Experiences of Adult Offspring Making Care Decisions

Experiences of Adult Offspring Making Care Decisions In normal aging, decline in mental skills is modest with no consequential decrease in ability to care for oneself. Normally, older adults are able to maintain activities of daily living (ADLs) such as bathing, dressing, transferring, and toileting, and instrumental activities of daily living (IADLs), which include shopping, cooking, housekeeping, laundry, and handling money (Schaie, 1989). Nevertheless, one in 10 persons over 65 and nearly half of those over 85 have Alzheimers disease, a form of dementia (The Alzheimers Association, 1999) and, thus, have problems with IADLs, ADLs or both, and need assistance with care decisions. Often these decisions are left to adult offspring who are ill prepared to cope with role changes and parent-caring responsibilities (Archbold, 1980; Brody, Johnsen, Fulcomer Lang, 1983; Brody, Kleban, Johnsen, Hoffman Schoonover, 1987; Cantor 1883; Stoller, 1982). What is the experience of these adult children as they negotiate their way through the their own internal voices, their family of origin and the healthcare system? Have we been asking the right questions when we assume that all is reduced to family obligation and responsibility? This project was designed to elicit and understand the experience of those adult offspring who are making care decisions for a mentally impaired parent. Chapter I includes background and significance of the project, the philosophical framework in which the project question is poised, the project question, and definition of terms. Background and Significance of the Project Although almost half (47%) of persons 85 and older will have mental impairment (Schaie, 1989), many elderly do not make plans for dealing with possible changes in mental status. As elderly â€Å"age in place†, it is frequently left to family members to decide about care and living arrangements. For most family members these care decisions about the care of elderly parent are difficult at best (Pfeiffer, 1995), and the number of people involved in making these decisions will increase as life expectancy increases and the population of the United States continues to age. Life expectancy is the average number of years people born in a given year are expected to live based on a set of age-specific death rates. At the beginning of the 20th century, life expectancy at birth was 47.3 years. Today, at the beginning of the 21st century, the average life expectancy has increased dramatically at birth to nearly 77 years. In addition, life expectancy for every age group has also increased during the past century. â€Å"Based on todays age-specific death rates, individuals aged 65 years can be expected to live an average of 18 more years, for a total of 83 years. Those aged 75 years can be expected to live an average of 11 more years, for a total of 86 years† (http://www.health.gov/healthypeople/Document/HTML/Volume1/goal.htm, August 14, 2000). Persons older than 65 now comprise 12.7% of the population of the United States (Statistical Abstract of the United States, 1999, http://www.census.gov/statab/www/states/md.txt, August 14, 2000). By the year 2020, 20% of the population will be older than 65 years (US Bureau of the Census, 1996). The largest percentage of growth is in elders 85 and over, a group at high risk for mental disorders such as Alzheimers disease. Almost 19 million Americans report they have a family member with Alzheimers, and 37 million know someone with the disease (The Alzheimers Association, 1999). Since 7 out of 10 people with Alzheimers live at home, lost productivity of caregivers is estimated to cost American businesses $26 billion a year plus $7 billion annually related to costs for health and long-term care (The Alzheimers Association, 1999). Other estimates put the cost of informal caregiving at $18 billion. In a project of 7, 443 of elders seventy and over taken from a national representative sur vey, the cost of informal care for mild dementia at $3,630 per person with double the cost for moderate dementia relatives and almost five times the cost for severe dementia (Langa, Chernew, Kabeto, Herzog, Ofstedal, Willis, Wallace, Much, Straus Fendrick, 2001). It is not surprising that the public is starting to ask for help with this complex issue. Previous research sought to identify predictors of placement decisions by family caregivers with dementia (Colerick George, 1986) when care options were few and rational mental models of decision making were thought to be superior to the human mind. At the turn of the 21st century, however, the healthcare environment offers multiple models of care for mentally impaired patients (Abraham, Onega, Chalifoux Maies, 1994). Decision making needs to be informed by the context of continuity of care, which now ranges from home and home-like environments to part time respite or adult day care to long term care services in nursing homes. Indeed, â€Å"patients and families are often surprised if not shocked about the actual services they may receive from various community-based or institutionalized services† (Abraham, Onega, Chalifoux Maies, 1994, p.165). In addition to the increasing complexity of choices, rational mental models of decision-making are in question and giving way to a more naturalistic project of how real world decisions are being made (Sloan, 1996). Rational standards, in which it is assumed people merely choose among options, do not take into consideration most contextual factors that impact on decision-making in real-world situations (Beach Lipshitz, 1993; Cohen, 1993). There is a stark contrast between the assumptions of rational decision-making and naturalistic decision-making. In the naturalistic decision making paradigm, problems are seen as ill structured rather than artificial and well structured. Solutions to these problems are made in uncertain, dynamic environments rather than static, simulated situations. Goals are shifting, ill defined or competing rather than clear and stable. There are action/feedback loops to decision-making process not one-shot decisions. Time stress is a factor and stakes are high i nstead of the presumed luxury of leisurely deliberation and absence of true consequences for the decision-maker (Orasanu Connolly, 1993; Zsambok, 1997). Research on the experience of making care decisions for mentally impaired parents needs to take into account the way decisions are made in the real world and the numerous opportunities for care assistance that are available today. The majority of middle aged, and even young-old Americans, will be faced with making decisions about care for a mentally impaired parent at a time in life when they are dealing with their own transitional issues, as well as those of the generations before and after them. Given the resulting emotional and financial cost, it would be wise to develop health policy about mentally impaired elder citizens and their offspring based on an understanding of the experience of making decisions about the care of a mentally impaired parent. Understanding what these care decisions mean to the increasing number of persons who must make care decisions for mentally impaired parents would lay the foundation for addressing issues in getting adequate assistance for these famili es. It would also help to provide a framework for policy decisions about the fragmented care system for the mentally impaired elderly, and decrease the cost to society in lost productivity. Clearly, the experience of making these decisions needs to be reexamined. Since the definition of naturalistic decision-making is â€Å"the way people use their experience to make decisions in the field setting† (Zsambok, 1997), it is incumbent upon the researcher to go into the field. Qualitative methodologies, which involve fieldwork can help build knowledge of the enormously complex and profound issue of making care decisions for mentally impaired family members. CHAPTER III METHODS Methods Design of the project Personal Reflections Part of the process in analyzing data during a qualitative project is the use of field notes. I have to admit that the process of recording field notes after each visit was a tiresome one for me. I choose to incorporate my thoughts and feelings about the phenomenon at hand, the relationships with my respondents, and the data, in the form of tape recorded field notes immediately after each visit, which were later transcribed. I have never considered myself disciplined enough to be a consistent and in-depth journaler but do consider myself a very reflective person. I guess what happens to me is once I start to put down thoughts and feelings into a very personal form, I dont know when or if I can stop. I also wanted to keep some of my personal issues private and did not initially understand who might be reading these notes. In addition, the interviews were so intense and so moving that I thought I would never forget one word, one thought, one emotion, or one observation that I had experienced before, during and after the encounter with each respondent. Well I guess it easy to imagine that, indeed, I have forgotten some of my reactions. I have been impressed and surprised by how valuable reading my field notes were during this project. When I was growing up, I was exposed to several close relatives who either had dementia or a type of mental illness where they were experienced delusions. My own grandfather experienced delusions and hallucinations when I was about 11 and was hospitalized in a mental institution for some time. I do remember some of his erratic behavior, he stayed right next door to our house, which enabled us to visit him anytime, so I had experienced being around a relative with mental conditions. I was surprised to learn that many of the respondents who had taken a mentally impaired parent into their home stated that they did not feel particularly close or even liked their parent while growing up or in subsequent adulthood. On the other hand, many family that their parents had had hard times during their lifetimes and wanted to make this part of their lives easier. Indeed, many family the parent had become part of the nuclear family and took them everywhere with them. I couldnt help but wonder, how ever, that the parents dementia might make things somewhat easier for these adult children regarding painful memories. One of the difficulties I encountered during this project was role change. I was the listener, the interpreter, and the one becoming vicariously part of their experiences. It was hard not to intrude and offer some input and advice when I family it was being solicited or challenge assumptions when needed. I was surprised and shocked about how deeply this affected me. Another challenge was the feelings I had to deal with after each interview. It was difficult sort out at first what my feelings were versus what I had ‘empathized during the interview and hadnt let go of. After many interviews I family tired, very tired and fatigued, sometimes depressed, sometimes overwhelmed and some times angry. On the other hand, some interviews energized me and where I had gone to the interview very tired after a busy day at work, I drove home feeling great until my real fatigue actually caught up with me. One helpful strategy was to have one of my committee members review some of my field notes. I learned from that feedback to pay attention to my feelings and use them to inform myself about how that particular respondent interacted with the world. Although there were many personal issues that came up during interviews which held personal meanings for me and from which I had to distance my own reactions from the respondents, there were also professional issues which got to me. When the ‘system, be it healthcare, political or whatever let these informants down, I took it personally. It made me very angry that in our very rich, very evolved society we do not offer supports and safety nets for those who are dealing with such difficult and challenging isse4s such as making care decisions for a mentally impaired parent. I am hoping my anger will drive me to work on legislative issues and to continue research in this area. CHAPTER IV RESULTS The five themes and nineteen categories (see Table 1) presented in this chapter emerged from sixty-seven codes rendered from the raw data. Raw data consisted of nineteen transcripts from interviews with twenty-two adult offspring who self-identified as primary decision-makers for mentally impaired parents. Findings collapsed into five main themes: Level of Contact ; Interpersonal Conflict; Personal Sharing; Providng Assistance; and Giving Gratitude. These themes suggest that, indeed, adult offspring in this project did go through a reiterative decision-making process when making care decisions for a mentally impaired parent. At various times during the course of numerous decision-making processes, adult offspring struggled to find that Level of Contact internally, as reality set in that parents were no longer able to make effective and safe care decisions. There was the need to Interpersonal Conflicty as they contemplate where they, as adult children, fit into this picture and what r esponsibilities they will accept while negotiating with other siblings. Other phases of the decision-making process involve: Personal Sharing as they stepped up to the plate and made and implemented decisions; inevitably having to alter course as circumstances and levels of energy changed (Providng Assistance); and Self Sufficiency where they reinforced their decisions by being thankful that their situation (or perception of their situation) was more tolerable than others in similar circumstances. Nineteen sub-themes or categories flowed from the five themes. Level of Contact consisted of Defining Condition, Safety Concerns, and Role-Reversion. Interpersonal Conflict involved a Conscious Choice, Strained Family Relationships, Sharing the Load and Sole Responsibility. A Thread of Memory on the part of the parent sustains adult offspring in the Personal Sharing stage of the decision-making process. In this stage, the adult offspring would be Guessing Needs of the parent, Getting Information, looking at Finances, and Expressing Goals. Caregiver Wear and Tear, Time Constraints, and Problems with Care triggered a Providng Assistance phase. Adult offspring would respond to these stressors by Dealing with It and Becoming Assertive with the parent. Finally adult offspring would use mental coping strategies to confirm their decisions and the accompanying hardships by Comparing with Others and turning to Spirituality (Self Sufficiency). Theme I. Level of Contact Category 1. Defining Condition All but three of the interviews contained a category of Defining Condition of the parent. Adult offspring went through a process where they had to let go of their past preconceptions of parents capabilities and put their own words to the startling fact that the parent needed help with care decision making. Sometimes this became much clearer after the parent was in the household a number of years. One respondent who had taken his mother in before the onset of dementia was able to describe her condition after several years of living with her. She used to get on the bus and run around and all that stuff. When she took that fall she developed this what I call this old persons syndrome. She became so deathly afraid of falling again that her movements became choppier and choppier and tighter and tighter and the tighter they got the more prone she was to kind of losing her balance a little bit and then she would get scared more. She has physically gone down hill a lot since then. Mentally, well mentally shes gone down a lot too. Dementia, as I understand, is about a ten-year disease and she is probably three to four years into it. She probably had some symptoms of dementia four years ago, but it has gotten significantly worse since then. I think it has been four years. Although this respondent was able to clearly acknowledge symptoms of dementia, he still had difficulty accurately defining which symptoms were pertinent to the dementia and to the type of dementia involved. I said well my mother doesnt have Alzheimers, my mother has dementia. She said oh it is the same thing. I said well no its not, it is a significantly different thing. Alzheimers is a variation of dementia, dementia is a much broader category. If my mother has Alzheimers it wouldnt be safe to leave her alone because Alzheimers, as I understand it, is a spatial disorientation to where they can feel they are not where they need to be and they need to go where they want to go. Now they may be right there, but they dont feel it and so they go. My mother doesnt have Alzheimers. She plants, she is right where she wants to be and she knows it. But she does have dementia, that mental sense of connection to what just happened. And the gal said well we treat them both the same. Well how can you do that, they are both two separate issues and for one you should do this and for the other you should do that. Its frustrating. This adult son as he was trying to define the condition to himself, limited his conception to physical components of Alzheimers however inaccurately. How he defined his mothers condition to himself influenced what decisions he made and implemented in the Personal Sharing stage. Indeed, he had recently undergone an investigation by the Department of Aging (from which he was cleared of all charges) for leaving his mother alone and for cleanliness issues. Another respondent described how she was able to put words to the deteriorating condition of her mother. This respondent was a registered nurse with her masters degree and chose to define the condition through objective tests and outside opinions. No, she was not. She was totally independent and totally well until about the age of 82. So, that is getting to be close to five years now, she is 86. Then she began to get lost driving and not to be able to do what you and I would do if we were lost to stop and find out where we were, draw a map and follow it home, she couldnt do it anymore. At that point I took her toI had a wonderful physician who was a geriatric specialist and she got us in touch with some psychological testing services and we went through a battery of those and came up with the fact that what she should for her level of functioning prior to that date, she was losing an awful lot of executive ability. You probably know better than I exactly what that encompassed. So that is the point at which somebody had said to me she truly has some dementia developing, it is not just normal forgetfulness, it is dementia. Then I began to intervene with things like finances and make sure that she got to doctors. You know, just gradually taking on more and more responsibility. Note how this daughter accurately describes and defines her mothers condition, relying on her own observations and objective tests, a method of assessment which she probably is familiar with through her professional nursing career. Once the diagnosis was established, she got on with Personal Sharing phase by examining finances and making and keeping doctors appointments. This was an only child, born of parents who were also only children of which only the mother was living. These circumstances necessitated that the daughter did not have the luxury of dealing with siblings and determining her place in all of these decisions for her mentally impaired mother. Another adult daughter defined her mothers condition by the things she was still able to observe and how she functioned. Yeah. She is so observant. On the way home from [the daycare facility] the other day she said you know I am just intrigued by the cloud formations. She said I look up and I see all these configurations in the cloud. Coming down 29 she said have you ever thought about the laying of asphalt on that road, that is such a steep hill. How did they lay all that asphalt without it trickling down hill? So I mean shes not out of it. And every Sunday morning I dont know what triggers it she wakes up at six oclock and says is it time to go to mass. The other mornings of the week she will say what day is today. But somehow Sunday she knows it is Sunday. She will say now what time is it. Be sure to fast long enough to go to communion. She is a big help to me with her hands. She folds all the laundry. She cleans up all the plates and Sunday afternoon she took the fern and gave it a haircut all afternoon, it took quite a while to do it. She cuts up the salad, she makes fruit salads, she will wash ve getables, she will wash beans, anything she can do with her hands. Focusing on the positive might impact on this respondents ability to acknowledge continuous regression and might negatively influence the Personal Sharing phase when the inevitable physical decline begins and nursing home care must be considered. I mean if the time comes when she can no longer go to the Center or she is so feeble I would then have to make the choices to whether I was going to have somebody come in during the day to care for her and then I would be the caregiver until I got home from school until the next morning or put her in assisted living. I doubt that she will ever need nursing care, although one never knows. I mean nursing home care. She would be more likely to go into an assisted living. And as to where I would take her I dont know. Two other respondents defined their mothers and mothers-in-law mental impairment by attributing it to being taken advantage of by a preacher. Respondent: I truly believe that the religious aspect of this deteriorating her rather than helped her. Ive had extensive kinds of confrontations on her about she and God. This man always prayed with her and just a week ago did she say I believe in God. I think this man was her avenue and had her believing she was an avenue to God. Wife: And shes been in church all of her life and taught Sunday school. Respondent: I think it was a brainwash. I think this lady right now could still be playing the piano and doing everything she wanted to do if she hadnt of gotten too involved with him. Interviewer: So you think some of her thinking difficulties have to do with being involved with the church. Respondent: I know so. Three years, two years or more before this happened she always raised money for the preacher. She was the league chairman. She was going to give him this appreciation and I told her I was not taking her back there for her to take a bunch of money a thousand dollars or so out of the bank to give to some preacher. She said if you dont take me Ill catch the bus. It took her fourteen hours to go to West Virginia. It almost killed her. They continued talking about their journey to define in their own words what was happening to their parent despite what others were telling them. Wife: Then the people told us that she had gotten to the point where she was not bathing, had weird stuff on her hands, dirty, nasty stinking and he was steadily draining her and the neighbors and the church people had been telling us this and of course we didnt believe it not as strong a woman as momma was. But, they said she was even begging in the church for money for him and she would call us here and people kept sending bank statements to them that checks were bouncing. And he found out because he asked about a savings account and she said what savings account and we know that his father left her plenty of money. She doesnt have a dime except for money that she gets Respondent: And we have a beautiful house like this in West Virginia and we have borrowed on it. We go there and live four weeks out of the year. Two months out of the year we are there, we just came back. But, yeah I really think that this man really deteriorated her mind. Any time something would go wrong for himI hadnt paid attention to it. She would tell Wife that she called the preacher and he prayed with her and things were okay. I think that can happen to an old person and its called brainwash. Brainwash is a strange thing. The respondents kept coming back to the fact that their mother was taken advantage of by a preacher but incorrectly attribute this as a cause of her mental impairment rather than a consequence of it. On the other hand, they were able to seek out a doctors opinion and had some understanding of dementia. And I started questioning him about her and he said why dont I just get the chart and discuss it with you. I said because I am going to be taking her away from here and she can not get over here to see you properly. She has to pay somebody for everything that they do. So, he started out with dementia and I said what is dementia. I said is that Alzheimers what is it. He said a form of it. He said she will do well for a good while and I cant tell you how long, but he said she will start deteriorating and this will take over and it will appear to be almost like Alzheimers. He said she always has some deficiencies here in the spine at the base and that is going to be crippling and she would be wheelchair bound. He said other than that there was some enlargement of the heart which is normal for this age, 95 or 96. That is how we found out. There was always no problem everything is all right. Because we never went to see her business because she took care of everything. But when we found i t out that is when we made the decision. She had always said she would come and live in her room at the right time and the room was fixed, it was all ready Of course she has been unhappy many, many times in the beginning when we brought her here. She always wanted to send money back to the preachers wife, which she used to always buy her clothes all the time and making commitment always for that group. I guess people like who they like. I think they took advantage of her, I know so. This man was also an only child and it is evident that he moved into the Personal Sharing phase with the support of his wife while short-circuiting the Interpersonal Conflict stage due to his clear place in the family and no siblings with whom to negotiate. Category 2. Safety Concerns As adult children moved through the Level of Contact phase, they inevitably encountered issues about the safety of the parents behavior. They were often still unsure about whether these safety concerns were real since many times at the beginning of the course of the mental impairment, they were being told of these behaviors by others and not directly observing them for themselves. Thus presented quite a dilemma. The adult offspring were still struggling with defining the parents condition and not believing that the parent they knew could no longer be counted on to behave in an appropriate and safe manner. Looking back on being told of his mothers erratic behavior about finances and being drained of her life savings by a local preacher, one adult son remarked: Well it really was at a point that something I should have addressed ten years ago when I was told by distance relatives and friends and classmates there in the town that he was doing this. I just came to grips to where I just didnt believe it and you all told me and I didnt do anything about it. You all were right. I should have called this guy on the carpet way back. Hey man what are you doing. As I tell Wife Im not sure that would have been right either because then it is hearsay. This respondent was much more comfortable intervening in the situation once he had concrete evidence of the unsafe manner in which his mother was handling her finances and ability to live on her income. What happens is I have fact. I have the canceled checks. I know things that hes done. I have people that have seen him take her to the stores where she can cash checks and wait on the money, all of that. Safety Concerns whether they were about finances, getting lost in familiar surroundings, leaving appliances on such as stoves, falling or being unable to perform routine activities of daily living particularly eating regularly were effective at helping the adult offspring to move through the Level of Contact phase only when they were real to the adult son or daughter. The implications of seeing a formerly competent parent falter at taking care of themselves in an appropriate and safe manner seemed to be almost impossible until unsafe behaviors were personally observed. One adult daughter put it this way: Um, so it went on like that and then, what really brought it to a head was one morning I knew she needed milk. She could get her cereal but for some reason that was the thin that she really wanted so thats what she did, um, and I thought, well Ill drop the milk by and shell have milk for her cereal and then Ill come by at lunchtime and see, you know, see whats going on. So ordinarily, my mother slept very well and slept a little bit later in the morning, so I thought, well, you know, I let myself in and put the milk in the refrigerator and then thought, well, Ill just take a little peek, maybe shes awake, and I went around the corner and my mother, yeah she was awake but she was also on the floor surrounded by her covers, didnt know how shed gotten there, didnt know who she was, didnt know who I was at first, but she was so upset and you know, didnt have any idea how long shed been there, so I got her back up on the bed. She didnt hurt anything, cause the bed was low and she just sor t of slipped off of it. I think she used to take a medication. Sometimes it would make her a little sleepy, you know and she used to get up in the middle of the night to go to the bathroom and I think that maybe when she went back she may have missed the bed for some reason. I dont know how she did it, but she was OK, so I called my husband, I called my job and I called the doctorfrom then on it just seemed that things just went very quickly Another adult daughter talked about the time she realized that it was no longer safe for her mother to live alone. What happened one day, my mother stayed with them, they had a house and what happened was my mom she went to the dentist and they gave her some anesthesia and I think it just made her more confused and she was lost, we couldnt find her. She had left the house about ten oclock that morning and everybody was wondering where is mother, where is mother and we couldnt find her. So I think around like ten oclock or something like that we called the police and eventually we found her. She was over in the old neighborhood where she used to live prior to staying with them. So, I just took her at my house and I kept her like six months because I Experiences of Adult Offspring Making Care Decisions Experiences of Adult Offspring Making Care Decisions In normal aging, decline in mental skills is modest with no consequential decrease in ability to care for oneself. Normally, older adults are able to maintain activities of daily living (ADLs) such as bathing, dressing, transferring, and toileting, and instrumental activities of daily living (IADLs), which include shopping, cooking, housekeeping, laundry, and handling money (Schaie, 1989). Nevertheless, one in 10 persons over 65 and nearly half of those over 85 have Alzheimers disease, a form of dementia (The Alzheimers Association, 1999) and, thus, have problems with IADLs, ADLs or both, and need assistance with care decisions. Often these decisions are left to adult offspring who are ill prepared to cope with role changes and parent-caring responsibilities (Archbold, 1980; Brody, Johnsen, Fulcomer Lang, 1983; Brody, Kleban, Johnsen, Hoffman Schoonover, 1987; Cantor 1883; Stoller, 1982). What is the experience of these adult children as they negotiate their way through the their own internal voices, their family of origin and the healthcare system? Have we been asking the right questions when we assume that all is reduced to family obligation and responsibility? This project was designed to elicit and understand the experience of those adult offspring who are making care decisions for a mentally impaired parent. Chapter I includes background and significance of the project, the philosophical framework in which the project question is poised, the project question, and definition of terms. Background and Significance of the Project Although almost half (47%) of persons 85 and older will have mental impairment (Schaie, 1989), many elderly do not make plans for dealing with possible changes in mental status. As elderly â€Å"age in place†, it is frequently left to family members to decide about care and living arrangements. For most family members these care decisions about the care of elderly parent are difficult at best (Pfeiffer, 1995), and the number of people involved in making these decisions will increase as life expectancy increases and the population of the United States continues to age. Life expectancy is the average number of years people born in a given year are expected to live based on a set of age-specific death rates. At the beginning of the 20th century, life expectancy at birth was 47.3 years. Today, at the beginning of the 21st century, the average life expectancy has increased dramatically at birth to nearly 77 years. In addition, life expectancy for every age group has also increased during the past century. â€Å"Based on todays age-specific death rates, individuals aged 65 years can be expected to live an average of 18 more years, for a total of 83 years. Those aged 75 years can be expected to live an average of 11 more years, for a total of 86 years† (http://www.health.gov/healthypeople/Document/HTML/Volume1/goal.htm, August 14, 2000). Persons older than 65 now comprise 12.7% of the population of the United States (Statistical Abstract of the United States, 1999, http://www.census.gov/statab/www/states/md.txt, August 14, 2000). By the year 2020, 20% of the population will be older than 65 years (US Bureau of the Census, 1996). The largest percentage of growth is in elders 85 and over, a group at high risk for mental disorders such as Alzheimers disease. Almost 19 million Americans report they have a family member with Alzheimers, and 37 million know someone with the disease (The Alzheimers Association, 1999). Since 7 out of 10 people with Alzheimers live at home, lost productivity of caregivers is estimated to cost American businesses $26 billion a year plus $7 billion annually related to costs for health and long-term care (The Alzheimers Association, 1999). Other estimates put the cost of informal caregiving at $18 billion. In a project of 7, 443 of elders seventy and over taken from a national representative sur vey, the cost of informal care for mild dementia at $3,630 per person with double the cost for moderate dementia relatives and almost five times the cost for severe dementia (Langa, Chernew, Kabeto, Herzog, Ofstedal, Willis, Wallace, Much, Straus Fendrick, 2001). It is not surprising that the public is starting to ask for help with this complex issue. Previous research sought to identify predictors of placement decisions by family caregivers with dementia (Colerick George, 1986) when care options were few and rational mental models of decision making were thought to be superior to the human mind. At the turn of the 21st century, however, the healthcare environment offers multiple models of care for mentally impaired patients (Abraham, Onega, Chalifoux Maies, 1994). Decision making needs to be informed by the context of continuity of care, which now ranges from home and home-like environments to part time respite or adult day care to long term care services in nursing homes. Indeed, â€Å"patients and families are often surprised if not shocked about the actual services they may receive from various community-based or institutionalized services† (Abraham, Onega, Chalifoux Maies, 1994, p.165). In addition to the increasing complexity of choices, rational mental models of decision-making are in question and giving way to a more naturalistic project of how real world decisions are being made (Sloan, 1996). Rational standards, in which it is assumed people merely choose among options, do not take into consideration most contextual factors that impact on decision-making in real-world situations (Beach Lipshitz, 1993; Cohen, 1993). There is a stark contrast between the assumptions of rational decision-making and naturalistic decision-making. In the naturalistic decision making paradigm, problems are seen as ill structured rather than artificial and well structured. Solutions to these problems are made in uncertain, dynamic environments rather than static, simulated situations. Goals are shifting, ill defined or competing rather than clear and stable. There are action/feedback loops to decision-making process not one-shot decisions. Time stress is a factor and stakes are high i nstead of the presumed luxury of leisurely deliberation and absence of true consequences for the decision-maker (Orasanu Connolly, 1993; Zsambok, 1997). Research on the experience of making care decisions for mentally impaired parents needs to take into account the way decisions are made in the real world and the numerous opportunities for care assistance that are available today. The majority of middle aged, and even young-old Americans, will be faced with making decisions about care for a mentally impaired parent at a time in life when they are dealing with their own transitional issues, as well as those of the generations before and after them. Given the resulting emotional and financial cost, it would be wise to develop health policy about mentally impaired elder citizens and their offspring based on an understanding of the experience of making decisions about the care of a mentally impaired parent. Understanding what these care decisions mean to the increasing number of persons who must make care decisions for mentally impaired parents would lay the foundation for addressing issues in getting adequate assistance for these famili es. It would also help to provide a framework for policy decisions about the fragmented care system for the mentally impaired elderly, and decrease the cost to society in lost productivity. Clearly, the experience of making these decisions needs to be reexamined. Since the definition of naturalistic decision-making is â€Å"the way people use their experience to make decisions in the field setting† (Zsambok, 1997), it is incumbent upon the researcher to go into the field. Qualitative methodologies, which involve fieldwork can help build knowledge of the enormously complex and profound issue of making care decisions for mentally impaired family members. CHAPTER III METHODS Methods Design of the project Personal Reflections Part of the process in analyzing data during a qualitative project is the use of field notes. I have to admit that the process of recording field notes after each visit was a tiresome one for me. I choose to incorporate my thoughts and feelings about the phenomenon at hand, the relationships with my respondents, and the data, in the form of tape recorded field notes immediately after each visit, which were later transcribed. I have never considered myself disciplined enough to be a consistent and in-depth journaler but do consider myself a very reflective person. I guess what happens to me is once I start to put down thoughts and feelings into a very personal form, I dont know when or if I can stop. I also wanted to keep some of my personal issues private and did not initially understand who might be reading these notes. In addition, the interviews were so intense and so moving that I thought I would never forget one word, one thought, one emotion, or one observation that I had experienced before, during and after the encounter with each respondent. Well I guess it easy to imagine that, indeed, I have forgotten some of my reactions. I have been impressed and surprised by how valuable reading my field notes were during this project. When I was growing up, I was exposed to several close relatives who either had dementia or a type of mental illness where they were experienced delusions. My own grandfather experienced delusions and hallucinations when I was about 11 and was hospitalized in a mental institution for some time. I do remember some of his erratic behavior, he stayed right next door to our house, which enabled us to visit him anytime, so I had experienced being around a relative with mental conditions. I was surprised to learn that many of the respondents who had taken a mentally impaired parent into their home stated that they did not feel particularly close or even liked their parent while growing up or in subsequent adulthood. On the other hand, many family that their parents had had hard times during their lifetimes and wanted to make this part of their lives easier. Indeed, many family the parent had become part of the nuclear family and took them everywhere with them. I couldnt help but wonder, how ever, that the parents dementia might make things somewhat easier for these adult children regarding painful memories. One of the difficulties I encountered during this project was role change. I was the listener, the interpreter, and the one becoming vicariously part of their experiences. It was hard not to intrude and offer some input and advice when I family it was being solicited or challenge assumptions when needed. I was surprised and shocked about how deeply this affected me. Another challenge was the feelings I had to deal with after each interview. It was difficult sort out at first what my feelings were versus what I had ‘empathized during the interview and hadnt let go of. After many interviews I family tired, very tired and fatigued, sometimes depressed, sometimes overwhelmed and some times angry. On the other hand, some interviews energized me and where I had gone to the interview very tired after a busy day at work, I drove home feeling great until my real fatigue actually caught up with me. One helpful strategy was to have one of my committee members review some of my field notes. I learned from that feedback to pay attention to my feelings and use them to inform myself about how that particular respondent interacted with the world. Although there were many personal issues that came up during interviews which held personal meanings for me and from which I had to distance my own reactions from the respondents, there were also professional issues which got to me. When the ‘system, be it healthcare, political or whatever let these informants down, I took it personally. It made me very angry that in our very rich, very evolved society we do not offer supports and safety nets for those who are dealing with such difficult and challenging isse4s such as making care decisions for a mentally impaired parent. I am hoping my anger will drive me to work on legislative issues and to continue research in this area. CHAPTER IV RESULTS The five themes and nineteen categories (see Table 1) presented in this chapter emerged from sixty-seven codes rendered from the raw data. Raw data consisted of nineteen transcripts from interviews with twenty-two adult offspring who self-identified as primary decision-makers for mentally impaired parents. Findings collapsed into five main themes: Level of Contact ; Interpersonal Conflict; Personal Sharing; Providng Assistance; and Giving Gratitude. These themes suggest that, indeed, adult offspring in this project did go through a reiterative decision-making process when making care decisions for a mentally impaired parent. At various times during the course of numerous decision-making processes, adult offspring struggled to find that Level of Contact internally, as reality set in that parents were no longer able to make effective and safe care decisions. There was the need to Interpersonal Conflicty as they contemplate where they, as adult children, fit into this picture and what r esponsibilities they will accept while negotiating with other siblings. Other phases of the decision-making process involve: Personal Sharing as they stepped up to the plate and made and implemented decisions; inevitably having to alter course as circumstances and levels of energy changed (Providng Assistance); and Self Sufficiency where they reinforced their decisions by being thankful that their situation (or perception of their situation) was more tolerable than others in similar circumstances. Nineteen sub-themes or categories flowed from the five themes. Level of Contact consisted of Defining Condition, Safety Concerns, and Role-Reversion. Interpersonal Conflict involved a Conscious Choice, Strained Family Relationships, Sharing the Load and Sole Responsibility. A Thread of Memory on the part of the parent sustains adult offspring in the Personal Sharing stage of the decision-making process. In this stage, the adult offspring would be Guessing Needs of the parent, Getting Information, looking at Finances, and Expressing Goals. Caregiver Wear and Tear, Time Constraints, and Problems with Care triggered a Providng Assistance phase. Adult offspring would respond to these stressors by Dealing with It and Becoming Assertive with the parent. Finally adult offspring would use mental coping strategies to confirm their decisions and the accompanying hardships by Comparing with Others and turning to Spirituality (Self Sufficiency). Theme I. Level of Contact Category 1. Defining Condition All but three of the interviews contained a category of Defining Condition of the parent. Adult offspring went through a process where they had to let go of their past preconceptions of parents capabilities and put their own words to the startling fact that the parent needed help with care decision making. Sometimes this became much clearer after the parent was in the household a number of years. One respondent who had taken his mother in before the onset of dementia was able to describe her condition after several years of living with her. She used to get on the bus and run around and all that stuff. When she took that fall she developed this what I call this old persons syndrome. She became so deathly afraid of falling again that her movements became choppier and choppier and tighter and tighter and the tighter they got the more prone she was to kind of losing her balance a little bit and then she would get scared more. She has physically gone down hill a lot since then. Mentally, well mentally shes gone down a lot too. Dementia, as I understand, is about a ten-year disease and she is probably three to four years into it. She probably had some symptoms of dementia four years ago, but it has gotten significantly worse since then. I think it has been four years. Although this respondent was able to clearly acknowledge symptoms of dementia, he still had difficulty accurately defining which symptoms were pertinent to the dementia and to the type of dementia involved. I said well my mother doesnt have Alzheimers, my mother has dementia. She said oh it is the same thing. I said well no its not, it is a significantly different thing. Alzheimers is a variation of dementia, dementia is a much broader category. If my mother has Alzheimers it wouldnt be safe to leave her alone because Alzheimers, as I understand it, is a spatial disorientation to where they can feel they are not where they need to be and they need to go where they want to go. Now they may be right there, but they dont feel it and so they go. My mother doesnt have Alzheimers. She plants, she is right where she wants to be and she knows it. But she does have dementia, that mental sense of connection to what just happened. And the gal said well we treat them both the same. Well how can you do that, they are both two separate issues and for one you should do this and for the other you should do that. Its frustrating. This adult son as he was trying to define the condition to himself, limited his conception to physical components of Alzheimers however inaccurately. How he defined his mothers condition to himself influenced what decisions he made and implemented in the Personal Sharing stage. Indeed, he had recently undergone an investigation by the Department of Aging (from which he was cleared of all charges) for leaving his mother alone and for cleanliness issues. Another respondent described how she was able to put words to the deteriorating condition of her mother. This respondent was a registered nurse with her masters degree and chose to define the condition through objective tests and outside opinions. No, she was not. She was totally independent and totally well until about the age of 82. So, that is getting to be close to five years now, she is 86. Then she began to get lost driving and not to be able to do what you and I would do if we were lost to stop and find out where we were, draw a map and follow it home, she couldnt do it anymore. At that point I took her toI had a wonderful physician who was a geriatric specialist and she got us in touch with some psychological testing services and we went through a battery of those and came up with the fact that what she should for her level of functioning prior to that date, she was losing an awful lot of executive ability. You probably know better than I exactly what that encompassed. So that is the point at which somebody had said to me she truly has some dementia developing, it is not just normal forgetfulness, it is dementia. Then I began to intervene with things like finances and make sure that she got to doctors. You know, just gradually taking on more and more responsibility. Note how this daughter accurately describes and defines her mothers condition, relying on her own observations and objective tests, a method of assessment which she probably is familiar with through her professional nursing career. Once the diagnosis was established, she got on with Personal Sharing phase by examining finances and making and keeping doctors appointments. This was an only child, born of parents who were also only children of which only the mother was living. These circumstances necessitated that the daughter did not have the luxury of dealing with siblings and determining her place in all of these decisions for her mentally impaired mother. Another adult daughter defined her mothers condition by the things she was still able to observe and how she functioned. Yeah. She is so observant. On the way home from [the daycare facility] the other day she said you know I am just intrigued by the cloud formations. She said I look up and I see all these configurations in the cloud. Coming down 29 she said have you ever thought about the laying of asphalt on that road, that is such a steep hill. How did they lay all that asphalt without it trickling down hill? So I mean shes not out of it. And every Sunday morning I dont know what triggers it she wakes up at six oclock and says is it time to go to mass. The other mornings of the week she will say what day is today. But somehow Sunday she knows it is Sunday. She will say now what time is it. Be sure to fast long enough to go to communion. She is a big help to me with her hands. She folds all the laundry. She cleans up all the plates and Sunday afternoon she took the fern and gave it a haircut all afternoon, it took quite a while to do it. She cuts up the salad, she makes fruit salads, she will wash ve getables, she will wash beans, anything she can do with her hands. Focusing on the positive might impact on this respondents ability to acknowledge continuous regression and might negatively influence the Personal Sharing phase when the inevitable physical decline begins and nursing home care must be considered. I mean if the time comes when she can no longer go to the Center or she is so feeble I would then have to make the choices to whether I was going to have somebody come in during the day to care for her and then I would be the caregiver until I got home from school until the next morning or put her in assisted living. I doubt that she will ever need nursing care, although one never knows. I mean nursing home care. She would be more likely to go into an assisted living. And as to where I would take her I dont know. Two other respondents defined their mothers and mothers-in-law mental impairment by attributing it to being taken advantage of by a preacher. Respondent: I truly believe that the religious aspect of this deteriorating her rather than helped her. Ive had extensive kinds of confrontations on her about she and God. This man always prayed with her and just a week ago did she say I believe in God. I think this man was her avenue and had her believing she was an avenue to God. Wife: And shes been in church all of her life and taught Sunday school. Respondent: I think it was a brainwash. I think this lady right now could still be playing the piano and doing everything she wanted to do if she hadnt of gotten too involved with him. Interviewer: So you think some of her thinking difficulties have to do with being involved with the church. Respondent: I know so. Three years, two years or more before this happened she always raised money for the preacher. She was the league chairman. She was going to give him this appreciation and I told her I was not taking her back there for her to take a bunch of money a thousand dollars or so out of the bank to give to some preacher. She said if you dont take me Ill catch the bus. It took her fourteen hours to go to West Virginia. It almost killed her. They continued talking about their journey to define in their own words what was happening to their parent despite what others were telling them. Wife: Then the people told us that she had gotten to the point where she was not bathing, had weird stuff on her hands, dirty, nasty stinking and he was steadily draining her and the neighbors and the church people had been telling us this and of course we didnt believe it not as strong a woman as momma was. But, they said she was even begging in the church for money for him and she would call us here and people kept sending bank statements to them that checks were bouncing. And he found out because he asked about a savings account and she said what savings account and we know that his father left her plenty of money. She doesnt have a dime except for money that she gets Respondent: And we have a beautiful house like this in West Virginia and we have borrowed on it. We go there and live four weeks out of the year. Two months out of the year we are there, we just came back. But, yeah I really think that this man really deteriorated her mind. Any time something would go wrong for himI hadnt paid attention to it. She would tell Wife that she called the preacher and he prayed with her and things were okay. I think that can happen to an old person and its called brainwash. Brainwash is a strange thing. The respondents kept coming back to the fact that their mother was taken advantage of by a preacher but incorrectly attribute this as a cause of her mental impairment rather than a consequence of it. On the other hand, they were able to seek out a doctors opinion and had some understanding of dementia. And I started questioning him about her and he said why dont I just get the chart and discuss it with you. I said because I am going to be taking her away from here and she can not get over here to see you properly. She has to pay somebody for everything that they do. So, he started out with dementia and I said what is dementia. I said is that Alzheimers what is it. He said a form of it. He said she will do well for a good while and I cant tell you how long, but he said she will start deteriorating and this will take over and it will appear to be almost like Alzheimers. He said she always has some deficiencies here in the spine at the base and that is going to be crippling and she would be wheelchair bound. He said other than that there was some enlargement of the heart which is normal for this age, 95 or 96. That is how we found out. There was always no problem everything is all right. Because we never went to see her business because she took care of everything. But when we found i t out that is when we made the decision. She had always said she would come and live in her room at the right time and the room was fixed, it was all ready Of course she has been unhappy many, many times in the beginning when we brought her here. She always wanted to send money back to the preachers wife, which she used to always buy her clothes all the time and making commitment always for that group. I guess people like who they like. I think they took advantage of her, I know so. This man was also an only child and it is evident that he moved into the Personal Sharing phase with the support of his wife while short-circuiting the Interpersonal Conflict stage due to his clear place in the family and no siblings with whom to negotiate. Category 2. Safety Concerns As adult children moved through the Level of Contact phase, they inevitably encountered issues about the safety of the parents behavior. They were often still unsure about whether these safety concerns were real since many times at the beginning of the course of the mental impairment, they were being told of these behaviors by others and not directly observing them for themselves. Thus presented quite a dilemma. The adult offspring were still struggling with defining the parents condition and not believing that the parent they knew could no longer be counted on to behave in an appropriate and safe manner. Looking back on being told of his mothers erratic behavior about finances and being drained of her life savings by a local preacher, one adult son remarked: Well it really was at a point that something I should have addressed ten years ago when I was told by distance relatives and friends and classmates there in the town that he was doing this. I just came to grips to where I just didnt believe it and you all told me and I didnt do anything about it. You all were right. I should have called this guy on the carpet way back. Hey man what are you doing. As I tell Wife Im not sure that would have been right either because then it is hearsay. This respondent was much more comfortable intervening in the situation once he had concrete evidence of the unsafe manner in which his mother was handling her finances and ability to live on her income. What happens is I have fact. I have the canceled checks. I know things that hes done. I have people that have seen him take her to the stores where she can cash checks and wait on the money, all of that. Safety Concerns whether they were about finances, getting lost in familiar surroundings, leaving appliances on such as stoves, falling or being unable to perform routine activities of daily living particularly eating regularly were effective at helping the adult offspring to move through the Level of Contact phase only when they were real to the adult son or daughter. The implications of seeing a formerly competent parent falter at taking care of themselves in an appropriate and safe manner seemed to be almost impossible until unsafe behaviors were personally observed. One adult daughter put it this way: Um, so it went on like that and then, what really brought it to a head was one morning I knew she needed milk. She could get her cereal but for some reason that was the thin that she really wanted so thats what she did, um, and I thought, well Ill drop the milk by and shell have milk for her cereal and then Ill come by at lunchtime and see, you know, see whats going on. So ordinarily, my mother slept very well and slept a little bit later in the morning, so I thought, well, you know, I let myself in and put the milk in the refrigerator and then thought, well, Ill just take a little peek, maybe shes awake, and I went around the corner and my mother, yeah she was awake but she was also on the floor surrounded by her covers, didnt know how shed gotten there, didnt know who she was, didnt know who I was at first, but she was so upset and you know, didnt have any idea how long shed been there, so I got her back up on the bed. She didnt hurt anything, cause the bed was low and she just sor t of slipped off of it. I think she used to take a medication. Sometimes it would make her a little sleepy, you know and she used to get up in the middle of the night to go to the bathroom and I think that maybe when she went back she may have missed the bed for some reason. I dont know how she did it, but she was OK, so I called my husband, I called my job and I called the doctorfrom then on it just seemed that things just went very quickly Another adult daughter talked about the time she realized that it was no longer safe for her mother to live alone. What happened one day, my mother stayed with them, they had a house and what happened was my mom she went to the dentist and they gave her some anesthesia and I think it just made her more confused and she was lost, we couldnt find her. She had left the house about ten oclock that morning and everybody was wondering where is mother, where is mother and we couldnt find her. So I think around like ten oclock or something like that we called the police and eventually we found her. She was over in the old neighborhood where she used to live prior to staying with them. So, I just took her at my house and I kept her like six months because I

Tisis

The researchers investigated only on the comparison between Zamias and Dolan as to which is the better decontrolling agent. This study concentrated only on the use of Escherichia coli and Staphylococcus erasures which is a gram negative and a gram- positive bacteria respectively. Significance of the Study This study will be conducted to determine the Overran blimp (zamias) and Citrus uranium Lain. (Dolan) acidity to be used as an alternative decolonize in Gram Staining. In the world of Medical Technology, practice of repairing smears on a slide is a part of it.The ethanol-alcohol mixture is commonly used as decolonize, but there is a necessary need for finding an alternative decolonize. The need for finding an alternative decolonize will be more environmental friendly. This project is aimed to produce a natural stain decolonize for plant and animal tissues that is inexpensive and whose sources are indigenous, abundant and more efficient way in finding a natural substance that will ma tch the components in the alcohol. Setting of the study The study will be conducted in Centre Escalator University located in Medical, Manila.Centre Escalator University is a private, non-sectarian higher education institution with an enrolment of over 20,000 students in its three campuses; Manila, Magmata, and Mallows. Centre Escalator University was founded on June 3, 1 907 by Library Availing and Carmen De Ulna and was originally called Centre Escalator De Senoritas. The research will be conducted at Centennial Research Laboratory at Conception Caligula Hall and Generous De Leon Science Center at Centre Escalator University. Conceptual framework The Gram stain is the most important and universally used staining technique in the bacteriology laboratory (S.W. Joseph, et. L. 2000). In relation to the study, the researchers decided to make an alternative decolonize for Gram staining with the use of the fruit extract of Zamias and Dolan which is commonly found in the Philippines. The process will include the extraction procedure using a juicer to obtain the extract. The fruit extract of Zamias and Dolan will undergo photochemical property screening. The Gram staining procedure will entail the use of Staphylococcus erasures and Escherichia coli that will serve as test organisms to test the effectiveness of Zamias and Dolan as a decolonize.Definition of terms Antibacterial. Useful in curing or preventing the action of harmful bacteria. Ascorbic acid. Vitamin C that is present in citrus fruits and synthetically manufactured fruits. Decentralization. The process of removing stains or coloring agents. Escherichia coli. Bacterium found in human intestine. Gram staining. It is the procedure in microbiological used to differentiate between gram positive organisms and gram negative organisms. Osmotic pressure. It is the pressure required to prevent the passage of water through a semi-permeable membrane from an area of low concentration of solute.Oxalic acid. Used for ble aching or as a clearing agent. Pedagogical. Polymer that is composed of polysaccharide and peptide chains found in bacterial cell wall. Phylogeny. It is the evolutionary origin and development of a particular group of organism. Photochemical property. Property or chemical components relating to plants. Smear. A preparation of substance for microscopic examination. Staphylococcus erasures Species of non-motile bacteria living on skin and mucous membrane. Sapiens. Any of several naturally occurring water soluble glycoside, able to form a ladder. Susceptible.It is the increase likelihood of being affected by, a physical or mental disease or disorder. CHAPTER 2 THE RESEARCH QUESTIONS Overran blimp (Zamias) belongs to the genus Overran, family Oxidative (Babushka et al. , 2013). Other name of Overran bimbo include Creole: bumbling plum, billion ; English: blimp, cucumber tree, tree sorrel ; Filipino: zamias; French : blimp, billion coralberry blimp. Zamias is a small tree, growing 5 to 1 2 meters high with a short trunk dividing into a number of upright branches. Leaves are pinnate, 20 to 60 centimeters long, with hairy archaic and leaflets.Leaflets are opposite, 10 to 70 pairs, oblong, 5 to 10 centimeters in length. Panicle growing from the trunk and larger branches are hairy, 15 centimeters long or less. Flowers are about 1. 5 centimeters long, and slightly fragrant. It bears flowers which are small, fragrant, 5-pedaled, yellowish-green or purple marked with dark purple. Fruit is green and edible, about 4 centimeters long, subliminally, or with 5 obscure, board, rounded, longitudinal lobes (Bras, 2001). The outer skin is glossy, very thin, soft and tender and the flesh is green, jelly-like, juicy and extremely acidic.Young fruits are green in color which turns yellowish as they ripe (Roar et al. , 2009). The blimp is a native of the Mollusks and cultivated throughout Indonesia and semi-wild every. â€Å"here in the Philippines and much grown in Ceylon and Burma. It is commonly found in Brazil, Cuba, Philippines, Sir Lankan, Bangladesh, Manner and Malaysia. In 1793, the blimp was very popular among the Asiatic residents of those countries as it must be in Hawaii. (Babushka, et al. , 2013). Overran fruits are acidic and with high fiber content and are rich sources of vitamin C, antioxidants and are low in fat.Overran fruits are high in minerals such as calcium, phosphorus, iron and potassium (Babushka et al. 2013). Overran fruits are rich sources of vitamin C, antioxidants and are low in fat. The fruit contains potassium oxalate or high levels of oxalic acid which may be used to remove iron-rust stain from clothes and to impart shine to brassieres. Chemical constituents include amino acids, citric acid, candying-3-O-b-D-glycoside, phenols, potassium ion, sugars, and Vitamin A (Rarity et al. , 2011). Fruit extract yield flavorings, sapiens ND torpedoing. Bark yields alkaloids, sapiens, and flavorings.The oxalic acid in blimp range between 10. 5 and 14. OMG/g in green fruit and 8. 45 to 10. MGM/g in ripe fruit, levels comparable to those reported from tea leaves. Because of high oxalic acid content, fruit used to remove stains from clothing and for washing hands, removing rust and stains from metal blades. Extracts showed antimicrobial activity against E. Coli, S. Typhoid, S. erasures and B. Cereus. It can also be used as a dietary ingredient to treat hyperglycemia and a potential source for the isolation of active principle for cancer therapy. It is also a potential source of intolerability drug.The activity may be caused by either or both of the steroidal glycoside and potassium oxalate constituents. Babushka, et al. , 201 3) Dolan (Citrus uranium), belongs to the family Reeducate, it is a small, erect tree with smooth, greenish white shots with spine-scent thorns. It is an aromatic variety of citrus that produces highly bitter, acidic fruits. Leaves are oblong to supplicate, 10 centimeters long by about 4 centimeters w ide Petiole is narrowly winged. Flowers are white, bisexual, solitary or few clustered, smooth and growing from the upper most leaf axial.Fruit is nearly spherical, 5-9 centimeters in diameter ad annihilate or not, the skin is orange-red and tight; partition inside with yellowish juice sacks. Taste is usually sweet occasionally sour. Citrus uranium extracted and primary parasitological constituent p-synergies are extensively used in weight management products and as thermometric agents. It is also known as â€Å"chi-shih† or â€Å"Chi shih† in traditional Chinese medicine. (Hung, et al. , 2011) The most important biological active constituents of the C. uranium fruits are phenylalanine alkaloids, activation, synergies, trainee, N- antihistamine and hardening.Aperitif, aromatic, stomach, tonic, astringent, mildly criminate, colleague, antibacterial, antithetic, untangling, antispasmodic, unintuitive, diaphragmatic, digestive, unmanaged, stimulant, vermiform. Dried rind is considered aromatic, stomach, tonic, astringent, and mildly criminate. It is rich in vitamin C, flavorings and volatile oil. Citrus flavorings have potential antioxidant, anti-aging anti-cancer, antiviral, anti-inflammatory activity, and cholesterol lowering potential. Bitter orange has a complex chemical make-up. It is perhaps most known for the volatile oil in the peel.It gives bitter orange its strong odor and flavor which account for its medical effects. Today, bitter orange is used pharmaceutical, cosmetics ND soaps. As a dietary supplement, this herb has been used to stimulate appetite, treat ringworm-type infections, relieves stomach upset and aid insomnia. Both the fruit and peel of this herb are typically included in over the counter nasal decongestants and weight loss products. It has also been used in applications such as indigestion, constipation and support of easing inflammation due to skin bruising and muscle pains.This herb has documented positive entropic effects , showing improvements to blood circulation through the heart and cerebral tissues due to its amine content. Gottfried, 201 0) According to Succumbing the juice of the fruit is used in removing ink stains from clothes and for washing the hair of women and can be used for bleaching freckles and as a cheap remedy for itching acne vulgarism and purists vulvae. Escherichia coli is a gram negative, facultative anaerobic, rod-shaped bacillus that is commonly found in the human colon and is part of its normal flora and was found by Theodore Escherichia, a German bacteriologist in 1885.E. Coli possess adhesive familiar and a cell wall that consists of an outer membrane containing alphanumerically, a periphrasis space with a pathological layer, and an inner, cytoplasm membrane. Some strains are palliated and capable of accepting and transferring plasmid to and from other bacteria. Such property enables E. Coli under bad/stress conditions to survive. They grow best at ICC and when cultured in an Eosin Methyl Blue (EMBED) culture media, it will exhibit colonies with distinct greenish-metallic sheen.When stained with Gram Stain, it will appear purple under the microscope because its cell wall's composition prevented the loss of the primary stain when decolonize and it prevented the entry of the secondary stain. Mammon, 201 1) Staphylococcus erasures is a gram positive, cuscus that is commonly found in human respiratory tract. S. erasures colonizes mainly the nasal passages, but it may be found regularly in most other anatomical locales, including the skin, oral cavity and gastrointestinal tract. It was found by Rosenberg in 1884 as yellow colonies on a culture media. Toward,2012) The cell wall envelope of S. erasures is a complex protective surface organelle, composed of pedagogical, proteins, polysaccharides and secondary wall polymers. On blood agar plates, colonies of S. erasures are frequently rounded by zones of clear beta-hemolytic. The golden appearance of colonies of some strains is the etymological root of the bacteria's name; erasures meaning â€Å"golden† in Latin. When stained with Gram Stain, it will only retain the secondary stain because its cell wall is thin causing easy decentralization of the bacteria.

Personnel Administration

Personnel Administration This lesson complies with the following course outcomes: CO 3: To analyze the policy and decision making process in public administration CO 5 : To discuss the importance of ethics in public administration Synopsis While the country’s public administration is considered an important machinery of the government, the people; men and women who devote their time more than eight hours a day are the key to successful public service. The public administrators of any country share the same goal to deliver services as best as possible to the citizen.Unlike their counterpart in the private sector, employees of the public sector made up a huge team of officers and staff paid through public fund to deliver services. In Malaysia alone, the public service is an employer to more than 1 million people around the country. Thus, the administration of these personnel surely isn’t a joking business. As time goes by and with the introduction of sophisticated managem ent systems and technologies, the personnel of the public service need to be trained and re-trained continuously to keep up. 89Personnel Administration in the Public Sector While the country’s public administration is considered an important machinery of the government, the people; men and women who devote their time more than eight hours a day are the key to successful public service. The public administrators of any country share the same goal to deliver services as best as possible to the citizen. Unlike their counterpart in the private sector, employees of the public sector made up a huge team of officers and staff paid through public fund to deliver services. In Malaysia alone, the ublic service is an employer to more than 1 million people around the country. Thus, the administration of these personnel surely isn’t a joking business. As time goes by and with the introduction of sophisticated management systems and technologies, the personnel of the public service need to be trained and re-trained continuously to keep up. So, who are these massive staff of the public service? Of course, they must be people with good calibre and worthy to be appointed into the service. One of the most important characteristics of modern public personnel dministration is the merit system or a system of appointment and promotion based on recognized ability and capability such as tertiary education, skills and experience. Historically, Prussia, one of the constituent states of what was to become modern Germany, was the first modern nation to institute a merit system. It was this German civil service that inspired Max Weber’s famous â€Å"ideal-type† bureaucratic model. In 1789, this system was The mertit system adopted by France, British-India in 1830s and in Britain in 1850s. 1 pposses any criteria of recruitment and promotion based on political preferences, nepotism and discrimination, also known as the â€Å"spoils system†. 1 Jay Shafritz, Albert Hyde and David Rosenbloom (1986). Personnel Management in Government: Politics and Process, New York: Marcel Dekker. 90 With the huge number of staff working for the public service, government ought to give attention to their welfare and career advancement. You see, working with the public service is actually a career because government provide opportunity for each staff to improve himself/herself throughout heir years of service. They can be trained, promoted, and transferred for job enrichment. All these are done through what we called public personnel administration. Public personnel administration covers â€Å"all activities that forecast on the number and type of employees which an organization will need and then find, and develop them with necessary skills† (Robert D. Gatewood). It is â€Å"concerning both the management of and the policy making for people, and positions in the government bureaucracy† (Nicholas Henry). Important functions of Personnel Adm inistrationSome of the most important functions of personnel administration include the followings: †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ Formulation of rules and regulations for an appointment which include terms and conditions of employment Establishment of suitable and reasonable remuneration system or the reward system Recruitment Promotion to encourage the most suitable and qualified people to apply and fill in the job Provision of attractive and long term career development Provision of sufficient and suitable training and development Application of fair and just disciplinary system Provision of fair and equitable welfare system Application of attractive pension system upon retirement 91As a career employment, each job in the public sector is well thought of before initializing recruitment. The government is very careful in identifying the needs of each job. For example, a government’s clerk should be able to conduct functions that are required from him/her at whichever department or agency. That is why the basic requirements needed for a person to fill in the post of a government clerk would be the same across the country. Thus, the government would need to enlist those needed requirements and advertise them to encourage qualified persons to apply and finally fill in the post. The process can be applied to all jobs within the public sector. The government should also be an ‘equal opportunity employer’.What it means is that public sector jobs should not only open to specific races, gender or religious background. The government must be an employer to all. However, there are some posts in the government that would require special criteria and skills. Take for example, anyone who would like to join the armed forces, police force or any other regimented bodies should pass the medical tests. This requirement cannot be considered as discriminating against those who are medically unfit. It is just that some occupations would require individual who possesses certain skills and capabilities. When one is hired into the service, the job should prepare him/her for further advancement.This is done through training, development, transfer, attachment and promotion. Employees undergo annual appraisal process in which the department would be able to tell the persons about their performances and readiness to shoulder more important responsibilities. These processes are well explained in Max Weber ideal-type bureaucracy as you have learned in the previous lessons. Among them is the guaranteed reward or compensation paid to the employees in terms of monthly salary. Now lets us look at the different processes of personnel administration. 92 Human Resource Planning In the previous section, I have briefly explained some of the processes involved in human resource planning.Planning is a very important aspect of personnel administration. If you failed in your personnel planning, then the productivity o f the organization will be at stake. According to Edgar Schein, â€Å"†¦ if you wrongly hired a person to any posts, then you would need to spend a lot of money to train and re-train the person to put him/her at par with requirements of the job†. Well, that is considered if he/she has the right attitude. It the public sector, there are numerous rules and procedures to follow that once a person is hired, it is difficult to fire under normal circumstances. Thus, taking in the right the person for a particular job is very, very critical.It all begins proper planning for the job by the personnel manager or administrator. Firstly, the manager should perform an in depth study about what the job will perform and ultimately a ‘list of duties or functions’ will be made ready for the job. Some call it the ‘job specifications’. Second, the manager needs to identify the right qualifications, skills and experiences of the potential candidate. Third, the mana ger also needs to ascertain the remuneration and other allowances for the candidate. Forth, the manager should also concern in identifying various training programs for the candidate’s later professional development. Criteria and Methods of RecruitmentWhen a public manager has prepared the request for a new post or to fill in a vacant post, approval needs to be gained from the higher authorities. This may refer to a higher office such as from a district office to the state office, from state office to the main office say in Putrajaya or from the main office to the Central Agency, Public Service Department (JPA). The request from the original manager will be studied and upon approval from the central agency, the request will be submitted to the Public Service Commission (SPA) for recruitment exercise. Some agencies are given the empowerment to hire when JPA has granted the ‘warrant to hire’. However, most hiring by government departments except for part time and c ontractual jobs are conducted by the SPA. 93Some of the criteria that will be considered for hiring purposes would include the followings: †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ Academic qualification Age Skill (technical staff) Working experiences Health Working ability Attitude (cooperation, passion and etc) Interest in work The recruiting bodies (either SPA or the relevant agencies) would first need to advertise vacancies in a wide communication medium. This would include newspapers, television and radio channels, websites, letters to associations etc. It is very important that the government use all these mediums to reach almost everyone that are qualified to fulfill its role as an equal-opportunity-employer. Candidates will then be short-listed and call for interviews. The persons who are responsible to conduct interviews should be well prepared and equipped with instruments or questions that are relevant.Since interview sessions would certainly make ca ndidate exposed some of their own personal information, the interviewers should exercise confidentiality and professionalism. At the end of the process, when a candidate is selected, he/she would receive a letter of appointment together with the job specifications, remunerations and terms of the appointment. Training and Development New staff is at their best when they first joined the organization. However, as time goes by, he/she would need training and development to continue to be relevant to the organization. New methods of doing a job, technology and skills change almost everyday. Thus, every employee needs to be trained and re-trained.The public is very generous in proving fund for employees’ training and development. So, it is not surprising that each one of then should fulfill at least 36 hours of training time in a year. Some organizations provide more than 36 hours! 94 Training and development encompasses three main activities: training, education, and development. Training refers to activities that are focused upon the enriching the job a particular staff is currently holding. They are meant to help him/her to perform well in the job. They can be conducted on the job or can also be held outside the organization. Training is makes the person more competent in the things he/she does. 2 Training is an event.Training has a beginning and end. Participants are exposed to knowledge and skills associated with new concepts during the event. Many organizations think, all we have to do is conduct some training and everyone will embrace the new: strategy, system, method, process, procedure, tactic or tool. They will go back to work the next day, use the new way and execute flawlessly within a short period of time. 3 Training usually refers to some kind of organized (and finite it time) event — a seminar, workshop that has a specific beginning data and end date. It's often a group activity, but the word training is also used to refer to specific i nstruction done one on one. Education activities focus on the jobs that an individual may potentially hold in the future. These activities are planned to move up an individual staff to a higher position and responsibility. 5 Finally, development focuses on activities that the organization plan to continuously improve an employee not only his/her skills but also attitude, esprit d’ coup, productivity and quality. Development is a process. IT is a much bigger, inclusive â€Å"thing†. For example, if a manager pairs up a relatively new employee with a more experienced employee to help the new employee learns about the job, that's really employee development. If a manager coaches and employee in an on-gong way, that's employee development.Or, employees may rotate job responsibilities to learn about the jobs of their colleagues and gain experience so they might eventually have more promotion opportunities. That's employee development. Thomas N. Garavan, Pat Costine, and Nor een Heraty (1995). â€Å"Training and Development: Concepts, Attitudes, and Issues†. Training and Development in Ireland. Cengage Learning EMEA. pp. 1. 3 4 2 http://ezinearticles. com/? Whats-The-Difference-Between-Training-and-Developmen t? &id=1038575 http://performance-appraisals. org/faq/trainingdevelopment. htm Derek Torrington, Laura Hall, and Stephen Taylor (2004). Human Resource Management. Pearson Education. pp. 363 5 95 Different Kinds of Training and Development 1. On-the-job Training and LecturesThe two most frequently used kinds of training are on-the-job training and lectures, although little research exists as to the effectiveness of either. It is usually impossible to teach someone everything she needs to know at a location away from the workplace. Thus on-the-job training often supplements other kinds of training, e. g. , classroom or off-site training; but on-the-job training is frequently the only form of training. It is usually informal, which means, unfor tunately, that the trainer does not concentrate on the training as much as she should, and the trainer may not have a well-articulated picture of what the novice needs to learn.On-the-job training is not successful when used to avoid developing a training program, though it can be an effective part of a well-coordinated training program. Lectures are used because of their low cost and their capacity to reach many people. Lectures, which use one-way communication as opposed to interactive learning techniques, are much criticized as a training device. 2. Programmed Instruction (PI) These devices systematically present information to the learner and elicit a response; they use reinforcement principles to promote appropriate responses. When PI was originally developed in the 1950s, it was thought to be useful only for basic subjects.Today the method is used for skills as diverse as air traffic control, blueprint reading, and the analysis of tax returns. 3. Computer-Assisted Instruction (CAI) With CAI, students can learn at their own pace, as with PI. Because the student interacts with the computer, it is believed by many to be a more dynamic learning device. Educational alternatives can be quickly selected to suit the student's capabilities, and performance can be monitored continuously. As instruction proceeds, data are gathered for monitoring and improving performance. 96 4. Audiovisual Techniques Both television and film extend the range of skills that can be taught and the way information may be presented. Many systems have electronic blackboards and slide projection equipment.The use of techniques that combine audiovisual systems such as closed circuit television and telephones has spawned a new term for this type of training, teletraining. The feature on † Sesame Street † illustrates the design and evaluation of one of television's favorite children's program as a training device. 5. Simulations Training simulations replicate the essential charac teristics of the real world that are necessary to produce both learning and the transfer of new knowledge and skills to application settings. Both machine and other forms of simulators exist. Machine simulators often have substantial degrees of. physical fidelity; that is, they represent the real world's operational equipment.The main purpose of simulation, however, is to produce psychological fidelity, that is, to reproduce in the training those processes that will be required on the job. We simulate for a number of reasons, including to control the training environment, for safety, to introduce feedback and other learning principles, and to reduce cost. 6. Business games They are the direct progeny of war games that have been used to train officers in combat techniques for hundreds of years. Almost all early business games were designed to teach basic business skills, but more recent games also include interpersonal skills. Monopoly might be considered the quintessential business game for young capitalists.It is probably the first place youngsters learned the words mortgage, taxes, and go to jail. Source : http://ezinearticles. com/? Six-Types-of-Training-and-Development-Techniques&id=1944536 97 Roles of Public Service Commission (PSC) and Public Service Department (PSD) There are constellation of information from the SPA and JPA websites about their functions, history and other things that you can learn from. Please visit these two websites and perhaps you want to ask them something related to this course. Good Luck! Public Service Commission (PSC) Website. Public Service Department (PSD) Website. 98 Lesson 7 Assignments Please check with your Seminar Facilitator for a list of assignments for this lesson. 99 100 Similar essay: Theories Actually Seen in Practice in Ojt

The Importance Of Office Comfortable For Clients - 1484 Words

A. Engagement Process Before meeting with a new client, I believe that the office should be made to be feel comfortable for the client. To make the office comfortable for clients, I would try to have a nice atmosphere when clients walk in with relaxing music. Once in the office, I allow the client to decide where they want to sit so they feel that they have some control of the situation. If it’s an option, I would have a couple different options for seating in my office for this reason. I would also make sure that there is not anything too distracting, and have a white noise machine to block out outside noise. During the engagement process, it is important to establish rapport. In establishing rapport, I tell Pat that he is in†¦show more content†¦During the initial sessions, I think it is important to learn why the client is there from the client’s perspective. I use a not-knowing approach to learn more about why Pat is there from his perspective and what his goals are. Thi s would allow for me to learn about the client’s wants, goals, strengths, and successes from their perspective (De Jong Berg, 2001). Once I know what his goals are, I can partner with him to figure out a plan and interventions to achieve his goal or ways to modify them. Learning what he considers the goal of seeing a social worker allows me to know what skills we could work on building or improving. It is important to learn what the client wants to accomplish and how they plan to do so. Letting Pat tell me about himself also allows for me to see what his strengths are without me guiding him too much. This may also allow for the client to realize his own strengths and feel more empowered. Doing this would allow me to learn what stage of change Pat is in. It is important to know what stage of change a client is in so I do not push them too much on certain issues before they are aware and ready to deal with these issues. 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