Application of Course Knowledge in Advanced Practice Nursing

Questions
Application?of?Course?Knowledge: Answer all questions/criteria with explanations and detail.
·   
a.  Describe one source of big data that you are likely to use in your future advanced practice nursing role.  
b.  Identify the types of information that can be obtained from this source.  
c.  Examine three ways data from this source can be used to impact client care. 
d.  Discuss the role of the advanced practice nurse in data stewardship. 

Answer
1. Source of Big Data in Advanced Practice Nursing
The last source is the data collected from wearable devices. Wearable devices are electronic tools that can be worn on the body. Often, these devices have sensors attached to them and can be connected to the internet to transfer data. The big data source that comes out from wearable devices is very broad and varies from device to device, but it includes all information about a person’s health, from lifestyle to vital signs and even location. The purpose of this data collection is to make the user self-aware about their own health, and the data can be shared with healthcare providers to constantly keep track of the patient’s condition. The use of these devices is increasing mainly due to the evolution of smartphones and the simplicity to make the devices compact and user-friendly. APN can use this data to constantly monitor the patient’s condition from home, and in the long term, can assess if by using the device, the patient’s health outcome increases.
Another source is Clinical Decision Support Systems (CDSS), which is a computer program designed to help clinical decision making. It accomplishes this by taking data from the patient, combining it with available knowledge, and providing possible courses of action. CDSS is designed to help clinical decisions in which arriving at a single well-accepted answer is difficult. It usually aids in patient assessment, forming a diagnosis, and selecting therapy. These systems are usually based on a knowledge base that can be created from various sources, including medical journals, expert opinions, etc., and it also uses an inference engine method to provide the user with a solution. CDSS has shown high potential in improving healthcare quality and reducing costs. It can also be used in managing chronic diseases and reducing adverse events that usually occur in the medication process. APN can use the big data from CDSS to correlate the clinical decisions made and the patient’s outcome to show if CDSS really improves patient care and to improve the CDSS itself.
There are three sources of data which are the EHR, CDSS, and wearable devices that serve as a new method of APN to collect various data in formulating a clinical decision. Big data in Electronic Health Records (EHR) refers to the vast data on patients that includes demographic information, medical history, medication, etc. that can be managed and reviewed systematically. It also provides a tool for clinical quality and performance measures to improve healthcare. APN can use EHR data to measure and report healthcare quality and outcomes, to analyze patient safety, to compare the effectiveness of different treatments, etc. and it can also help in developing a clinical practice guideline that will lead to evidence-based practice to improve patient outcomes. In the long term, the guideline will be assessed and refined in a continuous cycle. EHR assists in the progression toward improved care, improvement in the health of the population, and lower healthcare costs.
1.1 Electronic Health Records (EHR)
The source of data when relating EHRs to nursing comes from the information that is put into EHRs by the patient or the family of the patient. Data also comes from the patient’s visits to healthcare facilities. EHRs help improve patient care because they can contain the information that was collected in multiple care settings, assisting the coordination of care provided by nurses and other healthcare professionals. For example, if a patient has visited the emergency room multiple times for one issue, all the information from these visits will be contained in one place in the EHR. This will prevent the patient from receiving the same treatment multiple times and increase the probability of diagnosing the problem.
An electronic health record (EHR) is defined as the “systematized collection of a patient’s health information in a digital format.” This includes a variety of types of data, including demographic, medical history, medication and allergies, immunization status, laboratory test results, radiology images, and vital signs. They are real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs have the potential to access the record simultaneously and independently, increasing accuracy of diagnoses. This, in turn, increases patient safety and the overall quality of care. EHRs help with diagnoses and treatments made by healthcare providers. With the patient’s overall information available, providers are able to determine, based on statistical data, what the best diagnosis or treatment plan should be. This has the potential to increase the cost-effectiveness of the treatment, enhancing the healthcare that patients receive. With the large amount of information available in EHRs, they encourage better management of chronic diseases by detecting the warning signs and ensuring patients receive the appropriate treatments.
1.1 Electronic Health Records (EHR)
1.2 Clinical Decision Support Systems (CDSS)
Clinical decision support systems have been in use for more than 30 years (Kawamoto et al., 2005). However, they are only now beginning to take hold in healthcare. CDSS can take the form of “active”, meaning the system solicits the user with inferences and recommendations, or “passive”, meaning the system waits for the user to access it for support (Delpierre et al., 2004). Most are integrated into EHR systems and provide assistance in making clinical decisions by filtering knowledge and patient information to offer the best possible assessment and plan (Kawamoto et al., 2005). Data mining with CDSS makes use of algorithms to search databases and form patterns, generating information which was not previously known (Greene et al., 2014). At present, the most widely used CDSS applications are for preventive care and chronic disease management. However, they are underutilized in medical oncology compared to other fields and have been shown to improve adherence to guidelines and potential outcomes (Tolbert et al., 2013). CDSS align with the nursing process and best practices by providing assessment of the patient, diagnoses, identification of outcomes, planning, and implementation. The WHO has described this as the key to quality care and the gold standard within the information age. This attribute to evidence-based practice should enable greater use of structured data collection techniques and documentation at the point of care, thereby enhancing the quality of big data from said encounters.
1.3 Wearable Devices
Health informatics professionals have been especially successful in developing wearable devices which monitor health status and health behaviors continuously in real time in an efficient and non-invasive manner. Wearable devices have been categorized into two types: those which are worn on the body, which has been further subcategorized according to the body part, and smart accessories (smartphones). They are designed to measure certain health parameters and behaviors valuable to the maintenance of health and management of chronic conditions. Examples of these health parameters and behaviors include heart rate, blood pressure, body temperature, physical activity, eating, and sleep patterns. The data collected from wearable devices has been referred to as quantified self data, defined as self-knowledge through self-tracking with technology. The term was coined by scholars from the Quantified Self community, an international collaboration of users and makers of self-tracking tools who share an interest in self-knowledge through self-tracking. Wearable devices provide multiple forms of big data using both structured and unstructured data, thus offering vast potential to improve patient outcomes through health data analysis, enhanced clinical decision-making, and improved patient engagement.
2. Types of Information Obtained from the Source
2.1 Patient Demographics
2.2 Medical History
2.3 Vital Signs
2.4 Laboratory Results
2.5 Medication Records
3. Impact of Data on Client Care
3.1 Personalized Treatment Plans
3.2 Early Detection of Health Issues
3.3 Improved Clinical Decision Making
3.4 Enhanced Patient Safety
3.5 Efficient Resource Allocation
4. Role of Advanced Practice Nurse in Data Stewardship
4.1 Ensuring Data Privacy and Security
4.2 Data Collection and Analysis
4.3 Collaborating with Interdisciplinary Teams
4.4 Implementing Evidence-Based Practice
4.5 Continuous Quality Improvement

Barriers to Effective Care Coordination and Proposed Solutions

Questions
Barriers to Effective Care Coordination:
Identify and explain at least 3 major barriers that can hinder effective care coordination for chronic conditions.
Examples:
Fragmented healthcare systems with limited communication channels between providers.
Lack of patient engagement and understanding of their care plan.
Socioeconomic disparities impacting access to healthcare resources and technology.
Propose solutions to overcome these barriers and create a more coordinated care system.

Answer
1. Fragmented healthcare systems
Effective coordination requires good communication between those involved, so limited communication channels between providers can act as a major barrier to coordination. Communication can be limited in a number of ways, the most simple being the inability to contact a specific individual. This was a common issue witnessed by the author while on a GP attachment. Secretaries often did not take messages from other healthcare providers or would take a message and not pass it on. Email contacts between providers are rarely available, and faxing is now outdated. Phone calls between providers are, of course, a good way of communication. However, without a direct line to the individual, the call is often lost. The use of voicemail is not an effective form of communication.
1.1 Limited Communication Channels
Healthcare systems have areas of specialization divided amongst different providers. This can lead to a patient receiving care from multiple providers within the same health issue, resulting in duplication of tests, uneven care provided, and varied outcomes. Patients with complex needs and chronic diseases often require treatment from multiple providers and specialties. Coordination of care for these patients is often inadequate due to the division of specialization among providers (James, 2003). Effective coordination is an essential component of good healthcare delivery and can be defined as the deliberate organization of patient care activities between two or more participants involved in a patient’s care to ensure that it is safe, efficient, and cost-effective. Coordination can be complex, involving tasks from different individuals across varying facilities and specialties (Gittell et al., 2000).
Introduction to Fragmented Health Care Systems
1.1 Limited communication channels
Providers in hospitals do not receive timely information about the discharge of their patients from the hospital or consultations with specialists. The quality and completeness of clinical information available at the time of a consultation was also identified as a problem, as well as difficulties in obtaining further information from hospital doctors. Changes in patients’ medications were often unclear and undocumented. General practitioners reported that they often had to admit patients to hospital because they could not obtain the medical or paramedical support necessary to sustain them at home or in a residential care facility. In some cases, hospital doctors would not accept patient referrals. These access block problems were perceived by general practitioners to be due in part to public and/or private hospital specialists having waiting lists of their own private patients, and being less inclined to treat public patients. Failure to provide follow-up treatment advice to referring doctors was described as a disincentive to further referrals. In mental health services, the lack of a booking system for patient appointments often complicated the task of arranging specific follow-up treatments. Most of New Zealand’s new health initiatives involve some level of care coordination from primary and community care. Examples include early discharge schemes, health of the older person and disability services programs, needs assessment and long-term care following the closure of hospital beds and the shift of a wider range of medical and surgical treatments from secondary to primary care. At present the potential gains of these initiatives are often not fully realized because they are not underpinned by improved communication and coordination with secondary care services. In some cases primary care doctors have been forwarded discharge and treatment change information for their patients months after the event, and because there is often no guarantee that hospital services will re-accept referred patients, primary care teams may give up on attempts to obtain further services that their patients still require. A lack of clear communication and understanding between the providers of secondary and primary care has also meant that some of the changes to service delivery described in the Introduction have occurred in a way that is ad hoc and unplanned.
1.2 Lack of information sharing
Virtual care coordination (e-health) has become more and more common, and is the use of IT services to plan and manage patient care. Most advances are in web-based, patient-to-provider cases, as they are easy to schedule, document, and revise. These cases have maximum coordination, but think about a patient who needs to see a specialist or get a procedure done. The patient instance again has much coordination with a defined specialist and a procedure time, but these cases are not easily transferable between different sectors of the health care system. He currently still has to fax or email procedure details, with possible drug specifications to his private practice proceduralist, which is basically less than a handoff, so this information could get lost or missed in potential coordination to a follow-up case.
The main issue with destroying the concept of an effective care coordination is that although there are several different forms of care coordination, most cannot be accurately displayed or compared to the traditional method of physician to patient, and the vegetative and emergency cases. Most of this essay is based around the transfer of information from one health care system to the next, and across the broad spectrum of managing the case. Care coordination has shifted to a multidisciplinary team effort over the past decade. The concept of care coordination is taking health care out of the passive mode and the linear patient to provider model, to design patient cases with an emphasis on preventing medical mistakes and anticipating potential setbacks.
1.3 Inadequate coordination between providers
Changes are needed to ensure the right type of coordinated mental health care is provided. For this to happen, mental health specialists must define in common terms what successful coordination will look like. It is too easy to say that coordination is occurring when a patient is seen by various providers in the same agency. Measures of coordination often involve event monitoring and evaluation of treatment effectiveness on the part of the patient and involved providers. Successfully coordinated care will result in a greater effectiveness of simpler treatments in the primary care setting and less need for referral to severe psychiatric medication management. With better measures of successful coordination, it will be possible to reward managed care organizations and provider groups that are coordinating mental health services and more effectively treating mental health patients.
Inadequate coordination between healthcare providers can adversely affect patient care. A healthcare provider may recommend different medications or a treatment course that interferes with treatment priority or diagnosis from another provider. Recommendations for, but no direct referrals to, psychological evaluation or therapy can be interpreted as stigmatizing patients and result in less motivation to follow a treatment course. Patient non-adherence is common in this chaotic healthcare system scenario, as patients often feel confused about proper treatment and may not believe therapy treatment will be effective. Then healthcare providers may misinterpret non-adherence as resistance rather than a problem with access and coordination, resulting in further exacerbating mental health problems. This lack of coordination for mental health treatment is in stark contrast to the care coordination in primary care and general medical settings.
2. Lack of patient engagement and understanding
2.1 Limited health literacy
2.2 Insufficient patient education
2.3 Ineffective communication with patients
2.4 Non-adherence to care plans
3. Socioeconomic disparities impacting access to healthcare resources
3.1 Financial barriers
3.2 Limited availability of healthcare facilities
3.3 Inadequate transportation options
4. Technological challenges in care coordination
4.1 Lack of interoperability between systems
4.2 Inconsistent use of electronic health records
4.3 Limited access to telehealth services
5. Proposed solutions for fragmented healthcare systems
5.1 Implementing care coordination platforms
5.2 Enhancing communication channels between providers
5.3 Establishing care teams and care coordinators
6. Proposed solutions for lack of patient engagement and understanding
6.1 Improving health literacy programs
6.2 Enhancing patient education materials
6.3 Promoting shared decision-making
6.4 Utilizing digital health tools for patient engagement
7. Proposed solutions for socioeconomic disparities
7.1 Expanding access to affordable healthcare services
7.2 Implementing transportation assistance programs
7.3 Addressing social determinants of health
8. Proposed solutions for technological challenges
8.1 Advancing interoperability standards
8.2 Encouraging widespread adoption of electronic health records
8.3 Expanding telehealth infrastructure and reimbursement policies

Cardiac and Respiratory Dysfunction Prevention and Improvement

Questions
Identify a cardiac or respiratory dysfunction and its cause. Outline the key steps necessary to prevent the dysfunction and improve health status.
Answer
1. Introduction
The heart and lungs are two vital organs in the body that work together to sustain life. The heart pumps blood, which carries oxygen, to all parts of the body. The blood then returns to the heart, so it can be pumped to the lungs to receive oxygen. Finally, the oxygen-rich blood is pumped back to all parts of the body. The heart is made up of specialized cardiac muscle, which does not become tired. The lungs are responsible for providing the oxygen and removing carbon dioxide. When the heart or lungs malfunction, it causes a decreased quality of life and can be life-threatening. Cardiac and respiratory dysfunctions lead to a decreased quality of life where a person may have difficulty completing everyday activities, such as climbing stairs, cleaning, grocery shopping, and taking care of their family. During severe dysfunction, a person may not be able to care for themselves and they may need to spend a lot of time and money on healthcare. Some dysfunctions can be life-threatening, for example, congestive heart failure or acute respiratory distress syndrome. Any therapy or lifestyle changes that can prevent or improve these dysfunctions can greatly increase the quality of life for that person and even be life-saving. Cardiac and respiratory disease is the leading cause of death in the United States. According to the American Heart Association, 8,100,000 people have a heart attack or angina. There are almost 650,000 cases of heart failure diagnosed each year, and it is the only cardiovascular disease that is increasing in incidence. The AHA estimated that the cost for heart failure in 2008 was 34.8 billion dollars, and by 2030 this will increase to 98.1 billion. With the statistics so high, it is important to further develop techniques to prevent and improve cardiac and respiratory dysfunctions.
1.1. Overview of Cardiac and Respiratory Dysfunctions
Cardiac dysfunction usually refers to the heart’s inability to maintain adequate blood circulation to meet the body’s needs. In an ideal situation, this would occur during both rest and activity. There are many different types of cardiac dysfunction including heart failure, cardiac ischemia, and arrhythmias. Respiratory dysfunction refers to inadequate gas exchange, and can be due to either inadequate ventilation or perfusion. Respiratory failure occurs when gas exchange is so poor that it does not meet the body’s metabolic demands, whereas respiratory insufficiency is a state in which there is a significant decrease in gas exchange that does not meet the body’s metabolic demands. Similar to cardiac dysfunction, respiratory dysfunction can occur during rest or during activity.
Cardiac and respiratory dysfunctions occur for a variety of reasons and in response to numerous stimuli. In order to understand how and why dysfunction occurs, it is useful to first understand the normal process of cardiac and respiratory function. Dysfunction of one system often leads to dysfunction of the other, and in fact it is hard to isolate one system from the other.
1.2. Importance of Prevention and Improvement
Prevention of the initial development of heart and lung diseases through treating the risks and underlying pathophysiological processes is obviously an effective strategy. Most cardiac and lung diseases are caused or made worse by modifiable lifestyle and environmental factors. Hypertension, dyslipidemia, and diabetes have a multiplicative effect on the risks of cardiac failure and stroke, and due to their high prevalence in the population, effective treatment of these conditions would prevent a large number of cardiac events. Randomized controlled trials have shown that management of cardiovascular risk factors in hypertensive and diabetic patients can be effective in terms of reducing cardiac events, with and even without reduction in blood pressure or glucose levels.
The idea of prevention and improvement is something that is not only important, but imperative in the context of cardiac and respiratory dysfunction as it is exactly the strategies that are needed to take the pressure off ailing health systems worldwide. Acute care for decompensated major chronic or acute cardiac and respiratory disease is consuming large amounts of healthcare expenditure in western countries. In Australia alone, heart disease costs $5.9 billion per year, and lung diseases cost $2.5 billion. By focusing on prevention and quality improvement, hospital care could be reduced substantially, freeing up funds for other resources, as well as achieving further benefits to patients. Primary and secondary prevention are integral parts of improving patient outcomes and are necessary to reduce the growing prevalence of cardiac and respiratory diseases.
2. Understanding the Dysfunctions
2.1. Causes of Cardiac Dysfunction
2.1.1. Coronary Artery Disease
2.1.2. Hypertension
2.1.3. Heart Valve Disorders
2.2. Causes of Respiratory Dysfunction
2.2.1. Chronic Obstructive Pulmonary Disease (COPD)
2.2.2. Asthma
2.2.3. Lung Infections
3. Preventive Measures for Cardiac Dysfunction
3.1. Regular Exercise
3.2. Balanced Diet
3.3. Stress Management
3.4. Smoking Cessation
4. Preventive Measures for Respiratory Dysfunction
4.1. Avoiding Environmental Triggers
4.2. Proper Ventilation
4.3. Vaccinations
4.4. Avoiding Smoking and Secondhand Smoke
5. Improving Cardiac Health
5.1. Medications and Treatment Options
5.2. Lifestyle Modifications
5.2.1. Healthy Eating Habits
5.2.2. Regular Physical Activity
5.2.3. Stress Reduction Techniques
5.3. Cardiac Rehabilitation Programs
6. Improving Respiratory Health
6.1. Medications and Treatment Options
6.2. Pulmonary Rehabilitation Programs
6.3. Breathing Exercises
6.4. Airway Clearance Techniques
7. Conclusion

Case Study Analysis: Patient Care Coordination for Chronic Conditions

Questions
Case Study Analysis:
Choose a specific chronic condition (e.g., diabetes, heart disease, asthma).
Identify a case study of a patient with this chronic condition.
Analyze the strengths and weaknesses of the patient’s current care coordination plan.

Answer
1. Introduction
At present, there is an increasing number of people with chronic diseases. The evidence for this claim is in the 133 million Americans, or almost 1 in 2 adults, living with a chronic condition, and this figure is predicted to increase by more than 30% between 2000 and 2020 to 157 million with 81 million having multiple conditions. Projections suggest that chronic diseases will account for three-fourths of the total health care costs in 2023 – more than $4 trillion (Saint T, et al 2000). Chronic diseases are health problems that require ongoing management over a period of years or decades. They include, among others, arthritis, asthma, cancer, COPD, cystic fibrosis, diabetes, cardiovascular disease, and any form of mental retardation. A recent survey identified a total of 139 million Americans living with these diseases. These chronic conditions impact the lives of the people affected in many different ways. In 2000, the Surgeon General’s report on health and behavior revealed that 22% of people living with chronic diseases had limitations in daily activities compared to 3% of those without a chronic condition. People living with chronic condition are also at risk of dying prematurely. It has been shown that 90% of Americans’ annual deaths are caused by chronic diseases and 77% of employer costs are due to productivity losses in employees with chronic conditions. Healthcare providers have also been alerted to pay special attention to their patients living with a chronic condition. In 1998, the National Health Interview Survey (NHIS) reported that 70% of visits to a doctor’s office involved treatments for people with one or more chronic condition. With a large population affected by chronic diseases, care coordination is fundamental in assisting individuals to manage their conditions and improve their overall quality of life. Care coordination is a process that encompasses a wide array of functions and services that help patients with chronic conditions manage their health. Coordination involves organizing patient care and involves information sharing and communication between all participants concerned with a patient’s health to achieve safer and more effective care. Primary care physicians and patients play central roles in care coordination. Information from The Commonwealth Fund analysis in the Tri-Annual National Survey 2007 reported that patients with chronic conditions receive better care from primary care physicians versus specialists. Primary care physicians also report that chronic care management is one of the most challenging aspects of their job. This indicates that care coordination efforts need to improve in linking the efforts of generalists and specialists for patients living with chronic conditions. Improved care coordination ensures that the patient’s needs and preferences for managing their chronic condition are met and that healthcare decisions are agreed upon and followed by the patient. Coordination also supports the self-management of patients to become more involved with their care and in turn achieve clinical and personal goals they have set to improve their overall health. With these points in mind, this paper is centered on the case analysis of a patient named Clarence, living with diabetes, and the coordination efforts between healthcare providers to improve his health outcome.
1.1. Background of the Chronic Condition
Chronic diseases can be difficult to manage. They often need a lot of health services to manage their condition. This is what we call coordination of care. Coordination of care is a fragmented and an ad hoc enterprise with little standardization from patient to patient. Good, clear communication is key to effective care coordination. This is often lacking between primary care physicians and specialists, as well as between these providers and the ancillary services that play such a large role in managing chronic disease, such as pharmacies and laboratories. The way care is often managed and coordinated across the primary and specialty care settings, hospitals, home health agencies, and nursing homes provides an array of dangerous pitfalls for the patients and is an inefficient and expensive way to manage chronic disease. The case for this patient is all too common. This elderly patient has several chronic medical problems: congestive heart failure, hypertension, diabetes, and chronic kidney disease. The plethora of medical issues alone can create its own fragmented care and care coordination impaired by the individual concerns of each specialty involved in this patient’s care. As we detailed the patient’s experience throughout the hospitalization and elegant discussion of the pros and pitfalls of each stage of this patient’s care, it became clear that the systems currently in place provide many obstacles to effective care coordination. Good communication between providers with regard to the patient’s wishes and prior discussions about the care plan is an essential early stage in caring for a patient with chronic disease. Often the patients are not always clear to the physician about their own wishes, and many patients with multiple specialty involvement may have conflicting plans on how to address various issues in their health. This is an instance in which medical decision making becomes complex and difficult. Often a decision on paper A cannot be effectively communicated to provider B. Occurrences like this can lead to the patient’s avoidance of hospitalization for re-admission for an episode of heart failure symptoms.
1.2. Importance of Care Coordination
Care coordination is important to avoid gaps, overlappings, and delays in delivering the care that we need. Coordination may avoid, for example, conflicting treatments among our specialists or duplicate tests. Information is passed on about our needs and the activities of all the people involved in our care. With good information and a clear plan, the activities of the different people involved in our care are more structured and productive. Any changes in our health or the way we are managing our health problem are monitored, and the care plan is revised as necessary. In contrast, without effective care coordination, it is left to us to tell different health professionals what other health professionals are doing for us. We and our family members are forced to understand and keep track of the care that we are receiving and to recognize when it is not going well. Oftentimes, healthcare providers are not even informed about certain treatments or tests that the other providers have ordered. Good care coordination can prevent such burdens on patients and communication errors among providers. Information about changes in the patient’s health can fall through the cracks, with the result that no one takes responsibility for revising the care plan. A chronic care patient’s best choice among treatment strategies may not be considered because different providers are acting independently and no single professional takes responsibility for synthesizing the opinions of the various specialists involved.
2. Case Study Overview
2.1. Patient Profile
2.2. Description of the Chronic Condition
3. Current Care Coordination Plan
3.1. Care Team Composition
3.2. Communication and Information Sharing
3.3. Care Plan Implementation
3.4. Monitoring and Follow-up
4. Strengths of the Current Care Coordination Plan
4.1. Effective Communication Channels
4.2. Comprehensive Care Plan
4.3. Regular Monitoring and Follow-up
5. Weaknesses of the Current Care Coordination Plan
5.1. Fragmented Communication
5.2. Lack of Patient Engagement
5.3. Inadequate Care Plan Updates
6. Opportunities for Improvement
6.1. Enhanced Communication Strategies
6.2. Patient Education and Empowerment
6.3. Integration of Technology
7. Recommendations for Care Coordination Enhancement
7.1. Strengthening Interprofessional Collaboration
7.2. Implementing Patient-Centered Approach
7.3. Utilizing Health Information Exchange
8. Conclusion

Chest Pain and Differential Diagnosis

Question
Submit a research paper in APA format regarding Chest Pain and Di8erential Diagnosis. The student is to pick any three (3) di8erential diagnoses that can be associated with chest pain and their approach in various clinical settings. Research paper due in week 5. See Rubric below Include the following components in your research paper: 1. Title Page 2. Introduction (general) 3. Mention research studies (at least three articles) that validate the information presented in your paper. (Publication date should be no more than five (5) years old). 4. Conclusion 5. References Page Criteria Rating Points Exemplary
Answer

1. Introduction
Differential diagnosis of chest pain is particularly difficult because of the variety of potential causes. It is generally assumed that the more severe the symptoms, the more serious the underlying condition, and thus the differential diagnosis tends to focus on life-threatening cardiac and non-cardiac causes. This is particularly the case in patients with acute onset of severe chest pain and/or other symptoms suggestive of myocardial ischemia. A working knowledge of cardiac and respiratory anatomy, together with an understanding of referral patterns from different regions of the chest, are valuable in formulating a differential diagnosis. This can then be refined by further history and examination; for example, the character and timing of the pain and any exacerbating or relieving factors. With acute pain, it may, however, be difficult to determine these features, and the patient may be too ill to provide a reliable history. In some cases, therefore, the history and examination may serve only to determine the severity and stability of the patient’s condition.
Chest pain is a symptom that is frequently encountered in the practice of emergency medicine. It may present with a variety of clinical conditions ranging from life-threatening diseases to benign ones. On the other hand, differential diagnosis involves differentiation of a condition from others which presents in a similar manner. Failure to do this frequently results in misdiagnosis of the condition, resulting in improper treatment. The aims of the differential diagnosis of chest pain are to exclude life-threatening conditions, determine the underlying cause of the symptoms, and find an accurate diagnosis. This may not always be achieved, and thus a unifying diagnosis is made when no specific organic etiology can be identified. This text will discuss the differential diagnosis of chest pain, working through the acute and chronic cases.
1.1. Definition of Chest Pain
Chest pain is one of the most common symptoms that bring an individual to the emergency department, outpatient clinic, or primary care office. While the majority of patients with chest pain do not have a serious illness, those who do are at risk of significant morbidity and mortality if not diagnosed and treated promptly and effectively. An efficient and directed approach to the patient with chest pain relies on a good understanding of the underlying pathophysiology of the various disease processes that may cause chest pain. It is also important to recognize that atypical presentation of a disease is more common than typical presentation. The mechanism of chest pain can be varied; from simple musculoskeletal discomfort to a life-threatening cardiac or pulmonary event. Chest pain is often categorized into cardiac and non-cardiac causes. However, it is perhaps more useful to classify the pain by the underlying mechanism. This approach allows a better understanding of the disease process and is more clinically relevant, especially as musculoskeletal and gastroesophageal chest pain can often mimic cardiac pain.
1.2. Importance of Differential Diagnosis
Non-cardiac chest pain (CP) can be defined as chest pain emanating from the chest that does not originate from the heart. This seems like a simple enough definition to understand, but in practice, it can be quite the opposite. The term “non-cardiac chest pain” seems to imply that it is chest pain that is not originating from the heart. This would lead one to believe that the origin of pain is musculoskeletal or that of a psychological cause. However, non-cardiac chest pain is defined by intent. It is chest pain that is free of known cardiac cause. This is an important concept to understand. There are many patients that suffer from CP that, in reality, is of known non-cardiac cause. One simple example is a patient with chest wall pain from a viral illness. Often times, this patient will undergo extensive testing or even unnecessary time admitted to the hospital because a cardiologist wants to rule out cardiac cause of the chest pain. A more serious example is the patient who is diagnosed with GERD that is confronted with an atypical presentation such as angina and is hospitalized with suspected unstable angina or MI. The term “non-cardiac chest pain” can sometimes lead to incorrect assumptions and thus lead to unnecessary testing or potentially harmful treatments for the patient’s true underlying cause of CP.
2. Common Causes of Chest Pain
2.1. Coronary Artery Disease
2.2. Gastroesophageal Reflux Disease
2.3. Pulmonary Embolism
2.4. Musculoskeletal Causes
2.5. Anxiety and Panic Disorders
3. Approach to Differential Diagnosis
3.1. History Taking
3.2. Physical Examination
3.3. Diagnostic Tests
3.3.1. Electrocardiogram (ECG)
3.3.2. Chest X-ray
3.3.3. Echocardiography
3.3.4. Stress Testing
3.3.5. Laboratory Tests
4. Differential Diagnosis 1: Coronary Artery Disease
4.1. Risk Factors
4.2. Clinical Presentation
4.3. Diagnostic Approach
5. Differential Diagnosis 2: Gastroesophageal Reflux Disease
5.1. Pathophysiology
5.2. Clinical Features
5.3. Diagnostic Evaluation
6. Differential Diagnosis 3: Pulmonary Embolism
6.1. Pathogenesis
6.2. Signs and Symptoms
6.3. Diagnostic Workup
7. Clinical Settings for Differential Diagnosis
7.1. Emergency Department
7.2. Primary Care Clinic
7.3. Cardiology Clinic
8. Research Studies on Chest Pain and Differential Diagnosis
8.1. Study 1: Title and Findings
8.2. Study 2: Title and Findings
8.3. Study 3: Title and Findings
9. Conclusion
10. References

Chinese Army Unit 61398 as an Advanced Persistent Threat

Question

Answer
1. Introduction
The question is emerging about why detection and prevention of APTs was so low in 2013. The low detection is happening because target industries lack the capability to detect APT activities. APT attackers have high skill to cover up their activities and delete traces, making it hard to detect. Another reason is that the capabilities of traditional security measures such as anti-virus, intrusion detection and prevention, and firewall are not enough to detect and prevent APT. The existing security measures are only capable of detecting known attacks and malware, whereas APT attackers are using new malware and attack methods to compromise the target efficiency. Known malware and attack methods are actually still of minor use. This is what happened to Coca-Cola. Even though they have an information security program and traditional security measures, these are not enough to prevent their information from APT attacks. In 2009, Coca-Cola detected an APT attack plot on their networks. The attacks involved a group of hackers who were using advanced malware and remote system administration tools to gain unauthorized access to Coca-Cola’s network and affect the company’s operations. These APT attackers were trying to build persistence to stay within Coca-Cola’s network and steal sensitive information for a long time. But unfortunately, from 2009 to 2012, Coca-Cola lost its sensitive files to APT attackers. The results of forensic investigation on data stored in Coca-Cola’s breached systems have found that the malware had already deleted traces and the attackers had cleaned the remote administration tools. This investigation was conducted after Coca-Cola received reports of its sensitive files being copied by malware to unknown locations. In this case, migration of data from a well-known location, the unusual deleted file evidence, and support from reports can be indications of APT attacks.
1.1 Definition of Advanced Persistent Threat
Although the term “advanced persistent threat” has been popular since the early 2000s, it actually dates back to 2006. It is widely believed that the origin of the term APT comes from the United States Air Force. It is thought that they were the first people to use the term to describe a specific type of cyber threat. This belief is strengthened by a quote from a Lt. Col. Greg Rattray in 2009 stated, “The Airforce, by 2006, had identified the complete process of an advanced threat.” This quote shows that by that year they had a complete understanding of the processes and life-cycle of APT.
APT should not be confused with the term AET (Advanced Evasion Technique) which was proposed by network security firm Stonesoft. AET refers to means and methods that penetrate and exploit IT network vulnerabilities, while effectively evading network security systems, appliances, and controls. The AET attacks are the delivery and exploitation phase in the Cyber Kill Chain SM, the APT is the overarching structure and framework for the entire cyber kill chain.
An advanced persistent threat (APT) is a wide-ranging, sophisticated, sustained, and targeted attack against a specific group of people with the aim of achieving a specific agenda. An APT attack includes a number of different steps and a lot of different techniques often spanning a long period of time (such as several months or years). Anti-forensics methods, such as attempts to delete or alter log files, and false data injection, can also be and are often used in APT attacks, increasing the difficulty and complexity of detecting the attack and attribution.
1.2 Overview of Chinese Army Unit 61398
Chinese Army Unit 61398 is a cyber-warfare information operations unit of the People’s Liberation Army (PLA) of China. Though there is no public information about this unit’s numerical designator, it is commonly referred to by the identifier “61398”. Analysts have confirmed that APT activity surrounding Operation Shady RAT is being conducted using the resources of 61398, and APT attacks are traced back to infrastructure around Shanghai. It is unknown how many people work for 61398, but the number is suspected to be quite large and most likely staffed by a variety of military and civilian personnel. This is deduced from the sheer number of English-speaking APT operators observed online in Operation Shady RAT data who may or may not be native English speakers and the wide range of network intrusions into all sectors from this particular threat group.
2. History of Chinese Cyber Espionage
2.1 Early Cyber Espionage Activities
2.2 Emergence of Chinese Army Unit 61398
3. Tactics, Techniques, and Procedures
3.1 Target Selection and Reconnaissance
3.2 Exploitation and Delivery of Malware
3.3 Command and Control Infrastructure
3.4 Data Exfiltration Techniques
4. Notable Cyber Attacks Linked to Unit 61398
4.1 Operation Aurora
4.2 Operation Shady RAT
4.3 Operation Aurora Panda
5. Motivations and Objectives
5.1 Economic Espionage
5.2 Military and Political Intelligence Gathering
5.3 Support for Chinese Industries
6. International Response and Diplomatic Impact
6.1 Accusations and Denials
6.2 Diplomatic Tensions and Consequences
7. Countermeasures and Defense Strategies
7.1 Network Segmentation and Isolation
7.2 Intrusion Detection and Prevention Systems
7.3 Employee Education and Awareness Programs
7.4 Incident Response and Recovery Plans
8. Future Implications and Trends
8.1 Evolution of Chinese Cyber Operations
8.2 Collaboration with Other Threat Actors
8.3 Impact on Global Cybersecurity Landscape

Climate Change and the Christian Community

Questions
In each of our weekly forums we will be using the “three R approach.” 
Ideally, your post should be about three paragraphs long and be completed by Wednesday evening.  
1. Resonate: What did you agree with? What spoke to you? 
2. Resist: What did you disagree with? What did you struggle with? 
3. Relevant: What did you take away from you this week? How can this material be applied to your life and others?
Video on Stephen Matthew.  
This is all about our climate change with the Christian community and the world.

Answer
1. Resonate
Stories of the impacts of climate change tend to not resonate with the above populations as they do with smaller population centers and subsistence farmers in poor regions. Where it does begin to have an impact, questions about whether it was caused by anthropogenic or natural factors may lead to varied answers. Nevertheless, they agree that if it is an issue that is impacting the poor and will continue to do so in the future, that this is unacceptable.
According to reports from the Pew Center on Religion and Public Life, U.S. religious groups that feel climate change is a serious problem are in the minority. The most concerned tend to be Mainline Protestants and Catholics, and it appears that Evangelicals and Black Protestants tend to be the least concerned. At the same time, all of these groups tend to think that they personally are less concerned than their compatriots. This data could suggest that many simply do not know about climate change and what sort of impact it could have; but it could also suggest that no matter how much is known, it isn’t seen as an urgent problem.
Importance of preserving God’s creation. There are clearly some Christians who believe that climate change is just not an important issue – if it is even an issue at all. There are others who care deeply about the issue, and yet when surveying the public at large, climate change never quite makes it to a position of priority.
1.1. Agreeing with the importance of addressing climate change
Climate change has become a very significant issue in recent years. It has become a reason for concern in all areas of society, even in the Christian community. To some, it may seem odd that an issue which is often politically charged should gain real attention within Christianity. However, when one carefully examines the issue in terms of Christian ethics and morality, it becomes quite clear that climate change is an issue which should be of great importance to all Christians. The world’s climate is a key part of all God’s creation. When this climate is disrupted in ways which harm the poor and powerless, damage other species and ecosystems, and threaten the well-being of the earth itself, it is a clear violation of commands to love our neighbors, to care for the poor, and to be stewards of creation. Most of the impact of climate change now and in the future represents a quite unfair burden on those in the poorer countries, who are the least equipped to deal with rapid change, and who have often done the least to cause the problem. This is a matter of injustice, and God is a God of justice. These issues are very complex and are not productively addressed in the polarized political environment in which climate change is often placed. However, it is clear that this is a moral issue, and it is the duty of Christians to consider the moral implications of climate change, and to advocate on behalf of the world’s poor and of future generations.
1.2. Finding common ground between climate change and Christian values
Creation care is a value shared by most Christians regardless of their theological persuasion. Despite the debate over how one interprets Genesis and the issue of dominion over creation, most agree that humans are called to be stewards of the earth. Discussions about the earth being a precious gift from God and it being loaned to present and future generations are common. The impact of climate change and damage to the environment upon future generations is a clear indication that there is a moral issue surrounding the way we are treating the earth. People are now accustomed to hearing about climate change in political and economic terms, but there are few who recognize it as a spiritual and moral issue. It is an opportunity for the church to remind people of the importance of living a life that is consistent with their values and beliefs. By addressing the issue of climate change in such a way, it will engage Christians from all traditions and provide an opportunity to make a difference in the world.
To proffer solutions, it is important to understand the problem. Although many Christians may disagree with issues surrounding global warming and environmental degradation, it is hard to ignore the implications upon humankind and the earth. Many of the fundamental issues of climate change are intertwined with Christian values such as justice for the poor and preservation of creation. The effects of climate change will no doubt impact the world’s poor more than anyone else, and it is these people who have contributed least to the problem. Recent natural disasters such as the tsunami in Southeast Asia or Hurricane Katrina have shown how poor communities are the most vulnerable to such calamities. Although these events may not be a direct result of climate change, it is an example of what we can expect in the future to a greater extent. Scriptures such as “speak up for those who cannot speak for themselves, for the rights of all who are destitute…” (Proverbs 31:8) resonate with the issues surrounding climate change and its effects on the poor.
2. Resist
2.1. Disagreeing with the prioritization of other issues over climate change
2.2. Struggling with the integration of scientific evidence and religious beliefs
3. Relevant
3.1. Taking away the urgency of climate action from the discussions
3.2. Applying climate change knowledge to personal lifestyle choices
3.3. Considering the impact of climate change on future generations
4. Stephen Matthew’s Video
4.1. Overview of Stephen Matthew’s perspective on climate change and Christianity
4.2. Analyzing the key arguments presented in the video
4.3. Reflecting on the potential influence of Stephen Matthew’s message
5. Climate Change and the Christian Community
5.1. Understanding the role of the Christian community in addressing climate change
5.2. Exploring the intersection of faith and environmental stewardship
5.3. Examining the challenges and opportunities for collaboration between Christians and environmental activists
6. Conclusion
6.1. Summarizing the key takeaways from the discussions
6.2. Emphasizing the importance of collective action in tackling climate change

Cognitive Theorists’ Approach to Depression and Suicidal Ideation

Question
Discuss how cognitive theorists (Kelly, Beck, and Ellis) might address a client with depression and suicidal ideation. After reviewing cognitive therapies in your textbook, what interventions might you suggest. Explain and justify your response.
2. In what ways can spirituality or religious beliefs, or lack of, influence an individual’s personal decision-making process, and how might this impact the choices they make in various areas of their life, such as relationships, career, and personal goals?

Answer
1. Introduction
The introduction provided by David Lester is brief but straight to the point and covers all necessary areas. Lester starts by discussing the severity of the healthcare issue that is depression and quotes a Spanish saying “There is no greater pain than being blind in Granada” which he changes to “There is no greater pain than depression.” A short account of the symptoms and severity of depression is discussed, and then Lester moves onto the topic of suicide. Suicide is a sensitive topic but a necessary one in the field of psychology and healthcare. People relate great sadness and negativity to suicide as something people feel is “the easy way out,” but as Lester points out, “The act of suicide is one of shooting oneself in the head while one in dead aim at one’s foot,” essentially stating that people are self-destructive rather than simply destructive of life, and suicide is the ultimate reflection of this. This puts the severity of depression into an easily understandable perspective. Lester concludes his introduction with an outline of the theoretical development of cognitive theory and finishes with a statement of what he will discuss in this book. This introduction is suitable with no major flaws.
Cognitive Theory of Depression and Suicidal Behaviour by David Lester opens up with a clear and to the point introduction that states the implications of cognitive theories and their strategic development. Tony Beck’s Cognitive Theory and Therapy of Anxiety and Depression also opens with an explicit introduction about the extent of the problem of depression and its link with suicide. In this essay, I will give an overview of these introductions and compare them to my own introduction to the topic of cognitive theories and depression, specifically outlining what I have done differently and the reasons for this.
1.1. Overview of cognitive theorists
As cognitive theory offers an explanation of the onset and maintenance of depression, theories are best researched using causally related treatment studies. i.e. the most convincing tests of a theory come from studies where the cause of a particular disorder or disorder symptoms is manipulated and a change in the dependent variable is observed. Beck has described depression as a disorder of negative thinking, and there is much empirical evidence showing that when depressed people make inferences about self, world, and future they characteristically do so in a negative way, and the same is true for their interpretations of ongoing experience. Following on from this, there is now a large body of research showing that depression is associated with memory biases for mood congruent material and the use of cognitive avoidance strategies. This is only a very general overview of the research within depression, suffice to say Beck’s model has enjoyed a great deal of empirical support and as such it has been adapted and extended so that it can offer a cognitive theory of depression in all its richness and diversity. This is important as according to Beck, a good theory of depression should be able to explain how a single etiological mechanism can cause a disorder with such a wide range of different symptoms.
Research within the field of cognitive psychopathology has now been extended to the field of clinical psychology and there have been a large number of studies of depression and more recently studies of other psychological disorders. Major Depressive Disorder, hereafter referred to as depression, is diagnosed according to the standards provided in the Diagnostic and Statistical Manual of Mental Disorders edited by the American Psychiatric Association. Symptoms of depression include loss of interest or pleasure, significant change in weight or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, and impaired concentration or indecisiveness. In its severe form, depression is a highly debilitating, long-lasting, and pervasive condition.
Cognitive theory is a theoretical model of mental disorder that postulates that a relatively small number of recurrent cognitive processes are implicated in the various forms of psychopathology. Of these, cognitions that negatively bias the interpretation of ongoing experience or otherwise inferred meaning of an event or stimulus are seen as particularly important. Beck’s (1967) influential model is exemplary. This model holds that depressive symptoms are caused by the latent cognitive structures within the mind. When these cognitive structures take on a negative schema, they can activate a negative self-referent cognitive process when the person is faced with a situation that resembles a particular schema. This can lead to the production of a series of negatively biased automatic thoughts. It is these thoughts that cause the overt psychological and behavioral symptoms of depression. Following on from this, negative automatic thoughts are thought to arise from underlying cognitive errors.
1.2. Importance of addressing depression and suicidal ideation
Depression is a serious and debilitating illness, which affects mental, emotional, and physical health of an individual. It is often reflected in low mood, feeling of sadness, and aversion to activity. Depression increases cognitive vulnerability to negative schema about self, world, and future. A recent research (NIMH, 1999) shows that depression is the top contributor for the suicide and suicide rate is higher in the elderly person, who have medical illnesses, college educated and who live alone, suicide risk is always higher in presence of the symptoms of hopelessness. About 60-70% of people who committed suicide suffer with major depression or bipolar (manic-depressive) disorder and people in this group are the most treatable great proportion of suicide can be averted by the effective treatment of depression and other psychiatric illnesses. Suicidal persons directly express their negative self-schema and hopelessness in a way they talk about their selves and future, and their feeling towards leaving and escaping from an intolerable situation reflect the state of cognitive deconstruction which increasingly becomes activated when hopelessness and negative schema intensifies and diversifies. As Brown and others have suggested, suicidal act is the final common pathway of a broad range of biological and psychiatric states said to increase the risk of such behavior, it can be the consequence of impulsive, aggressive act or carefully planned and executed by the individual who would otherwise make considered rational decision. Cognitive theory of suicide states that suicidal intent is correlated with strong feelings of hopelessness and helplessness, and absence of alternative way of solving the problems, when the hopelessness and helplessness is too severe then the individual will become focused on taking his own life.
2. Cognitive Theories and Depression
2.1. Albert Ellis’ Rational Emotive Behavior Therapy (REBT)
2.1.1. Challenging irrational beliefs
2.1.2. Identifying and disputing negative thoughts
2.1.3. Developing rational alternatives
2.2. Aaron Beck’s Cognitive Therapy (CT)
2.2.1. Recognizing and restructuring negative automatic thoughts
2.2.2. Examining cognitive distortions
2.2.3. Behavioral activation techniques
2.3. George Kelly’s Personal Construct Theory
2.3.1. Identifying and modifying negative constructs
2.3.2. Constructive alternativism
2.3.3. Role of core beliefs in depression
3. Interventions for Depression and Suicidal Ideation
3.1. Psychoeducation on cognitive distortions
3.1.1. Teaching clients about common cognitive distortions
3.1.2. Providing examples and exercises for recognition
3.2. Cognitive restructuring techniques
3.2.1. Guided thought records
3.2.2. Socratic questioning
3.2.3. Cognitive reframing
3.3. Behavioral activation strategies
3.3.1. Setting achievable goals
3.3.2. Encouraging pleasurable activities
3.3.3. Monitoring and challenging negative behaviors
4. Conclusion
4.1. Summary of cognitive theorists’ approach
4.2. Importance of addressing depression and suicidal ideation
5. References

College Teacher Burn-out and Strategies for Alleviation

Questions
Required: This PowerPoint must include the meaning of College Teacher burn-out and the causes? What are some fun things College teachers can do to alleviate teacher burn out?  
Submission: 5 PowerPoint slides, APA format, must include colorful pictures, laughter, and 1-2 fun activities for teachers. 
Answer
1. Introduction
At a time when American higher education is under increased scrutiny from the general public, governing boards, and government officials, there is a documented increase in job-related stress for faculty and administrators. This stress, if not managed effectively, can lead to burnout and a variety of negative consequences for individuals and their institutions. It affects the quality of teaching, student-teacher interaction, and the climate of learning and leadership in postsecondary institutions. Although faculty at all types of institutions are experiencing increased levels of stress, research suggests that those at two-year colleges and regional comprehensive universities are especially prone to burnout (Bryson, 2013). This may be related to the fact that postsecondary professionals at institutions that serve as the primary entry point to higher education for underprepared and disadvantaged students face an environment that is inherently stressful. The same can be said for teaching and student affairs faculty at institutions that serve minority and underrepresented groups.
This essay is designed to explore and clarify the new phenomenon of faculty syndrome and its effects; identify the factors that contribute to college teacher burnout; heighten awareness about the importance of addressing this problem and suggest strategies for individuals and institutions to cope with and alleviate burnout. This section provides an overview of the nature and extent of faculty burnout and the consequences for the individuals affected, students and institutions. Subsequent sections identify the causes of burnout; discuss the various ways in which individuals respond to and cope with stressful work situations, and suggest strategies for individuals and colleges to reduce job-related stress and prevent burnout. Later sections will address the role of academic leaders and administrators in dealing with faculty burnout. The essay closes with an annotated bibliography of books and articles that will provide readers with additional resources to help them understand, recognize and cope with faculty burnout.
1.1 Definition of College Teacher Burn-out
In order to consider college teachers’ burnout and strategies for alleviation, it is firstly necessary to understand the phenomena being addressed. ‘Burnout’ is a state of chronic physical and emotional depletion comprising lowered vitality, depression, and a cynical, negative attitude towards oneself and others. There are three key words here – ‘state’, ‘chronic’ and ‘depletion’. It is a psychological concept referring to a person’s reaction to chronic interpersonal stress, and this reaction is defined by the three descriptors above. It is a gradual process, building up over time, with the person not realizing what is happening until they reach complete exhaustion. It is this chronic and gradual process of depletion which marks it different from other stress conditions. The depletion represents a state of having lost all resources, and the person can see no end to their feelings and has nothing left to give. The consequences of this are negative changes in the person’s attitude and behavior, and this may be noticed by others around them. Burnout is not a mental illness, as the symptoms can be seen as the body’s adaptive response to a stressful work situation. However, it can have serious effects on a person’s mental and physical health, and it is not something that will go away of its own accord.
1.2 Importance of Addressing Teacher Burn-out
From a teacher’s perspective, prevention and early intervention are the key to promoting teacher well-being and effective practice. The nine symptoms of burnout are fairly predictable and have been shown to unfold in a consistent sequence. The sequence begins with the teacher’s characteristic enthusiasm for the job. When this enthusiasm is channeled into an impossibly high set of expectations for self and students, the teacher may become frustrated that students do not appreciate all the effort put into class preparations. This frustration leads to disillusionment regarding teaching and a very strong desire to be doing anything other than teaching. As the teacher begins to distance him/herself from the students emotionally, a sense of impending failure can lead to guilt and anxiety. This negative self-perception and sense of failure is inevitably confided to close others who may try to reduce the teacher’s feeling of failure by giving advice on how to teach better. This advice is usually interpreted by the teacher as one more indication that others are not satisfied with his/her performance. This can lead to alienation from colleagues and further withdrawal from the job. Any intervention in this downward spiral must be multifaceted and aimed at increasing teacher skills and self-efficacy while decreasing the classroom demands that incited the initial enthusiasm to unrealistic levels.
Addressing college teacher burnout is important in making all the stakeholders aware of the disease that has been eating up the teachers from inside and reflects on all their actions. This disease has a severe impact on the life of the teacher, students, and the college management. It has been said that teaching is the noblest of all professions, but the disease has made it one of the most abusive and tiring work. The disease starts eating into the teacher very slowly and affects all areas of his/her life, be it personal or professional. It is also said that the teacher is vital for students’ learning. It is not only the method, material, and students’ interest that matter, but the motivation from the teacher plays a large role in student learning.
2. Causes of College Teacher Burn-out
2.1 Workload and Time Management
2.2 Lack of Support and Resources
2.3 Emotional and Mental Exhaustion
3. Strategies for Alleviating Teacher Burn-out
3.1 Prioritizing Self-Care
3.2 Establishing Work-Life Balance
3.3 Seeking Professional Development Opportunities
3.4 Building Supportive Relationships
3.5 Incorporating Mindfulness and Stress-Relief Techniques
4. Fun Activities for College Teachers
4.1 Engaging in Hobbies and Interests
4.2 Participating in Social Events and Gatherings
4.3 Exploring Nature and Outdoor Recreation
4.4 Traveling and Exploring New Places
4.5 Trying New Sports or Fitness Activities
5. Conclusion

Comparing Walmart Financial Statements under IFRS and GAAP

Question
Prior to beginning work on this discussion forum, read Topic 6 International Accounting Standards in Appendix A in the course textbook, Using Financial Accounting. Next, review the Walmart Case Study.
Compare and contrast the differences in the Walmart financial statements if the company were to use International Financial Reporting Standards (IFRS) rather than Generally Accepted Accounting Principles (GAAP). Be sure to discuss specific accounting differences between the two.
Debate the pros and cons this would create for Walmart. Be sure to be specific and support any opinions.
Describe any legal or ethical challenges this convergence may create using the country you selected in prior courses.

Answer
1. Introduction
Globalisation is happening in the world, and the movement toward IFRS might seem like a natural evolution of U.S. accounting standards. However, IFRS is more principle-based while U.S. GAAP and has developed rules over time. IFRS is also more detailed and precise than IAS. The movement of IFRS might sound good for the global economy, but people do not like changes. It is evident that the U.S. will resist IFRS convergence until it has seen that the development of IFRS is successful and will benefit the U.S. economy. Until full convergence, there will be a long period where both standards are used domestically and internationally (Mala, 2010). This issue is important because Walmart operates globally, and will also affect accounting students, since most accounting students study U.S. GAAP and IFRS is not a main course yet.
Walmart is a US public multinational corporation, which operates a chain of discount department stores and warehouse stores. Walmart was incorporated in 1969 and trades publicly on the New York Stock Exchange. Walmart is the second largest public corporation according to the Fortune Global 500 list in 2013, the world’s largest give store retailer with over 2 million employees worldwide, and is the biggest private employer in the world. Walmart is a family-owned business and is the biggest grocery retailer in the United States. It has stores in more than 50 countries under 69 different banner names (Farfan, 2012).
1.1. Background information
After the accounting scandals in the early 2000s, the International Accounting Standards Board and the Financial Accounting Standards Board have attempted to work towards a unified set of accounting standards between the IAS/IFRS and the US GAAP. It is believed that one set of accounting standards will provide a greater degree of transparency of a company’s position. Throughout this paper, the accounting policies of Walmart are reviewed and the effects of the IFRS convergence on these are highlighted. I’ll also take a look at their financial statements taking note of any defined effects through changes in accounting policy or errors with relation to the Restatements provided. Walmart has faced continual issues over the years in regards to producing reliable financial statements. Between misrepresented amounts to errors in classes of inventory, Walmart has undergone several restatements of their financial statements communicated the need for a change in accounting policies to better represent them accurately. It has taken Walmart several restatements to understand the effect of changes in inventory levels. With the mistakes made it is clear that another guideline and/or standard would have helped Walmart in understanding and representing the effects of changes in inventory with relation to LIFO liquidations. This can be clearly seen with the changes in inventory levels from 2009 to 2010. By moving their operation towards Canada from the US, Walmart showed a drastic reduction in levels of inventory by over $1 billion. This had no effect on cost of sales when represented, when in actuality it must have been assumed that all inventory under previous acquisition cost was sold in Canada.
1.2. Purpose of the comparison
The purpose of this comparison is to assess the financial statements under IFRS and U.S. GAAP to determine whether there are economic consequences from reporting to investors, creditors, or other stakeholders. A high quality financial reporting system can build a basis for a capital market in a country and attract international capital to flow into that country, which in turn has a significant impact on the economic growth in that country. A major development in the world of financial reporting is the convergence of IFRS and U.S. GAAP. In 2001, the IASB and FASB agreed to work together, in mutual respect and in the best interest of investors and others, as a way to bring the two sets of standards closer. In February 2006, the IASB and FASB set forth a plan for convergence where projects would be undertaken but a revised standard in order for IFRS and U.S. GAAP to align, and potentially result in elimination of difference between the two standards for particular issues. This plan included many phases and continual assessment and monitoring from both boards. Although this was the case, in 2012, the SEC made an announcement that it would no longer provide a statement that indicates whether or not IFRS would be incorporated into U.S. capital markets. This was due to a number of reasons that include separate discussions on future reporting standards for US domestic issuers and the oversight and infrastructure funding of IFRS. A decision has yet to be made, however, the standard setting environment continues to evolve along with potential global acceptance of IFRS. For these reasons, Walmart was chosen as a company to compare financial statements. With many countries still having their own, in some cases unique set of accounting standards, companies engaging in international business or investments are faced with having to convert their financial statements into various standards. This can be an extremely complex process, inhibiting comparison of financial statements and in some cases misinterpretation due to language barriers and lack of understanding of a particular standard. As of the company’s 2011 annual report, Walmart has retail outlets in 15 different countries, each faced with a separate local standard and the potential for varying global acceptance of IFRS. It would be in these companies’ best interests to follow the developments in the standards environment and prepare for the potential adoption of IFRS. For this reason, these comparisons may, in fact, provide an understanding of what future changes may affect the way in which Walmart reports its financial position and performance.
2. Overview of International Financial Reporting Standards (IFRS)
2.1. Explanation of IFRS
2.2. Key principles of IFRS
3. Overview of Generally Accepted Accounting Principles (GAAP)
3.1. Explanation of GAAP
3.2. Key principles of GAAP
4. Comparison of Walmart Financial Statements under IFRS and GAAP
4.1. Income statement differences
4.1.1. Revenue recognition
4.1.2. Expense recognition
4.2. Balance sheet differences
4.2.1. Valuation of assets and liabilities
4.2.2. Treatment of intangible assets
4.3. Cash flow statement differences
4.3.1. Classification of cash flows
4.3.2. Treatment of interest and dividends
5. Pros of Walmart adopting IFRS
5.1. Enhanced comparability with global companies
5.2. Simplified financial reporting for multinational operations
5.3. Access to international capital markets
6. Cons of Walmart adopting IFRS
6.1. Costs of transitioning to IFRS
6.2. Potential loss of industry-specific guidance
6.3. Increased complexity in financial reporting
7. Legal challenges of convergence in the selected country
7.1. Impact on local laws and regulations
7.2. Compliance with international standards
7.3. Potential conflicts between IFRS and local laws