Reducing Hospital Readmissions with Telephone Follow-ups

Reducing Hospital Readmissions with Telephone Follow-ups

Chamberlain College of Nursing NR451 RN Capstone Course Capstone Project Milestone 1: Practice Issue and

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Evidence Summary Worksheets For Use July 2018 Student Name: Rosa Yanez Date: DIRECTIONS 1. 2. 3. 4. Refer to the guidelines for specific details on how to complete this assignment. Type your answers directly into the worksheets below. Submit to the Dropbox by the end of Week 3, Sunday at 11:59 p.m. MT. Post questions about this assignment to the Q & A Forum. You may also email questions to the instructor for a private response. Practice Issue Worksheet List the topic and include the citation for the systematic review you have selected from our approved list (optional: an additional scholarly source of support): Hospital Readmissions Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., & … Montori, V. M. (2014). Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. doi:10.1001/jamainternmed.2014.1608 What is the nursing practice issue you have identified related to the topic you have chosen? Are patients who receive adequate discharge planning, follow up appointments, medication reconciliation and home care services less likely to be re-admitted to the hospital within 30 days of discharge versus those who do not. Fully describe the scope of the practice issue: Readmission has been a problem in the healthcare fields for a long time and the level of readmission has increased in the recent years. This increase has led to the need to identify the ways and the factors that can be applied to help in the reduction of re-hospitalization. To this end, the provision of follow up appointments, home care services, medical reconciliation and others have been identified to help in the reduction of readmission. The issue will compare the use and the lack of use for patient to observe the outcome. NR451 W3 MS1 Practice Issue and Evidence Summary Worksheets 7/2018 DP 1 Chamberlain College of Nursing NR451 RN Capstone Course What is the practice area? _X_ Clinical ___ Education ___ Administration ___ Other (List): How was the practice issue identified? (check all that apply) ___ Difference between hospital and community practice _X__ Safety/risk management concerns ___ Clinical practice issue is a concern __X_ Unsatisfactory patient outcomes ___ Procedure or process is a time waster ___ Wide variations in practice ___ Clinical practice issue has no scientific base __X_ Significant financial concerns __ Other: Describe the rationale for your checked selections: Readmission covers a wide range of concerns and the checked concerns are the primary ones associated with this practice issue. For instance, the cost of readmissions to the health care system is substantial. Hospital are financially penalized for high rates of readmissions. Some readmissions are preventable, and that being readmitted is undesirable for most patients, reducing avoidable readmissions presents a potentially large opportunity to reduce cost, improve quality, and improve the patient experience simultaneously. What evidence must be gathered? (check all that apply) _X_ Literature search _X_ Clinical Expertise _X_ Guidelines ___ Financial Analysis ___ Expert Opinion _X_ Standards (Regulatory, professional, community) ___ Patient Preferences ___ Other NR451 W3 MS1 Practice Issue and Evidence Summary Worksheets 7/2018 DP 2 Chamberlain College of Nursing NR451 RN Capstone Course Describe the rationale for your checked selections: Literature research is essential in gathering data on the various trends that have been observed by other scholars in the rates of readmission on hospitals and specifically to certain diseases. Additionally, guidelines from scholars and approved manuals are important as they demonstrate what is considered the best practice in such cases. Expert opinion would be gathered from hospital management, nurses and doctors, it would be invaluable in giving a localized view of the issue at the hospital level. Experts are often at par with current research and have first hand experience in the field. Regulatory standards and legal provisions are paramount in this research since they show the direction that facilities are expected to turn in case of certain cases. They could demonstrate weakness in facility practices or they themselves could have fundamental flaws. The regulations that are relevant are those that pertain to hospital discharge procedures and cases of return patients. These regulations and procedures can be from the government or industrial bodies and policies. EVIDENCE SUMMARY WORKSHEET Directions: Please type your answers directly into the worksheet. Describe the practice problem in your own words with reference to the identified population, setting and magnitude of the problem in measurable terms: The main problem is that the number of patients who were being readmitted after 30 days was increasing from 1990 to 2013. The situation was affecting the effectiveness of the treatment services which were being offered in hospitals. As a measure of the problem tested interventions were introduced in the process and it was found out that in 42 cases there was a drop of patient readmission by 1.6 times when the tested intervention was used as compared to a situation where no test was conducted. Type the complete APA reference for the systematic review article you chose from the list provided. It must be relevant to the practice issue you described above. Include the APA reference for any additional optional supplemental scholarly source related to the review you wish to use. Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., & … Montori, V. M. (2014). Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. doi:10.1001/jamainternmed.2014.1608 Identify the objectives of the article: NR451 W3 MS1 Practice Issue and Evidence Summary Worksheets 7/2018 DP 3 Chamberlain College of Nursing NR451 RN Capstone Course To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features—including their impact on treatment burden and on patients’ capacity to enact post-discharge self-care—that might explain their varying effects. Provide a statement of the questions being addressed in the work and how these relate to your practice issue: Summarize (in your own words) the interventions the author(s) suggest to improve patient outcomes. The author suggests on the introduction of the tested interventions to improve the situation. In this case when patients come to hospital complete test should be conducted within 24 hours to identify the issue. From the test then the right treatment should be given to the patient. With the right treatment then it means that cases of readmission will be reduced at the end. The fact is right identification of the issue will mean that the problem in question can be handled on time and effectively making sure that the patient is not readmitted. Giving post discharge care becomes easy. The use of supportive discharge interventions aimed at avoiding readmissions. Summarize the main findings by the authors of your systematic review including the strength of evidence for each main outcome. Consider the relevance to your project proposal for the Milestone 2 project paper. (If an optional supplemental source is also used, include a statement of relevance to it as well.) It was found out that after conducting the randomized trials there was positive and also effective responses as to the use of the tested intervention as it reduced risk of 30 day readmission. With this it was found out that with effective intervention it was easy to enact the post discharge care. As the main evidence and strength of the finding it aligns with CuCoM finding which argued that provision of comprehensive patient support reduce early hospital readmission. With this it aligns with the proposal which aims at reducing readmission cases. Outline evidence-based solutions that you will consider for your project. Post-acute care services Follow up appointments Medical reconciliation Home care services Discuss any limitations to the studies that you believe impacts your ability to utilize the research in your project. NR451 W3 MS1 Practice Issue and Evidence Summary Worksheets 7/2018 DP 4 Chamberlain College of Nursing NR451 RN Capstone Course The studies were conducted in single academic center which means the applicability is limited. A wide array of centers would have given better results as compared to single source. The scale used to measure the intervention is not very clear. It means that even the results can have a problem. NR451 W3 MS1 Practice Issue and Evidence Summary Worksheets 7/2018 DP 5 Running head: TYPE SHORT TITLE IN ALL CAPS Title Your Name Chamberlain College of Nursing NR451 RN Capstone Course Term and Year 1 TYPE SHORT TITLE IN ALL CAPS 2 Your title here This paragraph(s) is to introduce the paper. State the problem and potential solutions backed by evidence. Briefly, introduce the nursing focused plan. Remember this is a scholarly APA assignment so you cannot use first person. Remember also that you will keep all the bolded headings and just remove the non-bolded content when you start your paper. Change Model Overview In this first paragraph, provide an overview of the ACE Star model Evidence-Based Practice Process. Feel free to state why nurses should use this model as a guide to facilitate change. Under each of the second level headers listed below, you now link your identified topic to the ACE Star model EBP Process. Define the Scope of the EBP Restate your practice issue. Why is this a problem? Give statistics and information to back the scope of the problem at your facility/work area. How does this problem impact healthcare on a broader scale? Stakeholders You will be the leader of the team since this is your project. Who will you also include in your team? Make sure you choose relevant stakeholders. You should have no more than eight members. Do not list your team members by name but instead by position (pharmacists, charge nurse, etc.). Determine Responsibility of Team Members Why are the members chosen important to your project? What are their roles? Evidence TYPE SHORT TITLE IN ALL CAPS 3 Conduct internal/ external search for evidence. What type of evidence did you find in addition to you Evidence Summary? EBP guidelines? Quality improvement data? Position statements? Clinical Practice Guidelines? Briefly discuss the strength of this research. This is not where you describe the results of your studies. This is done in the following steps. Summarize the Evidence In this section, you need to synthesize the information from the systematic review article. What are some of the evidence-based interventions you discovered in your Evidence Summary that do you plan to use? Be sure and cite all of your references, in proper APA format, from any and all articles into this one paragraph. Develop Recommendations for Change Based on Evidence What is your recommendation based on the research? Ideally, you will have found enough support in your evidence to proceed with implementing your pilot program. Translation Action Plan You have not implemented your project yet, therefore, this section will be hypothetical. Develop your plan for implementation. What are the specific steps you will take to implement your pilot study? What is the timeline for your plan? Make sure you include a plan for evaluation of outcomes and method to report the results. Process, Outcomes Evaluation and Reporting What are the desired outcomes? How will they be measured? How will you report the results to the key stakeholders? Identify Next Steps TYPE SHORT TITLE IN ALL CAPS 4 How will you implement the plan on a larger scale? Will this be applicable to other units or the facility as a whole? What will you do to ensure that the implementation becomes permanent? Disseminate Findings How will you communicate your findings internally (within your organization) and externally (to others outside of your organization)? Conclusion Provide a clear and concise summary. Review the key aspects of the problem as well as the change model. Be sure to include important aspects of the five points of the ACE Star change model EBP process and ways to maintain the change plan. TYPE SHORT TITLE IN ALL CAPS 5 References
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Group discussion Part 1 and 2

Group discussion Part 1 and 2

Discussion 2

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Betty, the chief nursing officer, had to make a decision about buying 120 new hospital beds for patient rooms. After she interviewed nurse mangers at the units where the beds were going to be placed, Betty compiled her findings and decided to contact a well-known equipment company to obtain prices and contracts. The equipment company’s executive salesperson, Jim, discussed options at length with her and invited her and her significant other to an upcoming all-expenses-paid lavish retreat at a five-star hotel in Hawaii to see demonstrations of the beds and to hear a comprehensive sales pitch. Betty thought to herself, “We badly need some relaxation and stress relief. Hawaii would be so much fun. Would it be wrong for us to go?”

If you were Betty, what would you do? Give your rationale. Justify your answer with an ethical framework—a theory, approach, or principle.
Do you consider this situation a conflict of interest? Why or why not? Give your rationale.
What policies, if any, should be in place regarding a scenario such as this one? Do you have any such policies in place at work for similar situations? Do such policies impact day-to-day activities in any way? Explain( 350-450words) ……* Discussion 2 : Write about failing to take responsibility for injurious practices. Examples in nursing. (150-250 words)

APA Format, No Plagiarism, Discussion Board with with two responses

APA Format, No Plagiarism, Discussion Board with with two responses

Instructions: Minimum word count of 250 words excluding references. Each response should be supported by two

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references. References should be peer-reviewed, scholarly and professional. References should not be older than 5 years. Responses in the forum should be in APA format. Please answer the following question: Research the topic of “Patient Portals” associated with Electronic Health Records (EHR). Perhaps the EHR at your facility has an attached or integrated Patient Portal where patients can communicate back and forth with their provider (physician or mid-level or physician’s office personnel). Discuss quality and safety advantages, disadvantages and potential problems which may be associated with Patient Portal use and what can be done proactively to avoid those problems. Discussion board Instructions 4345 Post a scholarly response to two peer postings. Each response should be supported by two references. References should be peer-reviewed, scholarly and professional. References should not be older than 5 years. Responses in the forum should be in APA format. Minimum 200 word not including references. QUESTIONS: Healthcare information technology is identified as an essential tool for advancing improvement in patient outcomes. Nurses, physicians, interprofessional teams, patients and families rely increasingly on HIT to communicate, manage information, mitigate error potential, and make informed decisions. Describe how HIT can be used to improve patient outcomes. (Do not choose as your topics the following: smart pumps, bar-coded medication administration or monitors interfaced to automatically document in the EHR. Be more creative in your topic choice.) Please Respond to the following discussion board# 1: Since the first personal digital assistant (PDA) came about in 1993 by Apple and 1996 by Palm Pilot (Zeldes, n.d) technology has grown leaps and bounds. Just think electrocardiograms used to be done using three wires and suction cups to having it print out in seconds to having mobile health (mHealth). MHealth has many different takes on assistance to help serve clinicians and patient for better outcomes on managing medical care and treatments. Using mHelath devices like smart phones, tablets or laptops helps to decrease visits to the office or hospitals, “increase medication/treatment compliance, improve information access, providers are able to have access to newest and greatest treatments by way of evidence-base practice” (Macskill, 2015). mHealth has made improvements on how to help patients have a better quality of life. Some of the things that have come about the emerging mHealth are wearable devices/sensors, imaging from afar, and lab on a chip (Steinhubl, Muse, and Topol, 2015). Patients with heart failure (HF) have been using mobile devices in managing HF on outpatient bases. With the use of smart phones, tablets or laptops, patients have showing improved self-management, improved quality of life (QOL) and lower mortality (Cajita, Hodgson, Budhathoki, and Han, 2017). Some of the disadvantages of using mhealth in older adults is they have poor vision, poor memory, decreased dexterity and are not tech savvy (Cajita, Hodgson, Budhathoki, and Han, 2017). Patients with HF class IV, sudden cardiac death (SCA), cardiac transplant wait list, post myocardial infarction and non-ischemic cardiomyopathy, can wear this ZOLL LifeVest wearable defibrillator to help bridge them until they have a more definitive plan of care (ZOLL, n.d-a. b.). The LifeVest is to be worn at all times except when bathing. The LifeVest is has sensing electrodes and self-gelling defibrillator electrodes inside to detect cardiac rhythm that is designed to detect ventricular tachycardia (VT) or ventricular fibrillation (VF). It is designed to shock the patient if VT is longer than 30 seconds (Reek, Burri, Roberts, Perings, Epstein and Klein, (2017). ReferencesCajita, MI., Hodgson, NA., Budhathoki, C., and Han, H. (2017). Intention to use mhelath in older adults with heart failure. Journal of Cardiovascular Nursing. 32(6) pp E1-E7. DOI: 10.1097/0000000000000401. Macskill, R. (2015, February 03). The benefits of mobile health strategies. mHealth Intelligence. Retrieved on August 7, 2018 from https://mhealthintelligence.com/news/the-benefits-of- mobilehealth-strategies.Reek, S., Burri, H., Roberts, PR., Perings, C., Epstein, AE., and Klein, HU., (2017). The wearable cardioverter-defibrillator: current technology and evolving indications. European Society of Cardiology. Europace 2017: 19. 335-345. Doi: 10.1093/europace/euw180 Steinbul, SR., Muse, ED., and Topol, Ej. (2015). The emerging field of mobile health. Sci Transl Med. 2015 Apr 15: 7(283): 283 rv3. Doi: 10.1126/scitranslmed.aaa3487. Retrieved on August 7, 2018.Zeldes, N. (n.d.) The first PDA – Nathan Zeldes. Retrieved on August 6, 2018 from . www.nzeldes.com/HOC/Newton.htm. a. ZOLL (n.d). ZOLL lifevest. Retrieved on August 7, 2018 from https://lifevest.zoll.com/about-us/. b.ZOLL (n.d.) ZOLL lifevest wearable defibrillator. Retrieved on August 7, 2018 from https://lifevest.mymarketingbench.com/…/1/21-90020000/20C0027LAM.pdf. Question: Describe healthcare information technology issues related to confidentiality, security and ethics. Include one example for each issue identified. Please respond to the following discussion board #2: As healthcare continues to expand its use of health technology, more risks and benefits are being identified. While technology makes sharing health information easier, cellphones and computers also pose a threat to information security and patient confidentiality. In order to protect this information, the government regulates how information can be shared. “As required by the Personal Health Information Protection Act (PHIPA), smartphones must be configured to operate in a secure manner when used to transmit or store personal health information” (Tran et al., 2014). These features include, “encryption of transmissions, password protection, and automated data wiping” (Tran et al., 2014). If providers’ phones don’t support this technology or they are using their personal cellphones they are risking information security. Although technology makes accessing information more efficient, the protection of patient information needs to be a standard for providers. All patients have the right to confidentiality which includes the right to have their information kept private. One study found that, although many medical students utilize cellphones for communication only 50% felt that they had been educated on appropriate use of patient information (Hall & McGraw, 2014). Without the proper training, providers may send messages containing patient identifiers and sensitive personal information which threatens patient confidentiality. Furthermore, technology can be an ethical challenge. Providers need to gain patient consent before sharing sensitive information. With the use of more technology, “patients frequently do not read or fully understand privacy policies, and consent shifts the burden of privacy protection to the patient, who may not be able to make meaningful privacy choices” (Hall & McGraw, 2014). If patients cannot fully understand what providers are asking, it is not ethical for them to share information. References Hall, J. L., & McGraw, D. (2014). For telehealth to succeed, privacy and security risks must be identified and addressed. Health Aff, 33(2), 216-21. doi: 10.1377/hlthaff.2013.0997. Tran, K., Morra, D., Lo, V., Quan, S. D., Abrams, H. & Wu, R. C. (2014). Medical students and personal smartphones in the clinical environment: The impact on confidentiality of personal health information and professionalism. J Med Internet Res, 16(5), 132. doi: 10.2196/jmir.3138.
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Healthcare Finance

Healthcare Finance

The president of Gentiva Health Services is considering increasing her number of Medicare patients served next year

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However, to do so she must begin to use RNs for client visits, which Medicare reimburses at $45 per visit. An RN costs $35 per hour versus the current cost of $15 for an LPN or nurse’s aide. The president believes she can increase her patient visits by 15% by accepting Medicare patients. She is also aware that if she increases her Medicare patients, the company’s administrative costs will increase by approximately $10,000 per year because of the claims file complexity.

Use the following websites to gather data:

10K Annual Report
10Q Quarterly Report
Use the following volumes for your calculations:

Volume for the year:

Flexible budget: 6,000 visits
Static budget: 5,945 visits
Actual budget: 5,889 visits
Prepare a two-page report that addresses the following:

How many more visits will the company generate if it accepts Medicare patients?
What would be the estimated profit or loss associated with the Medicare service line?
Would you recommend that Gentiva Health Services increase its number of Medicare patients served? Why or why not?
The second task is: Business Plan

Review the quarterly report and develop a business plan for the organization for its upcoming financial year. Be sure to include the following in your organized business plan:

Organization segment
Marketing segment
Financial segment
Projected cash flow statement
Projected income statement
Projected balance sheet
Feel free to take liberties with information needed that is not available in the report.

You may find the quarterly report at

Gentiva® Health Services Reports Third Quarter 2014 Revenue and Adjusted EBITDA Results

To support your work, use your course and textbook readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Submission Details:
Your assignment should be addressed in an 8- to 10-page document.
Submit your documents to the Submissions Area by the due date assigned.
Please follow:

No Plagiarism!

Must have 3 or more references with citations!

Along with a reference page in APA format!

Thank you!

polypharmacy in the frail elderly patient

polypharmacy in the frail elderly patient

The purpose of this assignment is to increase the nurse practitioner’s awareness and sensitivity to pharmacokinetic changes and prescribing implications occurring in frail elderly related to these changes and potential adverse effects of polypharmacy in the frail elderly patient.

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Instructions

Identify a patient from your clinical site that is age 65 or older and takes at least 12 prescription medications, over-the-counter (OTC) medications, and herbal supplements.

Describe your patient including age, gender, ethnicity, medical diagnoses, medication allergies, and list of prescriptions/OTC medications/herbal supplements including dosage, route, and frequency.
Describe 3 age related changes that can affect pharmacokinetics and pharmacodynamics.
Using Beer’s criteria, review the patient’s medication list to identify medications that are potentially inappropriate. What medications should be continued? What medications should you consider stopping? What are potential alternative medications that could be used in place of the medications that you would consider stopping?
What are two challenges you as an NP face with regard to regulation of complementary and alternative medications in care of the frail elderly?
As an NP, what is one specific strategy you will use to assess medication reconciliation including CAM and over the counter medications in the frail elderly population?
PLEASE YOU CAN MAKE UP A PATIENT AND INCLUDE 2 REFERENCES IN APA FORMAT

Topic 4 DQ 2

Topic 4 DQ 2

Please write a paragraph with your opinion based on the text bellow. Please include citations and references in case you need to used for the question:

Some specific health problems that

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can be positively affected by regular exercise include: hypertension, diabetes, obesity, mental health, and arthritis. Hypertension can be significantly improved by incorporating thirty to forty-five minutes of aerobic exercise 5-7 times per week. Aerobic activities that are recommended for the middle-aged adult include: bicycling, walking, and swimming. Engaging in regular aerobic activity has been shown to decrease both the systolic and diastolic blood pressure (Dimeo, 2012). According to the CDC, 1 in 3 adults suffer from hypertension; with the incorporation of regular exercise, the prevalence of hypertension can be reduced (2016). Arthritis is another disease that middle-aged individuals deal with; patients who suffer from arthritis have shown improvement with the incorporation of regular exercise and activity. Previously, physicians would encourage patients with arthritis to rest their joints, but physical activity has been proven to reduce pain, increase function, and improve mood, mobility, and quality of life (CDC, 2016). Activities that should be encouraged in the middle-aged adult suffering from arthritis can include: yoga, tennis, and golf. Mental health has shown improvement with the incorporation of a regular exercise, due to the release of endorphins. Mental health disorders such as anxiety and depression have shown improvement through adding regular exercise into everyday life (Sharma, 2006). Patients who use physical activity in their daily lives have reported increased self-esteem, and is often used in the treatment plan of patients with depression (Edelman, 2014).

Nurses must promote physical activity in all patients, not just middle-aged adults, or patients who already are showing signs or symptoms of a disease process. Using the patient’s interests as a motivating factor is essential in achieving positive outcomes. Utilizing the patient’s interests will increase the likelihood that the patient will be motivated to engage in regular exercise and other activities and continue the routine into the future. Assessment of barriers and hesitation is also important when developing a plan of care for each individual patient.

References

Center for Disease Control (CDC) Physical Activity for Arthritis. (2016, October 26). Retrieved August 6, 2018, from https://www.cdc.gov/arthritis/basics/physical-acti…

Dimeo, F., Pagonas, N., Seibert, F., Arndt, R., Zidek, W., &Westhoff, T. H. (2012). Aerobic Exercise Reduces Blood Pressure in Resistant Hypertension. Hypertension, 60(3),653-658.

Edelman, C., Kudzman, E.C., & Mandle, C. L. (2014). Health Promotion throughout the life Span (8 th ed.). St. Louis, MO: Elsevier.

Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for Mental Health. Primary Care Companion to the Journal of Clinical Psychiatry, 8(2), 106.

Topic 4 DQ 2

Topic 4 DQ 2

Please write a paragraph with your opinion based on the text bellow. Please include citations and references in case you need to used for the question:

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Regular physical exercise and activity performed by the middle-aged adult can reduce the risk of health problems including heart disease, type 2 diabetes, and arthritis. The prevalence of heart disease in the U.S equals 610,000 deaths per year (Centers for Disease Control and Prevention, 2017). Type 2 diabetes contributes to 90-95% of all cases and in 2015 1.5million new cases where diagnosed in the U.S in adults 18 years or older (Diabetes.org, 2017). The CDC estimates by 2040 there will be an average of 26% of adults over the age of 18 that will have been diagnosed with some form of arthritis including rheumatoid arthritis, fibromyalgia, gout, and lupus (Centers for Disease Control and Prevention, 2018). The nurse can perform a physical activity screening to determine what activities the patient enjoys participating in and how much exercise a person is incorporating into their daily lives. The CDC recommends participating in low intensity, moderate aerobic exercise for 150 minutes per week to reduce the risk of heart disease, type 2 diabetes, and arthritis. An approach the nurse could use to gain cooperation from the patient would be helping them to incorporate the desired amount of exercise into their daily living through activities and exercise they enjoy participating in. Nurses can also utilize the National Physical Activity Plan located at www.physicalactivityplan.org, which encourages health care workers to promote physical activity guided by a comprehensive, evidence-based strategic plan (American Journal of Nursing, 2015, para. 10). This plan is designed to help health care workers promote physical activity by making this topic a “vital sign” that health care workers assess and discuss with their patients, establish that inactivity is a treatable and preventable health conditions, provide health care workers with physical activity education, and use the health care system to promote physical activity in hopes that all American’s will become physically active and work, live, and play in environments that support an active lifestyle (American Journal of Nursing, 2015).

References

American Journal of Nursing. (2015). The Evolution of Physical Activity Promotion. Retrieved from https://journals.lww.com/ajnonline/Fulltext/2015/0…

Centers for Disease Control and Prevention. (2017). Heart Disease in the United States. Retrieved from https://www.cdc.gov/heartdisease/facts.htm

Centers for Disease Control and Prevention. (2018). Arthritis Related Statistics. Retrieved from https://www.cdc.gov/arthritis/data_statistics/arth…

Diabetes.org. (2017). National Diabetes Statistic Report, 2017. Retrieved from http://www.diabetes.org/assets/pdfs/basics/cdc-sta…

People of Indian Heritage, Turkish Heritage and Vietnamese Heritage

People of Indian Heritage, Turkish Heritage and Vietnamese Heritage

2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 1 Chapter 37 People of Turkish Heritage Marshelle Thobaben And

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Sema Kuguoglu Overview, Inhabited Localities, and Topography Overview Türkiye (Turkey), as it is written in Turkish, means “land of Turks.” It is located in the Northern Hemisphere, almost equidistant to the North Pole and the equator. The shape of Turkey resembles a rectangle, stretching in the east–west direction for approximately 1565 kilometers (972 miles) and in the north–south direction for nearly 650 kilometers (404 miles). It is bordered by Georgia, Armenia, and Nahcivan (Azerbaijan) to the northeast; the Islamic Republic of Iran to the east; Iraq and Syria to the south; Greece and Bulgaria in the Thrace to the west; and Russia, Ukraine, and Romania to the north and northwest (through the Black Sea). The Anatolian peninsula is the westernmost point of Asia, divided from Europe by the Bosporus and Dardanelles straits. Thrace is in the western part of Turkey on the European continent. Turkey has a diverse geography. It is only slightly larger than Texas with a total area of 783,562 square kilometers (486,882 sq. mi.). Its land area is 769,632 square kilometers (478,227 square miles) and water 13,930 square kilometers (8565 square miles). About 3 percent of Turkey lies in Southeastern Europe (Thrace) and the remainder in Southwestern Asia also called Anatolia or Asia Minor. The sea surrounds Turkey on three sides. The Mediterranean Sea turns into the Aegean Sea along the west coast of Turkey, facing Greece. In the northern part of the Aegean, Çanakkale Bogazi (the Dardanelles) give passage to the Marmara Denizi (Sea of Marmara), which then opens into the Black Sea through the Istanbul Bogazi (the Bosporus) (CIA World Factbook, 2011). A comparable diversity can be seen in the human history of Turkey where over the past ten thousand years various civilizations have risen and fallen due to invasions by newcomers, disease epidemics, and natural disasters such as earthquakes. It continues to be a land of educational, religious, and cultural diversity. The first historical reference to the Turks appears in Chinese records dating back around 200 BC, which refer to tribes called the Hsiung-nu (an early form of the Western term Hun). They lived in an area bounded by the Altai Mountains, Lake Baykal, and the northern edge of the Gobi Desert, and are believed to have been the ancestors of the Turks. In AD 552 many ethnic Turks began to converge under the Gokturks, and later under the Uygurs of Turkistan, followed by the Mongols. In the 10th century, Turkey became fully Muslim and accepted the Arabic script. Under the influence of the Muslim religion, Turkish language and literature were developed, and the building of mosques, schools, and bridges began (CIA World Factbook, 2011). The Seljuk Turks defeated the Christian Byzantine Empire in 1071, resulting in the first of the Christian crusades against Muslims. The Seljuks contributed to medical science and established medical institutions and hospitals in most cities. When the Seljuk Empire collapsed at the end of the 13th century the Ottomans established rule and in 1453 claimed Constantinople as the capital, renaming it Istanbul. The modern Turkish State is a descendent of the Ottoman Empire. Based on a tolerance of differences among its subjects, the Ottoman Empire endured for 600 years and at its height stretched from Poland to Yemen and from Italy to Iran. In 1876 a constitutional monarchy was established under a sovereign sultan, but separatist movements, their subsequent repression, and an emerging Turkish nationalism resulted in the “Young Turk” revolution of 1908 and the erosion of the sultan’s powers. During this time, modest advances in women’s rights began, including the unveiling of nurses in the Balkan Wars and more educational opportunities for women. An armistice at the end of World War I left the Empire stripped of all but present-day Turkey, occupied by Greek, French, British, and Italian armies, and established independence for Armenia and autonomy for Kurds in eastern Anatolia. However, the 1 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 2 2 Aggregate Data for Cultural-Specific Groups Treaty of Lausanne in 1923 officially ended Allied occupation, partitioning Armenia between Russia and Turkey, reinstating the Kurds, and proclaiming an independent Republic of Turkey, with Ankara as its new capital. Although Westernization had begun before independence, Turkey’s president, Mustafa Kemal Atatürk, became synonymous with Westernization and secularism. During his presidency from 1923 to 1938, he initiated many reforms, including banning the fez, outlawing polygamy, instituting marriage as a civil contract, abolishing communal law for ethnic minorities, removing Islam as the state religion, promoting nationalism and pride, instituting educational and cultural reforms, making surnames obligatory, changing the weekly day of rest from Friday to Sunday, and electing 17 female deputies to the National Assembly. Atatürk died on November 10, 1938, but he is still revered as the father of Turkey, and his image can be found in most government and public offices. Turkey remained neutral in World War II, but the postwar economy and Cold War politics prompted U.S. economic and military aid in 1947, forging the political ties that endure today. Despite three bloodless military coups in 1960, 1971, and 1980, Turkey has a multiparty democratic system, a Republican parliamentary democracy. Turkey joined the United Nations (UN) in 1945, became a member of the North Atlantic Treaty Organization (NATO) in 1952, an associate member of the European Community in 1964, and began accession membership talks with the European Union in 2005. Voters approved a referendum in September 2010 that made several constitutional changes including Parliament having increased oversight and diminishing the power of the judiciary and the military; additionally, it provided wider democratic freedoms for Turkey’s citizens (CIA World Factbook, 2011; Information Please, 2011). Turkey remains strategically important to the West and is a strong ally of the United States because of its geopolitical location and its cultural and religious ties. What is presented about the Turkish culture in this chapter is based on studies from Turkey and on observations of and experiences with Turkish immigrants in the United States. remainder in villages (CIA World Factbook, 2011; Turkey’s Statistical Yearbook [TSY], 2010). The capital city of Turkey is Ankara, but the historic capital, Istanbul, remains the financial, economic, and cultural center of the country. Until the 1950s most Turks were peasants living in isolated, self-sufficient villages with their extended family and practical folk-belief system. Depeasantization, migration, and urban settlement have continued, and today squatter housing districts populated by rural “immigrants” in major cities have resulted in permanent low-income neighborhoods juxtaposed against modern urban development. Changes in the social structure and people’s expectations are also shifting. For example, older people’s ability to live in their familiar housing environments, particularly, in large cities and metropolitan areas is forcing the government to change its policy and to strive to provide affordable housing and care centers for them (Turel, 2009). Over the past two decades, Turkey has been hit by several moderate to large earthquakes that resulted in a significant number of casualties and heavily damaged or collapsed buildings. This has been as a result of inadequate seismic performance of multistory reinforced concrete buildings, typically three to seven stories in height. A recent study indicates that a considerable portion of existing building stock may not be safe enough in Turkey (Inel, Ozmen, & Bilgin, 2008). References and further reading may be available for this article. To view references and further reading you must purchase this article. As a result of extensive foreign trade, larger coastal cities are undergoing many changes, which have resulted in an urban environment with a dual character, representing the traditional old way of life and the ensuing new class. Every aspect of life and society is being affected, including changes in values, recreational activities, mass communication and media, and women’s status. Observations suggest that everyday practices of the people, as well as their folk beliefs, are truly changing. However, the Turks still depend on nuclear and extended family and friends for adjustment, job possibilities, and money. Heritage and Residence Reasons for Migration and Associated Economic Factors Turkey is one of the 20 most populated countries in the world and has the second largest population in the Middle East, and in Europe, after Germany. The first national recorded population of the Republic of Turkey was 13.6 million in 1927. The population in 2010 was 73.722.988 with 26 percent of the population age 14 years and younger, and 7 percent age 65 years and older. Roughly, 70 to 75 percent of the population is Turkish, 18 percent Kurdish, and 7 to 12 percent other minorities. Approximately, 75 of the population lives in cities, such as Istanbul, Ankara, Izmir, and the The U.S. Census Bureau (2011) reported 190,000 people of Turkish descent living in the United States. The majority of them lived in the Northeast (39 percent) and the least in the Midwest (13 percent). The Turkish immigrant population in the United States differs significantly from most of the Turkish population that inhabits Europe, in terms of both demographic makeup and socioeconomic status and integration. A high proportion of Turks in the United States come from the elite and upper-middle classes, interspersed 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 3 People of Turkish Heritage with smaller groups of middle-class students and skilled laborers who are supported privately or by the government. Economic reasons, such as unemployment and poor salaries, are the major reasons Turks leave to work in other countries (İcduygu, 2008). Although Turks have emigrated throughout the world, many have lived in Western Europe since the 1960s and in 1970s North Africa and the Middle East, largely as a result of “guest worker” programs. Since the 1990s, Turkish workers have also moved to the neighboring former communists’ countries such as Russian Federation and Ukraine (İcduygu, 2008). A large “Turkic belt” stretches from the Balkans across Turkey, Iran, Central Asia, the former republics of the Soviet Union, and deep into the borders of Mongolia. This belt includes many ethnic Turks who may share cultural, linguistic, religious, and certainly historical links with the people of Turkey. Research studies have indicated that any concern about excessive “brain drain” from the immigration of some of Turkey’s intellectual, academic, and other highly skilled professionals to the United States is unfounded; it has not created a threat to Turkey’s economic, scientific, social, and cultural development. Additionally, Turks living in the United States usually maintain strong bonds with their Turkish families and pass on their Turkish cultural values, traditions. and language to their children born in the United States (Köser-Akçapar, 2006). Turks who have lived or studied in the United States generally have higher status and greater employment opportunities in Turkey. Educational Status and Occupations Education is highly valued in Turkey by all socioeconomic groups. Coeducational primary and secondary education is provided at no cost and is guaranteed under the Constitution. It consists of public and private school at all levels, ranking from preprimary (1 year), primary (8 years), high school (4 years), and universities (4 to 6 years). In 1997, 5 years of compulsory primary school was extended to 8 years including the middle schools. Primary school starts at age of 7 and ends at 13. High schools were extended from 3 to 4 years in 2005. High school includes a number of options, including general, technical, trade, vocational, and theological training. Higher education institutions include universities, faculties, institutes, higher schools, vocational higher schools, conservatories, and research and application centers (TSY, 2009). Students who wish to pursue a university education must take a state examination that determines both their admission to the institution and their subject of study. In a recent study it was reported that only 22 percent of the students who took the nationwide competitive entrance examination were placed in a university program in Turkish universities. Turkey’s university 3 distance education program, one of the largest in the world, annually accepts only about 15 percent of students who apply (Tasçı & Oksuzler, 2010). A high level of education exists among people of Turkish descent living in the United States. Significant numbers hold advanced degrees, and most are employed in professional, managerial, and technical occupations. Turkey’s Statistical Yearbook (2009) reported that of the 48 percent of Turkey’s working age population who participated in the labor force, 70.5 percent were men and 26 percent were women; 45.8 percent worked in urban areas (69.9 percent male and 22.3 percent female) and 52.7 percent in rural areas (72 percent male and 34.6 female). Of those workers employed in the agriculture sector, 46 percent were unpaid family workers; 76.9 percent of the unpaid family workers were female, while 23.1 percent were male. The unemployment rate was estimated to be 14 percent in 2009 (TSY, 2009). Persons not in the labor force composed 52.1 percent of the working-age population. The main subgroups were persons who were busy with household chores (44.9 percent), students, and disabled and retired persons (TSY, 2009). For cultural reasons, many women have continued to maintain their traditional roles and do not work outside the home because it interferes with their household responsibilities, including caring for their children, and it may require them to work with men from outside their immediate family. Communication Dominant Language and Dialects A Uralic-Altaic language, Turkish is spoken by 90 percent of the population. The Turkish language has approximately 20 dialects, including Yakut, Chuvash, Turkoman, Uzbek, Kazakh, and the language of the Gagavuz people. Differences in some of the dialects are so great that they are considered separate languages. Through the centuries, Turks borrowed from Arabic and Persian languages, and bits of “Turkified” French and English can also be found. Until 1928, Turkish was written in Arabic script, but under Atatürk’s direction, a Turkish alphabet was developed based on Latin script. The Turkish alphabet is much like the English alphabet, although it does not have a “w” or an “x,” and additional sounds are symbolized by an “i” without a dot; a “ğ,” an “ö,” and a “ü” with accents; and an “ş” and a “ç” with a cedilla, symbolizing “sh” and “ch,” respectively. The Turkish language does not distinguish gender pronouns such as “he” from “she” or “her” from “his”; therefore, Turks learning English may inadvertently confuse these pronouns. However, Turkish does distinguish a formal from an informal “you,” signifying the importance of status in Turkish society. 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 4 4 Aggregate Data for Cultural-Specific Groups Typical of many Mediterranean cultures, speaking in loud voices is common; this may not signify anger, but rather excitement or deep involvement in a discussion. It can be common for more than one person to speak at the same time or to interrupt another person, which is not necessarily considered rude. However, someone of lower status should not interrupt someone of higher status. Cultural Communication Patterns In the Turkish’s culture group affiliation is valued over individualism. In fact, identity may be determined by family membership, group, school, or work associations. An individual’s behavior is expected to conform to the norms or traditions of the group, and Turks tend to be more people and relationship oriented than Americans. Although Turks may take longer than Americans to form friendships, these relationships last longer, formality is decreased significantly, and interdependence is encouraged as a source of strength. In this group-oriented culture, Turks generally do not desire much privacy and tend to rely on cooperation between family and friends, although competition between groups can be fierce. Turks value harmony over confrontation. However, Turkish communication style is characteristic of Mediterranean cultures in which the outward show of feelings is less restrained. For women, expressions of anger are usually acceptable only within same-sex friendships and kinship networks or toward those of lower social status. Generally, women are not free to vent their anger toward their husbands or other powerful men. Children are very accustomed to being held, hugged, and kissed by family and friends of the family. Touching, holding hands, and patting one another on the back are acceptable behaviors between same-sex friends and opposite sex partners. It is common to see same-sex friends, especially among the older generations, holding hands or linking arms while walking. Likewise, personal space is closer between same-sex friends and opposite-sex partners; physical proximity is valued as a sign of emotional closeness. Very strict Muslims generally do not shake hands or touch members of the opposite sex, especially, if they are not related. Health-care providers are usually looked upon as professionals and touch is allowed and expected when necessary. Eye contact may be used as a way of demonstrating respect. When interacting with someone of higher status, a person is expected to maintain occasional eye contact to show attention; however, prolonged eye contact may be considered rude or interpreted as flirting. Turkish people tend to dress formally; men wear suits rather than sports jackets and slacks on social occasions. Women tend to dress modestly and wear skirts and dresses rather than slacks. Black clothing accented with gold jewelry is quite popular. More traditional Muslim women may wear very modest clothing and cover their heads with a scarf, either black or a colorful print. However, styles continue to change, and denim jeans and casual dress are becoming common among young people for less formal occasions. Turks tend to openly display emotions such as happiness, disgust, approval, disapproval, and sadness through facial expressions and gestures. Two unique gestures in Turkish culture include signals for “no” and signs for approval or appreciation. “No” is indicated by raising the eyebrows or lifting the chin slightly while making a snapping or “tsk” sound with the mouth. Appreciation may be expressed by holding the tips of the fingers and thumb together and kissing them. This signal is commonly used to express appreciation for food. Various phrases are commonly used by Turks. Allahaismarladik (God watch over you) is said to someone leaving and is responded to with gule gule (go with smiles). Ellerine saglik (health to your hands) communicates appreciation for a good meal, and the cook responds with afiyet olsun (good appetite). Cok yasa (live long) is said after someone sneezes with a response of sen de gor (you see a long life, too). Masallah (God protect from the evil eye) is said, for example, when one has a healthy baby or when one has achieved something good, whereas insallah (God willing) is said when something is wished to happen. Turkish people take pride in keeping their homes immaculately clean, and one is expected to remove one’s shoes inside the home. Most hosts in Turkey and many in the United States offer slippers to their guests. Whether wearing shoes or not, showing the sole of one’s foot is considered to be offensive in Turkish culture. Women are expected to sit modestly with knees together and not crossed. Tortumluoğlu, Bedir, and Sevig (2005b) conducted a qualitative study in a village in eastern Turkey by examining individual cultural communication characteristics. Comments from the participants included the following: • According to our religion, men who are not our legal husband are not allowed to listen to our voices. A woman cannot speak out loud and cannot laugh in the community; she would be like bad woman (woman over 65 years old). • We do the duties of the bride (act like a servant) for our husband’s relatives and mother-in-law. We can never speak near them. To speak would be disrespectful (bride, 15 years old). • If the person across from us is a woman, we hug and kiss, but if he is a man outside the family, we don’t touch him. We will not eat at the same table with men outside the family; we won’t be together 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 5 People of Turkish Heritage with them at weddings; we won’t sit next to them on the bus; we wouldn’t go near them without covering our heads and bodies. We don’t look them in the eye (women over 65 years old). • We’re uncomfortable being examined or given a shot by a man because they are strangers. It is very sinful to go to a man even our husband and open what is covered (female, age unknown). • I would not take my wife, daughter, or daughterin-law to a male doctor. I would not show them to unrelated men (man over 65 years old). • Even if I knew my wife would die, I wouldn’t take her to a male obstetrician (boy about 15 years old). Temporal Relationships Turks tend to have a relaxed attitude about time; social visits can begin late and continue well into the night. Whereas punctuality in social engagements is not highly important, in business relationships punctuality among Turkish Americans is gaining in importance. Format for Names Turks value status and hierarchy. Demonstrating respect for those of higher status is mandatory and determines the quality of interactions with a person. A variety of titles are used to show respect and acknowledge status. Strangers are always greeted with their title, such as Bey (Mr.), Hanim (Mrs., Miss, or Ms.), Doktor (Dr.), or Profesör (Professor). Members of the family are also addressed using specific titles that recognize relationships, such as agabey (older brother or older close male friend), amca (uncle or elderly male relative or stranger), abla (older sister or older close female friend), teyze (maternal aunt or older female relative or older female stranger), and yenge (wife of a brother or paternal uncle). When friends or family members greet, it is customary for each to shake hands and to kiss one another on each cheek. Traditionally, when greeting someone of very high status or an elderly person, one might grasp his or her hand and kiss it and then bring it to touch one’s forehead in a gesture of respect. Family Roles and Organization Head of Household and Gender Roles In a very traditional Turkish home the father is considered the absolute ruler. The concept of izin (permission to leave to do something specific) captures this significance. In rural and traditional families, women may require izin from the head of household for doing simple things, such as shopping, traveling, or visiting their nurse midwife, physician, or dentist. The justification is that the one who earns the money may spend the money. The person who bestows izin is responsible for the protection of the izinli (person who requires the izin). Izin exhibits a structure of authority that is 5 both hierarchical and patriarchal; therefore, women typically require izin more often than do men. A young wife (gelin) may require izin from her husband and from her mother-in-law. All are ultimately responsible to the gelin’s father-in-law, who is usually the absolute ruler of the traditional extended family (Tortumluoğlu, Bayat, & Sevig, 2005a; Tortumluoğlu, et al., 2005b). Less-traditional families show more equality between spouses, especially in nuclear families in which the wife is well educated and works outside the home. Yet remnants of traditional family structure prevail and the husband often takes on the role of ultimate decision maker, especially in matters of finance. Women may work full time outside the home in addition to assuming full responsibility for running the daily activities inside the home. Modern Turkish women tend to be more Westernized than some of their Middle Eastern or Muslim counterparts. The first institution for higher learning for women in Turkey was established in 1910. In 1917, women earned the right to divorce and to reject polygamous marriage. Atatürk’s new republic abolished the old legal system based on religion and secularization, giving women equal rights to education and no longer requiring them to wear veils and long overgarments. Legal marriage does not permit polygamy, although some may practice it outside the law. Women have had the right to vote since the early 1930s. In 1966, a charter of the International Labor Organization passed the equivalent of an Equal Rights Amendment, requiring equal wages to both sexes for work of an equal nature. Family Goals and Priorities A woman’s age and the number, age, and gender of her living children can influence her status in the family and the community but varies depending upon such things as education, religious practice, socioeconomic level, urbanization, and professional achievement. Generally, a young gelin (woman aged 15 to 30 years) has the lowest status, middle-aged” woman (30 to 45 years) has intermediate status, a “mature” woman (45 to 65 years) has the highest status, and an “old age” woman (65 years or older) is highly respected but not very powerful. Working outside the home is associated with status positively in the urban context and negatively in the rural context. Professional employment and education raise the status of women. Thus, health-care providers may find significant variations regarding gender roles when working with Turkish American patients. Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are held very dear in the Turkish family, and they are expected to act as young children, not small 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 6 6 Aggregate Data for Cultural-Specific Groups adults. They are accustomed to receiving attention from family, friends, and visitors. Kissing children and pinching their cheeks is quite common. Once children enter school, they are expected to study hard, show respect, and obey their elders, including older siblings. This concept is referred to as hizmet (duty or service). As children age, they are socialized into more-traditional gender roles. Girls are expected to help care for younger siblings, to help at mealtimes, and to learn to cook. Traditionally, children are not allowed to act out or talk back to their superiors. Light corporal punishment is generally acceptable. Circumcision is a major rite of passage for a male child. This is a time of celebration within the extended family, and newly circumcised boys are honored with gifts. Traditionally, boys can be circumcised up to the age of about 12, although the modern trend is to perform the circumcision in the hospital shortly after birth. Rankina and Aytaç’s (2008) research found that the religiosity of the parents, the vast majority of whom were Muslim, had no effect on the schooling of Turkish children, whether male or female. In contrast, patriarchal family beliefs and practices discouraged the education of children, particularly girls. Their findings also showed a father’s disapproval of daughters going out in public without a headscarf reduced the likelihood of girls finishing or going beyond primary school. Thus, family cultural traits may continue to represent a significant barrier to gender equality in education (Rankina & Aytaç, 2008). As children reach adolescence, they are expected to continue to work hard in school and show respect for superiors. The U.S. and Western culture and lifestyles are exported to Turkey via the various social networks. O’Neil and Güler (2010) explored the meaning high school and university students attached to American popular culture and found no evidence that that American popular culture was in danger of overwhelming Turkish culture. Young adults like to move back and forth between indigenous and foreign products, including American ones, and as a result the researchers felt this continued to embody a multiplicity and hybridity that has characterized Turkish culture for centuries. Young people in the urban areas may talk more about sex and engage more freely in sexual activity than previous generations; however, sexuality largely remains a taboo and is regarded as a forbidden topic for social and cultural reasons. Though not common among rural Turks, urban adolescents are beginning to date in pairs, in addition to the more traditionally accepted practice of group outings. However, sexual interaction is strongly discouraged among youth and the unmarried, especially young women. Virginity in unmarried women is a strong cultural value. According to a study conducted with university students in Turkey, 82.4 percent of female students and 86.5 percent of male students were virgins when they married, because of social rules and religious beliefs. Sixty-two percent of female students practiced sexual abstinence (Tortumluoğlu, Ersay, Pamukçu & Şenyüz, 2006). Parents are expected to provide sexual education within the family but often have insufficient knowledge on the subject. Kukulu, Gursoy, and Gulsen (2009) recommended that structured sex education that incorporated knowledge of specific aspects of the Islamic culture experience would help to promote healthy sexual behavior and decrease sexual myths, such as marrying a virgin increases sexual satisfaction. Successful completion of high school or university education is a first step toward adulthood. Although education earns respect in the family, the concept of hizmet still applies. A further step for men is the completion of required military service (askerlik), the duration of which varies depending on the population and the needs in Turkey. In addition, employment and earning money are symbols of adulthood for both men and women. Marriage is perhaps the most important developmental task for adulthood. Young people generally live in their parents’ home until they are married, unless school or work necessitates other arrangements. This practice may be quite different among assimilated Turks in America. The Turkish word for marriage, evli, translates to “with house.” Family remains an important factor in marriage. Marrying into a “good family,” having a high-status occupation, and achieving wealth are means of attaining higher social status for both the individual and the entire family. Family members’ accomplishments raise the entire family’s status, whereas failures have an equally broad effect. Thus, individuals must always consider what impact their actions will have on the family. Often, they consult parents or other family members before making major decisions. Arranged marriages occurred most often among less-educated, older individuals. Family initiated marriages range from rare contractual agreements between parents to the relatively common introduction and gentle encouragement of a newly formed couple. The more traditional family will “choose” a spouse for a son by considering the individual’s personality, talents, and appearance. For a daughter, it is more important to consider the individual and his family because she marries into the husband’s family. Elders are attributed authority and respect until they become weak or retired, at which time their authoritative roles diminish. However, respect always remains a factor. Although financial independence is valued in Turkish culture, independence from the family is not encouraged. Adult children, especially men, remain an integral 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 7 People of Turkish Heritage 7 part of their parents’ lives and parents expect their children to care for them in their old age which is regarded as normal, not as an added burden. Grandparents play a significant role in raising their grandchildren, especially if they live in the same home. The extended family is very important. Even the apparent increase in nuclear households does not rule out the networks among closely related families. Whether or not they live under the same roof, a young family may still live under the supervision of the husband’s parents or, at least, maintain an interdependent relationship. In many Turkish families, aunts, uncles, cousins, and in-laws form the extended family. Visits with local relatives are assumed and mandatory when traveling. Extended family members have a social relationship and may also play an authoritative role within the network. A cooperative relationship, which includes sharing child care, labor, and food, when necessary, and providing companionship, is essential between women in an extended family or neighborhood. sense of belonging in a less relationship-oriented American work milieu. Hierarchical structure is highly pervasive throughout Turkish culture and the workplace is no exception. Turkish employees expect an authoritative relationship between superior and subordinates. However, indirect criticism is expected and appreciated in order to “save face.” A Turk may be highly offended if openly criticized, especially in front of other people. They may be reticent about asking questions for fear of exposing a lack of knowledge. Yet, Turks may exhibit modesty when applying for a job or a promotion relying more on the recommendations of others than on pointing out their own strengths. Because military service is mandatory for men who wish to maintain their Turkish citizenship (even those living abroad), young Turkish men who reside outside Turkey may need to take an extended leave to complete their military service. Alternative Lifestyles Issues Related to Autonomy Divorce is becoming more common, but it remains socially undesirable, especially for women, for whom remarriage opportunities may be limited to divorced or widowed men. Widows, however, are generally taken care of by their late husband’s families and depending on their age and socioeconomic background may have the option to remarry. Premarital cohabitation and unwed motherhood are strongly discouraged, especially among more-traditional families, although living together before marriage is not uncommon in larger cities and among immigrant Turks. Even though being a gay man or lesbian is not a crime or considered a disease, homosexuality is only beginning to be received “at a distance.” In Oksal’s (2008) study of familial patterns of attitudes toward lesbians and gay men, he found that young adults’ attitudes toward lesbians and gay men were more liberal than those of their parents. However, on the whole, Turkish family members have quite negative attitudes toward homosexuality, most likely linked to religious beliefs. Most Turkish people are in agreement with Islamic values that regard homosexuality as a sin and unacceptable (Oksal, 2008). Because most Turkish immigrants speak English, language barriers in the workplace may be only subtle. However, dealing with differences of opinion between parties of equal hierarchical level may present difficulty. Turks perceive that aggressive face-to-face confrontation may cause relationships to deteriorate; therefore, the dominant means of conflict resolution is collaboration reinforced by compromise and forcing. Compromise and avoidance behaviors are more likely among peers, whereas accommodation behaviors are used with superiors. Their way of handling differences of opinion is brisk and clear-cut when an authority relationship exists between the two parties. Turkey is known for its high-power distance (the psychological and emotional distance between superiors and subordinates), respect for authority, centralized administration, and authoritarian leadership style. In Turkish culture a manager’s authoritative control is often more important than the achievement of organizational goals. Workforce Issues Culture in the Workplace Because Turkey is a group-oriented culture, the Turkish workplace may be more team oriented than in the United States. Turkish relationship orientation may lead to dependence on personal contacts and networks to accomplish tasks, and from the American perspective, developing these relationships and networks may appear as nepotism or as too much socializing. In contrast, the Turkish immigrant employee may not feel a Biocultural Ecology Skin Color and Other Biological Variations The Turkish population is a mosaic in terms of appearance, complexion, and coloration because of historical migration and inhabitance patterns. Appearances range from light-skinned with blue or green eyes to olive or darker skin tones with brown eyes. Mongolian spots, usually found at or near the sacrum, are common among Turkish babies and should not be confused with bruising. Racially, 75.6 percent of the men and 77.7 percent of the women are in the brakisefal (having a short, broad head) category, which is a 2780_BC_Ch37_001-019 03/07/12 10:06 AM Page 8 8 Aggregate Data for Cultural-Specific Groups shared symbol of the Dinaric Alpines (Gültekin & Koca, 2003). Diseases and Health Conditions According a recent health survey (TSY, 2008) that was sent to all settlements in the territory of the Republic of Turkey, 71.9 percent of men and 55.5 percent of women stated their general health status was good or very good; 75.2 percent of men and 58.8 percent of women living in urban areas stated their health was good or very good; while only 63.8 percent of men and 48.4 percent of women in rural areas stated their health status was good or very good (TSY, 2008). Life expectancy at birth in 2010 was estimated to be 72.23 years for the total population (70.37 years for males and 74.19 years for females) (CIA World Factbook, 2011). The leading causes of death include major vascular diseases (ischemic heart disease, stroke), chronic obstructive lung disease and lung cancer in men, perinatal problems, lower respiratory infections, and diarrheal diseases. Injuries cause about 6 to 8 percent of deaths, although this may be an underestimate (Akgun et al., 2007). There is also a high prevalence of obesity, hypertension, and diabetes, especially in Turkish women. Malaria is still problematic in the southeast part of the Turkey (CDC, 2011). Lactose intolerance rises among populations farther south and east in Europe. The Black Sea region tends to have a relatively high incidence of helminthiasis (intestinal worm). Endemic goiter associated with iodine deficiency, despite iodine prophylaxis (ID), still exists in 27.8 percent of the Turkish population. It has been eliminated in most of the urban population; however, it is prevalent in rural areas and in particular geographical regions (Erdoğan et al., 2009). Tuberculosis continues to be prevalent in the Aegean areas and in southeastern Anatolia. Behçet’s disease (BD) is a systemic inflammatory disorder of unknown etiology with a strong genetic component. It is characterized by recurrent attacks of oral aphthous ulcers, genital ulcers, skin lesions, uveitis or other manifestations affecting the blood vessels, gastrointestinal tract, and respiratory and central nervous system; the inflammatory lesions at particular sites, such as the eyes, brain, or major vessels can result in permanent tissue damage and cause chronic manifestations or even death (Gul, 2007). It is prevalent in Japan and China in the Far East to the Mediterranean Sea, including countries such as Turkey and Iran, and usually starts in the second and third decade of life. The male-to-female ratio is approximately equal, although BD runs a more severe course in men and in those aged
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Case Study of the Reproductive System .

Case Study of the Reproductive System .

Case studies of the Reproductive System.

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Alicia is a nurse who specializes in reproductive heath. She plans on leading a wellness class for the community at the clinic on breast self-examination. a 40-minute class, consisting of 20 minutes of educational content and 20 minutes to evaluate the participants, will be offered four different times. Participants at the free clinic can sign up for the classes. Each session can take eight participants. The nurse is using the latest guidelines from the American Cancer Society ( ACS) as a handout to give the women who attend the class. The Web site the nurse used as a resource was from the ACS, available at: www.cancer.org/docroot/CRI/content/CRI_2_6x_How_to_perform_a_breast_self_exam_5.asp.
b) Design a teaching plan for the session.

Mrs. Matin is a 48-year-old patient with breast cancer, who is undergoing a right modified radical mastectomy for infiltrating ductal carcinoma. Preoperatively, she explains to the OR nurse how the cancer was found on her most recent mammogram. She said that she had been experiencing some fullness in her breast, but could not definitively palpate a mass. She also explains that she chose the modified approach for surgery , as she is planning on having breast reconstruction later.
b) Postoperatively, how does the nurse assess for lymphedema?

c) What patient education does the nurse plan for Mrs. Martin related to hand and arm care after surgery?

d) What actions can the nurse take to ease Mrs. Martin’s anxiety related to looking at her surgical site for the first time?

David Martinez is a 57-year-old patient. is admitted to the surgical unit after robotic-assisted laparoscopic radial prostatectomy with nerve sparring for early stage cancerous tumor confined to the prostate. The client has six small incisions in the abdomen with small 4×4 dressing with clear dressing dry and intact. The client has a JP drain in place with clear, red-colored drainage with 50mL present and an indwelling urinary catheter drainage clear, red-colored urine. The surgeon ordered ketorolac (Toradol) for pain management and belladonna and opiate (B&O) suppository every 8 hours, as needed, for bladder spams.
b) For what potential complications should the nurse observe, and what actions should the nurse take if the complication develops?

c) The surgeon removes the JP drain the next day and discharge instructions should the nurse provide the patient? What follow-up care is anticipated for him?

Manny Perez is a 70-year-old man, is admitted with the diagnosis of adenocarcinoma of the penis. He presents with painless wart like growth on the skin of the glans of the penis.
b) What are the early and late manifestations of cancer of the penis?

c) What are the management goals for cancer of the penis?

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Please write a Paragraph answering to this discussion below with your opinion. Please include citations and references in alphabetical order in case of another source.

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The primary purpose of the Affordable Care Act (ACA), is to help more people receive better access to cost-effective, quality healthcare. The ACA reduces insurance premiums, offers prescription drug discounts, and prevents insurance companies from denying coverage to children under the age of 19 that may have pre-existing conditions (Cook, 2014). The ACA supports no charge evaluations to help keep Americans healthy. Services include: immunizations, assessment of blood pressure and cholesterol levels, as well as cancer screenings such as colonoscopies and mammograms; also included in the plan are prevention programs such as smoking cessation and obesity management (Cook, 2014). The goal is for all Americans to have access to reasonable-priced health insurance. To reduce costs, middle and low-income families receive tax credits, and the Medicaid program is expanded to cover more people in need (Cook, 2014).

With more people now having insurance coverage, the demand for quality providers has increased. The government has established multiple avenues for workforce development, such as scholarships and loan repayments; so that prospective providers are able to afford the necessary education required to serve the population (American Nurses Association, 2014).

For example, the purpose of Nursing Workforce Diversity Grants (NWD), is to develop an opportunity for people who are minorities or from disadvantaged backgrounds to enter the nursing workforce (American Nurses Association, 2014). Additionally, increasing the exposure to people of different backgrounds is one way also to foster cultural competence between the caregivers themselves, as well as toward their patients.

Nurses have a reputation as trusted sources of health information; this creates a valuable role when it comes to informing people of the benefits available to them, and how they can be accessed (Wakefield, 2013). For many Americans, it is their first time to have coverage; the ACA gives nurses a chance to improve our communities health by conveying the message of attainable, cost-effective care to the uninsured (Wakefield, 2013).

Reference

American Nurses Association. (2014). Health Care Transformation: the Affordable Care Act and More. Retrieved from https://www.nursingworld.org/~4afc9b/globalassets/…

Cook, C. (2014). Key Features of the Affordable Care Act (Obamacare). Retrieved from https://aclawlib.wordpress.com/2014/02/10/key-feat…

Wakefield, M. (2013). Nurses and the Affordable Care Act: A call to lead. Retrieved from