Self-management of patients with continuing care needs

Self-management of patients with continuing care needs In essence, patient self-management in relation to their health, encompasses a patients ability to handle an illness experience, to cope with undergoing treatment or make suitable lifestyle changes (Mulligan 2009). The concept was introduced to the health field by Kate Lorig who reached conclusions patients health and subsequently health service costs connected to them being an inpatient can be reduced by encouraging self-management (Lorig 2001). These ideas are utilized in the generic long-term conditions model which emphasizes patients are not happy to be in hospital unless it is completely essential (DOH 2010), (Appendix 1). Effective self-management is also widely thought to reduce the likelihood of hospital admission, and many argue patients prefer to be given access to the information necessary to facilitate a respected voice in decision making processes (Gibson et al 2004, Newman et al 2004). Linked to self-management is also the concept of self care described as a requirement for success in controlling many chronic illnesses including diabetes (Berg 2007), and asthma (Cortes 2004). Self care is also described holistically as essential to the well-being of those with chronic illnesses with continuing care needs in nursing homes (Bickerstaff et al 2003), in the community, (Sharkey 2005), in hospital, intermediate, or rehabilitative settings (Singleton 2000, Coleman 2004). Conversely, low self-esteem, low health literacy, and/or deprivation are barriers to utilization of self-management strategies (Williams et al 2011). Those most likely to participate in self-management are young, middle-class females (Coben 2005). Whilst those lacking literacy skills may not manage as well and family care-giving actions differ between ethnic and socio-economic groups (Larsen 2009). People who suffer a disproportionally high prevalence rate for chronic conditions are those with learning disabilities (Presho 2009) and ability to comprehend and enact management regimes might affect the efficacy of education initiatives with this population. The Expert Patient Program, a 6 week, lay-led course teaching self-care, is a prominent initiative expected to be more cost effective than usual care (NSF 2010, Richardson 2007). Although the EPPs effectiveness to enable improvements in patients self management ability regarding physical symptoms has been disputed (Gately 2007). Perhaps this is due to complex combinations of assorted medications, lifestyle adaptations, and bothersome side effects which are implicated as adversely affecting patients perseverance with management plans (Barlow 2002, Touchette 2008). GP business care plans developed in the UK propose introducing courses using self-management handbooks could reduce expenditure on asthma management (Appendix 4). Yet Cortes argues such asthma education programs neglect specific needs of older people identified as price of medication, problems undertaking management plans, poor quality of life, and troubles accessing health care (Cortes 2004). These opinions contradict the development of Lorigs ideas that self-management enables the best quality of life, but since healthcare information has the greatest effects on outcomes when it is goal orientated (Bodenheimer 2002, Barlow 2002, Kralik et al 2004), maybe older peoples self management goals need more attention. Concurrent with increased longevity and lifestyle factors like poor diet, obesity and related chronic disease is predicted to increase greatly in prevalence (Wang 2010, Mulligan 2009, Armstrong 2005, and Keen 2010). Diabetes has well recognized links between weight and illness progression (Patel 2003), and has also recently been blamed for advancing cognitive deterioration through vascular dementia (Luchsinger 2001). Therefore tightening diabetes control in early stages may vastly improve future health as illness limits mobility, and dementia/retinopathy hamper potential to access self-care resources (Sinclair 2000). Notably due to widespread sensitivity over weight, healthcare professionals should be non-judgmental towards patients with chronic conditions, especially considering psychological and psychosocial implications connected to adjustment to an illness, including guilt, fear, stigma, confidence loss, and isolation (Presho 2008). It was observed during a TIDE (Type 1 Diabetes Education) diabetes specialist nurse led session that those with busy manual working lives find it difficult to take time to self-manage by adjusting insulin to activity levels or establishing a routine of carbohydrate counting and insulin adjustment. Others find calculations following the DAFNE (Dose Adjustment for Normal Eating) structure, hard to understand. Several patients who had suffered previous traumatic hypoglycemic episodes felt anxious about reducing insulin intake, and reported differences in advice from GPs, and nurses as well as confusion over new insulin analogues and devices. This indicates understanding patients as unique individuals, timing and convenience of interventions are important. Furthermore providing clear, consistent advice appeared allied to development of positive attitudes towards nurses education interventions. Studies suggest structured education in type 1 diabetes has improved patients maintenance of glucose targets and a reduction in occurrences of hypoglycemia changed peoples attitudes to education (Heller 2009). Also those with greater understanding of and confidence in adjusting insulin appropriate to activity, with less anxiety over following a fixed regime to avoid hypoglycemia achieve top self-management in type 1 diabetes (Whitehead 2008). On a stroke rehabilitation unit, patients with multiple conditions, particularly diabetes, asthma, and Parkinsons had restricted motor function. Yet nurses could provide encouragement for patients to express concerns, to relieve some psychological distress or help empower patients with the required self-confidence to make decisions (Costello 2009). Patients expressed difficulty with waiting for physios to engage in movement improving circulation, but self-administered some medication and carers views and choices underpinned care planning as recommended in Essence of Care benchmarks, via regular carers group meetings (DOH 2010). Chronic disease is the leading cause of death worldwide (Larsen 2005) and literature establishes dependent peoples needs are equality, rehabilitation, and independence. Furthermore security and dignity are important to older peoples mental health (Presho 2008). On a local scale Manchesters operational plan illustrates emergency admissions for asthma is greatest in the North East and prevention is being addressed with annual health checks provision improving recently. Whilst the national continuing care framework commenced in 2007 promises to ensure national equity of access to NHS funding for continuing care (NHS 2010). Significantly Our Health and Wellbeing Today (DOH 2010) suggests national morbidity is greatest from circulatory disease, which is particularly high in lower socioeconomic groups. These groups also have the greatest prevalence of anxiety and depression and have increased likelihood of having chronic conditions such as diabetes, which has led enquiring researchers to suggest depression as a factor that precipitates and perpetuates chronic conditions (Chapman 2005). Socioeconomics is also reported to determine medication adherence in asthmatics (Kaptain 2009). Victim blame might occur if expectations patients follow structured management programs ignore social contexts of illnesses, (Lindsay 2009) so emphasis should be on developing realistic goals. The kings fund review of self-management highlights that patients perceptions of self management differ according to how they receive a diagnosis, and these attitudes can change over time. Differentiation was noted between diagnosis of asthma or diabetes, where it was felt greater clarity existed, than of Parkinsons disease for which diagnosis takes longer (Coben 2005). Disclosing a medical condition could also have implications for patients quality of life, and a study of anecdotes from Parkinsons patients demonstrated those with confidence to disclose their illness subsequently achieved greater measured anxiety reduction (Presho 2008). Notably research shows patients fret significantly about psychological consequences of physical disability (Miller 2006). Concealment could be due to perceived stigma and misconceptions about the disease or depression about associated decline, physical disability and being a burden (Moore Knowles 2006). Alternatively challenges of symptom management such as sleeping problems and fatigue, sexual dysfunction and cognitive impairment might lead to depression (Schrag, Jahanshahi, Quinn, 2001; Schreurs, De Ridder, Bensing, 2000). Similarly emotional responses to asthma can impact upon attitudes towards taking prevention medication which enables control, and alongside non-adherence patient stress increases leading to depression, anxiety or inability to cope (Kaptain 2009). Interventions aimed at managing pre-diabetes and mild asthma, that miss-managed, could contribute to the development of diabetes mellitus and chronic airway disease (Murphy 2007), are well developed and promoted by the charities Diabetes and Asthma UK (Appendix 3). It is especially important to promote good control since poor control negatively impacts on the affected persons quality of life and also their families (NICE 2008). Also individuals reportedly favor self-management because controlling their health affords greater sense of autonomy (Corben 2005). The EPP has incentives of providing greater knowledge about treatment decisions with the underlying expectancy patients have authentic understanding of their own conditions, and greater recognition of patients roles should give them self-confidence to protect future health (DOH 2001). Illness progression might be reduced by lifestyle changes, therefore nurses have a role in promoting patients independence, well-being, and in encouraging active ageing (NMC 2009). In 2005 the Kings fund report highlighted that major challenges to promoting self management were; developing professionals supportive skills, improving services and information available to facilitate patients self-management, and becoming more flexible to fit compatibly around patients other commitments (Rosen 2005). Dorothea Orem created a comprehensive model of nursing which can be applied to individuals to assess level of self-care ability (Appendix 2). Orem conceptualizes nursing as doing for a disabled person with a self-care deficit, or assisting them/family to do for their selves (Orem 2003). Further to this Orem formulated three systems of nursing to apply, of which partially compensatory nursing seems appropriate for stroke patients, whilst a supportive-educative role suits structured education sessions (i.e. TIDE). The effects of an education intervention delivering the DESMOND program (Appendix 5) for patients with type 2 diabetes to newly diagnosed patients over a period of 6 hours measuring cost effectiveness and quality adjusted years are reported by a randomized trial to have positive effects particularly on reducing patients weight and the amount they smoke (Gillett 2010). Issues of self-efficacy and self-management prominent features of the DESMOND that have been found to build patients confidence (Davies 2008, Skinner 2006) are key to developing a sense of well being in rehabilitation (Presho 2008). Nevertheless, concerns nurses might have include doubts about the patients being experts after what is actually a relatively short training period (Lindsay 2009). Moreover, there could be internal conflicts for nurses between applying structural protocols (i.e.) or professional ethics, and accepting a patients wish to continue a harmful behavior or health neglect. Farrell argued in 2004, active teaching on conditions and problem-solving to address medical issues better promotes self-efficacy than passivity (Farrell 2004). Yet it is important patients are equipped with enough knowledge to act as concordant partners and are supported with taking medications (Murphy 2007) (Appendix 7). Involving relatives in demonstrations of using metered dose inhalers is helpful with dependent asthmatic elders because direct patient observation by nurses supervising medication is often impossible once they have returned from hospital, (Schlenk 2004). Ability to encourage self-management requires nurses to listen, and respond to the concerns and preferences of people in their care (NMC Code), as well as sharing in a way people can understand, the information they want or need to know about their health (NMC code). This may include providing written supplementation to verbal information such as education leaflets or management diaries, and allowing adequate time for adjustment and decision making. Patients whose physical function has deteriorated significantly and continues to decline may be in a too highly dependent illness phase to benefit from strategies to return to normal function (Larsen 2009). Cochrane authors conclude evidence showing contracts improve patient adherence to health-promotion in adult asthma studies is limited (Bosch-Capblanch et al 2007), which suggests patients intentions when agreeing to follow advice is unreliable for predicting management outcomes. Patient self-reports are a simpler method of gleaning non-adherence information, are inexpensive, and possible in most settings (Schlenk 2004 cited by Ruppar 2008). Research observes patients with Parkinsons disease using Alexander Technique had a reduction in depression and improved capacity to manage their disability (Clark 2003). The essence of care is about getting to know and value people as individuals, (NMC Guidance for the care of Older People 2009) and nurses can recognize and respect peoples role in their own care. Evidence also suggests motivational interviewing can reduce depressive attitudes towards illness situations and to encourage positive action to improve health outcomes, therefore perhaps GPs and practice nurses should increase these services (Home and Carr 2009). Nurses can arrange social workers to speak to the patient, to engage with their family, find out their needs, compile appropriate packages of care and request doctors provide explanations of the mechanisms causing a stroke in dedicated wards which usually provide speech and language therapy, occupational, and physiotherapy. Dedicated stroke wards are shown by studies to improve outcomes after two years of patients who were independent prior to their stroke vis-à  -vis ADLs without lengthening stay (Glader 2001 and Cochrane Stroke Unit Trialists Collaboration 2007). It can be a stressful time for patients and family having to make continuing care decisions; therefore patients might seek support from others who have been in their situation (Help the Aged 2009). Gathering information allows patients to manage their illness alongside doctors, and sharing plans with friends and family, explaining their importance, can help them to follow them, there are purportedly around 6 million carers in the UK combining caring with paid employment, saving  £57 billion a year in care costs (Campling 2006, Costello 2009). Not every patient has supportive family members so professionals and expert patients, and charities can be significant. Especially interventions tailored to marginalized patients needs such as X-PERT education for type 2 diabetics undertaken in Urdu (Diabetes UK 2009). In critical phases of illness, which may be the point where a patients continuing care needs begin, patients relatives main needs are for information, support and proximity (Henneman 2002). In the case of Parkinsons disease conveying to patients families the hope that there are strategies for managing the condition, particularly in early stages, might reduce fear, negative impact and sense of stigma (Moore Knowles 2006). Managing pain and discomfort is often considered a challenging aspect of caring, and psychological aspects also cause pain. Total illness effects make it important for patients to have supportive family members to listen to them to find out potential causes/remedies (Costello 2009). Practitioners should be sensitive to needs of carers as well as patients, and evidence suggests nurse-led stroke carer sessions, responding to individuals concerns would be helpful (Smith 2004). A study using the stress and coping model (Lazarus and Folkman) to identify a relationship between sleep deprivation and depression in family care-givers found that individuals self-reports underestimated their problems (Carter 2003). People may feel that because they know their relative they are capable of best comprehending and providing for them, and this could lead to guilt about accepting assistance with care (Nolan 2000). Research into respite care suggests family carers expressed needs for information, skills training or education and emotional support (Hanson 2001). To decrease feelings of powerlessness and support independence for those with chronic conditions Larsen proposes five interventions to recommend to carers (Appendix 6) (Larsen 2009). Peak-flow monitoring, allergen avoidance, and the Buteyko method of symptoms control for mild asthma, based on correctly dosing steroids to maintain safe asthma control are found to be effective (McKeown 2003), as are diet, exercise, supplements and anti-diabetic medication as preventative strategies for type 2 diabetes, reducing heart attacks, microvascular disease, and death (Patel 2003). Though some studies suggest effectiveness reduces 1-3 months post intervention (Siminerio 2007). Subsequently insight into self-management adherence remains complex and under-researched, but supports identifying barriers to adherence and taking action to remove these (Touchette 2008). In liberating the NHS the symbiosis of adult social care, carers, and the NHS is recognized and promises are made to improve the convenience of services to patients (DOH 2010). To reiterate, according to the UK governments policy overall evidence suggests self-care results in beneficial outcomes and better service utilization, but this is largely based on primary studies as systematic reviews are reportedly too time consuming (DOH 2005-7). Systematic reviews also indicate clinical benefits for diabetic and hypertensive patients (Jordon and Osborne 2007). Although psychological benefits to patients appear widely well recognized (Lindsay 2009), patient self-determination requires more than medical management, (Greenhalgh 2009). Contrary to commissioners intentions studies show attendance at health services does not necessarily decrease following education sessions, although this may not indicate poor management as it could reflect success of techniques teaching patients confidence to converse with clinicians (Griffiths 2007). Since GPs are also accused of stalling EPP progress, dubious about its efficacy and under referring patients (Jordon Osborne 2007) it follows that nurses might take a key role in involving patients. The basis behind the EPP being best practice are aims to increase patient beliefs in health services efficacy, personal confidence, and ability to self manage (DOH 2010), therefore nurses are following policy implementing programs RCTs suggest achieve these outcomes (DOH 2005-7). Finally research highlights the importance of having clearer, comprehensive, shared definitions of self-management between health disciplines to reduce patient confusion and so professionals collaborate better (Godfrey 2011). References Armstrong, D. (2005) Chronic Illness: Epidemiological or social explosion, Chronic Illness, 1: 26-7 Barlow, J. H., Sturt, J., and Henshaw, H. (2002) Self-management interventions for people with chronic conditions in primary care: arthritis, asthma diabetes: Health Education Journal; Vol 61, issue 4, p 365-78 Barlow, J., Wright, C., Sheasby, J., Turner, A. and Hainsworth, J. (2002) Self-management approaches for people with chronic conditions: a review, Patient Education and Counseling, Vol 48, p 177-87 Berg, G.D., Wadhwa, S. (2007) Health Services outcomes for diabetes disease management program for the elderly: Disease Management; Volume 10, p 226-234 Bickerstaff, K. A., Grasser, C. M., McCabe, B. (2003) How elderly nursing home residents transcend losses of later life: Holistic Nursing Practice; Vol 17; Issue 3, p 159-165 Bodenheimer, T., Lorig, K., Holman, H., Grumbach, K. (2002) Patient Self-management of Chronic Disease in Primary Care: The Journal of the American Medical Association; Vol 288, Issue 19, p 2469-2475 Bosch Capblanch X, Abba K, Prictor M, Garner P (2007) Contracts between patients and healthcare practitioners for improving patients adherence to treatment, prevention and health promotion activities. Cochrane Database of Systematic Reviews (2): Art. No.: CD004808 BTS/SIGN (2008) British Guideline on the Management of Asthma: British Thoracic Society (21.02.11) http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/sign101%20revised%20June%2009.pdf Carter, P. (2003) Family Caregivers Sleep Loss and Depression Over Time: Cancer Nursing; Volume 26 Issue 4 p 253-259 Campling, F., and Sharpe, M. (2006) Living with a long-term illness: Oxford University Press Chapman, D. P., Perry, G. S, Strine, T. A., (2005) The Vital Link Between Chronic Disease Depressive Disorders: Preventing Chronic Disease, Public Health research, practice and policy; Volume 2, No 1 Clark, Chambers, C. (2003) Parkinsons disease: Self-Care Measures You Can Take: American Holistic Nurses Guide to Common Chronic Conditions: John Wiley Sons; New Jersey Cochrane (2011) Organised inpatient (stroke unit) care for stroke: Stroke Unit Trialists Collaboration; The Cochrane Database of Systematic Reviews, Issue 3 http://www2.cochrane.org/reviews/en/ab000197.html Corben, S., and Rosen, R. (2005) Self-management for Long-term Conditions, Patients perspectives of the way ahead; The Kings Fund: UK Cortes, T., Lee, A., Boal, J., Mion, L., Butler, A. (2004) Using focus groups to identify asthma self care and education issues for elderly urban-dwelling minority individuals: Journal of Applied Nursing Research; Volume 17, Issue 3, p 207-212 Costello, J. (2009) Caring for someone with a Long-term Illness: Manchester University Press; UK Davies. M. J., Heller, S., Skinner, T. C., Campbell, M. J., Carey, M. E., Cradock, S., Dallosso, H. M., Daly, H. Doherty, Y. Eaton, S. Fox, C., Oliver, L., Rantell, K., Rayman, G., Khunti, K. (2008) Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial: British Medical Journal, Volume 336, No 7642 DOH (2010) BENCHMARKS FOR THE FUNDAMENTAL ASPECTS OF CARE: Benchmarks for Self Care; Essence of Care 2010 (Access 02.03.11) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119968.pdf DOH (2010) Equity and Excellence: Liberating the NHS; Her Majestys Stationary Office, UK DOH. (2010) Generic Long Term Conditions Model; (Accessed online 14/02/2011) http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915 DOH (2005-7) RESEARCH EVIDENCE ON THE EFFECTIVENESS OF SELF CARE SUPPORT http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_081251.pdf DOH. (2010) Self Care Local Business Case Tool User Guide http://selfmanagement.co.uk/self-care-resources (Accessed Online 14/02/2011) DOH. (2010) Making the case for self care education: http://selfmanagement.co.uk/self-care-resources DOH (2001) The expert patient: a new approach to chronic disease management 21st century Gately, A., Rodgers, C., Sanders, A. (2007) Re-thinking the relationship between long term condition self-management education and the utilization of health services: Social science and Medicine; Volume 65, p 934-945 Farrell, K., Wicks, M, Martin, J. C. (2004) Chronic Disease Self-Management Improved with Enhanced Self-Efficacy: Journal of Clinical Nursing Research; Volume 13, No 4, p 289-308 http://cnr.sagepub.com/content/13/4/289.full.pdf+html (04.04.11) Gibson PG, Powell. H., Coughlan J., Wilson A. J., Abramson M., Haywood, P., Bauman, A, Hensley MJ, Walters, E. H. (2004) Self-management education and regular practitioner review for adults with asthma: The Cochrane Library Issue 2. Chichester: John Wiley Sons. Gillet M, Dallosso HM et al (2010) Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis; British Medical Journal, Issue 341, p 4093 Glader, E. L., Stegmayr, E., Johansson, L., Wester, P. O. (2001) Differences in Long-Term Outcome Between Patients Treated in Stroke Units and in General Wards: Journal of Stroke; Volume 32, p 2124-2130 Godfrey, C. M., Harrison, C. M., Lysaght , R., lamb, M. (2011) Care of self care by other care of other: the meaning of self-care from research, practice, policy and industry perspectives: International Journal of Evidence Based Healthcare; Volume 9, Issue 1, p 3-2 Greenhalgh, T. (2007) Chronic Illness, beyond the expert patient: British Medical Journal; Vol 338, p629-31 Griffiths, C., Foster, G., Ramsay, J., Eldridge, S., Taylor, S. (2007) How effective are expert patient (lay led) education programs for chronic disease? British Medical Journal: Volume 334, p 1254-1256 Hanson, E. J., Tetley, J., Clarke, A. (2001) Respite care for frail older people and their family carers: concept analysis and user focus group findings of a pan-European nursing research project: Journal of Advanced Nursing; Volume 30, Issue 6, p1396-1407 Heller, S., Shearer, A. Bagust, D., Sanderson, A, and Roberts, S. (2004) Cost-effectiveness of flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes in the UK; Journal of Diabetic Medicine, issue 21, 460-467 Heller, R. S. (2009) Structured education in type 1 diabetes: British Journal of Diabetes Vascular Disease; Volume 9, no 6, p 269-272 http://dvd.sagepub.com/content/9/6/269.full.pdf+html (02.03.11) Help the Aged (2009) Common Assessment Framework for Adults proposals to improve information sharing around multi-disciplinary assessment and care planning Jordon, J., Osborn, R. (2007) Chronic disease self management education programs: Challenges ahead; Medical Journal of Australia, Volume 182, Issue 2, p 84-87 Keen, A., Hillson R. (2010) Six years on: delivering the Diabetes National Service Framework; Parliamentary Under State Secretary for health National Clinical Director for Diabetes; DOH (19.02.11) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_112511.pdf Kaptein, A. A., Klok, T., Moss-Morris, R., Brand, L. P. B. (2010) Current Opinion in Allergy and Clinical Immunology: No 10, p 194-199 Kennedy, A., Reeves, D., et al (2007) The effectiveness and cost effectiveness of a national lay led self care support programme for patients with long-term conditions: a pragmatic randomised control trial J. Epidemiol. Community Health Issue 61; pages 254-261 Larsen, P., Lubkin, I. M. (2009) Chronic Illness: Impact and Intervention; 7th ed, Jones Bartlett, Canada Lindsay, S., Virjhoef, H. J. M. (2009) A sociological focus on expert patients: Health Sociology Review; Vol 18, Issue 2, p 139-144 http://www.atypon-link.com/EMP/doi/pdf/10.5555/hesr.18.2.139?cookieSet=1 Luchsinger, J. A., Tang, M., X., Stern, Y., Shea, S., Mayeux, R. (2001) Diabetes Mellitus and Risk of Alzheimers Disease and Dementia with Stroke in a Multiethnic Cohort: American Journal of Epidemiology; Volume 154, No 7, p 635-641 http://aje.oxfordjournals.org/content/154/7/635.full.pdf+html Michie S, Miles J, Weinmann J (2003). Patient centeredness in chronic conditions: what is it and does it matter? Patient Education and Counseling, vol 51, pp 197-206 Miller, N. (2000) Hard to swallow: Dysphagia in Parkinsons disease; Journal of Age and Ageing; Volume 35, issue 6, pages 614-618 Moore, S., Knowles, S. (2006) Beliefs and Knowledge about Parkinsons Disease: E-Journal of Applied Psychology: Clinical and Social Issues, Volume 2, Issue 1, p 15-21 Mulligan, K., Steed, L., Newman, S. (2009) Chronic Physical Illness: Self-Management and Behavioral Interventions; Open University Press, England Murphy, A. (2007) Asthma in Focus: Royal Pharmaceutical Society of Great Britain; Cornwall Newman S, Steed L, Mulligan K (2004) Self-management interventions for chronic illness Lancet, volume 364, pp 1523-37 NICE (2008) Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over; http://www.nice.org.uk/nicemedia/live/11945/40099/40099.pdf NHS (2004) NHS Continuing Care Report to the House of Commons Health Committee: Stationary Office; http://www.parliament.the-stationery-office.co.uk/pa/cm200405/cmselect/cmhealth/399/399i.pdf (27.03.11) Nolan, M., Delasegga, C. (2000) `I really feel Ive let him down: supporting family carers during long-term care placement for elders; Journal of Advanced Nursing, Volume 31, Issue 4 p 759-767 Orem., D. (2003) Self Care Theory in Nursing: Selected papers of Orem Springer Publishing Company Patel, A. (2003) Diabetes in Focus: Understanding inevitably leads to hope; Pharmaceutical Press, UK Rosen, R., Asaria, P., Dixon, A. (2007) Improving Chronic Disease Management, an Anglo-American Exchange: The commonwealth Fund Report; The Kings Fund Rosen, R., Corben, S. (2005) Self- Management for Long Term Conditions, Patients Perspectives on the way ahead: Managing Long Term Conditions; Working report, Kings Fund Ruppar, T. M., Conn, V. S., Russell, C. L. (2008) Medication adherence interventions for older adults: literature review: Journal of Research and Theory for Nursing Practice, Volume 22, Issue 2, p 114-147 Schlenk E. Dunbar, J., Engberg, S. (2004) Medication non-adherence among older adults: a review of strategies and interventions for improvement: Journal of Gerontological Nursing, Volume 30, Issue 2, p 46 Schrag, A., Jahanshahi, M., Quinn, N. P. (2001) What contributes to depression in Parkinsons disease? Journal of Psychological Medicine, Volume 3, Issue 1, p 65-73 Schreurs, K. M. G., De Ridder, D. T. D., Bensing, J. M. (2000) A one year study of coping, social support and quality of life on Parkinsons disease: Journal of Psychology Health; Volume 15, p 109 Sharkey, J., Ory, M., Browne, B. (2005) Determinants of self-management strategies to reduce out-of-pocket prescription medication expense in homebound older people: Journal of the American Geriatrics Society; Vol 53, Issue 4, p 666-674 Siminerio, L. M. (2007) Is the Diabetes Educator Our Next Endangered Species? Lessons From the American Bald Eagle: Diabetes Spectrum; Volume 20, no 4, p 197-198 Sinclair, A., J., Girling, A. J., Bayer, A., J. (2000) Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-

My Community Service Taught Me About Leadership Essay -- Volunteer Wor

In the past four years of my life, voluteer work has left an indelible mark on my heart and mind. When I became a voluteer, I had a very vague notion of leadership. As my high school days come to an end, I am left with the feeling that I have finally come into my own shoes, discovering the things that are important to me and those that are not. I have found my personal leadership style, and I now pay attention to the leaders I come across each day. For this reason, voluteering has been both an enlightening and inspiring experience, for I am surrounded by peers, mentors, and the voluteer program director, all of whom are leaders with creative visions of their own. At the beginning of the school year, my voluteer project goal was to organize a program about emotional and verbal abuse that would be welcomed into area high schools. I wanted the program to include speakers who could share their personal experiences in emotionally destructive rela... ...th this single life that I have been given. I am going to touch as many other lives as I possibly can. The moments we spend leading others to find their own personal definitions of happiness are worth so much more than ours alone. Sometimes to see the beauty and meaning in the small things, we must rid ourselves of all the "fluff' that threatens to distract us. Time is too precious and our gifts, as leaders, too valuable to be wasted on things that do not touch our hearts. My Community Service Taught Me About Leadership Essay -- Volunteer Wor In the past four years of my life, voluteer work has left an indelible mark on my heart and mind. When I became a voluteer, I had a very vague notion of leadership. As my high school days come to an end, I am left with the feeling that I have finally come into my own shoes, discovering the things that are important to me and those that are not. I have found my personal leadership style, and I now pay attention to the leaders I come across each day. For this reason, voluteering has been both an enlightening and inspiring experience, for I am surrounded by peers, mentors, and the voluteer program director, all of whom are leaders with creative visions of their own. At the beginning of the school year, my voluteer project goal was to organize a program about emotional and verbal abuse that would be welcomed into area high schools. I wanted the program to include speakers who could share their personal experiences in emotionally destructive rela... ...th this single life that I have been given. I am going to touch as many other lives as I possibly can. The moments we spend leading others to find their own personal definitions of happiness are worth so much more than ours alone. Sometimes to see the beauty and meaning in the small things, we must rid ourselves of all the "fluff' that threatens to distract us. Time is too precious and our gifts, as leaders, too valuable to be wasted on things that do not touch our hearts.

Assessing Young Learners’ Speaking Ability in the Fifth Grade of Three Elementary Schools in Padang Essay

CHAPTER I INTRODUCTION A. Background of the Problem Communicative view development in English learning makes the focus on English teaching changed. What once became structurally focused, it now moves toward meaningful language-focused. Students are not asked to memorize structure-based dialogues without knowing the meaning anymore. There are no more grammatically controlled sentences for students’ meaningless repetition. Dialogues, if used, center around communicative functions and are not normally memorized (Richards & Rodgers, 1986). That makes the teaching of speaking becomes the core part of English teaching. Just like the adults, young learners today are also taught speaking meaningfully and communicatively. However, young learners have distinctive characteristics compared with adult learners. One of them is children are still developing cognitively, linguistically, socially, emotionally, and physically (Teaching Knowledge Test Young Learners: Handbook for Teachers, 2010). In other words, in teaching speaking to them, teachers need to consider children’s development of skills in the native language first. Young learners also enjoy rhythmic and repetitive language more than adults do. They are more likely to play with language than adults are, and they can be more effectively engaged through stories and games (Peck, 2009). The different techniques and approaches in teaching speaking to young learners lead to different ways in the speaking assessment. This is the problem faced by Indonesian young learners’ teachers nowadays. Most teachers do not know how they should assess their young learners’ speaking ability; some finally choose to skip the speaking assessment and focus on pencil-paper-tests. Thus, this research is conducted to discover and reveal ways of assessing young learners’ speaking ability. B. Identification of the Problem Based on the background above, the speaking assessment techniques used for young learners should be different from the adult. It should be suited with their cognitive, linguistic, social, emotional, and physical development. As we looked upon Language Assessment: Principles and Classroom Practices by Brown (2010) and integrated it with curriculum standard in Indonesia, KTSP 2006, young learners will be better to be assessed in imitative and intensive speaking categories, such as imitating teachers’ saying, directed response tasks, read-aloud tasks, and dialogue completion tasks. Alternative assessments such as interviews and conferences can also be applied for them. C. Limitation of the Problem In this research, the problem will be focused on the speaking assessment techniques in the fifth grade of three selected elementary schools in Padang. D. Formulation of the Problem * What kind of speaking assessment technique used by elementary school English teachers? * Why do they use such techniques? E. Purpose of the Research The purpose of this research is to discover and reveal the technique used by English teachers to assess elementary school students’ speaking ability. F. Significance of the Research Theoretically, this research is aimed to give a description of how speaking assessment for young learners done in Indonesia. Practically, some techniques used by English teachers provided here can be a source of alternative speaking assessment. CHAPTER 2 REVIEW OF RELATED LITERATURE A. The Nature of Assessment There has been various explanation of what assessment is. Brindley (as stated in Linse, 2005) refers assessment as â€Å"collecting information and making judgments on a learner’s knowledge†. It means that in assessing students, we need to find out what students know about the subject being taught and how far that understanding has reached the learning indicator. In the same line with Brindley but with an addition, Brown (2010) states assessment as â€Å"an ongoing process of collecting information about a given object of interest according to procedures that are systematic and substantively grounded.† In his statement above, Brown implies that the process of collecting and judging students’ understanding is not done orderly in one single time; it is done continuously. Harris and McCann (1994) also give an essential note that in doing assessment teachers have to measure the performance of their students and the progress they make, as well as diagnose the problems they have and provide useful feedback. In other words, collecting and judging students’ intelligence is not enough; finding out what becomes students’ problem and giving advice to them to overcome the problems is also important to create a more successful learning process. Based on the theories above, it can be seen that assessment involves collecting information about students’ knowledge and judging their understanding in order to diagnose the learning problems they have so that students can get useful feedback to be more-successful learners. B. The Nature of Speaking As stated in the previous chapter, today’s English teaching focuses more on communicative purpose of language learning than in the past. It leads to the more important consideration of speaking skills than in previous time. Just like assessment, there is also various definition of speaking. One of them is from Lingua Links (1998) that defines speaking as productive skill in the oral mode that involves more than just pronouncing words. Referring to today’s communicative view, of course speaking cannot be thought as just pronouncing words; it needs to be meaningful, and communicative. Furthermore, Noonan (2003) states that, if pronunciation included, speaking involves three areas: mechanics (pronunciation, grammar, and vocabulary), functions (transaction and interaction), and social cultural norms and rules (turn-taking, rate of speech, etc). All of them are connected to each other and prove that speaking is not only about what is uttered, but also the meaning and social purpose. C. The Nature of Young Learners Young learner is a child who is in their first six year of formal education, from age 6 to 12 (Teaching Knowledge Test Young Learners: Handbook for Teachers, 2010). Many experts argue that it is beneficial to teach the children English since young age. TKT Young Learners (2010) notes one of the advantages that those children will have positive self-esteem toward English and it will help them to learn English more once they are adult. That is why teaching English to young learners considered important today. However, young learners have characteristics that make them different from the adults (Teaching Knowledge Test Young Learners: Handbook for Teachers, 2010). First, they are still morally, cognitively, psychologically developed. Based on Piaget’s theory of cognitive development, children in age 6-12 years old are still in concrete operational thought stage, they already have the ability to do logical reasoning and understand reversibility with the help of concrete objects (Santrock, 1998). It means that explaining theory will not do for them, we need to make them move, do games, sing, etc. Second, young learners often have no obvious reason for learning English. Unlike adults who want to do it because of the career-related reasons or teenagers that do it to pass an exam, young learners do not have concrete reason why they must learn English. However, it does not mean they are not motivated to learn English; their goodwill, energy, and curiosity to learning overcome that. Third, they may not always have well-developed literacy skills to support their learning of English. Many children in the age of 6-12 years old are just getting to know their first language. It means that as a teacher we need to not have too-high expectation and do more. Fourth, young learners often learn slowly and forget quickly. It is related to the first characteristic that young learners are still developed morally, socially, and cognitively. Their still-ongoing developments in those basic things make them forget easily and learn slowly. This is why songs, agmes, and chants do best for them. D. Principles of Assessing Young Learners According to METU Open Course Ware (2006), principles of assessing children’s language learning are: 1. Assessment should be seen from a learning-centered perspective. It means that we cannot get a true assessment by testing kids what they can do alone. It has been stated by many experts that the goal of learning English is to be able to communicate meaningfully in English. Testing students, let alone young children, as a tool to get true assessment will not congruent with the real goal of English learning and it will just be wasting time. 2. Assessment should support learning and teaching. This is something that is not also becomes a problem with young learners, but also with the adult. Before performance-based assessment is introduced, teachers chose paper-and-pencil tests as their source of assessing (Puppin, 2006). It becomes a problematic then since students do not see the connection between the learning and the test they are doing, ; they see them as two different incongruent things. If the assessment done is congruent with the learning they did, children will feel that what they have learned is useful. 3. Children and parents should understand assessment issues. Their understanding will make the assessment process more meaningful since they can participate and supports greatly on behave of children’s English development. On the other hand, if they do not understand why the teacher does this and that, there will be no good communication between these three subjects to help children’s development. E. Techniques of Speaking Assessment Brown (2010) states some techniques of speaking assessment based on students’ language development level: Imitative Speaking This kind of assessment is intended to see whether students can imitate saying in English correctly. Eventhough it focuses on the accuracy of repeating words, it does not mean that it cannot be communicative and meaningful. Besides, in recent years many experts have discovered that an overemphasis on fluency can sometimes lead to the decline of accuracy in speech. Intensive Speaking There are four tasks in this kind of assessing: directed response task, oral questionnaire, and picture-cued task. In oral questionnaires, students are first given time to read the dialogue to get its main idea and to think about the appropriate lines to fill in. Then, as the tape, teacher produces one part orally; the students respond. In directed response task, students elicit a particular grammatical form of a transformation of a sentence. Such tasks are clearly mechanical and not communicative, but they do require minimal processing of meaning in order to produce the correct grammatical output. Picture-cued task requires a description from the students. Pictures may be very simple, designed to elicit a word or a phrase, or composed of a series that tells a story or incident. This task is meaningful since sometime a little sense of humor is injected. Responsive Speaking Assessment of responsive tasks involves brief interactions with an interlocutor, differing from intensive tasks in increased creativity given to the student and from interactive tasks by somewhat limited length of utterances. The kinds of this assessment are question and answer, giving instructions and directions, and paraphrasing. Questions and answers involve oral interaction with teacher.

Definition of and Examples of Words With a Glottal Stop

Definition of and Examples of Words With a Glottal Stop In phonetics, a glottal stop is a stop sound made by rapidly closing the vocal cords. Arthur Hughes et al. describe the glottal stop as a form of plosive  in which the closure is made by bringing the vocal folds together, as when holding ones breath (the glottis is not a speech organ, but the space between the vocal folds) (English Accents and Dialects, 2013). The term is also called a  glottal plosive. In Authority in Language (2012), James and Lesley Milroy point out that the glottal stop appears in limited phonetic contexts. For example, in many  dialects of English it  can be heard as a variant of the /t/ sound between vowels and at the ends of words, such as  metal, Latin,  bought, and cut  (but not ten, take, stop, or left). The use of the glottal stop in place of another sound is called glottalling. The glottal stop is inside us all, says David Crystal, part of our phonetic ability as human beings, waiting to be put to use. We use one every time we cough. (The Stories of English, 2004) Glottal Stop Examples and Observations Glottal stops are made quite frequently in English, although we rarely notice them because they do not make a difference in the meaning of English words...English speakers usually insert a glottal stop before initial vowels, like in the words it, ate, and ouch. If you say these words naturally, you will probably feel a catch in your throat just as you [do] in the expression uh-oh.(T. L. Cleghorn and N. M. Rugg, Comprehensive Articulatory Phonetics: A Tool for Mastering the Worlds Languages, 2nd ed., 2011) Glottalization   Glottalization is a general term for any articulation involving a simultaneous constriction, especially a glottal stop. In English, glottal stops are often used in this way to reinforce a voiceless plosive at the end of a word, as in what?(David Crystal, A Dictionary of Linguistics and Phonetics, 1997) words: light, flight, put, take, make, trip, reportmultisyllabic words: stoplight, apartment, backseat, assortment, workload, upbeatphrases: right now, talk back, cook the books, hate mail, fax machine, back-breaking Uhs We often make this stop- its the sound we make when we say uh-oh. In some languages, this is a separate consonant sound, but in English, we often use it with d, t, k, g, b or p when one of those sounds happens at the end of a word or syllable...We close the vocal cords very sharply and make the air stop for just a moment. We dont let the air escape. This glottal stop is the last sound of these words: You also hear it in words and syllables that end in t a vowel n. We dont say the vowel at all, so we say the t n: button, cotton, kitten, Clinton, continent, forgotten, sentence.(Charlsie Childs, Improve Your American English Accent, 2004) Changing Pronunciations Nowadays younger speakers of many forms of British English have glottal stops at the ends of words such as cap, cat, and back. A generation or so ago speakers of BBC English would have regarded such a pronunciation as improper, almost as bad as producing a glottal stop between vowels in the London Cockney pronunciation of butter...In America, nearly everybody has a glottal stop in button and bitten.(Peter Ladefoged, Vowels and Consonants: An Introduction to the Sounds of Languages, Vol. 1, 2nd ed., 2005)

Free Essays on Gang Life

gang life Gang Life In life, teenagers and adult’s join gangs for difficulties in their life. They feel that they need a group of people to understand and support them through the rough stage of their life. In the novel, The Outsiders, by S. E. Hinton Ponyboy is a fourteen-year-old boy who is a part of the gang called the greasers. His whole remaining family are greasers. Gang life can lead to death and trouble. In The Outsiders, Ponyboy is in a gang with all of the people he grew up with in the neighborhood, including his two brothers, Sodapop and Darry. In a fight against the socials, the enemy of the greasers, Ponyboy and another member of the greasers named Johnny were outnumbered five-two. In order to save Ponyboy’s life, Johnny killed a member of the socials named Bob. This proves that gang life can lead to death. After Johnny killed Bob, they went to their friend Dally to help them get out of their situation. Dally told them to go to an old abandoned church on the top of J ay Mountain. Dally told them to stay there until he got there. On the fifth day Dally got there and took them to get something to eat. When they got back to the church, the church was on fire. As a crowd gathered around, Ponyboy and Johnny realized that there were children trapped inside. They both went in to rescue them. As they made their way out, a piece of timber caught him across the back and he was burned very badly. Ponyboy didn’t get burned but got knocked out by Dally when he tried to go back into the fire to save Johnny. A couple of day’s later Johnny died. If Johnny weren’t part of a gang, he would have never killed Bob and he wouldn’t have been at the church running away from the police. As soon as Ponyboy got back from the hospital, a rumble between the greasers and the socials was about to take place. Ponyboy fought despite being hurt and sick. After the greasers beat the socials, Dally and Ponyboy went to the hospital to tell Joh... Free Essays on Gang Life Free Essays on Gang Life gang life Gang Life In life, teenagers and adult’s join gangs for difficulties in their life. They feel that they need a group of people to understand and support them through the rough stage of their life. In the novel, The Outsiders, by S. E. Hinton Ponyboy is a fourteen-year-old boy who is a part of the gang called the greasers. His whole remaining family are greasers. Gang life can lead to death and trouble. In The Outsiders, Ponyboy is in a gang with all of the people he grew up with in the neighborhood, including his two brothers, Sodapop and Darry. In a fight against the socials, the enemy of the greasers, Ponyboy and another member of the greasers named Johnny were outnumbered five-two. In order to save Ponyboy’s life, Johnny killed a member of the socials named Bob. This proves that gang life can lead to death. After Johnny killed Bob, they went to their friend Dally to help them get out of their situation. Dally told them to go to an old abandoned church on the top of J ay Mountain. Dally told them to stay there until he got there. On the fifth day Dally got there and took them to get something to eat. When they got back to the church, the church was on fire. As a crowd gathered around, Ponyboy and Johnny realized that there were children trapped inside. They both went in to rescue them. As they made their way out, a piece of timber caught him across the back and he was burned very badly. Ponyboy didn’t get burned but got knocked out by Dally when he tried to go back into the fire to save Johnny. A couple of day’s later Johnny died. If Johnny weren’t part of a gang, he would have never killed Bob and he wouldn’t have been at the church running away from the police. As soon as Ponyboy got back from the hospital, a rumble between the greasers and the socials was about to take place. Ponyboy fought despite being hurt and sick. After the greasers beat the socials, Dally and Ponyboy went to the hospital to tell Joh...

English Essay Example | Topics and Well Written Essays - 500 words - 43

English - Essay Example There is a systematized industry and motif working behind the embalming of bodies and Jessica wanted to bring these points before the common mass, just to make it stronger that the procedure considered inevitable is not at all mandatory. An expert on death and dying, Jessica Mitford is completely against embalming dead bodies after death and puts forward many valid points in support of her contention. Her motive of writing this essay is explicit from the very beginning of the literary piece. She has placed a strong objection regarding the secrecy maintained during embalming. Another major purpose of writing this essay was to make it clear that the process of embalming is barbaric and it is evident that her real goal in writing this essay was to reach the common mass so that common people should understand, how barbaric the practices are and the mystery that actually lies behind the closed doors of the funeral parlors. She clearly claims that the ritual of embalming in North American funeral tradition is grotesque. Yet, people seem to remain ignorant about it. By highlighting these points, she wanted to create a common awareness against these rituals and tried to correct them. She brings out evidences to make her contentions more concrete. She wanted to show that a planned industry works behind these traditions which try to make burial a pleasurable thing. This ritual, according to Jessica, only prevails in North America and does not occupy any place in the tradition of other areas apart from it. She writes with specific examples. She brings forth the example of the ritual of open - casket ceremony only common in North America. She ends her essay with the following line that completely complements her intentions behind writing the essay:   Ã¢â‚¬Å"He has done everything in his power to make the funeral a real pleasure for everybody concerned. Consequently well over 90

M5A1-Conflict Essay Example | Topics and Well Written Essays - 750 words

M5A1-Conflict - Essay Example There conflict scenario entails several positives (for resolution) and negatives (for resolution) in favor of management group and in favor of the employee group. Some positives for resolution that are in favor of management include the high experience and training that is provided to the employees to build performance review systems and information systems. Accordingly, the low turnover, the visionary leadership of the three business partners and fair and comparable salaries will also help Metro services in resolving the conflict. In addition, 92 percent of employees assert that the owners have positive attitudes towards specialists and while 78 percent assert agree that Metro services offers opportunities to work in various companies. Some negatives for resolution that face the management include the inability to allow the specialists an opportunity in negotiating fees with the contracting companies, and lack of promotion opportunities in the company. In addition, the failure to ho ld employee/owner meeting for the past three years is a challenge for the management group in resolving the conflict. ... Accordingly, employees are allowed to demonstrated individual performance and 64 percent claim that the company offers job security. In addition, 80 percent of employees perceive the salary as fair and comparable and 74 percent assert that specialist positions allow them to utilize their knowledge and skills. Some negatives that may hinder employees in cooperating during the conflict resolution include lack of adequate opportunities for promotion, the confrontation with Mr. Baker that happened in 1999 and inability of the management to belief that there is a union movement by employees since it will be detrimental to all concerned. Some of the points of contention that relate to the positives and negatives include the possibility of implementing a bonus sharing system for the excess profits earned by the management. Some positive points of contention that may create conflictual conditions include the job security since some employees perceive six months full time position as temporal position that does not guarantee any job security. Another contention is the intention of employee to create a union since the management group does not believe whether such movements are necessary when the salaries and additional benefits like 401K securities are fair. The last contentious issue is the monitoring of contracting companies and requirement for a higher performance level than agree with contracting companies. The refusal of temporary specialists to participate in negating fees with contracting companies will also be contentious. Time phased strategy of addressing the conflict The management must analyze the employee survey and identify the source of conflict in the organization. The management must identify any barriers in