a subject area.
Interviewer: Do you like to give lectures?
Rachel: Yes, I don’t mind now. I can’t believe I’m saying that, but I don’t mind!
Interviewer: And how about seminars?
Rachel: I don’t mind seminars either. I think the old-fashioned way of expecting students to work for seminars has gone and that’s the hardest thing, you can’t go to a seminar and expect all the students to have prepared. So seminars can actually be really hard work, perhaps harder than lectures.
Interviewer: And are you involved in any other sorts of teaching?

Rachel: I do try and do different things; I have a module where I do try and take the students out on field trips, which I really enjoy and I think that’s really, really useful. And I’d like to see more of that, I’d like to see more students getting out and about – they’re studying the world, they should get out and be more interactive with the community that’s around us.
Interviewer: How about workshops?
Rachel: To be honest I can’t see the difference between a workshop and a seminar. I do try to do things differently and use film and try to get them to act out things as well. We try to get the student to imagine they are in a particular situation and how that would feel, so I don’t know if some people would call that a workshop rather than a seminar.
Interviewer: Okay, if you personally need advice or guidance, where does that come from?
Rachel: I don’t know. Probably colleagues – it would probably be informal amongst my colleagues.
Interviewer: So what would you say your preferred method of teaching would be?
Rachel: I think a combination really. I think lectures are good, but it’s quite good to break lectures up, if you can, into activities. But if you have a large number of students then you’re limited. I just think that a combination of different things – film, lecture, activities or sometimes you get students to think about things. We’ve got a debate in one of our seminars so we get them to split up into two camps, and one’s got to argue for and one against. I think a whole host of things because if you use the same thing over and over again it’s boring for you and it’s boring for them so it’s as much of a varied approach as possible.
Interviewer: And how do you find fitting everything in, with your time management and juggling everything?
Rachel: Stressful and hard at the moment, but you do. I think some people probably do it by not being available to students and that’s hard because then the students know that you are available and you’re the sort of person that they want to go and talk to – they’ll come and see you and not see anyone else. So in a sense if students see you as being student-centred and student-friendly then all your appointments will be filled up and you’ll have a constantly full diary. But people who aren’t like that have a lot more time and I think that is really hard for you to gauge in higher education. A lot of the people who students don’t go and see are perhaps the ones who are seen as the leaders within the subject areas; students go to see the workers, the teachers, and obviously they have more contact with students and so students go and see them, so I think it’s quite difficult.
Interviewer: And what do you think about student motivation and participation?
Rachel: It varies; you’ve got some students who are fantastic and they’ll attend everything and, if they’re not going to attend, they’ll let you know. Then you’ve got some who you don’t even know, and you couldn’t even put a name to a face if they turned up. I think higher education as a whole needs to think about what we want to do in terms of attendance of students because it’s something which is going to get worse. You’re now in a position where students could be sitting exams having attended no lectures or seminars and they might pass but they might not pass so I do think there needs to be a central approach to the whole faculty.
Interviewer: Do you think that’s got anything to do with students working?
Rachel: Yeah I think it’s a lot to do with students working, but I think it’s also because some don’t take it that seriously, and also because they see it as something they’re paying for, so if they don’t go it’s up to them. And I think that there is a real shift from the time when I was at university when you went to everything – you attended. But if you hadn’t read you didn’t attend because you didn’t dare go to a seminar – you hadn’t read and you’d be picked on to say something so you’d rather not go to the seminar. I think there’s a real change that has occurred in the last ten years.

Psychosocial Aspects of Substance Abuse/Dependence Treatments

Order Description

Alcohol
Cassidy is a 40-year-old female who is seeing you today for advice around alcohol consumption following encouragement by friends. Cassidy is currently separated from her husband and they have two children aged 8 and 10. She is working part time as an Assistant in Nursing and enjoys her job. With the exception of staying at home when the children were younger, she has always maintained employment. Cassidy has limited family support as she has one brother and both her parents are ageing and unable to help look after the children. Her family members are reported to be social drinkers, though her maternal grandfather was described as a ‘heavy drinker’.
Cassidy started drinking alcohol socially from the age of 16, with regular drinking (mainly on weekends) occurring 7 years ago, 12 months after the birth of her last child. For the past year, she has been drinking between 2 to 3 litres of wine across the week, with her alcohol consumption being heavier on the weekends and non-work days. On these days, her drinking is beginning to start around lunch time, stops when the school day ends and recommences when she is cooking tea. On work days, Cassidy begins drinking whilst cooking tea. On all nights, her drinking session usually does not end until she goes to bed. During your assessment, you note that Cassidy is concerned about: starting to be ‘snappy’ with the children; not being the mother she used to be; wanting to drink more; and finding it difficult to get up in the morning.
Psychosocial Aspects of Substance Use/Dependence Treatments
Mark: 40
In six (6) pages please address this part of the essay with the following psychosocial treatment points of consideration for your chosen case scenario (that is, you must relate the diagnosis and treatment to the patient in the vignette):
• What social factors contribute to the maintenance of the substance using behaviours for your (vignette) patient?
• Any special considerations for your (vignette) patient (for example age/gender/culture)
• Would you take an abstinence or harm minimisation approach for your (vignette) patient? Why? (Make sure you define harm minimisation).
• What psychosocial intervention(s) if any would you select for your (vignette) patient? Why? For example, if you select motivational interviewing, please ensure that you also include (i) an overview of the theoretical underpinnings or framework of the intervention you have chosen (for example, motivational interviewing’s theoretical underpinnings of the Transtheoretical Model).
• A brief review of the evidence-base (citing up to a total of six references in that section of your assignment) with a particular focus on research conducted on your (vignette) patient’s demographics.
• What relapse prevention strategies would you consider for your (vignette) patient? Why?
• If pharmacotherapy was also required for your (vignette) patient, how would (or could) you integrate the two treatment approaches?
Make sure that you answer all aspects of the marking criteria below AND that you connect the selected treatment to your (vignette) patient in the case scenario and why that treatment is appropriate for them.

Identified social factors in context of using for your (vignette) patient
/5
Special considerations identified for your (vignette) patient
/2
Rationale for abstinence or harm minimisation approach (and definition) for your (vignette) patient
/4
Selected appropriate treatment(s) for your (vignette) patient
/3
Demonstrated an understanding of the theory for the selected treatment(s) for your (vignette) patient
/7
Provided evidence that the treatment(s) selected are evidence-based for your (vignette) patient
/5
Identified appropriate Relapse Prevention strategies for your (vignette) patient
/8
Integration of Pharmacotherapies into Psychosocial Treatments for your (vignette) patient
/3
Implemented appropriate referencing style for your (vignette) patient
/3

Concept Analysis Paper
Description
In this paper you will demonstrate scholarly, graduate school level writing and critical analysis of existing nursing knowledge. Your final paper will be 7–10 pages (excluding title page and references), using APA format with at least 8–10 scholarly nursing sources of information.
Directions:
For your final submission, you will take a concept of interest (“trauma” will be the concept of interest) to you and develop it into a final concept analysis paper. You may select a single word (concept) that you have wondered about or discovered in your readings.
The Unit 9 Assignment will focus solely upon the discipline of nursing with the inclusion of nursing scholarly sources to substantiate the literature review. Locate evidenced-based articles (based on research studies in nursing) that use the concept or discuss the concept.
For this paper you will:
•    Identify the concept and purpose for studying the concept.
•    Describe reasons for this concept being of interest to nursing and its body of knowledge.
•    Define the attributes of the concept and relevant uses.
•    Provide a summary of the concept as described in each article with examples of how the term was defined.
•    Provide the theoretical and operational definition of the concept based on the review of literature. (Theoretical is pure definition and operational is how it is used in practice.)
•    Apply the concept as it relates to your practice (medical floor or also known as medical surgical floor) and how you will use this concept in the future.
•    Describe the value of these concept analyses to your understanding of nursing knowledge.

Grading Rubric

Describes the concept and purpose of studying the concept in a well-developed paragraph.
Thoroughly describes multiple reasons with good rationale in a well-developed paragraph.
Describes all pertinent defining attributes of the concept, using nursing and other literature in a well-developed paragraph.
Provides review of literature for a minimum of 8 to 10 scholarly articles that discuss or define the concept; literature review findings are summarized.
Provides a theoretical and operational definition of the concept in a well-developed paragraph.
Provides an application of the concept to your own practice model in a well-developed paragraph.
Describes value of concept analyses to student’s development in a well-developed paragraph.
Text, title page, and references page are consistent with APA format.

Ideas and information from other sources are cited correctly.

Rules of grammar, word usage, and punctuation are followed.

Assignment is spellchecked and proofread.

Overall style is consistent with that expected of formal, professional work.

Strategies to enhance emotional intelligence

Order Description

Dear writer

Answer this question as new graduate nurse as good leader
Allocated students will research the topic ‘Strategies to enhance emotional intelligence’ and complete a PowerPoint presentation to their peers illustrating how competence in the topic area will make them a good leader, i.e. to manage patients, staff and work well as a team member.

this speech presentation ,
could you please add the main point or outline in 2 slides PowerPoint. and the rest of the words writer it in papers.

Introduction (Strategies to enhance emotional intelligence)
Becoming part of the team is much more than TeamSTEPPS® even though using all of the prescribed elements of TeamSTEPPS® contributes significantly to team success in acute situations. As a new graduate registered nurse you will have to settle in to a new situation. However, even highly desirable change can be stressful at the beginning.  Emotionally you need to see any move as an adventure, a chance to learn and expand. Since it is inevitable, aim to get absolutely everything you can out of it. Regulating your emotional responses is critical, so develop a plan to explore all of the new situation and the people involved. See any new situation as a fresh start and be a new person in a new area.

Emotions matter is the overarching principle with regard to emotional intelligence (Yale Centre for Emotional Intelligence 2013). Early researchers had to overcome the commonly held notion that emotions were to be taken out of the equation and that people could function independently or were considered robotic. Emotional intelligence can affect decision making and is considered more important than IQ with regard to future success (Yale Centre for Emotional Intelligence 2013).

Emotional intelligence is defined as: a type of social intelligence that involves the ability to monitor one’s own and others’ emotions, to discriminate among them, and to use the information to guide one’s thinking and actions.
(Johns Hopkins University n.d., p. 1)

The skills to recognise emotions, understanding emotions and how they affect behaviour, labelling emotions accurately which means having a sophisticated vocabulary to describe the full range of emotions, expressing emotions appropriately, regulating emotions effectively are critical in nursing (Yale Centre for Emotional Intelligence 2013). By sensing others feelings and perspective, taking an active interest in their concerns the emotionally intelligent nurse does not take things personally and is able to accurately identify the emotional side of issues, such as the fear that underlies what appears to be demanding behaviour.

Emotional intelligence involves being able to use your emotions effectively (Yale Centre for Emotional Intelligence 2013):
•Positive mood may enable problem solving and creativity. An increase in confidence with regard to capabilities. Improved memory may also be present at these times.
•Anxiety motivates better preparation for tests and exams etc.
•Mood swings may assist with considering a wider variety of outcomes and better preparation.
•Negative mood may enable empathy or a focus on detail or critique.

Regulating emotions is helpful to the new graduate registered nurse; tune in to people, their interests, their concerns, so that your own self-consciousness reduces. People paid the compliment of undivided attention do respond positively in most instances. If you have tried your best then the problem is probably the other person’s, a headache, concerns at home, a recent loss or many other reasons that could have doomed your encounter from the beginning. Having empathy for other people is one of the keys to emotional intelligence. Show people you like them, greeted by a smile, genuine warmth and sympathetic interest, even those who are shy and insecure (these insecurities afflict preceptors and other staff at all levels) are likely to respond positively. Emotionally you need to send out positive signals, negative thinking such as ‘I am dreading this, I wish I could go home … no one will talk to me’, will show on your face and body language, you will be sending out subconscious signals that people will feel. It is often you who create your own reality.

There are many responsibilities and accountabilities that cannot easily be tested as an undergraduate (Hickey 2009). The skills to endure hardship, the skills of emotional intelligence and conflict are all strategies that may assist the NGRN (Hart et al. 2012).

Further information

Activity 3—Emotional intelligence competencies in nursin

You will be directed through a number of exercises by your lecturer including the following:

In your groups/as a whole group:

1   Review the pre-tutorial activity where you consulted the ‘Nursing core performance standards and capabilities and emotional intelligence’, developed by Johns Hopkins University, and asked yourself ‘how successful am I in each of these areas?’.
?If you feel comfortable, discuss any insights that result from completing the self-assessment.
?What areas do you need to work on, if any?

2   Undertake activities with regard to RULER and the MOOD METER as directed:

Recognising emotions in self and others

Understanding the causes and consequences of emotions

Labelling emotions accurately

Expressing emotions appropriately

Regulating emotions effectively

It includes valuing the importance of learning and teaching these skills to promote effective personal, social and workplace success.

(Sourced from: Yale Centre for Emotional Intelligence 2013, ‘Ruler Overview,’ http://ei.yale.edu/ruler/ruler-overview/)

DISCUSSION FORUM 6

Dream Water
The Anti-Energy Drink
by Sheila Shayon

“Dream Water is the world’s WORST energy drink.” That’s the pitch from two entrepreneurs David Lekach, CEO, and Adam Platzner, Partner & CMO who are disintermediating the sleep aid category with their product.

If you are one of the 50-70 million Americans who suffer from sleep disorders, help is here. Dream Water is an all-natural, non-caloric product made from GABA (Gamma-Aminobutyric Acid) for relaxation, Melatonin to help induce sleep, and 5-htp (Tryptophan) to improve the quality of sleep. It takes effect 20 to 40 minutes after consumption on average, and unlike many OTC and prescription sleep aids on the market, it’s non-addictive and has no side effects or morning grogginess. Functional beverages sales are in the tens of billions of dollars annually in the United States and pharma sleep aids are in the multiple billions says Lekach. For OTC sleep aids alone, Packaged Facts expects the total market to near the $759 million mark by 2013.

Produced by Dream Products, LLC, Dream Water is available as an 8 oz. bottle in “I Dream of Kiwi… and Plum” and “Lullaby Lemon w/ hints of tea” flavors, or a concentrated 2.5 oz. shot “Lullaby Lemon w/ hints of tea” and “Snoozeberry” (blueberry and pomegranate flavors).
Their first retail partnership in 2009 was with Duane Reade in New York and was publicized as Dream Water Puts the ‘City That Never Sleeps’ to Bed. “Duane Reade prides itself on supporting the launch of innovative products that clearly fulfill the needs of our customers,” said Joe Magnacca, SVP and chief merchandising officer of Duane Reade. “Dream Water is just such a product and we welcome them to our stores.” Now available at Walmart, Walgreens, Paradies Shops (airport retailer) and other stores, the product has distribution in over 10,000 doors nationwide.
We are a nation besieged by insomnia:
•    Annual cost for treatment of insomnia estimated at $10.9 billion
•    Individuals sleeping fewer than six hours each night had a 70% higher mortality rate than those that slept seven or eight hours a night
•    40% of insomniacs reported the use of either over-the-counter medications or alcohol in an inappropriate attempt to alleviate their sleep problems
•    Insomnia may be 40% or higher for women over the age of 40
•    From age of 16 to 50, men lose about 80% of their deep sleep.
•    15% of elderly people stay in only stage 1 or light sleep.
[Source: the National Commission on Sleep Disorders Research report to Congress, Wake up America: A National Sleep Alert] It’s widely-known by now that disengaging from all electronics at least an hour before a consistent bedtime, warm milk, and moderate exercise, may help counteract insomnia, but Dream Water is a near guarantee. There are caveats: people under the age of 18, pregnant or nursing women, those taking other medication – should consult a doctor before imbibing; not recommended to drink more than 1 serving in a 24-hour period. BC spoke with Lekach and Platzner about their dream product.
BC: Why are you marketing Dream Water as a “sleep enhancer” and not a beverage?
DW: A key differentiator between our product and others in the marketplace is that Dream Water is a liquid dietary supplement (much like 5-Hour Energy or other functional shots) that is positioned as a mainstream sleep enhancer that delivers natural sleep ingredients in a liquid form. We find that the growth in the functional beverage category reflects consumer demand for liquids more and more as a preferred delivery method for the helpful or necessary vitamins and supplements that can help the consumer achieve a healthier lifestyle. Our goal is to merchandise Dream Water in the sleep aid aisle, because that is where consumers shop for their sleep solutions. That said, as proper merchandising at the point of sale marketing is critical in communicating the product’s proposition to its potential consumer, we do believe in merchandising our product at key ancillary locations at the front of the store (near to the register) in order to establish Dream Water as a more mainstream product; one that is the exact opposite of an energy shot.
Can the packaging be greener?
We applaud all manufacturers who use very “green” packaging in their product designs. We hot fill our shots (don’t use preservatives) and we have worked within the materials mix available to us at this moment to make the best possible 0-calorie natural sleep enhancer. On the bottle itself it says “Please Recycle. Pretty Please.” and we are always looking at ways to continue to encourage sustainability.
Any celebrity endorsements?
Paris Hilton as well as several other celebrities, including Sofia Vergara, have started to tweet about our product. Paris has said that Dream Water is tremendously helpful for her. So she tweeted about Dream Water last month saying “Going to bed. Just had some dream water”. It really works. Already feeling sleepy. Sweet dreams everyone.” What was great about this tweet in particular was that she was going to sleep at around 8am EST and didn’t tweet again as a result for the whole day, lending authenticity to the communication to her followers.
QUESTIONS FOR DISCUSSION:
1.    Define and explain for Dream Water: Core Product, Actual Product, and Augmented Product. (Ref: Slides 3 to 8).
2.     Which factors could affect Dream Water’s adoption? Why? (Ref: slides 17 to 21. You can use factors in slide 21 as your framework ).

Choose a particular aspect of a culture related to a clinical encounter/experience you have had

Order Description

The purpose of this paper is to demonstrate your understanding of the theoretical concepts
discussed in the course and your ability to apply the theory to practice. Choose a particular aspect of a culture related to a clinical encounter/experience you have had. There are several different elements that are critical to this assignment:
•Description: Begin with a description of your chosen aspect of a culture related to your clinical
encounter.
•Reflection & Analysis: Analyze the chosen aspect/scenario/encounter from the emic
(insider) as well the etic (outsider) perspective. In your analysis include reflections from
your own experiences and views, nursing science literature, and concepts from the cultural
care framework.
•Conclusions & Implications for practice: Conclude with the summary of the “gaps: that exist
between perspectives and identify strategies for addressing the gap from a nursing
practice perspective.
•The length of the paper is expected to be 5 pages not including title page and references.
In addition to the relevant ideas from the textbook and professional nursing associations you must include at least 5 scholarly references that you located independently (students are not to share resources).

Scholarly Paper must be submitted to the course professor through Moodle (Due Midnight of
October 15, 15%).

Grading Criteria:
Substance: Sound ideas relate directly to your examination of the aspect of a culture in the scenario/encounter from both a personal and a scientific perspective; analysis and synthesis of ideas, incorporating relevant course literature and course concepts.
Clarity: Includes introduction and conclusion; logical flow of ideas; precise use of language; appropriate APA format; grammatically correct sentences; no spelling errors; overall coherence.
Originality: Accurate, meaningful, and creative integration. (Compare 2 cultures of your choice and the text book uploaded must be one of the references.)

Various types of Social Norms

Order Description

In a single Word document, please type your response to the 2 essay questions listed below. Each answer should be approximately 2 pages, double spaced, Times New Roman, 12-point font with 1” margins.

1. Identify the various types of social norms and give an example of each as they are found in the field of nursing. If need be, explain why this norm is categorized this way. In addition, identify the different types of sanctions and discuss the sanctions associated with the various nursing social norms you have identified.

2. Explain the similarities and differences between the three major sociological perspectives of functionalism, conflict theory, and symbolic interactionism. Identify which perspectives use a macrolevel or a microlevel of analysis.