This essay will focus on a reflective practice where I will discuss my experience while working with a community matron with the aim of offering treatment to patients who suffered from chronic long-term health complications. The community matron I worked with was a highly experienced senior nurse who was involved in working closely with several patients. My mentor decided to work in the community settings as it would enable us to gain a clear in insight of the services that are necessary to be implemented for improving the access to health care among the patients. Furthermore, it had the potential of promoting our understanding of chronic health issues that exist in the society. A chronic or long term health disorder refers to the prevalence of a human health condition that is long lasting or persistent in the associated effects (Gunn et al. 2012). Most commonly, the term chronic or long term is applied for denoting diseases that persist for more than six months (Schulman?Green et al. 2012). During the first year of my placement, I was engaged in assisting the community matron to offer treatment and therapeutic interventions to patients present in the ward, who were mostly suffering from respiratory disorders, COPD, hypertension and cardiovascular failure.
However, the rehabilitation centre for dementia and stroke patients was selected for further practice as it would lead to an effective collaboration within community settings and would facilitate my clinical expertise. Dementia has become a significant health issue owing to the large number of individuals who are affected by it (Prince et al. 2013). The term dementia is used to describe a range of symptoms that are manifested by memory loss, mood alterations and problems in reasoning and communication. It usually occurs among elders. There is a progressive loss of cells in the brain in this condition (Dupuis et al. 2012). On the other hand, stroke refers to the condition that encompasses an interruption of blood supply to the brain. This deprives the brain of the essential nutrients and oxygen and results in their death (Laver et al. 2012). The high prevalence of these two diseases in the community can be attributed to the decision taken by the community matron to work with multidisciplinary teams in community hospitals and rehabilitation centres (Fauth et al. 2012).
There is a strong correlation between physical and mental health. The prevalence of strong association between mental and physical health conditions results in long lasting impacts on the overall wellbeing and quality of life of the affected individuals. This in turn increases the pressure on community health services that are funded by the governments and the access to healthcare facilities (Reiner et al. 2013). The WHO considers poor or low mental health as a major risk factor that predisposes individuals to long term illnesses. There are several social determinants of health that influence the likelihood of developing these illnesses. Most often patients fail to realize the physical impacts of dementia on the human body. With a progress in dementia, the status of physical health declines. Dementia often results in the development of jerky movements, loss of appetite, insomnia, difficulty in swallowing food and loss of control over bowel movements.
Furthermore, research evidences suggest that the first symptoms of dementia are often physical, rather than mental. These symptoms are generally manifested in the form of poor physical performance (Richardson et al. 2013). Therefore, it is essential for an individual suffering from dementia to stay fit and healthy both mentally as well as physically. A significant association between stroke and physical status can be attributed to the fact that physical activities have shown improvements in heart function and lipid profiles in person by reducing the level of total cholesterol (Lerdal and Gay 2013). Adequate physical exercise facilitates lowering of blood pressure and maintenance of a stable heart beat. A good physical health also increases insulin sensitivity, thereby reducing the severity of diabetes (Billinger et al. 2012). This, in turn improves the balance, endurance, strength and long-term brain health. Adherence to a healthy and nutritious diet helps in facilitating proper brain functioning.
In recent years, there has been a huge increase in the recognition of mental issues that create adverse impacts on the health of individuals. The National Health Service (NHS) has been developed in England with the primary objective of delivering good healthcare to all people. With certain exceptions related to optical services, prescriptions and dental services, the NHS offers free healthcare service to all UK residents. Furthermore, it can also be stated that the NHS caters to more than 54.3 million people and includes more than 111,127 community health services, medical and dental staff. Furthermore, there has been a huge expansion of the mental health services in England over the past years (Nhs.uk 2017). The government has aimed to reform the Mental Health Act, 1983, to offer help to people who suffer from serious mental illness such as, schizophrenia or bipolar disorder. There are more than 800,000 people living in the UK, who suffer from dementia. The government has framed new policies that aim to increase the diagnosis rate of dementia. It also intends to reward the GP practices for providing support and timely diagnosis to individuals suffering from dementia (Gov.uk 2017). Furthermore, the government of England also aims to commit itself to protecting the population from major health threats, and also formulates and makes amendments to health policies for providing people a fulfilling and healthier life.
This reflective practice will focus on my experiences during the first year of placement at the community hospital and rehabilitation centre. I was initially placed on a ward where I had to assist a community matron in treating patients suffering from long-term illnesses. However, my mentor suggested that we should work with multidisciplinary teams in a community hospital. Our primary interest was addressing the needs of dementia and stroke patients, while functioning as a team under the community organization. I was initially nervous and sceptical of collaborating with other healthcare professionals and visiting the community centres and patient homes. We started working with physiotherapists, occupational therapists, nurses and nutritionists during the placement. I also had to pay visits to some elder patients suffering from stroke and dementia, who were being provided in-home medical care. While working with occupational therapists, I faced difficulty in understanding specific terms related to therapeutic activities exercises that the dementia patients were made to follow. I also lacked a sound understanding of certain terminologies that were used by the physiotherapists, while caring for the stroke sufferers. Thus, I demonstrated a lack of skills and knowledge in other disciplines.
One major challenge was language barrier. There were some patients, who spoke in languages other than English due to their different ethnicity. My failure to understand what they wanted to communicate, with regards to their medical needs added to my frustration. Furthermore, most often the stroke patients we visited suffered from aphasia that caused widespread damage to several areas of their brain. This often resulted in impairment of their speech. Thus, most often I faced difficulty in understanding what the patients tried to convey, while providing them care. I was extremely upset on seeing the sufferings of the dementia patients. The patients nearing the end of their life faced problems in remembering their names, bed and getting up time, meal time, and mobility and also forgot how to swallow food. This added to my emotional distress.
Another major challenge that I encountered during my placement was the lack of continuity in long-term care. I was quite anxious to notice that there was lack of proper communication during patient handover between a plethora of areas related to care and diagnosis. Inadequate hand-off communication led to breakdowns in care continuity, which was manifested in the form of my misinterpreting the fluid-balance and food charts of the patients. I also suffer from a phobia of domestic animals like dogs and cats. I often had to visit elderly patients at their homes, where they had dogs. Even when they reassured me that I would not get harmed, it made me really uncomfortable and nervous. This acted as a major distraction and led to a lack of concentration while communicating with the patients and their family.
Caring conversations encompass delivery of a patient-centred care and development of an empathetic relationship. These conversations are of utmost importance for healthcare professionals, who intend to engage in significant conversations with the patients and their family (Mikesell 2013). Caring conversations play an important role during shared decision making related to the intervention that will be administered on the clients. Therefore, it can be stated that engaging in an effective caring conversation will enhance our clinical practice and will also create significant improvements in my future practice (Dewar 2017).
Such caring conversations are primarily directed towards bringing about improvements in advance healthcare planning (Decker and Shellenbarger 2012). Constructive conversations with the patients suffering from stroke in the community hospitals, rehabilitation centres and homes gave me the opportunity to identify my strengths and weaknesses. This will act as an asset that will help me bring innovation to my nursing practice. Caring conversations had the objective of providing assistance to the family members, who would advocate on behalf of the stroke and dementia sufferers. Evidences from research suggest that a caring conversation should have certain essential aspects, non-adherence to which will result in poor healthcare delivery and patient dissatisfaction (Levy?Malmberg and Hilli 2014). The major parameters that are essential for effective caring conversations are as follows-
First impression is the major determining factor in the context of delivering appropriate healthcare services, by engaging in an effective caring conversation. The initial encounter with the patients is crucial because being indifferent to the woes of patients suffering from chronic disease displays a lack of willingness to help the patient (Devik, Enmarker and Hellzen 2013). It is therefore considered meaningful and decisive as the tone for the entire conversation is set by the first impression (Ek et al. 2014). The nursing professionals should be successful in providing the patients a clear insight of the therapeutic services that will be offered to meet their physical and mental health needs. Making the patient feel that they are wanted and cared for will act as a promoting factor (Bridges et al. 2013).
Findings from studies help us to realize the importance of establishing a trust in the nurse-patient relationship. The underlying principles of an effective caring conversation illustrate the necessity of genuineness, respect, active listening, empathy, confidentially and trust (Dinç and Gastmans 2013). Trust establishment is considered as the foundation for such conversations as they promote the interpersonal relationship in nursing. It is essential to make the vulnerable patients develop a trust on the healthcare professionals, to facilitate nursing (Dinç and Gastmans 2012). The environment where the conversations take place is crucial in determining whether the patients are able to rely on the nurses. In addition, research evidence also states that a trustworthy conversation is facilitated by being consistent and honest with the patients, listening to them carefully, and treating them respectfully.
Research evidences suggest that nursing profile requires us to strengthen the bonds with our patients by developing an effective nurse-client relationship. Thus, the caring conversations act as encounters that help us to provide best available treatment to the clients, thereby enhancing patient satisfaction (Tanay et al. 2014). Thus, it is our moral duty to be honest and open with our patients at all times. This generally involves making correct judgments about disclosure of critical clinical information (Cleary et al. 2012). Therefore, the factor governs the participation of the patient and the family members in an effective communion. Most often elderly patients who are being offered in-home medical care services, report lack of adequate time in cases of home health care. Nurses often spend less time managing the health issues of the frail and elderly. Therefore, devoting inadequate time to the frail and chronically ill patients is a major factor that inhibits delivery of patient centred care (Haugan 2014). A caring conversation is considered successful; only when it is accompanied by positive attitudes and exchange of information (Wiechula et al. 2016). Therefore, it can be deduced that our work as a nursing professional requires us to develop a sound understanding of the healthcare demands and lives of the patients. I displayed an interest in understanding the life experiences and the wishes of the stroke and dementia patients, with the aim of contributing efficiently to their treatment in the community setting.
Shared decision making and autonomy are other aspects that directly influence such encounters. Family involvement is essential in case of providing treatment to patients who suffer from chronic disorders (Barry and Edgman-Levitan 2012). The nursing work ethics demands that the patients and their families should never be considered as passive receivers of personalized care services. Thus, maintaining patient dignity is crucial and can be promoted by ensuring that fact that the patients are involved during important decision making process (Oshima Lee and Emanuel 2013). Involving the clients helps in gaining their informed consent on the proposed clinical procedures. Conversing with the patient and family personally and socially helps the nurses to connect with them, there by setting the scene for shared decision making (Hain and Sandy 2013). Most often frail and elderly patients, who are nearing the end of their life, fail to decide for themselves and are not able to participate in independent decision making (Légaré and Thompson-Leduc 2014). Thus, involving the family members during decision making will allow them to speak for the elderly.
Another factor that creates a negative impact on such encounters is the presence of long waiting hours. Usually, nurses often fail to adhere to timely administration of the proposed therapeutic intervention to the patients (Kaya et al. 2012). They also demonstrate a lack of time management techniques while visiting the patients at their homes. This creates a negative impact and gives the patients a realization that they are unwanted and their healthcare needs are not being given adequate importance. It makes the patients as well as their family members feel frustrated and increases their worries (Dahlen, Westin and Adolfsson 2012). Therefore, it can be stated that there are certain factors that can impede effective patient-nurse caring conversation.
Language acts as the means that helps patients to access the available healthcare system and enables them to take proper decisions to meet their health needs (Sentell and Braun 2012). In addition, language also acts the means that is used by healthcare providers such as, nurses for accessing the beliefs of their patients on health and illness (Crosby 2013). The major problem that arose in this context was my difficulty in understanding the language that most of my patients used to communicate. This can be attributed to the fact that there has been a dramatic increase in the number of immigrants in the UK in the past decades (Diamond et al. 2012). While paying visits to the patients who had suffered from stroke or dementia, at the community hospitals and their homes, I failed to understand what they tried to convey on their healthcare demands. This communication failure imposed barriers in my delivery of healthcare services. Such a poor understanding had the chances of misdiagnosis of the patient’s condition, which in turn could have resulted in health complications and adverse effects.
Aphasia is a common speech disorder that is often associated with stroke and dementia. Both the health disorders give rise to conditions where the speech gets occasionally slurred and the patients make sounds that are understandable as speech (Mesulam et al. 2012). Evidences from research studies state that the two health abnormalities results in damage to the left hemisphere of the brain that results in an impairment of both language expression and understanding (Maas et al. 2012). Language recovery is not an easy process. This contributed to my failure to comprehend what were the decisions of the patients regarding their own health. Thus, I had to engage their family members in the discussion, where the latter often advocated on behalf of the patients. I should have emphasized on the essential aspects of therapeutic interventions by using appropriate gestures and should also have modified the complexity of the conversation, to understand the wishes of the patients.
Our role as a nurse requires us to use a plethora of practical and theoretical knowledge in our practice. There is a need to gain a considerable amount of new nursing knowledge for providing appropriate level of nursing care to the patients. I displayed a lack of clinical knowledge and competence related to occupational therapy and physiotherapy interventions that were being applied on the patients. It is imperative for nurses to explore the professional beliefs and discard the theories and beliefs that are without relevant clinical merit. Therefore, demonstration of adequate clinical knowledge enables nurses to justify their actions and stop poor and unsafe practices (Shin and Cho 2012). The fact that nurses are expected to demonstrate a wide range of knowledge and clinical skills added complexity to the situation. Although, there is less likelihood for reversing the physical and cognitive performance of the patients by administration of these therapies, the patients most often demonstrate improved function through adaptation and compensation.
The community hospital where I assisted the matron, involved a number of healthcare staff, and social service providers who worked together to deliver tailored services to the patients. I lacked a sound understanding of the range of occupational therapy and physiotherapy interventions that are required to provide assistance to dementia and stroke patients. I was not acquainted with the one-handed techniques, adapted equipments, break activities and cognitive rehabilitation that are essential for assisting stroke patients. Furthermore, this clinical incompetence also made me fail to understand the importance of such therapies in dementia. Had I demonstrated a sound understanding of these skills, I would have been able to educate the family members and the patients on the functional implications of the therapies, which would have created significant improvements in patient outcomes.
The patient record acts as the principal repository of information that concerns the healthcare of the patient. The medical records comprise of medical notes that are made by nurses, physicians, lab technicians and other members involved in the healthcare team (Caine and Hanania 2012). Furthermore, it can be stated that continuity of care is associated with improving the quality of healthcare service over time. I demonstrated a failure of recording patient continuity during patient handovers (Gottesman et al. 2013). This acted as a major barrier in delivering seamless healthcare services through coordinating and sharing information between the team members. The fluid and food chart of patients provide essential information that helps in their nutritional assessment and also assists in determination of subsequent treatment plans. Lack of effective communication, between the providers involved in the healthcare team, lead to a disruption of patient continuity. This contributed to my failure in understanding the medical records of the patients and created problems in their assessment. Thus, this challenge created difficulties in accurate documentation of relevant clinical information.
Health promotion interventions related to prevention of stroke involve selection of a healthy diet that is low in the content of saturated fats, cholesterol, and trans fat. Adherence to a diet, rich in fibres stroke by lowering the cholesterol levels. Limiting sodium intake also helps in lowering blood pressure, thereby reducing the chances of stroke (Lam et al. 2013). Obesity and sedentary lifestyle are other risk factors that predispose an individual to stroke (Jauch et al. 2013). The NHS also promotes increasing awareness on the ill effects of smoking and alcohol consumption on irregular heartbeats and heart diseases (Party 2012). Thus, there is a need to manage the underlying risk factors in order to prevent stroke. On the other hand, several public health interventions have also been formulated that seek to reduce the burden of dementia across the UK population.
Although at present there is no available cure for dementia, showing compliance to regular physical exercise, diet, managing risk conditions such as, high blood pressure and type 2 diabetes, and abstaining from excessive smoking and alcohol consumption helps in reducing the risk of developing vascular dementia (Bowen 2012). Several dementia friendly communities have been formulated by the government to delay or reduce the need of intensive long-term care. These communities are supported by commissioners and public health agencies to ensure that people who are affected with dementia are provided with necessary support. In addition, the directors of Public Health in England recognise dementia as a major priority and support the development of these communities (Wiersma and Denton 2016).
The clinical placement in community health care setting allowed me to reflect on my practice as a nurse. Initially, I faced difficulty in understanding the concept of community nursing. I was unaware of the roles and responsibilities that community health nurses have. This placement helped in my professional and personal development. It helped me understand that community health nurse’s function as consultants, healthcare providers, advocates, educators and collaborators with other health professionals, for obtaining healthy outcome of the entire community. As part of health care teams, community health workers (CHWs) function as a part of healthcare teams and help in enhancing the effectiveness and nursing practice of public health practitioners (Gopalan, Mohanty and Das 2012).
It made me realise that effectively communicating with patients, belonging to diversity and ethnic groups requires utilisation of a variety of strategies that focus on individual health needs of the patients and their families, in a community setting. I understood that therapeutic communication involves use of reflection in practice, shared decision making, verbalizing implied thoughts and acknowledging the feelings of the patients and their family members. Treating the patients with dignity and respecting their autonomy is another important aspect of community health nursing. The reflective practice helped me identify my strength and weakness. It helped me understand that the foundations of a holistic health care delivery are based on an effective nurse-client relationship. Such a therapeutic relationship focuses on efficient communication, trust, empathy and cultural sensitivity.
Owing to the fact that community health care is a multicultural environment, it is expected from me to care for all patients, regardless of their cultural and ethical background. This begins with eliminating language barriers (Anderson and St Hilaire 2012). Therefore, it is essential for me to assess the language needs of all patients and request for translation services whenever required. Developing my verbal and nonverbal communication skills will help me to foster a healthy relationship with the patient. I will be able to better understand their needs and provide them reassurance.
On the other hand, I also need to increase my clinical competence. It is extremely essential for all nursing staff to improve their clinical nursing skills with the help of evidence-based resources. These resources help nurses to develop their competency, communication skills and critical thinking skills. Therefore, I intend to increase my competency by an extensive study of evidence-based researches that will help me know about the different diseases or conditions that prevail and the best interventions and therapies available to treat the patients. Keeping my professional knowledge up to date will further as an essential step for improving my nursing skills.
I will also try to reduce my phobia of domestic animals, for preventing all forms of distractions that create hindrances in my role of providing holistic care to the patients at their homes. Another major challenge that I faced occurred during the clinical handover of the patients, which resulted in mistakes in the medical records. An ineffective communication led to several problems in correct documentation of the food and fluid intake charts of the patients. Thus, there is a need for further improvement in this aspect of nursing. I wish to develop a professional development plan for working on my weaknesses with the sole aim of improving my nursing practice.
|
Target |
Development process |
Requirements |
Time required |
Evidence of completion |
|
Improve my communication skills. |
I will learn the appropriate words while talking to patients; I intend to understand the basic non-verbal gestures that will help me communicate with frail and elderly patients and those from different cultural backgrounds who find difficulty in comprehending speech. |
Read available books on non-verbal communication skills; Enrol at a communication skill enhancement course; asking for interpreters or translators |
5-10 months |
Positive responses from patients and family members |
|
Increase my nursing competency |
I want to improve my nursing competencies for professional growth and enhancing patient outcomes |
Engaging with healthcare professionals from other departments; attending webinars and conferences; joining professional nursing clubs to share ideas |
1 year |
Capability to understand the therapeutic terms used by team members; efficient administration of the said interventions across all disciplines. |
|
Improving patient continuity |
I want to reduce chances of errors in medical records during patient handover |
Educating myself on the use of electronic record systems; regular feedback; clarifying doubts during handover |
10-11 months |
Less reports of medication errors |
|
Increase active listening skills |
I intend to allocate more time to patients and pay attention to what they say. |
Joining an active listening course |
6 months |
Development of a good rapport with patients |
Table 1- Professional development plan
Thus, it can be concluded that the clinical placement was extremely beneficial for me as it helped me to identify my strength, clinical competency, and weaknesses.
References:
Anderson, D.R. and St Hilaire, D., 2012. Primary care nursing role and care coordination: an observational study of nursing work in a community health center. Online journal of issues in nursing, 17(2), p.E1.
Barry, M.J. and Edgman-Levitan, S., 2012. Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine, 366(9), pp.780-781.
Billinger, S.A., Mattlage, A.E., Ashenden, A.L., Lentz, A.A., Harter, G. and Rippee, M.A., 2012. Aerobic exercise in subacute stroke improves cardiovascular health and physical performance. Journal of neurologic physical therapy: JNPT, 36(4), p.159.
Bowen, M.E., 2012. A prospective examination of the relationship between physical activity and dementia risk in later life. American Journal of Health Promotion, 26(6), pp.333-340.
Bridges, J., Nicholson, C., Maben, J., Pope, C., Flatley, M., Wilkinson, C., Meyer, J. and Tziggili, M., 2013. Capacity for care: meta?ethnography of acute care nurses’ experiences of the nurse?patient relationship. Journal of Advanced Nursing, 69(4), pp.760-772.
Caine, K. and Hanania, R., 2012. Patients want granular privacy control over health information in electronic medical records. Journal of the American Medical Informatics Association, 20(1), pp.7-15.
Cleary, M., Hunt, G.E., Horsfall, J. and Deacon, M., 2012. Nurse-patient interaction in acute adult inpatient mental health units: a review and synthesis of qualitative studies. Issues in Mental Health Nursing, 33(2), pp.66-79.
Crosby, S.S., 2013. Primary care management of non–English-speaking refugees who have experienced trauma: a clinical review. Jama, 310(5), pp.519-528.
Dahlen, I., Westin, L. and Adolfsson, A., 2012. Experience of being a low priority patient during waiting time at an emergency department. Psychology research and behavior management, 5, p.1.
Decker, J.L. and Shellenbarger, T., 2012. Strategies for nursing faculty to promote a healthy work environment for nursing students. Teaching and Learning in Nursing, 7(2), pp.56-61.
Devik, S.A., Enmarker, I. and Hellzen, O., 2013. When expressions make impressions—nurses’ narratives about meeting severely ill patients in home nursing care: A phenomenological-hermeneutic approach to understanding. International journal of qualitative studies on health and well-being, 8(1), p.21880.
Dewar, B., 2017. Caring Conversation Framework to promote person centred care: synthesising qualitative findings from a multi-phase programme of research. International Journal of Person Centered Medicine, 7(1), pp.31-45.
Diamond, L.C., Luft, H.S., Chung, S. and Jacobs, E.A., 2012. “Does This Doctor Speak My Language?” Improving the Characterization of Physician Non?English Language Skills. Health services research, 47(1pt2), pp.556-569.
Dinç, L. and Gastmans, C., 2012. Trust and trustworthiness in nursing: an argument?based literature review. Nursing inquiry, 19(3), pp.223-237.
Dinç, L. and Gastmans, C., 2013. Trust in nurse–patient relationships: A literature review. Nursing Ethics, 20(5), pp.501-516.
Dupuis, S.L., Gillies, J., Carson, J., Whyte, C., Genoe, R., Loiselle, L. and Sadler, L., 2012. Moving beyond patient and client approaches: Mobilizing ‘authentic partnerships’ in dementia care, support and services. Dementia, 11(4), pp.427-452.
Ek, K., Westin, L., Prahl, C., Österlind, J., Strang, S., Bergh, I., Henoch, I. and Hammarlund, K., 2014. Death and caring for dying patients: exploring first-year nursing students’ descriptive experiences. International journal of palliative nursing, 20(10), pp.509-515.
Fauth, E., Hess, K., Piercy, K., Norton, M., Corcoran, C., Rabins, P., Lyketsos, C. and Tschanz, J., 2012. Caregivers’ relationship closeness with the person with dementia predicts both positive and negative outcomes for caregivers’ physical health and psychological well-being. Aging & mental health, 16(6), pp.699-711.
Gopalan, S.S., Mohanty, S. and Das, A., 2012. Assessing community health workers’ performance motivation: a mixed-methods approach on India9s Accredited Social Health Activists (ASHA) programme. BMJ open, 2(5), p.e001557.
Gottesman, O., Kuivaniemi, H., Tromp, G., Faucett, W.A., Li, R., Manolio, T.A., Sanderson, S.C., Kannry, J., Zinberg, R., Basford, M.A. and Brilliant, M., 2013. The electronic medical records and genomics (eMERGE) network: past, present, and future. Genetics in Medicine, 15(10), pp.761-771.
Gov.uk (2017). Dementia – GOV.UK. [online] Gov.uk. Available at: https://www.gov.uk/government/policies/dementia [Accessed 30 Dec. 2017].
Gunn, J.M., Ayton, D.R., Densley, K., Pallant, J.F., Chondros, P., Herrman, H.E. and Dowrick, C.F., 2012. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Social psychiatry and psychiatric epidemiology, 47(2), pp.175-184.
Hain, D.J. and Sandy, D., 2013. Partners in care: patient empowerment through shared decision-making. Nephrology Nursing Journal, 40(2), p.153.
Haugan, G., 2014. The relationship between nurse–patient interaction and meaning?in?life in cognitively intact nursing home patients. Journal of Advanced Nursing, 70(1), pp.107-120.
Jauch, E.C., Saver, J.L., Adams, H.P., Bruno, A., Demaerschalk, B.M., Khatri, P., McMullan, P.W., Qureshi, A.I., Rosenfield, K., Scott, P.A. and Summers, D.R., 2013. Guidelines for the early management of patients with acute ischemic stroke. Stroke, 44(3), pp.870-947.
Kaya, H., Kaya, N., Pallo?, A.Ö. and Küçük, L., 2012. Assessing time-management skills in terms of age, gender, and anxiety levels: A study on nursing and midwifery students in Turkey. Nurse Education in Practice, 12(5), pp.284-288.
Lam, O.L., McMillan, A.S., Samaranayake, L.P., Li, L.S. and McGrath, C., 2013. Randomized clinical trial of oral health promotion interventions among patients following stroke. Archives of physical medicine and rehabilitation, 94(3), pp.435-443.
Laver, K., George, S., Thomas, S., Deutsch, J.E. and Crotty, M., 2012. Virtual reality for stroke rehabilitation. Stroke, 43(2), pp.e20-e21.
Légaré, F. and Thompson-Leduc, P., 2014. Twelve myths about shared decision making. Patient education and counseling, 96(3), pp.281-286.
Lerdal, A. and Gay, C.L., 2013. Fatigue in the acute phase after first stroke predicts poorer physical health 18 months later. Neurology, 81(18), pp.1581-1587.
Levy?Malmberg, R. and Hilli, Y., 2014. The enhancement of clinical competence through caring science. Scandinavian journal of caring sciences, 28(4), pp.861-866.
Maas, M.B., Lev, M.H., Ay, H., Singhal, A.B., Greer, D.M., Smith, W.S., Harris, G.J., Halpern, E.F., Koroshetz, W.J. and Furie, K.L., 2012. The prognosis for aphasia in stroke. Journal of Stroke and Cerebrovascular Diseases, 21(5), pp.350-357.
Mesulam, M.M., Wieneke, C., Thompson, C., Rogalski, E. and Weintraub, S., 2012. Quantitative classification of primary progressive aphasia at early and mild impairment stages. Brain, 135(5), pp.1537-1553.
Mikesell, L., 2013. Medicinal relationships: caring conversation. Medical education, 47(5), pp.443-452.
Nhs.uk (2017). NHS Choices Home Page. [online] Nhs.uk. Available at: https://www.nhs.uk/pages/home.aspx [Accessed 30 Dec. 2017].
Oshima Lee, E. and Emanuel, E.J., 2013. Shared decision making to improve care and reduce costs. New England Journal of Medicine, 368(1), pp.6-8.
Party, I.S.W., 2012. National clinical guideline for stroke. Retrieved from- https://bsnr.org.uk/wp-content/uploads/2014/05/national-clinical-guidelines-for-stroke-fourth-edition.pdf
Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W. and Ferri, C.P., 2013. The global prevalence of dementia: a systematic review and metaanalysis. Alzheimer’s & Dementia, 9(1), pp.63-75.
Reiner, M., Niermann, C., Jekauc, D. and Woll, A., 2013. Long-term health benefits of physical activity–a systematic review of longitudinal studies. BMC public health, 13(1), p.813.
Richardson, T.J., Lee, S.J., Berg-Weger, M. and Grossberg, G.T., 2013. Caregiver health: health of caregivers of Alzheimer’s and other dementia patients. Current psychiatry reports, 15(7), p.367.
Schulman?Green, D., Jaser, S., Martin, F., Alonzo, A., Grey, M., McCorkle, R., Redeker, N.S., Reynolds, N. and Whittemore, R., 2012. Processes of self?management in chronic illness. Journal of Nursing Scholarship, 44(2), pp.136-144.
Sentell, T. and Braun, K.L., 2012. Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. Journal of health communication, 17(sup3), pp.82-99.
Shin, K.A. and Cho, B.H., 2012. Professional self-concept, critical thinking disposition and clinical competence in nursing students. Journal of Korean Academy of Fundamentals of Nursing, 19(1), pp.46-56.
Tanay, M.A., Wiseman, T., Roberts, J. and Ream, E., 2014. A time to weep and a time to laugh: humour in the nurse–patient relationship in an adult cancer setting. Supportive Care in Cancer, 22(5), pp.1295-1301.
Wälivaara, B.M., Sävenstedt, S. and Axelsson, K., 2013. Caring relationships in home-based nursing care-registered nurses’ experiences. The open nursing journal, 7, p.89.
Wiechula, R., Conroy, T., Kitson, A.L., Marshall, R.J., Whitaker, N. and Rasmussen, P., 2016. Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient?. Journal of advanced nursing, 72(4), pp.723-734.
Wiersma, E.C. and Denton, A., 2016. From social network to safety net: Dementia-friendly communities in rural northern Ontario. Dementia, 15(1), pp.51-68.
Essay Writing Service Features
Our Experience
No matter how complex your assignment is, we can find the right professional for your specific task. Contact Essay is an essay writing company that hires only the smartest minds to help you with your projects. Our expertise allows us to provide students with high-quality academic writing, editing & proofreading services.
Free Features
Free revision policy
$10Free bibliography & reference
$8Free title page
$8Free formatting
$8How Our Essay Writing Service Works
First, you will need to complete an order form. It's not difficult but, in case there is anything you find not to be clear, you may always call us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download