Category: Caring

If you were to ask parents why they might have their son circumcised most would probably answer hygiene. This decision is also almost always made directly after birth or in other words neo-natal. The consenting parties in most cases are the birth parents who are in most cases told nothing by a doctor and themselves likely know very little about its risks. All of this is compounded with the fact that a decision must be made quickly reducing their chance to take into account ethical questions that arise with irreversible procedures. Among these questions are Is it ethically acceptable to surgically alter the natural genitals of a child without a compelling therapeutic reason; and Who is the appropriate person to give permission for elective, nontherapeutic cutting of an infants genitals. These are questions are worthy of further consideration because they can only pertain to baby boys, they would never be asked in the case of an adult or baby girls who are protected from circumcision by federal law (18 U.S. Code § 116). So why must these questions be considered in America {amount of male newborns a day}. Established rules on human rights and medical ethics do not support the removal of healthy, functional tissue, unless that person elects to do so voluntarily.

Historically in the united states the one that made the decision was the doctor. In most situations the first time a mother held her child the procedure would have already been performed. However, in the 1970s medical ethics changed to a point where it was acknowledged that the patient had a right to make decisions about their child’s body. This is not far enough as the person whose body is affected most by this decision is not the parent but the child himself. Circumcision is often referred to as a personal choice but how can it be if the person who has been circumcised didn’t make the choice.

In medical ethics there are 4 fundamental principles they are; Non-maleficence, Beneficence, Autonomy, and Justice (Jahn). Non- maleficence is the idea that the proposed intervention will not cause unnecessary harm. Most would think of this harm as only physical but what many don’t consider is emotional or sexual harm that may manifest in the child’s future. Beneficence deals with the idea that the patient may stand to benefit from proposed intervention. At present this is the most common justification for the procedure. The most commonly cited benefit is a small amount of protection against HIV(Sazabo). However, this would only ever benefit a small proportion of males and so is no justification for the procedure to be as common as it is. In addition, there are also far more conservative ways of warding off infection by way of basic hygiene and safe sex behaviors. Autonomy is when the patient has a recognized right to make their own decisions about medical interference. This is the most important principal because respects the patients right to self determination and knowing what is best for themselves. In all cases of neo natal circumcision this principle is infringed upon. The final principal of medical ethics is justice which is the idea of fairness and discrimination and is this medical intervention deserved based on benefits and burdens. As no other type of patient is treated this way the answer is obviously no, this is unjust.

On top of medical ethics principals, the united nations have made a number of pertinent statements on human rights. Like medical ethics these human rights statements are based on the inherent dignity of all human beings and the rights derived from it. In 1948 the united nations Made their Universal Declaration of Human Rights. This declaration lists children as having the same rights as adults. However, because of inherent vulnerability of children they were granted unique protections at the convention on rights of the child in 1989. Of the rights listed in 1948 that pertain to circumcision are; The Right to Life, Liberty, and security of person (United Nations). In international human rights law, the phrase security of person can be taken as meaning the physical integrity of every person. Also in 1948 people were granted a Right to freedom from cruel, inhumane and degrading treatment. As we have already seen above circumcision fails pass medical ethics and could be easily argued as infringing on any of the those three. The convention of 1989 enumerated several more rights that impugn neo natal circumcision. Among these is the right to opportunities for children to develop physically, mentally, morally, spiritually, and socially in a healthy and normal manner, and in conditions of freedom and dignity. Another right given was right to protection from all forms of mental and physical violence, injury, or abuse, including sexual abuse. The third and most poignant the right of protection from traditional practices prejudicial to the health of children. (United Nations)

Circumcision is a non-therapeutic medically unnecessary, irreversible amputation of a normal, healthy, functional body part from aa non-consenting person. Even when there is no disease or deformity present in the newborn baby this surgery is offered. It is offered for social, religious and most often for the cosmetic preference of the parents. Most amputative surgeries are offered as a last resort due to their irreversible nature and the effect of such surgeries will permanently alter the patient’s life. In almost any other case the such a procedure would be ethically ok because it is made by an informed consenting adult. There is no medical professional whose code of ethics would allow them to perform an amputative surgery at a non-patient’s request. Yet this is done everyday to baby boys without anesthetic based solely on the whims of their parents. In cases with no valid medical reason neo natal circumcision is unethical and morally impermissible because it violates a person’s sovereignty over their own body as well as their autonomy.

The issue of private versus publicly funded health care remains controversial, with nations around the world employing a combination of these systems to varying degrees of success.

Regardless of the system in place, millions of people still have inadequate access to health care, which can lead to poor health outcomes and decreased quality of life. In order to regulate standard of care, governments should implement universal health care systems that allow all citizens, irrespective of socioeconomic status, to receive free and timely health services, thus removing the need for private health care. This notion is supported by well-known international standards and ethical principles, which assert that (1) access to health care is a fundamental human right, (2) wealthier individuals have a moral obligation to assist those in need, and (3) benefits would be widespread, leading to more prosperous societies.

Firstly, access to quality health care is a fundamental human right according to longstanding international codes and the ethical principle of justice. In December 1948, the United Nations General Assembly published their Universal Declaration of Human Rights, which outlined essential human rights for all people and all nations. Of interest, Article 25 of the Declaration states that “everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, medical care and necessary social services” (United Nations, 2020, para. 26). Therefore, as medical care is a universally acknowledged human right, governments have an obligation to uphold this decree and provide accessible services for all citizens. Similarly, the World Health Organisation has established Sustainable Development Goals to address global sustainability and human development issues. Goal 3 aims to “ensure healthy lives and promote wellbeing for all ages” (United Nations, 2020, para 1). In order to fulfil this goal, worldwide governments should look to implement universal health care, which would provide all people with high quality preventative and curative health services without financial burden. Universal health care is also underpinned by the ethical principle of justice. In health care ethics, justice refers to the fair and equitable allocation of resources and services amongst all people (Australian Catholic University [ACU], 2020, section 5.2). By providing much-needed health services to all people, rather than just those who can afford it, governments would be able to safeguard the physical and mental wellbeing of their citizens, and uphold not only the fundamental principle of justice, but also human dignity and respect. Evidently, governments have a great responsibility to work towards universal health care, and so too do certain individuals within society.

Secondly, according to the ethical principle of beneficence and the ethics of care theory, individuals in better health and financial situations have a duty to contribute to the health care of those with lower socio-economic statuses. Universal health care is funded with revenue from income taxes and therefore relies on wealthier individuals paying tax for the medical care of others (Paek, Meemon, & Wan, 2016). This is justified using the ethical principle of beneficence, which commonly refers to the moral obligation to act for the benefit of others “by preventing or removing possible harms” (Ashcroft, Dawson, Draper, & McMillan, 2007). One such harm includes the significant financial burden that private health insurance can pose on low-income earners. Universal health care aims to spread the financial burden among the entire community so that it is not fully borne on an individual who falls ill (Mathauer, Vinyals Torres, Kutzin, Jakab, & Hanson, 2020). The ethics of care theory also encourages others to assist those in need. This theory suggests that decisions be made based on compassion, empathy and a sincere concern for the vulnerable members of society (Schuchter & Heller, 2018; ACU, 2020). In accordance with this theory, healthier people should be motivated to contribute to the health care of others, understanding that it is morally and ethically right. Whilst those in better life circumstances would bear the majority of the financial burden associated with universal health care, the benefits of this system would be widespread.

Finally, universal health care has the potential to benefit entire communities, in line with the ethical principle of utilitarianism. Utilitarianism was originally developed by philosophers Bentham and Mills in the 19th century to encourage followers to “act in such a way to generate the maximum quantum of well-being, happiness or utility” (Marseille & Kahn, 2019). Universal health care promotes utilitarianism as it enables more people to secure benefits than the privatised schemes currently employed in many countries. Furthermore, by providing access to free, high quality health services, individuals would likely recover from illnesses/injuries faster (and possibly avoid illness in the first place due to preventative health care measures). As a result, these individuals would require less time away from work and would have increased productivity, enabling them to be active members of society. Improved quality of care via a universal system would also help to build trust and solidarity from the public (Sumriddetchkajorn et al., 2019). Benefits of this nature have been achieved in Thailand, where universal health care has been implemented since 2002. The Thai government provides all citizens with free essential health services including annual physician check-ups, health promotion strategies and chronic disease management in all stages of life (Paek et al., 2016). Since its introduction, this preventative and curative health care scheme has increased Thailand’s life expectancy from 71.8 to 74.2 years, and has led to better utilisation of outpatient services and improved health-related quality of life (Sumriddetchkajorn et al., 2019). As demonstrated in Thailand, universal health care is a feasible, successful system that is capable of producing wide ranging benefits for entire communities.

Patients share critical health related information with caregivers and Health organizations. They do so with a belief that their data would be kept confidential. Any breach of data confidentiality can lead to critical patient information being leaked to unwanted agencies and can cause severe trust deficit between health agencies and patients.

To protect the sensitive data about the patient’s health information, the Health and Human Services of the US department (HHS) enacted a HIPPA privacy rule in 1996. This federal law informs the Healthcare agencies about the authority they have, and in turn assures the patients, to control the flow of patient’s personal information without being disclosed to third party agencies or individuals except in the case if the agency or the individual is associated with protecting the public’s health and well-being.

Any breach in HIPAA regulations by health agencies, calls for strict legal penalties and monetary implications. The Health and Human Services of the US department (HHS) enacting the HIPPA regulations, ensures the following:

• Investigate any complaints related to the violations
• Regularly evaluate the conduct of the covered organizations and ensure that they are following compliance
• Provide education through outreach to promote compliance with the regulations

Organizations covered under HIPAA regulations

You might want to check whether your organization falls under HIPAA regulations purview or not. You would need to comply with the regulations if you are one of the following:

• Healthcare Provider: Any Healthcare provider, small or big, who is receiving patient records and entering them electronically, needs to comply with HIPAA data transmission guidelines
• Insurance Providers: Any insurance player, who is dealing with Health plans including Medicare, Medicaid, Choice, Supplement and long term Health plans (including employer sponsored plans), need to comply with HIPAA guidelines
• Intermediate Health Agencies: Any agency or organization, who receives patient data for processing, from other entities, for example clearing houses, needs to be compliant.
• Analytics firms: Any business analyst, who utilizes patient data to perform certain analytics to inform business decisions, needs to follow HIPAA guidelines.

Types of HIPAA breaches

HIPAA violations can be accidental, when violations occur due to maximum disclosure of PHI beyond the minimum required or intentional, when a company or practice fails to report breaches or fails to correct on time. HIPAA breach can happen, intentionally or unintentionally, due to multiple reasons:

• Unencrypted Data: When a patient’s health information is unsecured, it can be easily accessible to anyone, and the data can be lost or used unauthorized by hackers.
• Theft of Data: The device with PHI information needs to be always encrypted, and secured with a password, to avoid loss or theft of data, in case the device is stolen or lost.
• Lack of Training or Awareness: Unskilled workforce or lower awareness can lead to insensitive handling and transfer of data from one device or one channel to other, leading to security risks
• Insufficient Measures to avoid Hacks: Failed measures to protect data, and irresponsible logs maintenance can lead to hacking attacks on the data

Implications and penalties for HIPAA violations breach

Depending on whether you have violated the HIPAA norms intentionally or unintentionally and depending on the level and extent of breach, you can be charged under the Civil law or Criminal law or both. The Civil law leads to monetary implications for the Health agencies and individuals, while the criminal law can gives you a hard jail term.

Under the Civil law, the HIPAA breach can be classified in 4 categories and accordingly penalties will be imposed:

• Tier 1 Breach: Tier 1 breach typically deals with unintentional breach or when the offender is unaware of the breach. In such cases, a penalty in the range of $100 to $50,000 can be imposed, depending on the extent of the breach and its impact.
• Tier 2 Breach: Also known as second degree breach, this happens when the company is aware of the breach, however no timely action is taken to rectify the issue. In such cases, penalties in the range of $1000 to $50,000 can be imposed.
• Tier 3 Breach: In such cases, the entity neglects the rule by choice. In such cases, the penalties can range between $10,000 to $50,000 per violation
• Tier 4 Breach: In such cases, the companies did the violation by choice and presently, there is no way in which the violation can be corrected. The penalty for such cases is $50000 and above. The maximum penalty of $1.5 Mn can be imposed in total.

In case, an organization or individual tries to obtain patient data through unlawful means, criminal cases can be instigated against the parties. The criminal breaches can be of 3 types:

• Tier 1: 1-year jail term in case of reasonable cause or no knowledge of the violation
• Tier 2: 5-year jail term in case of Acquiring protected health information (PHI) under fake pretenses
• Tier 3: 10 years of jail time in case of Obtaining protected health information (PHI) for personal gain or with malicious intent

Multiple examples of violations and corresponding penalties have been observed in the past. In February 2019, $3 million was fined by Health and Human Services (HHS) to Cottage Health, which also runs Goleta Valley Cottage Hospital, Cottage Rehabilitation Hospital, Santa Ynez Cottage Hospital, and Santa Barbara Cottage Hospital in California. The penalty was levied due to repeated offence of unbarred electronic PHI, which impacted over 60,000 patients over a span of 2 years. In May 2019, a Tennessee diagnostic medical-imaging practice named Touchstone, was asked to pay $3 Mn as they exposed the data of more than 300,000 patients.

How to prevent HIPAA violation and protect against penalties

Though you might not want to intentionally violate HIPAA norms and guidelines, there can be cyber attacks, which can lead to data theft and can land you into trouble with HIPAA agencies. To prevent and hedge against these cyber risks, you should do the following:

• Proper Business Agreements: Initiate proper business agreements, with third party players, who share patient’s PHI. This ensures liabilities at the partner end as well, to avoid any data breaches.
• Strengthen Transmission Security: Encrypt the PHI that is shared on your network. Follow the industry best practices and latest technologies for strengthening transmission security

Conduct Cyber Risk Assessment tests to quantify, benchmark, and mitigate the financial impact of cyber-attacks on your business. Take a risk assessment test by Now Insurance, which uses leading corporations for cyber insurance, supply-chain risk, and security assessments.

• Cyber Security Insurance: With the increasing threats of hacking and data breaches, it is imperative to insure business with strong Cyber security insurance plans. Now Insurance offers some of the better insurance plans, available in the market, that cover both cyber and Professional Liability, and include a $25K HIPAA sublimit.

Conclusion

A small negligence in handling patient data can handover to you hefty fines running in millions of dollars and can land you in jail. This can happen, without your knowledge, because of an unwarranted cyber attack, Hence, it is important that you take all the necessary measures to protect and encrypt patient data and take some steps to prevent cyber attacks. Also, have a good Cyber security insurance, as even after following diligent steps, any unwarranted cyber attack on the patient data can leave you penniless and broken for life.

The role of the paramedic within the NHS unscheduled care agenda relates to direct urgent or emergency patient care. In context to paramedics, it is directly about urgent care and emergency care, both types of care requiring assessments and planned interventions. (Making connections with the challenges of unscheduled care, 2012). Paramedics have the duty when called out to assess all aspects of the patient, from their called complaint to their social history. Paramedics must take everything into consideration in order to effectively implant a planned intervention to prevent an emergency which will require immediate care or assistance in the near future. After assessing patients, paramedics have to make the critical decision to admit patients to a hospital, to refer them to other health services or to leave them at home, but they must have valid and strong evidence to support that decision. (Paramedic – Scope of Practice Policy, 2017). The main role is to go through efficient triage and thorough examinations in order to provide a pre-hospital temporary treatment which can also be a planned intervention. The Scope of Practice Policy published by the College of Paramedics describes the paramedic role as a role where paramedics ‘holistically assess, and if required treat and manage service users presenting with physical or mental health complaints; either as the result of injury, illness, or an exacerbation of a chronic illness.’ (Paramedic – Scope of Practice Policy, 2017). They are the first clinical or healthcare professionals that a member of the public will come into contact with, therefore policies and procedures have been set in place by paramedic regulatory bodies such as the Health and Care Professions Council (HCPC), College of Paramedics which are also known as the British Paramedic Association and the National Institute for Health and Care Excellence (NICE). These bodies provide guidance and support to ambulance services, so every student and qualified paramedic is able to safely provide care to patients, be able to use the correct techniques and necessary equipment effectively to holistically support members of the public.

The unscheduled care agenda does have some issues within it that effects the duty of the paramedic and how patients receive treatment, according to the NHS Grampian website, they state that ‘over recent years, services that provide unscheduled care have been under increasing pressure’ (Nhsgrampian.org, 2019). Paramedics are apart of the many services that face pressures when it comes to giving patient care, as well as being able to admit patients into hospitals as the hospitals and the departments within them, face their own pressures. In a wider multi-disciplinary team, paramedics are able to lessen the pressures on further services; they are able to work on a patient, be able to administer care and treatment on scene and either make a referral to other services that prevent the patient from going into hospital for a minor issue, or they assess and treat patients and leave them at home with advice. In most cases, a hospital is not where a patient needs to be unless they have symptoms that concern paramedics. With care essentials and equipment being limited on an ambulance, paramedics face the pressures of making the decision on whether a patient should go to hospital or not but in the best interest of many patients, they try to keep the care close to home and prevent people going into hospital and having to wait many hours to receive care. Paramedics work with multiple professionals in a multi-disciplinary team in order to achieve this goal, they work within the community which means that they also work with professionals outside of health care such as fire services, police services, and social services but when it comes to care, paramedics work with medical and mental health professionals for further clinical advice or referrals, such as specialist or advanced paramedics when it comes to receiving immediate advice. When it comes to patients who have multiple and complex conditions, paramedics can work with other services in a multi-disciplinary team to give patients the right care the first-time round in a safely managed environment like their homes or in community care settings. This then results in fewer people being admitted into the Emergency Department and having to wait long periods of time as well as the number of subsequent general admissions to the hospital being lower. (Health Education England, 2019). Paramedics like every other health care professional will do things such as safeguard confidential information which is protected and practiced under the Data Protection Act 1998 and when it comes to either receiving information or handing over information to other professionals, they must ensure that consent from the patient is provided as well as that any information given should be for reasonable causes, such as giving the name, address and case code to a receptionist at Accident and Emergency when booking the patient into hospital. If patients have concerns or if they wish information to be disclosed confidentially, paramedics when doing a clinical handover should attempt to disclose information in a private setting. When working with other professionals in a wider multi-disciplinary team, it would be beneficial for paramedics to use clear communication as well as be able to work well with other members in their service as well as others as then, barriers can easily be overcome through the support of others.

There are many contemporary issues that could impact Paramedic practice, some being more minor to others such as the lack of training and the lack of people following policies and procedures to the mental health of paramedics and academic standards in order to qualify and work. Education in paramedic practice has become a heated contemporary issue as it affects current paramedics and future qualified paramedics, it is something that is currently happening and being reviewed by the HCPC which is the regulatory body that consulted on changing the registration requirements to degree level in March 2018 (Timms, 2018). This contemporary issue was commissioned by the Department of Health and Social Care once the Allied Health Solutions in 2013, published a report called the Paramedic Evidence-based Education Project; also known as PEEP. It was then when it was decided that the paramedic profession should be studied at BSc Degree for then in 2017 the HCPC consulting on changing the registry requirements but only approving it in March. (Timms, 2018). The change was justified by regulatory bodies wanting to ensure that future paramedics were trained to the standards for contemporary practice and that students would be able to develop critical thinking as well as develop and gain evidence-based practice skills during their 3 years of study (Health and Care Professions Council, pp8-18, 2018). Doing a BSc Degree course in Paramedic Science/Practice is going to be needed in order to get onto the HCPC register and will be in full action in 2024, current paramedics who are already on the HCPC register are not directly affected but many are unable to go down the route of joining an ambulance service and partaking in short training programs before they go out and work on the road. There is a current threshold level of qualification for entry to the HCPC register and that is something that is ‘equivalent to Certificate of Higher Education’ (HCPC 2017) but paramedics who hold this qualification are unable to progress further into the paramedic role and become specialist or advanced paramedics or even work their way up into another job in the ambulance service or related NHS careers without holding a BSc Degree. This then means that people who already work within ambulance trusts such as technicians or clinical care assistants will have to apply to university and do a BSc Degree in order to progress and become a paramedic. For people who want to be paramedics, such as students, they are able to go straight into university and do their 3-year degree and be eligible to register, but current workers they may have to find time to do the course as well as have to pay the tuition fees of the course which costs around £9250.00 (University of Sunderland, 2019) and they are found on course fees of the university of choice.

The impact on the role itself due to the educational standards rising for registration effects the paramedic role both positively and negatively. In the positive aspect, the general role of the paramedic becomes more clinically advanced; all qualified workers will be at the same level of clinical and critical understanding and will all be able to work together and make clinical decisions in the best interest of patients which then is due to everybody having a BSc Degree and working on the same band. With patient standards rising and the paramedic profession becoming a profession where qualified members are now autonomous practitioners, paramedics will be able to work with patients in more of a clinical setting while ensuring the holistic needs of the patient are met. There are other out of curriculum and work opportunities that trainees and qualified workers can take part in, advanced paramedics are able to prescribe medications, only if they take on a prescribing course to become independent prescribers but it is only limited to prescribe medicines that are not controlled drugs until relevant legislation is updated. (Collegeofparamedics.co.uk, 2019). Now and in the near future the amount of people living with illnesses such as chronic illnesses will increase, meaning that the healthcare requirements to care for these people will increase. With the number of these patients increasing, paramedics deal with a broader range of complex and high quality care patients, but paramedics must be balanced with the skill and education level in order to deliver effective treatment for complex cases (Long Term Conditions Compendium of Information, 2012) therefore the new standard of them having a BSc degree was raised and is being put into place and once student paramedics graduate and register with regulatory bodies, they should be able to provide a broader range and better treatment methods within service users home or other services using their clinical decisions and skills, resulting in less hospital admissions. Educational standards can also affect the role of paramedics in the National Health Service (NHS) as well as unscheduled care, in 2016 a study was completed and it was discovered that there was a retention of paramedics within ambulance services who were affected by career and development opportunities that led to staff shortages (Harris, 2019). Due to that lack of development opportunities, paramedics and other workers in ambulance services were not able to develop their own skills and understanding of health and social care and that led to the number of qualified and experienced staff reducing. The lack of paramedics then effects the NHS and the unscheduled care agenda as may have led to current paramedics at the time, taking to people to hospital without making the correct clinical decision but with education now being available as well as it being a requirement, this is avoidable as all people in the workforce will be able to make accurate clinical decisions with valid evidence supporting their decisions and do it in the best interest of the patient. Paramedics may have not been able to follow the unscheduled care agenda due to their lack of education, but current paramedics are being made aware and have access to courses which teach them and make them aware of new policies and procedures that they follow such as the College of Paramedics, holding conferences for their members to participate in. (Collegeofparamedics.co.uk, 2019). Unfortunately, there is no standardised approach to all aspects of education to paramedics (Hee.nhs.uk, 2019) meaning that the issue will not be completely resolved, but with making the entry requirements and the registration standards higher, in order for the outcome to be more balanced, paramedics will be able to provide care and meet the needs of the unscheduled care agenda.

Paramedics have an important role in the unscheduled care agenda, as they are the primary source for emergency and urgent care, they have to make the important decision which then later can affect the whole agenda as it follows patients. There are contemporary issues like what was discussed which affects current paramedics and the future generations of paramedics, it affects how they work and also effects service users but once the implemented strategies, to change the problems, have been put into place, the role of the paramedic and how they practice may change and benefit the unscheduled care agenda in relation to urgent and emergency care.

In this essay I will use the Rolfe’s Reflective Model (Rolfe et al. 2001), which by asking three question what, so what, then what, will help me to self-reflect on my nursing practise. I will also focus on using 3Cs from the 6Cs framework launched by Department of Health in 2012 (Baillie, 2017), as they are essential in nurses work. The 3 C’s which chose to focus on are communication, care and compassion .The 6Cs are the values which empower health care professionals to deliver the highest quality care to patients, help people to stay independent, maximise their well-being, improve health, build and strengthen leadership, and provide a positive experience of care (NHS,England,2015) . I will discuss about how professional or unprofessional use of this values can positively or negatively impact on patients psychological, and physical wellbeing.

The first C that I will focus on is communication which is an essential component in nursing and in providing the patients with high standards of care (Papagiannis, 2010). The second C is compassion, and how important it is to provide high quality care based on empathy, respect and dignity (Clarke ,2014) Third C that I will focus on is care, as we need to make sure that care is right for patients, and consistent, and that we provide patient-centred care, as good care can improve health (NHS, England, 2015).

Nursing and Midwife Council ( NMC) (2018) code declares the need to respect people’s confidentiality and this is a reason for me to not use patient’s real name in my essay, I will use pseudonym or just call them as a patient or service user.

While working as an EU adaptation nurse on General Surgical Ward I met a patient with Alzheimer Dementia who was diagnosed with bowels obstruction and admitted to my ward. With the late stage patient condition change and patient started to received End of Life Care(EOL) Patient was bed bound and patient needs help with all activities of daily living such as washing, dressing, feeding, administration of medication. I was looking after this patient and provide care to him. While communicate with patient I spoke in slow and short sentences, with smile on my face and I remain calm. I was observing patient reaction because I was not sure whether patient understood what I am saying. I was repeat what I have already said.

At first, I was scare and quite nervous when I interacted with the patient. I was already aware of his condition; hence, I was in a dilemma as to how I can communicate with patient.This experience helped me realise that communication is truly an important part of nursing practice. Rimal et all (2009) state that communication is the way that people exchange information. The most commonly used is verbal communication but there is also non-verbal communication like written or electronic communication, body language, gestures, and sign language . Webb (2011) indicate that communication is an important tool use to deliver a high standard of care, which enable patient to voice out their needs, engage in the care, help to build a therapeutic relationship and to comply with their treatment. Kourkota &Papathansiou (2014) declare that good communication is vital to effective nursing and successful outcome of nursing care of patient. Communication skills and technique such active listening, questioning and appropriate use of verbal or non-verbal communication are crucial. It is important as well to being friendly, cheerful, and being an effective listener (Stein-Parbury,2013). However I realised that communicating with a patient with dementia is more difficult than I have actually expected. Dementia affects the ability to communicate (Nazarko,2015). Service user condition was definitely the barrier that hindered effective communication. Even though I spoke in clear, short and simple sentences, there were still instances when the patient did not understand what I said . McNamara (2016) point out that communication with people with dementia in 90% is nonverbal. I release how important is to spend the time with this patient, talk to him, listen him, observe him and use physical touch as a form of non-verbal communication to give service user reassurance ,comfort and breaking down barriers (Gleeson and Higgins,2009). The experience also led me to realise the importance of valuing non-verbal communication. This experience shows me that observe patient’s bodily gesture, facial expression, presence or absence eye contact can help to interpret a patient’s feelings, mood and also attitude towards the nurse and the intervention given by the nurse(Videbeck,2010). I learned how important is that nurse is able assess not only patient who can verbalise but also those with non-verbal communication signs and the nurse can truly understand patient feelings and needs.

I need to improve my communication skills with patient with dementia or learning disabillity or even with aggressive patients. I would like to take a part of training about communication skills in different situation to make sure I will be able to communicate and understand my patients and their needs.

When patient with dementia was admitted to my ward ,he was looking like he is struggling with personal hygiene. Patient had strong odour and patient did not have shave for long time. Patient was refusing any personal care . The situation was difficult for me as there was the barrier with communication because patient suffer dementia .I was trying to be empathic and do understand patient feelings ,trying to put myself in patient’s shoes and I was trying to go through with that situation with my patient. However this was the first time for me to be with patient at the end of patient life .I was not sure what should I do and what not to do. I feel lost in this situation.

Everyone who became ill, they became particularly vulnerable, most of the time they need assistance from others ,in these situation, patients want to be treated with care and compassion (Proctor et al,2013).Compassion is the ability to feel for another living being., sees the suffering in others, and it is motivation to help others and wishes to heal the emotional. physical and spiritual hurts (Johnson,2008;McConnell,2015) . Bradshaw (2011) point out that Florence Nightingale said that compassion is one of certain virtues and qualities in good nurses character . The most vulnerable moments and intimate experience nurses share with people they look after.(Daly et al,2010). However, according to Gilbert (2013) we should remember that to express compassion we need to transpire sympathy(being able to feel for others) and empathy (being able to understand others feeling).

Compassion is important however t when health care provider working in busy environment, with lack of staff , with lots of pressure from management and in stress make them be struggle to work and not to be able to provide high quality care (Nolte et al,2017) . Potter et al (2013) state when a nurse displays the more empathy with patient ,there is the higher risk of compassion fatigue ,where the emotional effort required to show compassion is exhausted. It is the emotional and psychological distress that creates because of continuing self-sacrifice coupled with long exposure to difficult situation. Compassion fatigue makes a person to reduced feeling of compassion towards suffering person (Bush, 2009; Cocker & Joss, 2016). Compassion fatigue is often linked with the study of burnout. Maslach(2001) and Stamm(2010).state that burnout is a syndrome including emotional tiredness, depersonalization and a reduced sense of individual achievement (Maslach, 2001; Stamm,2010). While compassion fatigue is fast beginning, burnout is a slowly continuing condition generally seen in a heavy organisational environment (Slatten et al, 2011).

When I spend time with my patient I was helping him with personal care, assisted with meals, hold his hand , I spend time with patient, I was reading patients favour book. The situation was new for me ,I was not sure if I show compassion in care I provide, I would like to read and learn more how to show compassion . I would like to learn how to help myself to deal with stress, trigger situation to not feel burnout and to make sure I am showing compassion .

Diabetes Mellitus can be a tricky disease. I use the word “tricky” because of all the complications that can be associated with Diabetes to include Hyper/Hypoglycemia, Diabetic Ketoacidosis (DKA), and Hyperosmolar Hyperglycemic Nonketotic State (HHNS) to mention a few. Not including how blood sugar is directly affected by overall patient status and wound healing or surgery, which is a common patient profile in the hospital setting. With these complications it is important to consider how we manage this disease and focus on prevention. Insulin, a hormone naturally produced by the pancreas, is given to diabetic patients who either do not produce an adequate amount of insulin or are insulin-resistant in attempt to reduce their blood sugar levels. The two most common routes for administering insulin is for these patients is to either have them on a basal-bolus regimen or having the insulin administered on a sliding scale. The basal-bolus regimen is where the patient has a basal (same) amount of insulin, typically long lasting, given at the beginning of the day and given bolus (additional) injections to keep their blood sugars within a normal range. The sliding scale insulin, typically given in a hospital setting, is just a bolus of insulin before mealtime based on the patient’s current blood sugar level and the amount of carbohydrates they are going to consume. Healthcare workers are continuing to use this sliding scale method begging the question, which regimen is better? To evaluate, healthcare workers must weigh 2 components against one another: 1) which regimen is most therapeutic? 2) Which regimen is most cost-effective? These are the questions we will be attempting to answer.

One article showed the effect of the different insulin administration regimens when compared to different orthopedic surgery clients (Victoria L. Phillips, 2017). When measuring outcomes, it was found that basal-bolus insulin (BBI) improved patient outcomes and decreased the amount of time spent in the intensive care unit (ICU). It was also noted that their blood glucose levels were on average 14.6% lower (within normal range) when compared to sliding scale insulin. In a data analysis of multiple studies (8) regarding different patient profiles/departments in the hospital, it was found that there was no significant difference in patient outcomes (Colunga-Lozano L, 2018). However, it was found that blood sugar was consistently managed more effectively (on average 14.8mg/dL) when using BBI. Both studies showed that BBI significantly reduced hospital/patient costs. This is something that healthcare workers should continue looking into with the growing limitations of Medicare on cost per patient (CPP) and payment policies. Something interesting that was not originally intended to be researched, was that with BBI there was a significant decrease in hospital acquired infections, most likely related to the limited number of injections (Victoria L. Phillips, 2017). This assists hospitals in paying Medicare penalties and also limiting infection costs.

Having recently gone through nursing school, the only experience I have had with Diabetes is in the ED in an acute situation or in Med/Surg where it seems “everyone” has Diabetes. I thought that sliding scale insulin was simply the best way to manage blood sugar levels from all of the injections that I have given without question. Now that I have read these articles, I am more aware of Diabetes management. I now realize that, maybe not including patients in acute hyperglycemic states, that hospitals should be moving more towards a BBI system to manage Diabetes for the patients benefit and for the benefit of the hospital. I would certainly recommend this article to other healthcare providers. I think that it is so easy to let certain practices go unchecked without question. If anything, I would hope that this article would cause nurses and certain physicians to question their treatment plans instead of falling into old habits. It can only benefit them and the patient, why not question the norm? I do believe that a transition into making BBI the standard of diabetic care should be proceeded with caution as there is still not many trials to confirm that this is the best form of care in all healthcare settings. We can confirm from this article that BBI is effective in orthopedic surgery clients, but I would need to continue researching how it affects other hospital departments in order to confidently say it should become the standard of care. Like I said, I would only hope that reading this article would cause other nurses to question their diabetic treatment routines and that is what I hope to take with me into my career. There are so many patients in the hospital setting that I see with Diabetes and I just hope not to grow numb to looking at each patient situation individually.

Nursing theories are important to the practice of nursing. More importantly, theory-guided practice is important, as a nurse in any role, particularly in the role as an advanced practice registered nurse. It enables the nurse to deliver effective, efficient, and holistic care (Saleh, 2018). Theory guided practice is becomingly increasingly important in nursing that it was suggested that it should become the future of nursing (Saleh, 2018).There are numerous theories in nursing practice taught in nursing school. Some of the numerous examples of major nursing theories include: Watson’s theory of caring, Orem’s Self-Care Theory, Madeline Leiniger’s Transcultural Nursing theory, or Patricia Benner’s Novice to Expert theory. These theories are designed to help guide each individual nurse in his/her practice. In practice, each nurse chooses the theorist that best fits his/her practice based on how he/she views the four paradigms of nursing- the patient, the nurse, the client’s health, and the environment. The purpose of this paper is to introduce the author as a nurse, describe the four meta paradigms of nursing contained in each nursing philosophy/theory, and describe two practice-specific concepts unique to the author.

The author is a 52-year-old woman, married for over 33 years, mother of three sons and grandmother of two. She began her nursing career in an emergency department setting in Atlanta, Georgia for five years. She worked in a level 1 trauma center as a staff nurse for the clinical decision unit, emergency and trauma department. In collaboration with physicians with various specialties, the author provided care for a diverse population of patients with both acute and chronic illnesses and trauma. The author was also employed with the DeKalb Board of Health for a year as a public health nurse, where her responsibilities included: visiting Spanish and English speaking patients in their homes to assess their living environment and provide resources needed to families to properly care for patients in the home setting and assist with arranging for transportation to health care appointments. In addition to home visits, the author coordinated setting up health fairs in local communities with an effort to deliver primary prevention through administering vaccinations to various populations- pediatrics, adults, and the elderly patient or engage in secondary prevention through offering blood pressure screenings or glucose and cholesterol checks. The author is currently working at the Veterans Affair (VA) hospital, a federal facility where she cares for adult patients that are in active duty in the United States Military and veterans from all branches or the military that ranges in ages 18 and up with acute or chronic health issues. Patients present to the emergency room with a wide range health issues to include: medication refills, mental health evaluations, suicidal and or homicidal ideations, post-traumatic stress disorder, chronic and acute pain, strokes, cancer, exacerbation of chronic conditions (i.e.- asthma, congestive heart failure, etc.) and more. In collaboration with the emergency room team and other specialties, we stabilize and care for these patients. These patients will either be admitted to the hospital, referred to specialty units or transferred out for advance services or trauma care.

Metaparadigm is defined as the global concepts specific to a discipline and the global propositions that define and relate the concepts (Peterson & Bredow,2017, p. 4). Each metaparadigm has to have several domains. These domains are a classification system to identify the constructs or phenomena that are the focus of any discipline. Specific to the discipline of nursing, the four paradigms most commonly cited in most nursing theories include: man/person, health, society/environment, and nursing. According to Fawcett, a major nursing theorist cited in Peterson & Bredow (2017), he offers the following definition for the four metaparadigms of nursing:

The patient as individuals, families, communities, and other groups who are involved in nursing. Environment refers to the person’s social network and physical surroundings and to the setting in which nursing is taking place. It also includes all local, regional, national, cultural, social, political, and economic conditions that might have an impact on a person’s health. Health refers to a person’s state of well-being at the time of engagement with nursing. It exists on a continuum from high-level wellness to terminal illness. Nursing refers to the definition of the discipline, the actions taken by nurses on behalf of and/or with the person, and the goals or outcomes of those actions (Fawcett, 2000, p.7).

The author views the patient as a client coming to seek care for an alteration in health pattern or prevent an alteration in health pattern. For example, when a client comes in to the VA to seek treatment, there is an active alteration in health pattern that exists to bring the client there. However, when working at the health department, the nurse was providing preventive care through measures of early detection (i.e.-glucose monitoring) or prevention through providing immunizations and teaching.

The author views the nurse as not only having the role of providing immediate care to the client that she interacts with but also providing teaching to prevent complications from occurring as a result of that health alteration. The author views her role in this client-nurse relationship as being a resource to help her client understand better about his/her condition, ways to manage their condition, and preventive measures needed to be taken to prevent complications in the future.

The author views the client’s health as not optimal at the time of interaction because there has to be an alteration in health pattern in order for the client to seek care at an emergency department. For example, the author sees patients in acute exacerbations of certain conditions (i.e.- heart failure, diabetes, asthma, etc.), trauma, or acute pain. Furthermore, the author sees this as opportunities for education to improve a client’s overall health status.

The author views the environment as where care is being tendered to the patient. This setting is not limited to the hospital. It could be where the patient desires for care to be delivered at. For some patients, this may be outpatient (i.e.- rehabilitation center) or at home (i.e.- home health services). Furthermore, Fawcett defines the environment as the client’s social networks and physical surroundings. To this aspect, the author views the environment as being a contributor to the patient’s overall well-being and health status. For example, if the patient is surrounded by a supportive environment with limited exposure to toxins and carcinogens (i.e.- second-hand smoke or alcohol exposure), the client is healthier as compared to one who is exposed to this type of environment. Additionally, clients in a low socioeconomic setting has a variety of barriers present to attaining good physical health. Some of these barriers includes lack of access to a primary care provider, a good grocery store that sells nutritious foods, and lack of clean environmental water.

Two practice-specific concepts that are specific to this author’s day-to-day nursing practice includes: transcultural nursing care and caring. Transcultural nursing practice is defined as: “The delivery of culturally congruent, meaningful, high-quality, and safe healthcare to patients of similar or diverse cultures” (Albougami, Pounds & Alotaibi, 2016). The Meriam-Webster dictionary defines caring as “the act of feeling or showing concern for or kindness to others (2019). Narayanasamy ACCESS model and Watson’s theory of human caring will help elaborate on these two specific concepts.

Nurses from all specialties encounter patients from all walks of life, cultures and ethnicity in their practice. Cultural competency training is integrated throughout nursing school and hospitals to enrich nurse’s knowledge of various cultures and help nurses deliver culturally sensitive care to patients. As an emergency room nurse at a large public hospital and level one trauma center in the city of Atlanta, the author encounters patients from numerous ethnicities, cultural groups, and patients with a variety of socioeconomic status, ranging from rich to homeless patients. The author is a Catholic female of Mexican origin with very strong cultural ties to her cultural background. The author provides culturally competent care for all patients she encounters in practice in a non-bias manner.

Narayanasamy ACCESS model was chosen to help explain the delivery of transcultural nursing care. This was a model formulated by Narayanasamy that can be used as guidance to aid nurses in providing acceptable transcultural care (Vogel, 2016). In this model, “A” stands for assessment. With assessment, the nurse should determine the patient’s cultural upbringing, health beliefs and health practices. The “C” stands for communication. With communication, the nurse needs to be aware of both verbal and non-verbal cues as she is communicating with the patient. The other “C” stands for cultural negotiation and compromise. This means that the nurse should be aware of patient’s cultures and views on holistic care and be able to negotiate with patient to keep patient safe from harm and assist healing. The “E” in this model stands for establishing respect and rapport. By listening and displaying caring and respect for the patient’s cultural values, the nurse is not only showing respect for the patient but also helps establish a rapport that is essential to establishing trust at the beginning of the patient’s care. The “S” in this model stands for sensitivity. The nurse should be able to deliver culturally sensitive care to all patients. The final “S” in this model stands for safety. Through establishing a trusting relationship with his/her patient, the nurse is allowing the patient to have a sense of safety in which their cultural practices is honored (Vogel, 2016).

The second concept specific to this author’s nursing practice is caring. As a professional nurse, the author cares for patients with compassion and understanding. She creates a trusting relationship and listens to her patients and understands their fears and concerns. She addresses patients fears and concerns and advocates to create a safe and healing environment. Opinionated, the author believes that caring is a quality that is not taught in textbooks rather is an inherited quality a person is born with and chooses to use in nursing.

Watson’s Theory of Human Caring is a theory in nursing that is used to help explain the concept of caring in nursing practice. This theory was developed by Dr. Jean Watson in an attempt to define nursing as a blend between science and human caring (Watson Caring Science Institute, 2019). There are three major elements to this theory. These three elements includes: carative factors, transpersonal caring relationship, and caring occasion/caring moments (Watson Caring Institute, 2019).

The first element of this theory is the ten carative factors. The ten carative factors core to this theory includes: 1) sustaining humanistic-altruistic values by practice of loving-kindness, compassion and equanimity with self/others. 2) being authentically present, enabling faith/hope/belief system; honoring subjective inner, life-world of self/others 3) being sensitive to self and others by cultivating own spiritual practice, 4) developing and sustaining loving, trusting-caring relationships, 5) allowing for expression of positive and negative feelings through authentically listening to another person’s story, 6) creatively problem-solving-‘solution-seeking’ through caring process 7) engaging in transpersonal teaching and learning within context of caring relationship, 8) creating a healing environment at all levels; subtle environment for energetic authentic caring presence, 9) Reverentially assisting with basic needs as sacred acts, touching mind body and spirit of others; sustaining human dignity and 10) being open to spiritual, mysteries, allowing for miracles (Watson Caring Institute, 2019).

The second element of this theory is a transpersonal caring relationship. This is a relationship characterized by a special kind of human care relationship. In describing this kind of relationship, Watson describes it as going beyond an objective assessment, with the nursing showing more concern towards the patient’s own subjective assessment of their own health care situation (Watson Caring Institute, 2019).

The third essential element of this theory is a caring occasion/caring moment. This describes a moment when there is an opportunity for the nurse and patient to interact in a caring manner (Watson Caring Institute, 2019).

In conclusion, theory guides practice in nursing. The two practice-specific concepts this author uses most common in practice includes: transcultural nursing and caring. Narayanasamy ACCESS model and Watson’s caring theory further elaborate on these two concepts. Becoming a culturally competent nurse in a diverse community helps the author deliver proper health care to patients from multiple ethnicities and cultural groups. As a nurse, it is essential to deliver care that goes beyond the physical symptoms to the patient and rather focus on caring for the individual holistically.

References

1. Albougami, A., Pounds, K. & Alotaibi, J. (2016). Comparison of Four Cultural Competence Models of Nursing: A Discussion Paper. Internal Archives of Nursing and Health Care. 2(4). DOI: 10.23937/2469-5823/1510053
2. Fawcett, J. (2000). Middle Range Theories: Application to Nursing Research (4th ed.). Philadelphia, PA: Wolters Kluwer
3. Merriam-Webster (2019). Caring. Retrieved from: https://www.merriam-webster.com/dictionary/caring
4. Ozan, Y. D., Okumuş, H., & Lash, A. A. (2015). ORIGINAL PAPER. Implementation of Watson’s Theory of Human Caring: A Case Study. International Journal of Caring Sciences, 8(1), 25–35. Retrieved from https://search-ebscohost-com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=rzh&AN=103751480&site=eds-live
5. Peterson, S. J., & Bridow, T. S. (2017). Middle Range Theories: Application to Nursing Research (4th ed.). Philadelphia, PA: Wolters Kluwer
6. Saleh, U. (2018). Theory Guided Practice in Nursing. Journal of Nursing Research Practice. 2(1): 18.
7. Vogel, S. (2016). Transcultural Nursing in Australia. Ausmed. Retrieved May 10, 2019, from https://www.ausmed.com/cpd/articles/transcultural-nursing-australia.
8. Watson Caring Science Institute (2019). Watson Caring Science Theory. Retrieved on May 10, 2019. Retrieved from: https://www.watsoncaringscience.org/jean-bio/caring-science-theory/

The following essay focuses on the principle purpose of care and discusses the importance of the 6C’s within the healthcare profession. The 6C’s of nursing were established so that care is delivered to the patients in a constructive and structured manner Secure Healthcare Solutions, (2016). Nurses who function on these core values ensure that the patients are safe, protected and aided well, when providing them with the required care Secure Healthcare Solutions, (2016). Care/caring is a term that is extremely bonded with nursing. This is because nurses provide the patients with the nursing care to help them improve and sustain their health, as well as caring and supporting for the families during the period of illness or disability Sapountzi-Krepia, (2001). Person centered care and compassionate care is also discussed in this essay to highlight how nurses focus on putting patients’ desires, needs and goals at heart of everything they do so that it is central to the care and nursing process (Professor Jan Draper and Dr Josie Tetley, 2016).

The values and behaviors of the 6C’s are Care, Compassion, Competence, Communication, Courage and commitment Jayne Hardicre (2014). These core values of nursing were entrenched by the NHS England chief nursing officer Jane Cumming. She advocated the 6C’s to encourage the healthcare staff to focus on putting patients at the heart of everything they do Jane Cummings (2012). It is suggested by Jayne Hardicare (2014) that enclosing the actions of the 6C’s into healthcare profession would further enhance the quality of care. The 6C’s of nursing gave the nurses a way to assess their job to confirm that the best care is delivered to patients Nursing Standard (2013).

It is important for nurses to be non-judgmental and respectful when treating the patients as it enables them to trust their nurse, when they are being provided with the required care Nursing Standards, (2013). Nurses should always be aware of keeping patients’ dignity protected and making sure that their beliefs are in consideration Nursing standards, (2013). Nurses must always be compassionate even when the patient is very difficult, as showing compassion is central to how patients view the care that is given by the nurse Secure HealthCare Solutions, (2016). Additionally, communication is a very important part of the nursing profession as it enables nurses to build a relationship with their patients. This then also helps the nurses in finding out the information about the patient, resulting in faster diagnoses and appropriate treatments HealthCare Solutions, (2016). Moreover, nurses have the duty of care to their patients. Therefore, it is important for nurses to have the courage to do what they believe is right and be determined enough to face the fear of difficulties British Journal of Nursing, (2014). Also, nurses should be committed to their job in order to make sure that their patients’ needs are being met (Royal College of Nursing Institute, 2015).

According to nurses, compassionate care is not simply about easing pain and discomfort but is also about undergoing what patients experience and enabling them to retain their dignity and independence British Association of Critical Care Nurses (BACN), (2014). It is stated by Merriam Webster, (1843) that compassionate care is a sympathetic awareness of a patients distress mixed with a determination to reduce it. Both definitions, given by the nurses and Merriam Webster, link together as they both believe that it is important to feel what patients’ experience in order to make them feel as comfortable as possible during the hard time (Royal College of Nursing Institute, 2015).

When nurses are providing patients with the care that they require; it is important that they are being compassionate. This is because compassionate care enables the patients to be more comfortable during the period of illness, pain or when their emotional or mental health is causing them stress Moira K. McGhee, Contributor, (2019). Compassionate care also helps the patients with building up the confidence that they necessitate to assemble them for extensive recovery and to face a surgical procedure (Moira K. McGhee, Contributor, 2019).

Care can be defined as the feeling which displays concerns for an individual who may require physical, psychological, emotional or cultural needs National Institute for Health Research (2014). Caring is a significant part of nursing as it involves making a difference in patients’ emotional needs as well as physical ailments Faraz Mughal (2014). According to Linda Watterson (2017), caring is the core business of the nursing organization as it helps the patients, by providing them with the care that is expected, and improves the health of the whole community. According to Nursing Standards, (2013) when empathy is shown by a nurse, it strengthens the combined relationship between the patients and the nurse. This then benefits the nurse in finding out the symptoms and causes of the illness and proving patients with the appropriate treatment and proper diagnose (Nursing Standards, 2013).

It is stated by Dr Jean Watson, (1997) that nurses must be in attendance, reassuring and understanding of a patient’s feeling without showing any judgement or crossing intimacy boundaries. The theory is based on the centrality of human caring and on the caring-to-caring transpersonal relationship. It is suggested by Watson that a patient cannot be treated as an object and that he/she cannot be separate from self. Her theory encloses the entire world of nursing with the importance placed on the relational procedure between the care provider and care recipient (Dr Jean Watson, 1997).

It is also very important to ensure that person centered care is in consideration when caring for patients. This is because person centered care enables nurses to focus on putting patients’ needs, wants and desires at the heart of everything they do, so that it is central to the care and nursing process Professor Jan Draper and Dr Josie Tetley, (2016) According to IOM (Institute of Medicine) (2015), person centered care is about providing patients with a respectful care and making sure that their preferences, needs and values are deliberated. Bob Price, (2006) agrees to the definition given by IOM, as he defines person centered care as a term which is used to demonstrate an interest in patients own experience. Both definitions educate the nurses on building a strong relationship with the patients by showing an interest in their own experience IOM, (2015) and Bob Price, (2006), It also guides the nurses on making sure that patients and families are part of developing and planning their care plan. For nurses to be able to do this, they must provide the patients and the families with consent forms Department of Health, (2000). Consent forms inform the patients about the treatment, test or examination that they will be receiving. It is very important that patients’ consent is received before the procedure as it is an important part of medical ethics and international human rights law Department of Health, (2000)

Biomarkers are small protein or peptide molecules which are part of cell receptors, cell signalling molecules involved in cell-cell signalling or cell protein kinase activation and transfer of signal to the nucleus with the regulation of gene transcription. Biomarkers have functional significance in the recognition of different stages of cancer, therapy for cancer, and identification of different types of cancer of different organs according to the biomarker present. It is also used for the diagnosis and analysis of mutations in various proteins and identification of single nucleotide polymorphism in genes, screening of diseases, classification of diseases in humans and development of target inhibitor molecules against the biomarkers [1][2]. Various other studies have indicated the presence of autoantibodies against proteins of the cells which act as biomarkers in different grades of cancer and autoimmune response[3].

Keywords: Biomarkers, ovarian cancer, breast cancer, prostate cancer, pharmacological markers, drug screening.

Introduction to applications of biomarkers

Potential applications of biomarkers include the analysis and screening of protein molecules, characterization, post-translational modifications like glycosylations, and prediction of structure of molecules. Other applications include the analysis and study of phosphorylation patterns and protein-protein interactions of protein biomarkers during activation of cell signalling mechanisms inside the cell. Biomarkers are used for the study of pharmacological inhibitors, study of mutations in biomarker proteins due to somatic and germline mutations in genes during transfer of characters and traits from one generation to another in humans. The other functions are analysis of subunit of protein biomarkers and their activation mechanism in cells during cancer, therapy models for identification and recognition of cancer of different organs, study of storage of biomarkers in various organelles as well the study of sorting and targeting of folded and misfolded protein biomarkers in endoplasmic reticulum, golgi apparatus along with their degradation by chaperone pathway[2]. Transcriptome-based genomic and proteomic techniques are used for the analysis and characterization of biomarkers involving digestion of peptide with enzymes like trypsin and study of peaks by mass spectroscopy, two-dimensional gel electrophoresis and isoelectric focusing[4].

Traditional applications of biomarkers

Applications of biomarkers involves the study of these molecules in various cancer diseases like hepatocellular cancer, prostate cancer, lung, liver, stomach, oral, nonsmall lung cancer, head and neck cancer, ovarian cancer and cervical cancer. Various techniques like peptide mass fingerprinting, surface-enhanced laser desorption studies, immunoaffinity metal chelations studies with nickel metal and biomarker protein molecules in columns, differential gel electrophoresis, cation exchange and anion exchange chromatography are essential for cancer studies. The other techniques are stable isotope labeling of amino acids in cell culture, multi-dimensional techniques, matrix-assisted laser desorption studies, mass spectroscopy and capillary electrophoresis along with the study of post-translational modifications of amino acids in biomarker proteins are essential for the studies of proteins.[2,4](Fig no.1). Further microbial proteomics study is performed to study the pathogenicity clusters in bacteria, infection-causing proteins in bacteria, genome analysis of bacteria and protein toxins

Fig no.1—The applications include the techniques used in the identification and screening of biological biomarkers source-Mining the plasma proteome for cancer biomarkers [9].

causing disease in humans, antimicrobial proteins involved in killing other different microorganism population of bacteria in microbial consortium [4].In addition to this, miRNA profiling has been performed for the study of cancer biomarkers with the study of the regions of binding of protein biomarker miRNA along with target therapy for the analysis of inhibition of miRNA expressions and its downregulation and upregulation in various grades of cancer[5].

Emerging roles of biomarkers

The protein biomarkers are analysed in various cancerous organs for example glycoprotein CA-125, VEGF(vascular endothelial growth factor), transferrin, apolipoprotein A1 level and transthyretin levels, carcinogenic embryogenic antigen (CEA) in ovarian cancer, prostate-specific antigen, prostate acid phosphatases, and serum acid phosphatases in prostate cancer. Hepatocyte growth factor, survivin, alpha-fetoprotein, neuroserpin levels in hepatocellular carcinoma, atrial natriuretic factor in heart diseases, alpha-synuclein, PINK proteins(PARK), glial fibrillary acidic protein, galectin in Parkinson disease, chemokine ligand, tau proteins in Alzheimer’s disease, estrogen receptor. Her-2 EGFR receptor in breast cancer, and KRAS mutations in colorectal carcinoma. [1,2,4].Various scientific committees have proposed the classification and nomenclature for protein biomarkers in organ cancer along with the significance and role of biomarkers[1].

(New pharmacological drugs for screening of biomarker and drug inhibitor response in cell lines) Further pharmacological screening is performed for the efficiency, the affinity of binding, inhibition of biomarker protein in cells and drug-biomarker protein interactions in cell lines(Fig no.2). The drug-mediated targeting to the cancerous organ is performed with the help of liposomes, virus-mediated therapy, nanoparticles, micelles, dendrimers, photodynamic therapy, fluorescent labelling of biomarker protein molecules and visualisation by biomedical imaging[11] along with pharmacological docking, affinity studies, inhibition studies of drug and protein biomarkers like drug-EGFR(HER-2) mediated therapy[12] and drug interaction with mTOR signaling pathway proteins with rapamycin[13].The anti-EGFR receptor protein which is a biomarker binds to the inhibitor drug molecules and prevents the phosphorylation of the tyrosine amino acid on the EGFR receptor thus preventing the activation of cell signaling [12]. Major protein biomarkers used in drug metabolism include cytochrome P450 enzymes in liver[15]. Further pharmacodynamics and pharmacokinetics curves are plotted for the affinity of binding of drugs to various protein biomarkers in the cell lines under investigation. Additionally, the role and characterization of biomarkers include markers with mutations in proteins in cancerous cells, biomarker antigens for cancer detection, protein biomarkers in immunohistochemistry and fluorescent staining of cells and tissues in pathology. The other roles of biomarkers are radiolabeled protein biomarkers, quantum dot labeled biomarkers, biomedical imaging of fluorescent biomarkers in in-vivo studies of rats, circulating DNA found in tumour cancer cell lines and in blood of patients and pharmacodynamics and pharmacokinetics studies of drug-protein biomarker interaction[14].

(New pharmacological drugs for screening of biomarker and drug inhibitor response in cell lines)

(Drug-docking studies of protein biomarker inhibitor response in vivo in humans and mice.)

(Binding affinity studies of drugs and proteins example for Alzheimer’s disease)

(Clinical validation of inhibitor and drugs used for targeting cancer.)

Fig no.2—The screening of drug-biomarker protein interaction is confirmed along with mechanism of action of drugs, monitoring of effects of the interaction of drugs, diagnosis and treatment of cancers in patients [10].

No.

Role

Biomarker

Characteristics

Example disease

Author/year

1 Ovarian cancer

Carcinogenic embryogenic antigen A and CA-125(carbohydrate antigen-125)

Present in ovarian cancer

cystadenocarcinoma

Sorenson et al.,2011, sreeja sarojini et al.,2012,Samimi et al.,2014.

2 Prostate cancer

Prostate specific antigen

Present in prostate cancer

Prostate adenocarcinoma

Chatterjee et al.,2012,Gu etal.,2014,Meng et al.,2013.

3 Hepatocellular carcinoma

Hepatocyte growth factor

Receptor on hepatic or liver cells

Hepatocellular carcinoma

Forner etal.,2012,Goodman etal.,2007,Hashem B etal.,2011.

4 Breast cancer

HER-2 EGFR receptor

Present of cell surface of mammary cells

Breast carcinoma

Yu et al.,2012,Tam et al.,2010, Makki et al.,2015.

5 Parkinson disease

Alpha –synuclein, glial fibrillary acidic protein

Aggregates of proteins in neurons

Neuronal disorder

Jankovic et al.,2014,Hauser etal.,2013,Clebak et al.,2013

6 Alzheimers disease

Tau proteins

Aggregates in neuronal cells

Neuronal disorder

Mattson et al.,2010,Palmer etal.,2011,Olokoba et al.,2011

Table-1 Shows various cancer diseases with biomarkers and their characteristic features.

Case studies of biomarkers

The study involves the sample analysis of urine of patients with cancer as compared to normal urine samples for the analysis of homovanellate, 4-hydroxy phenylacetate, the levels of metabolic products like 5-hydroxyindolyl acetate and urea formedmin the body under two different prevalent conditions. Microarray analysis was performed along with statistical normal distribution analysis of the normal cell samples and cancer cell patient samples to study the levels of metabolic analytes. Further breast cancer adenocarcinoma cell samples were analysed for BRCA gene in patient samples. The analysis of urine samples was done by gas chromatography and mass spectroscopy after preparing the samples in buffer and digesting them with beta-glucoronidase enzyme[6]. The P-value was calculated for the intensity of binding in microarray samples along with the study of the levels of tyrosine metabolism analytes in cancer samples and normal samples. The other study was conducted on ovarian samples of cancer from patients with the study of random intensity scatter distribution plots of the genes involved in ovarian cancer regulation[7].

A study of prostate cancer revealed the levels of sarcosine in cancer samples and normal samples along with the study of statistical parameters like mean, median, mode, and area under the curve for the intensity profile of the metabolite levels in samples under study[8]. Further high-performance liquid chromatography was done to purify the sarcosine in the samples under study and to analyse its levels under experimental observation.

Conclusion

The study helps in the analysis of various grades of cancer affecting different organs by the study of particular expressions of protein biomarkers in various organs of the body. Various methods like immunohistochemistry and fluorescence in situ hybridization were performed to analyze the location and levels of biomarkers in cell and tissues under study [1]. There is a range of protein biomarkers used for the study of cancers in different organs according to the role of these protein biomarkers in cell signaling, kinase phosphorylation, and transcriptional regulation in tumor and cancerous cells as compared to normal cells[2]. The applications involve the use of various techniques like mass spectroscopy for the study of biomarker proteins and their amino acid characterization in the sequence along with post-translational modification[2,3]. The autoimmune antibodies formed in the body against self-altered proteins of the body also act as protein biomarkers in various autoimmune diseases[3]. The particular protein markers specific to organs and tissues were studied in samples under experimental analysis[1,4].miRNA levels were analyzed in various cancer samples along with the study of its regulation in the genome[5]. Further microarray analysis was performed to study the levels of breast cancer genes like BRCA[6], ovarian cancer genes[7] and antigen prostate-specific antigen in cancer samples and normal samples as well as sarcosine metabolite samples with statistical analysis[8].

References

1. Cancer biomarkers–N. Lynn Henrya, Daniel F. Hayes b-Molecular Oncology, 6 (2012) 140e1 4 6.
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3. Serologic Autoantibodies as Diagnostic Cancer Biomarkers—A Review–Pauline Zaenker and Melanie R. Ziman., Cancer epidemiology, biomarkers and prevention., September 20, 2013;
4. The cancer secretome: a reservoir of biomarkers–Hua Xue, Bingjian Lu and Maode Lai., Journal of translational medicine., 2008, 6:52.
5. MicroRNAs in cancer: Biomarkers, functions and therapy–Hayes J, Peruzzi P, Lawler S., Trends in Molecular Medicine, vol. 20, issue 8 (2014) pp. 460-469.
6. Combining tissue transcriptomics and urine metabolomics for breast cancer biomarker identification–Hojung Nam1, Bong Chul Chung2, Younghoon Kim1, KiYoung Lee3 and Doheon Lee1—Bioinformatics, Vol. 25 no. 23 2009, pages 3151–3157.
7. Study design and data analysis considerations for the discovery of prognostic molecular biomarkers: a case study of progression free survival in advanced serous ovarian cancer,Li-Xuan Qin and Douglas A. Levine2, Qin and Levine BMC Medical Genomics (2016) 9:27.
8. A case control study of sarcosine as an early prostate cancer detection biomarker-Donna P. Ankerst1,2,3*, Michael Liss2, David Zapata2, Josef Hoefler1, Ian M. Thompson2 and Robin J. Leach2,4., Ankerst et al. BMC Urology (2015) 15:99.
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Caring Reflection Paper

Values and attitudes inform the way in which health services are delivered and received. To achieve this, nurses should have the ability to perceive the independence and diversity of clients in different steps in their journey. This paper tries to explain the definition and the necessities of caring. This article also considers the challenges that may be accrued in the caring process.

Caring and Nursing

Caring is an important feature of nursing which includes assistive, supportive, and facilitative acts for individuals or groups. Practical care involves the relationship, mutual recognition and involvement of the nurse and the client (Kozier et al., 2018).

There are different theories about the importance of caring. Jean Watson thinks that ‘Human care is the basis for nursing’s role in society, and nursing’s contribution to society lies in its moral commitment to human care.’ Simone Roach came up with the five C’s of caring: commitment, conscience, competence, compassion, and confidence. The five C’s are viewed as helpful for enhancing associate and patient connections and expanding a nurse’s chances for professional success. Considering both theories of Watson and Roach, the practical nurse shows that the medical aspect of nursing is not the only sight of patient care but also a lot of nurses can feel sympathy and give the clients comfort. Patients may experience stress about their conditions, it is important for nurses to treat a patient’s physical discomfort as well as his or her emotional needs. Patients look to nurses as their advocate, so sometimes a compassionate nurse is all patients need to reduce their anxiety (Kozier et al., 2018).

Understanding how knowledge and care form the critical nursing dyad is crucial to providing effective, safe and quality care. Knowledge is particular information about something specific, and care is behaviour that shows compassion and respect for others. Knowledge is outlined and described during a range of ways. Five fundamental patterns of knowing in nursing are empirical, ethic, personal knowledge, aesthetics, and social politics. A nurse would possibly use all or some of these knowledge methods when providing care (Finkelman & Kenner, 2014)

Caring in nursing is depend on the ability of nurses in making a good relationship with clients. Caring reactions are as changed as clients’ need. So, it is the art of nurse to make a good pattern based on knowing the client, nursing presence, empowering the client, sympathy, and capacity (Kozier et al., 2018).

Being a nurse means seeing, hearing, smelling, touching and dealing with certain things that are not so pleasant in life. As it is clear, caring for others as a nurse is not easy at all. Nurses face everything from the biggest to the most amazing situations that would squirm or run the normal person.

When a person wants to care of a family member tends to suffer from both the ability for imminent loss and the inability to resolve the issues. A family have to be accompanying the patient, because the hospitalization removes him from his social environment, which he considers to be safe and constant, and is inserted in another environment that presents itself cold, unknown and fearful. Assisting the family with a sick relative outside the therapeutic possibilities of cure require a great deal of sensitivity from the nurse since she has many concerns regarding care and attention to her relative. It is also incumbent on nurses to train family members with the purpose of helping them to understand more about the future responses of the disease and the diversity and possibility of care. I think the family and the patient should be considered as a unit of care since the assistance offered to one of them also significantly affects the other. Last but not least, I believe A cultural approach to care must be adopted, that is an approach in which nurses take into account standardized, learned values, beliefs and ways of life (Matos & Borges, 2018).

Challenges to Caring

Even as one of the most worthwhile professions, nursing isn’t without its challenges. In my point of view, protecting themselves from feeling overwhelmed is the most challenging thing for nurses (Cooper, 2001). There are some steps which I can use to reduce this feeling. I should not be a brooder, the sooner introduce myself, the easier it becomes to feel more comfortable with my new unit. Have a ‘go-to’ crew, I should try to find at least one nurse, one doctor, and another team member who are most eager to guide me. I need to ask questions. I need to accept that I am the most important patient and take care of myself. I need to keep in mind that I do not take things personally because it would be essential for a new nurse.

Conclusion

The nursing process consists stages that should be completed to assist the patient to overcome the diseases. The use of the Jean Watson and Simone Roach model help the nursing process succeed and become efficient. Our patient because of their depression and problems needs to have properly cared in different ways, it needs to be physiologically, physically and psychologically treated. The daily lifestyle of the patient is affected and nurses need to understand why this activity is carried out for their well- being. Patients should be properly informed about the benefits they will have if they cooperate with the agreed care plan. There are different questions in my mind about intimacy and ethics. We need to know more about the details and I hope to practice in multiplicity places as a student help me to figure out these facts and obstacles.

References

1. Anita Finkelman & Carole Kenner. (2014). Professional Nursing Concepts (3th ed.). Jones & Bartlett Learning.
2. Cooper, C. (2001). The art of nursing: A practical introduction. Philadelphia, PA: Saunders.
3. [bookmark: citation]Johnata da Cruz Matos & Moema da Silva Borges. (2018). The family as a member of palliative care assistance. Journal of Nursing UFPE, 12(9), 2399-2406. doi: 10.5205 / 1981-8963-v12i10a234575p2399-2406-2018.
4. Kozier, B., Erb, G., Berman, A., Snyder, S. J., Frandsen, G., Buck, M., Stamler, L. L. (2018). Fundamentals of Canadian nursing: Concepts, process and practice (4th Canadian ed.). Toronto, ON: Pearson.