Management Of Pressure Ulcers In Elderly Patients

Management Of Pressure Ulcers In Elderly Patients Pressure ulcers are an injury that damages skin and the layer(s) of tissue beneath, which have been exposed to pressure (NHS, 2014). They can occur in patients of varied ages; however, the most vulnerable age group who are at risk of developing pressure ulcers are patients aged 75 and above (Hope, 2014). Elderly patients tend to have co-morbidities due to the ageing process, which can sometimes leave them with limited mobility or bedridden and this then can put them at further risk of developing pressure ulcers (Jaul, 2010). Due to having a growing elderly population, it is extremely important to address the risks of pressure ulcers. There is no particular environment in which pressure ulcers occur, as they are a concern in all settings where social care is being provided, medical treatments are carried out including private homes. This paper will review the evidence regarding the risks and management of pressure ulcers. The focus of this paper will be elderly patients and the follo wing topics will be discussed; risk assessment, patient assessment, pressure recognition and removal, non-surgical treatments/advice, complications of pressure ulcers and surgery. On recognition of a pressure ulcer or the possibility of one developing on a patient, a suitably trained health or medical professional should do a documented risk assessment (NICE, 2014). This risk assessment should cover two interlinking areas, risk factors and signs/symptoms. It is important to assess an elderly patients current health status and not just the status of their health as documented previously on records or on admittance to see a professional, as a variety of factors can affect the development of a pressure ulcer some factors more rapidly than others. Questioning into previous medical history and also looking at previous medical notes is often very informative and usually allows the professional to know of any co-morbidity which could present a further risk or act as an indirect cause of the development of a pressure ulcer. Diabetes and musculoskeletal disorders are often flagged up on assessments as a factor which can impact a pressure ulcer (Benbow, 2012). Sometime s due to the elderly patient suffering from a type of dementia, their ability to communicate or remember life events deteriorates and therefore they cannot provide the professional assessing the ulcer with key medical information. Also, some patients may be in trauma or are not conscious; this, again, makes the information gathering stage of the patients current health status difficult for the assessing professional. In such complex cases, the patients wider network such as relations or the multi-disciplinary team of health and social care professionals who have previously supported the patient may have more knowledge on the patients life history. Nursing home staff are required by the Care Quality Commission to keep records of their residents care plans and more specialist homes have routine logs written about their residents; these often can act as a good indicator of physical, mental and behavioural status and changes which have occurred with the elderly patient (CQC, 2015). Determining any other condition which an elderly patient may suffer from is important, because this needs to be considered in the patients care plan and management of the Pressure ulcer as it could have direct impact on the healing of a pressure ulcer. For example, if the elderly patient has diabetes, their wound healing process maybe prolonged (Leik, 2013). Furthermore, as elderly individuals have thinner skin; this already puts them at greater risk of skin damage due to pressure. Musculoskeletal disease such as osteoarthritis is usually diagnosed in elderly individuals and it can limit the mobility of the patient or their ability to do specific activities (NHS, 2014). This may result in patients being in the same position for long periods of time, which may then put pressure on that area of the body, putting them at greater risk of developing a pressure ulcer. Also, elderly individuals who are less mobile are more likely to have poor circulation, which can impact on the time taken for a pressure ulcer to heal. Therefore, blood flow should also be taken into consideration when doing the risk assessment. Above are some examples of how the management of Pressure ulcers can become complex; there are more diseases such as terminal diseases and other medical conditions that need to be taken into consideration when planning the care or prevention of a pressure ulcer. Often both the lack of nutritional intake and loss of weight are two interrelated common concerns in elderly patients, unless the cause is due to a different factor such as underlying pathology of disease. Therefore, in addition to including these factors in the risk assessment, health education to encourage the patient to eat needs to be provided to the patient, their relations and health and social care staff supporting the patient. Health advice/education/guidance is important because an underweight elderly individual is more likely to have less tissue around their bones and possibly poorer blood vessel quality, hence making them more at risk of damage from pressure and also poorer healing (MNT, 2014). Also, a lack of protein in an elderly patients diet, which supports tissue growth and repair, can also cause greater damage to their skin from pressure. Low nutritional intake can also cause fatigue and frailty in elderly individuals and this can impact an elderly individuals engage ment and ability to do daily activities (Morelli and Sidani, 2011), hence impacting their psycho-social status, which may disengage them from supporting their own health, whether it be by following the guidance of a medical practitioner or by being active in their healthcare decisions generally (Morelli and Sidani, 2011). This then can make patient centred care difficult for those providing care for the elderly patient, as patient choice/preference is compromised and indication of pain, which is usually expressed verbally via description or recommended pain scales such as Braden or Waterlow, may not also be provided by the patient (Nice, 2014 and Benbow, 2012). Therefore, the patients involvement in managing the pressure ulcer is vital. Pain management is difficult in Pressure ulcer management if the elderly individual has an altered perception of pain due to a spinal cord injury or other related nerve damage injuries. This may prevent the patient from recognizing that they have an ulcer developing, hence delaying the treatment of the ulcer (MNT, 2014). Therefore, it is good practice if the elderly individual is a patient in hospital to routinely ask the patient if they have seen any abnormalities on their skin and also recommend them to change positions regularly. Alongside the detailed risk assessment, a pressure ulcer assessment/skin assessment should be done on recognition of a pressure ulcer developing. This is not only to manage the Pressure ulcer but also to be aware of those individuals who may have difficulty, as mentioned above, in detecting changes in their skin or possibly even possess a disability. Complaints of pain from the patient should be considered in the skin assessment, followed by a categorization of the ulcer as a stage 1,2,3 or 4 Pressure ulcer (NICE, 2014). This will include assessing discolouration, variations in heat, firmness and skin moisture. The categorization of the Pressure ulcer is extremely important because it allows suitable preventative measures to be put within the individuals care planning, to try to maintain the skins integrity and to support healing (NHS, 2014). The overall patient assessment will directly impact decisions on the frequency of positioning for the patient and the suitability of the support surface on which the patient is sitting or lying (Benbow, 2012). These changes are vital to pressure removal and hence, managing the development of the Pressure ulcer better because they will be included in a repositioning timetable that health and social care professionals will work to as part of the care plan. The frequency of positioning varies based on the risk, patients physical ability/state and also their acceptance to be regularly repositioned; for example, a patient in a wheelchair may need to be repositioned every 15 minutes due to the pressure of sitting in the same position for long periods of time. Elderly patients who are bedridden should be repositioned every couple of hours, depending on the need determined in the risk assessment (NICE, 2014). A physiotherapist can often advise on repositioning that will be safe and that will also allow pressure release. Equipment can also support pressure removal. Cushions on wheelchairs not only provide comfort but they can also lessen the pressure on the hip and upper leg area of the body. However, some specialists advise that air, water or foam filled support devices are better than traditional cushions (Benbow, 2012). Small pillows/foam pads can also support areas of the body from touching each other, such as between the knees or ankles. These can also be used for comfort and support when laying in different angled positions; for example, when a patient is lying on their side, their legs may need further support (Benbow, 2012). Reclining chairs/automated chairs can also be set at different positions to support pressure removal. Patients, relatives and supporting professionals need to ensure that the skin of the patient is regularly checked, as repositioning regularly can also cause skin damage due to the skin of an elderly individual being thinner. Specialised mattresses can also reduce pressure in comparison to standard mattresses. Furthermore, some specialist mattresses can be connected to an air flow system which can automatically regulate the pressure, hence making the care and management of pressure ulcers in bedridden patients easier for health professionals or carers/relatives. This may be a change that medical/health professionals recommend to elderly patients at home or even for patients in long term care/rehabilitation; however, research is still lacking on how much contribution mattress change actually has on directly lessening the risk of pressure ulcer development (Vanderwee et al, 2008 and UCSF, 2011) in comparison to other cost effective changes. Depending on the wound of the ulcer and the skin damage, often dressings and ointments are used to manage the pressure ulcer and to manage infection. Antibiotics may be prescribed, but not often, as usually antiseptic creams can be applied directly on the wound to prevent the spread of infection to connecting tissues. Ointments and creams may also be used to prevent or treat skin damage such as incontinence-associated dermatitis. The skin assessment should be able to identify those at risk of developing such dermatitis, as these patients often have one or more of the following conditions: incontinence, oedema or dry skin (NICE, 2014). Dressings which have been specially designed to promote wound healing and cell regrowth should be used on a pressure ulcer wound. Examples of suitable dressings include hydrocolloid dressings and aliginate dressings (NHS, 2014). These dressings also can support the regulation of skin moisture, which is important to manage the Pressure ulcer. Research an d development into wound repair technology is advancing and specially designed dressings give less trauma to the patient upon removal. Therefore, the correct dressing is vital as unsuitable dressings may cause further skin breakdown. As briefly mentioned earlier in this paper, the patients diet may need altering to ensure that the elderly patient is taking nutrients which will support wound healing. Hydration is also important to maintain skin moisture and avoid flaky skin (Convatec, 2012). Hydrotherapy can also be used to keep skin clean, with possible natural removal of dead cells. In some cases, the wound healing process may be compromised due to necrotic tissue and this dead tissue will need to be removed via a debridement method. Debridement methods vary depending on the clinical situation. Larvae therapy can be used as an alternative method to debridement; this therapy consists of putting maggots on the wound for a few days via a dressing and gauze. Maggots can also promote healing due to the release of a substance that kills bacteria. Sometimes when grade 3 or 4 Pressure Ulcer wounds do not heal or they become complicated cases, surgery is needed. This is usually either surgery which directly closes the wound or flap reconstruction. To conclude, this paper has attempted to cover the overall management of pressure ulcers in elderly patients. Despite, the treatments and clinical practice carried out by medical/health professionals being similar to younger patients, the risks of pressure ulcer development and healing due to the ageing process are different. Also, co-morbidity is more identifiable in elderly patients and skin structure/composition differs due to the thinning of the skin. There are clear guidelines on managing pressure ulcers by NICE; however, further research needs to be done to optimize the management of pressure ulcers in elderly patients (Cullum, 2013). Bibliography Benbow, M. (2012) Management of Pressure ulcers. [Online] Available from:Â  http://www.nursinginpractice.com/article/management-pressure-ulcers Care Quality Commission. (2015) Regulation 17 – good governance. [Online] Available from:Â  http://www.cqc.org.uk/content/regulation-17-good-governance Convatec. (2012) The Role of Modern Wound Dressings in Stage I Pressure Ulcers and Patients at Risk of Pressure Ulcer Formation. [Online] Available from:Â  http://www.convatec.co.uk/media/9572137/aquacel-foam-dressing-shown-to-protect-against-ski-11546.pdf Cullum, N. (2013) Study reveals pressure ulcer research uncertainties. [Online] Available from:Â  http://www.manchester.ac.uk/discover/news/article/?id=10016 Jaul, E. (2010) Assessment and management of pressure ulcers in the elderly: current strategies. Journal of Drugs and Aging. 27 (4). p. 311-325. Leik, M.T.C. (2013) Adult-Gerontology Nurse Practitioner Certification Intensive Review: Fast Facts and Practice Questions. 2nd ed. Springer Publishing Company: New York. Medical News Today. (2014) What are bedsores (pressure ulcers)? What causes bed sores? [Online] Available from:Â  http://www.medicalnewstoday.com/articles/173972.php Morelli, V and Sidani, M. (2011) Fatigue and Chronic Fatigue in the Elderly: Definitions, Diagnoses, and treatments. Clinics in Geriatric Medicine. 27 (4). p. 673 – 686. National Health Institute. (2014) Osteoarthritis. [Online] Available from:Â  http://www.nhs.uk/Conditions/osteoarthritis/Pages/Introduction.aspx National Health Service. (2014) Pressure ulcers – Treatment. [Online] Available from:Â  http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Treatment.aspx National Institute for Health and Care Excellence. (2014) Pressure ulcers: prevention and management of pressure ulcers. [Online] Available from:Â  https://www.nice.org.uk/guidance/cg179/resources/guidance-pressure-ulcers-prevention-and-management-of-pressure-ulcers-pdf University of California at San Francisco. (2011) A critical analysis of Patient Safety Practices – evidence report no.43. [Online] Available from:Â  http://archive.ahrq.gov/clinic/ptsafety Vanderwee, K, Grypdonck, M, Defloor, T. (2008) Alternating pressure air mattresses as prevention for pressure ulcers: A literature review. International Journal of Nursing Studies. 45 (5). p. 784-801

Literature Review on Bulimia Nervosa and its Relation to the Personality Trait Introversion

Bulimia nervosa (BN) is one of the three major eating disorders commonly addressed in the field of psychology. The disorder is primarily characterized by an abnormal eating behavior that usually involves binging on food for a certain period of time as a response to personal stressors. Often referred to as a binge/purge syndrome, the eating disorder may involve such behaviors as induced vomiting, laxative and diuretic abuse, excessive exercise and unnecessary fasting. The disease usually has an onset age between 15 and 18 years and is said to affect 1-5% of (young) women in general.The disorder is generally hard to detect due to several reasons. These reasons include: a) bulimics are good at hiding their rituals; b) most weigh within normal range for their height, sex and age and only a few are under or overweight; and c) they demonstrate appropriate and normal eating habits in public circumstances. Furthermore, â€Å"eating disorders have for a long time been thought of as a culture -bound syndrome concerning white, middle class women, and often have not been thought to exist in other societies or cultures.However, studies show that eating disorders are present also in non-western societies, though not as prevalent† (Ekeroth, 2005, p. 19). Some signs and symptoms bulimics may exhibit include dental and gum diseases due to gastric acid exposure; irregular menstrual periods; swollen parotid glands; gastrointestinal problems such as bloating, constipation, and ulcers (gastric and duodenal); and electrolyte imbalances as a result of dehydration with accompanying symptoms such as hypotension, dizziness and light headedness (Sewell, 2000 ,p. 5-6).The diagnosis of BN is primarily accomplished through the determination of the following criteria: â€Å": a) recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time); b) a feeling of lack of control over eating behavior during the eating binges; c) regularly engagi ng in self-induced vomiting, the use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain; d) a minimum of two binge-eating episodes a week for at least three months; and e)persistent over concern with body shape and weight† (Sewell, 2000, p. 6). In the paper written by Tracy Sewell (2000), she discusses the prevalence of eating disorders (ED) as affecting an estimated 2-3% of post pubertal girls and women with an additional 5-10% of whom have â€Å"subclinical† eating disorders. Apparently, a significant number of girls are psychologically distressed suffering in quiet disturbance which makes their cries for help harder to hear and easier to ignore.As it were, girls tend to perceive their bodies, as it moves away from the thin prepubertal look, as overweight – resulting in unhappy feelings and the development of maladaptive methods of coping such as extreme dietary measures (p. 98-99). Sewell (2003) discusses several variables as affecting the incidence of the disorder. One such variable researchers have often associated with the disorder is the self-esteem levels/values of women.Issues often surrounding the disorder include body shape dissatisfaction which have been found to be highly correlated with the disorder as having both a mediating and moderating effect depending on outcome measures used. Additionally, she notes that â€Å"disordered eating can be conceptualized along a continuum, ranging from concern with weight and normal eating, to â€Å"normative discontent† with weight and moderately deregulated/restrained eating, to anorexia nervosa and bulimia nervosa† (3).â€Å"Normative discontent,† however, does not necessarily mean a psychiatric diagnosis or categorization, the condition itself – in its own right – can cause considerable distress and thus is a potential risk factor for developing BN syndrome (3). Perception plays a vital role in the pathology of the disorder. Most studies done on the subject reveal that bulimic women tend to report significant distortion of their body parts. They are greatly dissatisfied with their bodies which lead them to perceive themselves as larger than they really are and thus desire to become much smaller (Sewell, 2000, p.102). Apparently, there is a high connection between depression, body esteem, body image pre-occupation (Sewell, 2000, p. 103); Baigrie & Giraldez, 2008, p. 173; Watson, 2008, p. 6-7) teasing, anxiety, hostility, boredom, dietary restraint (Baigrie & Giraldez, 2008), neuroticism, obsessive compulsive disorders [OCD], borderline personality disorder [BPD] and extroversion (Watson, 2008, p. 6-7) with the development of eating disturbances in young women with low self-esteem.Sewell’s (2000) research into the subject of BN reveals that there are several correlated factors in the development of the disorder. One such factor is the onset of adolescence which is viewed as a turbulent time of â€Å"storm and stress† as the young woman’s family values come into conflict with societal, peer and media-espoused values. Numerous studies have established that adjustment problems peak during this time and thus contribute to the struggle for identity and independence (p. 6-7). Additionally, she found that certain predictive symptoms of BN can be found as soon as early childhood.These include eating and digestive problems such as problems with self-control of eating behaviors as well as eating-related family struggles. Notably, it was discovered that parents of bulimics – most especially the father – demonstrated personality profiles suggestive of disturbed affect, weak internal controls, unmodulated expression of hostile impulses and absent emotionally satisfying intrafamilial ties. It was also found that relatives of bulimics were more likely to suffer frequently from affective disorders, alcoholism and drug use disorders (p.8 ). Furthermore, it was discovered that the families of individuals with bulimia and bulimia-like symptoms were characteristically lacking in commitment, help, support, and filled with anger, aggression and conflict. Additionally, they were also found to be â€Å"disengaged, chaotic, conflictual, and lacking in expressive communication† (p. 9-10). It was also discussed in the same research that feminine and masculine traits were also correlated with the development of the disorder, especially towards the development of a distorted body-image.Apparently in the case of eating disorders, feminine traits were valued negatively compared to masculine traits and this has led women to have more negative self-concepts than men do (Sewell, 2000, p. 11). In fact, it was found that: both masculine and feminine gender-typed women who strongly adhered to a superwoman ideal were at greater risk for eating disorders than androgynous superwomen were. In contrast, androgynous superwomen had rel atively low potential for disordered eating and appeared comparable to women who regardless of gender typing rejected the superwoman ideal.(Sewell, 2000, p. 13). Another area of correlation, according to the same research, is in the area of self-esteem. Apparently, low self-esteem is linked to indicators of psychological distress such as depression, neuroticism, anxiety, poor general adjustment and eating disorders. According to studies, it is generally accepted that those who have low self esteem have a greater risk of developing eating disorders (Sewell, 2000, p. 14). The issue of body image in bulimics has been found to have distinctions between body-size distortion and body dissatisfaction.The former is described to be a â€Å"perceptual† disturbance where the patient appears unable to assess personal size accurately. The latter, on the other hand, has a more attitudinal (cognitive and affective) nature and has no disturbed size awareness. To quote: â€Å" [in] this type patients assess their physical dimensions accurately but they react to their bodies with extreme forms of disparagement or occasional[] aggrandizement† (Sewell, 2000, p. 15). These two types are also known to operate separately or conjointly, depending on the complexity of the disorder.Depression was also found to be highly correlated to the development of bulimia. Research indicates that around 60% of all bulimics suffer from a form of depression and that these feelings may be rooted in troubles with socialization. Studies have shown that socialization encourages the development of feminine characteristics in young women, however, the same activity also predispose them to develop â€Å"learned helplessness† – a form of maladaptation pattern towards stress.This may be due to the imposition of the â€Å"thin ideal† primarily on women which results in the higher frequency of depression in the group (Sewell, 2000, p. 16). In fact it was found that â€Å"dep ression was related to eating attitudes in fifth and sixth grade girls [which] suggest that preoccupation with food and dieting in girls begins in the fifth and sixth grades and increases in the seventh and eighth grades, a time when most girls are completing puberty† (Sewell, 2000, p. 18).Additionally, Sewell (2000) described in her research two sets of variables which the author predicted to have either predisposing effects (variables A) or precipitating effects (variables B) on the development of eating disorders. Findings for the research indicated that variables designated as B (which included self esteem and body shape dissatisfaction) had a more direct relationship in predicting eating disorder risk (p. 50-51). Apparently, it was also found that dieting can be an entree into an eating disorder especially if it were accompanied by certain risk factors and intensified by certain issues (p.51). Other findings discussed by the author included several psychological measures designed to estimate the presence of risk factors such as the Rosenberg Self-Esteem Inventory, Body Shape Questionnaire, endorsed sex roles, Social Insecurity Subscale and the Interoceptive Awareness Subscale (Sewell, 2000, p. 52-53, 57, 106, 108). According to the research, those who are at risk of developing eating disorders usually score high in the Rosenberg Self-Esteem Inventory – a measure indicating the presence of lowered self-esteem.Scoring high in the Body Shape Questionnaire test, on the other hand, indicates greater body shape dissatisfaction. These two measures combined indicate a greater risk for respondents falling within the clinical diagnosis range (p. 52-53). In terms of reported sex role, those who endorsed an androgynous sex role orientation were found to have higher body mass indices (BMI) and scored lowest in the Eating Attitudes Test (EAT), supporting findings in literature which state that those individuals with a more androgynous sex-role orientation generally score highest in self-esteem (p.57). Meanwhile, high scores on the Social Insecurity Subscale reflects the level of perceived tension, insecurity, disappointment, unrewarding and generally poor quality of social relationships while the Interoceptive Awareness Subscale, on the other hand, measures confusion and apprehension in recognizing and accurately responding to emotional states.It also reflects one's lack of confidence in recognizing and accurately identifying sensations of hunger and satiety (p. 108). Interpreting these various data led Sewell (2000) to the following conclusions: numerous literatures indicate decreased self-esteem leads to a greater likelihood of being diagnosed with an eating disorder.Similarly, increased body shape dissatisfaction and poor body image are strongly related to eating disorders and those individuals who indicated they â€Å"always† exercise were more likely to be diagnosed with an eating disorder than those who indicated they ex ercised less frequently. This also agrees with findings in the literature that indicates individuals who have an eating disorder are inclined to engage in great amounts of exercise, rather than exercise in moderation. (p. 52-53).These, therefore, are the gist of Sewell’s findings on BN and other eating disorders: a) the disorder is highly predisposed by depression; b) several complex co-morbidities precipitate the development of eating disorders; c) failed, faulty or maladaptive social and familial interactions can affect the likeliness of developing the eating disorders; and d) BN and other eating disorders display high levels of body distortion and dissatisfaction which all point towards lowered body and self esteems.In a separate study conducted by Kerstin Ekeroth (2005) where the author tackled psychological problems in adolescents and young women, she found that â€Å"patients with bulimia nervosa (BN) scored higher than both patients with anorexia nervosa (AN) and thos e with an eating disorder not otherwise specified (EDNOS) on most problem scales,† supporting the findings of Sewell and other literatures. Additionally, the author also mentions that AN-bingers/purgers (an AN subclass similar in behavior with bulimics) scored higher in externalizing behaviors than pure restrictors (p. 4).In terms of co-morbidity, the author also found strong relations with depression. However, the author also warns that starvation may cause symptoms similar to primary depressive disorder and thus has a potential to influence initial depression ratings. Similarly, it was also found that there are elevated frequencies of social phobia in both AN and BN patients. In fact, an estimated 75% of AN and 88% of BN patients had anxiety disorders predating the eating disorder (Ekeroth, 2005, p. 25-26). Additionally, the author described several personality disorder clusters usually found in persons with eating disorders.According to this description, BN patients most co mmonly demonstrate cluster B personality disorders. Cluster B personality disorders include borderline, antisocial, histrionic, and narcissistic personality disorders. Among these, it was found that borderline personality disorder is the most frequently reported. Additionally, BN patients also categorize under a cluster labeled C which includes disorders such as avoidant, dependent and obsessive-compulsive personality disorders. Apparently this cluster is commonly reported equally in both BN patients and AN patients (Ekeroth, 2005, p.27-28). Several studies have also reported that a higher frequency of suicidal behavior, drug use, and stealing are found in girls with BN indicating impulsivity disorders. As the author writes: Bulimic behavior is often thought of as an expression or manifestation of a failure to control impulses to eat, and to get rid of the food afterwards. In addition, earlier studies have found that girls with bulimia not only have lower impulse control and elevate d rates of impulsive behavior but also express more aggression compared to girls with AN.(Ekeroth, 2005, p. 29). This is further supported by the fact that many patients with BN seem to have disinhibitory problems. A possible explanation for this is that dieting and starvation has been found to not only influence mood lability but is also disruptive to the different psychoneuroendocrinological systems (Ekeroth, 2005, p. 30). The author also discussed that patients with eating disorders often experience conflicted relations with friends and family, and usually withdraw from social interaction.Despite this general characterization however, AN patients were found to be active in school and in sports. In complete contrast, BN girls were reported to have received less support from friends and family, experienced negative interactions and conflicts more frequently, and have less social competence (Ekeroth, 2005,p. 32). Furthermore, correlations identified by the author revealed the follow ing data: [C]orrelations between the internalizing and externalizing dimensions were 0. 51/0.49 (boys/girls), and for anxious/depressed, and aggressive behavior the correlations were 0. 49/0. 45 (boys/girls). Moreover, self-destructive/identity problems correlated high with anxious/depressed (r = 0. 78/0. 82 boys/girls) as well as with the internalizing dimension (r = 0. 77/0. 78 boys/girls) (Ekeroth, 2005, p. 40), revealing that a high correlation exists between self-destructive/identity problems with anxiety/depression and internalizing dimensions of persons with eating disorders.Other findings included in the paper also reveal that BN patients score higher on somatic complaints, attention problems, delinquent behavior, aggressive behavior, externalizing, and total problems compared to AN and EDNOS patients. This was supported by the fact that BN patients report higher degrees of problem externalization especially concerning delinquent behaviors compared to AN patints (Ekeroth, 20 05, p. 43). Additionally, BN patients were also reported to have more problems compared with AN patients.Similarly, BN patients were also reported to have more problems â€Å"than EDNOS patients on anxious/depressed, self-destructive/identity problems and internalizing† (Ekeroth, 2005, p. 41). These findings were in line with previous reports that girls with ED score significantly lower on competence, interpersonal sensitivity, depression, anxiety, and psychoticism (Ekeroth, 2005, p. 48) – reinforcing the idea that â€Å"[f]eelings of self-competence and having close and good relations to family and peers might be important factors influencing coping potential and treatment outcome† (Ekeroth, 2005, p.43) of patients with eating disorders. Evidently, lack of competence is on of the common features in persons with eating disorders. However, like most constructs, this aspect is not easily defined (Ekeroth, 2005, p. 58). Additionally, the author discusses: Bulimic b ehavior has been linked to impulsivity†¦[h]owever, the definition of impulsivity is not clear-cut and simple. Impulsivity consists of two different aspects, lack of planning and urgency (the tendency to act rashly when experiencing negative affect), and that it is urgency, which is linked to bulimic behavior.Others have pointed at the distinction between internally and externally directed impulsive behavior, and suggest that general psychopathology is related to internally directed impulsivity (e. g. self-harm), while bulimic pathology is more specifically associated to externally directed impulsivity (e. g. theft). (Ekroth, 2005,p. 53). However, despite all these information, it is still generally regarded that there is still large uncertainty about the relevant distinction between AN-r (restrictive type), AN-b/p (binging/purgative type), and BN.(Ekeroth, 2005, p. 33). The findings in both Sewell’s and Ekeroth’s research were also supported by a third study condu cted by Baigrie and Giraldez (2008). The focus of this study however was on the subject of binge eating and its relation to coping strategies employed by [Spanish] otherwise normal adolescents. In the said study, it was found that among respondents for the study, those who reported binge eating characteristically had higher BMIs, lower self esteem, depressive symptoms and were less satisfied with their body image (p. 173).Additionally, the study also determined that those who scored higher in the Eating Disorders Inventory (EDI) were more likely to have lower self esteem, more irrational thinking, decreased use of cognitive and behavioral coping strategies and increased use of avoidance coping (p. 174). In terms of coping strategies, the study found that the binge-eating group scored highest in three of the four areas of coping (introversion, positive hedonist coping, and avoidance coping) with introversion and avoidance coping garnering higher mean scores (Baigrie and Giraldez, 200 8, p.177). As the author’s discussed: it was expected that the adolescents who binge eat would use more avoidance coping strategies (unproductive coping) and fewer problem-focused strategies (positive coping) compared to the adolescents who do not binge eat. The results confirmed [that] adolescents who binge eat use avoidance coping more frequently than those who do not binge eat. (Baigrie and Giraldez, 2008, p. 177). Several studies also focused on the aspect of extraversion and introversion in correlation with eating disorders (Miller et al., 2005; Hitti, 2008; Watson, 2008[? ], p. 6-10,23; Carmo and Leal, 2007, p. 1). In these studies, it was found that lower extraversion (i. e. introversion) was related to disordered eating especially in women who score high in neuroticism – indicating that neuroticism and introversion may be risk factors in developing eating disorders (Miller et al. , 2005). This is supported by all previously discussed literature and by Miranda H itti (2008) in her article where she states â€Å"shyness and introversion are risk factors for anxiety disorders, especially social anxiety disorder.† As previously discussed, anxiety disorders are common co-morbidities among persons with eating disorders. An assumption can therefore be made that since neuroticism and introversion are risk factors for developing anxiety disorders, they are therefore indirect factors towards the development of eating disorders such as bulimia. Additionally, in the study conducted by Isla Watson (2008), it was determined that extroversion has a negative relation with eating disorders.Extroversion is defined as being markedly engaged with the world and dealing with external factors in an energetic, positive manner such that extroverted individuals gain pleasure from attention and their actions are often spontaneous and lack regard for others. Furthermore, â€Å"[c]ompelling evidence has shown that extroversion increases after weight is restore d during recovery from an eating disorder† and that it is often not expressed in anorexic individuals therefore calling for a need to watch out for the polar trait introversion (Watson, 2008, p.10) due to the fact that introversion is a common feature of eating disorders (Watson, 2008, p. 23). This idea is further reinforced by the findings of Claudia Carmo and Isabel Leal where the authors negatively correlated extroversion and awareness with the Eating Disorders Inventory (EDI) subscales, allowing the authors to conclude that extroversion and awareness are protective factors against the development of eating disorders (p. 1).In summary of all the literature discussed so far, the subject of BN and eating disorders in general seem to be highly correlated and associated with anxiety and personality disorders. It is also pointed out that these psycho-behavioral disorders are a probable result of several contributing factors such as families that are disengaged, chaotic, conflict ual, and lacking in expressive communication, negative self concepts, and poor quality of social relationships.These factors contribute to the development of depression, neuroticism, anxiety, poor general adjustment and lowered self esteem. Furthermore, these mentioned characteristics also define personality clusters found in persons with eating disorders such as BN. Though BN patients are generally more aggressive and demonstrative of delinquent behavior, distinctions between BN, AN-r, AN b/p and EDNOS is not very clearly defined. Therefore, findings about extroversion and introversion may generally apply to all of these eating disorders.If anything, the fact that extroversion is proven to be negatively related to eating disorders, the inverse thus is also plausible: introversion is positively related with eating disorders. How this affects BN however is still unclear since most of the literature discussed here so far characterize BN as specifically associated with externally direc ted impulsivity – a behavior that somewhat mirrors extroversion. However, since BN patients also have co-morbid anxiety and personality disorders it cannot be ruled out automatically that these individuals do not have introvertive traits.The mere fact that the characteristics lowered self esteem, avoidant coping, decreased social competence, and social phobia frequently come up as descriptive traits of the anxiety and depressive disorders found in these individuals all point to the likelihood that these individuals may have some form of introversion and that BN patients probably compensates for this by â€Å"acting out† in order to cover for the insecurity that is very definitive of eating disorders. ReferencesBaigrie, S. S. , Giraldez, S. L. (2008). Examining the relationship between binge eating and coping strategies and the definition of binge eating in a sample of Spanish adolescents. The Spanish Journal of Psychology vol. 11 no. 1:172-180. Carmo, C. , Leal, I. (20 07). Dimnsions of personality and eating disorders. University of Algarve Portugal, Department of Psychology. Ekeroth, K. (2005). Psychological problems in adolescents and young women with eating disturbances.Doctoral Dissertation for Goteborg University, Department of Psychology. Hitti, M. (2008). Variations in RGS2 Gene Linked to Shyness in Kids, Introversion in Adults. WebMD Health News Reviewed by Louise Chang, MD. Retrieved March 17, 2009 from http://www. webmd. com/mental-health/news/20080303/shyness-gene-teased-out Miller, J. L. , Schmidt, L. A. , Vaillancourt, T. , McDougall, P. and Laliberte, M. (2005).Neuroticism and introversion: A risky combination for disordered eating among a non-clinical sample of undergraduate women. Elsevier Ltd. Sewell, T. (2000). Developing risk factor profiles for Anorexia and Bulimia Nervosa in young adults. Thesis for the University of Manitoba for the Faculty of Graduate Studies. National Lirary of Canada. Watson, I. (2008). Personality factor s & their relation with attentional bias to food words. Rsearch for the University of Wales, Bangor.

Perfect Pizzeria: Case study Essay

Job satisfaction is a key driver to corporate success. It is clear that at Perfect Pizzeria employees are dissatisfied with their work environment. In order to overcome job dissatisfaction, one might influence employee motivation by applying the expectancy theory – the theory of motivation that suggests employees are more likely to be motivated when they perceive their efforts will result in successful performance and ultimately, desired rewards and outcomes (McShane and Travaglione 2007, p146). The effort-to-performance (E-to-P) expectancy is the belief that increased effort will lead to increased performance. In the present case, the company has no systemic criteria in hiring and formal training for mangers reduce the capability of performing the job successfully. Also, the indistinct role perception for night managers to perform regular employees’ duties and for assistant managers to learn bookkeeping and management reduce efficiency. In order to strengthen the individual’s belief that s/he is able to perform the task, the company should select the appropriate person with the required skills to do the job and to clearly communicate the tasks required for each position. Furthermore, managers should provide the necessary support to get the job done and to create workforce harmony. The performance-to-outcome (P-to-O) expectancy is the belief that performance at a certain level will result in the attainment of outcomes. The case suggested that employees are not reward based on their performance as they only earn the minimum wage. On the other hand, mangers are rewarded based on the percentage of food unsold or damaged, which is not highly correlated to performance. In order to increase the belief that good performance will result in valued outcome, the company should transparent the process that determines employee’s reward and explain the outcome that will result from the desired performance. Most importantly there should be an accurate measure of job performance in place. The outcome valence (V) is the importance that the individual places upon the expected outcome. Employees may mainly motivated by money and equality, which is deprived at the present situation. In order to ensure rewards are valued by employees, the company should distribute bonus for desired  performance and promote fairness within the company. The MARS model of individual behaviour highlights four factors that influence employees’ behaviour and explain the current resulting performance (McShane and Travaglione 2007, p36). The inequality of reward to performance discourage efforts (motivation), the mismatch of individual competencies with job requirement undermine employees’ performance (ability), the replicate of duties between night managers and regular employees and assistant managers dimmed their assigned tasks (role perceptions), and the retaliatory measures between managers and employees restrains employees to achieve their performance potential. To overcome the motivation problem, the company should promote equality in the distribution of rewards. The Equity theory suggests that employees strive for equity between themselves and other workers, therefore positive outcomes and high levels of motivation can be expected only when employees perceive their treatment to be fair – when the ratio of employee outcomes over inputs is equal to other employee outcomes over inputs (McShane and Travaglione 2007, p154). The first move to adjust the under-reward inequity for employees is to make them engage in organizational citizenship by mobilizing qualified workers to full-time job. The company should have a competency-based reward system in place. When employees show exceptional competence in workforce, their pay will get increase with the skills demonstrated in order to reinforce the probability of that specific behavior – positive reinforcement. On the other hand, instead of having a percentage of food unsold or damaged b onus scheme, managers should be rewarded based on their performance and qualification. This would be an equitable solution for both managers and employees. To overcome the ability problem, the company should select employees whose existing competencies best fit the required tasks. This mismatch of ability can be seen where relatively young and inexperienced managers are performing challenging tasks, whereas having highly educated employees responsible for less challenging tasks. A solution for that is to increase the capability of college qualified employees through job design. Having the required  knowledge and educational background employees may get promote to perform those challenging tasks. To support multi-skilling, the company should exercise job rotation by moving employees from one job to another to enable them to learn several jobs. Moreover, job enlargement also increases skill variety, and work efficiency and flexibility. To ensure high satisfaction and performance, employees need to have autonomy as well as job knowledge. As shown in the case, with the absence of supervisor the unsold or damaged food percentage remained at a low level. This led us to another important point – job enrichment. The heart of job enrichment is to give employees more freedom. To avoid the misuse of freedom, value congruence within the organization become significant, as such all employees share a common value to achieve a common objective. To overcome the problem of role perceptions, the process of goal setting is dominant by clarifying employees their role perceptions by establishing performance objectives (McShane and Travaglione 2007, p149). The goal has to be specific and relevant. For example, the role of night managers is to control the operation in the evenings (relevant) and to report the accurate employee mistake and burned pizza (specific). Yet the night managers should be committed to accomplishing the challenging goal set. This refers back to the E-to-P expectancy, the more belief that the goal can be accomplished, the more committed the night mangers are to the goal. Last but not least, to overcome the tension between managers and employees the building up of organizational commitment is essential. Managers should treat employees with justice and support, in which to retrieve the benefits employees had – free pizzas, salads or drinks to build affective commitment and organizational justice discussed above. In addition the building up of trust is equally important, therefore to intimidate with a lie detector ought to be abolished. Employee feel obliged to work for an organization only when they trust their leaders. Therefore, with high levels of affective commitment employees are less likely to leave the organization, and have a higher work motivation as well as somewhat higher job satisfaction. Reference List McShane, S. and Travaglione, T. (2007), Organizational Behaviour on the Pacific Rim, 2nd Edition, North Ryde: McGraw-Hill Australia.

The Conflict Of The Rwandan Civil War - 889 Words

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