Rebellion against romanticism Essay Example for Free

Rebellion against romanticism Essay Realism can be seen as a rebellion against romanticism, which, according to realists, did not depict life accurately and was prone to over-sentimentality. Realists did not believe in the structure and symmetry common in romantic fiction. Realists viewed life as irregular, where individuals were always confronted with ethical dilemmas. The realists also valued the individual, and thus characterization was considered a central aspect of the novel. This also means that realists explored the psychology of a novels characters. The values of realism extended to and influenced Henry James. James also dealt with ethical issues and the complex working of the mind in his fiction, and even became considered the â€Å"father of the psychological novel. † James, however, unlike realists in general, did not write in an attitude of optimism. A theme that James explored deeply is the conflict of America (the New World), which for him represented innocence and optimist, and Europe (the Old World), which for him represented worldliness and decadence. He wrote of Americans visiting or living in Europe, where American and European customs were in conflict. Because he lived back and forth in America and Europe, he was able to observe firsthand the differences between the values and customs of the New World and the Old. James was also interested in spiritual phenomena, which was of much popular interest in his time. This also influenced him into writing ghost stories, such as The Turn of the Screw. James, as a writer, was primarily a realist, and much of his work can be categorized as psychological realism. He was a master of the psychological novel. Like other realists in his time, was interested in writing about â€Å"everyday things† and paid careful attention to detail in his writings. He strove for an accurate depiction of American life, often in the context of Old World, European society.

Two Middle Range Theory Evaluation Paper

Two Middle Range Theory Evaluation Paper The purpose of this paper is to evaluate two middle range theories abilities to test the concept of comfort for the practice question Do neonatal nurses who care for dying infants who attend an end of life care educational training program compared to neonatal nurses who do not attend the program experience a difference in comfort levels (Comfort Level for Caring for Dying Infants (CLCDI)) when caring for a dying infant? A summary of two middle range theories the Comfort Theory (Kolcaba, 1994) and the Theory of Self-Efficacy (Resnick, xxxx) will be summarized and then critiqued using Smith and Liehrs (xxxx) Framework for Evaluating Middle Range Theory. The discussion will conclude with a summary of strengths and weakness of the theories and a research hypothesis to reflect that reflects the most appropriate theories conceptual definitions and propositions. Introduction Background Despite nurses as frontline caregivers for dying patients and their families many nurses have identified that they struggle with the responding adequately to the emotional devastation to parents and siblings when caring for a neonate with an unresolved terminal condition (Frommet, 1991). With the advances in neonatal care and life sustaining treatments, sick and very preterm infants do not often die in utero, at birth, or shortly after birth, but instead they often live much longer in a healthcare paradigm of comfort care and dignified death. This relatively new emersion of the end of life model integrates a more holistic approach which considers a more comprehensive view of the patients needs (emotional, spiritual, and medical) (Mallory, 2002; Mallory, 2003; WHO, 2002). With this paradigm shift, health care professionals are obligated to assess the adequacy of their own knowledge, attitudes, and beliefs about death and dying. Multiple studies regarding nurses preparation for dealing with death and dying have consistently found that nurses that nurses do not feel educationally prepared to care for dying patients and insist that healthcare professionals should receive additional education on end of life care to bridge the deficit gap (Frommet, 1991; Robinson, 2004; White, Coyne, Patel, 2001; Beckstrand, Callister, Kirchhoff, 2006). These findings have led to a further observation that nurses caring for these complex patients regularly experience moral distress from competing principles of their personal, collegial, organizational, and religious/spiritual ethics (Frommet, 1991). Practice Problem To help ease this moral distress an evidence based end-of -life educational training program for NICU nurses has been successfully implemented in several neonatal intensive care units (NICUs) to increase the nurses comfort level of caring for neonates and their families at the end of life (Bagbi, Rogers, Gomez, McMahon, 2008). To determine if an evidence based end of life educational program impacts nurses comfort levels in caring for dying infants and their families a question was developed using the population (P) intervention (I) compared to (C) outcome (O) format (Newhouse, Dearhold, 1997). The following discussion will focus on this PICO question Do neonatal nurses who care for dying infants who attend an end of life care educational training program compared to neonatal nurses who do not attend the program experience a difference in comfort levels (Comfort Level for Caring for Dying Infants (CLCDI)) when caring for a dying infant? During the intervention a monthly 1 hour, neo natal end of life education program will be conducted over a 6 month period of time based on research about what nurses would like to know about caring for a dying infant (Robinson, 2004). For the purpose of this problem, comfort is defined as the ability of the NICU nurse(s) to show adequate knowledge and skills in providing neonatal end of life care for dying babies and their families. For this problem comfort will be measured as a score on the ordinal scale of Comfort Level Caring for Dying Infants (CLCDI). The instrument consisting of 15 items, measured on a 5 point Likert type scale equates scores of 1=never; 2=rarely; 3=sometimes; 4=often, 5=always measures the level of comfort a NICU nurse has caring for dying infants as opposed to their perception toward pediatric or neonatal end of life care (Bagbi, Rogers, Gomez, and McMahon, 2008). In evaluating the score, the higher the reported score the greater level of comfort NICU nurses have in caring for dying babies. Testing the Concept of Comfort A portion of Kolbacas (1991) Theory of Comfort and Resnicks (2008) Theory of Self-Efficacy, two middle range theories, will be used to test the concept of comfort for providing an organizing structure. Based on previous studies about nurses comfort when caring for patients, propositions five and six of Kolbacas Theory of Comfort seem to be a promising fit for this problem (Kolbaca, 1991, Kolbaca, XXX). These propositions collectively propose that patients, nurses, and other members of the healthcare team agree upon desirable and realistic health seeking behaviors (HSBs) and if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSBs, comfort is further enhanced (Kolbaca, 1991). However, comfort as defined conceptually in this case as knowledge and skill can alternatively be equated with a sense of competence or self-efficacy of the NICU nurse to care for a dying infant and their family. There are many examples in the nursing literature linking self-efficacy to knowledge and skill (xxxx, xxxxx).) Self-efficacy, knowledge, and skills are also central to Banduras theory, which is the basis for Resnicks (xxxx) Self-Efficacy theory. Self-efficacy as described in Resnicks (xxxx) Theory of Self-Efficacy for this context is described as the judgment about the nurses ability to organize and execute a course of action required to attain designated types of performances. The theory states that perceived self-efficacy, defined as the individuals judgment of his or her capabilities to organize and execute courses of action, is a determinant of performance (Resnick, xxxx). Self-efficacy beliefs provide the foundation for human motivation, well-being, and personal accomplishment (Resnick, xxxx). According to Resnick (XXXX) theory individuals with higher levels of self-efficacy for a specific behavior (caring for a dying infant) are more likely to attempt that behavior. There are many examples in the literature using the Theory o f Self-Efficacy to support nursing education interventions (xxxxx, xxxxx). For these reasons, Resnicks Theory of Self-Efficacy (xxx) will be used to test the concept of nurses comfort or knowledge and skill (self-efficacy) in caring for dying infants and their families. The purpose of the following discussion is to summarize, describe, analyze, and evaluate these theories using the Framework for the Evaluation of Middle Range Theories (Smith, 2008) and conclude with a synthesis and research hypothesis to reflect conceptual definitions and propositions of the theory with the best fit. Theory Summaries: Comfort and Self-Efficacy Kolcabas Comfort Theory The Comfort Theory is a humanistic, holistic, patient need based nursing derived middle range theory (Kolbaca, xxxx). The concept of comfort has had a historic and consistent presence in nursing. In the early 1900s , comfort was considered to be a goal for both nursing and medicine, as it was believed that comfort led to recovery (McIlveen Morse, 1995). Over time comfort has become an increasingly minor focus, at times reserved only for those patients for whom no further medical treatment options are available (McIlveen Morse, 1995). The term comfort is used as a noun (comforter), adjective (comforting), verb (to comfort), or adverb (comfort the patient) (xxx). It is also used as a negative (absence of discomfort), neutral (ease), or positive (hope inspiring). Webster (1990) defines comfort as relief from distress; to soothe in sorrow or distress; a person or thing that comforts; a state of ease and quiet enjoyment free from worry; anything that makes life easy; and the lessening of misery or grief by calming or inspiring with hope. The origin of comfort is confortrare which means to strengthen greatly(Kolcaba, 1992). Based on the diversity of these terms comfort is a complex term. Kolcabas (1991) concept analysis of comfort helped to clarify the role of comfort as a holistic concept for nursing. This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients (David, 2002). Over a period of years and revisions Kolcaba (1994) developed the comfort the ory which continues to evolve and change with changes as recent as 2007 (Figure 2). Kolcaba (1994, 2001, 2003) has defined comfort as the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental). The terms relief, ease, and transcendence are types of comfort that occur physically and mentally (Figure 2). The terms are defined based on definitions from medicine, theology, ergonomics, psychology, and nursing (Kolcaba Kolcaba, 1991). Relief is the state of having a discomfort mitigated or alleviated. Ease is the absence of specific discomforts. Transcendence is the ability to rise above discomforts when they cannot be eradicated or avoided (e.g., the child feels confident about ambulation although (s)he knows it will exacerbate pain). Transcendence, as a type of comfort, accounts for its strengthening property and reminds nurses to never give up helping their children and family members feel comforted. Interventions for increasing transcendence can be targeted to improving the environment, increasing social support, or providing reassurance. The three types of comfort occur in four contexts of experience: physical, psychospiritual, sociocultural, and environmental. These contexts were derived from an extensive review of the nursing literature on holism (Kolcaba, 1992). When the three types of comfort are juxtaposed with the four contexts of experience, a 12-cell grid is created, which is called a taxonomic structure (TS) (Figure 1) . Taken together, these cells represent all relevant aspects (defining attributes) of comfort for nursing and demonstrate the holistic nature of comfort as an important goal of care. All comfort needs can be placed somewhere on the taxonomic structure, and the cells are not mutually exclusive. A sample pediatric case study using the TS as a guide for a holistic comfort assessment is demonstrated below (see Figure 1). The concepts for the middle range for Comfort Theory include comfort needs, comfort interventions, intervening variables, enhanced comfort, health-seeking behaviors, and institutional integrity (Kolcaba, 1994). All of these concepts are relative to patients, families, and nurses (Kolcaba, 2003; Kolcaba, Tilton, Drouin, 2006). There are eight propositions which link the above concepts together. All or parts of the Comfort Theory can be tested for research (Peterson Bredow, 2010). In the comfort theory, Kolcaba asserts that when healthcare needs of a patient are appropriately assessed and proper nursing interventions carried out to address those needs, taking into account variables intervening in the situation, the outcome is enhanced patient comfort over time (Kolcaba, 2007). Once comfort is enhanced, the patient is likely to increase health-seeking behaviors. These behaviors may be internal to the patient (eg, wound healing or improved oxygenation), external to the patient (eg, active participation in rehabilitation exercises), or a peaceful death. Furthermore, Kolcaba asserted that when a patient experiences health-seeking behaviors, the integrity of the institution is subsequently increased because the increase in health-seeking behaviors will result in improved outcomes. Increased institutional integrity lends itself to the development and implementation of best practices and best policies secondary to the positive outcomes experienced by patients (Kolcab a, 2007). To translate the concepts to practice the effectiveness of a holistic intervention can be targeted to the taxonomic structure for enhancing comfort in a specific patient, family, or nurse population over time. Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental).The comfort theory has been operationalized in many research settings with a variety of patient and target populations ranging from end of life care to the comfort of nurses (xxxx). Resnick Theory of Self-Efficacy Self efficacy is described as a way to organize an individuals judgment of his or her capability to execute a course of action. The Theory of Self-efficacy states that self-efficacy expectations and outcome expectations are not only influenced by behavior, but also verbal encouragement, reflective thinking, physiological sensations and role or self-modeling (Bandura, 1995).. Through self evaluation an individual judges their capability to perform and established self expectations which is visually depicted in the conceptual model (Appendix 2) (Resnick, 2008). Resnicks Theory of Self Efficacy is based on Banduras social cognitive theory and conceptualizes person-behavior-environment as triadic reciprocity the foundation for reciprocal determinism (Bandura, 1977, 1986). Most of the research into self-efficacy beliefs among older adults has been quantitative and has consistently supported the influence of those beliefs on behavior. However, it has not been established how efficacy beliefs actually influence motivation in older adults, or what sources of efficacy-enhancing information help strengthen those beliefs. Kolcabas Comfort Theory: Description, Analysis, and Evaluation Theory Description Historical context. The Comfort Theory is a humanistic, holistic, patient need based nursing derived middle range theory (Kolbaca, xxxx). The concept of comfort has had a historic and consistent presence in nursing. In the early 1900s , comfort was considered to be a goal for both nursing and medicine, as it was believed that comfort led to recovery (McIlveen Morse, 1995). Over time comfort has become an increasingly minor focus, at times reserved only for those patients for whom no further medical treatment options are available (McIlveen Morse, 1995). The term comfort is used as a noun (comforter), adjective (comforting), verb (to comfort), or adverb (comfort the patient) (xxx). It is also used as a negative (absence of discomfort), neutral (ease), or positive (hope inspiring). Webster (1990) defines comfort as relief from distress; to soothe in sorrow or distress; a person or thing that comforts; a state of ease and quiet enjoyment free from worry; anything that makes life easy; and the lessening of misery or grief by calming or inspiring with hope. The origin of comfort is confortrare which means to strengthen greatly(Kolcaba, 1992). Based on the diversity of these terms comfort is a complex term. Kolcabas (1991) concept analysis of comfort helped to clarify the role of comfort as a holistic concept for nursing. This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients (David, 2002). Over a period of years and revisions Kolcaba (1994) developed the comfort the ory which continues to evolve and change with changes as recent as 2007 (Figure 2). Structural Components. Assumptions. Kolcabas Theory of Comfort (1994) makes four basic assumptions about reality. She assumes that humans beings have holistic responses to complex stimuli; comfort is a desirable holistic state that is germane to the discipline of nursing; human beings actively strive to meet, or to have met, their basic comfort needs, and that comfort is more than the absence of pain, anxiety, and other physical discomforts (Kolcaba , 2009). Concepts. Kolcaba defines six concepts of comfort which are relative to patients, families, and nurses (Table 1) . The term family, as defined by Kolcaba (2003) encompasses significant others as determined by the patient (Kolcaba, 2003; Kolcaba, Tilton Drouin, 2006). The first concept is of comfort needs which is the relief/ease/transcendence in physical, psychospiritual, sociocultural and environmental contexts of human experience. Comfort interventions in the model are defined as interventions of the health care team specifically targeting comfort of the patient, family and nurses. Intervening variables are positive or negative factors over which the health care team has little control, including physical limitations of the hospital or patients home, cultural influences, socioeconomic factors, prognosis, concurrent medical or psychological conditions. Health-seeking behaviors are those behaviors of patient, family or nurses (conscious or unconscious) which promote well-being; may b e internal, external or towards promoting a peaceful death. The final concept, institutional integrity, added in most recently, are values, financial stability and wholeness of health care facilities at the local state or national levels. Propositions. To help test the concept of nurses comfort caring for dying infants, propositions five and six of Kolcabas comfort theory are examined. These propositions state that patients, nurses, and other members of the healthcare team agree upon desirable and realistic health seeking behaviors (HSBs) (five) and if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSBs, which further enhances comfort (six). These propositions provide rationale for why nurses and other health care professionals should focus on the patient, family, or in this case the nurses comfort beyond altruistic reasons. Because health seeking behaviors include internal and external behaviors almost any health-related outcome important in a healthcare setting can be classified as a health seeking behavior (Peterson Bredow, 2010). The desirable and realistic health seeking behavior (HSB) for this study is nurses comfort (knowledge and skills) to relieve moral di stress in caring for a dying infant and their family. Several studies support that moral and other types of distress are frequently observed in nurses who care for dying infants (Frommet, 1991) and most importantly indicate that nurses are seeking education regarding patient end of life issues (XXXXX). It is believed that reducing this distress and frustration can be affected through an effective end of life educational programs and is likely to improve the knowledge and skills nurses need to help increase their comfort level in caring for dying infants (xxxxx). Functional Components. Visualizing the concepts in the conceptual model, the Theory Analysis and Evaluation To analyze and evaluate Kolcabas Comfort Theory (1994) the substantive foundation, structural integrity, and functional adequacy of the theory using Smith and Liehrs (2008) Framework for the Evaluation of Middle Range Theories is discussed below (Appendix 1). Substantive foundations. Assessing the substantive foundation of a middle range theory is based on four criteria (Smith, 2003). The first criterion evaluates whether the theory is within the focus of the discipline of nursing. Kolcabas comfort theory successfully addresses four concepts comprising the metaparadigm of nursing, defining the concepts as they correspond to the theory (Dowd, 2002; Kolbaca, 2007) as well as presents a diagram of how the Comfort Theory relates theoretically to other nursing concepts (Figure 2) (Kolcaba, 1994) . Nursing is described as the process of assessing the patients comfort needs, developing and implementing appropriate nursing interventions, and evaluating patient comfort following nursing interventions. Person is described as the recipient of nursing care; the patient may be an individual, family, institution, or community. Environment is considered to be the external surroundings of the patient and can be manipulated to increase patient comfort. Fi nally, health is viewed as the optimum functioning of the patient as they define it. The ability of the framework to suggest interventions that help guide nursing interventions to increase comfort supports the discipline of nursing, and in doing so meeting the first criteria. The second criterion evaluates whether the assumptions are specified and congruent with the focus. The four assumptions in the Comfort Theory are explicitly stated and so meet the second criteria. Comfort theory (xxxx) assumes that humans beings have holistic responses to complex stimuli; comfort is a desirable holistic state that is germane to the discipline of nursing; human beings actively strive to meet, or to have met, their basic comfort needs, and that comfort is more than the absence of pain, anxiety, and other physical discomforts (Kolcaba , 2009). Because the Comfort Theory (XXXX) substantially describes the concept of comfort at the middle range level of discourse, the third criterion of the substantive foundation is met. Kolcabas (1991) concept analysis of comfort helped to clarify the role of comfort as a holistic concept for nursing. This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients (David, 2002). The Comfort Theory provides an excellent description, explanation, and interpretation of the comfort concept in multiple domains and practice settings. Comfort theory is at the middle range level in that is defined in a measurable way and can be operationalized in both research and practice settings. The final criterion for this category evaluates if the origins are rooted in practice and research experience. The Comfort Theory has been used in numerous practice and research settings to provide a framework where patients have comfort needs and enhancing their comfort is valued. It has also been used to enhance working environments, especially for nurses, and most recently as a framework for working toward national institutional recognitions. More specifically parts are all of the theory have been used to test the effectiveness of holistic interventions for increasing comfort (xxxxxxx), to demonstrate the correlation between comfort and subsequent HSBs (xxxxx) and to relate HSBs to desirable institutional outcomes. It has also been used as a framework for helping families make difficult decisions about end of life (xxxxx). International and national healthcare institutions have also used Comfort Theory to enhance the work environment for nurses (xxxx). In these cases, nurses comfo rt is of interest and is theoretically related to the integrity of the institution. Summarize specific studies and tools used here. Structural integrity. There are four criterion for evaluating structural integrity. The first criterion is that the concepts are well defined. The concepts (defined above) of comfort needs, comfort interventions, intervening variables, enhanced comfort, health-seeking behaviors, and institutional integrity are clearly defined and easy to understand. There are numerous examples of applying the concepts in the literature for further clarification (xxxxx). The second criterion of structural integrity is that concepts within the theory are at the middle range level of abstraction. The concepts of the Comfort Theory-comfort needs, comfort interventions, intervening variables, enhanced comfort, health seeking behaviors, and institutional integrity are near the same level on the ladder of abstraction at the middle range level. They are more concrete because they can and have been operationalized and measured (xxxxx). The third criterion of structural integrity is that there are no more concepts than needed to explain the phenomena. Overall, the concepts adequately explain the phenomena of comfort. The theory is synthesized and organized in a simple manner. Lastly, the fourth criterion evaluates whether the concepts and relationships among the concepts are logically presented with a model. In the Comfort Theory (1994) model the ideas are integrated to create an understanding of the whole phenomenon of comfort in a model. The Comfort Theory (1994) model is a great example of presenting the concepts and statements in a linear logical order so the appreciation of the theory can be recognized (Smith, 2003). Functional adequacy. Because the criterion for functional adequacy overlap somewhat the five criterion will be discussed collectively. The five criterion include: theory can be applied to a variety of practice environments and clients; empirical indicators have been identified; published examples exist of research and theory in practice; and that the theory has evolved through scholarly inquiry. The Comfort Theory easily meets all of these criterions. For example, the Comfort Theory has been used widely in a variety of research in practice settings and patient and family populations. Even though the Comfort Theory has been used most widely with patients and families at the end of life and surrounding holistic palliative care nursing interventions, there has been a broad application of the theory in other populations as well including mothers in labor (xxxx), Alzheimer patients (xxxx), pediatric intensive care unit patients and families (xxxx), patients on bedrest (xxxx), those underg oing radiation therapy (xxxx) and for infants comfort and pain (xxxx). Most recently research of using the theory in practice has expanded to support institutional nursing recognition and comfort in the nursing working environment. In each of the populations mentioned above a psychometric comfort instrument has been developed as empirical indicators of concepts in the theory. However, the empirical indicators extend beyond empiricism and some include perceptions, self reports, observable behaviors and biological indicators (Ford-Gibloe, Campbell, Berman, 1995; Reed, 1995). The Comfort Theory (1994) has also been revised with the latest revision in 2007. The empirical adequacy of the Comfort Theory is evidence of the maturity of this theory (Smith, 2003). Summary The Comfort Theory (1994) is a well defined and well tested theory. Its strength lies in the versatility, adaptability, and testability of the concepts. The comfort theory clearly defines the concepts in the theory and the relationship between them. Because the comfort theory meets most of the substantitive foundations, structural integrity, and functional adequacy criteria the Comfort Theory (1994) is a strong middle range theory. An area that could increase the generalizability especially for nursing institutions is a change in the term in the model of nursing interventions to comfort interventions (xxxxx). Resnicks Self-Efficacy Theory: Description, Analysis, and Evaluation Theory Description Historical context. Resnicks Theory of Self Efficacy is based on Banduras social cognitive theory and conceptualizes person-behavior-environment as triadic reciprocity the foundation for reciprocal determinism (Bandura, 1977, 1986). The cognitive appraisal of these factors results in a perception of a level of confidence in the individuals ability to perform a certain behavior. The positive performance of this behavior reinforces self-efficacy expectations (Bandura, 1995). Structural Components. Although it is not explicitly stated, the core of this theory assumes that people can consciously change and develop or control their behavior. This is important to the proposition that self-efficacy also can be changed or enhanced through reflective thought, general knowledge, skills to perform a specific behavior, and self influence. This perspective is rooted in the model of triadic reciprocality (foundation for reciprocal determinism) in which personal determinants (self-efficacy), environmental conditions (treatment conditions) and action (practice) are mutually interactive influences. Therefore, improving performance depends on changing some of these influences (Bandura, 1977). In order to determine self-efficacy an individual must have the opportunity for self evaluation to evaluate how likely it is he or she can achieve a given level of performance. Concepts. The two major components of self efficacy include self-efficacy expectations and outcome expectations (Table 2). Self-efficacy expectations are judgments about the personal ability to accomplish a given task. Outcome expectations are judgments about what will happen if a given task is accomplished. These two components are differentiated because individuals can believe a certain behavior will result in a specific outcome, however, they may not believe they are capable of performing the behavior required for the outcome to occur (Bandura 1977, 1986). For example, a NICU nurse may believe attending an end of life education series will increase his/her knowledge and skill and ease moral distress, but may not believe that they could provide sensitive care for some ethical, religious, or moral reason. It is generally anticipated, but not always realistic that self-efficacy will have a positive impact on behavior. There are times when self-efficacy will have no or a negative impa ct on performance (Vancouver, Thomspon, Williams, 2001). Bandura (1977, 1986, 1997) suggests that outcome expectations are based largely on the individuals self-efficacy expectations, which generally depend on their judgment about how well they can perform the behavior; can be disassociated with self-efficacy expectations; and are partially separable from self-efficacy judgments when extrinsic outcomes are fixed. Because the outcomes an individual expects are the results of the judgments about what he or she can accomplish, they are unlikely to contribute to predictions of behavior (Bandura, 1977). Judgments about ones self-efficacy is based on four informational sources including enactive attainment, vicarious experience, verbal persuasion and physiological state. The first source, enactive attainment, or the actual performance of a behavior has been described as the most influential source of self-efficacy information (Bandura, 1986,; Bandura Adams, 1977). There has been repeated empirical evidence that actually performing an activity strengthens self-efficacy beliefs due to informational sources (Bandura, 1995). The second source, vicarious experience or visualizing other similar people perform a behavior, also influence self-efficacy (Bandura, Adams, Hardy, Howells, 1980). Conditions that impact vicarious experience include amount of exposure or experience to the behavior (least experience causes greater impact) and amount of instruction given (influence of others is greater with unclear guidelines) (Resnick Galik, 2006). Another source verbal persuasion or exhortation i nvolves telling an individual he or she has the capabilities to master the given behavior. Verbal encouragement from a trusted, credible source in counseling or education form has been used alone to strengthen efficacy expectations (Castro, King, Brassington, 2001; Hitunen et al. 2005; Moore et al., 2006; Resnick, Simpson, et al., 2006). The final information source physiological feedback or state during a behavior can be important in relation to coping with stressors, health functioning, and physical accomplishments. Interventions can be used to alter the interpretation of physiological feedback and help individuals cope with physical sensations, enhancing self efficacy and resulting in improved performance (Bandura Adams, 1977). Propositions. To help test the concept of nurses comfort caring for dying infa

Pulmonary Embolism as Manifestation of Right Atrial Myxoma

Pulmonary Embolism as Manifestation of Right Atrial Myxoma A  case report and review of literature Abstract We present a case of a 55-year-old man who suffered from shortness of breath and syncope; he was sent to our department for suspecting pulmonary embolism. We proceeded Computed tomography pulmonary angiography (CTPA) and Transthoracic echocardiogram (TTE) , confirmed the diagnosis which was caused by right atrial mass. After the surgery the patient was diagnosed as right atrial myoma (RAM) with pulmonary myoma emboli without no adverse event. The residual emboli were partially improved after one month anticoagulation. We reported this case and review of the relevent literature to help clinicians improve the understanding of diagnosis and treatment of pulmonary embolism caused by RAM. Key words: pulmonary embolism, right atrial myxoma, treatment Pulmonary embolism, most commonly originating from deep venous thrombosis (DVT) of the legs, ranges from asymptomatic, incidentally discovered emboli to massive thromboembolism causing immediate death. PTE is a life-threatening disease with a high morbidity. Annually, as many as 300,000 people in the United States die from acute PTE, which is much more common in China at present than 10 years ago (1). About 50-70% emboli of pulmonary embolism originated from deep venous thrombosis (DVT), most of which in lower extremities. Such patients without DVT should screen occult cancer. Although cancer associated venous thrombosis was widespread described, the emboli from benign tumor are less mentioned (2). Majority of the atrial myxoma complicated pulmonary emboli are tumoral, thrombotic emboli were less reported (3,4). We report a rare case of RAM with a pulmonary localization mimicking pulmonary emboli. Case presentation A 55-year-old man was admitted to emergency room with gradually increased shortness of breath for 2 months, syncope and right chest pain for 6 hours. He had a habit of long time sitting and a history of 20 pack-year smoking, and stopped smoking 10 years prior to admission. Initial assessment revealed cyanosis and right breath sound decreased. No pitting edema in lower extremities. Laboratory tests showed ALT 52IU/liter; 93IU/liter; D-Dimer >10ÃŽ ¼g/ml; NT-proBNP 3544 Ñâ‚ ¬g/ml; Troponin I 0.49 ng/ml. Arterial blood gases revealed severe hypoxemia, oxygenation index was 89mmHg; Electrocardiogram showed Sà ¢Ã¢â‚¬ ¦Ã‚  Qà ¢Ã¢â‚¬ ¦Ã‚ ¢Tà ¢Ã¢â‚¬ ¦Ã‚ ¢. CTPA revealed right main (Figure 1a), both lobar(Figure 1b,1c) and segmental (Figure 1d) pulmonary arteries(PA) multiple filling defects; right atrium irregular mass(Figure 1d). TTE showed enlargement of right chambers and a right atrial 54*47mm mass attached to the top wall, clear margin, irregular and partial rough on surface, l oose in internal structure, moving along with cardiac cycle, mild prolapse through the leaflets of the tricuspid valve and orifice of inferior vena cava, moderate regurgitation of tricuspid valves with mild pulmonary hypertension. Compressed venous ultrasonography showed negative in both lower limbs. The surgical approach was through a medial sternotomy under extracorporeal circulation. The right atrium wall was opened and a gelatinous consistency tumor with necrosis, fragile, measuring 40*50mm, adhering to the inter-atrial septum (Figure 2), a 30*20*70mm tumor embolus in the right main PA, the distal end was near right upper PA. The tumor cells expressed CD34 and calretinin, and were negative for CK and SMA. The histopathological examination confirmed myxoma (Figure 3) in right atrium and right pulmonary artery. The patient was treated warfarin (target INR, 2-3) for 1 month. Repeated CTPA showed left lower PA filling defect with no improvement after 2 months (Figure 4c), right and other left PA filling defect resolved (Figure 4a, 4b). 2 years follow-up he was asymptomatic. Discussion Cardiac tumors are less common, most of which are from metastasis. The incidence rate of primary cardiac tumors (PCTs) in autopsy ranges from 0.02 to 2.8†°. 30-50% of PCTs are myomas, 75% in the left atrium and only 10-20% arising in the right atrium, which may developing from embryonic or primitive gut rests (5,6,7). Histologically, they consist of an acid-mucopolysaccharide rich stroma. Polygonal cells arranged in single or small clusters are scattered among the matrix. The clinical manifestations of RAM may remain asymptomatic or appear with constitutional, obstructive or embolic symptoms according to the size, fragility, mobility, location of the tumor as well as body position and activity (5,8). Nonspecific constitutional signs, which present in 10-45% of patients with myxoma, are fatigue, fever, dyspnea, chronic anemia, weight loss, general arthralgia, and increase of IL-6, ESR, and CRP (8). Therefore the results of laboratory tests may mimic those for rheumatic disorders. These signs are more common for patients with large, multiple, or recurrent tumors, and usually recovered after resection (9). Pulmonary embolism of RAM fragments or thrombi from the surface may also occur, resulting in dyspnea, pleuritic chest pain, hemoptysis, syncope, pulmonary hypertension and right heart failure even sudden death. Acute abdominal pain was mentioned in two cases (10). Embolic event in cardiac myxoma is common, with the incidence ranging from 30% to 40% (5) . In the cases of RAM with pulmonary embolism, a smaller size, villous or irregular surface and multi-foci are most common factors associated with embolization (11). The duration period was ranging from 1 day to 3.5 years. The age of patients ranged from 17 to 76 years (mean age 42.8 years), with a higher incidence in women (20/35, 57%). In these cases RAMs are usually attached by a short pedicle to the inter-atrial septum (22/35), mostly in fossa ovalis, others are in free wall, crista terminalis, Koch triangle and multiple origins. Most of the patients were diagnosed with TTE (Transthoracic echocardiography), CT, transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI), others were with angiography and autopsy. In almost all cases treatment was surgical with removal of the intra-atrial myxomas and the pulmonary emboli, which are usually tumoral. Majority of such patients recovered well after surgery. Four preoperative deaths, two postoperative deaths were reported. Right atrial thrombosis, transient ischemic attack (TIA), ischemic hepatitis and renal failure were the rare complication (Table 1). TTE and TEE are the most commonly used diagnostic methods in the detection and initial description of atrial myxomas (23). TTE is nearly 95% sensitive for the confirmation of cardiac myxomas, and TEE reaches nearly 100% sensitivity (45). TTE facilitated bedside test to safely detect myxomas in fatal pulmonary embolism as in our patient. TEE produces explicit images of small tumors (1 to 3 mm in diameter), especially in fat patients with poor TTE images (46). The TEE also permits a clearer picture of the attachment of the tumor and more precise characterization of the size, shape, surface, inner structure and location of the mass (47). Although TEE is a semi-invasive diagnostic test with a very low rate of significant complications, lethal pulmonary embolism during TEE procedure has been reported (22). Superior to echocardiography, multi-detectors spiral computed tomography (MSCT) and cardiac magnetic resonance imaging (CMR) are more accurate in determining the relationship to normal intra-cardiac structures and tumor infiltration into the pericardium, extension to adjacent vasculature and mediastinal structures, pulmonary arteries emboli and surgical planning (48,49). RAMs manifest as a low-attenuation intra-atrium mass with a smooth, irregular or villous surface on MSCT. Calcifications are seen in about 14% and are more common in right side lesions. Arterial-phase contrast enhancement is usually not apparent, but heterogeneous enhancement is reported on studies performed with a longer time delay (50,51). Varying amounts of myxoid, calcified, hemorrhagic, and necrotic tissue gives them heterogeneous appearances on T1 and T2-weighted images. Delayed enhancement is typical and usually patchy in nature. Steady state free preceesion (SSFP) sequences may slow prolapse through the tricu spid valve in diastole phase and can suggest the attachment point of a stalk lesion. Reconstruction of cine gradient recalled echo (GRE) images enables assessment of lesion mobility and attachment (52). 18F-FDG PET/CT can help the noninvasive preoperative confirmation of malignancy (41). Mean SUVmax was 2.8 ±0.6 in benign cardiac tumors and significantly higher in both malignant primary and secondary cases. (8.0 ±2.1 and 10.8 ±4.9). The SUVmax of myxoma is ranging from 1.6 to 4. Malignancy was determined with a sensitivity of 100% and specificity of 86% with a cut-off SUVmax value of 3.5. A weak correlation between the SUVmax and the size of tumors is found due to the partial volume effect, cardiac motion and respirtatory movement (53). Angiography is an invasive investigation that presents an additional risk of inducing migration of the tumor and only suitable for suspected acute coronary heart disease (37). Surgical removal of the RAM with pulmonary embolism is the first treatment of choice and usually curative (44,45). The crucial aspects of surgery are measures for bi-caval cannulation to prevent intra-operative embolism (27), en-bloc excision of the myxoma with a wide cuff of normal tissue, removal of fragments in pulmonary arteries, and conducted under moderate or deep hypothermia, low circulatory flow or total circulatory arrest based on the extent and sites of the emboli (44). Surgical treatment leads to complete resolution with low rates of recurrence and good long-term survival. The overall recurrence rate is about 1–3% for sporadic atrial myxoma (5,54), which grows an average of 0.24–1.6 cm per year. The risk of recurrence pulmonary embolism after resection has been reported to be 0.4% to 5.0% and interval from excision to recurrence is reported ranging from a few months to 8 years (55). The reasons of RAM recurrence include multifocal origin, incomplete surgical resection, familial disposition or abnormal DNA ploidy pattern. Postoperative annual TTE, V/Q scan for long-term observation should be followed up to detect eventual recurrence of new myxoma and pulmonary embolism. Excision of the recurrent lesions may be the only choice of treatment because of the poor role of chemotherapy and radiation (28). Pulmonary emboli from RAM are usually tumoral, although discriminating myxomas from thrombi in pulmonary arteries is difficult. Daniel T et al (56) presented the first case of paradoxical pulmonary embolism in the presence of a left atrial myxoma withouingt intra-cardiac shunting, potentially secondary to a combination of hemolysis, hemeoxygenase-1 up-regulation, systemic hypercoagulability/hypofibrinolysis, and regional venous stasis. Pulmonary thromboembolism complicated to RAM improved by coumadin therapy in a refused surgery patient (40). In our case the surgery do not remove the right side emboli, while anticoagulation was helpful for residue emboli remission, which confirmed coexistence of myxoma and thrombi. We suggest anticoagulation may be the useful in unresectable myxoma with pulmonary embolism. The duration of anticoagulation in pulmonary thromboembolism is at least three months, but the course in patients with RAM is still unknown. Conclusion According to review of the literature, RAM may not be timely diagnosed, or even totally undiagnosed. Because of the fragile consistency of RAM, pulmonary embolism are the most common comorbidity and mortality disease, usually be fatal. Surgical removal of masses from the atrium and pulmonary arteries is almost uneventful. Although the association between right atrial myxoma and pulmonary embolism has been described, the presence of thrombi was less mentioned. We suggest anticoagulation may be a choice of treatment after operation, especially in incomplete resection cases. Annual TTE and V/Q are suggested for a period of 8 years when the risk of recurrence is reported. Competing interests The authors declare that they have no competing interests.

The Hard Nut Essay -- Drama

The Hard Nut ============ The Hard Nut Is Based On The Nutcracker and Mouse King by ETA Hoffmann, the dance company they used was the Mark Morris Company and the music is by Tchaikovsky. The director of the Hard Nut has not been original, as he has used the same music from the original Nutcracker. The video is a live recording. Act 1 The opening scene starts with three people on the stage dressed as young children, they have their backs to the audience and are dressed in a black and white style, and the curtains are drawn. The curtains go up and Act One Begins. The scenery is black and white there is also a big door bigger than the characters on the stage. The three main characters on the stage are children we can tell this by the way they are acting and the facial expressions they pull. The director is dealing with gender issues a lot of the women are played by men. The dance style they are using is ballet. The huge door opens and the set changes to a living room style setting. It is around Christmas we can tell this, as there is a Christmas tree in the corner of the stage. The characters are dressed in green and red which are the colours of Christmas. In the days were the musical is set they did not have coloured televisions the television starts to go colour and the music starts to be multipurpose as if there is a fire. Throughout the play the use of humour is quite big. The three children are now obviously in their Christmas suits the oldest girl showing off all dressed up whilst the other is quiet and dressed in pink different from the rest, she is overlooked by people very sensible and very shy. Everybody on the stage pairs up and are dancing in duets apart from the youngest child who is in the pink, she is being ignored but is trying hard to involve herself. The girl then notices a man coming into the house she makes a fuss and everybody notices and acts surprised. The man appears to be a joker always wants to be the centre of attention and loves the quiet girl. He brings in two life size presents and the young girl and boy open them, two giant toys come out and begin a duet but they are using the people around them to do the duet including the children. They are using sharp isolated movements acting like robots, using different motifs. The family then get back into partners and begin the duets again... ... look on their faces and start running around in circles and the kiss again! The characters start to run diagonally across the stage in duets and form a huge circle. The use lots of pirouettes all at the same time and then exit the stage with leaps. It leads to the girl and the nutcracker again, showing that they are deeply in love. They perform another duet and kiss again and again. They use movements to show they are in love like smooth runs and turns. They travel away from each other and come back together showing they are reaching for each other’s love! The music becomes grand and they both take centre stage, a new drop down sheet comes down with all different toys on and the music gets faster and faster. They run of and the black and white scene from the start comes back. The stage is now back to the opening scene with the television programme on. The maid comes in going mad and turns the television off. The audience start clapping as the characters come on in duets bow and go through the door apart from the girl and the nutcracker. They finally come on last and the curtain goes up all the characters are in positions and the girl and nutcracker join them.

Susan Smith :: essays research papers fc

Susan Smith In the blink of an eye, North America was informed of Susan Smith's tragic loss of her two young boys. No one would have guessed that such a violent crime could have occurred in a small town . Throughout the ordeal , police began to see the flaws in Susan Smith's story. This lead to suspicions, causing the police to make Susan Smith their prime suspect. Days later, Susan Smith confessed to the hideous crime she committed, leaving the nation in disgust. The actions of Susan Smith, which were based on her background and the events in question have left a profound social and legal impact on society's views of violent crimes. Susan Smith lived what most would consider a normal life up to the time before the event concerning the murder of her two children. The only exceptional incident in her past was the suicide of her father when she was eight years old. Susan met her future spouse David Smith, at the age of nine- teen. The couple later went on to have two children, Michael and Alex. She was described as "well-known and well-liked" by her friends, neighbours and relatives. None of her friends or neighbours could have expected Susan Smith to commit such a horrible crime. The event took place in a small town in Union, South Carolina. On October 25th Susan Smith explained that she was "heading east on Highway 49 when she stopped at a red light at Monarch Mills about 9:15 p.m., and a man jumped into the passenger seat." She described the man "as a black male in his late 20s to early 30s, wearing a plaid shirt, jeans and a toboggan-type hat." She said that the abductor held her at gun point and told her to drive. She drove northeast of Union for about 4 miles. Then the man suddenly told her to stop the car. Mrs. Smith said she asked if she should pull over, but the man said for her to stop in the middle of the road. She claimed that she begged for the release of her two children, who were still strapped in the back seat, but it was to no avail. The town sent out thousands of volunteers to search through "over five hundred square miles for the children." The story later went national but there was still no sign of the children or the attacker. The town Sheriff, John Wells, with the help of an FBI computer system went after every lead that came in from psychics, crackpots and well-meaning citizens.

Causes of students sleeping in class hours

It is a bad habit Of each every one Of us, mostly we experienced it because Of many reasons, and social media is the major reason of our laziness. Social media is not always positive. Students usually multi-task while studying, they check their social media sites while on the process of studying. Their ability to concentrate on the task at hand is significantly reduced by the distractions in posting comments, tweeting and online gaming. Later on they will be totally distracted by their social media activities thus forget about the subjects that hey should focus on, in the first place.This is one very common problem faced by the students not only in this present era but most likely since the formal education was being taken and introduced. The popularity of social media can caught the attention of many students like us. There's no doubt that students are energetic and actively engaged in online communities such as: posting comments, tweeting and online gaming. A. Statement of the Prob lem Laziness occurred because our attention is caught by the social media and we're not aware that our interest in our studies is now losing. In this kind of search, we prepare some questions about this.What are the contributions of social media to the laziness of the students? Why is it that the social media is the number one cause of the laziness of the students? What can we do to overcome this bad habit? B. Hypothesis In this research, we give some answer on the following questions. This answer would be the possible answer of the students about this. For students, who always feel lazy, bored, not interested and sleepy during class hours. It is because they prefer using computers in useless things. Instead of using it on doing your homework, lessons, and projects.Some students feel lazy during class hours for the reason that they're lack of sleep and rest. Some of them are still using computers, browsing nonsense things or playing online games even if it is late at night. We can a void this laziness by having a motivation or a goal. By setting our minds that we should use computers in a good way. Don't use computers too much in doing our school works, we can still browse some information from a reference book. C. Significance of the Study We all know that we can avoid this kind of activity. This research can change their bad habit. This can help them to stay focus on their studies.This research provides awareness to those students who are always lazy when it comes to study but so energetic when it comes to social networking sites. This can also help them to know and realize that using computers for your school works has a bigger difference than using computers to any useless things. Eke, online gaming and always using social networking sites while studying, that's why they can't stay focus on their studies. D. Scope and Delimitation's of the Study Our research is focused on the contributions of social media activities to the jazziness of the students.Through this research we will have more knowledge and deep understanding about its contribution. The selected students of San Guillemot Academy from grade seven to fourth year are our respondents. Thirty (30) students from grade seven, thirty (30) students from grade eight, thirty (30) students from Third year and ten (10) students from fourth year. For a total of 1 00 respondents. Bored, not interested in class, not interested to the subject and sleepy because you're lazy and all you want to do is to use computer time to time.Chapter II Theoretical and Conceptual Framework Review of Related Literature Cutting back on sleep for school work is counterproductive Students who Stay up late to cram for a test or finish a project have lower comprehension and worse performance in the classroom as a result, research shows. By Mary Mclean August 22, 2012 Los Angels Times The old aphorism that â€Å"you snooze, you lose† doesn't apply to students who stay up late to cram for a test or finish a class project. New research shows that sacrificing sleep for school work is a bad trade.Researchers from Class Jane and Terry Semen Institute for Neuroscience and Human Behavior enlisted students from three Los Angels high schools to help them figure out whether academic performance suffered the day after a late night of studying. It turned out their hunch was correct: Lost sleep resulted in less comprehension during class and worse performance on tests, according to their report, published online Tuesday in the journal Child Development. â€Å"Sacrificing sleep for studying seems to be counterproductive,† said Andrew J.Fulfilling, a developmental psychologist at UCLA and the stud's senior author. The researchers gave 535 teenagers checklists to keep track of their sleep and duty time for three 14-day periods when they were in ninth, 10th and 12th grades. The UCLA team found that regardless Of how much time a high schooled normally spends on homework each day, a student who gives up sleep for extra study time will have trouble the next day understanding material in class and be more likely to struggle with an assignment or test the opposite of the student's intent.The researchers didn't quantify the increased risk for academic problems following a longer-than-usual study session, but they said the number of problems was â€Å"surprisingly greater. † The allegations held up no matter how academically ambitious the student was, as measured by the amount of time spent studying on a typical day, and it became stronger as students progressed through high school. The results rang true to Aka Daniels, a college-bound senior at the Los Angels Center for Enriched Studies, a Mid-City magnet school. On occasions when she's stayed up late to study, she's had more trouble absorbing material in class, she said. I'd have to retrace myself at night,† she said. The finding â€Å"makes a lot of sense,† said Mona el-Sheikh, a professor of human velvet een and family studies at Auburn University whose research includes sleep. Several new studies are showing that the quantity and the quality of sleep are important for remembering new information and consolidating learning, she said. Students who get too little sleep don't have enough time to process what they study, she added; even just one night of sleep deprivation can have a negative effect.Parents should do what they can to make sure their children have sufficient and consistent sleep, she said. Fulfilling said he could not disclose which schools took part in the research. The dents varied in ethnic and economic backgrounds, as well as in their level Of academic achievement. Their checklists revealed that study time did not change over the course of high school -? the average was just over an hour per day -? but sleep time decreased by an average of 41. 4 minutes. Ready, willing, and able?Sleep hygiene education, motivational interviewing and cognitive behavior therapy for inso mnia in an Australian high school setting Journal Article By Mineral Cain Publication: Education and Health Date: 2012 Cognitive behavior therapy for insomnia is well-regarded as an effective retirement for insomnia in adults. Previous studies also suggest that CB-I can be successfully applied to adolescents experiencing insomnia and other sleep problems, which most commonly involve delayed sleep timing. The recommended treatment involves a combined program of morning bright light therapy, stimulus control therapy, and education about sleep hygiene.Improving sleep pattern regularity by getting up earlier on weekends (I. E. , at a time closer to the weekday wake-up time) can play a particularly important role in increasing total sleep time during the week and decreasing daytime leafiness. Recent research suggests that the school classroom may be a promising arena for the dissemination of sleep interventions for adolescents. However, many of the earlier studies in this area have been plagued by problems such as inappropriate outcome measures, small sample size, lack of control group, and lack of follow-up data.Reporting has also been poor, with a number of studies presented only in abstract form. Results have been mixed: some studies showed improved knowledge about sleep, despite having no data about actual changes in sleep habits or behaviors; another duty measured sleep habits but found no change from pre- to post- treatment. Finally, some studies found changes in sleep habits from pre- to post-treatment, although these results must be interpreted with caution due to the previously mentioned problems of small sample size, lack of control group, and lack of follow-up data.A series oft studies conducted by researchers at Flinders University in Adelaide, Australia, attempted to overcome the limitations of previous research by conducting randomized controlled trials evaluating school-based intervention programs aimed at improving the sleep of adolescents. Full det ails of these studies can be found in earlier publications; however, an outline of the main findings are presented here, along with recommendations for others planning school-based interventions for adolescent sleep problems.Impact of Delaying School Start Time on Adolescent Sleep, Mood, and Behavior Journal Article By Judith Owens Publication: Arch Pediatrics's Med Date: 2010 Objective: To examine the impact of a 30-minute delay in school start time on adolescents' sleep, mood, and behavior. Design: Participants completed the online retrospective Sleep Habits Survey before and after a change in school tart time. Setting: An independent high school in Rhode Island. Participants: Students (n=201) in grades 9 through 12. Intervention: Institution of a delay in school start time from 8 to 8:30 AM.Main Outcome Measures: Sleep patterns and behavior, daytime sleepiness, mood, data from the Health Center, and absences/tardiest. Results: After the start time delay, mean school night sleep d uration increased by 45 minutes, and average bedtime advanced by 18 minutes (95% confidence interval, 7-29 minutes [24th=3. 36; PC the percentage of students getting less than 7 hours of sleep decreased by 79. 4%, ND those reporting at least 8 hours of sleep increased from 16. 4% to 54. 7%. Students reported significantly more satisfaction with sleep and experienced improved motivation.Daytime sleepiness, fatigue, and depressed mood were all reduced. Most health-related variables, including Health Center visits for fatigue-related complaints, and class attendance also improved. Conclusions: A modest delay in school start time was associated with significant improvements in measures of adolescent alertness, mood, and health. The results of this study support the potential benefits of adjusting school schedules to adolescents' sleep needs, circadian rhythm, and developmental stage. Middle School Start Times: The Importance of a Good Night's Sleep for Young Adolescents Journal Article By Amy R.Wolfs Publication: Behavioral Sleep Medicine Date: 2007 With the onset of adolescence, teenagers require 9. 2 hrs of sleep and experience a delay in the timing of sleep. In the â€Å"real world† with early school start times, however, they report less sleep, striking differences between their school-weekend sleep schedules, and significant daytime sleepiness. Prior studies demonstrated that high coolers with later school starts do not rather delay bedtime but obtain more sleep due to later wake times. This study examined sleep-wake patterns of young adolescents attending urban, public middle schools with early (7:1 5 a. . ) versus late (8:37 a. M. ) start times. Students (N = 205) were assessed at 2 time periods. Students at the late- starting school reported waking up over 1 hrs later on school mornings and obtaining 50 min more sleep each night, less sleepiness, and fewer tardiest than students at the early school. All students reported similar school-night bedtime , sleep hygiene practices, and weekend sleep schedules. Related Studies Sleep Complaints Affecting School Performance at Different Educational Levels By James F. Page and Carol F.Swastikas Published online 2010 November 16. Prepossessed online 201 0 July 21 Abstract The clear association between reports of sleep disturbance and poor school performance has been documented for sleepy adolescents. This study extends that research to students outside the adolescent age grouping in an associated school setting (98 middle school students, 67 high school students, and 64 college students). Reported restless legs and periodic limb movements are significantly associated with lower Spa's in junior high students.Consistent with previous studies, daytime sleepiness was the sleep variable most likely to negatively affects high school students. Sleep onset and maintenance insomnia were the reported sleep variables significantly correlated with poorer school performance in college students. This s tudy indicates that different sleep disorder variables negatively affect performance at different age and educational levels. Keyset;rods: adolescent, college, sleep, restless legs, school, insomnia, GAP Introduction A growing body of work documents the association between disordered sleep and school performance.Students who report insomnia, inadequate sleep, daytime sleepiness, irregular sleep patterns and/or poor sleep quality do not perform as well in school as others (Blue et al. , 1990; Link and Nicolai- Israel, 1995; Hoffman and Strength, 1 997; Wolfs and Sarandon, 1 998, 2003; Shin et al. , 2003; Mailman,2005). Children enrolled in remedial school programs report significantly more sleep problems (Blunder and Chervil, 2008). Reported abnormalities in sleep including sleep latency [SSL]>mini and more than one arousal per night at least two nights/week have shown an association with an increase in school failure rates (Kahn et l. 1989). A large study in the Spanish secondary sc hool system (N=11 55, mean age 14) found a significant correlation between class failure and sleep complaints, and morning sleepiness (Solaced et al. , 2005). Better school performance is associated with more time in bed, better sleep quality, fewer nighttimes arousal, less napping and less difference between weekday and weekend sleep times (Link and Nicolai-lesser, 1 995; Hoffman and Strength, 1997; Wolfs and Sarandon, 1998).The association between sleep complaints and poor school performance is supported by in-lab experimental studies that demonstrate negative effects for sleep deprivation, sleep restriction, and sleepiness on laboratory measures of motor skill, memory, attention and problem solving in children and adolescents (Shades et al. , 2002; Teaser et al. , 2002; Sarandon et al. , 2004). Experimental restriction Of sleep in students (ages 6-12) has been shown to lead to academic difficulty in the classroom as well as increased severity of school related attention problems (Fallen et al. 2005). There are suggestions in the literature that sleep variables affecting school performance differ based on age and educational level. In seven year olds, short sleep duration is associated with higher emotional liability (Nixon et al. , 2008). Adolescent aged delayed sleep phase develops at the onset of puberty with the associated daytime sleepiness affecting school performance in the high school aged population (Wolfs and Sarandon, 2003; Mailman, 2005). In a large study of Canadian high school students (N=3,235, mean age 16. ) twenty-three percent of students felt that their grades had dropped in high school because of daytime sleepiness (Gibson et al. ,2006). A similar study in Korean high school students N=3,871 , mean age 16. 8) reported excessive daytime sleepiness (DES) to be present in 15. 9% of students. DES was significantly associated with perceived sleep insufficiency, two or more insomnia symptoms and low school performance (Joy et al. , 2005). The p roportion of students reporting insomnia appears to increase with increasing age and higher educational level.Among Japanese adolescents, both difficulty initiating sleep and reported insomnia gradually increase from 7th to 12th grade (Kanata et al. , 2006). Up to 30% of college students report chronic Severe sleep difficulties including both daytime sleepiness and insomnia with 1 1 % meeting criteria for delayed sleep phase syndrome (DADS) (Brown et al. , 2001 , 2006). Sleep disturbances are likely to continue to affect school performance in adults. Cognitive function test scores have been noted to fall in both medical students and residents after sleep deprivation (Wallach et al. 2003). Disordered sleep has also been noted to effect behaviors other than school performance. For example, daytime sleepiness was shown to negatively affect student participation in extracurricular activity (Gibson et al. , 2006). Studies have documented the effect of disordered sleep on the behavioral a nd emotional performance of elementary' school children (Meandered et al. , 2006; El-Sheikh et al. ,2007). Children with fragmented sleep score lower on tests of neurologically functioning and have increased parent-reported levels of behavior problems (Shades et al. 2002). In adolescent boys reported tiredness and sleepiness associated with lower perceived academic performance is also associated with negative mood states, problematic alcohol use, perceived mistreatment or abuse, antisocial behavior, intention to use or current use of illegal drugs, ND feelings of isolation (O'brien and Mindful, 2005; Anyone et al. , 2007). Treatment protocols proposed and utilized in the treatment of sleep disturbance in students A variety of treatment protocols have been proposed for general application in student populations.The finding that early high school start times are associated with student reports of less sleep and increased sleepiness has led to proposals for changes in school start time s (Dexter et al. , 2003; Joy et al. , 2005). In some states and communities school Start times have been changed based on legislation. It is currently unclear hither this approach leads to an improvement in school performance (Liaison et al. , 2002). In elementary students treatment suggestions for sleep complaints include attempts to resolve the marital conflicts (El-Sheikh et al. , 2007).Emphasis on the behavioral basis of daytime sleepiness in high school students has led to the development and application of co-educational programs emphasizing sleep hygiene (Joy et al. , 2005; Gibson et al. , 2006). Melatonin used as a pharmacological treatment for adolescents aged 10-?1 areas in the treatment of DADS has been shown to exult in fewer of these students reporting school difficulties (Ginsberg et al. ,2006). Some studies have suggested, based on data derived from high school studies, that co-educational treatment approaches and delayed class start times be utilized in the treatment of college students (Brown et al. 2006; Gibson et al. , 2006). In the effort to improve school performance at all educational levels, there appears to be a tendency to apply one-size-fits-all programs for the treatment of sleep disturbance based on data from high school studies (Brown et al. , 2006). This study presents data evaluating the association between questionnaire-reported sleep disturbances and school performance in three separate groups of students extending from grade 6 through college (age range 10-?54).It is the authors' hypothesis that the sleep variables affecting school performance in elementary school and junior high differ from those affecting school performance in high school, and those affecting college students. If this hypothesis is correct, it becomes increasingly important that future research studies and treatment protocols should clarify the age and educational level association of sleep disorder variables with school performance. Materials and Methods Th ree samples of students were analyzed for this study: middle school (grades 6-8), high school (grades 9-11) and college students.The first samples were assessed in the science and heath classes at associated middle and high schools in Pueblo, Colorado near the end of the 2005 school year. The college sample was assessed in psychology, nursing and medical classes at the local community colleges as part of an invited presentation on â€Å"Sleep in Young Adults† in 2007. Although all three studies used the same questionnaire instrument, because of differences in the settings, statistical imprisons were made within, but not across the three educational levels.An RIB approved, 18-question frequency-based pediatric sleep disturbance questionnaire, based on validated and indexed questions (Chervil et al. , 2000, 2003; Page et al. , 2007), was used for all three samples. The questionnaire consisted of five ordinal response categories: I-?never; 2=rarely (once a month); 3=sometimes (o nce a week); 4=occasionally (twice a week); 5=always (every night). In order to simplify interpretation of the data and reduce categories with small numbers of responses, we aggregated the sleep ATA to compare response categories 3-5 to categories 1 and 2.This differentiated those who reported having the sleep problem at least once a week from those who had it less often. Assessment of school performance was based on self reported GAP (Range 2. 0-4. 0), which is a common method for defining academic performance in sleep research (Blue et al. , 1990; Hoffman and Strength, 1997; Wolfs and Sarandon, 1 998; Mailman, 2005). Although questionnaires were distributed to 238 middle and high school students, only 165 (69. %) reported their GAP While only the students porting GAP could be analyzed for this study, chi-square analyses revealed that none of the sleep variables differed significantly between those who provided GAP data and those who did not. In addition, a proportion of post- seco ndary school students were enrolled in either nursing or medical training programs that did not rate performance based on GAP and therefore could not be included. This study included 98 junior high students (Grades 6-8), 67 high school students (grades 9-11) and 64 college students (mean age 27. , range 17-?59). GAP was not normally distributed and therefore was split at the Edwina to form two groups within each educational level: Low GAP and High GAP. Within each of the three educational levels, chi-square analyses, using Fisher-exact one-sided tests, were run to compare each of the sleep disturbance variables by GAP (low or high). Results Table 1 displays descriptive information for demographic and sleep variables for the three groups. Notably, there were more Hispanic students in the two younger groups and more African American and white students in the college group.There were also substantially more males in the college group than the two younger groups. However, within each ed ucational group, there were o significant differences in age, ethnicity or gender by GAP. For all three groups, the most common sleep associated problem was feeling unrepressed/tired in the morning, followed by having trouble waking up in the morning. The least common behaviors were trouble with breathing when sleeping and taking sleep medication. Table 1 Demographic and sleep variables for all three groups.

Analyse Your Own Strengths and Weaknesses in Counselling Skills Essay

Use your work from P3 and analyse (consider in detail) it e. g. what are your strengths in counselling skills, why you think they are your strengths and where do you use them. What are your weaknesses, why do you think they are your weaknesses and what can you do to turn them into strengths. For Egan’s first stage I think the strengths that I have in counselling would be that I explained to the client about the contract and confidentiality that is included into the contract that is kept between the counsellor and the client and so with this I was able to use this to be able to show the client that this is a professional relationship and so this is explains the guidelines of what is going to happen between the counsellor and client within the sessions and outside of sessions if contact is needed. This is a strength because the client will think that I am professional because we need to go through the contract first before the starting of any sessions so then they know what is going to happen in the sessions that they are having. It would also be a strength because if I did not explain the contracting at the start of the session then the client would not know what the counsellor does about contacting, name, address, and also if they have been referred here by their GP and explain to them if they need more specialised help and so they would explain at the start if the counsellor would have to refer their client onto someone more specialised so this would be a client that might have drinking or drugs problems and so they would need to explain first that they might refer later on in the sessions and the warning of sending them on. I was also able to explain that confidentiality was also a strength because if the client didn’t know that the confidentiality during the sessions then they might not be open to telling me the counsellor about what their issue is and so then I might take the information that they have said already and be able to spread so I was able to explain the confidentiality so that they know that all they say will stay between me and the client unless they are at risk of harming themselves or others and so I would have to break confidentiality there and I would alarm them of that I am breaking confidentiality by informing others of what they have done. This is a strength because I was able to explain all about confidentiality so that the client is able to know all the information they needed about what is going to happen in the counselling sessions. I would use confidentiality with every patient I am with because they will not trust me otherwise and I would not be able to help them with their issues and that they would want me to keep everything they said otherwise I might be putting them at risk of being harmed. Another strength that I had was that I was able to give unbiased information which means that I was not adding any of my own opinion to the advice that I was giving the client. I think that this was a strength because I didn’t let myself give biased information which could lead me into trouble if they followed my advice, this would also cause the client issues if they were being abused and they followed my advice and I put them at harms way because I told them to make a decision about what their circumstance was and that I could potentially lead them into getting more hurt than they already was. I would use this strength with all the clients that I am attending to because then I am not reliable to be subject to being prosecuted because I told them that they should do this and that and so this meant they might be homeless, severely hurt or even worse that they have lost everything because of one little thing that I have said to them and so unbiased information also protects me the professional from not being subjected to court because of seeing them in the sessions and providing this information to them. Eye contact is a strength of mine because establishing eye contact with the clients that I have to work with allowed me to be able to show them that I was listening to what they have to say and so this made it so that I was not being rude to them because of not looking at them and so this meant they was able to express more to me because of me the professional able to pay attention and see the emotion they are expressing with what they have to say and if they are not saying anything then seeing the emotion that they are able to transpire by being quite but are wanting to express what they want to say without actually saying it. I think this is a strength because they need eye contact to know who they are talking to especially if its couple or group counselling that is taking place. I would use this when being with my clients because they would need to be able to know that I am being assertive to them when they are expressing what they have bottled up for a long time and so this allows them to know that they can trust me. During the session a strength that was pointed out what that I was able to reflect throughout the session and this is a strength because it showed that I am being assertive and being able to reflect back to the client everything they said and also expressing the same emotion that they told me back to them to show them what they are doing and so this shows them what emotion they are putting in with their words so that they know how they are feeling about a certain topic. I think this is a strength because they are able to show that I am not only listening but also taking in the information if I am able to reflect it back to them with the same emotion they are using and so this helps for when I have to give them unbiased information that can relate to the presenting issue. I would use this with the clients I have in the counselling sessions to show that I am capable of helping them if I have the knowledge of what they have said to me and be able to transfer it back to them for the next session so that they are able to vent it all to me so then they can have help. Summarising was also a strength that I was able to do in the counselling session because at the end of the session I was able to take in all the information that the client has discussed and summarise it so that they know I was able to do this by listening to everything they said. I think this is a strength because the client is going to trust me more and then we can start building a helping relationship by being able to make sure that everything that the client has said I take it into account even if it’s the smallest thing. This would be used when I am with clients because showing them that I am able to summarise all what they have discussed shows that I want to help them with their presenting issue. Showing professionalism and exploration are a strength because I was able to represent myself that I am professional and not being personal so that the client can only see me as a professional and not someone who is being non-professional and so this is a strength because then they are not able to now personal things about me that are private and will only make the client confused of who is in the room my personal self or the professional side and that exploration I was able to find more information about the client by asking open questions so that I was able to help them with the presenting issue at hand. I would use this with the clients because then I am not letting them see my other side and sticking to professionalism and that exploring is an easier way to finding all the information the client has on that topic and so this means being able to help a lot faster and maybe even resolving the issue. The weaknesses that occurred in the first stage was that at the start of the session I was not being focussed, this is a weakness because then I was not paying attention to the client and they might have said something important or urgent that needs attending to for example if they said they was going to kill their family and I ignored that then I could potentially making her family at risk of being hurt or even murdered because I was not paying attention. To turn this into a strength I need to be more focussed that means I need to be focussed as soon as they enter the room so that I do not miss anything they say or express on their face. Another weakness was that I was also judgemental to the client with what they say and this is a weakness because I should not being judging them on what is going on with their life or how they look because I do not know them or their life so this could have been the way they was born and judging them only makes me feel guilty about what I am thinking about them and can lead me into getting distracted. I can turn this into a strength by making sure that no matter who my client is I am not allowed to judge because nobody is perfect and not all people have the same life as me and so that they may need more help. Egan’s second stage I think that the strengths I have are that I was challenging the client by asking open questions so that they are forced to tell me more information and not just a simple yes or no answer and something that they would have to think about, this is a strength because it made them feel like I was caring because I was asking the open questions to be able to dig deep into the presenting issues and so this would help me be able to resolve the issue and help them with their life. I would use this to e able to tackle the client that have difficulty in expressing what they want to say because they are either scared, worried or terrified of what my reaction might be. Another strength I have is repeating the issue to the client to allow them to continue where they might have left off, I think this is a strength because it might be that they were heading is the right direction because this might be about the presenting issue that they have and so allowing me to repeat it to them to continue allows them more chance to get everything they’ve probably wanted to say off their chest. I would use this with every client I see because at least I am showing them that I remember what they said and also allowing them to remember so they are able to express what they want. The weaknesses that I occurred through the second stage was that I made the client feel uncomfortable by leaving awkward silences I think this is a weakness because if it’s a new client then this means I still am trying to know this person and they might not be happy that they would tell a complete stranger all about the secrets they have been hiding for years and so this meant I was waiting on them to answer one of my open questions or waiting for them to present an issue that I am able to help them with, the way I would turn this into a strength is that instead of waiting on them to answer me I could get them to do activities like drawing or ball game so that they are able to trust me and start the conversation going. Another weakness was that I introduced myself again and so this is a weakness because this could be passed on to the client as though I am forgetful of who my clients are so I need to introduce myself again and this could lead the client in not trusting me beca use if I have to do this then I probably can not remember the conversations that I am having with my clients and who they are. To turn this into a strength I need to not introduce myself again but make sure that they are aware that I am there as a professional and so the introduction needs to be happening at the start of a new client. The strengths that occurred in the third stage was that that I was able to look back at the last session which is reflecting and this is a strength because I was more able to express all the emotion they had put into the conservations over time and so this means that I can help them more and they can see what emotion they are expressing to me when I mention a certain topic and develop on this because if a topic that they mentioned is a lot more expressed than another than this can help the client be able to think more about this topic and if it can resolve the presenting issue. I would use this with my client because they need to know that I am being aware of what they are saying to me and also the emotion they are putting into it. Another strength was that I was able to recap on the SMART targets that were set in the second stage and so this is a strength because when recapping on these targets it can help the client be able to show me that they have achieved some of their targets and also review the ones that have not been met and see if we cant change it to make it smarter so that they don’t feel like they are unable to achieve it, I would use this strength with all my clients because being able to set SMART targets enables not only me but also the client to be focussed on what they want to do so this might mean setting a target such as if my client was pregnant and needed to tell the father than this means the target will be able to help her be able to tell him using the SMART example and that this might make her feel better because if she can do this then she will be able to set other targets than can do with this subject and if she cannot for fill the target for some reason then maybe we can change the target to ones that are easier. The weaknesses that occurred in the third stage was that I spoke too much to the client and this is a weakness because this meant that I was overloading the client with too much information that they might not be able to take it all in and so feel really confused with what I am saying and then feel like they are not able to ask again because I might say it all again and overload them. I think that to turn this into a strength is that when I need to tell them information is too inform them first that I need to give them information and make it clear to them and then ask if they got everything I said and that they understand. Another weakness was that I was not focused again which meant that I didn’t turn it into a strength because I was able to do it again and this mean that this is a weakness because I didn’t listen to my own advice of being able to turn it into a strength and so this means that I need to be more focussed otherwise it can lead to consequences on the client and also me the professional. To turn this into a strength is that I need to stay focussed on every client that I see even if I don’t believe the client or that I know they are telling lies because they have changes their story from the previous session.