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The role of a nurse in a prevention and a treatment of intestinal parasites of children
JANDOVÁ, Anna
The best-known intestinal parasites are Pinworms, Roundworms, Tapeworms and the disease called Toxocarosis. The oftenest parasite is, according to sources, the Pinworm. Intestinal parasites affect mostly young children of pre-school age, sometimes even older. The first goal of the thesis was to investigate parents' awareness of the prevention of parasitic diseases in children. There is a hypothesis set to this goal: Parents of children who suffered from parasitic disease are more informed than parents of children who have not had this disease. The second goal was to map the specifics of nursing care for children with parasitic diseases at GPCHA practice. A research question was chosen for this aim: What are the specifics of nursing care at GPCHA in parasitic diseases? In methodology, the empirical part was chosen and it was a qualitative - quantitative research survey. For the quantitative part, the interrogation method and technique of non-standardized questionnaire was used. The research sample of quantitative survey consisted of 223 respondents, it means parents whose child is aged from 0 to 6 years. The questionnaires were distributed on social networking and others in a nursery school in Týn nad Vltavou. At the very beginning, respondents were acquainted with the topic of the thesis. The results of a quantitative survey were processed with the help of a data matrix and were further processed within twenty-arranged bar charts. To verify the hypothesis, we used the Chi- Quadrat test, which in this case is not satisfactory, therefore, there had to be chosen to merge the responses. An interrogation method, technique-depth interview was used in the qualitative part. The research group consisted of five nurses; three nurses working at GPCHA in Týn nad Vltavou and two working at GPCHA in České Budějovice. While processing the interviews, there open coding was used and an analysis of interviews was conducted by using the method of Pencil and Paper Interview. The results of this bachelor thesis will be published in the journal Paediatrics practice.
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The Use of the Addictive Drugs by the Seniors
KOPAČKOVÁ, Dominika
The bachelor thesis deals with using addictive substances by senior citizens. The age cathegoty 60+ should not be omitted when speaking of using addictive substances. Even senior citizens are users of some addictive substances, especially drugs. The thesis is divided into two parts, theoretical and explorative one. There are four chapters in the theoretical part (Old age and ageing, Substance addiction, Addictive substances and their classification, Usage of addictive substances in the old age) and summarizes the knowledge from recent literature about this topic. First, the old age and ageing are described. This chapter deals with ageing and old age of the human. This work describes the right mental hygiene, too. Multi-factorial manifestation of the old age (biological, psychological and social) is mentioned as well. In the second chapter there are described the factors that increase probability of the addiction origin. These factors can be genetic, biological, and psychological. There are mentioned some system models of the formation, development and maintenance of addiction, dependence and definition of the signs that addiction manifests. The third chapter divides addictive substances between legal and illegal. There are their effects, impacts on the human organism decribed. The group of legal addictive substances are included tobacco, alcohol, drugs and certain foods. Illegal substances represented here by cannabis, hallucinogens, stimulants, opiates. The last fourth chapter focuses directly on the addictive behaviour of the senior citizens. Seniors are also users of substances with addictive potential. At first alcoholism is mapped, other chapters devote addiction to nicotine, drugs and narcotics. The main goal of the thesis is to determine whether seniors use an addictive substance. A partial goal of is to find out the extent and cause of using addictive substances by the senior population. To find out these goals there were used the principles of quantitive research. To collect the data there were used questionnaires, created all by the author. The questionnaires were created with open and closed questiones and used in the printed form. The research has been conducted in Sušice and its close surroundings in February 2015. Respondents were the people with the least age limit of 70 years. These were 40 people living in their households or home for elderly. The results show that also amongst senior citizens can be found those ones who use the addictive substances. Current problem are by the doctor prescribed drugs. Today´s senior citizen uses drugs regularly, very often also combination of more drugs. Seniors often use medication to relieve the pain because the pain occurs more frequently. They use drugs to help them sleep better, too. The next group of addictive substances, which this chapter deals with, are drugs with a shoothing effect. There are smokers between the senior citizens who bare this bad habit from their midlife. Some research shows that cannabis helps people with Parkinson's and Alzheimer´s disease. Seniors do not use cannabis for these purposes because it is not legal. Alcohol is drunk by older people on occassion, on the other hand there are also people who drink such an amount that is not considered as not-risky. Seniors do not drink so much on one occasion, compared to the young generation. In the thesis this problem is described more detailed. Results of the research can be used by lay public to understand issues of addictive substances better. This thesis can be source of information for students of healt-social fields of study and it can improve the awareness about reasons of using addictive substances amongs senior citizens.
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Effect of a graduate of field of study Special Education - tutorship in practice of providers of social care
SALABOVÁ, Jana
Theoretical part of the thesis is divided into 4 main chapters. First one deals with the helping professions generally, their definitions and definition of the Special education - Tutorship branch of study per se.It also briefly touches the subject of readiness of the future graduates to deal effectivelly with the challenges of a career in the field of social services. Chapter number two is called Special education and it defines the subject of special education itself, it's purpose and inner structure. Third chapter focuses on social services. It brings up it's definition and types and forms of social services.It also contains the examples of the institutions which fall into this category and it's providers. Chapter number four, which happens to be the last one in the theoretical part of the thesis, covers the role and purpose of graduates of the special education - tutorship studies. It brings up the definition of a social worker, necessary prerequisites as well as beneficial personality traits and feautures. In a subchapter of chapter four is a short description of a pedagogue tutor. Definition who he actually is, who are proper candidates for this position, what are desired personality traits we look for in tutors and the actual content and purpose of their work in institutions providing social services. The end of chapter four is dedicated to a position of a social worker. His activities, the position and definition of a personal assistant and again personality traits needed for a successful career in this field. The objective of the practical part of the thesis is to describe working of Special education - tutorship studies graduates in practice. Particularly their experiences "from the field", how do they evaluate the level of skill of fresh graduates during their first encounters with the reality, how satisfied are they with their choice of a career so far and what was their motivation to pursue such career. Practical part of the thesis includes qualitative research. To meet the above objectives, data collection technique had been chosen using a structured interview with the respondents, who were graduates of Special education tutorship studies. You can tell by the results of this thesis that graduates in the field of social services apply mostly to lower positions as a social service workers, even though they are qualified to perform as a social workers. The age of clients with whom the respondents work ranges from childhood to senior. The motivation that led those questioned respondents to the decision to choose the area of social services varies. Some reported that they were influenced by the actual practical experience during their studies at the university, when both the work itself and their enthusiasm for the target group played role. Others expressed they had previous experience working with people with disabilities or they just wanted to acquire new experiences. Also, involvement of a family member and their previous education was a motivation. Job satisfaction is evident from observed data, and it also contributes to work done accurately and responsibly. Personal benefits for the respondents according to findings are usually their usefulness at work, new experiences they are getting and last but not least advances of their clients. As the biggest advantage the respondents usually mention variability of their work, target group and the clients in itself and the fact, that their work is highly satisfying and they basically work in a very pleasant team of individuals. On the other hand, not exactly satisfying financial reward and challenging working hours are mentioned as disadvantages. Special education - tutorship studies - the branch they've studied, is by the majority of respondents considered to be beneficial for them and they especially highlight practical impact of practice they completed during their studies and which included visits to various relevant institutions.
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A nursing issue: peripheral venous catheter
TOMÁNKOVÁ NOVÁKOVÁ, Monika
Peripheral venous catheter is used to access the venous system. It is one of the most commonly used invasive procedures in health care facilities. This procedure falls within the competence and daily tasks of nurses. Therefore this type of nursing care is susceptible to risk of proceeding routinely which might result in conscious or unconscious errors. Peripheral venous catheter needs to be introduced into the patient's vein in the following cases: planned parenteral nutrition, infusion or transfusion therapy, application of intravascular medication or contrast media, rehydration, blood sampling (which can be performed immediately after introducing the peripheral venous catheter and before administrating medication) and also during an emergency care for critically ill (such as cardiopulmonary resuscitation). Nurses should be as knowledgeable as possible about this issue so that the peripheral venous catheter can be introduced well and fulfil its purpose. It is important to ensure that nurses obtain all the necessary information about their patients before inserting the catheter and that they are able to properly inform the patients about the procedure and to communicate with them. Next, nurses should be familiar with the correct procedure for inserting catheters, they should be informed about possible contraindications and know how to choose the correct type of catheter as well as where to place it. Furthermore, nurses should care for this vascular access correctly and provide the patient with enough information about taking care of the catheter after the procedure. Finally, nurses should be aware of their own potential errors and also of possible complications. Therefore they should employ aseptic technique so that they can eliminate nosocomial infections. The thesis is divided into a theoretical and an empirical part. The theoretical part focuses on the history of peripheral venous catheters and their types, indications and contraindications, necessary equipment, nursing care, complications, etc. The empirical part consists of a research. The aim of the thesis was to map the use of peripheral venous catheters in hospitals as well as to identify factors that may lead to problems among the patients with peripheral venous catheters. Four research questions were assigned to these aims. 1. What is the procedure prior to inserting a peripheral venous catheter? 2. What are the standards of caring for patients with an inserted peripheral venous catheter? 3. In which steps of caring for peripheral venous catheters do the nurses lack knowledge? What equipment do the nurses prepare in order to insert a peripheral venous catheter? The Bachelor's thesis was conducted using a qualitative research survey. The methods of collecting data included semi-structured interviews and participant observations. The research was carried out only in one hospital ward and it was anonymous. First, the data were collected by means of a semi-structured interview. The nurses were asked 14 questions (see Appendix 8). During this interview, several more subquestions were added. The results of the interviews were then grouped into several categories for the sake of clarity. The second method of collecting data was participant observation. The observed facts were recorded into an observation sheet (see Appendix 9). The same nurses who were interviewed were also observed. This Bachelor's thesis has been written in order to provide a basic overview of the peripheral venous catheters. It could be used as an information source for more experienced as well as novice nurses. The practical output of this Bachelor's thesis is a nursing care standard concerning peripheral venous catheters. This standard was missing in the hospital ward and could help the nurses to take care of these vascular accesses, to proceed correctly and eliminate possible errors (see Appendix10).
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A historical view of the army nurse profession.
PAVLÍKOVÁ, Andrea
The thesis deals with the profession of a military nurse. We can assert that the official study of military, non-medical health-care related qualifications and its use in practice not only for military purposes dates back to the fifties of the last century. However, women as health care professionals, consequently in uniforms, have always been an actual issue. The development of health care activities always existed, however, we must not neglect influence of scientific and medical findings. The historical timeline of development of medical care in the battle field was recorded and ranges from pre-historical healing. The way of Christian medicine was negatively influenced by the Catholic Church. The dark period of the Middle Ages had actually wrested medical performance from the hands of specialists and the suffering were left to the "tender" mercies of the priests. The following part of the thesis concerns modern medicine where enlightenment reforms were exercised. Some of the original six-month courses for military surgeons were organised in this period of time; they weretransformed into Military Surgical Academy, out of which the famous Josefinum originated. A expression of humanity which supported a form of health care of war veterans was demonstrated by constructing buildings for invalid people. The second half of the nineteenth century is characterized by the phenomenon of the presence of nuns in military hospitals. This study goes further in depth of professionally organized healthcare right in the battle field, which dates back from the era of wars in the Crimea.This stage describes the transformation of caring into nursing which requires the necessity of specialized preparation of persons providing nursing practice. In addition, Henry Dunant engraved himself into the history of the profession of a nurse, as the founder of the Red Cross, who first trained health care professionals for working within armed intentions of the state. The continuation of this action sketches out the process of providing first aid in principal armed conflicts of the twentieth century. It describes the functioning of commander operated military health service of that time. WWI drove Czech medical staff to both sides of the front where they provided medical help to the injured. Nurses of the WWII already performed their duties in uniforms as the rightful members of the army. The thesis also mentions post-war usage of military health care professionals in secret foreign missions and their specialized erudition.Last but not least, it marginally discusses contemporary possibilities of modern health care service of the Army of the Czech Republic. The goal of the endeavours of writing this thesis was to chart out clearly the development of the profession of a military nurse within the historical context, focusing mainly on women coming from Czech regions. In order to make the history background concerning specific female participants of the world war conflicts understandable to the reader, this paper reports, in broader extension, peculiar medical and nursing findings, already from the era of prehistoric civilisations. The history study method were applied for the purpose of the theoretical thesis. The methodology is based on searching, studying, sorting and the consecutive systematic objective describing of the events from the past times with the intention to propose comprehensive report on the subject given. It was necessary to study inexhaustible amount of sources to obtain awareness of historical connections. Factual information was derived by analysing of primary and mainly secondary documents. The thesis sketches out histories of military health care and the profession of a military health care professional stemmed from the exploration of appropriate written sources and conclusion of the basic findings. The intentions of the work are not only to clarify the past but also to contribute to solutions of every-day issues.
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Supervision in psychiatric nursing
RŮŽIČKOVÁ NEUŽILOVÁ, Michaela
Basic theoretical background The theoretical part of the thesis explores the issue of supervision and focuses on psychiatric nursing. It is divided into several parts. The first part is focused on supervision, briefly characterizes supervision as such, then it describes its divisions, functions and methods. It also explores the participants of supervision, the agreement on supervision, transcultural supervision and Balint groups. The following part describes historical development of psychiatric nursing, briefly presents the personality of Joyce E. Travelbee. In the conclusion of the theoretical part of the thesis the problems of education and competence of nurses in psychiatric care are introduced, marginally mentioning the Turku declaration. The aim of the work The main aim of the thesis is to investigate the awareness of nurses working in psychiatric care of the clinical supervision options. The task of the second objective is to find out the opinion on supervision of nurses working in psychiatric care. The third objective is focused on means to assist nurses working in psychiatric care in their personal development and growth within their practices. The purpose of the fourth objective is to find experience with supervision of nurses working in psychiatric care. The methods used Qualitative investigation was chosen for the empirical part of the thesis. The method used for data collection was in the form of semi-structured interview. The interviews with the respondents were taken down using a voice recorder and transcribed, qualitative data was then analyzed by pencil and paper encoding technique and semantically organized into 27. groups of categorization. The selection of a research sample was intentional, consisting of twelve nurses working in psychiatric care in the Czech Republic. Results The research focused on nurses who do not have personal experience with supervision revealed that they have certain awareness of the supervisory process, however not quite sufficient to be able to describe the nature and function of supervision in its entirety. Their knowledge is rather theoretical. They understood supervision as help to solve disharmonious relationships in the workplace, as well as it could improve communication skills of the nurses, it would also assist in dealing with crisis intervention and prevent burnout syndrome. The results regarding nurses who do not participate in the supervisory process clearly indicated that they have insufficient support and the opportunity for both their professional and personal growth in their workplace, while this important could be solved by supervision. The research, which covered only nurses who have had personal experience with supervision and regularly participate in it, showed that their knowledge and skills related to the supervision process are quite sufficient to be able to understand and use supervision practically in the whole range. These nurses sees supervision as a benefit that would allow them not only to understood themselves, but also to learn how to manage challenging situations that are a part of their profession. Supervision gives them confidence, provides support and teaches them to deal with people who are part of their work process. Supervision has become a tool for preventing burnout and showed them how to use their own potential effectively. Conclusion This thesis is focused on the use of supervision in psychiatric nursing. Working with mentally challenged patients is very demanding, therefore supervision plays its justified role there. If you do not know yourself and you are not able to solve your own problems, you can never effectively and comprehensively address the problems of others, who are often desperately waiting for your help. The results will be presented at professional seminars designed not only to nurses working in psychiatric care.
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The role of nurses and their impact on the care of patients with total hip arthroplasty.
SLABÁKOVÁ, Květoslava
Total hip replacement is one of the most extensively and highly effective operating methods in orthopaedics. The patients are brought back the self-sufficiency, life without the pain and noticeably motion restriction. Irreplaceable function here is a role of the nurse, who helps the patient to return back to his common life...The aim of this work was to find out, how the patients feel the role of the nurse and its influence to given nursing care before and after the total hip replacement as the less fulfilled. There were following research questions set: How the patients feel the role of the nurse before and after the total hip replacement? How the patients before and after the total hip replacement feel the interpretation of the nurse roles? How the patients before and after the total hip replacement feel the role of the nurse and its influence to given nursing care. Which of the nurse roles are felt by the patient as the unsatisfactory in postoperative care? The patients before and after the total hip replacement feel through the everyday nurse activities the nurse in her role of the caregiver and education giving person, following the nurse vindicator and the nurse bearer of changes. The patients feel the care thanks these roles as a quality, holistic and continual. Nevertheless was the role of the education giving named as the least fulfilled. In connection with these research results was created a manual, a Guide book for the patients before and after the total hip replacement. This Guide book was given to testing purposes. This Guide book was appreciated by the patients very positive despite a large amount of information, which were surprising for many of them. We gained some data, which gave the impulse to complete the information in the Guide.The created Guide book can´t replace the effective communication of the patient with the medical staff, which could be always the most suitable "source" of information.
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Coping strategies in children´s fear and pain in relation to nursing care
PROCHÁZKOVÁ, Zuzana
For the nurse, taking care of hospitalized children is important not only pediatric nursing knowledge, personal and social preconditions, but also the theoretical and practical competency of methods and techniques, which are used for identification and effective influencing of pain and fear. The aim of this thesis was to identify the main sources of fear of the hospitalized preschool and young school age children and to find out the effective methods and principles of the cooperation with children, alternatively with their accompanying parents in order to moderate the fear of the small patient. Then the thesis tried to chart the nursing diagnostic and evaluation procedure of the pain and get the most used nursing methods of non-pharmacological pain relief. To obtain the necessary data, the qualitative research was used with a semi-structured interview as a research instrument. The first research group consisted of 12 nurses, the second group consisted of 12 children ´s patients of preschool and young school age. The majority of the asked nurses thinks, that children´s patients are afraid especially of non-familiar environment, then of the awaited pain and of the solitude without parents. However, the most patients said, that they were afraid especially of pain, then of non-familiar environment, restriction of their needs, hostile attitude of the medical staff and of the other neighbouring patients. They were also frightened of the death and of the darkness. Most reported nurses mean, that the most effective solution of the children ´s fear is the friendly attitude of the medics. They also mentioned the fact of taking the focus off the fear and the presence of the parents is also beneficial. The nurses ´ answers were in conformity with patients opinion in two fields - friendly attitude of the medics and taking the focus off the fear. Then the children mentioned abiding of their specifics in connection to falling asleep and the demand of beying treated by the same sister or by few same sisters. All respondents also talked about the benefit of parents presence. Regarding the principles of the cooperation, nurses answered the importance of united medical procedures, especially the proper way of information transfer. Then the respondents nurses mentioned the psychical and emotional support for children and their accompaniments, the atmosphere of confidence and the value of well done education. Also the need of calm, silence and privacy was stated. Unlike nurses, children and their parents regarding to principles of the cooperation prefer the psychical and emotional support, then the importance of enough information was mentioned. The fourth research question bears on the methods used for children pain monitoring. The nurses said, that the intentional interview with the patients or with the parents was used as a main technique, that was stated by patients as well. Research question number five said: What are the most used nursing methods of non-pharmacological pain relief at children? Most responded nurses mentioned the distraction of children attention from the painful incentive, then the importance of physical methods, relief position and purposeful preparation for the unpleasant intervention. Nurses also named the helpful contribution of the parents, relaxing exercises and the method of imagination. Regarding the pain treatment, it was noted, that all patients prefered the analgesic therapy. Then they quoted the distraction of their attention from the painful incentive, the friendly attitude of the medics, using the ice compress and the relief position. In the pain acute phase, children required mostly calm, comfort and privacy. All children also considered the presence of parents as very helpful. The theoretical and empirical part of the thesis are suitable for being studied by nurses taking care of children and it can be helpful for nursing quality improvement at children ´s wards in hospitals.
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Lifestyle of patients with peripheral arterial disease before and after surgery
REZKOVÁ, Helena
Theoretical background: Peripheral arterial disease is a serious disease of Loir limb arteries which originates from atherosclerosis. The theoretical part deals with the lifestyle. There are mentioned basic risk factors of chronic forms. Further described are the pathophysiology changes generated on the basis of atherosclerosis and related causes for the origin of the disease. Subsequently there are explained methods of classification, developed clinical symptoms, diagnosis and therapy. This section also looks at the role of a nurse in the care of patients with peripheral arterial disease. Objectives: The aim of this work was to evaluate how patients with peripheral arterial disease changed their lifestyle after invasive vascular surgery. There were provided the following research questions: How do patients with peripheral arterial disease approach to the prevention of risk factors? What is in patients with peripheral arterial disease the main impuls for the possible change of their lifestyle? What influences surgery patient's attitude to risk factors for peripheral arterial disease? How crucial is a lifestyle change in patients after surgery for peripheral arterial disease? Methods: The theoretical part is processed using expert sources. The empirical part of the theses was processed using qualitative research. The chosen technique for data collection was semi-structured interviews with patients, with prepared open questions. The research was done in several phases - the first interview was conducted at the patient admission department (before surgery), followed by the next phase after three months, and 6 months after surgery. The interviews were recorded on a prepared form, then transcribed into electronic form and analyzed by open coding method. Results: The research showed that surgery can sometimes be triggered by changes in the patient's lifestyle. The first interviews in the preoperative period focused on how respondents felt, what was their lifestyle before surgery for atherosclerotic changes of the lower extremities. One of the questions was focused on patient knowledge about risk factors for the development of PAD and possible prevention. The second phase of interviews took place 3 months after the surgery. It dealt with the question about the respndents´ lifestyle, the respondents in the postoperative period, whether there were any changes. Some positive changes occurred in eating and there were some changes in doing physical activity. The third stage was carried out six months after surgery, again in order to detect changes in lifestyle. Minor changes came in smoking habits, the issue of diet and physical aktivity. Questions were also focused on the psychological level. We found out who helped patients and what was most motivating in implementing changes. In the conclusion/summing up question the patients marked themselves ow they managed to make a change. Conclusion: The number of patients with peripheral arterial disease and other cardiovascular diseases is increasing. The basis is the start to modify risk factors, namely tobacco use,dietary habits, physical activity. The medical staff members participate on changes in patients´ lifestyle by appropriate education. The problem occurs when the patient despite the support of close people can not cope to carry a twist in their life. There should a medical staff member offer a professional help to deal with this important step. Practical use: The aim is to draw attention to the expansion of education about lifestyle changes for patients diagnosed with PAD also in the postoperative period. Patients who are released to home care should receive enough information that would convince them to change their attitude towards their health, and that surgery is only one of the ways to prevent further attacks and complications. Results can improve communication with patients and focus on increasing their awareness and possibly offer assistance.
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The need for security and safety in connection with a planned surgery with the patient's perspective and nurses
BOHDALOVÁ, Jaroslava
A planned operation performance always affects patient´s needs for assurance and safety. It is important to provide necessary information connected with the planned operation performance itself so that the patient can feel assure and safe. The key role for the patient and her/his needs for assurance and safety is in general nurse´s hands because she is the closest person to the patient and can help to inspire her/his needs for assurance and safety with konfidence best through the aid of her knowledge and skills that she should have as well as through the aid of her attitudes. The target of the thesis was to find out how a planned operation performance affects patient´s needs for assurance and safety and how a general nurse inspires patient´s needs for assurance and safety connected with a planned operation performance with confidence. The following research questions were stated: How does a planned operation performance affect patient´s needs for assurance and safety? How does a general nurse affect patient´s needs for assurance and safety connected with a planned operation performance to inspire her/him with confidence? What is insufficient in filling patient´s needs for assurance and safety before a planned operation performance? How can a general nurse help a patient control her/his fear and state of anxiety related to a planned operation performance? The method qualitative research with the use of depth interview was used to figure out the investigation. The respondents were willing to record the interview which were verbally rewritten and then subjected to the contents analysis by the method paper and pencil. From the research it is clear that a planned operation performance affects patient´s needs for assurance and safety in a negative way disregarding to her/his previous experience. Patient´s worries and negative feelings can be eliminated by a general nurse who treats her/him as equal, taking up an individual approach, informing her/him about all performances and proceedings, having a calming and welcoming way of communication, using empathy and listening as well as trying to meet patient´s wishes according to her possibilities. The research reveals the advantage of patients´ readiness for planned operation performances. Patients can learn it in the framework of educational proceeding in the out-patients´ department at the same time when they learn that they are going to be operated. The research also shows that general nurses do not have enough knowledge in the sphere of therapeutical communication. The results indicate that it would be suitable to start educating patients as soon as it is known how their disease will be solved and treated in order to reduce the negative impact of surgical treatment to patients´ needs for assurance and safety. General nurses should complete their knowledge and skills to be able to help patients to cope with their difficult life-situation. On the basis of the research investigation and after the consultation with the senior nursing officer, the training course will be organized. The topic of the training course will concentrate on communication with patients before planned operation performances with a view to therapeutical communications and therapeutical interviews. Other discovered facts, for example, the lack of information provided to patients and possibilities regarding better patients´ readiness for planned operation performances will surely be solved by the hospital management.
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