GERS 1301 Dr. Rhynes-Hicks Assignment 2: Something’s Gotta Give Movie Review With:

BSBPMG522 – Undertake Project Work BSBPMG522 – Undertake Project Work BSBPMG522 –

BSBPMG522 – Undertake Project Work

BSBPMG522 – Undertake Project Work

BSBPMG522 – March_2018

Student name:

Assessor name:

Date of assessment / evidence:

Venue:

451 PITT STREET, MANNING BLDG, HAYMARKET, SYDNEY, NSW

Qualification title:

10656NAT – Diploma of Enterprise Resource Planning

Unit(s) of competency assessed:

BSBPMG522 – Undertake Project Work

Instructions to the student:

To complete this unit’s assessment, you are required to complete all the tasks in this booklet and demonstrate specific tasks and skills.

Assessment

Case Studies

? Satisfactory

? Not Satisfactory

? Not Completed

Instructions to the assessor

To complete this unit’s assessment, the student is required to answer all questions in this booklet and demonstrate specific tasks and skills.

Once the booklet is completed, you are to make the assessment decision. Please refer to the marking guidelines when making this decision.

Context of Assessment

Assessment tasks will be completed in the College, including the computer lab, using provided software and documentation.

Assessment outcome:

(please tick to indicate)

Competent

Not Yet Competent

Is re-assessment required?

Yes

No

Date of re-assessment

(if applicable)

Date declared competent:

(if different to date of assessment)

Student:

The assessment process, including assessment information, competency requirements, student rights and appeals were clearly explained.

I have been provided with feedback on my assessment and agree/disagree (delete what is not applicable) with the assessment result.

Student signature:

Date:

Assessor:

The assessment process, including assessment information, competency requirements, student rights and appeals were clearly explained.

The assessment was valid, reliable, flexible and fair.

I have provided the student with feedback on their assessment.

I certify this assessment record is accurate.

Assessor signature:

Date:

Comments:

*Please see Moodle for feedback on assessment(s)*

Assessment – Submission Guidelines

All work must demonstrate a satisfactory standard of literacy (i.e. standard spelling and correct grammar).

All assessment tasks must be submitted via Moodle Submission Link by due date i.e., two weeks after the receipt of assessment task details.

Students are advised that extensions beyond the due date must be negotiated with the relevant facilitator in advance.

Marked assessments will be returned with written feedback comments in the Moodle website within one week from the final submission date (at the end of the TERM).

Resubmitted assessments must include the original corrected submission.

Students are required to keep a soft copy of all work submitted.

Please submit WORD files only

Assessments not including this submission form or without student name will not be accepted

Draft assessments will not be graded

Read the following document, answer all the questions therein and complete all tasks required.

Project Scenario: Open a new Fitness Studio in Sydney CBD

A group of investors GMSC Pty Ltd is launching a project to open a new Fitness Studio in Sydney CBD. The CFO has sponsored this new project and you has appointed you as Project Manager.

GMSC is currently operating a Vocational Institute but changes in legislation for the students Visa applications are making the current market less and less profitable. GMSC is currently using part of the Manning Building 5th and 2nd floor and will use to same premises to start the new business.

After consulting the ASQA, GMSC agreed to complete the current business operations at the end of 2018 Quarter 3.

The target for the new Fitness Studio is to serve people working in public and private offices in the Central Station area, from Monday-Friday. Opening hours will be between 6 AM and 8 PM. The expected offer to the customers will be: Body Building, Pilates, Yoga, Zumba and General Fitness.

The project team will file in advance a Permit Request to the Council and perform all the preliminary tasks to be able to start the construction at the end of Q1. Final training is expected to start in June 2019 and the Fitness Studio to start to operate in early July.

A preliminary estimation, based upon a similar project, has provided an estimation of 1.2 M$.

TASK 1: General Knowledge Questions:

Why is gathering requirements important in project management? Identify and describe 5 reasons.

People who are involved in or affected by project activities are? (underline the correct response)

project mangers

project stakeholders

project steering committee

organisational employees

Who could be the project sponsor? (underline the correct response)

a company financially supporting then project

a group of company stakeholders

a key stakeholder who is responsible for reporting on the outcomes of the project

a key stakeholder who has developed the idea for the project and is responsible to make funds available for the project

What are the benefits of Quality Assurance over Quality Control?

Sometimes it may be important to compress your project schedule. Describe two techniques that could be applied to compress a project schedule. Clearly identify why each might be required and what effect they will have on project cost/time/quality,

The project Control Change Process could require two approval points. Explain the reason for this approach.

What is the difference between residual risk and a risk contingency?

A project expected duration is 12 months and the current budget (BAC) is $240,000. The planned value profile for this project is linear (spending is the same month after month). After seven months the project figures are: CPI=0.9, SPI=0.95. Calculate the project Actual Cost (AC) after 7 months.

TASK 2: Project Charter

Name of the Project:

Background:

Goals:

High Level Scope:

Key Stakeholders:

Project Milestones

Project Budget

Key Risks

Approval Signatures

[Name], Project Client

[Name], Project Sponsor

[Name], Project Manager

TASK 3: Project WBS

For this project collect 5 key deliverables (for example: opening hours, number of rooms, number of customers……) and write a high level project scope (at least 200 words).

Identify 3 of the key deliverables and prepare for each a WBS using at least 5 break down levels.

Deliverable 1

Deliverable 2

Deliverable 3

Level 1

Level 1

Level 1

Level 2

Level 2

Level 2

Level 3

Level 3

Level 3

Level 4

Level 4

Level 4

Level 5

Level 5

Level 5

Project Title:

TASK 4: Communication Plan

Identify 4 internal and 4 external stakeholders for this project.

Develop a project COMMUNICATION PLAN.

Target Audience

Communication Needs

Messenger

Media/Channel

Frequency

Project Title:

c. Hold a consultation meeting with project team members and take their views into account. To do this, pair up with 2 or more students (you will each serve as a team member for the other) and hold a meeting. Discuss your project plan, including WBS and project charter. You must upload your notes/minutes and the observation checklist signed by your Trainer.

Marking Guide: Meeting Observation Checklist #1

Student’s Name

Trainer or Observer’s Name

Jasmin Hill

Unit of Competence

BSBPMG522 Undertake Project Work

Date of Assessment

Location

Demonstration Tasks

Meeting

Materials and Equipment

Note-taking materials

Tasks to be observed, demonstrated or simulated

Yes

No

Comment

Did the Student attend/perform the Meeting

Did the Student effectively interact and communicate with others?

Eye Contact

Body Language

Appropriate language

Use active listening

Ask Questions

Paraphrase or Summarise

Take Minutes/Notes

Did the student cover the points outlined in the assessment guidelines for this task?

Comments

Result : S/NYS

Assessor Signature:

TASK 5: Risk Register

Identify five project risks and populate a risk register.

Risk ID

RISK Category

Risk Description

Responsible

Project Title:

Using the following risk matrix calculate the risk rating

Risk ID

Risk Likelihood

Risk Consequence

Risk Rating

Project Title:

Apply a mitigation risk response strategy and provide a risk re-assessment for the five identified risks. Use the Red, Amber, Green approach to categorise the risks.

Risk ID

Description of mitigation process

Residual RISK Likelihood

Residual Risk Impact

Residual Risk Rating

Project Title:

TASK 6: Project Quality

After the opening, the Fitness Studio is facing an unexpected drop on the number of clients. Using an Ishikawa/Fishbone Diagram, identify the possible causes of this reduction. Provide at least 4 causes and 8 sub-causes.

Please use a template from the web or use the provided excel template. In both cases the diagram must be attached here.

TASK 7: Project Schedule

Referring to the one of the deliverables of Task 3 create a Gantt chart.

Please use excel, gantt software or Odoo to perform the task. The chart must be attached here.

TASK 8: Project Budget

Referring to the one of the deliverables of Task 3 create a related Budget. You can use the provided template. The chart must be attached here (you can upload one file only).

Assumptions:

Duration 1 week (each task)

Working hours 8/day

Labour cost 45$/hr

Simulate material cost, heads, travel and other costs

TASK 9: Change Request

After 6 months from the start of the project, you realised that a key task is missing. The task will deliver a significant impact in terms of scope, budget and schedule. Please provide an example and prepare a project change request. As project Manager, you will reject the proposed change: please provide a clear explanation.

Project Change Request

Issued by

Description and reason

Impact on scope

Impact on budget

Impact on schedule

Impact on the Risk Register

Change authorised:

YES

Reason:

NO

Reason:

Date

Date

Project Title:

Project Sponsor:

Project Manager:

TASK 10: Project Finalisation and Review

Hold a meeting to review the project and obtain necessary sign-offs. To do this, pair up with 2 or more students (you will each serve as a team member for the other) and your trainer (as project sponsor) and hold a PIR and project finalisation meeting. Discuss your project plan, any issues that arose in the project and project delivery and lessons learned from the project. You must upload your notes/minutes of project lessons learned and the observation checklist (below) signed by your Trainer.

Marking Guide: Meeting Observation Checklist #2

Student’s Name

Trainer or Observer’s Name

Jasmin Hill

Unit of Competence

BSBPMG522 Undertake Project Work

Date of Assessment

Location

Demonstration Tasks

Meeting

Materials and Equipment

Note-taking materials

Tasks to be observed, demonstrated or simulated

Yes

No

Comment

Did the Student attend/perform the Meeting

Did the Student effectively interact and communicate with others?

Eye Contact

Body Language

Appropriate language

Use active listening

Ask Questions

Paraphrase or Summarise

Take Minutes/Notes

Did the student cover the points outlined in the assessment guidelines for this task?

Comments

Result : S/NYS

Assessor Signature:

BSBPMG515 – March_2018

Page 13 of 13

BSBPMG522 – February_2019

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SCBCH2002 2021 ASSIGNMENT: Insulin associated diseases Insulin is a polypeptide hormone that

SCBCH2002 2021

ASSIGNMENT: Insulin associated diseases

Insulin is a polypeptide hormone that plays a key role in regulation of blood glucose. In a healthy individual, insulin is secreted as blood glucose levels rise; the rate of insulin secretion is proportional to blood glucose levels. Insulin then acts to lower blood glucose levels via diverse actions, including:

Stimulation of cellular uptake of glucose and glucose utilisation, including lipid synthesis

Inhibition of pathways that release alternative fuels (fatty acids, amino acids, ketones) so that glucose utilization is maximised

Inhibition of gluconeogenesis and glycogen breakdown, minimising release of additional glucose

Inhibition of secretion of a range of other hormones, including glucagon, cortisol, growth hormone and catecholamines (eg. epinephrine)

Stimulation of glucose uptake and utilisation was thought to be the primary mechanism by which insulin controlled blood glucose levels. We now know that the inhibitory effect of insulin, in particular reduced glucose release from the liver due to inhibition of gluconeogenesis and glycogenolysis, is more important. The mechanism of action of insulin is very complex, as shown below.

Illustration reproduced courtesy of Cell Signaling Technology, Inc. (www.cellsignal.com).

Illustration reproduced courtesy of Cell Signaling Technology, Inc. (www.cellsignal.com).

While the detailed signalling pathways depicted are outside the scope of this course, you should note that insulin signalling also promotes protein synthesis and cell growth.

This incredible complexity was summarised very neatly by the cartoonist Chuck* almost 40 years ago. We have learnt a lot since then!

(*in Kahn, CR, What is the molecular basis for the action of insulin? Trends in Biochemical Sciences, 4 (11), N263 – N266, 1979)

Diabetes mellitus, caused by insulin deficiency, is often described as ‘the most important metabolic disease of man’ and is also a significant disease in domestic animals. The International Diabetes Federation (IDF) estimated that, in 2019, worldwide:

diabetes was directly or indirectly responsible for the deaths of over 4 million people

463 million people were living with diabetes; projected to increase to approximately 700 million people in 2045

People with diabetes are more likely to become severely ill with the COVID-19 virus because (i) the immune system is compromised, making it harder to fight the virus, and (ii) the virus may benefit from an environment where blood glucose is elevated.

There are two major forms of Diabetes mellitus: types 1 and 2. Type 1 diabetes (T1D) is caused by a lack of insulin due to destruction of pancreatic ? cells, usually due to autoimmune responses; insulin replacement is always required. Type 2 diabetes (T2D) is associated with failure to produce sufficient active insulin and/ or an inadequate insulin response, also known as insulin resistance. Because T2D is a multifactorial disease, many different treatment options are available; insulin replacement may not be necessary. In humans, T1D comprises 5-10% of the diabetic population, depending on ethnicity and geographic distribution. Interestingly, diabetes in cats is analogous to T2D, but dogs typically develop an autoimmune form of diabetes, similar to T1D.

Diseases associated with insulin excess are rare, and usually involve overproduction of insulin by the pancreas due to the presence of an insulinoma (insulin secreting tumour).

The assignment

In this assignment, you will be asked to investigate one aspect of insulin associated disease in humans and animals. The number of students allocated to each topic will be restricted, as indicated on the SCBCH2002 Moodle page. Students who choose their assignment topics early in the semester will therefore have a wider choice.

Choose one of the following topics:

The majority of horses presenting with laminitis also display insulin resistance. Explain the link between laminitis and insulin resistance and discuss appropriate treatment/ management strategies.

List the signs and symptoms that would be observed in an individual with an insulinoma, explaining why each would be present. How would the individual be treated?

Summarise and discuss the scientific evidence supporting the statement that ‘dogs typically develop an autoimmune form of diabetes, similar to T1D.’

In Australia, insulin therapy for T1D involves a number of synthetic insulin analogues. Choose one analogue from the list below, describe how its structure differs from natural human insulin and discuss the reasons for, and consequences of, that structural change.

Drug name

Brand name

Insulin aspart

Novorapid or FiAsp

Insulin lispro

Humalog

Insulin glulisine

Apidra

Insulin detemir

Levemir

Insulin glargine

Optisulin or Semglee

Would a predatory animal that hunted for its own food be more or less likely to develop diabetes compared to an animal relying on canned pet food? Discuss the dietary changes that could be beneficial in a cat diagnosed with diabetes.

Many different drugs are used to treat T2D in Australia; they can be grouped into seven classes as shown below. Choose one class from the list below and explain how the drugs in this class act to aid blood glucose control. Indicate whether drugs of this class are effective alone, or whether they are more effective in combination with drugs of another class.

Biguanides

Sulphonylureas

Thiazolidinediones (Glitazones)

Alpha-glucosidase Inhibitors.

Glucagon-like peptide-1 agonists

Dipeptidyl peptidase 4 (DPP4) inhibitors

Sodium-glucose transporter (SGLT2) inhibitors

Islet cell transplantation is a prospective therapy for diabetes that is currently in the clinical trial phase. Discuss the potential advantages and limitations of this approach.

Drugs that inhibit the action of glucagon are being considered as potential therapy for diabetes. Discuss this approach.

Instructions:

Page limit:

4 pages of clearly legible font, including diagrams.

This page limit does not include your reference list

Referencing:

This assignment must be fully referenced.

Sources of information may include texts, journals and reputable web sites.

Harvard (Australian) referencing style must be used, as indicated in the Course Description.

You will find a link to the appropriate referencing guide on the SCBCH2002 Moodle site.

Assignment Marking Criteria

This assignment will contribute 20% of your total mark in SCBCH2002.

100% of the mark will be awarded based on how well you demonstrate your understanding of the topic.

Marks awarded

Clear description of insulin associated disease and/or treatment

4

Well-constructed summary of scientific evidence

12

Demonstrated understanding of biochemical principles

4

Deductions

Referencing

Use of poor-quality references

-2

Inappropriate referencing style

-2

Grammar and style

Serious flaws

-4

Marks will be deducted if:

your assignment exceeds the page limit

you do not cover the topic in sufficient depth

your writing style is poor (grammatical errors, poor spelling)

you use poor quality or inappropriate references

you use an inappropriate referencing style[supanova_question]

PULIC RELATIONS 4 Running head: PULIC RELATIONS 1 North Carolina State Laws,

Writing Assignment Help PULIC RELATIONS 4

Running head: PULIC RELATIONS 1

North Carolina State Laws, Chapter 50 B (Domestic Violence) 

Policy Field Map 

North Carolina State Laws, Chapter 50 B (Domestic Violence)

(A)

Policy Identification

North Carolina categorizes domestic violence as a crime, as it is provided in chapter 50 B. However, domestic violence only occurs whenever persons who have a personal relationship are involved in a violent act to handle their issues. As is provided in chapter 50 B, domestic violence involves the intentional cause of injury on someone or the intention of causing bodily injury (Goodmark, 2018). Elsewhere, the chapter also categorizes domestic violence as placing one’s life of the complainant or member from the aggrieved in fear of serious physical harm or harassment to the point of inflicting substantial emotional distress. In most cases, domestic violence is majorly experienced with former or current spouses, people of the opposite gender living together or once lived together, or individuals who are related as siblings or parents. In other cases, there can be people who have a common birth or those who are current household members. Domestic violence happens to people who share or once shared a common form of relationship and have something to relate with the other (Wachter, Dalpe & Heffron, 2019). Domestic violence cases in the current day have increased at a huge rate, a factor that is worrying alarming. If this issue is not well addressed, there is fear that it might become a disaster because there are more than ten cases reported about domestic violence every day in the world. In the United States, domestic violence has widely spread as it is worldwide, affecting approximately ten million victims annually (Goodmark, 2018). Women are the most affected members when domestic violence takes place as one in every four women is a victim of domestic abuse.

Institutions Related to the Policy

Among the related institutions that are affected by domestic violence, issues are the funding institutions. Whenever domestic violence occurs, there are damages made and to restore them, they require finances too. For instance, those hugely affected by domestic abuse and who require medical attention have to incur much cost as they seek medical attention. Rehabilitation and therapeutic institutions are very costly, and since they help much in helping the involved persons get helped, services must be paid, and that means patients have to withdraw their savings to have the issue well facilitated. Also, where domestic violence involves fights between the persons, chances are that property is damaged and at some point, it will require to be replaced, affecting the overall finances. In such a case, unnecessary funds are used if property damage is made, yet the funds could have been used elsewhere and more profitably. When the cases are presented in the court of law, those found guilty are charge, and this affects their financial status, yet it was something that could be avoided. In that case, the funding institutions are hugely affected, yet all these are unnecessary effects that could have been handled better.

The other institution which is affected as a result of domestic violence are the legal accountability processions. For instance, when domestic violence cases happen in North Carolina, among other places, they are subjected to the legal institutions which help settle the issue. Crime does not solve any problem; instead, it worsens the situation, and for that reason, legal authorities intervene to help solve the challenges. Due to the high increase in domestic violence cases, legal authorities have been loaded with numerous cases to solve domestic abuse (Goodmark, 2018). The number of these cases as they are handled every day affects the many other legal accountability processes since they are many and cause many inconveniences in the long run. For instance, courts have always been handling cases to do with domestic violence, and as these cases increase, they affect other cases which are on bail since they keep on pilling up. Police, on the other side as part of the legal accountability institutions, are always on their toes to address such as they happen. It becomes a challenge everyday domestic violence cases are reported, and they require to be addressed. Legal accountability has to get always involved when such cases happen because if they were reluctant to address this issue, the cases would be worse than they are today. When legal institutions help resolve domestic violence cases, they help reduce the chances and possibility of more related cases.

Service linkages capture other institutions which provide their service in helping deal with this challenge. For instance, hospitals are the other institutions that are highly involved when domestic violence cases are reported. Victims of domestic abuse that are directly and hugely affected incur much cost as well aspen much time in the health facilities as they get their help (Wachter, Dalpe & Heffron, 2019). When domestic violence involves body injury, among other serious physical harms, victims seek helps from medical facilities. Medical facilities are hugely involved in various ways because the victim might not have had physical harm but might have had psychological damages. Hence, such people would be required to attend therapeutic facilities, which greatly help deal with the trauma caused to the victims. Domestic violence causes much damage because it is done by people who should be showing love and helping through challenges but not causing any damage. That is why those involved in any form of domestic abuse have challenges in handling any other form of a close relationship. Psychological damage pierces much deeper and domestic abuse is responsible for causing such kind of harm (Wachter, Dalpe & Heffron, 2019). When the victims visit some therapeutic facilities, they are taught about the various ways of addressing challenges other than using violence. The damage which is caused by domestic violence could be avoided if those who get involved would have better ways of resolving their issues. Survivors of domestic violence confront numerous obstacles, and they need much help from health facilities because lack of appropriate attention might trigger other health challenges.

(B)

(C)

Forces in the policy field that structure the public service intervention strive to have the issues addressed with great concern since issues are getting rampant every day. Laws are put in place to ensure that those involved in these cases get punished for their actions. For instance, North Carolina chapter 50 categorized domestic violence as a crime and set various rules to govern people’s relations among themselves. The formation of chapter 50 is one factor that shows that the state so the need and addressed it before it kept worsening. Through this, there are members who are restrained from domestic violence acts because they knew the law was on the watch of their actions. Thus, in one way, the intervention of the law helped deal with this challenge, given that it set a consequence of those who would get involved in such cases.

References

Goodmark, L. (2018). Decriminalizing domestic violence. University of California Press.

Wachter, K., Dalpe, J., & Heffron, L. C. (2019). Conceptualizations of domestic violence-related needs among women who resettled to the United States as Refugees. Social Work Research, 43(4), 207-219. [supanova_question]

This assignment requires the student to identify, retrieve, summarize, and synthesize relevant

This assignment requires the student to identify, retrieve, summarize, and synthesize relevant literature focused on a specific clinical question (PICO) or project purpose agreed upon with Faculty and the immersion mentor. The assignment must use AMA format and should include a DNP Project Title, PICO question or Purpose, Problem Statement, and References. This document will be used to support the beginning of the DNP Project development. 

DNP Project Title: Identify a title that incorporates key components of the PICO Question or Purpose. The title should not include more than 80 characters. The title will often be revised prior to the Approval Meeting (Deliverable 5).

PICO Question or Purpose: A format used to guide the development of the DNP Project is the formulation of a PICO clinical question (population, intervention, comparison and outcome) or purpose. Most often the PICO question or purpose will be revised and refined by the evidence and discussions with the DNP Project Team.

Problem Statement: There are a number of resources available to guide the development of a succinct problem statement (see Moran et al., 2020, pgs. 133-135, 282-283). Please address the following six components in developing the Problem Statement:

“1. Problem identification: What is wrong with the current situation?

  2. Background: What is the nature of the problem, the context of the situation that readers need to understand?

  3. Scope of the problem: How big a problem is it; how many people are affected?

  4. Consequences of the problem: What is the cost of not fixing the problem?

  5. Knowledge gaps: What information about the problem is lacking?

  6. Proposal solution: What is the basis for believing that the proposed study would contribute to the solution of the problem?” (Polit & Beck, 2008, pg. 92).[supanova_question]

13 Topic of research: Perspective, Attitudes and Beliefs of Nurses regarding the

13

Topic of research:

Perspective, Attitudes and Beliefs of Nurses regarding the use of palliative sedation as an effective end-of-life intervention- a literature review

Introduction

Palliative care is a specialized form of nursing care that aims to provide a peaceful and dignified dying experience to the patients suffering from life-limiting illness. Even though, there have been a lot of advancement in this discipline, still there are some cases in which patient experiences immense sufferings. These sufferings are in the form of uncontrolled physical and psychological symptoms such as pain, anxiety, restlessness, breathing difficulty, agitation, and distress. In order to provide comfort and control sufferings of the patients, palliative sedation is widely used in hospitals, nursing homes and home care across the globe. Palliative sedation is defined as the administration of sedative medications (midazolam, haloperidol, morphine) to produce a decreased level of consciousness in the patients going through the final stages of their life, with the intention of enhancing comfort and providing a good and dignified death to the patients. Palliative sedation can be differentiated into various types on the basis of its usage (acute and intermittent) and dose administered (light, mild and deep). Intermittent palliative sedation can be used for temporary relief of suffering, while continuous palliative sedation is practiced until death of the patient (Ziegler et al., 2017). Even though, its usage is more common nowadays and there are various guidelines available, yet this practice is subject to ethical, legal and clinical debate.

Purpose

The purpose of this literature review is to explore nurses’ perception, attitudes and beliefs on the practice of palliative sedation as an effective end-of-life intervention.

Results

Search Strategy

Search databases such as MEDLINE, CINAHL and Academic Search Complete and major host such as EBSCO host and Cambridge Journals were used for data collection. Articles were searched in September, 2020 and to address the search criteria, PICO technique was utilized-

Population- Nurse OR Nursing staff OR Registered Nurse

Intervention- Palliative sedation OR Sedation

Comparison- Attitude OR Belief OR Perception

Outcomes- Effective end-of-life care

The search resulted in a pool of 8612 articles. Inclusion criteria and exclusion criteria were applied which resulted in 23 articles. Inclusion criteria were original peer-reviewed articles that were published in English language between the years 2011-2020. While, exclusion criteria were applied using evaluation of the abstract and title of the articles. After applying exclusion criteria, duplicate articles, concept articles, review articles, reflection and those articles that did not included nurse’ opinion were excluded. Finally the remaining 23 articles were assessed using Clinical Assessment Skills Programme (CASP) tool, on the basis of quality of research, participant size, data collection strategies, ethical consideration and presence of limitations. Using CASP criteria, those articles that scored less than 8 out of 10 were eliminated and 14 articles were selected for thorough review. The search strategy has been summarized in the flow chart below.

IDENTIFICATION

IDENTIFICATIONFlow chart representing summary of the search strategy

Search terminologies

Nurse OR registered nurse OR nursing staff

Attitude OR belief OR opinion OR perception

Palliative sedation OR sedation

Search terminologies

Nurse OR registered nurse OR nursing staff

Attitude OR belief OR opinion OR perception

Palliative sedation OR sedation

Databases/Host Used

CINHAL Complete

Academic Search Complete

MEDLINE

Cambridge Journals

EBSCO host

Databases/Host Used

CINHAL Complete

Academic Search Complete

MEDLINE

Cambridge Journals

EBSCO host

(n- 8612)

(n- 8612)

SCREENING

SCREENING

Exclusion Criteria

Duplicate Articles

Articles that did not talk about nurses’ experience of sedation

Reflection

Title and abstract not relevant to the topic

Exclusion Criteria

Duplicate Articles

Articles that did not talk about nurses’ experience of sedation

Reflection

Title and abstract not relevant to the topic

Articles including for study (n- 14)

Articles including for study (n- 14)

INCLUDED

INCLUDED

ELIGIBILITY

ELIGIBILITY

(n- 23)

(n- 23)

Inclusion Criteria

Peer-reviewed articles

English language

Topic related

Nurses’ perspective

10 years old articles

Inclusion Criteria

Peer-reviewed articles

English language

Topic related

Nurses’ perspective

10 years old articles

9 Articles that scored less than 8 out 10 on the basis of CASP score were eliminated (n-9)

9 Articles that scored less than 8 out 10 on the basis of CASP score were eliminated (n-9)

Summary of the reviewed articles

The data collected from the 13 articles can be summarized in the table below-

Author, Year and Country of origin

Study design

Data collection

Sample size and population

Analysis

Key findings

Limitations

CASP score

Anquinet et al. (2015)

[Belgium

UK

Netherlands]

Retrospective case study design (qualitative)

In-depth qualitative interviews

25 general practitioner (9 BE, 10 NL, 6 U.K) and 26 nurses (11 BE, 8 NL, 7 U.K) that were caring for 29 adult cancer patients who received continuous palliative sedation until death at home.

Thematic analysis

In Netherland and Belgium, the decision to sedate lies completely in the hands of general practitioner and nurses has no involvement in it.

In U.K, the decision to sedate is a joint decision between the nurse and GP and the practice of sedation is mostly performed by district and palliative nurses.

In all the countries, nurses felt emotional burden and ethical dilemmas while performing palliative sedation.

The study was limited to a small population of GPs and nurses and included relatively small numbers of cases and interviews.

8

Arevalo et al. (2013).

[Netherlands]

Cross sectional study (Quantitative)

Structured questionnaire

576 nurses (111 nurses working in homecare, 121 nurses working in nursing homes/hospices and 344 nurses working in hospital) that have ever been involved in the practice of continuous palliative sedation participated

Descriptive analysis

Nurses providing palliative sedation in home setting felt less involved in decision making, felt less supported, had less medical supplies and less resources and faced lower levels of family satisfaction as compared to nurses working in nursing homes and hospital. This could be because in nursing homes and hospital nurses work as a part of palliative team and felt more involved in decision making and more supported by multi-disciplinary team.

The study is limited to 23 institutions (hospitals, home care organization and nursing homes) of Western Netherland region only as random study was not possible because of unavailability of database with contact information of nurses in Netherlands.

9

Brinkkemper et al. (2011)

[Netherland]

Cross-sectional study (quantitative)

Web-based structured questionnaire

387 medical technical assistance nurses working in home care settings

Descriptive analysis

Most nurses were aware of the existing Dutch guidelines on palliative sedation and half of the nurses stated to have good or excellent knowledge about the guidelines.

One-fifth of the nurses mentioned that they refused to carry out palliative sedation as they perceived that indication by GP to be wrong or unclear.

This study only included perspective of nurses’ and does not involve opinions of other healthcare professionals involved with the procedure of palliative sedation.

8

De Vries & Plaskota (2017).

[United Kingdom]

Phenomenological study (Qualitative)

Semi-structured interview

7 hospital nurses (all females, with a median age of 43 years) who had cared for at least one patient that have underwent palliative sedation.

Thematic analysis

This study indicated that the primary goals of nurses administering palliative sedation was to provide “peaceful death” and management of refractory symptoms.

This study also explored various ethical problems faced by the nurses when providing palliative sedation as end-of-life care. These challenges were related to sedating young people, family request of initiating sedation, making medication decisions, families’ and nurses’ beliefs that palliative sedation hastens death.

Only female nurses participated in the study as male nurses might have different opinion regarding sedation.

The study is limited to a very small population of 7 nurses from the same hospital settings therefore, the result of this study does not reflect the experiences of nurses working in different healthcare settings.

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Dwyer & McCarthy (2016).

[Ireland]

Phenomenological study (Qualitative)

Face-to-face Interview

10 palliative care nurses having minimum 1 year experience working in hospital in Ireland

Thematic analysis

Study identified four themes that summarized the views of nurses. These themes were- information sharing; timing of the palliative sedation; level of sedation and palliative sedation.

In this study the nurses emphasized on the importance of gaining informed consent from the patient and family and sharing information honestly with them; importance of starting sedation at the right time (not too early and not too later); importance of giving the correct dosage and avoiding high dosage and importance of using other palliative care interventions before using sedation.

Overall nurses were in favor of good death and wanted patient to die with dignity and peacefully.

Study only presented the views of nurses that have at least one year of experience that may have limited the range of concerns that are faced by inexperienced nurses.

Other limitation is that the single setting and small size of the population limits the variations in findings.

8

Gielen et al. (2011).

[India]

Ground theory methodology (Mixed method)

Semi-structured questionnaire and face to face interview

14 physicians and 13 nurses working in different palliative-care programs in New Delhi (seven participants were female and ten were male)

Descriptive analysis

Nurses interviewed in this study believed that if pain killers and sedatives are properly titrated then administering them even in high dose (when required) is not an ethical problem.

The nurses interviewed considered mild sedation acceptable but opposed the practice of deep and continuous sedation as they argues that it may cause unacceptable side effects, kills a person socially and avoid them from having an active death by hindering in their basic daily activities.

The sample size and sources were small and limited to only one region of the country.

.

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Gielen et al. (2012)

[Belgium]

Large scale quantitative study

Questionnaire

415 nurses working in Flemish palliative care (49 male nurses and 366 female nurses)

Latent-class analysis

Majority of the nurses disagreed with the statement that euthanasia would be more considerate than palliative sedation.

Most nurses agreed that in cases of deep and continuous sedation, artificial hydration or nutrition should be not be given.

58.5% of nurses were in favor of deep or continuous sedation while 41.5% nurses were opposed of deep or continuous sedation as they believed that symptoms management should be tried to control using mild or intermittent sedation first before proceeding to continuous sedation.

The data was collected before the issuing of the palliative-sedation guideline by the Flemish Palliative Care Federation.

The study did not explored problems faced by nurses in administering palliative sedation in patient experiencing psychological distress

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Inghelbrecht et al. (2011)

[Belgium]

Two-phased large scale study (quantitative)

Questionnaire

1678 nurses working in different health settings (hospital, nursing home and home care)

Statistical analysis

In 48.4% of the case when continuous deep sedation decisions were made partly with the intention of hastening death.

Nurses reported that continuous deep sedation produced life-shortening effect in 44.4% of the cases.

Communication regarding continuous deep sedation occurred between nurses and relatives more often than between nurses and patients.

Nurses might have difficulty in recalling all the details about the patients and the communication process of the continuous deep sedation (CDS).

Study lacked details about wishes of the patients in terms of CDS practice.

Lokker et al. (2018)

[Netherlands]

Retrospective study (Mixed method)

Questionnaire followed by semi-structured face to face interview of the nurses willing to participate

36 nurses (34 female and 2 male) working in hospital, nursing home or primary care

Thematic analysis

In some situations, nurses were constrained from taking action when they felt that administration of palliative sedation was in the patient’s best interest.

Some nurses experienced pressure from family and physicians to be actively involved in palliative sedation, while they felt this was not in the patient’s best interest.

Nurses experienced moral distress when they were unable to act in patient’s best interest and felt “Powerless”

As the data collection was not aimed at gaining saturation of the topics studied, there is a possibility of missing some relevant information

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Nilsson & Tengvall (2013)

[Sweden]

Qualitative

Semi-structured interview

14 nurses (12 female and 2 male nurses) working in palliative care unit and advanced home care

Thematic analysis

Many nurses stated that they were able to influence decision and stated the importance of active participation in the decision making process regarding palliative sedation. Some nurses see palliative sedation as a part of palliative care symptom relief.

Nurses believes that media has a negative influence about the perception of palliative sedation as euthanasia.

The interviews with the nurses were short and only lasted for 15-30 minutes.

Only 14 out of the 70 nurses invited participated which was a very less response as required.

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Patel et al. (2012)

[USA]

Focus group (qualitative)

Group discussion among the recognized focus groups

9 oncology nurses, 10 intensive care unit nurses and 12 hospice nurses (total n- 41)

Thematic analysis

Nurses felt that presence of standardized policy and procedural guidelines are paramount for promoting clinical competence, enhance active participation in decision making and reduce institutional system related errors.

Administration of palliative sedation requires specialized skills including, excellent communication skills to communicate with patient, families and other care provider, accurate assessment skills, cultural competency and ability to work in teams.

The study only included nurses working in day shift, night shift nurses might have different response.

Nurses had almost same ethnicity due to which study was unable to collect opinion of other cultural groups.

Raus et al. (2014)

[Belgium]

Focus group study (qualitative)

Group discussion covering several topics and answering several questions

8 physicians and 13 nurses from a mixed healthcare settings (hospital palliative care units, hospital oncology ward, home care)

Comparative analysis

Factors as stated by nurses and physicians that promote or demote the use of continuous sedation at the end of life include- patient’s current state (nurses and physicians agreed that sedation should only be performed when the life expectancy of patient are very short 7-14days maximum and are suffering intensely), deliberation and communication (presence or absence of good communication between the patient, families and health professionals), existence and use of guidelines (existence of guidelines makes the use of CS easier) and possibility of alternative interventions

The study is not random and consisted of small population size and presented both physicians and nurses opinions.

8

Zinn & Moriarty (2012).

[Scotland]

Cross-sectional study (qualitative)

Semi-structured interview

Five hospital nurses working in hospitals in Scotland (all participants were female and had an average of 17 years of experience as a nurse)

Thematic analysis

Nurses considered palliative sedation appropriate intervention for ending refractory sufferings (total pain, terminal distress and breathlessness) in patients with limited survival time.

Nurses needs a lot of courage to discuss palliative sedation with families and face ethical implications related with this practice.

Experience, good communication skills are essential to successfully perform palliative sedation and respect patient’s dignity

Limited sample size.

Lack of diverse opinions.

Biased selection procedure- all nurses were from same hospital.

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Zuleta et al. (2018)

[Colombia]

Phenomenological approach (Mixed method)

Questionnaire (quantitative) followed by focus group discussion (qualitative)

41 nurses working in acute ward, pediatric ward, adult critical care ward, pediatric critical care ward, oncology and palliative care units of three Colombian hospitals

Descriptive analysis

Nurses had a high level of knowledge regarding the basics of palliative sedation (PS).

Nurses reported to gain basic knowledge from their experience but not from formal training.

Participants agreed that limited knowledge about the objectives of sedation therapy made them believe that they are providing damage to the patient (performing euthanasia, hastening death), caused emotional distress and caused moral dilemmas regarding appropriateness of their actions.

The study is not generalized due to its small sample size.

The study includes responses of nursing working in hospitals with palliative care units but does not reflect the responses of those nurses working in hospitals without palliative care unit resulting in limited diverse opinions.

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Discussion

Palliative sedation is indeed a very controversial topic which is indicated in the reviewed literature. Nurses’ attitudes, beliefs and opinions recognized in the reviewed literature are classified into following themes: nurses’ involvement in decision making regarding palliative sedation; palliative sedation as an intervention for controlling refractory symptoms and palliative sedation versus euthanasia. Each of the themes presents different views of nurses working in different health settings.

Nurses’ involvement in decision making regarding palliative sedation

Nurses are the stake holders in providing effective end of life care to the dying patients as they spend most of the time with patients and their families. Current literature appeals that nurses’ participation in decision making regarding palliative sedation is paramount.

No or minimal involvement in decision making

The findings of a retrospective case study on 26 nurses working in home care settings across Belgium, Netherlands and U.K revealed that in all the three countries final decision to sedate were completely in the hands of physician. Most of the nurses that participated in this study felt that they were not involved in the process of decision making (Anquinet et al., 2015). Their findings is correlated with another study that concluded that nurses working in home care felt less involved in decision making, as compared to nursing working in hospitals and nursing homes (Arevalo et al., 2013). This study was a cross sectional study which was performed on 576 nurses working in hospitals, home care and nursing homes in Netherlands (Arevalo et al., 2013). Both of the studies used excellent evidence-based data collection techniques that were in-depth interviews and quantitative questionnaire that produced large pool of data (Anquinet et al., 2015; Arevalo et al., 2013). Therefore, both the study provided diversity in opinions and were generalized to the whole population of nurses (Anquinet et al., 2015; Arevalo et al., 2013).

Involvement in decision making

Nilsson and Tengvali (2013) conducted a qualitative study on 14 nurses working in a hospital in Sweden. The study used semi-structured interviews and outcomes demonstrated that the nurses were encouraged to participate in decision making and their inputs were also considered. Nurses interviewed in this study also stated that decision making regarding palliative sedation must include patients (if possible), their families, and the multi-disciplinary team involved in caring for patient. This statement is supported by a retrospective study (mixed-methods) in which data was collected via questionnaire and semi-structured interviews. This study supports the previous study by claiming that nurses, who were a part of palliative care team, experienced less “emotional burden”, felt more supported and witnessed better communication and job satisfaction as compared to those nurses that were not a part of palliative care team (Lokker et al., 2018). Both of the studies were rich in data and used correct methodology for data collection and presentation. Still, the studies conducted by Lokker et al (2018) produced more promising results as it was a mixed-methods study.

Importance of standardized policy for effective decision making

Some articles also emphasized on the importance of using a standardized policy to guide the practice of palliative sedation (Brinkkemper et al., 2011; Patel et al., 2012). Brinkkemper et al (2011) carried out a cross sectional study using web-based structured questionnaire. This study depicted that presence of a guideline or a policy resulted in less conflict of interest between the nurses and physicians and facilitated decision making process. Similarly, another qualitative study involved group discussion amongst the participating nurses in which nurses expressed the importance of standardized policies and guidelines, stating that they enhances cultural competence, active participation in decision making and most importantly helps in preventing conflicts in the decisions based on palliative sedation (Patel et al., 2012). The former study had good amount of sample size, excellent data collection and analysis technique, however, this study was only specific to medical technical assistance nurses and did not included nurses working in other health settings. On the contrary, the later study used focus group discussion using qualitative approach. The data was excellently presented using thematic analysis. The limitation of this study was that it utilized focus group method for data collection which might not be an effective strategy as there is a high possibility that participants in the study may have influenced each other’s responses.

Palliative sedation as an intervention for controlling refractory symptoms

Palliative sedation is considered as an essential and necessary component of end-of-life care for managing uncontrollable symptoms in patients suffering from terminal illness. To support this statement, Dwyer and McCarthy (2016) conducted a phenomenological qualitative study amongst 10 hospital nurses in Ireland. Their studies produced significant results showing that all of the nurses that participated in the interview, supported the practice of palliative sedation as a treatment option for controlling physical and psychological symptoms such as pain, dyspnea, agitation, restlessness and anxiety. Their study is backed up by Zinn and Moriarty (2012), who performed cross sectional study using face-to-face interview with five female Scottish hospital nurses and shared an encouraging result that 4 out of 5 nurses believe that palliative sedation is best intervention for providing peace and dignity as it ends the suffering of patients and their families. Both studies used exceptional data collection methods and strategies, yet small sample size and lack of diversity amongst the participants limits the generalizability of the findings.

There were some studies that are in opposition of the practice of palliative sedation for management of refractory symptoms. To explore the opinions of Indian nurses and physicians towards the use of palliative sedation, the researchers conducted a ground theory methodology using questionnaire and face to face interviews (Gielen et al., 2011). Participants argued that palliative sedation is not an appropriate method for controlling pain as it still leaves the sedated patient in immense pain (Gielen et al., 2011). Not only this, another study was organized by Raus et al (2014), which included 13 nurses working in Belgium’s hospital, home care and nursing homes. This study discovered that a major fraction of participants questioned the “interpretation of last resort” and argued that there are alternatives to the practice of palliative sedation. These nurses stated that these alternatives could be use of various support therapies and interventions, such as family support, music therapy, counselling and showing more support and compassion to the patients, for management of non-physical symptoms (Raus et al., 2014). Both studies used excellent methodology for data collection and produced essential and argumentative data that were rich in quality of evidence. Nonetheless, there were some limitations associated with the studies in terms of small sample size, localized data due to which these study could not be classified as a generalized study.

Palliative sedation versus Euthanasia

There has been a lot of debate on the relation of palliative sedation and euthanasia. The findings of the studies have illustrated difference of opinion as the bulk of the literature argues that palliative sedation cannot be considered as euthanasia, while other believes that palliative sedation is directly or indirectly linked to euthanasia.

Palliative do not hastens death or produce life-shortening effects (slow euthanasia)

Gielen et al (2012) conducted a large scale quantitative study with the help of questionnaire. 415 nurses working in Flemish palliative care units participated in their study and data showed that nearly 76% of the participating nurses disagreed that Euthanasia is preferred over palliative sedation; 63.2% nurses disagreed that palliative sedation makes voluntary euthanasia unneeded and only 28.7% nurses agreed that palliative sedation intentionally shortens a patient’s life (slow euthanasia). To provide clearer picture of nurses’ perception of palliative sedation and Euthanasia some authors conducted a phenomenological study using mixed method analysis on 41 Colombian nurses and found that most of the nurses believe that media has a negative influence on the attitude of public towards palliative sedation and a misconception that palliative sedation is slow euthanasia (Zuleta et al., 2018). To support their belief, nurses states that voluntary euthanasia is defined as intentional administration of lethal drug (on patient’s wish) to end a person’s life, while on the other hand, palliative sedation is the administration of drugs such as midazolam for relieving patient’s uncontrollable refractory symptoms. Nurses also stated that if the drug is titrated properly and given in correct dose, then it doesn’t hasten or cause death (Zuleta et al., 2018). Studies conducted by Gielen et al (2012) and Zuleta et al (2018) included quantitative and mixed-methods for data collection which produces rich quality of results. The latter study used mixed-methods strategy therefore this study stood better than the former in terms of quality of findings, data collection strategies and generalizability of the data. However, both study had limitations that both studies were specific to palliative care nurses hence the opinion of other nurses were not included in the study.

Palliative sedation hastens death or produce life shortening effect (slow euthanasia)

Studies conducted by Inghelbrecht et al (2011), indicated that out of total 250 cases of palliative sedation, in 48.4% of the case, palliative sedation decision were made to hasten the death (“slow euthanasia”) while in 44.4% of the case, palliative sedation produced life shortening effect. It was a quantitative study conducted using questionnaire that was distributed to 6000 nurses all across Belgium, however only 1678 nurses participated, this low response is a major drawback of this study as the questionnaire were not distributed correctly. But being a quantitative study including responses from different discipline of nursing across the country, the findings were generalized, unbiased, had variations in opinions and rich statistical values. Not only this, a qualitative study conducted on seven British nurses using semi-structured interview, discovered that nurses experienced ethical dilemmas especially when administering high dosage and thought of palliative sedation as the cause of death. The advantage of this study is that being a qualitative study, it was able to collect rich information. This data was excellently processed and published using thematic analysis. The only limitation of this study was that it is a biased and non-generalized study. These findings were relevant in support of the arguments against the practice of palliative sedation.

Conclusion

This review summarized the attitudes of nurses surrounding the use of palliative sedation in patient suffering from terminal illness. Ethical as well as clinical issues surrounding this practice were discussed. Complex and varying opinions of nurses in terms of decision making, justification of palliative sedation and correlation of palliative sedation were discussed in the reviewed literature. Most nurses believed that nurses felt involved in the decision making process, felt that palliative sedation is an essential intervention for relieving uncontrollable symptoms and felt that palliative sedation is not intended to promote euthanasia, however, variations from these belief were also observed in the current literature. Almost all of the studies concluded with a recommendation that education and training, presence of standardized guidelines, effective communication and need to explore alternatives (psychological and spiritual) is crucial for providing high quality, safe and patient-centered palliative sedation practices.

References

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Ankit Bhardwaj

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