Nursing Operating Budgets

Essay Nursing Operating Budgets

Synopsis

Nursing Operating Budgets – The capital budget will be defined. The non-labor operating budget will be explored. The labor budget for a thirty bed telemetry unit with a nurse to patient ratio of 1.6: 1 will be examined. Line items on a capital budget, non-labor operating budget and labor budget will be examined. The elements which compose a staffing mix will be examined. The ramifications of operating with a marginal staff will be examined.

Labor Budget

Research has demonstrated that increased levels of patient staffing are directly related to improved teamwork in health care facilities. Increased levels of staffing are a causal attribution of the quality of care and lower staff turnover. Lower vacancy rates and staff turnover have been linked to increased levels of patient staffing. Nursing teamwork is directly related to the physical characteristics of the health care facility such as number of beds, case mix index and nurse staffing. The type and level of nurse staffing is related to patient outcomes .The relationships which will be demonstrated in this research paper are the relationship to nurse staffing, nurse teamwork, staff confidence, team orientation, back up, a collective mental model and effective team orientation (Kalisch et al., 2011).

In budgets, the labor costs for a thirty bed telemetry unit, 1.15 FTEs are allocated per nurse staffing personnel. A thirty bed telemetry unit and a 1.6:1 nurse to patient ratio would require thirty RNs, eighteen nursing assistants, one director of nursing and unit secretary. The salary staffing mix is 70% RN, 25% nursing assistants. The shifts would be 60% with rotating shifts (Kalisch et al., 2011).

The approximate salary for a director of nursing is $140,000 per year. The director of nursing is required to have five years of experience in nursing administration, a BSN and critical nursing experience (ihirenursing.com, 2013). The total salary for a registered nurse is between $40, 157 and $79, 759 per year. The duties of RN care are the following: teacher, healer, administrator and counselor. A nimble mind is required in addition to an associate’s degree, a diploma or a bachelor’s degree. Registered nurses with BSN degrees are offered the opportunity to move into management and augment their salary (payscale.com). The annual salary of a nursing assistant is $18,995- $31, 719. The nursing assistant composes approximately 25% of the labor budget for a thirty bed telemetry unit (payscale.com). Unit secretaries and directors of nursing compose approximately 5% of the staffing mix. The unit secretary salary is between $20, 164- $36,362.

Calculating the Labor Budget

In calculating the nursing budget, we must analyze the average daily census (ADC). The ADC is calculated by totaling the number of patients in a year and dividing by the number of days in a year. The ADC is multiplied by the Average Nursing hours per patient day (NHPPD). This gives us the average NHPPD per year. The average total nursing staff direct care FTEs divided per 2080 hours gives the number of nursing staff direct care FTEs. 2080 divided by the number of productive hours of each FTE gives the percentage of productive hours per FTE. 2080 divided by the number of productive hours gives the actual number of FTEs. Two week vacation which total eighty hours, ten sick days which total eighty hours, eight holidays which total forty eight hours and two education days must be included. The total staffing budget for a thirty bed telemetry unit, including director of nursing, unit secretary is $2,446,000 (see attached spreadsheet line 8). An example of a line item in the thirty bed telemetry unit nursing budget is benefits for the nursing staff is $611, 500. This is another example of a labor budget line item (hrsonline.org).

Nurse staffing is very important because of the influence that it has upon patient safety and patient perceptions of quality care. Urinary tract infections, shock, upper gastro intestinal hemorrhage and pneumonia are very sensitive to nursing care. The majority of the negative patient outcomes have been documented due to the premise that a negative patient outcome is more likely to be recorded. Lower nurse to patient ratios have been linked to higher incidences of non-fatal adverse patient outcomes. This research has not d3emonstrated that lower nurse staffing levels are associated with increased mortality. Higher nurse staffing is related to a 2% decrease in adverse patient outcomes. Research has demonstrated that a 21% increase in hospital patient acuity between 1991 and 1996. A decline of 14.2% in the ratio of licensed nursing staff to acuity related patient day of care has been realized within the five years from 1991 to 1996. Research has also demonstrated that;

40 % of nursing professionals are unhappy with their working conditions.
35.7 % of nursing professionals classified the quality of care in their health care facility as outstanding.
44.8% of nursing professionals have noticed a decrease in the quality of care at their health care facility.
83 % of nursing professionals reported an increase in the average daily census (ADC).
34.4% of nursing professionals perceive that there is enough RN to supply high quality care.
33.4% believed that their health care facility has enough staff to accomplish the assigned tasks (Stanton, 2012)

A Markov cohort simulation is applied in determining the cost effectiveness of suggested staffing versus median staffing in patients requiring acuity based treatments. The cost effectiveness of suggested staffing versus median staffing is $321,000 per discounted quality of life year gained. This aspect is especially important in patients who require acuity based treatments from the health care facility (Ganz et al., 2005).

Various budgets are applied by health care organizations. These budgets are implemented in order to coordinate the situation of a program or initiative. The operating budget is implemented in order to coordinate to the daily transactions over an accounting period (Danna, 2011). An example of a line item in an operating budget is revenue. A salary operating budget would contain benefits as a line item. Capital budgeting is the method by which the finance team decides whether or not to invest capital resources in particular projects or assets. An example of a capital budget line item is clinical furnishings (hrs.online.org)

The elements of a capital budget decide which capital equipment will be purchased and which facilities will be renovated, constructed, or rented. These components enable the finance management team to ascertain the depreciation costs which will need to be included in the following accounting period. Depreciation costs compose part of the operating budget. Capital budgeting decisions will be realized before the operating budget finalization. Items which are included in the capital budget are major pieces of clinical and office furnishing. These items include but are not limited to office equipment, X-ray machines, magnetic resonance imaging (MRI), computerized topographical devices (CT scanners) and positron emission tomography scanners (PET scanners). The facility and fixed improvements (i.e., plumbing and wiring) are also elements of the capital budget (gehealthcare.com).

The operating budget includes the expenses related to equipment (i.e., capital equipment maintenance and financing). Labor and staffing expenditures are also part of the operating budget; In addition, education supplies, medications and printing supplies are elements of the operating budget.

In the strategic planning process, the quantity of capital equipment will be decided. Details which must be considered are the depreciation expense which remains on existing equipment and the objective of the health care facility in its development. The primary purpose of the capital budget is to classify the capital items to be procured in the following accounting period. These items require a capital proposal which must be received six to twelve months prior to acquisition. The department administrator will usually compose the initial draft of the request. This draft will be refined and submitted to the finance managers for viability. The elements of the capital budget are the following;

Specifications of the item which requires capital funding.
Conditions which require the acquisition and implementation of the capital item.
The financial influence of the acquisition on the target market, unit, patients and nursing personnel.
Initial price estimates.
Decision making standards which approach the strategic mission and objective of the health care organization (gehealthcare.com)

The annual capital and operating budget required by a thirty bed telemetry unit with a nurse to patient ratio of 1.6: 1 can be classified into the capital budget which considers equipment, building and other initiating expenses and the operational budget which will provide for continuing expenses. These continuing expenses may include medical supplies, salary and benefit expense. The establishment of a twenty four hour, seven day a week should include the following line items as capital expenditures. This is an example of a justification of a line item in the nursing capital budget: The cost of thirty beds is $212,000. In order to justify the expense of the beds, the following must be considered;

Increase in nursing efficiency.
Decrease the application of specialty beds.
Decrease the number of accidents.

The beds which are to be incorporated in the thirty bed telemetry unit must have the following:

Exit notification system.
Scale.
Inflatable and deflate mattresses.
Ability to be adjusted to a ninety degree sitting position.
Ability to be raised and lowered from the floor.
Ability to automatically disengage the headboard in order to facilitate the administration of CPR.

In a thirty bed telemetry unit, the savings of acquiring thirty beds is $12,645.00. The benefits of this acquisition result in the elimination of two specialty beds which cost $23,400.00. The acquisition of the thirty beds will also result in the reduction of injury to staff and patients (Hardy, 2004).

The expense of new hospital construction programs vary from $900,000.00 to $1,300,000.00 per bed. This strategy must be well considered in order not to bring the health care organization to bankruptcy. If these changes are well implemented, the project is designed to improve the facility’s ability to attract patients, increase long term operational performance and to realize a return on the capital expense (Rich & Hosking, 2013).

Research has demonstrated that increased levels of patient staffing are related to improved teamwork in health care facilities. Increased levels of patient staffing are also related to the quality of care and staff turnover. Lower staff turnover and a lower vacancy rate have been linked to increased levels of patient staffing. Nursing physical teamwork is related to the characteristics of the health care facility. These physical characteristics are: the number of beds, case mix index and nurse staffing. The level and type of patient staffing is directly related to the following;

Patient results.
Patient safety.
Diminishing the patient fall rates.
Clinical mistakes
Better nursing staff performance (Kalisch et al., 2011)

Hospital	Bed Size	Units In Study	Age > 35 Years	Gender Female %	BSN> Educational Level	Experience > 2 Years	Occupation (%RN)	Full Time (%)	Rotating Shift (%)
1	760	15	51	90	51	72	65	88	60
2	317	12	69	87	31	75	61	82	55
3	304	7	78	92	37	89	59	83	55
4	913	18	54	90	55	69	84	80	59
Total		52	60	89	46	74	70	83	58

The HPPD rates for which the units participated in the survey varied from 6.27 to 21.30. The average was 11.02. The average RN rate was 8.91 with values varying from 3.75 to 20.89. The average skill mix is 0.79 with values varying from 0.53 to 1.00. The average case mix index (CMI) was 2.28 with values varying from 0.83 to 6.93. A positive relationship between the number of hospital beds and the nursing teamwork ratings was established. The higher the level of HPPD, RN HPPD and skill mix, the higher the level of nursing teamwork (Kalisch et al., 2011)

The concept of assisted living is defined as a philosophy which is different from other types of residential care. This system supports autonomy, privacy and respect. Many health care facilities divide their beds into wars or designated areas. The Nursing Home Reform Act is also known as the Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987). This legislative act requires that a health care facility supply a level of care which facilitates the patient “to attain and maintain the highest practicable physical, mental and social wellbeing”. As defined by these legislative acts, the number of square feet required per bed is sixty square feet.

The number of direct care FTEs multiplied by the actual FTEs;

Ascertain the ratio of nursing staff classification to the nursing staff mix. Multiply the percentage of each nursing staff classification.
Ascertain the cost of the nursing staff by entering the salary and benefits for each nursing classification.
Ascertain the ratio of the staff that would be appropriate by shift. Divide this ratio of the staff required by each shift to ascertain the FTEs in each nursing classification.
Ascertain the percentage of full time staff compared to the part time staff. Divide this ratio by the number of FTEs by the full time or part time percentage.

The elements of a capital budget determine which capital equipment will be purchased, which facilities will be renovated, rented or constructed. These components will enable the finance management team to ascertain which capital budget decisions will be made before the operating budget finalization. Items which are included in the capital budget as line items are major clinical furnishings, including office equipment. The facility and fixed improvements are elements of the capital budget (gehealthcare.com). The non-labor operating budget includes the expenses related to equipment, labor and staffing expenditure. Educational supplies, medications, medical supplies and printing supplies compose the operating budget (see lines 10 – 19 on spreadsheet). The annual operating budget includes RNs (70%), technicians (25%) and support staff (5%). In calculating the budget 1.15 FTEs is allocated to each registered nurse (hrsonline.org). Research has demonstrated that increased staffing levels are related to improved teamwork in health care facilities. Increased staffing levels are directly related to the quality of patient care and lower staff turnover. Nursing teamwork is related to the physical characteristics of the health care facility. These characteristics include the number of beds, case mix index and nurse staffing (Kalisch et al., 2011). A Markov- cohort simulation is applied in determining the cost effectiveness of suggested staffing versus median staffing in patients requiring acuity based care. The cost effectiveness of suggested staffing versus median staffing is $321,000.00 per discounted quality of life years gained. This aspect is especially important in patients who require acuity based treatments from the health care facility (Ganz et al., 2005).

Bibliography

Assisted Living Facilities. Encyclopedia of Everyday Law (2013)

Danna, D. (2011) Learning and Mastering the Operating Budget Strategies for Nurse Managers.com.

Dunham- Taylor, J. (2009) Financial Management for Nurse Managers. Merging the Heart with the Dollar. Jones and Bartlett Publishers

Ganz, D. (2005) Cost effectiveness of recommended nurse staffing levels for short stay skilled nursing facility patients BMC Health Serv Res 5:35

GE Health Care Financial Service (n.d.) Capital Analysis Self Tutorial Module 1. How Decisions are Made

Hardy, P. (2004) The impact of nursing care and other health care attributes on hospitalized patient Satisfaction and behavioral intentions Journal of Health Care Management May, 2004

Heart Rhythm Society (2012) Education Women’s Leadership

I Hire Nursing (2013) Director of Nursing Oakland, CA

Kalisch, B. (2011) Nurse Staffing Levels and Teamwork: A cross Sectional Study of Patient Care Units in Acute Care Hospitals Journal of Nursing Scholarship, Vol. 43(1)

Rich, D & Hosking A (2013) First the strategy, then the bricks, 3^rd Edition

Stanton, M. (2012) Hospital Nurse Staffing and Quality of Care Research in Action 14 March 2012

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Borderline Personality Disorder

According to DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) personality disorders are defined by maladaptive personality characteristics which begin during early years of life and have serious and consistent effects on functioning (Diagnostic and statistical manual of mental disorders, 2000). Borderline personality disorder (BPD) is a common reason to visit a psychiatrist (Skodol, Gunderson, Pfohl, Widiger, Livesley & Siever, 2002). BPD affects 2 percent of adults (mostly young women) (Swartz, Blazer, George & Winfield, 1990). Patients with BPD present a high rate of self-injury (without intent of suicide) and a significant rate of suicide attempts and completed suicide (Soloff, Lis, Kelly, Cornelius & Ulrich, 1994).

The patients of BPD are many times in need of mental health services and approximately 20 percent of hospitalizations in the psychiatric department are of BPD patients (Zanarini, Frankenburg, Khera &. Bleichmar, 2001). A patient with depression or bipolar disorder mostly endures the same mood for weeks while a patient with BPD may experience angers (intense bouts), anxiety and depression that may endure for only hours or at the most for a day (Zanarini, Frankenburg, DeLuca, Hennen, Khera & Gunderson, 1998). A study performed by Zanarini & Frankenburg (1997) showed that most of the patients with BPD report a history of neglect, separation (as young children) or abuse. Another study performed by Zanarini (2000) concluded that 40 % to 71% of Borderline Personality Disorder & Attachment Theory.

Origin of Borderline Personality Disorder

Children who have been exposed to psychological and physical neglect, sexual and physical abuse and maltreatment are at risk of developing BPD. The mental trauma faced by these children is due to neglect and abuse by a primary caregiver. This trauma disrupts the normal and healthy development of secure attachment. And as a result these children develop disorganized attachment (anxiety and depression). The children who are neglected are at risk of social rejection, incompetence feeling and social withdrawal. Neurobiological dysfunction can be caused because of abuse and neglect by primary caregiver. In order to develop a capacity of regulating emotions and developing a coherent sense of self the child has a requirement of attachment from the primary caregiver.

Attachment Theory and Borderline Personality Disorder

As per the ethological perspective of John Bowlby (1977, 1980, 1991) BPD can be considered as a condition of significant insecure attachment (with significant oscillations between detachment and attachment & between yearning and longing). The working models present in affect regulation and a lack of coherence (mainly in relationships with others) (Bowlby, 1973). The sorrow of detachment faced in early childhood negatively impacts the psychology of the person and this result in heightened sensitivity to loss and separation. It is also important to note here that since these feelings and thoughts are disconnected to the happenings in early childhood these individuals are unable to understand the reason behind their reaction. Research scholars (Melges & Swartz, 1989) have compared the fluctuations in the behaviour of BPD patients to prickly porcupines – they are of the opinion that patients with BPD are in need of someone but when someone comes close to them they drive themselves away as a result of fear. Thus BPD patients are looking for secure attachment but they fear rejection, anxiety and anger that could result (Bowlby, 1979). Melges and Swartz (1989) are also of the opinion that patients with BPD are preoccupied with regulating space. They do not feel the “invisible elastic” of attachment (Bowlby, 1969, p. 45). Also they are unable to protect themselves from anxiety of separation (Adler & Buie, 1979). The influence of certain types of experiences as related to family can be the cause of separation anxiety (Bowlby, 1988). John Bowlby’s “The seminal developmental theory” for treatment of BPD patients (Bowlby, 1969; Bowlby, 1973; Bowlby, 1980) has gained great attention. Bowlby proposed that human beings face pressures of natural selection in order to evolve behavioural patterns (example, clinging, smiling and proximity seeking ), that evoke in adults the caretaking behaviour (example, soothing, holding and touching).

These behaviours are reciprocal and encourage the development of an affective and enduring tie between caregiver and infant, which forms attachment. It is the result of these parental responses that internal models of the self and others are developed in infants which act as templates in the functioning of relationships later in life (Bowlby, 1973).

The Findings and Proposals of Bowlby the Following Is True In Case Of Attachment (Bowlby, 1973)

1. Model Of Self: The Internal Working Of It Is Related To The Degree Of Acceptance And Love One Has In The Eyes Of Primary Attachment Figures.

2. Model Of Others: The Internal Working Of It Is Related To How Available And Responsive Attachment Figures Are Expected To Be.

Attachment plays a very crucial role in the development of an external environment from which the child develops a safe and secure internal model of the self. Security on the grounds of attachment as perceived by the child results in his or her exploration of the world with confidence; this confidence springs by the availability of the caregiver. Security in attachment thus promises consistent, coherent and positive self-image. It also provides a feeling of being worthy of love and expectation that the important ones to him or her will be responsive and accepting. We here note that Bowlby has presented to the scientific mind the importance and need of attachment as essential to infants and children. Thus, attachment can be considered as an essential ingredient in the production of a psychologically healthy life. Now let us consider BPD patients, it is a case where the security in attachment is absent and there is a split and malevolent representation of self and others (Kernberg, 1967). In the life of BPD patients we usually observe angry, manipulative and needy relationships (Benjamin, 1993).

A number of scientific studies and intellectual thoughts have considered that intolerance of aloneness is the main defining characteristic of BPD and it is essential to note here that the descriptive criteria of DSM are also of the same opinion (Adler & Buie, 1979). Thus, the concepts and theories of attachment in many ways relate to DSM diagnostic criteria. Gunderson (1996) proposed that the early attachment failures actually constitute the cause of intolerance. He noted that in times of distress and sorrow patients with BPD are unable to invoke a “soothing interject” and this is due to unstable and inconsistent attachments to early caregivers. The above proposed scientific thoughts of Gunderson (1996) are same as that of Bowlby’s concept of insecure attachment.

The Scientific Observations Of Gunderson (1996) The Following Points Are True In Case Of Patients With Borderline Personality Disorder:

A Feeling of Insecurity on Grounds Of Attachment, Especially Pertinent To:

Plea for Attention
Pleas for Help
Checking For Proximity
Clinging

A Feeling of the Following in Borderline Personality Disorder Patients:

Denial Of
Dependency Needs
Fearfulness About

Based on the comparison of theories of object relations and attachment (Lyons-Ruth & Jacobvitz 1999) distinguished between normal processes (in early development) of separation individualization from the disorganized conflict behaviour (for attachment figures) by toddlers who are at significant risk for development of psychopathology. She identified that in infants the disorganized insecure attachment as a risk factor in the later development of BPD. Thus, we can state that as per the findings of Lycos-Ruth those infants who are victims of insecure attachments during the early years of life are at risk of developing BPD during later years of their life.

Attachment Therapy

In 1990, ATTACh (Association for Treatment and Training in the Attachment of children) was created in order to address the need of society and families to deal with critical attachment and bonding issues. ATTACh has cited important principles of attachment therapy and this includes the following:

1. Attachment therapy can be defined as a therapeutic process that is designed with the aim to define, develop and promote reciprocal attachment relationship and that which completely meets the criteria of that therapeutic process as defined and developed by ATTACh.

2. The aim of treatment by attachment therapy is to address the attachment problems and enable patients with healthy attachment relationships.

3. The emphasis in attachment therapy is laid on touch, physical and emotional closeness, reciprocal behaviours, empathy, atonement, communication, playfulness and humour. The attachment and bonding therapists are therefore required to treat with attention to the physical and psychological safety and wellbeing of the children and adults.

4. Family systems approach is of prime importance in attachment therapy. Thus there is need to correct child’s relationship with his or her primary caregiver.

5. It is essential to assess and study the following;

Psychological history
Educational history
Treatment history
Medical history
Attachment & Social history (including breaks in attachment)
Developmental history (including prenatal and birth)
Intellectual and Cognitive skills and deficits
Family functioning
Differential diagnosis (including DSM and ICD diagnoses)

6. Parents and children form the most active group of treatment regimen. Attempts are made to develop healthier patterns of interaction and communication.

7. To assist parents to develop parenting strategies in order to support positive attachments.

8. Description of any shortcomings attachment therapy might have for treating this issue and what else could be fused with attachment therapy to meet these needs.

Criticisms of Attachment Therapy

1) The application of attachment therapy for treatment of patients with BPD is equated with rebirthing or holding therapy and the techniques used to achieve the results are dangerous.

2) During the treatment of patients with BPD the attachment therapists make use of criteria that are even beyond those provided by the DSM-IV-TR (Zeanah 1996; Boris et al 2004). The strong correlation between insecure attachment and pathological parent-child interaction as shown by attachment therapy are beyond the symptoms listed in the DSM criteria (Bowlby 1944, 1973).

3) The attachment therapists many times over diagnose BPD.

Almost 87% to 96% of the children, who experience abuse, neglect or both, show an insecure attachment (Crittenden, 1988).
Between 50% and 80% of the adopted children have attachment disorder symptoms (Carlson, Cicchetti, Barnett & Braunwald, 1989).
Approximately 20% of children living in homeless shelter and nearly two thirds in foster care are identified with attachment disorders (Boris, Wheeler, Heller & Zeanah, 2000).

4) Attachment therapy is not supported with “empirical evidence” While attachment therapy can provide treatment of BPD, studies have revealed the effectiveness of other therapeutic methods as well. These methods have been briefly described below:

1. Psychotherapy

Randomized controlled studies have presented the efficacy of dialectical behaviour therapy and psychodynamic / psychoanalytic therapy (Bateman & Fonagy, 2001). The treatment provided in these trials comprises of three key features;

Meetings with an individual therapist (once a week)
Group sessions (one or more in a week)
Meetings of therapists for supervision or consultation

The psychotherapist’s approaches include a building of a strong therapeutic alliance and monitoring the suicidal or self-destructive behaviours. Other essential component of effective treatment plan for patients with BPD includes managing feelings, promoting reflection action (and not impulsive action), reducing patient’s splitting tendency, and limiting the behaviours related to self-destruction. There is some empirical data that supports individual psychodynamic psychotherapy.

2. Group Therapy

Group therapy for BPD patients is supported with research findings that indicate that it can be helpful (Greene & Cole 1991). Note: However, the benefit of family therapy in the treatment of BPD patients is not evaluated yet with research studies.

Descriptions of how dimensions of cultural context impact the issue you are discussing. How might this inform your treatment? I strongly believe that psychologists should not be racists. Today we are required to treat patients of different ethnic groups and countries during our clinical practice. Even an expression of detachment or neglect can hurt hard the patients with BPD. As discussed above the patients with BPD are in need of love and acceptance, care and attachment, understanding and touch, soothing approach and closeness. If a psychologist will distinguish on the grounds of colour, race, region and country then s/he won’t be able to perform well because for the treatment of BPD patients with attachment therapy it is essential to shower true attachment. Roentsch (1985) defines racism as: “Let there be no misunderstanding. A racist is anyone who accepts the existence of racial collectives”. Amongst doctors there is a belief in the a priori inferiority of non-white (Eysenck, 1990: pp. 215-220). The facts on racism reveal that we divide the world into ‘in-group and out-group’ or ‘us and them’ (Baron and Byrne, 1994: pp. 228-229). An important study first conducted by Clark and Clark (1947, in Baron and Byrne, 1994: 256) showed that a significant proportion of non-white children had internalized the attitudes of white racist. Thus the reaction of non-white adolescents towards white psychologists can be considered to be different from the reaction towards non-white psychologists. These racists’ feelings need to be addressed with maturity and patience. The dealings, behaviour and communication need to be such monitored that the feeling of racism is absent.

Self-issues that may impact a clinician’s conceptualization and treatment of this issue from an attachment perspective. How might one’s cultural context inform what they see and how they see it? What should clinicians be cautious of? Bonus points for examination of your own “self” in relation to treating this issue from an attachment perspective.

During my school times I lost my best friend because of racial differentiation attitude of a teacher. I was very much in harmony with my non-white friend. We had a high level of understanding and we loved spending time together. We were best friends for 3 years. However, my teacher did not like us being friends. She was white and disliked non-white people. Though she did not show it openly but it was obvious by some of her remarks at different times about non-white people. My teacher asked me to quit my friendship with the non-white girl. At first I was very much hurt by my teacher’s approach but then I agreed to it. This is because my teacher said that she will assure that I will get better grades in school if I agreed to what she said. My friend was very much hurt when I broke friendship with her. And after doing this I felt guilty for doing something really wrong. Even several years after quitting friendship with her, I feel sorry for my decision. Actually for some part of my life I had started thinking the way my teacher thought. I use to respect my teachers and had a feeling that they are always right. This is the reason why I started feeling that my teacher’s attitude towards non-white people was right. However, my thoughts have changed to good after leaving school. Now, I am equally friendly towards both non-white and white. I have both non-white and white as my friends. But sometimes the thought that I was once a racist makes me feel guilty. When I recollect that I was once a racist, I lose confidence in dealing with non-white people. I noted this when I was working on the treatment of a BPD patient who was non-white. I need to be more confident in my dealing with non-white people. I need to feel sure that I no more differentiate between non-white and white. I think I will gain this confidence when as a result of my sincere work several non-white BPD patients will get healed.

Describe what the early, middle and ending phases of therapy might look like for treating this issue based on what you have learned. Please also include some possible interventions and assessment methods. Attachment theory has been applied to both children and adults suffering from detachment. Bowlby (1969) formed a lifelong attachment behavioural system which encourages secure attachment. The attachment thus begins with the child’s requirement of secure attachment from the primary caregiver. The behaviour of attachment is organized and revolves around primary care giver. The feelings of attachment are elicited during the period of mental or physical discomfort or stress (1969). As per Bowlby’s (1969) perspective BPD can be considered as a condition of significant insecure attachment. There exists number of oscillations between detachment and attachment. The early childhood experiences of BPD patients are that of detachment, neglect, abuse, separation and loneliness. Thus the systems that mediate the feelings of attachment and positive behaviour are distorted and deactivated. In addition to this BPD patients have intense fear linked with loss and separation. However, since BPD patients do not remember their childhood time when they were neglected and abused they are unable to understand the reason behind their behaviour. I think a therapist is required to develop a secure and genuine attachment relationship with the BPD patients. The patient should feel completely secure in his or her relationship with the therapist. S/he should have no fear of loss or separation as related to relationship with the therapist. Development of a ‘secure’ attachment can help establish happiness in the life of the patient.

BPD patients are in need of love but the fear of loss and separation drives them away from people. It is therefore crucial that this fear of loss and separation should be dealt in the first phase of treatment. The patient with BPD should be counselled in such a manner that s/he starts gaining confidence in building secure relationships. The approach of the therapist should be driven by ‘attachment’ and ‘love’. Thus, while attempting to heal the BPD patient of the fear of separation, the therapist should try to build his or her own place in the heart of the patient. The approach should not only aim to heal the fear but also to open ways for love and attachment. The therapist should make the patient feel that s/he really cares for him. That it is not just a routine responsibility or duty to address the need of the patient. The therapist should show that s/he has started loving the patient and has become attached with him. S/he has started caring for the needs and essential requirements of the patient. A feeling of attachment should spring from within the heart of the therapist and should touch the emotions of the patient. Parents of the patient should be educated on the basics of attachment.

They should be taught the need of touch, eye contact, motion, love, compassion, care and attachment. The issues related to behaviour should be addressed and the pitfalls should be examined. The treatment should include a review of the attachment issues of the parents’. The parents should be educated on good ways to bring up the child. The attachment from parents and primary care taker are essential for answering the need of BPD patients. Gregory C. Keck states that holding the child or adolescent gives rise in an emotional response and intensity that cannot be achieved by any other medicine or therapeutic regimen. Therapist should educate the parents or the primary caretaker to hold the child or adolescent. The therapist should work to build in attachment between the child/adolescent and the parents/primary caretaker. Building of relationship and providing security and affection from parents or primary caretaker should be assured.

The therapist should also spend time to build in attachment between the child/adolescent and himself

The therapist should also work to repair the relationship that has been broken. S/he should try to develop more peaceful and lovable feelings between the child/adolescent and the parents/primary caretaker. The therapist can also do the holding of the child/adolescent and then s/he can transfer the responsibility to the parent or primary caretaker. The therapist is also required to make an important clinical judgment with regard to the suitability of the primary caretaker or parent for such an attachment. Guidance and education as related to the attachment should be provided by the therapist. In addition to holding ‘eye contact’ is an important part of attachment therapy. Eye contact opens the door to the heart of the person and builds attachment.

In conclusion, the therapist should believe in building relationships of attachment. A feeling of security should be the base of such attachments. Broken attachments should be repaired and new attachments should be built-in. The therapist should form attachment of the patient with himself or herself. In addition to this attachment should be built between the parent/primary caretaker and the child or adolescent. Education should be imparted on developing attachment. Today, in the modern days parents find little time for their children. Many times they forget to care for their own child. The child gets hurt each moment by a lot of anxiety, depression, neglect and loneliness. The child loses the charm of attachment and feels that s/he won’t get attachment from anyone. I believe that in order to begin with attachment therapy it is essential for the therapist to first build attachment between himself and the child/adolescent. Therapist should also build in attachment between himself and the parents of the child/adolescent. This is because the parents who feel attachment from the therapist will be more responsive and agreeable to treatment.

Attachment Can Create Wonders in the World of Therapy and Therapeutics

Attachment speaks to the heart and touches the emotions to bring forth a feeling of recovery. I strongly believe that attachment therapy is the best suit for patients with BPD. This is because attachment can repair the broken hearts, the fading hopes, the dying relationships and the detached home. I would strongly recommend attachment therapy as a method of choice for the treatment of patients with BPD. Children and adolescents want someone to speak to their heart, someone who understands their need of attachment and addresses to their requirement of love, touch, care and affection. During all the phases of treatment this should be kept in mind and should be reflected in approach and practice of the therapist.

Conclusion

Attachment theory is a good addition to the knowledge of psychology and its application can be beneficial for the treatment of BPD patients. While dealing with patients of BPD the psychologist should not have racist attitude and his or her approach should be confident.

References

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Childhood Obesity

Physical inactivity, nutrition, genetics and psychological factors are the main causes of prevalence in childhood obesity

Sources: Langwith, J. (2013). Childhood obesity. Detroit: Greenhaven Press

This book by Jacqueline gives an overview of what childhood obesity encompasses. In the book, she talks about childhood obesity being a global health concern and health risk factors associated with childhood obesity. She also talks about the various causes of childhood obesity. They include Type II Diabetes, cardiorespiratory diseases, cancer, and hypertension, stroke, and sleep apnea and liver disease. She argues that children who are obese have a high risk of having a shorter life expectancy and also the controversies surrounding childhood obesity.

In her book, she talks of two main causes of childhood obesity which are genetic factors and stress, the effectiveness of anti-obesity programs, and whether bariatric surgery is appropriate for children the role government should play, focusing on contributing factors, and personal stories of people dealing with childhood obesity. This book is a credible source that will prove useful in the final research paper since it gives detailed information on the issue of childhood obesity. Jacqueline provides general views and clear evidence, and she is not biased in any way. This book will be useful in putting up a strong argument on genetic and psychological factors being causes of childhood obesity. (Langwith, 2013)

Jimerson, M. N. (2009). Childhood Obesity, Farmington Hills, MI: Lucent Books

The author of the book touches on childhood obesity, by talking about what it is its causes and the effects it has on the affected kids, its health risk factors, how it is to live with it as a child and future prevention measures. He says that childhood obesity could be prevented if parents carefully determined the environments they bring up their children. By parents and guardians encouraging their kids on healthy eating habits and an increase in participation in physical activity, cases of childhood obesity will be reduced. He urges parents to maintain their kids body weight, reduce the number of adverts promoting unhealthy food.

To support the suggested preventive measure, he provides information about medical issues of childhood obesity such as diabetes, emotional problem. This book is a credible source in the research as it talks about the main causes of childhood obesity. The book’s details are based on evidence making it of undoubted quality. The book having discussed diet and physical inactivity as the main causes of childhood obesity will help me in arguing out my case (Jimerson, 2009).

Juettner, F. B. (2010). Childhood Obesity. San Diego, CA: Reference Point Press

This book is a reliable and provides unbiased information on the issue of childhood obesity. Source to research on whether physical inactivity, nutrition, genetic factors and psychological factors are the main causes of prevalence in childhood obesity; The books discusses in depth on the origins of childhood obesity, how much of a problem childhood obesity has been all over the world. It also focuses on the causes of obesity which the author discusses in depth. He also tries to answer the question: can obesity in children be prevented and can it be reserve. It also discusses a few controversies that exist on the issue of childhood obesity. The information in the book goes a long way in helping one understand childhood obesity better and what exactly it entails. This source is credible and can be used towards the final projects. The book will provide information to strengthen the argument that the main causes of childhood obesity are physical inactivity, nutrition, genetic factors and psychological factors (Juettner, 2010).

Smith, J. C. (1999). Understanding Childhood Obesity. Jackson: University Press of Mississippi

The author of this book talks of physical inactivity as the main cause of childhood obesity. He urges growing children to exercise daily to help them grow healthy and avoid cases of childhood obesity and the health risk factors associated with it. He outlines the type of physical activities that kids need to undertake, through the help of their parents to remain physically fit. By parents acting as role models to their children in terms of physical activity, obesity in children will be reduced. This will act as a source motivation and could influence the child to do the exercises by themselves at a different time to help reduce some of the weight they have. This book is a reliable source to the research paper as it will because it in figuring out what motivates the child to exercise; is it an incentive by their parents? It will give an understanding on the causes of childhood obesity or is it through only bad eating habits. The information quality of this book is great though it does not focus on all the causes of obesity. This source is supportive to the argument that physical inactivity is associated with childhood obesity (Smith, 1999).

Institute of Medicine (U.S.). Koplan, J., Liverman, C. T., Kraak, V. I., Institute of Medicine (U.S.). & Institute of Medicine (U.S.). (2005). preventing childhood obesity: Health in the balance. Washington, D.C: National Academies Press

The authors of this book talk more on the extent of childhood obesity and the consequences it has on children with it. It also develops an action plan to fight with childhood obesity and make it a national public health priority. The authors also try to create awareness on the existence of childhood obesity through advertising, public education, through the media groups. This information passed to the local communities, homes and schools to help them eradicate the issue of childhood obesity in the society. This book is a credible source in the research paper as it talks about of the preventive measures of childhood obesity. The book mainly looks at childhood obesity in the United States and may seem biased to other areas in the world. The book will only help in arguing out what the consequences of childhood obesity are (Koplan, Liverman and Kraak, 2005).

Dehghan, M. Akhtar, N. and Merchant, A (2005) Nutritional journal: childhood obesity, prevalence and prevention

This article talks more on the causes of childhood obesity such as physical inactivity in that, children prefer playing video to having healthy activities such as swimming or playing in the playgrounds, poor dietary such as high caloric intake, foods with a high level of sugars, genetic factors, how cultural environment influences obesity among children and psychological factors. Impact of advertising junk food and also the preventive measures towards eradicating childhood obesity such as Parents being role models to their children on healthy eating and exercising at an early age. The article has a lot about the health risk factors associated with childhood obesity like type II diabetes, cardio respiratory diseases and stroke. It is a credible source as it has detailed information on the causes and prevention of childhood obesity. The information in the article will strengthen the argument on how poor diet or nutritional habits cause childhood obesity (Dehghan, Akhtar and Merchant, 2005).

Donahue, E. Paxson, C, Haskins and Ron (2006) Future of children: fighting obesity in the public schools

The article acknowledges how childhood obesity has increasingly grown the United States. It recognizes efforts schools are making toward fighting childhood obesity and encourages that more should be done such as including physical activities in the schools’ curriculum and making it mandatory as it will increase the chances of every child being physically active. Also, the article gives detailed information on how and why the government should take part in fighting this pandemic of childhood obesity. Information on the call to take action from congress to put more restrictions on the diet program in the school system; It gives more detail on setting up detailed goals and objectives for change in public school thus making it a credible source (Donahue, Haskins, Paxson and Ron, 2006).

Clinic, M (2006) Child Obesity

In the article, it is clear that childhood obesity is a serious problem globally and especially the industrialized nations. The article continues to give an explanation on the main causes of childhood obesity such as eating fast foods, foods with a high level of sugars and the e health risk factors associated with childhood obesity. It explains the processes of diagnosis and screening, effects it has on children and preventive measures that can be taken. This article is a very credible source in the research paper as it has detailed information on the causes of childhood obesity. Though it has great information, it lacks to provide enough supporting material of their conclusions (Mayo Clinic, 2006).

Centers for Disease Control and Prevention. (2010.) Childhood Obesity

This source states the many facts which have accrued as a result of childhood obesity. It shows how cases of childhood obesity have increased over the past thirty years with a higher percentage of children in the United States of age6- 11years being obese. This source defines obesity as having excess weight for a particular height. The causes of obesity Are also given in this article such as high caloric intake, environmental factors, genetic factors, behavioral factors and physical inactivity. It is clear that kids are the most affected and fall in this unhealthy balances and standards. This is a very credible source as it has information on the causes of childhood obesity as it also gives the preventive measures of this disorder among children. This source is very credible since it provides statistical evidence on issues relating to childhood obesity. The article looks at childhood obesity in the United States and may be questionable in terms of quality when talking about obesity globally. The source will support the argument that childhood obesity is on the rise (Centers for Disease Control and Prevention, 2010).

Centers for Disease Control and Prevention. (2006). Nutrition and the Health of Young People

This is a helpful source as gives more information on healthy eating, associated with the reduction of diseases associated with poor diet such as heart diseases, diabetes, cancer and stroke. Information on healthy eating among kids is given in order for the proper growth of children and prevents cases of child obesity. The article gives detailed guidelines for a recommended diet rich in grains, low fats dairy products, fat free for children. Schools are also are able to promote healthy eating among children by ensuring that only nutritious and the. The school food programs should provide appealing foods. Also, physical activity and nutrition program should be included in the school curriculum. The source will be supportive in the argument that poor diet causes childhood obesity (Centers for Disease Control and Prevention, 2006).

Did you find any useful knowledge relating to childhood obesity in this post? What are the key facts that grabbed your attention? Let us know in the comments. Thank you.

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