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It may be helpful to think of analysis of theory as neces- sary for adequate study of a nursing theory and evaluation of theory as the assessment of a theory’s Analysis and Evaluation utility for particular purposes cheap 40mg prednisone overnight delivery. Guides for theory of Nursing Theory evaluation are intended as tools to inform us about theories and to encourage further development buy prednisone 20mg on-line, re- It is important to understand definitions of nursing finement cheap prednisone 5 mg online, and use of theory discount 20 mg prednisone mastercard. There are no guides for theory (as described in Chapter 1) before moving theory analysis and evaluation that are adequate to theory analysis and evaluation 40 mg prednisone for sale. These have tions is adequate for study of any nursing theory, continued in use over time and offer direction for choose the definition that seems to best fit with guides in use today. For ex- ory should: ample, one of the definitions by Chinn and Jacobs (1987) or Chinn and Kramer (2004) may be chosen • define the congruence of nursing practice with for using theory in research. The definition by Silva societal expectations of nursing decisions and (1997) may be more appropriate for study of nurs- actions; ing theory for use in practice. Another way to think • clarify the social significance of nursing, or the about this is to consider whether the definition of impact of nursing on persons receiving nursing; nursing theory in use fits the theory being analyzed and and evaluated. Look carefully at the theory, read the • describe social utility, or usefulness of the theory theory as presented by the theorist, and read what in practice, research, and education. The whole The following are outlines of the most fre- quently used guides for analysis and evaluation. Parts about nursing theory of the individual nursing of the theory without the whole will not scholar and offer various interesting approaches to be fully meaningful and may lead to mis- the study of nursing theory. The guidelines set forth questions that tion of these elements may take place, as summa- clarify the facts about aspects of theory: purpose, rized here: concepts, definitions, relationships, structure, as- sumptions, and scope. These authors suggest that • Relations between structure and function of the the next step in the evaluation process is critical re- theory, including clarity, consistency, and sim- flection about whether and how the nursing theory plicity works. Questions are posed to guide this reflection: • Diagram of theory to further understand the theory by creating a visual representation • Is the theory clearly stated? Questions for analysis in this frame- work flow from the structural hierarchy of nursing knowledge proposed by Fawcett and defined in Chapter 1. The questions for evaluation guide ex- amination of theory content and use for practical Nursing theory, knowledge development purposes. Following is a summary of the Fawcett through research, and nursing practice are (2000) framework. In order to en- For theory analysis, consideration is given to: hance both nursing practice and nursing the- ory, it is incumbent upon the practicing nurse • scope of the theory to study theory, just as it is upon the theorist • metaparadigm concepts and propositions in- to study the practice of nursing. Considering cluded in the theory a commitment to study nursing theory raises • values and beliefs reflected in the theory many questions from nurses about to un- • relation of the theory to a conceptual model and dertake this important work. This chapter to related disciplines presented some of the questions worth con- • concepts and propositions of the theory sidering before undertaking extensive study For theory evaluation, consideration is given to: and deciding on a theory to guide practice. Analysis and evaluation of nursing theory • significance of the theory and relations with are the main ways of studying nursing structure of knowledge theory. Literature presents a number of dif- • consistency and clarity of concepts, expressed in ferent guides to analyzing and evaluating congruent, concise language theory. Aesthetic Meleis (1997) states that the structural and knowing grounded in an explicit conception of nursing. Fundamental patterns of knowing in nurs- are assumptions, concepts, and propositions of the ing. Integrated knowledge de- nurse-client interactions, environment, and nurs- velopment in nursing (6th ed. The structure of nursing knowledge: Analysis care through self-awareness and reflection (pp. Parker Study of Theory for Nursing Practice A Guide for Study of Nursing Theory for Use in Practice Study of Theory for Nursing Administration Summary References Nurses, individually and in groups, are affected Theories and practices from related disciplines by rapid and dramatic change throughout health are brought to nursing to use for nursing purposes. Nurses practice in increas- The scope of nursing practice is continually being ingly diverse settings and often develop organized nursing practices through which accessible health The scope of nursing practice is continu- care to communities can be provided. Community ally being expanded to include additional members may be active participants in selecting, knowledge and skills from related designing, and evaluating the nursing they receive. This guide was tice in hospitals, an increasing number of nurses developed for use by practicing nurses and students practice elsewhere in the community, taking the in undergraduate and graduate nursing education venue of their practice closer to those served by programs. The guide may be used to to provide nursing often realize that they share the study most of the nursing theories developed at all same values and beliefs about nursing. It has been used to create surveys of nursing nursing theories can clarify the purposes of nursing theories.

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Roth (1979) asked patients what they thought peptic ulcers were caused by and found a variety of responses buy 10mg prednisone mastercard, such as problems with teeth and gums buy discount prednisone 40 mg on line, food 5mg prednisone for sale, digestive problems or excessive stomach acid prednisone 10mg visa. Roth also reported that 30 per cent of patients believed that hypertension could be cured by treatment generic prednisone 5mg with amex. If the doctor gives advice to the patient or suggests that they follow a particular treatment programme and the patient does not understand the causes of their illness, the correct location of the relevant organ or the processes involved in the treatment, then this lack of understanding is likely to affect their compliance with this advice. This study examined the effect of an expert, directive consulting style and a sharing patient-centred consulting style on patient satisfaction. This means that it is possible to compare the effects of the two types of consulting style without the problem of identifying individual differences (these are controlled for by the design) and without the problem of an artificial experi- ment (the study took place in a natural environment). Theoretically, the study examines the prediction that the educational model of doctor–patient communication is problem- atic (i. Background A traditional model of doctor–patient communication regards the doctor as an expert who communicates their ‘knowledge’ to the naïve patient. Within this framework, the doctor is regarded as an authority figure who instructs and directs the patient. However, recent research has suggested that the communication process may be improved if a sharing, patient-centred consulting style is adopted. This approach emphasizes an inter- action between the doctor and the patient and suggests this style may result in greater patient commitment to any advice given, potentially higher levels of compliance and greater patient satisfaction. Savage and Armstrong (1990) aimed to examine patients’ responses to receiving either a ‘directive/doctor-centred consulting style’ or a ‘sharing/ patient-centred consulting style’. Methodology Subjects The study was undertaken in a group practice in an inner city area of London. Overall, 359 patient were invited to take part in the study and a total of 200 patients completed all assessments and were included in the data analysis. Design The study involved a randomized controlled design with two conditions: (1) sharing consulting style and (2) directive consulting style. Procedure A set of cards was designed to randomly allocate each patient to a condi- tion. When a patient entered the consulting room they were greeted and asked to describe their problem. For example, the doctor’s judgment on the consultation could have been either, ‘This is a serious problem/I don’t think this is a serious problem’ (a directive style) or, ‘Why do you think this has happened? For the treatment advice the doctor could say either, ‘It is essential that you take this medicine’ (a directive style) or, ‘What were you hoping I would be able to do? Each consultation was recorded and assessed by an independent assessor to check that the consulting style used was in accordance with that selected. Measures All subjects were asked to complete a questionnaire immediately after each consultation and one week later. This contained questions about the patient’s satisfaction with the consultation in terms of the following factors: s The doctor’s understanding of the problem. This was measured by items such as ‘I perceived the general practitioner to have a complete understanding’. This was measured by the statements ‘I felt greatly helped’ and ‘I felt much better’. Results The results were analysed to evaluate differences in aspects of patient satisfaction between those patients who had received a directive versus a sharing consulting style. In addition, this difference was also examined in relation to patient characteristics (whether the patient had a physical problem, whether they received a prescription, had any tests and were infrequent attenders). When the results were analysed to examine the role of patient characteristics on satisfaction, the results indicated that the directive style produced higher levels of satisfaction in those patients who rarely attended the surgery, had a physical problem, did not receive tests and received a prescription. Conclusion The results suggest that a directive consulting style was associated with higher levels of patient satisfaction than a sharing consulting style. This provides support for the educational model of doctor–patient communication with the doctor as the ‘expert’ and the patient as the ‘layperson’. In addition, it suggests that patients in the present study preferred an authority figure who offered a formal diagnosis rather than a sharing doctor who asked for the patient’s views.

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Those who take laxatives for a long time may need to go off them slowly to allow the bowels to return to normal function buy prednisone 20 mg lowest price. Eat whole-grain breads and cereals (made with wheat bran cheap 10mg prednisone amex, whole oats buy generic prednisone 40mg, rye generic prednisone 10 mg overnight delivery, and flaxseed) buy prednisone 10mg with mastercard, fresh fruits (especially strawberries, apples, and rhubarb), dried fruits, vegetables, and legumes. Foods to avoid: • Refined and processed foods are high in sugar and contain little fibre. In one study, two-thirds of the infants had constipation that was relieved when cow’s milk was removed from their diet. Lifestyle Suggestions C • Increase physical activity, as exercise helps stimulate intestinal and bowel contractions. The longer you delay going to the toilet once you feel the urge, the more water that is absorbed from the stool and the harder it becomes. Top Recommended Supplements Fibre supplements: Products containing psyllium husks, flaxseed, oat bran, guar gum, glucommannan, and fenugreek are effective and can be taken regularly. Start with a small amount (one tablespoonful daily) and gradually increase to allow your bowels to adjust. Probiotics: Supplements containing these “friendly bacteria” help to restore the normal gut flora and have been shown in studies to relieve constipation. Complementary Supplements Aloe vera juice: Aids bowel movements by working as a stimulant and improving intestinal contractions. Magnesium: Aids intestinal function and helps stool retain water; may be deficient in those with constipation. These diseases affect the digestive system and cause the intestinal tissue to become inflamed, develop sores, and bleed. These diseases can be painful and debilitating and may lead to life-threatening complications, especially if untreated. Crohn’s disease and ulcerative colitis are very similar in that they both inflame the lining of your digestive tract and can cause severe bouts of watery or bloody C diarrhea and abdominal pain. Where they differ is that Crohn’s disease can occur anywhere in your digestive tract, often spreading deep into the layers of affected tis- sues whereas ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. Symptoms may come and go and those affected may also experience long periods of remission. Stress can aggravate symptoms, and was once considered to be the underlying cause, but that is no longer the case. Many practitioners, especially those with knowledge of nutrition and preventative medicine, feel that diet may be responsible for triggering these diseases. Both diseases are rare in developing countries and among cultures that eat whole, unprocessed foods. As well, it wasn’t until the mid-1900s that these diseases became a problem in North America. Consumption of fast foods and processed and refined foods and ingestion of chemical food additives is common. It is also possible that the inflammation may stem from the immune system’s response to infection with a virus or bacterium. Since the diseases are more common among those with a family history, genetic mutations may also be to blame. While there is no known medical cure for Crohn’s disease or colitis, there are a variety of lifestyle approaches, supplements, and medications that can reduce the symptoms and even bring about long-term remission. Some people with these diseases experience inflammation in other areas of the body (joints, skin, and eyes). Depending on your situation and the severity of the symptoms and intestinal damage, your doctor may prescribe drug therapy to control the inflammation. Commonly used drugs include sulfasalazine, mesalamine (Asacol), and corticosteroids, such as prednisone. As well, these drugs have serious side effects, so it is important to discuss the benefits and risks with your doctor. Iron supplements are used for anemia, which occurs from chronic intestinal bleeding. For severe cases, surgery to remove the diseased portions of the bowel may be necessary, but this is always the last resort. One study of people with colitis found that 100 mL of aloe vera juice twice daily resulted in a complete remission or an improvement in symptoms in 47 percent of cases, compared with 14 percent of those given a placebo. Herbal teas made from chamomile, slippery elm, and marshmallow can be very soothing to an inflamed gastrointestinal tract. The best sources of these fatty acids are salmon, herring, mackerel, albacore tuna, and sardines.

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The death must have occurred during restraint cheap 5 mg prednisone with mastercard, and the individual must have col- lapsed suddenly and without warning discount 5mg prednisone with mastercard. A full external and internal postmortem examination must have been performed by a forensic pathologist order prednisone 40 mg line, which did not reveal macroscopic evidence of signifi- cant natural disease order prednisone 5 mg line, and subsequently a full histological examination of the tis- sues must have been performed order prednisone 40 mg fast delivery, which did not reveal microscopic evidence of significant natural disease. There must be no evidence of significant trauma or of the triad of asphyxial signs. A full toxicological screen must have been performed that did not reveal evi- dence of drugs or alcohol that, alone or in combination, could have caused death. The small numbers of these deaths in any single country or worldwide makes their analysis difficult; indeed, to search for a single answer that will explain all of these deaths may be futile. The bringing together of these deaths 348 Shepherd under a single classification would make the identification of cases and their analysis easier. The problem for the police is that when approaching and restraining an individual, they cannot know the background or the medical history nor can they have any idea of the particular (or peculiar) physiological responses of that individual. The techniques that are designed for restraint and the care of the individual after restraint must allow for safe restraint of the most vulner- able sections of the community. New research into the effects of restraint may possibly lead to a greater understanding of the deleterious effects of restraint and the development of safer restraint techniques. Although this experimental work is being performed, the only particular advice that can be offered to police officers is that the prone position should be maintained for the minimum amount of time only, no pressure should be applied to the back or the chest of a person restrained on the floor, and the individual should be placed in a kneeling, sitting, or stand- ing position to allow for normal respiration as soon as practical. It should be noted that an individual who is suffering from early or late asphyxiation may well struggle more in an attempt to breathe, and, during a restraint, this increased level of struggling may be perceived by police offic- ers as a renewed attempt to escape, resulting in further restriction of move- ment and subsequent exacerbation of the asphyxial process. Officers must be taught that once restrained, these further episodes of struggling may signify imminent asphyxiation and not continued attempts to escape, that they may represent a struggle to survive, and that the police must be aware of this and respond with that in mind. Since these matters were first brought to forensic and then public atten- tion and training and advice to police officers concerning the potential dan- gers of face down or prone restraints, especially if associated with any pressure to the chest or back improved, there has been a decrease in the number of deaths during restraint. However, even one death in these circumstances is too many, and it is hoped that by medical research, improved police training, and increased awareness of the dangers of restraint that these tragic deaths can be prevented. Positional asphyxiation in adults: a series of 30 cases from the Dade and Broward County, Florida, medical examiners offices from 1982 to 1990. Effects of positional restraint on oxygen saturation and heart rate following exercise. The effect of simulated restraint in the prone position on cardiorespiratory function following exercise in humans. The effect of breath holding on arterial oxygen saturation following exercise in man. All these fac- tors can be affected by drugs and alcohol, greatly increasing the risk of acci- dents. Many medical conditions (and their treatments) may impair fitness to drive and are considered first. In many jurisdictions, including Canada, Australia, and the United Kingdom, it is the motorist’s responsibility to inform the licensing authority of any relevant medical conditions. Similar requirements generally apply in the United States, except that six states (California, Delaware, Nevada, New Jersey, Oregon, and Penn- sylvania) require physicians to report patients with seizures (and other condi- tions that may alter levels of consciousness) to the department of motor vehicles (1). Drivers have a legal responsibility to inform the licensing authority of any injury or medical condition that affects their driving ability, and physicians should take great pains to explain this obligation. Occasionally, especially when dealing with patients suffering from dementia, ethical responsibilities may require doctors to breach confidentiality and notify patients against their will or without their knowledge (2); this situation is discussed in Subheading 2. When in doubt about the appropriate course of action, physicians should consult the appropriate guidelines. In Australia, the Austroads Guidelines for Assessing Fitness to Drive provides similar information (4). In the European Union, where Euro- pean Community directives have developed basic standards but allow dif- ferent countries to impose more stringent requirements, there is still variation from country to country. The situation is even more complicated in the United States, where each state sets its own rules and where federal regulations for commercial vehicles apply as well. Often, much of the required regulatory information can be acquired via the Internet or from organizations and foun- dations representing patients who have the particular disease in question. It should be assumed that all adults drive; drivers with disabilities should be given special consideration and may require modification of their vehicle or have certain personal restrictions applied. Cardiovascular Diseases Several studies have demonstrated that natural deaths at the wheel are fairly uncommon and that the risk for other persons is not significant (5,6). Even so, requirements for commercial drivers are generally much more rigid than for individuals, and in the United States, the Federal Highway Adminis- tration prohibits drivers with angina or recent infarction from driving.

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Because a doc- tor possesses expertise does not necessarily make him or her an expert witness every time a report is requested cheap prednisone 10mg with mastercard. A report may be required for a variety of reasons order 40mg prednisone, and its nature and content must be directed to the purpose for which it is sought discount prednisone 5 mg with mastercard. Is it a report of the history and findings on previous examination because there is now a crimi- nal prosecution or civil claim? Is it a request to examine the patient and to prepare a report on present condition and prognosis? Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim? The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity prednisone 10 mg line. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report cheap prednisone 40mg with mastercard. If necessary, the appropriate consents should be obtained and issues of confidentiality addressed. A medicolegal re- port may affect an individual’s liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed.

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