Rheumatoid Arthritis

• ABSTRACT/INTRODUCTION

Rheumatoid arthritis (RA) is an inflammatory arthritis that influences almost 1% of the world’s adult population. It is described by symmetric polyarticular inflammation of the synovium, normally of the small joints of the hands (MCP and PIP), wrists and feet (1). This aggravation brings about agony and stiffness, and can prompt dynamic joint harm bringing about deformations and loss of capacity. Related organ harm likewise adds to serious handicap. Despite the fact that it is not completely confirmed ecological and genetic components are thought to be connected to rheumatoid arthritis inflammation.

• BACKGROUND INFORMATION
• Probable Cause
  • Environmental
• Recent investigations have expanded our comprehension of ecological exposures that may contribute to RA, for example, smoking and alcohol consumption. Different factors, for example, birth weight, breastfeeding, financial status and area of birth have additionally been exhibited to add to chance (2).
  • Genetic
• Current investigations concluded an indeterminate decision revealing significantly diverse gene arrangement in different subjects. Also, albeit various genes have been selected that may be helpful for future therapeutic reactions, the job of many genes in the pathogenesis of RA is obscure (3).
  • Epigenetic
• There is no doubt that epigenetic modifications affect RA. Several studies demonstrated that epigenetics contribute to the aggressive, intrinsic activated phenotype of RASF and also the first in vivodata point to the beneficial effects of drugs modifying epigenetic patterns in animal models. However, more data are needed to clarify which modifications are causative for the disease onset and which epigenetic changes occur during chronic disease states (4).

• Symptoms and Signs

Rheumatoid arthritis (RA) is an inflammatory rheumatic disease with progressive course affecting articular and extra-articular structures resulting in pain, disability and mortality. Persistent inflammation leads to erosive joint damage and functional impairment in the vast majority of patients (7).

• Statistics
  • RA influences a small measure of the populace, however it seen to happen three fold the amount in ladies than their male partners. Albeit rheumatoid arthritis disease is not inherited, a relative with RA expands the odds of having the disease by a huge sum (5)
• Current therapies and treatments
  • As of lately, treatment choices in view of better comprehension of infection pathology have prompted gigantic changes in the administration of this disease. The rapacious utilization of DMARD and biologic DMARD treatment has enabled patients to accomplish enhanced capacity and diminished joint destruction (1).
• Case Studies
  • A thirty-year-old female presents swollen joints that are stiff and painful in the morning symptoms continue to advance with no family history of RA (5).
  • A thirty-eight-year-old female gradually developed painful wrist over 3 months (6).

Bibliography

• Kahlenberg JM, Fox DA. Advances in the Medical Treatment of Rheumatoid Arthritis. Hand clinics. 2011;27(1):11-20. doi:10.1016/j.hcl.2010.09.002.

• Liao KP, Alfredsson L, Karlson EW. Environmental influences on risk for rheumatoid arthritis. Current opinion in rheumatology. 2009;21(3):279-283. doi:10.1097/BOR.0b013e32832a2e16.

• Kurkó, J., Besenyei, T., Laki, J., Glant, T. T., Mikecz, K., & Szekanecz, Z. (2013). Genetics of Rheumatoid Arthritis — A Comprehensive Review. Clinical Reviews in Allergy & Immunology, 45(2), 170–179. http://doi.org/10.1007/s12016-012-8346-7

• Klein K, Ospelt C, Gay S. Epigenetic contributions in the development of rheumatoid arthritis.Arthritis Research & Therapy. 2012;14(6):227. doi:10.1186/ar4074.

• Geha RS, Notarangelo L.Case studies in immunology a clinical companion. New York, NY: Garland Science, Taylor & Francis Group, LLC; 2016.

• Chapel, H., Haeney, M., Misbah, S. A., & Snowden, N. (2014).Essentials of clinical immunology. Chichester, West Sussex, UK: Wiley Blackwell.

• Heidari, B. (2011). Rheumatoid Arthritis: Early diagnosis and treatment outcomes .Caspian Journal of Internal Medicine, 2(1), 161–170.

CYSTIC FIBROSIS

1. Introduction

Cystic fibrosis (CF) is an autosomal recessive disease that is most common amongst Caucasians (Calvez et al., 2017). CF is most common in children and has often been regarded as a children disease even though it has also been diagnosed in adults through methods such as sweat test (Calvez et al., 2017). The mutation of the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) chloride channel gene is the cause of CF (Calvez et al., 2017). The common CF mutation is the phenylalanine gene deletion (Calvez et al., 2017). The gene deletion leads to the alteration of the CFTR protein (Calvez et al., 2017). The protein folds and is fast degraded (Calvez et al., 2017). Severe forms of pulmonary infections in CF patients are caused by Burkholderia cenocepaciai (Nunvar et al., 2017). The causes will be discussed later in detail. In the US, approximately 12 million people are CF carriers and each year 2,500 children are born with CF. About 30,000 Americans, 3,000 Canadians and 20,000 Europeans have CF. The disease affects Caucasian more often as compared to the other ethnic and racial groups. In Asian Americans, CF affects 1 in every 50,000 babies while it affects 1 in every 30,000 African American babies. Approximately 1 in every 22 Caucasians are carriers. CF patient’s conditions can have quality lives following early diagnosis and proper medical regime is followed.

2. Symptoms:
   • Respiratory Signs and Symptoms

The symptoms presented in the patients include the recurrent or chronic cough. The cough can be hacking and dry at the beginning. In the early stages, the cough produces mucoid while in the later stages, it produces purulent sputum. In the infants, there may be prolonged symptoms associated with bronchiolitis. In some patients, paroxysmal cough is followed by vomiting. The patients will also experience recurrent pneumonia, recurrent wheezing, pneumothorax (trapping of air or gas within the chest and lung walls), atypical asthma, digital clubbing (bulbous and enlargement of toes and fingers) and hemoptysis. In some cases, there may be history of chest pain, nasal polyps, hemoptysis (coughing up of blood), dyspnea on exertion, and recurrent sinusitis (Bennett et al, 20142). Nasal polyps refer to the fleshy growths that are found inside the nose. They occur to 15% to 20% of the CF patients. The other symptom is further, the allergic bronchopulmonary aspergillosis which affects 10% of the CF patients is also a symptom. It is an infection of the lungs or bronchi that can lead to inflammatory lesions formation.

• Digestive Signs and Symptoms

Meconium ileus may occur in 7-10% of the patients. For the patients with simple meconium ileus, they usually present abdominal distention when they are born (Doulgeraki et al., 2017). Eventually, it progresses to bilious vomiting, progressive failure in passing meconium and the progression in the distension of the abdomen. In the complicated cases of meconium ileus, the patients have severe distension of the abdomen at birth, accompanied by edema and erythema of the abdominal wall. Respiratory distress can occur in the severe cases of abdominal distension. In neonates, the symptoms may include various surgical findings at birth. The findings include perforation, meconium peritonitis, intestinal atresia and volvulus. The other symptom in the neonates is the intestinal obstruction when the child is born. In a few of the cases, the meconium passage may be delayed by between 24 and 48 hours after the birth of the baby. Moreover, there may be cases of prolonged cholestatic jaundice.

Children and infants are presented with increased stool frequency. This higher frequency suggests a failure to thrive, mal-absorption (presence of oil or fat drops in their stools), rectal prolapse or ileocecal (intussusception) (Doulgeraki et al., 2017). The patients that have pancreatic insufficiency will have mal-absorption of proteins, carbohydrates, and fats as well as fat-soluble vitamin deficiency. However, the carbohydrate malabsorption is not severe as compared with that of proteins and fats. The patient fails to thrive even in the cases where the patient has an adequate appetite, foul-smelling flatus or flatulence, abdominal pain that is recurrent. The malabsorption results in steatorrhea which is characterized by frequent, large, poorly formed, greasy and foul-smelling stool. Some patients present with anorexia without the occurrence of steatorrhea. Some of the patients may present with a history of gastrointestinal tract bleeding or jaundice as a consequence of the hepatobiliary involvement.

The abdominal symptoms (AS) are the hallmark of CF which is a multi-organ disease. The CF’s abdominal involvement is the least and insufficiently understood as it normally compared to the various pulmonary manifestations (Tabori et al., 2017). The study by Tabori et al., (2017) focused on the abdominal pain and the other non-pain abdominal symptoms, eating and appetite disorders as well as bowel movements and quality of life-related symptoms. The most abdominal symptoms that are noted in CF include lack of appetite, loss of taste, abdominal pain, flatulence, abdominal distention (Tabori et al., 2017). The most interesting element is that children experience more pain as compared to the adults while the abdominal distention is mostly reported in the adults (Tabori et al., 2017). The abdominal pain is mostly reported in the epigastric regions, umbilical and dorsum (Tabori et al., 2017). The pain reported in terms of frequency is at least once every week (Tabori et al., 2017). The abdominal pain in the majority of the CF patients is 45 minutes although the pain can last for 5 hours or longer (Tabori et al., 2017). The pain is most frequent during stressful events, just before the bowel movements and during meals (Tabori et al., 2017).

3. How to Diagnose

There are a number of tests and methods that are used in the screening for cystic fibrosis. The most effective method that is used is the sweat test also known as the sweat chloride test. The test is used to measure the amount of salt that is present in the skin of the adult or child. The sweat test involves the use of pilocarpine – a chemical – and mild electric current to induce sweating on the skin. The skin is wrapped in a pad and plastic to absorb the sweat that is released (Langen et al., 2015). The sweat is collected for a period of 30 minutes. For children when the chloride (Cl-) concentration is higher than 60 mmol per liter, this is an indication that the patient has cystic fibrosis. However, when the concentration of chloride is higher than 80 mmol/L in adults, it is an indication of cystic fibrosis. This is because adults have higher amounts of chloride in their sweat as compared to children. Due to the low sweat production by newborn children, 50mg of sweat is collected for a period of 45 minutes, and then an immunoreactive trypsinogen test (IRT) is done instead of the sweat test (Kharrazi et al., 2015). However, when enough sweat can be collected in the newborns or infants who are less than three months, CF is indicated by chloride concentrations that are more than 40 mmol/L.

The second method of screening is the IRT. As stated above, this test is carried out on newborn babies who cannot produce enough sweat for the sweat test (Kharrazi et al., 2015). IRT test is undertaken by drawing the blood of the newborn baby a few days after birth. The blood test involves the evaluation of the protein trypsinogen presence. When the test is positive, CF can be confirmed through genetic testing or other forms of mutation analysis. The sensitivity of a combination of mutation analysis and IRT is between 90% and 100%.

Thirdly, there is the use of Nasal Potential Difference (NPD). NPD is carried out based on the electric potential differences that occur as sodium and chloride ions move across the cell membranes lining the airway (Ng et al., 2015). The electric potential differences are the amount of energy that is needed to move the electrical charge from one place to another. Surface electrodes are used to measure the NPD. The abnormal transport of Na+ and Cl- in the patients with CF is abnormal thus allowing for the determination. This test is applied and is very helpful in the cases where the genetic tests and the sweat tests are inconclusive.

Moreover, there is the genetic test or mutation analysis. This test analyzes the DNA for the presence of one of the mutations that can cause CF. A sample of the blood of the patient is collected for the testing. However, the test cannot detect all of the gene mutations that cause CF thus it has a sensitivity of approximately 80-85% (Ng et al., 2015). Further, it cannot be used to determine the symptom severity, i.e., it cannot be used to determine whether the CF will be mild or fatal based on the genotype. The test is mostly used in the cases where the sweat test is negative, but there are still suspicions that the patient may have CF.

Other methods of diagnosis include medical history where the physicians look for the various symptoms. The medical history can be analyzed beginning from infancy. The other diagnostic method is the family history. Since CF is a disorder that is inherited, the family history with CF is an indication that the gene is in the lineage (Ng et al., 2015). Finally, there is the prenatal CF diagnosis. The genetic testing can be done before birth by chorionic villus biopsy where the tissues that develop into the placenta are tested or amniocentesis where cells are removed from the amniotic fluid.

4. Causes

The genetic causes of cystic fibrosis are discussed to illustrate the microscopic properties of the disease. Cystic fibrosis (CF) is caused by the CFTR (cystic fibrosis transmembrane regulator) gene mutation (Furgeri et al., 2018). The genetic mutation as a cause of CF has also been noted in Prados et al., (2017). The other cause is the presence of bronchiectasis as found in cross-sectional observational and descriptive study that was undertaken on patients who are older than 60 years in Madrid and Valencia in May 2012 (Prados et al., 2017). Bioactive lipids have also been considered to be markers in CF (Bragonzi et al., 2017). Moreover, the pathogenesis in CF may be contributed to by a host of proteases (Bragonzi et al., 2017).

The risk factors are discussed to illustrate the macroscopic properties of the disease. The risk factors include race and family history. CF is common amongst the Caucasians of Northern European ancestry or descent. However, the disease is known to occur amongst all ethnic groups. The carrier frequency for the Caucasians of the United States and Europe stands at about 1:25 while for other groups such as Iranians, the carrier frequency is 1:40. The most common CFTR gene mutation is the p. Phe508del. The frequency of the above gene mutation amongst the Caucasians is 70%, between 44% and 13% among Indians, Turkish, Arab and Turkish populations (Tabaripour et al., 2012). Further, the people who have a history of CF in the family also have an increased risk of the disorder. This is because the disorder is hereditary.

5. Disease Pathophysiology

5.1 Physiological Processes/Mechanisms of Cystic Fibrosis

CF is characterized by an abnormality in the epithelial ion transport (Cholon & Gentzsch, 2017). This results from the mutation in the CFTR gene which is an ion channel that mediates chloride (Cl-) and HCO3- transport of absorptive and secretory epithelial cells in a number of organs such as intestines and lungs (Cholon & Gentzsch, 2017). The CFTR also leads to an increase in the Na+ uptake through the ENac channel (Cholon & Gentzsch, 2017). The enhanced update of Na+ leads to the airways dehydration as the salt saps up the water in the airways (Cholon & Gentzsch, 2017). This is the major cause of mortality and morbidity that are linked to CF as the airway surface liquid (ASL) homeostasis is disturbed leading to sticky and viscous mucus (Cholon & Gentzsch, 2017). The above abnormal mucus leads to airway obstruction, mucus stasis, inflammation, persistent infection and the increased decline of the functioning of the lung (Cholon & Gentzsch, 2017).

The patients also show platelet activation which is a market of the clinical status of the disease (Lindberg et al., 2018). The patient will experience increased platelet-monocyte complexes circulation (Lindberg et al., 2018). There is also an increase leukocyte activation levels (Lindberg et al., 2018). CFTR blockade has an impact on the release mediators by platelets which are involved in the inflammation response (Lindberg et al., 2018). The blockade of CFTR on the platelets reduces the formation of lipoxin A4 (LXA4) which is an anti-inflammatory mediator that helps in the modulation of neutrophil inflammation (Lindberg et al., 2018). The dysfunction of CF platelets can contribute to the chronic inflation which is a common mark of CF (Lindberg et al., 2018).

• Functional Changes Associated With Cystic Fibrosis

There are a number of functional changes that occur as a result of Cystic Fibrosis. The CFTR mutation leads to the defect of HCO3- and Cl- epithelial ion transport. This leads to the impairment of the mucociliary clearance (MCC) and airway surface liquid (ASL) due to the sticky and thick mucus that is produced. Secondly, the defective MCC also leads to chronic infections, bronchiectasis, and progression in the loss of the lung functions. Bronchotracheal HCO3- and Cl-secretion contribute to the MCC and ASL height through the effects of the mucin expansion and extracellular hydration. The defects in the HCO3- and Cl- as a result of CF leads to acidic and dehydrated ASL (Sellers et al., 2017). The epithelial Na+ channel deregulation leads to Na+ hyperabsorption. This dehydrates the ASL layer further. This leads water to move out of the mucus layer and out of the periciliary layer. The above coupled with an increase in the viscosity of the mucus as a result of the acidity leads to viscous and thick mucus which impairs the MCC and compresses the cilia.

6. Normal Physiology

This section will discuss the normal physiology in relation to the pathophysiology and symptoms of cystic fibrosis. CFTR is an ABC transporter which has a modular design made up of two membrane-spanning domains (MSDS) and 2 nucleotide-binding domains (NBDs) (Wang et al., 2014). The NBDs use the ATP hydrolysis energy to pump various substrates across the cell membranes through the use of MSDs formed transmembrane pathways (Wang et al., 2014). The mature form (Wild-type CFTR ¬ 170-kDa) is a member of the ABC (ATP –binding cassette) transporter superfamily (Calvez et al., 2017). The CFTR chloride channel stated above is regulated by protein divalent cations, protein kinases, phosphatases and the protein-protein interactions (Calvez et al., 2017).CFTR, as an ABC transporter, is unique in that it functions as a selective and low conductance gated channel of chloride through the ATP hydrolysis and binding cycles at the NBDs (Wang et al., 2014). Bozoky et al. (2013) noted that CFTR gene is tightly regulated by a disorder and intrinsic protein segment that is distinguished by a regulatory domain (RD) (Bozoky et al., 2013). The RD are the various consensus phosphorylation sites (Bozoky et al., 2013).

7. Disease Treatments

There are a number of treatment options for CF that are currently available. First, there are the medications. Some antibiotics are prescribed to the patients to help them get rid of the lung infection and other infections. The antibiotics are administered in capsules, tablets, and liquids. In the very severe cases, infusions or injections can be used. The other medications that are also used include the mucus-thinning medication which is administered to make the mucus less sticky and thinner. This helps the patient to cough the mucus thus significantly improving the function of the lung. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin and ibuprofen are also used to reduce fever and pain associated with CF. Bronchodilators are also used to relax the muscle of the tubes that carry air to the lungs. This help in increasing the airflow in the airways. The medications are taken through the use of nebulizers or inhalers. CFTR modulators have been used in the last ten years to target the primary defect directly (Hagemeijer et al., 2007). There is also the use of Omalizumab which helps in the stabilization of the lung function which leads to the improvement of patient’s nutritional status (Perisson et al., 2017)

The second treatment option is the Chest Physical Therapy. This is done to loosen the thick mucus found in the lung. This makes it easier for the patient to cough the mucus up (Ari, 2015). The treatment is performed between 1-4 times per day. The commonest technique used is by placing the patients head over the edge of the bed and clapping with cupped hands on the side of the chest. Mechanical devices are also used in the chest therapy. Such devices include inflatable vest which removes the chest mucus through high-frequency vibrations. Chest clappers can also be used to imitate the effects of the cupped hands clapping along the chest.

Pulmonary rehabilitation (PR) is also used for the treatment of CF. It is a program that is made up of exercise and education to help the patient to increase their stamina, manage their breathing and decrease the episodes of breathlessness brought about by the mucus blockage of the airways. The PR combines diet, education, breathing techniques and exercise to help the patients have control of their symptoms and a better quality of life. The research is also focused on therapies that would help to increase the quality of life and the life expectancy of the patients (Kerem, 2017).

Finally, there are surgical procedures which include surgical insertion of feeding tubes, lung transplant, and bowel surgery. Bowel surgery involves the removal of a specific section of the bowel. It is done to relieve the bowel blockages. The surgical insertion of the feeding tube is done directly into the stomach in the cases where the CF interferes with the nutrient absorption and digestion (Ari, 2015). The lung transplant is undertaken to replace a damaged lung with a healthy lung. The lung transplant is mostly used when the CF causes the patient to have severe breathing difficulties. In some severe cases, both lungs can be removed. However, there are grave complications to this procedure as it can lead to pneumonia and other ailments.

8. Future

The current research is focused on the medications and other methods of treatment that can be used in the patients with CF such as the application of gene therapy. The focus is on medications as well as surgical procedures. The future research on CF is focused on the clinical evaluation of the impacts of the drugs that have been developed for instance the ivacaftor that was approved by the FDA in 2012 (Hubert et al., 2018). There are a number of possible research areas screening for torsional bone strength and bone density for children with CF. Research can also be undertaken to determine the effects of protective commensal migration on the pathogen colonization of the lungs of patients with CF.

9. Conclusion

CF is an autosomal recessive disease that is most common amongst Caucasians children. The mutation of the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) chloride channel gene is the cause of CF. There is a number of categories of symptoms such as the digestive and respiratory symptoms. The symptoms indicate what should be looked at in the patients. The causes are both genetic and family related.  CFTR is an ABC transporter which has a modular design made up of two MSDs and 2 NBDs. CF is characterized by an abnormality in the epithelial ion transport. CFTR modulators have been used in the last ten years to target the primary defect directly. There are a number of treatment methods that are applied to improve the quality of life of the CF patients and also reduce the pain while increasing their lifespan.  Current research is focused on improving life expectancy and the effectiveness of the drugs. CF patient’s conditions can have quality lives following early diagnosis, and the proper medical regime is followed.

References

Ari, A. (2015). Use of Aerosol Drug Therapy in Pulmonary Rehabilitation. Toraks Cerrahisi         Bulteni, 6(1), 69-76.

Bennett, D. S., Kane, M., Aramburo, M., & Varlotta, L. (2014). Monitoring and Blunting as      Predictors of Internalizing Symptoms Among Youths With Cystic Fibrosis. Children’s    Health Care, 44(2), 155-168.

Bozoky, Z., Krzeminski, M., Chong, P. A., & Forman-Kay, J. D. (2013). Structural changes           of CFTR R region upon phosphorylation: a plastic platform for intramolecular and      intermolecular interactions. FEBS Journal, 280(18), 4407-4416.

Bragonzi, A., Horati, H., Kerrigan, L., Lorè, N. I., Scholte, B. J., & Weldon, S. (2017).            Inflammation and host-pathogen interaction: Cause and consequence in cystic           fibrosis lung disease. Journal of Cystic Fibrosis, 1-6.

Calvez, M., Benz, N., Huguet, F., Saint-Pierre, A., Rouillé, E., Coraux, C., Trouvé, P.       (2017). Buserelin alleviates chloride transport defect in human cystic fibrosis nasal   epithelial cells. PLOS ONE, 12(11), 1-21.

Cholon, D. M., & Gentzsch, M. (2017). Recent progress in translational cystic fibrosis            research using precision medicine strategies. Journal of Cystic Fibrosis, 1-9.

Doulgeraki, A., Petrocheilou, A., Petrocheilou, G., Chrousos, G., Doudounakis, S., & Kaditis, A. G. (2017). Body composition and lung function in children with cystic fibrosis and     meconium ileus. European Journal of Pediatrics, 176(6), 737-743.

Furgeri, D. T., Marson, F. A., Correia, C. A., Ribeiro, J. D., & Bertuzzo, C. S. (2018). Cystic fibrosis transmembrane regulator haplotypes in households of patients with cystic     fibrosis. Gene, 641, 137-143.

Hagemeijer, M. C., Siegwart, D. J., Strug, L. S., Cebotaru, L., Torres, M. J., Sofoluwe, A., &          Beekman, J. M. (2007). Translational research to enable personalized treatment of       cystic fibrosis. Journal of Cystic Fibrosis, 1-6.

Hubert, D., Dehillotte, C., Munck, A., David, V., Baek, J., Mely, L., …Lemonnier, L.         (2018). Retrospective observational study of French patients with cystic fibrosis and a        Gly551Asp- CFTR mutation after 1 and 2 years of treatment with ivacaftor in a real-      world setting. Journal of Cystic Fibrosis, 17(1), 89-95.

Kerem, E. (2017). Cystic fibrosis: Priorities and progress for future therapies. Paediatric       Respiratory Reviews, 24, 14-16.

Kharrazi, M., Yang, J., Bishop, T., Lessing, S., Young, S., Graham, S., & … Feuchtbaum, L.           (2015). Newborn Screening for Cystic Fibrosis in California. Pediatrics, 136(6),      1062-1072.

Langen, A. V., Dompeling, E., Yntema, J., Arets, B., Tiddens, H., Loeber, G., & Dankert-          Roelse, J. (2015). Clinical evaluation of the Nanoduct sweat test system in the diagnosis           of cystic fibrosis after newborn screening. European Journal of Pediatrics, 174(8),      1025-1034.

Lindberg, U., Svensson, L., Hellmark, T., Segelmark, M., & Shannon, O. (2018). Increased         platelet activation occurs in cystic fibrosis patients and correlates to clinical status. Thrombosis Research, 162, 32-37.

Ng, R. Y., Marson, F. L., Ribeiro, J. D., Ribeiro, A. F., Bertuzzo, C. S., Ribeiro, M. O., & …           Sakano, E. (2015). Nasal Potential Difference in Cystic Fibrosis considering Severe     CFTR Mutations. Disease Markers, 1-11.

Nunvar, J., Capek, V., Fiser, K., Fila, L., & Drevinek, P. (2017). What matters in chronic            Burkholderia cenocepacia infection in cystic fibrosis: Insights from comparative    genomics.PLOS Pathogens, 13(12), 1-24.

Perisson, C., Destruys, L., Grenet, D., Bassinet, L., Derelle, J., Sermet-Gaudelus, I.,             …Corvol, H. (2017). Omalizumab treatment for allergic             bronchopulmonaryaspergillosis in young patients with cystic fibrosis. Respiratory     Medicine, 133, 12-15.

Prados, C., Lerín, M., Cabanillas, J., Gómez-Carrera, L., Álvarez-Sala, R., Martinez, M., …Quirós, S. (2017). How are the ancient cystic fibrosis patients? Cystic fibrosis             diagnosed over 60 years-old. Respiratory Medicine Case Reports, 21, 49-51.

Sellers, Z. M., Illek, B., Figueira, M. F., Hari, G., Joo, N. S., Sibley, E., … Wine, J. J. (2017).            Impaired PGE2-stimulated Cl- and HCO3- secretion contributes to cystic fibrosis airway disease. PLOS ONE, 12(12), 1-20.

Tabaripour, R., Niaki, H. A., Douki, M. R., Bazzaz, J. T., Larijani, B., & Yaghmaei, P. (2012).            Poly Thymidine Polymorphism and Cystic Fibrosis in a Non-Caucasian Population.      Disease Markers, 32(4), 241-246.

Tabori, H., Arnold, C., Jaudszus, A., Mentzel, H., Renz, D. M., Reinsch, S., … Mainz, J. G.    (2017). Abdominal symptoms in cystic fibrosis and their relation to genotype,        history, clinical and laboratory findings. PLOS ONE, 12(5), 1-19.

Wang, Y., Wrennall, J. A., Cai, Z., Li, H., & Sheppard, D. N. (2014). Understanding how     cystic fibrosis mutations disrupt CFTR function: From single molecules to animal    models. The International Journal of Biochemistry & Cell Biology, 52, 47-57.

The Number of constitutional Violations in the Watergate Scandal

The power that leadership positions give to the leaders can be a strong temptation for them to break laws to protect their interest. Precisely, the presidency of a superpower country enables the presidents to do countless things while in office. This influence can be constitutional or unconstitutional. Thus, researching for the number of offenses that President Nixon’s administration committed is essential in demonstrating the essence of an oversight body in monitoring the conduct of government officials. The agency will be investigating the offenses done to cover up the significant crimes. Therefore, researching the number of felonies in the Waterhouse scandal will expose more constitutional violations that the government did to cover up the scandal.

Background and Significance

Although there are enough agencies to investigate and expose felonies within the government, the cover-ups to these offenses remain unnoticed. Since people are also affected by the cover-ups too, there should be enough constitutional bodies to investigate the conduct of the involved individuals from the period before the exposure of offenses to that after the scandal. This step would help to compensate both the individuals affected by the major crime and the cover-ups. This research project will investigate president Nixon’s administration before and after the exposure of the Watergate scandal to determine the number of cover-ups. The research will use the data from newspapers, journals, government publications, scholarly articles and books to do the research. However, the study will not document classified information that could threaten national security.

Literature review

Already, there are research projects that provide insight into the Watergate scandal. These projects include publications such as “Watergate:  The Presidential  Scandal  That Shook America” and “Combining information from sources that varying credibility”. These publications only cover the major scandal and ignore the cover-ups. This negligence warrants the need to research on the cover-ups.

Research Designs and Methods

The research will use descriptive research methods for the study. Mainly, the project will analyze the government publications and survey the internet for newspaper publications related to the scandal. The project will take two weeks, one week for analyzing government publications and the other for surveying the web for related content and compiling a final report. This period will be enough to cover all the aspects of the research.

Research implications

The research project will reveal the cover-ups that the government did to prevent the public from knowing the truth about the water house scandal. Although the revelation may be controversial, the information will not be contentious enough to threaten national security. The compilation of the final report will be careful enough to provide illustrations that will only justify the essence of investigating cover-ups. Eventually, the project will demonstrate the need for studying cover-ups while maintaining the nation’s safety.

In conclusion, investigating the number of felonies in the Watergate scandal is an essential step in correcting all the mistakes that are related to any scandal. Since there is less work done on the importance of investigating cover-ups, the research project will be an essential reference point for similar projects in future. Thus, the initiative will guarantee justice to individuals affected by either the scandal or the cover-ups.

Requirements  Specification and System Development Life Cycle

Compare and Contrast

            Even though unambiguous and understandable cover the same thought of clarity of message, they can still be contrasted. This is because, unambiguous weighs a thought in one dimension so as to create a single lane of thought thus closing chances of a thought having any another interpretation (Zielczynski, 2008). It is mostly brought about by acronyms that have not been defined, incomplete command or a misplaced word. Understandable on the other hand means that a requirement should use correct grammar written in a uniform style. Additionally, must or may should be replaced by shall (Zielczynski, 2008).

Complete defines the total inclusion of every needed component and condition likely to occur, such that no addition is required on the system (Zielczynski, 2008). Furthermore, for a requirement to be complete, it should have adequate criteria. On the contrary, concise refers to provision of a large-sum amount of information comprehensively and in brief words that are simple and clear (Zielczynski, 2008). Moreover, both refer to provision of adequate information to the system.

Correct means that the function is accurate, with facts that are true, and without errors(Zielczynski, 2008). Modifiable  means that the function is prone to being changed in form according to the requirements by containing one element that can be traceable and not having a requirement that gets expressed once with minimal chances of overlapping with another (Zielczynski, 2008). Both try to gauge the accuracy of the function to the specifications.

SDLC

A standard is a term used at the University of Kansas to define the least number of the needed phases and thoughts needed for the development and implementation of newly developed software and system( Ks 66045, n.d).

Standards have several uses such as: providing lowest level requirements for the works of developing the application (GO-ITS, 2007). Secondly, it provides a wide measure for making sure that the methodology used in development of an application goes hand in hand with its standard (GO-ITS, 2007). Thirdly, it outlines major features of a lifecycle methodology in addition to providing direction for a generic. Additionally, they intensify an application’s quality by suitable commenting and creating standardized labeling conventions (GO-ITS, 2007).

References

Zielczynski, Peter (2008). Requirements Management Using IBM® Rational® RequisitePro®. informIT the trusted technology learning source, Retrieved from http://www.informit.com/articles/article.aspx?p=1152528&seqNum=4

KS 66045, Lawrence (n.d). Systems Development Life Cycle (SDLC) Standard. INFORMATION TECHNOLOGY POLICY, Retrieved from http://policy.ku.edu/IT/systems-development-life-cycle-standard

GO-ITS (2007). Application Development Standard: Standards for SDLC. Information & Technology Standards, Retrieved from dr6j45jk9xcmk.cloudfront.net/documents/1890/go-its-54-application-development-standards-for.pdf

Recreation Facility Research Paper.

A recreation facility is a building, a place or a space that offers leisure services or fulfilment of someone’s hobbies of relief and relaxation, pleasure, amusement and fun.

A Research on Westmount Recreation Centre, Ontario- Canada.

Westmount Recreation Centre is a recreation facility located at Lynbrook Drive, Hamilton, Ontario.

It was established in September 2013. It was designed with a highly architectural skills aimed at accessing the surrounding ice rinks, offering a café and a lounge area attractive to potential recreation seekers. Having won many awards acquired the trust of both the Canadian government and both the citizens and tourists at large, it boasts of various service and event hosting such as hockey games done in the ice rinks, free skating outdoor pool and a wading pond, locker rooms, multi-purpose activity rooms for fitness classes, and meetings, teen center, parking area, a storm water management system and electric vehicles charging stations.

Benefits of Westmount Recreation Centre

1. Benefits to the community

1. Recreation and parking services

Providing avenues for relaxation and enjoyment, the recreation facility offers a cool of mind to the community utilizing its services. Westmount also offers parks that improve the image of the community and raises its socioeconomic status. With recreation activities, self-destructive behaviors are reduced, hence building a morally upright individuals in the community.

1. Boosting sports

Sports brings about social cohesion, improves community relationships and enhances interpersonal relationships in the community. There is also active involvement in the community since individuals are brought together through such sporting activities.

1. Benefits to the environment.

Utilization of land: Opening up of recreation amenities, parks and spaces help utilization of land that would otherwise stay idle and in dereliction. Land is converted into a highly acclaimed heritage through provision of such facilities.

1. Benefits to the economy

1. Employment creation

Canadian citizens are employed to offer services at the Westmount such as maintenance of pool, chef services at the café, cleaning of the area, security and equipment operation. This helps increase per capita income, therefore balance in the country’s economy.

1. Business attraction

Business persons are encouraged to offer services at the Westmount Centre, such as opening up of shopping malls, provision of recreation equipment and offering security contracts. With the growth of business, there is assured growth in general business income with which diversification of investments is wayward.

• Government revenue

According to Ontario Recreation Facilities Association (ORFA), recreation facilities such as sports and park services provides for over 12% of Canada’s revenue. The collection of this revenue is through charges and duties paid by the management, the tax policy compliance and the business taxation services. These tax revenues are ploughed back to develop other public services such as schools and hospitals, hence boosting the economy.

1. Personal health benefits

Recreation facilities helps improvement of individual health through relieving stress, keeping fit and being happy. According to Ontario Ministry of Health Promotion Report (2006), recreation services reduced cost of medical care from 2 billion to 1.6 billion a year. A healthy living has since been encouraged though adoption of recreation activities building state of the art centers such as Westmount.

Challenges

1. Maintenance cost

Initial capital required to set up a recreation facility is way too expensive and require some massive investment. However, this cost does not recess, as occasional maintenance is required to keep the facility in good state, healthy and attractive. Costs of employing maintenance staff, equipment and machine is high and if not well budgeted for, may drive the management into losses.

1. Vandalism

Due to high number of recreation seekers, and availability of children, most of the equipment is prone to vandalism. Breakages to the sports facilities such as hockey sticks, skates and protective gears is unavoidable. The management of the facility is therefore required to plan for these inconveniences.

1. Overcrowding

The facility faces high number of visitors especially during holidays such as Christmas, New Year celebrations and Valentine’s Day. Difficulty in providing services to all these people is eminent. Overcrowding also lead to service rationing, hence non-satisfaction at the individual level.

1. Safety and risk management

With frequent ice falls, the management of the facility faces challenges of providing effective ways of curbing cold effects. Many children also tend to experience accidents during skating, footballing and swimming.

1. Competition

There are several recreation service providers within and around Ontario that offer competitive threat to Westmount. They include Ontario White Lake Park, Huntington Park, Ryerson Recreation centre, Central Memorial Recreation Centre and many more.

1. Changing tastes and demands

With evolution in recreation technology, park management and resource diversification, customer preferences keep changing with time. Demand for state of the art facilities poses economic and creativity challenges to the management of the Westmount recreation centre.

Strategies to deal with the Challenges

1. Effective budgeting will help in facility cost management related to maintenance and operations. Seasonal budgeting for such costs helps meet maintenance uncertainties. Strategies on dealing with such cists is also essential, involving coming up with mentainance policies where the facility is closed for a while for upograding and maintenance.
2.  Vandalism is an unavpoidable risk. The facility managers can leverage their costs and ensure customers pay fot the risks of vandalism at a relatively moderated cost. Kids should also be given guidsnce of their parents/guardians or the facility staff.
3. Diversification of the facility will help accommodate high crowds at a time. The facility can also open a subsequent recreation centre adjacent to the main center where they can redirect people to enhance their accommodation. They cabn also manage the number of people entering the facility at a time, and the individual time spent within the facility based on the cost one is willing to pay.
4. According to Rechner (2010), risks related to recreation activities cannot be prevented, but can be highly managed through provision of safety policies. The management can therefore invest in provision of this safety services especially to the children and the elderly people.
5. Investing in research and design (R&D), innovation and technology will help the facility not only to stay a top of the competitive scale, but also win the recreation taste of the leisure seekers (Westmount Recreation Centre Professional, 2015). Development of such skills in technology and research will help realize worldwide trends in recreation such as recreation management portal, modern security and safety measures and provision of state of the art pool with underwater gym.

REFERENCES

Rechner (2010). “Letter to the Editor: Outdoor Recreation Stimulates the Economy”. Washington Post.

Sanders, Duncan (2017). Ontario Recreation Operations. London.

Westmount Recreation Centre Professional (2015). Progressive Report on Westmount Recreation Centre, Ontario.

Ontario Recreation Facilities Association, ORFA (2007). Investing in Healthy and Active Ontarians through Recreation and Parks Infrastructure: A summary of trends and Recommendations.

Ontario Ministry of Health Promotion (2006). Plan for Healthy Eating and Active Living: A Report on Health Trend and Management.

Racism in the Civil War

Racism in the Civil War

Racism is and has been present in the United States since the colonial era, but at several

points in time throughout the history of this country, racism and its societal impact has reached a

fever pitch, one of them being the Civil War, fought from 1861 to 1865. It is argued amongst

historians and other academics that the Civil War was not fought with the intent to free the

slaves. Southern states were furious over President Abraham Lincoln’s election and his unclear

stance on freeing the slaves, which the South did not want. Divided over geographical lines and

what to do in regard to slavery, the North and South bitterly battled in the war, at the core of

which was racism. The war, nor the signing of the Emancipation Proclamation by President

Lincoln, was about freeing the slaves and recognizing their humanity. Racism was at the heart of

the war and the debate of slavery and states’ rights. It ran rampant throughout the war in more

ways than one.

To provide context, it is important to note that President Lincoln knew fully well the

injustices and harshness of slavery. While not an abolitionist in any form, he knew that slavery

was wrong ethically, socially and morally and had a significant lack of knowledge or direction

about what to do about it legally. It was not in Lincoln’s interest or desire to free the slaves and

provide their economic, social and political equality to whites (Pruitt, 2012). Lincoln believed

that African Americans had the right to improve their lives yet opposed them having civic duties

like voting and serving on juries, or even marrying interracially. Those in the North opposed

slavery; their Southern slaveholder and secessionist counterparts wanted to secede from the

Union to maintain slavery as an economic institution. Southerners argued that per states’ rights,

they were entitled to protect slave property anywhere in the country. Northerners argued that

other rights were violated by states’ rights and the Fugitive Slave Law of 1850.  With the

Emancipation Proclamation, slaves were freed only in parts of the Southern states where he held

no authority, yet the South refused to concede to even that stipulation. War soon erupted between

the North and the South; it was not until a Union victory against the Confederacy that the slaves

were ordered to be completely freed, thus changing the way of life as both sides knew it.

Racism was not only limited to the regional sides of the Civil War. Within it,

abolitionists and slaves alike hoped for the opportunity to fight in the war to not only help the

Union win, but to forge the path of social justice, or at least their own freedom. However, the

South and President Lincoln feared that by arming African Americans, they would pressure

border states to secede and prevent a union Victory. Although state militias had long excluded

African Americans from the armed forces, the Second Confiscation and Militia Act of 1862

allowed them to enlist in the Union army to secure a victory. Few Black men militants saw

meaningful work and were instead delegated to menial, labor-intensive jobs for which they were

paid very little, if at all. Even in one of the most notable units, the 54^th Massachusetts Infantry,

racism continued as they were paid scarce sums and served in domestic and security roles like

guards and scouts. They were seen as they always had been, despite the military uniform: as

inferior, less intelligent, less skills and less brave. By the war’s end, nearly 50,000 men had died

fighting for a country that saw them as inferior to Whites. The Reconstruction following the

Civil War made no better conditions for African Americans. Their lives then became impacted by

“black codes” in the South to control their behavior and maintain order that positioned Whites as

authority.

The television industry has undergone substantive changes over the last few decades. As mentioned by Jeff Yang, in the late 2000’s, newly released movies and TV shows took a new spin to depict multiculturalism. This paper dwells on the Quantico, an ABC Studios TV-show, as an example of how American television embraced characters of different ethnicities in the latest years.

Quantico premiered in September of 2015 on ABC. The show has two seasons and a total of 44 episodes. The premiere of the third season is scheduled for April 2018. The series is now available on Netflix, and is popular among the international audience, especially in Canada, Australia, and India. The plot of the series revolves around the recruits at the FBI Academy who undergo training in Quantico, Virginia. Upon graduating, the main character, Alex Parrish, becomes the main suspect in the most damaging terroristic attack since September 11. The story goes in two timelines – the past where Parrish and her fellow recruits undergo training at the academy, and the present, where Alex tries to prove her innocence. The show is a drama thriller and was aired on Sundays at 10:00 pm, and is aimed at adult audiences. The viewers and critics praised the series for the performance of the main character, Priyanka Chopra, and the diversity of the cast.

The main character in Quantico, Alex Parrish, is among the brightest examples in modern television of how international cast livens up and attracts a broader audience to a show with a somewhat traditional plot line. Performed by a Bollywood superstar Priyanka Chopra, the character has an unusual cultural twist that was welcomed by the audience. Moreover, Chopra was the first South Asian to headline an American drama series. Critics described the actress as charismatic and stated she was the most valuable human asset of the show. For her performance, Chopra received two People’s Choice Awards for “Favorite Actress In A New TV Series” and for “Favorite Dramatic TV Actress” becoming the first South Asian actress ever to win such awards. It should be noted that Chopra was born and raised in India, and had no background in the United States. This proves that the American television has undergone a substantive change starting from its origins. Today, it not only includes Americans with various racial and ethnical backgrounds but also casts international stars to attract more attention to the show.

Such a trend can be attributed to a variety of reasons. Firstly, as mentioned Yang, the modern era of television is focused on providing more diversity. The TV shows are giving a more realistic picture of a typical American citizen. Descendants of immigrants are portrayed more realistically; they do not have to have a perfect American accent or be of a typical American appearance. In contrast, diversity on a TV screen attracts a wider range of viewers with similar roots who can relate to characters. Secondly, a typical American superstar agent, as pictured in the majority of the older TV-series, is a Caucasian male, and the majority of them look alike. Such images do not leave any emotional reaction in the viewer anymore because there are so many of them and so few distinctive features. In Quantico, the central character is a female and is Indian, which makes her stand out among other similar characters. Such a move by the producers and its warm reception by the audience proves that even the modern television has gone further in its strive for diversity.

Indeed, in the late 1990’s – early 2000’s a new spin in the history of television has brought to screens many new stars of Latino background, who were not perfectly tailored in accordance with the traditional Hollywood standards (Yang). However, today the producers have realized that there are is more diversity in America, and started to include characters with Asian, Middle East, and other origins. The cast of Quantico is in all senses multicultural and therefore appeals to a broader audience than more traditional casts including Caucasian, Latino, and African American actors. The agent recruits, who are the center of narration, include the mentioned Alex Parrish, Simon Asher from Brooklyn, Shelby Wyatt, who is also referred to as “southern belle”, Nimah Anwar, who is originally portrayed as a conservative Muslim wearing a hijab, Ryan Booth with typical good looks of a US guy, and a Mormon Eric Packer. The multinational cast is a sign of the “opening of both minds and borders” (Yang).

In my opinion, Nimah Amin is a particularly interesting character, given her background and a mysterious personality. Nimah is very reserved in her relations with other recruits. Her religion and origin make others prejudiced against her despite her deep love for America and patriotism. It turns out that Nimah has a twin sister and the two of them pretend to be one person switching positions during training at the FBI Academy. During the toughest training, the twins wear hijab and prove that their religion does not prevent them from being remarkable recruits. Moreover, they often have to be tougher and better than their fellow students as to fight the prejudice against them being female and Muslim. Later on in the series when their secret is revealed, Nimah’s individuality is pictured more vividly: she does not wear hijab anymore because she is not as religious as her sister, and she does not have to pretend any longer. Such a transition is a great example how Muslim women do not always fall within the generally accepted stereotypes and are much more than just a mask they are wearing. It should be very informative for the audience, especially in the light of general misconceptions about the Muslims. There is also an interesting twist to Nimah’s character when it turns out she belonged to a terrorist organization Citizen Liberation Front. She joined the organization because she thought that America would never accept people who are different. Thus, her never-ending fight with stereotypes and unwillingness of people to accept her as a person, and not as a representative of a religion, has led her to “fight dirty.”

In summary, Quantico is an excellent example of a modern TV series that provides both an interesting plot and remarkable characters. The series introduces a bright and catchy main character Alex Parrish, played by a Bollywood star Priyanka Chopra. The main character of an unusual origin received positive feedback from both audience and critics and brought numerous awards to the foreign actress, which means that today the US viewers are more receptive to the international cast than they used to be at the dawn of television (Yang). Moreover, the series was recognized for the diversity of the cast, which included characters with different cultural and religious backgrounds. Such a variety of characters attracts a broader audience, including people from other countries, and helps to fight general misconceptions associated with particular cultures. One of the characters that stands out the most is Nimah Amin who is a Muslim trainee with a mysterious personal story. Her evolution throughout the series shows how representatives of other cultures may feel outcasts in the American society because of the unwillingness of people to accept anyone who is different. Overall, the series is a representative of the new generation of TV products aimed at a broader audience that recognize and celebrate the diversity of the Americans and depict them more realistically on the screen.

Works Cited

Yang, Jeff. “Fresh On The Screen: How TV Is Redefining Whom We Think Of As ‘American’”. National Public Radio, Code Switch: Race and Identity, Remixed. 

Applied Business Project

Applied business projects typically entail a substantial amount of research work that provides the intern with a chance to use their knowledge and skills through the investigation and analysis of a complex business problem or management issue forming the basis of the internship. During my internship, my applied project business project revolved around the question how the digitization of retail sales impact marketing strategies in the telecommunications industry in India.

At Mobilinq my position as an intern was that of an assistant manager. I got the opportunity through a referral from family/ friend. During the short tenure, I gained invaluable experience and insight in the telecommunications industry. I directly got to see how competitive the sector is in India.  The research project conducted was helpful both to the organization and to me as an Individual. My mentor played a crucial role both in the research and the learning process.

I knew the telecommunications industry was big but I did not quite comprehend its real size up until during the research. India potentially has a vast of financial potential per the results of the analysis. The key players in this industry include the Media. Apparently, the Media industry is the most critical drivers of the telecommunications industry. I also realized just how much the telecommunications industry is dependent on the digitization of news and the central role played by digital advertising agents both local and international ones.

Per the analysis, the future of the telecommunications industry is set to be influenced heavily by analytics firms. For instance, I learned that companies like Iconisation are predicated on offering new digital products to stimulate the growth of the telecom sector. Consequently, firms dealing in telecommunications are advised to invest more in omnichannel sales.  Such services could open up new research areas like the effectiveness of the new platforms in growing the industry as a whole.  Additionally, I saw that the introduction of numerous digital process would increase the number people online. The current avenues for measuring customer satisfaction can be improved by digitizing them to evaluate the growing user base.

Moreover, I was able to understand the vast potential in social media as more and more people are joining it. This trend is the new frontier for businesses and radical marketing strategies. For example, through social media, I discovered that people could channel feedback directly about a product to the manufacturer while firms get direct access to their clients without intermediaries.

As far as the limitations of the analysis go, I think I found at least Five in my analysis. The first one is the external factors considered during the study. Most of them were highly dynamic which made it hard to predict the how and why these factors would influence the direction of the telecoms sector. The second element is subjective depending on the person going through the results. The presentation or discussion of the analysis may appear simple, but it is sufficiently detailed and well researched. All the attributing factors are discussed to a degree of impact which makes the observing eye value the analysis. Thirdly, collecting all the vast amount of data involved utilizing pertinent information obtained from external sources. Although the process was both tiresome and costly, it strengthened my resolve and critical thinking skills. Fourth, the analysis was limited by the scarcity of freshly updated information. Fortunately, I was able to find reliable data from as recent as 2016.  Fifth, the sheer size of data used in the analyses may sidetrack the readers from the relevant findings. Accordingly, I carefully laid out both the results and the discussion in a way that the reader would easily blend the secondary information with the primary findings. Therefore, the analysis had a few limitations, but I managed to navigate out successfully.

The internship was also crucial in building upon my professional and personal competencies. I acquired the practical knowledge in international marketing. Through the research and my interactions with the marketing team, I learned how to apply the concepts I had acquired in class about selling the right product to the right customer. I was also able to gain skills in operational management.  Hence, I now know how to handle day to day operations including but not limited to customer handling, inventory management with adequate planning and due business practices. Furthermore, my assistant managerial position accorded me first-hand insight on how to be a competent manager. I was able to apply the academic theory through contributing to managerial effectiveness and handling time pressures. Finally, through the internship, I gained competencies in financial performance management. I can now apply the concept in real life accounting situations like profit and loss statements, balance sheets and other financial records. As a result, the internship opportunity at Mobilinq has been significant in advancing my business knowledge and skills.

In conclusion, applied business project are great opportunities for an intern. I got a position at Mobilinq where I have been interning as an assistant manager. While at the job I researched into the telecommunications industry. While undertaking the research, I was able to view the sector from whole other perspectives. There were visible trends and links all over. Although the analysis I use presented some limitations, I was able to overcome them.  Also during my tenure at the company, I was able to put into practice the theories I had learned in class as well as acquire practical competencies.

Preparing a Learning Activity

Topic: Saving plan through home cooking

Cooking is a skill that subsists among arts acquired from the ancient days and is still appreciated to date. You must acknowledge that there is no such thing as perfect food –only the idea of it-and that making people happy is the only reason why people strive towards perfection in cooking (Thomas, 2105). Broadly, when we reflect on the art of cooking, the reason we cook and the various sub-cultures and cultures of food that exist globally; that reason simply is nourishment. It is only through cooking that lasting memories are formed for instance, a memory as humble as wonderful cherry or a beautiful piece of toasted bread (Thomas, 2015). Home cooking, moreover, balances the nourishment and food memories with excitement and joy. Despite the excitement one gets in mastering the culinary art, home cooking allows a family to enjoy numerous health, life style and financial benefits.

Firstly, home cooking improves and enriches an individual’s life. Once you start making meals in your home, you attain organizational skills, time management skills, good planning skills, and confidence and creativity skills among others. Also, home cooking gives you control over ingredients and thus allowing you to evade unhealthy preservatives and additives used in fast and processed foods (Pujitha, 2014). Additionally, it offers you the chance to more nutritious recipes and control over the quality of your diets which are critical contributors to good health. Further in improving ones health, home cooking renders the chance to regulate not only quality but also the quantity of food you take. In that light, having complete control over the type and amount of food you eat, cooking at home helps you in weight management since you will tend to stick to more reasonable quantities (Pujitha, 2014). In comparison with eating out, making of home meals is very convenient and the food if well prepared with required ingredients is more tasty and safe.  The reason many people prefer eating out is because they are lazy to cook, they think their food is not tasty or they do not know how to make good meals. However, we have videos, books and articles that counter these excuses through teaching individuals how to make delicious homemade cuisines that are cheap and easy as well as training them to cooking proficiently (Pujitha, 2014). Lastly, home cooking can be deemed a saving plan as it is cheaper than eating out. When eating from a restaurant, you not only pay for the food you eat but it also drags other payments along such as for the services, the building and staff. Again, in the case of frozen and packaged foods, alongside the cost of the food, you are charged with extra costs of shipping and packaging as well. Through appreciating homemade meals, these food expenses can be cut down and only part of the money spent when eating outside could be used to make delicious and nutritious diets while the rest saved to be used on other things.

Outline

1. Introduction and overview of the topic. (4mins)
2. Ask for two volunteers who will be asked a few questions on daily expenses, health benefits, and comparison between eating out and making homemade meals. (2mins each)
3. Show two videos covering the questions one on people who eat out and the other on those cooking at home which includes health records and expenses.( 3mins)
4. Brief discussions with the next person on where you place yourself in line with the videos.( 1min)
5. Go to teaching the main topic giving examples while engaging them.(6mins)
6. Allow them to ask question and allow answers to come from among them too. (3mins).
7. Have them form random groups for accountability, give an assignment, and an evaluation template as you wrap up the learning (extend a little).

In enhancing the audience motivation to learn, there is need to incorporate the Wlodkowski’s five pillars of, enthusiasm, expertise, clarity, empathy and cultural responsiveness. On expertise, after introducing the topic, examples will be obtained from a sample of students testimonies in preceding classes on the amounts of money saved by cooking at home, health scales and how it has improved their lives as well as from the tutor’s own example. Through the volunteers and responses from the discussion after the videos, a tutor will evoke experiences, attitudes and goal perspectives. This takes us to empathy where the tutor will identify with the various attitudes and experiences through examples from personal experiences or those of the previous class to augment the learning session (Tubarks, 2011). Further, enthusiasm requires that the tutor walks the talk meaning that as a tutor one should be the best example. Hence, as a doer, the tutor should  have a template showing how much she has been saving from eating homemade meals, her family’s health record that would depict home meals effect on health and the various culinary skills they have acquired which led to improvement of their meals and themselves. The tutor should articulate the topic in terms understood by everyone in their class. In clarifying, the sentences should be simple; questions and examples given should be easy to comprehend and straight to the point so that everyone is able to grasp the concept (Tubarks, 2011). Additionally, the tutor should be able to demonstrate step by step how to fill the template and record the number of times they eat out, how much they spend, the number of times they have cooked and how much they have saved. Also they should have a record on the number of times they have had hospital visits and if home cooking has improved their lives or not in the remarks column. Since every class represents diverse culture, economic strata, race and ethnic groups, it is important that the lecturer creates an environment that is culturally responsive. The tutor will achieve this by using examples that cut across these various groups and respecting the diverse opinions and perspectives, attitudes and experiences even in the event where they disapprove or disagree. A tutor through creating random groups renders a platform for the students to respect one another, appreciate their differences, to participate and to ask questions.

One of the tools that could be used to ensure inclusion of diverse culture is active participation methods (Linda, 2012). This could entail, asking them questions, allowing them to ask questions as well as getting answers from themselves before finalizing the topic. Students could also be called forward to demonstrate and explain their eating habits, show how much they spend on eating outside or how much they save from eating homemade meals and how cooking has enhanced their health and aid in begetting personal skills. Active participation without any prejudice will create a free spirited environment where students are directly involved. Hence, the tutors through engaging them and giving examples from their various cultures will not only appeal to their conscious on diversity but will also enhance effective learning (Linda, 2012). Moreover, cooperative learning and interactive approaches could be another critical tool in a classroom setting of people from diverse culture (Linda, 2012). In ensuring effectiveness and efficiency of this tool, the teacher should create a classroom where students are safe to contribute to discussions as well as ask questions. By respecting the views, opinions and attitudes of the students toward cooking and its importance, the lecturer will be at the forefront in demonstrating respect that the rest of the class will adhere to. The interactive sessions should be spontaneous such as after the video the lecturer could encourage them to speak to the person next to them on their views creating a rapport between them.

Reference

Thomas Keller. MAD: What is cooking? April 11, 2015.

Pujitha Reddy. ListCrux: Top 10 Reasons Why you should learn to Cook Today.                                                 October 4, 2014.

Linda Dusenbury. Education World: Creating a Safe Classroom Environment.2012.

Tubarks-The Musings of Stan Sktabut : What makes a motivating instructor? 19                                                 January,2011.

The Impact of Enhanced Orientation Programs on Nurses’ Retention Rate:

Certified Home Health Agency’s Strategy for Decreasing the Cost of Visiting Nurses’ Turnover

According to National Healthcare Retention and RN  Staffing Report (“NSI Nursing Solution, Inc,” 2016), the cost of nurse turnover can cost a hospital as much as $8.1 M annually (p. 4). Among  the US five geographic regions, North East has marked the third top for a high nurses’ turnover – 20.3 percent, after South  East and South Central that marked a nurse turnover at 26.8 percent (“NSI Nursing Solution, Inc,” 2016, p. 2) .  The trend of a high turnover rate for registered nurses continues to rise state and nationwide. At Northwell Health at Home, a Certified Home Health Agency (CHHA), which  is a division of Northwell Health Network, the percentage of newly hired nurses leaving the organization within the first year of the employment reached out an alarming point of  59 percent.

Educators and clinical facilitators at Northwell CHHA) have recognized that nurses joining the technologically and increasingly complex health care environment need a minimum of one year to grasp the specifics of home health care.  It takes time to train a nurse who is  fully confident in providing safe and effective care. It takes time and resources to make an efficient home health nurse who is able to weather the climate of a continued change in  health care industry. Home health providers must adhere to the specific standards and recognize the unique needs of the patients they served. The organizations must secure a  steady workforce of highly competent nurses to ensure that the clients’ comprehensive healthcare demands are met.

Problem Statement

Poor retention of nursing forces has been creating the need for a continued search for new nurses. This has not only been time consuming for  the managers and  talent acquisition specialists but also proved to be costly for the organization On average, for every RN that turns over,  it costs the organization 1.5 times that RN’s salary. For that reason alone “RN  turnover is a statistic that should be on everyone’s radar”  (Boston-Fleischhauer, 2016). Orientation, in-services, mentorship and preceptor program must allow for increased productivity of each nurse, in order to prevent a financial loss of revenue for  the organization (Boston-Fleischhauer, 2016).. Northwell Health system’s goal is to be an the Employer of Choice which means that people want to work for the company and the most talented workers stay with the organization throughout their careers. In return, the organization values the employees by providing many incentives, including awards, benefits, and motivational programs.

Northwell Health at Home educators and managers collaborate closely with the Human Resources (HR) Department during the process of planning and hiring. Reports from HR collected at the exit interviews indicated “feel overwhelmed” as the main reason nurses have been leaving the organization. Nurses felt inundated by the amount of daily visits, extensive documentation of the visits- a requirement  imposed by Centers for Medicare & Medicaid Services (CMS), and Information Technology advances that for many nurses was hard to grasp within only 2-4 days of training at a computer lab during presently offered  2 weeks long orientation program.. The previous attempts to reduce the nurses’ turnover by decreasing the number of daily visits not only did not bring any positive results in nursing retention but negatively affected the organization’s financial goals.  Educators had to look at the variables that the organization can change in order to increase the nurse retention and give the employees the opportunity  to stay with the organization for a long time. It was decided to focus further on nurses’ education during the orientation programs.

Clinical Practice Problem

Northwell Health at Home strategic plan that addressed the issue of nurses’ turnover led to generating the preceptor program  based on  Neal Theory Model of Home Health Nursing Practice (Neal, 1999) that  provides  a conceptual framework recognizing home care nursing as a specialty.  The research-based model lines up a three-stage process for the  new hired home health nurses: Dependence, Moderate Dependence, and Autonomy (See Appendix).  It argues that when nurses receive the appropriate training and support, they are more likely to be engaged at an organization and remain there for longer periods of time. The proposed strategic plan is to implement the preceptor program that provides educational support to the new hires with the result being increased retention. The goal of the preceptor program is to create a successful and autonomous in their practice nurse convinced that the company is her/his Employer of Choice.  The  improved and  better outlined nursing orientation program supports individualized and fluid-allowing adjustment based on the nurse’s education progress. The new program should enhance the nurse’s ability to adapt in home care throughout the awareness of clinical change and the willingness to accommodate to change (Neal, 1999).

Leaders must demonstrate their understanding of the key issues that impact turnover in the organizations. The development of new ideas to improve education and retention are of critical importance to achieve higher quality performance for nurses. The goal of the enhanced preceptor program is to  ensure that they have the tools available to acquire knowledge, and access to resources on a continuous basis. The clinical leaders must provide knowledge and input regarding training and education for nurses, along with recognizing the importance of leadership in executing this effort (Porter-O’Grady & Malloch, 2016).

The performance improvement project was designed to decrease the cost of visiting nurses’ turnover rates, to increase the retention rate, and improve the job satisfaction at Northwell Health at Home CHHA. The enhanced orientation program will make it easier to identify training and competency gaps, empower nurses into controlling assignments based on their competencies, eliminate chaotic job atmosphere, and correct imbalanced job-work life (Cuddy, 2015). Futhermore, “beyond the financial costs of increased turnover, the disruptions to productivity, team dynamics, and care quality from turnover have been recognized and solidly documented” (Boston-Fleischer, 2016, para. 3). T

The additional goal of the redesigned orientation program is to prevent the domino effect that the dissatisfied and overwhelmed nurses have on their co-workers. These nurses share their “negativity” resulting in more nurses resigning which increases the workflow of the remaining nurses. A preceptor program will support new employees by providing educational training that  would make a confident in their job professionals. The program will also present a  positive approach which would hopefully trump the negativity.

Context and Climate of the Practice Environment

Northwell Health at Home CHHA  serves over 30,000 patients annually. Hospitals, primary care physicians (PCP) and sub-acute rehabilitation centers may refer patients for home health care services (Ellenbecker, Samia, Cushman, & Alster, 2008, Chapter 13).  The clients come from all age groups including maternal – child and pediatrics. Home health care is a system of care provided by skilled practitioners, such as nurses, physical therapist, speech-language therapy,  medical supplies, equipment, and durable medical equipment to patients in their homes under the direction of a physician.. Northwell Helath at Home also provides infusion, hospice at home, and home health aide (HHA)  services. The goals of home health care are to help individuals to improve function and live with greater independence, to promote the client’s optimal level of well-being, CHHA nurses work closely with the physicians, physical therapists and  social workers to assist the patient to remain at home and  avoid hospitalization or admission to long-term care institutions.

Following the nationwide trend to gain a larger share of the consumer health market, many acute care facilities within New York’s five boroughs, Long Island, Westchester and Putnam counties have merged with Northwell Health organization to become a part of a clinically integrated network. Provider consolidations make it easier to share electronic records systems and to enhance a seamless flow of information between hospitals, providers, and insurers. This, in turn, helps coordinate the care of patients eliminate redundant costs as the network expands; furthermore, the affiliated post-acute providers must also grow to support cross-continuum care. It is known that “organizations recognize that nursing is core to the strategic achievement of outcomes, including clinical, financial, and growth/market share. Retaining top nursing talent is a strategic priority, not just for the nursing enterprise, but for the entire health care system” (Boston-Fleischer, 2016 para. 4). According to the author, the investment in nurse retention is critical, beginning with employment and commencing forward to increase retention.

SWOT Analysis

The Strength of Northwell Health at Home lies in the fact that we are the leaders in timely initiation of care with 98.8 percent  as compared to the NY state – 95 percent and nationwide 93.2 percent,  and we have the lowest hospital re-admission rate of 15.8 percent with 17.1 percent, and 16.5 percent respectively We  offer specialty clinical programs for patients discharged from the acute facilities post Heart Failure,  joint replacement, CABG, and  COPD exacerbations. Between June 1, 2016  and May 31, 2017 we were recognized for the lowest Diagnostic Related Group (DRG) penalty for hospital re-admissions related to the above diagnosis (Northwell Health and Home, 2018, pp.6-7).

The great Weakness of Northwell Health at Home organization is the nursing staff turnover.

The Opportunities are related to the growing aging population in the catchment area..

The Threats to the organization are the increased government regulations and decreased insurance/government reimbursement.

Interdisciplinary Communications and Collaboration

At Northwell Health the  educators and department managers collaborate closely with the Human Resources department during the process of planning and hiring. Within the CHHA organization, the nurses work together  with the physical therapists and social workers TO create plans of care for each patient. The performance improvement project was designed to decrease the cost of visiting nurses’ turnover, increase their retention, and improve job satisfaction at Northwell at Home CHHA. The enhanced orientation program will make it easier to identify training and competency gaps, empower nurses into accepting assignments based on their competencies, eliminate the chaotic job atmosphere, and correct an imbalanced job -work life (Cuddy, 2015). It is believed that “beyond the financial costs of increased turnover, the disruptions to productivity, team dynamics, and care quality from turnover have been recognized and solidly documented” (Boston-Fleischhauer, 2016, para. 3).

For a Certified Home Health Agency such as Northwell Health at Home, the identification of a strategic plan is essential to ensure that the organization can meet its goals and objectives in providing excellence in patient care at all levels and stay in compliance with the organization  Mission, Vision and Values (MVV) statements (Northwell Health, 2017-2018, p. 7).  Centers for Medicare & Medicaid Services (CMS) outlines the rules for the Medicare and Medicaid Condition of Participation (CoPs) to which the organization must strictly follow. One rule is related to the use of Outcome and Assessment Information Set (OASIS) data collection instrument to standardize patient assessment and transmits the data to CMS, which supports reimbursement for skilled services (Department of Health and Human Services, 2017). The enhanced orientation program for nurses allows a greater emphasis of the extended OASIS hands-on training program.

Achieving optimal quality of care throughout the home health division is essential and requires effective leadership to continuously monitor progress to improve direct care to patients in their homes and in the different stages of transition (Joshi, Ranson, Nash, & Ransom, 2014). It is essential that organizational employees rely upon the expert knowledge of leadership to implement a strategic plan which is flexible and can take on new opportunities as they emerge (Joshi et al., 2014). It is also imperative for the organization to establish a comprehensive workforce strategy to ensure that changes in the healthcare landscape are supported by experts who can manage these needs effectively, particularly as patients transition from one phase of care to the next (Datz, Hallberg, Harris, Harrison, & Samples, 2012).

The Stage of the Organization’s Strategic Plan

Northwell Health at Home, the strategic plan, which is currently under development, requires significant feedback from nurses and therapists. The guidance from a variety of leaders from different divisions ensures that the organization has the educational tools available to keep the best nurses who will serve the patients in an ethically responsible manner while meeting or exceeding financial gain in revenue. Operational assessments can offer feedback regarding any bottlenecks in the process or staffing issues which could have a significant impact on performance outcomes (Jarousse, 2012). From the nursing leadership perspective, the development of a strategic plan requires extensive input from staff nurses regarding their needs and the development of new directives. This is  to ensure that the organization has the staffing and resources available to provide home care for patients in a timely manner (Drenkard, 2012). There must be a greater emphasis on understanding the dynamics of the nursing profession and the overall development of new ideas to facilitate collaboration and to strengthen quality of care for all patients (Drenkard, 2012).

Literature Review

Understanding the dynamics of the home health care system requires an extensive review of existing research to determine the nature of current strategies, areas where successful outcomes have been achieved, and areas where improvements are required. This process is necessary to understand how to best move forward with a strategy at the home health level which is timely, appropriate, and practical for the needs of an organization going forward. Existing literature will offer a means of understanding how home health organizations respond to the needs of nurses to not only improve satisfaction rates but to also improve retention rates in the future, using methods and strategies which may be successful in aiming to promote nurse satisfaction and timely care and treatment for all patients.

One of the most critical aspects of nurse turnover is the type of leadership that exists at the employing organization. One of the key factors to consider is the rate of job satisfaction among caregivers, and if there are limitations in this regard, it can be difficult for organizations to retain nurses and keep them engaged over time (Donoghue & Castle, 2009). The authors indicate that leaders may be one of four types: the consensus manager, who engages the group for feedback and uses this to make decisions; the consultative autocrat, who may obtain feedback but makes all of the decisions independently; the autocrat, who does not seek feedback and makes all decisions; and the shareholder manager, who does not share information with staff members which is important to their roles and makes all decisions without feedback (Donoghue & Castle, 2009). These factors play a significant role in how employees perceive their leaders and their effectiveness and may also play a role in determining if they want to remain with the organization for a longer period (Donoghue & Castle, 2009).

Steinmetz, de Vries, & Tijdens (2014) address the significance of turnover in the healthcare system and how it may be impacted not only by the organization and its climate, but also the wages that are earned. From this perspective, it is also known that “working part-time hours, overtime and a long commuting time decrease the intention to stay with the same employer…job dissatisfaction is a strong predictor for the intention to leave” (Steinmetz et al., 2014). In this context, job retention rates are affected by a variety of different characteristics and require management teams to examine the tools that are available to better support employees so that they are more likely to stay with their employers than to leave after a brief tenure. It is also necessary for organizations to obtain feedback from employees and to acknowledge that they have different needs which must be addressed to improve their likelihood of remaining with the organization longer.

Castle, Degenholtz, & Rosen (2006) examined the significance of job satisfaction in the nursing home environment, obtaining the feedback of 251 caregivers over 2.5 years and every six months. The study results indicate that there are lower levels of satisfaction associated with compensation, the opportunity to obtain a promotion, and management; therefore, it is important to evaluate the different options that are available to improve these areas and to determine how employees can remain in these roles to reduce turnover (Castle et al., 2006). Most importantly, organizations in home health face similar challenges because they require their employees to be active performers and contributors to the organization. However, this cannot be effectively accomplished if they do not have a strong infrastructure in place which will provide home health workers with a variety of options to expand their careers, to increase their wages, and to work under managers who support their cause.

Al-Hussami (2008) addressed the significance of job satisfaction for nurses relative to organizational commitment, education, and type of leadership style in the nursing home environment. It is known that “retention and recruitment of nurses have shown that low wages and poor job satisfaction are the primary reasons why nurses leave their positions. Their dissatisfaction is often attributed to heavy workloads, leadership styles, motivation, inadequate training, and lack of respect” (Al-Hussami, 2008, p. 287). In this context, it is important for nurses to have the tools available to them to be proactive and to acknowledge the importance of meeting expectations, while also aligning with the organization through its support for nurses (Al-Hussami, 2008). In a study of nurses in four nursing homes in the Miami, FL area, it was determined that nurses who possess strong loyalty to their organizations and overall higher job satisfaction are likely to remain with their organizations for longer periods of time; therefore, nurse leadership has a responsibility to pay greater attention to the needs of nurses who work in these organizations and to acknowledge that their level of loyalty to the organization is associated with their level of job satisfaction within their current roles (Al-Hussami et al., 2008). These factors are critical in supporting expanded training and dedication to nurses to ensure that they not only perform effectively in their roles, but also have the resources available to them to be productive and satisfied over the long term (Al-Hussami et al., 2008).

Russell, Rosati, Rosenfeld, & Marren (2011) address the significance of continuity within the home health care industry and how this may contribute to greater outcomes for patients and improved overall health. The development of strategies to address retention rates are critical because they offer employees a reason to remain within their roles and to focus their efforts on patient care that will have a positive impact on patient health (Russell et al., 2011). For home health nurses, getting to know patients and establishing relationships with them is critical for the patient and for the nurse because it offers a means of satisfaction that the patient has continuous care from the same nurse and the nurse can provide care that is consistent and appropriate (Russell et al., 2011). Therefore, it is necessary for organizations to focus their efforts on creating continuity, which will allow nurses to be better engaged and make them more likely to remain in their roles (Russell et al., 2011).

Sims-Gould, Byrne, Craven, Martin-Matthews, & Keefe (2010) address the importance of home health care workers and the factors which contribute to their desire to enter the field and remain with their employers. It is believed that many home health workers are satisfied with these roles and find it rewarding to aid patients in this setting, but the motivation behind entering this workforce is not as well known (Sims-Gould et al., 2010). The development of new opportunities for growth within the home health sector is of critical importance to current employees, and the potential for a career path is also likely to impact new employees in the field; therefore, motivations may include skill development, autonomy, making a difference in the lives of patients, job security, and workplace regulations (Sims-Gould et al., 2010). Home health workers can be further motivated by their efforts to contribute at a high level, but they require comprehensive training and knowledge to accomplish these goals within the profession to support a greater likelihood of remaining with their organizations over the long term (Sims-Gould et al., 2010).

Action Plan for Change – Overview

The development of an enhanced orientation program for Northwell Health at Home is an important step towards improving retention rates and reducing staff turnover. It  provides employees with a greater understanding of their roles and responsibilities at the organization. The enhanced, adjusted to the  individual’s needs training should help to recognize how  the employees can contribute to the organization at a high level This will also determine if the employees are a good fit for the organization in achieving the company’s goals and objectives.

The  expansion of the currently offered orientation program for nurses is an essential factor in improving their retention rates. The primary aim of this initiative is to provide nurses with a comprehensive educational program which includes extensive training to conduct routine home health visits, along with the development of other tools which will be effective in employee engagement from the beginning of their employment. The issue driving the development was to design a strategic plan that would address increased government regulations and decreased insurance/government reimbursement. Without addressing this issue, the role of the home care nurse becomes increasingly difficult additionally resulting in poor retention.

The new nurse has difficulty with problem solving and critical thinking because she/he is  preoccupied and overwhelmed with juggling all the aspects of home care at once. At the beginning, the nurse is uncertain of her role that there is little time or energy to take the broader view or to think in an objective, critical way to assist in problem solving. The new nurse spends a lot of time concentrating on remembering and following the rules and have difficulty prioritizing.

Action Plan for Change – Milestones

The proposed enhanced orientation program will run for 6 weeks which triples its current time span. The first two tweeks that consists of the Classroom IT Integrated Orientation will be spent with the educator who introduces  new to home care nurses to the theory, government  regulations, and objectives of  home care. Educator will lead orientee through the learning process to acquire knowledge regarding logistics in order to feel certain what to tell and recommend to the patient. Nurses will learn about Joint Commission Standards, NYS Department of Health and  Federal regulations, incident and complaint reporting, as well as how to locate all Network policies, and procedures. They will become familiar with recognizing the types of home care agencies, who pays for home care services, and the Prospective Payment System (Centers for Medicare and Medicaid Services (CMS), 2017). They will learn how to differentiate the Primary MD who will sign the home care orders for the specific patient’s needs of the home care episodes, how to construct a home care patient plan of care including all orders and CMS- 485 (Department of Health and Human Services Centers for Medicare and Medicaid Services, 2002), and agency rules for conducting medication reconciliation process. The first orientation’s milestone addresses stage one of  Neil Theory – Dependence.

The practical application of Moderate Dependence – stage 2 of Neil Theory will take place during the following  three to four weeks when each orientee  will spend time with the preceptor in the field to gradually put the learned in the classroom skills into practice. After the first two days when the nurse shadows the preceptor,  the rest of the in-field orientation period will be dedicating to improve the hands-on clinical skills under the preceptor’s guidance to  gain the confidence which gradually will led to increasing from 1 to 3  the Start of Care (SOC) per week visits and daily revisits from 3 to 6.  After at least of 2 weeks into field visits, the orientees will gain the experience in utilizing the OASIS assessments (Department of Health and Human Services Centers for Medicare and Medicaid Services, 2017), illustrate competency in infection control, wound care, , multidisciplinary communication, and coordination of care throughout the implementation of TeamSTEPPS (Agency for Healthcare Research and Quality (AHRQ), n.d.). Furthermore, the nurses will demonstrate the correct usage of laptop and its applications with a virtual  back- up of the IT technicians, adherence to HIPAA guidelines and agency policy, and  practice in the home health attendant (HHA) training and supervision. The preceptor will observe the nurse’s progress by documenting the indications of movement from stage 1 to stage 2 which are demonstrated by the nurse being able   to:

• Do a procedure she/he didn’t think they go do before
• Be less fearful
• Get to know geographical areas
• Develop confidence in assessing patients/meeting needs
• Improve time management skills
• Become more confident in decision making and more assertive
• Pick up things previously missed
• Adapt and learn to prioritize
• Define their role and begin understanding of other’s role
• Learn to self-evaluate and become calmer

The progress will also be measured by a descriptive self-report survey to elicit data from the nurse orientee for the preceptor to decide whether the role of a nurse was truly adopted from dependence/moderate dependence to stage 3 – Autonomy.  According to Neil Theory the role and process may temporarily change by moving the autonomous nurse back to dependence/moderate dependence stage to fully complete the process of adaptation by allowing and promoting fluid-allowing adjustment that suits each nurse at her/his paste of learning and adaptation.

An organization must recognize that the employees need the reasons to find the company attractive. This increases their likehood of remaining with the organization for longer periods of time. It is anticipated that a detailed orientation effort will allow employees to better understand how they fit with the organization and will recognize that they can play a role in improving patient health. These efforts will demonstrate the importance of engaging employees at the onset of their employment and enabling them to provide feedback as necessary during orientation and beyond so that they are taken seriously and can be effective in their roles.

Conclusion

The need for change is required because retention rates within the home health industry are difficult to maintain due to the demands of nurses who fill these positions and how they respond in their roles. Most importantly, it is necessary to retain employees who perform well and  make a valuable contribution to an organization at a high level. This is the essential component of the home health care industry and requires employees who are satisfied with their roles and who can commit to the organization over the long term.  However, accomplishing this task without providing employees with a positive work environment is very difficult and makes a significant difference in how employees perform. The culture of the organization is significant in this process and must demonstrate that employees are valued and have support  to meet their needs effectively. The development of a comprehensive orientation program is necessary because the organization should provide nurses with the resources required to perform their roles efficiently to achieve satisfaction within these roles. It is anticipated that when the organization supports a positive and meaningful approach to training and education for home health nurses, they will feel valued and will likely be more engaged in their roles.

The development of an orientation program for nurses at Northwell Health at Home requires an extensive understanding of Neal Theory and how it aligns with current organizational needs to promote greater effectiveness within the home health sector. Most importantly, this theory supports the training of home health nurses and provides them with a comprehensive set of tools and resources that will have a positive and lasting impact on their performance as they move forward in their careers. Nurses are likely to effectively respond to their organizations and take their roles seriously when they have the framework in place and a direction for which the organization is headed in the future. The availability of different tools and resources to support nurses is instrumental to support nurses’ alignment with the goals and objectives of the organization; furthermore, it provides them with an opportunity to function effectively in their roles and to be productive in this capacity (Neal, 1999).

Neal Theory (1999) supports the need for home health nurses to identify with their roles through a stage of dependence, whereby they begin to acclimate to these roles and to acknowledge their place in the organization. This requires a high degree of adaptation to the home health setting, which is very different from the traditional hospital or clinic environment and requires adjustments regarding how to administer procedures and tests, along with managing paperwork and other needs. During moderate dependence, nurses have acclimated to their roles more effectively and have the resources available to be productive in the home health environment; furthermore, they can support their patients because they are more comfortable with the home health environment and understand how to move forward in an effective manner Finally, nurses develop autonomy and can contribute at a higher level to the organization, taking the lessons that they have learned and adapting them to their roles. This process supports their growth as home health nurses and demonstrates their level of comfort, their assertiveness in this capacity, and their ability to utilize critical thinking skills to meet the needs of their patients (Neal, 1999).

References

The American Organization of Nurse Executives (2015). Nurse executive competencies:

Post-acute care.

Boston-Fleischhauer, C. (2016, July 27). How nursing leaders are changing the C-suite: A Q&A

with Advisory Board’s new CNO. Advisory Board.

Castle, N. G., Degenholtz, H., & Rosen, J. (2006). Determinants of staff job satisfaction of caregivers in two nursing homes in Pennsylvania. BMC Health Services Research, 6(1), 60.

Cuddy, J. B. (2015). Development of an evidence-based nursing orientation Program for a

community health system. Walden University. Walden Dissertation and Doctoral Studies, 1-80.

Donoghue, C., & Castle, N. G. (2009). Leadership styles of nursing home administrators and their association with staff turnover. The Gerontologist, 49(2), 166-174.

Ellenbecker, C. H., Samia, L., Cushman, M. J., & Alster, K. (2008). Patient safety and quality:

An evidence-based handbook for nurses. Patient safety and quality in home health care. Bethesda, MD: National Center for Biotechnology Information, U.S. National Library of Medicine.

Joshi, M.S., Ranson, E.R., Nash, D.B., and Ransom, S.B. (2014).  Healthcare quality book.

Top of FormHealth Administration Press. Chicago, IL.

Mahmoud, A. H. (2008). A study of nurses’ job satisfaction: the relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. European journal of scientific research, 22(2), 286-295.

Medicare and Medicaid program: Conditions of participation for home health. (2017). Retrieved

from https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-00283.pdf

Medicare program integrity manual. Transmittal 23. (2002).

Neal, L. J. (1999, March). The Neal theory: implications for practice and administration. Home

Health Nurse, 17(3)(3), 181-187.

Porter-O’Grady, T., and Malloch, K. (2016).  Leadership in nursing practice; Changing the

landscape of healthcare (2nd ed). Jones & Bartlett Learning.Top of Form

Prospective payment systems – General information . (2017).

Romagnoli, K. M., Handler, S. M., & Hochheiser, H. (2013). Home care: more than just a

visiting nurse. BMJ Quality and Safety, 22(12), 972-974.

Bottom of ForTop of FRundio, A., Wilson, V., Meloy, F. (2016). Nurse executive review & resource manual.              American Nurses Credentialing Center. Silver Spring, MD.

Russell, D., Rosati, R. J., Rosenfeld, P., & Marren, J. M. (2011). Continuity in home health care:

is consistency in nursing personnel associated with better patient outcomes? Journal for healthcare quality, 33(6), 33-39.

Sims-Gould, J., Byrne, K., Craven, C., Martin-Matthews, A., & Keefe, J. (2010). Why I became

a home support worker: recruitment in the home health sector. Home Health Care Services Quarterly, 29(4), 171-194.

Steinmetz, S., de Vries, D. H., & Tijdens, K. G. (2014). Should I stay or should I go? The impact

of working time and wages on retention in the health workforce. Human resources for health, 12(1), 23.

Team STEPPS. (n.d.). Retrieved from https://www.ahrq.gov/teamstepps/index.html

Existentialism as Expressed by Kieslowski

Existentialism is a philosophical approach that originates from the nineteenth century Europe. The approach is in line with principles of atheism as it emphasizes that although individuals cannot determine their existence, they still have the free will to determine their essence once they are in existence. Considering the basic principles and the principles that informed this philosophical approach, this approach was a subject of great controversy in the nineteenth and twentieth-century Europe. People wrote philosophical discourses and made various works of art either in agreement or resistance to the basics of existentialism. Towards the end of the twentieth century, Krzysztof Kieslowski joined the debate when he directed the first part of a series of three films he famously dubbed ‘three colors.’ Apart from the fact that Kieslowski’s film invokes the principles of existentialism, the title of the film is, in itself, philosophical. Kieslowski alludes to the three colors of the French flag in his production; however, this allusion regards non-political views to the meanings of those. Blue, in the French flag, stands for liberty. Thus, personal freedom and liberty were key themes in the first film of the series. The plot of the film ‘three colors: blue’ surrounds the life of a widow, Julie. Julie’s husband and daughter died in an automobile accident to leave her in great anguish and emotional distress. Having been hospitalized after she survived the accident, Julie attempts suicide while in hospital. In dealing with her anguish and emotional distress, Julie attempts to detach herself from everything and anyone that reminds her of her husband by saying goodbye to her husband’s collaborator, emptying their house, putting the house up for sale, and escaping to a location where no one knows her. Her desire to seclude herself, however, fails as a boy innocently seeks to hand her across he picked at the accident site and to repeat her husband’s last words to her. She also reluctantly befriends a Lucille, an exotic dancer, who has an affair with her neighbor.  Through television, she learns that Olivier, her late husband’s collaborator, intends to complete one of her late husband’s works and that he had an affair; she is interested in knowing about her husband’s mistress. She tracks down Patrice’s mistress, Sandrine, and learns that the latter is pregnant for Patrice, her husband. She then arranges for Sandrine to have their house and agrees to collaborate with Olivier. Krzysztof Kieslowski’s ‘the three colors blue’ is a reflection of key existential themes in society such as freedom, loss, morality, and death.

Kieslowski’s production focuses on loneliness and the need for individuals to embrace fraternity, equality, and liberty in his attempt to address existentialism. In the film, Julie sought loneliness; however, the loneliness later turned out sour. Julie finds in her heart a place and a reason to identify herself with Sandrine and even see her as her equal by agreeing to hand her the house that her husband left for her. The concepts that Kieslowski attempts to bring out in these instances are consistent with Husserl’s historical a priori and his view of philosophy as a shaper of society. Historical a priori refers the order that underlies a given culture in a certain historical period (Crowell 65). Edmund Husserl, a German philosopher of the nineteenth and twentieth centuries, used a historical a priori to come up with the philosophy of existential phenomenology (Crowell 64). This philosophy argues that the essence of an existing object depends on the perceptions of the individual viewing it. In the same wake, the essence of Sandrine to Julie is influenced by her perception of her husband’s mistress; Julie does not perceive Sandrine as a competitor but as the mother of her lover’s baby. Although Julie has the liberty, as the rightful wife of Patrice, to mistreat Sandrine, she still finds in her heart the fairness to treat Sandrine as an equal and hand her part of Patrice’s fortune. Julie thinks beyond herself just as Husserl saw mathematics as more than just a series of numbers; Patrice mistreated both Sandrine and her, and as the mother of Patrice’s baby, Sandrine deserves part of Patrice’s fortune (Crowell 76).

‘The three colors: blue’ also expounds on the applicability of the key concepts of existentialism as expressed in the philosophy of Sartre in human society and on human behavior. Sartre’s philosophy of existentialism attempts to explain the absurdity and the meaningless of life; death is the biggest absurdity of life (Hayim 29). Kieslowski’s production focuses on this absurdity of death perfectly. The death of her husband and daughter seems to erase everything that Julie ever worked for. She, thus, looks to destroy all that they were continuing to work on and attempts to dissociate herself from all that they had worked for. Julie failing in an attempted suicide reveals another angle of the absurdity of death; death often strikes unsuspecting individuals who would do everything to avoid it and at times spares the ones who need it or deserve it most. Further, the fact that Julie resorts to tracking her late husband’s mistress and treating her well is perfect evidence of the meaninglessness of life and love relationships. Moreover, as Sartre argues, a person’s existence precedes their essence, and an individual’s will is the bridge between their existence and essence. For instance, Olivier existed before Patrice’s death; however, his essence changed after Patrice’s death. Olivier’s actions of continuing Patrice’s activities and agreeing to collaborate with Julie change his essence to Julie; he changes from her husband’s collaborator to her partner. Also, Julie’s actions are in line with Sartre’s proposition that an individual’s existence, freedom of choice, and responsibility underlie their essence (Hayim 36). Julie becomes a savior to Sandrine when she willingly decides to be responsible enough to hand Sandrine the house that she and Patrice had lived in. Additionally, in line with Sartre’s propositions, Julie decides to free herself and be the noble person who uses her freedom to better her life and that of others. Initially, she lacks the courage to face her current situation hence she suffers Sartre’s nausea (Hayim 51). However, she later decides to use her will to engage and help Sandrine. This leads to another of Sartre’s propositions – one’s responsibility to themselves and others. The boy who picked a cross at the accident scene feels that he owes responsibility to Julie and pursued his heart. His actions are pivotal in changing Julie’s perception of life. Julie later feels that she, as Patrice’s next of kin, owes responsibility to his unborn child hence her decision to assist Sandrine. Also, Julie’s actions prove the importance of commitment as Julie decides to stop her indifference to her surroundings. On interpersonal relations, Sartre describes other people as a torture to one (Hayim 46). In Kieslowski’s production, Julie recognizes the torture and anguish that the people who remind her of her former life cause her; she, thus, decides to defend herself by avoidance hence her attempt to seclude herself.

From Julie’s story, it is evident that if one employs existentialism as a means of sparking leadership in society, they can be able to find solutions to key problems that face man. As Lawler notes, Sartre’s existentialism means that one has the free will to make decisions (217). If one can combine these free will with the commitment to their responsibility to themselves and others, then they will have the motivation to do and lead others in doing things that are beneficial to themselves and the rest of the world (216). This view is highly relevant to Kieslowski’s production. In ‘the three colors: blue,’ Julie acts a leader. Julie outgrows the characters that Sartre compares to stones and plants and decides to be like the man who Sartre admires – a man who uses their liberty and free will to better their lives and those of others (Hayim 66). Julie understands her immense responsibility as the completer of her husband’s works; she appreciates that her husband’s works include those that she was unaware of. Once she understood these responsibilities, she became committed to the course of fulfilling them. She becomes the leader that seeks out Olivier and Sandrine with an intention of utilizing their situations to add value to her life and their lives. She agrees to partner Olivier in completing some of her late husband’s pieces and to support Sandrine by handing her their house. By doing these, Julie solves major problems that face herself, Olivier, and Sandrine; she is lonely, Olivier lacks a partner, and Sandrine is faced with a crisis – she is about to deliver an illegitimate child of a deceased man. Kieslowski, therefore, uses a real-life example to show that indeed using existentialism to spark leadership can be central to solving major problems that face humanity.

The discussion above confirms that Krzysztof Kieslowski’s ‘the three colors: blue’ is indeed a reflection of key existential themes in society such as freedom, loss, morality, and death. The film emphasizes the free will of all men to choose what is right and wrong. In line with Sartre’s existentialism and Husserl’s existential phenomenology, Julie rediscovers her freedom and uses it to pursue morality by perceiving Sandrine not as an enemy but as the expectant mother of Patrice’s child. With her will to pursue morality, Julie becomes committed to its course. As Lawler explains the relationship between Sartre’s philosophy and leadership, a will to do good and commitment to this course are what makes good leaders (218). Additionally, Kieslowski’s piece is built on the existential perceptions of death as Sartre brings it out in his philosophy. Death is indeed an absurd actor who strikes without warning and leaves detrimental effects.

Works Cited

Crowell, Steven. “Husserl’s existentialism: ideality, traditions, and the historical apriori.” Continental Philosophy Review, Vol. 49, No.1, 2016, pp. 67-83. Springer

Hayim, Gila J. Existentialism & Sociology: The Contribution of Jean-Paul Sartre. New Brunswick, U.S.A: Transaction Publishers, 1996.

Lawler, John. “The essence of leadership? Existentialism and leadership.” Leadership, Vol. 1, No. 2, 2005, pp. 215-231. Sage Journals

Three Colours: Blue. Directed by Krzysztof Kieślowski, 1993.