Critically evaluate the implications of public services outsourcing Essay

Critically evaluate the implications of public services outsourcing for the management of labour and industrial relations - Essay Example the outsourcing as an issue has drawn wide attention from different scholars, mostly those interested in the disentangling the effect of the value chain restructuring in the private firms. Nevertheless, there has been extremely limited systematic comparative research on the topic within the public sector organisations whereby the practitioners and the scholars majorly focus on the economic implications. The adoption of outsourcing strategies in the public sector has significantly impacted on the management of labour and industrial relations. Thus, drawing from the above, this paper aims at filling the gap, discussing the impacts of the outsourcing of the public services on the on the labour and the industrial relations structure in the public sector in the comparative perspective. The goal of this paper is twofold. First, it aims at disentangling the interplay of the restructuring towards the outsourcing of the public services, the terms of the employees and the dynamics and conditions of the employment relations in the various sectors across countries. Secondly, the study is focused on the examination of whether the impacts of the outsourcing cluster to result in the discernable convergent trajectories in any given sector or the country. Value chain analysis has been the alternative approach that revises on the thinking about how the outsourcing relationships should be structured and conceived. Outsourcing can be described as the form of the restructuring whereby â€Å"one organisation contracts with another for the provision of the particular goods and services† (Asher, 1987) instead of providing the goods or services directly. This inter-firm relationship directly impacts on the employment conditions and work organisation of the public services. The value chain analysis is a fundamental analytical tool for the disentangling how the external restructuring process impacts on the quality of the work and the employment relationships. The position of the

Business Administration (Research Article Critique) Lab Report

Business Administration (Research Article Critique) - Lab Report Example The following hypothesis may be developed for the present study: Interview schedule has been applied as the tool for data collection for the present study. Eighty seven respondents belonging to different age-groups, gender and area were selected on the basis of quota (non-probability) sampling for the interview. After the research process, the hypothesis was upheld. Balance in life maintains imperative significance in man’s life. The researches reveal the very fact that more healthy and satisfied the individuals be in a social set up, more will be the chances of the society and culture to grow and lead the world at large. It is therefore almost all societies of the world lay stress on the healthy and creative activities to make its culture a highly successful one. Though it is a fact beyond doubt that man cannot live without work, but it is also the reality that a balanced life containing professional commitment as well as recreational activities add more and more to man’s triumphs while climbing the ladder of his career life. It has aptly been stated that man is a social animal; all his needs and desires are fulfilled by living within a social set up and leading a gregarious life. He has to work hard from dawn to dusk in order to earn his bread on the one hand and keep the wolf from the door on the other. In the same way, he requires a balance life to make his life more and more comfortable. Modern industrialization and technological advancement has turned slow, sluggish and laggard life into very quick, fast and speedy one. Though demand for more and more technicalities and proficiencies in career life has got a significant boost and people look for delicacy as well as perfection in each and every profession, against which the professionals have to make hard efforts to prove their worth in this age of perfect

Management of Pain in Trigeminal Neuralgia

Management of Pain in Trigeminal Neuralgia Percutaneous management of pain in Trigeminal Neuralgia under computed tomography guidance Corersponding Author Dr. Mitesh Kumar Main Author Dr. Roy Santosham Co Authors Dr. Bhawna Dev Dr. Deepti Morais Dr. Rupesh Mandava Dr. R. Jeffrey Abstract Trigeminal Neuralgia (TN) is a brief, excruciating and perhaps the most severe pain known to man affecting the hemifacial region. It occurs mainly due to tortuous vessel compressing the trigeminal nerves, though in many cases, the exact etiology and pathogenesis remain undetermined. The first line therapeutic option for patients affected by TN is the medical line of management and patients refractory to the same, are offered various invasive procedures like balloon compression, gamma knife surgery, radiofrequency ablation, etc. In this paper, we present percutaneous management of the pain by injecting neurolytic drugs in the foramen ovale under Computed Tomography (CT) guidance as the new and promising technique of treatment in TN. Keywords Trigeminal Neuralgia, percutaneous management, CT guidance, neurolytic drugs Objective To evaluate the efficacy and safety of Computed Tomography guided percutaneous management of pain in trigeminal neuralgia using neurolytic drugs. Introduction Trigeminal Neuralgia is also known as tic douloureux, a term given to this painful disease by Nicolaus Andre in 1756 [1] . TN is a pain which typically is intense, brief, usually unilateral, recurrent shock like involving the branches of fifth cranial nerve [2]. It can be mainly classified into two types. First being, the classical TN (Type I), which is due to neurovascular compression, the most common vessel causing the same being superior cerebellar artery followed by anterior inferior cerebellar artery [3]. Second type is atypical TN (Type II), secondary to causes like trauma, tumor, multiple sclerosis or herpetic infections. The distinction between these two types is mainly based on clinical symptoms [4, 5] as Type I pain is episodic in nature whereas Type II pain is more constant. TN is often called by many as â€Å"the suicide disease† [6] as the patients who suffer from it would rather take their lives than bear the pain. The initial line of treatment for TN is medical management by drugs like Carbamazepine, Gabapentin, Oxcarbazepine among others. Patients of type I TN may also be advised microvascular decompression. Those patients who do not respond or have contraindications to the above mentioned drugs or experience no change in the intensity of the pain are called Refractory TN [7]. Such patients are advised invasive procedures like trigeminal nerve block neurolytic block, radiofrequency ablation, gamma knife surgery and balloon compression. We describe our experience in percutaneous management of pain by injecting neurolytic drugs in the foramen ovale under CT guidance in six patients, suffering from TN. Method and Materials used Pre procedural work up The pre procedural work up included clinical evaluation and thorough reading of the Magnetic Resonance Imaging (MRI) scans of all the patients to rule out any neurovascular conflict. Any patient with neurovascular conflict was considered an exclusion criterion in our study. These patients were reported taking the drugs for TN for over three months with no improvement in the pain. The pain score evaluation was done using Numeric Rating Scale [8] and Wong-Baker Faces Pain Rating Scale [9] as a baseline evaluating point to be compared to the same scoring system after the procedure. Routine investigations such as coagulation profile, liver function test, renal function test, HIV and HbsAg were done before the procedure. Numeric Rating Scale Patients rate pain on a number scale from 0-10, 0 being a depiction for no pain and 10 being the worst pain imaginable. Wong-Baker Faces Pain Rating Scale The Wong-Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker. The scale shows a series of faces ranging from a happy face at 0 (No Pain) to a crying face at 10 (Worst Pain Possible). The patient must choose the face that best describes how they are feeling. In our study, we use the Wong Bakers scale to assess the patients’ pain before and after the procedure. The neurolytic drugs and materials used in the procedure were 22 G spinal needle for block, 25 G needle for skin infiltration, 2% xylocaine , Iohexol Non ionic contrast medium, 100% alcohol, 1ml syringe and normal saline solution. The patient was put in the supine position with head placed in reverse occipitomental position (chin up and neck extended), turned 30 ° to the opposite side of the block. The foramen ovale was identified under CT guidance and a virtual track was made starting from a point which was 2-3cms lateral to the angle of mouth on the skin to foramen ovale (Figure 1). Once the trajectory of the needle and the foramen ovale was confirmed on CT scan, the skin at the point of entry was infiltrated by 2ml of 2% xylocaine using a 25G needle. Then, a 22G spinal needle was inserted at the same point and aimed in the direction of planned trajectory towards the foramen ovale (Figure 2). To prevent the needle from entering the oral cavity, a finger from inside the mouth can be used to guide the same [10]. Though, we did not apply this in any of our patients. Following this, negative aspiration was attempted to check for Cerebro Spinal Fluid (CSF) or blood aspirate. If the aspirate contained CSF or blood then the needle had to be readjusted. Then 0.5ml of mixture made from 1ml of iohexol and 2ml of 2% xylocaine was injected into the target site in order to check the spread of injectant and exact needle tip position. Once the tip of the needle touches the mandibular nerve root, the patient might complain of the exact similar pain which he/she has been suffering, thus confirming the accurate needle tip location. This injectant acts as a diagnostic block if the trigeminal ganglion is the pain generator with xylocaine providing anesthesia prior to alcohol injection. A mixture containing 3ml of 100% alcohol, 1ml of iohexol and 1 ml of saline was made. Of this 1ml of the mixture was injected into the foramen ovale (Figure 3 and 4). Post procedure check scan was performed to rule out any complication. Result Exact position of the needle tip in the foramen ovale was seen in all the six patients thus achieving 100% technical success. All these patients achieved a significant level of relief with an average pain score of two immediately after the procedure. Twenty four hours after the procedure, they rated their reduction of pain at an average pain score of one. Four out of the six patients ie Patient No. 1, 2, 4 and 6 were completely relieved of their pain with one year follow up without taking any medication. In Patient No. 3, the procedure was abandoned as during the diagnostic block, the injectant was seen tracking into CSF cistern and fourth ventricle. Patient No. 5 reported with a similar pain of TN within three months with a pain score of five, little less than the pre-procedure pain score of six. The pain was more severe in the pterygopalatine segment, hence a pterygopalatine block was carried out and the patient had a pain score of one twenty four hours after the procedure. Hence, the initial trigeminal neurolysis was partially successful in this patient. No post procedural complication was seen in any of our patients. Discussion The trigeminal nerve arises from the lateral pons at its superior to mid portion. It travels forward in posterior fossa and merges with the trigeminal ganglion in the Meckels cave. The trigeminal ganglion is located lateral to the cavernous sinus. It gives three divisions ophthalmic (V1) segment which emerges from superior orbital fissure, maxillary (V2) from foramen rotundum and mandibular (V3) from foramen ovale. The trigeminal nerve provides sensation for the face, mouth and supplies the muscles of mastication. TN mostly involves maxillary division and mandibular division of trigeminal nerve though it may also involve the ophthalmic division as well. The reported annual incidence rate of TN is about 4.5 per 100,000 persons [11] but the actual figures may be even much higher because of diagnostic challenges associated with the disease. TN is more common in females than males with a ratio of 3:2 and is usually seen after 50 years of age [11]. Trigeminal nerve block is an upcoming treatment in TN patients who are refractory to medical line of management. It relieves the pain and also reduces the side effects of drugs which are used for the treatment. Earlier studies were mainly done using x-ray or fluoroscopic guidance which had its own limitations in terms of image quality and two dimensional views. In contrast to this, CT scan provides excellent and direct visualization of foramen ovale leading to correct placement of needle [12] and thus scoring over fluoroscopy. This reduces the chances of injecting neurolytic agents at improper locations and thereby reduces the side effects. In our cases, initial check CT scan was done by injecting 1ml of iohexol to determine whether the needle is in exact location. This doubly ensured us about the location as well as the spread of injectant. This was different from previous studies done using fluoroscopy where a diagnostic block using xylocaine had to be given in order to confirm the location of the needle tip. We used a mixture of 3ml of 100% alcohol, 1ml of iohexol and 1ml of saline for trigeminal neurolysis however, Han et al stated that trigeminal nerve block with high concentration of lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain and shorter duration of pain prior to the procedure [13]. Alcohol spreads easily and should be used cautiously. The other agents which can be used but were not used in our study are phenol and glycerol. The side effects that may follow the procedure are numbness and hypoesthesia in the entire trigeminal nerve distribution. There can be abolition of corneal reflexes which can produce exposure keratitis and dryness of eyes. Improper injection of alcohol into CSF space can lead to arachnoiditis/ meningitis. CASE 1, 2, 4 and 6 These patients were suffering from trigeminal neuralgia with pain score ranging from six to eight before the procedure. All these patients have been taking carbamazepine for more than three months with no relief from pain. MRI showed no neurovascular conflict. These patients had a significant relief of pain with pain score at three months and twelve months being zero. None of these patients had to take oral medicines after the procedures. Fig 1: Site marked for needle Fig 2: Tip of the needle in foramen insertion ovale Fig 3: Dispersion of injectant in Fig 4: 3D reconstruction showing the foramen ovale needle tip in foramen ovale. Case 3 This eighty year old male came with complains of left sided trigeminal neuralgia. He had been taking carbamazepine for four months with no change in pain intensity. The procedure had to be abandoned as after injecting the diagnostic block, the injectant was seen tracking into the CSF cistern in the cerebello pontine angle and fourth ventricle (Figure 5). Fig 5: CT scan showing needle tip in the left foramen ovale Case 5 This forty seven year old female came with complains of right sided trigeminal neuralgia. She had been taking carbamazepine for three months without any relief in pain. MRI scans showed no neurovascular conflict. The procedure was successful with pain score of one immediately after and at twenty four hours after the procedure (Figure 6). However, this patient came back within three months of the procedure complaining of pain, which was more in the pterygopalatine segment. A pterygopalatine block was done with resultant pain score of one at twenty four hours after the procedure and two at nine months of the procedure. Hence, this patient showed partial response to trigeminal neurolysis carried out initially. Fig 6: CT scan showing the tip of the needle in right foramen ovale. Conclusion Percutaneous injection of alcohol, iohexol and saline mixture at the verge of foramen ovale under CT guidance is an effective and promising method to relieve pain in patients of TN refractory to medical line of management. This technique is inexpensive, cost effective and a relatively painless procedure. Being a minimally invasive technique, the chances of any infection and other post operative complications are less. Since our study involved only six patients, this technique needs to be further evaluated on a large sample size to substantiate the result of this procedure. Having said the above, we would like to emphasize that our initial experience of this procedure was quite impressing. Abbreviations TN Trigeminal Neuralgia CT Computed Tomography CSF Cerebro Spinal Fluid MRI – Magnetic Resonance Imaging References Andre ´ N. Traite ´ sur les maladies de l’ure`thre. Paris: Delaguette, 1756 Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994. P. 59-71 Jannetta PJ. Microvascular decompression of the trigeminal nerve for tic doloreux. In: Youmans ed. Neurological surgery 4th edn. WB Saunders Co. Philadelphia. 1996: 3404-15 Cruccu G, Gronseth G, Alksne J, et al. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol. 2008; 15 (10): 1013-28 Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008; 71 (15): 1183-90 Michael D. Chan, Edward G. Shaw, Stephen B. Tatter. Radiosurgical Management of Trigeminal Neuralgia. In: editor Pollock Bruce, Intracranial Stereotactic Radiosurgery, an Issue of Neurosurgery Clinics. Elseiver Health Sciences. 2013. pp. 613-621 Cruccu G, Truini A. Refractory Trigeminal Neuralgia. Non-surgical treatment options. CNS Drugs. 2013 Feb;27(2):91-6. doi: 10.1007/s40263-012-0023-0. Hartrick CT, Kovan JP, Shapiro S (December 2003). The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 3 (4): 310–6. doi:10.1111/j.1530-7085.2003.03034.x. PMID 17166126. Wong-Baker FACES Pain Rating Scale Foundation: Retrieved 6 December 2009. Michael J. Cousins In: trigeminal nerve block. Cousins and Bridenbaughs Neural Blockade in Clinical Anesthesia and Pain Medicine. Lippincott Williams Wilkins, 29-Mar-2012, 410 Allan B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen, Jeffrey J. Schaider, Ghazala Q. Sharieff. In: Bell’s palsy and trigeminal neuralgia. Harwood-Nuss Clinical Practice of Emergency Medicine. Lippincott Williams Wilkins. June 23, 2009, 786 Và ­ctor Whizar-Lugo MD, Francisco Anzorena-Vallarino MD, Roberto Cisneros-Corral MD, Ricardo Valdez-Jeres MD, Rogelio Hernà ¡ndez-Velazco DDS. Use of Computed Tomography Guide for Trigeminal Alcohol Neurolysis. Anestesia en Mexico: Volume 20 No. 1 (January-April 2008) Han KR, Kim C, Chae YJ, Kim DW. Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia. Int J Clin Pract. 2008 Feb;62 (2):248-54. Epub 2007 Nov 23.

Using Technology for Research and Learning in the Field of Education Es

Using Technology for Research and Learning in the Field of Education In the last decade technology has expanded greatly. Now, we can order movie tickets, make reservations, and even listen to music without ever leaving the comfort of our own homes. But technology tools are not only used for entertainment purposes. These tools also help us learn and explore new things. The purpose of this paper is to investigate the effectiveness of technology tools as they apply to learning and research within education. Tools for Teaching and Learning The computer is a very important tool used in education. â€Å"During the past three decades, computers have become the most talked about, written about, and ubiquitous machines ever to be imposed upon mankind.†( Rockart, 1995, p. 55). The ENIAC (Electronic Numerical Integrator and Calculator) is said to be the first computer. It was a â€Å"huge machine having thousands of vacuum tubes and consuming vast amounts of electrical power.† ( Merrill, 1996, p.54). By the early 1970’s, the regular computer was invented. Around the same time, something called the Internet emerged. The Internet is a worldwide network. It connects LAN’s, WAN’s, and other regional networks from all over the world together into one global network. Recently, the Internet has become very popular. It was predicted in 1996 that by the year 2000, most universities and many homes would have Internet connections. (Merrill, 1996). This prediction was correct. By linking a computer to t he Internet, one can gain access to a wide variety of additional resources and services. One can send e-mail, access electronic boards, and obtain a huge amount of information from different databases. Using e-mail greatly benefits students. With access t... ...ing. Retrieved October 8, 2001 from: http://ccaat.sas.upenn.edu/jod/teachdemo/teachdemo.html. Questia launches student research and paper-writing service. (2001). Information Today, 18, 34. Retrieved October 7, 2001 from Academic Search Premier Rockart, J. F., & Morton, M. S. (1995). Computers and the Learning Process in Higher Education. Berkeley, CA: McGraw- Hill. Scott, E. (2001). Using the internet, online services, and CD-ROMS for writing research and term papers. Book Report, 19, 80. Retrieved October 7, 2001 from Academic Search Premier. Schank, R.C., & Cleary, C. (1995). Engines for Education. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Publishers. Wilkes, D. (2001). Turning Math into a Positive Experience via Tech Tools. Media & Methods, 37, 185-204. Retrieved September 29, 2001 from Academic Search Premier.

About Bangalore Essay

Bangalore is India’s third most populous city and fifth-most populous urban agglomeration. Today, as a large and growing metropolis, Bangalore is home to some of the most well-recognized colleges and research institutions in India. Numerous public sectors, heavy industries, software companies, aerospace, telecommunications, and defence organisations are located in the city. Bangalore is known as the Silicon Valley of India because of its pre-eminent position as the nation’s leading IT employer and exporter. A demographically diverse city, Bangalore is a major economic hub and the fastest growing major metropolis in India. see more:essay on bangalore The city with an eclectic spirit, Bangalore has always attracted talents from all over India and across the world. It is a city with cosmopolitan culture. Just when one steps into the city he can feel its pulse. It is a city vibrant with its jazz festivals, fashion trends and the old age craft. The city accommodates one and all, so that everyone can happily co-exist. If you are very new to this city and it is education, which primarily brought you to this place, then there are a lot many things for you to seek, to learn to imbibe. To get your minds refreshed and to start learning with a new zest, with renewed energies it is important that you visit certain places, learn about its culture and be a part of Bangalore. Not just the places, the food of Bangalore also form a key area of interest for many. South Indian food is one of the healthiest as it is mostly non-greasy, roasted and steamed. A large selection of popular food is vegetarian. Rice is cultivated extensively and it forms an integral part of people’s diet. You can have your fill at any popular restaurant or eating joints in Bangalore. If you feel homesick and are on the look out for some home food, this city would not disappoint you. It makes you feel at home, providing you with all the facilities that you might require during your stay as a student. Most importantly, the climate of the place is very conducive for your stay.

Culturally Competent Nursing Care Essay

Culturally Competent Nursing Care The United States is a diverse accumulation of cultural backgrounds which can often set the stage for feelings of confusion, anger, mistrust, and a host of other emotions when dissimilar cultures disagree. Cultural competence in nursing can help eliminate these barriers and provide a platform for nursing to follow in the quest to understand a patient’s culture and background. When a nurse takes the time to learn about a given culture prior to providing care, it conveys she respects the patient’s right to their beliefs, customs, and culture. It does not necessarily mean the nurse agrees with their practices but it does show that she is willing to be open minded and deferential. It is the responsibility of the health care provider to take the time to educate themselves on the various cultures they may be exposed to in their work (Purnell & Paulanka, 2003). Evidence of Culturally Incompetent Care One act from the case study that exhibited cultural incompetence was the racial slur made by Connie when she referred to her clients as â€Å"This Mexican family†. If she would have taken the time to review the baby’s chart, she would have known that the family identified with the term Hispanic, not Mexican. Connie made a statement about the number of family members in the room and she gave the impression that the family was invading her work space unnecessarily. Connie identified that the family was speaking Spanish then stated she could not get them to understand her. Her tone indicated that the family was at fault for the lack of communication even though Connie did not bother to engage an interpreter. Connie even went so far as to label the family’s inability to understand her as noncompliance. She also proceeded to go about her task of putting in and intravenous (IV) line without establishing autonomy and getting informed consent from the mother. Connie’s action of cutting the â€Å"ragged, old red string† off the baby’s wrist without asking for permission first is proof of her cultural insensitivity. Many cultures tie strings around various parts of the body to ward off evil, aid  in healing, or as a symbol of faith. Connie knew she did something wrong because she admitted that the mother screamed at her when she cut the string. However, she did not take the time to understand why the mother was upset. She appeared to be more concerned with getting her nursing tasks done right away and with leaving for the day. Importance of Values, Beliefs, and Practices The iceberg model splits the nursing skill set into two parts; technical and behavioral. The tip of the iceberg represents what can be easily seen or the technical skills and knowledge a person has that allows them to perform their job. Examples of technical skills demonstrated by Connie were obtaining IV access and identifying the signs and symptoms of dehydration. These particular skills are considered visible to others so they correlate with the upper portion of the iceberg in the model. The lower part of the iceberg is under water or invisible and is indicative of the behavioral aspects of self that demonstrate who we are as a person. Understanding one’s own values, beliefs and practices helps when trying to understand those same characteristics in a different culture. Nurses need to understand how they view themselves and others before they can achieve cultural competence (Buffalo, 2001). The behavioral or lower portion of the iceberg is represented by social role, self-image, traits, and motives. The social role identifies with one’s image. It refers to how people want others to see them and how others actually do see them. The social role is important because it can establish how health care professionals determine what skill sets are important in their job. Self image is how people see themselves and once they understand themselves they can decide whether or not change is needed for personal growth. Another area on the hidden portion of the iceberg is traits or those characteristics and habits that determine how a person responds in a given situation. The last area of the iceberg is motives. Motives are formed early in life and are the driving forces behind personal actions. The status of the areas depicted in the lower part of the iceberg model also determine what characteristics are present on the visible portion of the model (Buffalo, 2001). Barriers to H ealthcare Communication is going to continue to be a huge barrier to healthcare for  this family. They live in Texas which is very rich in Spanish culture and the Spanish language is common. Health care workers are often bilingual so this family should not have any trouble being understood when they go in for care in their home state. The general population of Texas has been exposed to the Hispanic culture and can relate to the beliefs and practices that are followed. However, this family migrates to Northern Minnesota, an area that is mostly comprised of white, non-Hispanic, English speaking people of European descent. From a transcultural nursing standpoint, nurses from the Northern areas of Minnesota may not even know they are lacking because the degree of interaction with the Hispanic population in the healthcare setting is minimal. There will be language barriers, especially in the smaller, rural farming areas where the migrants tend to work. Many small rural hospitals do not have access to interpreters and it is common to have little to no cultural education provided to the employees. Unless there is a cultural change in this area of the country, communication will continue to be a problem. The disparity is one of population and geographic location relative to the Hispanic culture in Northern Minnesota (U.S., 2010). Cultural Sensitivity Information Additional information that could have been added to the kardex was the preferred method of communication so the nurse would know right away if an interpreter would be needed. Family demographics could have been put on there so the nurse had information regarding the cultural background. Notes could have been put on the kardex that identified the family dynamics so other nurses would understand why so many family members were present. The religious preferences would also be significant because that would give the nurse insight to the possible importance of certain charms, icons, or beliefs. Another item that could have been on the kardex was the history of the patient from the perspective of the clinic nurse. She may have passed on more information to Connie but as flustered as Connie was, that information was more than likely minimized or forgotten because it was not written down. Connie only gave the bare facts during report, then hurried out of the workplace, leaving Gina with mor e questions than answers. Provisions of Culturally Competent Care Gina recognized that she was lacking in cultural knowledge about this family and took the time to look up some information prior to interacting with them. She was respectful of the role of the elders and addressed each person accordingly, gaining some measure of respect in doing so. This helped her establish a mutually satisfying relationship with the family which in turn helped build trust. She also intervened and got an interpreter rather than allowing one of the younger teenagers to interpret. Gina also took the time to find out what interventions the family had provided and did not belittle them for their actions. Gina went from conscious incompetence to conscious competence and will more than likely advance into unconscious competence with time (Purnell & Paulanka, 2003). Transcultural Competency Model The Camphina-Bacote competence model identifies cultural competence as a process that a healthcare worker goes through to enable themselves to work in a manner that falls within the cultural context of a client. The model has five constructs: Awareness, skill, knowledge, encounters, and desire. The first construct of the model, awareness, asks healthcare workers to question their own cultural consciousness by identifying biases and prejudices they may have toward other cultures. It is an attempt to help one understand just how sensitive they may or may not be toward other cultures. The second construct focuses on whether or not the healthcare worker has the necessary skills to conduct a cultural assessment in a manner that will insure insightfulness. This is important for insuring that the assessment is properly done and that it contains information necessary to others who may rely on it. Having the skills alone is not enough; the person conducting the assessment also needs to have k nowledge of the culture. The assessor needs to research the culture to understand the worldview. There are many blanket questionnaires available to use for the assessment if one does not care about personalization. However, understanding the culture is important before the interview begins if the person conducting the interview wants to develop questions that are more in-depth and of a personal nature. The Camphina-Bacote model also recommends that the person conducting the cultural assessment determine what type of encounter they wish to use for the interaction. Some examples of encounters include face-to-face meetings, attending group cultural activities, phone interviewing, or any other type  of communication method. Some people may be more comfortable filling out a questionnaire, others may want to meet in a relaxed, public environment and still others might want the professional atmosphere of an office setting. Whatever type of encounter is chosen, it is important that the comfort of the person being interviewed is taken into consideration and a mutual setting is agreed upon. The last construct of the model is desire. If there is no desire on behalf of the professional to learn about cultural differences then the process of attempting to become culturally competent will fail. At the very best, the information gained will be inadequate and could cause more misunderstand and mistrust (Ingram, 2012). Ladder of Cultural Competency Based on the case study Gina was not being racists and was not blind to the patient and family’s needs or their culture. Purnell and Paulanka (2003) describe racism as a display of power in combination with prejudice: Gina did not exhibit either of these characteristics. She had a modest awareness and knowledge of the Hispanic culture and was sensitive to the family’s needs. Gina does not have the language proficiency yet so she would not be at the fifth step. Gina is on step four: Competence. She demonstrated her ability to provide culturally competent care for this family. Even though she did not already have all of the necessary information to care for this child, she knew where to go look for it and how to interpret it. She demonstrated that she valued the family’s cultural differences by taking the time to treat them with respect according to their beliefs. Utilization of an Interpreter Gina knew that the patient and the family had a right to have an interpreter provided. She also knew that it would be disrespectful to allow a younger person to translate for an older person. In addition, the younger teenager who offered to translate stated she spoke very good English but indicated that she only attended summer school while in Minnesota. What the teenager considered good English more than likely would not have been adequate to translate medical terminology. Gina made a very good decision when she brought in an interpreter. She also obtained a resource for herself because the interpreter could have had additional knowledge about the culture. The  Standards of Practice for Culturally Competent Nursing Care states that it â€Å"is critical that the healthcare system provides resources for interpretation when appropriate† (Douglas et al, 2009, p. 265). History of Present Illness Gina could have asked the mother or family what they felt the cause of the illness was. This would have given her insight as to whether the family believed the cause was physical or spiritual. If it was believed to be spiritual in nature, the family may have wanted to call in a Hispanic healer to perform a ceremony for the child. She asked how many days the child had diarrhea and could have asked whether the child’s diet had changed before her diarrhea started. She also could have asked if any other family members had experienced the same symptoms. Coming to Minnesota may have precipitated a change in diet for the entire family with the possibility of contaminated food. Gina could have addressed the pathophysiology of the illness by asking whether or not the child had experienced any functional changes. The family did indicate the they brought the child to the clinic after she became listless. Getting a background on other functional changes may provide clues to other factors that might be making the illness worse. For example, was the child falling down, crying a lot before she became listless, et cetera. Another area to look at would be the course of the illness. Gina could have the mother describe how the illness started and give a timeline of signs, symptoms, and interventions up to the present time. This could include the treatments the family provided along with what the expected outcomes were. Gina could ask the family whether or not they felt any of the interventions were successful, even if it was only mild success. It would also give Gina information about the remedies used so she could research and pass the information on to the health care provider. Two of the treatments supplied by the family were actually not conducive to good health. The manzanilla tea can cause diarrhea and the family was giving it to the child as a treatment for diarrhea. According to the CDC, greta is an orange powder used as a Hispanic remedy for stomach ailments. The powder contains concentrations of lead as high as 90% and contributes to lead poisoning (CDC, 2009). Getting the family’s perception on the illness is very important to increasing one’s awareness of how the family views the illness. Cultural Diversity Care Plans Cultural Preservation Practice| Nursing Diagnosis| Goal| Interventions| Gina provided care congruent with the culture via an interpreter. The family was unable to understand the plan of care for the child.| Knowledge deficit related to language barriers.| Patient will verbalize an understanding of the child’s condition and the need for the current treatment plan via an interpreter.| 1) Using an interpreter, explain the illness, causes, and treatment plan to the patient’s family.2) Have the primary care-giver demonstrate understanding by repeating back the plan of care and the potential benefits. 3) Allow for questions and answers.| Cultural Accommodation Practice| Nursing Diagnosis| Goal| Interventions| Gina attempted to put the family at ease by using an interpreter to find out what the family understands about the child’s illness and the interventions that were tried in the home environment. She discovered that the red string was on the child for good luck and to keep her safe from spirits.| Anxiety related to cultural lack of understanding of the illness and the treatment plan practices.| Collaborate with the family to identify treatments that are culturally acceptable and that can be used in conjunction with western medicine to address the child’s medical needs.| 1) Allow a spiritual advisor to place new red strings on the child and support a ceremony if need be.2) Explain the need for an IV and make sure it does not violate the family’s beliefs.3) Praise family for their efforts thus far.| Cultural Restructuring Practice| Nursing Diagnosis| Goal| Interventions| Gina found out the baby had been given manzanilla tea and greta. Neither of these remedies is a good choice. The manzanilla tea is used for constipation and the baby had diarrhea. According to the CDC, greta is high in lead content and causes lead poisoning.| Ineffective health maintenance related to lack of understanding.| Educate patient’s family on the illness and potential harm of some folk remedies and identify harmful remedies that the family needs to change.| 1) Provide family with culturally appropriate educational material in whatever configuration they require.2) Work with the family to develop a plan of action and identify alternatives to the harmful remedies.| Reflection Providing culturally competent care can be challenging at times and it requires nurses to be aware of their own limitations, strengths and beliefs. It was evident in the case study that Connie was not prepared to take on the task of developing her own cultural competence. Gina, however, showed good leadership ability and a willingness to learn about a culture different than her own in order to provide the best nursing care she could. Gina is the type of nurse that will continue to grow in her position and garner respect from her patients and co-workers. Her actions showed she was capable of doing what was in the best interest of the patient and family. Cultural competence does not just happen; nurses have to make it happen. References Buffalo State, (2001). Technical and behavioral success factors. Retrieved June 23, 2013, from The State University of New York: http://www.buffalostate.edu/offices/hr/pepds/sf/tb.asp. Centers for Disease Control and Prevention, (2009). Folk medicine. Retrieved July 17, 2013, from the National Center for Environmental Health: http://www.cdc.gov/nceh/lead/tips/folkmedicine.htm. Douglas, M., Pierce, J., Rosenkoetter, M., Callister, L., Hattar-Pollara, M., Lauderdale, J., & †¦ Pacquiao, D. (2009). Standards of practice for culturally competent nursing care: a request for comments. Journal Of Transcultural Nursing, 20(3), 257-269. Ingram, R. (2012). Using Campinha-Bacote’s process of cultural competence model to examine the relationship between health literacy and cultural competence. Journal Of Advanced Nursing, 68(3), 695-704. doi:10.1111/j.1365-2648.2011.05822.x Purnell, L., & Paulanka, B. (2003). Transcultural health care: A culturally competent approach. Philadelphia, PA : F. A. Davis Company. Sitzman, K., & Eichelberger, L. (2004). Understanding the work of nurse theorists: A creative beginning. Sudbury, MA: Jones and Bartlett Publishers. U.S. Department of Health and Human Services, (2010). Disparities. In Healthy People 2020. Retrieved June 26, 2013, from U.S. Department of Health and Human Services: http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx. Walsh, S. (2004). Formulation of a plan of care for culturally diverse patients. International Journal Of Nursing Terminologies & Classifications, 15(1), 17-26.