Kitchen Design Essay Example | Topics and Well Written Essays - 1500 words

Kitchen Design - Essay Example These being the changing Role of Women, Domestic Science, Industrialization, Food Safety and Health Determinants (Moody and Vineyard, 476). From these probably the two most important factors were the changing role of women in society and industrialization. Industrialization bought kitchen appliances in homes with microwaves ovens becoming the most popular appliance that later even replaced the traditional stoves in certain homes.The changing role of women is another factor worth discussing. With health issues being raised after the advent of the industrial revolution and people realizing the importance of kitchen for food safety, servants were being replaced by women in the kitchen. The abolition of slavery further limited domestic help in the kitchen. However, industrial appliances became the new servants for these women. While women accepted the kitchen, they were also exploring the corporate world and thus they began a dual life where they began managing both the kitchens and thei r jobs.Evolution of Kitchen DesignIn the early times, kitchens were very different from what we have today. The advent of the industrial revolution greatly changed the landscape of the traditional kitchens as modern kitchens were fitted with the industrial appliances and also had water fittings. At the turn of the twentieth century, kitchens came fitted with iron stoves, sewers and gas pipes. But industrialization in the twentieth century brought bigger changes in the original design of the kitchens.

Effects of Sleep Deprivation among Emergency Medical Services Workers Essay

Effects of Sleep Deprivation among Emergency Medical Services Workers - Essay Example Emergency medical service is one such field which requires utmost attention, even in the middle of the night. At times the workers are required to remain attentive continuously for more than 24 hrs, because it's a question of urgent medical requirements for someone. Studies have highlighted that if the workers are subjected to sleep deprivation regularly on many occasions; their body starts responding adversely, which in turn impacts their efficiency and accuracy at the workplace. If the worker is subjected to continuous sleep deprivation, the resultant fatigue could lead to effects like poor decisions, fatal accidents. It has been pointed out that continuous exposure to sleep disorders results in impairment of carbohydrate metabolism, weight gains and type-2 diabetes1. This in turn results in development of sleep apnea, which in turn reduces the quality of sleep, thus further resulting in deterioration of the carbohydrate metabolism and it gives rise to a brutal cycle of disorder. T herefore, experts are of the opinion that proper attention be paid towards this issue. This study is an effort to find out some such reasons and the resultant disorders. Today we live in a fast paced society, where competition is a rule rather than an exception, where all aspects of life are being viewed from the angle of sales and marketing. Be it a manufacturing unit or the healthcare sector, the competition is all pervasive. Healthcare services are a very crucial and integral part of the society. Health care becomes an issue, because while taking care of the competition we tend to ignore what we are supposed to do to lead a healthy life. Emergency medical services (EMS) are supposed to play a vital role in taking care of the emergency and trauma care system. The workers in these services provide emergency medical response to the sick and injured citizens. Though, the workers are placed in shift duties, but quite often it so happens that due to more number of emergency cases, they cannot leave the workplace even during extended working hours. Different levels of medical responses are included in the EMS. In general, the EMS includes, call handlers , emergency medical dispatchers, workers in the emergency telephone call centers, first responders like fire or police units, basic life support (BLS) ambulances, advanced life support (ALS) ambulances (USHS, 2007). The workers in these units are trained according to the requirements. Based on the reasons, the sleep deprivation is broadly divided into four categories; i. Based on lifestyle ii. Due to certain health complications iii. The medication side effects iv. Clinical disorders For an EMS worker the lifestyle becomes so irregular that it leads to other types of complications as well. Literature Review According to a study conducted by World Health Organization (WHO)2, the number of people with diabetes is sharply on the rise in recent years. This study found out that in the year 2000 the number of people affected with the disease was about 171 million worldwide. But more alarming is the projection for the year 2030, if we continue to adopt the existing lifestyle. It has been projected that by 2030 this figure might reach a whopping 366 million. Demanding working conditions often take its toll on the individuals' health as well as the actual output of the work. Emergency

James Cook's Voyage to Australia and The Subsequent British Research Paper

James Cook's Voyage to Australia and The Subsequent British Colonization - Research Paper Example James Cook, an inhabitant of England, was born in the year 1728. He was one of the most popular explorers of the 17th century. He also made a mark in the history of the world for his navigation and cartographic skills. Cook was promoted as a captain in the Royal Navy. Cook navigated to different parts of the world and was popular for his three distinct voyages in the Pacific Ocean. He was also the first to observe a European connection with Australia along the eastern coastline. He also gained distinction in becoming the first person to circumnavigate the coast of New Zealand. The legacy of knowledge which James Cook had was very influential among his successors. His role in the political history of the world is also a matter of huge importance as he took a major role in opening up areas along the Pacific which led to the colonization. In the three voyages undertaken by James Cook he travelled thousands of miles and helped in the mapping of various lands starting from New Zealand and continuing till Hawaii. In his expeditions he was reputed for surveying and naming certain features which was not done before. He was instrumental in marking islands in the maps of Europe which was one of his significant contributions. James Cook’s talent in surveying came into the forefront when he successfully mapped the coast of Newfoundland in 1760. He was the one who produced the large scale accurate maps of the island. His success in the very first voyage promoted him to the rank of a commander and was given the charge of identifying Terra Australis which was believed to exist in a place further from Australia. He was persuaded by Alexander Dalrymple who was a dignitary person belonging to the Royal society. During his second voyage he navigated along very high latitudes in the southern part and became the first person to cross the Antarctic Circle. In his expedition he took the possession over South Georgia and also surveyed and mapped the area. In his second voyage, Cook was also successful in the employment of the chronometer which helped him to study the accurate longitudinal positions. The chart of the Southern Pacific Ocean was made by the help of the chronometer and it gained so much accuracy level that those charts are still being used in the 21st century. He returned from the second voyage as a captain of the Royal Navy and he was felicitated with many awards and recognition programs. He was also declared to be the first navigator belonging from Europe in the House of Lords. Captain James Cook volunteered the third voyage in finding out the Northwest Passage. He set on for the voyage in the year 1776. During his last voyage James Cook became the first among the Europeans to visit the Hawaiian Islands. He also explored the western coast of the Northern part of America and he covered the Strait

Treatment for Renal Transitional Cell Carcinoma (TCC)

Treatment for Renal Transitional Cell Carcinoma (TCC) Dear All, Thank you for the new images Roz – it is interesting to follow this case as it unfolds. After reviewing the new CT images I would agree with Susie that they could indicate an alternative diagnosis of a transitional cell carcinoma (TCC) of the left kidney and ureter. I would like to investigate a couple of the many treatment options available for TCC and aim to answer the question put forward by Susie – ‘What treatment options are available to the patient?’ Renal transitional cell carcinoma (TCC) is a malignant tumour that stems from theepithelial cells lining the urinary tract. Upper urinary tract TCCs (UUTUC) – in this patient’s case involving the left kidney and ureter are uncommon. They account for only 5-10% of urothelial carcinomas (Siegel et al, 2012) although evidence indicates an increase in these malignancies (Jemal et al, 2009). The predisposition UUTUCs have for recurrence, metastases and their multi focal nature mandates aggressive clinical intervention (Cai et al, 2011). Treatment is strongly influenced by tumour stage, which correlates closely with prognosis. Surgical intervention is usually the preferred method of treatment for localised disease. Radical nephroureterectomy Radical nephroureterectomy (RNU) with excision of the bladder cuff is the gold standard treatment for UTUC (Margulis et al, 2009). The aim of surgery is to prevent tumour seeding via bypass of the urinary tract during tumour resection. Since the risk of tumour recurrence is considerable, resection of the distal ureter and its orifice is also performed. Recent research by Lughezzani et al, (2010) concluded that this method – removing the distal ureter and bladder cuff significantly improves survival rates. The traditional open surgical approach to RNUs is being challenged by less invasive approaches, e.g. laparoscopic. Simone et al, (2009), a prospective randomised study of 80 patients with non-metastatic UUUC demonstrated no superior effectiveness of laparoscopic surgery over open RNU, whilst the majority of recent research concludes superior outcomes for a laparoscopic versus open surgical approach (Ariane et al, 2012) and (Ni et al, 2012). Endoscopic Treatment Endoscopic ablation is sometimes indicated in patients with a solitary kidney, in bilateral kidney disease and where major surgery is contraindicated. Although now slightly dated, research by Keeley et al, (1997) is commonly cited in recent literature. Their study looked at the ureteroscopic management of 38 patients (41 kidneys) with upper tract urothelial tumours graded 1 3. After endoscopic treatment, 16 of the 21 (76%) with grade 1 disease were tumour free 4 had recurrences at a mean follow-up of 40.3 months. 9 of the 14 (64%) of grade 2 disease were tumour free 4 had recurrent disease at a mean follow-up of 27.6 months. Finally, 2 of the 5 (40%) grade 3 tumours were tumor free at a mean follow-up of 21 months – no recurrence rates were reported for this group. They concluded that ureteroscopic treatment of the upper urinary tract TCC minimises morbidity and provides excellent success rates in patients with solitary, low-grade tumours. Despite these findings, the tract recurrence risk is hard to calculate because relatively few endoscopic ablation treatments have been performed. Additionally, there is a reported risk of understating and under grading the disease with endoscopic management alone. In order to determine the optimal treatment pathway for a patient with TCC – renal function, tumour grade, stage and location must first be evaluated. I have only examined two of the treatment options available for TCC – would anybody else like to expand upon Susies question by examiningothers? I will not add any further questions as there are a few already outstanding. Kind Regards, Alana Show parent See this post in context RDM032_PRD1_A_2014-15 -> On-Line Case Discussions -> Case 12 -> Re: Case 12 by Alana McInally Wednesday, 19 November 2014, 11:51 PM Dear All, Thank you for posting this interesting case and uploaded images Susie. It appears that Noorayen and I have been working on the same topic over the last few days so although this post is likely to overlap in places, I hope to add insight and an alternative slant. I would like to examine the images and a possible diagnosis. In the right lobe of the liver, there appears to be large 67 x 49 mm, well-defined, heterogeneous mass predominantly hyperechoic in nature. Appearances are in keeping with a solid, rather than cystic, lesion. In the second ultrasound image, the liver lesion looks more isoechoic in echotexture with some internal and peripheral vascularity demonstrated when colour Doppler is applied. The sagittal section of the unenhanced CT abdo-pelvis image also highlights this area of low attenuation in the right lobe. These are unusual findings given the patient’s symptoms acute LIF pain. It would be interesting to know whether the patient has had any other tests carried out, for example any blood work prior to the scans? I agree with Noorayen that ultrasound appearances such as these could represent a Focal nodular hyperplasia (FNH). An FNH is a benign hyperplastic process which results in the normal constituents of the liver being arranged in an abnormally organised pattern – this is caused bya response to a congenital arteriovenous malformation'(Khan et al, 2013). An FNH is considered the second most common tumour of the liver following hepatic hemangiomas (Kang et al, 2010). In the majority of situations (80-95%), FNH arises as a solitary lesion, however, multiple lesions have been known to present themselves (Khan et al, 2013). Ultrasound characteristics of these lesions can vary, making diagnosis using one modality challenging. Lesions can range from hypoechoic, isoechoic to hyperechoic when compared to that of the surrounding liver tissue (Bates, 2011). Venturi et al, (2007) as well as other recent research – state that typical lesions usually demonstrate a large, well circumscribed mass, with a central feeding artery and a radiating spoke-wheel pattern of blood flow (Bates, 2011). It could be suggested that the second ultrasound image shows central blood flow within the lesion, in keeping with the typical appearances described. Although FNHs are normally asymptomatic, which is not in keeping with the patient’s LIF pain, it may indicate that the LIF pain and the liver lesion (located in the RUQ) are unrelated that the liver lesion is instead an incidental finding; this is consistent with the typical diagnosis of an FNH. Most diagnoses occur when patients undergo cross-sectional imaging or surgery for other problems and / or routine medicals (Palladino et al, 2014). Although the use of contraceptive agents is not proven to cause FNH, they may have a role in the development of these lesions. Additionally, they can also act as an irritant causing haemorrhage or infarctions to occur – resulting in symptomatic patients. Malignant transformation of FNH has not been reported (Chung and DeGirolamo, 2011) and FNHs rarely bleed or grow. As a result, the diagnosis of an FNH rarely impacts the patient’s medical management other than the accurate diagnosis of the lesion to prevent unnecessary biopsies, surgery, and further imaging of the lesion. Despite advances in medical imaging, it is difficult to discern an FNH from other focal hepatic lesions. As a relatively recent imaging modality, the use of Contrast-Enhanced Ultrasound (CEUS) to identify focal liver lesions is becoming increasingly common (Bartolotta et al, 2009). I will reiterate one of the three outstanding questions does anyone have any further differential diagnoses? Kind regards, Alana Show parent See this post in context RDM032_PRD1_A_2014-15 -> On-Line Case Discussions -> Case 3 -> Re: Case 3 by Alana McInally Tuesday, 18 November 2014, 9:38 PM Dear All, Lucy’s post on the function of the spleen in particular, the implications when it is removed was interesting to read, especially as the spleen’s function and morphology have, in the past, remained unstudied (Lahey and Norcross, 1948). Although they havebecomeless common, as the spleensimportance as an organ isrecognised, splenectomies are still performed and I would like to address Lucy’s question ‘What are the indications for a splenectomy?’. A splenectomy consists of the total or partial surgical removal of the spleen. Literature sources provide a wide spectrum of clinical scenarios for when a splenectomy may be indicated. A general consensus exists for a handful of diagnoses which require a splenectomy. These include: primary cancers of the spleen (very rare), splenic trauma and hematologic diseases. One blood disorder – Hereditary spherocytosis (HS) – often requires treatment via a splenectomy. It involves the loss of specific proteins in the red blood cell membrane, resulting in fragile cells which are further damaged when they pass through the spleen (Encyclopedia of Surgery). This damage ceases once the spleen is removed. Another hematologic disease primary immune thrombocytopenia (ITP) shows the highest cure rate (60-70%) after a splenectomy versus other treatments (Ghanima et al, 2012). Trauma to the spleen can result from damage or rupture from both blunt and penetrating injuries to the abdomen. Studies suggest 25% of trauma injuries are originally caused by medical intervention to the abdomen (Rull, 2012). Laparoscopic splenectomies are often indicated in splenic trauma to prevent internal hemorrhaging and potentially death (NHS Choices, 2014). There are also numerous other conditions where a splenectomy may be indicated / recommended these include: Splenic artery aneurysms surgical resection is often indicated in the presence of large splenic artery aneurysms (over 2 cm in diameter), because the risk of hemorrhage and rupture can be fatal if not treated (Bates, 2011). Multiple splenic abscesses relatively uncommon but have an associated high mortality rate (Provenzale et al, 2012). Some view percutaneous drainage combined with antibiotic therapy as the best management for solitary abscesses (Bates, 2011) whereas other research proposes a splenectomy is the best treatment for multiple abscesses. Splenomegaly – an enlarged spleen (more than 12 cm) (Bates, 2011) as an isolated indicator for a splenectomy is often unjustified. Best practice is to now investigate the underlying cause. Surgery is only indicated if the enlarged spleen is causing serious complications and/or if the underlying cause cannot be identified (NHS Choices, 2014). As Lucy mentioned, there are benefits and risks of a splenectomy. Most research recognises the associated life-long risk of bacterial infection following a splenectomy (Schilling, 2009), combined with the risks of invasive surgery. The general consensus shifts towards a conservative approach – attempting to preserve the spleen as opposed to invasive treatment (Akinkuolie et al, 2010). In our trust I found it hard to locate hospital guidelines and protocols for when splenectomies were considered appropriate. However, I came across one case where a patient had a partial laparoscopic splenectomy using wedge resection to treat splenic trauma. This allowed him to retain some splenic function and additionally he was fortunate enough to have an accessory spleen (present in 30% of the population) – which has the ability to grow and function when a large portion has been removed (Arra et al, 2013). Consequently his splenic function was comparable to that prior to surgery. This technique supports the recent advance towards a conservative outlook on splenectomies. It would be interesting if anyone else is aware of the guidelines in their local hospital for when a splenectomy is indicated? Kind regards, Alana

The Speech of Marcus Antonius in Julius Caesar -- William Shakespeare

The speech made by Marcus Antonius, called Antony, in Act Three, Scene Two of Julius Caesar shows that despite being considered a sportsman above all else, he is highly skilled with the art of oratory as well. In the play by William Shakespeare, this speech is made at the funeral of Caesar after he is killed by Brutus and the other conspirators. Brutus claimed earlier, in his own funeral speech, that the killing of Caesar was justified. He felt that Caesar was a threat, and too ambitious to be allowed as ruler. Much of this sentiment, however, was developed by the treacherous Cassius. Antony, on the other hand, felt that the conspirators were traitors to Rome and should be dealt with. This speech used a variety of methods to gradually bring the crowd to his side, yet maintain his side of the deal with Brutus. This deal was that he, â€Å"shall not in your funeral speech blame us...† (3.1.245) for the death of Caesar. Antony holds his end of the deal for the majority of the speech, yet by doing so convinces the crowd of Brutus' and the others' disloyalty. In many ways, this speech can be seen as the ultimate rhetoric, and it includes all three of Aristotle's methods of persuasion. This are the appeal to credibility, called ethos, the appeal to emotions, called pathos, and the appeal to logic, called logos. All three of these devices are used to great effect during the speech of Marcus Antonius. Antony begins with the now famous words, â€Å"Friends, Romans, countrymen, lend me your ears.†(3.2.62) In referring to the commoners as equals, they feel a sense of empathy even at the first line. This can be seen as a sort of ethos. He goes on to say that Brutus has said that Caesar was ambitious, and that this, if true, is a serious... ...2.248) Antony, though he kept to his bargain, brought the audience to his side in a variety of ways. He used all three methods of persuasion to his advantage. He claimed the killers of Caesar to be honorable and noble, and in the very act of doing so turned Brutus' followers against him. This shows the true ability of Marcus Antonius, and that he is a far greater threat than the conspirators recognized. This power of words is well known, and Aristotle's three methods of persuasion live on in modern speechwriters. Ethos, logos, and pathos are just as effective in our time as in that of Shakespeare, the Roman Empire, and wherever there are people to speak and people to listen. Thus even today, this speech of Shakespeare through Antony shows the sheer impact that mere words can have. Works Cited Shakespeare, William. Julius Caesar. New York: Simon, 1975.

Effects of Behavioral Interventions on Disruptive Behavior and Affect in Demented Nursing Home Residents Essay

Behavioral interventions might ameliorate them and have a positive effect on residents’ mood (affect). Objectives: This study tested two interventions—an activities of daily living and a psychosocial activity intervention—and a combination of the two to determine their efficacy in reducing disruptive behaviors and improving affect in nursing home residents with dementia. Methods: The study had three treatment groups (activities of daily living, psychosocial activity, and a combination) and two control groups (placebo and no intervention). Nursing assistants hired specifically for this study enacted the interventions under the direction of a master’s prepared gerontological clinical nurse specialist. Nursing assistants employed at the nursing homes recorded the occurrence of disruptive behaviors. Raters analyzed videotapes filmed during the study to determine the interventions’ influence on affect. Results: Findings indicated significantly more positive affect but not reduced disruptive behaviors in treatment groups compared to control groups. Conclusions: The treatments did not specifically address the factors that may have been triggering disruptive behaviors. Interventions much more precisely designed than those employed in this study require development to quell disruptive behaviors. Nontargeted interventions might increase positive affect. Treatments that produce even a brief improvement in affect indicate improved quality of mental health as mandated by federal law. Key Words: affect †¢ Alzheimer’s disease †¢ behavior therapy †¢ dementia †¢ nursing homes Nursing Research July/August 2002 Vol 51, No 4 proximately 1. 3 million older Americans live in nursing homes today (Magaziner et al. , 2000). By 2030, with the aging of the population, the estimated demand for long-term care is expected to more than double (Feder, Komisar, & Niefeld, 2000). Thus, nursing home expenditures could grow from $69 billion in 2000 to $330 billion in 2030 (Shactman & Altman, 2000). About half of new nursing home r esidents have dementia (Magaziner et al. , 2000). The disease has an impact on four major categories of functioning in persons with dementia. These are disruptive behavior (DB), affect, functional status, and cognition (Cohen-Mansfield, 2000). This article will focus on the first two categories. Disruptive behavior has received much more attention than affect has (Lawton, 1997), perhaps for three reasons. First, more than half (53. 7%) of nursing home residents display DB with aggression (34. 3%) occurring the most often (Jackson, Spector, & Rabins, 1997). Second, DB threatens the wellbeing of the resident and others in the environment. Consequences include: (a) stress experienced by other resiCornelia K. Beck, PhD, RN, is Professor, Colleges of Medicine and Nursing, University of Arkansas for Medical Sciences. Theresa S. Vogelpohl, MNSc, RN, is President, ElderCare Decisions. Joyce H. Rasin, PhD, RN, is Associate Professor, School of Nursing, University of North Carolina. Johannah Topps Uriri, PhD(c), RN, is Clinical Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences. Patricia O’Sullivan, EdD, is Associate Professor, Office of Educational Development, University of Arkansas for Medical Sciences. Robert Walls, PhD, is Professor Emeritus, University of Arkansas for Medical Sciences. Regina Phillips, PhD(c), RN, is Assistant Professor, Nursing Villa Julie College. Beverly Baldwin, PhD, RN, deceased, was Sonya Ziporkin Gershowitz Professor of Gerontological Nursing, University of Maryland. A Note to Readers: This article employs a number of acronyms. Refer to Table 1 to facilitate reading. 219 220 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 1. Acronyms Term Activities of daily living Analysis of variance Apparent affect rating scale Arkansas Combined Disruptive behavior(s) Disruptive behavior scale Licensed practical nurse(s) Maryland Mini mental status exam Negative visual analogue scale Nursing home nursing assistant(s) Observable displays of affect scale Positive visual analogue scale Project nursing assistant(s) Psychosocial activity Research assistant(s) Acronym ADL ANOVA AARS AR CB DB DBS LPN MD MMSE NVAS NHNA ODAS PVAS PNA PSA RA decreases in targeted behaviors (Gerdner, 2000; Matteson, Linton, Cleary, Barnes, & Lichtenstein, 1997). However, others reported nonsignificant reductions (Teri et al. , 2000), no change (Churchill, Safaoui, McCabe, & Baun, 1999), or increased behavioral symptoms (Mather, Nemecek, & Oliver, 1997). These studies used nursing home staffs to collect data, had sample sizes below 100, and measured an array of DB with different assessments. Only in the last decade have researchers investigated affect. Compared to studies to reduce DB, far fewer studies have measured interventions using affect as an outcome measure. Studies reported positive outcomes on affect from such interventions as simulated presence therapy (Camberg et al. , 1999), Montessori-based activities (Orsulic-Jeras, Judge, & Camp, 2000), advanced practice nursing (Ryden et al. , 2000), music (Ragneskog, Brane, Karlsson, & Kihlgren, 1996), rocking chair therapy (Watson, Wells, & Cox, 1998), and pet therapy (Churchill et al. , 1999). The studies on affect used global measures that relied on observer interpretation, which could have compromised objectivity. Theoretical Bases A number of conceptual frameworks have guided intervention research on persons with cognitive impairment (Garand et al. , 2000). The theoretical basis for this study was that individuals have basic psychosocial needs, which, when met, reduce DB (Algase et al. , 1996) (Table 2). The interventions, one focusing on activities of daily living (ADL) and the other focusing on psychosocial activity (PSA), and a combination (CB) of the two, were developed to meet most of the basic psychosocial needs that Boettcher (1983) identified. These included territoriality, privacy and freedom from unwanted physical intrusion; communication, opportunity to talk openly with others; self-esteem, respect from others and freedom from insult or shaming; safety and security, protection from harm; autonomy, control over one’s life; personal identity, access to personal items and identifying material, and cognitive understanding, awareness of surroundings and mental clarity. The section on study groups specifies which interventions were designed to meet which needs. Positive affect usually accompanies interventions that meet basic psychosocial needs (Lawton, Van Haitsma, & Klapper, 1996). Several researchers and clinicians have suggested that displays of affect may offer a window for revealing demented residents’ needs, preferences, aversions (Lawton, 1994), and responses to daily events (Hurley, Volicer, Mahoney, & Volicer, 1993). The study reported here dents and staff; (b) increased falls and injury; (c) economic costs, such as property damage and staff burn-out, absenteeism, and turnover; (d) emotional deprivation such as social isolation of the resident; and (e) use of physical or pharmacologic restraints (Beck, Heithoff, et al. 1997). Third, before the Nursing Home Reform Act (Omnibus Budget Reconciliation Act, 1987), nursing homes routinely applied physical and chemical restraints to control DB with only moderate results (Garand, Buckwalter, & Hall, 2000). However, the Act mandated that residents have the right to be free from restraints imposed for discipline or convenience and not required to treat the residents’ medical symptoms. Thus, research ers have tested a wide range of behavioral interventions to reduce DB and replace restraints. The Act (1987) also stipulated that all residents are entitled to an environment that improves or maintains the quality of mental health. Interventions that promote positive mood or affect fulfill this entitlement. Therefore, this article will report the effects of an intervention to increase functional status in activities of daily living (Beck, Heacock, et al. , 1997), a psychosocial intervention, and a combination of both on reducing DB and improving affect of nursing home residents with dementia. TABLE 2. Basic Psychosocial Needs Relevant Literature Literature suggests that behavioral interventions offer promise in managing DB. A wide range of modalities and approaches have been tested: (a) sensory stimulation (e. g. , music); (b) physical environment changes (e. g. , walled garden); (c) psychosocial measures (e. g. , pet therapy); and (d) multimodal strategies. Many studies found significant Territoriality Communication Self-esteem Safety and security Autonomy Personal identity Cognitive understanding Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 221 adopted the inference by Lawton et al. (1996) that frequent displays of positive affect when basic psychosocial needs are met might indicate improved emotional wellbeing. is leg continually and without apparent reason needs redirection. This intervention lasted 45–60 minutes a day during various ADL. PSA Intervention. A PNA also conducted the PSA intervention, which involved 25 standardized modules designed to meet the psychosocial needs for communication, selfesteem, safety and security, personal identity, and cogni tive understanding through engagement in meaningful activity while respecting the individual’s unique cognitive and physical abilities (Baldwin, Magsamen, Griggs, & Kent, 1992). The intervention was chosen because it: (a) provided a systematic plan for the PNA to address some of the participant’s basic psychosocial needs; and (b) represented clinical interventions that many long-term care facilities routinely used, but had not been formalized into a research protocol or systematically tested. Each module contained five psychosocial areas of content (expression of feelings, expression of thoughts, memory/recall, recreation, and education) and stimulated five sensory modalities (verbal, visual, auditory, tactile, and gustatory/olfactory). For instance, Activity Module I involved life review, communicating ideas visually (identifying and making drawings), clapping to different rhythms, massaging one’s face, and eating a snack. Initially, many participants tolerated less than 15 minutes of the activity but eventually habituated and participated 30 minutes. CB Intervention. This treatment consisted of both the ADL and PSA interventions and lasted 90 minutes daily. Placebo Control. This involved a one-to-one interaction between the participant and PNA. It controlled for the effect of the personal attention that the PNA provided to the three treatment groups. The PNA asked the participant to choose the activity, such as holding a conversation or manicuring nails. It lasted 30 minutes a day. No Intervention Control. This condition consisted of routine care from a NHNA with no scheduled contact between participants and the PNA. Instruments: Disruptive Behavior Scale. The 45-item disruptive behavior scale (DBS), designed to construct scores based on the occurrence and severity of behaviors, assessed the effect of the interventions on DB (Beck, Heithoff et al. 1997). Gerontological experts (n 29) established content validity, and interrater reliability tests yielded an interclass correlation coefficient of . 80 (p . 001). Geropsychiatricnursing experts weighted the behaviors using a Q-sort to improve the scale’s capacity to predict perceived patient disruptiveness. Factor analysis identified four factors (Beck et al. , 1998). Two corresponded to two—physically aggressive and physically nonaggressive—of the three categories from the factor analysis of the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, Marx, & Rosenthal, 1989). The third category of the Inventory was verbally agitated; in contrast, the factor analysis of the DBS produced a third and fourth category—vocally agitated and vocally aggressive. To obtain a score for the DBS, a trained individual completed a DBS form for every hour of a shift by check- Methods The primary aim was to conduct a randomized trial of the ADL and PSA interventions individually and in combination (CB) for their effect on DB and affect on a large sample of nursing home residents. The experimental design consisted of three treatment groups (ADL, PSA, and Combined) and two control groups (placebo and no intervention). Individual residents were assigned to one of the five groups at each of seven sites in Arkansas and Maryland, which controlled for site differences. To demonstrate the practicability of the interventions and assure adherence to the treatment protocols, certified nursing assistants were hired and trained as project nursing assistants (PNA). They implemented the interventions Monday–Friday for 12 weeks. Afterward, one-month and two-month follow-up periods occurred. Nursing assistants employed by the nursing homes (NHNA) recorded DB. To measure affect, raters were hired for the study to analyze videotapes filmed during intervention. Research Subjects: The sample initially consisted of 179 participants. The study design allowed for the detection of an improvement in DB scores on the Disruptive Behavior Scale (DBS) (Beck, Heithoff et al. , 1997) across time of at least 1. 6 units with a power of 80%. This power calculation assumed that the repeated measures would be correlated with one another at 0. 60. Inclusion criteria were age 65; a dementia diagnosis; a Mini Mental Status Exam (MMSE) (Folstein, Folstein, & McHugh, 1975) score of 20; and a report of DB in the previous two weeks. To form a more homogeneous group for generalizing findings, exclusion criteria were a physical disability that severely limited ADL; a psychiatric diagnosis; and a progressive or recurring medical, metabolic, or neurological condition that might interfere with cognition or behavior. Study Groups: ADL Intervention. A PNA used the ADL intervention during bathing, grooming, dressing, and the noon meal based on successful protocols that improved functional status in dressing (Beck, Heacock et al. , 1997). It attempted to meet residents’ psychosocial needs for territoriality, communication, autonomy, and self-esteem to promote their sense of safety and security. The intervention also tried to respect participants’ cognitive and physical abilities by prescribing three types of strategies specific to the individual participant. First, strategies to complete an ADL address specific cognitive deficits. For example, the person with ideomotor apraxia needs touch or physical guidance to start movements. Second, standard strategies are behaviors and communication techniques that work for almost everyone with dementia. For example, the caregiver gives a series of one-step commands to guide the resident to put on her shoe. Third, problem-oriented strategies address particular disabilities such as fine motor impairment, physical limitations, or perseveration. For example, a subject who rubs his hand back and forth on 222 Effects of Behavioral Interventions ing the behaviors that occurred. The score for a behavior was the frequency (0–8) times the weight. The item scores were summed to obtain each of the four subscale scores. Mini Mental Status Exam. The Mini Mental Status Exam (MMSE) (Folstein et al. 1975) provided a global evaluation of participants’ cognitive statuses for screening subjects for the study. Test-retest reliability of the MMSE is . 82 or better (Folstein et al. ). Cognition is assessed in seven areas, and scores lower than 24 out of 30 indicate dementia. Nursing Research July/August 2002 Vol 51, No 4 Observable Displays of Affect Scale. The Observable Displays of Affect Scale (ODAS) (Vogelpohl & Beck, 1997), designed to rate videotaped data, contains 41 behaviors categorized into six subscales of positive and negative facial displays, vocalizations, and body movement/posture. Raters indicate presence/absence of each behavior during five 2-minute intervals from a 10minute videotape. Scores range from 0–5 for each item. The range of scores for each scale is: facial positive (0–20), Aggression during bathing facial negative (0–20), vocal positive (0–45), vocal negative (0–50), body could stem from physical positive (0–30), and body negative discomfort or rough (0–40). Interrater reliabilities (Kappa handling coefficients) for the ODAS range from . 68–1. 00, and intrarater reliability is . 97–1. 00. Ten gerontological nursing experts established content validity (Vogelpohl & Beck). Apparent Affect Rating Scale. The Apparent Affect Rating Scale (AARS) (Lawton et al. , 1996) is designed for direct observation of persons with dementia and contains six affective states: pleasure, anger, anxiety/fear, sadness, interest, and contentment. (In later work, Lawton, Van Haitsma, Perkinson, & Ruckdeschel [1999] deleted contentment). Each item has a noninclusive list of behaviors that might signal the presence of the affect from which observers infer the affect. The observer assigns a score of 1 to 5 to measure the duration of the behavior. Visual Analogue Scales. The Positive Visual Analogue Scale (PVAS) and Negative Visual Analogue Scale (NVAS) (Lee & Kieckhefer, 1989; Wewers & Lowe, 1990) are two 10centimeter lines on separate pages for rating positive and negative affect. The PVAS has end anchors of â€Å"no positive affect† and â€Å"a great deal of positive affect. † The NVAS has end anchors of â€Å"no negative affect† and â€Å"a great deal of negative affect. † Scores range from 0 to 100. Procedure: The study consisted of six phases: (a) preliminary activities, (b) a three-week normalization/desensitization period, (c) a 12-week intervention period, (d) a onemonth follow-up period, (e) a two-month follow-up period, and f) a videotape analysis. Preliminary Activities. The institutional review boards at the University of Arkansas for Medical Sciences and the Univer- sity of Maryland approved the research. Each nursing home identified residents with dementia and sent letters informing persons responsible for the residents that researchers would be contacting them. Responsible persons could return a signed form if they did not want to participate. Willing responsible persons received a telephone call explaining the study followed by a mailed written description along with two consent forms. Those willing kept one consent form for their records and signed and mailed back the other. Screening involved a review of the residents’ charts, recording their diagnoses, and interviews with the staff to find evidence of DB during the previous two weeks. Each resident took the MMSE to meet inclusion criteria. Within each home, female residents who passed these screens were randomized to one of the five groups by a drawing, but males were assigned to the five groups to ensure even distribution of their small number. Simultaneously, research staff members were hired and trained. Normalization/Desensitization. For the next three weeks, each PNA accompanied a NHNA to learn the routines of the facility but did not help care for potential study participants. A videotape technician placed a camera that was not running in the dining and shower rooms to desensitize residents and staff to its presence. In addition, nursing home staffs participated in two-hour training sessions on the DBS. Throughout the study, a gerontological clinical nurse specialist trained any new NHNA and retrained if behaviors reported on the DBS differed from those she observed during randomized checks. Intervention. During the 12-week intervention period, the first three weeks were considered baseline and the last two weeks postintervention. The PNA administered the treatment/s or placebo five days a week. Every day, they asked participants to give their assent and espected any dissents. During weeks 11–12 (postintervention), the PNA prepared the participants for their departure by telling them that they were leaving soon. To facilitate data collection, a separate form of the DBS for each of the three eight-hour daily shifts was developed. Eight one-hour blocks accompanied each item of the scale. The NHNA placed a check mark in the block that corresponded to the hour when the NHNA observed the behavi or. The NHNA completed the DBS on all participants during or at the end of a shift. In addition, a technician videotaped participants in the treatment and placebo groups every other week during an interaction with the PNA and no intervention group monthly during an ADL. The technician monitored positioning and operation of the camera from outside the room or behind a curtain to respect the participants’ privacy. One-Month and Two-Month Follow-up. One month and two months after the research team left the nursing home, Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 223 esearch assistants (RA) retrained nursing home staffs on the DBS. The NHNA then collected DB data on their shifts Monday–Friday for one week. tervention, week 16 as one-month follow-up, and week 20 as two-month follow-up. Participants with fewer than six observations at any time period were omitted. For each period, a total DBS score represented an averVideotape Analysis. The videotapes ranged in length from age of the participant’s data for the t hree shifts of each day less than five minutes to 40 minutes, depending on the across the five days of the observation week. Therefore, activity and the participant’s willingness to cooperate with total DBS scores were obtained for baseline (M of weeks the treatment (baseline and control participants’ tapes 1–3), intervention (M of weeks 4–10), postintervention (M tended to be shorter). To standardize the opportunity for of weeks 11–12), first follow-up (M of week 16), and secbehaviors to occur, an editor took 10-minute segments ond follow-up (M of week 20). The same procedure from the middle of baseline and final treatment eek tapes yielded subscale scores for physically aggressive, physically and randomized them onto videotapes for rating. Because nonaggressive, vocally aggressive, and vocally agitated videotaping occurred to ensure appropriate implementabehaviors for each of the five time periods. tion of interventions, the treatment groups had more A repeated measures analysis of variance (ANOVA) usable videotapes than the control groups did. consisted of two between- subjects and one within-subjects A master’s prepared gerontological factors. The between-subjects factors nurse specialist intensively trained six were intervention group and state (AR raters on the Observer III Software or MD) to account for regional differSystem (Noldus Information Technolences in scoring DB, and the withinogy, 1993) for direct data entry and subjects factor represented DBS scores the affect rating scales. The raters for the five different time periods. Each reached . 80 agreement with the speanalysis allowed for testing by intervencialist on practice tapes before they tion group, time period, and state. The Screaming may started rating the study videotapes. nalysis of the interaction effect of She monitored reliability for each tape intervention group by time period express pain or monthly, retrained as needed, and rantested the hypothesis that the intervenself-stimulation domized the sequence of rating the tions would decrease DB across time in scales. The raters entered the ODAS treatment conditions as compared to and AARS data directly into a comcontrol conditions. The analysis was puter using the Observer. The system repeated five times, once for each suballowed raters to watch videos repeatscale of the DBS and once for the total edly in actual time and slow action to score. Level of significance was set at document behaviors objectively and 0. 05. The researchers believed that the precisely. The raters indicated their small group sizes justified the liberal perception of the participants’ positive and negative level of significance. For the videotape analysis, analyses of affect by placing a vertical mark at some point between covariance occurred for the 14 variables observed from the the two end anchors of the PVAS and NVAS. They videotapes during intervention. The baseline score served marked neutral affect as negative. s a covariate for the final score. While a multivariate analysis would have been desirable, it would have had Intervention Integrity: The PNA and video camera techniinsufficient power with this number of variables and subcian underwent two weeks of intensive training on general jects. The 14 univariate analyses do inflate the Type I error aging topics, stress management, information on dementia, rate. and confidentiality/privacy issues. Training also involved instruction on the study interventions, DBS, and research Results protocols. Of the 179 initial participants, 36 did not finish; the greatA gerontological clinical nurse specialist viewed treatest attrition occurred in the no intervention control group. ment and placebo videotapes biweekly in a private office to Attrition resulted from death (39%), withdrawal of fammonitor PNA compliance with research protocols, provide ily’s consent or at nursing home staff’s request (26%), discorrective feedback to PNA, and help PNA recognize and charge (18%), and change in health status/medications meet participants’ needs as they changed during treatment. hat did not meet inclusion criteria (17%). This left 143 The possibility for contamination appeared to be low participants: 29 in the ADL, 30 in PSA, 30 in CB, 30 in the because NHNA were unlikely to change their care practices placebo, and 24 in the no intervention, but 16 with incomand had little opportunity to observe PNA. Further, NHNA plete data were dropped. Table 3 gives the demographic were b linded to the hypothesis of the study, the nature of the statistics for the 127 participants with complete data. No interventions, and the participants’ group assignments, statistically significant demographic differences emerged although they probably could identify the no intervention among the five groups. In short, this sample primarily conparticipants. sisted of elderly, white females with severe cognitive impairment. Analysis: Reviewers checked for completeness of all data. For the videotape analysis, the final number was 84 The researchers designated intervention weeks 1–3 as baseparticipants with 168 videotape segments. Most were line, weeks 4–10 as intervention, weeks 11–12 as postin- 224 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 3. Description of the Sample by Intervention Group No Intervention 19 89. 5 78. 9 84. 2 86. 47 (6. 37) 11. 47 (6. 43) ADL Number in group Percent female Percent white Percent widowed Mean age (SD) M MMSE (SD) 28 78. 6 82. 1 64. 3 82. 29 (8. 40) 11. 44 (7. 69) PSA 29 82. 1 85. 7 66. 7 82. 18 (7. 64) 10. 65 (6. 76) CB 22 81. 8 77. 3 77. 3 82. 82 (9. 81) 7. 91 (5. 41) Placebo 29 75. 9 86. 2 75. 9 86. 45 (6. 92) 11. 11 (6. 39) Total 127 81. 0 82. 5 72. 8 83. 64 (7. 97) 10. 55 (6. 64) Note. ADL = activities of daily living; PSA = psychosocial activity; CB = combination. emale (79%) and widowed (69%) with a mean age of 83 (SD 7. 44). Participants had a mean score of 10 (SD 6. 34) on the MMSE, indicating moderate to severe cognitive impairment. Table 4 displays the means and standard deviations for the DBS overall and the four subscales across the five time periods for the five groups. No significant differences emerged for the interventi on-by-time interaction for any of the dependent variables. Thus, the results failed to support the hypothesis that the interventions would decrease DB across time in treatment groups as compared to control groups (statistical analysis tables on Website at: http://sonweb. nc. edu/nursing-research-editor). However, the main effect of state was significant in three analyses. Arkansas recorded significantly more behaviors than Maryland did for the dependent variables of physically nonaggressive (p . 001), vocally agitated (p . 001), and overall DBS (p . 002). Further, the main effect of time was significant for overall DBS (p . 002) and the four subscales of physically aggressive (p . 001), physically nonaggressive (p . 027), vocally aggressive (p . 021), and vocally agitated behaviors (p . 008). The significance resulted from increased DB after the PNA had left the home (generally from intervention or postintervention to first follow-up). For the videotape analysis, the hypothesis stated that treatment groups, compared with control groups, would display more indicators of positive affect and fewer indicators of negative affect following behavioral interventions. In general, neither the positive nor the negative affect scores were particularly high, indicating that this sample had relatively flat affect. Results from the analysis of covariance tests supported increased positive affect but not decreased negative affect. Compared to the control groups, the treatment groups had significantly more positive facial expressions (p . 001) and positive body posture/movements (p . 001), but not more positive verbal displays on the ODAS. The treatment groups displayed significantly more contentment (p . 037) and interest (p . 028) than the control groups did on the AARS. For the negative affects on the AARS, the treatment groups had a shorter duration of sad behaviors (p . 007) than the control groups did. Comparison of VAS scales likewise showed that the treatment groups displayed more positive affect (p . 012). Discussion In contrast to other studies (e. . , Hoeffer et al. , 1997; Kim & Buschmann. , 1999; Whall et al. , 1997), this study found no treatment effect on DB. The interventions were a synthesis of approaches believed to globally address â€Å"triggers† of DB and meet psychosocial needs (Boettcher, 1983). They did not address the specific factors that might have been triggering the particula r behavior (Algase et al. , 1996). Such triggers include under/over stimulation, unfamiliar or impersonal caregivers, and particular individual unmet psychosocial needs. For example, aggression during bathing could stem from physical discomfort or rough handling (Whall et al. 1997). Interventions much more individually designed require development. Increasing DB across all groups was reflected in the DBS scores at 1-month follow-up. Two factors may explain this increase. First, the PNA had warned participants that they would be leaving. Second, the ADL and CB participants no longer received care from the familiar PNA, and PSA, CB, and placebo participants no longer had a daily activity or visit. The increased stress and time constraints for NHNA as they resumed caregiving of the ADL and CB participants may explain the heightened DB in the control groups. Such changes may trigger increased behavioral symptoms in persons with dementia (Hall, Gerdner, Zwygart-Stauffacher, & Buckwalter, 1995). Two measurement issues may have affected outcomes. First, observers view behaviors differently (Whall et al. , 1997) and come to expect particular behaviors from certain residents (Hillman, Skoloda, Zander, & Stricker, 1999). If the NHNA were accustomed to a participant’s DB pattern, such as persistent screaming, they may have overlooked decreases in that behavior. Initial training and retraining of raters occurred as needed; however, some Nursing Research July/August 2002 Vol 51, No 4 Effects of Behavioral Interventions 225 TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and Time Period No Intervention (n = 19) Mean (SD) 408. 71 (427. 24) 303. 69 (408. 44) 281. 97 (410. 85) 418. 31 (630. 58) 292. 85 (405. 15) 114. 66 (202. 89) 90. 85 (182. 70) 77. 98 (173. 15) 130. 92 (257. 12) 128. 20 (195. 67) 191. 97 (157. 75) 117. 11 (112. 30) 118. 23 (137. 08) 154. 46 (225. 05) 100. 45 (153. 30) 55. 16 (74. 70) 42. 89 (54. 54) 33. 26 (47. 06) 64. 72 (77. 89) 28. 09 (37. 02) (continues) DB Category Time Period DBS total Baseline ADL (n = 28) Mean (SD) 172. 51 (191. 47) 182. 45 (181. 3) 164. 56 (154. 95) 207. 22 (205. 58) 190. 70 (291. 06) 20. 67 (30. 52) 32. 59 (51. 29) 15. 02 (26. 10) 44. 18 (100. 62) 21. 45 (36. 47) 95. 50 (105. 28) 87. 58 (87. 58) 85. 04 (89. 60) 88. 81 (85. 69) 148. 75 (187. 28) 22. 85 (32. 10) 28. 37 (32. 50) 21. 15 (26. 54) 30. 72 (48. 95) 18. 28 (24. 55) PSA (n = 29) Mean (SD) 348. 02 (467. 50) 306. 81 (393. 03) 303. 24 (367. 54) 373. 17 (533. 05) 300. 20 (366. 42) 85. 87 (199. 01) 83. 94 (167. 53) 82. 82 (166. 93) 113. 49 (235. 71) 81. 30 (151. 85) 162. 41 (206. 65) 130. 82 (142. 72) 133. 92 (145. 97) 141. 47 (188. 99) 164. 92 (223. 63) 49. 64 (93. 15) 43. 80 (64. 6) 37. 90 (53. 43) 54. 47 (90. 33) 40. 26 (45. 26) CB (n = 22) Mean (SD) 287. 66 (373. 73) 300. 84 (379. 33) 286. 21 (365. 78) 374. 10 (510. 10) 312. 83 (433. 18) 68. 84 (126. 18) 67. 14 (137. 79) 61. 04 (127. 78) 92. 68 (205. 52) 60. 40 (131. 54) 136. 67 (189. 03) 124. 64 (164. 49) 125. 99 (157. 78) 159. 97 (202. 75) 146. 53 (201. 83) 34. 49 (55. 91) 40. 73 (52. 60) 31. 18 (33. 85) 36. 95 (42. 70) 32. 82 (51. 32) Placebo (n = 29) Mean (SD) 325. 96 (337. 14) 337. 60 (328. 94) 336. 80 (366. 55) 389. 92 (434. 43) 319. 15 (384. 59) 49. 26 (90. 24) 62. 10 (112. 71) 59. 67 (106. 37) 76. 79 (165. 45) 48. 25 (101. 4) 167. 01 (177. 80) 164. 62 (161. 48) 175. 36 (189. 80) 201. 68 (212. 06) 87. 67 (127. 38) 47. 20 (79. 70) 39. 55 (57. 74) 32. 69 (55. 77) 29 . 30 (47. 60) 30. 18 (52. 85) Intervention Postintervention 1 month follow-up 2 month follow-up Physically aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Physically nonaggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up Vocally aggressive Baseline Intervention Postintervention 1 month follow-up 2 month follow-up 226 Effects of Behavioral Interventions Nursing Research July/August 2002 Vol 51, No 4 TABLE 4. Weighted Scores for Disruptive Behavior by Intervention Group and Time Period (Continued) NoIntervention (n = 19) Mean (SD) 47. 65 (97. 22) 68. 32 (103. 13) 68. 01 (116. 62) 84. 50 (112. 48) 73. 07 (117. 12) DB Category Time Period Vocally agitated Baseline ADL (n = 28) Mean (SD) 33. 49 (84. 39) 33. 91 (62. 52) 43. 17 (72. 10) 43. 48 (64. 39) 50. 53 (117. 95) PSA (n = 29) Mean (SD) 46. 92 (98. 70) 52. 84 (96. 03) 52. 50 (90. 78) 68. 22 (98. 89) 48. 89 (92. 33) CB (n = 22) Mean (SD) 62. 49 (98. 97) 70. 43 (110. 85) 69. 08 (107. 29) 82. 14 (118. 97) 75. 80 (129. 67) Placebo (n = 29) Mean (SD) 50. 0 (92. 05) 48. 25 (81. 63) 48. 59 (72. 20) 63. 74 (95. 30) 54. 11 (80. 61) Intervention Postintervention 1 month follow-up 2 month follow-up Note. Scores were created by assigning each behavior with a severity weight prior to summing and then averaging across day and then week(s). DBS = disruptive behaviors; ADL = activities of daily living intervention; PSA = psychocial activity inte rvention; CB = combination of the two interventions. NHNA appeared to continue to consider participants’ behaviors, such as repetitive questioning, to be personality characteristics or attention-seeking efforts rather than DB. Thus, they may have under-reported behaviors. Further, staff may prefer withdrawn behaviors, such as isolating self and muteness (Camberg et al. , 1999), and view them as nonproblematic. Second, categorizing a behavior as disruptive without understanding its meaning to the person with dementia may be conceptually flawed. For example, screaming may express pain or self-stimulation. Two design features may explain differences between the findings of this study and others. First, this study had both placebo and no intervention control conditions. Just a few other studies randomized subjects to treatment or control groups or included two control groups (e. g. , Camberg et al. , 1999). In most studies, control conditions preceded or followed treatment conditions (e. g. , Clark, Lipe, & Bilbrey, 1998). In both designs, subjects served as their own controls, which limits examination of simultaneous intra- and extra-personal events that might affect DB frequency. Second, many control groups came from separate units or different nursing homes (e. g. , Matteson et al. , 1997), which makes it difficult to control for differences in environment, staff relationships, and personalities. This study occurred at seven sites in two different geographical areas, but at each site, the randomization of female participants distributed the groups across all nursing units to control for environmental and staff characteristics. Acknowledged limitations include the following. First, in spite of the large overall sample, the group sizes were small (range 19–30) with the greatest loss in the no inter- vention group. Larger groups might have provided more definitive findings on the relationship between behavioral interventions and DB frequency as Rovner et al. (1996) did (treatment group 42; control group 39). Second, NHNA served as data collectors because using independent observers would have been cost-prohibitive. These results suggest that future intervention research should consider the individual characteristics of the person with dementia (Maslow, 1996) and the triggers of the behavior (Algase et al. , 1996). Studies that have individualized interventions have demonstrated decreased DB (Gerdner, 2000; Hoeffer et al. , 1997). Researchers need to continue to refine methods for identifying what works for whom (Forbes, 1998) to minimize the prevalent trial-anderror approach to DB management.

Puppy Mills

Tiffany Baldeo MWF 8:00-8:50am ENC1101 Informative Essay Puppy Mills, Be gone! Bulldogs on sale! Yorkie puppies available here! Have you ever wondered where all these cheap puppies for sale in pet stores come from? The answer is that they are produced in factory-like environments known as â€Å"puppy mills†. Puppy mills are large-scale dog breeding operations where profit is given priority over the well-being of the dogs. Puppy mills treat dogs like products, not living beings, and usually house them in overcrowded and unsanitary conditions without adequate veterinary care, socialization, or even food and water.The cute puppies for sale at your local mall were probably bred from dogs that don’t play outside or get groomed. Puppy mill dogs are typically kept in cages with wire flooring that injures their paws and legs and cages can be stacked up in a column, which means waste falls on the dogs housed below them. Compromised health and conditions like matting, sores, mang e, severe dental disease and abscesses are often widespread. Many puppy mill puppies are born with or develop overt physical problems that make them unsalable to pet stores, which mean they end up abandoned or just left to die.Many sick puppies do manage to end up at pet stores, though, where the new puppy owner unknowingly purchases the sick dog. Breeding dogs at the mills sometimes spend their entire lives outdoors, exposed to the elements, or crammed inside filthy structures. When a parent at a puppy mill is no longer able to produce, the dog may be given to the nearest shelter, abandoned, or even destroyed. Also, because the puppies produced in puppy mills do not have safe and healthy homes selected for them ahead of time, if they are not purchased by the time they hit a certain age, they may suffer the same fate.Female dogs usually have little to no recovery time between bearing litters. When, after a few years, the females can no longer reproduce or when their breed goes out o f style, the dogs are often abandoned, shot, or starved until they eventually die. Many pet stores with cute puppies for sale will tell you that they don't get their puppies from puppy mills. They'll say their puppies are all from â€Å"USDA licensed breeders. † If you dig a little deeper into what that actually means, you'll find that it's not worth much. The standards of care required by the USDA are woefully inadequate and not what most of us would consider humane.They leave a lot of room for dogs to be severely mistreated. Even if they were adequate, they're not enforced. Take a look at a scathing report done by the Inspector General on USDA's lax enforcement of the law regulating breeders and judge for yourself whether USDA licensing of puppy mills is enough to make you shop at stores that sell puppies. In fact, you only have to be licensed by USDA as a commercial breeder if you are selling puppies to pet stores or brokers. So USDA licensure is actually a pretty good ind icator that the breeders are, in fact, puppy mills.Small hobby breeders, who sell their dogs directly to the public, including those who only sell their puppies online, do not have to be licensed or inspected by USDA. Don’t support the industry. Most pet shop puppies come from puppy mills, and so do most dogs sold over the Internet. Pet shop puppies are separated from their mother at as young as six weeks of age. The health of the puppies is not always guaranteed. Purchasing a puppy for sale at a pet store or online often supports the horrible puppy mill industry. Buying anything in pet stores that sell puppies supports the industry, too.Buy all your pet supplies, toys, pet food, and kitty litter, from stores that do not sell puppies, or buy your pet supplies online from websites that do not sell puppies. Breeders or owners of large kennels are supposed to adhere to regulations and follow protocol when it comes to their business and the wellbeing of the animals that are in th eir facilities. The puppy mills project states that of the 3,000 USDA licensed breeding facilities, a large number of them have violations that go unpunished and led to the maltreatment of the animals behind the walls.The United States government should be making more strides to help the animals that must endure these horrific living conditions. The Animal Bill of Rights is being used by the Animal legal defense Club to show that there is a large amount of support that is going towards the promotion of more strict animal rights. They also need to help congress come up with harsher punishments for the people that feel that they are above the law and do not need to follow the laws when it comes to animals and abuse.The Fund also states in their website that in the United States about 45 states including the District of Columbia have a type of felony level animal cruelty provision which may be in forced in cases of animal fighting or death of an animal. States need to take a closer loo k at the puppy mill facilities or â€Å"breeding kennels† and take more drastic measures against people who violate regulations. It is not fair to the animals that they have to live in such conditions that can make them sick and feel unloved.