Recent Advances in Health Sciences Editors | ResearchGate

Recent Advances in Health Sciences

Editors A. Adil Çamlı Bilal Ak Ramiz Arabacı Recep Efe

ISBN 978-954-07-4136-9

ST. KLIMENT OHRIDSKI UNIVERSITY PRESS SOFIA  2016

Editors Assist. Prof. Dr. Ahmet Adil Çamlı Bezmiâlem University Faculty of Medicine Medical Sciences Division Fatih, Istanbul, Turkey

Prof. Dr. Ramiz Arabacı Uludag University Faculty of Sports Sciences Pysical Education and Sport Dept. Bursa, Turkey

Assist. Prof. Dr. Bilal Ak Toros University School of Health Sciences Health Management Division Yenişehir, Mersin, Turkey

Prof. Dr. Recep EFE Balikesir University, Faculty of Arts and Sciences Department of Geography Balikesir, Turkey

St. Kliment Ohridski University Press ISBN 978-954-07-4136-9

The contents of chapters/papers are the sole responsibility of the authors, and publication shall not imply the concurrence of the Editors or Publisher. © 2106 Recep Efe All rights reserved. No part of this book may be reproduced, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission of the editors and authors Cover Design: Murat Poyraz ii

CONTENTS Chapter 1 ........................................................................................................................ 1  Nursing Services in the Ottoman Empire  Behire SANÇAR  Chapter 2 ...................................................................................................................... 14  Posttraumatic Stress Disorder Among Veterans and Well-Being: What Can Nurses Do about It?   Derya ADIBELLI  Chapter 3 ...................................................................................................................... 26  What Is Nursing Informatics?   Hava GÖKDERE ÇINAR, Semra SÜRENLER, Nurcan ÖZYAZICIOĞLU  Chapter 4 ...................................................................................................................... 32  Transactional Analysis Approach in Patient-Nurse Communication  Zümra ÜLKER DÖRTTEPE, İlkay KESER  Chapter 5 ...................................................................................................................... 43  The Pain Management in Intensive Care Units  Dilek YILMAZ, Yurdanur DİKMEN, Dilek KARAMAN  Chapter 6 ...................................................................................................................... 54  Responsibilities of Nurses in Use of Complementary and Alternative Medicine in Cancer Patients: Importance of Reflexology and Progressive Muscle Relaxation Exercises  Hacer ALAN DİKMEN, Füsun TERZIOĞLU  Chapter 7 ...................................................................................................................... 69  Patient Satisfaction and Quality of Care in Pediatric Settings  Bedriye AK  Chapter 8 ...................................................................................................................... 77  Preoperative Anxiety and Postoperative Pain for Tonsillectomy in Adult Patients: The Effect of Education and Follow-Up Telephone Calls  Rahşan ÇEVİK AKYIL, Nadiye ÖZER, Özgür YÖRÜK  Chapter 9 ...................................................................................................................... 87  The Disease of Our Time: Vitamin D Deficiency and Hypovitaminosis D  Elif ÜNSAL AVDAL, Yasemin TOKEM, Berna Nilgün ÖZGÜRSOY URAN  Chapter 10 .................................................................................................................... 94  Abuse in Old Age and Nursery Approach  Çiğdem KAYA, Perihan SOLMAZ, Ebru KURDAL BAŞKAYA  Chapter 11 .................................................................................................................. 104  Strategies and Models for Evidence Based Nursing Practice  Yasemin YILDIRIM USTA, Songül ÇAĞLAR  Chapter 12 .................................................................................................................. 113  Use of Technology in Nursing Education  İlknur BEKTAŞ, Figen YARDIMCI  iii

Chapter 13 .................................................................................................................. 119  The Cost of Nursing Compassion Fatigue: A Literature Review .......................................   Yurdanur DİKMEN, Nasibe Yağmur FİLİZ, Handenur BAŞARAN  Chapter 14 .................................................................................................................. 137  Drug Errors and Nurses' Responsibilities for Their Prevention  Aylin PALLOŞ  Chapter 15 .................................................................................................................. 148  Physiology of Nervous System  Derya Deniz KANAN  Chapter 16 .................................................................................................................. 164  Pediatric Patient Safety  Figen YARDIMCI, İlknur BEKTAŞ  Chapter 17 .................................................................................................................. 174  Ergonomics in Delivery Rooms and its Importance  Nevin ÇITAK BİLGİN  Chapter 18 .................................................................................................................. 183  Pregnancy and Healthy Life Style Behaviours  Sezer ER GÜNERİ  Chapter 19 .................................................................................................................. 200  The Use of Simulation in the Improvement of the Clinical Skill and Competency of the Nursing Students  Yurdanur DİKMEN, Fatma TANRIKULU, Funda EROL  Chapter 20 .................................................................................................................. 217  The Effects of Gestational Diabetes on Postpartum Period  Gülşen IŞIK, Nuray EGELİOĞLU CETİŞLİ  Chapter 21 ................................................................................................................. 237  Results of Maternal Obesity  Nuray EGELIOGLU CETISLI  Chapter 22 .................................................................................................................. 243  Parents Attachment and Nursing Approach  Selma ŞEN  Chapter 23 .................................................................................................................. 249  Complementary and Alternative Medicine (CAM) in the Treatment of Infertility  Yasemin AYDIN, Merve KADIOĞLU  Chapter 24 .................................................................................................................. 263  Elderly Home Care Services  Nazife AKAN  Chapter 25 .................................................................................................................. 281  Non-pharmacological Methods Administered in Painful Interventional Procedures on Children  Fatma YILMAZ KURT, Aynur AYTEKİN, Sibel KÜÇÜKOĞLU  iv

Chapter 26 .................................................................................................................. 299  Nutrition Literacy in the Prevention of the Era’s Growing Problem Obesity  Büşra CESUR  Chapter 27 .................................................................................................................. 307  Adolescent Pregnancy and Nursing Approach  Selma ŞEN  Chapter 28 .................................................................................................................. 315  Complementary and Alternative Medicine Use in Pregnancy  Emine KOÇ, Şükran BAŞGÖL  Chapter 29 .................................................................................................................. 327  The Importance of Food Labels in Nutritional Literacy  Büşra CESUR  Chapter 30 .................................................................................................................. 332  The Importance of Breastfeeding Professional Consultation, Peer Education and Support  Zeliha Burcu YURTSAL  Chapter 31 .................................................................................................................. 338  Nursing/Midwifery Approaches to Fear of Childbirth  Dilek COŞKUNER POTUR  Chapter 32 .................................................................................................................. 350  Sexual Dysfunction in Women and Nursing Approach  Şükran BAŞGÖL, Emine KOÇ  Chapter 33 .................................................................................................................. 361  Using the Model to Assess Sexual Health  Funda EVCİLİ  Chapter 34 .................................................................................................................. 367  The Importance of Human Milk and Breastfeeding in Terms of Community Health  Zeliha Burcu YURTSAL  Chapter 35 .................................................................................................................. 373  The Use of Reflexology in Women's Health Reflexology  Nursen BOLSOY  Chapter 36 .................................................................................................................. 386  Peer Education and Sexual Health  Funda EVCILI  Chapter 37 .................................................................................................................. 393  Children with Specific Learning Disability  Hülya TERCAN, Müdriye YILDIZ BIÇAKCI  Chapter 38 .................................................................................................................. 405  The Study of Social Skills and Peer Attachment of Adolescent  Asya ÇETİN, Arzu ÖZYÜREK  v

Chapter 39 .................................................................................................................. 409  Supporting Memory Development in Early Childhood  Arzu ÖZYÜREK, Asya ÇETİN  Chapter 40 .................................................................................................................. 414  Role of Child Development Specialist in Early Intervention Process  Çiğdem AYTEKIN  Chapter 41 .................................................................................................................. 427  The Situation of the Children's Home in Turkey  Figen GÜRSOY, Fatih AYDOĞDU  Chapter 42 .................................................................................................................. 437  Normal Developing Siblings of Children Having Different Problems  Selvinaz SAÇAN  Chapter 43 .................................................................................................................. 452  Investigation of the Development of Premature and Non-Premature Children  Didem EMRE BOLATBAŞ, Müdriye YILDIZ BIÇAKÇI  Chapter 44 .................................................................................................................. 459  Epidemiology of Urinary Incontinence and Risk Factors  Ayten DİNÇ  Chapter 45 .................................................................................................................. 472  Approach to Inflammatory Bowel Diseases with Current Guidelines  Berna Nilgün ÖZGÜRSOY URAN, Elif ÜNSAL AVDAL, Yasemin TOKEM  Chapter 46 .................................................................................................................. 488  Balneotherapy and Health  Bülent ÖZDEMIR, Levent ÖZDEMİR  Chapter 47 .................................................................................................................. 494  Color Stability of Provisional Materials Used in Dentistry  Ayşe Nurcan DUMAN   Chapter 48 .................................................................................................................. 508  Enteral Nutrition  Hülya KAMARLI, Aylin AÇIKGÖZ  Chapter 49 .................................................................................................................. 524  The New Favorite of Children and the Young: Energy Drinks  Selvinaz SAÇAN, Hakan Murat KORKMAZ  Chapter 50 .................................................................................................................. 532  Energy Drinks: Contents, Effects and Awareness of Consumption  Fatma ÇELİK KAYAPINAR, İlknur ÖZDEMİR   Chapter 51 .................................................................................................................. 547  Some Wild Plants Commonly Used in Folk Medicine in Turkey  Sefa AKBULUT, Mustafa KARAKÖSE 

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Chapter 52 .................................................................................................................. 560  Mobbing; Effects on the Mental Health and Protection  Nermin GÜRHAN, Ebru KURDAL BAŞKAYA and Perihan SOLMAZ  Chapter 53 .................................................................................................................. 572  Smoking Behaviour Among High School Teachers in Turkey  Ayten DİNÇ  Chapter 54 .................................................................................................................. 580  The Effect of Developing Technology on the Family Structure and Family Relations  Derya ADIBELLI, Rüveyda YÜKSEL  Chapter 55 .................................................................................................................. 590  The Rules of Requirement in the Swimming Pools  Cemal GÜNDOĞDU, Evrim ÇELEBİ  Chapter 56 .................................................................................................................. 600  Gender Perspective on Leadership  Aslı ER KORUCU, Füsun TERZİOĞLU  Chapter 57 .................................................................................................................. 614  Legislation and Mobbing in Turkey  Nermin GÜRHAN, Ebru KURDAL BAŞKAYA, Çiğdem KAYA  Chapter 58 .................................................................................................................. 623  Hospital Management and Organization in the Ottoman Empire  Bilal AK  Chapter 59 .................................................................................................................. 640  Network Analysis; Accessibility to Hospitals with Remote Sensing and Geographic Information Systems Techniques: A Case Study of Konyaaltı, Antalya-Turkey  Mesut ÇOŞLU, Serdar SELİM, Namık Kemal SÖNMEZ, Dilek KOÇ-SAN  Chapter 60 .................................................................................................................. 648  The Organization of the Health Care Services in Turkey  Sabahattin TEKİNGÜNDÜZ  Chapter 61 .................................................................................................................. 670  The Role of Teamwork in Patient Safety at Healthcare Institutions  Şerife Didem KAYA, Aydan YÜCELER  Chapter 62 .................................................................................................................. 690  Theories of Play in the Context of Leisure  Ali TEKİN, Gülcan TEKİN, Emrah AYKORA  Chapter 63 .................................................................................................................. 704  Determining Some Physical and Physiological Parameters of Undergraduate Students  Fatma ÇELİK KAYAPINAR, İlknur ÖZDEMİR 

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Chapter 64 .................................................................................................................. 711  Electrical Muscle Stimulation and Its Use for Sports Training Programs: A review  Fatih KAYA, Mustafa Said ERZEYBEK  Chapter 65 .................................................................................................................. 734  Prohibited Substance Use in Sports and Therapeutic Use Exemptions  Halil TANIR  Chapter 66 .................................................................................................................. 745  Exercise is Medicine  Gözde ERSÖZ  Chapter 67 .................................................................................................................. 759  Muscular Endurance Training with Electromyostimulation: Is It Possible Torque Production in Fatigue?   Fatih KAYA, Salih PINAR, Elif Sibel ATIŞ, Andrew P. LAVENDER, Mustafa Said ERZEYBEK 

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Chapter 1 Nursing Services in the Ottoman Empire Behire SANÇAR INTRODUCTION The nursing history begins with the woman's role of healing (Yürügen, 2005). The birth of nursing which is one of the oldest health professions is based on antiquity. Known in the patient and interested in starting with help of nursing services are fond of medieval Europe to be at the Church on site and in the protection and nursing service is the majority religion among the officials for that period is "sacred" nursing, nurses voted as "Angel". The development of nursing in the world was effected by historical events like wars and natural disasters. It is useful to look at what nurses live when they were sick before talking about women patient care related activities in the Ottoman Empire period. Women had to adopt a closed home lifestyle, when they fell ill they tried to find a cure from either the women-doctors who learned to heal from their mothers or grandmothers or on their own. Home physicians and going to women's health organizations that accept woman-patients were applied only if it's just they can't handle cases when it becomes possible to be requested outside help required. Women were not in public life and they were accepted as "intimate". For this reason, receiving a treatment and care service has not been much of a pick up in question. Along with the innovation in the field of health, women's health attention trends continued in the second half of the XIX. century (Torun, 2008). In the XVIII. century, the industrial revolution created social changes have influenced the profession of nurse and the need of a nurse has been noticed. Founded around the industrial areas of cities, especially that industry employees and their families a lot of people have settled caused the illness and injury increase. In addition, along with increasing industrialization, middle class human communities began to increase. These people are conscious of helping weak in the lower class who are needer and care for the injured and ill. Also in this period, the woman emancipation efforts and supporting the development of women's rights has contributed to professional nursing (Ökdem et al., 2000; Öztürk, 2002). Addressing of "Nurse" was started to be used intended for German nurses firstly. In the years of 1912 – 1913 Balkan war, Gülhane Seririyat Academy and Hamidiye Etfal hospital while addressing the nurses from Germany used "schwester" in Turkish the word "nurse" had been used and this usage has come until today (Torun, 2008). In this section it will be presented about the concept and approach of nursing, patient care services in hospitals, military nursing in the battlefield, the role of the Red Crescent in health services, volunteer nursing, caregiver and nursing education and applications in the Ottoman Empire. 

Assist. Prof. Dr., Toros University School of Health Sciences, Nursing and Health Services Department

I. THE CONCEPT OF NURSING Ottoman nursing and patient care services based on fairly old when looking at written sources. Health services had an operability which cannot be underestimated in the management of head physician. Again during the reign of Bayezid II, it is known that there was the institution of caregivers and female caregivers called themselves as “Ana (Mother)” working at Enderun School Health House (Metintaş et al., 2013; Ak, 2000). Until this era it was not mentioned patient care-giving people in this organization structure yet. In fact, that the women make patient care and they tried to solve a few health problems their own way among the people are still located in the written sources but not indicated as a name of nurse or caregiver (Çavdar & Karcı, 2014). In the Ottoman Empire, along with the woman’s life in the house separate from the men health care was taken in charge by untrained men. The battles require increased losses with patient care. At Ottomans, there were only medical schools as health related educational institution. Some other health professions schools could be founded in the last period of the Empire. There always were midwives, cook women, bonesetters working with woman healers conducting the treatment issues by preparing drugs in the community. They grow up with master-apprentice method (T. C MEB, 2013). When we look at as a definition of Nursing, the first time the definition of nursing was made by Florence Nightingale in 1859. According to this definition, nursing is "the individual is renewed in a best way for that the nature can be effective on the individual best”. Nursing in terms of the essential needs like warming, ingestion, respiration provided by the nature for individual involves functions such as to help the patient who cannot eat, to help them rest and to warm up. Many nursing definition were made in the history of Nursing. Nursing definitions made by nursing theorists, professional organizations, and some organizations come until today. For example; Henderson said that "nurse is consciousness for unconscious, eyes for who cannot see, the moving power of a child and knowledge and assurance of young" and also revealed the importance of the nursing profession (Pektekin, 2013). In 1910 the Hilal-i Ahmer Ladies Center was established and women have begun to participate in the work and social activities. Day by day this Centre is more recognition, after a while the name was changed as "Hilal-i Ahmer Ottoman Women". At the next step Dr. Besim Ömer's leadership began work on the establishment of the Ladies Center and the ladies arm with the name of "society of the Ottoman delegation of Hilal-i Center" was completed in 20 March 1912 (Karal Akgün & Uluğtekin, 2000). In the written documents “Bimarhane Nizamnamesi” published in 1876 women caregivers were mentioned as “inas janitor” and their tasks and uniforms were stated. Inas janitors had worn "yeldirme (headscarf worn with light top), hijab shirt, apron, don (dating back to the inner ankles), dress, cardigans, socks, shoes, slippers or merkup some kind of shoes made out of yellow leather)". This information shows that nurses also had a uniform order at that time. According to 1865 Yearbook, Madam Lebibe, Madam Nesibe and Madam Hafize were nurses serving medical school in clinics in military with this uniform order. In the late Ottoman periods, footwear and uniforms worn by the caregiver women was not so different from the instance in the West. The patient carers’ uniforms were affected by the religious and social factors, uniforms of those which are just like the nurses in the west long skirt dress, completely covering the head covers and apron. Unlike in the West where dark dresses prefered, in the Ottomans 2

achieved resources white dresses are outstanding. It is not known whether it was effective or not, the Hadith "Dresses white ones. Because they are your the best dresses to wear” may be helpful to explain about that nurses wore white because of religious requirement during the Ottoman period. During care service nurses wore white color uniforms more, and in their civilian lives they go around with clothes designed specifically as well as the other countries (Yalçın et al., (2014). Nursing as fundamentally “care” action is trying to take shape as a profession since Florence Nightingale. The nursing profession needs to achieve what it should have the criteria of profession for the evaluation of professionalization efforts of nursing. In Turkey, it must be compared the criteria that a real profession is suit with nursing in order to evaluate the way mileage in the process of professionalization of nurses. According to criteria developed by Kelly nursing; 1. Must offer vital services to the health of society and humanity, 2. Must be constantly renewed and developed knowledge with the help of researches, 3. The service must contain the intellectual activities and individual responsibility must be a strong feature of the service, 4. Professional members should be educated in institutions of higher education (undergraduate), 5. Professional members should be in driving seat of its policy and control of actions and must be independent, 6. Services given by the members of the profession should motivate them 7. There must be codes of ethics that directs the members of the profession and guides the professional decisions, 8. There should be a professional organization that supports the development of the profession and select the application standards (Korkmaz, 2011). As a result of the personal efforts of Besim Ömer Pasha, nursing profession has been interested by the İstanbul's cultural environment and women began to work in hospitals in the Balkan war. Therefore 1912 is regarded as the year of the beginning of the nursing profession in Turkey (Ökdem et al., 2007). II. PATIENT CARE IN HOSPITALS After the medical function of hospital patient care is the most important function. The most important service expected in hospitals is that patients should be given patient care services as needed. Patient care services constitute a large part of hospital services (Ak, 1990). In the Ottoman Empire; there were a lot of health and patient care service organizations apart from the hospital. While many of patients were cared in homes, military units patient care was very seriously in the hospital too. Caregivers carried out a duty in hospitals. In the period of Sultan Bayezid, it is known that there were female caregivers working in Enderun School Hospital and called themselves as “Ana (Mother)” and institution of nursing (Metintaş et al., 2013). According to the staff records (1550) of Haseki Hospital it is seen that while there were 4 staffed nurses and 2 staffed caregivers 2 staffed nurses and 12 staffed female janitors in 1899 in Hamidiye-I Etfal children's Hospital (Ak, 2000). The Sultan II. Mahmud’s wife Bezmialem Valide Sultan made a 201-bed hospital 3

done at Çapa in 1845. This property of the hospital is that the name of “hospital” was used firstly for a health instution in the Ottoman Empire. It is known that the female patients were also at the Gureba hospital and "Inas Janitors" (female, girl janitors) have received the mission in patient care. Its importance in the history of nursing is founded by the Red Crescent Society of Turkey in 1925 "School Nurses Nurse" is the first application hospital. Since XVII. century, midwives in the “Concubines Hospital” providing service to members of the Court at the Palace, a woman providing inspection-treatment to the patients called “Patients Master” and her assistant called “Patients Kethüdası”, also caregivers called “Nine (Grandmother)” and the concubines who were their assistants were encountered. “Zeynep Kamil Hospital” founded by daughter of Kavalalı Ali Pasha Governor of Egypt and the the wife of the Grand Vizier Yusuf Kamil Pasha Zeynep Kamil has been allocated to women. Muslim caregivers women carried out a duty again in the Zeynep Kamil hospital in 1896 until Cemil Pasha brought a head nurse and eight nurses from Vienna. In 1895 Besim Ömer Pasha was assigned for the Figure 1: Hilal-i Ahmer midwifery education at Viladethane and (Kızılay) Clothing of Nurses improvements had been made (Torun, 2008). Today at the most important still ongoing service hospitals Gureba (needy) hospital and Zeynep Kamil Hospital records, and female caregivers care to patients is very clearly seen (Metintaş et al., 2013). Previously it can be seen from the records that female caregivers worked at Topkapı Palace Concubines and Enderun Hospitals . At the beginning of 1900, acceptance of female patients in the hospitals in İstanbul and in these hospitals female caregivers cared of patients have been known (Altıntaş, 1998; Sarı, 1996/97). III. MILITARY NURSING SERVICES In wars, they received wounds of the soldiers, the war also facilitate the spread and infection outbreaks in the areas of hygiene and order has had a devastating impact on the war. Wounded soldiers and soldiers too sick to treatment aimed at military medical and patient care is a very important task fulfilled and contributed to the development of the nursing profession. For example, in the Crimean War, it was seen that poor hospital conditions caused very large and unnecessary losses and thanks to Florence Nightangale these conditions could be improved (Khalkedon, 1996). The Turks have done several battles throughout history. There were staff to give moral support and patient care to patients with sick and injured in these wars for surgical applications and dress wounds. Medical soldiers had served for these jobs. Sometimes volunteer ladies or young girls taken patient care course have provided patient care services for injured soldiers. In addition, military help and aid society has been founded. In one corner of the School of Medicine in 1845 with the help of two-year courses 4

health care providers called "little Surgeons" were to be grown. They were learned circumcision, vaccines and dressing processes (Şehsivaroğlu et al., 1984). The title of today's Health Officer in Turkey small Surgeons are pioneers ”Male public health Nurses” grown to be run in rural areas more (Ulusoy, 1998). Britain, France, and Sardinia had joined the battle between the Ottoman Empire and Russia beginning in 1853 after a year. Decided to help its allies of the Ottoman Empire, beginning to use as hospital Selimiye barracks and military barracks after emptying them for all of their allies. But this was not met the requirements of daily care in the barracks (bandages, fractures to the Board, medicine, lighting etc.). In the newspapers in the United Kingdom; after that The French wounded soldiers were cared by French nurses and they had enough material by looking was written and British people were influenced by this news. On top of that, Defence Minister Sidney Herbert knowing Florence Nightingale very well and what he's capable of wrote him a letter to go to Turkey. Nightingale accepted the task and took immediate action. He made announcements to collect the nurse and the caregiver. 38 people accepted this call of Nightingale. Complementing his preparations Nightingale was sent to Turkey by the British Government as "the Representative Director of Female Caregivers of British Military hospitals” (Şentürk, 1983). On the evening of November 4 in 1854 coming to Istanbul, Nightingale and her team have been placed the Selimiye barracks. Miss Nightingale and his team have determined the problems about necessary medication and space to care the injured people built a portion of a 6 months turned in to the hospital. Nightingale and her team’s works gave a result as soon as possible and at the time due to the common infectious diseases with a high mortality rate was reduced. The French and British nurses’ works established an example for the nursing training (Kum, 1967). Nursing in the modern sense; During the Crimean War (1854-56), as a result of the disciplined work Florence Nightingale death rate decaying from 42% to 2% is considered to have begun with it. With her knowledge and compassion to patients injured F. Nightingale became a legend (Ak, 2000; Ak, 1987). İstanbul days of Miss Nightingale are composed of two terms. First is 1854-55 winter season, and the second is the season from 1855 spring until the summer when she returned to England. During the winter, although the weather was very cold there was no stove in her room. Florence watches wrote during the cold nights where one’s breathe in the air freezes. Figure 2: Florence Nightingale Officers said that the lamp was not off in her room until the morning (WoodhamSmith, 2006). The people of Istanbul was called her "Lamp Lady" and appreciated her works. After this public satisfaction at the period of Sultan II. Abdulhamit, 11 sister nurses imported from Germany to care wounded soldiers of Ottoman Army. During the first World War (1916) 7 Red Cross nurse gave the Turkish army’s wounded patients 5

care service (Şehsivaroğlu et al., 1984). When the Crimean War was over, the Selimiye barracks had been used by the Ottoman army and again in the first World War soldiers was brought the education and housing into use (Öztaş et al., 2005). After the first World War, the Hilal-i Ahmer women were beyond the history in terms of thought social In those years, because women were not respected as wise as and as powerful as men they were expected serving at disposal service under men to work or around the House. But Hilal-i Ahmer exceeded this opinion and women worked on their own initiative and are able to work with men, can make decisions, can set up organizations, both men and women work together, women could take care of men patients, men could take care of women patients. This was very important to Turkish social life (Metintaş et al., 2013). All these battles were momentous events because they revealed the fact that nurses needed to care for the wounded. But given contributions from the nurses coming from abroad were limited and they were not the solution for the Ottoman Empire. At Balkan wars (1912) there were many difficulties in finding a nurse and wounded soldiers were miserable have not been forgotten by the Turkish Society (Ulusoy, 1998). IV. RED CRESCENT AND NURSING II. Hilal-i Ahmer Association founded in the period of Abdul Hamid and one of the most important institutions of the Ottoman Empire was the most important benefit society with its activities (Şimşek, 2015). The Red Crescent founded on June 11 in 1868 as the name of "Ottoman Help Society for the Wounded and İll Soldiers" was born from the desire to help who was wounded or ill soldiers on the battlefield with no discrimination. Its name became "Ottoman Hilali Ahmer Society" in 1877. In the periods when the Red Crescent called as the name of Hilal-i Ahmer, the Red Cross known as Salib-i Ahmer was established as a product of Humanism highlighting “human” element without religion, language, race discrimination in the West. The given value “human” clearly has shown itself by helping wounded soldiers because they're only human without religion, language, race discrimination. In subsequent battles humanist approaches have continued to increase and human concept started to be cared. The humanistic authors of that time continuously called for peace and wrote to invite to Figure 3: Besim Omer Pasha, relieve the sufferings of the wounded without the Founder of the Red distinction. Crescent As a result of this humane approach powered by Jan Jacques Russeau’s opinion underlined that the unarmed soldiers cannot be described as an enemy thoughts of internatioanl aid agencies began to be formed and the Red Cross has been founded. In the Geneva Convention signed by the Ottoman Empire on 5 July 1865, it was adopted policies that contain entirely humane dimensions and standing of the political purposes. To the first International Red Cross Congress in 1867 in Paris representative of Ottoman Empire is Hungarian Dr. Abdullah bey and was elected for the Organization's permanent membership. In the Paris Conference, Abdullah bey promised to provide the 6

implementation of the Geneva Convention in the Ottoman Empire, when he came into the country, however, the authorities is not supported him. With the help of challenges of Abdullah Bey and Crimean Dr. Aziz Bey ongoing for a while “Mechurin ve Mardayı Askeriyeye İmdat ve Muavenet Cemiyeti” (Ottoman Help and Aid Ill and wounded soldiers Society) has been founded and it was headed by Marko Pasha the minister of medicine after a while. European countries have been aware of this society established in the Ottoman Empire in Berlin Congress in 1869. Although they succeeded to publish a newspaper called “Gazette Medicale” to advertize community policies and widely to get public interest in the country as well as abroad it has not become sufficiently understood and engaged. Indeed, it has existed for a while with personal efforts of Abdullah Bey but not much interest after his death in 1874 the society has had to split. On 14 April 1877 the Institution was officially established as Ottoman Hilal-i Ahmer Society. Shortly after the establishment of the Red Crescent, particularly in Islamic countries and India and many other countries started to send help (Çapa, 2010). The symbol with Red Crescent of Hilal-i Ahmer Society which was awarded by the international Red Cross Society because of its effort to help was started to be used as a symbol under the reconstructing process in the second constitutionalist period. II. After the proclamation of the constitutional monarchy, Hilal-i Ahmer used every opportunity in order to explain and get support from the government. For example in April 1910, visiting İstanbul in the parade organized in honor of the King of Serbia representatives of Hilal-i Ahmer “on a white background with the head of a band of red half-moon on left arm took part. In those years, in order to have an adequate staff in Hilal-i Ahmer whose the most important aim of them is to help the sick and wounded people courses where staff will give the health care has been opened by doctors. Besim Ömer Paşa and Asaf Derviş Bey known physicians of the era are the pioneers of the volunteer doctors who gave lessons to people who gave patient care. Besim Ömer Pasha is considered to be the father of Turkish nursing (Ak, 1977; Ak, 1978). Hilal-i Ahmer has undertaken major tasks in the Italo-Turkish War and in connection with this it has been restructured premises in 1911. According to the decision taken by the General Center of Hilal-i Ahmer on October 7 in 1911, medical teams were constructed to help wounded, sick soldiers and the public health requirements to be sent to the war zone. Three Hilal-i Ahmer medical teams were sent first the war areas centered at Tripoli, Homs and Bingazi. These teams constructed mobile hospitals and emergency teams as the first job at near the front. In Giryan where particularly typhoid epidemic has been seen as well as Hilal-i Ahmer in addition of it also German and British Salib-i Ahmer teams cared sick and injured with a big dedication (Karal Akgün & Uluğtekin, 2000). Besim Ömer Pasha who contributed moral and material support while reconstructing the Hilal-i Ahmer gave a lecture about Hilal-i Ahmer to women in Istanbul University Conference Room on January 27, 1914 on Tuesday. He said in the “the nature of woman and the position in medical science” section of this Conference: "Please imagine that a family man who is a hunter on the side of too heavy quivering febrile illness returns to the cave. Can you endure someone being disturbed and suffered around you without any consolation? In this case, what did this woman shut herself up in the cave do? She thought that the fire softening foods could ease pain. 7

Immediately after heating a stone that he could get his hands put to on his wife's aching the side. Do not you use hot bricks still? There is no doubt that the woman wound bleeding from the body's blood with falling from the trees resin oil or curry wounds with leaves dealing with animal skins, wrap the broken places is certain. The woman feels that motherhood and family referred to the service lives of those who struggle against patronage and to maintain protection for an important mission was the cause of nature that specifies the form of. Women cared first of all relatives and close relatives. Finally, she spread her mercy to all foreigners and people completely. Even those times the woman served as a “caregiver” because of her sensitivity, mercy and mother for a granddaughter firstly. Besim Ömer emphasized that women can use their abilities in patient care and they are creative in this area by using these expressions (Hacıfettahoğlu, 2010). In wars in history, nursing first steps started to be taken with care of the soldiers injured. V. NURSING EDUCATION In the Ottoman period, nursing education firstly started in the period of constitutional monarchy. But it was not previously experienced wars and some developments that occur for example in this topic is also a fact. Laying out the importance of the nursing profession in the Ottoman Empire and started the training institution is the Red Crescent (Sarı, 1996/97). In XIX. Century States that due to the accumulation in the field of health epidemics started coming up. Quarantine society was laid the foundations with the help of struggle, which was made by simple methods at first against epidemics such as plague and cholera causes numerous deaths at every period of history with modern shaping in XIX. Century Particularly concerns created by cholera has accelerated the establishment by health agencies by referring the states in collaboration against this unrelenting enemy. Organization of the foundations of the Ottoman Empire and in the disposal of sanitary diseases has followed a parallel course that brings out the known example (Çavdar et al., 2014). As an aid to physicians in the Ottoman palace, women caregivers worked there. In addition, in the years in 1800 according to the ruler held annual dictionary and daily of hospitals, in civil and military hospitals female caregivers served. In this annual and lists the names of the women in charge of caregivers, their tasks, fees, arrival and departure dates were written. "Midwife school" depending of the military medical school was established in İstanbul in 1843, the school gave its first graduates in 1846 and seen educational shortcomings addressed. These trainings are made much more intensive by Dr. Besim Ömer Pasha (Akalın). Nurse Education came up again with the constitutional monarchy (1876) and Dervish Pasha has put it to the application area. As a mediator, “Tannin” newspaper helped people who wanted to register for a course. On the other hand, some of the volunteers had attempted about this issue. For example, Elyanis İsrailiyyet School inas (women, girls) has decided to open a class for the nurse in Thessaloniki. Madame Kelpseman taking up this business has tried to find a doctor who teaches lectures on the other hand. The important thing is that a number of undertakings in this regard with constitutional monarchy has been emerged (Kurnaz, 2015). Of course, in this period, women are given by the patient care services today's sense of the "nursing" not be considered but these developments "a requirement for nursing agency" should be 8

judged as a process of development. The definition of Nurse began to be expressed for the first time towards the middle of the 19. Century. Although earlier caregiver and midwifery studies don’t contain nursing definition tasks exactly nursing services were provided by these two groups for years. There is no nursing as an institution so patient care services has continued under the name of midwifery and nursing. The founder of modern nursing is great physician of Turkey Besim Ömer Paşa (Akalın). Living in between the years 1862-1940 Dr. Besim Ömer Pasha joined the International Red Cross Conference on behalf of the Association of Hilal-i Ahmer in London in 1907 and that meeting met Florence Nightingale who was the guest of honour. During the Congress, Dr. Besim Ömer Pasha was given important ideas of modern nursing by Florence Nightingale’s chat and discussions and opened his horizons about the subject. Dr. Besim Ömer Pasha began to introduce this concept to those concerned and the importance that is given to a nurse by the modern European countries and shortcomings of the Ottoman State in this area shortly after he returned to Turkey. The beginning of any institutional nursing service is the year of 1854 is acceptable. Serving the first Turkish nurses training certificate is in 1912. Nursing courses were opened in 1913-1914 years in Darülfünun (Ottoman University) with the efforts of Dr. Besim Ömer Pasha and 300 nurses completed these courses served in World War 1 (Metintaş et al., 2013). in 1897, at the Ottoman Medical School Wonderful the class named “nursing style” was inserted to class of midwife and sick patient care work shall be included in the curriculum, this course was given by Dr. Kenan Tevfik (Sezenel). In 1908, with the arrival of civilian medical school faculty here into "Caregiver women's School" was opened. In 1909, "Nurse" book was written by Refik Munir (Keskingil) and Kenan Tevfik (Torun, 2008). In 1895, midwifery education was given by Besim Omer Pasha and he made improvements. Hilal-i Ahmer Ladies Center continued to work in hospitals and many other environments in an organized manner. As well as the contributions many ladies cared wounded soldier by going to battlefields if needed. To carry out this important task they participate the open courses from time to time and tried to be sufficient for health services. Society has given the birth certificate of nurse continuing courses. There is a title "Nurse" in the form of a wallet, and at the end of it there was a letter with a sign of "Ottoman Hilal-i Ahmer Society of Women Central-Umumi”. In this letter the nurse and the caregiver have taken place and information about the letter ended with the following sentence: "She's used to live in separate men and women while roaming around the country, the State of a person always up, unaware someone else hadn't yet run a feed the need mutual trust. Maybe you even thought of an immoral altruistic Services believe are hiding a secret. This false allegations and disprove and Ottoman women is worthy of the role to make the mission high utilities with the utmost care and fulfilling the spiritual and moral confidence during the given works, we think you will never neglect ". 353 women trained in caregiver courses and service as a professional, when the First World War started, applied to the Central Umumi. Other than that, the women attending the theoretical courses in Darülfünun Kadirga school district the ongoing women above the Balkan Wars they served in hospitals with non-any diploma or 9

certificate 156 women served as voluntary. For example, the Governor of Van, Tahsin Bey's wife, Mediha Lady, contributed to the care of the wounded as a nurse by going to the hospital under control of Asaf Dervish Pasha. Ladies Center also dealt with students who do not get the news because of the war and located in Europe To establish a connection with students and tell them to show the interest and care of all kinds of footwear for sent caregivers (Karal Akgün & Uluğtekin, 2000). Usually, another useless people were caregivers. For the first time in Gülhane, Dr. Rieder, Dr. Deycke and Dr. Blas with their lessons of trained medics have been graduated. Given a week of 26 hours of class and selected soldiers has been the first grown graduates practicing in a ceremony in 1902 and took diplomas and into the ranks of the army. The first regular hospital nursing was started at Gülhane and first trained caregivers were trained here (Ataç, 1996). The army has given big losses due to the shortage of nurse in the Tripoli (1911) and Balkan (1912) wars. Participating in Red Cross Washington Congress in 1911 Dr. Besim Ömer Pasha and Dr. Nihat Reşat Belger have seen that Nursing is a profession and is separate to the branches. Dr. Besim Ömer Pasha indicated the need for the nursing profession by affecting the Red Crescent (Hilal-i Ahmer). Hilal-i Ahmer considered this issue and appropriate funds for 6-month volunteer nursing course in Kadırga Hospital. A lot of courses were opened in the Auditorium of the İstanbul University in between 1913-14. Students has been explained the patient care applications (Ökdem et al., 2000). Besim Omer Pasha has opened caregiver courses for women in 1913-14. Graduated from these courses most of the approximately 300 caregivers cared wounded soldiers at Çanakkale Front (1915-16) and in the other fronts of World War I. In 1920, Americans established the private teaching of nurse in İstanbul to meet the nurse need for American Hospital today's name "Admiral Bristol Health high school". But Turkish families did not send her daughters to this school. A reference to the only the daughters of minorities made an application to the school. For this reason, during the Ottoman period and of the initial period of the Republic of Turkey, founded later health has remained extremely inadequate manpower (Ulusoy, 1998). VI. VOLUNTARY ACTIVITIES OF NURSING In Ottoman-Russian War (1877) a very small number of Turkish women worked. In Ottoman-Greek War (1897), Cemiyeti İmdadiye that was founded by Fatma Aliye Hanım and it has been the first society for help established by a woman. They served to wrap of the wounds of the injured in the war and are served in maintaining the rest (Toros, 2016). Munire İsmail, Kerime Salahur, Safiye Hüseyin Elbi Ladies have been awarded the Medal of Honor society given by Hilal-i Ahmer Society because of in Balkan Wars their efforts and achievements in the treatment of the typhus patients in the ship going to Germany (Metintaş et al. 2013). In Balkan War some ladies have sought in hospitals on a voluntary basis. But there is no any society related nursing so they could not be well-organized and large organizations troubles. To encourage the Turkish women nurses during the Balkan war Turkestan nurses came to İstanbul from Turkestan and from various countries Red Cross nurses and women working in the army played an important role. In 1908, a nurse school was opened in the school of Medicine. In the First World War, the need for orderly trained nurses has reached its zenith. Besim Ömer Pasha and 10

Red Crescent dealt with this issue and they founded Red Crescent Women's branch (1911). Women have always served the Red Crescent more than men (Sarı, 2000). In the Ottoman period women also sought as voluntarily to build hospitals and patient care as well as outreach work (Ökdem et al. 2000). A Hilal-i Ahmer Hospital was opened in Van with the help of Van Governor Tahsin Uzel’s wife Mediha Lady. Mediha Lady worked as a volunteer for caregivers for the eastern front of World War I injured in that hospital. Figure 4: Red Crescent Volunteer Nurses On the same dates due to the Haydarpasa hospital services charge nurse Hatice Çeker Lady was honored with the "Bronze Service Medal" by the Sultan (Metintaş et al., 2013). Nursing and its efforts were met with appreciation by the Palace. For example, at the same time, Hilal-i Honorary President of the Association of Crown Prince Yusuf İzzeddin Effendi, Nurse course the successful completion of the diploma of the Galley itself, indicating that appreciate them beautiful. Patient care in hospitals and social services has led to an environment of conversation for women İstanbul's genteel ladies with "Anatolia's valiant sons" of dating and so mutual conversation platform was born.

Figure 6: Table to Encourage Nursing

Figure 5: Table to Encourage Nursing

Despite these developments, the first nursing school facilitate was opened in İstanbul in 1920. "The American Admiral Bristol hospital nursery school", the school has to appeal to more minorities (Kurnaz, 2015). Besim Ömer Pasha had watercolorspaintings made to Western artists to emphasize the nursing to highlight the importance of patients within the hospital. These paintings were replicated on the postcards and stamps and ladies in this way were invited to nursing.

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Pasha, also with compassion in Genesis nursing has found more appropriate to women. Besim Omer Pasha stated that female nurses should also be mentally, spiritually and morally strong because nursing is a gentle task. Besim Ömer Pasha has opened nursing courses in the Red Crescent Center (1914), in Istanbul University (191415) and in Galley Birth Clinic (1916). A large number of ladies came by running to nursing courses opened at Military. Palace also gave importance to the Red Crescent and female nurses. Palaces and Government dignitaries participated in the graduation ceremony and graduates of the nurse's honor roll medals have been given by them. These courses were continued until the end of the war. Most of the lady who graduated from these courses performed the duty in the First World Figure 7: Hilal-i Ahmer War on several fronts on the bloodiest days in the war. (Red Crescent) Nurse The Sultan has pride with these (Akalın, 1914; Yalçın et Uniform (Kızılay, 2016). al., 2014; Hot, 1996/97; Kazancıgil, 1980). The Red Crescent has opened course in Bursa and Erzurum beside Istanbul. Eminent family girls had participated these courses. Founded under the chairmanship of Erzurum Governor Tahsin’s wife the Red Crescent Ottoman Ladies Group helped injured people and cared them in the hospitals of Red Crescent. 20 people the teachers college and a student nurse died for the sake of the task from infectious disease (Sarı, 2000; Torun, 2008; Ökdem et al., 2000; Akalın, 1914). REFERENCES Ak, B. (1978). Hemşire Sorunları Türk-iş, Sağlık İş Sendikası Yayın Organı, 2 s., Ankara. Ak, B. (1987). Hastane İdaresi ve Organizasyonu, (Mimograf), Hacettepe Üniversitesi, Sağlık İdaresi Yüksekokulu, s.11-16 Ankara. Ak, B. (1990). Hastane Yöneticiliği, Özkan Matbaası, 76 s., Ankara. Ak, B. (1997). Hemşireler ve Dertleri, s.4. Ankara Ak, B. (2000). Osmanlı Devletinde Sağlık ve Hastane Yönetimi (Bilal AK, Adnan, Ataç), Osmanlı Devleti’nde Sağlık Hizmetleri Sempozyumu Bildiri Kitabı, Ajans Türk Matbaası, s. 135, Ankara. Akalın, B.Ö. (1914). Hilal-i Ahmer’e Dair Konferanslarım. Ahmed İhsan ve Şükerası Matbbaacılık Osmanlı Şirketi, 1330 s., İstanbul. Altıntaş, A. (1998). Türk Hemşireliğinin başlangıcı. Sağlık Alanında Türk Kadını, Yayınlayan: N. Yıldırım. 373-387 s., İstanbul. Ataç, A. (1996). Gülhane Askeri Tıp Akademisi’nin Kuruluşu, Atatürk Kültür Merkezi Başkanlığı,Türk Tarih Kurumu Basımevi, 102 s., Ankara. Çapa, M. (2010). Kızılay (Hilal-i Ahmer) Cemiyeti (1914-1925). Türkiye Kızılay Derneği Yayını, Özel Matbaası, 12 s., Ankara. Çavdar, N. & Karcı, E. (2014). XIX. Yüzyıl Osmanlı Sağlık Teşkilatlanması’na Dair Bibliyografik Bir Deneme. Turkish Studies-International Periodical For the Languages, Literature and History of Turkish or Turkic Volume 9/4 Spring, 255-286, Ankara Hacıfettahoğlu, İ. (2010). Hanımefendilere Hilal-i Ahmer’e Dair Konferans, Doktor Besim Ömer,Türkiye Kızılay Derneği Yayınları, 3. Baskı, 9, 51-58 s., Ankara. Hot, İ. (1996/97). Besim Ömer Akalın’ın Hayatı (1862-1940). Yeni Tıp Tarihi Araştırmaları 12

2-3, 213 229 s. Karal Akgün, S. ve Uluğtekin, M. (2000). “Hilal-i Ahmer’den Kızılay’a”. Beyda Basımevi, 5-6, 12-13, 14-16, 20-22, 27, 31, 32, 40, 41, 47, 59, 61, 168-170, 174 s, Ankara. Kazancıgil, A. (1980). Ölümünün Kırkıncı Yılında Besim Ömer Paşa (1863-1940). Dirim, Yıl: 55,Eylül-Ekim, 237-247 s., Ankara. Khalkedon, (1996). Askeri Tıp ve Hemşirelik. Tıp Tarihi, Roche, Hürriyet Gazetecilik ve Matbaacılık,150,151 s., İstanbul. Korkmaz, F. (2011). Meslekleşme ve Ülkemizde Hemşirelik. H.Ü Sağlık Bilimleri Fakültesi Hemşirelik Dergisi, 59-67, Ankara. Kum, E. (1967). Hemşire ve Kadın. Kadının Sosyal Hayatını Tetkik Kurumu Aylık Konferansları (1953-1964), Ankara, s: 135-137 Metintaş, M.Y., Önder, S. & Elçioğlu, Ö. (2013). Cumhuriyet Döneminde Kurumsallaşan Bir Temel Sağlık Hizmet Alanı: Hemşirelik, Türkiye Klinikleri J Med Ethics, 21(2), 102-110. Ökdem, Ş., Abbasoğlu, A. & Doğan, N. (2000). Hemşirelik Tarihi, Eğitimi ve Gelişimi. Ankara Üniversitesi Dikimevi Sağlık Hizmetleri M.Y.O Yıllığı, (1): 1, 7-8, Ankara. Öztaş, C. & Uzal, U. (2005). Geçmişten Günümüze Selimiye Kışlası. 1. Ordu Komutanlığı Yayını, TBMM Basımevi, s: 44-49, Ankara. Öztürk, Y. (2002). Kızılay. Bütün Dünya Dergisi, Haziran, s.55-59, Ankara. Pektekin, Ç. (2013). Hemşirelik Felsefesi, Kuramlar, Bakım Modelleri ve Politik Yaklaşımlar. İstanbul Tıp Kitabevi. 48 s., İstanbul. Sarı, N. (1996/97). Osmanlı Sağlık Hayatında Kadının Yeri. Yeni Tıp Tarihi Araştırmaları, 2-3, s.11-64, Ankara. Sarı, N. (2000). Osmanlı Devletinde Sağlık ve Sosyal Cemiyetler ve Hemşirelik. Osmanlı Devleti’nde Sağlık Hizmetleri Sempoz. Kitabı, Ajans Türk Matb., s.238-239, Ankara. Şehsivaroğlu, N.B. (1984). Türk Tıp Tarihi. Uludağ Üniversitesi Yayını, Bursa. Şentük S. (1983). Hemşirelik Tarihi. AR Basım Yayım., 99-112 s., İstanbul. Şimşek, D. (2015). Abdülhamid Dönemi Osmanlı Hilal-i Ahmer Cemiyeti’nin Kuruluşu ve Teşkilatlanması, s. 308, Ankara. T.C Milli Eğitim Bakanlığı. (2013). Deontoloji ve Mesleğinin Sorumluluk ve Yükümlülükleri, s.9-10, Ankara. Toros, T. (2016). Aydın, Kalburüstü Pek Çok Hanım Fahri Hemşireliğe Koşmuştu. Yakın Tarihimiz, Milliyet Yayınları, 393-395 s., İstanbul. Torun, S. (2008). Kirim Savaşı’nda Hasta Bakimi ve Hemşirelik, Yayınlanmamış Doktora Tezi, T.C. Ç.Ü Sağlık Bilimleri Enstitüsü Deontoloji ve Tıp Tarihi Ana Bilim Dalı. Ulusoy, M. F. (1998). Türkiye’de Hemşirelik Eğitiminin Tarihsel Süreci. Cumhuriyet Üniversitesi, Hemşirelik Yüksek Okulu Dergisi, 2 (1), 1-8. URL: WPO (2016). https://www.kizilay.org.tr/kurumsal/tarihcemiz URL: WPO (2016). Kurnaz, Ş. http://www.kadimdostlar.com/topic/76961-osmanly URL: WPO (2016). Yürügen, B. (2005). http://www.hemsireyiz.biz/blogs/makaleler/archive. Woodham-Smith, C. (2006). “Florence Nightingale, Türkiye’de ve Dünyada Hemşireliğin Kuruluşu”. (Çev. Hasan İlhan), Alter Yayıncılık 1. Baskı, 143-146 s., Ankara. Yalçın, S. Ö., Torun, S. & Kadıoğlu, F. G. (2014). Tıbbın Kültür Tarihi Çerçevesinde Hemşire Üniformasının Evrimi, Lokman Hekim Journal, 4 (1): 6-15.

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Chapter 2 Posttraumatic Stress Disorder Among Veterans and Well-Being: What Can Nurses Do about It? Derya ADIBELLI INTRODUCTION Throughout the history, mortality rates in battles have been of primary importance. Due to survival rates, rehabilitation has been as significant as medical care during immediate treatment period (Eshel, 2009; Fecura et al., 2008). The first rehabilitation services occurred in armed forces; they were generally not considered appropriate for civilians. The increasing number of war veterans has enhanced medical development in this field. After the I. World War, life expectancy of patients, who experienced spinal cord injuries, was less than a year. Mortality rates were high and rehabilitation was almost absent. Howard Rusk, who was a pioneer in rehabilitation medicine, although there were several people and institutions that took care of disabled veterans’ faith, claimed that their care was bad. According to Rusk, there was a life quality beneath that disability and the cure of body was not enough; people should be cured interactively (Sütçü Çiçek, 2014). Soldiers, who are on active duty, suffer from serious injuries due to explosions and consequently suffer from polytrauma and experience several physical, psychological and social problems. Traumatic Brain Injury (TBI) TBI is defined as the physiological distortion of brain functions due to an external force or structural injuries that occur traumatically. Injuries can be penetrating or closed; they might be classified as light, medium and serious. Light TBI, which is generally called as a concussion when it is rapidly and properly controlled, does not leave sequel or tends to be solved with minimal functional sequela. This group includes symptoms that require expertise rehabilitation services in order to prevent from long term sequela. Reversely, patients with medium and serious TBI generally need to go into hospital and require intensive rehabilitation. Most of these individuals have permanent sequelea, which can be significantly reduced through a right intervention at the right time (Arıkan Dönmez, 2014). Burns Burns during wars and explosions is among the most important health problems. 510% of veterans suffer from thermal injuries; 18% of individuals, who are in the proximity of explosions, have inhalation injuries (Center of Disease Control-CDC, 2008). Rehabilitation of patients with burns is not limited to skin care. As there are several different types of burns with different levels, it is necessary to bandage on time and to dress wounds regularly in order to present from infection. 

Assist. Prof. Dr., Akdeniz University, Kumlcu Health Science Faculty, Antalya, Turkey

Orthopedical Injuries and Fractures Explosion injuries might cause partial extremity amputation, fractures and soft tissue injuries. Due to extremity loss, there have been soldiers with functional disability that might last lifelong (CDC, 2008). For this reason patient and family education is very important. Rehabilitation process and discharge plans should be integrated. Sensory, Visual and Hearing Disorders The use of improvised explosives in wars and confects cause visual and hearing disorders, whether traumatic brain injuries exist or not. According to National Alliance for Eye and Vision Research (2009), approximately 16% of war injuries affect eyes. Optic nerve trauma is the most serious of them all. As most of the families do when infants learn how to walk, similarly families’ readiness and supportive features play a significant role in the deliverance of veterans with visual or hearing disorders from dependency to independency (Arıkan Dönmez, 2014). Pain Trauma and pain stemming from injuries could be important problems in wars and conflicts. Pain management requires nurses to be careful and cautious to use analgesics for medical treatment of patients and the red herring method should be supported by medical treatment. In addition nurses should educate patients and their families about pain management. In a study by Lew et al. (2009) with 340 veterans, it was identified that 68,2% of veterans suffered from posttraumatic stress disorders, 81,5% of them experienced chronicle pain; the most common of these was headache and then pain in shoulders, legs and knees. Posttraumatic Stress Disorder Traumatic events such as terror and war, which are intentionally created by humans, cause terror and confidence loss among individuals; they might cause serious physiciatric disorders, particularly posttraumatic stress disorder (PTSD), depression, anxiety, alcohol and substance addiction (Afari et al., 2009; Richardson et al., 2010; Osorio et al., 2012). Posttraumatic stress disorder (PTSD) emerges when an individual is exposed to a traumatic stressor or he or she hears or sees it. The concept of trauma generally refers to social violence, terrorism, war between countries, civil war, traffic accidents and natural disasters (Keten et al., 2013). In DSM-IV, posttraumatic stress disorder is defined as a situation that might occur after severe trauma such as a real death or death treat, serious injury, an individual’s confrontation with a situation that threatens his physical integrity or witnessing such an event (Özgen & Aydın, 1999); it is defined in DSM-5 with the same content however the sickness group has been updated as Trauma and Precipitating Factor Associated Disorders. This study was carried out in order to evaluate what could nurses do for well-being during veterans’ posttraumatic stress disorder. It is found out that the common mental disease among war participants is PTSD; the most common reason for PTSD among men is exposition to conflict (Brand, 2003). In addition, it is mentioned that PTSD might lead to the avoidance behaviour, alcohol and substance addiction, aggressive behaviours and even to self-destruction (Gelder et al., 2005). 15% of American soldiers, who served in the Vietnam War (1964-1975), had PTSD during the war and PTSD was observed among 62% of them after the war (Richardson et al., 2010). Even 20 years after the war, PTSD development rate for 15

Vietnamese soldiers was 19,5% (Thanh et al., 2006). Recent studies found out that PTSD frequency among American soldiers since the Vietnam War fluctuated between 2-17%; this range for American soldiers, who returned from Iraq, was found 4-17% and again for British soldiers of the Iraq War was 3-6% (Richardson et al., 2010). The soldiers, who participated operations in Iraq and Afghanistan, showed indications of PTSD (40%), depression (46%) and substance addiction (39%). PTSD emerged in the literature after the II. World War. Although PTSD’s prevalence varies from person to person, it might increase due to risky situations such as war, conflict and natural disasters (Özgen & Aydın, 1999). The studies analysing the relationship between terror and PTSD increase indicate that the attacks, which cause physical injuries to individuals, whose wounds do not heal and the seriousness of the injuries constitute risks for PTSD’s prevalence (Verger et al., 2004). Furthermore being single, being close to the explosion during the assault, witnessing visually to the explosion, having lost someone because of the explosion, facing economic difficulties after the explosion and being unable to work due to injuries are among other risk factors for PTSD (Njenga et al., 2004) Studies identify that almost half of the injured from war and terrorist acts have PTSD (Graham et al., 2006: Abeyasinghe et al., 2012). The separate research on soldiers in the Vietnam War and American soldiers, who were deployed in Afghanistan, made 30% PTSD diagnosis although none of the soldiers were physically wounded (Reeves, 2007; Dedert et al., 2009). A study in Turkey on a similar population found out that 6,5% of the cases had PTSD diagnosis (Keten et al., 2013). A study on military population, who served in the south-eastern region of Turkey and applied to hospital, indicates that 20% of cases have major depression, 20% have diagnosis of schizophrenia based on clinical observation; social phobia, agoraphobia, panic disorder and other anxiety disorders are rarely observed (Sungur et al., 1995). Studies show that the existence of social support after trauma affects psychiatric progression of the disease (Brewin et al., 2000; Özaltın et al., 2004). Individual with better social support are less inclined to the disease and particularly to suffer from its serious forms. Ren et al. (1999) identified that different types of social support contribute significantly to different health levels. Again, this study demonstrates that social support provides benefits to traumatic situations that are not associated with military service; however wars and conflict have long term effects on health conditions of soldiers and social support is not beneficial for military oriented traumatic situations (Ren et al., 1999). Vogt et al. (2005) investigates gender differences. Accordingly, no differences between genders were identified in terms of perception of fear, being in a social environment, working difficulties and family relations. It is found out that both genders are at a similar level concerning the severity of PTSD’s symptoms and depression and anxiety is identified high particularly for women. Another study reports that posttraumatic stress symptoms are similar among women and men (Rona et al., 2007); despite a slight gender difference on behalf of men in PTSD diagnosis (Seal et al., 2007), traumatic cases that include sexual abuse is more common among women (Tolin & Foa, 2006). Another type of stress of women soldiers, which cause serious mental health problems, is the sexual trauma (Mattocks et al., 2012). These experiences include sexual abuse, sexual harassment and rape (Yaeger, 2006; Kimerling et al., 2007, 2010). A prominent feature of PTSD is sleep disorders. In the last century, increasing 16

interest of mental diseases due to traumatic events and aftermath, sleeping disorders stemming from PTSD has become a point of interest in compassion to sleeping disorders in other psychiatric discomforts. High incidences of nightmare associated with trauma, dozing off and frequent wake-ups accompanied by anxiety are observed in PTSD. In a study by Elbogen et al. (2012) on Iraq and Afghanistan veterans found relationship between major depression disorders, PTSD, traumatic brain injury and financial difficulties. These situations lead to economic problems such as unemployment and low income. Furthermore, most veterans remain homeless because of economic problems and homelessness might cause crimes and difficulties to access institutional sources. Veterans with low-incomes, which are not even enough to cover their basic needs, might have risky behaviours such as theft, homelessness, alcohol and drug use and suicide attempts. Hankin et al. (1999) identified that 31% of veterans suffer from depression, 20% from PTSD and 12% from alcohol addiction. The ones who are married and employed have lower levels of mental disorder. A study by Schnurr et al. (2009) emphasized the correlation between PTSD and homelessness. Another study determined that 85% of homeless veterans suffer from PTSD (O’Connell et al., 2008). Nevertheless, PTSD also leads to problems in marital adjustment. It was found out that PTSD among veterans negatively affect couples’ adjustment and cause breakups-ups and divorces (Riggs et al., 1998). PTSD negatively affects most of the life dynamics. It has impacts on persons’ social and interpersonal functions (Norman et al., 2007), marriage functions (Dekel & Solomon, 2006), parents and intrafamilial functions (Cohen et al., 2008) and functions that are associated with work. Nonetheless, another study emphasized that PTSD increases job loss (Breslau et al., 2004). PTSD is not an individual but a familial and societal burden. Families should try hard in order to reduce emotional situations to the minimum and take the risk of harming themselves or others into consideration (Lew et al., 2009). Clinical Approach for PTSD Treatment of Veterans It is suggested that pharmacotherapy and psycho-therapy should be applied at the same time in treatment of posttraumatic stress disorder. It is considered beneficial to apply psycho-therapy, when the symptoms are not too severe, and when they are severe it is useful to apply both pharmacotherapy and psycho-therapy together (Önder & Tural, 2004). Some cohort studies on this issue demonstrate that both psycho-therapy and pharmacotherapy enhance life quality of veterans with PTSD in the psycho-social context. Some studies measure life quality that is associated with psycho-social and physical health; a study identified that treatment can develop psycho-social health but can not lead to changes in physical functions (Malik et al., 1999); however another study found out an opposite result (Mueser et al., 2008). The aims of pharmacotherapy in PTSD are to regulate sleeping order, to reduce complying thoughts and nightmare, to overcome the avoidance behaviour, fix repression, reduce the behaviour of selfdestruction, decrease dissociative and psychotic symptoms (Önder & Tural, 2004; Andreasen & Black, 2006). It is emphasized that the most useful mental approach in posttraumatic stress disorder is the method of exposure (Nash & Nutt, 2007; Öztürk & Uluşahin, 2008). When an individual confronts a thing, a place or a person that lead to constellation of traumatic event, he or she anxiously prefers to avoid these situations. Exposure therapy aims to provide insensitivity to such situations by gradually 17

increasing confrontation of them mentally or in real life. The research on health conditions of veterans identified a negative correlation between PTSD and life quality. In a study, on male Vietnam veterans, found out relationships between PTSD and effective disorder, substance abuse and anxiety disorders (Zatzick et al., 1997). Rehabilitation of Veterans and Well-being People who have experiences with chronic diseases or disabilities go to hospital with acute problems but for very different needs. These needs are sometimes medical, sometimes psychological. A person with amputee leg and the one, whose appendix was removed, are not the same. One situation requires short time for total healing; another requires a lifelong rehabilitation. An individual after a case of amputation or a war/conflict cannot go home in a stable condition; he cannot live his previous life. There should be regulations in this individual’s and his family’s life. In a long term unhealthy situation, there is usually not a total “healing” but adaptation (Sütçü Çiçek, 2014). In psychology, the concept of subjective well-being is examined with the concept of happiness; subjective well-being is defined as an individual’s personal evaluation and judgement of his or her life (Diener, 1994). The study by O’Toole et al. (2009), on Australian veterans of the Vietnam War, revealed that war-oriented PTSD is related with diseases in advanced ages; the study found that half of veterans received medical treatment for mental well-being. Horner et al. (2010) found out that working veterans have better psychological well-being than unemployed ones; full-time employees also have better psychological well-being in comparison to those who are part-time employed. In a study Kashdan et al. (2006a), it was identified that veterans with PTSD diagnosis had lower general and daily well-being levels and mental gratitude conditions (2006b), than those without PTSD diagnosis. Nevertheless, it was found out that repetitively performed “mantram”, which is a sacred expression in some studies, played a considerable role in posttraumatic stress disorder management of veterans and helped to reduce severity of anxiety and stress symptoms and to increase life quality (Bormann et al., 2005, 2008, 2012). A study observing plasma cortisol level, spiritual well-being level and suicidal tendencies of Crotian veterans identify that plasma cortisol level is low when spiritual well-being is high. The study also demonstrates that there is a positive correlation between cortisol level and suicide risks; it also emphasizes that spiritual-based attempts for veterans might be effective in preservation of mental and physical health (Mihaljevic et al., 2011). Another study investigating the impacts of outdoor recreation program on enhancement of psycho-social well-being identified that this program increases positive mood and helps to reduce negative mood, anxiety, depression and stress symptoms (Vella et al., 2013). Prevention on public health is classified as primary, secondary and tertiary prevention. Tertiary prevention mostly deals with prevention of diseases from relapsing, secondary prevention aims to increase psycho-sociality through treatment, to prevent repetitive hospitalisation and enhance social communication. It is important to establish social support systems in order to reintegrate veterans into the society (Çam & Bilge, 2014). In rehabilitation of veterans, skills training, cognitive rehabilitation, occupation and work rehabilitation are among important improvement fields. Skill training programs are rehabilitation programs that are developed for veterans to have particular skills, which can help to improve self-care by using social learning skills and 18

behavioural techniques and interpersonal relations. In social skills training, behavioural studies such as eye-to-eye contact, starting a conversation, asking questions, tone of voice control, interpersonal distance control, appropriate gestures and mimics are very important steps (Çam & Bilge, 2014). Nevertheless, cognitive rehabilitation aims to improve basic data processing skills. Through cognitive exercise, maintenance of memory, attention, planning and conceptual capacities and correction of inefficiencies in these issues are aimed. One of the most important problems for individuals with traumatic mental disorders is unemployment and the feeling of being useless. Various types of manual labour, in which individuals can learn and develop their hand skills, arts like music, painting, dance, folklore and some sports activities are beneficial in terms of both making use of time and increase of self-satisfaction. In this context, more importantly these individuals are directed to production and employment. Physical and emotional changes stemming from a crippling situation cause a patient to live an intensive personal experience. Whatever the contribution of rehabilitation professionals to an individual’s success, it is considered that these roles are only supportive and encouraging of an individual’s own potential (Sütçü Çiçek, 2014). It is necessary to achieve maximum functional acquisition for rehabilitation patients, to learn new ways in order to cope with vital changes, to adapt new lifestyles, to sustain daily routines and to prevent from problems. An approach consisting of prevention of problems and encouragement of good health is an important factor to achieve the best result and to prevent from later complications (Çınar, 2014). When preventative approaches are included in the care process, life quality increases and care expenses decrease (Hoeman, 2008). What Can Nurses Do About It? Acute stage nursing services include recognition of posttraumatic stress disorders that appear in early stages for individuals who are exposed to trauma and provision of treatment and support to those who are in a risk group in terms of psychiatric disorders (Keskin, 2014). It is necessary to educate families, to help family members for their unity and to prevent from more trauma, to help individuals to satisfy their basic needs and to maintain their biological rhythms against symptoms during earlier stages (Kulaksızoğlu et al., 2009; Van Heeringen, 2012). This also requires a comprehensive interdisciplinary team service including physiotherapists, occupational therapists, speech-language pathologists, psychologists, neurophysiologists, neurosurgeons, dieticians, rehabilitation experts for visual and hearing impairment, audiologists and most importantly families. In order to be eyes and ears of the patients, to meet needs of patients and their families and to facilitate progress towards the upmost function and independence, the team is dependent upon nurses and their coordination. The reactions should be supportive in acute phase, emphatic and direct, acceptable and appropriate. Reassuring explanations should be made towards feelings and fears of patients that these experiences are normal and expected reactions. It is necessary to make patients feel that their problems are understood, shared, not judged or interpreted. It is also essential to establish eye contact on a level that does not disturb patients and to consider facial expressions and emotional manifestations of patients. A good and effective listening, provision of opportunities to patients for telling their feelings and ideas, attempts to understand them and sharing their problems are important. Another nursing attempt that can be made is to reduce an individual’s isolation through group discussion 19

techniques and case studies. Group discussions encourage and prompt people to experience and reactions to others, who are exposed to similar traumatic events. Apart from that, it is important to keep the group homogenous for group discussion. Gathering people with different type of exposures might increase traumatic situations of some individuals in a group. It is beneficial to ask a person to tell his problems in a group and share them with his or her close circle (Boran, 2011; Van Heeringen, 2012). Cognitive behavioural reaction is among the significant nursing attempts for posttraumatic stress disorder (Keskin, 2014). This therapy aims to reset behavioural changes stemming from the experienced trauma and cognitive changes to pre-traumatic situation. As traumatic experiences are the focus of this approach in early stages of the therapy process, an individual’s symptoms might go worse. Narration of the event once more might cause this person to remember details and memories that he is trying to forget for a long time. This might trigger the symptoms. An individual’s perception about his disorder is also important. In therapy, it is possible to speak about emotions and ideas. In later stages, an individual is made to face his hears and thoughts. The person is tried to be adapted through exercises; he is trained against the anxiety and fear with trauma stimulants (radio voice, darkness, being alone, some sounds). This implementation can be conducted step by step through focusing on the anxiety creating stimulants (Chang et al., 2010; Van Heeringen, 2012). Events that lead to mental trauma not only threaten an individual’s life and his physical integrity, but also values about himself and his place in the world; it shakes the basic feeling of confidence towards himself and universe. When an individual begins to perceive the world as dangerous and himself as insufficient, this thought leads to the perception of “loss of control”. Loss of control leads to fear, despair and hopelessness and these feelings help to maintain his situation through depression and anxiety (Çervatoğlu-Geyran, 2000). Adaptation might be difficult due to beliefs and thoughts such as inefficient support services of the society, an individual’s position that he is personally held responsible or his feelings that he is personally responsible for a particular traumatic event (Oflaz et al., 2010). In addition, cultural factors play a role in possibility of PTSD, individual’s expression and reaction to medical treatment (Çervatoğlu-Geyran, 2000). For this reason, immediately after the event, individuals should be encouraged to sleep, rest and spend time with friends and family that they can express themselves in a more comfortable way; they need to continue to do daily life activities. In this point care and support by nurses is as important as the medical treatment (Buck, 1991; Jabez, 1993). Individuals need relations that provide support and help, reordering of old relations and encouragement about this issue. Nurses, with their knowledge and skills of communication, can help individuals to express their feelings and thoughts concerning traumatic experiences; they might help individuals to interiorise these experiences and consequently to move on in life. A key point to remember for employees, who will work with people that experienced traumatic events, are these people’s features concerning difficulties to seek for help and accept the offered assistance. Therefore, establishment of a trust relationship is of primary importance. However, it might be difficult due to an individual’s behaviours such as avoidance, alienation and even feeling doubtful about others. Such individuals require a non-judgemental approach. Nurses should be ready to listen terrifying stories including severe injuries, devastating experiences and pain depending on trauma. When a nurse cannot tolerate these, an 20

individual may not work on losses and changes on his life. If an individual is not able to establish a connection between a traumatic event and symptoms, nurses should explain about this connection. Another feature of an individual that experiences trauma is his need to verbally express his emotions such as anger (Kalayjian, 1994). While working with a traumatic person, the aim is to remove him from the role of victim to a person who can move on his life. Improvement of problem solving behaviours and their use to resolve daily stress situations might increase a person’s control over his environment. For this reason, it is important for a person after a trauma to be in an environment in which he can estimate events. This control can be achieved in controllable environment where social and emotional supports exist. It is indicated that a supportive environment might stabilise an individual’s life and it can constitute a buffer against unexpected additional stresses. In the literature, it is mentioned that being in a supportive environment after trauma lightens the impacts of it; additionally social support before trauma has a protective effect. Nevertheless after trauma, people with psychological problems may not take advantage of social support or they may lose it due to their problems. In addition, it is necessary to consider that social support in complicated structure of social relations may not always be useful (Aker, 2000). CONCLUSION As in regular professional life during wars or peace time, in addition to provide primary care for patients and the wounded, nurses have additional and important responsibilities and roles such as leadership in organisation of services, provision of psychological assistance, determination and prevention of risk factors (Oflaz, 2008). Nurses should be aware of the fact that they are potential sources of correct information for individuals who suffer from wars and cases of emergency; therefore they need to learn necessary steps for emergency, preparation for war and its reaction (Kalayjian, 1994). For this reason, in basic nursing training and postgraduate in service training, nurses in crisis teams should be taught about psychological reaction of people, who experienced traumatic events, appropriate attempts and principles of psychological first aid; this training will contribute significantly to both prevention of chronically traumatic reactions and potential risks and prevention of mental health of the society. REFERENCES Abeyasinghe, N.L.; Zoysa, P. De.; Bandara, K.M.; Bartholameuz, N.A.; Bandara, J.M. (2012). The prevalence of symptoms of post-traumatic stress disorder among soldiers with amputation of a limb or spinal injury: a report from a rehabilitation centre in Sri Lanka. Psychol Health Med 17 (3), 376-381. Afari, N.; Harder, L.H.; Madra, N.J.; Heppner, P.S.; Moeller-Bertram, T.; King, C.; et al. (2009). PTSD, combat injury, and headache in veterans returning from Iraq/Afghanistan. Headache 49, 1267-76. Aker, A.T. (2000). Travma sonrası stres bozukluğunun bilişsel ve davranışçı tedavileri. 3P Dergisi 8, 38-46. Andreasen, N.C. & Black, D.W. (2006). Anxiety disorders. Introductory Textbook of Psychiatry Washington, D.C: American Psychiatric Press. Arıkan Dönmez, A. (2014). Politravma, In: Özdemir L, Sütçü Çiçek H (Çeviri Eds), Rehabilitasyon Hemşireliği, Uygulamaya Güncel Yaklaşım. 1. Basımdan Çeviri, Nobel Akademik Yayıncılık Eğitim Danışmanlık Tic. Ltd. Şti, Ankara, 323-326 pp. Boran, B. (2011). Travmaya psikolojik yaklaşım, Toplum ve Hukuk Araştırmaları Vakfı 21

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Chapter 3 What Is Nursing Informatics? Hava GÖKDERE ÇINAR, Semra SÜRENLER, Nurcan ÖZYAZICIOĞLU INTRODUCTION In today’s world, organizations became an informatics organization. Organizations became capable of getting the information that they want to have, producing new information, and utilizing them for their organizations day by day. Hence, businesses realized the importance of knowledge management (Adıgüzel & Derya , 2010). Knowledge management in an organization is defined as the planning, organisation, guidance, and control of sharing activities with members of organization. Some of these activies are; Information production, obtainment, utilizing for business processes (Adıgüzel & Derya, 2010). Today in which information became the power, and communication became a must, informatics became a part of every sphere of life (Bal, 2010). Informatics; Is a science which is about the operation of human knowledge and communication in technical, economical and social areas in automatic machines in a rationalist way. Nursing Informatics, Describes how to reach the information, how to obtain, use, record and keep data (Mutluay & Özdemir,2014). The first informatics studies in Nursing was formed in 1974 within the body of International Medical Informatics Association. Nursing Informatics was accepted as an inseperable part of International Medical Informatics Association. Scholes and Barber described this in 1980 as the implementation of computer technology to every areas of nursing. It was accepted by American Nurses Association in 1992 as a new area of expertise (Parker,2014). At the same time the importance of the necessity of information informatics in databases was mentioned among ICN aims. “Setting the international standards that can enable the comparison and specification of nursing practices, creating the information that is going to affect decisions about the use of resources, health results, patient necessities, nursing initiatives, creating the information that is going to affect education and politics; paving the way to develop a nursing database that is used in researches which will guide policies by comparing and defining nursing cares of families and countries ……………..” www.icn.ch In the 2014 Health Information Management Systems Society Nursing Informatics Workflow survey, the results showed: • 60% had master’s or doctoral-level education • 41% had more than 16 years of clinical experience before becoming informatics nurses 

Lecturer, Uludağ University, School of Health, Nursing Department, Bursa, Türkiye. Assoc. Prof. Dr., Uludağ University, School of Health, Nursing Department, Bursa, Türkiye.

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• 46% had more than 7 years of informatics experience (Parker,2014). Studies about the Turkish Healtcare Informatics field has begun with the deduction of computer contribution lots from the insured people and with the application of pharmacy information systems module in the SSK hospitals. The Project of Health Information Systems in Turkey • In 1991, First health projects with the Ministry of Health and in cooperation with The World Bank, In1995, within the second health projects • In 2003, It has begun with the studies of Hospital Information Management Systems and Healthcare Conversion Program by The Ministry of Health. (Köse, 2012) • About the health information system at the present time; • Standart definition of institution, • Attendant doctor’s data bank, • Universally approved sickness classification, It has came into use in the sector by identifying and harmonizing standart coding systems such as; medicine and medical equipment coding ( Işık & Akbolat, 2010 ) Nursing, which has an important place in the health sector, is a practical discipline. Nurses, are the biggest health team group which decides which product to use, when to and where to use, determines the need of patients and care with them directly. That is why, nurses are the first users of the computerized system. Both quantitative and qualitative data is registrated to the registration system by nurses. Because of this, Nursing Informatics supports; • To synthesise the nursing knowledge • To act faster in improving nursing knowledge • Also , communication among the other health discipline • To manage the care of patient, • To manage the information related to nursing period (Köse ,2012; Özel & Ürkmez & Demiray & Cebeci, 2014) Nursing Informatics • Learning the environment • Collaborate between occupations • Planning of care of patient Also to be able to use the Healthcare Informatics and technology, for converting the knowledge to data to improve the quality of patient care. Disadvantages • Computers can reduce communication with patients/healthy individuals. • People’s privacy can be violated • Not being able to use computers due to lack of knowledge and skills for nurses (Bilgiç & Şendir,2014). Clinical applications, management services and education are the areas that the system is used (Schneıder, 2014; Baykal & Ercan , 2014; Mutluay & Özdemir, 2014). Nursing Informatics Systems Clinical Applications: • Patient evaluation, • Following, 27

• Preparation of care plans, • Presentation and evaluation of care, • It is has been used for education and preparation discharge of patient. Related to Administration: • Patient classification, • Personnel recruitment, • Personnel management, • Planning , • Budgetting, • It has been used for preparing watch lists, decision-making and evaluating of performance. Related to Training: • It has been used for preparing training program, • Implementation and evaluation (Schneider, 2014; Baykal & Ercan, 2014; Mutluay & Özdemir, 2014 ). The most common usage areas of nursing information systems in healthcare facilities located; 1-Nursing decision support systems, reminders, stimulants and call systems 2-Patient monitoring systems 3-Bedside Recording System (point of care systems) 4-Mobile communication systems (Baykal & Ercan, 2014) The most common usage areas of nursing information systems in healthcare facilities located; 1-Nursing decision support systems, reminders, stimulants and call systems 2-Patient monitoring systems 3-Bedside Recording System (point of care systems) 4-Mobile communication systems (Baykal & Ercan, 2014) Nursing decision support systems, reminders, stimulants and call systems Created in electronic environment, CDSS (Clinical Decision Support System), serves for using and creating mutual solutions among the disciplines, and also increasing data’s sharing speed. The areas Clinical Desicion Support Systems are used; 1) In Health institution management services, analyzing the cost, managing the clinic data and evaluating the quality 2) For the aim of helping to identify the sicknesses, improving the systems which are being used as literature scanning and clinical guidance, 3) For planning the treatment and making the tests for the purpose of supporting the decisions related to patient 4) For guiding nurses and doctors; drug interactions, warming mechanisms, medicine prescription help and routine procedure transactions, 5) For interpreting the signal; while interpreting of monitoring and radiology data, 6) During the lab service (Demirhan & Güler, 2011). Clinical decision support systems (CDSS) associated with nursing diagnosis system Clinical decision support system (CDSS) is an electronic system designed for supporting clinical decision making which offers essential assessments and 28

recommendations to physicians based on patient information. Considering the increasing importance and use of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT). Systematized Nomenclature of Medicine=SNOMED Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) is a comprehensive computer processable collection of medical terms providing codes, terms, synonyms and definitions covering diseases, findings, procedures, microorganisms, substances, etc. (6). Rules derived from SNOMED-CT would provide the opportunity of arriving at more responsive and complicated decision support systems. Among advantages several points can be cited: ability to update health care information such as medical guidelines, indications and contraindications, smart and accurate data gathering, medical training and absence of necessity for designing a whole new classification of health care information and terminology (Maheronnaghsh at al.,2013; Aydın, 2011). Among the Classification Systems Which Are Approved by the American Nurses Association (ANA); • North American Diagnosis Association/ NANDA • Nursing Intervention Classification /NIC • Nursing Outcomes Classification/NOC • Omaha System • Clinical Care Classification • Home Health Care Classification/HHCC) • Internatınal classıfıcatıon for nursing practıce /ICNP • The patıent care data set /PCDS • The perioperatıve ve nursıng data set /PNDS (Ay, 2008; Aslan & Emiroğlu, 2012; Kacaroğlu & Karabacak & Ecevit ,2015) What is the aim of nursing classification system? There is a need to have a standard language and terminology to convert and to computerize the data which is obtained from the nursing informatics systems. So nursing data will become evaluable, distinguishable and comparable (Baykal & Ercan , 2014) . Reminders, stimulants, call systems: The result of the stimulants and reminders which are created by the system within the health informatics systems; • The number of patient observation increases, • Trustworthiness and accuracy of observation increases, • Drug, medical and data errors decrease, • Nursing quality increases, • Patient satisfaction increases, • Drug interactions, allergic reactions, and mortality rate decreases. In addition, it provides to clear up the communication problems between patient and nurse, to increase the productivity of patient care services and quality level, and to save time. Pager service, is to deliver the patient information to nurses as a message with a hardware which is connected to cell-phone. In wireless phone services, patient messages which comes with wireless phone connection is delivered to nurse vocally. Positioner service delivers the instant location information of nurses to nursing paging service (Mutluay & Özdemir, 2014). 29

Patient monitoring systems: Cardiopulmoner monitor, pulsimeter and fetal monitors warn nurses against to abnormal rates and block repetitive situations. Bedside recording systems: The system that helps recording in controlling patient’s care plans, medication forms etc. That service could be used both at the bedside and by nurses as mobile devices. Mobile communication systems: The systems that are used for meeting the connection needs of nurses who are on the go permanently and used for making patientnurse communication easier (Baykal & Ercan , 2014) CONCLUSION Information technologies make the data of the nurse and the publishing and sharing of accumulation easy and it also makes reaching for the information simple . In addition to these, it also supports the nurses while they are making clinical decisions. Having enough knowledge of computer and information technologies is a significant factor for developing the data processing of these nurses. In Turkey's curriculum of becoming nurses, Among 30-150 hours, the lecture called data processing has some areas which have different names such as ‘Basic Computer Technologies’ , ‘The basic use of information technologies’ , ‘Computer’ and as ‘Computer sciences’. However, the nurses who are responsible of working in health maintenance fields need some support especially in some fields such as interior services, constantly education programs and the use of computer and information technologies and also the management of information. Before identifying the fields where these nurses are going to work, we should not define the basic computer and its technological information and not give the responsibility for the coincidental commission. What’s more ; The educational staff needs to be improved , the data processing nurse needs to be defined and to raise the consciousness of the data processing nursing, we need to cooperate with other staff working in the health field and the ones who provide information technologies. REFERENCES Adıgüzel, O., Derya , S. (2010). Kamu Hastanelerinde Çalışan Hemşireler Kurumlarındaki Bilgi Yönetimi Uygulamalarını Algılama Düzeylerine İlişkin BirAraştırma. SDÜ Fen Edebiyat Fakültesi Sosyal Bilimler Dergisi 22 ; 191-206 Ay, F. (2008). Uluslararası Alanda Kullanılan Hemşirelik Tanıları ve Uygulamaları Sınıflandırma Sistemleri. Türkiye Klinikleri J Med Sci 28:(4),555-61 Aydın, N. (2011). Klinik Karar Destek Sistemleri ve Hemşirelikte Kullanımı.Hemşirelikte Eğitim ve Araştırma Dergisi, 8(3): 59-63. Aydın, N. ( 2010). Hemşirelikte Bilgi Teknolojileri /Sistemleri, SABİYAB Dergisi 5; 28–33 Bal, G.C. (2010). Üniversite Hastanelerinde Bilişim Teknolojilerinin Stratejik Kullanımına İlişkin Karşılaştırmalı Bir Araştırma (Doktora Tezi, Selçuk Üniversitesi). http://acikerisim.selcuk.edu.tr:8080 /xmlui/handle/123456789/2663 Baykal,Ü.T.; Ercan, E.T, (2014). Sağlık ve Hemşirelik Hizmetlerinde Bilgi Sistemlerinin Yönetimi. Hemşirelik Hizmetleri Yönetimi.İstanbul Bilgiç, Ş, Şendir, M. (2014). Hemşirelik bilişimi. Cumhuriyet Hemşirelik Derg.3:(1), 24-28 Demirhan, A.; Güler, İ. (2011). Bilişim ve Sağlık . Bilişim Teknolojileri Dergisi 4(3),13-20 Işık.O., Akbolat, M.(2010). Bilgi Teknolojileri ve Hastane Bilgi Sistemleri Kullanımı: Sağlık Çalışanları Üzerine Bir Araştırma.Bilgi Dünyası 11: (2),367,370 30

Kacaroğlu, A. V.; Karabacak, B. G.; & Ecevit, Ş.A. (2015). 2012-2014 NANDAIHemşirelik tanılarının Yaşam Aktivitelerine Dayalı Hemşirelik Modeline göre sınıflandırılması. International Journal of Human Sciences, 12(2), 1626-1636. Korkmaz, G. A.; Emiroğlu, O. N. (2012). Hemşireliğin Görünürlüğünü Artırmak İçin Standardize ve Kodlu Bir Sınıflama Sisteminin Kullanılması: Klinik Bakım Sınıflama Sistemi. Sağlık Bilimleri Fakültesi Hemşirelik Dergisi. Syf: 69–79 Köse, A. (2012). Hemşirelerin Bilgisayar Kullanım Durumlarının Belirlenmesine Yönelik Bir Ampirik Çalışma–Trabzon İli Örneği. Bilişim Teknolojileri Dergisi 5:(1), 37-43 Maheronnaghsh, R. ; Nezareh, S.; Sayyah , M. K.; Rahimi-Movaghar, V. (2013). Developing SNOMED-CT for Decision Making and Data Gathering: A Software Prototype for Low Back Pain. Acta Medica Iranica 51: (8), 548-554. Mutluay, E.; Özdemir, L. (2014). Sağlık Bilişim Sistemleri Kapsamında Hemşirelik Bilişiminin Kullanımı. F.N. Hemişelik Dergisi (22) : 3,180-186 Özel, H. Ö., Ürkmez., Ö. D. Demiray., S. Cebeci, S. (2014). Hemşirelik Bilişimi ve Hastane Bilgi Yönetimi Sistemi.Ok meydanı tıp dergisi 30(3):158-160. Schneider, J. S. (2014). Nursing Informatics. Home Healthcare Nurse 32: (8) , 497-498 Parker, C.D. Nursing informatics leadership: Helping craft the profession’s future. URL: WPO (2014) http://ovidsp.tx.ovid.com/sp-3.20.0b/ovidweb.cgi

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Chapter 4 Transactional Analysis Approach in Patient-Nurse Communication Zümra ÜLKER DÖRTTEPE, İlkay KESER INTRODUCTION People have to communicate with each other both in their daily life and in working life. The fact that people mutually convey their feelings, thoughts, wishes and expectations by using words and behaviors is an indication that they perform communication. The communication process is a dynamic process in which information, feelings, thoughts, and attitudes are shared through symbols among people and groups or at the social level. Communication is also an integral part of life and an indispensable phenomenon in the individual self-expression that allows for the information transfer among individuals (Cüceloğlu, 1998; Özcan, 2006). Although the concept of communication has very different definitions, the common point of these definitions is the interaction (Tabak, 2003; Özcan, 2006). Although interpersonal relations are important in all occupational groups, they make the nurse's ability to communicate effectively with other individuals important, especially in nursing which is a profession established on human relations. It is very important for nurses to learn and know themselves, other people, people's behaviors, society, culture, knowledge and skills related to their profession and to exhibit them in the best way. When these processes are realized, nurses can develop and maintain positive relationships, succeed in the profession and experience job satisfaction. There are various instructive models and approaches for the professionals working in the healthcare field about in what ways and under which conditions behaviors are formed. Among these, the transactional analysis theory developed by Eric Berne is an approach that has been a current issue, the use of which has become widespread, and is important for the nurses to understand the behaviours and reactions against patients. The objective of this section is to emphasise the use of transactional analysis in terms of the communication with the patients in the light of the current literature. 1. COMMUNICATION Communication is a process during which individuals mutually exchange information. In communication, messages are sent and received verbally using words and non-verbally with the behaviours that accompany words (Cüceloğlu, 2002; DeVito, 2008). Effective communication helps relationships. It ensures both being able to transmit one’s requests from a person and learn the wishes of that person. It helps 

Lecturer, Uşak University, Vocational School of Health Services, Emergency and First Aid Program  Assist. Prof. Dr., Akdeniz University, Nursing Faculty, Department of Psychiatric Mental Health Nursing

mutual understanding between individuals. Considering the process of communication, the main items in the classical communication model of Berlo (1960) may help this process: a. A person has the need to communicate with another person (Stimulus). For example, the need for information, advice and opinion may be the stimulant for the need of communication. b. The individual sends messages in order to start the interpersonal connection (sender). c. The expression of the information or situation sent to the other person is the message. d. The message can be sent via media including auditory (hearing), visual (seeing), tactile (touch), olfactory (smell) or with any of these combinations. e. The person who receives the message (receiver) interprets the message and responds to the sender with a feedback. The feedback shows whether the message is correctly understood by the receiver Verbal communication consists of the words that individuals use to talk to one or more users and express themselves. Words ensure that the speaker or listener understand each other with word groups or sentences in addition to being used for naming objects and expressing the concepts that are discussed. In verbal communication, in addition to all words used by individuals when talking, the whole physical, social, emotional and cultural environment in which communication takes place affects the content of the communication. The content also includes such situations as making the message sent or received clear (Videbeck, 2011; Phutela, 2015). Non-verbal communication consists of the behaviours that accompany verbal communication such as body language, eye contact, face expression, the tone of voice, acceleration and deceleration in speech and the distance of the individual from the listener. Non-verbal communication shows the thoughts, emotions, needs and values of the speaker without awareness (Rayudu, 2010; Phutela, 2015). The process indicates all non-verbal messages used by the speaker in order to give content and meaning to the message. The content component of the communication process requires the assessment of the behaviours of the speaker in order to evaluate whether the listener approves together with verbal communication and interpreting of the accent in the use of the words and non-verbal behaviours. It means that the message is correctly transmitted when the content and process are approved (Kidwell & Hasford, 2014). For example, when a patient in depressive mood says “I know that this is not who I am supposed to be. I need help”, this is accompanied by a sad expression and a sincere and candid tone of voice, the process here shows that the content is correct. However, when the content and process are incompatible, i. e. what is told by the speaker does not approve the behaviours, then the speaker does not transmit the correct message. Non-verbal communication provides more appropriate messages than verbal communication (Videbeck, 2011). 1.1. Communication in the field of health Communication is important in having access to health care, maintaining health and increasing the health status of individuals. According to Healthy People 2010 guide, health communication includes the communication techniques used in order to 33

make decisions and give information that will increase the health of individuals and the society and relevant studies. Thus, communication has an important integrative role in terms of health. Centres for Disease Control and Prevention (2010) express that communication in the field of health is at various levels. These are:  Individual: It is indicated as the most important target in the changes and communication with regard to health, and the objective of health communication is to positively affect an individual in all aspects in addition to the behaviours of the individual.  Social network: The relations of the individuals and the groups to which they belong are effective in their healthy behaviours. Health communication programs may also be in communication with these groups and share things in the groups.  Associations: Associations include groups that officially operate in the defined structure. Associations can give their members information related to the messages on health, announce news and inform them about their rights.  Community: Communities formed on being well can be effective in adopting ideals that support a healthy lifestyle and decrease social and physical damages.  Society: When considered as a whole, the society affects the behaviours, norms, values, ideas, rules, physical, economic, cultural and knowledge environment of the individuals. The communication in the field of health is becoming a developing and distinguished field in health care, community health, the private sector and non-profit organizations. Thus, authors and associations attempt to define and develop the concept of communication in the field of health. The communication in the field of health has a multidisciplinary approach. Although this approach leads to a degree of differentiation between the definitions, definitions may vary by different viewpoints. Actually, when definitions are analysed, most of them focus on behaviours or social, organizational or political changes that may affect the effect, support, strengthening individuals, communities, health professionals, adopting specific groups and individuals, society and health outcomes (Thomas, 2006; Schiavo, 2014). 1.2. Communication in nursing Communication may be in various forms such as verbal/non-verbal and written communication. While it seems like this variation facilitates the mutual information exchange between individuals, it is actually not that easy. Especially in the profession of nursing, communication tends to be a complex process. This requires effective communication as information exchange between individuals occurs quite frequently in nursing practices (Kraszewski & McEwen, 2010; Boyd & Dare, 2014). The attitudes and behaviours of the nurses towards patients are important in terms of rendering quality health care service (Özcan, 2006; Fortinash & Worret, 2008; Wrycraft, 2009). The destruction of communication in health care may lead to devastating results. For example, important information such as the treatment plan or drugs used by the patient can be skipped, or unpleasant results may be encountered in terms of the health of the patient when a nurse does not transfer the patient who will have an operation during the shift change. When a nurse communicates, it is necessary to pay attention to especially how the person in front of them is affected and interprets their message. It will be helpful to 34

take into consideration the following information in particular (Boyd & Dare, 2014): a. The qualities of the person that we communicate with (children, adult patients, student, patient with learning disabilities, etc.) b. The place where the communication takes place (hospital, maternity ward, patients receiving care at home, etc.) c. Past experiences of the sender or receiver d. Personal perceptions of the sender or receiver (if available) e. Timing of the message Making individuals feel that they are valuable, there is a belief that they will be respected when they express themselves and accepting that they and their unique environment are a whole are important for effective communication (Dökmen, 2010). Thus, it is necessary not to decide on what is right on behalf of an individual and always consider the values of an individual and his/her unique values. In the effective communication, the use of therapeutic communication techniques such as the use of silence, active listening, reflection, discovery, making clear, focusing, summarizing is also important in ensuring and maintaining effective communication. The use of ineffective communication techniques in patient-nurse communication such as underestimating the feelings, judging, changing the subject, not listening, giving orders, criticising and preaching interrupts the patient-nurse communication and ensures that it results negatively (Varcarolis, 1998; Fortinash & Worret, 2008; Videbeck, 2011; Boyd & Dare, 2014). 2. TRANSACTIONAL ANALYSIS THEORY There are various guiding models and approaches on how and under which conditions individual's behaviours are formed in communication. Communication models can be considered as a process that is shaped by the use of the information process channels from the sender to the receiver in general (Boyd & Dare, 2014). While there are different models for professionals in the field of health, according to the information quoted by Özcan (2006) from Wilson and Kneisle (1988), communication theories are classified under four groups as Therapeutic Communication Theory, Cause-Effect Relationship in Communication Theory, Neurolinguistic Programming and Transactional Analysis Theory. Among them, the transactional analysis is a recent approach with an increasingly widespread use, and important in facilitating the understanding of the behaviours and reactions of the patients. The Transactional Analysis Theory (TA) developed by Eric Berne (1910-1970) can be called as a combination of the incredible power and potential of human brain and nature. This approach allows for the use of knowledge, intelligence, and creativity, in addition to being a lively and dynamic process. When we look at the origins of the TA approach, it takes its cognitive and behavioural aspects from psychoanalysis as it considers the patient as the focal point, in addition to adopting the phenomenological and existentialist approaches (Lister-Ford, 2002). This approach that is still developing has an integrative role with its cognitive, affective, behavioural, physical and psychological concepts and applications. That it has such a role makes TA more comprehensive, and it becomes an approach that can be adapted for psychotherapy and communication as it adopts being flexible in communication and helping patient needs and interventions. 35

2.1. Structure of the transactional analysis theory Eric Berne explains the philosophy of the theory as follows (Berne, 1998; Akkoyun, 2007): a. People are OKEY: It means "Everyone is valuable no matter what they do and who they are.” Each individual is equal although there are differences between them. He talks about perceiving the individuals as a whole with their phenomenological areas. b. Everybody has the capacity to think: Individuals has the capacity to understand what goes around inside and around them. Everybody, except for those who have a serious brain injury, has the capacity to think. An individual has the ability to decide on one’s own in the events he/she experiences, and the power to solve a problem when gets help. c. Everyone decides on what is going to happen in one’s life on one’s own: Individuals decide on their own how and to what extent they will be affected by oneself and the environment they integrate with and how to react to it. Berne formed this theory of four components that consecutively complete one another and emphasised that the previous stage is understood before passing to the next stage. These components are called as ego states, transactions, psychological games, and life scripts. (Berne, 1961; Berne, 1966; Berne, 1972; Steward, 1996). 2.1.1. Ego states by the structural analysis According to the structural analysis, ego states are divided into three, being parent (P), adult (A) and child (C). Child, parent and adult ego states are mentioned in the personality of the individual (Steward, 1996; Tudor, 2001). It creates a chart of important experiences of an individual in the early period (child) and important people that have an effect on the individual and combines them with the principle of “now and here” (adult). The mistakes made in fulfilling the needs of a child may disturb a child’s mental balance by leaving serious effects on the child and creating negative psychological effects (Lister-Ford, 2002). The emotions, thoughts, behaviours and approaches in parent ego state are obtained from individuals’ own parents or caregivers (Berne, 1961). The parent ego state can be defined as the Figure 1: Ego States. part of the personality that preaches and gives Source: Solomon (2003). orders to people on how to behave. An individual’s parent ego state is divided into two, being supportive or prejudiced style. Here, while there is a calm, loving, allowing and limit setting structure in the supportive parent ego state; there are prejudiced thoughts, emotions, and beliefs in the prejudiced parent ego state (Solomon, 2003).

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Table 1: Words, Voice Tone and Body Language Examples in Parent Ego State. Source: Gürgen (1997).

Parent Ego State

Words Always Never Don’t do that You have to do You should do Never forget Remember the rules What others will think In our days Let me help Don’t be afraid You’re wrong Explain yourself Don’t cry Be polite Be quiet Listen

Voice Tone Criticizing Patronizing Encouraging Authoritarian Relaxing Hard Sympathetic Protective

Body Language Showing with finger Disliking glance Frowning A serious expression Embracing Patting on the back Patting one’s head Crossed arms Looking over the glasses

The adult ego state is named as a data processing centre that is operated in a controlled manner. An individual is in the Adult ego state if while he/she reacts to others and the environment or sends stimulants, he/she guides his/her energy in such a way that moves these records or has similar experiences to these records. Table 2. Words, Voice Tone and Body Language Examples in Adult Ego State. Source: Gürgen (1997).

Adult Ego State

Words I believe Who What When Where How Which In other words Probably Frequently My intention The reason for this My response was as follows What do you think Real Let’s try Let’s find

Voice Tone Open Interrogative Relaxed Realistic Far from emotion Compatible In normal tone

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Body Language Eye contact Head shaking Upright posture Quiet A questioning glance A careful expression Thoughtful Vigilant Relaxed

This part of the personality processes the data heard, seen and thought correctly, determines solutions for the problems, and assesses the existing data without basing on prejudiced thoughts or emotions (Berne, 1996; Martin, 2011). In this approach, the personality of the individual functions not with the child or parent ego state only, but in the form of finding the appropriate behaviours and solutions by perceiving the information correctly and considering the facts (Tudor, 2010).The child ego state is the group of emotion, thought and behaviour patterns that an individual has created while using one’s own potential in order to cope with life, that also bears the traces of one’s childhood (Berne, 1996; Keçeci, 2007). The free child ego state reflects natural, loving, carefree, adventurous, honest child, who is indifferent to rules. The adapted child acts in accordance with the rules and norms of the cultural environment, rather than being natural. The adapted child uses such communication patterns such as “please, thank you, I’m sorry”. When the message comes from the free child, it is excessive; and submissive when it comes from the adapted child (Martin, 2011). Table 3. Words, Voice Tone and Body Language Examples in Child Ego State. Source: Gürgen (1997).

Child Ego State

Words In my opinion Terrible Help me Terrific Oops… I want Super Stupid How nice

Voice Tone Cynical Coquettish Tearful Screaming Excited Obedient Emotional Caressing Submissive

Body Language Laughing Bent double Seating Shy eyed Tearful Big eyes Grimacing Wandering around Pouting

2.1.2. Transactions Transactions that are used as a communication model in TSA can be named as another unique side of this approach. Transactions are especially in which ego state individuals talk when they communicate with one another. The ego states used by individuals in communication sometimes increase communication while sometimes they put the process in a complex and incomprehensible structure. Transactions are basically in two forms, these being straight and transverse (Solomon, 2003): Straight Transactions: They are easy to understand and the message is clear. The messages are either straight or parallel.

Nurse: Why didn’t you take your medicine? (harsh voice, beetle brows) (parent/child) Patient: Please...I don’t want to take it? (wobbly voice, shy looks) (child/parent)

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Patient: When does the visit start? (with a calm voice, eye to eye communication) (adult/adult) Nurse: At 1 pm. (calm voice, neutral face expression) (adult/adult)

Nurse: You are again late for shift delivery time? (harsh voice, eye to eye communication with beetle brows) (parent/child) Nurse: I am sorry... (wobbly voice, bowed posture) (child/parent)

Figure 2: Straight Transactions Source: Solomon (2003).

Transverse transactions: In the transverse transaction, an individual sends a message to the person that is contacted from any ego state, however, the other person replies from another ego state than the ego state that is targeted by the message sender. Transverse transactions generally result in misunderstanding (Keçeci, 2007). Nurse: Why didn’t you take your medicine? (harsh voice, beetle brows) (parent/child) Patient: I’m not going to ask you for permission for when to take my medicine! (harsh voice, holding up one’s hand) (parent/adult)

Generally speaking, transactions follow three rules (Berne, 1996; Martin, 2011):  The more comprehensive the transactions are, the more chances of survival they have (such as adult-adult ego state transactions)  If there is a change towards transverse transaction in communication (Parent ego state/child, child ego state/parent), it is interrupted and a problem occurs.  The results of hidden transactions are determined at a psychological level rather than social level. 39

Patient: When does the visit start? (with a calm voice, eye to eye communication) (adult/adult) Nurse: Why do you always ask me things? (cynical voice, making a grimace) (child/adult)

Figure 3: Transverse Transactions Source: Solomon (2003).

Transactions ensure to understand how the reflection of one’s inner world affects the communication with the other and the models of these reflections. This provides benefit in therapeutically using the knowing oneself and communication of the nurses with the patient in terms of developing our communication (Ertem & Keçeci, 2013). 2.1.3. Psychological games Berne indicated that psychological games are formed as a result of hidden transactions and play a role in the unconsciousness of the Adult ego state. A person, who fails to solve one's problem and is unconsciously overwhelmed with the weight of the problem either faces one's problem or manipulates others in order to get support. Games are learned behaviours and most people play their favourite games at different intensities (Berne, 1996). Psychological games are repeated behaviours used by an individual consciously or unconsciously to a certain extent. Psychological games can be enriched and maintain the life scenarios of the individual. Psychological games start at the early periods of life, and the structure of psychological games is determined by the life scenarios and the positions of individuals in life (Shankar, 2015). While games are learned behaviours, each person definitely plays games in his/her daily life. 2.1.4. Life scripts An individual starts to assess one’s environment and interpret the incidents starting from very young ages. They react within the framework of this assessment. This unconscious state is called “Life Script” in the Transactional Analysis. This script includes the tendency and opinion of the individual about oneself (Berne, 1996). Life scripts are future plans made by an individual unconsciously with the effect of the sensitivities in early childhood period and the environment around oneself. Individuals are shaped by the environment in which they grow up since their birth (parents, caregivers or people they live with while they grow up), and they advance with the effect of their past experiences while making decisions on their lives. The most important feature of life scripts is the decisions made by an individual in the early period. The content of the messages received by individuals from the environment on how they should be and live affects them with all aspects and may push them to desired and non-desired life positions (Solomon, 2003). Similarly, nurses should take into consideration the life positions of the patients when they communicate with the patients they encounter. While some patients have positive life positions, some may 40

have negative life positions. The nurse can observe an individual well, start the therapy process with those who have a negative perception, or in case they are not qualified enough in this sense, make a suggestion and guide the patient in receiving support in this subject. The analysis of the personality of the patients with these four main components in the transactional analysis increases their level of awareness, they become stronger in taking their lives under control and may positively change their future life. 2.2. Importance of using the transactional analysis approach in patient-nurse communication That the communication process with the patient is effective and successful is important in rendering health care service. It is believed that having knowledge and skills on the transactional analysis approach within the therapeutic communication process established with the patient can be effective in facilitating this process. That nurses have information and make research about the transactional analysis approach may increase successful communication skills by affecting the communication with the patient and environment. At the same time, that the nurse can see the patient with the point-of-view of this approach in therapeutic communication process (which ego state is used when communicating, which life position is used and the perception of this, the assessment of the transactions used, etc.) may ensure making effective nursing diagnoses and make the intervention steps more suitable for the patient. The transactional analysis approach is effective in the patient-nurse communication process and ensures achieving certain targets both in terms of the individual and the advisor. These targets are autonomy, awareness, being able to give normal reactions and sincerity, and can be considered as the focal point of the philosophy and practice of the transactional analysis approach (Lister-Ford, 2002). The suitable approaches in the communication with the patient are regarded as the basis of effective care in nursing, which requires professionalism. The transactional analysis approach among the approaches that can be used for communication may be beneficial in knowing oneself and the patient for the nurse. The nurse can review both one’s past experiences, ego states and which transactions are used and those of the patients. It is believed that the transactional analysis will be beneficial both during the therapy and communication process in the patient-nurse communication. REFERENCES Akkoyun, F. (2007). Transaksiyonel Analiz: Psikolojide işlemsel çözümleme yaklaşımı (3 b.). Ankara. Berlo, D. K. (1960). The process of communication. San Francisco: Reinhart Press. Berne, E. (1966). Games people play. New York: Oxford University Press. Berne, E. (1996). Games people play: the psychology of human relationship. New York: Ballantine Books. Berne, E. (1961). Transactional analysis in pscyhoteraphy. New York: Groce Press. Berne, E. (1972). What do you say after you say hello? New York: Grove Press. Berne, E. (1998). What do you say after you say hello? (19 b) London: Corgi. Boyd, C., & Dare, J. (2014). Student survival skills: communication skills for nurses. USA: Wiley-Blackwell. Centers for Disease Control. (2010). Healthy people 2010: Final review. Cüceloğlu, D. (2002). Keşke'siz bir yaşam için iletişim donanımları. Remzi Kitabevi. 41

Cüceloğlu, D. (1998). Yeniden insan-insana (18 b.). İstanbul: Remzi Kitabevi. DeVito, J. A. (2008). The interpersonal communication handbook (12 b.). Boston: Pearson Education. Dökmen, Ü. (2010). Sanatta ve günlük yaşamda iletişim çatışmaları ve empati (43 b.). İstanbul: Remzi Kitabevi. Ertem, M.Y., & Keçeci, A. (2013). Ego states of nurses working in psychiatric clinics according to transactional analysis theory. Pakistan J. of Med. Sci., 32 (2), 485-490. Fortinash, K.M., & Worret, P.A. (2008). Psychiatric mental health nursing. California: Mosby Elsevier. Gürgen, H. (1997). Örgütlerde iletişim kalitesi. İstanbul: Der Yayınevi. Keçeci, A. (2007). Hemşirelik eğitiminde iletişime yeni bir yaklaşım: Transaksiyonel analiz. Ulusrarası İnsan Bilimleri Dergisi, 4 (2), 1-12. Kidwell, B. & Hasford, J. (2014). Emotional ability and nonverbal Communication. Psychology & Marketing , 31 (7), 526-538. Kraszewski, S. & McEwen, A. (2010). Communication skills for adult nurses. New York: Op en University Press. Lister-Ford, C. (2002). Skills in counselling & psychotherapy series: Skills in transactional analysis counselling & psychotherapy. London: Sage Publications. Martin, C. J. (2011). Transactional analysis: A method of analysing communication. British Journal of Midwifery, 19 (9), 587-593. Özcan, A. (2006). Hasta-hemşire ilişkisi ve iletişim. Ankara: Sistem Ofset Bas. Yay. San. Tic. Ltd. Şti. Phutela, D. (2015). The importance of non-verbal communication. IUP Journal of Soft Skills , 9 (4), 43-49. Rayudu, C. S. (2010). Communication. India: Himalaya Publishing House. Schiavo, R. (2014). Health communication: from theory to practice (2 b.). San Francisco: Jossey-Bass. Shankar, R. K. (2015). Transactional analysis: A new perspective. Human Capital, 48-50. Solomon, C. (2003). Transactional analysis theory: The basics. Transactional Analysis Journal, 33 (1), 14-22. Steward, I. (1996). Developing counselling series: Developing transactional analysis counselling. London: SAGE Publications Ltd. Tabak, R. S. (2003). Sağlık iletişimi. İstanbul: Literatür Yayıncılık Dagıtım Pazarlama San. ve Tic. Ltd. Şti. Thomas, R. K. (2006). Health communication. USA: Springer Science & Business Media. Tudor, K. (2001). Brief therapies series: Transactional analysis approaches to brief therapy: What do you say between saying hello and goodbye? London:Sage Publications Ltd. Tudor, K. (2010). The state of ego: then and now. Trans. Analysis J., 40 (3-4), 261-277. US Department of Health and Human Service. (2000). Healthy people: understanding and improving health (2 b.). Washington: US Goverment Printing Office. Varcarolis, M. (1998). Foundations of psychiatric mental health nursing (Third Edition b.). Saunders Company. Videbeck, S. L. (2011). Therapeutic communication. S. L. Videbeck içinde, PsychiatricMental Health Nursing (s. 98-117). Philadelphia: Lippincott Williams & Wilkins. Wilson, H. S. & Kneisle, C.R. (1988). Psychiatric nursing. California: Addison-Wesley Publishing Company. Wrycraft, N. (2009). Introduction to mental health nursing. Berkshire: Open University Press. 42

Chapter 5 The Pain Management in Intensive Care Units Dilek YILMAZ, Yurdanur DİKMEN, Dilek KARAMAN INTRODUCTION By the communities living in the different locations throughot the history,pain , which is as old as the history of humanity, has been perceived differently and solutions for the pain has been searched. It is hard to make a description of pain. The word ‘pain’ is derived from the Latin word ‘poena’, which is used to describe punishment, revenge and torture. Pain, according to the social psychology context, is accepted as an essential keystone of a person’s cognitive system (Özlü, 2014). Pain, is a subjective experience seen by everybody (Aslan, 2002). The most popular and valid description of ‘pain’ is made by the International Association for the Study of Pain (IASP). According to this description; pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Aslan, 2002; Aydın, 2002; Kılıç & Öztunç, 2012). As can be understood from this description, pain is conceived as an unpleasantry emotion or a sense. Thus, it is always subjective. Consequently, when comenting on the pain, not only the physical concept but also the subjective concept should be kept in mind and it should be based on the pain description of the patient (Aslan, 2002). Pain, has been seen since the start of the history of mankind, despite the significant improvements in the contemporary health sciences, can still be seen and is still one of the major reasons that patients require medical assistance. Millions of patients from all around the globe, appeals to the medical facilities with a pain issue. Unfortunately, necessary precautions are ineffective and pain of the most of the patients can not be dealt with. It is also known that, life quality of these patients decline due to the pain, hospitalization period extends and death ratios increase (Aslan & Badır, 2005) Thus, pain experience and a comprehensive management of the pain process should be a main focus point. Pain in the intensive care unit and its negative consequences Intensive Care Units, are units designed for the patients under life-threatening conditions and comprised of highly technological devices in order to give most benefit and requires an interdisciplinary team approach (Terzi & Kaya, 2011). Although there has been important progresses in the intensive care technology and in the conditions of the refractory patients, the mortality rate in these intensive care units are still considerably high (Kumsar & Yılmaz, 2013). Pain is a frequent problem in the intensive care units. Patients in the intensive care 

Lecturer, Uludag University, School of Health, Department of Nursing Assoc. Prof. Dr., Sakarya University, School of Health, Department of Nursing  Lecturer, Bülent Ecevit University, Ahmet Erdogan Health Services Vocational School, Department of Health Care Services 

units are exposed to pain-increasing reasons such as; invasive initiations, trauma, still staying for long periods, routine nursing care and existing health problems (Hery et al., 2006). Additional to the pain in the resting period; procedures taken related to surgery, trauma, burnts or cancer are related to the pain in the intensive care units (Barr et al., 2013; Stanik-Hutt et al., 2001). Thus, the volume of pain experienced by the patients in the intensive care units can vary from minor to severe levels (Demir, 2012; Pasero, 2003). According to a related research; most pain-causing implementations of invasive initiations are position change, central venous catheter implementation, wound treatment, tracheal aspiration, wound drainage and removal of femoral catheter (Puntillo et al., 2004). Additionally other pain causes in intensive care untis are; cathether used for various reasons, installment and removal of drainages, inactivitiy for long periods, incisions, wounds and pressure wounds, wound treatment, noninvasive and invasive ventilation methods, aspirations (tracheal and endotracheal), wound dressing changes, existing illness, surgery area, duration and the type of incision, body position of the patient during the surgery and rehabilitation methods (Demir, 2012; Herry et al., 2006; Young et al., 2006). According to studies, 44-69% of the patients in the intensive care units experience pain (Chong & Burchett, 2003; Demir, 2012; Uyar & Korhan, 2011). According to Payen and colleauges (2007) with Chanques and colleagues(2007), both in internal and surgical intensive care units, pain incidence is 50% or above (Chanques et al., 2007; Payen et al., 2007). In the literature, insufficient treatment of the initiation-related pain is still a big problem for many of the patients (Puntillo et al., 2001). Physiologic and negative consequences of the nonresolved pain in the intensive care units are important and last long. Intensive care unit patients oftenly descrip the pain as an anxiety and sleep deprivation causing reason for years. Negative results can be seen due to pain. Catecholamine increase in circulation causes arterial vasoconstriction, tissue perfusion to decay and partial oxygen pressure decreases (Akça et al., 1999). Other responses to the pain could be hyperglisemia, catabolic hypermethabolism caused by the lipolisys and burning of muscules (Hedderich & Ness, 1999). Catabolic simulation and hypocsemia also deteriorates the recovery of wound and increases the risk of infection. Due to all of these reasons, identification of pain of the intensive care patients and treatment are important. Pain findings intensive care patients Pain is an experience, requiring immiediate attention, oppresing patient, decaying behavior and decisions, on other hand causing pain-resolving activities to be conducted, causing changes in the behavioral responses and automatic changes (Uyar & Korhan, 2011). An organism gives physiologic, psychologic and behavioral responses to pain. Physiologic finds are; sweating, tear drops, nausia and vomit, pale skin; increase in the blood pressure, hearthbeat and respiration (Brown et al., 2004). Psychologic responses are confusion, anxiety, fear, rage, changes in the cognitive and verbal functions, anger, discomfort (Karayurt & Akyol, 2008). Behavioral responses to the pain in the intensive care patients are contraction in damaged organs or pulled away from the stimulus of the region, incisions, inactivity, pulling the leg, wrinkling face, chewing the intubation tube, rhytmic swinging, legs 44

shaking, kicking, pulling the nurses and the doctor's arm, person specific position and posture (Badır & Aslan, 2003; Esen et al., 2010; Uyar & Korhan, 2011). Most frequent behavioral pain response seen in the intensive care unit is wrinkling face (Stotts et al., 2007). Most common response of patients with a cognitive disorder is discomfort. It is recorded that patients with endotracheal tube may show wrinkling face, frowning, holding arms of nurses, moving feet and arms symptoms (Pasero & McCaffery, 2000). Consequently, body movement can be used as a communication method by the intensive care patients with intubation (Demir, 2012). Evaluation of pain in intensive care patients Detection, identification of the pain and given responses to the pain varies across individuals (Çöçelli et al., 2008). Due to the fact that pain is individual-specific; it is required that a comprehensive patient history should be taken, all of the aspects of the patient should be known, constant monitoring should be conducted and effective methods should be taken in order to evaluate the level of pain (Aslan, 2002). While evaluating a patient with the pain complaint; physical, environmental, social and psychologic aspects should be considered and it should be remembered that these aspects can interact with each other and affect the level of pain (Çöçelli et al., 2008). The easiest evaluation method of pain symptom is to ask the patient whether there is a pain or not. But, this questioning is insufficient. In the evaluation, the level, type, features, the relationship with the body and time, affecting conditions of the pain should be known (Aslan, 2002). Due to its objectivity, objective evaluation criterias used for the evaluation of the severity of the pain could be used for the adult patients without talking ability and child patients. The features and changes of the pain are evaluated by an observant. Examples of objective pain evaluation methods are; physiologic, neurologic and biochemical measurements, neuropharmacologic methods, behavioral and electroensefalographic evaluations (Güzeldemir, 1995). International health institutions (APS-American Pain Society, JCI-Joint Commission International), pain management is inefficient because pain evaluation and treatment is not conducted within a system and correctly (Dihle et al., 2006; Erden, 2015). In the medical literature, ideal pain evaluation method in the intensive care unit shoul consists of; 1. The source of the pain should be determined (dressing changes, position changes, aspiration, etc.) 2. If possible, it should be asked to explain the patient's pain, • scale should be used in determining the severity of pain • If the pain intensity cannot be determined, short yes/no questions should be asked to the patients.(do you have any pain, is it on the surgery area? etc.) 3. Symptoms of pain should be monitored 4. Pre and posttherapeutic interventions should be re-evaluated in the form of pain that is stated (Erden, 2015; Esen et al., 2010; Yuceer, 2011). Routine pain evaluations of the adult intensive care patients are closely related to the clinic results. The most trustworthy source of the identification of the intensity of the pain is the patient itself. Consequently, it is hard to describe the pain itself. Legitimate and safe tools should be used for pain evaluation. Payen and Chanques (2012) showed in their study that with the use of proper methods used for pain evaluation, mechanic ventilation duration and intensive care duration of the patients 45

decline (Payen & Chanques, 2012). Additionally, an effective pain evaluation with the use off analgesic medicine, intensive care period and mechanic ventilation period is closely related (Barr et al., 2013). First step in the pain management process is accurate and valid definition of the pain (Blenkharn et al., 2007; Demir, 2012; Karayurt & Akyol, 2008). Owing to the fact that deprivation of verbal communication of the intensive care patients, single-aspect or multi-aspect evaluation of the pain is most impossible (Demir, 2012; Karayurt & Akyol, 2008). Thus, pain identification tools concerning the physiologic and behavioral symptoms ofintensive care specific pain. These scales are mentioned below (Barr et al., 2013). Behavioral pain scale In order to evaluate the pain behavior with the children who cannot express themselves verbally, ‘Behavioral Pain Scale’ has been developed which consists of body position of the patient, extremities and adaptation to the ventilation in 1993. Payen and colleagues have searched the validity and trustworthiness of these scales with the adult intensive care patients and modified these scales for common use. Behavioral Pain Scale (BPS), is comprised of 3 different sections (facial expression, upper extremity behaviors, adaptation to the mechanical ventilation) and total 12 articles. Each section receives points from 1 to 4 (Payen et al., 2001) (Fig. 1). Least pain score is 3 and the most pain score is 12. Increase of the point shows that intensity of the pain is increasing (Karayurt & Akyol, 2008; Payen et al., 2001). It is also reported that the Behavioral Pain Scale is also a valid and safe scala for patients who cannot express themselves, motor functions intact and postoperative intensive care and trauma patients, whose behaviors that can be observed, except with brain injuries (Barr et al., 2013). Table 1: Behavioral pain scale

Behavioral pain scale for children Facial expression, legs, body movement, crying and consolation scale, has been developed by Merkel and colleagues in 1997 in order to evaluate the pain with the children. This tool consists of 5 different sections; facial expression, legs, body movement, and consolation. Each section is worth between 0 and 2 and total 0 to 10. Increase in the pain point show that the pain intensity also increases (Karayurt & Akyol, 2008). 46

Nonverbal adult pain scale This measure is based on the behavioral pain scale in the evalutaion of the chil pain evaluation amd reorganization for the adult patients. Some sections of the child behavioral pain scale crying, legs and consolation are removed and awakeness, physiology (life indications) and respiration evaluation sections are added. Nonverbal pain scale for the adults are comprised of 5 sections. Each section worths 0 to 2 and in total 0-10 (Odhner et al., 2003) (Fig. 2). 0-2 points mean no pain, 3-6 points mean mild pain and 7-10 points mean intense pain (Karayurt & Akyol, 2008; Topolovec-Vranic et al., 2010). Table 2: Nonverbal adult pain scale Categories 0 1 2 Occasional grimace, Frequent grimaca, No particular Face tearing, frowning, tearing, frowning, expression or smile wrinkled forehead wrinkled forehead Seeking attention through Restless, excessive Activity Lying quitely, normal movement or slow, activity and/or (Movement) position cautious movement withdrawal reflexes Lying quitely, no Splinting areas of the Guardind positioning of hands Rigid, stiff body, tense over areas of body Change over past 4 Change over past 4 hrs in hrs in any of the Physiologic I Stable vital signs (no any of the following: following: SBP> 30 (Vital Signs) change in past 4 hrs) SBP> 20 mmHG, mmHG, HR|>25 HR|>20 /min, RP>10/min /min, RP>20/min Dilated pupils, Physiologic Warm, dry skin Diaphoretic, pallor II perspiring, flushing SBP, systolic blood pressure; HR, haert rate; RR, respiatory rate. Critical-care pain observation tool Critical-Care Pain Observation Tool is developed by Gèlinas and colleagues (2006), in order to identify the pain of the Canadain intense care patients. This tool is comprised of 4 different sections including behavioral matters such as; facial expression, body movements, muscle tension, adaptation to the ventilation for the intubed patients and groaning for the extubed patients. Each section worths between 0 and 2 and in total 0 to 8. (Demir, 2006; Gèlinas et al., 2006). Critical-Care Pain Observation Tool is similar to Behavioral Pain Scale in terms of being a valid and safe scala for patients who cannot express themselves, motor functions intact and postoperative intensive care and trauma patients , whose behaviors that can be observed, except with brain injuries (Barr et al., 2013). Pain assessment and intervention notation- P.A.I.N P.A.I.N is developed by Puntillo and colleagues (1997). In this notation, 6 pain expression (facial expression, body movement, body position, groaning, pale skin, sweating) and three different physiologic responses to the pain (hearthbeat speed, blood pressure and respiration) is included (Puntillo et al., 1997). Sections are given below: First section (Pain Identification): identification of the pain according to quantitative pain evaluation method (0-10) is made. Nurse observes the behavioral responses to the 47

pain (facial expression, movements or the body position). Second section (Possible problems affecting analgesic methods): is related to the possible issues affecting analgesic methods. These are instability of the homdynamic levels of the patient, changes in the respiration and extensive sedation. Third section (Analgesic treatment decision): This is the part where decision related to analgesic treatment is made after all of the definitions are made. It is suggested that this tool should be used on the patients with chest and abdomen surgeries, implemented by nurses and should be redone within every 4 hours (Demir, 2012). Pain assessment algorithm Pain Assessment Algorithm, is developed in England by the Blenkharn and colleagues for the intensive care patients who cannot communicate. In this algorythm; tachycardia, hypertension, perspiration, pupil dilation, grimace, pain or unease movements are included. Unfortunately, this algorythm is not clinically tested and it is hard to say it is valid (Demir, 2012). Pain management in the intensive care patients Although it is known that, pain control pressurizes the neuroendochryonologic stress responses and decreases morbidity and mortality risk; it is still reported that pain treatment in the intensive care units are insufficient, patients still suffer from pain in spite of the analgesic treatment (Haljamäe et al., 1990; Erden, 2015). In the medical guide related to the usage of sedatives and analgesics, it is suggested that necessary analgesic should be provided for the treatment of pain (Erden, 2015). Barr and colleagues (2013) has mentioned in their studies that, pharmacologic and nonpharmacologic approaches should be used before the removal of the chest tube on the intense care patients, in order to ease the pain. Pharmacologic initiations used for the intensive care patient pain management Currently, pain and analgesy is widely discussed. Although studies related to pain have been conducted since 1960’s, studies related to the definition and recovery of the pain is still important (Derebent & Yiğit, 2006). Pain treatment changes due to the intensity of the pain, pain recognition level, physical variables (age, sex, body mass index, chronic diseases etc.) and the pain type (nociteptive, neuropathic) (Erden, 2015). Narcotic agents should be used primarily in the intensive care pain treatment. Opoids such as; phentaline, hydromorphine, methadon, morphine and remiphentaline are anagelsics most commonly used in the pain management (Barr et al., 2013) (Fig. 3). Choosing a proper opoid and dosage for an adult patient is related with many factors such as pharmacokinetic and pharmacodynamic aspects (Barr et al., 2013). Frequently used opoids have long half-life periods and cause side effects at dosages for the intended analgesy level(discharge of histamine, hypotension, respiratory depression, gastrointestinal side effects). Low levels of opioids, do not cause anxiolisis during analgesy, but at high levels sedative effects can be observed (Calderon et al., 2001; Sarıcaoğlu et al., 2005). It is suggested to primarily use morphine, due to its long effect for the stable patients in terms of hemodynamics; but for hemodynamically instable patients, due to histamine discharge, no hypothention and its faster effect; fentanyl is suggested (Sarıcaoğlu et al., 2005). Fentanyl, provides quick impact and due to hemodynamic reasons such as the failure to discharge histamine, is preferred in unstable patients. 48

Fentanyl is received more by the central nervous system compared to morphine. This makes fentanyl a more potent analgesic (Akçabay, 2002). Morphine, having a strong analgesic effect comes together with release of histamine and cardiovascular instability and vasodilation. Thus, it is suggested for the hemodynamially stable patients. Meperidine, should be particularly preferred in treating post-surgical pain because it causes a much shorter effect compared to morphine. But it should be used carefully with intensive care patients because their methabolite is neurotoxic (Brush & Kress, 2009; Erden, 2015). Additional to the opioids, non-opioid analgesics such as acetaminophen and Nonsteroidal Antiimflammatory (aspirin, diclofenac, naproxen etc.) are used in the intensive care units. Analgesia benefits from the effects of these drugs to prevent or reduce inflammation. These agents reducing the narcotic need pain in the postoperative management of the patients with direct tissue inflammation thoracic, abdominal or other surgical procedures (Brush & Kress, 2009; Erden, 2015). Another pharmacologic initiation ‘patient controlled analgesy’ also known as PCA, is a pain control system used for awake and aware patients. With this method, intravenous opioid is implemented by an infusion pump as subsequent dosages activated by the patient’s will. Time gap is named as ‘Lockout interval’. Because, within this period, patient cannot activate the pump. ‘Lockout interval’ is close to the necessary time for every drug to take action. Mostly lockout interval for fentanyl is 5 minutes, for morphine is 10 minutes. Patient satisfaction is more compared to common intravenous drug use and especially popular among postoperative patients (Akçabay, 2002). Non-pharmacologic initiations used in intense care patient pain management Another pain management treatment implementations are non-pharmacologic methods. In recent years, usage of these methods, not only by itself but also a combined usage with pharmacologic methods decreases or finishes the intensity of pain, are getting more popular (Özveren, 2011). According to the study of Özveren and Uçar (2009) with the student nurses; sole usage of non-pharmacologic methods frequency is 6.5 %, a combined usage of these methods with pharmacologic methods frequency is 92.6%. Nonpharmacologic methods used for controlling the pains, are a part of the complementary elements of a comprehensive pain ease approach. It is thought that, these methods help the standard medicine treatment. While the effects of drugs used for pharmacological treatment of somatic pain; non-pharmacological methods are used in the treatment of pain in terms of emotional, cognitive, behavioral and sociocultural influences (Kılıç & Öztunç, 2012; Akça & Arslan, 2015). Additionally, it is reported that these methods decrease anxiety of the individual; eases sleep deprivation and supports individual in spiritual terms (Aslan, 2010). Also these methods, increases the sense of control, activity level and working capacity; decreases the sense of powerlessness (Kılıç & Öztunç, 2012) and side effects of pharmacologic methods (Arslan & Çelebioğlu, 2004; Özveren, 2011). Nonpharmacologic methods are more safe and sound compared to pharmacologic method in terms of cost and a low possibility of side effects (Barr et al. 2013). Nonpharmacologic methods are classified differently form the peripheral treatments, cognitive-behaviorist treatments and all the other similarly classified treatments (Kılıç & Öztunç, 2012; Özveren, 2011). A limited number of studies is available related with the pain management of the 49

intense care patients. According to these studies; effects of music therapy, relaxation techniques are identified (Erstad et al., 2009; Uyar & Korhan, 2011). In the light of the previous studies; in the study of Davis and Cunningham (1985) in coroner intense care unit, music decreases the pain and anxiety also enables relaxion of the patients. According to another study conducted in the coroner intense care unit, classical music has a positive effect on the anxiety and pain (White, 1992). According to Bolwerk (1990)’s study with the patients with myocardial infarction history; music has a decreasing effect on pain. According to O’Sullivan (1991)’s study on the coroner and surgical intense care patients; patients have listened to classical music and it is observed that their pain and anxiety has decreased after the treatment. According to other studies related to this subject, music treatment has a significant impact on the pain management (Chlan et al., 2007; Erstad et al., 2009). Additionally, music therapy has an effect on the decrease of the new born baby intense care units (Caine, 1991; Hatem et al., 2006; İmseytoğlu & Yıldız, 2012). Within a limited number, some relaxion techniques used in the literature has also helped to ease pain of the intense care patients (Barr et al., 2013; Erstad et al., 2009). Apart from that, interactions with patients, patient trainings, elimination of irritations (reorganization of the raction of the endocreanal tube etc.), frequent body position change, aspiration for the comfort of the patient, mouth care and massage are among the nonpharmacologic implementations in the intense care units (Sarıcaoğlu et al., 2005). Although it is known that, not only a lower possibility of side effects compared to pharmacologic agents, but also it decreases the consumption of analgesics and it allows an efficient analgesy usage (Erden, 2015; Yuceer, 2011), there has been only a few scientific researches on the nonpharmacologic method implementation for the purpose of pain management in the intense care units. CONCLUSIONS Intense care patients experience pain at different levels. For the effective pain management of the patients, correct evaluation and treatment is necessary. For an effective pain management; methods with low possibility of side effects, low cost and higher level of safety should be primary concerns. For this reason, effective pain management in the intense care unit concerning researches should be based on evidence. It is also suggested that these research results should be disseminated among intense care units and policies and strategies should be developed. REFERENCES Akça, O.; Melischek, M.; Scheck, T.; Hellwagner, K.; Arkiliç, C.F.; Kurz, A.; Kapral, S.; Heinz, T.; Lackner, F.X.; Sessler, D.I. (1999). Postoperative Pain and Subcutaneous Oxygen Tension. Lancet 354, 41–42. Akçabay, M. (2002). Yoğun Bakım Ünitesinde Sedasyon Ağrı Kontrolü ve Paralitik İlaç Kullanımı. Available at: http://www.yogunbakimdergisi.org/managete/fu_folder/200203/html/2002-2-3-151-161.html, July, 2016. Arslan, S. & Çelebioğlu, A. (2004). Postoperatif Ağrı Yönetimi ve Alternatif Uygulamalar. İnsan Bilimleri Dergisi 1, 1-7. Aslan, F. E. (2002). Ağrı Değerlendirme Yöntemleri. C.Ü. Hemşirelik Yüksekokulu Dergisi 6 (1), 9-16. Aslan, F. E. (2010). Ağrı. Karadakovan A, Aslan FE, (Eds). Dahili ve Cerrahi Hastalıklarda Bakım kitabı içinde (bölüm 3, sayfa 137-160). Nobel Kitabevi: 2010:137-160. 50

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Güzeldemir, M.E. (1995). Ağrı Değerlendirme Yöntemleri. Sendrom 11-21. Hatem, T.P.; Lira, P.I.; Mattos, S.S. (2006). The Therapeutic Effects of Music in Children Following Cardiac Surgery. J Pediatr (Rio J) 82 (3), 186-192. Hedderich, R. & Ness T.J. (1999). Analgesia for Trauma and Burns. Crit Care Clin 15, 167– 184. Herry, K.; Coyne, P.J.; Key, T.; Manworren, R.; McCaffery, M.; Merkel, S. (2006). Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing 7 (2), 44-52. İmseytoğlu, D. & Yıldız, S. (2012). Yenidoğan Yoğun Bakım Ünitelerinde Müzik Terapi. İ.Ü.F.N. Hem. Derg 20 (2), 160-165. Karayurt, Ö.& Akyol, Ö. (2008). Yoğun Bakım Hastalarında Ağrı Değerlendirilmesi. Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi 11 (4), 96-104. Kılıç, M. & Öztunç, G. (2012). Ağrı Kontrolünde Kullanılan Yöntemler ve Hemşirenin Rolü. Fırat Sağlık Hizmetleri Dergisi 7, 35-51. Kumsar, A.K. & Yılmaz, F.T. (2013). Yoğun Bakım Ünitesinin Yoğun Bakım Hastası Üzerindeki Etkileri ve Hemşirelik Bakımı. Hemşirelikte Eğitim ve Araştırma Dergisi 10 (2), 56-60. Odhner, M.; Wegman, D.; Freeland, N.; Steinmetz, A.; Ingersoll, G.L. (2003). Assessing Pain Control in Nonverbal Critically Ill Adults. Dimens Crit Care Nurs 22 (6), 260-267. Özlü, Z.K. (2014). Ağrıya Kültürel Yolculuk. Sağlıkla Hemşirelik Dergisi 14, 40-41. Özveren, H. & Uçar, H. (2009). Öğrenci Hemşirelerin Ağrı Kontrolünde Kullanılan Farmakolojik Olmayan Bazı Yöntemlere İlişkin Bilgileri. Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Dergisi 1, 29-72. Özveren,H. (2011). Ağrı Kontrolünde Farmakolojik Olmayan Yöntemler. Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Dergisi 1, 83-92. Pasero, C. (2003). Pain in The Critically Ill Patient. Journal of PeriAnesthesia Nursing 18 (6), 422–425. Pasero, C. & McCaffery, M. (2000). When Patients Can’t Report Pain. Am J Nursing 100 (9), 22-23. Payen, J.F.; Bru, O.; Bosson, J.L.; Lagrasta, A.; Novel, E.; Deschaux, I.; Lavagne, P.; Jacquot, J. (2001). Assessing Pain in Critically Ill Sedated Patients By Using a Behavioral Pain Scale. Crit Care Med. 29 (12), 2258-2263. Payen, J.F.; Chanques, G.; Mantz, J.; Hercule, C.; Auriant, I.; Lequillou, J.L.; Binhas, M.; Genty, C.; Rolland, C.; Bosson, J.L. (2007). Current Practices in Sedation and Analgesia for Mechanically Ventilated Critically Ill Patients: A Prospective Multicenter PatientBased Study. Anesthesiology 106, 687–695. Payen, J.F. & Chanques, G. (2012). Pain Assessment in the ICU Can Improve Outcome. Clinical Pulmonary Medicine 19 (1), 21-26. Puntillo, K.A.; Miaskowski, C.; Kerhle, K.; Stannard, D.; Gleeson, S.; Nye, P. (1997). Relationship Between Behavioral and Psychological Indicators of Pain, Critical Care Patients’ Self reports of Pain and Opioid Administration. Critical Care Medicine 25 (7), 1159-1166. Puntillo, K.A.; White, C.; Morris, A.B.; Perdue, S.T.; Stanik-Hutt, J.; Thompson, C.L. et al. (2001). Patients’ Perceptions and Responses to Procedural Pain: Results from Thunder Project II. Am J Crit Care 10, 238–251 Puntillo, K.A.; Morris, A.B.; Thompson, C.L.; Stanik-Hutt, J.; White, C.E.; Wild, R.E. (2004). Pain Behaviors Observed During Six Common Procedures: Results from Thunder Project II. Critical Care Medicine 32 (2), 421-427. O’Sullivan, R.J. (1991). A Musical Road to Recovery: Music in Intensive Care. Intensive 52

Care Nurs. 7 (3), 160-163. Sarıcaoğlu, F.; Akıncı, S.B.; Dal, D.; Aypar, Ü. (2005). Yoğun Bakım Hastalarında Analjezi ve Sedasyon. Hacettepe Tıp Dergisi 36, 86-90. Stanik-Hutt, J.A.; Soeken, K.L.; Belcher, A.E.; Fontaine, D.K.; Gift, A.G. (2001). Pain Experiences of Traumatically Injured Patients in a Critical Care Setting. Am J Crit Care 10, 252–259. Stotts, N. A.; Puntillo, K. A.; Stanik-Hutt, J.A.; Thompson, C.L.; White, C.E.; Wild, R.E. (2007). Does Age Make a Difference in Procedural Pain Perceptions and Responses in Hospitalized Adults?. Journal of Acute Pain 9 (3), 125-134. Terzi, B. & Kaya, N. (2011). Yoğun Bakım Hastasında Hemşirelik Bakımı. Yoğun Bakım Dergisi 1, 21-25. Topolovec-Vranic, J.; Canzian, S.; Innis, J.; Pollmann-Mudryj, M.A.; McFarlan, A.W.; Baker, A. (2010). Patient Satisfaction and Documentation of Pain Assessments and Management After Implementing the Adult Nonverbal Pain Scale. American Journal of Critical Care 19 (4), 345-354. Uyar, M. & Korhan E.A. (2011). Yoğun Bakım Hastalarında Müzik Terapinin Ağrı ve Anksiyete Üzerine Etkisi. Ağrı 23 (4), 139-146. White, J.M. (1992). Music Therapy: An Intervention to Reduce Anxiety in The Myocardial Infarction Patient. Clin Nurse Spec 6 (2), 58-63. Young, J.; Siffleet, J.; Nikoletti, S.; Shaw, T. (2006). Use of a Behavioral Pain Scale to Assess Pain in Ventilated, Unconscious and/or Sedated Patients. Intensive and Critical Care Nursing 22 (1), 32-39. Yuceer, S. (2011). Nursing Approaches in the Postoperative Pain Management. J Clin Exp Invest 2 (4), 474-478.

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Chapter 6 Responsibilities of Nurses in Use of Complementary and Alternative Medicine in Cancer Patients: Importance of Reflexology and Progressive Muscle Relaxation Exercises Hacer ALAN DİKMEN, Füsun TERZIOĞLU INTRODUCTION Cancer is a worldwide health challenge and becomes more and more important as to high rate of morbidity and mortality with the passing years (Çakır & Biliç, 2014). It was reported in 2012 that 14.1 million new cancer cases were seen, 8.2 million deaths arose from cancer, and 32.6 million individuals lived with cancer all over the world (WHO, 2012). While the aging and increasing population of the world puts a financial burden on budgets of all countries due to cancer and leads to changes in medical expenditures, an estimated 27 million new cancer cases, annual 17 million deaths led by cancer and 75 million additional cancer patients diagnosed within the last five years are hoped to be reached by 2030 (WHO, 2008). As well as rapidly increasing cases of cancer, recent advances experienced in diagnostic and therapeutic modalities have lengthened life span of patients and caused health professionals to seek novel modalities for cancer patients to spend rest of their lives in comfort and with less pain (Özçelik & Fadiloğlu, 2009). One of these novel medical procedures is also complementary and alternative medicine (CAM). The use of CAM is getting increased both in general population and among cancer patients (Özçelik & Fadiloğlu, 2009). Many procedures are present among CAM techniques such as herbal remedies, vitamins/minerals, green tea, massages, homeopathy, acupuncture, reflexology, aromatherapy, yoga, therapeutic touching, hypnotherapy, chiropractic manipulation and relaxation (Sood et al., 2007; Turan et al., 2010). The frequencies of CAM used in cancer patients vary from a country to another, and the rates encountered in USA, Turkey and European countries are reported as 74.6% (Sood et al., 2007), 46.2% (Kav et al., 2008) and 36% (Molassiotis et al., 2006), respectively. Women, especially gynecologic cancer patients, mostly choose CAM among patients with cancer, and the rate of users is reported as 40.3%. However, most of the patients get information about the use of CAM through informal or unscientific ways (Molassiotis et al., 2006), and so may apply to incorrect procedures. Due to these incorrect procedures, it is a must that health professionals and especially nurses, having to care for patients, should be involved in CAM procedures (Turan et al., 2010).

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Assist. Prof. Dr., Selcuk University, Faculty of Health Sciences, Department of Midwifery, Konya  Prof. Dr., Istinye University Dean of Faculty of Health Science, Director of Nursing Services MLPCare, Topkapı, Istanbul, Turkey

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) CAM is described as medical procedures and health care systems that are yet to be accepted as a part of contemporary medicine (National Center for Complementary and Alternative Medicine, 2014). While complementary medicine is used as supportive therapy along with contemporary medicine, alternative medicine has been used as a second option to contemporary medical procedures. CAM therapies are likely to be classified under four headings (Barnes et al., 2008): 1. Biology-based therapies, such as herbs, probiotics and vitamins/minerals. 2. Body-mind interventions, such as meditation, deep breath exercises, imaging, progressive muscle relaxation (PMR) exercises, hypnotherapy, yoga and energy workouts. 3. Manipulative and body-based therapies, such as massages, reflexology, osteopathy and chiropractic manipulation. 4. Alternative medical systems from antiquity, such as acupuncture, traditional Chinese medicine and traditional Indian medicine called Ayurveda, and contemporary medical modalities, such as homeopathy and naturopathy. Medical, economic and sociologic importance of CAM has started to draw an attention and to be used commonly (Molassiotis et al., 2006). While the rate of using CAM by general population was 34% in USA in 1990, the rate increased to 62% in 2002 (Rafferty et al., 2002). Mao et al. (2007) reviewed that a study performed in individuals with and without cancer, 40 percent of 1904 patients were found to use CAM, and an additional 62 percent to pray for healing. The most common CAM techniques used by cancer patients were found as herbs (20%), deep breath exercises (14%) and meditation (9%). The rate of individuals without cancer, however, was determined to be 35% in the same study. Compared to general population, the rate of using CAM by cancer patients is at a higher rate (Mao et al., 2007). In a study investigating the frequency of CAM by cancer patients in 14 European countries, the highest rates were found in Italy (38%) and Turkey (37%). In the study, 79 percent of CAM users were determined to be treated with chemotherapy and women patients to choose such modalities further (Molassiotis et al., 2005). CAM techniques found as the most commonly used ones in studies rank from the highest as body-mind exercises, such as relaxation and deep breath exercises, imaging, praying and hypnosis; herbal therapies, such as green tea and urtica urens; vitamins/minerals; manipulative treatments, such as massage, reflexology and electromagnetic therapy; acupuncture; and, energy work outs (Gruenige et al., 2001; Molassiotis et al., 2005; Navo et al., 2004; Swisher et al., 2002; Supoken et al., 2009; Ugurluer et al., 2007). Cancer patients use CAM mostly to fight against cancer and to improve their physical and emotional well-being (Molassiotis et al., 2006; Uğurluer et al., 2007). Reflexology as an instrument in complementary medicine The involvement of reflexology into medical practices has been increasing in recent years, and the practices have started to draw nurses’ attention (Demiralp & Oflaz, 2011; Wang et al., 2008). Started by applying controlled pressure with the thumbs or index fingers on reflex points of all endocrine glands and all body parts on hands, feet and ears, reflexology is a non-invasive, reliable and holistic complementary therapeutic modality (Booth, 1994; Givens, 2004; Musella, 2009; Tabur & Başaran, 2009; 55

Wilhelm, 2009). By activating the self-treatment mechanism of the body through reflexology, a physiological relaxation in the body and a balance in energy flow are obtained (Musella, 2009). Thanks to reflexology, blood flow is sped up by stimulating manually blood circulation and nerves, so oxygen reaches cells easily, lymphatic flow increases, toxic materials in the body are excreted out of the body swiftly, endorphine is released to decrease pain, and homeostasis develops (Booth, 1994; Musella, 2009; Tabur & Başaran, 2009; Tiran & Chummun, 2004; Wilhelm, 2009). In reflexology procedures, working on feet is more effective and easier. Reflex points of organs are more marked and larger on feet, compared to hands and ears. Additionally, feet, including more than 7000 nerve ends, are quite tender and sensitive parts of the body (Tabur & Başaran, 2009; Wilhelm, 2009). Disorders, stress, blues, trauma and other negative occurrences may prevent energy flow in the body (Wilhelm, 2009), leading to the accumulation of crystallized materials such as urea, uric acid and calcium on nerve ends and the obstruction of capillary circulation (Givens, 2004; Tabur & Başaran, 2009). As a consequence of these obstructions, some organs are neurologically over stimulated, and more blood flow occurs while other organs are under stimulated, and less blood flow reaches all parts of the body (Tabur & Başaran, 2009; Wilhelm, 2009). However, this unbalanced situation slowly leads organs not to perform well (Wilhelm, 2009). An experienced reflexologist feels these obstructions on his/her fingertips as a seed of rice while performing massage (Givens, 2004) and can increase blood flow by opening up the obstructed veins through massage and pressure, as well as helping free nerve stimulation (Givens, 2004; Wilhelm, 2009). Well-balanced distribution of blood flow and stimulation to all other parts of the body, however, makes the body more energetic and reinforces immune system (Wilhelm, 2009). A séance of reflexology is started on right foot and continues 30 min as total. Just as all areas on both feet may be stimulated in general while performing reflexology, definite areas may also be worked either on left or right foot, according to the patient’s complaint (Tabur & Başaran, 2009). The effect mechanism of reflexology and developed theories Reflexology is estimated dating back to 2500-2300 BC, and modern reflexology, described as “zone therapy”, was founded by a physician, William Fitzgerald, in the late 19th century (Todd, 2009; Wilhelm, 2009). Additionally, a reflexology map indicating reflex points on feet accounting for organs was developed by Eunice Ingham (18791974) with help of her own experiences and of findings in previous studies (Tabur & Başaran, 2009; Todd, 2009; Wilhelm, 2009). To many reflexologists, the term “zone therapy” is today accepted as the foundation of modern reflexology discovered by Fitzgerald and systematized as a more complete technique by Ingham (Todd, 2009). In reflexology, when a pressure is applied to the related points on feet, hands and ears, nerve ends on these bodily parts are electrochemically stimulated and activated, the stimulation is perceived by peripheral nerve system due to stimulated nerve ends, and a message formed by peripheral nerve system is conducted to central nervous system via afferent neurons after reaching a ganglion. The message passing through the ganglion is conducted to specific organs and glands via efferent neurons, and a response is established to the message (Putmana & Sunde, 1999; Wang et al., 2008; Xavier, 2007). Thanks to reflexology method, relevant organs and glands are stimulated. The physiological effects of reflexology are definite, and the mechanism is 56

explained with six theories, including energy, lactic acid, perception of nerve receptors, stimulation of nerves (theory of autonomic-somatic integration), gate control, and sympathetic and parasympathetic theories (Bishop et al., 2003; Cade, 2002; Hughes, 2009; Stephenson et al., 2000; Tabur & Başaran, 2009; Wilhelm, 2009). Theory of energy The theory explains the “zone theory” developed by Fiztgerald. Reflexologists perform their work on 10 energy areas constituting a longitudinal line on the body. An obstruction preventing energy flow in a definite area is believed to prevent the performance of other bodily parts existing in the same area in a healthy manner (Bishop et al., 2003; Cade, 2002; Hughes, 2009; Stephenson et al., 2000; Tabur & Başaran, 2009; Wilhelm, 2009). Lactic acid theory This is a theory based on the fact that lactic acid is accumulated on feet as micro crystals; reflexology inserts them into circulation again by dissolving these crystals; as a result, reflexology allows energy and blood flow to run by opening up obstructions (Ricks, 2005; Stephenson et al., 2007; Tabur & Başaran, 2009; Wilhelm, 2009), and getting rid of toxins out of the body (Tabur & Başaran, 2009; Wilhelm, 2009). Theory of perception of nerve receptors Electrochemical messages are formed by stimulating the nerve ends on feet, hands and ears through reflexology, and with the help of neurons, relevant organs are stimulated (Stephenson et al., 2007; Tabur & Başaran, 2009). Reflexology makes organs relaxed by decreasing stresses and tensions related to physical problems, and such a relaxation affects neuropeptides leading to an autonomous response, as well as endocrine and immune systems (Cade, 2002; Hughes et al., 2009; Stephenson et al., 2007; Tabur & Başaran, 2009). Nerve stimulation theory (Theory of autonomic-somatic integration) Feet, hands and ears are sensitive to pressure, torsion and moving. Human skin includes several types of nerve receptors, each with different anatomic and physiologic characteristics. In nerve stimulation theory, it is considered that a pressure is applied to receptors through open ionic channels in plasma membranes of cells during reflexology procedure and provides a potential local moving for the message to be transmitted to brain. In other words, reflexology is believed to have a direct effect on muscles as a result of the collection of sensory messages from feet, hands and ears due to motor stimulants from the internal connection of neurons in spinal cord to muscles (Bolsoy, 2008; Mollart, 2003; Tabur & Başaran, 2009; Tiran & Chummun, 2005). Gate control theory While defining the effect of gate control theory on the eradication of the best known pain so far, Melzack and Wall unified medical theories with contemporary biopsychological theories. In the theory, it is assumed that a control point or an opening gate, allowing pain signals to be transmitted, is present on spinal cord and nervous system. Upon opening the gate, pain signals are hypothesized to reach brain, but not to reach when the gate is closed. The gate can be closed via medicines, relaxation techniques, positive emotions, massages and reflexology (Paulo, 2011; Scholmesteers, 2005; Stephenson, 1997). As a result, pain signals are prevented to reach brain.

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Sympathetic and parasympathetic theory This notion is a recently accepted theory converging reflexology with contemporary medicine. According to the principles of the theory, the reflex points on left hands and feet to stimulate parasympathetic nervous system having a relaxing and sedative effect on the body, and on right hands and feet to stimulate sympathetic nervous system with a speeding-up and refreshing effect on the body are worked. In short, sympathetic and parasympathetic theory accepts to be worked on different hands and feet in principle. For example, left foot or hand is worked in a patient experiencing pain, and so an improvement and relaxation are achieved in the patient by stimulating parasympathetic nervous system (Tabur & Başaran, 2009).

Figure 1: Reflex points of organs on feet 58

General benefits of reflexology As a complementary therapeutic modality, reflexology is today used in many fields of medical science, such as neurology, gastroenterology, psychiatry, algological, physical treatment and rehabilitation, cardiology, pulmonary and oncology (Akçay, 2014), as well as its use in many health challenges (Tabur & Başaran, 2009; Wilhelm, 2009). General benefits of reflexology are listed as follows (Anderson, 2005; Botting, 1997; Hodgson, 2000; Magill & Berenson, 2008; Musella, 2009; Tabur & Başaran, 2009; Tiran & Chummun, 2005; Tovey 2002; Wilhelm, 2009): • To increase quality of life by alleviating cancer pains and adverse effects of chemotherapy, • To arrange the functions of sympathetic and parasympathetic nervous systems, • To decrease stress and tension, • To make patients feel a deep relaxing and refreshing emotion, • To ameliorate blood circulation and to eradicate obstructions in nervous system, • To decrease such complaints as headache, nausea and obstructed sinuses, • To obtain oxygen to be transmitted to cells, and to excrete toxins out of the body by making lymph nodes work better, • To improve joint and general pains, • To correct unbalanced hormonal activity, • To eradicate such psychological problems as depression, panic attack and anxiety, • To eradicate complaints like migraine, insomnia and fatigue, • To eradicate complaints of dyspepsia, constipation, diarrhea and reflux in adults, • To prevent colic pains in infants, • To eradicate nocturnal bed wetting in children, • To use a supportive therapy in the treatment of autism, cerebral palsy and speech defects in children, • To prevent joint disorders, nerve compression and muscle stiffness, • To prevent premenstrual syndrome, dysmenorrheal and menopausal complaints, to decrease or increase birth contractions (cervical dilatation), to help uterus involution in postpartum period and to ease lactation. Contraindications of reflexology • Acute infections and febrile disorders, • Mental disorders, • Deep vein thrombosis, • Challenges requiring surgery, open injuries and emergencies, • Stones in gall bladder and kidneys, • Malignant melanoma and tumors on feet, • Ante partum hemorrhage and preeclampsia, • Blood pressure fluctuation, • First trimester of pregnancy, risk of abortion, threat of premature birth (Lett, 2002; Musella, 2009; Tabur & Başaran, 2009; Wilhelm, 2009).

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Studies of reflexology performed in cancer patients Given studies related to reflexology, as consistent with the findings by Tsay et al. (2008) determining that reflexology decreases pain and anxiety symptoms in patients with stomach cancer in post-operative period (Tsay et al., 2008), Quattrin et al. (2006) also detected similar findings in patients with different types of cancer on chemotherapy (Quattrin et al., 2006). As parallel to the results of the study by Yang (2005), demonstrating that reflexology is effective in decreasing the symptoms of pain, fatigue, anxiety, high blood pressure, insomnia and depression in cancer patients (Yang, 2005), Kim and Oh (2011) also reviewed a great number of studies and alleged that reflexology is beneficial in the control of similar symptoms (Kim & Oh, 2011).

Progressive muscle relaxation exercises in the context of complementary medicine Relaxation with the meaning of having a rest, eradication of tension and relaxing was first described by American physician Edmund Jacobson in the 1920s, and the book “Progressive Relaxation”, related to the topic, was published in 1938 (Dayapoğlu, 2009). PMR exercises are a set of techniques aimed at decreasing muscle tension by forming a deep relaxation (Isa et al., 2013) and based on a theory, the neuromuscular hypertension theory, that several negative emotional states and psychosomatic disorders 60

lead to muscle tension in the body by triggering anxiety (Nickel et al., 2005). The exercises are a series of procedures including consciously contracting and relaxing of big muscle groups sequentially by the time a relaxation is achieved in all muscles (Varvogli, & Darviri, 2011). Via PMR exercises, oxygen is aimed to be reduced, involved in blood and become active in the circulation. With the help of activated oxygen, the accumulation of lactic acid leading to pain and fatigue in muscles and occurring during stress is decreased or lost. Accepted as natural analgesic of the body and the hormone of happiness, endorphin hormone is also increased during PMR exercises, and leads to the decrease of pain and anxiety. The World Health Organization (WHO) also recommends the use of PMR exercises in the management of acute pains (Dehdari et al., 2009; Tovey, 2002). Based on literature, it is considered that PMR exercises are effective in the control of symptoms experienced by cancer patients by increasing quality of life (Dehdari et al., 2009; Demiralp, & Oflaz, 2011; Demiralp et al., 2010; Isa et al., 2013; Luebbert et al., 2001; Molassiotis et al., 2002; Pizarro et al., 2007; Yoo et al., 2005). PMR exercises are the compile of easily-learned and invasive techniques with no adverse effects. Individuals become well-aware of muscles by looking into their whole bodies and learn how to consciously relax their muscles by realizing muscle tension occurring within stressful events. The idea of relaxing and subsequent relaxation decrease muscle tension by stimulating cerebral cortex stops the release of lactic acid and prevents pain (Ergen, 2010). Benefits of progressive muscle relaxation exercises PMR exercises are used to achieve the following (Anderson & Seniscal, 2001; Dayapoglu, 2009; Ghafari, 2009; Kaplan, 2012; Kartal, 2011; Pawlow & Jones, 2002; Sheu et al., 2003; Wilk & Turkoski, 2001; Varvogli & Darviri, 2011). • To reduce the release of cortisone and to decrease anxiety, • To decrease blood pressure and higher hearth rate, • To decrease the sensitivity to pain, especially headache, • To decrease muscle tension, accumulation of lactic acid in muscles and fatigue, • To manage the rehabilitation duration after cardiac disorders more successfully, • To strengthen immune system by stimulating thymus gland in the use of diaphragm with slow and deep breath exercises while performing PMR exercises. Diaphragmatic exercises done in respiration make heart, lungs, stomach and intestines work better by massaging them although these organs cannot be reached externally. • To increase quality of life by improving physical and mental health. The use of progressive muscle relaxation exercises in cancer patients PMR exercises are a group of interventions investigated and used at most (87.5%) to cope with the adverse effects of chemotherapy in training cancer patients (Chan et al., 2011; Luebbert et al., 2001; Molassiotis et al., 2002). In a meta-analysis where 10 studies performed in USA were reviewed, PMR exercises were reported to have four important effects in the control of symptoms during chemotherapy (Molassiotis et al., 2002). Firstly, PMR exercises are effective in decreasing nausea-vomiting and other adverse effects led by chemotherapy. Secondly, PMR exercises may prevent or delay the adverse effects of chemotherapy on a large scale if patients are taught prior to chemotherapy or obtained to perform the exercises. Thirdly, patients can perform PMR exercises safely on their own during the following chemotherapy séances; and finally, 61

challenges arising from stress seen in patients who continue the exercise even after chemotherapy treatment were determined to be decreased (Molassiotis et al., 2002). In studies performed in patients with breast cancer, PMR exercises were detected to cause significant decreases in fatigue experienced by cancer patients (Demiralp et al., 2010; Rabin et al., 2009; Schmidt et al., 2013; Potthoff et al., 2013). In some other studies where different types of cancer were investigated, it was also detected that pain symptoms stemming from cancer were decreased at a significant level due to PMR exercises (Anderson et al., 2006; Kwekkeboom et al., 2008; Kwekkeboom et al., 2010). In literature, there are some studies investigating that PMR exercises are effective in coping with anxiety experienced by cancer patients (Cheung et al., 2003; Goerling et al., 2014; Lee et al., 2012; Lovejoy et al., 2000; Kim & Seo 2010; Pizarro et al., 2007). In the study performed by Kim and Seo (2010) in patients with different types of cancer on chemotherapy, PMR exercises were found to decrease the level of depression to a great extent (Kim & Seo, 2010). However, in another study performed in 66 patients with gynecologic and breast cancers, and treated with radiotherapy, the study group was asked to continue PMR exercises for two to three weeks following radiotherapy by training the patients as to PMR exercises and guided imaging. After the interventions, a significant decrease was observed in terms of depression scores in the study group, compared with the control group (Pizarro et al., 2007). Developing coping strategies with the adverse effects of cancer treatment and chemotherapy, and backing up cancer patients emotionally are a difficult and bothering process for health care professionals and especially for nurses. PMR exercises are safe, effective, widespread and cost-effective interventions used to manage the adverse effects and to change mental processes and behaviors (Molassiotis et al., 2002). RESPONSIBILITIES OF NURSES IN COMPLEMENTARY AND ALTERNATIVE MEDICINE As a result of increased interest in CAM techniques shown by individuals and cancer patients, health care professionals and nurses having to meet the medical needs of society are required to play a key role in practicing CAM procedures (Turan et al., 2010). Nurses are of a crucial importance in the use of CAM in order to provide safe health care and the most appropriate professional group in the provision of CAM techniques (Crider, 2009; Khorshid & Yapucu, 2005). There is a close association between Cam techniques and nursing care. Such an association originates from a holistic approach to cancer patients by these two fields. The goals of CAM techniques, such as reiki, reflexology, massages, meditation and relaxation are consistent with the applications of nursing performed to decrease anxiety, stress, pain and other disorders related to cancer, to a great extent (Chong, 2006). The inclusion of CAM techniques into health care of cancer patients by nurses will increase the quality of care and cooperation with patients (Chong, 2006; Crider, 2009; Lengacher et al.,2006; Tovey & Broom, 2007).So, the cooperation between nurses and cancer patients may provide that CAM procedures are given place in literature related to nursing care for cancer patients further (Chong, 2006; Lengacher et al., 2006; Tovey & Broom, 2007). Therefore, professional nurses with theoretical information and capable of problem solving are required to include CAM techniques into health care in the context of independent nursing roles (Turan et al., 2010).Additionally, nurses should develop their information on CAM techniques, carry this information into practice (Turan et al., 2010), investigate 62

pros and cons of CAM techniques and give information to both cancer patients and their relatives/friends and healthy individuals, as well as performing scientific studies related to CAM (Muslu & Öztürk, 2008). CONCLUSIONS AND RECOMMENDATIONS Nurses are front-line health care providers facing and having communication with patients and other members of the society, compared to the other segments of medical science. Given the psychological and physiologic benefits of CAM techniques in cancer patients and their relative/friends, nurses are the groups required to know these techniques at most due to this characteristic. Reflexology and PMR exercises with no adverse effects and in the context of complementary medicine are also among the applications nurses can use safely in the improvement of quality of life of cancer patients and in the management of cancer symptoms. When integrated with nurses’ professional information and experiences, these interventions can be used in both clinical settings and home care. REFERENCES Anderson, L. (2005). Part One: the Ancient Healing Art of Rexlexology. Nursing & Residential Care 7: (7), 311-313. Anderson, K. O.; Cohen, M. Z.; Mendoza, T. R.; Guo, H.; Harle, M. T.; Cleeland, C. S. (2006). Brief Cognitive-Behavioral Audiotape Interventions for Cancer-Related Pain. Cancer 107: (1), 207-214. Anderson, R .E. & Seniscal, C. A. (2001). A Comparison of Selected Osteopathic Treatment and Relaxation for Tension-Type Headaches. Headache 46: (8), 1273-1280. Akcay, S. (2014). Geleneksel ve Tamamlayıcı Tıp (GTT) Uygulamaları Yönetmeliği Sonrası. Toraks Bülteni 44, 23. Barnes, P. M.; Bloom, B.; Nahin, R. L. (2008). Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. National Health Statistics Report 12, 1-23. Bishop, E.; McKinnon, E.; Weir, E.; Brown, D. W. (2003). Reflexology in the Management of Encopresis and Chronic Constipation. Pediatric Nursing 15: (3), 20-21. Bolsoy, N. (2008). Perimenstruel Distresin Hafifletilmesinde Refleksolojinin Etkinliğinin İncelenmesi. (Doctoral thesis). Ege Üniversitesi, Izmir. Booth, B. (1994). Reflexology. Nursing Times 90: (1), 38-40. Botting, D. (1997). Review of Literature on the Effectiveness of Reflexology. Complementary Therapies in Nursing and Midwifery 3: (5), 123-130. Cade, M. (2002). Reflexology. The Kansas Nurse 77: (5), 5-6. Çakır B. & Bilir, N. (2014). Jinekolojik Kanserlerin Epidemiyolojisi. Serdar Günalp & Kunter Yüce (Ed.). Temel Kadın Hastalıkları ve Doğum Bilgisi kitabı içinde (bölüm 3, sayfa 635). Ankara: Güneş Tıp Kitabevleri. Cheung, Y. L.; Molassiotis, A.; Chang, A. M. (2003). The Effect of Progressive Muscle Relaxation Training on Anxiety and Quality of Life After Stoma Surgery in Colorectal Cancer Patients. Psycho-Oncology 12, 254-266. Chong, O. (2006). An Integrative Approach to Addressing Clinical Issues in Complementary and Alternative Medicine in an Outpatient Oncology Center. Clinical Journal of Oncology Nursing 10: (1), 83-88. Crider, D. L. (2009). Principles of Cancer Management: Complementary and Alternative Medicine (CAM). In: Susan Newton, Margaret Hickey & Joyce Marrs (Ed). Mosby’s Oncology Nursing Advisor: A Comprehensive Guide to Clinical Practice. Chapter 3, p. 63

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Chapter 7 Patient Satisfaction and Quality of Care in Pediatric Settings Bedriye AK The concept of quality has increasingly become a strategic keyword for many institutions while it has also been considered to be a major factor that determines the customer choice. The concept of quality commonly refers to characteristics of a good or a service that cover one’s certain needs (Çelebi, 2015). The concept of quality is now a prominent issue and unavoidable demand in all parts of life (Çelik, 2013). Furthermore, it has been regarded as one of the major criteria in the assessment of services, particulary in helath services. The assessment of quality in medical services is in direct relation with meeting the patient expectations and maintaining a long term satisfaction (Çelebi, 2015). Health services encompass all diagnostic, treatment, care, and rehabilitation practices as well as protection of disease and the promotion of public health (Somunoğlu, 2012). The primary target of health services is to improve medical care, optimize health conditmions, respond to patient needs, and maintain top quality in providing services (Yurtsever, 2015). A quality service should be a must for all service organizations. Four significant aspects of a quality service must be thoroughly evaluated in quality assessment in order to ensure the best quality service, which are;

   

accessible optimal process and service quality efficient use of resources minimal service related problems client and personnel satisfaction (Ovayolu & Bahar 2006).

While providing a quality health service, the primary focus is to satisfty clients socially, culturally, and economically. While the health service quality was evaluated only with the feedback derived from medical professionals in the past, today, the assessment of quality also includes the views of patients and their relatives (Yurtsever, 2015). The service quality is generally characterized with environmental factors, presentation of the service, service timing, expertise of care providers, sustainability, reliability, precision and flexibility. In addition, evaluation and perception of health service quality are also identified with patient waiting time, politeness and consistency of care providers, service accessibility, service precision, problem solution skills of care providers in case of emergency (Şahin et al., 2005). Many hospital currently develop new quality policies and determine quality indicators for their institutions, which particularly elicit the role of nursing services in maintaining a quality care. Among a variety of criteria to define the quality of health services, patient satisfaction stands at the top of the list (Ovayolu & Bahar, 2006). For instance, patient satisfaction takes precedence of all other quality criteria in the wide spectrum defined by American Nurses Association (ANA) and it is considerably 

Assist. Prof. Dr., Abant İzzet Baysal University, Bolu Health School. Nursing Department.

priotirized in medical services (Ovayolu & Bahar, 2006). National health care policies also determine the quality of health care to a great extent. Currently, many countries adopt and implement liberal policies in providing public services, which is particularly highlighted by client-oriented public services provided in these countries, especially in the United States (Pape, 2003; Yılmaz, 2005). Quality management offices in hospitals help to enhance service quality by redefining attitudes and behaviors of the health professionals and by producing solutions to meet changing patient demands (Huber et al. 2008). It has further been reported that patient satisfaction is a significant indicator of nursing care assessment and standardizing service quality (Sevil & Ertem, 2007) and that it has been considered to be a key evidence to cost-effective use of resources especially considering increasing costs of health services (Kıdak & Aksaraylı, 2008). Two major approaches are universally employed in the assessment of quality of care. The first approach evaluates and monitors the quality processes by identifying and qualifying care standards. The second approach, on the other hand, merely focuses on patient satisfaction. Identifying care standards is of utmost importance in the assessment of care quality. It has often been emphasized that the quality of nursing care can only be improved and evaluated by setting the care standards for each individual nursing care. (Sevil & Ertem, 2007). A nursing process specifically designed for meeting individual needs is a sine qua non of a quality care practice when characterized with a set of universal standards. In order to attain a satisfactory quality care in nursing services, nurses should be familiar with technological know-how and evidence based nursing practices as well as critical thinking skills. Nursing, like many other professional practices, inevitably relies on scientific knowledge to keep up-to-date with professional developments and increasing public demand, which deliberately requires to devise nursing processes (Dikmen, Ak & Yorgun, 2016; Ak, 2013). Establishing a standardized nursing care based on nursing processes will certainly enhance and maintain a quality care and provide positive feedback for the institutional preferability, patient satisfaction, and job satisfaction. American Nurses Association (ANA) defines service quality as a sum of activities that will provide patients with optimum nursing care (Ovayolu & Bahar, 2006). Quality nursing practices guarantee a safe care enviroment and cooperation with other health professionals. Moreover, quality nursing practices assures a satisfactory service experience for both service receivers and carers. Since a quality nursing care prioritizes feedback from patients and care providers, it easily meets the demands of patients/patient relatives and health professionals. A quality nursing care also motivates health professionals for further research and life long learning to improve their professional knowledge and practice, which will eventually accredit nursing practice as a scientific field of research (Karadağ & Uçan, 2006). The standards defined by Joint Commission of International (JCI), Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Magnet Recognition Program that recognizes the quality of nursing services are widely used as assessment criteria for patient and patient relative satisfaction (Tokat, 2009). The patient satisfaction was first researched in nursing care in 1956 in the United States. Patient satisfaction has recently become an outcome criterion in evaluating health care quality in the United States and the United Kindgom as well as several other developed countries (Kürtüncü Tanır & Kuguoğlu, 2012; Köşgeroğlu, Acat &Karatepe, 2005). 70

Patient satisfaction commonly refers to meeting patient expectations or patient perceptions of nursing care. Patient satisfaction is related to the patient expectations as well as patient perceptions of care. Indeed, patient satisfaction can be defined as an outcome of a comparison between expectations and perceptions (Ibanez, Hartmann & Calvo, 2006). Satisfaction, however individually different it might be, is closely associated with the presentation of the service, kind and genial service, material quality, comfort, cleanliness, and respecting the privacy of the patient (Ulus & Kublay, 2012). Patient satisfaction entails the evaluation of informing the patients, attending behaviors of the health professionals, kindness, psychosocial support, empathy, service speed, convenient timing, and competence of the care providers (Boudreaux, 2004; Çelik, 2013). Care quality can also be improved by analyzing the satisfaction levels of patients and their relatives and planning a thorough nursing care, which, in turn, ensures a better evaluation of the results and a better quality nursing care based upon the patient expectations and demands (Schmidt, 2003, Kürtüncü Tanır & Kuguoğlu 2012). The primary service receivers in pediatric hospitals and clinics are children and their parents. Therefore, the feedback to be derived from parents of pediatric patients are particularly important to evaluate the care results (Ulus & Kublay, 2012) Parents play a significant role in the care of pediatric patients, which necessitates a family centered care in pediatric units. Parents are an indispensible part of children’s life in family centered care. Family centered care is believed to relieve emotional stress of hospitalization and boost self-reliance of children (Çavuşoğlu, 2013). The process of nursing care is fundamentally influenced by parents’ support, participation, and contribution to the health care (Taşdelen, 2006) an it is substantially functional to decrease the negative effects of hospilitazation on children. Hospitalization upsets the children’s and their parents lives and each family member is affected in their own way. Parents stay in the hospital with their children and their emotional and physical needs are naturally affected. Parents of pediatric patients experience intense stress, anxiety, guilt, and despair. They accordingly expect to take good care of their children in hospital, feel secure and trust the health professionals in the unit, get support and information when needed (Arıkan, Tüfekçi & Taşkekin, 2010; Taşdelen, 2006 ). They become dissatisfied when their needs and expectations aren’t met. Their emotional needs are found to be closely associated with their psychosocial satisfaction (Varni, 2000). The cooperation between parents and nurses is the building stone of quality assessment in pediatric setting that family centered care (Espezel & Canam, 2003). A majority of studies on the evaluation of care quality in pediatric clinics have elaborated parent satisfaction in which it was reported that clinical care, informing the parents, physical facilities, and communication between parents and health professionals were key components of parent satisfaction (Kürtüncü Tanır & Kuguoğlu, 2012; Tokat, 2009; Heyland & Tranmer, 2001; Haines & Childs, 2005; Latour, Hazelzet & Heijden, 2005; Latour, Hazelzet, Duivenvoorden & Goudoever, 2008; Arıkan, Saban & Gürarslan Baş, 2014; Ulus & Kublay, 2012; Arıkan et al., 2010; Lam, Anne & Chang, 2006; Erden, Pamuk, Ocal & Aypar, 2006; Şahin et al., 2005; Aşılıoğlu, Akkuş & Baysal, 2009; Power & Franck, 2008; Maijala, Luukkaala & Astedt-Kurki, 2009; Williams, 2013; Al-Akour, Gharaibeh & Al-Sallal, 2013 ). Hospitalization is a fearsome experience for children that triggers anxiety. Along with the disease itself, a pediatric patient also struggles against adverse effects of the 71

disease, painful medical procedures, and separation from their family, friends, and school (Şen Beytut, Bolışık, Solak & Seyfioğlu, 2009). Hospitalization sometimes even causes crisis for children. Children in hospital go through traumatic experiences resulted from unfamiliar people and atmosphere, unfamiliar medical instruments, and unfamiliar sounds and smells. Hospitalization also causes anxiety, fear, agitation, agression, and tension (Başbakkal, Sönmez, Celasin & Esenay, 2010; Törüner & Büyükgöneneç, 2012) . Unlike adults, children hardly cope with negative experiences as they are bodily, emotionally, socially, and cognitively immature, which diversifies their needs (participation in care activities, sensitivity in communication, physical and emotional support, playing games, etc.) (Bjork, Nordstrom & Hallstrom, 2006; Kennedy etal., 2004). Health professionals are expected to organize psychological, social, and educational programs in such a way that children can accept and consent to the medical interventions and care, which will eventually cause a less stressful experience of care. While planning these programs, it is crucially important to take children’s expectations and perceptions of care into serious consideration. It is strongly suggested that satisfaction levels of children will pave the way for a better pediatric care quality. Pediatric nurses will be better guided with the expectations of children about nurses or health professionals in general. However, health professionals commonly prefer to communicate with the parents rather than the children in hospitals assuming that communicating with children can be time-consuming or that they can better communicate and solve problems when they interact with adults. Such behaviors can be misinterpreted by children and they may think they are underestimated by grown-ups. Although parents can best recognize their children’s needs and expectations, they may occasionally fail to identify their immediate needs or reactions, which urges to incorporate children’s perceptions and perspectives into the assessment of care quality (Pelander, Leino- Kilpi & Katajisto, 2007a). Likewise, United Nations Children’s Rights decrees that children have a right to freely express their own ideas about the matters by which they are directly influenced (http://www.unicef.org/crc). Children may express themselves in different ways in accordance with their cognitive development level. However, it has been commonly accepted that children attain the cognitive maturity to truly evaluate the care quality after four years old (Lindike, Nakai & Johnson, 2006). Children can express themselves better as they develop linguistic and cognitive skills. Once children acquire such skills to express themselves, they are also capable of evaluating the nursing care that they are given. It would be very legitimate to argue at that point that the true evaluation of the nursing care can only be made by children as children don’t veil their true reactions. Therefore, it would be best to assess the medical care from children’s perspective through painting, story telling, or simlpy asking and answering questions depending on their age and cognitive development (Lindeke et al., 2006; Pelander etal. 2007a; Pelander & Leino-Kilpi, 2004). Children’s clinics should be organized so as to provide physical or social comfort for children and their parents (Çavuşoğlu 2013). The negative effects of hospitalization can only be minimized to satisfy children when they can be made to feel like home. Health professionals in pediatric clinics shouldn’t allow the socialization of children to be interrupted which can cause traumas for children. Therefore, all health professionals should carefully adopt a convenient approach for each individual child considering their 72

developmental characteristics. It should be kept in mind that raising an awareness towards developmental characteristics of a pediatric patient doesn’t only facilitate medical care but also contributes to the parent satisfaction. Pediatric nurses are equally effective in relieving the distress of hospitalization. Pediatric nurses can turn the negative influences upside down by creating the optimum care environment and employing appropriate approaches (Çimete, Kuğuoğlu & Çınar, 2013). However, parents can better identify children’s needs but children should clearly express their own needs and reactions to the care. It shouldn’t be forgotten that the best and the most objective evaluation can ben done by the primary care receivers. Bentham proposes that human life is based on two principles, satisfaction and suffering and believes that human beings tend to reach satisfaction and refrain from sufferings (Işık & Meriç, 2010). On the other hand, medical problems bring more sufferings and drive satisfaction away. Health professionals often encounter unhappy people suffering from painful diseases and treatments when they deliver medical services. Hospitals represent pain and suffering for children as well. Pediatric nurses, relying upon Bentham’s philosophy, know that they can increase satisfaction on the condition that they can decrease suffering. Nurses can achieve these results only by following a nursing process based on a scientific methodology established around family centered care, atraumatic care, and individualized care models. An individualized nursing care program is a prerequisite of increasing the quality of care in pediatric clinics if designed with a considerable emphasis on emotional states of children and their parents, their opinions, preferences, experiences, perceptions, beliefs, and values (Radwin & Alster, 2002; Suhonen, Välimäki & Leino-Kilpi, 2002; Suhonen, Välimäki & Leino-Kilpi, 2005). Since patient satisfaction is identified with the patient's perception of the individualized care in the treatment of medical problems (Suhonen et al., 2005), the evaluation of nursing care quality in pediatric setting would be reasonably regarded as a concrete evidence of the patient satisfaction when conducted by children thenselves. Overall satisfaction, on the other hand, is characterized with experiences, individual and social values, experiences, and perceptions (Kan, 2014) and patient satisfaction is associated with their perception of care programs individually designed for their problems (Özer, Köçkar &Yurttaş, 2009). Therefore, an inquiry on the satisfaction levels of children as the primary care receivers of pediatric clinics will provide a feedback about the quality of care as well as provided data about how it should be of the quality and quantity of the care for the care providers. Nevertheless, despite a large number of studies on parent satisfaction, no studies so far has particularly dealt with children’s satisfaction in Turkey. A few studies on children’s satisfaction that were conducted abroad merely analyzed pain management, game environment, and communication. The results of these studies indicated that children expressed their discontent with pain management, insufficient game environment, lack of communication and information (Magaret, Clark, Warden, Magnusson & Hedges, 2002; Chesney, Lindeke, Johnson, Jukkala & Lynch, 2005; Pelander et al., 2007a; Pelander, Lehtonen & Leino- Kilpi, 2007b; Lindike et al., 2006; Pelander & Leino-Kilpi, 2004 ; Pelander, Leino- Kilpi & Katajisto, 2009). Evaluation of the care quality is fundamental to providing a quality pediatric care. It is considered to be vital to include children’s opinions and perceptions in the medical care as objective and reliable measurment tools. Reliable measurement tools are required in the evaluation of pediatric care by children themselves but literature review 73

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Chapter 8 Preoperative Anxiety and Postoperative Pain for Tonsillectomy in Adult Patients: The Effect of Education and Follow-Up Telephone Calls Rahşan ÇEVİK AKYIL, Nadiye ÖZER, Özgür YÖRÜK INTRODUCTION In adults, tonsillectomy is the most frequently performed throat surgery (Salonen, Kokki, & Tuovinen, 2001). In this group of patients, postoperative pain is an important problem (Hiller, Silvanto, Savolainen, & Tarkkila, 2004; Salonen, Kokki, & Nuutinen, 2002; Thorneman & Akervall, 2000). Postoperative pain is the principal cause of morbidity in adult tonsillectomy patients. This pain can affect the patient’s nutrition, ability to return to work, discharge from the hospital, and overall satisfaction with the procedure. On the first postoperative day, tonsillectomy patients commonly suffer severe pain (Park, et al., 2007; Toma, Blanshard, Eynon-Lewis, & Bridger, 1995). This pain has traditionally been treated with opioid analgesics, morphine, steroids, and non-steroidal anti-inflammatory drugs (NSAIDs) (Hanasono, et al., 2004; Isik, Arslan, Ozsoylar, & Akcabay, 2009; Naesh, et al., 2005; Ozalevli, Unlugenc, Tuncer, Gunes, & Ozcengiz, 2005). After tonsillectomy, however, analgesia is often inadequately administered because of the feared side-effects of opioids, such as emesis and excessive sedation (Salonen, et al., 2001). Morphine use results in a high incidence of postoperative nausea and vomiting compared with other forms of analgesia (Isik, et al., 2009). NSAIDs may also cause adverse effects such as gastric irritation, renal dysfunction, and increased perioperative bleeding (Salonen, et al., 2002; Salonen, et al., 2001). It is also well-known that they prolong blending time and can increase blood loss during and after surgery (Kam, 2000). Non-pharmacological treatment strategies have been discussed and described as complementary to pharmacological pain treatment (Idvall, Holm, & Runeson, 2005). It is reported that these methods can help relieve pain in pediatric patients. They consist of a wide variety of approaches which do not involve the use of drugs (Caty, Tourigny, & Koren, 1995; Pederson, 1996; Polkki, Vehvilainen-Julkunen, & Pietila, 2001). Physical non-pharmacological methods, including massage, transcutaneous nerve stimulation (TENS), heat and cold applications, and positioning, as well as rubbing the painful area, have been recognized as effective pain relief measures (McCaffery, 1990; Mobily, Herr, & Nicholson, 1994; Polkki, et al., 2001). Anxiety occurring before surgery is another important problem for both patients and health care teams. It is advisable that the patient not fear the upcoming procedure in 

Assoc. Prof. Dr., Adnan Menderes University, Söke Health School, Nursing Department. Aydın, Turkey  Assoc. Prof. Dr., Ataturk University, Faculty of Health Sciences, Erzurum  Prof. Dr. Atatürk University, Faculty of Medicine, Otorhinolaryngology Division.

order to avoid unnecessary anxiety (Kiyohara, et al., 2004). In the literature, it is reported that the practice of providing the patient with preoperative information can reduce anxiety (Bondy, Sims, Schroeder, Offord, & Narr, 1999; Hughes, 2002; Kiyohara, et al., 2004; Klopfenstein, Forster, & Van Gessel, 2000; Spielberger, 1970). Additionally, much research has also revealed that patients want to know, prior to surgery, more details about what they can anticipate, such as expectations of pain, anesthesia duration, risk of impairment of daily activities, and estimated length of stay in the hospital (Bugge, Bertelsen, & Bendtsen, 1998; Bunker, 1983). In the literature, there have been many studies aimed at evaluating pain management using education and/or non-pharmacological methods in children after tonsillectomy (Huth, Broome, & Good, 2004; Idvall, et al., 2005; Wiggins & Foster, 2007); however, there is no study evaluating these measures when used with adult patients. The present study tested the hypothesis that providing information before surgery will reduce patients’ anxiety, and that follow-up telephone calls made for seven days after surgery can decrease postoperative pain in adult patients who have undergone tonsillectomy. MATERIAL AND METHODS Study design This was a randomized, clinically controlled study, and it was carried out between May 2009 and January 2011. Patients were assessed preoperatively in hospital on the day before surgery, and received follow-up telephone calls on their first, second, third, fourth, fifth, sixth, and seventh postoperative days. The State-Trait Anxiety Inventory (STAI Form I-II) (Spielberger, 1970) was completed on a preoperative day and then on the day of surgery, while the telephone interviews took place on seven consecutive days following surgery. The quantitative data-collection methods on postoperative days used the Visual Analogue Scale (VAS). Sample selection and size Patients were identified from the surgical admissions list and invited to participate in the study on the day of hospital admission at their preoperative visits. The majority of patients come to the hospital 48 hours before surgery and during that time undergo laboratory testing and visit with an anesthesiologist. Patients were randomly allocated to one of two groups. If they were aged under 18, had chronic pain caused by another illness, presented with a complication for surgery, or were cognitively impaired and could not understand the questionnaires, patients were excluded from the study. The power calculations were performed using the following conditions: significance level α=0.05, 80 percent power, and a least relevant difference of 10 percent. The number was calculated as 64 patients in each group; there was thus to be a total of 128 patients in the two groups, one group for intervention and one for control. Based on the expected drop-out rate, the inclusion of 70 patients in each group was planned. However, a total of only 83 patients were found to be eligible because of the inclusion criteria of the study. of the 83, six patients were omitted from the study because the VAS evaluation or other crucial item was missing from the documents of four control-group patients and two intervention-group patients on one or more of the postoperative days. The study thus consisted of a total of 77 patients; the intervention group had 39 patients and the control group had 38. 78

Ethical considerations Approval to conduct the study was obtained from the Ethics Committee of the Health Science Institution. Research instruments A questionnaire on demographic characteristics, the State-Trait Anxiety Inventory (STAI I and II), and the Visual Analogue Scale (VAS) were used to collect data. To measure the patient’s experience of pain over time, the main instrument used was the VAS. A telephone interview was used to supply further education and information to the intervention group. State-Trait Anxiety Inventory (STAI I and II) State-Trait Anxiety Inventory (STAI) (Spielberger, 1970) was developed to assess state-and-trait anxiety levels. STAI is a reliable and valid measure that can be used in both clinical and general populations (Spielberg, 1983). STAI consists of two subscales, each containing 20 items scored from 1 to 4. The state anxiety subscale measures the anxiety at the moment of scoring. Trait anxiety measures dispositional anxiety or anxiety in general. The items are summed up per scale, and transformed into scores between 20 and 80. Higher scores on the STAI indicate a higher intensity of anxiety. The Turkish version of the STAI has been validated previously (Öner & Le Compte, 1983). In the present study, Cronbach’s alpha for each subscale was found to be 0.96 for the state anxiety subscale and 0.98 for the trait anxiety subscale. Visual Analogue Scale (VAS) The visual analog scale (VAS), used in research settings for assessment of pain, overcomes some of the shortcomings of categorical scales (Huskisson, 1983). A commonly used visual analog pain scale consists of a 100-mm line, anchored at each end with terms describing the amount of pain felt e.g., from "no pain" to "worst pain possible". The subject makes a mark on the line corresponding to the amount of pain felt, and the distance from the "no pain" end of the scale to the mark is measured. Thus, visual analog scales provide data on pain in the form of a continuous variable which is sensitive to small changes in pain. In the present study, the pain on postoperative days was measured on a 100-mm horizontal VAS: the left end was marked “no pain” and the right “worst possible pain”. The results were recorded in millimeters. Data collection procedure On the preoperative day, each patient completed a questionnaire on demographic characteristics, as well as STAI I and II questions, as the pre-test. After that, the control group was given routine information about the operation by the researcher for approximately 10 to 15 minutes. The preoperative oral information covered general information about the operation, anesthesia, and postoperative pain. The intervention group received routine preoperative oral information and individual education given by the same researcher for approximately 35-40 minutes. The individual education covered detailed information about the operation, including estimated surgery duration, possible complications, and ways of reducing postoperative pain with non-pharmacological methods. The content of the education is shown in Table 1. Additionally, a booklet containing this detailed information was given to the patients in the intervention group.

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Table 1: The major headings for the individual education sessions The content of the education What is a tonsil? What is tonsillitis? When is tonsillectomy necessary? How is tonsillectomy done? Is there any risk in tonsillectomy? How long is the surgery? What should be done prior to tonsillectomy? What are the problems that may develop after tonsillectomy? What are the issues normally considered after the surgery? Duration of stay in hospital Finding out more after the surgery Pain reduction methods Relaxation methods Finding out more after discharge Emergency situations requiring referral to doctor

On each patient’s surgery day, the patient completed STAI I and II again as the last test, and was then given a document that included the VAS for each postoperative day, on which the patient could record perceived pain; the document also included sections for recording pain location, pain-triggering activity, and the number of analgesics used. On seven consecutive postoperative days, the patients in the intervention group were given a follow-up telephone call. In the telephone interviews, individual education, as summarized above, was repeated, and patients’ questions were answered. All study documents were gathered from all patients at their hospital appointments on the eighth postoperative day. Statistical analysis The analysis of data for baseline characteristics, including location of pain, activity that triggered pain, and use of analgesics at home, was performed using an unmatched ttest, chi-squared test or Fisher’s exact test. The post-test means of STAI I and II were analyzed using analysis of covariance (ANCOVA). In this analysis, the pre-test results were used as the covariate. VAS means obtained for seven postoperative days were analyzed by repeated measures of analyses of variance (ANOVA) within one factor (groups; two levels: intervention and control) and among seven factors (measure times; seven levels: day 1, 2, 3, 4, 5, 6 and 7) in order to identify the possible interactions between the groups, and to evaluate the effects of each day of measured VAS means for each group. Bonferroni was used as a post-hoc test. A level of significance of 0.05 was used. All analyses were performed using the Statistical Package for the Social Sciences version 10.0 (SPSS Inc., Chicago, IL, USA) RESULTS The distribution of 77 patients according to the baseline characteristics is described in Table 2. The mean age was 23.89 years in the control group, and 23.23 years in the intervention group. Female was the majority gender in each group (55.3 percent and 53.8 percent, respectively). There were no statistically significant differences between the groups in terms of baseline characteristics.

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Table 2: Baseline characteristics

Age (Mean (SD)) Sex (n (%)) Marital status (n (%)) Educational level (n (%)) Stayed in hospital before (n (%)) Experienced surgery before (n (%)) Type of previous surgeries (n (%)) Types of anesthetic taken before (n (%))

Male Female Married Single Lettered Primary education High school Yes No Yes No Nose surgery Hernia operation Other Local General Epidural/Spinal

Control (n=38) 23.89 7.38 17 44.7 21 55.3 13 34.2 25 65.8 14 36.8 24 63.2 17 44.7 21 55.3 13 34.2 25 65.8 7 53.8 3 23.1 3 23.1 7 53.8 6 46.2 -

Intervention (n=39) 23.23 5.55 18 46.2 21 53.8 14 35.9 25 64.1 13 33.3 26 66.7 22 56.4 17 43.6 22 56.4 17 43.6 8 36.4 4 18.2 10 45.5 8 36.4 10 45.5 4 18.2

p 0.524* 0.657§ 0.877§ 0.747‡ 0.306§ 0.060§ 0.410‡ 0.229‡

SD; standard deviation * Un-matched t-test § Fisher’s exact test ‡ Chi squared-test

Distribution of the pre-test means and standard deviations obtained for state-andtrait anxiety subscales for the two groups are shown in Table 3. These means were used as covariates. Table 3: Distribution of the pre-test means and standard deviations obtained from two groups for state-and-trait anxiety subscales Control Mean (SD*) 54.57 (7.95) 45.42 (4.64)

State Anxiety Trait Anxiety

Intervention Mean (SD*) 50.500 (5.98) 44.29 (4.71)

*SD; Standard Deviation

According to the results of ANCOVA, there were no statistically significant differences between the groups in terms of state-and-trait anxiety, as determined after giving information on preoperative day to each group (p= 0.686 for state anxiety and p=0.213 for trait anxiety) (Table 4). Table 4: Distribution of the post-test estimated marginal means and standard deviations obtained from state-and-trait anxiety subscales for each group, and the results of ANCOVA

State Anxiety Trait Anxiety

Control Mean* (SD) 51.06 (5.02) 44.32 (4.29)

*Estimated marginal mean

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Intervention Mean* (SD) 51.27 (7.09) 44.54 (3.84)

p value 0.686 0.213

On the postoperative days, it was found that there were no statistically significant differences between the groups in terms of the location of the perceived pain or activity that triggered pain (Table 5). The patients in each group reported the throat and ear as the major pain sites, and eating as the major activity triggering pain. Table 5: Distribution of pain location and pain-triggering activity reported by participants Perceived location of pain Pain-triggering activity

Throat Throat and ear Breathing Eating

Control number (%) 10 (26.3) 28 (73.7) 17 (44.7) 21 (55.3)

Intervention number (%) 7 (17.9) 32 (82.1) 12 (30.8) 27 (69.2)

p value 0.376* 0.206*

* Fisher Exact test

It was also found that there were no statistically significant differences between the groups in terms of the amount of analgesia taken on the seven postoperative days, although the majority of patients (64.1 percent) in the intervention group took fewer than three analgesic tablets (Table 6). Table 6: Distribution of analgesia (paracetamol) used for seven postoperative days. The number of analgesics 5 tablets 3-5 tablets Fewer than 3 tablets

Control number (%) 5 (13.2) 17 (44.7) 16 (42.1)

Intervention Number (%) 2 (5.1) 12 (30.8) 25 (64.1)

Total Number (%) 7 (9.1) 29 (37.7) 41 (53.2)

p value 0.128*

*Chi-square test

Distribution of VAS means and standard deviations in millimeters on each postoperative day and for each group are shown in Table 7. Table 7: Distribution of VAS means and standard deviations in millimeters on each postoperative day and in each group Postoperative Day 1 2 3 4 5 6 7

Control Mean (SD) 82.05 (8.89) 84.71 (9.12) 71.84 (17.21) 59.73 (12.62) 54.21 (14.07) 51.84 (13.72) 43.42 (9.37)

Intervention Mean (SD) 81.15 (10.21) 81.38 (9.11) 64.61 (11.71) 56.84 (12.86) 50.38 (6.79) 36.82 (8.82) 31.05 (5.90)

Table 8: Results of repeated measurement of analysis of variance Source Intercept

Type III Sum of Squares 1986877.380

df 1

Mean Square 1986877.380

Group

5707.094

1

5707.094

Error

34487.878

75

459.838

F 4320.817 12.411

p value 0.000 0.001

The results of repeated ANOVA measures showed statistically significant differences between the groups (p< 0.001) (Table 8). On each postoperative day, it was found that the perceived pain, expressed as VAS value, in the intervention group was lower than in the control group. There was a difference of 13 mm in pain in favour of the intervention group on the seventh postoperative day. 82

DISCUSSION AND CONCLUSIONS The findings of the present study revealed that individual education and follow-up telephone calls with patients on postoperative days had an effect on perceived postoperative pain. The results showed that the perceived pain of the intervention group on postoperative days was lower to a statistically significant degree than that of the control group (p < 0.001). In each group, the pain was the highest on day two postsurgery. A meta-analysis (Devine, 1992) including 191 studies reported that preoperative education has an effect on postoperative pain, although this meta-analysis did not include studies with the same categories of illness, intervention and measurement of effect (Glindvad & Jorgensen, 2007). Glindvad and Jorgensen (Glindvad & Jorgensen, 2007) reported that postoperative individual education lasting 30–60 minutes, followed by a telephone interview, did not lessen postoperative pain at rest, and resulted in only a 7-mm measurement (on a 100-mm VAS) while moving in patients having undergone surgery for inguinal hernia. Shuldham et al. (2002) showed that patients in an experimental group who participated in a day of education offered by members of a multidisciplinary team prior to admission for surgery did not feel any effect on pain on the third postoperative day, or six months after coronary bypass surgery. In the present study, the results showed that preoperative education could have an effect on postoperative pain. However, in the literature, there are no studies evaluating the effect of individual education and follow-up telephone calls on postoperative pain in adult patients who have undergone tonsillectomy. One study evaluating a total of 2554 patients who had undergone tonsillectomy, adenoidectomy, or both and who had a follow-up telephone interview reported that the follow-up telephone call after surgery is a safe postoperative-recovery evaluation tool and provides an opportunity for costsavings for both patients and their caregivers (Jones, Yoon, & Licameli, 2007). Similar to our findings, this study also reported that the highest level of pain was perceived on the second postoperative day for most patients. As well, various other studies have reported that educational interventions can decrease cancer pain (Dalton, Keefe, Carlson, & Youngblood, 2004; de Wit, et al., 2001; Syrjala, et al., 2008; Ward, et al., 2008; Yates, et al., 2004). Although several studies reported that preoperative anxiety could be reduced by providing patients with salient information about their surgery (Bondy, et al., 1999; Hughes, 2002; Kiyohara, et al., 2004; Klopfenstein, et al., 2000; Spielberger, 1970), the present study found that neither state nor trait anxiety was decreased by this preoperative education. Similarly, in the cardiac surgery patients, it was reported that the information produced no benefit (Bergmann, et al., 2001; Done & Lee, 1998; Shuldham, et al., 2002). Although individual education did not help decrease anxiety before tonsillectomy, the findings of the present study revealed that it may be useful in reducing postoperative pain when combined with follow-up telephone calls. It is well known that nurses play an important role in helping patients manage postoperative pain in short-term surgicalcare situations (Glindvad & Jorgensen, 2007). Our results emphasize once again that nurses are important members of the health care staff for management of post-operative pain. We did not, however, have a large enough number of patients to declare anything conclusive, which is a major limitation of the present study. Further research including a higher number of patients may or may not support our results, and is needed. 83

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135, 175-186. Thorneman, G. & Akervall, J. (2000). Pain treatment after tonsillectomy: advantages of analgesics regularly given compared with analgesics on demand. Acta Otolaryngol 120, 986-989. Toma, A.G.; Blanshard, J.; Eynon-Lewis, N.; Bridger, M.W. (1995). Post-tonsillectomy pain: the first ten days. J Laryngol Otol 109, 963-964. Ward, S.; Donovan, H.; Gunnarsdottir, S.; Serlin, R.C.; Shapiro, G. R.; Hughes, S. (2008). A randomized trial of a representational intervention to decrease cancer pain (RIDcancerPain). Health Psychol 27, 59-67. Wiggins, S. A. & Foster, R. L. (2007). Pain after tonsillectomy and adenoidectomy: "ouch it did hurt bad". Pain Manag Nurs 8, 156-165. Yates, P.; Edwards, H.; Nash, R.; Aranda, S.; Purdie, D.; Najman, J.; Skerman, H.; Walsh, A. (2004). A randomized controlled trial of a nurse-administered educational intervention for improving cancer pain management in ambulatory settings. Patient Educ Couns 53, 227-237.

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Chapter 9 The Disease of Our Time: Vitamin D Deficiency and Hypovitaminosis D Elif ÜNSAL AVDAL, Yasemin TOKEM, Berna Nilgün ÖZGÜRSOY URAN INTRODUCTION Vitamin D has a special place among vitamins since the need for vitamin D is mostly met by synthesis of ultraviolet rays in the skin. Vitamin D synthesized in the skin becomes active after being processed in liver and kidneys twice (hydroxylation). At the same time, some part of the synthesized vitamin D is stored primarily in fat tissue. It is known that humans are usually capable of storing enough vitamin D for 3-4 months (Champe et al., 2007; Hyppönen et al., 2008). The relationship between vitamin D and human health was determined in the early 1900s, when fish oil, rich in vitamin D, was observed to be effective in the the treatment of a bone disease known as “rickets”. Rickets is a disease mostly seen in the first year of life, when growth rate is at its peak, and induced by lack of calcium and phosphorus, which constitute the cement of bones. Since vitamin D is essential for intestinal calcium and phosphorus absorption, vitamin D deficiency leads to “rickets” in children and “osteomalacia” in adults (Champe et al., 2007; Holick, 2008; Hyppönen et al., 2008). Rickets had become a common disease among children during the Industrial Revolution with the addition of air pollution to the rainy English climate, therefore it is also known as “English disease”. Rickets has been prevented from being a problem since the beginning of this century especially in European countries by enriching foods such as bread and milk with vitamin D and promoting sunbathing (Holick, 2008; Hyppönen et al., 2008). Vitamin D is a fat-soluble vitamin and also may be synthesized in endogenously suitable biological environments, therefore is a group of sterols with hormones and hormone precursors. The most important effect of vitamin D is on calcium and phosphorus metabolism and bone mineralization (Champe et al., 2007; Hollick, 2008). That being said, vitamin D deficiency and Hypovitaminosis D have been found in recent years to be involved in many chronic diseases including common cancers, cardiovascular diseases, metabolic syndrome, infectious and autoimmune diseases (Hyppönen et al., 2008; Pearce & Cheetham, 2010). The spectrum of these common diseases is particularly worrying because observational studies have shown that vitamin D deficiency is wide-spread in the northern part of the world, which includes several industrialized countries (Uçar et al., 2012). “The epidemic of vitamin D deficiency is spreading rapidly in Turkey and in the 

Assoc. Prof. Dr., İzmir Kâtip Çelebi University, Faculty of Health Sciences, Department of Nursing, İzmir.  Lecturer, MSc., İzmir Kâtip Çelebi University, Faculty of Health Sciences, Department of Nursing, İzmir.

world… “ Vitamin d deficiency is now regarded as a global epidemic (Öngen et al., 2008). In a recent study conducted in England, it has been reported that more than 50% of the adult population suffer hypovitaminosis D and 16% suffer serious vitamin D deficiency during winter and spring (Uçar et al., 2012). In another recent study conducted by Uçar et al. in Ankara region, a very high percentage of vitamin D deficiency (51.8%) has been found and hypovitaminosis D has been reported to be observed 20.7% of the population (Öngen et al., 2008; Holick et al.,2011). Approximately 90% of vitamin D found in human body is synthesized in the deepest layers of the skin using sun rays (Holick et al., 2011). It is not sufficient to take vitamin supplements in case of vitamin D deficiency unless the individual is exposed to a sufficient amount of sun ray. It has been shown that around 10,000 to 25,000 IU of vitamin D is synthesized in the body of an individual exposed to sun rays for 30 minutes at noon. Vitamin D received from vegetables and animal products is absorbed in small intestine and transferred to blood. Vitamin D requires bile salts since it is oilsoluble (Uğurlu, 2000). Therefore, vitamin D absorption reduces during liver diseases in which bile flow decreases. For this reason, patients with liver-gallbladder diseases have a greater need for vitamin D. Vitamin A allows for vitamin D activation. However, excess of vitamin A reduces vitamin D activation. For this reason, vitamin A should not be used insensibly. Some cod liver oils contain 150-12,000 times more vitamin A compared to vitamin D in terms of unit. High consumption of cod live oil to intake more vitamin D without paying attention to this fact will be harmful. Fish oil, on the other hand, can be safely consumed. Because unlike cod liver oil, fish oil does not contain any vitamin D or vitamin A (Uğurlu, 2000; Holick et al., 2011). Vitamin D has many functions other than bone health: 1. Prevents the formation of cancer. 2. Strengthens the immune system and prevents the development of autoimmune diseases. 3. Vitamin D deficiency increases the risk of type 2 diabetes by reducing insulin secretion. 4. Reduces inflammation. Only 10% of vitamin D in human body is received through food (egg, offal, fish, animal fats). Vitamin D found in breast milk and cow’s milk have good absorbability. Those who live in sunny countries and are exposed to sun rays on a sufficient level should have a vitamin D level above 40ng/mL (Uğurlu, 2000; Pearce & Cheetham, 2010). Experts point to the increased vitamin D deficiency cases in Turkey. More than 1 billion people in the world suffer from this disease. In Turkey, on the other hand, two out of every three adults have vitamin D deficiency. The disease mostly goes unnoticed during youth and mid-life. However, it is possible to detect it via blood measurements. With advanced age and vitamin D deficiency, mild complaints appear such as weakness in muscles, frequent falling and and cramps especially at night and widespread body aches (Holick, 2011). Vitamin D sources and metabolism The main vitamin D source is the photochemical formation of vitamin D3 (cholecalciferol) from 7-dehydrocholesterol via ultraviolet B (UVB) rays. Vitamin D3 88

is converted to inactive products with over-exposure to sunlight. It is possible to intake vitamin D through diet with ergocalciferol (vitamin D2) found in plants and cholecalciferol (vitamin D3) found in animal tissues. Vitamin D is most abundantly found in fish, liver and egg yolk. Vitamin D2 and D3 received through diet are combined with chylomicrons and transferred to circulation via the lymphatic system. Vitamin D2 and D3 received through diet and endogenously synthesized are stored in fat cells and secreted to circulation as necessary (Holick, 2007; Öngen et al., 2008). Vitamin D synthesized in the skin or received through diet is not biologically active. It is firstly converted to 25-hydroxyvitamin D [25(OH)D] by 25-hydroxylase enzyme and then to 1,25-hydroxyvitamin D [1,25(OH)2D], also known as calcitriol which is the biologically active form, by 1-alpha-hydroxylase in kidneys. 1-alphahydroxylase enzyme is the key enzyme in vitamin D synthesis. Parathormon (PTH), calcium (Ca), phosphorus and fibroblast growth factor 23 (FGF 23) are involved in the regulation of this enzyme (Holick, 2007; Öngen et al., 2008). 1,25(OH)2D shows its effect through vitamin D receptors found in small intestine, kidney and other tissues. It increases Ca absorption from small intestine and decreases Ca loss from kidneys, thus maintains blood calcium level, which is its main function. In addition, 1,25(OH)2D vitamin has biological effects such as inhibiting cell proliferation, inducing terminal differentiation, inhibiting angiogenesis, inducing insulin production and inhibiting renin production (Dawson-Hughes et al., 2005; Holick, 2007). Vitamin D and metabolites are removed through bile after being inactivated 25-hydroxylase found in many tissues (Holick, 2008; Öngen et al., 2008). Vitamin D levels In order to assess the level of vitamin D of an individual, 25(OH)D, which has a half-life of 2-3 weeks and shows both vitamin D intake and endogenous vitamin D synthesis is checked. Biologically active form 1,25(OH)2D is not suitable for ideal measurement since its half-life is 4-6 hours and its level is 1000 times lower compared to 25(OH)D. A large number of studies have been conducted for identification of vitamin D deficiency and hypovitaminosis D and determination of normal 25(OH)D range. In the light of these studies, it is accepted that if 25(OH)D level is below 20 ng/mL, the individual has vitamin D deficiency, if it is between 21-29 ng/mL, the person has hypovitaminosis D, if it is above 30 ng/mL, the individual has sufficient vitamin D (preferred range is 40-60 ng/mL) and if it is above 150 ng/mL, the individual has vitamin D intoxication (Dawson-Hughes et al., 2005; Öngen et al., 2008). Who Should Be Checked for Vitamin D Level? • Those with bone diseases (osteomalacia, osteoporosis, paget's, etc.), • Those with symptoms related to musculoskeletal system suggesting vitamin D deficiency, • Those with risk factors related to vitamin D deficiency and hypovitaminosis D (dark-skinned individuals, those who are not sufficiently exposed to sunlight, elderly, obese individuals, those experienced pregnancy in short intervals, lactating women, those with malabsorption conditions, those who use anticonvulsant and glucocorticoid drugs, etc.). WHAT PROBLEMS DOES VITAMIN D DEFICIENCY CAUSE? Low vitamin D levels lead to a reduction in amount of calcium stored in bones, 89

which increases the risk of bone fractures. It can be suggested that vitamin D deficiency was a rare condition in the past when people would work in fields, farms, gardens or in other words, ‘outside’. It has become much more common problem along with office life (Dawson-Hughes et al., 2005; Bischoff-Ferrari, 2012). In addition to indoor areas; intestinal diseases, liver or kidney disorders may lead to vitamin D deficiency as well. Also, certain drugs may have a negative effect on vitamin D. The risk of vitamin D deficiency increases with advanced age even in healthy individuals for whom everything appears to be normal (Gerdhem et al., 2005; Bischoff-Ferrari, 2012). Osteoporosis and Bone Loss: Intestines cannot absorb calcium on an adequate level without vitamin D. On the other hand, blood calcium level is of critical importance for proper function of the heart, nerves and muscles. Therefore, the body cannot allow blood calcium level to drop and the system transfers the calcium in bones to blood. Thus, blood calcium level remains on a normal level and both the heart and nerves continue to work properly. However, bones pay the cost in this case and weaken due to calcium loss (Akpınar & İçağasıoğlu, 2012).Many study results have shown that vitamin D deficiency leads to an increase in the risk of bone loss and fracture in hip bone and other bones. Muscle and Nerve System: Osteoporosis increases the risk of fracture. Falls cause fractures as much as osteoporosis and vitamin D may help in both cases. It has been shown in a 2004 study that vitamin D supplement reduces the risk of falling by 22%. Vitamin D may be effective in improving muscles and body balance (Gerdhem et al., 2005; Mosekilde, 2005). Cardiovascular Diseases: Vitamin D is important in vascular health. Osteoporosis is associated with increased risk of coronary artery disease and low blood vitamin D value is associated with increased coronary artery calcification. No correlation has been found between high blood pressure and vitamin D, however vitamin D deficiency is known to increase the risk of heart attack and heart failure (Holick, 1996; Mosekilde, 2005). Prostate Cancer: Men usually perceive osteoporosis as a women’s disease and do not pay much attention to the subject. However, vitamin D deficiency is not a risk factor for osteoporosis alone. Prostate cancer is a subject that men cannot ignore and associated frequently with vitamin D in recent years (Holick, 1996).Vitamin d plays an important role in regulation of cell growth. Various experiments have shown that vitamin D helps prevent uncontrolled cell proliferation, which characterizes cancer. Vitamin D also contributes to limiting the spread of and killing cancer cells (Holick, 1996; Holick, 2012). Studies have shown that the risk of prostate cancer is reduced in men who live in sunny climates and have high blood vitamin D value. There is a need for further research to be sure about this fact. There are also studies providing findings which suggest that vitamin D reduces the risk of colon, breast, pancreas and renal cancer (Holick, 2012). Other Health Problems: Vitamin D deficiency is believed to create a risk factor for the following health problems (Holick, 2012):  Obesity • Immune system diseases • MS disease • Rheumatoid arthritis 90

• • • • • • • • •

Calcification Gout Parkinson's disease Depression Alzheimer's disease Chronic fatigue syndrome Fibromyalgia Chronic pain Gingival diseases

WHY HAS VITAMIN D BECOME SO “POPULAR” IN RECENT YEARS? The reason behind the “popularity” of vitamin D in recent years is not the increase in rickets prevalence, but the increased attention paid to non-bone-related effects of vitamin D. Vitamin D has receptors in many tissues other than intestines, which is its primary effect area, such as breast, bone marrow, nerve cells and immune system and it has been shown in some studies that vitamin D is involved in function of more than 230 genes. In recent years, attention has focused on non-bone-related effects of vitamin D and studies on vitamin D’s association with many diseases, cancer in particular, have "invaded" medical journals, so to speak. Also, debates on “threshold values” for vitamin D deficiency, hypovitaminosis D and normal vitamin D level in adults and children have intensified (Holick, 1996). Especially in the United States, some researchers (especially Dr. Michael F. Holick) suggest that bone diseases such as rickets occur in heavy forms of vitamin D deficiency and proneness to other diseases increase in milder cases of vitamin D deficiency. Such articles have frequently emphasized that a vitamin D level below 30 ng/ml marks the beginning of risks and caused for concern in the society and encouraged healthy individuals to have their vitamin D level checked and use a high dose of vitamin D. In their articles, these physicians give the impression that vitamin D is a “cure-all”, especially for enhancing the immune system. We know that similar lectures are given in Turkey as well. In the last 5-6 years, such lectures have lead to trends such as “having one’s vitamin D level checked” and “taking vitamin D ampuls” in Turkey (SB, 2012). PREVENTION AND TREATMENT APPROACH FOR VITAMIN D DEFICIENCY Under normal conditions, 90-95% of vitamin D found in human body is synthesized in the skin with the effect of sun rays. Vitamin D received through foods does not make a considerable difference unless intentionally added. Sunlight is the main source and when sufficiently taken advantage of, there is no need for extra vitamin D. There are studies which reveal that exposure of hands, face and arms to sunlight for 515 minutes twice a day is enough to meet vitamin D need of human body in Northern America (Boston, 42° North) (SB, 2012).There is evidence showing the ability to synthesize vitamin D after UV exposure is reduced in elderly by a quarter to one-fifth compared to adults under 30. It may be difficult to take advantage of the sun as a vitamin D source due to cloudy weather, ozone density, air pollution, altitude, season, time of day, difference in skin color and similar factors (Holick, 2012; Bischoff-Ferrari, 2012). 91

In order to prevent vitamin D deficiency, Institute of Medicine (IOM) recommends that infants are given a daily vitamin D supplement of 400 IU for the first year and those between the ages of 1-70 are given 600 IU/day and those above 70 are given 800 IU/day. These doses recommended by IOM may increase 25(OH)D level up to 20 ng/mL, which is considered to be sufficient for bone health, however they are not enough for the 30 ng/mL level recommended by Endocrine Society. For this reason, in order to prevent vitamin D deficiency, the Endocrine Society guideline recommends a daily vitamin D supplement of 400-1000 IU for the first year for infants (safe up to 2000 IU), a daily vitamin D supplement of 600-1000 IU for children and adolescents between the ages of 1-18 (safe up to 4000 IU) and a daily vitamin D supplement of 1500-2000 IU for adults over the age of 18 (safe up to 10000 IU). However, higher doses may be required for obese individuals, those with malabsorption syndrome and those who use glucocorticoid and antiepileptic drugs (SB, 2012). Endocrine Society recommends various treatment strategies for those with vitamin D deficiency depending on age and underlying medical conditions (Dawson-Hughes et al., 2005). • For infants and toddlers aged 0–1 yr who are vitamin D deficient, treatment with 2000 IU/d of vitamin D2 or vitamin D3, or with 50,000 IU of vitamin D2 or vitamin D3 once weekly for 6 weeks to achieve a blood level of 25(OH)D above 30 ng/ml, followed by maintenance therapy of 400–1000 IU/d. • For children aged 1-18 yr who are vitamin D deficient, treatment with 2000 IU/d of vitamin D2 or vitamin D3, or with 50,000 IU of vitamin D2 or vitamin D3 once weekly for 6 weeks to achieve a blood level of 25(OH)D above 30 ng/ml, followed by maintenance therapy of 600-1000 IU/d. • For all adults who are vitamin D deficient, treatment with 6000 IU/d of vitamin D2 or vitamin D3, or with 50,000 IU of vitamin D2 or vitamin D3 once weekly for 8 weeks to achieve a blood level of 25(OH)D above 30 ng/ml, followed by maintenance therapy of 1500-2000 IU/d. • In obese patients, patients with malabsorption syndromes, and patients on medications affecting vitamin D metabolism, a higher dose (two to three times higher; at least 6000–10,000 IU/d) of vitamin D to treat vitamin D deficiency to maintain a 25(OH)D level above 30 ng/ml, followed by maintenance therapy of 3000–6000 IU/d. CONCLUSION Vitamin D deficiency is a global problem. Approximately 36% of young adults and 57% of inpatients in the United States have been diagnosed with vitamin D deficiency. These values are higher in Europe. In the past, vitamin D intake was associated with the protection against rickets (rachitism) risk in children. In recent years, vitamin D deficiency has been reported to be associated with cancer, hypertension, multiple sclerosis, pathogenesis and/or progress of diabetes, however its relationship with these diseases is much weaker compared to bone-related diseases. It has been shown in various studies that it is necessary to consume higher doses of vitamin D in order to ensure it shows a protective effect and contributes to treatment. Despite of the close relationship between vitamin D and human health, physicians and patients do not have adequate knowledge about hypovitaminosis D. Researchers, clinicians, physicians and patients should be more aware about the high prevalence of vitamin D deficiency. 92

Vitamin D deficiency and hypovitaminosis D are commonly seen in Turkey and in the world. It is obvious that people cannot sufficiently benefit from sunlight nowadays, which increases the importance of consuming foods enriched with vitamin D and vitamin D supplement treatment. REFERENCES Akpınar, P.; İçağasıoğlu, A. (2012). The Relation Between Vitamin D and Quality of Life. Türk Osteoporoz Dergisi, 18: 13-18. Bischoff-Ferrari, H.A. (2012). Relevance of vitamin D in muscle health. Rev Endocr Metab Disord, 13: 71-77. Bischoff-Ferrari, H.A.; Willett, W.C.; Orav, E.J.; Lips, P.; Meunier, P.J.; Lyons, R.A. (2012). A Pooled Analysis of Vitamin D Dose Requirements for Fracture Prevention. N Engl J M, 367: 40-49. Champe, P.C.; Harvey, R.A.; Ferrier, D.R. (2007). Biyokimya. Ulukaya E. (Çev. Ed.) D Vitamins. Third Edition. 85 pp., Nobel Tıp Kitapevleri, Izmir, Turkey. Dawson-Hughes, B.; Heaney, R.P.; Holick, M..F; Lips, P.; Meunier, P.J.; Vieth, R. (2005). Estimates of Optimal Vitamin D status. Osteoporos Int, 6: 713-716. Gerdhem, P.; Ringsberg, K.A.; Obrant, K.J.; Akesson, K. (2005). Association Between 25hydroxy Vitamin D levels, Physical Activity, Muscle Strength and Fractures In The Prospective Population-based OPRA Study of Elderly Women. Osteoporos Int, 16: 1425-1431. Holick, M.F. (1996). Vitamin D and Bone Health. J Nutr, 126: 1159-1164. Holick, M.F. (2007). Optimal Vitamin D Status for The Prevention and Treatment of Osteoporosis. Drugs Aging, 24: 1017-1029. Holick, M. F. (2008). Vitamin D: A D-Lightful Health Perspective. Nutr Rev., 66: 182-194. Holick, M. F. (2012). Vitamin D: Extraskeletal Health. Rheum Dis Clin North Am, 38: 141-160.

Holick, M.F.; Binkley, N.C.; Bischoff-Ferrari, H.A.; Gordon, M.C.; Hanley, D.A.; Heaney, R.P. (2011). Evaluation Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 96: 1911-1930. Hyppönen, E.; Boucher, B.J.; Berry, D.J.; Power, C. (2008). 25-hydroxyvitamin D, IGF-1, and Metabolic Syndrom at 45 Years of Age: A Cross-sectional Study in The 1958 British Birth Cohort. Diabetes, 57: 298-305. Mosekilde, L. (2005).Vitamin D and The Elderly. Clin Endocrinol (Oxf), 62: 265-281. Öngen, B.; Kabaroğlu, C.; Parıldar, Z. (2008). D Vitamini’nin Biyokimyasal ve Laboratuvar Değerlendirmesi. Türk Klinik Biyokimya Dergisi, 6: 23-31. Pearce, S.H.S.; Cheetham, T.D. (2010). Diagnosis and Management of Vitamin D Deficiency. BMJ, 340: 56-64. Uçar, F.; Taşlıpınar, M.Y.; Soydaş, A.Ö.; Özcan, N. (2012). Ankara Etlik İhtisas Eğitim Araştırma Hastanesi’ne Başvuran Hastalarda 25-OH Vitamin D Düzeyleri. Eur J Basic Med Sci, 2: 12-5. Uğurlu, H. (2000). Osteomalazi, Paget Hastalığı. In: Beyazova M, Gökçe-Kutsal Y (Ed). Fiziksel Tıp ve Rehabilitasyon, 1894-1902pp, Güneş Kitabevi, Ankara, Turkey. URL. SB (2012). http://www.saglik.gov.tr./TR/belge/1-12659/ (Accessed 03 June 2016).

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Chapter 10 Abuse in Old Age and Nursery Approach Çiğdem KAYA, Perihan SOLMAZ, Ebru KURDAL BAŞKAYA INTRODUCTION Old age (senility) is a process which acquires biological, psychologic and sociological dimensions together with the progression of chronologic age (Tufan, 2002). It can be defined as the loss of physical and mental power without any return, the decrease in balancing potential of the organism between internal and external factors, the physical and mental recession of a person by handling it as a physiological fact (Uysal, 2002). World Health Organization (WHO) defines old age (senility) as the decrease in adaptation ability of a person gradually (Aslan, 2012; Kutsal, 2003). Advances in Medicine and Technology have enabled health services to become more effective. Life expectancy of the world has got longer and population rate of old people in societies has increased due to the reasons such as people’s awareness about protection and improvement of health since the beginning of 20th centuries, improvement in nutrition conditions, development of basic public health services, increase in early diagnosis and treatment opportunities of diseases, getting many infectious diseases under control and decrease in fertility rate (Akdemir, Görgülü, & Çınar, 2008; Çilingiroğlu & Demirel, 2004; Kıssal & Beşer, 2009). 542 million of 60 ages and over of people population in the world in 2015 is predicted to be about 1,2 billion until 2025 and 2 billion until 2050 (Krug, Dahlberg, Mercy, Zwi & Lozano, 2002; Kıssal & Beşer, 2009; Sethi et al. 2011; WHO 2014). According to United Nations data, 60 ages and over population which was 600 million in 2000 became 700 million in 2006 and it is expected to constitute 22 % of total world population by reaching 2 billion in 2050. Elder group which was 70 million people in 200 is expected to increase 5 times in 50 years in future (Aslan, 2012). Elder adults population rate has been increasing in both developed and developing countries. The increase in elderly population rate in the world and in Turkey led to many problems in economic, social and health sectors and elder abuse and neglect started to become one of the prior issues (Akdemir et al., 2008; Lök, 2015). Access from agricultural to urban and industrial layout led families to immigrate from rural areas to cities and extended family structures turned into nuclear families. Women taking on elderly care responsibility participated in business life in cities and old people who had prestiges in families for years began to be considered as burdens for families with the complicated life conditions in cities (Kıssal & Beşer, 2009; Tıktık, 2007). Economical difficulties experienced with physical and social changes in elderly period elder abuse and neglect may become a current issue in cases where elder adult care could not be supported sufficiently at home or institutions. (Kıssal & Beşer, 2009; 

Lecturer, Ç. Kaya, Uşak University, Department of Health Services. Lecturer, P. Solmaz, Uşak University, Department of Health Services.  Lecturer, E. Başkaya, Uşak University, Department of Health Services. 

Koştu, 2005). Since majority of healthcare professionals concentrate on child abuse, elder abuse has usually been a forgotten issue. Elder abuse attracted attention in American society in 1970’s first. The first example in which goverment authorities got interested in this issue was observed in the USA: It started to be discussed at the national level in 1978 within domestic violence and private elder abuse law was prepared in 1979 (Akdemir et al., 2008). In researches elder abuse is defined as domestic or interpersonal violence which happens at their own homes and which was generally commited by their adult children and their partners (Kıssal ve Beşer, 2009; Moyer, 2013). Old people’s own houses, hospitals, nursing houses and daily health care centres can be included in places where abuses and neglects may happen most. Studies indicate that abuse and neglect may happen in all societies at every economic level in each ethnical and religious fractions. According to Toronto Declaration of International Elderly Abuse Prevention Institution and World Health Organization (WHO) “elder abuse is single or repeating inappropriate behaviours which hurt older people or get them stressed in a trusted relationship.” It may also be defined as “a behaviour threatening or damaging health and well-being of an elder adult” or “ exposure of an elder adult to an unapproved behaviour in that culture by an adult in a certain period of time.” (Krug et al., 2002; Kıssal & Beşer, 2009; Lök, 2015; Pillemer, Burnes et al. 2016) . Frequency rate of elderly abuse in whole world ranges from 1% and 35%. The variability of elder abuse rates derives from the difference according to research type and model. Studies were conducted for the identification of elder abuse rates in many countries. However, according to many researches, these rates are the visible side of an iceberg and in fact elder abuse is foreseen to have rate much more than observed. (WHO, 2008; Artan, 2016). It is reported that every year one of twenty five Canadian is the victim of abuse or neglect., 40% of the events generally constitutes of financial abuse which is the most common abuse type and 38% of them constitutes of emotional abuse which occurs as humiliation, harassment and social discrimination and 23% of them constitutes of physical abuse (Akdemir et al., 2008; Wilson, Ratajewicz & Asirifi, 2011). In a study conducted in Australia it was determined that physical abuse occured at 30%, psychological occured at 55%, financial abuse occured at 81%, sexual abuse occured at 4% and neglect occured at 25% rates. Again in a study conducted in Japan the highest abuse prevalance is 17,9%. It was determined that neglect was the first with 7.7%, financial abuse was the second with 6,4% and sexual abuse was the last with 1,3% rates (Fadıloğlu & Şenuzun Aykar, 2012). However, in Ergin's study on 756 elder people in 2012 it was determined that 14,2% of elder adults was exposed to an abuse and neglect of any type in 12 months (psychological with 8,1%, neglect with 7,6%, financial with 3,5%, physical with 2,9% and sexual abuse with 0,4%) It was seen that fifty nine elder people was exposed to more than one abuse. It was reported that 68,1% of the abusers was the children of elder adults, 12,9% was their partners and 9,5% was their sisters and brothers. It was identified that psychological abuse and neglect were observed in women (psychological with 10,1%, neglect with 9,6%) more than men (psychological with 6,2%, neglect with 5,7%). It was also identified that psychological abuse was observed more at those who live in extended families, who do not have any social insurance and who are handicapped. 39,7% of elder people said that they expect more 95

interest from state to elder adults, 8,8% of them said that they should be cared at the houses of their family members and only 2,9% of them said that elder adults may be cared in nursing houses when it is required. NCEA (National Centre of Elderly Abuse) declares that only 16 % of abuse cases are reported (Acierno et al., 2010). In a study which includes the ideas of health care professionals one of each three professionals were identified with an abuse case. However, only 50% of them recorded these acts (Cooper, Selwood & Livingston, 2009; Fadıloğlu & Şenuzun Aykar, 2012). In a similar study while abusive act rate identified by those working in emergency department was 68 %, only 27 % of them was reported (Fadıloğlu & Şenuzun Aykar, 2012). In spite of mandatory reporting rules, it is still thought that all identified abusive acts were not reported (Caceres & Fulmer, 2012). TYPES OF ELDER ABUSE Five types of elder abuse were identified. These are listed as: • Physical abuse, • Psychological abuse, • Sexual abuse, • Financial and right abuse • neglect (Uysal, 2002; Akdemir et al., 2008, Kıssal & Beşer, 2009, Fadıloğlu & Şenuzun Aykar, 2012; Ergönen, 2012; Gülen et al., 2013; De Donder et al., 2015; Artan, 2016; Pillemer, Burnes et al., 2016). Physical Abuse They are the acts such as damaging body using force by a person who looks after the older adult and who is trusted by the older adult, causing pain and disability, physical prevention, fedding by force and keeping in bed. Kicking, slapping, pushing, hitting, shaking, beating or malicious drugging, etc. are some examples. Psychological Abuse They are the behaviours which give mental pain or stress verbally or non-verbally by a trusted person of an older adult. Verbal attacks, contempts, insulting, intimidation, threatening, humiliation, continuous criticism, frightening, calling by a nickname, deracinating by force, etc. are some exmples. Sexual Abuse They are the acts of forcing an older adult to any kind of sexual activity out of his or her desire. Touching, rape, stripping by force, taking sexual photographs without any consent or desire, etc. are some examples. Financial and Right Abuse In this act money or goods of an older adult is abused or stolen legally or illegally by a trusted person. Violation of civil and legal rights of older adults without mental disabilities, use of their goods, money, bank / pension accounts or other assets without permission or illegally, dispossession of the older adults from their own houses and getting letter of attorney by cheating are some examples of financial and right abuses. Elder Neglect It is the act of denying the needs such as food, drinks, medicine, medical devices (prothesis, glasses, hearing aid) from elder adults consciously or unconsciously, afflicting elder adults emotionally or physically by behaving reluctantly for fulfilling 96

caring responsibilities or rejecting them, obviating the needs such as eating, clothing, heating, personal hygene, obviating emotional-social stimulus, leaving alone for a long time, etc. are the examples. Elder neglect is divided into two groups as nursery neglect and self-neglect. Nursery Neglect; is the failure the person who is obliged to look after older adults (family members, personnels of social institutions, private nurses) to provide their daily needs. It is also defined as the older adults’ failure to take the required services and care or taking them insufficiently in case of physical weakness, mental diseases, disability. Self-neglect; is the failure of older adults to provide self-care. Symptoms and assessment criteria may vary according to the types of abusive acts. Questions for the symptoms of abusive act types and the assessment of abuse are presented as a table. (Table 1) (Kuzeyli Yıldırım, 2005; Akdemir et al., 2008; Fadıloğlu & Şenuzun Aykar, 2012, Gülen et al., 2013; Danesh and Chang 2015). Table 1: Symptoms According to Types of Abuse and Questions for Abuse Assessment Types of Abuse

Physical Abuse

Psychological Abuse

Sexual Abuse

Symptoms of Abuse

Questions in Abuse Assessment

 Scars like bruises on neck and arms, whip or rope tracks on wrists and ankles, repeating unexplained wounds, conflicting weasel words and attitudes about injuries, brokens, untretaed wounds, bleedings, broken glasses If the nurse rejects the older adult to be appreciated alone, notes are taken.  Laboratory results are appreciated.  Serum levels of the used medicine are checked.  No answers from the older adults to the questions, no communication, suspecious and unreasonable fear, lack of interest in social relationships, chronical physical and psychological health problems can be listed.  Agitation, paranormal personality situations are appreciated. Delusions, dementia and depression are also appreciated.  Bruises on thoracic or genital area, sexually transmitted diseases, unexplained vaginal or anal bleeding, spotted, torn or blooded clothings or underwears  Since the older adult who exposed to sexual abuse would be affected negatively

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Is there anybody trying to hurt you? Have you got any wound on you? Is there anybody you fear? Has anybody touched or tried to touch you without permission before? Questions to be asked when physical abuse is suspected (i.e. bruise on eyes);  How did it happen?  When did it happen?  Did a person do it?  Are there any other bruises on you?  Have you ever experienced something like that before? Is there anybody you fear? Is there anybody scaring or shouting you? Is there anybody insulting and cursing you? Do you live in a gloomy or stressful atmosphere? Do you have a nurse? Does the nurse take medicine or drink alcohol?

Is there anybody you fear? Has anybody touched or tried to touch you without permission before? Has anybody tied you before? Is there anybody who forced you to do something you do not want? Do you live in a gloomy or stressful atmosphere?

Financial and Right Abuse

Nursery Neglect

Self-Neglect

psychologically, symptoms of psychological abuse may be observed.

Do you have a nurse? Does the nurse take medicine or drink alcohol?

 The situations such as changes in take-home pay amounts, unexplained withdrawals or transfers to other accounts, changes in bank account names, unpaid bills, immitating the patients’ signatures are appreciated.

Who pays your bills? Have you ever been to a bank with your nurse? Has the nurse ever got your account? Is your procuration on your nurse? Have you ever signed an unknown document? Did anybody take your belongings without asking for? Has anybody talked to you about this issue? Have you ever stayed alone for a long time? Is there anybody who failed when you needed? Has anybody forced you to do anything you do not want to? Do you live in a gloomy or stressful atmosphere? Do you have a permanent nurse? Does the nurse take medicine or drink alcohol? How often do you have a bath? Have you ever rejected to take prescription medicine? Have you ever failed to provide food, water, clothes for you?

 Bedsores, emaciations and weight loss and collapses in eyes, dehydration, poor personal hygene, dirty bed and clothes, untreated mental or physical diseases, unsafe unhygenic living conditions, animal invasions, faecal and urinary scents  Dehyratation, malnutrition, poor personal hygene, unsafe living conditions, animal invasions, poor clothing, urinary and faecal scents are appreciated.

REASONS OF ELDER ABUSE AND NEGLECT Reasons of elder abuse and neglect are presented in Table 2 as domestic, cultural, institutional factors and the factors about nursery and older adults (Uysal, 2002; Akdemir et al.,2008;Kıssal & Beşer, 2009; WHO 2011; Fadıloğlu & Şenuzun Aykar, 2012 ; Day, Boni, Evert & Knight, 2016; Pillemer, Burnes, Riffin, & S.Lachs, 2016). Table 2: Reasons of Elder Abuse and Neglect Domestic Factors Cultural Factors Institutional Factors Factors about nurses

• Violence background in family, • Lack of information and skills about caring, experiencing stress or social isolation, • Financial burden of living together with older adult or caring him or her • Senility perception of older adults, • Faiths and values of society about senility and respect for elder adults • Weakness and vulnarability of elder adults living in institutions, • Personnels in institutions may work for long or short hours with low salaries, • Indifferent attitudes of institution managers and personnels about abuse and neglect symptoms, their values and customs and upbringings and educations. • Illnesses of the nurse, • Low self-esteem, • Personality problems such as inability to control opinions and behaviours, • Mandatory caring responsibility or not adopting the caring responsibility • Failure to get on well with the older adult and feeling anger, • Drug or alcohol addiction, • Experiencing unemployment, conflicts in marriage, personal crises in

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Factors about Older Adults

• • • • • •

financial and medical issues, Financial dependence on older adults, Physical and mental disability of older adults, No ability for self-protection and safe, Dependence on other people in providing needs, Alcohol or drug addiction, Continuous fall down problem, incontinance and violant verbal behaviours

DIFFICULTIES IN IDENTIFYING ELDER ABUSE The most significant point in elder abuse is that older adults, families, society and health care professionals are not exactly aware of the problem and there are difficulties in identification of abuse. These difficulties can be listed as: Personal Handicaps Older adult’s; • Fear to be judged and accused by the nurse. • Shame about the behaviours of family members or fear that family members would behave worse when he or she tells the event to anybody and send him or her to an institution (Koştu, 2005;Yıldırım Y.,2005; Bilgili 1999). • Fear that nobody would believe him or her (Koştu, 2005; Bilgili, 1999) • Lack of confidence about the system (Bilgili, 1999). • Feeling guilty about the event, feeling unwilling to inform about the abuse or share it with anybody (Oh, Kim, Martins, Kim, 2005; Kıssal & Beşer,2009). • Regarding family as divine, thinking that intenvention in family life by other people is not ethical (Koştu, 2005; Bilgili, 1999). • Rejection of such a problem in his or her family, unawareness of it and not knowing how to express it (Oh, Kim, Martins, Kim, 2005). • Not considering the event seriously enough (Bilgili, 1999; Aslan, 2012) Inefficiency to access information and resources • Unawareness of older adult of the resources about how and where to get help • Economic or social dependence of older adult (Erlingsson, Saveman & Berg,2005) Healthcare Professionals and Institutional Handicaps • Healthcare professionals’ such as nurses, doctors, social workers unawareness about which questions to be asked for identifying elder abuse and lack of information about the issue. • Healthcare professionals’ insufficient and reluctant behaviours to inform and report the problem • Worries of healthcare professionals about taking responsibilities for assessment and action. (Koştu, 2005; Bilgili, 1999; Oh, Kim, Martins, Kim, 2005; Erlingsson, Saveman & Berg, 2005). PREVENTION OF ELDER ABUSE Main purpose of the prevention of elder abuse is to preserve older adults and prevent the latter abuses. (Kuzeyli Yıldırım, 2005) Older adults do not say that they were abused or neglected because they fear to be exposed to violence again and they fear the family bonds to be broken and they fear and worry about the legal process and being sent to a social institution by leaving the family. For that reason the most 99

effective method for the prevention of abuse and neglect is to raise awareness in healthcare professionals, older adults and society. Infromation about this issue are as follows (Kışsal, Beşer, 2009; Sayan, Durat, 2004; Uysal, 2002;Kanno, Ai,2011; Alon, Berg-Warman,2014; APA, 2012). Precautions that can be taken by other adults Common Precautions • Not staying alone at home, • Living with a person having no violence or drug usage background in the past, • Keeping always available the telephone number of a person to be trusted ( a doctor, a friend, etc.), security units, institutions or agencies providing preservative services. Social Precautions • Maintaining social relationships and improving social circle, • Maintaining social relationship with old friends and neigbours even they are separated, increasing friendship out of home, • Desire of his or her friends to visit at his or her own house, • Participating in social activities and volunteer programmes. Legal Precautions • Getting support and advice from people who will protect him or her legally in possible inability cases in the future, for instance a lawyer to represent him or her or a legal power, • Maintaining legal and social contacts periodically, • Revising bank accounts or social insurance documents, • Not signing any documents without reviewing them or without any trusted person. Precautions that can be taken by families • Building close relationships with older neighbours and friends, • Analyzing the power and skills of his or her family in ensuring long term home caring services, • Exploring alternative caring resources, • Determining potential abilities before and planning to make discussions based on wishes of older adults, • Not preferring personal care at home although it is not sufficient for meeting the demands and taking on responsibilities and economical aspects, • Not ignoring his or her positive aspects and restrictions, • Not preventing the independence of older adults or not including in privacy unless it is not necessary. Social Precautions • Maintaining direct financial contribution to the caregiver families, • Researching other civil organizations that would perform more comprehensive elder service programmes, • Encouraging both public and private enterprises to help the caregiver families, • Advertizing current support services and jobs for caring, • Increasing certificate programmes of elder caring support personnel education and maintaining them on ministry supervision, 100

• Giving basic education for public personnels about case management and service delivery, • Providing educations for security personnels, service personnels, doormen and society, • Including the subjects about elder abuse in lessons for all cirricula beginning from primary education, • Including notifications by press and media organs for the prevention of elder abuse and increasing social sentivity and awareness, • Knowing, recognizing and informing all types abuse, mistreatments and neglect which are crimes legally, • Establishing a phone line for the notification of elder abuse and regional interdisciplinary teams and unions of forces, • Establishing all necessary counselling services such as mental health and family councelling services, • Providing and maintaining income, social and health services for older adults, • Establishing treatment programmes for alcohol and drug usage, • Increasing older adult rights and giving educations to older adults for claiming rights and self protection, • Arising awareness for the positivity and productivity of old ages and performing educations, • Addition to these precautions, educations for health care professionals about the assessment and interventions for elder abuse and neglect, assessment of abuse with scales and developed protocols at each stage of health care centers whenever the people over 65 ages apply to may also be suggested (Fadıloğlu, Şenuzun Aykar, 2012). ELDER ABUSE AND NURSERY APPROACH In conclusion, abuse and neglect which is observed in all world and require a multidisciplinary approach for the solution is an evitable social problem which hurts older adults physically, mentally and socially and reduces life quality. Since nurses are always together with older adults, they are in the most significant position in identifying real and suspecious cases and intervening them. Nursery approaches about this issue are that: • Nurses should have sufficient knowledge about elder abuse (identifiying and reporting elder abuse, performing suitable attempts and providing consultancy to society). • Nurses should know the social resources which the person exposed to abuse would use and should be in relationship with these resources. • Nurses should inform caregivers about the alternatives which they can get help and support (health organizations, civil services, home health care service, voluntary organizations, etc.). • Nurses should give education to the caregivers about the required subjects ( elder nutrition, hygene and activity requirements of older adults, etc.), therefore she should prevent the abuse and neglect which may derive from unawareness and inexperience. • Nurses should appreciate older adults applying to the institution due to an injury or during at home visit in terms of bause risk as a good observer. 101

• Nurses should provide the older adults to be taken under protection by performing legal notifications of abuse cases that she identified. • Nurses should inform older adults and families about where and how they can get help in case of abuse. • Nurses should help older adults exposed to abuse to acquire self confidence and self esteem by providing sufficient support (visiting frequently, teaching methods for overcoming stress, reinforcing social supports, acquiring hobbies, etc.) during rehabilitation process. • Nurses should contribute to deterrant legislative regulations for abusers by increasing awareness of the society and the people directing the society. REFERENCES Acierno, R, Hernandez, M. A., Amstadter, A.B. et al. (2010).Prevalence and correlatesof emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Am J Public Health 100(2):292-7. Akdemir, N., Görgülü, Ü, Çınar, F. İ. (2008) Yaşlı İstismarı ve İhmali. Sağlık Bilimleri Fakültesi Hemşirelik Dergisi;67-75. Alon, S & Berg-Warman, A. (2014 )Treatment and Prevention of Elder Abuse and Neglect: Where Knowledge and Practice Meet—A Model for Intervention to Prevent and Treat Elder Abuse in Israel. Journal of Elder Abuse & Neglect,26:150–171 American Psychological Association (2012).Elder Abuse & Neglect In Search of Solutions URL:http://www.apa.org/pi/aging/resources/guides/elder-abuse.aspx (Accessed 20.05. 2016 Artan, T.(2016). Huzurevinde Kalmakta Olan Yaşlılarda Yaşlı İstismarının Bir Türü Olarak Ekonomik İstismar. HSP, 3(1):48-56. Aslan, H. (2012). Yaşlıların İstismar ve İhmal İle Karşılaşma Durumları ve Etkileyen Faktörler, İnönü Üniversitesi, Sağlık Bilimleri Enstitüsü, Hemşirelik Anabilim Dalı, Yüksek Lisans Tezi, Malatya Baker, M. W., Heitkemper, M. M. (2005). The roles of nurses on inter professional teams to combat elder mistreatment. Nursing Outlook. 53(5): 253-59. Bilgili, N. (1999). Yaşlı istismarı ve ihmali. Hacettepe Üniversitesi Hemşirelik Yüksekokulu Dergisi. 6 (1-2), 67-77 Caceres, B.A., Fulmer, T. (2012) Mistreatment detection. Boltz M, Capezuti E, Fulmer T, Zwicker D, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: Springer Publishing Company, 544-62 Cooper C, Selwood A, Livingston G. (2009) Knowledge, detection, andreporting of abuse by health and social care professionals: a systematic review. Am J Geriatr Psychiatry;17(10):826-38. Danesh, M. J. and A. L. Chang (2015). "The role of the dermatologist in detecting elder abuse and neglect." J Am Acad Dermatol 73(2): 285-293 Day, A, Boni, N, Evert H & Knight, T. (2016). An assessment of interventions that target risk factors for elder abuse. Health and Social Care in the Community s:1-10 De Donder, L., De Witte, N., Brosens D., Dierckx, E., Verté, D. (2015). Learning to Detect and Prevent Elder Abuse: The Need for a Valid Risk Assessment Instrument. Procedia Social and Behavioral Sciences, 191, 1483 – 1488 Ergönen, A.T. (2012) Yaşlıya yönelik ihmal ve istismar. Türkiye Klinikleri Aile Hekimliği Özel Dergisi, 3:94-98 Erlingsson, C. L., Saveman, B., Berg. A.C. (2005). Perceptions of elderabuse in Sweden: Voices of older persons. Brief Treatment and Crisis Intervention. 5(2): 213-227. Fadıloğlu, Ç, Şenuzun Aykar, F.(2012). Yaşlıda istismar ve ihmale yaklaşım. Ege Tıp 102

Dergisi / Ege Journal of Medicine, 51; Ek Sayı / Supplement : 69-77 Gülen M, Aktürk A, Acehan, S, Seğmen M. S, Açıkalın A & Bilen, A. (2013).Yaşlı İstismarı ve İhmali .Arşiv Kaynak Tarama Dergisi . Archives Medical Review Journal; 22(3):393-407 Kanno H & Ai A.I. (2011). Japanese Approach to Elder Abuse: Implications for Prevention in Emerging Developed Countries Indian Journal of Gerontology ,25( 4):516-531 Kıssal, A, Beşer, A. (2009). Yaşlı İstismar ve İhmalinin Değerlendirilmesi. TAF PrevMed Bull, 8(4):357-364 Koştu, N. (2005). Yaşlı İstismarı ve İhmalinin Önlenmesinde Halk Sağlığı Hemşiresinin Rolü. Özveri Dergisi;URL:http://www.ozida.gov.tr./ozveri/ou3/ou3makaleler.htm (Accessed on:11.05.2016). Krug, E. G., Dahlberg, L.L., Mercy, J.A., Zwi , A.B., Lozano, R. (2002). World report on violence and health. World Health Organization, Geneva. Kutsal, Y. (2003). Yaşlanan insan ve yaşlanan toplum. Hacettepe Toplum Hekimliği Bülteni; 3-4:1-6. Kuzeyli Yıldırım Y. (2005). Yaşlı istismarı ve önlenmesi. Ege Üniversitesi Hemşirelik Yüksek Okulu Dergisi; 21(1):167-74. Lök, N. (2015). Türkiye'de Yaşlı İstismarı ve İhmali: Sistematik Derleme Psikiyatride Güncel Yaklaşımlar-CurrentApproaches in Psychiatry; 7(2):149-156 Moyer, V. A. (2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive Services Task Force recommendation statement. AnnalsIntMed, 158:478-486. Oh, J., Kim, H. S., Martins, D., Kim, H. (2006). A study of elderabuse in Korea. International Journal of Nursing Studies .43, 203–214 Pillemer, K., D. Burnes, C. Riffinand M. S. Lachs (2016). "Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies." Gerontologist 56 Suppl 2: 194-205 Sayan A & Durat G. (2004).Yaşlı İstismarı ve İhmali: Önleyici Girişimler. Atatürk Üniv. Hemşirelik Yüksekokulu Dergisi, 7(3): 97-106 Sethi, D., Wood, S., Mitis, F. et al. (eds) (2011). Report on preventing elder maltreatment. World Health Organization, Regional Office for Europe, Copenhagen s: 29-39 Tıktık A. (2007). Türkiye’de Yaşlıların Durumu ve Ulusal Eylem Planı. Sosyal Sektörler ve Koordinasyon Genel Müdürlüğü 2007 URL: http://www.sp.gov.tr/documents/ Turkiyede Yaslıların Durumuv e Yaslanma Eylem Plani.pdf (Accessed on:11.05.2016). Tufan, İ. (2002). Antik Çağdan Günümüze Yaşlılık. İstanbul: Aykırı Yayıncılık: 87 Uysal, A. (2002). Dünyada Yaygın Bir Sorun: Yaşlı İstismarı ve İhmali. Aile ve Toplum Eğitim-Kültür ve Araştırma Dergisi,2:(5), 43-50 Wilson D. M, Ratajewicz SE., Els C, Asirifi M.A. (2011). Evidence-based approaches to remedy and alsotoprevent abuse of community-dwellingolderpersons. Nurses Pract:1-5 World Health Organization. (2008). URL: http://www.who.int/ageing/publications/ ELDER _DocAugust08.pdf

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Chapter 11 Strategies and Models for Evidence Based Nursing Practice Yasemin YILDIRIM USTA, Songül ÇAĞLAR INTRODUCTION In recent years, alongside other medical sciences, the attention to evidence based practices in the science of nursing has gradually increased because of its positive contributions to care quality and occupational professionalism. The reason behind evidence based practices becoming o widespread can also be seen as health professionals being protected against increasing social pressure and the wedge between research and clinical application closing (Newhouse et al., 2005). Evidence based practice is defined as “Using the available evidence honestly, openly, in an acceptable manner in decisions regarding individual patient care”(Sackett et al., 1996). The evidence based practice movement started in 1972 with the British doctor Archie Cochrane examining health care decisions systematically and stating that the decisions should be evidence based (Fineout-Overholt et al., 2005). Then, evidence based medicine (EBM) was first used in the training of medicine students in the McMaster University in Canada in 1992, and was later bused in the solution of clinical problems. Then, it was widened as Evidence Based Practice (EBP) and Evidence Based Health Care (EBHC) (Kocaman, 2003). Evidence based nursing practices mean the use of empirical research data for more successful and reliable nursing care (Meijel et al., 2004).These applications consist of the process of solving a care based problem by using the preferences and values of the patient, clinical experience and skill, patient care data, and the best evidence obtained from studies (Makic et al., 2013). The science of nursing works non stop to perform successful application changes (Brady and Lewin, 2007). Evidence based practices have benefits for both health care systems and nurses (Eizenberg, 2011). Nurses who support health care with scientific sources case errors in care to decrease and acre and patient satisfaction to improve (Stevens, 2013). Additionally, providing care with the best evidence at hand is one of the standards of professional nursing, and nurses also improve the infrastructure of evidence based practices by doing so (Satterfield et al., 2009). For this reason, there exists centers developed for evidence based nursing practices; in 1998 in the Case Western Reserve University, the Sarah Cole Hirsch institute was founded to gather information in order to reach the best nursing applications. In Australia, Research and Evidence Based Practices Centers were founded in the Joanna Briggs Institute and the Rochester University (Brady and Lewin, 2007). The active participation of nurses in the decision making processes of increasingly 

Assoc. Prof. Dr., Abant İzzet Baysal University, Bolu Health Vocational School, Department of Nursing.  Res. Assist., Abant İzzet Baysal University, Bolu Health Vocational School, Department of Nursing.

more practices requires nurses to make more efficient decisions hat don’t allow for application errors, and thus, to use the most reliable evidence (Mantzoukas, 2008). In evidence based nursing practices, first the type of evidence should be determined. Alongside this, whether the evidence to be used prevents the study to be performed should be determined beforehand (Gerrish et al., 2007). The most reliable sources are meta analyses obtained from randomized controlled studies. Nurses can reach these sources through the databases of libraries such as Cochrane and AHRQ. The Cochrane database is the basic storage unit for sources on the subject (Pape 2003). Databases such as Sigma Theta Tau International in the Online Journal of Knowledge Synthesis for Nursing, CINAHL, MEDLINE, and EBN can also be used. Nurses need a guide consisting of correct, applicable, and novel evidences to use in he decision making process during applications. The use of the evidence based practice process ensures a systematical approach to rational decision making and thus the best and most reliable/ most accountable application (Newhouse et al., 2005). STRATEGIES in EVIDENCE BASED NURSING PRACTICES The successful application of strategies built in developing evidence based practices depends foremost on reliable evidence. Alongside this, factors that may cause nurses to accept or decline evidence based practices should be determined beforehand (Brown et al., 2009). Even though the importance of evidence based practices to the nursing occupation is well known, the obstructions in the levels of knowledge of clinical nurses and the transference of information still have important roles in the use of present research evidence (Black et al., 2015). Certain personal and institutional obstructions can prevent nurses to shy from evidence based practices (DiCenso et al., 2013). The lack of time and resources to perform research at the institution worked at, excessive patient loads, lack of management and institutional support on the subject, the institution being closed to changes, and many such reasons prevent evidence based practice even if the nurses are willing (Melynk and Fineout-Overholt, 2011). In order to remove those obstacles, strategies to obtain organizational support to evidence based practice should be determined, time arrangements should be made so that nurses can perform research, and access to electronic sources should be given. Additionally, a research team of nurses to be formed within the institution can play an important role in the realization of evidence based practice (DiCenso et al., 2013). One of the most important strategies is teaching students during their nursing training how to perform research and how to use the results obtained from such research in clinical practice (Fineout-Overholt et al., 2005). The lack of skill and knowledge regarding evidence based practices, negative thoughts and prejudices, thoughts on experience based care being better, and not knowing how to perform research using scientific resources are the personal obstacles nurses face on the subject (Melynk and Fineout-Overholt, 2011). For this reason, giving the knowledge, attitudes, and skills on evidence based practice in patient care should be a teching goal in the training plan of students (Haggman-Laitila et al., 2016). Expert nurses and clinical nurses should increase their application skills and care quality through evidence based practice. Academicians should act as examples for both students and clinical nurses regarding evidence based practices, consolidating awareness (Fineout-Overholt et al., 2005). Models help strategies used in evidence based nursing practices to be realized and guide nurses in defining and schematizing the evidence based practice process (Pape 105

2003). Additionally, they aim to understand and analyze the components of evidence based practices, and realize novelization and correction efforts with contemporary designs, aims, and applications (Pearson et al., 2005a). Even though each model has a different perspective with regard to research results being translated into application, they have some similarities regarding certain steps and procedures (Polit and Beck, 2008). Additionally, every model can be more advantageous or disadvantageous according to the institution where it will be sed, and this may cause some difficulties in usage (Houser and Oman, 2011). For these reasons, the models to be used in evidence based nursing practices should be selected as a result of a fine examination. The characteristics of the models used in evidence based nursing practices Models to be used in evidence based nursing practices should have certain characteristics:  It should make the studies necessary for the completion of an evidence based practice project easier  Should have the educational components that will help nurses evaluate and criticize the strength of evidence  Should be able to guide in reflecting application changes to the clinical environment  Should be applicable in special areas of expertise (Schaffer et al., 2013). These models were separated into 4 thematic fields: 1. Evidencebasedpractice, Research Use, and Infromation Transformation Processes 2. Strategic/institutional development theory to support change and the acceptance of new information 3. The analyses and transformation of knowledge for application 4. Research(Mitchell et al., 2010). In order to understand various aspects of evidence based practice, certain models were developed by nurses. There are 47 models developed for the field in the literature (Stevens, 2013). Here, some widely used models were mentioned. Some widely used models for evidence based practice; 1. ACE STAR Model of Knowledge Transformation (Stevens 2004, Kring 2008) This interdisciplinary model developed by the Academic Center for Evidence Based Practices touches on both the adaptation and application stages of the evidence based practice model (Schaffer et al., 2013). This model can be used in both academic and clinical studies. The ACE model consists of a 5 pointed star showing the 5 stages of information transformation: 1) subject determination (original study 2) the analysis or summary of evidence 3) transformation to clinical suggestions 4) application in the clinical environment 5) evaluation. The model starts with determining the subject and ends with evaluation (Pape 2003). The structure of the model is simple, encompasses known processes, stresses certain aspects of evidence based practice, and the model is used only with evidence obtained as a result of studies (Houser and Oman, 2011). Obtainingg information and translating it to application in nursing is necessary for a successful clinical decision making process The use of this model in nursing helps this process. Scientific literature, which is diluted in various stages, is turned into information to be used in decision making (Stevens, 2013). 106

2. Advancing Research and Clinical Practice through Close Collaboration (ARCC)(Ciliska et al. 2011) The model was formed in 1999 by Bernadette Melnyk. The Control Theory and the Cognitive Behavioral Theory pioneered the formation of this model (Wallen et al., 2010). Levin et al (2011) performed the pilot study of the ARCC model by working with nurses in house care units (Schaffer et al., 2013). The ARCC model is used in hospital and society applications and is tested as a strategy for bettering application results (Schaffer et al., 2013). The most important basis of the model is to provide the best evidence for nurses who provide care. The aim of the model is to select the most appropriate evidence for health policies, making the necessary decisions to meet the need for health care, and thus obtain better and more effective patient outcomes (Rycroft-Malone and Bucknall, 2013).In the model, evidence must be obtained from multiple sources, and the best source should be reached for decision making (FineoutOverholt et al., 2005). It defines the important factors in translating evidence to application specifically, and makes forming hypotheses between environmental components and various factors easier (Rycroft-Malone and Bucknall, 2011). 3. Iowa Model (Titler et al., 2001) The model was developed in 1994 by the IOWA Hospital Clinics and the IOWA Nursing University (Pape 2003). It was revised and restructured in 2001 by Dr. MaritaTitler et al (van Achterberg et al., 2008). In the beginning, the model was developed for the utilization of the research results of the nurses and other health personnel in the betterment of health care (Titler et al., 2001). In the application of the model, the participation of all nurses form the officers working at clinics to the head nurse is required. Clinical nurses play an important role in the realization and continuation of the application (Houser and Oman, 2011). There are 7 stages in evidence based nursing practices taking the Iowa Model as basis. The first is the selection of a subject for evidence based practice. The second is the formation of a team to develop, apply, and evaluate the subject. The third is the surfacing of evidence that will define the sources to guide the research and key terms. The fourth is the scaling of evidence according to strength. In the fifth stage, team members come together to form suggestions for application and form an evidence based practice standard. The sixth stage is where factors such as evidence based written policies, processes, and guidelines are taken into consideration and evaluated. The seventh stage where evaluations for translating evidence into practice, and cooperation is performed (PalasKaraca and Şahin, 2015). 4. Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse et al. 2007) This model was formed as a result of the nursing training leaders working at the John Hopkins University School of Nursing and John Hopkins Hospital working together (Schaffer et al., 2013). It takes the 3 basic cornerstones of professional nursing as basis; application, training, and research (Dearholt, 2012) It is a strong problem solving approach in the clinical decision making process. The model helps with providing clinicians with an evidence based practice environment and tools, the necessary information and skills, and a supportive working environment (Houser and Oman, 2011). In the model, when research on a subject is being performed, information from both the study and the clinical experiences of nurses can e used. The model can be 107

used in accreditation efforts, quality efforts, and the determination of practices and standards just like it can be used in many other areas including determining institutional and other beliefs, the status of clinics, the use of technology, and institutional errors and priorities (Rycroft-Malone and Bucknall, 2013). The process begins with determining a subject, problem, or practice related problem. This step is very important since it affects the selection of sources and methods to be used in the following stages. The question to be formed and the evidence to be used regarding the subject is determined, and the evidence is gathered and analyzed. Whether the information gathered as a result of analysis can be translated into application is evaluated. If the data supports change, the evidence is evaluated and the personnel, patients,, families, and health workers in the institution are informed, and the application starts. This can be widened into local and regional application if necessary (Dearholt, 2012). 5. Promoting Action on Research Implementation in Health Services Framework (PARIHS) (Kitson et al.1998) A framework was formed in 1998 by Kitson et al in order to guide the evidence of the Royal College Nursing Institute in the United Kingdom in being translated into evidence (McCormack and Kent, 2011, Rycroft-Malone, 2004). In time, concept analyses and further studies were performed and the model was revised (Stetler et al., 2011). This model shows te importance of building a bridge between the place the application will be performed at and the novelty (including evidence and the source of evidence)(van Achterberg et al., 2008). For a successful evidence based nursing application, three dimensions are important. There are strong relations between these dimensions, and each has a “low” or “high” value rate (Houser and Oman, 2011). These three dimensions, namely evidence, environment, and easers, affect the success of evidence based practices with their strength and value (Schaffer et al., 2013) Kitson et al have stated that the type of evidence, the experience of the users, and the choices of nurses were effective factors in the use of research (Rycroft-Malone, 2004). The appropriateness of the evidence for the nurse, its utility, understandability, the understanding capacity of users, cost effectiveness, and success are all important in selecting evidence. Even if the institution has evidence, physical capacity, time of access, utility ease of the evidence, the openness and attractiveness of the evidence all lay important roles in providing willing users with evidence. Additionally, the user’s perception of research results as appropriate for needs, the user’s readiness for change, sufficient user information levels, and sufficient user information utilization capacity all have importance (Rycroft-Malone and Bucknall, 2013). 6. Stetler Model (Stetler 2001, Ciliska et al. 2011) The Stetler model was developed in 1976, revised in 1994, and updated in 2001(Hughes, 2008). As a result, the five step process was formed. The 1st Stage is the completion of preparations, contextual evaluation, and the determination of the evidence to be used. The 2nd stage is the definition of the determined evidence. The 3rd stage is comparative evaluation/decision making, where the evidence is critically examined, analyzed, and decisions are made taking into consideration internal and external factors. The 4th stage is betterment through application and translation for changes in application. The 5th stage is evaluation, the scaling of the implemented change, and its evaluation (Schaffer et al., 2013). The aim of the model is to surface evidence on a specific subject, ensure the applicability of research, ensure that all of the 108

evidence is usable and transformable for other applications, and evaluate the use of evidence in patient care (Rycroft-Malone and Bucknall, 2013). The model guides users on which research type will be used, how the evaluation will be performed, and how criticism can be done (Houser and Oman, 2011). 7. The Joanna Briggs Institute Model (JBI,2005) The model was developed in 2005(Pearson, 2011). This model conceptualizes the clinical decision making process that ensures the best care by using the best evidence, and taking into consideration the occupational decisions of health care workers and patient decisions (Pearson et al., 2005a). The JBI model explains the 4 basic components of the evidence based health care process; producing evidence based health care, the synthesis of evidence, the transference of evidence and information, and the use of evidence (Pearson et al., 2005b). This model starts by determining a special question on a subject affecting general health care. Then, information and evidence is collected and analyzed. The specific group, culture, and environment conditions are determined. Whether the evidence to be used is appropriate for this group is evaluated by health workers. If the results obtained are beneficial for both the patient and the health care system, they are used in application (Pearson et al., 2007). This model actually forms a framework for the development of other frameworks and models to be used in health care (Pearson, 2011). The model stresses the importance of information obtained from evidence by health workers, and can be used in the formation of evidence based practice, the decision making process es of the patients, and the clinical decision making processes of health personnel. Additionally, the model is useful with regard to how the information gained in bachelor’s and master’s education will be translated into practice and its benefits regarding global health (Pearson, 2011). 8. Ottowa Model (OMRU) (Logan ve Graham, 1998; Logan et al., 1999; Graham & Logan, 2004; Stacey et al., 2006) The model was formed as a comprehensive interdisciplinary model by Logan and Graham (1998). It was revised in later years to be used in both research studies and applications (Logan and Graham, 2011). The model can be used both descriptively and explanatorily. As a planned theory of action, the steps and actions necessary for the implementation of the application were detailed extensively, and thus the process can be grasped easily in a sufficient manner(Rycroft-Malone and Bucknall, 2011). This model contains six elements, namely the application environment, the group where the novelty will be applied, the evidence based novelty, strategies for implementing the novelty, adaptation, and health outcomes (Rycroft-Malone and Bucknall, 2013). Each element affects each other (Logan and Graham, 2011). In the use of the model, a three stage process is followed as determining the evidence based application, monitoring, and evaluation (Logan and Graham, 2011). In the model, social components affecting nursing knowledge were also taken into consideration. The patients and their health statuses play key roles in all stages of the process, including the basis of the research. Additionally, the social environment is very important. The evidence to be used should be obtained ethically (Rycroft-Malone and Bucknall, 2013). 9. Diffusion of Innovation Model (Rogers, 1995) The model was formed by Rogers (1995) (Temel and Ardahan, 2011). The model 109

consists of 5 stages, namely gaining information, persuasion, decision making, application, confirmation (Pape, 2003). In this model, 4 elements are determined, namely novelty, communication channels, time, and social system, and additional factors including users, social structure, environmental factors, those who have developed the novelty, and the characteristics of the novelty were stressed to have important roles (Temel and Ardahan, 2011). The application stage of Rogers includes detailed information through direct applications and the calculation of indirect effects that help repeating applications (Pape 2003). Making the determined changes according to the needs of the institute forms the restructuring stage. In recent years, certain new models based on these models were formed. These include Reavy and Tavernier’s (2008) The Evidence- Based Practice Model for Staff Nurses, and Tolson, Booth and Lowndes’ (2008) Caledonian Development Model. As a result, it can be seen that there are various models from which nurses can benefit when implementing evidence based practice. Nurses should select models according to the evidence type they will use and the region where they will make applications. During the process, the concepts and steps of the model should be followed, since this is extremely important for the success of evidence based practice. Alongside this, evidence based practice models develop as they are used in nursing applications, becoming more comprehensive. In order to form new models, the models should be supported at various research levels and implemented. In this way, the development of new models can be pioneered and the quality of care can be improved, making translating evidence based practices into clinical environments easier. REFERENCES Black, A. T., Balneaves, L. G., Garossino, C., Puyat, J. H. & Qian, H. 2015. Promoting evidence-based practice through a research training program for point-of-care clinicians. J Nurs Adm, 45, 14-20. Brady, N. & Lewin, L. 2007. Evidence-based practice in nursing: bridging the gap between research and practice. J Pediatr Health Care, 21, 53-6. Brown, C. E., Wickline, M. A., Ecoff, L. & Glaser, D. 2009. Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. J Adv Nurs, 65, 371-81. Dearholt, S. 2012 The Johns Hopkins Nursing Evidence-Based Practice Model and Process Overview In:Dearholt, S. L. & Dang, D. (eds.) Johns Hopkins Nursing Evidence-Based Practice : Models and Guidelines (2nd Edition). Sigma Theta Tau International Dicenso, A., Cullum, N. & Ciliska, D. 2013. Implementing evidence-based nursing: some misconceptions In:Ciliska, D.,Haynes, B. & Marks, S. (eds.) Evidence-Based Nursing : An Introduction. John Wiley & Sons Eizenberg, M. M. 2011. Implementation of evidence-based nursing practice: nurses' personal and professional factors? JAdv Nurs, 67, 33-42. Fineout-Overholt, E., Melnyk, B. & Schultz, A. 2005. Transforming health care from the inside out: advancing evidence-based practice in the 21st century. J Prof Nurs, 21, 33544. Gerrish, K., Ashworth, P., Lacey, A., Bailey, J., Cooke, J., Kendall, S. & Mcneilly, E. 2007. Factors influencing the development of evidence-based practice: a research tool. Journal of Advanced Nursing, 57, 328-338. Haggman-Laitila, A., Mattila, L. R. & Melender, H. L. 2016. Educational interventions on

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evidence-based nursing in clinical practice: A systematic review with qualitative analysis. Nurse Educ Today, 43, 50-9. Houser, J. & Oman, K. S. 2011. Evidence-Based Practice An Implementation Guide for Healthcare Organizations, Canada, Jones & Bartlett Learning. Hughes, R. G. 2008. Patient Safety and Quality An Evidence-Based Handbook for Nurses. Kocaman, G. 2003. Hemşirelikte Kanita Dayali Uygulama.Hemşirelikte Araştırma Geliştirme Dergisi, 5, 62-69. Logan, J. & Graham, L. D. 2011. The Ottawa Model of Research Use In:rycroft-malone, j. & bucknall, t. (eds.) Models and Frameworks for Implementing Evidence-Based Practice. Wiley. Makic, M. B., Martin, S. A., Burns, S., Philbrick, D. & Rauen, C. 2013.Putting evidence into nursing practice: four traditional practices not supported by the evidence. Crit Care Nurse, 33, 28-42. Mantzoukas, S. 2008. A review of evidence-based practice, nursing research and reflection: levelling the hierarchy. J Clin Nurs, 17, 214-23. Meijel, B. V., Gamel, C., Swieten-Duijfjes, B. V. & Grypdonck, M. H. F. 2004. The development of evidence-based nursing interventions: methodological considerations. Journal of Advanced Nursing 48, 84-92. Melynk, B. M. & Fineout-Overholt, E. 2011. Evidence-Based Practice in Nursing & Healthcare - A Guide to Best Practice, China, Wolters Kluwer Health | Lippincott Williams & Wilkins. Mitchell, S. A., Fisher, C. A., Hastings, C. E., Silverman, L. B. & Wallen, G. R. 2010. A thematic analysis of theoretical models for translational science in nursing: mapping the field. Nurs Outlook, 58, 287-300. Newhouse, R., Dearholt, S., Poe, S., Pugh, L. C. & White, K. M. 2005. Evidence-based Practice. Aspen Pub./JONA, 35, 35-40. Palas Karaca, P. & Şahin, N. 2015. The use of Iowa Model on development of evıdencebased care. hemşirelikte Eğitim ve Araştırma Dergisi, 12. Pape, T. M. 2003. Evidence-based nursing practice: To infinity and beyond. The Journal of Continuing Education in Nursing, 34. Pearson, A., Wiechula, R., Court, A. & Lockwood, C. 2005a. The JBI model of evidencebased healthcare. Int J Evid Based Healthc, 3, 207-215. Pearson, A., Wiechula, R., Court, A. & Lockwood, C. 2007. A Re-Consideration of What Constitutes "Evidence" in the Healthcare Professions. Nursing Science Quarterly, 20, 85-88. Pearson, A., Wiechula, R. & Lockwood, C. 2005b. The JBI model of evidence-based healthcare. Int J Evid Based Healthc, 207-215. Polit, D. F. & Beck, C. T. 2008. Nursing Research: Genereting and Assesing Evidence for Nursing Practice. 8 ed. Rycroft-Malone, J. 2004. The PARIHS Framework—A Framework for Guiding the Implementation of Evidence-based Practice. J Nurs Care Qual, 19, 297-304. Rycroft-Malone, J. & Bucknall, T. 2011. Analysis and synthesis of models and frameworks. Rycroft-Malone, J. & Bucknall, T. 2013. Evidence Based Nursing : Models and Frameworks for Implementing Evidence-Based Practice Linking Evidence to Action : Linking Evidence to Action (5th Edition),Somerset, NJ, USA, John Wiley & Sons. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B. & Richardson, W. S. 1996. Evidence based medicine: What it is and what it isn't - It's about integrating individual clinical expertise and the best external evidence. British Medical Journal, 312, 71-72. 111

Satterfield, J. M., Spring, B., Brownson, R. C., Mullen, E. J., Newhouse, R. P., Walker, B. B. & Whitlock, E. P. 2009. Toward a Transdisciplinary Model of Evidence-Based Practice. The Milbank Quarterly, 87, 368-390. Schaffer, M. A., Sandau, K. E. & Diedrick, L. 2013. Evidence-based practice models for organizational change: overview and practical applications. J Adv Nurs, 69, 1197-209. Stetler, C. B., Damschroder, L. J., Helfrich, C. D. & Hagedorn, H. J. 2011. A Guide for applying a revised version of the PARIHS framework for implementation. Implement Sci, 6, 99. Stevens, K. R. 2013. The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. OJIN, 18. Temel, A. B. & Ardahan, M. 2011. Hemşirelik Araştırmalarının Kullanımı, Engeller ve Araştırma Kullanımında Değişim Modelleri. HEMAR-G, 13, 63-70. Titler, M., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L., Buckwalter, K., Tripp-Reimer, T. & Goode, C. 2001. The Iowa model of evidence-based practice to promote quality care. . Critical Care Nursing Clinics of North America, 13, 497-509. Van Achterberg, T., Schoonhoven, L. & Grol, R. 2008. Nursing implementation science: how evidence-based nursing requires evidence-based implementation. J Nurs Scholarsh, 40, 302-10. Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J. & Hastings, C. 2010. Implementing evidence-based practice: effectiveness of a structured multifaceted mentorship programme. J Adv Nurs, 66, 2761-71.

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Chapter 12 Use of Technology in Nursing Education İlknur BEKTAŞ, Figen YARDIMCI INTRODUCTION Nursing is an important profession which has important roles in maintaining the health. Nursing offers health care services in line with the needs of an individual and family (Terzioğlu, et al., 2012). Therefore, it is aimed to develop the information, behaviors, and attitudes at the highest level in the nursing education (Göriş, Bilgi, Bayındır, 2014). Combining theoretical knowledge with the application and having competence are very important skills in the nursing education. The use of the technology in the nursing education has become indispensable in order to meet the needs of students who have different learning capacities (Yüksekdağ, 2015; Benner, 2009). The technological support which ensures students to experience risky situations provides a continuous learning process from the studentship to professional life (Işık and Kaya, 2011). Similar to other educational fields, technology is frequently used in the nursing education and it is becoming increasingly common. 1. Computer Technology and Web Support in Nursing Education Computer and internet use is the largest communication network throughout the world. The use of internet is rapidly spreading. Thus, it is easier to access the information day by day with the help of computers and internet access (Kurban, 2015; Kısa and Kaya, 2006). The accessibility and communication services are widely used in various fields particularly in education, health, defense, industry, and the public sector (Işık and Kaya, 2011; Şahan, 2011). Therefore, computer has become an indispensable tool for educational institutions. The integration of the computer and internet access increases the functionality of the computer and it assists the rapid dissemination of the information (Gonen et al., 2016). The use of the technology in education is practical for students as well as academicians. However, it is very important to integrate the technology into the curriculum and determine the goals (Kurban, 2015; Kısa and Kaya, 2006). It is required that academicians should know how the information is transferred when they integrate the technology into their courses. Recent changes in the health care system alter the needs of individuals and health care professionals (Işık and Kaya, 2011). Health care requirements of the society have changed due to natural disasters, wars and chronic diseases and thus health care needs of individuals have increased. Nurses and academicians should closely follow the rapid alterations in health care services in order to give a good quality health care to individuals (Worrell and Profetto, 2007). Nursing was limited to the implementation of the psychomotor skills until recently. However, nursing has become a professional 

Lecturer, Dokuz Eylül University, Faculty of Nursing, İzmir Assist. Prof. Dr., Ege University, Faculty of Nursing. İzmir

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profession which allows to criticize, research, implement evidence-based care, and make decisions in case of critical situations (Dikmen and Usta, 2013). Therefore, nursing education should also support the continuous development of skills such as critical thinking and making good decisions in addition to the nursing basics. When the nursing education is supported by alternative trainings methods, theoretical, laboratory and clinical processes are positively affected. In this regard, computer support is very important in nursing education. Students can repeat the topics by using course materials which are prepared by using computer and internet facilities. Written and visual materials which are prepared by academicians with the help of computer programs facilitate learning abstract concepts (Edeer and Dicle, 2014). It is very important to combine the theoretical knowledge with practice and to have a qualification in nursing profession. Technology is an important part of the nursing education in order to meet the requirements because it eliminates the differences in learning processes (Yüksekdağ, 2015; Benner, 2009). Computer-aided training is one of the most important education methods and strategies (Durmaz,2012). Particularly webbased education supports the learning processes and clinical practice application skills (Şenyuva and Kaya, 2014; Karabağ, 2013). The computer support ensures the continuity of the nursing education via providing an opportunity to access the information in an easy and rapid way (Novotny and Wyatt 2006). In studies, it has been emphasized that web-based nursing education is needed in order to access to information without the limitations of time and space. It has been specified that students also want to interact with academicians during the nursing education. Therefore, students consider that the nursing education is more efficient when the traditional education is also supported by web-based and technology-aided methods (Adams and Timmins, 2006; Koch et al., 2010). Therefore, it has been emphasized that computeraided education is very important but it cannot replace the traditional nursing education held in classes or clinics under the supervision of academicians (Adams and Timmins, 2006; Koch et al., 2010). Students, clinical nurses, and academicians encounter problems during accurate and reliable applications and creating a common language (Akyüz et al., 2007). The increased number of nursing students, less number of academicians, and lack of physical conditions negatively affect the nursing education (Erenel et al., 2008). The insufficient number of nurses in university hospitals prevents the cooperation of students with nurses who are working in clinics. Nurses sometimes perceive the students as a work load (Sabancıoğulları et al., 2012; Karadağ et al., 2013). These problems can be solved by integrating the technology in the nursing education. Even though various technological materials are used in nursing education in Turkey, it is not at the desired level because of the high costs (Atasoy and Sütütemiz; 2014; Karaöz, 2003; Dil et al., 2012; Akyüz et al., 2007). Technological materials that are used in the nursing education are listed below (Durmaz, 2012; Karabağ, 2013). 1. Simulation Technology in Nursing Education Simulation means “mimicking” (TDK, 2016). Simulations are very important in order to increase the experience of students during the nursing education. Simulations are important training materials which provide students an opportunity to learn nursing practices (Göriş et al., 2014). The complexity of the nursing education and various problems in clinical applications increase the importance of simulations in the nursing 114

education. Simulations are classified according to the degree of reality and they help students to better understand the courses (Terzioğlu et al; 2012). Simulations provide a learning environment by minimizing the environmental risks. Equitable learning principles are used in simulation-based trainings and it ensures each student to learn the implementation of nursing practices and applications. In case of simulation-based education, the experiences of students are prioritized, students are encouraged to practice, and their training is also supported by feedbacks (Şendir and Doğan; 2015). In the nursing education, learning tools, which are selected to develop nursing skills of students, should support students to implement the nursing practices. Materials that are used in the nursing education should be attractive, durable, and appropriate to each student (Hacıalioğlu 2011). The clinical environment is very important in nursing education. Clinical training ensures students to transfer their knowledge into a real life and thus they gain the skills such as critical thinking and problem solving (Dikmen and Usta; 2013). Additionally, nursing practice implementation within the scope of patient safety has recently been emphasized and a board can impose sanctions on nurses or students. Risks of erroneous nursing practices can be decreased by simulations which are known as instructive materials (Mıdık and Kartal,2010). Recently, the contribution of simulations in the nursing education has been frequently emphasized in Turkey. Each simulation should have “fidelity” feature which means “realism” or in other words “literalness”. Simulations should mimic all possible clinical situations and they should further provide a learning environment to the student in order to give realistic responses. Simulations that are used in the nursing education should also offer different solutions to different problems. Simulator offers different solutions which can be selected by students when they encounter with an unexpected situation or when the problem is changed. Students can transfer their knowledge into a real life with the help of these characteristics and simulations (Cant and Cooper,2009). Simulation Types Used in Nursing Education; 1. Low-tech simulations are composed of simulated/standardized patients such as • Three-dimensional models of organs • Basic plastic mannequins • Animal models and • Human cadavers (Göriş, Bilgi, Bayındır, 2014). 2. High-tech simulations: • Video-based simulators (or screen-based simulations), • Realistic, high-fidelity procedural simulators, • Realistic high-tech interactive human simulators, • Virtual reality and haptic systems (Göriş, Bilgi, Bayındır, 2014). The use of simulations in the nursing education gives students an opportunity to gain experience in difficult applications (Aebersold and Tschannen; 2013). In this way, the self-confidence of nurses increases and they can improve their clinical decision making skills (Jeffries; 2005). Students can provide health care and make decisions in a safety environment without fear of making mistakes. Furthermore, they can also gain teamwork and management skills (Bucknall, Forbes, Phillips, Hewitt, Cooper and 115

Bogossian, 2016; Kathleen, 2007; Alinier, 2003). Simulations provide feedbacks to students and thus ensure them to better learn the nursing practices (Alinier, 2003). Students can have the opportunity to practice and repeat nursing applications without fear of harming patients (Faulcon, 2015). Students learn nursing skills in clinics but they feel anxiety because of their insufficient experience (Gore, Hunt, Parker, and Raines 2010). This directly affects the clinical performance of students and it negatively affects the learning process. It has been shown in various studies that simulation-based training leads to decrease in anxiety levels of students and they have higher selfconfidence and desire while they were practicing clinical applications with the help of simulation-based training (Horsley and Wambach 2015; Gore et al., 2010). Furthermore, simulation-based training can also be used to evaluate whether or not the goal of nursing education is achieved. CONCLUSION Nurses and students have an intense period of theoretical and clinical training period during their nursing education. It is aimed to train the skilled and sensitive nurses at the end of this period. The dynamic structure of the health system requires to have well educated nurses and the continuous improvement of the nursing education. In this context, the nursing education should give students opportunities to better apply nursing practices. Therefore, the use of the technology should be encouraged in the nursing education. Studies emphasize that a computer technology has important roles in learning processes in the nursing education. Furthermore, nurses have important responsibility for the integration of computer technologies in nursing courses. There are risky implementations in the nursing practices and simulations are instructive materials which decrease these risks in terms of patient and student safety. The computer and simulation-based training approach increases the motivation of the nursing students. In this way, students can find solutions to problems which can arise from the learning differences. Furthermore, psychomotor skills can also be sufficiently repeated. In addition to these advantages, it is required to provide a well structured curriculum in order to integrate the technology in the nursing education. Nursing discipline is not only composed of application skills and it is a profession which aims to convert the theoretical knowledge to behavior and attitude. Therefore, it is very important that students benefit from the knowledge and experience of nurses, ask questions to them, and get feedbacks. It is important to improve the interaction between students and nurses when the technology is integrated into the nursing education. RFERENCES Adams, A., Timmins, F. (2006). Students views of integrating web-based learning technology in to the nursing curriculum – A descriptive survey. Nurse Education in Practice. 6(1): 12–21. Akyüz, A., Tosun, N., Yıldız, D., Kılıç, A. (2007). Klinik öğretimde hemşirelerin, kendi sorumluluklarına ve hemşirelik öğrencilerinin çalışma sistemine ilişkin görüşleri. TSK Koruyucu Hekimlik Bülteni, 6(6), 459-464. Alinier, G. (2003). Nursing students' and lecturers' perspectives of objective structured clinical examination incorporating simulation. Nurse Education Today.23(6), 419-26. Benner, P, Supthen, M., Leonard, V., Day, V. (2009). Educating nurses. A call for radical transformation. Erişim tarihi: 24.08.2015. Bucknall, T. K., Forbes, H., Phillips, N. M., Hewitt, N. A., Cooper, S., &Bogossian, F. 116

(2016). An analysis of nursing students’ decision‐making in teams during simulations of acute patient deterioration. Journal of advanced nursing. Cant, R.P., Cooper, S.J. (2009). Simulation-based learning in nurse education: systematic review. Journal of Advanced Nursing. 66(1): 3-15 Dikmen, Y. D., & Usta, Y.Y. (2013). Hemşirelikte Eleştirel Düşünme. SDU Journal of Health Science Institute/SDÜ Saglik Bilimleri Enstitüsü Dergisi, 4(1), 31-38. Durmaz, A. Hemşirelik Öğrencilerinin Ameliyat Öncesi ve Sonrası Hasta Bakım Yönetimini Öğrenmesinde Bilgisayar Destekli Simülasyon Tekniğinin Etkisi. Dokuz Eylül Üniversitesi Sağlık Bilimleri Enstitüsü, Doktora Tezi, 2012, İzmir . Edeer, A. D., & Dicle, A. (2014). Ameliyat Öncesi ve Sonrası Bakım Yönetiminin Bilgi İşleme Kuramına Dayalı Bilgisayar Destekli Simülasyonda Yapılandırılması. Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi, 7(3). Erenel, A., Ş. Dal, Ü. Kutlutürkan, S., Vural, G. (2008). Hemşirelik Dördüncü Sınıf Öğrencilerinin ve Hemşirelerin İntörnlük Uygulamasına İlişkin Görüşleri. Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Dergisi; 15 (2), 16–25. Faulcon, R. Y. (2015). Innovative Teaching Strategies with Simulation Technology in Nursing Education. VOICES IN EDUCATION, 47. Gonen, A, Lev-Ari, L., Sharon, D., & Amzalag, M. (2016). Situated learning: The feasibility of an experimental learning of information technology for academic nursing students. Cogent Education, 3(1), 1154260. Gore, T., Hunt, C. W., Parker, F., & Raines, K. H. (2011). The effects of simulated clinical experiences on anxiety: Nursing students' perspectives. Clinical simulation in nursing, 7(5), e175-e180. Göriş,S., Bilgi, N., & Bayindir, S. K. (2014). Hemşirelik eğitiminde simülasyon kullanımı. Düzce Üniversitesi Sağlık Bilimleri Enstitüsü Dergisi,1(2), 25-29. Hacialioğlu, N. (2013). Hemşirelikte Öğretim Öğrenme ve Eğitim. Nobel Tıp Kitabevleri, İstanbu Horsley, T. L., & Wambach, K. (2015). Effect of nursing faculty presence on students' anxiety, self-confidence, and clinical performance during a clinical simulation experience. Clinical Simulation in Nursing, 11(1), 4-10. Işik B, Kaya, H. (2011). Bilgi ve İletişim Teknolojilerinin (BİT) Öğretme-Öğrenme Sürecine Entegrasyonunda Hemşire Eğitimcilerin Rolü. Florence Nightingale Hemşirelik Dergisi, 19(3), 203-209. Karabağ, A.A. Web tabanlı Öğretimin Hemşirelik Öğrencilerinin Aritmetik İlaç Dozu Hesaplama Becerilerine Etkisinin İncelenmesi, HAcettepe Üniversitesi Sağlık Bilimleri Enstitüsü Hemşirelik Esasları Programı Doktora Tezi, Ankara, 2013. Karadag, G., Kayaaslan, H., Kılıc, S. P., Ovayolu, N. & Ovayolu, O. (2013) [Difficulties Encountered by Nursing Students in Practices and Their Views about Nurses]. TAF Preventive Medicine Bulletin, 12 (6), 665-672. Turkish. doi:10.5455/pmb.1-1353569323 Kathleen, A. K. (2007). Associate degree nursing students’ perceptions of learning using a high-fidelity human patient simulator. Teaching and Learning in Nursing. 2(2), 46-52. Kisa, B., Kaya, H. Hemşire Öğretim Elemanlarının Teknolojiye İlişkin Tutumları. The Turkish Online Journal of Educational Technology – TOJET. 5(2):77-83 Koch, J., Andrew, S., Salamonson, Y., Everett, B., Davidson, M.P. (2010). Nursing students’ perception of a web-based intervention to support learning.nurse education today.; 30(6): 584–590. Kurban Kuzu, N. (2015). Eğitimde Teknolojinin Entegrasyonu, Hemşirelikte Öğretim ve Eğiticinin Rolü,. Anı Yayıncılık. 73-98. Lıi, A.M. (2016). Simulation-Based Clinical Skill Training to Promote Effective Clinical 117

Learning with Simulation Evaluation Rubrics in Nursing Education. International Journal of Information and Education Technology, 6(3), 237-42. Aebersold, M. & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. OJIN: The Online Journal of Issues in Nursing. 18 (2). Midik, Ö, Kartal, M. (2010). Simülasyona dayalı tıp eğitimi. Marmara Medical Journal. 23(3): 389-99. Novotny, Jm, Wyatt ,Th. (2006). An overwiev of distanceeducationand web-basedcourses. In J. M. Novotnyand R. H. Davis (Eds), Distance Education in Nursing. New York, NY: Springer. (pp. 1-11). Jeffries, P. (2005). A Framework for designing, implementing, and evaluate simulations used as teaching strategies in nursing. Nursing Education Perspectives, pp. 96-103,. Sabancıoğulları, S., Doğan, S., Kelleci, M., & Avcı, D. (2012). Hemşirelik Son Sınıf öğrencilerinin İnternlik Programına İlişkin Görüşlerinin Belirlenmesi [Determining the opinions of final year nursing students on the internship program]. Dokuz Eylül Üniversitesi Hemşirelik Yüksekokulu Elektronik Dergisi, 5 (1), 16-22. Şahan, H.H. (2011). “İnternet Tabanlı Öğretim”. (Ed: Özcan Demirel), Eğitimde Yeni Yönelimler, Ankara: Pegem A Yayıncılık, s. 223-233 Şendir, M, Doğan, P. (2015). Hemşirelik Eğitiminde Simülasyonun Kullanımı: Sistematik İnceleme. Florence Nightingale Hemşirelik Dergisi, 23(1), 49-56. Şenyuva, E., Kaya, H. ( 2014 ). Effect self directed learning readiness of nursingstudents of the web based learning. Procedia – Socialand Behavioral Sciences. 152 (7):386 – 392 Terzioğlu, F., Kapucu, S., Özdemir, L., Boztepe, Ö. G. D. H., Duygulu, Y.D. D. S., Tuna, A.G.D.Z., & Akdemir, N. (2012). Simülasyon yöntemine ilişkin hemşirelik öğrencilerinin görüşleri. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi, 19(1), 016-023. Worrell, J.A.,& Profetto-Mcgrath, J. (2007). Critical thinking as an outcome of contextbased learning among post RN students: A literature review. Nurse education today, 27(5), 420-426. Yüksekdağ, B.B. (2015)Hemşirelik eğitiminde bilgisayar teknolojisinin kullanımı. Açıköğretim Uygulamaları ve Araştırmaları Dergisi; 1 (1):103-118.

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Chapter 13 The Cost of Nursing Compassion Fatigue: A Literature Review Yurdanur DİKMEN, Nasibe Yağmur FİLİZ, Handenur BAŞARAN INTRODUCTION Compassion fatigue is being defined as physical, emotional and mental exhaustion observed in caregivers that causes prevalently decreased motivation, skills and energy for empathy and caregiving for others. Compassion fatigue may put a caregiver in a tired, overwhelmed, helpless and hopeless state regarding their own condition or life (Mc Holm,2006). It is especially pointed out that individuals working with people who have been in agony for a long time, find themselves, unexpectedly in agony as well (Jenkins & Warren, 2012). The nurses experience severe compassion fatigue as a result of being compassionate to their patients trauma, pain and agony as well as emhpasizing and long term exposure to their traumas.. For this reason, compassion fatigue is defined as the cost of nursing as a natural result of caregiving relationships (Şirin & Yurttaş, 2015). Conceptual Framework: Compassion Fatigue The notion of compassion fatigue was described by Nurse Joinson (1992) as the indirect emotional effect of helping people who are experiencing traumatic stress in the first hand (Şirin & Yurttaş, 2015; Joinson, 1992). Later on, researchers have come to the consensus that chronic fatigue, anger, hate towards work and world-weariness were symptoms of compassion fatigue and used these symptoms as determinants (Potter et al., 2010). Compassion fatigue indicates physical, emotional and mental fatigue caused by caregiving to patients in pain and physical stress. this reason, an alternative concept called “compassion fatigue” has been suggested for the state which was previously defined as a secondary traumatic stress disorder. Therefore, this concept of defines the interventions performed by individuals working in the health sector on victims who are experiencing post traumatic stress disorder or the effect of the therapeutic encounter with them (Figley, 2002). Compassion fatigue, is the result of physical, emotional and spiritual of chronic sacrifice and is caused by long term exposure to conditions such as pain of others, compassion and empathy. Therefore, the concept of compassion fatigue describes the emotional, physical and mental fatigue or exhaustion caused by exposure to chronic trauma. Compassion fatigue is consuming the individuals energy, desire, ability to love, nourishment, care and diminishes the sense of empathy for the pain of others (Coetzee & Klopper, 2010). These critical determining specifications have been used to develop a theoretical definition. Factors that cause compassion fatigue and their results are summarized in a concept map (Figure1).

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Assoc. Prof. Dr., Sakarya University, Faculty of Health Sciences, Nursing Department Res. Assist., Sakarya University, Faculty of Health Sciences, Nursing Department.

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Figure 1. Compassion Fatigue Mind Map

Compassion fatigue is seen as a risk in almost half of the professions where an individual is assisting a traumatised person. In other words, this is because compassion fatigue occurs within any caregiving relationship where empathy forms to some other individuals (Sabo, 2011). In the present case, its commonly observed in forensic nurses and those who work in the oncology, pediatrics, intense care clinics, emergency departments and nurses who work at hospice clinics. Nurses give their full attention to their traumatised patients and disregard their own self-care needs when focusing on the need of patients. Therefore, a situation develops where the compassion energy of nurses is being spent on the patients exceeds their own reparation processes and the healing power is unsufficient. At the same time, compassion fatigue is correlated with the caregiver relation between the caregiver and the patient. The formed relation between the caregiver and patient, shared experiences, empathy, stress and a given reaction to stress are the identifying features of compassion fatigue. The psychological response given to the conflicting factors of empathy and pain continuously increases stress, therefore causing compassion fatigue (Figley, 2002). Performed studies show that following conditions are consisting the risk factors of compassion fatigue; choosing the caregiving occupation without any specific reason, transition periods, losses, overwhelming work load, not being appreciated, feeling of insufficiency and being not able to catch up, caregiving to traumatised and pain experiencing children (Potter et al., 2010; Gök, 2015). Symptoms of Compassion Fatigue Compassion fatigue is the result of a progressive and cumulative progress which emerges in the form of compassion stress occurring after long-term, continuous and intensive contact with patients, adding something from oneself and exposure to stress that cannot be relieved for a period of time (Coetzee & Klopper, 2010). The physical, emotional/psychological, social, mental and spiritual symptoms of compassion fatigue 120

are emerging during this process. The most common symptom of compassion fatigue is emotional numbness. According to the results of studies conducted on the subject of compassion fatigue symptoms are often observed in emotional, physical and social spaces (Coetzee & Klopper, 2010; Gök, 2015). The symptoms of compassion present in emotional, physical and social areas are summarised in Figure 2 through the compilation of information present in the literature.

Figure 2: Symptoms of Compassion Fatigue (Gök, 2015; Cootzee & Klopper, 2010)

Each of these symptoms may be used to confirm the existence of compassion fatigue. However, it is pointed out that, in order to be able to say that a nurse has compassion fatigue, more than one symptoms have to be observed. The reason for this is the fact that compassion fatigue is experienced on an individual basis, which makes the structuralisation of these symptoms difficult (Gök, 2015). Effects of Compassion Fatigue and Methods for Coping Nurses experiencing compassion fatigue may be reluctant, angry, and insusceptible against patients during the process. Desensitisation refers to a situation where the patient is seen at a lower status than a human. The possibility of misinterpretation in a desensitised state is increasing significantly for the nurse. The moral and profession values of nurses experiencing compassion fatigue will most often change adversely. Compassion fatigue that is developing with this desensitisation and these changes is considered as an important reason for increasing medical errors, decreasing patient satisfaction and job quitting (Maiden, Georges, Connely, 2011; Romano, Trotta, Rich, 2013). Nowadays it is vital for nurses to keep working with empathy and compassion. However, behaving with empathy and compassion increases the risk of compassion fatigue. Emergency precautions have to be taken in order to not lose nurses who are devoted to their patients. The critical importance to decrease compassion fatigue is to 121

acknowledge that compassion fatigue exists. It is important to create a constructive working area where people may talk and acknowledge the fact that compassion fatigue might happen to anyone. Environments that contain intervention and support are more easily accepted by nurses and helps them seek support and help in a more relaxed fashion. Several interventions for the prevention of compassion fatigue development are given in Table 1. Many of these interventions are applicable in the work environment, however some of the necessitate organisational support (Harris & Quinn Griffin 2015). Table 1: Several Precautions for the Prevention of Compassion Fatigue Preventions  Provide training about contributing factors to compassion fatigue.  Create suitable break times at work to take a rest.  Take turns in care of complex patients.  Provide quiet rooms for staff.  Encourage to keep a private diary.  Find common ways to share difficult experiences.  Provide consulting services.  Provide physically healthy nutritional choices.  Promote social support groups and meetings outside of work. (Harris & Quinn Griffin 2015). Discussing compassion fatigue in occupational meetings will help during the acceptance of this condition and normalize the condition itself. During the daily meetings of their departments, administrators may provide training for couping with compassion fatigue. The personnel may discuss the patient care conditions and intervention methods. Administrators, clinical nurse experts and personnel instructors have to carry out discussions in order to decrease compassion fatigue and develop new planned approaches through the present examples. Accepting the contributions provided by the employees to the patients and the organisation provides energy to individuals and nurse units. The appreciation of the compassionate care of the nurses by the unit leaders will be helping that individual in the fight against the feeling of exhaustion. In addition to this, the nurses may support their gratitude expression, positive thinking and emotional care, deep breathing exercises, physical care, diet and exercise, development of social support systems, occupation supporting interpersonal relationships and prayer, yoga, meditation, spiritual self-care and artistic activities (Şirin & Yurttaş, 2015). The most important factors in the protection against compassion fatigue are primarily; awareness, professional and personal self- care (Hiçdurmaz & İnci, 2015). In this respect, it is important that the physical, mental/emotional, social and spiritual self-fulfillment of the nurses is maintained at an adequate level. Yassen (1995) argued that the prevention of compassion fatigue may be performed at three levels. These are primary (education, awareness workshops and self-care plans), secondary (support groups, through supervision and consultation), tertiary (informing through intervention and individual therapy) protection (Yassen, 1995). Additionally, the mindfulness-based stress reduction program, which is a stress decreasing method that is being utilized in many clinics for the prevention and treatment of compassion fatigues, is used as well. These programs teach individuals how to willingly cope with; stress, pain, disease and the demands of daily life (Cohen, Wiley, Capuano, Baker, Shapiro, 2004). In addition, psycho-educational applications are also interventions used 122

for the treatment of compassion fatigue. Compassion is a natural result of working with individuals experiencing fatigue, trauma or stressful events. For this reason, nurses are an occupational group that experience severe compassion fatigue as a result of being compassionate to their patients trauma, pain and agony as well as emhpasizing and long term exposure to their traumas. In almost every study conducted in the literature regarding this topic, it has been reported that nurses are experiencing moderate levels of compassion fatigue and that one-third of them are in the high risk group of experiencing compassion fatigue. In this context, the literature investigation was carried out in order to increase the awareness regarding the compassion fatigue and its effect experienced by nurses and to point out the definition, effects, and importance of compassion fatigue in nursing. MATERIALS AND METHOD Searching and Choosing the Employees Sample Definition The study was carried out retrospectively by literature survey. For this reason; a survey was conducted in 2016 on CINAHL (the Cumulative Index to Nursing and Allied Health Literature), Ovid, ProQuest and Scopus databases with ULAKBİM Turkish Medical Index and the Turkish Thesis Search Engine with various Turkish and English combinations using the keywords “Compassion fatigue and nursing,” “secondary trauma and nursing,” “secondary traumatic stress and nursing”. Related research that has been published in national and international journals between 20062016 was evaluated. Verbal or poster notices related to this subject which was presented in congresses were not included within the scope of the study. Inclusion Criteria The following criteria were looked for during the selection of the studies to be included in the study; • Being a research paper, • Being a study that evaluated compassion fatigue in nursing, • Having a sample group consistent of nurses and healthcare professionals, • The inclusion of the defined keywords, • Usage of a Turkish or English publishing language, • Publishment in the last ten years (2006-2016), • The presence of the complete text of the study. No limitations were defined regarding the design of the study and studies performed in all patterns have been included. All titles and abstracts of the related papers identified by electronic searches were reviewed independently by researchers. In cases where the title or abstracts of the papers were not sufficiently clear, the complete text of the relevant study was dissected for the determination of compatibility with the inclusion criteria of our study. The exclusion criteria of the studies which were excluded from our study have been recorded as well. The determination process of the dissected studies is given in Table 2. The dissections of the researches were compared afterwards and 5950 sources of the included 6.003 studies were excluded from consideration of the exclusion criteria. The complete texts 53 studies were used as sources for the systematic dissection.

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Table 2. The determination process of the studies included into dissection

Examination of the databases Potentially associated studies = 6.003 study articles Exclusion Criteria; Non included Studies = 5.950 -Absence of the original research article -Inability of reaching the full content -Other publish date than 2006- 2016. Studies compatible with the inclusion criteria=53 Data Analysis In order to summarise the data, a standard data abstraction form was developed and evaluated. Studies independently included by researchers were summarised in accordance with the data summarisation form. Later on, the summaries were compared and a consensus was reached among the researchers. Following articles were present in the summarisation form: Content of the Data Summarisation Form  Author and year of the study,  The country of origin of the study,  Purpose of the study,  Research design,  Size of the samples,  Factors associated with the research,  Findings of the research,  Theoretical framework of research. Limitations of the Research Since a constant danger of insufficiency was present during the literature review and the literature was obtained with only present resources, studies with valid results for this study may have not been included. One part of the dissected studies had insufficient sample sizes, therefore limitations are present regarding the analysis of the data. RESULTS The results of the literature reviewed in this survey are provided under three main topics, these being; the defining properties of the studies, the level of compassion fatigue and factors related to compassion fatigue. 1. The Identifier of the Investigated Research Facilities This study includes 53 papers which have been published between the years 20002016. The publishing year, place of origin, design, design features and purpose of this reviewed paper are presented in Table 1. Only 5 studies about compassion fatigue have been carried out between the years 2000-2005 and 48 studies have been published between 2006-2016. The vast majority of these studies (n: 30, 56%) were published between the years 2006-2010, while the others (n:15, 28%) have been published between 2010-2016. The vast majority of the studies (n:37, 69.9%) were conducted in the United States of America. The investigated studies have of descriptive, experimental and qualitative research patterns. 88.6% of all studies are descriptive studies, whereas 11.3% are experimental and 5.6% are qualitative studies. A total of 8648 participants are present in the surveyed 124

53 studies of different fields, these being; pediatrics (n:10, 18.8%), emergency and trauma (n:10, 18.8%), oncology (n:6, 11.3%), psychiatry (n:7, 13.9%), general services (n:11, 20.7%), hospice (n:3, 5.6%), sexual abuse victims treatment units (n :2, 3.7%), operating room (n :1, 1.8%), intensive care unit (n:2, 3.7%), public health (n:1, 1.8%), nursing (n:1, 1.8%). While the samples of 73.5% of the dissected studies were including nurses, 26.5% of the studies were including healthcare professionals such as nurses as well as physicians, social workers etc. The following data collection tool was the most frequent tool used for the measurement of compassion fatigue levels (52.8%); The Professional Quality of Life Scale (ProQOL), whereas less frequently used tools are; The Compassion Fatigue Self Test (CFST), The Secondary Traumatic Stress Scale (STSS), The traumatic Stress Institute Belief Scale (TSI) The Trauma and attachment Belief Scale (TABS), Pen inventory an Impact Events Scale- Revised (IES-R). 2. The Level of Compassion Fatigue The inspected practices showed that the level of compassion fatigue displays difference depending on the working field o the nurses. It has come to known that compassion fatigue level is higher (50-60%) among nurses working in the psychiatry unit compared to those working in other fields. Long-term care taking healthcare staff working in emergency rooms, trauma units, the oncology department, general clinics and public health, display moderate-low levels of compassion fatigue (Table 3). Table 3. Examined studies compassion fatigue levels by nursing work fields Nursing Department

Pediatric unit

Emergency room

Trauma unit

Level of Compassion Fatigue

From low to high and severe level

Equal to or less than average, moderate, and high risk level

High risk

- Low level (Jackson, 2002) - Moderate-high level (39%) (Robins et al., 2009) - Severe level (20%) (Berger & Gelkopf, 2010) - High level (Meadors, et al., 2009) - Low level (Jill Berger., et al. 2015) - Low level (Rika M.L., et al., 2013) - Equal to or less than average level (Cowgur, 2006) - Were Diagnosed with STS (DominguezGomez & Rutledge, 2009) - Were High Risk (Hopper, 2010) - Moderate level (Reese, 2008) - Low Than Average Level (Stacie Hunsaker., et al., 2014) - High level (Saeed Ariapooran, 2014) -High level STS (Emer Duffy., et al., 2014) - Were High Risk Compassion Fatigue (Nkosi, 2002) - Presented with STS (Von Rueden, et al., 2010) - high risk compassion fatigue (Katherine A. Hinderer., et al., 2014)

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Using Tools CFST (66) CFST ProQOL ProQOL LEC CFST, MMSS TABS STSS ProQOL R-III ProQOL R-IV ProQOL R-V CF, BO, MPSS STSS CFST Penn Inventory ProQOL R-V

Psychiatric unit

Oncology unit

General Clinic

Hospice unit

High level

Low and Moderate Level

Low and Moderate Level

Moderatehigh level

SANE (sexual assault nurse examiner)

Moderate level

Long term facilities Public health clinics

Low level Low level

- Were High Risk (Monroe, 2008) - Low level of STS (Lauvrud et al., 2009) - Were High Level (Newell & MacNei, 2011) - Moderate-High Level (Mangoulia et al., 2010) - High Level of STS (Gad Zerach & Tal Ben-Itzchak Shalev, 2015)

CFST ProQOL R-IV ProQOL -IV ProQOL R-III

- Low level (Rohan, 2005)

PTSD, LEC, MHLC, PTGI, ProQOL-IV ProQOL R-III

- Low level (Qinal et al. 2009)

STSS

- Moderate level (Porter et al., 2010)

ProQOLR -IV

- High level (Patricia Potter., et al. 2013) - Low level (Yoder, 2010) - Moderate level of emotional exhaustion (Smit, 2006) - Moderate level (Burston & Stichler, 2010) - High level of VT (war-related) (LevWiesel et al., 2009) - Low-average level (operating room) (Dogbey, 2008) - Fluctuation level (Tara L., et al., 2015) - High level (Lesly Kelly., et al., 2015). - High level (Patricia Potter., et al. 2010) - High level (Joana Duarte., et al., 2016)

ProQOLR -IV ProQOL R-IV ProQOL ProQOL CFST (40) ProQOL R-III

- Moderate level (Miyuki H Komachi., et al. 2012) - Moderate level (Desley G. Hegney., et al 2014) - High level (Gök, 2015) - High risk (Abendroth & Flannery, 2006)

ProQOL ProQOL V ProQOL V ProQOL V, SCS, EPQ-R, SCI, LES-R-J, SSO ProQOL V, DASS ProQOL , CF, CS, BO ProQOL V ProQOL R-III

- Moderate level (Alkema et al., 2008)

ProQOL R-III

- Moderate level (French, 2006) - Moderate level of STS (Townsend & Campbell, 2009) - Low level of emotional exhaustion (Glidewell, 2000) TSI - Low level (Frank & Karioth, 2006)

ProQOL CFST (66) TSI CFST (30)

2. Variables Affecting the Level of Compassion Fatigue The study survey has determined that personal variables such as younger age, female gender, singleness, previously experienced traumatic experiences, personal stress, excessive empathy, burnout, anxiety and coping strategies are related to compassion fatigue. In addition to this, it has been observed that occupational variables such as receiving continuous training, illegal working hours, excessive workload, 126

workplace insecurity, perceived medication errors, job stress and lack of institutional support are factors which are increasing the level of compassion fatigue. Additionally, health care professionals who; are married, have prior experience with trauma patients, have high job satisfaction, are aware about the concept of compassion fatigue, have sufficient knowledge and skills in nursing, are feeling spiritually good, receive enough peer support and social support from colleagues have been observed to experience lower levels of compassion fatigue. Beside this, the studies have shown that the level of education and experience variables have inconsistent correlations with compassion fatigue. DISCUSSION This literature investigation which was carried out in order to increase the awareness regarding the compassion fatigue and its effect experienced by nurses and to point out the definition, effects, and importance of compassion fatigue in nursing, includes 53 studies which have been published between the years 2000-2016. The majority of these studies (n: 30, 56 %) are seen to be published between the years of 2006-2010 Over half of the studies (n:37, 69.9 %) have been conducted in the United States of America. Only one qualitative study has been carried out in Turkey, the study belonging by Gök (2015) has been conducted on intensive care unit nurses and aims to research the compassion fatigue. This study, is important by reason of being the first study made about the compassion fatigue in nurses at Turkey. According to the result of this study, nurses face often compassion fatigue, it has been reported that in order to deal with this situation, the nurses prefer the strategy of isolating themselves within or outside of the occupational environment, both physically and mentally. Besides this, one of the reasons that no studies have been carried out on this topic is the fact that Turkey is lacking a standard scale for the measurement of the concept of compassion fatigue. The investigated studies have descriptive, experimental and qualitative research patterns. While the samples of 73,5 % of the studies include nurses, 26.5% of the studies include healthcare professionals such as nurses as well as physicians, social workers etc. The Professional Quality of Life Scale (ProQOL) has been used mostly (52.8%) as a data collection tool, other tools have been determined to be used less frequently. In addition to this, the lack of measurement tools for the measurement of compassion fatigue in nurses is emphasised in the literature as well (Dikmen & Aydın, 2016). No specific tool for the measurement of compassion fatigue has been developed in Turkey as of yet. For this reason, it is obvious that standard measurement tools are required in Turkey for the certain and correct measurement and the definition of the concept of compassion fatigue, primarily considered to be the cost of nursing. In this survey study, nurses working at different clinics have shown significantly different levels of compassion fatigue experiences. Compassion fatigue level of the psychiatry unit nurses is higher compared to other clinics (Monroe, 2008; Mangoulia, Fildissis, Koukia, Alevizopoulos & Katostaras, 2010; Zerach & Tal, 2015). Regarding the employees of the Pediatric Clinic; studies consisting all levels, low to high are present in this field (Jackson, 2002; Robins, Meltzer & Zelikovsky, 2009; Meadors, Lamson, Swanson, White & Sira, 2009). Long-term caretaking healthcare staff working in the field of Emergency rooms, trauma units, oncology, general clinics and public health, show moderate to low levels of compassion fatigue (Rohan, 2005; Reese, 2008; 127

Mangoulia, Koukia, Alevizopoulos, Fildissis & Katostaras, 2015; Desley, et al 2014). However, it can be seen that different measuring tools are used in most of the studies. Therefore, if these results are taken into consideration, it is quite difficult to compare the levels of compassion fatigue of the nurses under consideration of their fields of expertise in general, as well as to determine in which field the levels of compassion fatigue are higher. Compassion fatigue is a very different and complex concept (Dikmen & Aydın, 2016). This concept can be affected by extrinsic factors of the patient and nurse as well as intrinsic factors. These differing study results, even if they seem like they have been affected by external factors, can also be caused by intrinsic factors (sample features, individual features, etc.) as wells as the working environment (Table 3). In the reviewed studies, it can be observed that several variables are related with the level of compassion fatigue. Compassion fatigue may differ, depending on the number of patients and the personal circumstances of the nurses (Tara et al., 2015; Sacco, Ciurzynski, Harvey & Ingersoll, 2015). Therefore, these findings are supportive of the idea that compassion fatigue is influenced by individual and occupation factors. Studies carried out by Burtson and Stichler (2010) and Kelly (2015) report that compassion fatigue is primarily affecting young nurses with less experience. Yoders (2010) in the other hand reported that nurses with the lowest experience (less than 10 years) are experiencing more compassion fatigue than moderately experienced nurses (10-19 years). Again, Berger (2015) pointed out in his study that being younger than 40 years old with nursing experience of 6-10 years are compassion increasing factors. These results may be correlated to the increase of skills related finding effective solution strategies for problems and coping with stress more easily. The marital status is an important variable in the surveyed studies. Similar to the results of this literature survey, the studies of Sacco et al. (2015) showed higher levels of compassion fatigue in single nurses. Ariapooran (2014) reported in his study, that nurses receiving sufficient social support from their environment have lower levels of compassion fatigue. This situation may be related to higher familial and social support levels of married nurses. Having a satisfactory family life, communicating with colleagues and friends in order to find solutions can be considered as effective factors for lowering compassion fatigue. Hunsaker (2015) reported in his study that personal and occupational factors such as age, educational level, years of experience are affecting the levels of compassion fatigue. It has been reported in a study carried out by Sacco et al. (2015) on intensive care unit nurses that; the compassion fatigue levels in nurses with a post-graduate education are higher whereas Kim (2013) has reported in his study that a plausible relationship is present between the education level of nurses and the level of compassion fatigue (Kim 2013; Sacco et al., 2015). In the study of Potter et al. (2010), it has been determined that the risk of compassion fatigue is significantly higher in graduate nurses in comparison to associate degree nurses. The individuals with a higher occupational degree have higher idealist expectation which in turn may be indicative of higher risk of compassion fatigue. However, even though the properties of education level and occupational experience are varying among the surveyed studies, (Townsend & Campel, 2009; Porter, 2010; Frank & Karioth, 2006; Lauvrud et al., 2009; Martin 2006; Roney, 2008; French, 2006; Reese, 2008; Meadors et al. 2009) high degree compassion fatigue has been observed in nurses who are; young, undereducated, single and who seem to have more problems in their lives. These results may help during the 128

identification of risk groups and may guide them in this regard. CONCLUSION 53 studies published between the years 2000-2016 have been surveyed in this literature study that are related to the three keywords compassion fatigue in nursing. It has been observed that the vast majority of the studies have been carried out in a defining pattern and that ProQOL was used for the measurement of compassion fatigue. The vast majority of the studies have been conducted in the United States of America. Only one relevant subject study has been observed in Turkey. The inspected practices determined that the level of compassion fatigue shows difference by the working field of nurses. Therefore, these findings are supportive of the idea that compassion fatigue is influenced by individual and occupational factors. Compassion fatigue is seen more in nurses who are; young, undereducated, single and who seem to have more problems in their lives. For this reason, nurses are an occupational group that experience severe compassion fatigue as a result of being compassionate to the trauma, pain and agony of their patients as well as emhpasizing with them and long term exposure to their traumas. This is why nurses need to be supported in order to protect themselves from compassion fatigue and to cope with it. Considering Turkey it is especially required that the subject of compassion fatigue is brought to the agenda, understood, that it receives the necessary interest and that compassion fatigue protection and treatment programs are created. For this reason, extensive studies are necessary in Turkey which lay out the different aspects of the compassion fatigue experienced by nurses. In addition to this, the study of the conditions of nurses experiencing compassion fatigue under considerations of the effects on the quality of care and the development of corporate policies as well as strategies for the effective battle against this condition may be recommended. The results of these studies may be helpful to administrative nurses and instructors for the understanding of the condition in which nurses experience compassion fatigue. Additionally, if the fact that a secure and qualified occupational environment affects the caregiving quality provided to patients by nurses is considered, supporting the nurses against compassion fatigue and training them coping strategies against this condition via on-the-job training will have a positive effect on their occupational life. Table 5. Examined studies related to compassion fatigue Author Glidewell

Year 2000

Jackson

2002

Nkosi

2002

Maytum, Heiman & Garwick

2004

Rohan

2005

Purose To investigate the relationships between burnout and vicarious traumatization. To examine compassion fatigue, compassion satisfaction and burn out. To determine whether a relationship exists between compassion fatigue and coping style. To identify the triggers and coping strategies for compassion fatigue and prevent burnout. To explore the possibility of vicarious traumatization.

129

Sample 160 nurses 32 health care professionals; 50% nurses 2 trauma unit nurses 7 care coordinators, 4 case managers, 7 nurses, 1 manager, 1 practitioner 90 oncology nurses (49.7%), 39 social

Abendroth & Flannery Cowgur

2006

Frank & Karioth

2006

French

2006

Hilliard

2006

Smit

2006

Alkema, Linton & Davies Dogbey

2008

Maiden

2008

Martin

2008

Meadors & Lamson

2008

Monroe

2008

Reese

2008

Rogers, Babgi & Gomez Aycock & Boyle

2008

DominguezGomez & Rutledge Lauvrud, Nonstad & Palmstierna Lev-wiesel, Goldblatt, Eisikovits, & Admi Meadors, Lamson, Swanson, White, & Sira

2006

2008

2009 2009 2009 2009

2009

To assess problematic work-related stress and enhance work-related satisfaction. To describe the influence of caring for trauma victims on the development of vicarious traumatization. To measure the risk for compassion fatigue. To identify the manifestations of compassion fatigue, and to identify factors of compassion fatigue. To evaluate the effects of music therapy on compassion fatigue and team building. To investigate the levels of burnout, compassion fatigue and compassion satisfaction. To assess problematic work-related stress and enhance work-related satisfaction. To explore the relationships among unit culture, work stress, compassion fatigue, and sense of wellbeing. To determine the accuracy of the IVs; moral distress and compassion fatigue in predicting medication scores. An examination of the effects of working with traumatized individuals. To describe the scope of compassion fatigue. To explore the levels of compassion and burn out. To investigate the relationship between spirituality and compassion fatigue, compassion satisfaction, and burn out. To assess knowledge and comfort via an educational intervention. To identify resources available to oncology nurses to manage compassion fatigue. To investigate the prevalence of secondary traumatic syndrome.

workers, 52 physicians 17 nurses in 37 professional hospices 123 emergency unit nurses 117 public health nurses 30 sexual assault nurse examiners 17 nurses, social workers, and chaplains 237 nurses, 75 doctors 17 nurses in 37 professional hospices 138 operating room nurses 205 critical care nurses 37 psychiatric nurses 185 health care providers in critical care units with children, 62.2% nurses 51 psychiatric nurses 89 emergency health care providers (nurses, flight paramedics, chaplains, and physicians) 82 neonatal nurses 101 oncology nurses 67 emergency room nurses

To explore relations between, and occurrence of, job satisfaction, burnout and post traumatic stress symptoms. To assess post-traumatic stress symptoms and vicarious traumatization versus posttraumatic growth.

70 psychiatric nurses

To examine the impact of secondary traumatization.

167 pediatric health care professional (13.8% nurses)

130

76 nurses, 128 social workers

Quinal, Harford & Rutledge, Robins, Meltzer & Zelikovsky

2009

Townsend & Campbell Berger & Gelkopf

2009

2009

2010

To explore the prevalence of secondary traumatic stress. To assess the impact of providing care to patients, compared two comparison groups of professionals. To explore correlates of secondary traumatic stress and burnout. To assess the level of secondary traumatization, and stress and trauma in infants, young children and parents. To examine the relations of compassion satisfaction, nurse job satisfaction, stress, burnout and compassion fatigue.

33 nurses (76.7%) in 42 oncology staff 136 nurses in 314 health care professional settings 110 sexual assault nurse examiners 80 well baby clinic nurses (42 treatment group and 38 control group) 126 nurses (medical, surgical, emergency room, intensive care units 109 nurses; 49 emergency nurses, 32 intensive care unit staff, 16 nephrology unit staff, 12 oncology unit staff 174 psychiatric nurses

Burtson & Stichler

2010

Hopper, Craig, Janvrin, Wetsel & Reimels

2010

To investigate the prevalence of compassion satisfaction, burnout, and compassion fatigue.

Mangoulia, Koukia, Alevizopoulos, Fildissis & Katostaras Potter Deshields, Divanbeigi, Berger, Cipriano & Norris Roney

2010

To investigate the risk of secondary traumatic stress/compassion fatigue and burnout.

2010

To explore the prevalence of burnout and compassion fatigue.

132 nurses and 21 patient care technicians, medical assistants, technologist

2010

93 emergency nurses

Von Rueden, Hinderer, McQuillan, Murray, Logan & Kramer Yoder

2010

To explore the incidence of compassion fatigue and compassion satisfaction. To determine the incidence of secondary traumatic stress.

178 nurses

Patricia Potter

2010

To describe the prevalence of compassion fatigue. To examine the prevalence of burnout and compassion fatigue among oncology healthcare providers.

Newell & MacNeil

2011

Miyuki

2012

Potter

2013

2010

To determine the degree of burnout, compassion fatigue, and compassion satisfaction. To evaluate the prevalence and factors associated with secondary traumatic stress among general hospital nurses. To evaluate a resiliency program designed to educate oncology nurses about

131

262 level 1 trauma center staff

153 healthcare providers included RNs, medical assistants, and radiology technicians 87 mental health professional staff and 78 administrative staff 176 nurses 13 oncology nurses

Rika

2013

Katherine & Hinderer

2014

Hunsaker

2014

Ariapooran

2014

Duffy

2014

Desley, Hegney

2014

Berger., et al.

2015

Tara L., et al.

2015

Kelly., et al.

2015

Zerach & Shalev

2015

Mangoulia., et al.

2015

Gök

2015

compassion fatigue. To investigated whether compassion fatigue mediated associations between nurse stress exposure and job satisfaction, compassion satisfaction, and burnout, controlling for pre-existing stress. To determine the prevalence and severity Compassion Fatigue, Compassion Satisfaction, and Secondary Traumatic Stress in Trauma Nurses. To determine the prevalence of compassion satisfaction, compassion fatigue, and burnout in emergency department nurses throughout the United States and to examine which demographic and workrelated components affect the development of compassion satisfaction, compassion fatigue, and burnout in this nursing specialty. To determine the prevalence of the symptoms of CF and BO and the role of perceived social support in predicting these symptoms in Iranian nurses. To measured emergency department nurses’ self-reported levels of secondary traumatic stress. To explore compassion fatigue and compassion satisfaction with the potential contributing factors of anxiety, depression and stress. To determine the prevalence and severity of compassion fatigue among pediatric nurses and variations in prevalence based on respondent demographics using a crosssectional survey design. To establish the prevalence of compassion satisfaction and compassion fatigue critical care nurses and to describe potential contributing demographic, unit, and organizational characteristics. To examine compassion fatigue and compassion satisfaction in acute care nurses across multiple specialties in hospital-based setting. To examined posttraumatic stress disorder symptoms, secondary traumatization and vicarious posttraumatic growth among Israeli psychiatric nurses who were compared to community nurses. To investigate the prevalence of secondary traumatic stress/compassion fatigue, burnout and compassion satisfaction in psychiatric nurses, and their risk factors. To examine the compassion fatigue on

132

251 Pediatric Nurses

128 trauma nurses

1,000 selected emergency nurses

173 nurses

117 nurses 132 nurses

239 pediatric RNs

221 nurses

491 direct care registered nurses 196 nurses

174 psychiatric nurses

10 intensive care nurses

Yu., et al.

2016

Duarte., et al.

2016

nurses working in intensive care units. To describe and explore the prevalence of 650 oncology nurses predictors of professional quality of life (compassion fatigue, burnout and compassion satisfaction) among Chinese oncology nurses. 280 nurses To explore how empathy and selfcompassion related to professional quality of life (compassion satisfaction, compassion fatigue and burnout). In addition, we wanted to test whether self-compassion may be a protective factor for the impact of empathy on compassion fatigue.

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Chapter 14 Drug Errors and Nurses' Responsibilities for Their Prevention Aylin PALLOŞ INTRODUCTION Medication safety is an important part of patient safety. Safe, effective drug therapy is one of the most important responsibilities of nurses. Not infrequently, a patient’s life will depend on nurses abilility to give drugs accurately and safely. In addition, nurse must keep up with the latest drug information. Despite all the drug information available and a variety of strategies have been developed in an effort to prevent medication errors, medication errors remain one of the greatest threats to patients’ well-being and leading cause of lawsuits against nurses, physicians, and hospitals (Henry, 2014; Kazaoka, Ohtsuka, Ueno & Mori, 2007). DRUG ERRORS: SOURCES, TYPES AND REASONS Medication errors are avoidable events that may happen during the process of prescribing, compounding, dispensing or administering a medication. They can result in a near miss injury or death. These errors can involve the wrong client, medication, dose, time, reason, route or documentation (Vural, 2013; Alcan, Tekin & Civil, 2012) Types of error and factors leading to these errors should primarily be determined and identified so that the necessary measures could be taken against the drug errors. Sources and reasons of drug errors as well as the errors that may show up are given below (Kazaoka et al., 2007; Vural, 2013; Wright, 2009; Wolf, Hicks & Serembus, 2006; Alcan et al., 2012). Table 1: Reasons of error and type of error of drug Manufacturers Reasons of error Type of error  Manufacturing of drugs with similar names  Administering the wrong  Manufacturing of drugs with similar packages drug  Use of various unclear abbreviations (for ex: LA,  Drug overdose XL, XR)  Lack of information by the drug manufacturers about the drugs Table 2: Reasons of error and type of error of healthcare institutions Reasons of error Type of error  Lack of drug administration policies  Errors related to the  Staff shortage storage, distribution,  Lack of adequate equipment for drug administration preparation and  Environment (noise, insufficient lighting, excessive administration of drugs coldness or warmness) 

Lecturer, Uludağ University, School of Health, Nursing Department

     

Failure to calibrate the equipment used Omission of inspections Absence of registration systems Inadequacy of drug distribution systems Deficiencies related to the examination of the patients Imposing penalties on drug errors Table 3: Reasons of error and type of error of physicians

Reasons of error  Physician does not have adequate information about the patient  Fatigue and lack of concentration  Work overload  Lack of knowledge  Failure to prescribe the drug that the disease requires  Failure to select the drug according to the patient  Failure to determine the drug dose according to the patient  Failure to consider the other existing diseases in the selection of the drug  Failure to take drug interactions into consideration  Illegible wording of orders  Unwritten orders  Failure to warn the patient not to continue using the old drugs in drug changes  Use of non-standard abbreviations  Including too many drugs into the order

Type of error  Use of unnecessary drugs  Wrong drug dose  Drug interactions  Wrong drug  Using wrong route of administration

Table 4: Reasons of error and type of error of nurses Reasons of error  Distraction  Increasing workload  Assignment of unrelated works  Inexperience  Shift changes  Temporary personnel  Pharmacies not serving for 24 hours  Emergencies  Lack of knowledge  Erroneous or deficient records  Miscommunication  Stress  Fatigue  Loss of orders  Newness of the drug  Handwriting illegible/unclear  Transcription inaccurate/omitted  Poor drug calculation skills  Procedure/protocol not followed  Monitoring inadequate/lacking

Type of error  Administration of wrong drug  Administration of wrong dose of drug  Use of wrong administration route  Wrong timing of drug administration  Wrong rate of drug administration  Administration of the drug to the wrong patient  Not administering the drug at all  Failure to record the administered drug  Extra dose  Wrong administration technique

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Incorrect medication activation Brand names look alike Brand names sound alike Pump, improper use Computer entry Measuring device Table 5: Reasons of error and type of error of patients

Reasons of error  Elderliness, childhood or mental disability of the individual  Suffering from weariness resulting from chronic disease  Denying the disease  Failure to comprehend the importance of the treatment  Although being not informed adequately about the drug administration, not communicating this situation with the healthcare provider  Not providing information about the herbal drugs used

Type of error  Use of unprescribed drugs  Not using the prescribed drugs  Administering the drug at wrong dose, timing or conditions  Early discontinuation of drugs

MEASURES NEEDED TO BE TAKEN IN TERMS OF NURSES IN DRUG ADMINISTRATION ERRORS A systematic approach to nursing care, the nursing process helps guide to develop, implement and evaluate care and ensure delivering safe, consistent, and effective drug therapy to the patients. The nursing process consist of five steps, including assessment, nursing diagnosis, planning, implementation, and evaluation. Even though documantation is not a step in nursing process, nurses are legally and professionally responsible for documenting all aspects of nursing care before, during, and after drug administration (Henry, 2015). When administering medications, nurses use knowledge, skill, attitude and judgment about the client and medication to assess, plan, administer, evaluate and document the care. Accountability and safe medication practice is supported when the nurse giving a medication carries out all the steps involved including preparing and documenting (www.crnbc.ca). ASSESSMENT The first step in the nursing process, assessment involves gathering information that’s essential to guide patient’s drug therapy. Assessment is an ongoing process that serves as a baseline against which to compare any changes in patient’s condition; it’s also the basis for developing and individualizing patient’s plan of care (Henry, 2015). During diagnosis, nursing records should be received, physical examination should be carried out and data should be collected from laboratory results and other healthcare team members. A comprehensive nursing history concerning drug administration should contain the following information:  Demographic attributes (age, height, weight, education level etc.)  Medical history (kidney and liver diseases, chronic diseases, surgery history, family history)  Allergy history (drug, food allergy etc., allergic reactions, symptoms and findings during allergic reactions, side effects, undesirable effects etc.) 139

 Drug history (constantly used drugs – drug dose, frequency of drug administration, route of administration, since when it has been used, whey it is used, use of prescribed or unprescribed drugs, antioxidants, vitamins, use of drugs recommended by friends, use of herbal supplements, use of herbs etc.)  Nutrition history (dietary habits and frequency, food preferences etc.)  Habits of the individual (daily consumption of caffeinated beverages, use of alcohol and smoking, drug-substance addiction etc.)  Current state of health of the individual (presence of kidney, liver, gastrointestinal system diseases which may affect drug metabolism; pregnancy and lactation period in women; diseases leading to cognitive-sensory-motor functions; diseases contraindicating the use of drug etc.)  Knowledge level of the individual (what is known about the drugs used – why they are used, how and when they are used, side effects, when and how to stop drugs, storage of drugs, training requirements etc.)  Attitude of the individual towards drugs (using drugs voluntarily/involuntarily, compliance/non-compliance with the treatment regimen, abuse of drugs)  Socio-cultural status (religious belief, habits and beliefs about drug administration, lifestyle, using complementary and alternative medicine etc.)  Economic situation (health insurance, income, purchasing power for drugs in case of a long-term treatment) Physical examination made prior to drug administration should include the following information:  Physical examination to be made prior to drug administration is of great importance to determine the ability of the patient to receive the drugs. Assessment is carried out by using the physical examination methods. The following are identified:  Swallowing reflex,  Gastrointestinal motility,  State of the skin,  State of the muscle mass,  Veins.  Vital signs are received. Laboratory findings  Laboratory findings are used in order to monitor serum drug levels, effects and side effects of drugs and to determine the drug doses to be used in the treatment. Thus, laboratory findings are needed prior to drug administration. For instance, if it is known that a drug is harmful to kidney functions, serum creatinin levels should be measured prior to drug administration; blood coagulation tests should be carried out prior to anticoagulant therapy; and serum potassium levels should be measured prior to diuretic treatment.  Also, data are collected from;  medical records of the patient,  other members of the healthcare team,  family of the patient (Akansel, Özdemir & Çıtak, 2003; Abrams, 2001; Aucker &Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor, Lillis & Le Mone, 2001; Ozdemir, Özdemir,Utkualp & Özdemir, 2015; Özdemir, Kocoğlu & Utkualp, 2015a; Çakırcalı, 2000; Herdman & Kmitsuru, 2014; Henry, 2015; Lynn, 2015; Tosun, 2013; Kaya & Palloş, 2013; Özdemir, 2016; Özdemir A., 2016; 140

Palloş, 2016). NURSING DIAGNOSIS Based on information derived from the assessment and physical examination findings, the nursing diagnoses are statements of actual or potential problems that a nurse licensed to treat or manage alone or in collaboration with other membrers of the healthcare team (Abrams, 2001; Aucker & Aucker, 1999; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Herdman & Kmitsuru 2014, Henry, 2015; Lynn, 2015; Tosun, 2013). Common nursing diagnoses related to drug therapy are;  Acute Pain  Disturbed body image  Impaired skin integrity

 Knowledge deficit  Anxiety  Ineffective breating pattern  Fear  Noncompliance (drugs)  Ineffective health management  Impaired swallowing

 Constipation  Diarrhea  Disturbed sleep pattern  Self-concept disturbance  Risk for aspiration  Fluid balance deficit/risk for  Risk for injury  Social isolation  Risk for infection  Ineffective sexuality pattern

Planning In this phase, expected results from the nursing diagnoses determined with respect to the recommended drug administration as well as the most correct and most appropriate interventions to reach these results are planned together with the patient. Aims/expected results with respect to the drug administration:  The individual can use the drugs as recommended,  The individual and his/her family have knowledge about drug administration and they express that they have learned the drug administrations,  The need of the individual for the drugs reduces,  Preventing use of unnecessary drugs,  Preventing the individual from adverse effects of drugs,  The individual can use drugs in an accurate and safe manner,  The individual expresses its concerns about drug administration,  Factors affecting the compliance of the individual to the treatment are determined,  The individual monitors control appointments/follow-ups (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Herdman & Kmitsuru, 2014; Lynn, 2015; Tosun, 2013; Henry, 2015). Implemantation In this phase, individualised care requirements are met and also the continuity of the care is ensured. Patient education including the information and skills aiming at facilitating the adaptation of the patient to the new state is provided During this phase;  Know about the effects, side effects and potential interactions  Follow the eight rights: right client, right medication, right dose, right time, right route, right drug form, right reason, and right documentation. 141

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Educate your client about the drug’s purpose, dosing schedule, expected benefits and possible side-effects, proper storage, any special instructions and written information provided.  Monitor and evaluate client response and reactions to the drugs  Bireyde tedaviye uyumu etkileyen faktörler belirlenir.  Follow agency policy for documenting (Abrams 2001; Akansel et al., 2003; Aucker & Aucker, 1999; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Herdman & Kmitsuru, 2014; Henry, 2015; www.crnbc.ca). Eight Rights  Responsibilities of the nurses for determining and administering the right drugs  Storage of all drugs to be used in the units (including those brought by the patients themselves) in the rooms of the nurses and/or other rooms under the supervision of the nurses.  Drug orders are correctly received and understood (Nurses take orders from physicians. Before carrying out a medication order: determine that the order is clear, complete, current, legible and appropriate, and verify that the order, pharmacy label and/or medication administration record (MAR) are complete. A complete order includes: client name, date prescribed, medication name, dosage, route, dose frequency, quantity to be dispensed (if appropriate), administration time, prescriber signature)  If you believe a medication or dose is inappropriate or could harm a client, consult with a pharmacist, clarify the order with the prescriber and advocate for the client. If you still believe the order is unsafe or inappropriate, inform the prescriber you cannot give the medication. The prescriber may choose to give the medication independently. Make sure the issue is referred to an administrator or appropriate committee for resolution.  Accept verbal/telephone orders only when circumstances require it and there are no other reasonable options. Follow agency policy for accepting and recording these orders (Record the time and date, the order as stated by the prescriber. Read the order back to the prescriber to confirm it is complete and accurate. Record the prescriber’s name and title. Sign your name and title on the order).  Verbal orders should not be accepted for the drugs included in the high risk drugs list,  Learning fundamental information about each drug to be administered (For ex: Indication, contraindication, therapeutic effects, side effects, instructions related to the use),  Benefiting from the authorised persons (pharmacist, physician) and sources of information (drug guides, prospectus etc.) in case that they do not have knowledge about a drug  Preparing and storing drugs in well-lit environments, availability of artificial lighting installation in the places where the drug cabinets stand,  Ensuring that emergency drugs are kept in a separate closet,  The drug label and drug card should be read and checked four times: before taking the drug from the shelf, before pouring the drug into the glass, before 142

putting the drug back and if it is over, before throwing it away,  Changing the label on the drug provided that it is dirty or worn,  The drugs that are brought by the patients, were used at home and will be used in the hospital should be received with the "Patient Drug Reception Form" and placed in the drug cabinet of the patient, (When dispensing, consider the type and amount of medication, your client’s needs. Only dispense medications to clients under your care. You must hand the medication directly to your client or their delegate. Dispense medication in packaging appropriate for your client. The label must be legible and include: client’s name, drug name, dosage, route, directions for use, quantity dispensed, date dispensed, your initials and the agency name, address and telephone number, and any other information appropriate/specific to the medication)  Not using abbreviations in drug names. Preparing lists for the abbreviations that should not be used in drugs and keeping them in view,  Making sure that the correct drug is used since the names of the drugs are similar,  Placing the drugs which have similar wording, pronunciation and packages as well as the different pharmaceutical forms of the same drug at different shelves in the cabinet,  Placing the paediatric drugs separately from the other drugs in the cabinet,  Keeping the List of Drugs with Similar Names and List of Drugs with Similar Packages prepared in order to prevent the misuse of the drugs which have similar wording, pronunciation and packages by the pharmacy executive in sight in the pharmacy, in the departments where the patients are followed up and treated and in the areas where drugs are prepared. Lists should be updated in parallel to the drug circulation and should also be checked at least once a year and revised when needed (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Çakırcalı, 2000; Tosun, 2013; Henry, 2015; Alcan et al., 2012; Lynn, 2015; www.crnbc.ca).  Responsibilities of the nurses in determining and administering the right dose:  Understanding and using the abbreviations and units of measure properly,  Forms of drugs and dosage forms vary depending on the chemical features of the drug, intended purpose and route of administration. While some drugs are administered in a single dose, the others are available in various forms. Nurses should be aware of these variations.  Calculating the drug doses correctly,  Knowing the minimum and maximum administration doses of a drug,  Investigating the differences from previous doses,  Consulting with the physician in cases where the dose is not understood or it is thought that the dose is not suitable for the individual,  Having a good command of the equipment used in drug administration (infusion pump, perfusator etc.), checking the calibration of the equipment,  Confirmation of the IV infusion calculations by two persons in order to make sure that they are correct 143

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Provided that the dose to be administered changes by the weight of the patient (for ex: paediatric, geriatric and cachectic patients), measuring and recording the weight of the patient correctly, and checking it during drug administration, Checking the order of the physician in terms of dose, concentration and rate of the drug while taking the drug from its place, preparing it and administering it, Physician orders for high risk drugs (narcotic drugs, concentrated electrolytes etc.) should be checked and prepared by two persons. Marking the drugs included in the high risk drugs list with red label, Taking the necessary measures for the drugs to be used in paediatric doses (Placing the paediatric dose drugs in separate shelves in the cabinets and listing the doses of the paediatric drugs that can be used in emergency cases by kilogram), Using written and applicable procedures and documents in order to prevent administration of wrong dose of the drug (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Çakırcalı, 2000; Henry, 2015; Alcan et al., 2012; Tosun, 2013; Lynn, 2015).

 Responsibilities of the nurses in administration of drugs at the right time:  Nurses should have knowledge as regards to why drugs should be administered at certain times and in which situations the time of administration may change,  Administering drugs at specified times and not leaving the drug intake to the patient. Providing the patient with training following the discharge (For instance, tetracycline group drugs prevent nutrient absorption. Thus, they should be administered in 1-2 hours following the meals (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Henry, 2015; Alcan et al., 2012; Lynn, 2015; Tosun, 2013).  Responsibilities of the nurses in drug administration through the right route: paying attention to whether the drug is administered through the right route and by using the right technique.  The route ordered for the drug administration (oral, IV, IM, SC, SL, topical, rectal, vaginal etc.), whether this route of administration is appropriate for the drug and whether the individual can receive the drug through the route ordered should be checked.  Nurses should be knowledgeable about the routes and methods of drug administration.  Physician orders should be checked.  Route of administration written on the drug should be checked during preparation and administration.  It should be ensured that the drugs are prepared with materials suitable for the route of administration (for instance, orally administered drugs are prepared with injectors not compatible with the vascular access or into drug

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glasses) (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Çakırcalı, 2000; Henry, 2015; Alcan et al., 2012; Lynn, 2015; Tosun, 2013).  Responsibilities of the nurses in determining the right patient in drug administration:  The identity of the patient should be confirmed appropriately and properly in order to prevent administration of the drug to the wrong patient. Identity confirmation should be made by  asking the patient his/her name,  checking the wrist band of the patient,  checking the name of the patient from the patient records,  In identity confirmation, all of four indicators including namesurname, birth date (day/month/year), protocol number and identity number should be used and room number should never be used in patient identification.  If it is necessary to prepare drugs for more than one patient concurrently, patient identities (name-surname, birth date, protocol number) and drug contents should certainly be written on the drugs prepared.  Use of barcode readers in identity confirmation in order to compare the identities of patients and information on the drugs will be useful in preventing possible errors (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Heath, 1995; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001; Çakırcalı, 2000; Henry, 2015; Alcan et al., 2012; Lynn, 2015; Tosun, 2013).  Responsibilities of the nurses in achieving the right effect in drug administration:  Nurses should know interactions of all drugs used by a patient with one another as well as the nutrients.  Patient should be informed about interactions.  Written documents should be created or electronic systems should be established so that the healthcare providers can easily follow the interactions, and these lists should be updated at specific intervals.  All drugs should be stored in their original packages and at the given conditions (Çakırcalı 2000; Tosun 2013).  Responsibilities of the nurses in keeping right records in drug administration:  Document on the agency record as soon as possible after giving medications. Include client name, drug name, date (and time if appropriate), dose, route, site, signature and title. When a record has room for initials only, sign the accompanying signature sheet (this should be filed with every client’s permanent record).  In some cases (Alzheimer etc.), patients can forget whether they received the drug or the drug can be administered one more time by another healthcare professional due to the lack of the record of drug administration. As a consequence, drug can be administered at a high or low dose. Thus, all drugs administered to a patient should be recorded right after the administration.  When you withhold or omit medications, document why, when and who was 145

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notified. For different reasons, patients may reject drug administration. The fact that the patient did not take the drug and the reason of this situation should certainly be recorded. Document only the medications you give. Do not allow others to document medications for you and do not document medications that anyone else has given (Çakırcalı, 2000; Alcan et al., 2012; Lynn, 2015; Tosun, 2013; www.crnbc.ca) Responsibilities of the nurses in determining the right forms of drugs: One drug can have several forms (capsule, tablet etc.). Nurses should know that the drug has several different forms and should administer the appropriate drug form ordered by the physician to the patient (Henry, 2015; Tosun, 2013).

EVALUATION Whether the aims/expected results identified in the planning phase have been achieved at the end of the nursing care provided in line with the needs of the individual should constantly be evaluated and if necessary, planning should be repeated in accordance with the changing needs. In this phase, the response of the individual to medication and efficiency of the training provided are evaluated (Abrams, 2001; Aucker & Aucker 1999; Kuhn, 1994; Herdman & Kmitsuru, 2014; Henry, 2015). In the phase of evaluation; expected and unexpected results, therapeutic effects, side effects and toxic effects of the drugs on the individual are monitored in relation to the medication administered (Aucker & Aucker, 1999; Lynn, 2015; Henry, 2015). Reasons of failure to achieve desired effects at the end of drug administration may include the following:  Drugs are not used as recommended,  Drugs do not make the desired effects on the individual,  Drugs are not administered to the individual at the appropriate dose,  Lack of knowledge,  Reluctance of the individual to use the drugs (Abrams, 2001; Aucker & Aucker, 1999; Craven, 2000; Kuhn, 1994; Potter & Perry, 2005; Taylor et al., 2001). REFERENCES Abrams, A.C. (2001). Clinical Drug Therapy Rationales for Nursing Practice. 6th Ed., Lippincott Williams&Wilkins Co., Philadelphia. Akansel, N., Özdemir, A. & Çıtak Tunç, G, (2003). Steroid İlaçların Uygulanmasında Hemşirenin Sorumlulukları. Hemşirelik Forumu 6(1), 12-15. Alcan, Z., Tekin, D.E. & Civil, S.Ö. (2012). Hasta Güvenliği Beklenmedik Olaylarda Hemşirenin Rolü. Nobel Tıp Kitabevleri, 1-21s, İstanbul,. Aucker, L.L. & Aucker, R.S. (1999). Pharmacology and The Nursing Process. 2nd Ed., Mosby Inc., United States of America. College of Registered Nurses of British Columbia (2013). Medications. https://www.crnbc .ca/Standards/Lists/StandardResources/3Medications.pdf (15.03.2016). Craven, R.F. & Hirnle, C.J. (2000). Fundamentals of Nursing Human Health and Function. 3rd Ed. Lippincott Co., Philedelphia. Çakırcalı, E. (2000). Hasta Bakımı ve Tedavisinde Temel İlke ve Uygulamalar. 3. baskı, İzmir Güven ve Nobel Tıp Kitabevleri, İzmir. 146

Heath, H.B.M. (1995). Potter and Perry’s Foundation In Nursing Theory and Practice. Mosby-Year Book Inc., Philedelphia. Henry, K. (2015). 2015 Nurse’s Drug Handbook. Jones&Barlett Learning, Fourteenth Edition, United States of America. Herdman, T.H. & Kmitsuru, S, (2014). NANDA International Nursing Diagnoses: Definitions and Classification, 2015-2017. Oxford:Willey Blackwell. Kaya, .N. & Palloş, A. (2013). Parenteral İlaç Uygulamaları. Hemşirelik Esasları Hemşirelik Bilimi ve Sanatı eds: TA Aştı, A Karadağ., Akademi Basın ve Yayıncılık, 767-815s, Kazaoka, T., Ohtsuka, K., Ueno, K. & Mori, M. (2007). Why Nurses Make Medication Errors: A Simulation Study. Nurse Education Today 27, 312–317. Lynn, P. (2015). Taylor Klinik Hemşirelik Becerileri Bir hemşirelik Süreci Yaklaşımı. Çeviri editörü: H. Bektaş, 3.basımdan çeviri, Nobel Akademik Yayıncılık Eğitim ve Danışmanlık Tic.Ltd.Şti, 151-277s, Ankara. Mathewson-Kuhn, M. (1994). Pharmaco-Therapeatics A Nursing Process Approach. 3rd Ed., F.A.Davis Co., Philadelphia. Ozdemir, A., Kocoğlu, G. & Utkualp, N. (2015a). Nutritional Supplement Use In High School Students. Oxidation Communications 38(3), 1296-1304. Özdemir, B., Özdemir, A., Utkualp, N. & Özdemir, L. (2015). Attitudes of Antioxidant Comsuption In University Students. Oxidation Communications 38(4), 1570-1579. Özdemir, A. (2016). Yaşlılık ve Balneoterapi, Uluslararası Tıp Tarihi Kongresi, 28-30 Haziran 2016, Program ve Özet Kitabı, s.67-68, İstanbul. Özdemir, B. (2016). Balneoterapi ve Kan Basıncı, Uluslararası Tıp Tarihi Kongresi, 28-30 Haziran 2016, Program ve Özet Kitabı, s.64, İstanbul. Palloş, A. (2016). Kaplıcaların Tamamlayıcı ve Alternatif Terapiler Arasındaki Yeri, Uluslararası Tıp Tarihi Kongresi, 28-30 Haziran 2016, Program ve Özet Kitabı, s.47-48, Potter, P., Perry A.G. (2005). Fundamentals of Nursing. 6th Ed. Mosby Inc., USA. Süzen, L.B. & Ay, F.A. (2012). İlaç Uygulamaları. Sağlık Uygulamalarında Temel Kavramlar ve Beceriler, ed. FA Ay, 4.baskı, Nobel Tıp Kitabevleri, 418-505, İstanbul. Taylor, C., Lillis, C. & Le Mone, P. (2001). Fundamentals of Nursing The Art & Science of Nursing Care. Lippincott Co., Philedelphia. Tosun, H. (2013). İlaç Yönetimi. Hemşirelik Esasları Hemşirelik Bilimi ve Sanatı eds: TA Aştı, A Karadağ., Akademi Basın ve Yayıncılık, 727-766s, İstanbul. Vural, H. (2013) İlaç Hataları. Hemşirelik Esasları Hemşirelik Bilimi ve Sanatı eds: TA Aştı, A Karadağ., Akademi Basın ve Yayıncılık, 863-879s, İstanbul. Wolf, Z.R., Hicks, R. & Serembus, J.F. (2006). Characteristics of Medication Errors Made by Studentduring the Administration Phase: A Descriptive Study. J Prof Nurs 22, 39–51. Wright, K. (2009). The Assessment and Development of Drug Calculation Skills In Nurse Education – A Critical Debate. Nurse Education Today 29, 544–548.

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Chapter 15 Physiology of Nervous System Derya Deniz KANAN 1. INTRODUCTION Nervous system regulates endocrine system with many inner functions; organizes and activates activities known as human behaviour. These activities involve easily observed bahaviours such as laughing, running, experiences such as feeling of anger, having an opinion or remembering an event in the past and a plenty of them. As nervous system is an advanced complex cluster of cells, some part of it forms communication network as the others are the supporters. Communication network is consisted of many neural circuits. 2. CELLS OF NERVOUS SYSTEM 2.1. Neurons Neurons are the cells that do the main function of nervous system. Their function is to carry information from body to brain, from brain to body and within brain itself by transmitting neural stimulations as electrical signals. Neurons are responsible for receiving, furthering and transmitting neural impulses, starting some specific cellular activities and excreting neurotransmitter and other information molecules. Nerve cells transmit stimulants coming from inside of body and outer environment to central nervous system and transmit responses formed in central nervous system to organs. Nerve cells have different structure from the other cells in the body; they can be in different shape and chemical content according to the places they are in. A nerve cell is consisted of three parts as cell body (soma), dendrits and axone. Cell body, as it is in other cells, is consisted of cytoplasm, nucleus and nucleolous. Many short extensions from cell body as tree braches are called as dendrits. The function of dentrits is to receive stimulants from other neurons and transmit to neuron body. Axon is a cytoplasmic extension that comes from body and does not show any branching. In each neuron there is one axon. As axon that comes from the body is responsible for carrying stimulants from nerve cell to the around, it connects cell nerve to the other cell nerve or muscle cell/cells (effectors) that function as a gland. It has an important role in message transmission. Axons end with many numbers of button-shape formations that involve numerous vesicles called as axon nodes or synaptic nodes. In vesicles there are molecules known as neurotransmitters that mediate in transmission of information carried in neuron as action potential to the other neuron. The axons of some nerve cells are covered with myelin sheath that is formed by glia cells. These neurons are called myelin neurons. Myelin sheath covers around axon with discontinuous formation called as Ranvier nodes. Myelin sheath isolates axon to be affected from stimulants of neighbouring neurons, provides action potential to spread 

Asst. Prof. Dr., Toros University, School of Health Sciences, Department of Nursing and Health Services, [email protected]

rapidly along axon and prevents data loss. In case of damage in myelin sheath, transmission decomposes. In myelin neurons action potential is carried by jumping from one ranvier node to another and this removal is called as saltotori transmission. Nerve cells cover our body like telephone network. Nerves transmit stimulants coming from every part of body to related centres and commands coming from central nervous system to related organs. The nerves that transmit stimulants to the organs of central nervous system are called as afferent nerves. The nerves that transmit commands to muscles and glands are called motor nerves (behaviour oriented nerves). The nerves that make connection between afferent nerves and motor nerves and place in central nerve system are called internerves. Internerve cells evaluate stimulants. In our sensory organs there are “special stimulant receivers” that receive stimulants regarding seeing, hearing, tasting, touching etc. Stimulants like light, sound, hot, sweet, pressure are transmitted to brain by these stimulant receivers in connection with nerve cells. So the brain evaluates these stimulants and transmits necessary commands to related organs. Generally a nerve cell receives datas via cell body and body extensions called dendrit. These datas are transmitted to the other cell via axon according to general condition in the cell and total effect of all received datas. In other words we can think neuron body and body extensions as a small central and axon as a telegram wire that sends data. Later, this data that was sent via axon was sent to one or thousands of nerve cells (or other cells like muscle and glands cells) via the branches of that axon and these cells again with the same mechanism do the function that this stimulant requires. 2.2. Glia Cells In nerve system there are not only nerve cells. Besides them, there are supportive cells that are more than ten times of nerve cells in number and form half of central nerve system as cluster. They are known as glia cells. Although they have various types, they generally help nerve cells and nerve systems to continue their functions. They function as supportive to neurons however they do not form action potential and contribute to transmission. Glial cells of peripherial nerves are Schwann cells. They form myelin cover in peripherial axons and make phagocytosis of wastes when necessary. Glial cells in central nervous system are oligodendrocytes, astrocytes, microglias and ependymal cells (Figure 1). Oligodendrocyte (cell having less extension) cells form axons that range strictly side by side in central nervous system in other words they form myelin cover that isolates electrical cables of nerves from eachother. These covers increase conductivity by providing isolation of nerve wires electrically by surrounding each of them. Microglia is the smallest glia cell.Its function is to protect nervous system against external substances and microorganisms. Microglias do phagocytosis in other words they destroy external substances by eating. Glia cells that are called as Astrocytes (star cell; astroglia) make important contributions to feeding of nerve cells as well as their chemical processes. Ependymal cells join coroid plexus structure that functions in BOS construction. In recent years many studies have been published that glia cells have more important duties in functioning of nervous system as it was thought before. Notably Glia cells have irreplaceable supporting function in production and transformation of messenger molecules as well as in functioning of nervous system. Besides they can 149

cause apparent changes in functions of nerve cells by affecting the surrounding that they make substance exchange. Accarding to some researchers they can even have more important roles than nerve cells in forming of cognition, epyleptic periods and events regarding other large cell clusters.

Figure 1. Glia types (URL 1)

3. TYPES OF NEURON According to their functions neurons are examined in three parts as afferent, inter andmotor. Afferent neuron carries stimulants coming from sensory organs to central nervous system. Inter neurons place in central nervous system, evaluate stimulants and form effect against these stimulants. Motor neuron (Efferent) carries stimulants coming from central nervous system to effector organs. According to their structure neurons are examined in three parts as unipolar, bipolar and multipolar. In Unipolar neuron there is one extension from body. This extension starts with dendrit and ends with axon. In Bipolar neuron there are two opposite extensions from body. One of these extensions is dendrit and the other is axon. In Multipolar neuron there are numerous extensions from body. The short extensions are called dendrit and the long ones are called axon. Although dendrits are numerous, axon is only one. 4. SYNAPSES Nerve cells are in relation with eachother. This close relation provides data flow that forms the basis of neural function. Data pessage points between nerve cells are called synapse. Synapses are special connection regions where an axon of a neuron (presynaptic neuron) makes with soma or dendrits of other neuron (postsynaptic neuron) (Figure 2). Although synapses are in different types and properties, almost all of them are responsible for data transmission. Shortly, nerve cells are main elements that take out brain functions by forming connections among eachother and providing communication with similar ways like electrical circuits. As a matter of course this electrical circuit system has a complexity far beyond that any human can imagine. Neurons make communication via synapses. There are two types of synapse as electrical and chemical. If an impulse passes from one neuron to other neuron with chemical substance it is called “chemical synapse” if it happens with electrical activity 150

it is called “electrical synapse”. Most of synapse transmission takes place with chemical synapses. There is 200-300 angstrom gap between two neurons in synaptic connection regions and this gap is called “synaptic gap”. According to contact regions of synaps to eachother are seperated into three as axodendritic, axoaxonic and axosomatic. When axon makes synaps with its cell and body it is called axosomatic synaps, when it makes synaps with dendrit it is called axodendritic synaps or when it makes synaps with an axon it is called axoaxonic synaps.

Figure 2.Synapses (URL 2)

In chemical synaps that form most of the synaps, neurotransmitters play role in transmission of stimulant. More than forty transmitters were obtained. The most important ones among them are acetylcholine, norepinephrine, histamin, gamaaminobutyric acid (GABA), glycine, serotonin and glutamate. Less number of synapses are electrical synapses that transmit stimulants directly or they are direct canals that transmit electric from one cell to the other. Most of them consist of little protein tubules. These structures which are called Gap junction provide free activation of ions from inside one cell to another. 4.1. Synaptic Transmission The action potential in presynaptic neuron ejaculates to synaptic gap with exocytosis and neurotransmitters in vesicles when it reaches to synaptic nodes. Later, neurotransmitters stimulate (exitation) or do not stimulate (inhibition) postsynaptic neuron by connecting to special receptors on postsynaptic neuron membrane that are special for them. When they are stimulated, action potential is still carried along axon of postsynaptic neuron. If there is inhibition postsynaptic neuron is not stimulated and neural transmission is interrupted at this point. Stimulation or inhibition of postsynaptic neuron depends on neurotransmitters released from presynaptic neuron. A large number of chemical agents that are obtained to perform a duty in synaptic transmission were found and their numbers show increase day by day as a result of numerous experiments. Acetylcholine, norepinephrine (noradrenalin), epinephrine (adrenalin), dopamine, serotonin, GABA, glycine, histamin are the names of important ones. Synapses are named according to the types of neuromediators that make impulse transmission. For example, synaps are called as noradrenergic where norepinephrine is released from presynaptic end and synaps are called as cholinergic synaps where acetylcholine is released. 151

5. NERVOUS SYSTEM Nervous system is an organ system that causes living creatures perceive their inner and outer environment, receives and processes data, provides transmission of signals to different regions in favour of cell network in body and regulates activation of muscles and organs. Nervous system is functionally examined in two parts. The first one is central nervous system that is consisted of brain and spinal cord and the second part is peripheric nervous system that is consisted of carnial nerves, spinal nerves and external ganglions. Peripherical nervous system is consisted of sensory organs, muscles, inner glands and neurons that make inner organs relation with brain and spinal cord. These neurons bring data to central nervous system and bring neural commands to muscles to apply taken decisions. Central nervous system coordinates all behaviours and functions of human body and provides it to function totally. The simplest function of nerve system is to transmit signal from one cell to the other or from one part of body to the other part. Its main function is to control body. For this, it receives data by using sensory receptors, sends it to central nervous system as signal by analysing this data, defines an approximate response by processing data and sends output signals to muscles and glands to activate this response. 5.1. Central Nervous System It is the section that evaluates and decides what kind of responses will form against changes in inner and outer environment. It is consisted of brain and spinal cord. 5.1.1. Brain It is the largest and the most complex part of nervous system. It takes the sensory data from spinal cord and related nerves, processes this data, conducts suitable coordination and beginning for motor output. An approximate adult brain weighs 13001400 gram. The brain is consisted of billions of neurons and trillions of glias. Brain and spinal cord are put under protection with meninx that surrounds them from outer to inner with triple membrane (Figure 3). Dura mater which is the outmost membrane holds on to inner surface of cranium. It is a thick, tough, two layer membrane that sticks to cranium. It connects brain to skull and protects it against external impacts. Between dura mater and arachnoidea mater there is subduralgap. Arachnoidea mater in the middle is made of collagen tissue. Thin collagen tissue connects fibers and two membranes. The part of arachnoidea mater that surrounds brain is called arachnoidea cranialis and it covers gyruses of brain. The part that surrounds medulla spinalis is called arachnoidea spinalis. BOS is in subarachnoidea gap that places between arachnoidea mater and pia mater. The innermost pia mater is the thinnest. It covers brain totally and plays an important role in feding of brain in favour of its small blood vessels. The brain that weighs approximately 2% of body uses about 20% of blood carrying glucose and oxygen. Brain provides its energy from aerobic destruction of glucose. Since there is no glucose storage in brain, its continuity is provided by rich blood vessels. If it is exposed to lack of oxygen or glucose for some reason, its functionality is prevented. In uncontrolled diabetes mellitus since glucose usage is insufficient, it can use its ketone bodies a little bit. In oxygen shortage since brain cannot achieve its energy, there occurs a brain damage or death in long term. Especially during birth if plasenta is pressured and oxygen cannor reach to fetus or lack of oxygen 152

occurs because of another reason such as late birth, serious damages can occur due to lack of oxygen time. Also depending upon aging and if there is embolisation in arteries feding brain due to arteriosclerosis plaques as in chronic hypertension, the condition that is called apoplexy comes out. The brain is examined by being seperated into 3 main parts; cerebrum, cerebral trunk and cerebellum.

Figure 3.The membranes surrounding the brain (URL 3) 5.1.1.1. Cerebrum-Cerebral Cortex Cerebrum is the biggest structure of brain. It seperates into two as right and left hemisphere with longitudinal fissure. Each hemisphere is consisted of a cortex, white matter and basal ganglia. Also each hemisphere is seperated into four lobes as frontal, parietal, temporal and occipital (Figure 4). The outmost layer of cerebrum is called cerebral cortex. Its name came from the word “crust” in Latin. Its thickness is between 2-6 mm. It contains numerous synaps and 50 billion neurons. When inner structure of brain is examined transversally, there is thin gray material in external part, White material in inner part and inside white material some gray substances are observed. Gray regions are consisted of neuron somas whereas white regions are consisted of myelin axons. Gray structure in outer part is cerebral cortex. The gray regions embedded in white material are thalamus, hypothalamus and basal ganglions that have very important functions. The surface of cerebral cortex in human is coated with many intrusions and outcrops. The outcrops in cortex are called gyrus and intrusions are called sulcus. Gyruses and sulcuses provide 1.5-4.5 mm deepness to cortex. The number of gyruses and sulcuses change according to the improvement of living creatures. For example as the number of these intrusions and outcrops are so many in human that is high level mammal, the number of them is low in low level mammals such as mouse, rat etc. Each hemisphere is seperated into four lobs with sulcus centralis and parietooccipital sulcus. Hemispheres connect to eachother at corpus callosum and comissura anterior region. For right and left each hemisphere specific regions of cerebral cortex has special functions. These regions are called cortex regions. The most known ones are; motor, sensory (touching, pressure, pain, hot-cold etc.) seeing, hearing and speaking fields. Visual centre places in occipital cortex whereas hearing regions place in temporal cortex. As touching, pressure, pain, hot-cold, taste and proprioceptive senses (actions of muscle and joints and senses regarding their position in space) place in postcentral gyrus, regions regarding motor activities of skeleton muscles place in precentral gyrus. The sensory region in postcentral gyrus is called somatic sensory region and motor region in precentral gyrus is called primary motor region. 153

Somatic sensory region and primary motor region in a hemisphere are in connection with the opposite side of body. For example as pain sensory of left leg is perceived in somatic sensory region of right hemisphere, spasm command to left leg muscles comes from primary motor region of right hemisphere. That is why bleeding or any kind of damage due to other reasons causeparalysis and sensory loss in opposite part of body. Cerebral cortex is responsible for controlling of volitional acts, directing of senses and regulating of high level mental and emotional functions.

Figure 4. Brain lobes (URL 4) There are many cortex maps that were done according to histological structure and functions (Campell, Brodmann, Von Economo, Vogt). Numeric mapping of Brodmann (1909) which is consisted of 47 fields still protects its validity.According to Brodman cerebral cortex is examined in 3 parts in terms of functionality; (i) Motor fields (ii) Sensory fields (iii) Association (interpretative) fields. Nerve cells, nerve fibres, neuroglia and blood vessels form the histological structure of cortex. There are 5 kinds of nerve cells: Pyramidal cells, Stellate cells, Fusiform cells, Horizontal cells of Cajal, Martinotti cells. The fibres under the cortex that form white matter provide the connections of cortex. These are; projection fibres, association fibres and commissural fibres. Projection fibres are efferent fibres that connect cortex to sub centres of central nervous system. Association fibres are the ones that connect different cortical regions in the same hemisphere to eachother. Commissural fibres on the other hand connect homolog regions that have similar structures and functions. Commissural fibres pass through corpus callosum. The functions of cortex seperate into five when they are examined according to the lobes: Frontal lob, Parietal lob, Temporal lob, Occipital lob, Limbiclob. 5.1.1.1.1. Frontal Lob It places in front of central sulcus. It form sone-third of total area of cortex. It is responsible for cognitive thinking and high cortical functions. It mainly seperates into three regions :(i) Motor cortex, (ii) Prefrontal and orbitofrontal cortex, (iii) Broca’s area. The back side of frontal cortex that is motor cortex and premotor cortex are 154

responsible for motor control. More frontal areas that are named as prefrontal cortex play an important role in behaviour control. Broca’s area is the region where speaking is formulated and brain sends behaviour commands to motor cortex. The damage in Broca’s area causes speech disorder. Prefrontal cortex is one of cortical structures that develop the latest. Its total maturation peaks in adolescence and continues to young adulthood. Prefrontal cortex collects data from all sources (sensory systems, limbic system, subcortical structures), gathers, formulates, applies, controls, make changes and judges. As a result it decides the behaviour. Frontal lob damages cause cognition and memory disorders besides personality changes. 5.1.1.1.1.1. Motor Cortex The region that is related to volitional acts the most is called motor cortex. Motor cortex controls volitional acts; it is the last decision centre regarding behaviours. Different parts of our body are represented in cortex. Right side of our body is reflected in left brain hemisphere whereas left part is reflected in right brain hemisphere. After electrical stimulants it was obtained that there are four seperate motor areas in cerebral cortex: (i) Primary motor cortex (4th area) (ii) Premotor cortex (6th and 8th area) (iii) Secondary motor area (iv) Supplementary motor area. 5.1.1.1.1.1.1. Primary Motor Cortex It is frequently known as motor cortex. It places in precentral gyrus and 30% of corticospinal tractus fibres start in this area. There are seperate somatotopical localisations of body parts in the cortex of this area. This is called “homonculus” and its shape is like overturned human configuration.The head and body are in upper extremity lateral face whereas legs are in medial face. This area is responsible for voluntary motor acts of controlateral body half. Subcortical afferents of 4th area mainly come from ventrolateral nucleus of talamus. The major projection of this area is formed by pyramidal tractus. 5.1.1.1.1.1.2. Premotor Cortex It is the name given to 6th and 8th area in front of primary motor cortex. Subcortical afferents of this area come from ventroanterior nucleus of talamus. Its efferents are on the other hand go to primary motor cortex, brain stem and spinal cord. 30% of corticospinal tractus fibres start in this area.There is frontal seeing area in premotor cortex. In conjugate view it sends fibres to PPRF. 5.1.1.1.1.2. Prefrontal and Orbitofrontal Cortex Talamus has rich afferent and effernt connections with limbic system, hypothalamus and parts in other lobes of cortex. This part of cortex is related with abstract thinking, association, integration of idea and activity, taking decision, foresight, mature thinking, memory, regulation of emotional reactions according to conditions and planning and starting of motor actions as in supplementary motor areas. As a result prefrontal cortex areas are the ones that complex answers in person such as calmness and over joy, sorrow, happiness, friendship and restlessness originate. However autonomic answers in emotional condition (blood pressure, breathing rate and changes in gastrointestinal activities) are provided by the ways projected from prefrontal area to hypothalamus.

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5.1.1.1.1.3. Broca’s Area It places in opercular and triangular part of inferior frontal gyrus. This area is the motor centre of speaking and is active in dominant hemisphere. Its function is to convert voices that are produced by areas of primary motor cortex regarding lip, tongue, palatum, farynx functioning in forming of voices, into language. In lesion of this area not being able to speak or fewness in spoken words come out. The patient can understand words however he cannot speak (motor aphasia, expressive aphasia, anterior aphasia) or decrease in number of words in speaking, grammatical mistakes, difficulty in finding a word or a kind of speaking that is not fluent such as delay, come out (motor dysphasia, expressive dysphasia, anterior dysphasia). “Paracentral Lobule” that places in interhemispheric part of frontal lob is the cortical inhibition centre of micturation and defecation. Anosmia is seen in lesion of orbital parts of frontal lob. 5.1.1.1.2. Temporal Lob Memory, learning, emotional balance and socialising are the properties that come out as a result of functioning of temporal region. Its important functions are emotional response, memory and hearing. In patients having right temporal lob lesions there are frequently loss of sensibility to nonverbal (such as music) audial stimulants. Left temporal lob lesions mostly affect modelling of language, awareness and memory. In medial limbic-emotional parts of temporal lob complex partial seizures are seen in epilepsy oriented patients. These seizures are characterised with unavoidable feelings and autonomous, disorder in cognitive and emotional functions. 5.1.1.1.3. Parietal Lob Parietal lob integrates emotional datas coming from various parts of body. It places behind central sulcus and extends to parietooccipital sulcus. Functioning of emotional modalities coming from talamus at high level are related with integration of neural datas coming from hearing, seeing and somesthetics cortical areas. It has also got motor function. It is seperated into 3 parts as primary somesthetics area, secondary somesthetics area and somesthetics association areas. 5.1.1.1.3.1. Primary somesthetic area Primary somesthetic area (3.1.2 areas) that places in postcentral gyrus takes its afferents from ventral posterior nucleus of talamus. This area is the area where superficial and deep somesthetic senses end. Here as the same in motor cortex there is sensory homonculus. The area that mouth, face and hand (especially thumb and index finger) covers is the largest. The senses of taste and senses belond to intraabdominal structures go to opercular region (43rd area) at the very bottom of postcentral gyrus and parainsular cortex. The fibres that join corticospinal tractus from primary somesthetic are are 40% of tractus and hemiparasis can be seen in anterior parietal lob lesions. Postcentral gyrus causes parestheses such as tingling, hypokinesis, pricking and electrification in controlateral of body during electrical stimulation and frequently causes pain and sense of behaviour. There is no disorder in senses such as pain, heat and touching in postcentral gyrus lesions. Because reaching of these senses to cognition happens at talamus level. In contrast perception of epicritic senses in cortical lesions is corrupted; in other words differences in severity of stimuluses are not recognised, localisation of stimuluses are corrupted, similarities and differences of materials contacting to body cannot be recognized and as a result of this cortical sensory disorders come out in patients. 156

5.1.1.1.4. Occipital lob In occipital lob, there are primary visual cortex (Brodman 17th area) and association areas (Brodman 18th and 19th area). It plays role in perception of visual data. The areas in inferior temporal visual association cortex are important in recognising of faces as well as in recognising of shapes and colours.From occipital lob to superior temporal-parietal area projections are important in perceiving of actions of objects. The lesions in primary visual cortex cause a kind of central blindness that is called Anton syndrome. Although patients do not see objects they are not aware about their blindness. It causes homonym hemianopsia on the opposite side. The seizures due to occipital lob can cause visual hallucinations. These hallucinations are frequently in the form of colourful lines or nets in contralateral visual area. 5.1.1.1.5.Limbic Lob It is a cortex ring around rostral brain stem that is consisted of g. parahypocampi, g. singuli and subcallosal gyrusin medial face of hemisphere. It is old and primitive and consists hypocampal formation and g. dentatus. It adjusts answers to stimuluses that distort or give pleasure to person. Limbic system is a region that provides control of factors that motivate movement and emotional condition regarding especially fear, anger and sexual behaviours. It regulates autonomic functions with hypothalamus. Vital behaviours regarding eating, searching food and protecting himself are among the functions of limbic system. The theory that still protects its importance today about neural substrate of emotions was suggested in 1937 by James Papez. Papez realized that emotional behavioral disorders come out in lesions of many subcortical structures. Papez asserted that emotional stimulants reach firstly to thalamus then are projected to hypothalamus and cortex. The stimulants coming from hypothalamus form physisological symptoms in body regarding behaviour whereas the ones reaching to cortex causes emotions to be felt. Papez showed a serie of connection from hypothalamus to anterior thalamus and singulate cortex. He also thought that emotional answers come out when singulat cortex unites impulses that come from sensorial cortex and hypothalamus. He also stated that cerebral cortex can control emotions as impulses coming from singulate cortex turn back to hypothalamus over hypocampus. This imaginary circuit that connects cortex and subcortical structures is called Papez circuit. 5.1.1.2. Brain Stem Brain stem connects cerebrum to spinal cord. It is a region that data carrying nerve fibres between upper centres and m. spinalis pass. In brain stem there are nucleuses that are seen as dark areas in White matter as a result of gathering of somas of neurons. These nucleuses in brain stem are an exit centre for 10 pair of 12 pair peripherical nerves (cranial nerves). In brain stem area there are respiratory and circuit centres that are very important for life called as vital centres.The reason of sudden deaths in neck fractures is the destruction of these centres. In addition to vital centres the centres of functions such as coughing, sneezing, vomitting, sucking and swallowing are also in brain stem. Also there is a region named reticular formation which is formed by wide neuron groups relating with events such as motor activities of skeleton muscles, sleeping-wakefulness. Diencephalon is consisted of midbrain, pons and medulla. Peripherical nerves go 157

in and out of central nervous system through spinalis and brain stem regions. 5.1.1.2.1. Diencephalon Hypothalamus,Thalamus and structures around 3rd verticles form diencephalon. 5.1.1.2.1.1. Hypothalamus It anatomically places lower part of thalamus and is formed with many numbers of nucleus. It is as big as peas and locates at the ground of brain. Hypothalamus is a centre having very important functions in regulation of inner condition (homeostasis). It is a place where hormone excretions are controlled; emotionla behaviours such as thirst, hunger-fullness, sleeping-awakefulness, body temperature, excitement, fear, anger are regulated. Hypothalamus also controls pituitary gland. It plays role in regulation of emotions, hunger, thirst and circadian rhythm. 5.1.1.2.1.2. Thalamus Thalamus takes emotional data from periphery and transmits to cerebral cortex. Also it transmits the data coming from cerebral cortex to spinal cord and other parts of brain. Its function is emotional and motor integration. Also thalamus has a function of strengthening and weakening stimulants. It provides the control of emotionla system with cerebral cortex. It also functions as a station where all sensory datas carried with afferent neurons except smelling are gathered and sent from here to areas in cortex. It can be said that thalamus is a centre where emotional datas are interpret. 5.1.1.2.2. Midbrain It places above pons, under cerebrum. It is the smallest part of brain stem. Midbrain is responsible for seeing, hearing eye and body movements. It makes important connections between motor system compounds especially between cerebellum, bazal ganglions and brain hemispheres. 5.1.1.2.3. Pons It is an onion shape places in lower part of brain stem. It is between midbrain and medulla oblongata. The cores of V, VI, VII and VIII.Cranial nerves are there. It forms a connection with different levels of central nervous system with descending and rising ways. It takes a role in controlling of breathing rate and depth. Its ventral part transmits datas regarding actions and emotions going from cortex to cerebellum. Its dorsal part on the other hand contains parts regarding breathing, tasting and sleeping. 5.1.1.2.4. Medulla Oblongata It is the part of spinal cord that goes along expanding. The control of autonomic reflexes regarding vegetative system is controlled by settled centres in medulla oblongata. Cohlear cores regarding hearing and many cranial nerves generate from medulla oblongata. 5.1.1.3. Cerebellum The word cerebellum comes from “small brain” in Latin. It places in dorsal of pons and medulla. Its anatomic structure resembles brain.As cerebral cortex cerebellum is seperated into hemispheres and there is cortex that surrounds hemispheres (Figure 5). It takes role in working of skeleton muscles in accordance and coordination with eachother and keeping our balance. As cerebellum achieving these functions, brain stem area is working in the direction of proprioseptive emotional datas coming from internal 158

ear, joints and muscles. In cerebellum patients the conditions such as looseness in muscles, trembling in hands during voluntary actions, dysmetria, speaking as drunk, are seen.

Figure 5.Cerebellum lobes and cores (URL 5). 5.1.2. Medulla Spinalis It places in a bone structure that is formed maany bones named as columna vertebralis. It is a cylindrical form with approximately little finger thickness that is formed by nerve tissue cells and is seperated into 31 sections. 8 of these sections are in neck region (cervical), 12 of them are in back region (dorsal or thoracic), 5 of them are in waist region (lumbar), 5 of them are in tanesi sacral region and 1 of them is in tail end. When inner structure of medulla spinalis is examined transversally, it is seen that there is thin gray material in butterfly shape in middle part and a white material is in outer part. Gray regions are consisted of somas and dendrits of neurons whereas white regions are consisted of myelin axons. Axons in medulla spinalis form nerve ways that are called tractus by extending from downward to upward and upward to downward. There are various tractuses in M. Spinalis and as each tractus starts and ends at the same point, they carry a specific typa of data from centre to periphery and from periphery to the centre. Two apophyses in the back of gray material of M.spinalis are called back horn whereas the ones in the front are called front horn. Back and front horns are in connection with axon bundles that are defined as back and front root. Afferent neurons that carry emotions such as touching, pressure, pain, cold, hot of either inner organs or somatic structures defined as skin, subdermal tissue, joints and skeleton muscles enter to central nervous system from back horn of medulla spinalis. Axons of these neurons form back horn whereas its somas place on bulging region on back root named as ganglion spinale. Its dendrits are single and are in connection with receptors. Motor neurons carrying the commands of centre to effector organ in periphery exit from front horn of m.spinalis and their axons form front root. So it is understood that the fibres that form back root bring various sensory datas and front root fibres bring motor datas to effector organ. Front and back root combines just ahead of m.spinalis and form nervous spinalis that has both sensory and motor property. Nervous spinalisare 31 pairs on both sides and form peripherical nerve system.The ways go up from spinal cord to brain transmit 159

sensory nerve stimulants whereas the ones go down transmit motor stimulants to muscles and glands. The ways going up and down make crosswise in spinal cord or brain. 5.2. Peripherical Nerve System Peripheric part of nerve system is formed with other nerve cells and fibres apart from brain and spinal cord. As gathering of neurons having similar functions in brain is called nucleus, neuron clusters in peripherical nerve system are called ganglion. Peripherical system is the one that brings datas taken from inner and outer environment via receptors to the centre and the commands of centre to the effector organ. Effector organs are muscle and gland cells. Neurons of peripherical system that make connection between receptor and centre are called afferent neurons whereas the ones make connection between centre and effector organ are called efferent neurons. Sensory nerves in peripherical nerve system bring stimulants to spinal cord and brain. The responses form there are carried to tissues, glands and organs by motor nerves. Peripherical nerve system is consisted of 43 pair of nerves. 12 pairs of these nerves are cranial nerves, te rest 31 pair of nerves are nervous spinalis. 5.2.1. Cranial nerves It connects brain with head, various parts of neck and body to eachother. Most of them carries both sensory and motor stimulant. They are totally 12 pairs. Their names are according to their primary functions and distribution of fibres. 5.2.2. Spinal nerves There comes 31 pair of spinal nerve from spinal cord. They provide bidirectional communication between spinal cord with arm, leg, neck and body by carrying both sensory and motor stimulants. They are named according to the levels they exit from vertebra. In terms of function Peripherical system is seperated into two parts assomatic andautonomous. Somaticpart is responsible for responses to outer environment changes whereas autonomous part is responsible for the responses to inner environment changes. 5.2.3. Somatic nerve system It is formed by afferent nerve fibres that send sensory data to central nervous system and efferent nerve fibres that innerve skeleton muscles. Afferent part takes stimulants coming from muscles, joints, tendones and sensory organs whereas efferent part evaluates these stimulants. Cell body is either in brain or in spinal cord and directly contacts with skeleton muscle. Somatic nerve that transmits nerve stimulant to skeleton muscles is callaed motor nerve. Cell stems of motor nerves place in spinal cord. Axon exits from spinal cord and continues as spinal nerve. When nerve reaches skeleton muscle, it seperates into branches and innerves muscle fibres. A motor nerve and the unit that all muscle fibres are innerved by this nerve is known as motor unit. 5.2.4. Autonomous nerve system It controls glands and flat muscles of inner organs. We do not mostly aware of its functioning because it functions involuntarily as reflex. For example we do not even aware of changes in our blood pressure or heart beat. The sensory stimulants are not perceived in autonomous nerve system so many autonomous stimulant cannot be repressed or change. 160

At the same time it receives somatic senses and stimulants coming from special sensory nerves. Autonomous nerve system has two movement nerve. The stem of the first one places in central nerve system, its axon is covered with myelin cover. Generally this extension has connection with an autonomic ganglion so it can go further. The stem of the second one places in ganglion, there is no myelin cover in axon and has connection with its affected organ. It seperates into two as sympathetic and parasympathetic as it goes to the organ. Both of them reaches every organ so it is called dual innervation.The cells that transmit stimulants are usually excreted from post ganglionic fibres. These are in sympathetic nerve system Norepinephrine, in parasympathetic nerve system Asetylcholine. Sympathetic system neurons exits from thoracal and lumbar regions of m.spinalis that is why this sytem is also called thoracolumbar system. Parasympathetic system is called craniosacral because some part of system neurons of parasympathetic system is formed cranial nerves (n.vagus, n.occulomotorius, n.glossopharingius, n.facialis) and the other part is formed by nerves exiting from sacral region of m.spinalis. In inner organs generally these two systems are together and on the same organ they always function oppositely. In other words as one of them increases the activity of organ the other one decreases. For example as sympathetic system increases rate and spasm of heart, parasympathetic system decreases; parasympathetic system increases spasm and excretion of stomach and intestine system whereas sympathetic system decreases. Pupil widens in sympathetic system whereas it tightens in parasympathetic system. Sympathetic system generally functions as a sytem that prevents organism against emergency and as a warning system. When encountered a dangerous or exciting event sympathetic system activation becomes dominate and the person becomes ready to fight against it. In such condition heart rate increases, as veins of skin and digestive system are tightened, veins of skeleton muscles are widen. The reason of this is to pump blood to skeleton muscles better, make them stronger to run away or fight. So, sympathetic system is accepted as energy consumer system. On the other hand parasympathetic system is accepted as energy protective system since it decreases heart rate, spasm and increases the activity of digestive system to make food into energy easily. These two systems make their effects on organs via neurotransmitters excreated from neurons. The neurotransmitters of sympathetic system neurons are noradrenalin (norepinephrine) whereas the ones of parasympathetic system is acetylcholine. Neurons excreating acetylcholine are cholinergic neurons, the ones excreating noradrenalin are called adrenergic. 5.2.4.1. Sympathetic nerve system It is a nerve system that acts parallel with senses. It becomes activated in emotional conditions such as fear, joy and excitement, blood pressure increases, heart beat increases and digestive decreases. Tonic constructor affects on blood veins in SNSextremities. With stimulants such as fear and anger prepares body “fight or run” reaction. Heart beat increases, pupils widen, skin sweats.Blood is directed to skeleton muscles. Sphincters in digestive and urinary systems are closed. Adrenalin (epinephrine) from sympathetic system neurotransmitters increases 161

heart activity and metabolism, as it widens bronchioles; it tightens noradrenalin (norepinephrine) veins and increases blood pressure. 5.2.4.2. Parasympathetic nerve system It generally functions as to balance Psympathetic nerve system. Preganglionic neuron places in nucleuses of brain stem and sacral medulla. It decreases heart, increases saliva and intestine excreations and intestine activities. Autonomous part of peripherical system is responsible for regulation of inner organ activities. Autonomous motor neurons end in flat muscles, heart muscle and glands, activates in relaxing of veins, increasing of intestine activities, regulation of heart spasm and rate. 6. REFLEXES Reflex is the fastest motor response of organşsm to the stimulant. For example when we touch a hot object, we yank away is a reflex response. During formation of reflex, nervous impulses follow an anatomic way that is called reflex arch. In reflex arch there are receptor, afferent neuron, a centre, efferent neuron and an effector organ. In reality reflex arch is the main unit of nerve system in terms of function.As a result of any defect at any point of this arch, the reflex does not occur. Afferent sensory nerves carry stimulants taken from receptor to medulla spinalis through the back roots of medulla spinalis. Efferent motor nerves exit from front horn of medulla spinalis. According to this back roots of medulla spinalis contain sensory, front roots contain motor fibres which is called Bell Magendie law. Reflex centre can be any central nervous system structure starting from m.spinalis to cerebral cortex (except cerebral cortex). For example as a result of patella reflex (hitting on tendone below patella, the sudden movement of leg) the centre is medulla spinalis. In reflex responses of pupil to light the centre is mesencephalon. In neurological examinations, if the structures beyond reflex arch are strong or not, are researched the reflexes which the centre is m.spinalis are simple reflexes. In reflex where complicated responses form, the centre is on the upper parts. The reflexes that are conducted by autonomous nerve system are called visceral reflexes. With visceral reflexes, homeostasis is provided. For example when oxygen decreases in tissues, the deepness and rate of braething are increased as reflex by stimulating breathing centre via receptors sensible to changes to oxygen quantities in blood. Similarly when blood pressure decreases, vein diameters are tightened, heart rate is incresed with the stimulation of vasomotor centre in bulbus and receptors sensible to changes to changes in blood pressure. REFERENCES Barrett, K.E.; Barman, S.M; Boitano, S.; Brooks, H.L. Çevirmen: Hakkı Gökbel (2015). Ganong’un Tıbbi Fizyolojisi, 24. Baskı, 752 sayfa, Nobel Tıp Kitabevi. Boron, W.F.; Boulpaep, E.L. (2012). Medical Physiology. Updated Decond Edition. 3487 pp., Elsevier. Hall, J.E. (2016). Textbook of Medical Physiology. Thirteenth Edition. 1145 pp., Elsevier. Köylü, H. (2014). Tıbbi Fizyoloji Klinik Anlatımlı. 524 sayfa, Nobel Tıp Kitabevi. Marieb, E.N. (1992). Human Anatomy and Physiology. Second Edition. 1104 pp., The Benjamin/Cummings Publishing Company. Preston, R.R.; Wilson, T.E. Çevirmen: Ümmühan İşoğlu-Alkaç, M. Numan Ermutlu, Bayram Yılmaz (2013). Lippincott Fizyoloji. 518 sayfa, Nobel Tıp Kitabevi. 162

Widmaier, E.P.; Raff, H.; Strang, K.T. (2014). Vander’s Human Physiology, The Mechanisms of Body Function. Thirteenth Edition. 707 pp., McGraw-Hill International Edition. URL 1: https://www.dreamstime.com/stock-photo-supporting-cells-neuroglia-glial-cellstypes-classification-microglia-astrocytes-oligodendrocytes-schwann-ependymalimage47597814 URL 2: http://psychpedia.blogspot.com.tr/2015/03/memories-may-not-live-in-neurons.html URL 3: https://www.emaze.com/@AOWZQCOQ/Human-Body-Cells URL 4: http://hardproject.weebly.com/cerebral-cortex.html URL 5: http://what-when-how.com/neuroscience/brainstem-ii-pons-and-cerebellum-part-2/

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Chapter 16 Pediatric Patient Safety Figen YARDIMCI, İlknur BEKTAŞ INTRODUCTION Quality in health care is a global initiative. Dramatic advances in medical technology, pharmaceuticals, genomics, and surgical interventions have enabled health care professionals to save more lives than ever before (Couglin, 2014). Patient safety is a serious global public health issue. Estimates show that in developed countries as many as 1 in 10 patients is harmed while receiving hospital care. of every 100 hospitalized patients at any given time, 7 in developed countries and 10 in developing countries will acquire health care–associated infections. Hundreds of millions of patients are affected worldwide each year (WHO, 2016 a). Industries with a perceived higher risk, such as the aviation and nuclear industries, have a much better safety record than health care does. There is a 1 in 1,000,000 chance of travelers being harmed while in an aircraft. In comparision, there is a 1 in 300 chance of a patient being harmed during health care (WHO, 2016 b). In the state of New York in 1984, about 3.7% of hospital patients experienced an error, two-thirds of which were preventable. The data, published by Dr. Lucian Leape and his colleagues in 1991, initiated discussions about unintended patient harm. Leape would later say, “I recognized that my colleagues and I had uncovered a huge problem, but we had no idea what to do about it.” In 1994, Dr Leape published an article entitled “Error in Medicine” in JAMA, in which he asked, “Can the lessons from cognitive psychology and human factors research that have been successful in accident prevention in aviation and other industries be applied to the practice of medicine?" Leape concluded that errors should be accepted as evidence of systems’ flaws, not character flaws. A Harvard Medical Practice Study revealed that approximately 4% of patients hospitalized had an unintended injury originating from a treatment that resulted in damage after discharge or prolongation of hospitalization (Leape, 1994; Frush & Krug, 2015). Errors generally are defined as intentional behaviors that are not malevolent but that lead to unintentional deviation from expected acts. Errors lower safety limits and increase the probability of accidents and adverse events. From a human factor perspective, it is not possible to have an error-free environment (Terzioglu, 2010). People can make mistakes by doing something wrong, not doing the right thing, or doing the right thing incorrectly or incompetently. James Reason, has author of comprehensive publications about the nature of human error, defined errors as situations in which people cannot obtain an expected result from planned actions (Reason, 2000; Yıldırım, 2012). Patient safety and a secure health service are the most important issues that require 

Assist. Prof. Dr., Ege University, Faculty of Nursing. İzmir Lecturer, Dokuz Eylül University, Faculty of Nursing, İzmir

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improvement in terms of health. These typically are expressed as the entirety of the measures taken by the health services to prevent people from being harmed by the health services. Another definition is to abstain from damaging patients while helping them. The National Patient Safety Agency has defined patient safety as preventing errors related to health services and reducing and relieving patient injury stemming from errors related to health services. Medical error is the unintended, unexpected results arising from a flaw during health service provided to the patient (Alcan, Tekin, Civil, 2012). Medical errors can occur anywhere in the health care system: hospitals, clinics, outpatient surgery centers, doctors’ offices, pharmacies, and patients’ homes. Errors can involve medications, surgery, diagnosis, equipment, and laboratory reports (AHRQ, 2002). The Institute of Medicine identified issues that should be improved in the health system for the 21st century and reported that health systems should be as follows: 1. safety (avoiding harm to patients while helping them), 2. effective (avoiding underuse and misuse of health services by providing services based on scientific knowledge and evidence-based medical practices), 3. patient- centered (treating patients by taking into consideration their preferences, needs, and moral values and ensuring that patients participate in all clinical decision making), 4. timely (accessible when needed and preventing waiting periods harmful to health), 5. efficient (avoiding waste, including waste of equipment and workforce, and providing a cost-effective health service), and 6. equitable (providing care that does not vary in quality because of ethnicity, gender, color, geographic location, and socioeconomic differences). These are true principles for everyone and every country. The most important principle probably is provision of secure service without injuring patients through the care that is intended to help them (IOM, 2001; Sayek, 2011). The concept of “first do no harm” has its origins in ancient medicine, dating back to the Egyptian physicians in 2400 BCE and reaffirmed during the time of Hippocrates circa 400 BCE. This credo of nonmaleficence continues in modern health care as an ethical and moral priority. “First do no harm” for nurses emanates from Florence Nightingale’s early work and her famous publication, Notes on Nursing, articulating the role and duties of the nurse. “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.” Despite the primacy of this ethos, hospitalized people are harmed more often than not during the course of their hospital stay (Couglin, 2014). PEDIATRIC PATIENT SAFETY Providing medical care is extremely complicated. Prevention of disease, diagnosis and treatment of new conditions, and care of patients with chronic diseases occur in an environment having a surprising number of variables. Interaction of pediatric patients with the health care system typically starts when they are in the uterus and continues until they are transferred to adult treatment. Between these two periods, children go to the hospital for various reasons such as well-baby visits, emergency department visits for acute injuries, physical examinations for sport and summer camps, immunization, 165

and care for chronic conditions such as childhood asthma and diabetes (Frush & Krug, 2015). Children and young people have health care needs different from those of adults. Most children receive safe treatment from the National Health Service, but some are exposed to preventable adverse events. (NHS, 2016; NHS, 2009) Pediatric care is complex because of developmental and dependency issues associated with children. How these factors affect the specific processes of care is an area of science about which little is known (Hughes, 2008). Children are more prone to medication errors and the resultant harm because of the following:  Most medications used in the care of children are formulated and packaged primarily for adults. Therefore, medications often must be prepared in different volumes or concentrations within the health care setting before being administered to children.  The need to alter the original medication dosage requires a series of pediatricspecific calculations and tasks, each significantly increasing the possibility of error.  Most health care settings are built primarily around the needs of adults. Many settings lack trained staff oriented to pediatric care; pediatric care protocols and safeguards; or up-to-date and easily accessible pediatric reference materials, especially with regard to medications. Emergency departments may be particularly risk-prone environments for children.  Children—especially young, small, and sick children—are usually less able to tolerate a medication error physiologically because of their still developing renal, immune, and hepatic functions.  Many children, especially very young children, cannot communicate effectively to providers regarding any adverse effects that medications may be causing (Joint Commission, 2008). The most common error in the hospital environment concerns medication administration. A medication administration error is defined as any preventable event that starts with administering a medication to a patient and emerges thereafter, including during observation after administration (Bülbül etal., 2014). Medication administration errors in children, especially dosing errors, are accompanied substantially by mortality and morbidity. Medication errors more frequently occur in children with complex medical problems and newborn babies. Higher rates of medication errors in hospitalized children younger than 2 years are related to medication diversity and differences in age, weight, and diagnoses. Medication errors most frequently occur in newborn babies in relation to rapid changes in body weight and difficulty in proper dosage calculation. In newborn babies, medication errors are reported in the range of 4% to 30%. Medication errors mostly occur in intensive care units and emergency departments and during resuscitation (Cavuşoğlu, 2014). PEDIATRIC PATIENT SAFETY IN THE EMERGENCY DEPARTMENT Emergency care is the provision of immediate medical care needed by a child or his or her family when the child is in an emotionally or physically jeopardized state. Children can be faced with a situation that requires emergency care during any period of their lives. Most of these are acute diseases and life-threatening emergency situations. (Yildiz, 2006) Acute disease involves severe but limited findings requiring 166

medical attention; however, an emergency unexpectedly occurs and is life threatening or can impair the quality of life (Yıldız, 2016; Yeşiloğlu, Ergüven, Karatoprak, Kalaycık, 2010). The growing number of patients who seek emergency department care for nonemergency reasons has led to crowded emergency departments. Overcrowded services endanger patient safety and affect the quality of care provided (Tekşam, 2009, Michelson, Monuteaux, Stack, et al.2012, Cha, Shin, Cho, Singer, Kwak, 2011). Treatment errors are also a significant cause of morbidity in pediatric emergency services (Shaw, Lillis, Ruddy, Mahajan, Lichenstein, Olsen, Chamberlain, 2013) The frequency of dosing errors in hospitalized children was measured to be 17.8%, but there is limited information about pediatric treatment errors in the emergency department (Hoyle, Davis, Putman, Trytko, Fales, 2012). Emergency health services have an important place within all health services. Prevention of improper emergency department use will contribute to patients with actual emergencies who seek care in the emergency department receiving better service, working staff having positive motivation, and unnecessary health expenditures being reduced (Yılmaz etal,2015). The emergency department is a health care unit in which service is provided continuously and equally to patients 24/7. The emergency department must provide rapid, accurate, and continuous service for most of the patients seeking care there, so the emergency department must be different from clinical services provided in other departments in terms of physical structure and workforce (Aşıklıoğlu, Akkuş, Baysal, 2009). Nursing functions performed in the emergency department are similar to nursing functions performed in other clinical areas. However, the duties and practices of nurses in the emergency department are complicated by many factors, such as limited time, emergency situations, patient relatives, the press, security forces, facilities in the emergency department, being obliged to work under managers' and other health care workers' eyes, and being able to obtain only limited patient information (Isır, Dülger, Yıldırım, 2006, Şelimen, Gürkan, 2009). Clinical orientation programs, in-service training, and continuing education programs are essential for emergency department staff professional development. Conducting evidence-based research with a multidisciplinary approach to ensure patients and their families receive quality care in better conditions, and reflecting the research findings in those practices, forms the basis for secure and quality health care in the emergency department (Savaşer, Çağlar, 2012). Suggestions for improvement of pediatric patient safety in the emergency department are as follows: 1. Raising everyone’s awareness of patient safety as the first priority: Providing orientation on patient safety for all employees Setting patient safety as the first agenda topic in medication and nursing unit meetings Providing performance measures of and encouragement concerning patient safety 2. Participating in important security procedures and forming a model: Handwashing Using a structured format in patient transfer Using teamwork training 167

Building simulated patient scenarios and false case codes with which clinical applications can be practiced 3. Conducting Safety Walks: Encouraging hospital and department leaders and people who are responsible to participate actively and regularly Keeping a record of defined risky situations 4. Encouraging the reporting of medical errors, and, to this end, using user-friendly mechanisms and software: Encouraging use of a voluntary reporting system Designing a system ensuring anonymity 5. Encouraging teamwork and providing effective team communication: Providing team resource management training and psychological training Using the SBAR method: S—Situation: What is happening at the present time? B—Background: What are underlying reasons of the patient’s current situation? A—Assessment: What do you think the problem is? R—Recommendation: What action do you propose to overcome the problem? Providing communication training in case of emergency 6. Recognizing fatigue, one of the most important risk factors, and implementing strategies to reduce fatigue in medical staff: Taking long working hours into consideration Attempting to reduce fatigue 7. Developing multidisciplinary, evidence-based clinical practice guidelines for pediatric emergency care: Implementing Assessing Updating 8. Encouraging use of clinical instruments for dosing management 9. Establishing a connection with efforts to increase nursing quality and security in pediatric emergency services and other departments related to children 10. Increasing cooperation among the emergency department and in-hospital or out-of-hospital care providers to increase security and the quality of care provided: Developing pre-hospital, evidence-based care protocols with emergency department staff for the treatment, triage, and transfer of children 11. Defining pediatric emergency care qualifications in all disciplines (physician, nurse, emergency medical technician) and determining basic and repeat education to acquire and maintain these qualifications: Updating resuscitation directives for basic cognitive and technical skills 12. Integrating pediatric care and every environment to provide patient- and family-centered care: Determining required training programs 13. Supporting education for a range of medical errors: Providing education to personnel, parents, and families 14. Supporting suggestions that will ensure special pediatric equipment, medications, and technologies, which are used by emergency care staff to improve patient safety, to be financed by public enterprises and the private sector (AAP, 2007; 168

AAP, 2013). PATIENT SAFETY IN THE NEONATAL INTENSIVE CARE UNIT The neonatal intensive care unit (NICU) involves many complex situations that may cause human error. These are associated with fatigue, a lack of communication, intense workload, and the structure of working team. The NICU is a chaotic environment in which errors take place because for many unexpected reasons. In the face of life-threatening situations, staff in the NICU must make the right decision and perform accordingly in a very short time. Patients in the NICU are usually babies who need complex multidisciplinary care. Every stage of this care involves risky situations and possible medical errors. The NICU affects not only highly sensitive and fragile premature babies but also the staff members who work in the unit. Overcrowded units, poorly designed working places, noise, insufficient lighting and ventilation, and insufficient areas for parents affect the health and security of all patients and staff. Poor lighting and an overcrowded and disorganized work environment generate stress leading to errors for nurses. High-level stress in the NICU produces burnout in nurses and other workers. Job satisfaction, emotional support, and self-care are important components to prevent burnout. Newborn babies experience intense medical treatment in the NICU. Insufficient evidence for pharmacotherapy initiatives and lack of newborn-specific forms increase the risk of medication error (Verklan, Walden, 2014). The incidence of medication errors occurring during the care of preterm infants (24 to 27 weeks’ gestational age) is reported to be as high as 57%, compared with 3% in the care of full-term infants. Medication errors occur 8 times more often in NICU patients than in adult patients. These data demonstrate that NICU patients require additional systemwide safeguards against medication errors, and NICU health care providers must be especially vigilant when working with medications (NANN, 2014). Patients in the NICU are very small and fragile, many with immature organ systems and superimposed serious illness. Such infants are likely to receive complex care, including a large number of medications, or invasive procedures for diagnosis and treatment over an extended hospitalization. Patient safety issues specific to the NICU are as follows: Medication and total parenteral nutrition errors Respiratory care and resuscitation-related and ventilator care–related errors Invasive procedures and health care–associated infections Patient identification errors Diagnostic errors errors (Raju Tonse, Suresh, Higgins, 2011). Patients in the NICU are undergoing maturational changes in drug-sensitive areas such as the renal, gastrointestinal, and hepatic systems, resulting in variable responses to drugs and the disease process. Medications are universally weight based, requiring calculations for each dose, but some of the drugs used also are based on gestational age, making dose calculation even more complex. NICU patients often have long hospital stays, which increases exposure to medications and medication errors. In premature infants, the immaturity of developing body systems affects the absorption, distribution, metabolism, and excretion of drugs, and, therefore, an exponential risk for medication errors is present. NICU patients are nonverbal and unable to participate actively in the patient identification process, which increases the likelihood of wrong-patient errors. Wrong-patient errors are common, with an incidence rate of 25% of reported 169

medication errors. The increased incidence of multiple-gestation births also has contributed to the misidentification of NICU patients. In addition, keeping identification bands in place on small patients can be challenging because of their fragile skin, their small wrist and ankle size, and the need to remove the bands for intravenous line placement (NANN, 2014). PATIENT SAFETY IN THE PEDIATRIC INTENSIVE CARE UNIT Preventable errors are a significant problem for the pediatric intensive care unit (PICU) as well as for all care environments. These errors can occur because of infections, medication errors, diagnosis errors, and complications due to operations (Cifra et al., 2015, Custer et al., 2015). The PICU is a high-risk environment because of the age groups of children, diagnoses, having many advanced types of technological equipment, and the requirements of complex health care (Agraval, 2009; Forni, Chu, Fanikos 2010; Grissinger, 2015). After medication errors, hospital-related infections frequently occur in the PICU. In addition, viral infections and surgical site infections are associated with PICU hospitalization (Fuster Jorge, 2008). Decubitus ulcers, injuries stemming from intravenous catheter infusion, diagnosis errors due to insufficient communication, late diagnoses, and late or incorrect treatment are other causes of errors in the PICU (Reader, Flin, Cuthbertson, 2007; Alvarez, 2006). These patient safety-threatening issues in the PICU may be prevented by redesigning the care system in the PICU. Understanding the necessity of redesigning the system could help improve patient safety in the PICU (Starmer, Sectish, Simon, 2013). With an understanding of the systemic nature of health care, pediatric critical care providers can learn from the safety models used in almost all other industries. First, these industries learn from accidents; both accidents and errors are studied extensively. This information is used to redesign systems to reduce or eliminate the possibility of future adverse events. There are three functions in forming a secure system: 1. Definition of the hazard or risk 2. Analysis of the hazard or risk 3. Mitigation of the hazard or risk In the first stage, health facilities with PICUs should determine hazards before errors occur. Managers and leaders in patient care units and the hospital can be models for risk identification, and the staff members determine specifics such as falling errors and medication errors. The second stage is to analyze real and possible hazards. Results obtained by performing analyses provide definite actions to be taken for secure practices. The third stage comprises implementation of the determined initiatives into the system and using them in subsequent practices. The Occupational Safety and Health Administration publishes a hierarchy for reducing harm to people. The least effective approach is training and education. More effective is the use of administrative controls. Even more effective is the use of barriers to reduce or mitigate hazards and harm. Finally, the thoughtful and purposeful use of design to eliminate hazards is the most effective strategy to avoid drug complications (Wheler, Wong, Shanley, 2014). REFERENCES Agraval, A. (2009). Medication errors: prevention using information technology systems. Br J Clin Pharmacol. 67: (6), 681–686. Alcan, Z.; Tekin, D. E.; Civil, Ö. S. (2012). Hasta Güvenliği Beklenmeyen Olaylarda Hemşirenin Rolü. Nobel Tıp Kitabevi. 233 s., İstanbul. 170

Alvarez, G.; Coiera, E. (2006). Interdisciplinary communication: An uncharted source of medical error? Journal of Critical Care. 21, 236- 242. American Academy of Pediatrics. (2007). Patient Safety in the Pediatric Emergency Care Setting. Pediatrics. 120: (6), 1367-1375. American Academy of Pediatrics. (2013). Joint Policy Statement- Guidelines for care of children in the emergency department. Journal of Emergency Nursing. 39: (2), 116-131. Aşıklıoğlu, N.; Akkuş, T.; Baysal, K. (2009). Çocuk Acil Servisinde Ebeveyn Memnuniyeti ve Etkileyen Etmenlerin Araştırılması, Türkiye Acil Tıp Dergisi. 9: (2), 65-72. Bülbül, A.; Kunt, A.; Selalmaz, M.; Sözeri, Ş.; Uslu, S.; Nuhoğlu. (2014). Çocuk Hemşirelerinin İlaç Uygulamaları ve Hazırlama Bilgi Durumunun Değerlendirilmesi. Türk Ped Arş. 49: 333-9. Cha, W. C.; Shin, S. D.; Cho, J. S.; Singer, A. J.; Kwak, Y. H. (2011). The association between crowding and mortality in admitted pediatric patients from mixed adultpediatric emergency departments in Korea. Pediatr Emerg Care. 27: (12), 1136-41. Cifra, C. L.; Jones, K. L.; Ascenzi, J. A.; Bhalala, U. S.; Bembea, M. M.; Newman-Toker, D. E.; Fackler, J. C.; Miller, M. R. (2015). Diagnostic Errors in a PICU: Insights From the Morbidity and Mortality Conference. Pediatr Crit Care Med. 16: (5), 468-76. Couglin, M. E. (2014). Transformative Nursing in the NICU Trauma-Informed AgeAppropriate Care Springer. 198 pp., Publishing Company. Custer, J. W.; Winters, B. D.; Goode, V.; Robinson, K. A.; Yang, T.; Pronovost, P. J.; Newman-Toker, D. E. (2015). Diagnostic errors in the pediatric and neonatal ICU: a systematic review. Pediatr Crit Care Med. 16: (1), 29-36. Çavuşoğlu, H. (2015). Çocuklarda İlaç Uygulama Hataları. Türkiye Klinikleri. 7: (2), 121-7. Forni, A.; Chu, H. T.; Fanikos, J. (2010). Technology utilization to prevent medication errors. Curr Drug Saf. 5: (1), 13-8. Frush, C. S.; Krug, S. E. (2015). Pediatric Patient Safety and Quality Improvement. 301 pp., Mc Graw Hill Education. Fuster Jorge, P. A.; Fernández Sarabia, J.; Delgado Melian, T.; Doménech Martínez, E.; Sierra López, A. (2008). Quality control of nosocomial infection in PICU. An Pediatr (Barc). 69: (1), 39-45. Grissinger, M. (2015). Medication Errors Involving Overrides of Healthcare Technology. Pa Patient Saf Advis. 12: (4), 141-8. Hoyle, J. D.; Davis, A. T.; Putman, K. K.; Trytko, J. A.; Fales, W. D. (2012). Medication dosing errors in pediatric patients treated by emergency medical services. Prehosp Emerg Care. 16: (1), 59-66. Hughes, R. G. (2008). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. IOM. (2001). Crossing the quality chasm: A new health system for the 21st century, National Academies Press, Washington, DC 2001. Isır, A. B.; Dülger, H. E.; Yıldırım, C. (2006). Acil Hemşiresinin Görevleri ile Hukuksal ve Etik Sorumlulukları. Türkiye Acil Tıp Dergisi. 6: (2), 90-96. Leape, L. L. (1994). Error in Medicine. JAMA. 272: (23), 1851-1857. Michael, A.; Cimino, M. S.; Kirschbaum, M. S.; Brodsky, L.; Shaha, S. H. (2004). Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med. 5: (2), 124-132. Michelson, K. A.; Monuteaux, M. C.; Stack, A. M. (2012). Pediatric emergency department crowding is associated with a lower likelihood of hospital admission. Acad Emerg Med. 19: (7), 816– 820. 171

NANN. (2014). Medication Safety in the Neonatal Intensive Care Unit. NANN Board of Directors Position Statement #3060. Raju Tonse, N. K.; Suresh, G.; Higgins, R. D. (2011). Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities, Pediatr Res. 70: (1), 109–115. Reader, T.W.; Flin, R.; Cuthbertson, B. H. (2007). Communication skills and error in the intensive care unit. Curr Opin Crit Care. 13: (6), 732-6. Reason, J. (2000). Human error: models and management. BMJ. 320: (7237), 768–770. Savaşer, S.; Çağlar, S. (2012). Çocuk Acil Bakım Hemşireliği: Tarihsel Süreç. Karaböcüoğlu, M.; Yılmaz, H. L.; Duman, M. editör. Çocuk Acil Tıp Kapsamlı ve Kolay Yaklaşım. İstanbul Tıp Kitabevi. Sayek, F. (2011). Hasta Güvenliği: Türkiye ve Dünya. Füsun Sayek Ttb Raporları / Kitapları - 2010 Birinci Baskı, Ankara Türk Tabipleri Birliği Yayınları. Shaw, K. N.; Lillis, K. A.; Ruddy, R. M.; Mahajan, P. V.; Lichenstein, R.; Olsen, C. S.; Chamberlain, C. M. (2013). Reported medication events in a paediatrc emergency research network: sharing to improve patient safety. Emerg Med J. 30, 815-819. Starmer, A. J,; Sectish, T. C,; Simon, D. W,; et al. (2013). Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 310: 2262-2270. Şelimen, D.; Gürkan, A. (2009). Historical development and current status of emergency nursing in Turkey. Ulus Travma Acil Cerrahi Derg. 15: (5), 413-415. Tekşam, Ö. (2009). Cocuk Acil Servislerinin Kalabalığına Genel Bakış ve Çözüm Önerisi Olarak Triaj. Hacettepe Tıp Dergisi. 40:125-132. Terzioğlu, M. (2010). Ekip Kaynak Yönetimi. Cinius Yayınları. Birinci Baskı, 407 s., İstanbul. URL: AHRQ. (2002). Patient Fact Sheet 20 Tips to Help Prevent Medical Errors in Children. AHRQ Pub. No. 02-P034. URL: Joint Commission (2008). http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm?print=y es[9/20/2010 11:54:27 AM]. Issue 39: Preventing pediatric medication errors | - Issue 39, Sentinel Event Alert. URL: NHS (2016). http://www.nrls.npsa.nhs.uk/resources/clinical-specialty/paediatrics-andchild-health/ URL: WHO (2016 a). http://www.who.int/features/factfiles/patient_safety/en/# URL: WHO (2016b). http://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index7.html URL: (2009). www.npsa.nhs.uk/nrls. Review of patient safety for children and young people. Van der Starre, C. (2011). Patient Safety in Pediatrics: a Developing Discipline. Erasmus Universiteit Rotterdam. ISBN: 978-94-6169-156-9. Verklan, M. T.; Walden, M. (2014). Core Curriculum for Neonatal intensive care nursingAWHONN. Fifth Edition. 915 pp. Elsevier Saunders. Wheeler, D.S,; Wong, H. R,; Shanley, T. P. (2014). Pediatric Critical Care Medicine. Volume 1. Care of the Critically Ill or Injured Child. Second Edition. Springer-Verlag London. Scanton MC. Patient Safety in PICU. Sf:101. Yeşiloğlu, Z. C.; Ergüven, M.; Karatoprak, E. Y.; Kalaycık, Ö.(2010). Çocuk Acil Servisinde Gözlem Altında Tutulan Hastalarda Akut ve Kronik Hastalıkların Demografik Değerlendirilmesi. Çocuk Dergisi. 10: (4), 171-178. Yıldırım, Ö. (2012). Sağlık Kuruluşlarında İnsan Faktörü Mühendisliğinin Önemi ve Hasta 172

Güvenliği Alanında Uygulama Örnekleri. Beta. Birinci Baskı, 228 s., İstanbul. Yıldız, S. (2006). Acile Başvuran Çocuk ve Aileye Psikososyal Yaklaşım. Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi. 9: (3), 69-77. Yılmaz, A. A.; Köksal, A. O.; Özdemir, O.; Yılmaz, Ş.; Yıldız, D.; Koçak, M.; Hızlı, Ş.; Andıran, N.; Günbey, S. (2015). Bir Eğitim Araştırma Hastanesi Çocuk Acil Kliniğine Başvuran Olguların Değerlendirilmesi Türkiye Çocuk Hast Derg. 1: 18-21.

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Chapter 17 Ergonomics in Delivery Rooms and its Importance Nevin ÇITAK BİLGİN INTRODUCTION The process of birth is one of the most unique life experiences that can be experienced by a woman in a lifetime. The delivery room has an effect on the delivery experience of the woman (Sayıner & Özerdoğan, 2009). In experiencing a positive delivery experience, not only individual related factors but also environmental factors have importance. The ergonomics of the delivery room affects both pregnant women and the health care workers working in this field. Ergonomic arrangements to the delivery room incentivize normal births, reduce interventions towards delivery, and increase the satisfaction of pregnant women with the deliveries (Jenkinson et al., 2013; Sheehy et al., 2011). With regard to health care workers, ergonomic arrangements are important for increasing satisfaction with work, decreasing erroneous medical applications and reducing occupation related health problems (Springer, 2007). ERGONOMICS IN THE HOSPITAL Ergonomics, which is a term that derives from the words “ergos”, which means work in Greek and “nomos”, which means law in Greek, has a meaning of compliance and appropriateness and aims for making the design, work, and life conditions for human use to be on a most appropriate level (Güler, 2004). Ergonomics is a multidisciplinary field and is closely related to physical, organizational and cognitive processes. Those who work at hospital environments and patients are in interaction with many fixed and portable technological devices. Additionally, the physical (noise, lighting, temperature, patient access, and use of tools), cognitive (communication difficulties, workload and stress, human machine interaction etc.) and organizational (human placement appropriate to work, employer and employee training, rotational working, use of protective gear etc.) conditions affect personal and systemic performance (Babayiğit & Kurt, 2013). ERGONOMICS IN DELIVERY ROOMS In delivery units, similar to hospital environments, the present ergonomic conditions affect both workers and service receivers (Sheehy et al., 2011). The increasing dependence to the use of technology in obstetrics and maternal care after the 1950’s and the demand for natural birth and more humanist maternal care have made the reorganization of ergonomic conditions mandatory (Yap, 1996). In a study performed in order to evaluate satisfaction with care during the delivery process, 75.6% of women were found to be not satisfied with intrapartum care (Mohammad et al., 2014). Arrangements made in the birth environment incentivize normal births and decrease interventions towards birth (Sheehy et al., 2011). Today, a very small number 

Assist. Prof. Dr., Abant İzzet Baysal University, Bolu Health School, Nursing Department.

of obstetrics hospitals provide comfort precautions that are effective in reducing the delivery pain of pregnant women and rooms where women can reduce their pain through non pharmacological methods that they choose and can undergo post-delivery processes such as labor (Gedey 2014). The delivery room designs of many hospitals make effective delivery applications harder. Delivery rooms are crowded with regard to not only people but also objects, and most of the delivery rooms have clinic like atmosphere (Hammond et al., 2014). For many women, the birth environment is unfamiliar and a source of fear and anxiety (Nilsson, 2014). However, it has been determined that arranging delivery rooms to be safe, serene and restful and the use of non-pharmacological techniques such as water delivery reduce intervention rates and cause positive birth experiences for women (Jenkinson et al., 2013; Gedey, 2014). Additionally the architectural, equipment related, aesthetic and inner design of the environment has an effect on the stress levels, social interactions and performances of the workers who work there (Hammond et al., 2014). THE ERGONOMIC DESIGN OF THE DELIVERY ROOM AND ITS EFFECT ON PREGNANT WOMEN In the design of the delivery room factors such as the safety of mothers and their babies, privacy, comfort, freedom of movement, possibility of reaching water during the birth process in order to reduce pain and the prevention of the risk of cross infection are important. Alongside this, equipment and services should be present in the room in a manner that is appropriate to the needs of the pregnant woman and without the need of being transported within the room (http://www.nationalarchives.gov.uk/2011; Jenkinson et al., 2013; Gedey, 2014). Generally, issues that should be considered during the ergonomic design of delivery rooms are as follows:  Room size and storage  Placement of the bed  Privacy  Shower and ensuite toilet  Hydrotherapy/the use of water during birth  Window and lighting  Noise  Décor, color, furniture and equipment  Freedom of movement during delivery and position  Odor-aromatherapy  The presence of supporting individuals and communication Room Size and Storage The size of delivery rooms change according to the necessary functional space required for delivery, single, twin deliveries or deliveries that require intervention, and whether there will be a delivery pool in the room. 24 m2space is needed for single births, while 26 m2 space is needed for twin births. In case of requiring a delivery pool in these rooms, an additional 9m2 of space is suggested (URL 1). In a room planned ergonomically for single births, twin births or births which require interventions; activities unrelated to birth such as resting, relaxing and watching TV and pre delivery activities such as delivery ball, chair and mat use should be performable, resuscitation tools that are mobile and mounted on the walls should be present for deliveries where the baby or the mother may need resuscitation, clinical hand washing should be 175

performable and a recuperation space should be available (URL 2). 4m2 space in the room should be reserved for the stabilization and if necessary the resuscitation of the newborn (Gedey, 2014). The storage space can be adjacent or close to the room. The storage space can be used to store items such as a mat, delivery chair, bean bag, foldable bed, portable lamp, small cart, serum hook, adjustable bed and mobile resuscitation tools (URL 3). Placement of the Bed While arranging the delivery environment, keeping the bed in the focal point of the room should be avoided. In a qualitative study performed with 21 Swedish women in order to evaluate their delivery experiences, women were found to feel under scrutiny in the delivery room and this was found to increase their anxiety (Nilsson, 2014). The bed being in the middle of the room causes the woman to feel that she should give birth as soon as possible (Jenkinson et al., 2013). In some delivery rooms designed for deliveries without complications, the bed can be designed to be completely removable or mounted in a wall. The use of pull beds and storage of emergency equipment in reachable closets both provides more space and removes the image of a medical environment (URL 4). In a study performed in order to determine the effects of the physical and aesthetic designs of delivery rooms of the obstetrics clinics of two hospitals in Australia, midwives were found to be affected by issues related to practical order and flexibility instead of the measurements of the room and that beds were seen to be the most important factor disrupting this flexibility. Moving the bed was also stated to cause distance from oxygen and the other exits (Hammond et al., 2014). Privacy In nature, when animals face a threat or are disturbed during delivery, the stress hormone catecholamine is released and stops birth. Similarly, when a woman giving birth doesn’t feel secure or there is an intervention to the normal delivery process, catecholamine levels increase and the delivery stops (Lothian, 2004). The provision of privacy during delivery is important since it prevents the stimulation of the neocortex (Odent, 2013). For this reason, the required importance should be attributed to privacy in delivery rooms, rooms where women can be alone should be provided and wide entrances and inner windows making the interior easily visible from the outside should be avoided. Knocking before entering the room should be standard practice. The doors should not directly open into the delivery room. Even if the door opens as such, obstacles to ensure physical privacy should be placed. Adjacent interiors can create a sense of being watched, so windows should be avoided and exterior windows should let light in while preventing the interior from being watched (Jenkinson et al., 2013; Gedey, 2014). Shower and Ensuite Toilet Wet surfaces should be antislip in all delivery rooms and there should be an ensuite toilet with adjustable lights jointed to the room. There should be a washbasin in the toilets to wash hands and the possibility to take showers (Gedey, 2014; http://www.nationalarchives. gov.uk/ 2011). This section should be big enough to accommodate a supporting person for the pregnant woman when necessary and should be designed in a manner allowing entrance with wheelchairs and other such equipment. There should be grasps on the wall to hold on to in case of need (Gedey, 2014).

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Hydrotherapy / The Use of Water During Birth Warm showering is a cost effective, hygienic, easy to use non pharmacological method of pain relief during delivery (Ratfisch & Güngör, 2009; Lee et al., 2013). An appropriate bath should be available in all delivery rooms. Bath design should provide comfort and reliability for both midwives and pregnant women. In a study, midwives stated that without the necessary bathtub height they need to work crouching and have a more narrow field of vision, and that they experience back pain as a result (Hammond et al., 2014). The bath should be reachable from both sides and should have corner protections. When fixed bath are not available, inflatable pools can be used. When the pregnant woman stands on her hands and feet in it, the bath should be deep enough to cover the perineum with water (Jenkinson et al., 2013). In a review containing 12 studies and 3243 women in Cochraine, it was determined that entering water in the first phase of the process reduces epidural / spinal analgesic use and shortens the first phase of delivery. No difference was found between those who enter water and those who don’t with regard to vaginal births with interventions, c sections, maternal and neonatal infections and admissions into the newborn units (Cluett & Burns, 2012). Windows and Lighting Natural light, since it regulates the natural biorhythm of the body in the first phase of the birth process, seems important. For this reason, all delivery rooms should have at least one window of sufficient size to allow natural light into the room, and allow a natural view to be watched (Jenkinson et al., 2013). Planning the windows to see a natural environment helps the woman feel in a peaceful natural environment (Gedey, 2014) and helps pain management (Ergenoğlu & Aytuğ, 2007). Ideally, the windows should have a rail system and should be operable in different ways. In order to support privacy and control the level of light, curtains or jalousies should be available and interior windows should be avoided (Gedey, 2014; Jenkinson et al., 2013). Lighting and heat should be controllable by the person according to needs (Ergenoğlu & Aytuğ, 2007). Even though the importance of light in health is well known, lighting is mostly ignored in birth environments. Bright artificial lights stimulate the neocortex and cause adrenaline secretion and slows or even stops the birth, dim lights supports the woman in internalizing and feelings of silence and privacy, easing the delivery process (Odent, 2013; Gedey, 2014; Lothian, 2004). Dim lighting also supports melatonin secretion in the body and increases oxytocin secretion (Gedey, 2014). The most easily controlled issue for women regarding the birth environment is the density of light. For this reason, light arrangements that make the woman feel the most comfortable should be supported except emergencies (Jenkinson et al., 2013; Ergenoğlu & Aytuğ, 2007). Appropriate lighting supports the birth environment being perceived as a calming and serene house environment instead of a clinical environment. Bright ceiling lights in the delivery room, although necessary in certain emergencies, should not be the only source of lighting and the level of lights should be controllable, with additional wall lights (Jenkinson et al., 2013). Noise Generally, the current sound levels in hospitals are above those recommended by the World Health Organization (WHO) (Short et al., 2011; Springer, 2007). Continuous high sound levels in the hospital environment affect cognitive processes negatively, 177

increase agitation and the use of pharmacological painkillers, causes sleep disorders, and reduces pain tolerance (Short et al., 2011; Ergenoğlu & Aytuğ, 2007). Additionally, these sound levels stress out the patients, their families, and health care workers, prevent communication, and cause clinical errors (Jenkinson et al., 2013). Providing sound insulation in hospitals may prevent health and communication problems, and is certainly important with regard to providing privacy (Ergenoğlu & Aytuğ, 2007). Making noise during delivery is a normal process and women want to make noise in the delivery room without fear of being heard (Jenkinson et al., 2013). Another factor that prevents background sounds and helps provide a sense of privacy in delivery rooms is the use of music. All delivery rooms should have a music system and the type and volume of the music should be chosen by the woman to give birth (Jenkinson et al., 2013). The use of music in the delivery room reduces the anxiety of the woman and increases confidence, and helps with relaxation and pain management (Mamuk & Davas, 2010). The music being listened to during the prenatal period also being listened to during delivery is stressed to have importance in causing positive effects. In order to help the woman listen to her inner voices and prevent outside voices, the use of headphones while listening to music may help (Jenkinson et al., 2013). However, evidence regarding the use of music during delivery decreasing pain is not sufficient (Başgöl & Beji, 2015). Color- Décor, Furniture and Equipment Colors, visual focus points including artistic works, portable and fixed furniture all affect the ambiance of the delivery room and the mood of the people in it (Hauck et al., 2008). A birth environment without bright lights and noise affects health positively and decreases anxiety (Sheehy et al., 2011). The ambiance in the rooms is a motivator not only for pregnant women but also for midwives (Hammond et al., 2014). Color-Décor Whites and creams in delivery rooms evoke a clinical environment while bright colors shouldn’t be used since they stimulate the neocortex (Jenkinson et al., 2014). The ideal colors for these rooms include deep and non-reflective blues, purples, pinks, greens, browns, yellows and soil colors since they are related to nature and birth (Hauck et al., 2008; Jenkinson et al., 2013). In a study by Hauck et al. (2008), the Snolezen rooms designed for pregnant women were found to contribute to women having positive birth experiences through making the use of complementary treatment combinations possible. Through light games, the presence of aquariums, relaxing music and aromatherapy applications appropriate to the preferences of pregnant women, pregnant women were seen to focus on environmental stimuli instead of delivery pain, relax better, control their environment better (lights, sound etc.) and feel themselves comfortable and secure just like in a home environment (Hauck et al., 2008). Furniture Wooden and similar looking materials are beneficial in order to provide distance from the clinical appearance in general hospital environments and increase connectivity to nature. The surfaces of the materials used in delivery rooms should be smooth and easily washable. Fixed furniture can be used to physically support women during delivery. For example, a delivery chair of appropriate shape and height can support a woman to vertically deliver. This furniture can be light wooden colors to provide a natural appearance (Jenkinson et al., 2013). 178

Equipment It is important for a delivery room to have tools that will support delivery which can be chosen by the woman herself such as a mat, a birth ball, a chair and rope and a birth chair (Gedey, 2014). These types of equipment support more frequent change of position to provide the descent of the fetal head to the birth canal. Birth chairs have been used in delivery for centuries. Chairs are especially beneficial to women who want to deliver crouching. They help overcome the muscle weakness that presents as a result of crouching for long periods (Jenkinson et al., 2013). Freedom of Movement During Delivery and Position Delivering in bed or in a lying position is a modern phenomenon Vertical positions were known to be used in delivery from the middle ages to the middle of the 18t century. In the 19th and early 20th centuries, most of the horizontal lying deliveries were performed in the house, and this was used as the basic delivery position. After the year 1979, 95% of births started to be performed in hospitals in developed countries, and the birth table, which replaced the bed, and women started to deliver in a horizontal lithotomy position (Yap, 2011). Freedom of movement in the delivery process and the use of vertical positions help the fetus to progress through the birth canal, increases oxytocin secretion and helps the delivery to be completed in shorter times (Gedey, 2014). Additionally, it increases benefiting from gravity, fetal well-being and supports the dilation of the pelvic cavity (Yap, 2011). In a review towards the effect of movement and posture during delivery in Cohraine where 22 studies and 7280 women were evaluated, vertical positions were found to decrease the need for assisted vaginal birth and episiotomy needs (Gupta et al., 2012). In another review in Cohraine, the use of vertical positions instead of horizontal or lateral position in labor was found to shorten the first phase of delivery, decrease the need for cesarean sections and epidural, and decrease the intensive care needs of the newborn (Lawrence et al., 2013). For this reason, delivery rooms should be of sufficient size to allow the woman to easily walk around, adapt to different positions, welcome supporting individuals, and preferably store helping tools such as birth balls. The number of fixed materials in the room should be ideally minimum and the maximum use of space is preferred (Gedey, 2014; Hammond et al., 2014). Odor-Aromatherapy Since the smell of hospitals is a source of anxiety for many people, one of the easiest ways of getting rid of the antiseptic odor of hospitals is to ask the woman to bring personal belongings from home such as pillows and sheets. These objects not only form a familiar environment, but also helps the individual carry the odors related to her home, which she feels comfortable with, to the hospital environment (Jenkinson et al., 2013) There is a strong connection between feelings and odor, and aromatherapy is stated to provide relaxation, decrease anxiety, fear, pain perception, nausea, and vomiting, and increase feelings of well-being (Mamuk & Davas, 2010). However, evidence supporting that aromatherapy decreases pain during delivery is insufficient (Başgöl & Beji, 2015; Ratfisch & Güngör, 2009). Communication and the Presence of Supporting Individuals The most important support that can be given to a woman during birth is protecting her privacy, preventing her from being disturbed unnecessarily and support her feelings of confidence that she can deliver (Lothian, 2004).Women being not pleased with 179

delivery affect their emotional well-being and their desire to have another baby. In a study conducted in Sweden with 2541 women to determine negative birth experiences, pain and loss of control as well as insufficient spousal support were found to decrease the satisfaction of women with birth (Waldenström et al., 2004). In another study conducted with women in the seventh week postpartum in Jordan, the participation of unknown and undesired individuals in delivery and the insufficient support of health care professionals for pain management were found to decrease satisfaction (Mohammad et al., 2014). In many studies, a couple participating in delivery preparation training is seen to be important with regard to increasing satisfaction with delivery. Through those trainings, the adaptation of women to giving birth increases and their birth fears decrease (Serçekuş & Mete, 2010; Coşar & Demirci, 2012). In a well-designed delivery room, the consideration of the food, drink and comfortable sitting needs of the individuals supporting the birth and the presence of dry sections in the toilet for use while supporting their spouses are important (Gedey, 2014). THE EFFECT OF THE ERGONOMIC DESIGN OF THE DELIVERY ROOM ON EMPLOYEE HEALTH The ergonomic designs in delivery units affect the health of not only pregnant women but also the employees. The wet and slippery surfaces in these sections, irregular tiling, personnel and shift numbers inappropriate for work requirements, insufficient lighting, noise, the aesthetic design and color selection of the rooms not being considered are among the environmental ergonomic problems frequently encountered by employees (Babayiğit & Kurt, 2013; Hammond et al., 2014; Springer, 2007; Özel, 2005). In studies performed in birth units, it was found that those who work continuously at night, shifted or a combination of those had lower job satisfaction compared to those who work during the day (Aksungur, 2009 ) and that an insufficient number of health care workers and excessive work load increase the risk of erroneous medical applications (Öztunç, 2012). Those who work in the delivery room are affected by issues related to practical order and flexibility instead of the measurements of the room. Beds in delivery rooms are the biggest factor disrupting flexibility. Some other problems regarding the workspace are the carts carrying the delivery equipment being too big to fit in the bathroom, the insufficiency of materials that help delivery such as bean bags and birth balls, and the sizes of the bathtubs not being ergonomic. All of those cause bad use of body posture and reduced job satisfaction (Hammond et al., 2014; Czupryna et al., 2012). Personnel that help delivery often work using body positions that are not natural. Working in inappropriate positions affects the musculoskeletal system of the employees negatively and causes strain in the neck and back and pain (Avery et al., 2010; Czupryna et al., 2012; Özel 2005). In a study performed in Finland, midwives were found to be able to use their backs in a straight position for almost 80% of their work duration when a delivery support chair is used, and this ratio was found to fall to 18% when a chair wasn’t used (Nevala & Ketola, 2012).

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CONCLUSION Delivery and delivery rooms are the source of fear and stress for most women. Avoiding negative birth experiences and defeating fear of giving birth is only possible through making not only medical arrangements but also arranging the delivery room to be an emotionally and physically secure and serene environment. Thus, it can be possible to both experience pleasurable and satisfying birth experiences and increase the job satisfaction of health care workers employed in the field as well as preventing occupational pain and diseases from presenting. REFERENCES Aksungur, A. (2009). Dr. Zekai Tahir Burak Kadın Sağlığı Eğitim ve Araştırma Hastanesi’nde çalışan ebe ve hemşirelerin iş doyumu ve yaşam kalitesi düzeylerinin belirlenmesi. Yayımlanmamış Yüksek Lisans Tezi. Hacettepe Üniversitesi. Ankara. Avery, D.M.; Reed, M.D.; Parton, J.M.; Marsh, E.E. (2010). Back and Neck Pain in Gynecologists. American Journal of Clinical Medicine 7: (1), 5-10. Babayiğit, M.A. & Kurt, M. ( 2013). Hastane Ergonomisi. İstanbul Med J 14: 153-159. Başgöl, Ş. & Beji, N.K. (2015). Doğum Eyleminin Birinci Evresinde Sık Yapılan Uygulamalar ve Kanıta Dayalı Yaklaşım. Düzce Üniversitesi Sağlık Bilimleri Enstitüsü Dergisi. 5: (2), 3239. Cluett, E.R. & Burns, E. (2012). Immersion in Water in Labour and Birth. CochraneDatabase of Systematic Reviews 2: 254-262. Coşar, Ç.F. & Demirci, N. (2012). Lamaze Felsefesine Dayalı Doğuma Hazırlık Eğitiminin Doğum Algısı ve Doğuma Uyum Sürecine Etkisi. S.D.Ü. Sağlık Bilimleri Enstitüsü Dergisi 3, 18-30. Czupryna, O.N.; Naworska, B.; Brzęk, A.; Nowotny, J.; Famuła, A.; Kmita, B.; Bak. K. (2012). Professional Experience and Ergonomic Aspects of Midwives’ Work. International J. of Occupational Medicine and Environmental Health 25: (3), 265-274. Ergenoğlu, A.S. & Aytuğ, A. (2007). Sağlık Kurumlarında Değişen Paradigmalar ve İyileştiren Hastane Kavramının Tasarım Açısından İrdelenmesi. Megaron- Y.T.Ü. Mim. Fak. Dergisi 2 : (1), 44-63. Gedey, S. (2014). Labor-Delivery-Recovery Room Design That Facilitates Non-Pharmacological Reduction of Labor Pain: A Model LDR Room Plan and Recommended Best Practices. Perkins+Will Research Journal 06: (1), 127-139. Gupta, J.K.; Hofmeyr, G.J.; Shehmar, M. (2012). Position in The Second Stage of Labour for Women Without Epidural Anaesthesia, Cochrane Database of Systematic Reviews 16: 5. doi:10.1002/14651858.CD002006.pub3. Güler, Ç. (2004). Ergonomi Tanımı, In: Çağatay Güler (Ed.) Sağlık Boyutuyla Ergonomi Hekim ve Mühendisler İçin. p.1, Palme Yayıncılık, Sıhhıye Ankara. Hammond, A.; Foureur, M.; Homer, C.S.E. (2014). The Hardware and Software Implications of Hospital Birth Room Design: A Midwifery Perspective. Midwifery 30: 825-830. Hauck, Y.; Rivers, C.; Doherty, K. (2008). Women's Experiences of Using a Snoezelen Room During Labour in Western Australia. Midwifery 24: 460-470. http://www.nationalarchives.gov.uk/doc/open-government-licence Health Building Note09-02. Children, young people and maternity services. Maternity care facilities 2011. (accessed: 02 October 2015). Jenkinson, B.; Josey, N.; Kruske, S. (2013). Birth Space: An Evidence-Based Guide toBirth Environment Design. Queensland Centre for Mothers & Babies, The University of Queensland. https://espace.library.uq.edu.au/view/UQ:339451/UQ339451_fulltext.pdf (accessed: 05 October 2015). Lawrence, A.; Lewis, L.; Hofmeyr, G.J.; Styles, C. (2013). Maternal Positions andMobility During First Stage Labour, Cochrane Database of Systematic Reviews 20: 8. doi:

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10.1002/14651858.CD003934.pub3. Lee, SL.; Liu, CY.; Lu, Y.Y.; Gau, M.L. (2013). Efficiacy of Warm Showers on Laborand Birth Experiences During The First Labor Stage. Journal of Obstetric Gynecologic & Neonatal Nursing 42: (1), 19-28. Lothian, J.A. (2004). Do Not Disturb: The Importance of Privacy in Labor. The Journal of Perinatal Education 13: (3), 3-6. Mamuk R.. & Davas N.I. (2010). Doğum Ağrısının Kontrolünde Kullanılan Nonfarmakolojik Gevşeme ve Tensel Uyarılma Yöntemleri. Şişli Etfal Hastanesi Tıp Bülteni 44: (3), 137-144. Mohammad, K.I.; Alafı K.K.; Mohammad, S.I.; Gamble, J.; Creedy, D. (2014). Jordanian Women’s Dissatisfaction with Childbirth Care. International Nursing Review 61: 278-284. Nevala, N. & Ketola R. (2012). Birthing Support for Midwives and Mothers - Ergonomic Testing and Product Development. The Ergonomics Open Journal 5: 28- 34. Nilsson, C. (2014). The Delivery Room: Is it a Safe Place? A Hermeneutic Analysis of Women’s Negative Birth Experiences. Sexual & Reproductive Healthcare 5:199–204. Odent, M. (2013). Sezaryen, Kuraldışı Yayıncılık, İkinci Baskı, 32-33 s., İstanbul. Özel, N. (2005). Hemşirelerin çalışma ortamında ergonomi kurallarına uyumunun belirlenmesi. Yayımlanmamış Yüksek Lisans Tezi. Marmara Üniversitesi. İstanbul. Öztunç, M. (2012). Kadın doğum kliniklerinde çalışan hemşire ve ebelerin hatalı tıbbi uygulama yapma durumları ve hatalı tıbbi uygulama nedenlerinin önemine ilişkin görüşleri. Yayımlanmamış Yüksek Lisans Tezi. Gazi Üniversitesi. Ankara. Ratfisch, G.Y. & Güngör, İ. (2009). Doğum Eyleminin Birinci Evresinin Yönetiminde Kanıta Dayalı Uygulamalar. HEMAR-G 53-64. Sayıner, F.D. & Özerdoğan, N. (2009). Doğal Doğum. Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi 2: (3), 143-148. Serçekuş, P. & Mete, S. (2010) Effects of Antenatal Education on Maternal Prenatal Postpartum Adaptation. Journal of Advanced Nursing 66: (5), 999-1010. Sheehy, A.; Foureur, M.J.; Catling P.C.; Homer, C.S.E. (2011) Examining the Content Validity of the Birthing Unit Design Spatial Evaluation Tool (Budset) within a Woman-Centred Framework. Journal of Midwifery & Women's Health 56: (5), 494- 502. Short, A.E.; Short, K.T.; Holdgate, A.; Ahern , N.; Morris, J.(2011). Noise Levels in an Australian Emergency Department. Australasian Emergency Nursing Journal 14: 26-31. Springer, T. (2007). Ergonomics for Healthcare Environments. Knoll. Available at: https://www.knoll.com /.../healthcare_ergonomi (accessed: 10 October 2015). Waldenström, U.; Hildingsson, I.; Rubertsson, C.; Andradestad, I. (2004). NegativeBirth Experience: Prevalence and Risk Factors in a National Sample. Birth 31: (1), 17-27. Yap, B.L. (1996). Ergonomic Design of a Physiologic Birth-SupportSystem. Available at: http://mro.massey.ac.nz/handle/10179/4614 (accessed: 15 October 2015). Yap, L. (2011). The Ergodesign of Childbirth. Available at:http://aut.researchgateway.ac.nz /bitstream/10292/3788/5/PBRF%20ERGONOMICS%20OF%20CHILDBIRTH%20 short.pdf. (accessed: 15 October 2015). URL 1. http://www.nationalarchives.gov.uk/2011 URL 2. http://www.nationalarchives. gov.uk/2011 URL 3. http://www.nationalarchives. gov.uk/2011 URL 4. http://www.nationalarchives. gov.uk/2011

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Chapter 18 Pregnancy and Healthy Life Style Behaviours Sezer ER GÜNERİ INTRODUCTION The health of women composing half of Turkey population is of great importance to be able to develop a healthy society (Mete, 1992). Despite being physiological, pregnancy, birth and postpartum are the periods when the requirements for health services increase (Özbaşaran & Yanıkkerem, 2004). Health behaviors of women during pregnancy have an important role for the infant and mother after birth. Health applications during pregnancy can be defined as the “activities affecting the health of pregnant, fetus and new-born. The health applications significant for the pregnancy results must be diagnosed and gained during prenatal care. These applications must involve balanced nutrition, proper amount of weight gain, regular exercise, dental care, educations of pregnancy and birth, not smoking, avoiding alcohol or illegal drugs and excessive medication, avoiding risky sexual behaviours or exposure to other infective agents (Lindgreen, 2005). Having an important position in woman health, a healthy process of gestation depends on a good knowledge of pregnancy care at all points and proper applications. Without obeying required rules and health behaviours, a gestation having a random course may lead to several dangers in terms of the mother and infant from the very beginning of pregnancy (Çakmakçı & Eşer, 2003; Köşgeroğlu, Açıkgöz & Ayrancı, 2004). Therefore, all pregnant and puerperants should be given care by well-educated primary health professionals (physician or midwife, and nurse) before, during and after delivery. PREGNANCY AND NUTRITION The purpose of nutrition in pregnancy is both balancing the reserves of nutritional elements by meeting the expectant’s own physiological requirements and providing the energy and nutritional elements necessary for the normal growth of fetus. During this period, basal metabolism increases by nearly 20% of normal rate. Meeting the nutritional elements required by this increase is of significance for the health of mother as well as that of fetus. Besides the health condition of mother, her nutrition also affects the growth and development of fetus. Insufficient nutrition during pregnancy increases the risks of anaemia, latency of fetus development, low birth weight baby, maternal diseases and death. The number of premature babies from undernourished pregnants is higher than the ones from normally nourished women. In the USA, 8,1% of the infants born in 2010 have a low birth weight (Yamaç, Gürsoy & Çakır, 2002; Uzdil & Özenoğlu, 2015). Nutrition during pregnancy is crucial for especially the cases having nutritional risks. Factors causing risks in nutrition are respectively adolescence, anaemia, abnormal weight gain before pregnancy, a large number of pregnancies, illness, smoking, alcohol 

Assist. Prof. Dr., Ege University, Faculty of Nursing, İzmir, Turkey

abuse. Again problems such as nausea, vomiting, pica, lactose intolerance may arouse during pregnancy (Yamaç et al., 2002). Every pregnancy leads to the waste of nutrition reserves in the mother’s body. As well as frequent deliveries, insufficient and unbalanced nutrition also causes several defects on the health of mother and fetus (Taşkın, 2016). Primary nutritional elements affecting the brain development before birth are iodine, iron, zinc, folic acid, vitamins B-12, B-6, E and A and essential fatty acids. Insufficient intake of these nutritional elements by women before and during pregnancy increases the risk of child’s brain disabilities (Baysal, 2003). While 63% of the women at fertility age suffer from anaemia due to insufficient nutrition in developing countries, this rate is known to be at 10% in developed countries (Köşgeroğlu et al., 2004). In Turkey, approximately 50% of the pregnants are known to have iron deficiency anaemia. Chronical malnutrition, anaemia and excessive fertility altogether affects the health of both mother and infant in a serious way (Taşkın, 2016). During pregnancy, only requirements of iron, folic acid and vitamin D increase by 100% as compared to preconception. The need for energy increases about 18% and protein increase is about 20-25%. However, the need for calcium, phosphor, thiamine, and vitamin B6 is about 33-50%. While the need for zinc and riboflavin is about 2025%, this need for selenium, iodine, magnesium, niacin, and vitamins A, B12 and C increases 18% (Yamaç et al., 2002). Fat deposition needed for essential energy in the third trimester and lactation peak in the middle of pregnancy. In the second trimester, blood volume, breast and uterus oil tissue of the mother increases. The weight gain in the third trimester is due to the fetus growth, increase of placenta and amnion liquid, and maternal edema. The effect of maternal nutrition on fetus weight is relatively more significant in the third trimester (Yamaç et al., 2002). All women must be brought to their ideal weight before gestation, be provided with a proper weight gain during pregnancy as well as a balanced and sufficient diet, and be educated in terms of mineral support via supplementary vitamin when necessary (Yamaç et al., 2002). In their study, İrge et al. (2005) has determined that 81,2% of women suffer from nutritional problems during pregnancy. It has been confirmed that 33,2% of the pregnants do not follow a regular diet and do not increase the number of their meals (İrge et al., 2005). Vegetarians are likely to compensate their daily dietary needs, however if there are major restrictions including milk and egg, they will be in need of iron, vitamin B12 and zinc support (Benson & Pernoll, 2002). In their research on expectants’ applications to develop fetal health Yılmaz, Dinç & Bal (2015) determined that of the pregnants, 70% (n=208) daily had three main meals and three snacks, 89% used folic acid in the first 3 months of gestation, 93% used iron preparate after the first three months of gestation, 87% used vitamins during gestation (Yılmaz, Dinç & Bal, 2015). According to the study of Yavuz & Aykut (2014), 13,1% of the pregnants used folic acid before gestation and 35,5% took vitamin-mineral supplements during gestation (Yavuz & Aykut, 2014). In their study on the nutrition of pregnants Taş , Üstüner, Özdemir, Dikeç & Avşar (2010) found such results: daily energy, protein, carbohydrate and fat intake at suggested levels; daily calcium, iron, zinc, vitamin A, vitamin D, thiamine, vitamin B6, folic acid and pulp intake under the suggested levels; daily phosphorus and vitamin C intake over the suggested values (Taş, Üstüner, Özdemir, Dikeç & Avşar, 2010).

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In their study on the dietary habits of the pregnants, Eren et al. (2015) determined that the dietary groups whose consumption increased at most as compared to preconception were fruits (51%) and vegetables (40,8%), while the ones whose consumption decreased mostly were tea (26,1%) and red meat (21%). It was observed that of the pregnants, 20,4% had never eaten fish, 13,1% never red meat, and 12,4% never white meat during pregnancy (Eren et al., 2015). According to the study by Yavuz & Aykut (2014) concerning the dietary group consumption status of pregnants, insufficient consumptions were the highest in meat, egg and legumes (86,7%), followed by milk and diary products (48,8%); the excessive consumptions included vegetables and fruits (50,4%), followed by grains (43,7%) (Yavuz & Aykut, 2014). PREGNANCY AND WEIGHT GAIN A balanced and healthy diet is very important to have a healthy child. It is quite significant to gain healthy dietary habits before gestation and continue these habits during pregnancy. Pregnancy is one of the most important circles of human life in terms of nutrition. The way of nutrition during pregnancy highly affects the health of mother and infant (James, Ster, Weiner et al., 2004; Taşkın, 2016, Uzdil & Özenoğlu, 2015). This fact created an idea in the society that a pregnant must eat for two persons. However, excessive nutritional intake in gestation is as harmful as insufficient nutrition in terms of the wellness of mother and infant (Taşkın, 2016). A woman with a normal weight gains 13 kg during pregnancy; and six of this weight is for fetus and uterus, four kg for body liquids, and three kg is for fat reserves. Insufficient or excessive weight gain brings certain problems against pregnancy (Yamaç et al., 2002). In order to improve maternal and infant health, women must have a normal Body Mass Index (BMI) and when trying to get pregnant and during pregnancy, they must gain weight as suggested in the weight guide by the Institute of Medicine (IOM) 2009 (Rasmussen & Yaktine, 2009). Suggestions of the USA Institute of Medicine’s World Health Organisation (WHO) about weight gain in pregnancy according to BMI are as follows; Underweight BMI 4000 g), having an unexplained stillborn or a baby with congenital anomalies in previous pregnancies, having gestational diabetes in previous pregnancies, having fasting serum blood glucose >140 mg/dl or random blood serum glucose >200 mg/dl (TDV, 2013; TEMD, 2013). Recently, it has been announced that male fetus carriage is related to a decrease in maternal beta cell functions in pregnancy and increased risk of gestational diabetes occurrence. In the retrospective community-based research conducted by Retnakaran & Shah (2015) in order to investigate the relationship between fetal gender, and the risk of diabetes occurrence postnatally and in the next pregnancy, all the women (n= 642 987) who had single live birth in their first pregnancy between April 2000 and March 2010 have been examined. According to the research results; the risk of developing type-2 DM for women with GDM is higher when having a female baby compared to having a male baby. Although male fetus carriage is related to increasing the risk of developing GDM, it does not strengthen the probability of recurrence. Instead, the increased GDM risk for the women who did not have GDM in their first pregnancies, arising from having male fetus in the second is especially more notable if the women had female child previously (Retnakaran & Shah, 2015). 1.3. Screening The aim of screening a disease is not to diagnose but to find out the patient group that is under risk. As perinatal morbidity is related to the degree of glucose intolerance, it is a necessary approach to perform screening in high risk group as early as possible (Kaya, 2007; Taşpınar, 2006). Risk assessment must be carried out as from the first prenatal examination, and fasting plasma glucose (FPG) must be measured (ADA, 2015). Glycolytic hemoglobin levels must be checked out in the pregnant individuals who have high FPG level (≥126 mg/dl). If the HbA1C test result is too high, it should be accepted as pregestational DM, and treated accordingly. Fasting blood glucose level must be measured in the first stage of pregnancy in the pregnants who belong to one of the high risk groups such as obesity, GDM history, glycosuria, or diabetes in first degree relatives. Even if the findings are outside the diabetic cut-offs (105 and/or the first our PG is >140 mg/dl despite two weeks of diet treatment, then the individual must proceed to insulin treatment. If obstetric risk factors are not present, there is no need for a different investigation apart from the normal pregnancy examinations. In order to maintain the glycemic control and to complete the pregnancy without problems; pre-prandial, post-prandial and at-night blood glucose measurement must be performed at least 3 days a week and 4-7 times a day.  If the FPG is ≥105 mg/dl and the second hour PG is ≥ 120 mg/dl, then the patient is treated with insulin. These pregnants who are under insulin treatment must be followed-up as pregestational diabetes patients. In the 28th, 32nd, 34th, 36th, 37th, 38th and 39th gestational weeks, pregnancy check-ups must be carried out (URL1; TEMD, 2013). 2. COMPLICATIONS OCCURING IN THE ANTENATAL PERIOD Some additional maternal and fetal risks exist in pregnancies that are complicated by diabetes compared to normal pregnancies. In 1920s, before the use of insulin, it was a rare occasion for the individuals with diabetes to get pregnant or to have a live birth. Although treatment potentials have developed since then, some complications are still more common among diabetic pregnants. (Taşpınar, 2006; Gilbert & Harmon, 2002; Reece & Homko, 2008). GDM is one of the most prominent among the reasons that increase the morbidity and perinatal mortality in the fetus and the mother. When sufficient glycemic control cannot be maintained, hypoglycemia, hyperglycemia, preeclampsia, polyhydramnios, infection, and preterm labor may occur in the mother while congenital anomaly, macrosomy, intrauterine growth retardation, and intrauterine death may occur in the fetus. (ADA, 2015; Taşkın, 2014; Taşpınar, 2006) (See: Figure 3, 4 and 5). 2.1. Maternal Complications 2.1.1. Hypoglycemia-Hyperglycemia Hypoglycemia is a quite serious problem occurring in the first trimester. The risk of developing hypoglycemia may increase due to lack of calorie intake resulting from pregnancy induced nausea and vomiting in the first trimester. These complications are encountered more often in the diabetic pregnants who are on insulin medication. If the situation is not responded with an immediate treatment, permanent neurological sequelae may occur (Taşkın, 2014; Taşpınar, 2006). Hyperglycemia is generally encountered in the second half of the pregnancy. Insulin need increases the most between 20th and 30th weeks of the pregnancy. Because the glucose remnant from the mother’s circulation will be directed to the fetus, metabolization of fat is faster in fasting periods compared to a non-pregnant individual. Diabetic ketoacidosis develops faster after accelerated fasting and ketogenesis (Taşkın, 2014; Taşpınar, 2006). 2.1.2. Preeclampsia Pregnant women with diabetes are twice at more risk of preeclampsia in comparison with normal pregnants, and this statement is especially valid in the presence 223

of vascular and renal problems. Perinatal mortality increases by 20 times compared to pregnants with normal blood pressure (Gilbert & Harmon, 2002; Kaya, 2007). 2.1.3. Polyhydramnios Amnion liquid being higher than 2000 ml is defined as polyhydramnios. Polyhydramnios occurs in approximately 18% of the diabetic women during pregnancy. It is considered to arise from the increased fetal urination due to fetal hyperglycemia. Increased glucose in the amniotic liquid as a result of glycosuria draws excessive water by osmotic effect, and therefore causes polyhydramnios. It is determined that amniotic liquid index is in parallel with amniotic liquid glucose level in diabetic women (Gilbert & Harmon, 2002; Taşkın, 2014; Taşpınar, 2006). In consequence of polyhydramnios; early labor, cord prolapse, ablation placenta, or early membrane rupture due to overextension in uterus may occur (Taşpınar, 2006). 2.1.4. Infection Approximately in 80% of all the diabetic women, an infection develops at least once during their pregnancies, and the occurrence of infection in any organ poses an important risk (Gilbert & Harmon, 2002). 300mg/day glycosuria linked to glomerular filtration rate, which increases in pregnancy period, may occur. Additional to normal glycosuria emerging in pregnancy; increased glycosuria in diabetes, pelvic floor muscle relaxation, increased urine retention in bladder, and vaginitis-especially monilial vaginitis-resulting from pH changes in vaginal channel are encountered very frequently.

Figure 3: Maternal Complications IU: Intrauterin, IUGR: Intrauterin Growth Retardation, PRM: Preterm Rupture of Membrane, UTI: Urinary Tract Infection, GFR: Glomerular Filtration Rate, PH: Power of Hydrogen )Kaya, 2007; Reece & Homko, 2008; Jain, Agerwal, Sankar, Deorari & Paul, 2010; Gilbert & Harmon, 2002; Metzger et al., 2007; Civak, 2008; Taşkın, 2014; Taşpınar, 2006; Nold & Georgieff, 2004).

Due to the increase in vaginitis incidence, the pyelonephritis and urinary tract infection risks are high in the pregnant women. The risk of preterm labor also increases 224

as a consequent of infection (Gilbert & Harmon, 2002; Taşkın, 2014; Taşpınar, 2006; Kaya, 2007). 2.1.5. Preterm Labor Preterm labor defines labors happening before the 37th week of pregnancy. In a woman with diabetes, the risk of preterm labor increases due to the enlargement of uterus volume, the existence of hypertensive disorders, and the urinary tract infections (Gilbert & Harmon, 2002). Preterm labor should be attempted to be stopped because of the possibility of underdeveloped lungs and serious neurological sequalea occurrence. Magnesium sulphate and calcium channel blockers should be used in preterm action as tocolytic agents. Beta mimetic agents should not be used as they cause hyperglycemia. If steroids are to be used in preterm action in order to enhance the lung maturation, blood glucose levels should be monitored frequently (Gilbert & Harmon, 2002; Nold & Georgieff, 2004; Taşkın, 2014; Taşpınar, 2006; Kaya, 2007). 2.2. Fetal complications 2.2.1. Spontan Abortus In diabetes, the missed miscarriage risk increases with insufficient glycemic control during embryonic phase. The hyperglycemic environment has a teratogenic effect for the fetus (Gilbert & Harmon, 2002). 2.2.2. Congenital Anomalies Congenital defects occur in the diabetic pregnants (especially in those with pregestational overt diabetes) 3-4 times more often (Nold & Georgieff, 2004). If appropriate glycemic control can be maintained in the 3rd-6th weeks of pregnancy which is the most teratogen-sensitive period; anomaly rates may be decreased to the levels of normal population (Taşpınar, 2006). The increase in the congenital anomaly incidence is considered to be rooted in the hyperglycemia-induced decrease of DNA and RNA secretion in the mother. Congenital anomalies encountered in the infants of diabetic mothers are: skeletal and nervous system defects like neural tube defects, congenital heart anomalies, gastrointestinal malformations, and congenital renal anomalies (Gilbert & Harmon, 2002; Taşkın, 2014; Nold & Georgieff, 2004). 2.2.3. Macrosomy Macrosomy is clinically defined as fetal weight being greater than 4000-5000g independent of the gestational age. When the fetal weight is evaluated according to the gestational age, the term LGA (Large for gestational age) applies to babies bigger than their gestational age. The concept of LGA expresses that the birth weight is above the 90th percentile for that gestational week (Taşpınar, 2006; Reece & Homko, 2008). The occurrence mechanism of fetal macrosomy is not thoroughly known; however, along with this, it can be stated that it develops in multifactorial interactions such as genetics, fetal nutrition, and environmental factors. In the developing process, there are two hormone-dependent and hormone-independent mechanisms. Insulin in hormonedependent development; and placenta weight, placental membrane surface, sufficient uterine and umbilical blood stream, and the ratio of substrates such as oxygen, glucose, and amino acid in hormone independent development play a significant role. The increase of maternal glucose causes fetal hyperglycemia. Insulin production by the fetal pancreas, stimulated by fetal hyperglycemia, causes hyperinsulinemia (Gilbert & Harmon, 2002; Civak, 2008). 225

Insulin sensitive tissues in the fetus such as liver, fat tissue, and muscles suffer from hypertrophy and hyperplasia; however, brain, kidneys, and femoral neck remain unaffected by this change. Because hyperinsulinemia does not have a notable effect on brain growth, diagnosis of macrosomy with biparietal diameter measurement gives misleading results. The referred parameter in ultrasonographic determination of LGA is abdominal circumference. It has been suggested that, in the case of fetal abdominal circumference in the 30th and 33rd weeks of pregnancy being above the 90th percentile for that gestational week, macrosomy is inevitable (Kaya, 2007). That obesity and GDM have relative risk factors for maternal and neonatal results related to macrosomy and LGA occurrence is a known fact. The fast increase in the prevalence is mainly attributed to environmental factors although macrosomy is affected by both genetics and environmental factors. It is considered to be crucial that maternal weight and metabolic changes such as GDM and Type-2 diabetes are among these factors. According to the results of the prospective and multicenter study conducted by Alberico et al., (2014), when the risk factors such as parity, mother’s length, gestational age in birth, and newborn’s gender are controlled; maternal weight, excessive weight gain in pregnancy, and gestational diabetes are stated to be the main causes of macrosomy. In this study, it is expressed that there is a significant relationship between the pre pregnancy Body Mass Index (BMI) and the neonatal birth weight. The risk of developing obesity at an early age is found to be higher in the macrosomic newborns of the diabetic and over-weight mothers (Alberico et al., 2014). 5th International Workshop-Conference on Gestational Diabetes Mellitus results indicate that excessive fetal growth increases the risk of birth trauma, maternal morbidity related to surgical birth, lifelong obesity in the babies, and glucose intolerance. It is also stated in the report that the cesarean birth rates increased in the patients with GDM in order to prevent a birth trauma (Metzger et al., 2007). The risk of shoulder dystocia, clavicle fracture, brachial plexus injuries, facial nerve injuries, cephal hematoma, intracranial bleeding, and asphyxia also increases in the fetuses who are bigger for their gestational age (Gilbert & Harmon, 2002). Shoulder dystocia, whose occurrence rate is between 0.3% - 0.5% in the normal pregnants, occurs 2-4 times more often in the diabetic pregnants (Taşpınar, 2006). 2.2.4. Intrauterin Growth Retardation (IUGR) IUGR occurs less often than macrosomy, and mostly in the women with pregestational diabetes. IUGR develops as result of the decrease in uteroplacental blood stream due to maternal diabetic vascular disease (Gilbert & Harmon, 2002). 2.2.5. Intrauterin Fetal Death Intrauterin deaths with unidentifiable causes are encountered in the pregnancies that are complicated by overt diabetes. These infants are big for their age, and they generally die in the 35th week or later before the birth. Serious prolonged hyperglycemia prevents the transportation of oxygen and carbondioxide. The occurrence of intrauterine fetal deaths can be made less often provided that a decent glycemic control is maintained. The incidence of intrauterine fetal deaths is around 1% (Gilbert & Harmon, 2002; Taşpınar, 2006).

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Figure 4: Fetal Complications (Kaya, 2007; Reece & Homko; Jain et al., 2010; Gilbert & Harmon, 2002; Metzger et al., 2007; Civak, 2008; Taşkın, 2014; Taşpınar, 2006; Nold & Georgieff, 2004).

3. COMPLICATIONS THAT OCCUR IN THE POSTPARTUM PERIOD 3.1. Neonatal Complications The anomalies in the glucose metabolism of the diabetic mothers cause some neonatal problems to develop more often (Taşpınar, 2006). Hypoglycemia, hyperbilirubinemia, hypocalcaemia, and polycythemia potentially occur more frequently in the infants of the women with GDM (Metzger et al., 2007). The risk of respiratory distress syndrome related to preterm birth exists, too, for these newborns (Taşpınar, 2006) (See: Figure 5). In the research done by Karagöl, Karadağ,, Zenciroğlu, Kundak & Okumuş (2012), the clinical findings and laboratory data of the newborns that were monitored in between 2005-2011 as the infants of the diabetic mothers and demographical features of the mothers have been studied. 84.9% of the mothers of these infants have GDM, and 34.9% of the babies are macrosomic. The rates of complications in the babies are found to be as follows: hypoglycemia, 32.5%; polycythemia, 27.9%; indirect hyperbilirubinemia, 25.5%, hypocalcaemia, 11.6%; congestive heart failure, 10.4%; hypoxic ischemic encephalopathy, 10.4%; respiratory distress syndrome, 4.6%; brachial plexus paralysis, 3.5%. In the study conducted by Turkmen et al. (2008), the mortality- morbidity causes and rates of 91 diabetic mothers and babies that were monitored in the neonatal unit in between May 1999-August 2006 have been evaluated. The rates of hypoglycemia, hyperbilirubinemia, hypocalcaemia, and congenital heart anomaly in the babies have been found to be 52%, 38%, 14%, and 13% respectively. 3.1.1. Hypoglycemia High level insulin secretion continues postnatally in the babies who have hyperinsulinism in the fetal period due to hyperglycemia, and during the first hours of their life, hypoglycemia develops following the surcease of transplacental glucose source (Gilbert & Harmon, 2002; Taşpınar, 2006; Nold & Georgieff, 2004). This is the most frequent and significant metabolic disorder that occurs in the babies of diabetic 227

mothers. Generally, hypoglycemia is observed in the first four postnatal hours, and mostly the baby recovers by itself (Nold & Georgieff, 2004). As the long-lasting hypoglycemia may cause convulsion, coma, and brain damage; these babies should be monitored closely (Taşpınar, 2006; Nold & Georgieff, 2004). 3.1.2. Polycythemia The case of hematocrin being greater than 65% is termed as polycythemia. Increased erythropoietin secretion induced by chronic hypoxia, which is the result of the prevention of oxygen and carbon dioxide transportation due to hyperglycemia, is considered to be the cause of polycythemia. The early damage of erythrocytes due to hyperglycemia can also be ranked among the causes of polycythemia (Taşpınar, 2006; Nold & Georgieff, 2004; Reece & Homko, 2008). 3.1.3. Hyperbilirubinemia Because of the chronic hypoxia due to hyperglycemia, the equilibrium mechanism of erythrocyte production becomes deteriorated. Hyperbilirubinemia occurs with the emergence of bilirubin, which is the result of the decomposition of erythrocytes (Gilbert & Harmon, 2002; Nold & Georgieff, 2004). One-fourth of the infants of diabetic mothers develop hyperbilibinemia, which is twice more frequent than the normal population (Taşpınar, 2006; Reece & Homko, 2008). 3.1.4. Hypocalcaemia Serum calcium level 30.0

Total Weight Gain (kg) 12.5-18.0 11.5-16.0 7.0 – 11.5 5.0 – 9.0

In second and third trimester (kg/week) 0.51 0.42 0.28 0.22

The suggested weight gain in the first trimester is between 0.5 and 2 kg. Effects of Maternal Obesity Maternal obesity negatively affects the health of mother and the new born through the pregnancy. Gestational diabetes and hypertensive diseases induced by pregnancy, which are observed frequently in maternal obesity, brings up the risks such as operative birth, anesthesia complications, wound infections and deep venous thrombosis. Increase in preterm birth, macrosomia, shoulder dystocia, intrauterine, neonatal or infant mortality is more frequent in obese mothers compared to mothers that has normal body mass index (Apay & Pasinlioğlu, 2009; Bulut& Mihmanlı, 2014; Daşıkan & Kavlak, 2009; Dixit & Girling, 2008; Sirimi, & Goulis, 2010; Yanıkkerem & Mutlu, 2012). Gestational Diabetes Gestational diabetes is defined as glucose intolerance at any degree that had first observed in pregnancy, no matter it starts before or persistent after the pregnancy. Maternal obesity usually observed together with gestational diabetes. Maternal obesity and gestational diabetes are related with the increase of inflammation in placenta and maternal white adipose tissue. Adipocytes and cytokines such as leptin, adiponectin, TNF-alpha, interleukin-6 excreted from white adipose tissue. Placenta shows a similar cytokine gene expiration profile except adiponectin. Inflammation resulted with excretion of cytokines thought to be related with increased insulin resistance in gestational diabetic pregnant. Gestational diabetes develops as maternal pancreatic beta cells cannot excrete enough insulin that can meet the increased need of insulin (Aghamohammadi, 2011; Dixit & Girling, 2008). In the study of Sebire et al. (2001), in which 287.213 pregnancy in London was analyzed, it was found that 38.4% of pregnant were obese and the frequency of gestational diabetes in obese pregnant was much more higher compared to ones that have normal body mass index. In the study of Aghamohammadi (2011), which was conducted by homogenizing age and parity, 250 obese and 259 non-obese pregnant were compared and it was found that the gestational diabetes ratio was 23.8% in obese and 2.7% in non-obese pregnant. Gestational diabetes effects development of diabetes in women’s future life. Type 2 diabetes might develop in next 15 years with the ratio of 70% in women that had gestational diabetes and 30% in women that has normal body index (Apay & Pasinlioğlu, 2009; Yanıkkerem & Mutlu, 2012). Hypertension and Preeclampsia Preeclampsia is a multi-systemic disease that affecting pregnancies with a ratio of 3%-10%. Maternal obesity and insulin resistance is an important risk factor for the development of preeclampsia. In the systematic review study of O’Brien, Ray & Chan (2003), 13 cohort study was analyzed and it was found that the preeclampsia risk was 238

doubled for each 5-7 kg increase in body mass index. In the study of Aghamohammadi (2011), in which obese and non-obese pregnant were compared, preeclampsia was observed in 20.8% of obese and in 5.8% of non-obese pregnant. Sebire et al (2001) declared in their study that preeclampsia was observed more in obese pregnant. Dystocia and Caesarean Section Maternal obesity increases the risk of both gestational diabetes and fetal macrosomia, so as a result it increases the risk of shoulder dystocia as well (Arrowsmith, Wray & Quenby, 2011). Aktulay, Yörük, Engin Üstün, Yapar Eyi & Mollamahmutoğlu (2011) conducted a study (n=5472) to analyze the effect of maternal obesity on the birth type. In their study 15% of women was obese and they found that caesarean section ratio of obese women was 47% where this ratio was 24.4% for women that hat has normal body mass index. Aghamohammadi (2011), Arrowsmith et al. (2011), Callaway, Prins, Chang & Mclntyre (2006) and Sebire et al (2001) declared in their studies that elective and emergency caesarean section ratio was higher in obese pregnant. Flatting on the back and holding to operating table in an emergency case is difficult for obese pregnant. In caesarean operation, difficult and unsuccessful intubation in general anesthesia, injection failure in epidural or spinal anesthesia, attempting more than once and disruption in breathing function might be seen. Also anesthesia risks increases very much for pre-eclampsia accompanying maternal obesity and/or Gestational Diabetes Mellitus (GDM) and intensive care might be required (Callaway et al., 2006; Daşıkan & Kavlak, 2009). Venous Thrombosis Pregnancy is an independent risk factor for deep vein thrombosis and pulmonary emboli. The venous thrombosis risk is 5-6 times higher for pregnant compared to normal women at the same age. Approximately one of the one thousand women has thrombosis after the birth issue. Obesity is one of the biggest risk factor for venous thrombosis and obese pregnant has the increased risk for venous thrombosis, especially the risk is much more for ones that make caesarean birth (Sirimi, & Goulis, 2010). Postpartum Infection However prophylactically more antibiotics used especially for the obese women that had caesarean birth, more infections of endometritis, incision point and urinary system develops in postpartum period. In the literature it was declared that wound site infection, genital track and urinary system infection in postpartum period developed more in obese pregnant as a result of increased gestational diabetes and caesarean ratio. Also inflammation and infection developed in adipose tissue at the caesarean area prevents vaginal birth in the next (Sebire et al., 2001; Aghamohammadi 2011). Lactation Problems Maternal obesity also causes problems in postpartum period. The diabetic, hypertension and infection risk of obese mother increases through their pregnancy. Because of this caesarean birth is an endemic issue for obese pregnant and all of these are effecting factors in breast feeding. Also more frequent occurrence of factors such as pain, anemia and delay in mobilization affect comfort of the mother negatively in postpartum period. More frequent occurrence of these problems in obese pregnant resulted with difficulties in breast feeding, decrease in the feeding frequency and nonsustaining in the breast feeding. (Amir & Donath, 2007; Li, Jewell, & Grummer239

Strawn, 2003; Sirimi & Goulis, 2010; Wojcicki, 2011) Kitsantas & Pawloski (2010) analyzed the effect of BMI on starting and continuing breast feeding. They found in their study that the ratio of breast feeding mothers was 69.3% and the average breast feeding period was around two months. In compilation study of McGuire, Dyson & Renfrew (2010) it was declared that obesity affect starting to the breast feeding and continuing. They mentioned in their study that maternal obesity caused some problems such as decrease in prolactin level, responding and delay. Failure in the breast feeding result in feeding the baby with ready food and this increases the obesity risk in future. Fetal and Neonatal Complications Maternal obesity increases the risk of congenital abnormalities in newborn such as neural tube defect (NTD), Down-syndrome, cardiovascular diseases, abdominal wall defect, cleft palate and cleft lip. In the literature it is declared that ultrasound that used to determine fetal abnormalities might be insufficient because of the week monitoring in obese women, and so congenital abnormalities might be missed in ultrasound scanning. Maternal diabetes, unidentified diabetes and hyperglycemia is a risk factor for congenital cardiac and neural system abnormalities. These issues are seen approximately three times more in obese women compared to ones that have normal BMI (Apay & Pasinlioğlu, 2009; Bulut& Mihmanlı, 2014; Daşıkan & Kavlak, 2009; Dixit & Girling, 2008; Sirimi, & Goulis, 2010; Yanıkkerem & Mutlu, 2012). In a case control study conducted by McMahon, Liu, Zhang, Torres & Best (2013), a relationship was found between the maternal obesity and NTD. In this study it was declared that NTD risk in obese mother was decreased by having high dose folate with a diet. In the study of Hildebrand, Källén, Josefsson, Gottvall & Blomberg (2014), it was found that the risk of newborn with Down syndrome is higher in obese mothers compared to ones that has normal BMI. Sebire et al (2001) declared in their study that the ratio of intrauterine death, birth issue before the 32th week, macrosomia newborn was higher in obese pregnant. Arrowsmith et al. (2011) analyzed 29.224 singleton pregnant to determine the effect of maternal obesity on birth issue and neonatal results and they found that macrosomia newborn ratio of obese mothers was higher compared to ones that has normal BMI. Also in this study it was found that shoulder dystocia and low APGAR score rates of newborn in obese mothers were similar to other mothers. In the study of Aghamohammadi (2011), it was found that APGAR score of newborn was low with a ratio of 12.5% in obese mothers, where it was found as 1.6% for non-obese mothers. In another study (n=58089) conducted by Chen et al. (2010) to analyze the relation of maternal obesity with neonatal APGAR score, it was found that APGAR score was low for 1.2% and very low for 0.3% of newborn. Also it was declared in this study that there was a statistically meaningful relation between maternal BMI and APGAR score. Aghamohammadi mentioned that placental deficiency, preterm birth and dysfunctional birth issue observed more in obese mothers and this might cause temporarily low APGAR score by increasing fetal acidosis. Also obesity in childhood and adolescent period, metabolic syndrome and type II diabetes in long term are some complications that might be expected for obese mother’s newborn that are overweight (Arrowsmith et al., 2011; O’Brien et al., 2003; Sebire et al., 2001).

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CONCLUSIONS Spreading obesity in pregnancy cause to problems in long and short period on the health of child and mother. Health professionals should be more sensitive to prevent obesity in pregnancy and give importance to antepartum monitoring and training of obese pregnant. They should be ready for risks that might be seen in postpartum period and they should support mother at breastfeeding. Additionally, because of the lack in the number of studies in the literature, there is a need for studies on complications of maternal obesity in antepartum and postpartum period and also on weight gain that obese pregnant should have in pregnancy. REFERENCES Aghamohammadi, A. (2011). Maternal Obesity and Preeclampsia. HealthMED 5: (6),14841487. Aktulay, A.; Yörük, Ö.; Engin Üstün, Y.; Yapar Eyi, EG.; Mollamahmutoğlu, L. (2012). Obezitenin Doğum Şekline Etkisi. The Joutrnal of Gynecology Obstetrics and Neonatology 8: (33), 1351-1353. Amir, L.S. & Donath, S. (2007). A Systematic Review of Maternal Obesity and Breastfeeding Intention, Initiation and Duration. BMC Pregnancy and Childbirth 7:(9), 1-14. Apay, S.E. & Pasinlioğlu, T. (2009). Obesity and Pregnancy. TAF Preventive Medicine Bulletin 8: (4), 345-350. Arrowsmith, S.; Wray, S.; Quenby, S. (2011). Maternal Obesity and Labour Complications Following Induction of Labour in Prolonged Pregnancy. BJOG 118, 578-588. Bulut, B. & Mihmanlı, V. (2014). Obezite ve Gebelik. Okmeydanı Tıp Dergisi 30: (1), 2428. Callaway, L.K.; Prins, J.B.; Chang, A.M.; Mclntyre, H.D. (2006). The Prevalence and Impact of Overweight and Obesity in An Australian Obstetric Population. Medical Journal of Australia 184: (2), 56-59. Daşıkan, Z. & Kavlak, O. (2009). Maternal Obesity: Pregnancy Complications and Management of Pregnant Woman: Review. Turkiye Klinikleri Journal of Nursing1: (1), 39-46. Dixit, A. & Girling, J.C. (2008). Obesity and Pregnancy. Journal of Obstetrics and Gynaecology 28: (1), 14-23. Hildebrand, E.; Källén, B.; Josefsson, A.; Gottvall, T.; Blomberg, M. (2014). Maternal Obesity and Risk of Down Syndrome in the Offspring. Prenat Diagn 4: (4), 310-315. Kitsantas, P. & Pawloski, L.R. (2010). Maternal Obesity, Health Status During Pregnancy, and Breastfeeding Initiation and Duration. The Journal of Maternal Fetal and Neonatal Medicine 23:(2), 135-141. Li, R.; Jewell, S.; Grummer-Strawn, L. (2003). Maternal Obesity and Breast-Feeding Practices. The American Journal of Clinical Nutrition 77: (4), 931-936. McGuire, W.; Dyson, L.; Renfrew, M. (2010). Maternal Obesity: Consequnces for Children, Challenges for Clinicians and Carers. Seminars in Fetal and Neonatal Medicine 15: (2), 108-112. McMahon, D.M.; Liu, J.; Zhang, H.; Torres, ME.; Best, R.G. (2013). Maternal Obesity, Folat Intake, and Neural Tube Defects in Offspring. Birth Defect Research 97, 115-122. National Health and Nutrition Examination Survey, 2014 www.cdc.gov/nchs/data/databriefs/db82.pdf NHANES, (2014). www.cdc.gov/nchs/data/databriefs/db82.pdf),. O’Brien, T.E.; Ray, J.G.; Chan, W.S. (2003). Maternal Body Mass Index and the Risk of 241

Preeclampsia: A Systematic Overwiev. Epidemiology 14: (3), 368-374. Sebire, N.J.; Jolly, M.; Harris, J.P.; Wadsworth, J.; Joffe, M.; Beard, R.W.; Regan, L.; Robinson, S. (2001). Maternal Obesity and Pregnancy Outcome: A Study of 287213 Pregnancies in London. International Journal of Obesity 25: (8), 1175-1182. Sirimi, N. & Goulis, D.G. (2010). Obesity in Pregnancy. Hormones 9: (4), 299-306. URL 1. WHO Obesity and Overweight, 2014 http://www.who.int/mediacentre/ fact sheets/ fs311/en/). WHO Obesity and Overweight 2014 http://www.who.int/mediacentre/factsheets/fs311/en/ Wojcicki, J.M. (2011). Maternal Pregnancy Body Mass Index and Initiation and Duration of Breastfeeding: A Review of the Literatüre. Journal of Women’s Health 20: (3), 341-347. Yanıkkerem, E. & Mutlu, S. (2012) Maternal Obesity: Consequences and Prevention Strategies. TAF Preventive Medicine Bulletin 11: (3), 353-364.

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Chapter 22 Parents Attachment and Nursing Approach Selma ŞEN INTRODUCTION Family is a social system with its unique structure, operation, and interpersonal connections. Mother-child is one of the most important part of a family. Although there are many views towards understanding family structure, it is important that family structure and attachment theories have similar and complimentary sides (Keskin, 2005). In psychology, attachment is defined as an individual's tendency to expect for affection from another individual and feeling safe when this person is around. Attachment is a term used to refer to the positive connection between the child and adult individual -mostly mother and child-. Attachment theory was developed after animal observations and experiments (Soysal et al., 2005). A child's attachment to the mother affects adult behaviours which pass down and are explained through Bowlby's attachment theory (Keskin, 2005). The first studies regarding attachment were carried out by John Bowlby and his colleagues (Soysal et al., 2005). Bowlby is a remarkable researcher to have carried out empirical and theoretical studies with respect to relationships in a infant's life and according to his Attachment Theory if an infant fails to develop safe attachment relationship with one person or more, her/his ability to develop close relationships in adulthood will lessen (Feeney, 1999). According to Bowlby, attachment has a vital importance for the child. As a result of animal observations, he concludes that following or attaching to the mother increases the infant's chance to survive and emphasizes that attachment in human beings has a more important function (Tüzün & Sayar, 2006). A constant and quality relationship with the caregiver is important for the infant's emotional and social development and in this relationship the caregiver is mother except for special cases such as death. Attachment occurs as a result of affection reflecting from the mother figure. If the mother develops a close, affectionate, and safe relationship with her own parents, this will reflect to her marriage and relationship with her child (Soysal et al., 1999; Greg, 2005). Parents are the key role in infancy for a healthy emotional development. The quality of the infant's relationship with the primary caregiver is closely related to many psychopathologies that emerge in the first three years of her/his life. Thus, determining the relationship patterns and dynamics in the infant-primary caregiver relationship is rather significant (Greg, 2005). Bolwby (1988) emphasized that newborn infants needed to develop a relationship with their caregivers. The relationship between the mother and the infant becomes apparent through seeking for affection. Goodfriend (1993) stated that in babies who were taken to special care unit right after labour, development slowed down or halted, 

Assist. Prof. Dr., Celal Bayar University Health Sciences Faculty, Midwifery Department

that these babies did not eat, experienced social withdrawal and had a sad expression on their faces (Soysal et al., 2000). According to the attachment theory, human beings are social beings and do not perceive other people as sole instruments to satisfy their basic needs. In this sense it is similar to Object Relations Theory. For some attachment theorists, the quality of the relationships an individual develops with others in adulthood and her/his expectations are determined with the attachment relationship with the mother developed in infancy. Attachment is composed of comfort and support that occur as a result of affection between the mother and the child in times of fear and stress. Attachment is a bilateral relationship and develops when both sides meet each other's needs. A newborn infant needs a mother or another caregiver to be nourished, cleaned, protected, and to warm. However, parents or other adults responsible for caring the child do not perceive caring for the child as a duty. They take this as a source of happiness and satisfaction. The tie between the parents and child strengthens as a result of the interaction between these individuals. Some behavioural characteristics of the child affect the development of this attachment. The behaviours which the infant shows when communicating with the parents and which develop in the first 9 months are called attachment behaviours. Sucking, snuggling/lying down, looking, smiling, and crying are main attachment behaviours (Morsünbül & Çok, 2011). Attachment is a dynamic process which might be affected from various factors. Attachment problems may occur in premature babies, multiple pregnancies, and babies with sensation disorders or serious illnesses, abused and adopted babies. Also, parents' mental or psychological problems, exposure to maltreatment and domestic stress may cause attachment problems. Furthermore, infant's temperament, illnesses, parents' emotional disorders, and being inexperienced (adolescent motherhood) may play a negative role on attachment (Özmert, 2006). Signs of inappropriate or unsafe attachment are as follows:  A reserved infant who ignores parents or does not seek comfort in them,  An infant who does not look for her/his parents and show similar intimacy towards all adults,  An infant with nourishment problems (overeating or undereating)  Depressed and reserved parents,  Domestic stress, conflict, irregularity (Özmert, 2006). MOTHER- INFANT ATTACHMENT Attachment is an infant’s feeling safe which develops following repetitive and positive mother-infant interaction. It is the process of love interaction between mother and infant (Kavlak & Şirin, 2009). Maternal attachment is the process in which love bonds emerge as a result of a satisfying and delightsome interaction between mother and infant (Mercer & Ferketich, 1994). Maternal attachment is an indicator of love that develops between mother and infant and becomes consistent through time. Attachment is an element of maternal role adaptation (Kavlak & Şirin, 2009). Maternal attachment is a unique relationship that develops in time, which affects a child's physical, psychological, and intellectual development. Mother-infant attachment process develops during pregnancy, labour, and post-partum period and is supported during mother-infant interaction in the postpartum period (Tilokskulchai et al., 2002).

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Bowlby defined maternal attachment as the warm, continuous, and close relationship between mother and child and as both sides' being satisfied with this situation (Söhmen, 2002). In their study, Rubin (1984) defined attachment as love and affection. Maternal attachment is one of the tasks in maternal role acquisition which starts in pregnancy, continues in postpartum, and supports development of maternity role and role satisfaction (Müller, 1996). Fennelet al., (1974) examined maternal behaviours of two mother groups. In the first group, mothers were allowed to interact with their babies in the first three days after the labour. The mothers in the second group saw their babies for shorter durations, hours later for identification and then nursed their babies for twenty minutes every four hours. After one month and one year it was found that mothers who had an early and longer contact with their babies were more attached to their babies. The mothers frequently stated that they missed their babies and needed to talk about their babies more. Also, they tended to attend doctors during examinations, relieve their babies when they cried and talk to them (Ünal, 2004). There are individual differences in parents-infant interaction. According to Sternet al., (1973) there might be changes in the characteristics of well adjusted mothers who adjusted best when their babies were 1 year old; however, it was found that what these mothers had in common was their ways of approaching their responsibilities. These mothers tended to be child-oriented and were attending to their babies emotionally. Parental-oriented care is a parental attitude which involves difficulties such as having adult needs, programs and being "competent" parents and raising a "competent" child (Ünal, 2004). Parents should be guided to develop safe attachment. The first step of this attachment is mother and infant staying in the same room and evaluating infant's hints coherently. Moreover, it is important that mother nurse the infant (eye contact, embracing the infant frequently) and that mother feel safe and comfortable during nursing (correct nursing techniques) to ensure safe attachment. Infants recognize voices and love human faces. Touching the infant, playing with her/him, and being coherent in terms of satisfying her/his needs will increase attachment. Physical contact should be increased (Özmert, 2006). FATHER- INFANT ATTACHMENT Parents play the key role to create a healthy emotional development during infancy (Soysal et al., 1999). Biologically, every child has parents and both of them play a significant role for the child's identity development. Not having one of the parents or being born from impregnation with sperms taken from an unknown donor might have important effects on the child's identity development. Both parents have an effect on the child's care and being harmed. Various studies have focused on the dynamics between the mother and children. Fathers have been assumed to be in the periphery of the child and to have less direct effects on the child's development (Erdoğan, 2004). Women's entering into business life, gender-based stereotypes decreasing, and men's searching for deeper meanings in their lives have caused them to develop closer relationships with their children. Although a father's relationship with the child is less than mother's, the relationship between the father and child has grown at a rate of 1/3. Also, children's access to their fathers has increased at a rate of 1/2. Emphasising 245

father's role on child's healthy development is important for mental health. First of all, it is a known fact that father's direct involvement in infant's care, quality of mother-child relationship, and quality of father-child relationship affect child's development and safe attachment. Also, accessing parents creates emotional support. Secondly, father-child relationship is known to be different from mother-child relationship. Fathers spend more time on supporting their children to be competitive and independent and on physical stimulants compared to mothers. Thus, fathers might affect some of the child's behaviours. A father's indirect participation in the child's care and financial contribution to the family budget affect infant's development (Erdoğan, 2004). Attachment theory is based upon creating safe infant-parent attachment when the infant sends signals and caregiver responds to these signals appropriately (Bowlby, 1953). However, it is not clear whether this term involves males or not. Recently, attachment theory has evolved in a way to involve father figure as well. Some studies were carried out to understand whether an infant feels attached to the father or not (Erdoğan, 2004). In the study done by Kotelchuk (1970) it was pointed out that it was possible to understand father-infant attachment when the infant showed anger for being separated from the father. It was also found that babies who were 12, 15, 18, and 21 months old, got angry upon being separated from the mother or father and felt relieved when they came near again. 50% of the babies preferred their mothers when they were separated from one parent, 30% preferred their fathers, and 20% preferred none of them (Kotelchuk, 1976). In their study Spelkeet al., (1973) observed that interested fathers who contributed to the child's care developed these findings and babies showed less and late anger reactions. However, there is no data regarding the 6-9-month-old babies who show stronger maternal attachment feelings. All these studies show that father-child attachment increases when the father participates in caregiving process, but since mothers are still the main caregivers in many families, preferred attachment figure continues to be mothers. Besides, it was shown in a number of studies that early and strong attachment occurred between father and child (Erdoğan, 2004). NURSES' RESPONSIBILITIES WITH REGARD TO INFANT-PARENTS ATTACHMENT Attachment is an expected and emotional situation which starts in the first days of life (Soysal et al.,. 2005). It is known that physical contact during the first hours and days after labour contributes to attachment (Yapıcı & Yapıcı 2005). In order for midwives/nurses to evaluate mothers' attitudes towards their babies appropriately, they should know that they are responsible for developing a normal attachment process and positive mother-infant relationship in the post-partum (Kavlak & Şirin, 2009). Nurses should help families start and continue love formation in the attachment process before, during, and after labour using conscious nursing approaches (Beydağ, 2007). During postpartum period, nurses should carry out regular observations to evaluate mother-infant relationship and make notes regarding the attachment process. Among appropriate attachment behaviours are calming down, caressing, embracing the infant, talking to the infant, using appropriate feeding techniques, making eye contact, and 246

calling her/his name (Taşkın, 2011). Nicknaming the infant, poor weight gain, being dirty and uncared, hindering hygienic care, and developing a serious rash are signs of insufficient attachment between the mother and infant. In this case, nurses should mentor the mother, talk about her feelings regarding the infant, and support mother's actions with respect to infantcare (Taşkın, 2011). Nurses should explain the infant's characteristics to the mother in a kind manner and give her a chance to declare her expectations from the infant. Also, nurses should inform the mother on infant's hearing, seeing and reflexes (Kavlak & Şirin, 2009 ). Nurses should empower family's coping strategies, help increase their confidence in infant-care and develop maternal/paternal roles (Beydağ, 2007). Nurses should support and encourage families to increase the quality of familyinfant interaction by considering that attachment is a multifactorial process (Kavlak & Şirin, 2009 ). Nurses should inform the families who cannot make contact with the baby for various reasons on the fact that this will not create direct problems and relieve them because although early contact is a factor that strengthens the formation of attachment relationship, it is not indispensable (Soysal etal., 2000). Nurses should explain mothers that continuing interaction is of great importance for the infant's development and will affect her/his whole life (Beydağ, 2007). Mothers with attachment problems should be observed and nurses should strive to prevent possibilities for future child abuse and neglect (Kavlak & Şirin, 2009 ). REFERENCES Bowlby, J. (1953). Child Care and The Growth of Love.12-16 pp., Great Britain: Hazell Watson & Viney Ltd. Great Britain. Erdoğan, A. (2004). Çocuğun Psikososyal Gelişiminde Babanın Rolü. Yeni Symposium 42 (4), 147-153. Feeney, J.A. (1999). Adult Attachment, Emotional Control, and Marital Satisfaction. Personal Relurionships 6 (1999), 169-185. Greg, M. (2005). Attachment in Early Childhood: Comments on van IJzendoorn, and Grossmann and Grossmann. Encyclopedia on Early Childhood Development 6, 1-4. Kavlak, O. & Şirin, A. (2009). Maternal Bağlanma Ölçeği’nin Türk Toplumuna Uyarlanması. Uluslararası İnsan Bilimleri Dergisi 6(1), 188-202. Keskin, S. (2005). Çocuk-anne İkili İlişkisi Koşullu mu?. Türkiye Klinikleri 25(6), 781-785. Kotelchuk, M. (1976). The Infant’s Relationship to The Father: Experimental Evidence. Lamb ME, editor. The Role of the Father in Child Development. p. 329-344, New York: Wiley. Mercer, R.T. & Ferketich, S.L. (1994). Maternal-Infant Attachment of Experienced and Inexperienced Mothers During Infancy. Nursing Research 43(6), 344-351. Morsünbül, Ü. & Çok, F. (2011). Bağlanma ve İlişkili Değişkenler. Psikiyatride Güncel Yaklaşımlar 3(3), 553-570 Müller, M.E. (1996). Prenatal and Postnatal Attachment: A Modest Correlation, JOGNN 25(2), 161-166. Özmert, E.N. (2006). Erken Çocukluk Gelişiminin Desteklenmesi-III: Aile. Çocuk Sağlığı ve Hastalıkları Dergisi 49(3), 256-273. Spelke, E.; Zelazo, P.; Kagan, J.; Kotelchuk, M. (1973). Father Interaction and Separation Protest. Developmental Psychology 9(1), 83-90. 247

Soysal, A.Ş.; Ergenekon, E.; Aksoy, E. (1999). Yenidoğan Döneminde Hastanede Uzun Süreli Tedavi Görmenin Bağlanma Örüntüsü Üzerine Etkileri: Bir Olgu Sunumu. Klinik Psikiyatri 2(4), 266-270. Soysal, A.Ş.; Ergenekon, E.; Aksoy, E.; Erdoğan, E. (2000). Doğum Türü Değişkeninin Bağlanma Örüntüsü Üzerindeki Etkilerinin İncelenmesi. Klinik Psikiyatri 3(2), 75-85. Soysal, Ş.; Bodur, Ş.; İşeri, E.; Şenol, S. (2005). Bebeklik Dönemindeki Bağlanma Sürecine Genel Bir Bakış. Klinik Psikiyatri 8(2), 88-99. Söhmen, T. (2002). Çocuk Ruhsal Gelişiminin Temel İlkeleri. 53/dahilibilimler/cocukruh/gelişim.htm, Tarama Tarihi: 18.12.2015 Taşkın, L. (2011). Doğum ve Kadın Sağlığı Hemşireliği, Sistem Ofset Matbaacılık Genişletilmiş II. Baskı, 474 s., Ankara. Tilokskulchai, F.; Phattanasiriwethin, S.; Vichitsukon, K.; Serisathien, Y. (2002). Attachment Behaviors in Mother of Premature Infants: A Descriptive Study in Thai Mothers. Journal of Perinatal&Neonatal Nursing 3(16), 69-83. Tüzün, O. & Sayar, K. (2006). Bağlanma Kuramı ve Psikopatoloji. Psikiyatri ve Nörolojik Bilimler Dergisi 19(1), 24-39. Ünal G. (2004). Bir Grup Üniversiteli Gençte Çekingenlik, Aleksitimi ve Benlik Saygısının Değerlendirilmesi. Klinik Psikiyatri 7(4), 215-222 Yapıcı, Ş., Yapıcı, M. (2005). Çocukta Sosyal Gelişim. Bilim Eğitim ve Düşünce Dergisi 5(2), 2-7.

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Chapter 23 Complementary and Alternative Medicine (CAM) in the Treatment of Infertility Yasemin AYDIN, Merve KADIOĞLU INTRODUCTION Infertility, for couples, is a psychologically threatening, emotionally stressful, economically expensive, painful because of the diagnosis and therapy procedures, and a complicated life crisis (Sezgin & Hocaoğlu, 2014). One of the basic instincts of humankind is procreation and generation instinct. Although, the idea of completion family, smallest unit of societies, with a child, it has left its traditional appearance and become an expanded concept universally. Individuals which could not play the role of parenthood, feel that they could not complete adult identity, and accept this situation as a big defectiveness. As a result of feeling of inadequacy, in time, they become isolated from their environment. Thereby, infertility, is not a simple gynecological syndrome, it is such a situation that affecting individuals negatively, especially women, in terms of biological, psychological and social aspects and thereupon, it decreases health and life quality (Eryılmaz et al., 2009). Infertility, prevails among mainly in developing countries, it affects 30% of the couples worldwide (WHO, 2003). According to the World Health Organization (WHO), infertility affects 50-80 million women around the world. Internationally compiled in 25 countries, in a meta-analysis study which was conducted with 172413 women, infertility prevalence stated as 3.5-16,7% in developed countries, 6.9-9.3% in less developed countries, and in the regions alike African regions below Sahra Desert, this rate stated as 6.6-26.4% (Boivin et al., 2007). One in ten women in world, one in seven couples in UK, one in six couples in USA has going through infertility problem (Kırca & Pasinlioğlu, 2013; Boivin et al., 2007). It is reported that this situation affects 1520% of the married couples in Turkey. According to European Infertility Guide, 25% of the couples cannot have a child in a year, 15% of them are in search for a treatment to infertility, 5% of them are not be able to have children even they want it dearly (Dohle et al., 1992). Infertility reasons are very complicated; therewith its therapy is complicated likewise. Treatments, which are applied for infertility, generally contain assisted reproductive techniques. During infertility treatment, in addition to assisted reproductive techniques, Complementary and Alternative Medicine (CAM) therapies are favored by patients often. Moreover, in consequence of proof essential studies, in treatment of infertility, biomedical treatment and CAM are proposed for its application on patients together (Bardaweel, 2014; Kessler et al., 2015). 

Dr., Department of Midwifery, Faculty of Health Sciences,Sakarya University, Sakarya, Turkey  MSc., Department of Nursing, Florence Nightingale Faculty of Nursing, Istanbul University Istanbul, Turkey

COMPLEMENTARY ALTERNATIVE MEDICINE SYSTEMS National Center of Complementary and Alternative Medicine (NCCAM), has defined CAM as a wide health area which consist of all health services that stay out of the politically dominant health system in a society or culture, methods, applications and theories and beliefs which accompanies to all mentioned. Alternative Medicine defined as every kind of health service that replaces medical treatments and applications which are not accepted by modern biomedicine or treatments, on the other hand, Complementary Medicine defined as, with medical treatment, consists of treatments and care systems that apply on patients in addition to medical treatment. Complementary and Alternative treatments are implemented in order to; enhance life quality, decrease side effects of symptom and drugs, provide physical and psychological support. Moreover, cultural sensitivity is an important component of complementary and alternative treatments, thereupon; complementary and alternative treatments became popular in infertility treatment. In literature, Complementary and Alternative Medicine approaches, which were used by individuals who try to cure their infertility problem, are limited. In a study, which was conducted in Australia, CAM methods, which used by 200 infertile women and men patient, evaluated and massage, acupuncture, herbal, vitamin and mineral supports were stated as the most common used methods (Stankiewicz et al., 2007). In a study, which was conducted by Bardaweel in Jordan, it was reported that 428 infertile male patients used at least one of the CAM methods, herbalism and multivitamin were the most popular among all (Bardaweel, 2014). In a study which was conducted in UK, 157 infertile patients from nursing homes, 181 patients from national health center were taken into research and it was determined that 63% of female patients, and 25% male patients were using CAM. In the study, 10% of women stated that CAM methods which they use, are effective in treatment of infertility and 22% of women said these methods help them to relax. Besides, it was stated that in this study, doctors were motivating infertile individuals to use CAM applications and they were taking feedbacks from the patients (Boivin et al., 2007). In a study which was conducted in USA, it was determined that 86% of 126 male and female patients, who are members of an organization that supports infertile couples, were using one of the CAM methods in addition to conventional medicine (Covington et al., 2006). In a study which was conducted with 995 doctors and 358 infertile patients, by Clark et al., 73% of patients believed that CAM therapies are beneficial, 23% of them were benefited from CAM therapies and 8% stated that they started CAM methods because of the recommendation of doctors. It was determined that, 60.4%of the doctors recommends acupuncture, 54.7 % recommend motivation and 40.9% recommend massage therapy as a CAM method (Clark et al., 2013). NCCAM classified Complementary and Alternative Medicine applications in to five different groups. • Alternative Medical Systems • Biologically Based Applications • Mind, Body Based Applications • Energy Therapies (Bio-area and Bio-electromagnetic) • Manipulative and body based applications

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1. Alternative Medical Systems Approaches which consist of cultural based systems like homeopathy, naturopathy and ayurveda. Studies which consist of alternative medical system applications on individuals, who are experiencing infertility problem, are limited. Homeopathy: It based on “treating similar with similar” principle. According to NCCAM, it defined as a method that provides treatment with diluted concentration of a substance which was produced with similar symptom s. In other words, it is a method that aims to increase individuals’ health situation with drugs which were selected exclusively for the patient (Sezer, 2015). Many of the Homeopathic drugs are in use of infertility and abortion treatment, sadly, in literature, limited numbers of studies were determined. It was stated that effectiveness of Homeopathy method can increase, if it combines with supportive reproduction techniques (Covington & Gutmann, 2006). When limited studies examined in literature; it was stated that, in a study which was conducted by Gerhard and friends (2002), homeopathic drugs, which were prescribed to 45 infertile male patients, were given for 10.3 months and important improvements in sperm intensity and sperm motility, especially at patients who were diagnosed with oligospermia, were stated (Gerhard and Wallis, 2002). Furthermore, improvement in health situation was stated, such as decrease in smoking and consuming of alcohol, overcoming the stress, protection from infections. Likewise, increase in sperm motility and semen amount of the infertile animals, which were treated with homeopathy, and decrease in sperm defects were determined (Lobreiro, 2006). In another study which was conducted with four pure blood bulls, which have reproduction disorder, homeopathic treatment was added into manures, and improvement in semen quality of bulls and semen amount was identified (De Souza et al., 2012). In Germany, in a study which includes women who were diagnosed with infertility and anovulation, homeopathy was applied on patients and positive results, such as increase in level of progesterone concentration at more than half of the patients and ovulation, were obtained. In comparison with placebo group, positive pregnancy results in homeopath group were found meaningfully high (Bergman, 2002). Ayurveda: It defined as “Art of Healthy Living”. Ayurveda, reveals the ways of long and healthy life and while doing this, gives recommendations about nutrition, lifestyle, physical and psychological health protection, uses meditation, yoga techniques and benefits from natural treatments and healings in case of an illness (Buduru & Vedantam, 2016). Ayurveda, targets to live a long and healthy life, by decreasing effects of time and taking immune system to its best state. When the literature examined, two studies, which includes Ayurveda implementation on individuals who are experiencing infertility problem, were found and one of them was a case report. In the case report, which was conducted in Germany, Ayurveda treatment, which includes nutrition and lifestyle modification,was implemented on 38 years old female patient, who was diagnosed with idiopathic infertility and has an unsuccessful 11 IVF treatment background. As a result of the treatment, it was stated that, pregnancy was positive (Kessler et al., 2015). In the study of Dayani and friends, which was conducted on 40 sub fertile patients who have polycystic ovary syndrome, effectiveness of Ayurveda treatment regimen on sub fertility was examined. 3 phases Ayurveda treatment was implemented on patients for 6 months and symptomatic relaxation and betterment in hormone levels were 251

determined. Besides, in the study, it was reported that sub fertile individuals with PKOS, can be cured successfully with Ayurveda regimen (Dayani et al., 2010). Naturopathy: This approach, which named as Naturopathy or natural medicine, comes from the idea that body can restore itself and able to maintain this situation. Naturopathy, built on proposition that humans are naturally healthy and with the removal of obstacles in front of the healing and stimulation of natural healing ability of human body, healing will be occurred (WHO, 2010). Basics of Natural medicine are diet, nutrition, homeopathy, physical manipulation, stress management and exercises. In literature, studies, which include naturopathic treatment approach with C.sinensis dietary supplement to infertile individuals, have encountered. Guo reported that when C. sinensis supplement was administered to 22 males for 8 weeks, it showed 33% increase in sperm count and 29% decrease in the sperm malformations, and 79% increase in the sperm survival rate (Guo, 1986). Huang et al. reported that C. sinensis dietary supplement can cause the prevention and improvement of adrenal glands and thymus hormones, and the infertile sperm count improved by 300% (Huang et al., 1987). 2. Biological Based Applications Biological based applications are based on natural substances, such as, vitamins, minerals, amino acids and nutriments (Bennington, 2010). Preferred for infertility treatment or in use to increase fertility ability, sadly, the evidences in literature are inadequate. Black cohash, blue cohash, dong quai, crampbark, netle leaves, false unicorn root, watergrass and St. John’s Wort, evening promise oil are the most common substances that in use for fertility, among women (Covington & Gutmann, 2006). However, more studies are needed to prove its efficiency on fertility treatment. Viteks/Chestetree plant is in use for ovulatory disorder at women. In a study, which was conducted double blind, in addition to nutrition, Viteks and green vitamin, and minerals has added and 4 months later, it was seen that luteal phase was getting longer and in this phase, progesterone level was increasing (Avcıbay & KızılkayaBeji, 2013). In a randomized controlled, double blind prospective study, 30 drops of Viteks implemented on infertile 96 women twice a day, for 3 months. In the end of the study, it was determined that; women who have amenorrhea, used viteks during the study, spontaneous menstruation and luteal hormone concentrations’ recovery were meaningfully high and pregnancy rates were two times more than the placebo group (Gerhard et al., 1998). In the studies which were conducted as randomize controlled, various views stated that, C vitamin which was taken for luteal phase problems, has increased progesterone concentration and pregnancy rate (Covington & Gutmann, 2006). In another studies, it was determined that high C vitamin support doses can create negative results (Gardiner, 2011). Positive results were stated when C vitamin used in follicular phase, on IVF treatment implemented patients (Covington & Gutmann 2006, Gutmann, 2010). Basically, vitamins and minerals are not enough in order to increase fertility and as a supportive fact, in the light of the proofs, it is suggested that it should be integrated to treatment plan (Gardiner, 2000). In a randomized controlled study, which examines phyto-estrogen activity, it was 252

determined that high doses of phyto-estrogen increases endometrial thickness at women who were implemented with clomiphene citrate, besides, it increases pregnancy rate of women who are treated with IVF treatment (Gardiner, 2011). It was stated that many plants, such as Trichopus zeylanicus, Vanda tessellata flower, Tribulus terrestrisare effective on men fertility, especially, libido, erection and ejaculation disorders and sperm abnormality like azoospermia and oligospermia (Nantia et al., 2010). It is possible to say that, some nutrition sources like L-carnitine, improves seminal parameters. Furthermore, there are studies exist that state it is effective on sperm count, motility and morphology (Özcan & Beji, 2016). Likewise other biological based agents, minerals affect semen capacity. Especially, zinc is primary resource for spermatogenesis. Vitamin supports are in usage of treatment of male infertility. As a result of randomized controlled studies, it was stated that C and E vitamins increase sperm quality (Moslemi & Tavanbakhsh, 2011). Moreover, views stated that B12 vitamin increases sperm count (Avcıbay & KızılkayaBeji, 2013). An antioxidant cure which consists of 6 mg of Lycopene, E vitamin, 400 IU vitamin, 100 mg of zinc, 25 mg or selenium, 0.5 mg of folate and 1.000 mg of garlic, has examined in a randomized controlled blind study and according to the result of the study, pregnancy rate of the group who takes antioxidant was found meaningfully high (Tremellan et al., 2007). In literature, it was stated that, many herbal nutriment and nutrition support make improvement in seminal parameters. Although, increase in sperm count and its motility, not always related with increase in pregnancy rate. Because of this reason, in order to determine the effect of vitamins, minerals and nutrition supports on pregnancy and effects on male fertility, more studies are needed. 3. Mind Body Based Applications Mind body model, is a health systems integrated approach that gathers modern medicine and traditional healing system (Barrows& Jacobs, 2002). Mind and body have effect on each other and in the continuity of health they are complementary to each other. According to NCCAM, mind body based applications were classified into 4 topics. These are; art therapy, meditation, biofeedback and yoga. The reasons behind why mind body based applications were chosen by infertile couples are; mental relaxation, managing the difficulties which came out during the treatment and psychosocial health support (Lemmens, et al., 2004). Art Therapy: It requires joint work of an art educator and therapist and it is such a therapy method that art integrates into medical treatment. Expression of individuals by art, transfer of inner and outer world senses through art, are expected (Woodcock, 2003; Lemmens, et al., 2004). It supports the patient in psychosocial way with an expressionist method. When communication support and oral therapy is not enough, it is such a way that provides efficient communication of individuals (Aydın, 2012). It is an alternative communication channel that helps patients to express their feeling about infertility and its effects in their lives (Manicom & Boronska, 2003). McMaster University Hamilton Health Sciences Centre stated that priority base is; to ensure efficient and secure medical treatment and search of ways in order to lower the emotional pressure on individuals. They stated that, art therapy is an efficient method to fight with difficulties during treatment (Hughes, 2010; Gardiner, 2011). It was reported that, among infertile women, art therapy is a strong healing tool for 253

expressing emotions with visual expression (Hughes& Silva, 2011). Expressing themselves reduce stress, anxiety and hopeless feelings, besides, infertile women stated that sharing which done in groups that made for art therapy, gives social wealth (Aydın, 2012).Creative art therapy, is a kind but strong way that helps couples to express themselves. Furthermore, it helps individuals to express themselves freely. Art therapy analyzes the images and art work of patients and guides them. It contributes individuals in terms of managing problems which came out during treatment process, and at the same time, it helps them to explore and express themselves, their bodies and emotions (Hughes &Silva, 2010). Expressing emotional burden may increase the chance of pregnancy. In the study of Hughes and Silva (2010), art therapy was implemented to 21 sub fertile women for 2 hours every week, during 64 months. Effects of art therapy on despair, depression and anxiety were examined and decrease in the levels of depressive mood and despair were determined (Hughes &Silva, 2010). Meditation: It is a technique that enables individuals to control their thoughts. Although, there are many varieties of meditation, it implemented in western medicine because of the facts that it improves psychological health and increases life quality. Meditation determines the effect of stress on body and fertile ability (Gutmann, 2010). In Peter’s (2004) study on 2055 people, identified meditation as the most commonly used method (Peter, 2004). In another study, 110 infertile women divided into 3 groups; meditation and yoga from relaxation therapies were implemented on first group, medical infertility treatment implemented on the second group, and both therapy and treatment were implemented on the third groups. After one year, groups were examined and pregnancy rate of second group found as 20%, and for the third group, which yoga and meditation implemented in addition to infertility treatment, the rate found as 50% (Özcan & Kızılkaya Beji, 2016). Biofeedback: It is a kind of behavior therapy that aims to change learned answers for stress creating factors. It is such an approach that helps individual to analyze self reactions which come out under stress. Biofeedback teaches the ways of understand the individuals’ own physical reactions and control (Peper, 2009). Studies, which intended to cure infertility with biofeedback, are very limited. In the study of BodombossouDjobo and friends, which was conducted in order to improve pelvic floor and endometrial thickness of infertile women who have thin endometrium, vaginal electrical stimulation was implemented on 41 patients, and later, they were required to continue Kegel exercises in home. Biofeedback was taught to patients in order to understand if the correct muscle groups are working or not during Kegel exercises. In the end of the study, positive results on endometrial thickness and pregnancy rate after IVF were obtained (Madafeitom Bodombossou-Djobo et al., 2011). Yoga: It means unity between mind, body and soul. Its content made of physical stances and breathing exercises. Yoga therapy focuses on energy systems in our body and different chakra areas (Sengupta, 2012). Yoga is a supportive method for enhancement of fertility ability. Yoga is a type of exercise that is designed to assist couples who are having difficulty getting pregnant (Gaware, 2009). Adhering to the basic principles of yoga, fertility yoga combines traditional yoga postures with postures that have been specifically developed in order to improve individual is reproductive health, thereby increasing their chances of getting pregnant. Yoga for fertility improves both female and male infertility by minimizing stress, which in turn balances the hormones of the body as well as one is mental health, thereby increasing a couple is 254

ability to conceive (Gaware, 2009). Studies report that stress affects IVF results negatively and changes pregnancy results. Thus, it is suggested to increase pregnancy chance during IVF stage. Hence, in the study of Valoriani on 143 women, yoga trainings were given for 3 months before IVF treatment, and according to study result, it was reported that stress level of women who do yoga, decreased meaningfully (Valoriani, 2014). In another study which was performed on 49 infertile women, 6 weeks of yoga classes were provided to participants during the IVF treatment process (Boivin et al., 2011; Pasch et al., 2012). In the end of the study, level scores of anxiety and depression were decreased and increase in life quality of participants was determined (Oron, 2015). Along with better management of stress, yoga therapy also helps to improve circulation, promote proper functioning of the internal organs. In men, practicing moolabandha has been associated with relieving spermatorrhea, preventing inguinal hernia, and controlling testosterone secretion. The practice of moolabandha is used to enhance awareness of genital arousal sensations, and in this way, may be a helpful adjunct for improving sexual desire and arousal (Sengupta, 2012). In addition, as men age, their production of dehydroepiandrosterone (DHEA), as well as testosterone and other androgens or sex hormones decline. It has been estimated that for every year over the age of forty, men's testosterone level drops by one percent. About 20% of men in their 60's have significantly reduced testosterone levels. As testosterone is a key hormone in men's sexual functions, aging-related decline in testosterone levels has a negative impact on men's sexual performance. Yoga therapy, by improving and integrating neuroendocrine axes, improves hormonal secretion. Thus, it improves sexual desire and overall reproductive health (Sengupta, 2012). 4. Energy Therapies According to NCCAM, Reiki, therapeutic touch, acupuncture and bioenergy has been identified as energy therapies. Scientific data related to effects of energy therapies on infertility, are very limited. These therapies are rarely in usage of infertility treatment and more proof based studies are needed (Gutmann 2010). Reiki: NCCAM classifies Reiki touch therapy as an energy therapy (Moquin et al., 2009). Reiki is an energy therapy that focuses electromagnetic fields outside of body and energy areas in the body and trained people implement it by touching energy centers of human body (chakras) (Bossi et al., 2008). When the proof based randomized controlled studies, which analyze reiki’s therapeutic effect, examined, it was reported that it has effects such as; pain relief (especially post-operative and cancer), anxiety/depression reduction, improvement in quality of life, fatigue reduction, blood pressure and heart rate regulation, ensuring comfort and relaxation(Erdoğan & Çınar, 2012).It was stated that Reiki lowers the stress, which originated from infertility, supports treatment and ensures a spiritual and mental relaxation ( Miles &True, 2003 ). Therapeutic Touch: Therapeutic touch, based on the assumption that body surrounds with energy fields called aura, is the usage of hands as therapeutic purpose. It provides healing to illnesses and symptoms, which occurred because of imbalance in the energy areas, by affecting energy areas with hands (regulation of energy, balancing etc) (Turan, 2015). Since 1986, studies related to therapeutic touch that, reliefs pain, reduces anxiety and stress, prevents diseases, ensures spiritual wellness, and supports 255

medical treatment, exist (Kissinger &Kaczmarek, 2006; Wardell&Weymouth, 2004).As an easy applicable and non invasive approach, studies, which evaluate its effects on infertility, are very limited. In the study of Eugster and Vingerhoets, therapeutic touch was implemented on women, who were taking IVF treatment, in order to ensure relaxation and decrease at the level of stress and increase in pregnancy rates were determined (Eugster&Vingerhoets, 1999). Acupuncture: In today’s world, acupuncture is implemented by experts as a complementary in different types, such as body, ear, laser and electro acupuncture, in the treatment of various illnesses. In 2002, World Health Organization added infertility in the illnesses list that acupuncture cures, and its usage in treatment of infertility has started (Weissa, Harrisa & Smitha, 2011).. Especially, results of initiatives which was done before IVF-ET (in vito fertilization-embryo transfer), during treatment and after, were evaluated with many randomized controlled study. Study results support acupuncture and state that it lowers the stress level of mother during IVF process, provides an optimal environment by increasing the blood supply to the uterus for implantation and reduces the sensation of pain of mothers during operations (Manheimer, Zhang & Udoff 2008; Yu, So & Gao 2008).Data related to randomized controlled study results were given at Table 1. In randomized controlled studies which discussed in a systematic compilation, acupunctures were evaluated, which were implemented on 1366 patients who had embryo transfer, and rates of live birth and pregnancy rates were found 65 % higher than rates of control group (Manheimer, 2008). Positive results obtained in the studies which were implemented on infertile men. In the study of Dieterle and friends (2009), 57 infertile patients, who were diagnosed with oligospermia, compared with the placebo group. Although, there were important improvements in low semen volume and the number of motile sperm after acupuncture, pregnancy rates were not compared (Dieterle et al., 2009). In another study which was conducted randomized, acupuncture was implemented on 16 sub fertile men, samples were collected before acupuncture and 1 month later, comparison had made, and significant improvements were determined on functional sperm count, increase in survival rate and spermatozoa-acrosome integrity per ejaculate (Sherman, 1996). Proof based studies are needed for to understand acupuncture implementation duration, frequency, and which stage of IVF would be appropriate for acupuncture implementation in order to get the most efficient results. 5. Manipulative and Body Based Applications It is one of the most common alternative and complementary medicine methods for the infertility treatment. Under the umbrella of manipulative and body based applications, a heterogeneous group, which consists of CAM therapies, exists. It includes methods such as chiropractic and osteopathic manipulation, massage therapy, reflexology technique. Manipulative and body based applications firstly focused on bones, joints, soft tissues, and body systems like circulatory system and their structure.

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Massage: One the most common methods in infertility treatment. Especially, deep tissue massages; lowers the levels of blood flow, blood pressure, heart rate and stress hormones (Kaye et al., 2008). In the programs which called as “Clear Passage Therapies”, with soft tissue massages, positive results such as increase in the motility of the fallopian tubes and a reduction in cohesions were obtained. Furthermore, with this therapy, it was reported that pregnancy rates increased by 60% (Cavington, 2006). In the study of Wurn and friends (2004), intense pelvic massage was implemented on 14 infertile women, whom ages range between 25 to 44, and in the treatment of cohesions, 70% of success was obtained (Wurn et al.,2004). In the half experimental study of Valiani and friends (2010), which was conducted on 30 women, who applied infertility centre with endometriosis diagnosis, massages, which include abdomen and sacral region, implemented as to be 20 minutes sessions and according to result of study, it was reported that massage therapy can be used in treatment of endometriosis, relieving pain and improving women health (Valiani et al., 2010). Massage also exerts positive effects in male infertility. Nevertheless, the mechanisms of clinical effects are unclear (Hu et al., 2013). Reflexology: It was defined as a technique that is implemented on all the glands, organs and body parts and associated reflex points in the hands, feet and ears and helps to normalization of body functions (Stephenson, 2003;Vennels, 2004). In this method, with the stimulation of sensitive nerves, important chemical substances releases, at the same time blood stream fastens, and health and wellness keep protected. Reflexology assists in re-balancing the mind/body connection enabling the recipient to regain homeostasis (Tiran, 2010). Reflexology may assist with sub-fertility in helping the couple to relax and become less stressed as well as balancing the Endocrine system which is responsible for hormonal levels (Tiran, 2010). In the literature, Holt and friends study (2009) on infertility and fertility was found. In this randomized controlled study, 26 women who diagnosed with anovulation, were implemented with foot reflexology and 22 women who diagnosed with anovulation, were implemented with sham reflexology and the inductive effect on ovulation was searched. According to study results, 42% of women who were implemented with foot reflexology and 46% of women who were implemented with sham reflexology, showed ovulation (Holt et al., 2009). RESULT AND SUGGESTIONS In world and Turkey, despite of fast increase in TAT methods usage, proof based studies are only valid for acupuncture, some herbal drugs and massage types. Solely, many CAM applications became a part of modern medicine. Hence, complementary and alternative therapies are commonly used, in addition to supportive reproduction techniques, in the treatment of infertility. Thereby, infertility consultants must improve themselves on this topic. There is a need to specialized hands for CAM applications, for this reason, certificate or diploma necessity is inevitable. Moreover, more proof based studies are needed for these applications, which vary with culture, geography and traditions.

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Chapter 24 Elderly Home Care Services Nazife AKAN 1. INTRODUCTION

Health is one of the fundamental human rights. The principles of Constitution of the WHO emphasizes that; “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” and “Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures” (WHO, 2006). States in the scope of social state perception must ensure the needs of health and care of their citizens within the bounds of possibility (Kocak & Tiryaki, 2011). Health right is included as s standard in the list of rights of the sources of national and international law (Temiz,2014). According to the Article 25/1 of Universal Declaration of Human Rights, it is belowmentioned: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” (UNICEF, 2004). Health right has been guaranteed by the law in Turkey. According to the Article 56 of the Constitution of the Republic of Turkey, it is below-mentioned: “To ensure that everyone leads their lives in conditions of physical and mental health and to secure cooperation in terms of human and material resources through economy and increased productivity, the state shall regulate central planning and functioning of the health services. The state shall fulfil this task by utilizing and supervising the health and social assistance institutions, in both the public and private sectors.” And according to the Article 61 of the Constitution, it is belowmentioned: “The aged shall be protected by the state. State assistance to the aged, and other rights and benefits shall be regulated by law”(T.C.Anayasası, 2011). 2. CONCEPTIONS OF LONG-TERM AND HOME CARE In the previous millennium, developments in the field of medicine and health with the scientific and technological developments had led to decrease in deaths depending on diseases and length of lifetime. In many countries especially Europe, population rate of the aged people has been increasing and it is estimated that this increase will also continue in the coming years. According to data from World Population Prospects: the 2015 Revision ,the number of aged people —those aged 60 years or over—has increased substantially in recent years in many of the countries and regions, and that growth is projected to accelerate in the coming decades. Between 2015 and 2030, the number of people in the world aged 60 years or over is projected to grow by 56 per cent, from 901 million to 1.4 billion, and by 2050, the global population of aged people 

Assist. Prof. Dr., Toros University School of Health Sciences Department of Nursing

is projected to more than double its size in 2015, reaching nearly 2.1 billion. Globally, the number of people aged 80 years or over, the “oldest-old” people, has been growing even faster than the number of aged people overall. Projections indicate that in 2050 the oldest-old will number 434 million, having more than tripled in number since 2015, when there were 125 million people over age 80. The older population is growing faster in urban areas than in rural areas (UN, 2015). According to definition of the UN, if the old-age population rate is between %8 and %10 of total population, the population of that country is considered as “old”, but it is over %10, that country is considered as “too old”. According to population projections it is estimated that old age population rate will increase to %10, 2 in 2023, %20,8 in 2050 and Turkey will be among the countries with “too old” population (TUİK, 2014). The most rapid old-age population growth in the next 15 years will be occurred in Latin America and Caribbean (%71), Asia (%66), Africa (%64), and North America (%43). Japan (%33), Germany (%28) and Italy (%28) has attained the old-age population rate in 2015. Aged dependency rate is the number of aged people per 100 people in working ages. It is estimated that one of the 6 people will be aged over 60 and 76 dependent aged people per 100 capita in 2030. While the number of aged people that 100 employees have to nurse is 11,3 in 2013, this number is expected to be 19 in 2030 (UN, 2015;TUİK, 2014). Demographic and epidemiological changes show that, world population will lead to dramatic changes in health care needs and increase the rate of care-dependent people. Non-contagious chronic diseases will be the reason of disability and death depending upon the growth of old aged population in coming decades. In addition to this, it is leading to movement limitation depending age, and long-term health care needs depending mental deficiencies (WHO, 2003). The need for long-term health care because of disability depending congenital disability and aging and rapid increase of demand has led a term long-term care to enter in the literature of World Health Organization. Long-term care is to provide services being medical or not medical to the people with chronic disease or disability or who cannot maintain their self-care for a long time. Senior practitioners who will provide care in multiple chronic diseases of aged people and with people who will do the expertise-free works such as safety, help for daily housework, dressing, nutrition, bathing in long-term health care. Long-term health care is generally for aged people, but it may demanded by people of all ages (Brodsky, Habib&Hirschfeld, 2003). As long as people grows old, disability rate depending chronic diseases also increase. In Turkey disability rate of individuals aged over 70 depending chronic diseases increased to %36 in 2002, while it is %24,44 of individuals aged between 5059 (TUİK ,2009; Oğlak, 2007). In long-term health care, many institutions and people should act coordinately. Long-term health care methods are divided two categories as formal and informal in terms of people and institutions participating in the service delivery ways and the service. Formal method: is a service method which professional institutions such as health organizations, municipal authorities and social services provide service. Informal method: is the way of health care provided with social support systems such as family members and society (Brodsky et all, 2003). The duration of long-term health care needs will vary according to the reason of revealer of the need. Chronic diseases, permanent disabilities, dementia, receiving help for fulfilling the daily life activities and the need of supervision are the reasons needed for long-term health care lasting for 264

months or years, while taking rehabilitation, sickness, wound or postoperative healing process requires care lasting for few weeks/months (Dölek Önal, 2012). Treatments of early or late complications emerging from chronic disease lead to long-time occupation of hospital beds and increase of cost. This also leads to social, psychological and medical problems depending patients’ staying in hospitals for a long time (Başgül, Keskin, Kara & Aksoy, 2012). Many people prefer to take care at home when asked to choose an institution or home (Boerma & Genet 2012). Chronic diseases lasting long, congenital problems, disabilities and insufficiencies emerging from aging directs states and health organizations to policymaking for residential health care services. Lower costs of home care services than institutional care pushes countries to make health policies towards increasing home care services (Tarricone & Tsouros, 2008). Many countries adopt the understanding about home care and “aging at one’s own place” in long-term follow ups and care services (Brodsky et all, 2003).New technological developments also help coordinate the home care, control the patients provided home care by professionals and give the complex treatments to be done with equipment support at home (Tarricone & Tsouros, 2008). 3. HOME CARE Home care is to provide health services to needers in their own place in the process of diagnosis and treatment, a chronic disease follow ups, and providing protective health and observation services without any health problem. The aim of home care service is to minimize the effects of the disease and disability through reaching the best treatment effecting daily life conditions at least and to enhance the patient’s quality of life at the same time. This service is also necessary for those preferring to stay home and whose treatment, care continues; but cannot take care service by their family circle and friends (THK 1). It is suggested that disabled care must be directed at home care as possible with Regulation on Health Care Service Supply of the Turkish Official Journal no 25751 and dated 10/03/2005 and the Law on the Disabled and Amendments in Some Laws and Secondary Laws published on 01/07/2005 no 5378. The government has undertaken to pay the home care service of the disabled people carrying specific conditions (Aydın, 2005). 3.1. Historical and Philosophical Development of Home Care Home care services emerged with provision of birth helping services at homes in ancient times. In medieval Europe, home care service was provided for the prevention of contagion of the diseases to other people in the way of social service such as housing, feeding. Such services created the infrastructure of organizedly providing help and care to people who were poor, sick and in need of care. At the beginning of 20th century, increase in industrialization and urbanization led to people’s impoverishment and deterioration of social conditions, this generated the social aid and care need. In England, private dispensaries were established for children and old people in need of care. Home care was provided by voluntary institutions under the leadership of the church for a long time. And organized home care emerged in 1859 for the first time. The English anthropologist William Rathbone who was impressed by the service of a nurse hired to car for his wife, established a voluntary nurses’ service to provide home care to poor 265

patients. Mary Robinson was the first nurse in Liverpool who provided nursing service at home. Mary Robinson also educated family members about patient care and health rules as well as nursing care. Florence Nightingale who is the leader of nursing services and education argued that women to take the charge in hospitals and home visits must be specifically educated and this assignment must be done in the framework of a plan. In Liverpool, the first school training nursing visitors to provide home care was opened in 1862 at the suggestion of Nightingale (Aksoy, Kahveci, Sencan, Kasım, & Özkara, 2015; Sezer, Demirbaş & Kadıoğlu, 2015). Nightingale supported the idea that nursing care can be provided in patients’ homeas well as hospitals and estimated that home care will substitute the hospital care in the coming years. Nurses can help patients maintain their daily lives and independencies in their home. According to Nightingale, the term home care has the same meaning as the normalization of daily life. Nightingale used the term home nursing in the early 1900s (Ogawa, 1997). Boston Dispensary is the first institution established in 1796 which provided home care in the USA. In the late 1800s visiting nursing organized by voluntary institutions linked to the church. These institutions used to assign compatible people who didn’t have license to provide care for patient people and their families. New York established a voluntary agency in Buffalo, which provided nursing care at home in 1885. In 1886, other voluntary agencies providing services like home care were established in Boston and Philadelphia. These institutions established Visiting Nurses Association in the later years (Rice, 2006a). In 1898, Los Angeles Health Department began to employ certificated nurses to visit poor patients at home. Therefore, home care services organized by the government have emerged. In the later years, the conceptions of public health nursing and visiting nursing were developed (Aydın, 2005). In 1890, there were 21 VNS (Visiting Nurse Association) in the USA and only nurses were employed in the majority of those. In 1908 some of them were guaranteed by New York Metropolitan Life Insurance. In the early 1900s, the majority of the society turned to take service from nurses for the solution of health problems caused by industrialization and rapid urbanization. In this period, many educated and uneducated nurses working freelance begun to provide 24 hour care per day to people who had acute and chronic diseases in their home.. In the same years, an organization named “Frontier Nursing Service” established in Kentucky provided educated midwives and family nurses and health care for poor mothers and children living in rural and mountain areas and who couldn’t benefit from health care services, also undertook the education of midwives and family nurses assigned in these areas. In the regions that Frontier Nursing Service provided service, premature births and mother and baby death rate reduced considerably (Rice, 2006a; Adams, 1986). Home health care services have continued to be freely provided by volunteers or community health care unit after the Second World War. Before 1960s, home care used to be considered as a public service. The basic mission of agencies such as VNA is to provide qualified home care service for all patients regardless of ability to pay. State subsidy, private foundations and donations and aid organizations has supported these agencies to maintain their missions (Rice, 2006a). In the half 1960s, the increase in the aged population, development of medical technology and the increase of demands for universal health system usage has greatly affected the home care industry. Home care services sector has become the second sector rapidly developed in America (NAHC, 266

2010).

Today, Medicare provides the biggest financial support for home care services and especially home nursing at home. In 1973, it has been decided that this home care service financed by Medicare to include disabled individuals under the age of 65. National Association for Home Care & Hospice was established in 1982 to place the home care to health centers, develop the care quality and protect the rights of cared patients. In 1990s, the scope of home care service has widened (laboratory tests, odontotherapies, rontgen opportunities etc.), and the number of institutions providing service has increased. In 1985, to prevent the unqualified service, Medicare has brought the evaluation for service quality rule to health care institutions to be paid (Rice, 2006a; Aydın, 2005; Özer & Şantaş, 2012). The development of home nursing and care services varies according to the differences in prosperity, social security and health care and financing systems of countries. Studies on social prosperity reform of the public institutions and legislative regulations increase this difference (Rice, 2006a). The history of the home care services is based on informal care serviced in the whole Europe.The largest home visiting program of Europe emerged in Denmark has been a role model with its successful service presentation. It was observed that home visitings reduced the baby mortality and sickness rate in the consequence of a pilot study started in 1937 in Denmark and implemented in 4 geographical regions (Yılmaz et al., 2010). In 20th century, aged people, children, people with physical and mental disabilities has started to take the important place in service institutions and hospitals. However, criticisms on the subject of having the right to commend on individuals’ health in Western Europe and Scandinavia has increased. From 1960s, attempts for long-time admission of the aged and children in hospitals, increase the number of nursing homes and dispensaries for children and disabled people and the reduction of long-term admission in asylums has begun (Kerkstra & Hutten, 1996). Policies such as community health, sustainable care, integrated care and home care has been offered as an alternative for hospital and institution care services and supported. Understanding the importance of the informal care and care provided by the family has founded the change in health care conception. In England and Scandinavia countries, there isn’t any policy about family-based approaches in terms of institutional guarantee, but there are formal community-based in terms of institution. However, in the recent times family-based care has been significantly emphasized. In Eastern Europe, the institutional health service practice continued until early 1990s. Even if all of the European countries support the important of necessity in caring in a wide framework for the defenseless groups, this means that its presentation and legislative regulations differ from country to another. In many southern European countries formal home care services are under developed, in some northern European countries informal care is less developed (Kerkstra & Hutten, 1996). In the recent years, “home hospital practice”, “home nursing”, “home aid” are the new practices of home care practices. When the European Union member states and others are observed, home care is a health field mostly caught on.Countries may adopt different approaches on the choice of target population, process of the evaluation of suitability for care, the type of service, how services to be provided and by who and financing mechanism, while regulating legislatives about long-term care. Ireland 267

government pays the total amount of home care services. Health part of the home care in Belgium, France, Italy, Portugal, England and Spain belongs to health care system, social aid is the part of social system. In Germany, home care services are divided two categories as medical nursing services and personal care and social support services. In Netherland, home care services include both nursing services and motherhood care services. In Norway and Denmark, the costs of health-aimed visits and companionship services are included in the scope of payment. Only several countries such as Austria, Germany, Israel, Japan and Netherland has entered the Laws into force regarding long-term care right. These countries has made legal insurance programs in which personal right are not limited with the budget limitations. The most of the programs include all age groups and provide comprehensive services also including the institutional care (Aksoy et al., 2015; Alnıgeniş, 2009).In all of the states of Canada, a huge enlargement regarding home care services within the health service occurred in 1990s. While expenses were met by each state’s own incomes, it also was supported by the federal government. Japan has the highest average life expectancy of the world and is the most rapidly aging country. According to Japanese traditions, the family has the primary responsibility in aged care. Therefore, the care of the aged people in need of care is provided by their family members in their home. Institutional care services are generally for orphans. Medical services are provided for people aged over 70 in both homes and institutions. After 2000, a separate insurance system has been developed for home care. The majority part of the expenses is made for home care is financed by this insurance supervised by municipalities. Municipalities support and finance the civil and private care services. On the other side, hospitals providing acute medical service have turned to centers providing integrated care service with the activity of home care insurance. These hospitals provide services such as cleaning and travel nursing for homes (Aksoy et al., 2015). 3.2. Home Care Practice In Turkey When history of the home care services are observed in Turkey, it is seen that travel doctor service was provided and patients were cared by family members in the Ottoman Empire in the 15th century. After the first quarter of the previous century, these practices in this field are conducted in institutional level and 4 phases by legislative regulations as many country. These are; 1) Home care practices made under the framework of Public Health Law (PHL), 2) Home care practices made under the framework of Law on Socialization of Health Services, 3) Home care practices made after 1980, 4) Practices made after Regulation on Home Care Services Presentation was published in the Official Journal no 25751 dated 10.03.2005 in 2005. In Public Health Law no 1593 introduced in 1930 and still effective, includes provisions such as diagnosis and treatment of contagious diseases at home, practice at home and supplier for mother-child observation. Both medical and social problems of the society were discussed with the home visits by doctors and nurses. The most typical characteristics of Law on Socialization of Health Services introduced in 1961 is to include home care service and protective health services. These services are the studies of immunization and pregnant and child follow-ups. These studies are made in homes of the risk groups as well as sanitariums and community 268

clinics. Home follow-up of the pregnant women, home births in suitable conditions, puerperal follow-ups and children aged between 0 and 6 follow ups are given to midwives, public health nurses are in charge of service supervisory. The same law assigned the public health nurses to observe the individuals with chronic disease. Law on nursing adopted in 1954 states that, nurses who are not liable to obligatory service can pursue their arts freely in any time. Relying on this Law, nurses provided home treatments to patients opening private workplaces mostly known as “health cabinet” in the past years. In 1980s, nurses opened private home nursing care institutions to for the treatments and cares of patients in hospital and dispensaries. Today, private home care companies have been being established to respond the need for home care service of the society. However, because financing of these companies are not included within the existing official insurance system, the majority of the society cannot benefit from these services. Private insurance companies finance the private home care institutions’ home care service for patients as not to exceed 2 months. Home care institutions adopting multidisciplinary approach have been introduced instead of home care institutions limited with only nursing care (Aydın, 2005; Özer & Şantaş, 2012). As in the world, increase in aged population and chronic diseases in Turkey, treatments of early and late complications depending these chronic diseases in hospitals leads to economic, social and psychological problems. From the discharge of the patients, needs regarding provision of home care has brought a need of legislative and social regulations (Altuntaş& Yılmazer, 2010). In the Regulation on Home Care Services Presentation entered into force in 10.03.2005, home care is defined as “providing health and care and observation services by the health team in the way of meeting their medical requirements including rehabilitation, physical therapy to patients with their families.” In the first step, it is provided opportunity to private health institutions to give home care services, conducted home care practices has been disciplined. Moreover, home care services are included in the scope of official insurance. With the amendments by Law on Amendments to Disabled and some Secondary Legislations published in 01.07.2005, it is adopted that disabled care shall be provided in home care as possible and payments of home care service of specific disabled people shall be made to care providers. With this regulation, home care service is included in the scope of official insurance. According to this regulation, home care is aimed to provide health and care and observation services by the suggestions of doctors and health team in the way of meeting their medical requirements including rehabilitation, physical therapy to patients with their families (URL- 1; URL-2 ). In recent years, especially metropolitans in Turkey, home care services are provided by private health institutions. When observed the structure of provided home care services, it is seen that mostly hospital-aid service presentation program is used. Moreover, some private companies provide home care independently with payments of undertakers for this service in 1st March 2011 with the amendments in Health Practice Declaration, home care services provided by the units of Ministry of Health is started to be paid by Social Security Institution in the scope of one-day treatment, in Turkey. Expenses made for patients of home care services are made by Social Security Institution (URL- 2).

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Home care services in Turkey are provided in the framework of transformation in health with the reasons such as increase in aged population and chronic diseases, reduction in health expenses, finance control, effect of the developing world and changes in the approach for health. Pursuant to the Regulation on Home Care Services Presentation, “Directive on Home Care Services Practice Methods and Principles submitted by the Ministry of Health” has entered into force on 01.02.2010. From the effective date of the Directive, mobile teams within health directorates and health units in home within the hospitals. Moreover, these services are provided through family doctors (Başgül, Keskin, Kara & Aksoy, 2012). 4. IMPLEMENTATION OF HOME CARE SERVICES The implementation of home care services was adopted in “Directive on Home Care Services Practice Methods and Principles submitted by the Ministry of Health”. In the Directive, provisions on organizations of home care services, assignment of the personnel to take part in the home care team, authorities and responsibilities, working of a health unit at home, scope of the service, application system, approval and transfer principals are included. 4.1. Categories of Hom Care Home care services can be divided to 4 categories; the scope, period, member improving service, quality and management. 4.1.1. The Scope of the Service Home care services are provided as medical treatment and nursing care and social services. 4.1.2. The Period, of the Service Can be divided as two categories: short-term and long-term. Short-term home care services is based on medical service and mostly provided in after-hospital recovery time. This period is generally limited with 30 days. Medical examination, control and follow-ups, physical therapy, psych therapy sections, health education (pregnancy, breast-feeding, patient care), baby care, vaccine follow-up, tests, analysis and Rontgen service, after-discharge follow-ups (orthopedic cases, long-term treatments, dressing, injection etc.), chronic diseases follow-up (advanced-level cardiac insufficiency, some cancer cure treatments, diabetic foot care etc.), and terminally (cirrhosis, cancer etc.) patients follow ups are included in the long-term home care.Long-term home care is based on social care with including medical care services and provided in cases needed care exceeding six months. 4.1.3. Member Improving Service Has divided into two categories: formal and informal care. Home care provided by professional or semi-professionals in different occupation groups is defined as “formal care”; the care provided by family members such as relatives and friends is defined as “informal care”. 4.1.4. Home Care Services in Terms of Management and Organization The coordination of home care services is fulfilled by Public Health Agency of Turkey. Moreover, Public Health Agency and Institution of Public Health Hospitals of Turkey is mutually responsible for working properly and completely in accordance with 270

this Regulation. Home care services are submitted via Training and Research Hospitals within Ministries and its subsidiaries, units established by general hospitals or field hospitals, Oral and Dental Health Centers and community health and Family Doctor Units. Applications to coordination center established by the Ministry are evaluated by the commission (Yılmaz et al., 2010; Altuntaş& Yılmazer, 2010). 4.2. Units of Home Care Services Units of home care services are divided into three types: 4.2.1. T-type Units of Home Care Services: are the units established under Community Health Centers. It is assigned to provide the home care services primarily. The team consists of doctor, aged care/home care technicians and assistant health employees educated especially for home care service. Psychologists, social workers and similar support members are in charge of service when needed 4.2.2. H-type Units of Home Care Service: are the units established under Public Institution of Hospitals of Turkey. It is primarily responsible for the services which are not possible to be provided by T-type units such as providing specialist physician consultation, physical therapy. It supports T-type units in accordance with planning of the Coordination Center. The team consists of 3 three people: doctor/ specialist physician, aged/home care technician and assistant health employees who are educated for home care service. Psychologists, social workers, physical therapists, dietitian and similar support members are in charge of service when needed. Specialist physician/s are included according to the needs of the patients. 4.2.3. D-Type Units of Home Care Service: are the units within Oral and Dental Health established under Public Institution of Hospital of Turkey. The team consists of a dentist with oral and dental health technician or dental prosthesis technician. Protocols can be made with ministries and/or municipalities and other public organizations and institutions in the framework of an integrated understanding and cooperation to optimize health, care social support and similar services. In these protocols, associations, foundations and similar establishments can be assigned upon their demands to provide home care and social support services (URL- 4). Following groups can be benefit from home care services:  Those who need care after surgery  Orthopedics and traumatology patients  Cardio, vascular and hypertension patients  Hemiplegia patients  Oncology patients  Lung and respiratory patients  Diabetes patients  Neurology patients  Those who need oxygen treatment  Puerperants and their babies  The aged and disabled who need care  Those who need wound care, injection, infusion and other nursing services  Those who need laboratory tests and analysis services  Those who need medical equipment in their homes (THK 1).

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Serviced provided in the scope of home care services:  Development and protection of health and prevention of disability  Providing self-care, self-help, mutual assistance, defensiveness  Medical and nursing care  Personal care service: dressing, bathing, shopping  Arrangements for the disabled person to meet her/his needs  Transfer process and provide opportunity to reach to public facilities  Rehabilitation services  Meeting the need of fundamental and private, supportive items, equipment and medicine  Specified support services  Relaxing and palliative care  Consultancy service and psychological support  Increasing the social interaction  Providing opportunity for physical activity  Supporting those who provides pre-care and post-care services  Educating and informing the patient and his family (THK 2 ). Patients may need health care or social services support according to their mental or physical disabilities or dependent status.  In home care services team may be included:  Doctors  Nurses  Social service specialist  Dietitians  Physiotherapist  Medical officers  Psychologists  Health technicians  Local managements  Voluntary or private institutions (Başgül et all. ,2012) 5. ELDERLY HOME CARE When defining old age period, biological, sociological, economical and chronological descriptions are used. World Health Organization (WHO) prefers a chronological description for this age group and considers the old age period as 65 years and above. In many countries of the world, share of the elderly population in the total population is increasing day by day. Population of people who are 60 years old and older was approximately 605 million in 2000; it is estimated that it will reach 1.2 billion in 2025 and 2 billion in 2050. In 2020, 274 million Chinese aged 65 and older population is expected to live. This population is more than the current population of the United States. Old age period is divided into age groups in itself: population of people between 65-74 years old, population of people between 75-84 years old, population of people between 85 years old and above. It is also expected that population of the elderly who are 80 years and above will increase in future years. The total population of the elderly in Turkey was 8% of the total population. It is calculated that this rate will be 10.2% in 2023 and 20.8% in 2050. Population of people, 272

who are 80 and older, which is defined as the oldest population, has a share of 21.2% in total elderly population. The three countries with the oldest population is Monaco with 29.5%, Japan with 25.8% and Germany with 21.1%. Turkey ranks number 94 in this sorting. Elderly dependency ratio was 11.8% in 2014; it is estimated this will reach 15% in 2023 (UN, (2015). Studies show that almost all of the elderly have a kind of a health problem. Musculoskeletal diseases, cardiovascular system infections, high blood pressure, diabetes, chronic lung diseases, anaemia, urinary tract infections, certain cancers, muscle and joint disorders, vision and hearing problems and fallings are among health problems that are common in the elderly. When we look at the causes of death of elderly people who passed away in 2013, we see that the most common reason was circulatory system diseases (46.8%), the second one was benign and malign tumours (17.7%) and the third one was respiratory system diseases (11.7%). While the rate of the elderly population who died from Alzheimer's disease was 3.4% in 2012, it reached 3.6% in 2013 (TUİK, 2014). Population aging brings along many problems for societies. With the increasing age, multiple physiological dysfunctions and mental retardation arises. Ability losses, which arise due to memory loss, decrease in thinking ability, mental confusion and due to loss of sense of time and place that arises at later ages, causes elderly people to be dependent on other people's support and care. Situations such as loneliness, discrimination against the elderly, not being able to benefit from health services are amongst other problems that the elderly face. In this period, the elderly and their family have to choose between social care and institutional care alternatives (Öztop, Şener& Güven, 2008;Ak ,1991). 5.1. Importance of Home Care from the Elderly People's and their Families' Perspectives Home care during old age has positive effects on physical health, psychological state, independency level, social participation, interpersonal relations, process of realising their own potentials and process of intellectual development. Aim of home care services is to improve the quality of life by enabling the elderly to live independently in their own homes or environments. Home care services is a service model, in which services aimed at taking care of the elderly people’s health problems and meeting their social requirements are provided, with the cooperation and coordination of members of different occupations. By this way, effects of diseases and disabilities are minimised, independency levels and life qualities of the elderly is improved and humanitarian properties of health care services are strengthened. Different occupational groups such as doctors, nurses, pharmacists, social services personnel, psychologists, physiotherapists, home economists, dieticians must take part in home care services depending on the health situation and care needs of the elderly. In order for the services offered to the elderly to be good quality and effective, people who provide services in this area should be experts in their fields, do this job fondly and assimilatingly, receive training in this field continuously and be supported materially and spiritually (Öztop et all, 2008). According to the "Turkish Family Structure" research, 59% of the elderly people live in rural areas while 41% of them live in urban areas. It has been found that ratio of elderly people living in Mediterranean, Eastern Marmara and Istanbul regions is bigger 273

compared to other regions. 75% of the elderly are between 60-74 and 23% of them are between 75-85. 94% of the elderly have health insurance; but it has been found that 61.9% of them describe themselves in medium-low socioeconomic status; 12.3% of them describe themselves in the lowest socioeconomic status and 21.5% of them regard themselves as poor or very poor. More than half of the elderly live in poor houses. 17.2% of the elderly perceive their health status as worse or much worse compared to their peers. The elderly people stated that they have difficulties performing some works: 35.1% of them doing housework,38.2% of them shopping, 42.9% of them travelling, 20% of them caring for themselves and 46% of them doing works out of the house. In the same research, when they were asked where they wanted to live in their old age periods, they preferred home care, their sons' house and retirement homes respectively. It was observed that home care preferences were higher in Aegean Region (42.0%), Eastern Marmara (37%), Istanbul (33.9) and Ankara 36.1) compared to other regions; it was also observed that those people who have a higher educational status prefer home care or staying at a retirement home. Preference for home care is 27.3% in primary school graduates and it is 43.5% in university graduates. However, by increasing the age range of those surveyed still stay at home next to the maintenance and son preference has been shown to also increase. While the ratio of the elderly who live alone was 17% in 2013, it increased to 17.3% in 2014. The most important source of happiness of the elderly people was their families with a rate of 71.4% in 2014. The second most important source of happiness was their children with a rate of 14.7% (Eryurt, 2014; TUİK,2014 ). This data show that a considerable number of the elderly living in Turkey need care and help and many of the elderly prefer staying either at their own house or their children's houses and demand for home care is going to increase gradually. The most important reason of this situation is that they want to live the last years of their lives in environments they are used to. Urbanisation, changes in working life and devolving on nuclear family has brought along institutionalising in child and elderly care. Since the human is a psychosocial creature, both the elderly and their children who are responsible for their care prefer home care to institutional care. However, caring for very old people who have poor health can cause their children, who provide care for them, to have psychosocial problems as well. In this case, formal and informal support systems are expected to step in. Modern home care services, which are implemented almost everywhere in the world and becoming more and more popular, is considered as the most appropriate way for protecting the health and improving the quality of life. Today, social policies devoted to the elderly in developed countries give priority to the elderly people to receive care services where they live with a sense of aging in place. Implementing a similar practice in Turkey will both reduce institutional care costs and satisfy the needs of the elderly more by allowing them to keep their relations with their environments. 5.2. International and National Approaches in Elderly Care Rate of the population of the elderly, which is increasing gradually, drives countries to take measures for integrating the elderly into social life and for chronic health and dependency problems that will arise in old age periods. In this context, a series of international studies that discuss old were conducted. Suggestions regarding the elderly in the 1st World Assembly on Ageing report in 274

1982: The elderly should not be exploited physically or mentally; they should be able to use educational and culture resources of the society, have the chance to improve their elderly potential; they should have basic freedoms and human rights; they should be able to use health services effortlessly, live in their own environments as much as possible; they should have a sufficient income; they should be able to live in a safe environment and take an active role in determining policies regarding themselves (Kutsal, 2011). WHO discussed "Active Ageing" subject in 1990. The following topics were included in the "Active Ageing" programme: preventing unexpected and untimely deaths in the late periods of ageing as well; preventing disability statuses related to chronic diseases; enabling the elderly to enjoy life at older ages as well; enabling them to take part in social, political and economic activities; making their health expenditures cheaper and ensuring that the state takes responsibility for these expenditures. There were some recommendations about the elderly people's nourishment, activities and enhancing their environment conditions in order for them to live healthily (Aslan,D.) The International Nurses Association discussed the "Healthy Ageing" theme in 1992. In March 1992, Ministry of Health discussed old age problems in Turkey at the 1st National Health Congress Other important developments about old age are that in 1994, old age subject was discussed at "International Population and Development" conference in Cairo, and WHO designated the year 1999 as the "International Year of Elderly". The aim of "The International Plan of Action on Ageing 2002" published by the second "World Assembly on Ageing" held in Madrid in 2002 is to enable people to age safely and with respect all over the world and to ensure that they live as citizens having all the rights in their societies. In this plan of action, the subjects that were discussed at the World Assembly on Ageing were improved. In declarations published by International Association of Gerontology and Geriatrics (IAGG) and European Union Geriatric Medicine Society (EUGMS), the importance of geriatrics was brought forward and it was emphasised that the phenomenon of ageing should be included in periods before and after the graduation of all the relevant professions. Within the scope of "The International Plan of Action on Ageing 2002" prepared at the 2nd World Assembly on Ageing, "National Committee on Ageing" was established with the participation of Directorate General of Social Services and Child Protection Agency (SHÇEK) and relevant non-governmental organisations, under the coordinatorship of Secretariat of the State Planning Organisation. Through this committee, "National Action Plan on Status of the Elderly in Turkey and Ageing" was prepared and it was accepted by the Higher Planning Council in 2007. In 2008, a workshop was organised for "national action plan on status of the elderly in Turkey and ageing" with the participation of all relevant institutions and organisations and under the coordinatorship of Social Services and Child Protection Agency of Prime Ministry, and in consequence of this event, the subjects and suggestions discussed were grouped under three titles. 1-The elderly and development 2-Enhancing health and welfare in elderliness 3-Providing supportive environments that offer opportunities

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5.2.1. The Elderly and Development Active participation in society and development process; ensuring social, cultural, economic and political participation of the elderly and enabling the elderly to take part in all phases of decision-making process. Labour and senescent force; providing employment opportunities for all old people who want to work. Development, migration and urbanisation in rural areas; enhancing living conditions and infrastructure in rural areas, preventing the elderly from being ostracised by the society in rural areas and participation of elderly migrants to new societies. Access to information, education and training; life-long equality of opportunities regarding vocational guidance and settlement service as much as the opportunities of education and educational renewal; benefiting from capacities and counselling of individuals from all age groups considering the benefits of their experiences they gained through their age. Intergenerational solidarity; strengthening intergenerational equity and solidarity. Eliminating the poverty; reducing poverty of the elderly. Social protection/social security, income assurance and preventing poverty; developing programmes for ensuring fundamental social protection/social security including disability allowances and health insurance for all people employed, providing the sufficient minimum income for all the elderly; especially for ones who are at a disadvantage socially and economically. Ensuring that the elderly can benefit evenly from food, housing, medical care and other services during and after emergencies, natural disasters and other emergencies and increasing the contributions of the elderly with respect to re-forming and re-structuring the societies and organising the social fabric after emergencies. 5.2.2. Enhancing Health and Welfare in Elderliness Improving the lifelong health and enhancing wellbeing; reducing the impacts of the factors that increase the risk of disease and dependency during old age periods, developing policies for preventing diseases in the old age periods and enabling all the elderly to take sufficient nourishment. Ensuring full access to health and care services; eliminating age and gender discrimination and all types of social and economical discrimination for enabling universal and equal access to health and care services; fulfilling the needs of the elderly; ensuring the sustainability of health and care services and ensuring active participation of the elderly in implementing and developing health policies about the elderly. Informing and training people who provide care services and the healthcare personnel about the needs of the elderly. Fulfilling the mental health requirements of the elderly. Ensuring that the elderly who have ability deficit can maintain their lives at the highest level of functional capacity and ensuring their full participation to the life. 5.2.3. Providing supportive environments that offer opportunities Houses and residence areas; promoting "ageing in their own environments" in the society considering personal preferences of the elderly, developing house and environmental designs which are affordable and which will encourage them to live independently considering their needs, especially the ones with ability deficits, providing accessible transportation systems. 276

Supporting the care and care providers; ensuring the continuation of services rendered to the elderly, supporting the elderly people’s, especially the women's roles in care services. Abuse, neglect and violence; eliminating all types of abuse, neglect and violence infringing the law, providing support services regarding the prevention of elderly abuse. Perspective on ageing; ensuring that authority, wise and productive characteristics and other important contributions are recognised by the society (Kutsal, 2011). European Union accepted the year 2012 as the Year for Active Ageing and Solidarity Between Generations. Within the framework of this study, it was aimed that the countries would be encouraged to implement the decisions of "The International Plan of Action on Ageing 2002" of the World Assembly on Ageing and that they would share experiences. The member states were recommended: To develop preventive health policies by focusing on national and local governments and the subjects of preventing disabilities and chronic diseases; To give universal and equal access to health consultancy, preventive services, quality health services and long term care services; To prevent all types of elderly exploitation; making housing and transportation opportunities -which will encourage the elderly to live independently- secure and appropriate for them to access and to provide tools that will give them adequate care and support at their homes (URL- 5). Geriatrics Research Centres have been founded in Turkey with the aim of investigating the problems of the elderly population. The Ministry of Health is carrying out a series of studies regarding protection and development of the health of elderly. In this context, "Elderly Health Branch Office" was established under "Head of NonCommunicable Diseases and Chronic Situations Department" within the body of Ministry of Health, General Directorate of Basic Health Services". In Turkey, responsibility regarding the elderly was given to General Directorate of Disabled and Elderly Services of T.R. Ministry of Family and Social Policies with Delegated Legislation on Organisation and Duties of the Ministry of Family and Social Policies No 633 on June 3, 2011 within the frame of the duties stipulated in "The International Plan of Action on Ageing 2002" issued at the 2nd World Assembly on Ageing (URL- 6). Provisions about home care and covering the elderly were added to the 14th Article of the Directive of the Ministry of Health on Implementation and Principles of Home Care Services. Accordingly, "Primary health, diagnosis, treatment, rehabilitation and consultancy services for patients for whom home attendant care is compulsory and who are disabled, old, bedridden or in a similar case and for people whose need for home care service is determined in accordance with the procedures and principles of this Directive shall be given via community health centres, family health centres and family physicians as required by the relevant legislation." Elderly care can be studied under three titles: acute care, subacute care and chronic care. Acute care: contains care of the elderly at the hospital. The aim of this care is to create a multi-purpose discharge plan with multidisciplinary cooperation along with medical treatment. Subacute care: it is for rehabilitation and a complex medical treatment and/or wound care. This group covers people has been discharged from the hospital and need nursing care .Chronic care: it is for the elderly who have multiple 277

chronic diseases and cannot live on their own in the society. A good care provided at home delays the need for settling in a hospital or a nursing home (Bilge, Elçioğlu, Ünalacak&Ünlüoğlu, 2014). 6. CONCLUSION As a result, it is required to convey home care services included in laws and regulations developed regarding the elderly care to the elderly in an effective and fair way and to evaluate and improve services in this area trough qualitative research. REFERENCES Adams, M. (1986). Aging.Gerontological Nursing Research. In: Joyce J. Fitzpatrick, Roma Taunton , Harriet H. Werley (Ed.) Annual Review of Nursing Research, Chapter 4, p.77, Springer Publishing Compani, New York. https://books.google.com.tr/books?id=HLPSCgAAQBAJ&printsec=frontcover&hl=tr#v =onepage&q&f=false (21.0.2016) Ak B. (1991). Yaşlılık Psikolojisi. Aile ve Toplum 1 (2) Haziran ISSN: 1303-0256. http://dergipark.ulakbim.gov.tr/spcd/article/viewFile/5000108002/5000100712 (21.0.2016) Aksoy, H.; Kahveci, R.; Şencan,İ., Kasım,İ., Özkara ,A. (2015). Evde Bakım Hizmetlerinin Tarihsel Gelişimi ve Uygulamaları. Hıstorıcal Progressıon and Implementatıon of Home Care Servıces Turk Med J 7(1), 118-123. http://www.journalagent.com/ttd/ pdfs/ TTD_ 7_1_118_123.pdf (21.0.2016) Alnıgeniş, E. (2009). Evde Bakım Hizmetlerine Bakış. http://www.sdplatform.com/Dergi/ 240/Evde-bakim-hizmetlerine-bakis.aspx (21.0.2016) Altuntaş, M.; Yılmazer, T.T. (2010). Evde Sağlık Hizmeti ve Günümüzdeki Uygulama Şekilleri. Home Health Care Servıce and Recent Applıcatıons In Turkey. Tepecik Eğit Hast Derg 2010; 20 (3): 153-8 (3),153-8. http://www.journalagent.com/terh/pdfs/TERH_20_3_153_158.pdf (21.0.2016) Aslan, D. Türk Geriatri Derneği Ulusal Yaşlı Haftası (18-24 Mart) Basın Bildirisi-Ankara. http://www.turkgeriatri.org/bildiri_uyh.php (21.0.2016) Aslan D. Aktif Yaşlanma Kavramı. http://www.turkgeriatri.org/sorulariniza_yanitlar.php?pg=aktif#content (21.0.2016) Aydın, D.(2005).Evde Bakım Hizmetleri. Sağlıklı Nesiller Derneği Sağlık ve Eğitim Yayınları 1. Başak Matbaası Ankara. ISBN 975- 00605 - 0 - 4 Başgül, Ç.; Keskin, İ.; Kara, H.; Aksoy ,M. (2012).Sağlık Alanında Yeni Bir Hizmet: Evde Sağlık Hizmetleri. Ankara İl Sağlık Müdürlüğü Evde Sağlık Hizmetleri Koordinasyon Merkezi, Bağdat Cad. No:16 Macunköy-Ankara. Bilge,U. ; Elçioğlu, Ö.; Ünalacak, M.; Ünlüoğlu İ. (2014). Türkiye’de Yaşlı Evde Bakım Hizmetleri. Euras J Fam Med 3(1), 1-8. Boerma, W.; Genet, N. (2012). Introduction and Background. In: Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman (Ed.) Home Care Across Europe. Current Structure and Future Challenges. Observatory Studies Series. Chapter 1, p. 1-20, ISBN 978 92890 02882 ,Printed in the United Kingdom. http://www.euro.who.int/__data/assets/pdf_file/0008/181799/e96757.pdf (21.0.2016) Brodsky, J.; Habib, J.; Hirschfeld, M. (2003). Long-Term Care Strategies In Industrıalızed Countries:Case Studies of Insurance Based and Non-Insurance Based Long-Term Care Systems. Myers-JDC-Brookdale Institute and WHO NMH/CCL, S-123-03. http://brookdale.jdc.org.il/_Uploads/PublicationsFiles/123-03-longtermcare-new-ESENG.pdf (21.0.2016) 278

Dölek Önal, B. (2012) . Evde ve Kurumda Uzun Dönemli Bakım. Klinik Gelişim; 25,95-99. http://www.klinikgelisim.org.tr/kg_25_3/16.pdf (21.0.2016) Eryurt, M. A.(2014). Türkiye'de Yaşlı Nüfus ve Yaşlılık Dönemiyle İlgili Yaşam Tercihleri. In. Mustafa Turğut, Semiha Feyzioğlu(Ed.) T.C. Aile ve Sosyal Politikalar Bakanlığı Aile ve Toplum Hizmetleri Genel Müdürlüğü. Türkiye Aile Yapısı Araştırması Tespitler, Öneriler. Bölüm 3, s 90-106. Çizge Tanıtım ve Kırtasiye Ltd. Şti., İstanbul. Kerkstra, A.; Hutten, JBF.( 1996). A Cross-National Comparison on Home Care in Europe: Summary of The Findings.In: Hutten JBF, Kerkstra A, (Ed). Home care in Europe. A country-specific guide to its organization and financing. Aldershot: Arena, p. 1-40. Koçak,O.; Tiryaki, D. (2011) . Sosyal Devlet Anlayışında Sağlık Politikalarının Önemi ve Sağlıkta Dönüşüm Programının Değerlendirilmesi: Yalova Örneği. The Housıng Problem in Turkey and its Main Dynamics. Istanbul Ticaret Üniversitesi Sosyal Bilimler Dergisi Yıl:10 Sayı:19 Bahar 2011 s.55-88 http://acikerisim.ticaret.edu.tr:8080/ xmlui/bitstream/handle/11467/591/M00417.pdf?sequence=1&isAllowed=y Kutsal,Y.G.(2011).Yaşlanan Dünyanın Yaşlanan İnsanları. http://www.geriatri.org.tr/ Sempozyum Kitap2011/3.pdf (21.0.2016) NAHC (2010). Basıc Statıstıcs About Home Care Updated, p.5 The National Association for Home Care & Hospice. http://www.nahc.org/assets/1/7/10hc_stats.pdf (21.0.2016) Ogawa, N. (1997). Florence Nightingale's concept of home nursing: an analysis of her writings . Kango Kenkyu Jan-Feb;30(1),63-75. Oğlak S. (2007).Uzun Süreli Evde Bakım Hizmetleri ve Bakım Sigortası. Turkish Journal of Geriatrics 10 (2), 100-108. Özer, Ö.; Şantaş, F. (2012) . Kamunun Sunduğu Evde Bakım Hizmetleri ve Finansmanı. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi 3(2), 96-103. Öztop, H.; Şener, A.; Güven, S. (2008). Evde Bakımın Yaslı ve Aile Açısından Olumlu ve Olumsuz Yönleri. Yaslı Sorunları Araştırma Dergisi (1),39-49.http://www.skb.org.tr/wpcontent/uploads/2012/09/EVDE-BAKIM-H-C4%B0ZMETLER%C4%B0.pdf (21.0.2016) Rice, R. (2006a). Home care nursing practice: Historical Perspectives and Philosophy of Care, Home Care Nursing Practice Concepts and Application. 4. basım, Mosby, United States. Sezer, A.; Demirbaş, H.; Kadıoğlu, H. (2015).Evde Bakım Hemşireliği: Mesleki Yetkinlikler ve Eğitim Standartları Home Care Nursing: Professional Competencies and Education Standards. Florence Nightingale Hemşirelik Dergisi 23 (2),160-165. ISSN 2147-4923. Tarricone R. & Toros A. D. (2008 ).The Solid Facts. Home Care In Urope. WHO Regional Office for Europe. ISBN 978 92 890 4281 9 http://www.euro.who.int/__data/ assets/pdf_file/0005/96467/E91884.pdf (21.0.2016) Temiz, Ö. (2014). Türk Hukukunda Bir Temel Hak Olarak Sağlık Hakkı. Ankara Üniversitesi SBF Dergisi. 69 (1), 165-188. T.C.Anayasası (2011). https://www.tbmm.gov.tr/anayasa/anayasa_2011.pdf (21.0.2016) TUİK (2014).İstatistiklerle Yaşlılar, Sayı: 18620 18 Mart 2015. http://www.tuik.gov.tr/PreHaberBultenleri.do?id=18620 (21.0.2016) THK1.Türkiye Halk Sağlığı Kurumu.Evde Bakım Hizmetlerinden Kimler Faydalanabilir? http://ailehekimligi.gov.tr/component/content/article/59-evde-bakm-hizmeti/150-evde-bakmhizmetlerinden-kimler-faydalanabilir.html (21.0.2016) THK 2. Türkiye Halk Sağlığı Kurumu .Evde Bakım Hizmeti Kapsamında. http://ailehekimligi.gov.tr/component/content/article/59-evde-bakm-hizmeti/147-evde279

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Chapter 25 Non-pharmacological Methods Administered in Painful Interventional Procedures on Children Fatma YILMAZ KURT, Aynur AYTEKİN, Sibel KÜÇÜKOĞLU INTRODUCTION According to frequently recognized definition of International Association for the Study of Pain, pain is an unpleasant biochemical condition or experience arising from a certain area of the region, associated with or without tissue damage, affected by previous experiences of individuals and intended for taking away the undesired condition (Uman et al., 2013). However, pain is subjective and personally identifiable. There is no physiological or chemical test to measure pain. Thus, McCaffery’s definition: “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” is one of the most accurate definitions of pain (Yardımcı, 2015). Painful interventional procedures such an injection administration, vaccination, and venipuncture are among the greatest fears of children. These fears mostly result in reluctance in children and parents towards interventional procedures and affect subsequent treatment and care experience of the children (Uman et al., 2013). In addition, fear and anxiety increases the pain in children (Blount, Pıra, Cohen & Cheng, 2006). Thus, the best pain relief method should be preferred. In pain control, nonpharmacological or cognitive - behavioral methods are an integral part of care of children suffering from pain (Yardımcı, 2015). Non-pharmacological methods used in pain control enable to make pain more tolerable, perceive pain less, decrease anxiety, and increase the effect of analgesics by strengthening children’s coping skills. Various non-pharmacological methods are used for pain control in children. Concerning selection of the method to be used, it is important for children and their parents to be aware of the method and to be eager for its usage. Non-pharmacological methods can be used alone or in combination with pharmacological interventions in pain control (Büyükgönenç & Törüner, 2013). The non-pharmacological methods used for pain control in children are generally collected under 5 main headings; 1- Cognitive/Behavioral Methods 2- Peripheral (Physical) Methods 3- Sensorial /Supportive Methods 4- Creating a safe environment 5- Assisting in daily living activities (He et al., 2010). The studies on children reveal that Cognitive/Behavioral, Peripheral (Physical) and sensorial/supportive methods are more widely administered (Schaffer & Yucha 2004, 

Assist. Prof. Dr., Çanakkale 18 Mart University, College of Health, Dept. of Nursing. Assist. Prof. Dr., Atatürk University, Faculty of Nursing

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Bellieni et al.,2006, Kahler, 2003, Piira, Hayes, Goodenough & VonBayer, 2005, Vervoort et al., 2008). 1. COGNITIVE/BEHAVIORAL METHODS Children are highly inclined to the pain control strategies that require using their imaginations and games. In cognitive and behavioral methods, it is aimed at ensuring pain control by utilizing children’s imagination ability and descriptions (Kuğuoğlu, 2014). This group involves methods such as “Distraction” and “Relaxation” emerging from the assumption that the pain has cognitive, sensorial and behavioral dimensions, and it is not only cognitive but also related to the meanings individuals assign to the pain ( Büyükgönenç & Törüner, 2013) 1.1. Distraction The general purpose for using distraction technique is to increase the pain tolerance and reduce the pain sensitivity by concentrating attention on a stimulus other than pain (Donna & Goldman, 2012). In these methods, children are distracted by using a different object and their mechanism to cope with pain is tried to be maximized (Blount, Pira & Cohen, 2006). This method can be applied on children of every age group via one or several visual, auditory, tactile or taste sense(s). Distraction method does not completely relieve the pain of the patient, but increases the pain tolerance (Yardımcı, 2015). Methods such as; "Watching Cartoon/TV ","Inflating Balloon", "Involvement of Parents in Distraction"," Listening to Music", "Using virtual reality glasses", "Using Distraction cards”, "Singing" and "Kaleidoscope" can be used for distraction. 1.1.1. Watching Cartoon / TV Watching cartoon / TV is one of the most widely used methods especially in children hospitals since it is cost-efficient, easily accessible, and source of amusement (Donna & Goldman, 2012). Wang, Sun & Chen (2008) assigned 8-9 year-old children, who underwent intravenous venipuncture procedure, into three groups as watching cartoon (n=100), administering psychological approach (n=100) and no intervention (n=100) and determined that making children watch cartoons during intravenous venipuncture was significantly effective in reducing pain. In their study Dovney & Zun (2012) used the method of watching cartoon as pain relief method during various painful procedures in emergency unit and evaluated the pain 5 minutes before, during, and 5 minutes after watching cartoons and concluded that watching cartoons was effective in reducing the pain. In their study, Bellieni et al., (2006) divided 69 children aged between 7-12 year who underwent venous blood collection, into three groups, did not administer any intervention to one group, administered distraction method to children in one group with their mothers and made the children in the other group watch cartoons. As a result, the lowest pain scores were observed in children watching cartoons. In their study, MacLaren &Cohen (2005) determined that the mean pain score of the group watching TV was lower than the group playing interactive games, and Bellieni et al., (2006) determined that the mean pain score of the group watching TV was lower than the group distracted by mothers. Several studies (Tak & Bon 2005; Cassidy et al., 2002) reported that watching TV/cartoon was not an effective method in reducing pain, generally numerous studies indicate that watching TV/cartoons reduces the pain 282

perception of children during painful procedures and can be used during painful procedures. 1.1.2. Inflating Balloon Inflating balloon is stated to be increasing intrathoracic pressure by decreasing venous return, activating baroreceptors with pressure increase by contraction of chest vessels and physiologically effective in reliving the pain (Gupta, et al., 2006). Inflating balloon is stated to be an effective method for distracting children during painful procedure in addition to its physiological effects. Gupta, et al., (2006) applied three different methods (no-intervention group, balloon inflating group and the group with plastic balls) on 75 children aged between 6-12 years who underwent establishment of vascular access and stated that pain levels of children in balloon inflating group and plastic ball group were lower than control group and the lowest pain level was observed in balloon inflating group. Manne et al., (1990) reported inflating balloon as an effective method for reducing the stress of the children and family during venipuncture. Caprilli, Vagnoli, Bastiani & Messeri (2012) determined that the mean pain scores of the children, who were made to blow bubbles for distraction, were lower than control group in a statistically significant way. In the study conducted by Mutlu & Balcı (2012) to examine the effect of the methods of inflating balloon and coughing in reducing the pain experienced during venous venipuncture, it was found that the children in control group experienced more pain during the procedure compared to those in balloon and coughing group and the difference between the groups was highly significant, and that both interventions were effective in reliving the pain during the procedure. In general, both the studies and physiological effects indicate that balloon inflating is an effective method in reducing pain in children due to distracting children. 1.1.3. Listening to Music /Singing Used for maintaining and developing mental and physical health, music therapy is a natural tool for nurses in pain management due to its ease of use. The use of music therapy enables to focus on a stimulus other than pain as in distraction method. Music therapy increases the pain tolerance of the individuals. Music therapy also increases endorphin release and relieves the individuals Uçan & Ovayolu 2008). Many studies prove that listening to music decreases anxiety, pain and aggressive behaviors, and relieved the children. Klassen, Liang, Tjosvold, Klassen & Hartling (2008) compared music group and non-intervention group of children, who were aged between 1 month and 18 years old and underwent a medical intervention, and stated that making children listen to music was effective in decreasing pain and anxiety. In their study, Nguyen, Nilsson, Hellstrom & Bengtson (2010) divided 40 children aged between 7-12 years, who underwent lumbar puncture intervention, in two groups (music group and control group) and stated that pain scores of the children listening to music were significantly lower compared to the control group. In a randomized controlled study conducted by Caprilli, Anastasi, Grotto, Scollo & Messeri (2007) they divided 108 children, who were aged between 4-13 years and underwent venous venipuncture, into two (2007) (music group=54, control group=54) and found that pain scores of music group were significantly lower, and also pulse and respiratory rates of the children were significantly lower before, during, and after the procedure. In their study, Nilsson, 2008; Allred, Byers & Sole 2010; Bradth, 2010; Hatem, Lira & Mattos, 2006; Kirby, Oliva & Sahler, 2010 also stated that music was effective in distracting children and decreased 283

mean pain scores of the children. In the randomized controlled study of Stevenson, Bivins, O’Brien & Gonzalez 2005, they divided 2-16 year old children, requiring venous intervention, into two groups and applied standard care to one group and applied distraction technique by singing and establishing verbal communication to the other group. In conclusion, they determined the stress score of the children in the 2nd group singing and establishing verbal communication was significantly lower than those in the standard care group. 1.1.4. Involvement of parents in distraction/Parent couching In their study, Cohen et al., (2006) reported the distraction methods (with comics, videos, toys, by talking) used by parents for their children during vaccination reduced the pain experienced by the children. Pain level in children was determined to be reduced by parents’ using toys appropriate to their vaccinated children’s age in the study of Cramer & Friedman (2005), parents’ rocking and talking to their children during procedure in the study of Felt et al., (2000), and parents’ talking to their children about the subjects not related to the intervention and having humorous approach in the study of Bustos, Jaaniste, Salmon & Champion ve ise (2008). Based on these results, it can be asserted that parents’ talking to their children and distracting them/parent couching can be used in children during painful procedures. 1.1.5. Using virtual reality glasses Virtual reality glasses is the method where the patients are shown the images taken from the computer by getting lenses to their eyes with a helmet in order to isolate the patient from the real life. Also, the patient is put on a headphone, so the hospital sounds are blocked and the patient listens to soothing sounds. As a result, the patients feels as if they are visiting another 3-dimensional world. Virtual reality stands out as a method used in reducing the pain especially in the patients with burns (Lange, Williams & Fulton, 2006). In their randomized controlled study Das, Grimmer, Sparnon, McRae & Thomas ise (2005) used virtual reality glasses on 5-18 year-old children with acute burn injuries and divided the children in two groups. They administered only analgesics to the 1st group, and used virtual reality glasses along with analgesics in the 2nd group. They determined that the pain scores were statistically significant in the 2nd group using virtual reality glasses. Gershon, Zimand, Pickering, Rothbaum & Hodges (2004) stated that among 59 7-19 year-old children diagnosed with cancer, children using virtual reality glasses had lower heart rate and pain levels compared to those not using in order to reduce the pain during medical treatment. Wolitzky, Fivush, Zimand, Hogdes & Rothbaum (2005), Gold, Kim, Kant, Joseph & Rizzo (2006), Hofmann, Doctor, Patterson, Carrougher & Furness (2000), Sander, Eshelman, Steele & Guzzetta (2002) pointed out the efficacy of virtual reality glasses in their studies. Even though the studies revealed that using virtual reality glasses was effective in distraction, other studies conducted on this subject (Nilsson, Finnstrom, Kokinsky & Enskar (2009); Leibovici, Magora, Cohen & Ingber (2009) determined that virtual reality glasses were not effective in reducing the pain. Based on these different results, it can be asserted that further studies are needed on this subject. 1.1.6. Kaleidoscope Kaleidoscope is a game material in which colorful patterns can be seen when looked inside. These patterns are obtained with reflection of the light and constantly 284

change as the kaleidoscope moves. Inner part of the kaleidoscope is black or a dark color. It has two mirrors adjacent to each other with a slope of 60°. There are materials such as colored glass pieces, feathers, sequins, little beads etc. between the mirrors. When it is looked from its one edge, polygons changing shapes, which would not look the same again, are mostly seen (Canbulat, İnal & Sönmezer,2013). In the randomized controlled study of Canbulat, İnal & Sönmezer (2013), they divided 188 7-11 year-old children into three groups and took blood from 1st group using distraction cards, 2nd group using kaleidoscope and 3rd group using no method. They determined that the pain scores of the 1st and the 2nd groups were significantly lower than the control group. Tüfekçi, Çelebioğlu & Küçükoğlu (2009) determined that kaleidoscope method used among 206 children aged between 7-11 years decreased significantly the pain level during venipuncture compared to control group. In their study, Karakaya & Gözen (2016), Hasanpour, Tootoonchi, Aein & Yadegafar (2006) determined that kaleidoscope was effective on mean pain score in medical interventions. Based on all these studies, it can be revealed that kaleidoscope can be used effectively for distracting the children during painful procedures and decreasing the pain perception. 1.1.7. Using distraction cards Distraction cards involve 5 cm* 8 cm cards, containing various hidden pictures and patterns. These hidden pictures and patterns can be seen only when the children look carefully. During the procedure, children are asked questions related to cards. I.e.: How many monkeys are there in the picture? Can you see the comets in the picture? How many blue flowers are there in the picture? Distraction cards is a new application (Canbulat, İnal & Sönmezer (2013). In the randomized controlled study conducted by İnal & Kelleci (2012), on 6-12 year-old children the researchers reported that the distraction cards used during venipuncture were effective in reducing procedural pain and anxiety. In their study, Şahiner & Bal (2016) divided totally 120 children aged 612 years in four groups, used distraction cards in 1st group, balloon inflation in 2nd group, cartoon music in 3rd group, and no intervention in 4th group during venipuncture. They observed that the group of distraction cards had the lowest level of pain and the control group had the highest score of pain. In the study conducted by Canbulat, İnal & Sönmezer (2013), on children in the age group of 7-12 years, they compared distraction cards and kaleidoscope in reducing procedural pain and anxiety during venipuncture and reported that distraction cards were more effective in reducing pain and anxiety. They also emphasized that using both visual and auditory stimuli together would be more effective in distraction. However, further studies to reveal the efficacy of the method in different medical procedures are needed. 1.2. Relaxation techniques Relaxation is unprompted loosening of the body muscles; thus, while stress and anxiety decrease, coping skills also increase. This technique tries to clean all the internal and external effects in the mind and the body (Yardımcı, 2015). Mental and physical relaxation contributes to the relive of the pain by reducing muscle strain. Relaxation methods are more effective in reducing mild and moderate levels of pain. It should be used with analgesics in severe pains. For relaxation; methods such as progressive muscle relaxation, breathing exercises, meditation, yoga, hypnosis, and guided imagery can be used. Four common points of all these methods are as follows; a quiet environment, a comfortable position, a passive attitude, and mental focusing 285

(Büyükgönenç & Törüner, 2013). 1.2.1. Progressive muscle relaxation Progressive muscle relaxation is a method suggested for children to identify and reduce their body tensions and also to control their anxiety and discomfort situations. Reducing body tension is a skill that can be taught. The first rule of the administration is a quiet and comfortable environment. Children are told to contract and relax their different muscle groups. Starting from hands and feet, they are directed towards shoulders, neck, chest, and abdomen (Rusy & Veisman, 2000). In their study, Broome, Lillis, McGahee & Bates (1992), determined that the behavioral reactions of the children, who underwent lumbar puncture where combination of relaxation techniques and breathing exercises was used, were changeable, but their pain levels reduced over time. Weydert et al., (2006), administered progressive muscle relaxation method on 22 5-18 year-old children, who came to the hospital due to abdominal pain, for 4 weeks and determined that progressive muscle relaxation method significantly decreased the number of experiencing pain per month. In the study conducted by Youssef et al., (2004) with the children with acute abdominal pain, they applied progressive muscle relaxation method without control group. In the controls made 10 months later, they reported that the pain was relieved in 89% of the children, and also their activity levels increased and the rate of not going to school decreased. In their studies, Pölkii, Pietila, Vehvilainen, Lauk-kala & Kiviluoma (2008), Huth, Broome & Good (2004), determined relaxation technique to be significantly effective in reducing postoperative pain in children. Based on the results of all these studies, applying relaxation exercises on children has a significant role especially in postoperative pain control. 1.2.2. Breathing exercises Controlled breathing techniques are strong fabian means and also have benefits such as slowing respiration down and relaxation (Blount, Pira, Cohen & Cheng, 2006). Applying this technique prevents the first response of many children to pain (holding breath). Deep breathing is taking deep and long breathes through the nose and breathing out slowly through the mouth (Yardımcı, 2015). If the children breathe in company with a couch at the beginning and are encouraged by the couch, the results are more successful. In the study of Sparks (2001), 105 children aged between 4-6 years were divided into three groups and the children were vaccinated by applying touching method in 1st group, blowing bubble method in 2nd group and no intervention in 3rd group. Touching and blowing bubble methods used in the first two groups were determined to reduce pain perception significantly. In another randomized study, shallow breath techniques and “blowing out the pain” method were applied in 149 children aged between 4-7 years and a significant decrease was found in their pain behaviors (French, Painter & Coury, 1994). Lal, McClelland, Phillips, Taub & Beattie (2001), compared bubble blowing, breathing exercises and placebo methods on the children aged between 4 - 8 years during establishing vascular access and determined that both breathing exercises decreased the pain score in children. In their study, Weydert et al., (2006) divided 22 children and teenagers, aged between 5-18 years, in two groups: applied guidance and progressive muscle relaxing technique to the 1st group, and applied only progressive muscle relaxing method to the 2nd group. As a result, the pain scores of the guidance progressive muscle relaxing method group decreased in a statistically significant way when they were applied with breathing 286

exercises. Based on all these studies, teaching children simple breathing methods provides an effective method in their struggling against disorders. It is extremely useful that sense of dominance takes the place of feeling of helplessness hospital setting causes. 1.2.3. Guided imagery Guided imagery is one of the cognitive-behavioral techniques and means children’s imagining a non-existing image while relaxed (Gerik, 2005). It is the method of blocking out the children from painful and scary events and directing them to emotions such as safety, control and success thanks to active imagination and images. The attention of the children are ensured to focus from the problem to the new image. A more realistic image is obtained with combination of senses such as hearing, sight, taste, smell, motion, position, and touching. The children are directed to active guided imagery and asked to dream that they are at a place where they want to be (beach, a colorful balloon, flying carpet etc.). The sounds, light, scent in the dream their feelings can be asked to increase the effect of the dream. While some children verbally involve in guidance, some involve by just listening (Huth, Daraish, Henson & McLeod, 2009). Huth, Broome & Good (2004), Huth, Daraish, Henson & McLeod, (2009); Pölkki, Pietila, Vehvilainen, Laukkala & Kiviluoma (2008), Weydert ve arkadaşları (2006) determined that imagery was effective in reducing the interventional or postoperative pain in children. 1.2.4. Hypnosis/Meditation Hypnosis can be defined as ability of focusing attention. Level of consciousness of the hypnotized person changes, thus his perceptions and senses can be changed, modified or developed (Yardımcı, 2015). Hypnosis is the mind-body process forming internal imagination. Aim of hypnosis in pain management is to enable the children, who are passive or cannot be helped, have pain control. The things to take into account is to concentrate the attention of the child on the relief of the pain rather than pain itself. Hypnosis/mediation is argued to be effective in reducing the pain during painful interventions by Michell, Accardi & Milling (2009); in children with chronic pain by Lonnie et al., (2002); during painful interventions in children with cancer by Richardson, Smith, McCall & Pilkington (2006); in children with cancer undergoing lumbar puncture by Liossi & Hatira (2003); and during painful interventions by Birnie et al., (2014). 1.2.5. Yoga Yoga enables muscles to become stronger, relax, posture to straighten, muscle flexibility, respiration to regulate and show positive effects on cardiovascular, digestive, endocrine systems. Yoga technique consists of three main sections. These are: asana (posture), pranayama (breathing exercises) and savasana (relaxation). The aim of this method is to provide all muscle groups contracted, enable muscle strength, flexibility and physical balance, and consequently provide physical and mental well-being. In addition, yoga is a stress management technique and provides relaxation, reduces pain and anxiety, and enhances sleep pattern (Tygeson et al., 2010). While there are many studies conducted abroad indicating that the use of hypnosis is effective in children (Brands, Purperhart & Deckers-Kocken 2011, Tygeson et al., 2010), no study indicating the use of this method was found in Turkey. Thus, related studies are needed to be 287

conducted in Turkey. 2. PERIPHERAL (PHYSICAL) METHODS Peripheral methods include skin stimulation interventions used for reducing the pain. Skin stimulation is temporarily applied with the purpose of relieving the pain. The effect of skin stimulation on pain relieving is explained in two ways. Firstly, according to Gate-Control Theory skin stimulation stimulates large diameter fibers, this stimulation suppresses small diameter fibers conveying the pain message and closes the gate for transmission of the stimuli felt as pain. The second one is that in some skin stimulations, release of endorphins which are body’s natural morphine, thus pain is decreased or relieved. Skin stimulation can be applied directly on or around the pain area, to opposite side of the pain area or to proximal of the pain area (Kbsch, Neveau & Vandertie, 2001). “Massage”, “Taking on the lap-Touching-Contact”, “Heat Therapy and Cold Therapy”, “Applying menthol on the skin”, “TENS (Transcutaneous Electric Nerve Stimulation)”, “Vibration (skin stimulation) ” are skin stimulation methods used in pain management. 2.1. Massage Massage enables the pain to be localized in a narrow area by stimulating tactile receptors in the skin. Rhythmic and repetitive movements are thought to have painrelieving effect by sedation and reducing crying. Massage increases the circulation, provides relaxation, decreases the stress hormone levels, increases the serotonin level, facilitates transition to sleep by increasing feeling of relaxation and makes the person feel better (Oakes, Anghelescu, Windsor & Barnhill, 2011). In a study examining the effect of massage therapy among non-pharmacological methods on decreasing the distress experienced by the children with burns during treatment, massage therapy was reported to have positive effects. The children, whose wounds were dressed simultaneously with massage therapy, were observed to display less distressed behaviors, make less introverted body movements, and the children in the group who did not receive massage therapy the children gave reactions such as grimace, crying, screaming, feet movements, hitting the places they could reach with their hands, increased body movement (O'Flaherty, Van Dijk, Albertlyn & Millar & Rode, 2012 ). In their study lasting for 3 years Cassilet & Vickers (2004) revealed that symptoms such as pain, fatigue, stress, anxiety and depression during interventions decreased at the rate of 50% with massage therapy in 1290 children receiving cancer treatment. In the randomized controlled pilot study conducted by Wilkie et al., (2000) on 29 children with cancer, it was determined that massage therapy administered twice a week was significantly effective in reducing the pain compared to the control group. They also determined that massage therapy had a significant effect in decreasing the respiration, pulse rate and level of pain in children. In the study of Uğurlu (2011), she divided 99 infants, who received 2nd dose of Hepatitis B vaccination, into three groups. She assigned the 1st group as control group, applied 1 minute of massage to the 2nd group, and 2 minutes of massage to the 3rd group. In her study, the pain scores of the infants in the massage group during and after the procedure were determined to be lower than those in control group. As a result, pain-reliving or pain-reducing effect of massage, which is one of peripheral techniques, has been determined by numerous studies.

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2.2. Taking the child on the lap-touching-contact Touching (taking the child on the lap, caressing) that is one of the methods mostly used by families and healthcare professionals, is important for all children, especially for young children who cannot express themselves verbally. Touching also helps development of the feeling of confidence in children. Frequently used as a communication method in newborns, physical touching/contact also plays an important role for calming down the newborn. Touching includes caressing, kissing, and taking on the lap (Efe, 2003). In the study conducted by Yılmaz, Gürakan & Saatçi (2002) to compare the effective factors on crying periods of the infants after heel-stick procedure, they determined that taking the infant on the lap during painful procedures is an effective method to relieve the pain. In their studies Moon & Cho (2001) revealed that parents’ using the method of holding hands of children undergoing painful procedures decreased anxiety and epinephrine level. In another study, it was determined that 3-10 year-old children were calmer and they moved less before and after their dental examinations when their hands were held by their parents during their examinations (Greenbaum, Lumley, Turner & Melamed 1993). In the study conducted by Peterson & Palermo (2004), they determined that parents’ touching their children with cancer and holding their hands during the intervention reduced the pain and anxiety levels. Vannorsdall, Dahlquist, Pendley & Power (2004) concluded that nurses’ holding hands of the children and touching them during painful intervention did not decrease their stress. All these study results reveal that taking on the lap-touching-contact method used by parents reduces the stress and pain levels of the children and the use of these methods in painful interventional procedures in children give positive results 2.3. Heat Therapy / Cold Therapy Heat therapy is an effective method used for pain relieving. Heat therapy relieves or reduces the pain by stimulating tactile receptors by activating the gate control mechanism, reducing ischemic pain with vasodilation, removing metabolic waste, increasing the release of endorphins, eliminating muscle spasm, reducing the effects such as pressure, tension and hypoxia in nerve endings as a result of changes in viscoelastic properties of tissues, raising the pain threshold, administering sedation, and creating relief in patients (Kwekkeboom, Kneip & Pearson, 2003). Its usage is useful in muscle spasms and chronic inflammatory cases such as arthritis after first 24-48 hours due to the fact that it can increase bleeding and edema after traumas (Oakes, Anghelescu, Windsor & Barnhill, 2011). Cold therapy is effective in reducing the pain in two ways. Firstly cold therapy relieves or reduces the pain by removing edema and muscle spasm. Secondly it is effective in relieving the pain by slowing down or blocking peripheral nerve conduction. Apart from these effects, it reduces the pain by activating the gate control mechanism, stimulating tactile receptors, and increasing the release of endogenous opioids. Cold therapy has a longer effect than hot therapy (Kozier, Berman, Snyder & Erb, 2008). In their study Hasanpour, Tootoonchi, Aein & Yadegarfar (2006), examined the effect of two non-pharmacological methods on intramuscular injection pain in 90 children aged between 5-12 years and they showed that local cold application decreased the injection-induced pain. In the study conducted by Şahiner, İnal & Akbay (2015) to examine the effect of local cold application and vibration method on pain development during vaccination in 7 year-old children, it was determined that both cold application 289

and vibration method reduced vaccination related pain. Similarly in their studies Birnie, Peter, Boerner, Noel & Chambers (2012), Moadad, Kozman, Shahine, Ohanian & Kurdahi Bahr (2016), İnal & Kelleci (2012), Trapanotto et al., (2009) determined that cold application reduced the pain experienced during painful procedures. Contrary to these studies, Farhadi & Esmailzadeh (2011), Taddio, Ilersich, Ipp, Kikuta & Shah (2009), determined in their studies that local ice application was not effective on pain scores. Based upon these results, it is observed that number of the studies about the use of heat therapy on children is limited, and the studies concerning cold therapy have different results. Further studies are suggested to be conducted to prove the efficacy of these two methods and generalize them to all painful interventional procedures. 2.4. Applying menthol on the skin Obtained from mentha plant, menthol is an agent used for both relieving the pain and refreshing. Mentholated creams can be in the form of lotion, liquid or gel. These creams create an effect such as warmth, chillness after they are applied to the skin. Local appliance of substances containing menthol provides a kind of external analgesia. Menthol application relieves the pain by distracting the person or decreasing the pain perception. Also in the literature it is known for menthol in the cream to reduce the pain by increasing endorphin release or closing the pain gates by stimulating cortex (Özveren, 2011). Number of studies conducted regarding the method of applying menthol on the skin in children undergoing interventional painful procedures is very limited in Turkey, and further studies are needed. 2.5. TENS (Transcutaneous Electric Nerve Stimulation) TENS has become important in pain treatment upon definition of Gate-Control theory by Melzack and Wall in 1965. TENS can be defined as applying controlled low voltage electric current to nerve system via electrodes attached to the skin. Pain relieving effect of TENS is described in two ways. Firstly, TENS stimulates sensory A fibers with high frequency stimulation. Impulses of this stimulation blocks the pathway going to the brain and closes the gate to the pain transition. Secondly, it affects pain perception by starting release of natural opioids in the body. TENS is widely used in acute and chronic pains. TENS can be administered by physiotherapists or nurses receiving special education (Özveren, 2011). In their study Lander, Kerrey & Oberle (1992) examined the effect of TENS on relieving the pain during venous interventions in 514 children aged between 5-17 years and found that the density and effect of pain were lower in the children in TENS group compared to the control group. As a result of this study, Lander, Kerrey & Oberle (1992) point out the importance of TENS in painful procedures. Munshi, Hegde & Girdhar (2000) determined that TENS significantly decreased pain perception in 5-12 year-old children undergoing dental treatment. While the number of the studies on reducing the interventional pain on children with TENS is limited; in the studies it is stated that TENS is an effective, safe and noninvasive method, and is suitable to be used in acute and chronic pain treatment. 2. 6. Vibration Vibration is a kind of electric massage. Especially hand vibrators reduces or relieves pain by causing numbness, paresthesia and anesthesia in the application area when a moderate pressure is applied. Vibration application shows its effect in reliving the pain immediately or in a few minutes. Vibration can be applied in cases of acute and 290

chronic muscle spasm and tension type headaches, neuropathic pains, phantom pains, rheumatoid arthritis, acute tendonitis, many chronic nonmalignant pains (Özveren, 2011). In their study, Elbay, Kaya, Uğurluel & Baydemir (2015) examined the efficacy of an injection system (DentalVibe) producing vibration impuls for reducing injection pain during administration of palatal local infiltration anesthesia in children, and determined that the DentalVibe injection system reduced injection pain during administration of palatal local infiltration anesthesia in children. Moadad, Kozman, Shahine, Ohanian & Kurdahi Bahr (2016), suggested that the vibration method applied during insertion of peripheral IV cannula to children aged between 4-12 years was an effective method for reducing the pain and these children had significantly lower pain scores. In the study conducted by Schreiber et al., (2015) to examine the effect of vibration method used during insertion of peripheral cannula to 76 pediatric patients (34 vibration, 36 control) in controlling pain in children; they determined that vibration method was effective in reliving the pain. In their studies Shilpapriyaet al., 2015, Aydınöz, Çelikel, Aydemir, Genç & Sezer (2014), Whelan, Kunselman, Thomas, Moore & Tamburro (2014), Canbulat, İnal & Akbay (2015) found results indicating the efficacy of vibration method. The studies conducted in recent years indicate that using vibration method has increased and a great majority of studies show that vibration can be very effective. 3. SENSORIAL/SUPPORTING METHODS Supportive methods include psychosocial care of children. In this method, techniques such as making the parents stay with the children during painful procedures, preparing the children/parents to the procedure/ informing are applied. 3.1. Making the parents stay with the children Leaving from parents can cause intensive stress to the hospitalized children and increases pain problems. In many hospitals, liberal policies such as parents’ staying for 24 hours, presence of parents in anesthesia induction and awakening unit are accepted. In such cases, parents should be guiding for their children for overcoming their fears and feeling comfortable (Yardımcı, 2015). While Simons, Franck & Roberson (2001), determined that parents can make important contributions to the pain assessment and care of their children, Jung & Wurdisch (2000) found that children’s being in touch with their friends and parents was one of the most important factors for increasing their coping, and parents had an important role in their children’s coping with pain and pain assessment. On the contrary to these positive results, Tüfekçi & Erci (2007) determined in their studies that presence of parents during painful procedures did not have a significant effect alone on children’s pain tolerances. In the study conducted by Boztepe, (2012) to examine the opinions of pediatric nurses about parents’ presence during painful procedures and indicated that 62.8% of the nurses thought that parents should not be with the children during painful procedures and that they stated that this increases the anxiety of the children and health personnel and affected the success of the procedure. Yet, presence of parents especially mothers during painful procedures on children is a helping factor for all age groups in reducing the pain and thus it is important that willing mothers support their children by standing by them.

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3.2. Preparing the Children/Parents to the Procedure/Informing Being controlled and farsighted is vital for the children. Due to the nature of hospitals some issues are able to be controlled less. By preparing the children/parents to the procedure/informing, ensuring a comfortable hospital environment and therapeutic games, children are informed about the situations or procedures. Fear of the unknown triggers excessive anxiety for the children and family. The difficulties which the individual under stress faces would cope with new experiences would increase. Children’s seeing the environment or playing with some equipments prior to the procedure increases their coping skills. In addition, thanks to this preparation, the family and the children have time to develop and apply a plan to cope with the procedure (Yardımcı, 2015). In her study, Tüfekçi & Erci (2007) examined the pain tolerance of children in regards to informing levels of parents and children and determined the pain tolerance of the children informed before the procedure was higher than those not informed. In the study of Pölkki, Pietila, Vehvilainen, Laukkala & Kiviluoma (2008), it was stated that informing the parents about the procedures to be administered to children made it easy for their children to cope with the pain. In the study of Boztepe, (2012) it was emphasized that explaining the procedure to children and parents was effective for less traumatic in painful produces administered by nurses. CONCLUSION In today’s world non-pharmacological methods can reduce or relieve the pain in pain management. Moreover, when used with pharmacological methods, nonpharmacological methods increase their effects and decrease amount of analgesics used and accordingly cost of treatment. In addition, non-pharmacological methods can be widely and effectively used in the cases where pharmacological methods are not used, and they do not have any adverse effect. Thus, today approach of using only analgesics which are among traditional pain relieving behaviors should be abandoned and when required, both methods should be used together or non-pharmacological approaches should be used alone. REFERENCES Accardi, M.C.; Milling, L.S. (2009). The Effectiveness of Hypnosis for Reducing Procedure-Related Pain in Children and Adolescents: A Comprehensive Methodological Review. J Behav Med. 32: (4), 328-339 Allred, K.D.; Byers, J.F.; Sole, M.L. (2010). The Effect of Music on Postoperative Pain and Anxiety. Pain Management Nursing 11: (1), 15–25 Bellieni, C.V.; Cordelli, D.M.; Raffaelli, M.; Ricci, B.; Morgese, G.; Buonocore, G. (2006). Analgesic Effect of Watching TV During Venipuncture. Archives Diseases in Childhood 91: (12), 1015–1017 Birnie, K.A.; Noel, M.; Parker, J.A.; Chambers,C.T.; Uman, L.S.; Kisely, S.R.; Mcgrath, P.J. (2014). Systematic Review and Meta-Analysis of Distraction and Hypnosis for Needle-Related Pain and Distress in Children and Adolescents. Journal of Pediatric Psychology 39: (8), 783– 808 Birnie, K.A.; Petter, M.; Katelynn, E.; Boerner, M.N.; Chambers, C.T. (2012). Contemporary Use of The Cold Pressor Task in Pediatric Pain Research: A Systematic Review of Methods. The Journal of Pain 13: (9), 817-826 Blount, R.L.; Pıra, T.; Cohen, L.L.; Cheng, P.S.(2006). Pediatric Procedural Pain. Behavıor Modıfıcatıon 30:(1), 24-49 292

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Chapter 26 Nutrition Literacy in the Prevention of the Era’s Growing Problem Obesity Büşra CESUR INTRODUCTION In parallel with the developments that took place in the scientific, technological and economic fields in the world in the last century, people can access many information in regard to their health through various sources (newspaper, magazine, radio, television, internet etc.) easily and fast. The individuals have to assess which information is correct and which suggestions are beneficial to themselves with the information sources that lack sufficient supervision and within the information pollution, and make necessary decisions for their health and make attempts in that direction (Cesur, 2015). At the root of health problems such as cardiovascular diseases with obesity being in the first place, many types of cancer, hypertension, diabetes, allergic diseases and osteoporosis, nutrition habits have a significant role (Allen & Gillespie,2001). Therefore, it is necessary to make conscious nutrition choices and applications for a healthy life. At this point, it is important for the individuals to be on the sufficient level of nutrition literacy (Cesur, 2015). WHO (World Health Organization) defines overweight and obesity as “excessive fat accumulation in the body that presents a risk to health” (WHO, 2016a). In adult males, 15-20% of the body weight consists of fat tissue, while it is 25-30% in females. WHO developed an index called as Body Mass Index (BMI) towards defining obesity, which is calculated via dividing the weights of the patients in kilograms to the square of their heights in meters. The distribution of the fat within the body is as important as the total fat. When the waist circumference is 94cm in males and 80cm in females it equals to 25 in BMI, and when the waist circumference is 102cm in males and 88cm in males it equals to 30 and above in BMI (Baysal, 2009 The method that is accepted the most in the World in obesity scanning of children is again BMI calculation Mei et al. 2002; Abnormal BMI is evaluated in specific percentile curves according to age and sex. If BMI is over 85. percentile in children older than 2 years old, they are evaluated as overweight, if it is over 95. Percentile, they are evaluated as obese or over-weight and if it is over 99. Percentile, they are evaluated as morbid obese (Barlow 2007; Önal &Adal, 2002, Berk, 2013). In children younger than 2 years old, >% 85 of the ideal weight in terms of months is called over-weight but not obese (Önal &Adal, 2002). While health problems in related to malnourishment decrease today, the problems in relation to the obesity and related diseases caused by over-nutrition, extreme energy intake and sedentary life increase (Shepard et al., 2001; Çayır et al., 2011 Among the elements affecting frequency of appearance of obesity around the World, there are; participation, age, sex, nutrition habits, life style habits, endocrine and metabolic 

Assist. Prof. Dr., Cumhuriyet University, Faculty of Health Sciences, Midwifery Department. Sivas

elements. Obesity is a type of disease that results in various significant problems such as cardiac problems, hypertension, diabetes, high cholesterol, respiratory diseases, joint diseases, menstrual irregularities, infertility, impotency, gallbladder diseases and lithiasis (Daşıkan&Kavlak, 2009; Krishnamoorthy et al., 2006; Galtier-Dereure et al., 2000). Causing the death of 2.8 million of people each year as a result of being overweight or obese, obesity has reached a global level of epidemic. Previously thought to be related to the countries with high incomes, obesity now is a preventable problem of public health that has reached epidemic levels in countries with low and middle income and in Turkey with increasing frequency (James et al., 2001; Deepa et al., 2009; WHO, 2016a; WHO, 2016b). According to WHO data, in the year 2014 generally, approximately 13% of the adult population of the world (11% male, 15% female) was obese. In the year 2013, it was stated that 42 million children below the age of 5 were overweight or obese, and in the year 2014, more than 1,9 billion adults aged 18 and above were overweight and 600 million of them were obese and that the prevalence of obesity worldwide increased more than two times between the years 1980 and 2014 (WHO, 2016a). When the studies conducted in regard to obesity in Turkey are evaluated; in a study conducted on cross-sectional and societal basis in the Turkish adult society between the years 1997-98, (TURDEP II- Turkish Diabetes Epidemiology Study) obesity prevalence for individuals aged above 20 was determined as 22.3% (males: 12.9%; females: 29.9%). In TURDEP II study that was conducted 12 years later, the obesity prevalence in Turkey was found to be 32%, and it was determined that obesity increased by 44%. The fact that overweightness is more prevalent in males while obesity is more prevalent in females strikes the attention (Satman, 2010). According to the study called Turkish Adult Risk Factor Study (TEKHARF), the obesity prevalence in males aged 30 and above is 25.2% and while in females it is 44.2%. It was determined that the prevalence in women after the age of fifty increased at a significant level (50.2%) (Onat, et al., 2001). Upon the analysis of the Turkish Statistical Institute (TÜİK) data calculated with the use of height and weight values of individuals, it was seen that 3.7% of the individuals aged 15 and above were overweight, and in terms of gender differentiation, 24.5% of the females were obese and 29.3% were overweight while these rates in males were 15.3% and 38.2% respectively (TÜİK, 2015). According to the results of Turkey Nutrition and Health Survey (TBSA – 2010), the obesity prevalence was found to be 30.3% in individuals aged 19 and above, this rate was 20.5% in males and 41% in females, and the rate of being overweight was determined as 34.6% (TBSA, 2010). And when the results of Turkey Demographic and Health Survey (TNSA), which is repeated every 5 years in Turkey and in which women aged between 15-49 were included, it is seen that obesity is increasingly growing within female population. According to these study results, the overweight prevalence among women aged between 15-49 (BMI=25-29.9 kg/m2) was 33.4%, 34.2% and 34.4% in the years 1998, 2003 and 2008 respectively, while obesity (BMI≥30 kg/m2) prevalence was 18.8%, 22.7% and 23.9%. As can be seen, there was a 5.1% increase in the last 10 years in female obesity prevalence. In TNSA-2013, the average BMI of the women aged between 15-49 was 26.7. The BMI of 55% of the women is above 25.0. While 84% of the women within the age group of 40-49 years old is overweight or obese, more than half of the women in this age group (51 percent) is obese (TNSA, 2013). Lactation is important in preventing obesity (California WIC, 2006). In TNSA300

2013, it is seen that 50 % of the children are started to be breastfed in one hour after the birth but the rates of being fed only with breast milk decrease considerably in the first six months. In an experimental study conducted in 2015, it was determined that all of the pregnant women (in the experimental and control groups) wanted to breastfeed. However, it was determined that all of the mothers supported for breastfeeding breastfed their babies in one hour after the birth but only half of the mothers in the control group breastfed their babies (Yurtsal & Koçoğlu, 2015). In a study, it was determined that almost all of the mothers believed in the importance of lactation (Evcili, et al., 2014). Breastfeeding, which is the natural way of nutrition, can be encouraged by nutritional literacy training during pregnancy within the nutritional literacy programmes. Hence, it can be said that the rates of lactation can be increased and thus the prevalence for obesity can be decreased. In terms of the health risks of the nutrients and what can be done, initially the health professionals’ caring and guiding the other individuals in the society is critically important. The data in literature shows that obesity increases in women especially among women of reproduction-age and pregnant women. Maternal obesity can cause many problems in terms of both mother’s health and also the child’s health in the future. It was stated that chances of getting cancer, paralysis, hypertension, diabetes and coronary cardiac diseases increase in the long run among mothers and also there is an increase in low life quality and consequently death rates. Maternal obesity which is seen before pregnancy is related to increase in infertility, pregnancy loss, polycystic over syndrome (PKOS) prevalence. The children of the women who are obese during gestational period face with cardiac and metabolic risks (Özdemir, et al., 2015). Furthermore, maternal obesity during pregnancy is related to gestational diabetes, preëclampsia, thromboembolic diseases and maternal death. Moreover, maternal obesity before and during pregnancy have negative effects on prenatal and postnatal development of fetus. It is stated that negative factors arising in mother negatively affect body image and mental health (Şener et al., 2011; Özdemir, 2015). It was stated that maternal obesity reduces breastfeeding frequency and causes problems of breastfeeding (reduce in prolactin level, decrease in sucking response, procrastination. Feeding baby with artificial foods due to lactation failure might increase the risk of obesity in baby. Krishnamoorthy et al., 2006; Larsen et al., 2007). Obese women’s body image which changes even more with gaining weight during pregnancy negatively affects life perspective of women and might cause women to have problems such as depression, stress and body image problems (Daşıkan & Kavlak 2009). In the recent years in Turkey, there has been more emphasis on the obesity problem in children. In a study called TOÇBİ (Surveillance on Growth Monitoring in School Aged Children in Turkey) (2011), the research was conducted on 12301 children in an age group of 6-10 years old that continue their education in140 elementary schools as an indicator to the school aged children aged between 6 – 10 in Turkey in General. Throughout Turkey, 6.5% of children were found to be obese [Boys: 7.5%, Girls: 5.4%] and 14.3% were found to be mildly obese/overweight [Boys 15.1%, Girls: 13.5%] (TOÇBİ, 2011). Obesity frequency in Turkey among children changes between % 1.6 (Elazığ) to % 8.4 (Antalya urban) and %7.8 (Bursa). Frequency of obesity in western parts of Turkey in large scale researches (Kocaeli, Bursa, Düzce) is around % 7. On the other hand, this rate is between 2-3% in similar researches in eastern parts. It was stated that this situation is related to prevalence of lifestyle that 301

causes adiposity in western cities (Hatun, 2012; Önal & Adal, 2014). In a research in which anthropometric measurement of 4.958 children was made in total in schools, while overweightness and obesity percentage among boys is 23,3% and 21,6% in girls, adiposity percentage in total is 8,3% and overweightness percentage is 14,2%. Özcebe & Bağcı Bosi, 2014). It is seen that obesity and related diseases pose a great threat in terms of society’s health unless any precaution is taken in accordance with all these studies conducted. In the literature regarding the nutrition literacy, it is emphasized that the level of literacy and health literacy had a key role in the progression, management and treatment of diseases related to nutrition such as cardiovascular diseases, cancer, diabetes and hypertension (Carbone & Zoellner, 2012). With the unification of nutrition science and literacy model and the creation of nutrition literacy vision in society, the increase of control of the people on their own eating habits and living a healthier life can be supported (Cimbaro, 2008). Thus, people with sufficient nutrition literacy can determine problems in regard to nutrition, correct the mistaken applications about nutrition he determined by accessing correct information and applies to health institutions where he can receive the necessary service when none of these are sufficient. Generally, the people with a sufficient level of knowledge on nutrition are expected to make healthy food choices (Parmanter, et el., 2000). Therefore, with the increase in nutrition literacy, not only the increased knowledge but also the healthy eating habits can be encouraged as well. However, though the individuals can be at sufficient level of nutrition literacy based on the various factors that affect nutrition literacy such as age, education and gender, they might need to be supported in terms of using the skills they have. In a study conducted by Uçar et al. (2012), it was determined that individuals that had high level of knowledge did not use the information regarding the nutrition knowledge, though they had sufficient level of knowledge about it. Similarly, Buttriss (1997) stated that individuals were unsuccessful in terms of using their own theoretical knowledge on healthy food choices. No significant relationship was determined between BMI and nutrition point averages in Rothman’s (2006) study, and no significant relationship was found between nutrition literacy and BMI in the study of Zoellner et al. (2013) and the study of Aihara and Minai (2012) (Aihara and Minai, 2012; Zoellner et al., 2013; Rothman et al., 2006). In a study conducted in Sivas in the year 2014, similarly, no significant relationship was determined between nutrition literacy and BMI (Cesur, 2014). However in this study, though the nutrition literacy general point of the individuals was at a sufficient level, according to the BMI assessment of the individuals, 36.5% of them were found to be at normal weights. These results give rise to the thought that the individuals do not use their nutrition literacy skills sufficiently. Also the fact that the level of nutrition literacy of the majority of the individuals is insufficient and limited especially in the fields of portion amounts and reading food labels and numeric literacy might be effective in this result. The individuals must ensure that the information that is found on the food labels and carry importance especially in the fight against obesity is first read by the individuals in the society, they must understand that what these information are and how they are used and decide whether or not to consume a food based on the information he gathered or determine how much to consume through simple calculations. In order for the individuals to make healthy food choices for themselves, the food labels must include 302

necessary information, be easy to read, presented in a standard format, and the lacking information of the individuals on basic nutrition knowledge must be compensated, and nutrition literacy skills such as insufficient levels of portions, reading food labels and performing simple mathematical operations. In the case that these skills cannot be improved, the increase in prevalence of seeing overweight and obese individuals and non-contagious diseases in the society will be unavoidable. In order for individuals to eat healthily in a society, there needs to be a national nutrition plan and policies created that can be adapted to scientific and technological advances and can be put into use effectively. All the foods to be consumed must be sufficient, healthy and safe from production up to their consumption for the individuals to be able to choose healthy and reliable food (DPT,2001). When setbacks are observed in these applications, the individuals with increased levels of nutrition literacy should be able to determine the lacking aspects and produce solutions, require services and contribute to the policy and program updates in regard to correcting these setbacks. Thus in the face of risks that might affect their own health, individuals will become conscious individuals that can assess their status and provide solutions. Obesity-preventive strategy should be implemented as of the early ages of life. Nursing mothers in neonatal and infancy periods should be supported physically and emotionally and they should be encouraged to only breastfeed at least until 6 months and to wet-nurse until the age of 2 since obesity incidence in babies who received breastmilk is lower during childhood (Önal & Adal., 2014, Yurtsal & Koçoğlu., 2015). Heights and weights of children should be measured every year to calculate BMI and their situations of nutrition and physical activity should be evaluated (Waters, et al., 2011; Önal & Adal., 2014). Nutrition literacy programs should be prepared about starting additional nutrients in 6th month, preparing additional food appropriately, regarding appropriate quality and amount of additional nutrients, preparation of baby formula if mother has to use ready-formulas and appropriate amounts to feed the baby. Considering social and cultural qualities around the country, nutrition literacy programs should be developed specific to preschool period, school period, adolescent period, adulthood and old age. In the fight against obesity from the period before birth till the geriatric age group, important responsibilities fall on the shoulders of all health staff. Thus, health professionals’ paying close attention to the health risks of foods and to precautions to be taken, and supporting guidance to other members of the society are crucially important (Karadag, et al., 2012; Yurtsal,2016). In the study of Cesur in 2014, it was determined that the primary sources the individuals trusted their information on nutrition, dieting or food were health personnel and dieticians. Alıcı and Pınar (2007), in their studies, stated that training given by the nurses to obese individuals was effective in the improvement/betterment of the metabolic, psychological parameters of the obese individuals and their life qualities (Kalichman, et al., 2002). In accordance with these findings, health personnel and dieticians must undertake active roles in gaining nutrition literacy skills for the purpose of improving health. The scope of health services throughout all steps with especially health services provided in primary care, needs to be widened to include interventions towards gaining nutrition literacy skills for the society.

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REFERENCESS Allen, L., Gillespie, S. (2001). "What Works? A review of the Efficacy and Effectiveness of Nutrition Interventions", United Nations Administrative Committee on Coordination Sub-Committee on Nutrition, Asian Development Bank, ACC/SCN Nutrition Policy Paper No.19. Babaoğlu, K., Hatun, Ş. (2002). Çocukluk Çağında Obezite, Sted, 11(1):8-10. Barlow, S.E. (2007). Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics;120(suppl 4):S164-S192.http://dx.doi.org/10.1542/peds.2007-2329C Baysal, A. (2009). Beslenme, Hatiboğlu Yayınevi, 12. Baskı, Ankara, 9-18. Berk, E.L. (2013). Orta çocukluk döneminde fiziksel gelişim, Aşırı kilo ve obezite, 11. Bölüm, , In: Infants and Children Prenatal through Middle Childhood (Traslation Ed. Işıkoğlu Erdoğan, N. Bölüm çevirisi: Palut Ekinci, B.), Nobel Akademik Yayıncılık,416-422. Buttriss, J.L. (1997) Food and nutrition: attitudes, beliefs,and knowledge in the United Kingdom. American Journal of Clinical Nutrition; (65), 1985-95. California WIC Association and the UC Davis Human Lactation Center (2006). Breastfeeding: The First Defense against Obesity. http://calwic.org/storage/documents/wellness/bf_paper1.pdf Carbone, E.T., Zoellner, J.M. (2012). Nutrition and health literacy: A systematic review to inform nutrition research and practice. J Acad Nutr Diet, 112(2):254-65. Cesur, B. (2014). The situation of Nutrition Literacy and Its Relation with the Quality of Life on the Adult Population of Sivas City Centrum, Cumhuriyet University, Sivas. Cesur, B. (2015). Nutrition Literacy, Sağlıkla Hemşirelik Dergisi, 21:54-56. Cimbaro, M.A. (2008). Nutrition literacy: Towards a new conception for home economics education, The University of British Columbia, Vancouver. Çayır, A., Atak N., Köse, S.K. (2011). Assessment of Obesity Frequency and Related Factors on Individuals Attending to the Department of Nutrition and Dietetics, Ankara Üniversitesi Tıp Fakültesi Mecmuası, 64(1),13-19. Daşıkan, Z., Kavlak, O. (2009). Maternal obesity: Pregnancy Complications and Management of Pregnant Woman:Review, J Nurs Sci;1(1):39-46. Deepa, M., Farooq, S., Deepa, R., Manjula, D., Mohan, V. (2009). Prevalence and significance of generalized and central body obesity in an urban Asian Indian population in Chennai, India, Eur J Clin Nutr;63:259-267. Devlet Planlama Teşkilatı (DPT) Müsteşarlığı İktisadi Sektörler ve Koordinasyon Genel Müdürlüğü, (2001). Ulusal gıda ve beslenme stratejisi çalışma grubu raporu, Yayın No DPT: 2670, Ankara, 40-54. Evcili, F., Abak, G., Tali, B., Yurtsal, Z.B. (2014).The Opinions of Mothers in the Early After Childbirth Period About Mother – Baby Bonding, Sted , (23)4. Galtier-Dereure, F., Boegner, C., Bringer, J. (2000). Obesity and pregnancy: complications and cost. Am J Clin Nutr;71(5 Suppl):1242S-8S Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü: Türkiye Nüfus ve Sağlık Araştırması (TNS, 2013). Ankara, Türkiye. Hatun, Ş. (2014). Çocukluk çağı obezitesinin dünya ve Türkiye’de sıklığı. Turkish J Pediatr Dis2012;1(2):7-14.Önal Z, Adal E, Obesity in Childhood Okmeydanı Tıp Dergisi 30(Ek sayı 1):39-44. James, P.T., Leach, R., Kalamara, E., Shayeghi, M. (2001).The worldwide obesity epidemic. Obes Res;9:228S-233S. Özcebe, H., Bağcı Bosi, A.T. (2014). Türkiye Çocukluk Çağı ( 7-8 Yaş )Şişmanlık 304

Araştırması,1. Basım,Ankara Özdemir, A. (2015). Maternal Obesity and Public Health, International Journal of Caring Sciences, 8(1): 217-220. Özdemir, A., Yurtsal, Z. B., Cesur, B. (2015). Obesity and the Preconception Period, Turkey at the Beginning of 21st Century: Past and Present (Ed: Efe, R., Ayısıgı, M., Duzbakar, O., Arslan, M.). ST. Kliment Ohridski University Press, Sofıa. Kalichman, S. C., Benotsch, E. G., Weinhardt, L.S., Austin, J. and Webster, L. (2002). Internet use among people living with HIV/AIDS association of health information, health behaviors and health status. AIDS Education and Prevention. 14(1), 51-61. Karadag, G., Aydın, N., Kayaaslan, H. (2012). Gaziantep University of Medicine and Nursing Students Read the Chapter Relating to Food Security Sensitivity and Feedback. TAF Prev Med Bull,11 (4), 439 Krishnamoorthy, U., Schram, C.M., Hill, S.R. (2006). Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies? BJOG;113(10):1134-40. Larsen, T.B., Sørensen., H.T, Gislum, M., Johnsen, S.P. (2007). Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study. Thromb Res; 120(4):505-9. Mei, Z., Grummer-Strawn, L.M., Pietrobelli, A., Goulding, A., Goran, M.I, Dietz, W.H. (2002). Validity of body mass index compared with other body composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr;75:978-985. Onat, A., Keleş, I., Sansoy, V., Ceyhan, K., Uysal, O., Çetinkaya, A. (2001). Rising obesity indices in 10-year follow-up of Turkish men and women: Body mass index independent predictor of coronary events among men. Türk Kardiyoloji Derneği Arşivi, 29:430-36. Önal, Z., Adal, E. (2014).Obesity in Childhood Okmeydanı Tıp Dergisi 30(Ek sayı 1):3944, Parmenter, K., Waller, J., Wardle, J. (2000). Demographic variation in nutrition knowledge in England. Health Educ Res (152), 163. Satman, I. (2010). TURDEP II Çalışma Grubu. TURDEP II Sonuçları. 2010. 13-17 Ekim 2010, Antalya. Shepard, T.Y., Weil, K.M., Sharp, T.A., Grunwald, G.K., Bell, M.L., Hill, J.O., Eckel, R.H. (2001). Occasional physical inactivity combined with a high-fat diet may be important in the development and maintenance of obesity in human subjects. Am J Clin Nutr. Apr;73(4):703-8. Şener, E.H., Uzun, A., Malas, M.A. (2011). Effects of Maternal Obesity on Prenatal and Postnatal Development of Fetus: Review, J Gynecol Obst;21(2):112-20. TÜİK Basın Odası Haberleri, Sayı:58/2015 http://www.tuik.gov.tr/basinOdasi/haberler/2015_58_20151008.pdf Türkiye Beslenme ve Sağlık Araştırması (TBSA,2010), Sağlık Bakanlığı, Hacettepe Üniversitesi, Sağlık Bilimleri Fakültesi, Beslenme ve Diyetetik Bölümü, Ankara. Uçar, A., Özdogan, Y., Özfer Özçelik A. (2012). Does nutrition knowledge change nutrition behavior?. HealthMED; 6 (6), 2028-2035. Waters E, de Silva-Sanigorski A, Hall, B.J., Brown, T., Campbell, K.J, Gao, Y., Armstrong, R., Prosser, L., Summerbell, C.D. (2011). Interventions for preventing obesity in children World Health Organization (Retrieved: 07.06.2016), http://www.who.int/mediacentre/factsheets/fs311/en/ 305

World Health Organization (Retrieved: 07.06.2016), http://www.who.int/features/factfiles/obesity/facts/en/ Yurtsal., Z. B. (2016).Midwifery Students Knowledge and Opinions About Food Additives, Oxidation Communications 39, No 2, 1753–1761 Yurtsal, Z. B., and Koçoğlu, G. (2015). The effects of antenatal parental breastfeeding education and counseling on the duration of breastfeeding, and maternal and paternal attachment, Integr Food Nutr Metab, 2(4): 222-230.

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Chapter 27 Adolescent Pregnancy and Nursing Approach Selma ŞEN INTRODUCTION In Latin adolescent means being "mature". Adolescence is the transition period from childhood to adulthood where final rapid physical and sexual development and social maturation occur (Bülbül, 2004). In broader terms, it is the transition period from childhood to adulthood biologically, psychologically, and socially (Yavuzer, 1998). According to WHO, age group 10-19 is defined as adolescence and age group 20-24 is defined as youth period (Bülbül, 2004). Adolescence involves one of the two rapid growth stages in human development (Akçan Parlaz, Tekgül, Karademirci & Öngel 2012, Yavuzer, 1998). During this period, many bodily and mental changes take place (Akçan Parlaz, Tekgül, Karademirci & Öngel 2012). Bodily development in this period is the basis for emotional, social, and mental maturation. In other words, adolescence begins with biological changes and ends with bodily, mental, and psychological development. It is the transition period in which individual proceeds from childhood to adulthood through psychological and social changes (Yavuzer, 1998). Many physical, psychological, and sexual development or reproductive health problems may arise in adolescence (Dölen, 2003). Among the most common problems adolescents have are intentional or unintentional accidents, smoking, drug and alcohol abuse, nourishment problems, sexually transmitted diseases, risky sexual behaviours, risky pregnancy, and abortus (Yavuzer, 1998). Also, individuals prepare for adulthood during this period and therefore problems that arise then might affect their whole lives (Günay & Öztürk, 1995). ADOLESCENT PREGNANCIES Although there is not a universal consensus on the definition of adolescent mother, it is generally accepted that pregnancy at or under the age of 18 is adolescent pregnancy (Dölen, 2008). WHO defines adolescent pregnancy as pregnancy in females aged 10-19 (WHO, 2009). The rate of women who became mother before 20 is a measure of adolescent fertility which is accepted as a significant health and social problem (Kovavisarach et al., 2010, Başer, 2000). Although adolescent pregnancies were reacted normally in the beginning of the century for short fertility durations, short life expectancy and creating a stable population, it began to be taken as a term threatening community health (Dölen, 2008). Adolescent pregnancies are one of the most important health and social problems of the 21st century (WHO, 2009). Prevalence of adolescent pregnancy is 5.3% worldwide due to social, cultural, and economical factors such as marriage age, traditional attitudes, religious beliefs, family 

Assist. Prof. Dr., Celal Bayar University Health Sciences Faculty, Midwifery Department

structure, education, financial status, and accessing family planning services (Molina et al., 2010). Adolescent pregnancy rates are lower in countries where sexual education is given in schools and where contraception methods are easy and widespread (Bulut et al., 2008). In developing countries, rates female literacy and education levels are lower than males'. Due to lack of education and traditional attitudes, early marriages and childbirths are common (Başer, 2000). Although females conceive children out of wedlock in developed countries, adolescent marriages are accepted and supported Turkey due to our cultural structure (Özcebe & Biçer, 2013, Bulut et al., 2008). The most important reasons for adolescent pregnancies in Turkey are early marriages or wanted or unwanted pregnancies out of wedlock, being unaware of or not using contraception methods sufficiently, low socio-economical and socio-cultural levels, tendency to smoke, abuse alcohol, have unplanned and unsafe relationships, sexual abuse, and desire to prove being physically developed (Dölen, 2008, Bülbül, 2004). Girls who marry at an early age conceive at an early age. Also, parents make their daughters marry due to economical problems and create a vicious circle Özcebe & Biçer, 2013, Bulut et al., 2008). Molina et al., (2010) stated that mothers of 42% of pregnant adolescents were also pregnant in adolescence (Molina et al., 2010) Despite being a physiological phenomenon, pregnancy becomes a psychological trauma for individuals who are in the development period. When adolescent females marry and give birth before being psychologically mature, they may experience troubles because of being misinformed. Adolescents are terrified of pregnancy and childbirth, and situations which are usual during pregnancy cause fear and anxiety in adolescent pregnancy. The younger one conceives, the effect pregnancy creates is bigger. For a healthy pregnancy, there must be a period of 5 to 7 years between menarche and pregnancy (Özcebe & Biçer, 2013). Adolescent females are not physically prepared for childbirth and maternal death risk is higher compared to mothers at their 20s (Yavuzer, 1998). For young mothers, pregnancy, parenthood, and interpersonal relationships are short but critical. Adolescent mothers have to face many new challenges such as identity development, making new contacts, and integrating abstract ideas (Whitman, 2001). Because metabolic, hemodynamic, and psychological burdens created by pregnancy overlap with conditions arising during adolescence, adolescent pregnancy falls into risky pregnancy category even in the absence of additional problems. POSSIBLE COMPLICATIONS IN ADOLESCENT PREGNANCY A number of structural and functional changes occur in the body during pregnancy. When a woman falls pregnant before completing her bodily, mental, and social development, both the mother and the baby is affected negatively (Öner & Yapıcı 2010). While trying to adapt to the changes in her body, adolescent faces being pregnant and a mother and this situation puts the organism into risk (Kütük, 2012, Grady & Bloom 2004, Orçin, Aras & Açık 2003, Sevil & Öner 2001). Therefore, adolescent pregnancy must be evaluated as high-risk pregnancy. Maternal Complications Adolescent pregnancy has various negative health results that affect both the baby and the mother in the short and long term and these results are physiological, psychological, sociological, and economical. Pregnancy and labour complications are seen in adolescent pregnancy 60% higher than other pregnancies (Kömürcü, 2008). 308

These results can be summarised as follows; Mortality rate is rather low in young women, but pregnancy-related mortality and morbidity rates are a great problem in adolescent women. When compared to women aged 20-29, maternal morbidity and mortality is 4 times higher in women under 18. Mortality rate in women under 15 is 60% (WHO 2009). Pre-eclampsia is one the greatest risk factors that can emerge during pregnancy. Other factors that might increase this risk are adolescent coming from a low socioeconomical background, malnourishment, and inadequate prenatal care (Taşkın 2011). When "toxaemia" which emerges due to hypertension during pregnancy is not diagnosed and treated ", "eclampsia" is seen more frequently in pregnant adolescents. Absence of bone-mineral content, iron deficiency anaemia, and malnourishment are also seen in adolescent pregnancy (URL 1). An adolescent who is not ready for motherhood cannot take care of the baby and herself. She cannot carry the burden of raising a child and may neglect herself. Since the development of pelvic bone, which is an important structure for labour, completes between the ages of 20 and 22, difficult labours are frequent in adolescent pregnancy (URL 1). Stillbirth, miscarriage, massive bleeding, premature labour, low birth weight baby are among other problems (Shawky, 2002). Psychological problems that are caused by economical and socio-cultural pressure increase problems faced during pregnancy (URL 1). In a 5-year retrospective study carried out by Nahathai et al., complication indications of 2480 pregnant adolescents aged 13-19, and 3909 adult pregnant women aged 20-25 were compared. According to the study results, pregnant adolescents received inadequate antenatal care and frequency of anaemia and low birth weight newborn were meaningfully higher (Nahathai et al., 2006). Keskinoğlu et al., found in their study carried out with 945 pregnant adolescents that 28% of adolescents developed some obstetric and neonatal complications, 18.2% had preterm actions, 12.1% had low birth weight babies, and 27.5% of them had caesarean section (Keskinoğlu et al., 2007). Kürkner et al., found that prolonged labour rate was higher in pregnant adolescents compared to adults (Kürkneret al., 1994). However, in the study carried out by Thaithae and Thato (2011) about 11000 pregnant adolescents's data was examined and it was revealed that risk of pre-eclampsia and preterm birth was similar to adult pregnant women. Moreover, it was also found that risks of preterm birth and IUGR increased in pregnant adolescents and this increase was clearer in adolescents aged 11-15 (Thaithae & Thato, 2011). According to one research published in Van in 2010, 11% of the 1872 women who conceived were under 19. Rate of exposure to domestic violence was higher in adolescent/child mothers compared to adult mothers (17% against 10%), inadequate antenatal care was higher (28% against 16%, p60

Schofield formula Man Woman (17.7 x W ) + 658 (13.4 x W) + 693 (15.0 x W) + 692 (14.8 x W ) + 487 (11.5 x W ) + 873 (8.1 x W ) + 845 (11.7 x W) + 588 (9.0 x W ) + 658

Harris Benedict formula BMHman = 66 + (13,7 x W) + (5 x H) - (6,8 x A) BMHwoman = 655+(9,56 x W)+(1,8 x H) - (4,68xA)

*W = kg body weight; H = cm height; A = age

 Daily energy requirements = BMR +/x Activity Factor +/x Trauma or Stress Factor In the calculation of daily energy requirements, the activity factor, trauma or stress 513

factors to be added to BMR have been formulated differently by various researchers (Table 3). While determining the energy requirement, BMR is multiplied by Long factors if these factors are used. If Scrimshaw is used, these factors are the percentages of BMR, and the energy requirement is calculated by the addition with BMR(Arslan, 1995; Mercanlıgil & Keçecioğlu,2011). Carbohydrates: The most important function of carbohydrates in the body is to generate energy, and therefore they are antiketogenic. In addition, it is also an important nutrient for the fluid and electrolyte balance (Erdem, 2013; Mercanlıgil & Keçecioğlu,2011). The excessive use of carbohydrates in EN negatively affects the metabolism. It causes liver fattening by increasing the hepatic lipogenesis. It also leads to the acceleration of the glycogenolysis and hyperglycemia along with the increase of the catecholamines by increasing sympathetic nervous system activation (Arslan, 1995; Mercanlıgil & Keçecioğlu,2011). To avoid these negative effects, 55-60% of the energy needed to be taken on a daily basis should be met with carbohydrates excluding some specific diseases (such as pulmonary diseases). Table 3: Activity and trauma/stress factors Activity and Trauma/Stress Factors Scrimshaw Factors Activity Confined to bed (comatose) BMR+ 0% Confined to bed BMR+ 10% (consciousness) Confined to bed (but mobile) BMR+ 15-20% Out of bed BMR+ 25% Ventilator dependent BMR+ 15% Stress Fever BMR+10-12% (for every 1˚C increase above normal temperature)

Long Factors Activity Confined to bed Out of bed

BMRx 1.2 BMRx 1.3

Trauma Minor surgery Trauma Sepsis Burns

BMRx 1.2 BMRx 1.3 BMRx 1.6 BMRx 2.1

Lipids: Lipids are also the sources of energy such as carbohydrates. The energy provided from glucose-to-the energy provided from fat ratio is desired to be 3/1 because everything that affects the carbohydrate metabolism affects the fat metabolism. 25-35% of the total energy needed to be taken on a daily basis is recommended to be provided from fat (Arslan, 1995; Erdem, 2013). In the nutrition of patients with the problem in the absorption and transport of the fats, the products containing medium chain fatty acids (MCFAs) should be selected because they do not require pancreatic lipase and bile salts and can be absorbed from the intestinal mucosa. Especially the products containing essential fatty acids are recommended to be preferred because of their positive effects on health (Erdem, 2013). Proteins: Proteins should constitute 15-20% of the total energy. The protein requirement of a young adult is 0.8-1.0 g/kg/day. However, the negative nitrogen balance occurs due to increased protein catabolism in cases of infections, malnutrition, burns, fever, stress, surgeries, trauma, and disease. The amount of protein that should be taken on a daily basis shows an increase to avoid excessive nitrogen loss (Arslan, 1995). It may also be necessary to make a protein restriction based on the patient's biochemical findings in liver failure and renal diseases. Therefore, the diseases of the individual must be taken into account while determining the amount of protein to be given in enteral nutrition. 514

3.2. Indications of the enteral nutrition Enteral nutrition is used in patients who cannot or will not be able to take nutrient and have a functional gastrointestinal system though partially (Yentür, 2008). Two main reasons for the implementation of the enteral nutrition support are to ensure the improvement of the swallowing disorder and nutritional status in the patient (Annual BANS Report, 2008). For the implementation of enteral nutrition: the psychological state of the patient should be stable, the patient and the people who take care of the patient should understand the treatment, give consent to it and have the capacity to perform it reliably, and the materials and products to be used during nutrition should be easily obtainable (Gündoğdu, 2010). Diseases with enteral nutrition indication are summarized in Table 4 (Reitz & Ridley, 1988; Nelson et al., 1986; Howard et al., 1986; Çekmen & Dikmen, 2014). While enteral nutrition can be applied temporarily, it can also be applied for lifelong and continuously in situations developing permanently (Yentür, 2008). Table 4: Indications of enteral nutrition Neurological and Psychiatric Disorders

Gastrointestinal Diseases

Head trauma Coma Anorexia nervosa Severe depression Multiple sclerosis Alzheimer's Parkinson's Dementia Brain lesions Muscular dystrophy Mental retardation

Short bowel syndrome Cystic fibrosis Chronic pancreatitis Gastrointestinal fistulas Gastrointestinal malignancies Situations that require bowel rest Malabsorption diseases

Esophageal Diseases Achalasia Benign esophageal strictures Neoplasms Ingestion lesions

Others Radiotherapy and Chemotherapy Burn Severe sepsis Preoperative preparation Postoperative nutrition

Organ Failures Liver failure Kidney failure

3.3. Contraindications of the enteral nutrition Enteral nutritional support has various contraindications although it is the first option to be preferred (Howard, 2004). The most important contraindication for EN is the mechanical obstruction (Yentür, 2008). The other contraindications of EN are summarized in Table 5 (Howard, 2004; Mercanlıgil & Keçecioğlu,2011). 3.4. Routes of applying enteral nutrition The selection of the EN route varies depending on disease, comfort, aspiration risk, gastrointestinal system pathology, estimated nutrition time and lifestyle of the patient and the patients’ or their relatives' ability to apply the selected method (McCrae & Hall, 1989). Oral nutrition is the method to be the first choice in the patient's nutrition. Oral nutritional support should be considered if oral nutrition leads to the lack of macro and micro nutrients in the patient. For the implementation of this route, the patient must 515

have a swallowing reflex but must not have any oesophageal or gastric obstruction (Akıncı, 2011; Yentür, 2008). If oral EN is applied, the whole nutrition is performed by giving enteral products during the day or enteral products are given as a support in addition to the patient's normal nutrition. Table 5: Contraindications of the enteral nutrition - Mechanical intestinal obstruction - Intestinal loss of function (severe inflammation or postoperative stasis, etc.) - Failure to provide intestinal access - High loss of intestinal fistula - Severe diarrhea, severe burns, multiple trauma - Hypomotility - Situations that require intestinal resting - Situations where nutrition with tube is relatively contraindicated

If EN is applied with the tube, stomach, duodenum or jejunum should be utilizable. The nasogastric tube or gastrostomy is frequently used for the stomach. Especially in recent years, percutaneous endoscopic gastrostomy (PEG) with easy removal, fewer complications and less occlusion risk that does not require general anesthesia and is easy and cheap to apply has been preferred in the gastrostomy application. Gastrostomy method is usually recommended for long-term nutritions. The nasoduodenal and prolonged gastrostomy for duodenum, and nasojejunal, prolonged gastrostomy and surgical jejunostomy for jejunum are the other methods used (Fig. 2). In tube nutrition, all the energy, and nutrient requirements that the patient should take during the day are met by enteral product solutions using different nutrition methods (such as bolus, intermittent and continuous infusion) (Mercanlıgil & Keçecioğlu, 2011; Gündoğdu, 2010; Howard, 2004).

Figure 2: Routes of enteral nutrition (Howard, 2004) 516

3.5. Products used in enteral nutrition and their features The products used in enteral nutrition are divided into two basic categories including polymeric solutions and elemental and semi-elemental solutions. Both solution groups are produced in three different forms including standard, diseasespecific and immunity-increasing (Çekmen & Dikmen, 2014). The protein structure of enteral products consists of unhydrolyzed, partially hydrolyzed and crystallized amino acids. The most important sources of protein in products are casein, lactalbumin, and soy. The hydrolyzed corn starch and maltodextrin are used as a carbohydrate source. Long chain and medium chain fatty acids are the most important fat sources. The fat content in products is effective on energy and flavor and also important in terms of providing the essential fatty acids and fat-soluble vitamins (A, D, E, K). In addition, some enteral nutrition products contain pulp/fiber which are polysaccharides, lignin, and oligosaccharides (inulin, fructooligosaccharides, and galactooligosaccharides) and cannot be digested in the small intestine (Mercanlıgil & Keçecioğlu, 2011; Güngör, 2013). The patient's clinical condition, tolerability for the product and nutritional needs (energy, protein, fat requirements) should be taken into account while selecting a product for the patient to be fed enterally. Classification of the enteral products is shown in Figure 3.

Figure 3: Classification of the enteral products (Güngör, 2013).

3.5.1. Polymeric products These products, which are commonly used in EN and characterized as standard products, are suitable for use both at home and in the hospital. They contain unhydrolyzed complete proteins such as casein and soy and the types of carbohydrate such as maltodextrin, oligosaccharide, and starch. They contain medium chain and long chain fatty acids as the source of fat. There are also minerals, vitamins and trace elements in their structure (Zadak & Kent-Smith, 2004; Mercanlıgil & Keçecioğlu, 2011). They are preferred to be used in patients whose digestive and absorptive functions are full or close to full and whose oral nutritional intake is limited because nutrients are not hydrolyzed in polymeric products (Güngör, 2013). They can be better tolerated because their osmolarity is close to the normal physiological levels (300 mOsm/L) (Zadak & Kent-Smith, 2004). Because the nutrient requirements of each patient are different, polymeric products are produced by being diversified as high-protein, highcalorie and fibred/fibrous in order to meet these requirements (Güngör, 2013). 517

3.5.2. Oligomeric and monomeric products They are also called as elemental and semi-elemental products. They require minimal digestion because they contain macronutrients which are enzymatically hydrolyzed by varying degrees (Zadak & Kent-Smith, 2004). They can be absorbed easily and nearly totally in the body, therefore, the need for bile acids and pancreatic enzymes is very low (Mercanlıgil & Keçecioğlu,2011). Their osmolarity is high because they consist of hydrolyzed, lower molecular weight macro nutrients. Elemental products do not contain lactose and gluten, and their residual rates are fairly low (Zadak & Kent-Smith, 2004; Güngör, 2013). Oligomeric products consist of the dipeptide, tripeptide, and free amino acids. They contain disaccharide and maltodextrin as the carbohydrate source, and their lipid content consists of medium chain and long chain fatty acids. Monomeric products contain free amino acids, glucose, oligosaccharides and medium chain and/or essential fatty acids (Zadak & Kent-Smith, 2004; Güngör, 2013). The flavor of the elemental products is bad because it is neutral, and their consumption is difficult. These products should be preferred in tube nutrition instead of oral nutrition because of their flavor. Furthermore, osmotic diarrhea is the most frequently encountered complication in the use of these products because of their high osmolarity (Zadak & Kent-Smith, 2004) . 3.5.3. Modular products These products contain single macronutrient such as glucose polymers, proteins, and lipids and can be used in addition to nutrients to change the energy and nutrient composition of the patient's diet (Mercanlıgil & Keçecioğlu, 2011). 3.5.4. Disease-Specific products: These are the specific products which have been developed to meet the diseasespecific nutritional needs. Today, there are products produced specifically for diabetes, pulmonary diseases, liver diseases, renal diseases, metabolic stress and immunity (Zadak & Kent-Smith, 2004; Güngör, 2013). The features of the products which are used exclusively for diseases are summarized in table 6 (Öngül, 1995; Güngör, 2013; Chen &Peterson, 2009). 3.6. Application methods used in enteral tube nutrition After the nutritional route is selected and the enteral product to be used is determined, it is primarily necessary to decide how this solution will be given to the patients to be fed by tube. The method to be used should be determined by the GIS functions, place of nutrition and the patient's toleration (Keçecioğlu, 1995; Howard, 2004; Mercanlıgil & Keçecioğlu, 2011). It is important that the selected enteral nutrition method should meet all requirements of the macro and micro nutrients and should not lead to the risk of infection. If the nutrition tube is placed down the gastrointestinal tract, it is necessary to be slower and controlled while giving nutrition and also to ensure that only the therapeutic drugs are given from the nutrition tube as recommended (Howard, 2004). Enteral tube nutrition can be performed in the forms of continuous, intermittent, overnight or bolus infusion. Psychological games start at the early periods of life, and the structure of psychological games is determined by the life scenarios and the positions of individuals in life (Shankar, 2015). While games are learnt behaviours, each person definitely plays games in his/her daily life. 518

Table 6: Properties of diseases specific formulas Diseases Diabetes

Renal Diseases Pre Dialysis Dialysis Liver Diseases

Pulmonary Diseases Stress/ Immune Modulated

Properties of Formulas Low carbohydrates, high fat High MUFAs and fiber content have influence on glycemic control Low protein, low electrolyte load, enriched essential amino acids High protein, high energy, low potassium and phosphate, added histidine, taurine, tyrosine and carnitine Contain large percentage of branched-chain amino acid, low in aromatic amino acid, high MUFAs, low protein, low electrolyte load High fat, low carbohydrates Glutamine, arginine, omega-3 fatty acids, nucleotides, antioxidants

3.6.1. Bolus infusion This represents that the specified amount of product is given at intervals, quickly and in excess quantity within a short period of time. It is applied 6-8 times a day and usually by 200-300 ml because it is appropriate to the normal nutrition physiology. It is the easiest method to use at home for patients and their relatives. This method, which is mostly applied by means of an injector, is generally used in patients who do not want to be dependent on the nutrition pump consistently. Attention should be paid not to give the product more than 400 ml at a time during nutrition because the incidence of aspiration and gastrointestinal problems is high (Keçecioğlu, 1995; Howard, 2004; Mercanlıgil & Keçecioğlu, 2011). Life scripts are future plans made by an individual unconsciously with the effect of the sensitivities in early childhood period and the environment around oneself. Individuals are shaped by the environment in which they grow up since their birth (parents, caregivers or people they live with while they grow up), and they advance with the effect of their past experiences while making decisions on their lives. The most important feature of life scripts is the decisions made by an individual in the early period. The content of the messages received by individuals from the environment on how they should be and live affects them with all aspects and may push them to desired and non-desired life positions (Solomon, 2003). Similarly, nurses should take into consideration the life positions of the patients when they communicate with the patients they encounter. While some patients have positive life positions, some may have negative life positions. The nurse can observe an individual well, start the therapy process with those who have a negative perception, or in case they are not qualified enough in this sense, make a suggestion and guide the patient in receiving support in this subject. 3.6.2. Intermittent infusion This represents that the enteral product is divided into equal parts within a period of 24 hours and given 3-6 times with resting intervals and at the 30-90th min of each meal (Howard, 2004; Mercanlıgil & Keçecioğlu, 2011). The product should not be given more than 150-250 ml at a time, and the application should be performed by nutrition bags as drop by drop or with a pump. This method provides convenience especially in enteral nutrition applied at home because it allows the patient to be more 519

active and freer during normal life. It is regarded more physiological than continuous infusion because it imitates the normal nutrition (Mercanlıgil & Keçecioğlu,2011). The cause of the problems encountered in the application of intermittent infusion is associated with the administration rate of the applied product rather than its amount (Keçecioğlu, 1995). 3.6.3. Continuous infusion This represents that the enteral product is given to the patient using infusion pump for 24 hours by 50-125 ml/h speed. The gastrointestinal adverse effects are less frequent compared to other methods because the amount of the nutrients coming to the stomach is minimized by this method. Continuous infusion is a method with an indication especially in diabetic patients whose blood glucose cannot be controlled, in those who cannot be fed orally for a certain time and in GIS dysfunctions (Mercanlıgil & Keçecioğlu, 2011). 3.6.4. Overnight infusion This represents that the selected enteral product is given to the patient during the night to set the patient freer all day long. It is a method that might be useful in patients with oral intake and in whom this is desired to be supported. However, it should not be ignored that it may cause problems due to excessive amounts of fluid loading during practice (Howard, 2004; Mercanlıgil & Keçecioğlu, 2011). 3.7. Planning and start of the enteral nutrition In enteral nutrition, it is primarily necessary to select the product which can be easily consumed and tolerated by the patient and which can ideally meet the energy and nutrients needed to be taken on a daily basis by considering the diseases and biochemical findings of the patient to be fed. Then, training should be provided to patients and their relatives regarding the application of nutrition by determining the route of EN and the nutrition method, and nutrition should be initiated. Enteral nutrition should be initiated with a standard isotonic product, the tolerability of which is easier. The recommended initial speed is 20-50 ml/h for isotonic products. This initial speed should be reduced in patients with malabsorption or fed by oligomeric products. The specified target dose should be achieved by increasing the speed of the product by 10-25 ml per hour according to tolerance. Both the amount and concentration of the enteral product should not be increased at the same time. When the concentration of the administration rate of the product is not tolerated, it is necessary to continue with the previous administration rate and amount until toleration is provided. It is necessary to return to the previous step in a case where the gastrointestinal intolerance is developed such as stomachache, nausea, and diarrhea (Mercanlıgil & Keçecioğlu, 2011). The head of the bed should be increased by 30-45 degrees during nutrition in patients who are fed by tube and are bedridden. If nutrition is performed with an infusion pump, attention should be paid to change the nutrition bags and sets at least every 24 hours. In addition, the patients and their relatives should be warned about giving water up to 25-50 ml to prevent tube occlusion after each nutrition in the bolus or intermittent infusion methods. To see whether the patient can tolerate the product, training must be provided for the patient and his/her relatives about performing the gastric residual control at least every 4 hours in continuous infusion and in each nutrition in the intermittent nutrition (Gündoğdu, 2010; Meseri, 2013; Yıldız, 2013). 520

EN nutritional support should be maintained until the energy or nutrient deficiencies of the individual are resolved, the patient's health condition is improved and he/she meets his/her all requirements with normal nutrition by the oral route. 3.8. Complications of the enteral nutrition It is inevitable that the patients with risky situations that will increase their enteral nutrition complications such as GIS dysfunction, brain fog, gastric-oesophageal reflux, lower esophagus sphincter dysfunction, immunodeficiency and advanced malnutrition during their hospital stay will have problems related to enteral nutrition (Odabaş Aksoy, 2013). The majority of the complications encountered in EN are caused by the incorrect application errors. The complications observed due to enteral nutrition can be gathered in 3 groups including mechanical, metabolic and gastrointestinal complications. These complications are summarized in figure 4 (Odabaş Aksoy, 2013; Mercanlıgil & Keçecioğlu,2011; Bodoky & Kent-Smith, 2004; Çekmen & Dikmen, 2014).

Figure 4: Complications of Enteral Nutrition

3.9. Advantages and disadvantages of the enteral nutrition The most important advantage of the enteral nutrition is that it is physiological. It ensures the protection of the gastrointestinal structure and mucosal integrity. It helps intestinal functions to return to normal in a short period of time. It is more reliable in terms of its low risk of infection and meeting the requirements. Its application is easy. It is more economical than parenteral nutrition. The incidence of metabolic and septic complications is low. Its ratio of causing mortality and morbidity is quite low (Çekmen & Dikmen, 2014). It has positive effects on the body's immunity because it contains antioxidant elements such as fiber, glutamine, vitamins A,E and C and selenium. Disadvantages of the enteral nutrition are as follows: it leads to diarrhea and nosocomial pneumonia. The planned energy and nutrient requirements may not be met if it fails to tolerate the product given to the patient. REFERENCES Annual BANS Report (2008): Artificial Nutrition Support in the UK 2000-2007, A Report by the British Artificial Nutrition Survey (BANS), a committee of BAPEN (The British Association for Parenteral and Enteral Nutrition), Editor in chief: Barry Jones Akıncı, S.B. (2011). Enteral Nütrisyon Uygulama Yöntemleri. Klinik Gelişim; 24: 20-5. Arslan, P. (1995). Enteral ve Parenteral Beslenmede Enerji ve Besin Öğeleri Gereksini521

mlerinin Hesaplanması. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): Enteral-Parenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Bodoky, G., Kent-Smith, L. (2004). Complications of Enteral Nutrition. In: Sobotka, L. eds. Basic In Clinical Nutrition. ESPEN. Boyacıoğlu, S. (1995). Enteral Beslenmede Genel İlkeler ve Beslenme Desteğinin Verilme Şekli. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): Enteral-Parenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Bozkurt, N. (1995). Malnütrisyon ve Hastaların Beslenme Durumlarının Değerlendirilmesi. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): Enteral-Parenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Chen, Y., Peterson, S.J. (2009). Enteral nutrition formulas: which formula is right for your adult patients? Nutr Clin Pract; 24(3): 344-55. Çekmen, N., Dikmen, E. (2014). Yoğun Bakım Hastalarında Enteral ve Parenteral Nütrisyon. Bulletin of Thoracic Surgery; 5(3): 187-197. Dağ, B. (2013). Nütrisyon Durumunun Değerlendirilmesi. Erdem, N.Z., Gümüşel, S. (Derleyen). Nütrisyonda Güncel Konular. Türkiye Diyetisyenler Derneği Yayını, Ankara. Erdem, N.Z. (2013). Kronik Kompleks Hastalıklarda Enteral-Parenteral Nütrisyon Gereksinimlerinin Belirlenmesi. Erdem, N.Z., Gümüşel, S. (Derleyen). Nütrisyonda Güncel Konular. Türkiye Diyetisyenler Derneği Yayını, Ankara. Gündoğdu, R.H. (2010). Evde Nütrisyon Desteği. İç Hastalıkları Dergisi; 17:257-267. Güngör, A.Y. (2013). Enteral Nütrisyon Ürünlerinin Nitelikleri. Erdem, N.Z., Gümüşel, S. (Derleyen). Nütrisyonda Güncel Konular. Türkiye Diyetisyenler Derneği Yayını, Ankara. Howard, L., Heaphey, L.L., Timchalk, M. (1986). A review of the current national status of home parenteral and enteral nutrition from the provider and consumer perspective. J Parenter Enteral Nutr; 10: 416-24. Howard, J.P. (2004). Indicationas and Contraindications of Enteral Nutrition. In: Sobotka, L. eds. Basic In Clinical Nutrition. ESPEN. Keçecioğlu, S. (1995). Enteral Beslenme Uygulamaları ve Geçiş Diyetlerinin Planlanması. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): Enteral-Parenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Keith, J. N. (2008). Bedside nutrition assessment past, present, and future: a rewiev of the Subjective Global Assessment. Nutr Clin Pract; 23: 410-6. Kılıçturgay, S. (1995). Malnütrisyon ve Hastaların Beslenme Durumlarının Değerlendirilmesi. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): Enteral-Parenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Kondrup, J., Allison, S.P., Elia, M., Vellas, B., Paulth, M. (2003). ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition; 22(4): 415–421.doi:10.1016/S02615614(03)00098-0 McCrae D, Hall, H. (1989). Current practices for home nutrition. J Am Dietet Assoc; 89: 233-40. Mercanlıgil, S.M., Keçecioğlu, S. (2011). “Enteral ve Parenteral Beslenme”. Diyet El Kitabı. (6 b.). Hatiboğlu yayınları, Ankara. Meseri, R. (2013). Evde Bakımda Beslenme. Fadıloğlu, Ç., Ertem, G., Şenuzun Akkar, F. (Edt). Evde Sağlık ve Bakım (1 b.). Göktuğ Basım Yayın ve Dağıtım, Sözkesen Matbaacılık, Ankara. Nelson, J., Palumbo, P. J., O'Brien, P. C. (1986). Home enteral nutrition observations of a 522

newly established programme. Nutr Clin Pract; 1: 193. Nutrisyon. pdf (2016). www.antalyaeah.gov.tr/guncel/nutrisyon.pdf. Odabaş Aksoy, N. (2013). Evde Enteral-Parenteral Nütrisyonda Karşılaşılan Sorunlar ve Multidisipliner Yaklaşım-Hemşire. Erdem, N.Z., Gümüşel, S. (Derleyen). Nütrisyonda Güncel Konular. Türkiye Diyetisyenler Derneği Yayını, Ankara. Öngül, Z. (1995). Enteral Ürünler, Sınıflandırılması, Genel Özellikleri ve Kullanım Alanları. Başoğlu, S., Karaağaoğlu, N., Erbaş, N., Ünlü A. (Derleyen): EnteralParenteral Beslenme. Türkiye Diyetisyenler Derneği Yayını:8, Çağın Basın Yayın, Ankara. Pekcan, G. (2008). Beslenme Durumunun Saptanması. T.C. Sağlık Bakanlığı Yayınları, Ankara. Reitz, M.V., Ridley, C.M. (1988). Current practices in home nutritional support. Nutr Supp Serv ; 8: 8. Sobotka, L. (2011). Nutritional support in different clinical situations. In: Allison SP, eds. Basic in clinical nutrition. 4rd ed. Prague: Galen Pr,: 433-6. Sobotka, L. (2011). Diagnosis of malnutrition. In: Allison SP, eds. Basic in clinical nutrition. 4rd ed. Prague: Galen Pr,: 269-271. Yentür, E. (2008). Evde Enteral ve Parenteral Beslenme. Türk Yoğun Bakım Derneği; 6(4): 28-33. Yıldız, B.D. (2013). Enteral ve Parenteral Beslenmede Veriliş Yolları. Erdem, N.Z., Gümüşel, S. (Derleyen). Nütrisyonda Güncel Konular. Türkiye Diyetisyenler Derneği Yayını, Ankar Zadak, Z., Kent-Smith, L. (2004). Ticari olarak hazırlanmış ürünler. In: Sobotka, L. eds. Basic In Clinical Nutrition. ESPEN.

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Chapter 49 The New Favorite of Children and the Young: Energy Drinks Selvinaz SAÇAN, Hakan Murat KORKMAZ INTRODUCTION As it could be understood from their name, energy drinks are the products that are marketed and whose consumption is encouraged for the purpose of increasing energy, liveliness, concentration and performance. The target audience of the manufacturers is the young adults between the ages 18-35 and the adults; and it is seen that the energy drinks are widely consumed by the children and the young between 13-25 and even their consumption by the children in younger ages increases day by day and it is very popular in the groups below the age of 18. As it is in the adults, these drinks have recently started to be consumed together with alcohol also in the young population in high school period. Such that; although the attention is drawn to the dangers of energy drinks with the death news in the press lately, the consumption rates continue to increase. When the historical process of the energy drink whose usage brings many risks with itself is examined, there are different views as to where it is produced and who produces them; and a view that it was firstly produced by a Japanese company in 1962 is accepted (Semerci, 2016). It is expressed that as it was seen in Austria in 1987, in Europe and Asia in the 1960s, the energy drinks met RedBull that is high-caffeine inclusive energy drink in the United States of America (the USA) in 1997. The market of energy drink grew with approximately 500 world-wide new brands in 2006 (Reissig, Strain & Griffiths, 2009 quoted from Johnson) and drastically grew with 200 new brands in the USA in 2007; and the sale of energy drink from 2002 to 2006 increased annually 55% on average (Reissig, Strain, & Griffiths, 2009 quoted from Packaged Facts). Energy drink got into market in 1998 in Turkey and the market of energy drink grew as much as 30% in 2011. While 36,3 million liters of energy drink was consumed in 2011, approximately 30+ million liters of energy drink was consumed in 2012. More than 40 brands compete with one another in Turkey in which consumption per person is 300 milliliters (Anonim, 2013). That the transitions from primary education to secondary education and from secondary to higher education are realized by testing system in Turkey brings along longer studying hours. This causes students to increase the use of energy drinks, caffeine, vitamin and other stimulants in order to relieve the exam anxiety, be alerted, and be awake and hearty. These products used unconsciously and in overdose affect the health of the young negatively. It has vital importance to raise awareness in children and young of the features of energy drinks, daily consumption amounts, possible health risks and the situations that might cause side effects in the case of using them. 

Assist. Prof. Dr., ADU, Faculty of Health Sciences, Department of Child Development, Aydın- Turkey  Assoc. Prof. Dr., Finance Manager, Guven Group Inc., İstanbul / Turkey

THE COMPONENTS OF ENERGY DRINKS The identification of the standards related to the ingredients of energy drinks and the registration processes have been realized by Ministry of Food, Agriculture and Livestock in Turkey. We can order the subject standards as the energy value of energy drinks provided from carbon hydrates being not less than 45 kcal in 100 ml, not being evaluated in the scope of the food with special nutrition purposes, caffeine not more than 150 mg /L, inositol not more than 100 mg/L, glucuronolactone not more than 20 mg/L, taurin not more than 800 mg/L and the volume of alcohol content not more than %0,05 (Türk Gıda Kodeksi Enerji İçecekleri Tebliği, 2006). Apart from having different ingredients, energy drinks usually contain taurin, caffeine, B vitamins and carbon hydrates and the proportions of these substances in drinks change (Bigard, 2010). According to the database of Innova Market Insights, five ingredients most commonly found in energy drinks have been given in Figure 1.

Figure 1. Five Ingredients Most Commonly Found in Energy Drinks (Source URL 1).

Being produced for the purpose of increasing the performance and endurance of employees working for long hours at the first stage, energy drinks contain the following ingredients; caffeine, B vitamins, taurin, sugar, guarana, ginseng and inositol (Semerci, 2016). The features of these substances: Caffeine: being one of the main components of energy drinks, caffeine is the stimulant of the central nervous system (Rehman, Bashir & Naz, 2012, Heckman, Sherry & Gonzalez de Mejia, 2010). FDA (Food and Drug Administration) explained that it accepted the safe caffeine amount in a day as 100 mg in 2007. Caffeine is an addictive substance. Therefore, while at first caffeine intake makes a person to concentrate more, after 1-1,5 months later deprivation symptoms, decrease in concentration and learning ability and lack of sleep problems have been reported in the case of consumption in low amounts (quoted from Pennay & Lubman, 2012 by Dikici, Yılmaz Aydın, Kutlucan & Ercan, 2012). The stimulants in energy drinks such as guarana and ginseng increase the effect of caffeine (Dikici, Yılmaz Aydın, Kutlucan & Ercan, 2012 quoted from Dalvi, 1986). Besides, it has been notified that as a result of caffeine poisoning to occur because of excessive consumption, fast heartbeat, vomiting, stroke and even death might take place and daily caffeine intake should be limited to 300 mg for children and women in reproductive period (Semerci, 2016). B vitamins: Group B vitamins are removed from the body easily and provide

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energy because they are water-soluble. There is no evidence of the benefit it provides to the organism in higher amounts intake. It has been reported in the research that B3 vitamin in 2 bottles of energy drinks is in high dose and the intake of niacin in high doses causes reactions such as burning in body, itch and redness (Lermioğlu, 2016). Taurin: Taurin is an aminoacid which is found in body in nature and we intake from meat and seafood (Lermioğlu, 2016), and it has protective effect against injuries by exercise ((Rehman, Bashir & Naz, 2012). Although it has been claimed that taurin increases the concentration and reaction speed as a result of interaction with caffeine, it couldn’t be proven. Taurin in energy drinks is overdose and there is no scientific evidence to prove that the subject overdose is safe or harmful (Lermioğlu, 2016). In a study about taurin carried out in Weill Cornell Medical Faculty in New York, it has been found that taurin has a tranquilizer effect in brain apart from its refreshing effect. Moreover, it has been reported that artificial taurin taken from outside might cause hypertension and heart diseases (Semerci, 2016). Sugar: The substances providing the effect of energizer in energy drinks are condense sugar and caffeine they contain. Sugar intake in high levels affects health negatively and poses a risk in terms of obesity. Guarana: Although it has been claimed that guarana, which has no certain evidence that it feels energetic, is effective when taken with caffeine, it has been stated that it might cause nervousness, sleep problems and heart and stomach diseases in overdose (Semerci, 2016). Ginseng: It is the main component of energy drinks and it has the effect of improving the mood and cognitive performance ((Rehman, Bashir & Naz, 2012). It strengthens the immune system and has anti-aging, antioxidant and anti-inflammatory effects. It has been detected that ginseng usage is safe in the tests done in human and animals but it has been notified that overdose consumption might cause hypertension, diarrhea and sleep problems (Heckman, Sherry & Gonzalez de Mejia, 2010). Inositol: Produced by intestinal flora with the food intake, Inositol (Lermioğlu, 2016) has been used in the treatment of depression and panic attack because it increases the effect of serotonin hormone (Rehman, Bashir & Naz, 2012). The Effects of Energy Drinks on Health It is known that the consumption of energy drinks has been increased due to its positive effects on cognitive and psychomotor performance. In fact, while these products have ingredient and amount notice compulsory as in medicines, there isn’t a compulsory of side effect notice. The subject products might cause undesirable effects in several systems such as gastrointestinal, cardiovascular, endocrine, urinary, neurological and in skin (Patel, Beer, Kearney, Phillips & Carter, 2013; Erdem & Eren, 2009). Various studies about energy drinks have given rise to thought that energy drinks might provide the transition to medicine and narcotic addicts. The effects of labeling such as “it swipes”, “energy inside you is enough for everything" and advertisements being exposed regularly to children and the young have been discussed (Reissig, Strain & Griffiths, 2009). Caffeine is an addictive substance and used because of its energizer and stimulant effect (Meyerburget & Castellanos, 2001). Although there are a limited number of researches about energy drinks, much research has been conducted abroad. In the study about the consumption and effects of 526

energy drinks with 496 college students in America, it has been reported that 67% of the students consume it to be awake, 65% to increase energy and 54% consume it with alcohol during party and 29% have concussion and throbbing, 22% have headache and 19% have heart-throb after the consumption of energy drinks (Malinauskas, Aeby, Overton, Aeby & Barber-Heidal, 2007). In the study carried out with 500 voluntary students in Ege University in Turkey, it has been detected that 78% of the students have consumed energy drinks at least once in their lives but 69% of them have no information about the ingredients of energy drinks. When it comes to the reasons of consuming energy drinks, it has been stated that 43% of them consume it to be awake, 61% to make a cocktail with alcohol and 35% for its taste. Even though it is written on the label that energy drinks should not be consumed with alcohol, 58% of the students have stated that there is not a warning on it (Iscioglu, Ova, Duyar & Koksal, 2010). In the study done in 2011 with 4342 adolescents, the relation between energy drinks consumption conditions and demographic variables of adolescents, use of drugs and injury conditions has been examined. It has been found that 49% of adolescents consume energy drinks in a year, the consumption of energy drinks is closely related to smoking and use of hashish, 13,8% of seventh graders and 19,1 % of all adolescents have consumed energy drinks in one week and there is no relation between consuming energy drinks and gender (Hamilton, Boak, Ilie & Mann, 2013). There must be a warning in energy drinks for the consumer to see easily saying that it should not be consumed with alcohol and it is not recommended for children, the elderly, the ones having hypertension, diabetes, metabolic diseases and renal impairment, pregnant and breastfeeding mothers and the ones having sensitivity to caffeine (Varım et al., 2015). However, it has been understood from the studies that energy drinks have been consumed for different purposes and consumers are not conscious of its possible effects. It appears as an important subject to search and to discuss the effects of energy drinks on physical and cognitive performance and its possible effects when consumed with alcohol and to inform the public about them. In the studies about this subject, it has been notified that 25-40% of the young consume energy drinks with alcohol in parties and it brings along serious injuries, sexual assault and risk of death. Consuming energy drinks having additives in different proportions with alcohol increases toxicity (Bigard, 2010). When the studies about energy drinks have been scanned, 121 studies have been reached and it has been understood that two out of three studies are scientific ones and the others have been conducted by government agencies and persons. A great part of the subject studies have been carried out in The USA; then in Europe, Canada, Australia, New Zealand and China respectively. According to the results of the studies, it has been indicated that 30-50% of teenagers and young adults consume energy drinks and these drinks might cause problems such as mental and behavioral problems, cardiac defects, diabetes and stroke in children, teenagers and adults having regular medication (Seifert, Schaechter, Hershorin & Lipshultz, 2011). In other studies conducted with university students, it has been reported that the use of energy drinks is pretty common; however, the information and conscious level of the young is very limited about the risks of these drinks on health (Şen, Dere & Koçak Şen, 2015, Attila & Çakır, 2011). Energy drinks and sports drinks have been compared among the young and they try to consume energy drinks as sports drink. Nevertheless, caffeine in energy drinks has diuretic effect. That the young consume energy drinks before sports activity slows 527

down the water absorption of sugar and caffeine in energy drink and prohibits the removal of dehydratation occurred due to perspiration (Lermioğlu, 2016). Nonetheless, sports drinks prevent excessive dehydration from body. As a result of the increase of dehydration with energy drinks during physical activity, cardiac muscle is affected by the body being dehydrated and cardiac insufficiency even death might occur (Semerci, 2016). Factors Affecting the Consumption of energy Drinks in Children and the Young In the study conducted with 916 students in the city of Rovigo in Italy in 20112012 for the purpose of identify the proportions of energy drink consumption of children and the young in early puberty period and to determine the relation between these consumption proportions and socio-demographic, environmental and behavioral factors, it has been found that 17,8% of the sixth graders and 56,2% of eighth graders consume energy drinks; the consumption of energy drinks is common among the children between 11 and 13 ages and consuming these drinks is related to smoking and drinking alcohol. Besides, it has been remarked that the awareness of the harms of energy drinks decreases the consumption rates (Gallimberti et al., 2013). The young consider these drinks as harmless because they are sold in markets, in internet, kiosk, petrol stations and herbalists; there is not an age limitation for the receiver and because of deficiency in information taking place about the products both in media and popular culture. When the developmental properties of puberty have been examined, it has been seen that the behavior of complying with the peer standards is more than in childhood period. This complying behavior reaches the peak point in eighth and ninth grade (Santrock, 2014) and once an independent identity from the group starts to form, the complying behavior begins to decrease (Bee & Boyd, 2009). The young person seeing oneself as in the center of the universe and as strong wants to be free in all decisions about oneself and environment. S/he starts to see the parents who s/he set identification with in previous years as weak and looks for new examples to identify with and inclines to the environment. S/he finds the peers around him/her who understand, support and like him/her and wants to be with them. S/he starts to behave like them to be with them and adopts the common terms and actions of the peer group (Köknel, 2014). It is thought that they consume more energy drinks with the effect of peer group indicating that they feel more energetic when they consume energy drinks and of whom popularity increases among the young. Fast physical changes during puberty and body image to occur in teenager affect the mental health of the teenager. The problems that teens have with their body image are strong during the whole puberty period but it gains more importance in early puberty period (Santrock, 2014). This causes the young to be more sensitive to the messages related to physical appearance. It has been determined that 30% of the communication problems between the young originate from physical change and development in the studies conducted with male and female students. Apart from the importance that the young give to physical appearance, they start to desire to show high performance in sportive activities and to be energetic and keep fit. Therefore, they might lean to energy drinks in order to increase the performance. However, it has been found in the repeated fast race studies of energy drinks that they do not provide an ergogenic (the method continually increasing endurance, speed and ability) benefit 528

(Gwacham & Wagner, 2012). Furthermore, teens show an increasing interest to media by being involved with it which provides convenience to express themselves (Greenhow, Robelia & Hughes, 2009). In the study conducted in 25 European countries with 9-16 age group using internet 25,142 children and parents, it has been found that 60% of the children is online every day, 26% of the ones aged 9-10, 495 of the ones aged 11-12, 73% of the ones aged 13-14 and 82% of the ones aged 15-16 have a profile in the internet. It has been specified that 60% of the children aged 9-16 in Turkey use the internet every day (AÇÇP, 2010). Children imitate both the people they see the most and the important, strong, successful and loved people (Freedman, Sears & Carlsmith, 2003). Therefore, if the use of energy drinks, alcohol, cigarettes and substance are done by the characters the young and children like the most in the television programs, the ratio of being imitated increases. Marketing techniques such as “it swipes”, “the energy inside you is enough for everything” in the advertisements of energy drinks in media affect the preferences and consumption of children and the young. Thus, in the study carried out by Dolekoğlu, Kara, Erel & DeShields (2010), it has been stated that consumers are more careful about the taste and price features of the product than the ingredients while buying (Şen, Dere & Koçak Şen, 2015). Sometimes, parents might support the children to consume energy drinks by thinking that it opens the minds of children without being aware of the differences between energy drinks containing caffeine and other beverages (Gallimberti et al., 2013 quoted from Oddy & Sullivan, 2009). RESULTS AND SUGGESTIONS It has been seen that children and the young consume energy drinks for the purpose of having fun usually before the sports activity in bars, discos and home parties. Energy drinks are mostly confused with sports drinks. Whereas sports drinks have the effect of eliminating the harmful effects of the dehydration after physical activity, energy drinks increase dehydration because of diuretic effect as a result of the interaction of caffeine in energy drinks. Besides, it has been found in research that the rates of consuming energy drinks with alcohol are pretty high especially in bars or friends meetings in houses. As a consequence of the tranquilizer effect of alcohol, stimulant effect of energy drinks and the effect of increasing dehydration from body of both cause serious health problems and even death. Apart from the fact that there is much news about this subject in media, the following news also draws attention. In Milliyet Newspaper in 2011; “Did the energy drink kill? In Izmir, claimed to drink two beers which he mixed with energy drink in his fiancée’s home, K.T. fell to the ground after a while, he couldn’t be saved despite to the intervention of health team”. In Haber Türk Newspaper in 2015; “22 years-old E.K. got worse after drinking energy drink in a friend’s home. “I have a problem in my heart. I am burning” said the young boy and passes away in the hospital”. It has been seen in the limited number of studies conducted with university students about the subject in Turkey that the information and the conscious level of students about the risks of health is very limited. For example; caffeine in energy drinks is not taken only with these drinks but it is taken to body with coffee and tea drank during the day and it might become excessive. The young usually ignore this situation. In the interviews with the young, they have stated that they have started to consume 529

energy drinks at 6th grade, their parents buy them as buying other drinks without considering harmful even sometimes parents consume them with alcohol and they see them as natural and useful products. Besides, it has been learned that children have started to consume energy drinks in secondary school but continued to consume in high school with alcohol. In the literature scanning about the subject, that there are a limited number of studied done with students in Turkey, there are not any studies with secondary or high school students, the sale of these products are not limited in terms of industry, it is encouraged by advertisements in mass media shows that there is a deficiency of awareness about the harms of these products to health. In this scope;  These products should be categorized in the group of addictive substances because they contain caffeine in high levels and alcohol in low levels,  All kinds of prohibitions about the sale, market, availability to the society of these addictive substances should be applied to these products,  Advertisements encouraging children and the young to these products should be banned,  Informative education should be given to families; they should be informed to be role models for their children,  Education should be given to children and the young about healthy eating habits, positive body image and social ability and informing studies should be done about the risks of these kinds of products on health. REFERENCES AÇÇP. (2010). Avrupa Çevrimiçi Çocuklar Projesi. Avrupa Çevrimiçi Çocuklar Araştırma Projesi Türkiye Bulguları. http://eukidsonline.metu.edu.tr/ Erişim Tarihi: 06.04.2014 Anonim. (2013). Türkiye’de Enerji İçecekleri pazarı ve Markaları ne Durumda? http://brandtalks.org/2013/04/turkiyedeenerji-icecekleri-pazari-ve-markalari-nedurumda/ Erişim tarihi: 05.03.2016. Attila, S. & Çakır, B. (2011). Energy-Drink Consumption In College Students and Associated Factors. Nutrition, 27, 316–322. doi:10.1016/j.nut.2010.02.008. Bee, H. & Boyd, D. (2009). Çocuk Gelişim Psikolojisi. Okhan Gündüz (Çev.). İstanbul: Kaknüs Yayınları. Bigard, A.X. (2010). Dangers Des Boissons Énergisantes Chez Les Jeunes Risks of Energy Drinks In Youths. Archives de Pédiatrie, 17 (11), 1625–1631. doi:10.1016/j.arcped.2010.08.001. Dikici, S., Yılmaz Aydın, L., Kutlucan, A. & Ercan, N. (2012). Enerji içecekleri hakkında neler biliyoruz? Dicle Tıp Dergisi, 39 (4): 609-613. doi: 10.5798/diclemedj.0921. 2012.04.0212. Erdem, S., Eren, P.A. (2009). Tedavi Amacıyla Kullanılan Bitkiler ve Bitkisel Ürünlerin Yan Etkileri. Türk Hijyen ve Deneysel Biyoloji Dergisi, 66(3), 133-141. Freedman, J.L., Sears, D.O. & Carlsmith, J.M., (2003). Sosyal Psikoloji. (Çev. Ali Dönmez). Ankara: İmge Kitabevi. Gallimberti, L., Buja, A., Chindamo, S., Vinelli, A., Lazzarin, G., Terraneo, A., Scafato, E. & Baldo, V. (2013). Energy drink consumption in children and early adolescents. Eur J Pediatr; 172:1335–1340. Doi.10.1007/s00431-013-2036-1. Greenhow, C., Robelia, E., & Hughes, J. (2009). Web 2.0 and classroom research: What path should we take now? Educational Researcher, 38 (4), 246-259. Doi: 10.3102/0013189X09336671. 530

Gwacham, N. & Wagner, D.R. (2012). Acute Effects of a Caffeine-Taurine Energy Drink on Repeated Sprint Performance of American College Football Players. International Journal of Sport Nutrition and Exercise Metabolism, 22, 109 -116. Hamilton, H.A., Boak, A., Ilie, G. & Mann, R.E. (2013). Energy Drink Consumption and Associations With Demographic Characteristics, Drug Use and Injury Among Adolescents. Can J Public Health, 104 (7): e496-e501. Heckman, M.A., Sherry, K., & Gonzalez de Mejia, E. (2010). Energy Drinks: An Assessment of Their Market Size, Consumer Demographics, Ingredient Profile, Functionality, and Regulations in The United States. Comprehensive Reviews in Food Science & Food Safety, 9, 303–317. doi:10.1111/j.1541-4337.2010.00111.x. Iscioglu, F., Ova, G., Duyar, Y., Koksal, M. (2010). Survey on Energy Drink Consumption and Awareness among University Students. Academic Food Journal, 8(5): 6-11. Köknel, Ö. (2014). Ergenlik Dönemi. (19. Baskı). Haluk Yavuzer (Ed.), Ana-Baba Okulu içinde (s.177-188). İstanbul: Remzi Kitabevi. Lermioğlu, F. (2016). Enerji İçecekleri. Erişim Tarihi: 05.02.2016 http://www.e-kutuphane.teb.org.tr/pdf/eczaciodasiyayinlari/ila_habr-eyll08/10.pdf. Malinauskas, B.M., Aeby, V.G., Overton, R.F., Aeby, T.C. & Barber-Heidal, K. (2007). A survey of energy drink consumption patterns among college students. Nutrition Journal, 6 (35):1-7. doi:10.1186/1475-2891-6-35. Meyerburg RG, Castellanos A. (2001). Cardiac Arrest and Sudden Cardiac Death, Heart Disease (Braunwald E., editor) 882-900. Patel, S.S., Beer, S., Kearney, D.L., Phillips, G. & Carter, B.A. (2013). Green Tea Extract: A Potential Cause of Acute Liver Failure. World J Gastroenterol, 19(31), 5174-7. doi: 10.3748/Wjg.V19.İ31.5174. Rehman, M., Bashir, S. & Naz, H. (2012). Does Short Term Consumption of Energy Drink and its Subsequent Withdrawal Produce Behavioral Toxicities? A Pilot Study in Adult Male Rats. Pak. J. Biochem. Mol. Biol.; 45(1): 49-58. Reissig, C.J., Strain, E.C. & Griffiths, R. R. (2009). Caffeinated Energy Drinks - A Growing Problem. Drug Alcohol Depend, 99 (1-3): 1–10. doi:10.1016/j.drugalcdep.2008.08.001. Santrock, J.W. (2014). Yaşam Boyu Gelişim: Gelişim Psikolojisi. Galip Yüksel (Çev. Ed.). Ankara: Nobel Yayıncılık. Seifert, S.M., Schaechter, J.L., Hershorin, E.R. & Lipshultz, S.E. (2011). Health Effects of Energy Drinks on Children, Adolescents, and Young Adults. Pediatrics, 127, 511–528. doi:10.1542/peds.2009-3592. Semerci, İ.Ö. (2016). Enerji İçecekleri. TÜBITAK Bilim Genç. Erişim Tarihi: 20 Nisan 2016. http://www.bilimgenc.tubitak.gov.tr/makale/enerji-icecekleri. Şen, L., Dere, H.E. ve Koçak Şen, İ. (2015). Üniversite Öğrencileri Arasında Enerji İçeceği Tüketim Davranışlarının Araştırılması: Afyon Kocatepe Üniversitesi Örneği. Türk Tarım – Gıda Bilim ve Teknoloji Dergisi, 3(6): 394-401. Türk Gıda Kodeksi Enerji İçecekleri Tebliği (Tebliğ No: 2006/47). Erişim Tarihi: 01.02.2016. http://www.resmigazete.gov.tr/eskiler/2006/10/20061004-15.htm. Varım, C., Varım, P., Atılgan Acar, B., Vatan, M.B., Kaya, T., Acar, T. & Tamer, A. (2015). Enerji İçecekleri Ruhu Kanatlandırıyor ya Bedeni ? J hum rhythm, 1(3), 79-82. http://www.caffeineinformer.com/energy-drink-ingredients URL 1. Taken from http://www.caffeineinformer.com/energy-drink-ingredients

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Chapter 50 Energy Drinks: Contents, Effects and Awareness of Consumption Fatma ÇELİK KAYAPINAR, İlknur ÖZDEMİR  1. INTRODUCTION Energy drinks were introduced to the world by the American scientist Dr. Enuf in 1949, and offered as an alternative to sugary sodas by supporting them with vitamins and sugar. Following this, it started to be used in Asia and Europe in 1960 (Reissig et al., 2009). The wide-spread use of them in the world started around 1980's, and it was made available in Turkey in 1990's. It is stated that about 25 different brands of energy drinks are sold in Turkey, that many more also take place on the shelves in small batches, and that the total number of brands reaches 42 (Dikici et al., 2012). There are various reasons for energy drinks to gain popularity so quickly in such a short time. This diversity is caused by the wide-spread and unconscious consumption of energy drinks of especially young adults and college students, athletes and also the people driving their vehicle for long times. The terms of energy drinks and sports drinks, which are two different concepts, need to be distinguished in order to raise consumer awareness. Energy drinks are classified in the group of soft drinks (non-alcoholic), and are a type of drink that increases physical performance, reduces fatigue and supports the development of cognitive performance (Malinauskas et al., 2009). In general, energy drinks are compounds containing water, carbohydrates (glucose, maltodextrin, sucrose), low amounts of B complex vitamins (thiamine, riboflavin, niacin, inositol, pantothenic acid, cyanocobalamin), vitamin C, minerals, electrolytes (sodium, potassium, phosphorous), the plants extracts (guarana, yerba mate, ginseng, ginkgobiloba), stimulants (caffeine, green tea, synephrine, yohimbine, tyramine, vinpocetine), glukoronolaktones, taurine, and L-carnitine (Zucconi et al., 2013; Ghosh, 2015). It is stated that the components of caffeine, taurine, aminoacids, glukoronolaktones, guarana, ginkgo biloba, carnitine, panax ginseng, yerba meta, green tea in this mixture increase energy, alertness, performance, speed up the metabolism, improve mental activities and help to concentrate (Committee on Nutrition and the Council on Sports Medicine and Fitness 2011). The main active components of energy drinks are caffeine of 80-141 ml/225g and often high amounts of carbohydrates (approximately % 9-10) (Ghosh, 2015). The energy shots, which is a special form of energy drinks; are low-calorie beverage concentrates containing a small amount of sugar, and sold in small cans having a volume of 60-90 mL (Schubert et al., 2013). Energy drinks and energy shots are consumed to support the energy needed before and after the exercise, to increase the endurance level, to keep the body awake by eliminating insomnia especially occurring 

Assoc. Prof. Dr., Mehmet Akif Ersoy University, School of Physical Education and Sport, Physical Education and Sport Teaching Department, Burdur, Turkey.  Lecturer, Pamukkale University, Acıpayam Vocational High School, Denizli-Turkey

during exam periods, or to raise mental condition when taken with alcohol. The caffeine, carbohydrate and other nutrients in energy drinks, provide a performance increase by affecting the mental focus and concentration, energy increase, the perception of fatigue, while sports drinks realize the performance gains by replacing the water and electrolyte lost through sweating during exercise (fluid support), and by ensuring the sustainability of endurance capacity (Committee on Nutrition and the Council on Sports Medicine and Fitness, 2011). Additionally, sports drinks generally contain carbohydrate and electrolytes (sodium, potassium, calcium, magnesium) in lower doses (6-8 g/100 ml) and in different forms (sucrose, fructose). Sports drinks do not contain any stimulants unlike the energy drinks (Committee on Nutrition and the Council on Sports Medicine and Fitness, 2011; Campbell et al., 2013). 2. THE COMPONENTS IN ENERGY DRINKS 2.1. Caffeine Caffeine, the basic and most important component of energy drinks, stimulates the central nervous system (Zucconi et al., 2013). Caffeine is a plant which is obtained from the leaves of over 60 varieties of coffee plants, and that belongs to the family of methylxanthine. Caffeine is also found in tea, cola, nuts and cocoa. Caffeine is absorbed quickly and increases the plasma volume within 30-60 minutes after its ingestion (Goldstein et al., 2010). The rate of absorption of caffeine varies according to its type, the amount of usage and chemical properties (Bonati et al., 1982). The amount of caffeine in alcohol-free energy drinks varies between 75-150 mg per bottle (Food Safety and Standards Authority of India, 2015) while this amount is 80-120 mg in coffee and 60 mg in tea per 250 ml (National Institute of Nutrition, 2010). The effect of caffeine on the body shows individual differences due to various reasons such as sex, weight and emotional state (León-Carmona and Galano 2011). The recommended maximum caffeine consumption in children should be 2.5 to 6 mg/kg/day, 100 mg/day in adolescents and a maximum of 400 mg/day in adults (Heckman et al., 2010). Caffeine is a powerful cardiovascular stimulant and helps improve mental and physical performance by increasing epinephrine stimulations. Intake of caffeine provides the occurrence of better performance with increased energy. Due to its chemical structure similar to adenosine, caffeine binds to adenosine receptors. Caffeine increases the activity of nerve cells by binding to adenosine receptors, consequently leading to adenosine's losing its somnolent effect, to an elevation of mood and alertness level. The latest studies show that average caffeine consumption protects against Alzheimer's disease due to its antioxidant effect (Carmona and Galano, 2011), that caffeine is consumed as it allows for lipolysis formation by reducing the intake of food (Yunusa and Ahmed, 2011) and, due to the diuretic effect of the caffeine contained in energy drinks it causes a big fluid loss and the disposal of a big amount of sodium in urine (Riesenhuber et al., 2006). Caffeine is known to be an ergogenic compound that increases the heart rate and blood pressure (Bichler et al., 2006), and when taken 200 mg and more, it is also indicated that it leads to problems such as insomnia, nervousness, headache, tachycardia, arrhythmia, nausea (Clauson et al., 2008) and anxiety (Misra, 2015) and also decreases the sensitivity to insulin (Lee et al., 2005). In short, despite the fact that the presence of caffeine in most of the energy drinks bears harmful effects in terms of health, it is commonly used by consumers since it leads to insomnia, improves durability, delay fatigue, increases reaction time (Schubert et al., 533

2013), improves memory, elevates the personal mood, and has a thermogenic effect (Ghosh, 2015). Low-calorie energy drinks, on the other hand, shortens the resting period and accelerates fat burning due to the acute-based thermogenic effect. Some energy drinks used before exercise (the one with thermogenic effect) provide exercise adaptation and a positive effect on body composition (Campbell et al., 2013).

Figure 1. Caffeine amounts according to types of drinks (www.pinterest.com, June, 10, 2016).

2.2.Guarana It is also defined with different names such as paulliniacupana, sapindaceous. It is a plant that grows in the Amazon rainforests, and is an ingredient commonly found in energy drinks (Higgins et al., 2010). Guarana seeds contain 2 to 7.5 % of caffeine, an amount not found in any other plant in the world (Beck, 2005). 1 g of guarana extract contains approximately 40 mg of caffeine (Finnegan, 2003). Due to its high caffeine content, guarana stimulates the central nervous system and has a thermogenic effect. Guarana extracts are consumed by people as a nutritional supplement due to its effects such as providing weight by suppressing the hunger feeling (Australia New Zealand Food Authority, 2001), enhancement of fitness and sexual performance, elevation of the cognitive capacity (O'Dea, 2003; Ray et al., 2005) . On the other hand, the presence of guarana and high amount of high fructose corn syrup in nearly all the energy drinks is indicative of the potential health risks of these beverages. Regular use of them can lead to weight gain. Only a few energy drinks have the diet version of guarana, and the taste of guarana is bitter. Most of the people consuming guarana outside its traditional use consume high-sugar products (Smith and Atroch, 2010). 2.3.Taurine Taurine (2-aminoethane sulfonic acid), is taken with various daily dietary foods such as seafood, meat, milk. Taurine; is a semi-essential amino acid naturally occurring in the body which is involved in the synthesis of methionine, an essential amino acid and cysteine, a non-essential amino acid. It has various bodily functions such as bile 534

acid conjugation, osmoregulation, membrane stabilization and synaptic activity of neuronal excitability regulation, modulation of Ca+2 levels in the cell, as well as its antioxidant effect (Birdsall, 1998; Redmond et al., 1998; Guizouarn, 2000). Energy drinks comprise about 1000 mg of taurine (31 mM/150 ml) (Clauson et al., 2008). In a normal diet order, 40 to 400 mg/day of taurine is taken (Australia New Zealand Food Authority, 2001). According to the European Commission report shows that an adult of 70 kg consuming 500 ml of energy drink per day consumes 29 mg/kg and 2000 mg/day (1000 mg/250 ml) of energy drink, and this amount of consumption is 5 times as much as the upper consumption limit, and 50 times as much as the lower consumption limit (European Commission - Scientific Committee on Food, 2003). Although it is adequately synthesized in the body, its concentrations may decrease for reasons such as stress, trauma, chronic illness, and need to be supplied from outside (Namba 1992). Although some energy drink companies have reported that they have a positive effect on exercise performance, this has not yet been scientifically proven. Though there is not enough clinical evidence to indicate its effectiveness in the treatment of epilepsy and diabetes (Birdsall, 1998), it can lower blood pressure (Militante et al., 2002). 2.4. Yerba mate (Ilex paraguariensis) This is an antioxidant with painkilling (anti-inflammatory) feature and reducing the symptoms of diabetes (anti-diabetic) . Due to its high concentrations of caffeine (78 mg per cup of yerba mate tea), it is a central nervous system stimulant (Yunusa and Ahmed, 2001). 2.5. Glucuronolactone It is added into some energy drinks with the name of energy mix. Glucuronolactone, naturally present in our body, is also existent in foods and fruits. Although it is argued by some studies that it reduces the fatigue created by exercise, more research results are required (Tamura et al., 1966). Daily dietary intake of it is 1-2 grams (European Commission – Scientific Committee on Food, 2003). Not enough research is available on the negative effect of glucuronolactone on health and on the healthy amount of use (Scientific Committee on Food, 2003; Higgins, 2010). 2.6. Yohimbine HCL It is a stimulant used in the treatment of erectile dysfunction (McKay, 2004). Although it is claimed to increase fat loss, this is not scientifically proven (Pittler and Ernst, 2004). 2.7. Ginseng These are vegetable stimulant substances used in the medical field. While the ginseng in energy drinks is said to increase mental, physical and sexual performance, to lower the blood pressure and to regulate blood glucose levels; this claim has been proven, yet (Ernst et al., 2002). 2.8. Inositol B group vitamins are water soluble vitamin types. It is effective in the structure of coenzymes working in vitamin characteristics, and in energy production on mitochondrial function. Vitamin B derivatives are divided into subgroups as thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine hydrochloride (B6), biotin (B7), inositol (B8) and cyanocobalamin (B12). Vitamin B plays a key role 535

in ensuring the transformation of the simple sugar found in energy drinks into energy. Each group of vitamin B has a variety of specific functions in the human body (Higgins et al., 2010). It is found in energy drinks since it increases physical and mental performance. While vitamin B deficiency causes fatigue, an excess of it does not provide increased performance. Vitamin B, taken with fortified foods or the daily diet, is usually enough for people. When taken in excess from energy drinks or other sources, vitamin B is evacuated with urine (Scientific Committee on Food, 2003; National Institutes of Health, 2011a, 2011b). Most energy drinks contain 225 g/2-3 milligrams of vitamin B6 (Higgins, 2010). Although vitamin B is said to lower inositol triglyceride and cholesterol levels, to reduce cardiovascular risk factors, to help eliminate sleep problems and anxiety with 1-2 g of myo-inositol per day, these claims have not been scientifically proven (Australia New Zealand Food Authority, 2001). 2.9. L-Carnitine L-carnitine, naturally synthesized in the liver and kidneys, plays a role in the energy metabolism (National Institutes of Health, 2011a, 2011b). It is not only effective in increasing the maximal oxygen consumption and reducing the rate of respiration, but also exhibits a stimulating effect on lipid metabolism (Lennon, 1998). Studies have reported that carnitine does not affect recovery during exercise and, if taken more than 3g/day, may cause nausea, vomit and diarrhea (National Institute of Nutrition, 2010, 2011a, 2011b; Dietary Guidelines for Indians, 2010). In most energy drinks, carnitine is not listed in the table of contents, in which case consumers must be informed and vigilant. While there is no clinical evidence that carnitine improves the durability performance and is effective in weight loss, it may have a protective effect on heart diseases. 2.10. Sugar Carbohydrates consist of monosaccharides (glucose, fructose, galactose), disaccharides (lactose, maltose, sucrose) and polysaccharides (starch, glycogen, cellulose) compositions. Carbohydrates form a large part of the daily diet. 300 g of carbohydrates are taken per day, a large part of which consists of starch (~160 g) and sucrose (~120 g). Additionally, an amount of lactose (~30 g), glucose and fructose (∼10 g) is taken. Plenty of cellulose, starch and sucrose are taken with plants foods; and glycogen and lactose with animal food. Because of their performance enhancing effects, carbohydrates are the contents of energy drinks. Energy drinks; outsourced mixtures designed to provide a high level of carbohydrate oxidation which contains carbohydrate in different amounts and types. Most of the energy drinks (except for sugar-free ones) contain high levels of sugar (sucrose, glucose, high-fructose corn syrup) and sweeteners in different forms to mask the bitter taste of caffeine. Although the rates of sugar vary depending on energy drinks, they contain an average of 21-34g/225g sugar. It is recommended by ACSM and ISSN that the digestible carbohydrate ratio in energy drinks be 6-8% in aqueous solutions. The carbohydrate ratios in some energy drinks are quite high (%11-12). The high carbohydrate content in energy drinks is a disadvantage since it causes digestive problems. The effect of carbohydrate intake on exercise performance depends on many factors. They vary depending on the type of carbohydrate taken, oxidation rate, and the amount of intake, exercise type, exercise intensity, exercise time, and also the athlete's tolerance dose (Campbell et al., 2013). 536

High doses of sugar intake carry the risk of diabetes and obesity for children. The range of citric acid present in sports drinks and energy drinks is pH 3 to 4. This low pH rate is effective in the formation of dental health problems by causing a calcium and mineral loss from the tooth enamels (Järvinen et al., 1991). 3. MIXTURE LEVELS OF RED BULL ENERGY DRINK Red Bull is an Austrian brand of drink which was created by adapting an energy drink in Thailand to European tastes, and a company organising sportive events under the same brand. Red Bull project is currently one of the world's leading energy drinks, which rose rapidly with the elaborate efforts made between 1984 and 1987. Their slogans are "Red Bull vitalizes body and mind." and "Red Bull gives you wings". It is sold in Turkey under the names of Red Bull, Red Bull Sugarfree, Red Bull Red Edition, Red Bull Blue Edition and Red Bull Silver Edition in cans of 250ml, 355ml and 475ml. As indicated on the cans, it should not be consumed with alcohol or by mixing with it. Again, on the commercial packaging, it is clearly not recommended for the consumption of particularly children, people under 18 years of age, those with high blood pressure, diabetics, pregnant and lactating women, those with a metabolism sensitive to caffeine. The manufacturer also recommends that the product is not consumed more than 500 ml per day. In the case of the customer's failure to comply with this recommendation, it may cause dehydration in the body, and problems that led to the heart attack in sensitive structures. While its popularity in Austria steadily rises, the big boom in sales occurred with getting into international markets. Red Bull drinks were approved by Germany for the first time in 1994. In 1997, it went through an overseas expansion with the countries in America, Australia and Southeast Asia. Its entry into the Japanese market was in 2006. The company has numerous sponsorships in the world of motor sports, especially Formula 1, a predominantly acrobatics air racing organization named Red Bull Air Race, a competition named Art of Can in the field of art and creativity (URL 2). The ingredients and quantities in the Red Bull energy drink are given in Table 1 4. MIXTURE LEVELS OF OTHER ENERGY DRINKS The contents and amount of caffeine according to the type of energy drinks are given in Table 2 (taken from http://nutritiondata.self.com/facts/beverages/7399/2, on 8th March, 2015). 5. A MIXTURE OF ALCOHOL AND ENERGY DRINKS There is an increasing trend among young people towards consuming energy drinks by mixing them with alcohol all over the world (Oteri et al., 2007; O'Brien et al., 2008; Thombs et al., 2010). This is due to the fact that stimulant effect of energy drinks masks the depressant effects of alcohol (Atilla and Cakir, 2011). It is also reported that energy drinks reduce the symptoms of alcohol intoxication, and as a result, increase the damage due to alcohol use (Reissig et al., 2009). While caffeine consumption combined with high amounts of alcohol has dangerous effects on heart functions, consumers do not realize their actual level of alcohol intoxication. A study showed that the participants consuming a mixture of energy drinks and alcohol felt a headache, fatigue, weakness and muscular incoordination to a lesser extent, while they showed lower values in terms of coordination and visual reaction time (Ferreira et al., 2006). Many people think that 537

they are not drunk observing their own physical symptoms, which leads, with a low poor ability of judgment, to a number of negative situations such as driving, unsafe sex (O'Brien et al., 2008), engaging in violence (Thombs et al., 2010). Table 1. The ingredients and quantities of Bull energy drink (Source: URL 1) Redbull (255ml) Total Calories Total Carbohydrates Sugar Vitamin B1 Vitamin B2 Vitamin B3 Vitamin B6 Vitamin B12 Sodium Calcium Potassium Sodium

Quantities ingredients 115 28g 27g 0.1 1.7mg 21,7mg 2.1 mg 4.5mcg 214mg 33,2mg 7.7mg 7.7mg

of

the

Other ingredients Taurine Guarana Inositol Glucuronolactone Sukrose, Citric acid Carbon dioxide

The studies in the literature have shown that the majority of those consuming energy drinks are young adults and college students. It is reported that they consume these drinks with substances such as alcohol (Arria et al., 2011), cigarette and marijuana. It is stated that this drink, when consumed with alcohol, leads to the emergence of behaviors such as unconscious decision-making, poisoning due to overconsumption, fighting and engaging in violence (Oteri et al., 2007; Miller, 2008). 6. EFFECTS OF ENERGY DRINK 1- Despite the presence of various nutrients in the content energy drinks and energy shots, physical and mental performance increases are due to the ergogenic support sources in caffeine and carbohydrates. 2- While caffeine provides an increase in mental and physical performance due to its ergogenic value, the potential benefits of the other substances contained in it have not been identified, yet. 3- Energy drinks taken 10-60 minutes before exercise may improve mental alertness, focus, anaerobic performance, and aerobic endurance. 4- Since energy drinks have lots of ingredients, the effects of safe drinks on mental and physical performance should be revealed. 5- It is reported in several studies that low-calorie energy drinks support weight loss during exercise and that they are effective in reducing the fat content in a small amount as an ergogenic drink. On the other hand, the high-calorie ones have an impact of weight gain. 6- While consuming energy drinks, athletes should be aware, that drinks with a high glycemic index have an impact on their metabolic levels, blood glucose levels, and insulin levels, and that caffeine and other stimulants have an impact on motor skills, and their performances. 7-Adolescents and children can consume these drinks once their parents have checked and approved the amounts of carbohydrates, caffeine and other nutrients in 538

them. 8- Random use of energy drinks or exceeding the daily intake dose can cause harmful and negative effects. Table 2. The contents and caffeine amount according to the types of energy drinks Product Name

Energy drink quantity (ml)

The amount of caffeine (mg/serving)

Full Throttle

480

144

Monster

480

Not known

Rock Star

480

160

RedBull

250

38

Burn

250

38

Coffee (brewed)

240

100

Coca-Cola

330

33

Content Guarana, taurine, carnitine, ginseng, vitamin B Guarana, taurine, carnitine, vitamin B, ginseng, inositol, glucuronolactone Guarana, taurine, carnitine, vitamin B, ginseng, inositol, ginkgo, milk thistle Sucrose, carbon dioxide, citric acid, taurine, inositol, vitamin B6, B12 Ginseng, glucuronolactone, guarana, taurine Taurine, inositol, glucuronolactone Water, sugar (sucrose/glucose syrup), carbon dioxide, caffeine.

9- Diabetics, those with cardiovascular disorders, those with renal failure, those with neurological disorders and patients receiving medication should consume energy drinks after the approval of a doctor due to the high glycemic index, and the stimulants present in caffeine and other nutrients (Campbell et al., 2013). 7. TREND OF ENERGY DRINK CONSUMPTION OF COLLEGE STUDENTS In a study investigating the energy drink consumption behaviors and consumption awareness of university students; consumption of energy drinks was found to be higher in man than women, and higher in college graduates than in high school graduates. It was also concluded that energy drink consumption was higher in smokers than in nonsmokers, higher in coffee-drinkers than in those drinking other types of drinks, higher in graduates than in undergraduates, it was stated that the students did not have a sufficient level of consumer awareness of energy drinks (Sen et al., 2015 ). The study conducted by Atilla and Cakir (2011) on students studying sport, art and medicine revealed that the consumption energy drink among art and sports students who did not have regular breakfast, did not smoke, were regularly engaged in sports were higher than their peers. Hıdıroğlu et al., (2013) conducted an energy drink survey on 390 medical school students, and the results showed that 13.3% of students regularly smoked cigarettes at least once a day, %32.6 consumed alcohol, 32.6% consumed energy drink only once, and %18.6 consumed this drink more than once. 127 students (32.6%) who consumed an energy drink at least once stated that they consumed them to increase the cognitive and physical performance. It is also noted that medical students had insufficient knowledge about energy drinks. In a study conducted by Malinauskas and colleagues (2007); the consumption of energy drinks was reported to be %51 among university 539

students, and the reasons for this consumption include meeting energy needs and the sports-related commercials in marketing this product. Oteri et al (2007) reported that energy drinks were consumed by college students and athletes since they provide a cognitive efficiency and performance increase, and Duchan et al (2010) thought that they were preferred due to the claims of the firms that they would increase energy and to the ergogenic effect of the substances and caffeine and other components in them. The energy drink consumption rate of college students was reported to be %73 by Froyland et al., (2004), and %86.7, by Kristiansen et al. 8. ENERGY DRINKS AS AN ERGOGENIC SUPPORT Most energy drinks are low in vitamins (thiamin, riboflavin, niacin, vitamin B6, B12, pantothenic acid, vitamin C) and electrolytes (sodium, potassium, phosphorus). Additionally, these substances found in energy drinks can increase the density of nutritional supplements. There are also studies that they improve performance during exercise as an ergogenic support. Some of the ingredients in the composition of energy drinks (taurine, ginkgo biloba, L-Tyrosine, citicoline, 5-hydroxy-L-tryptophan), stimulants (caffeine, guarana, green tea, synephrine, yerba mate, yohimbine, tyramine, vinpocetine) and ergogenic nutrients (panax ginseng, L-Carnitine, D-Ribose, β-Alanine, inositol, citrulline, quercetin) provides benefits for the development of mental activities and concentration. It is claimed that these substances found in the composition are potential ergogenic aids and that some of them increase the cognitive function and exercise capacity (Kreider et al., 2010; Rodriguez, 2009). It is stated that the cognitive stimulant effects of energy drinks arise from caffeine (Smit et al., 2004), while they do not improve the reaction time due to the high sugar content (18%), reduce the sleep time (Loyacano, 2000) and that a combination of caffeine and taurine does not have an effect on short-term memory (Bichler and others in 2006 ), that low doses of caffeine intake (12.5 to 50 mg), in spite of these facts, improve cognitive performance in young adults and elevate mood, and they improve cognitive speed and alertness at 200mg level (Dasey, 2007). Energy drinks can easily exceed the amount of caffeine needed for increasing the cognitive performance (Kohler et al., 2006). This will be especially faster when they are in cans of 450-670 grams. Baum and Weiss (2001) divided 13 people who were trained and doing resistance exercises with 3 different groups, and performed electrocardiogram measurements at different times (before drinks, 40 minutes after drinking, immediately before exercise and during the recovery period after exercise). The groups were given Red Bull, a similar drink with caffeine but without taurine, and a placebo drink (caffeine and taurine-free). As a result, it was observed that the cardiac output was increased in the group consuming Redbull only (80±21 before consuming Redbull, 98±216 in the recovery period), that this is due to the effect of caffeine and taurine found in the Redbull composition on cardiac contraction. With an increase in the cardiac output due to the consumption of energy drinks, more oxygenated blood is sent to the body and this provides an increase in the aerobic capacity. On the other hand, energy drinks consumed in large quantities force the heart and increase the risk of heart attack. Roberts et al (2008) gave energy drinks without calories for 28 days (336ml/day), and reported that the fat mass, compared to the control group, was significantly reduced. Stout et al (2008) investigated the effect of energy drinks consumed 15 minutes before the exercise and anytime on days that no exercises were performed on 540

changes in body composition and fitness levels. It was reported by Stout et al that the fat mass in the group consuming energy drinks decreased and aerobic capacity and depletion time increased compared with the control group; by Scholey and Kennedy (2003) that 250 ml of energy drink (35.5 g of glucose, 75 mg of caffeine, ginseng and ginkgo biloba) had a positive impact on secondary storage memory and attention; by Alford et al (2001) that an energy drink brand with high sales rate increased psychomotor performance (reaction time, concentration and memory), personal alertness and aerobic endurance in tests on a cycle ergometer (65-75% of heart rate) and aerobic performance (maintaining maximal speed). It was reported by Hoffman et al (2009) that they enhanced the reaction performance but did not have any effect on the anaerobic performance; by Ivy et al. (2009) that energy drinks improved the endurance performance in 12 professional male-female cyclists while they did not affect the depletion time; and by Perez et al (2015), that an energy drink containing approximately 3 mg/kg of caffeine enhanced the physical performance in female volleyball players. Based on these findings, it can be said that energy drinks may increase physical performance in training and cognitive performance, that they may have some ergogenic effects on weight losing applications while they may lead to platelet aggregation and endothelial structure deterioration, cardiovascular problems, high blood pressure, insulin sensitivity. For these reasons; while consuming energy drinks, the maximum amount of caffeine that should be consumed daily should also be considered. Excessive consumption should be avoided due to the presence of conflicting findings in the literature on energy drink consumption rates and its effects. 9. RELATIONSHIP BETWEEN HEALTH AND ENERGY DRINKS Since the synergist and negative effects the use of caffeine and carbohydrates and other nutrients and their doses are not fully understood and these doses change from drink to drink, they carry risks in terms of consumption. While a moderate consumption of energy drinks is beneficial in terms of health, consumption of drinks containing excessive amounts of caffeine lead to anxiety, restlessness, stomach problems and blood pressure problems (Bichler et al., 2006), muscle twitches (Bedi et al., 2014), headache (Espinosa and Sobrino 2015), dehydration (Griffith, 2008), seizures, cardiac arrest followed by energy drink consumption (Hunter et al., 2013), tooth enamel erosion resulting from the acid and sugars in drinks (Hasselkvist, 2009; Shelo et al., 2013). The risk of occurrence of these adverse effects may increase with the caffeine taken from other drinks as well as the high amount taken from the energy drinks. When examining the literature; Worthley et al. (2010) reported that, 1 hour after the consumption of a sugar-free energy drink of 250 ml (80 mg of caffeine, 1000 mg of taurine, 600 mg of glucuronolactone), it caused an increase in blood pressure, platelet aggregations, and endothelial structure deteriorations. Anderson and Horne (2006) stated that the heart of a 28-year-old motorbike racer, who consumed 8 cans of energy drink containing 80 mg of caffeine in a period of 5 hours had failed and he died. Another case occurred in the United States. A 28-year-old man consuming 3 cans of energy drinks of 250 ml before a basketball match was reported to lose consciousness after playing for 30 minutes, die as a result of sudden cardiac arrest (Hunter et al., 2013). This case has revealed the risk of caffeine consumption more clearly and confirmed that the dose of consumption should be adjusted accurately once again. In 541

addition, the high amount of carbohydrate in energy drinks leads to a sharp increase in the energy level by slowing down the absorption of nutrients in the blood, and it slows down rehydration and absorption during exercise. After taken into the body, high glycemic index sugars give energy with a quick burst and, make one feel good by increasing the performance. The sugar burn ends within 30-45 minutes of exercise, and it appears in the form of slowing-down in reflexes, a decrease in muscle strength and dizziness and a reduction in performance. Therefore, people with diabetes should avoid the energy drinks with a high glycemic index, and must not prefer low-carbohydrate energy drinks without their doctor's approval. The amount of the consumption of energy drinks is important; it was reported that the excessive consumption of them is dangerous for the heart due to the caffeine content (Anderson and Horne, 2006), that it has a negative effect on the kidneys (Riesenhuber, 2006),that it creates insulin resistance (Lee et al., 2005), and that it reduces the sleep time. Due to the reasons specified, those with cardiovascular disorders, those with renal failure, those with neurological disorders, and diabetics and patients receiving medication should consume energy drinks after the approval of a doctor due to the high glycemic index, and the stimulants present in caffeine and other nutrients. 10. RESULT In determining the energy drink consumption rates; people's living habits and dietary characteristics should also be considered. The consumption of tea, coffee and soft drinks have been taken during the day should be realized taking the effects of the caffeine and sugars in them and the gender and age factors into consideration. If this is ignored, it should be understood that serious health problem leading to death may occur. For this reason; media and written sources should be benefited in order for students to reach a higher level of knowledge and awareness on energy drinks. It should also be noted that the ingredients in energy drinks and their amounts change depending on the type of energy drink consumed. REFERENCES Alford, C., Cox, H., Wescott, R. (2001). The effects of red bull energy drink on human performance and mood. Amino Acids. 21(2):139–150. Anderson, C., Horne, J.A. 2006. A high sugar content, low caffeine drink does not alleviate sleepiness by may worsen it. Human Psychopharmacology: Clinical and Experimental, 21:299-303. Arria, A. M., Caldeira, K. M., Kasperski, S. J., Vincent, K. B., Griffiths, R. R., O’Grady, K. E. (2011). Energy Drink Consumption and Increased Risk for Alcohol Dependence. Alcoholism, Clinical andExperimental Research, 35(2), 365-375. Atilla S, Çakır B. (2011). Energy-drink consumption in college students and associated factors. Nutrition. 27: 316-322. Australia New Zealand Food Authority. (2001). Inquiry Report: Formulated Caffeinated Beverages. Erişim: 09 Aralık 2015, https://www.foodstandards.gov.au/code/applications/documents/A394_(full)_report.pdf Avcı, S., Sarikaya, R., Buyukcam, F. (2013). Death of a young man after overuse of energy drink. Am J Emerg Med. 31(1624), 3–4. Baum, M., Weiss, M. 2001. The influence of a taurine containing drink on cardiac parameters before and after exercise measured by echocardiography. Amino Acids, 542

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Chapter 51 Some Wild Plants Commonly Used in Folk Medicine in Turkey Sefa AKBULUT, Mustafa KARAKÖSE INTRODUCTION It is well-known that Anatolia is a cradle of civilisations. The cultural legacy which began with the Hittites around 1900 B.C. was further enriched by Phrygians, the Urartu, Lydians and many other civilisations (Karakuzulu, 2012). The Turkification of Anatolia began with the rise of the Great Seljuq Empire, which was later followed by the Ottoman Empire, another Turkish state that left a significant mark in history, and under which Anatolia experienced its most glorious period (Gümüş, 2013). With the Republic of Turkey founded in 1923, Turks continue to rule Anatolia. Anatolia, which has been a community of civilisations for 5000 years, has seen countless traditions, customs and cultures, many of which can be experienced today in their original or their inter-mingled forms. An important component of this cross-cultural synthesis is folk medicine and the herbal medications used for treatment. Folk medicine can be defined as the set of beliefs, attitudes and behaviors a community shares regarding diseases and health, or the set of beliefs, traditions and system of values that guides their medical practices. Certain anthropologists also call folk medicine as “home remedies” (Şar, 2008; Türkdoğan, 1991). Most folk medications are based on herbs, which are collected from nature, and then dried and stored for preparing remedies. These plants may be consumed raw, or as teas, pills, pastes, syrups or powders. These remedies may also be applied topically in raw form or as ointments, incense, oils, plaster or pastes (Şar, 1982). Folk medicine is often viewed not as complement to modern medicine, but rather as its alternative. For this reason, treatment methods based on folk medicine are often referred to as “alternative medicine”. Nowadays, alternative medicine is used as a recourse by people with limited financial means, or for conditions for which modern medicine has no remedy; others use alternative medicine out of belief. In certain cases, treatment through alternative medicine is sought before modern medicine. What sets alternative medicine apart from modern medicine is that in addition to providing treatment, it can also be used for prophylaxis (Uyar, 2013). Although there are no clear or strict distinctions between them, folk medicine in Turkey can be evaluated in three different groups as “pre-Islamic folk medicine practices,” “Islamic folk medicine practices,” and “folk medicine practices in modern Turkey” (Uyar, 2013). This mosaic and diversity of folk medicines is not just due to the existence of different cultures. It also has to do with the diversity of ecological 

Asst. Prof. Dr., Karadeniz Technical University, Faculty of Forestry, Department of Forest Engineering  Asst. Prof. Dr., Giresun University, Espiye Vocational School, Programme of Medicinal and Aromatic Plants

conditions, types of climates, geological cycles and geographic features in the country, which in turn leads to a great diversity of plant sources available for use. A numerical illustration of this is the fact that Turkey’s flora includes a total of 11,707 registered taxa belonging to the Pteridosperm, Angiosperm and Gymnosperm families, 3,649 (31.82%) of which are endemic (Güner, Aslan, Ekim, Vural & Babaç, 2012). The use of these plants for medicinal purposes by Anatolian people is known from Hittite period cuneiform tables (Kendir & Güvenç, 2010). Many ethnobotanical studies in Turkey report the use of medications or medicinal mixtures obtained from natural and cultivated plants in the treatment of diseases, especially in rural areas (Polat, Cakilcioglu, Kaltalioglu, Ulusan & Türkmen, 2015; Mükemre, Behçet & Cakilcioglu, 2015; Akbulut & Ozkan, 2014; Akyol & Altan, 2013; Polat, Cakilcioglu & Satıl, 2013; Çakılcıoğlu, Şengün & Türkoğlu, 2010; Yeşil & Akalın, 2009). Some of these are even traded and exported in raw or semi-processed formed, under the designation of “nonwood forest products” (Özkan & Akbulut, 2012). In folk medicine, drug treatment is usually used as last resort. Many of these folk medicines, known colloquially as “homemade medicines” or “old woman’s medicines,” are the products of empirical practices that have come to our day. Folk medications have a broad area of use in Anatolia, and are employed by a large segment of the population, especially in rural regions, through both rational methods or seemingly more “magical/mystical” practices (Şar, 2008). Knowledge on folk medications are obtained and compiled through folklore studies, herbal studies, botanical studies, and chemistry studies (Sezik, 1991). Information on folk medicine and medications in the past are also obtained through the works of Dioscorides, Avicenna (Ibn Sina), and Ibn al-Baytar (Ayten Turan, 2000). Reasons for the widespread use of folk medicine in Anatolia include the high ratio of rural population working on agriculture and animal raising (and who hence have easy access to medicinal plants); the transfer of traditions and customs between generations, and the ease with which folk medicine-related information can be remembered; the difficulties for people in rural areas to access modern healthcare centres; the ease of preparation and low cost of most folk medications; and the perception of folk medicine as supportive treatment for conditions which modern medicine cannot provide a definitive cure, or has difficulty treating effectively (Şar, 1982). The number of medicinal plants in Turkey used for treatment is not well known. Estimates on this number vary between 350 and 1000 in different sources (Özgen, Kaya & Coşkun, 2004; Başer, 2001; Koyuncu, 1990). Although Turkey has a rich flora, only 3 to 9% of these plants have known uses in folk medicine. This is due to the lack of written records and information on most of these plants, as well as the fact that many knowledge on many folk remedies from the past have not survived to our day. In addition, it is known that the same name might be given to different plants in different regions, and that the same plant might receive different names in different regions, which also contributes to the confusion regarding the name and use of these plants. The first regular and consistent records on Turkey’s flora was Davis’ work entitled “Flora of Turkey and the East Aegean Islands” (Davis, 1965-1985). PLANTS USED FOR TREATMENT PURPOSES AND THEIR PROPERTIES

“Medicinal plants” are plant whose certain parts or substances extracted from them are administered internally or externally to treat human and animal diseases (URL: İşler, 2016). In recent times, the preference for natural and organic products is 548

increasingly becoming more manifest in urban life - even if such products are not yet as widely used in urban centers as they are in rural areas. The increase in cancer incidence, as well as the lack of definite treatment for most cancers, is leading both rural and urban populations to seek prevention and remedy in natural products. People from all segments of society are resorting to alternative medicine against diseases for which modern medicine lacks a solution. One important indication of this is the increasing number of herbalists selling herbal medications in cities, and the growing sales of such remedies. According to one study on herbalists in Turkey, the ailments for which medicinal and aromatic plants are the most preferred include gastrointestinal system diseases, respiratory system disorders, skin diseases, anaemia and cardiovascular disorders (Akbulut & Bayramoglu, 2013). This study examines previous ethnobotanic studies and field knowledge to form a compilation on some of the natural plants used in Turkey to treat people diagnosed with the abovementioned diseases and other ailments, and the natural plants used in daily life as traditional treatment methods. Since there are many such plants, the examples provided below were selected amongst the most widely used species. Achillea millefolium L. (Asteraceae) (Yarrow) Vernacular name: Civanperçemi Description: Herbaceous perennial that can reach 100 cm in length. Its stem is has a simple, soft and pubescent structure. Leaves on the stem form an alternating sequence, and the base leaves have similar shapes. The leaves are pinnate and pubescent. The number of capitula varies between 50 and 150, although higher numbers are also observed. The inflorescences are shaped as false compound umbels, each having 4 to 6 ray-like flowers and 10 to 20 tube-like flowers. The flowering period of this plant is between June and September. It is distributed in subalpine and alpine areas, between an elevations of 500 to 3450 m (Baytop, 1963; Davis, 1965-1985). Part used: Flowers, leaves, the aerial parts Traditional therapeutic used: Stomachache, cough, shortness of breath, hemorrhoids, diarrhea, wound healing, antiseptic. Preparation: The plant’s leaves, flower or parts above the surface can be prepared into a tea through decoction. This tea is consumed as treatment for stomachache, hemorrhoids, shortness of breath, cough and diarrhea. It can also be administered externally to wounds as an antiseptic. Small quantities of the dried flowers are also used to alleviate diarrhea in children (Güler, Manav & Uğurlu, 2015; Saraç, Özkan & Akbulut, 2013; Kültür, 2007; Şimşek, Aytekin, Yeşilada & Yıldırımlı, 2002). Allium cepa L. (Amaryllidaceae) (Onion) Vernacular name: Soğan Description: Bulbous plant whose stem is narrows and becomes hollow towards its base. The cross-section of the leaves is semi-circular. It has large, bracts that surround its flowers’ anthers. The perianth is star-shaped, while the flower parts are coloured greenish-white. The plant blooms between the months of June and August. It is a cultivated plant (Davis, 1965-1985). Part used: Bulb Traditional therapeutic used: Sprain, edema, bruised, digestive, urethritis, 549

arteriosclerosis, cicatrizant. Preparation: Crushed bulbs with salt is made compress to place sprained, bruised and edema. Bulbs are eaten raw to treat urethritis and to facilitate digestion. Herb tea obtained by infusion of bulbs is used to treat arteriosclerosis rheumatism, and cicatrizant (Polat et al., 2015; Hayta, Polat & Selvi, 2014; Tetik, Civelek & Cakilcioglu, 2013; Ugulu, 2011). Allium sativum L. (Amaryllidaceae) (Garlic) Vernacular name: Sarımsak Description: Bulbous annual standing at a height of nearly 100 cm. Its oval, eggshaped bulbs consist of nearly equal-sized 5 to 15 cloves. The plants have 4 to 10 leaves, which are spined and have a flat cross-section. The flower clusters consist of the few number of flowers, while the color of the plant itself can be greenish-white, greenish-pink or, in rare cases, entirely white. Blooming occurs between the months of June and August. It is a cultivated plant (Davis, 1965-1985). Part used: Bulb Traditional therapeutic used: Snakebite, hypertension, ringworm. Preparation: Crushed bulbs are eaten raw or with yoghurt to treatment of hypertension. Several crushed clove of garlic is made compress to place snakebite. Crushed cloves are applied externally rubbing to the area of ringworm (Polat et al., 2015; Hayta et al., 2014; Tuzlacı & Şenkardeş, 2011; Ugulu, 2011; Çakılcıoğlu, et al., 2010). Bellis perennis L. (Asteraceae) (Common daisy) Vernacular name: Koyungözü, papatya, yoğurt çiçeği Description: A short herbaceous perennial with creeping roots and rosette leaves. The rosette leaves are spoon-like in shape, and the plant may reach 30 cm in size. The false stem (scape) carrying the capitulum is approximately 10 cm in length. The radial flowers number between 30 and 50, and generally have a slightly pinkish-white underside. The flower blooms between March and August, and generally lives in moist areas, especially forests, up to an elevation of 2000 m (Davis, 1965-1985). Part used: Flowers Traditional therapeutic used: Cold, flu, sore throat, dyspnea, bronchitis, stomachache, strengthen hair, urinary inflammations, tranquilizer. Preparation: The plant’s flowers can be prepared into a tea through decoction or infusion. The tea is used as a treatment for urinary tract infections and for respiratory tract diseases such as the common cold, flue and bronchitis. The tea is also consumed as a tranquiliser, and may be applied externally to strengthen hair (Polat et al., 2015; Akbulut & Özkan, 2014; Demirci & Özhatay, 2012; Hayta et al., 2014; Uysal, Onar, Karabacak & Çelik, 2010). Equisetum arvense L. (Equisetaceae) (Field horsetail) Vernacular name: Atkuyruğu, kırkkilit otu, zemberekotu Description: The plant has two types of stem, sterile and non-sterile. Individuals with sterile stems are 20 to 80 cm in length, have dull green colored, are cylindershaped, and have 8 to 12 deep longitudinal grooves. The branches are positioned 550

peripherally, have four sharp corners, and have four deep ridges inside. Non-sterile, reproductive plants, on the other hand, become active earlier in the spring than sterile individuals. Reproductive individuals are 25 cm in length, and have a simple stem with a brownish colour. Their preferred habitat is generally fields and river banks up to an elevation of 1700 m (Baytop, 1963; Davis, 1965-1985). Part used: Leaves, stem Traditional therapeutic used: Diuretic, urinary system disorders, pass a kidney stone and sand, hemostatic, gum inflammations and tonsillitis. Preparation: Herb tea obtained by infusion of dried leaves and dried stems is used to treat diuretic, urinary system disorders, pass a kidney stone and sand, hemostatic. Gargle is made in gum inflammations and tonsillitis (Güler et al., 2015; Fakir, Korkmaz & Güller, 2009; Everest & Ozturk, 2005). Due to the poisonous plant is not recommended long term use. Helichrysum spp. (Asteraceae) (Everlasting flower) Vernacular name: Altınçiçeği, yayla çiçeği, sarıçiçek, ölmez çiçek Description: A pubescent or nodal herbaceous perennial that is lignified near the soil surface. Leaves are simple shaped, fully-edged, banded, and with a spear-tip or spoon-like shape. The leaves are arranged helically. The capitulum is of terminal false umbel type, and with an upside-down pyramid or cylinder shape. The involucrum bracts are organised in an array that is disorderly at first, but then gradually becomes orderly. The flower receptacle is hairless and smooth. The flowers are of golden-yellow color, and are all hermaphrodite or females with edges. The corolla is tube-shaped and with nodes. The pappus hairs are yellowish, while the achene are cylinder-shaped (Davis, 1965-1985). Part used: Flower, flowering stems Traditional therapeutic used: Wound healing, passing kidney stones, tenesmus, stomachache, ear pain, relieving shortness of breath, coughs, asthma, colds. Preparation: The species that are the most used ethnobotanically are Helichrysum arenarium, H. armenium, H. orientale, and H. plicatum. Ointments prepared from the plant’s flowers are generally used for treated wounds. Decoctions prepared from the plant’s flowers or capitulum are used for passing kidney stones, treating stomachache, and relieving shortness of breath and asthma. The capitulum can also be inspired from the nose to relieve ear pain. Keeping the capitulum in olive oil for a certain time of time provides a syrup that can then be used for treating coughs and colds (Gürdal & Kültür, 2013; Saraç et al., 2013; Tetik et al., 2013; Demirci & Özhatay, 2012; Tuzlacı & Erol, 1999). Hypericum perforatum L. (Hypericaceae) (Perforate St John's-wort) Vernacular name: Sarı kantaron, gevrik, binbirdelik otu Description: Herbaceous perennial with a stem that can reach 110 cm in length. The leaves are arranged in an opposing sequence, have an egg-like or ellipsoid shape, and are almost without a petiole. Their length varies between 5 to 35 cm, and have various holes across their structure. The flowers are yellow coloured with five petals and black glandular and pubescent edges. Flowering time is between the months of May and August. The plant grows in moderately humid and dry habitats up to an elevation of 551

2500 m (Davis, 1965-1985). Part used: Flower, all plant Traditional therapeutic used: Sedative and tranquillizer, eczema, burn injury treatment, wound healing, painkiller, stomachache. Preparation: Herb tea obtained by decoction or infusion of flowers is used to be sedative and tranquillizer, painkiller, stomachache. Medical water obtained by decoction of all parts of the plants is used to treat external eczema. Centaury oil prepared with olive oil and the flowers is used as wound healing and burn ointment (Akbulut & Özkan, 2014; Güneş & Özhatay, 2011; Yücel, Tapırdamaz, Yücel Şengün, Yılmaz & Ak, 2011; Çakılcıoğlu et al., 2010; Ezer & Mumcu Arısan, 2006). Juglans regia L. (Juglandaceae) (Walnut) Vernacular name: Ceviz Description: This woody plant is approximately 30 m high and 2.5 m wide. The stem is silvery-gray coloured and without cracks. The outline of the pubescent compound leaves varies between 22 and 35 cm. The leaves have fully crenated edges, and elliptic or inverted egg-like in shape. The plant forms flower clusters consisting of separate male and female flowers. The green fruit is a drupe, is between 4 to 6 cm in diameter, and a lignified endocarp. The flowers blooms in May. Its preferred habitats are forests with oak or mixed deciduous trees; calcareous rocky slopes; and area with gravel inside valleys that are rich in alluvions. Furthermore, the plant has largely been cultivated for its fruit and naturalised (Davis, 1965-1985). Part used: Leaves, fruit, young shoots Traditional therapeutic used: Headach, stomachache, expectorant, sore throat, rheumatism, goiter, dermatologic disorders like as syphilis, eczema, herpes, and papula. Preparation: The leaves are externally put on forehead for headache. Herb tea obtained by decoction of leaves is used to treat stomachache, sore throat, and expectorant. Herb tea obtained by infusion of leaves is used to treat skin diseases like syphilis, eczema, herpes, and pimples. Leaves and decoction obtained from young shoots are used externally to treat rheumatism by wrapped in a cloth. Unripe fruits are eaten to treat goiter (Gürdal & Kültür, 2013; Ugulu, 2011; Tuzlacı & Eryaşar Aymaz, 2001; Tuzlacı & Tolon, 2000; Tuzlacı & Erol, 1999). Malva neglecta Wallr. (Malvaceae) (Common mallow) Vernacular name: Ebegümeci, Ebe Kömeci Description: Herbaceous annual with a creeping stem that can reach height of 60 cm. Leaves are circular with five to seven lobes, while the edges of the leaves are sparsely crenated. Flowers emerge as bundles from beneath the leaves. Upper sepals have a striped appearance. The petals, on the other hand, are pubescent at their base, and have purple-white colour. Flowering occurs between May and August, and the plant prefers habitats such as steppes, fields, road sides and abandoned uncultivated lands up to an elevation of 2000 m (Davis, 1965-1985). Part used: The aerial parts Traditional therapeutic used: Stomachache, nephrite, abscess, and inflammations. 552

Preparation: Decoctions prepared from the green parts of the plant are used for treating stomachache and renal infections. It also has two different forms of use for boils and infections on the skin. One involves the preparation of an infusion from the green parts of the plant, which is then pressed topically against the boil or infected area. The second method involves the boiling of the green parts and the mixing obtained liquid with a certain amount of starch. This mixtures is then made into a paste that is topically applied to the relevant area. (Polat et al., 2015; Hayta et al., 2014; Yücel et al., 2011; Çakılcıoğlu, et al., 2010; Sarper, Akaydın, Şimşek & Yeşilada, 2009). Mentha longifolia (L.) L. (Lamiaceae) (Horsemint) Vernacular name: Pünk, nane, çay nanesi Description: Herbaceous and pubescent perennial of various forms and with a sharp, mouldy smell. Its stems emerging from rhizomes can reach a height of 120 cm during flowering season. Its leaves, which rarely have petioles, are elliptic or spear-tip shaped, and can be as large as 9 cm. The base of the leaves is heart-shaped, while the lead edges have a double row of sharp crenations. The plant forms long and branching flower clusters, while blooming occurs in the months of June and August. It can be found on river banks and swampy areas between elevations of 600 to 2300 m (Davis, 1965-1985). Part used: Leaves Traditional therapeutic used: Stomach disorders, common cold, respiratory tract infections, vermifuge, carminative, diabetes, rheumatism, eczema. Preparation: Herb tea obtained by decoction or infusion of leaves is used to treat common cold, respiratory tract infections, vermifuge, rheumatism, and eczema. The essential oils obtained from leaves can be applied directly to stomach disorders, carminative, and diabetes (Akbulut, 2015; Elçi & Erik, 2006; Everest & Ozturk, 2005; Şimşek et al., 2002). Petroselinum crispum (Mill.) A.W.Hill (Apiaceae) (Parsley) Vernacular name: Maydanoz Description: Herbaceous, non-pubescent biannual reaching a height of 50 to 80 cm. Its leaves lack any trichome, and have an overall triangular, egg-like shape. Flower clusters have a joined umbel structure. Flowering season is between June and August, and the plant can be found distributed up to an elevation of 2000 m (Davis, 1965-1985). As a widely cultivated plant, Petroselinum crispum, or parsley, is mainly found in artificial habitats created by humans. Part used: Leaves, stem, root Traditional therapeutic used: Stomach disorders, pass kidney stones, mouth sores and halitosis, hemorrhoids, urinary inflammations, oedema. Preparation: Either the entire green parts of the plant, or just its leaves or stems, can be used to prepare a decoction that is consumed to treat many of the aforementioned ailments. It is also chewed and consumed raw to treat bad breath or mouth sores (Hayta et al., 2014; Tuzlacı & Şenkardeş, 2011; Ezer & Mumcu Arısan, 2006; Yeşilada et al., 1999).

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Plantago major L. (Plantaginaceae) (Broad-leaved plantain) Vernacular name: Sinirotu, damar otu Description: Herbaceous perennial with rosette-structured leaves and reaching a height of 50 cm. The leaves have an overall elliptic and egg-like shape, with irregular edges that are crenated or wavy. Flower clusters are branch-like. The flowers’ sepal are green and without trichome. Petals also lack trichomes. A fruit capsule may have up to about 30 seeds. Blooming occurs between June and August. Plants may grow at different elevations up to 2440 m, and can easily grow in habitats such as stream and rivers banks, fosses, paths, agricultural lands, prairies and disused fields (Davis, 19651985). Part used: Leaves Traditional therapeutic used: Cardiovascular diseases, stomach disorders, urethritis, cancer, abscess. Preparation: Leaves are used by decoction to treat cardiovascular diseases, stomach disorders, urethritis, and cancer. The crushingly obtained poultice, fresh leaves are externally applied to the abscess. Or leaves are heated at mild fever short a while and then are applied pressure to the abscess (Akbulut & Özkan, 2014; Akyol & Altan; 2013; Özgen et al., 2012; Elçi & Erik, 2006; Ezer & Mumcu Arısan, 2006; Yeşilada et al., 1999). Salvia spp. (Lamiaceae) (Sage) Vernacular name: Adaçayı Description: Shrubby plants that are generally perennial, although rarely biannual or annual species also exist. These species have a fairly strong aromatic smell. The stems are either erect or creeping, and may be nodular or without nodules and trichomes. The leaves are unsplit, and have a lyrate or lobed structure. The simose type flower clusters are either sparse or closely spaced. Sepals have a bell-like shape. Flowers can be white, pink, yellow, blue or purple. There are two stamens, which have short stalked. The style has two lobes. The nut-like fruits are glabrous (Davis, 19651985). Part used: The aerial parts, leaves, flowers Traditional therapeutic used: Cold, flu, stomachache, antipyretic, sore throat, tonsillitis, digestive, cough. Preparation: The most ethnobotanically used species are Salvia verticillata, S. fruicosa, S. multicaulis, S. syriaca, and S. officinalis. Among these, S. officinalis is not found naturally in Turkey, but is grown in cultivation. The green parts of the plant, and especially the leaves and flowers, are made into a tea through decoction, or sometimes infusion. One or two cups a day of this tea is consumed as a treatment for flu, the common cold and stomachaches, or as an antipyretic and cough suppressant. It can also be used as a mouthwash against mouth sources or tonsilitis. The plant is also consumed raw to alleviate heartburn (Güler, Kümüştekin & Uğurlu, 2015; Güler et al., 2015; Hayta et al., 2014; Kilic & Bagci, 2013; Çakılcıoğlu, et al., 2010; Uysal et al., 2010).

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Sambucus ebulus L. (Adoxaceae) (Dwarf elder) Vernacular name: Otsu mürver Description: Herbaceous perennial with rhizomes and aromatic smell. The compound leaves of this plant has opposite arrengement, and its leaflets consist of three to six pairs. The plant gives white flowers, and blooming occurs between the months of July and August. The plant is usually found between elevations of 500 to 2000 m, and its main habitats are deciduous forests and road clearings (Davis, 1965-1985). Part used: Leaves, fruit Traditional therapeutic used: Skin disorders, insect repeller, hemorrhoids, rheumatism, laxative. Preparation: Fresh leaves or juices obtained through decoction are applied topically to insect bite sites or areas with skin diseases. The juice is also be to repel insects that damage the wooden structure of houses. The mature fruits are consumed as a remedy for hemorrhoids and constipation. The leaves can also be pressed on joints or added to bath water as a relief for rheumatoid pain (Akbulut & Bayramoglu, 2014; Doğru Koca & Yıldırımlı, 2010; Yeşilada et al., 1999). Thymus spp. (Lamiaceae) (Thymes) Vernacular name: Kekik Description: Small, sometimes cushion-shape shrubby perennial whose lower sections are lignified. The margins of its leaves are flat or curved. The leaves may or may not have petioles, and are marginally pubescent towards the base of the leaf blade. Bracts, calyxes and leaves lack petioles, and are covered with transparent or red oil glands. The flower clusters each consist of more than two flowers. The sepals are prominently double-lipped. Flowers are purple, pink, cream or white coloured. Flowers have four stamens, and the fruits lack trichomes (Davis, 1965-1985). Part used: The aerial parts Traditional therapeutic used: Cold, flu, stomach disorders, dyspnea, antihypertensive, sedative, tonsillitis. Preparation: The most ethnobotanically used species are Thymus kotschyanus, T. longicaulis, T. cilicicus, T. vulgaris and T. sipyleus. In addition to their curative uses, that are also widely used as spices in meat dishes. The plants are used to prepare a tea usually through infusion, but sometimes through decoction - that is consumed once or twice a day to treat seasonal illnesses such as the common cold and flu; to alleviate digestive system ailments such as stomachaches; to reduce blood pressure; and to treat tonsilitis and shortness of breath (Kalankan, Özkan & Akbulut, 2015; Mükemre et al., 2015; Polat, Cakilcioglu & Satıl, 2013; Gürdal & Kültür, 2013; Tuzlacı & Şenkardeş, 2011; Kültür, 2007). Urtica dioica L. (Urticaceae) (Stinging nettle) Vernacular name: Isırgan, Sırgan Description: Coarse perennial herb with an extensively spreading, matted root system, forming clumps, 30-150 cm tall. Flowering takes place from June to September. Stinging nettle grows on forests, shaded ravines and rocks, margins of streams, between 500-2700 m above sea level (Davis, 1965-1985). 555

Part used: Leaves, seeds Traditional therapeutic used: Hemorrhoids, stomach disorders, rheumatism, cancer, urinary tract diseases and urologic diseases, dermatological disorders. Preparation: Leaves are used by decoction, fresh or cooked. Pulverulent seeds are used with honey (Akbulut & Özkan, 2014; Akyol & Altan; 2013; Özgen, Kaya & Houghton, 2012; Ezer & Mumcu Arısan, 2006; Şimşek et al., 2002; Yeşilada et al., 1999). Zea mays L. (Poaceae) (Maize) Vernacular name: Mısır Description: An annual plant which branches from its lower nodes, has an erect and rigid structure, a diameter of 2 to 6 cm, and 4 m. or more different heights. The leaf blade is 90 cm or longer, and wavy leaf edges are 12 cm broad. The male flower cluster is 30 cm long and has an erect appearance. The female flower cluster, on the other hand, is 20 cm long, and has a very long style. At the end of the flowering period, the flower cluster moves out of the tip to assume a hanging positions. The dry fruits with single seeds are generally wedge-shaped and have pressed sides. Flowering occurs between June and October. Agricultural lands and abandoned fields are their favored habitats (Davis, 1965-1985). Part used: Styles Traditional therapeutic used: Diuretic, kidney stone, rheumatism. Preparation: Styles are mostly prepared decoction form, sometimes infusion form. 2-3 cups per day for the aforementioned diseases consumed (Güler, Kümüştekin & Uğurlu, 2015; Güler et al., 2015; Polat et al., 2015; Hayta et al., 2014). CONCLUSION AND RECOMMENDATIONS It can be seen that leaves, flowers and green parts are the most commonly used portions of medicinal plants employed for traditional treatments. In addition, other vegetative and generative organs such as the bulbs, stems, shoots, fruits, roots, seeds and stylus of the plants can also be used for treatment. The most commonly method of use is the preparation of decoctions and infusions. Aside from these, the plants may also be applied as tinctures, extracts, essential oils, electuary, maceration, ointments, salves and medicinal oils. The plants are most commonly used for the treatment of gastrointestinal diseases (such as stomach disorders), respiratory diseases, urinary tract disorders, skin diseases, kidney stones, and rheumatoid pain. The ethnobotanical properties of these plants used in folk medicine were discovered over many years through trial-and-error and experience. However, it is known that some of the plants traditionally used for treatment purposes among local peoples actually contain toxic compounds that cause various ailments, and even resulted in death in certain cases. For this reason, studies such as this on the medicinal properties and uses of different plants are for information purposes only. Such information such not be viewed as prescriptions, and careless use should be avoided. It is also known that the compounds and essential oils in plants may have different effects on different individuals. Although plant-based medications have less side effects than synthetic medical drugs, it is important to bear in mind that role also plays and important role. For this reason, the administration of such plants for medical 556

purposes should be performed under the control of a phytotherapy specialist. Regardless of their origin, no plant-based medications or mixtures should be used regularly as a habit. REFERENCES Akbulut, S. (2015). Differences in the Traditional Use of Wild Plants between Rural and Urban Areas: The Sample of Adana. Ethno-Med., 9(2), 89-100. Akbulut, S. & Bayramoglu, M.M. (2014). Reflections of Socio-economic and Demographic Structure of Urban and Rural on the Use of Medicinal and Aromatic Plants: The Sample of Trabzon Province. Ethno-Med., 8(1), 141-150. Akbulut, S. & Bayramoglu, M.M. (2013). The Trade and Use of Some Medical and Aromatic Herbs in Turkey. Ethono-Med., 7(2), 67-77. Akbulut, S. & Ozkan, Z.C. (2014). Traditional Usage of Some Wild Plants in Trabzon Region (Turkey). Kastamonu Univ. Journal of Forestry Faculty, 4(1), 135-145. Akyol, Y. & Altan, Y. (2013). Ethnobotanical Studies in the Maldan Village (Province Manisa, Turkey). Marmara Pharmaceutical Journal, 17, 21-25. Ayten Turan, F. (2000). Türkiye’de Halk İlacı Araştırmaları. T.C. Kültür Bakanlığı, ISBN: 975-17-2473-2, 68 s., Ankara. Başer, K.H.C. (2001). Sustainable Wild Harvesting of Medicinal and Aromatic Plants: An Educational Aproach. Harvesting on Non-Wood Forest Products, Seminar Proceedings, 2-8 October, pp. 349-355, Menemen/İzmir, Turkey. Baytop, A. (1963). Türkiye'nin Tıbbi ve Zehirli Bitkileri. İstanbul Üniv.Yay.No.1039, Tıp Fak. Yay.No.59, 503 s., İstanbul. Çakılcıoğlu, U.; Şengün, M.T.; Türkoğlu, I. (2010). An Ethnobotanical Survey of Medicinal Plants of Yazikonak and Yurtbasi Districts of Elazig Province, Turkey. J Med Plant Res, 4(7), 567-572. Davis, P.H. (1965-1985). Flora of Turkey and the East Aegean Islands. Edinburgh at the University Press, Vol. I-IX, Edinburgh. Demirci, S. & Özhatay, N. (2012). An Ethnobotanıcal Study in Kahramanmaraş (Turkey); Wild Plants Used for Medicinal Purpose in Andırın, Kahramanmaraş. Turk J. Pharm. Sci., 9(1), 75-92. Doğru Koca, A. & Yıldırımlı, Ş. (2010). Ethnobotanical Properties of Akçakoca District in Düzce (Turkey). Hacettepe J. Biol. & Chem., 38(1), 63-69. Elçi, B. & Erik, S. (2006). Güdül (Ankara) ve Çevresinin Etnobotanik Özellikleri. Hacettepe Üniversitesi, Eczacılık Fakültesi Dergisi, 26(2), 57-64. Everest, A. & Ozturk, E. (2005). Focusing on the ethnobotanical uses of plants in Mersin and Adana provinces (Turkey). Journal of Ethnobiology and Ethnomedicine, doi:10.1186/1746-4269-1-6. Ezer, N. & Mumcu Arısan, Ö. (2006). Folk Medicines in Merzifon (Amasya, Turkey). Turk J Bot, 30, 223-230. Fakir, H.; Korkmaz, M.; Güller, B. (2009). Medicinal Plant Diversity of Western Mediterrenean Region in Turkey. Journal of Applied Biological Sciences, 3(2), 33-43. Güler, B.; Manav, E.; Uğurlu, E. (2015). Medicinal Plants Used by Traditional Healers in Bozüyük (Bilecik–Turkey). Journal of Ethnopharmacology, 173(2015), 39–47. Güler, B.; Kümüştekin, G.; Uğurlu, E. (2015). Contribution to the Traditional Uses of Medicinal Plants of Turgutlu (Manisa–Turkey). Journal of Ethnopharmacology, 176(2015), 102–108. Gümüş, M. (2013). Türklerde Vatan Kültürünün Oluşumu: Anadolu Tecrübesi. TurkishStudies - International Periodical for the Languages, Literature and History of 557

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Bitkilerin Kullanılış Amaçları Üzerinde Etnobotanik Bir Çalışma. 14. Bitkisel İlaç Hammaddeleri Toplantısı, 29-31 Mayıs 2002, Bildiriler Kitabı, s. 434-457, Eskişehir. Tetik, F.; Civelek, S.; Cakilcioglu, U. (2013). Traditional Uses of Some Medicinal Plants in Malatya (Turkey). Journal of Ethnopharmacology, 146(2013), 331–346. Tuzlacı, E. & Şenkardeş, İ. (2011). Turkish Folk Medicinal Plants, X: Ürgüp (Nevşehir). Marmara Pharmaceutical Journal, 15, 58-68. Tuzlacı, E. & Eryaşar Aymaz, P. (2001). ). Turkish Folk Medicinal Plants. Part IV: Gönen (Balıkesir). Fitoterapia, 72(2001), 323-343. Tuzlacı, E. &Tolon, E. (2000). Turkish Folk Medicinal Plants. Part III: Şile (İstanbul). Fitoterapia, 71(2000), 673-685. Tuzlacı, E. & Erol, M.K. (1999). Turkish Folk Medicinal Plants. Part II: Eğirdir (Isparta). Fitoterapia, 70(1999), 593-610. Türkdoğan, O. (1991). Kültür ve Sağlık-Hastalık Sistemi. Milli Eğitim Bakanlığı Yayınları: 2213, Bilim ve Kültür Eserleri Dizisi: 522, Araştırma ve İnceleme Dizisi: 17, İstanbul. Ugulu, I. (2012). Fidelity Level and Knowledge of Medicinal Plants Used to Make Therapeutic Turkish Baths. Ethno-Med, 6(1), 1-9. Ugulu, I. (2011). Traditional Ethnobotanical Knowledge about Medicinal Plants Used for External Therapies in Alaşehir, Turkey. Int. J. Med. Arom. Plants, 1(2), 101-106. URL: İşler, N. (2016). http://www.mku.edu.tr/getblogfile.php?keyid=1030 Uyar, A. (2013). Halk Hekimliği Kapsamında Yozgat Ocakları. Bozok Üniversitesi SBE Yüksek Lisans Tezi, 101 s., Yozgat. Uysal, İ.; Onar, S.; Karabacak, E.; Çelik, S. (2010). Ethnobotanical Aspects of Kapıdağ Peninsula (Turkey). Biological Diversity and Conservation, 3(3), 15-22. Yeşil, Y. & Akalın, E. (2009). Folk Medıcınal Plants in Kürecik Area (Akçadağ/MalatyaTurkey). Turk J. Pharm. Sci., 6(3), 207-220. Yeşilada, E.; Sezik, E.; Honda, G.; Takaishi, Y.; Takeda, Y.; Tanaka, T. (1999). Traditional Medicine in Turkey IX: Folk Medicine in North-West Anatolia. Journal of Ethnopharmacology, 64, 195–210. Yücel, E.; Tapırdamaz, A.; Yücel Şengün, İ.; Yılmaz, G.; Ak, A. (2011). Determining the Usage Ways and Nutrient Contents of Some Wild Plants around Kisecik Town (Karaman/Turkey). Biological Diversity and Conservation, 4(3), 71-82.

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Chapter 52 Mobbing; Effects on the Mental Health and Protection Nermin GÜRHAN*, Ebru KURDAL BAŞKAYA** and Perihan SOLMAZ*** INTRODUCTION Mobbing is a well known fact which has pretty big effects on people’s mental and physical health. Even we can say that what makes mobbing so important is its impact on people’s mental health. For a full understanding of it, let's take a short trip on the concept of mobbing. The meaning of mobbing in Turkish is the psychological violance, psychological terror, psychological abuse, psychological attack, moral abuse, tyranny in workplace and we can enlarge these definitions if we want. However, what is important here is that the action happens in work place and it affects our psychology. If we consider that we spend most of our times at work place and with the people there, we come face-to-face the fact that the events in work place influence other parts of our lives. The fact that our emotional-social-sexual lives influence each other and again our social life consists of work, home and other environment are another well-known facts. A positive or negative event in these fields will closely affect our all other fields. For all of these reasons mobbing has an important role in our lives and we often see it recently. Mobbing has been mentioned more recently because of an increase in job opportunities, employee numbers and technology and the development of a competitive environment. With the concept of mobbing other definitions have also occured as “doers” and “exposed/victims”. While doers are handled as a group, exposed can be categorized as two group as directly affected and indirectly affected. Although mobbing has a heavy psychological effect on victims, it is accepted that mobbing adopters do it because of psychological problems. Therefore, we can say that mobbing has an important effect on people’s mental health. Here I will try to analyze the mobbing for the mental health of both victims and adopters as much as possible (Tınaz, 2006; Tutar, 2004; Gürhan, 2013). 1. PERSONALITY OF THE VICTIM AND THE MOBBING ADOPTE Personality of the victim and the mobbing adopter have always been wondered. Although what kind of personality the adopter has and why they do have been wondered, the personality of the victims has been wondered as well and has still been wondered, too. Thus, when mobbing is begun to be told anywhere, maybe the first questions that come to the mind are how the personality of the adopter and the victims are or whether they have any special qualifications. Results of many studies performed *

Assoc. Prof. Dr., N. Gürhan, Gazi University, Faculty of Health Sciences, Nursing Department, Ankara, Turkey. ** Lecturer, E. Başkaya, Uşak University, Health Service Vocational School, Health Care Sercive Department, Uşak, Turkey *** Lecturer, P. Solmaz, Uşak University, Health Service Vocational School, Health Care Sercive Department, Uşak, Turkey

due to this curiosity indicate that adopters and victims of mobbing have some qualifications indeed. 1.1. When we look at the personality of the adopters of mobbing; there are some underlying facts which the adopters do mobbing. In other words, we see the t1op of the iceberg and behave according to it but the reasons under the iceberg are the real reasons for mobbing. As a result of researches, we can state the behaviours that we often see in adopters like this. In general adopters of mobbing are the people who have the characteritics such as being untalented in life, making roles in interpersonal affairs, not managing to make clear communication, being dishonest, desiring to show themselves superior as it is, enjoying hostility, looking for pleasure, being bored, stiffening prejudice, believing to have privilages, trying to take revenge of things that they do not have, having higher ego with misleaded competition instinct and narsistic personality and the need for increasing prestige. Again researchers define the mobbing adopters with the concepts of the need for excessive control, coward, angry and hungry for power. According to Leymann, behaviours of a mobbing adopter occur with jealousy and hostility feelings emerging from mistrust and anxiety feelings. All of these negative characteristices are suggested to be understood by their counterfeiter, honourless and imposter attitudes and their uncaring behaviours for differences and other people. According to the results of a study, people choose mobbing in work place in order to cover their own defects. The anxiety / fear and despair about their status and prestige cause them generally to denigrate other people (Leyman, 1996; Leyman & Gustafsson, 1996). If we try to group and categorize these personalitiy-behavior qualifications of these people into some grups, however, main personality characteristics of intimidation actors can be grouped as the following according to Davenport and his friends known by their studies on this topic (Davenport, Scwartz, Elliot, 2003): They have antipathetic personalities: They have excessively controlling, coward and limited character. They always want to be strong. They do not avoid trying to vicious and tricky actions. They narcissistic personalities: It is an attitude and behaviour disorder of the people who are regarded as clinically socially retarded, use power to control the scared people and consider themselves superior to other people. They are egocentric under threat: If intimidation actor has a bloated ego, it may react extremely in an unpleasant event. Because its bloated self-perception has the potential to increase its response factor. Trying to make their own norms organization policies: Pro-psycho-terrors adopting the intimidation as a policy are on behalf of the obeidence, not the initiative, of the discipline, not the autonomous behaviours, of the fear, not the motivation. They always remind rules and set up new rules. Being prejudiced and emotional: Behaviours of intimidation actors have no rational base and explanation. Not only a victim can be exposed to violance depending on some reasons such as religious, social or ethnical, but also a good performance, an opportunity, a promotion or an award of victim is enough for “mobbing” actors to act (Işık & Taner, 2008; Kaplan & Sadock, 2009; Morris, 2002). As a result of many studies, various categorizations have been performed and we see them everywhere. Here, we will use a categorization including all these

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categorizations and definitions and share them with you as much as possible. However, we will sometimes see categorizations called personality disorders. However, I think that handling the adopters as the personality disorder will bear highyly problematic results. Dignosing the personality disorder is very hard and while there are DSM IV TR criteria for diagnosing and there are not any criteria for mobbing adopters or victims withing these critieria, it is highly difficult to include them in disorder (Köroğlu, 1994). Therefore, here I will rather try to present the results of the studies conducted for personality qualifications by categorizing. Having a bad personality: These people usually refer to vicious and tricky actions. They are excessively controller, coward and nervous. They try to overcome their fears and lack of confidence by smearing other people (They are the example of our nice proverb of “throw dirt enough and some will stick”). These people deal with other people since they can not control the fear in their mind and can not cope with their problems. They tend to use power in a way to prevent the moral development of others in order to hide their own sick personalities. For that reason, they always look for a scapegoat in their lives. Believing to have privileges: Owners and those with upper administrative positions in the hierarchy of the organization think they are privileged to apply their power to emplyees. These people suggesting that they are leaders are not actually leaders. They threaten the people they have targetted for losing or changing their jobs. They want everything to be fulfilled as they want and they often remind that they are the master or the boss. They have no toleration when they do not find the person they look for in his or her place. They want the person who they are looking for to be ready at any moment, otherwise they do not tolerate it and they want everything to happen as they desire to be. Having a narcissistic personality: Those with a narcissistic character see themselves over the law and moral principles with the expectation of continuous special interest since they see themselves as a great power and genius and believe they deserve everything. They may use every method to promote rapidly in hierarchical stages. They may be cruel to individuals who do not exhibit admiration and appreciation they expect to. They generally try to find their balance by charging their grief that they do not tolerate to hear to other people. We can say that the most difficult people to cope with in mobbing process are these narcissistic people. 1.2. When looking at the characteristics of the person exposed to mobbing, the risk of being mobbing victim is valid for everyone in all work places and all cultures. Although the mechanism of mobbing process works different in different work places, a very typical and similar method is generally followed in this process. Studies indicated that the people who prefer mobbing do this to the people with special characters more in general. Although there is no certain type of personality who is a candiate to the role of the victim in mobbing, “nice / polite people” are the targets of the adopters as well. Because the adopters believe that these people would resist the least. i.e. kind /polite people are easy hunts for the adopters. Similarly, “undefended people” are the target. Because these people retaliate or resist less to the people who do mobbing. However, unlike kind and undefended people, mobbing adopters choose “the best and brilliant” people most. Mobbing adopters give harm to successful people reaching their targets brilliantly, slowly and slyly with the feeling of inadequency in general. Of course, 562

mobbing adopters may choose the people out of these three definitions above as the target. However, current studies indicate that these three images – “nice / polite people”, “undefended people” and “ the best and brilliant people” – are the most common targets of mobbing adopters. In the studies about this topic again no common point was found that would cause these actions in backgrounds or personalities of the people targetted to mobbing. Even it was concluded that majority of the victims were intelligent, creative, success-oriented, work-addicted people with superior qualifications. Especially the people with developed creativity may be exposed to intimidation policy by the traditionalist former employees who do not want any change in the system. Studies by Yuceturk indicate similar situations, too (Parlemantry Comission on Equel Opportinios For Women and Men, 2011; Yücetürk, 2012). Interviews with the victims of mobbing present that these people have superior qualifications. They also present that these people are intelligent, talented, creativei success-oriented, honest, reliable, work-addicted people who are not in need of recommendation and enjoy dealing with opinions, not people and events, self-confident, easy going, qualified, partly judgmental but not accusive. It is stated that the people with high emotional intelligence, therefore, flexible, sensitive structure who can review their behaviours highly feel the behaviours and feelings of the others, create new ideas and appreciate the world with different perspectives may be exposed to mobbing more. Careers of these people have a lot of positive qualifications. Sense of belonging of these people without any politic behaviours for their organizations develops extremely and they are identifed with their jobs. Since the creative people especially create new ideas, they are exposed to mobbing more. These people are selected with the concern that they may threaten the personnel with higher position. Also a person has some unchangable qualifications. For instance, skin colour, gender, personal appearance, accent, less or more good manner and education than his or her colleagues. All of these information indicate that there are a lot of reasons to be exposed to mobbing. An opinion such as employers apply not the employees and successful ones, especially apply to the lazy ones is valid for this situation. Indeed, when we look at our proverbs, we can see that we have some proverbs confirming these situations: "Fruitless tree can not be stoned." 2. MOBBING WITNESSES So far we have talked about mobbing victims and mobbing adopters, but there are mobbing witnesses who are as important as the adopters for the victims. If we ask that who these witnesses are, we can see that they are those who do not directly include in the process such as colleagues, masters and managers, but sometimes include in the process, feel the process and experience its reflections. If you are silent in an event, the fact that you accept it should not be forgotten. So witnesses may become the mobbing adopters by collaborating with them. Not only have they negative effects on dose increase and time extension of mobbing, but also they are influenced by mobbing as well. The personality of witnesses is also as important as the personality and behaviours of mobbing adopters and mobbing victims. If we group the witnesses according to their personalities: 2.1. Political observer: They are the people who are always on behalf of reconciation in any conflict. Also they are those who are beloved or hated by the other people since they have a mediator role. This type of observer is under the risk of 563

becoming a victim in the future as a result of the reactions in the organization. 2.2. Let alone observer: This type of observers usually try to keep away from all goings-on since they do not usually enjoy, show up and join any events much. They do not declare anything about the topic or the event. Not only they do not help mobbing adopters, but also they are completely indifferent and insensitve for mobbing. 2.3. Very manipulative observer: They work for a particular opinion and view, in fact, although they pretend not to interfere anything. Thus, this type of observers support the mobbing adopter or reject helping the victims with the fear of mobbing treat for themselves. They may act together with the mobbing adopter easily if there is any advantage of the vicitm position. 2.4. The extra interested observer: It is a kind of observer who is interested in others and the problems of others. They try to join in private sphere and subjects of the others by force with just the sense of curiosity out of them and the purpose of help. Even the victim looking for help gets disturbed in time and tries to find solutions. 2.5. Stooge observer: They are loyal to mobbing adopter blindly. They do what the mobbing adopter say, but they also do not want this qualificaiton to be identified. They get the advantages of this behaviour from the mobbing adopter. Of course, the fact that there are not any norms for the mobbing adopters, witnesses and victims to be brought out is an important factor. Because normsa re important for determining statndart behaviour in an environment. In many communities anti-social and aggressive behaviours are out of norms. People do not lean to these behaviours with the fear of disapproval and denounciation. If this fear abolishes, the desire for preserving social norms also reduces. When people sometimes behave as members of a group, they obey the rules of the group set up in aggressive or anti-social behaviours instead of considering on their own personal norms. If there is no obligation about this topic or, on the contrary, norms support these behaviours, people also behave aggressively and antisocially. For instance, gangs exhibit aggressive and antisocial behaviours because these behaviours are approved in the group and all types of aggressive behaviours are supported (Lawrence, 2001). Silence norm, the most important one among the norms in terms of witnessing mobbing, prevents the members of the group to talk about the norms anf change them. If there are denying the abuse and silence rules in the group of psychological abuse witnesses, they never exhibit a behaviour like supporting the victim or stopping the abuse by stepping forward. Another factor of the success of the attacker is also the silence of witnesses. When we look at the reasons for the witnesses to remain silent; • In the first step, the witnesses stay silent, because what they don't understand what is going on. Then, the attacker of the victim manages to win over the witnesses by attracting attention to wrong behaviors of the victim through cheating and manipulation. Sometimes it may take a long time to realize the truth for the witnesses (Debout & Larose, 2003). • After noticing, they also continue to stay silent because they feel guilty since they did not react in time, but they are unwilling to take responsibility for it (Debout & Larose, 2003). • If the attacker is a manager, it is very difficult to object. They may feel 564

themselves threatened by people since they think they may also experience it. • After all, witnesses may not see the abuse when they start taking some advantages like undertaking the role of victims (Breard & Pastor, 2002). • Denial is a defense mechanism commonly seen in the witnesses without responses. They manage to get rid of the painful emotional burden of the external reality by denying and ignoring. event can be denied through an idealism like "People can not be so bad". An egoistic denial may be in question through the opinion of "Everything is allright for me; people do not treat me bad". A vicious denial may be through the comment of "Everyone can not be treated like this, that means they do something to deserve it". They may agree the common denial through the response of "Nobody talks about it, so there is no roolm for conflicting with people now (Bilhera, 2006). • Managers’ ignorance of the abuse and failure in diagnosis and response cause the abuse to expand (Einarse, Raknes, Matthiesen, 1994). 3. EFFECTS OF MOBBING The effect of mobbing is not only on the victims of mobbing. Mobbing impacts wide range of results about victims, results about businesses where mobbing is applied and results about society and national economy. Because people often define themselves by their work. For that reason, problems occuring in working life have a special meaning. So these problems at work cause problems in family and society. Mobbing is important because of the emotional and other negative effects on the group and all society. And there is an undoubfully accepted fact that prestige and respect are the rights for everyone and in this respect how an individual is treated at work is a problem of fundamental human rights. In other words, mobbing is a violation of the individual's fundamental human rights. The fact that people exposed to mobbing will develop health problems is also another identified and accepted fact by researches. The effect of the act of mobbing adopter without considering the purpose on the victim depends on the damage of this effect to the victim and persistent behaviours for maintaining mobbing. The most interesting point in mobbing is that mobbing adopters or group are not aware of the damage and think that the guilty of all events is “incoordination” of the victim. Hence the mobbing adopters consider their behaviors as a precaution for the attitudes towards them. For that reason, coping with the passive attacker is exhibit understanding and sincere behaviours in suitable atmosphere in order to cover their bad behaviours. We can not restrict the effects of mobbing only on individuals, because an individual will affect his or her environment as much as he or she is affected. So we can say that mobbing has organizational and social effects as well as individuals. We can say that this is a vicious cycle, because an individual affected as much as he or she is affected in organization and society and social and organizational effect will influence the individual again. Mobbing can be appreciated as a rapidly spreading infectious illness from this perspective. It is an infectious illness that will destroy all society unless precautions are taken. As a result of studies it was also documented that mobbing reduces the productivity. Then we also see that mobbing as a cost factor affecting total labour productivity.

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3.1. The effects on the individuals; Mobbing should also be regarded a severe trauma (an event after torture, earthquake, rape, etc.) and post-traumatic effects should also be handled while analyzing the effects on individuals. Then we can say that post traumatic stress disorders can be seen in people exposed to mobbing. All kinds of psychological trauma destroy the psychological and biological coping skills. After a trauma, the perception of an individual about himself / herself and the world would never be the same in the past. The new self and world perception may generally be negative and it is experienced by the individual as desperation and insignificance. Also the fact that there is a close relationship between the level of post traumatic function disorder and the loss of relationship and interpersonal supports was also indicated by studies. If stress is not controlled or avoided, it causes the progress of physiological stimulation and fear. In untreated and advanced mobbing cases post traumatic stress disorder, insomnia, eating disorders can be seen and seen various psychosomatic illnesses which occur as physiological illness but originally it is a psychological illness may happen to individuals. Mobbing victims begin the day with working stress and they do not want to go to work. The desperate situation of the individual threatens the individual’s health seriously. The frequency, repeatation and duration of mobbing are the factors affecting the victims most. Since everybody has different tolerance time, the effect of the damage may vary. Although depression is told to be occured without any reason or as genetic factors, stress factors and environmental conditions are known to trigger depression. The process beginning with self-confidence damage and eigenvalue loss in individuals may reach to introversy in a while and then heavy depression as the time passes. While at first stage groundless crying, insomnia, amnesia, asthneia, anorexia, temper, concentration problems occur in people suffering from mobbing, at second stage the symptoms such as stomach problems, depression, unwillingness for going to work, temper, mental and behavioural changes ad being late for work are added to the symptoms in the first stage. At third stage the volume of depression increases and panic attack and anxiety occur. Even in heavier psychological pressure tendency for accidents, suicide opinions at victims can be seen at last stage (Davenport et al. 2003). When we look at the conducted studies, we can see that unfortunately, there are a few studies about mobbing in Turkey. Although there has not been an increase in researches and legal procedures through social acknowledments recently, we can say that we have not got the researches for the effects of mobbing on individuals yet. According to the results of a study by Dr. Leyman in Sweden, 15 % of suicide cases are derived from mobbing. This indicates that it will be useful to make wide range of researches on the relationship between suicide and mobbing in all world primarily in Turkey. When we have a look at the results of some studies on the effects on individuals, it was found out that 94 % of victims had anxiety, 82 % had concentration problems, 76 % had obsession and 41 % had depression according to a study result in the USA (Namia & Namia, 2003). The depression rate in a study in France is 69 % (Hirigojen, 2001). According to a study result in EU, neurological disorders are 52 %, digestive disorders are 47%, overfatigue is 72 % and cardiological disorders are 37 % (Bread & Pastor, 2002). Psychological problems derived from mobbing are mentioned as suffering not illness. The reasons of these problems may be charged on the mobbing adopter deliberately.

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3.2. Organizational effects; Emotional abuse is a very important problem that organisations experience. The first result of emotional abuse in organizations is that it may cause a stressful atmosphere in organization. Dominant stress in organizations disturbs each employees in the organization, reduces the productivity and may cause the devotion of the employees to lose. Since the employees focus on the problem they experience, it makes the desired group work hard in organization. They can not work in coordination to manage the works well. The happening chaos and disturbance reflect on the image of organization and cause the organization to be recognized negatively. This process affects the whole organization from the top to the bottom and causes many disturbance, conflict, and chaos in the organization. Belonging feelings of the individuals for the work place and organization decreases and the individuals watch for an opportunity to pass the organizations with better working atmosphere. Obtained experience is also lost when the qualified employees leave the organization and so to say, organization begins to lose blood. In parallel with the loss of trained and experienced professional expert personnel, while the time and costs for the employment of new employees and their education and mastering increase also the cost of the company, sometimes it can cause financial losses. After all, mobbing causes not only psychological disorders but also huge economic losses in victims. It is suggested by scientists that the cost of individuals to the society who become ill after mobbing process is more than the annual income. On the other hand, since many people exposed to mobbing do not regard the tension they experience as illness, they do not try the treatment. Another effect of mobbing process to the organization will also be the compensation claims of the employees. Although this process has not been defined by legislations in Turkey yet, some countries have accepted the compensation claims of workers for the physical and mental diseases caused by the stress at work. Legislative procedures and payments for this process will also increase the costs. Then, we can easily say that employees and administrators should know this process well, recognize it and take precautions in order to work in more profitable and peaceful environment. 3.3. Social effects; So many negative effects of mobbing on organizations and individuals also affect the society. Emotional violance not only affects the individuals exposed to violance, but also it gives harms on family members, witnesses of the attack and the people want to support the victim. Families have to bear the emotional and economic consequences of emotional violance. Health costs of the inviduals suffering emotional violance place on economic burden on the state as well as the organization. Also, as a result of emotional violance, a society with professionally disqualified, emotionally exhausted, unhealthy and unoccupied people emerges. Economical costs of mobbing victims to their countries is unignorably high. According to the data based on the studies by Leymann in 1990, oragnizational annual cost of a victim ranges between 30,000 and 100,000 USD. According to the National Institute for Occupational Safety Report, total cost of mobbing in the workplace is more than 4 billion dollars in 1992 in USA. According to a report prepared by Griffith University Management Department in Australia, mobbing costs employers $ 36 billion a year. According to a study by British Chamber of Commerce in 2000, mobbing brings $ 2 billion to the UK each year (Parlemantry Comission on Equel Opportinios For Women and Men, 2011). In Turkey, there is no 567

work for this situation yet. 4. WHAT SHOULD WE DO TO PROTECT OUR MENTAL AND PHYSICAL HEALTH AGAINST MOBBING We have talked a lot about the effects of mobbing so far, but we don't want you to be pessimistic. If so, we would have mobbed you while we were explaining mobbing. I'll try to give you some information in “what can we do?” section. Some precautions and alterative studies for preventing and saving from mobbing can be listed as follows: 4.1. Legislative aspect; Sweden, Norway, Finland, Austria and Germany agree that it is a requirement for protective legislations of professional security which may enhance the emotional welfare in working life. Laws should be enacted by considering important dangers in workplaces caused by mobbing. Mobbing in the workplace should be regarded as a social problem and awareness of mobbing should be increased. At the same time, while wide ranges of studies are conducted in this field for Turkey, discussions also should be allowed. Indeed, in April 2011 Turkey accepted the need for enacting laws in Turkey and in April 2011 “ psychological violence” (mobbing) at work and recommendation for solution “commission report” was prepared by the Turkish Grand Assembly woman-man equality of opportunity commission (Parlemantry Comission on Equel Opportinios For Women and Men, 2011). Works for legislation have still been going on. Also Council of Higher Education established a Mobbing Commission. Again in 2010 a mobbing announcement line of Alo 170 was established and it has been working actively since then. There is a mobbing society located in centre Ankara. When you apply to the society, you can get some help. Also, educations are organized by the society throughout the country. While mobbing is handled as a topic in many congresses and Symposiums, publications about the topic have been rapidly increasing. 4.2. In organizational aspect; We can say that there is no kindness and professional ethics in work places with the advance of science and technology. At the same time, economical and social circumstances such as global economic crisis, inflation, decrease in unionization or union’s loss of their existence of reality created the circumstances causing mobbing behaviours to the employees at work. In order to fight against mobbing, there should not be any uncertainity at critical topics such as inhouse status and distribution of roles, everything should be defined clearly, not causing dilemmas and therefore there should not be any room for mobbing. Although mobbing can be seen in all work places, some emerging conditions are mentioned. Mobbing happens rather in organizations with very strict hierarchic system, authocratic management style, inadequate communication in working group and bad behaviours and they all increase the risk. According to what Özmete reported, some researchers found out that mobbing happened in non-profitable sectors such as education and health services more frequently than in profitable big companies. The reason for this is that less experienced individuals in management have much more possibility to become manager at non-profit companies than profitable companies and also financial pressure in non-profit organizations causes mobbing to increase. There are also studies contrary to this opinion. Without any relationship with the business of employees or occupational status, there are some special working place conditions triggering mobbing. These are: • Keeping the cost of human resources minimum, 568

• • • •

Extremely strict hierarchical structure, The failure of the open communication policy, Poor communication network, The weakness of conflict solving skills, and ineffective complaint in the workplace and conflict management, • Weak leadership, • A combination of factors such as education which are not effective for differences. Here, of course, attitudes and behaviours of the management are the most important factor. Provided that managements or managers conşider mobbing as a big danger for their organizations or companies, existing conditions causing mobbing will continue to sphacelete. Therefore, mobbing should be regarded as a danger first and settlements should be created for that. Transparency should be ensured in management, in order to do this attendence to the decisions should be emphasized and an atmosphere that all employees would participate the decisions should be created. The effeciency of communication process should be provided in the institution. Honesty principle should be accepted as the basic value for a well- functioning communication. It should not be forgotten that there would not be a correct and healthy information flow in a company without honesty. On the other hand, a good communication will prevent the gossips. It should be cared for complaint and performance assessment mechanisms to work very healthily. Therefore, mobbing basing on the belief of injustice can be prevented. While looking at the sufficiency of the candidates in employment process, their personality and emotional intelligence should be emphasized and whether they are problematic people at work or not should be considered (Miller, 2000). Number of staff, qualifications, intensive periods, rotation, special requirements should be determined. Management should be based on clearity, dialogue and respect basis. Information and communication should be increased between public and personnel. Business practices should be adjusted accroding to the regulations of costumer flow, waiting time and flexible work. Business designing should be adjusted according to business content, business autonomy, working speed, business burden. Working hours should be considered in terms of overtime, night shifts, shifts, flexible work, resting hours. In appointments qualifications and psychological attitudes of candidates should be considered and special educations about violence and mobbing should be organized besides occupational education. These educations should be organized according to positions of employees (as managers – administrators and employees) and repeated periodically. Education starting with the definition of mobbing and going on with recommendations for solutions should be lectured by the experts. Also, mobbing should be tried to be prevented by educations such as solutions for conflicts, dare, coping with stress, anger management. Risk at workplace should be identified. Healthy working environment • Roles and business definitions are clear. • There are collaborative relationships. • Goals are common and shared. • Relationships are clear. • There is a healthy organization structure. • Sometimes there may be conflicts and frictions. 569

• • •

Strategies are clear and friendly. Conflicts and discussions are clear. There is a direct communication.

Mobbing environment • Roles are unclear. • Non-cooperative relations are dominant. • It is impossible to foresee the future. • The relationship are unclear. • There are some organizational difficulties. • Long-term and non-ethical responses are observed. • Strategies are meaningless. • The existence of conflict is rejected and they are covered. • There are indirect and sloopy communication. 4.3. In environmental aspect; Designing of the physical environment in the workplace should be performed. Noise control, colors, scents, lighting, ventilation, transportation, waiting rooms, staff rooms, parking places, facilities, fixtures and fittings, security and alarm systems, etc should be handled with much care by the employees and others. Some recreational activities such as physical exercise, relaxation techniques, fun activities should be performed for relief at working places. In the living areas parks, hiking and sports fields should be established. 4.4. Individual aspect; • Support of family and other close friends is essential in working life, therefore they will find a place where they exist out of work and they are appreciated. • Tarhan lists what individuls should do when they suffer from mobbing as follows: • First of all, you should not accept “The role of the first victim”. • It is important to inform the management about the process. • Feelings and experiences should not be kept inside. Because suppressed feelings will damage. • You should think and collect data first. • You need to think about the background, the connections and the details of the event. • The biggest mistake to enter the battle field of the other side. • That person wants you to make an emotional response. • If you react by thinking, you will have him or her think. • Finding some ways to make things and those who think of Mobbing is the best solution. • The fact that you judge yourself by self-criticism, you manage to percieve yourself in the responsibility of the problem and you have it felt also a have positive effect. CONCLUSION As a result, people working for all public institutions and organisations and private sector experience mobbing (psychological violence). If people know about mobbing, they may protect themselves from mobbing and also help other victims. The fact that emergency nurses and patrol police officers are sentitive for this social issue and 570

educated adequately will have an effective role in identfiying the people under the risk of violence and initiating the attemps for preventing the violence. REFERENCES Bilheran, A. (2006). Le harcelement Moral, Paris: Armand Colin. Breard, R. & Pator, P. (2002). Harcelements: Les Reponses, Paris: Editions Liaisons. Davenport, N., Schwartz, R. D., Elliot, G. P. (2003). Mobbing: İşyerinde Duygusal Taciz. Sistem Yayıncılık, İstanbul. Debout, M. & Larose, C. (2003). Violence au Travail. Paris:VO Edition Einarse, S., Raknes, B.I., & Matthiesen, S.B. (1994). Bullying and Harassment at Work and Their Relationship to Work Environment Quality. An Exploratory Study. European Work and Organizational Psychologist, 4(4), 381-40. Gürhan, N. (2013). A dan Z ye Mobbing. Akademisyen Yaynları. Ankara Hirigojen, M.F. (2001). Le Harcelement Moral Dans la Vie Professionnelle. Paris:Syros. Işık, E., Taner, E., & U, Işık. (2008). Güncel Klinik Psikiyatri. Ankara: Goldon Print Matbaası. Kaplan, I. & Sadock, J. (2009). Klinik Psikiyatri El Kitabı. Bozkurt, A. (Ed) Nobel Tıp Kitapevi . Köroğlu, E. (1994). DSM IV Tanı ölçütleri Başvuru El Kitabı. Hekimler Yayın Birliği. Lawrence, C. (2001). Social Psychology of Bullying in the Workplace. Bulding a Culture of Respect-Managing Bullying at Work. N.Tehrani ( Ed). London: Taylor and Francis, 6176. Leyman, H. ( 1996). The Content and Development of Mobbing at Work. European Journal of Work and Organizational Psychology. 5(2), 165-184. Leyman, H. & Gustafsson, A. (1996). Mobbing at Work and the Development of Post Travmatik Stress Disorder. European Journal of Work and Organizational Psychology. 5(2), 251-275. Miller, K. (2000). They Call It “Mobbing”; A new kind of workplace harassment or an old one with a new name?, Either Way, Europe are upset, Newsweek, Newyork, August: 14. Morris, C. G. (2002). Psikolojiyi Anlamak. (Ed) Ayvaşık. H.B.ve M. Sayıl. Türk Psikologlar Derneği Yayınları. Ankara. Namia, G. & Namia, R. (2003). The Bully at Work; What You can do Stop the Hurt and Reclaim Your Dignity on the Job. Naperville:Sourcebooks. TBMM Kadın Erkek Fırsat Eşitliği Komisyonu (2011). İşyerinde Psikolojik Taciz (Mobbing) ve Çözüm Önerileri Komisyon Raporu. Ankara. Tınaz, P. (2006). İşyerinde Psikolojik Taciz (Mobbing). İstanbul: Beta Basım Yayım, Tutar, H. (2004). İşyerinde Psikolojik Şiddet Sarmalı: Nedenleri ve Sonuçları. Journal of Administration Sciences. 2(2). Yücetürk, E .(2012). İşyerlerindeki Yıldırma Eylemlerini Önlemede Sendikaların Rolü: Nitel Bir Araştırma. Çalışma ve Toplum.

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Chapter 53 Smoking Behaviour Among High School Teachers in Turkey Ayten DİNÇ INTRODUCTION Tobacco use is one of the most important and preventable public health problems in the world as well as in Turkey due to the negative effect of various substances in tobacco on human health (Bilir, Çakır, Dağlı, Ergüder & Önder, 2010). Tobacco kills approximately 6 million people and causes more than half a trillion dollars of economic damage each year (WHO, 2013). Tobacco use is recognized as the major cause of preventable death (Russo, Nastrucci, Alzetta, Szalai, 2011; WHO, 2009). It has been reported that tobacco smoking is the number one cause of cancer (Schroeder, 2012). Additionally, tobacco smoking is a prevalent risk factor for cardiovascular and respiratory disease such as coronary heart disease, lung cancer and tuberculosis (Basu, Stuckler, Bitton & Glantz, 2011). Although cigarette addiction is common worldwide, the studies conducted in developed countries in the recent years have revealed that the prevalence of smoking has been decreasing (WHO, 2009). World Health Organisation developed MPOWER approach in order to assist protection of public health by fighting against the tobacco epidemic (WHO, 2009) . Being one of leading tobacco producing countries of the world until recent times, Turkey has achieved a substantial progress in tobacco control in a short time. According to Global Tobacco Control Report 2013 of WHO, Turkey is the first and only country to achieve all of the six MPOWER criteria at the highest level. This report states “this progress is a testament to the Turkish government’s sustained political commitment to tobacco control, and is an excellent example of collaboration between government, WHO and other international health organizations, and civil society”. However, the tobacco use still constitutes one of the serious health problems in Turkey. Despite a slight decrease in last 15 years, about one-third of the population over the age of 15 have been still smoking. When smoking status is examined in terms of gender, the rates of everyday smokers are as follows: 37.3% in males and 10.7% in females. Tobacco use is more common among men than women (WHO, 2013). Teachers have an important responsibility in tobacco control given that they are highly respected in their communities as they influence the evolution for each aspect of life (Al-Naggar, Jawad, & Bobryshev, 2012; Ghouth & Bahaj, 2006). It has been recognized that teachers are important role models for students, conveyors of tobacco prevention curricula and key opinion leaders for school tobacco control policies (AlNaggar et al., 2012; Konan, 2012). In addition, teachers have daily interaction with students and thus represent an influential group in tobacco smoking control. However, this potential can be limited if teachers use tobacco especially in the presence of students in school premises. Studies have shown that the children whose parents smoke at home or whose teacher smokes, take their parents or teachers as role-model and begin 

Assoc. Prof. Dr., Canakkale Onsekiz Mart University, School of Health Sciences Canakkale, Turkey

to smoke at an early age (Coşkun, Karadağ, Ursavaş & Ege, 2010; Kwamanga, Odhiambo and Amukoye, 2003; Ünlü, Orman, Cirit, Demirel, 2002). Teachers should show exemplary behaviours by taking both personal and social responsibility. Tobacco usage rate of teachers was found to be between 27.6-62.3% in the studies conducted in Turkey (Aydın, Uyar, Kul&Elbek, 2011; Coşkun et al., 2010; Çoban & Sungur, 2013; Kutlu& Çivi, 2007; Sertoğullarından, Özbay, Ekin, & Yaşar, 2011; Talay, Altın & Çetinkaya, 2005; Unsal, Hamzacebi, Dabak, Terzi & Kirisoğlu, 2008; Ünlü et al., 2002; Yorgancıoğlu, Danacı, Çelik & Topçu, 2002). One of the basic principles in the fight against smoking is to reduce the rate of smoking initiation. Important tasks fall to teachers, the easiest group to reach young people, in order to achieve this. Therefore, it is very important to primarily evaluate attitudes and knowledge of teachers about smoking and to overcome the resultant deficiencies. This descriptive study was conducted in order to determine the smoking behaviours and opinions of the teachers serving in high schools and their equivalents located in city centre of Çanakkale. MATERIALS AND METHODS All teachers (n=347) serving in the 8 high schools and their equivalents, where this study was allowed to be conducted, in the city centre of Çanakkale in western Turkey were included in the study. The study was conducted with 314 teachers who accepted to be interviewed. Researchers prepared a questionnaire evaluating socio-demographic characteristics, smoking status, level of knowledge about the harms of smoking, legislative regulations on tobacco control, and the views on the objectives of tobacco control of teachers. The questionnaire was applied to teachers working in the selected schools through face-to-face interview between 15 October-7 December 2015. Smoking habit was classified into 2 groups, as smokers (at least 1 per day), non-smokers. Data Analysis The data collected were analyzed using SPSS-16.0 for Windows Descriptive statistical methods for each question were carried out according to the different demographic data on the collection of respondents. Statistical evaluation was accomplished using the Pearson chi-square test to test the relationship of sample characteristics and categorical variables. P value of less than 0.05 was regarded as significant. Ethical Considerations The purpose of the investigation was explained to the participants and a verbal informed consent was obtained. Furthermore, all study participants were told that they had the right to withdraw from the investigation at any time and that all information would be kept strictly confidential. The study was approved by the University of Çanakkale Onsekiz Mart Human Research Ethics Committee (Permission No: 224/201516) and Çanakkale Provincial Directorate of National Education. RESULTS While 57% of teachers who participated in the study were male (n=179), 43% were women (n=135). Their average of age was 39.79 ± 7.62 (20-60) years, 82.8% of teachers (n=260) were married and 17.2% (n=54) were single. 32.2% of the teachers 573

were smoking. The rate of smoking was 33% in male teachers and 31.1% in female teachers; and there was no statistical difference (p = 0.412) (Table 1). Smokers and nonsmokers had similar characteristics in terms of marital status and age (p = 0.522, p = 0.293) (Table 1). Table 1: Socio-demographic features and smoking habits of the teachers Socio-demographic features n Gender Female Male Marital status Married Unmarried Age range (years) ≤30 31-40 41-50 >50 χ² test

Smokers %

Non-smokers n %

p value

42 59

31.1 33

93 120

68.9 67

p=0.412

84 17

32.3 31.5

176 37

67.7 68.5

p=0.522

9 55 32 5

26.5 36.2 33 16.1

25 97 65 26

73.5 63.8 67 83.9

p=0.150

Table 2: Reason for starting cigarette smoking among school teacher smokers (n=101)* Emulation and curiosity Peer influence Stress factor Family Fun * More than one answer was given.

n 42 40 28 7 25

% 41.6 39.6 25.5 6.9 24.8

The average age of smoking initiation was 18.46±4.77. Reasons to start smoking involved emulation and curiosity at the rate of 41.6 %, peer influence at the rate of 39.6%, and stress factor at the rate of 25.5% (Table 2). When smoking related complaints were examined, it was determined that 53.5% of the smokers had a complaint about the bad taste that cigarette leaves in the mouth, 33.7% about tickling sensation in their throats, 20% about breathing difficulties, 17.8% about sputum, and 14.9% about nighttime and morning coughs. It was determined that 48.5% of smokers considered to quit smoking. 77.6% of those wanted to quit because of the economic burden, 71.4% because they thought that smoking caused detrimental effects on themselves and their environment. While 44.2% those who did not want to quit smoking/who were undecided about it stated that they had excessive desire for smoking and they became angry when not smoking, 21.2% expressed that they suffered from concentration impairment when they did not smoke. Only 10.9% of smoker teachers stated that they were getting help to quit smoking (Table 3).

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Table 3: Distribution of smoking-related complaints and opinion on smoking cessation (n=101). Complaints (n = 101)* Nighttime and morning cough 15 14.9 Bad taste in the mouth 54 53.5 Anorexia 8 7.9 Difficulty in breathing 21 20.8 Wheezing during breathing 14 13.9 Expectorating 18 17.8 Tickling sensation in the throat 34 33,7 Chest pain 9 8.9 Thinking of quitting smoking (n=101) Yes 49 48.5 No 23 22.8 Undecided 29 28.7 Reasons why they want to quit smoking (n=49) * Because it is harmful to the health 31 63.3 Economic reasons 38 77.6 Detrimental effects on themselves and their environment 35 71.4 Reasons not to quit smoking (n=52)* Irritability 23 44.2 Headache 6 11.5 Concentration impairment 11 21.2 Excessive smoking request 23 44.2 Sleeping disorder 6 11.5 Obesity 3 0.6 Getting help to quit smoking (n=101) Yes 11 10.9 No 90 89.1 * More than one answer was given

While 81.8% of the non-smoker teachers indicated that they disapprove smoking of role models of the society such as teacher, this rate was 18.2% among the smoker teachers, and the result was statistically significant (p = 0.000) (Table 4). When opinions of teachers about "The Law on Prevention and Control of Harms of Tobacco Products" were examined, 73.5% of non-smoker teachers found the law positive, this rate was 26.5% in smokers (p = 0.002) (Table 4). DISCUSSION In numerous campaigns held against smoking all over the world and in Turkey in recent years it has been presented that members of occupational groups having one-toone relationship with the society have important roles. The fact that teachers have particularly an important role amongst these occupations has been highlighted in numerous studies (Al-Naggar et al., 2012; Ghouth & Bahaj, 2006; Coşkun et al., 2010; Kwamanga et al., 2003; Ünlü et al., 2002). It is a known fact that individuals mostly start smoking in adolescence period and teachers' attitudes towards this matter affect adolescents. (Aydın et al., 2011; Çoban & Sungur, 2013; Kutlu & Çivi, 2007; Sertoğullarından et al., 2011).

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Table 4: Perceptions of teachers about smoking and their opinions on “The Law on Prevention and Control of Harms of Tobacco Products" Teachers’ Opinions Smoking of Teachers Considered normal Considered inappropriate Undecided Opinions on Law No: 4207 Positive Negative With limited effect χ² test

Non-smokers n %

Smokers n

%

p value

43 157 12

42.6 81.8 57.1

58 35 9

57.4 18.2 42.9

p=0.000

169 9 38

73.5 37.5 63.3

61 15 22

26.5 62.5 36.7

p=0.002

In this study, examining opinions of teachers about smoking, the rate of smoking habit among teachers was found to be 32.2%. On the other hand; while the rate of smoking in male teachers was 33% in this study, this rate was 31.1% in female teachers. Similar to this study, other related studies have shown that the rate of smoking among teachers in Turkey is quite high ( Aydın et al., 2011; Coşkun et al., 2010; Çoban & Sungur, 2013; Kutlu & Çivi, 2007; Sertoğullarından et al., 2011; Talay et al., 2005; Unsal et al., 2008; Ünlü et al., 2002; Yorgancıoğlu et al., 2002). However, these data have also pointed out that there has not been a significant change in the group of teachers in the use of tobacco over years. Therefore, teachers should be urgently considered as primary target group in terms of smoking cessation services. When studies conducted abroad have been analysed, prevalence of smoking among teachers is 3.2% in Australia, 7.8% in Malaysia, 8% in Yemen, 7% in Bahrain, 14.5% in India, 17% in Bangladesh, 17.8% in Tunisia, and 27.2% in Iran and these rates are lower compared to Turkey (Al-Naggar et al., 2012; Alnasir, 2004; Ghouth & Bahaj, 2006; Erick & Smith, 2013; Harrabi et al., 2011; Heydari, Youse, Hosseini, & Ramezankhani, 2013; Rahman, Karim, Ahmad & Suhaili, 2011; Savadi, Wantamutte, & Narasannavar, 2013). A higher prevalence was reported in a Syrian study which found that the smoking rate of school teachers was 52.1% in males and 12.3% in females (Maziak, Mzayek & Al- Moushareff , 2000). Much higher prevalence was reported in a study from Nepal, which found that 57.1% of the school teachers used any form of tobacco (Sah SK, 2007). There was no significant relationship between smoking habits of teachers and their age and marital status in this study. Different from our results, smoking rates among female and male teachers were found respectively as 10.5% and 0.4% in Botswana, and 12.3% and 52.1% in Syria (Erick & Smith, 2013; Maziak et al., 2000). Interestingly, the results of studies conducted among primary school teachers in Belgaum City, India and secondary school teachers in Yemen, indicated that female teachers in these studies did not smoke. Low prevalence of smoking among female teachers could be because traditionally it is a taboo for women to smoke ( Ghouth & Bahaj, 2006; Savadi et al., 2013). A similar study of Unger et al. (2003) who reported that there was no association between smoking and marital status. Different from our results, the studies conducted in Botswana and Malaysia have revealed that there is a significant relationship between smoking and marital statuses of teachers (Al-Naggar et al., 2012; Erick & Smith, 2013). 576

This study did not determine a significant relationship between smoking habits of teachers in terms of age groups. Studies conducted in Botswana and Malaysia had similar results with this study (Al-Naggar et al., 2012; Erick & Smith, 2013). The studies conducted have demonstrated that the age of smoking initiation in Turkey was between 13 and 21 years (Çoban & Sungur, 2013; Kutlu &, Çivi, 2007; Talay et al., 2005; Yorgancıoğlu et al., 2002). In this study, the age of smoking initiation was 18.46±4.77. The habit of smoking has been increasing among young people, especially in developing countries (WHO, 2009). Reasons to start smoking were found to be emulation and curiosity at the rate of 41.6 %, peer influence at the rate of 39.6 %, and stress factor at the rate of 25.5%. A study conducted in Indıa reported that; the reasons to start tobacco use were, fun (44.82%), (27.58%) for imitation, (24.16%) due to peer pressure (3.44%) for relieving tension (Savadi et al., 2013). A study conducted in Malaysia reported that; the main reason for start smoking was found to be a need for relaxation (33.3%), followed by stress-relief (28.2%). Another study found that the exposure to factors was significantly associated with the initiation of tobacco use; these were 70.8% for relief stress and tension; 24.2% family problem (Sah, 2007). When smoking related complaints were examined, it was determined that 53.5% of the smokers had a complaint about the bad taste that cigarette leaves in the mouth, 33.7% about tickling sensation in their throats, 20% about breathing difficulties, 17.8% about sputum, and 14.9% about nighttime and morning coughs. In the study conducted by Ünlü et al., (2002) it was found that while 41.3% of the smokers did not have any complaints, 24% were complaining about morning coughs, 16.3% about frequent respiratory tract infection, and 11% about expectorating. In this study, it was determined that 48.5% of the smokers were considering about quitting smoking. In another study conducted in Turkey, the rate of those wanting to quit smoking was determined as 80.6% (Gencer, Ceylan, Yengil, & Ethemo, 2007). In this study, reason of 77.6% of those wanting to quit was economic burden, 71.4% thought that smoking caused detrimental effects on themselves and their environment and 63.3% wanted to quit since smoking is harmful to the health. While 44.2% of those who wanted to quit smoking /who were undecided about it stated that they had excessive desire for smoking and they became angry when not smoking, 21.2% expressed that they suffered from concentration impairment when they did not smoke (Table 3). In this study, it was determined that teachers were not willing enough to quit smoking. The fact that those who wanted to quit smoking were doubtful about the effective smoking cessation methods has showed that they should be informed about harms of smoking in fight against smoking and supports for smoking cessation should be increased. As a matter of fact, only 10.9% of smoking teachers stated that they were getting help for quitting smoking. In their study, Poulsen et al. (2002) emphasized the importance of anti-smoking trainings targeting teachers and prohibition of smoking within school areas in terms of creating “smoke-free schools”. In Turkey, smoking in public bodies and agencies as well as public transport vehicles was prohibited with “Law No: 4207on Prevention and Control of Harms of Tobacco Products” in 1996. The schools-related clause of this law states: “tobacco products will not be consumed in the indoor and outdoor areas of buildings belonging to preschool institutions, training centres, primary schools, secondary schools, culture and social service institutions including private educational 577

institutions”. Nevertheless, smoking rate in school gardens was found as 31.68% in this study. Other studies conducted in Turkey have shown that even though the teachers are aware of this prohibition, they do not act enough according to this prohibition (Coşkun et al., 2010; Sertoğullarından et al., 2011). While 81.8% of the non-smoker teachers indicated that they disapprove smoking of role models of the society such as teacher, this rate was 18.2% in the smoker teachers, and the result was statistically significant (p = 0.000). When opinions of teachers about "The Law on Prevention and Control of Harms of Tobacco Products" were examined; 73.5% of non-smokers found the law positive and this rate was 26.5% in the smokers (p = 0.002). Negativity in perceptions of smoker teachers is remarkable. It appears that the teachers should interiorise this law more. CONCLUSION In conclusion, even though the rate of smoking is lower compared to some of other cities in Turkey, the rate of smoking among teachers in the city of Çanakkale has still been quite high. The role of teachers is undeniable in attitudes of students towards smoking. Therefore, important tasks fall to teachers to prevent students from starting to smoke and to encourage smoking students to quit. In this regard; organising trainings to inform teachers, and also making consultancy for smoking teachers regarding smoking cessation programs are recommended.

REFERENCES Al-Naggar, RA., Jawad, AA., & Bobryshev, YV. (2012). Prevalence of Cigarette Smoking and Associated Factors Among Secondary School Teachers in Malaysia. Asian Pacific Journal of Cancer Prevention : APJCP, 13(11), 5539–43. Alnasir, FA. (2004). Bahraini School Teacher Knowledge of the Effects of Smoking. Annals of Saudi Medicine, 24(6), 448–452. Aydın, N., Uyar, M., Kul, S., Elbek, O. (2011). Öğretmenlerin 4207 Sayılı Yasa Konusundaki Farkındalıkları TAF Prev Med Bull, 10, 543–8. Basu, S., Stuckler, D., Bitton, A., Glantz, SA. (2011). Projected Effects of Tobacco Smoking on Worldwide Tuberculosis Control: Mathematical Modelling Analysis. BMJ, 343. Bilir, N., Çakır, B., Dağlı, E., Ergüder, T., & Önder, Z. (2010). Türkiye'de Tütün Kontrolü Politikaları. World Health Organization Report. Available from: URL: http://www.euro. who.int/document/E93038. Coşkun, F., Karadağ, M., Ursavaş, A., & Ege, E. (2010). Öğretmenlerin Sigara İçme Alışkanlıkları ve Yeni yasaya Bakışları. Solunum Dergisi, 12(3), 119–124. Çoban, SA., & Sungur, G. (2013). Öğretmenlerin Sigara Kullanım Konusundaki Davranışları ve Görüşleri Turkish Thoracic Journal, 98–102. Erick, PN., & Smith, DR. (2013). Prevalence of tobacco smoking among school teachers in Botswana. Tobacco Induced Diseases, 11(24), 2–5. Gencer, M., Ceylan, E., Yengil, E., & Ethemo, G. (2007). Şanlıurfa'da İlköğretim Okulu Öğretmenlerine Uygulanan Sigara Anket Sonuçları. Turkiye Klinikleri Archives of Lung, 8, 5–9. Ghouth, SB., Bahaj, AA. Prevalence and Attitudes of Smoking Among Secondary School Teachers in Hadramout Coastal Districts, Yemen. Online J Health Allied Scs. 2006;2:1 Harrabi, I., Maatoug, JM., Belkacem, M., Gaha, R., Lazreg, F., Boussaadia, A., Ghannem, H. (2011). Les Factures Determinants le comportment Tabagique Chez les Enseignants de la ville de Sousse, Tunisia. Ann Cardiol Angeiol, 60, 92–6. Heydari, G., Youse, M., Hosseini, M., & Ramezankhani, A. (2013). Cigarette Smoking , Knowledge, Attitude and Prediction of Smoking Between Male Students , Teachers and

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Clergymen in Tehran , Iran , 2009. International Journal of Preventive Medicine, 4(5), 557– 64. Konan, N. (2012). İlköğretim Okulu ve Lise Öğretmenlerinin Sigara İçme Alışkanlıkları. Sosyal Bilimler Dergisi, 2(11), 74–98. Kutlu, R & Çivi, S. (2007). Konya İli Lise Öğretmenlerinin Sigara İçme Sıklığı ve Etkileyen Faktörler. TSK Kor Hek, 6, 273–8. Kwamanga, DHO., Odhiambo, JA., Amukoye, EI. (2003). Prevalence and Risk Factors of Smoking Among Secondary School Students in Nairobi. East Afr Med J, 80, 207–212. Maziak, W., Mzayek, F., & Al- Moushareff, M. (2000). Smoking Behavior Among School Teachers in the North of the Syrian Arab Republic. East Mediterr Health J, 6, 352–8. Poulsen, LH., Osler, M., Roberts, C., Due, P., Damsgaard, MT., Holstein, BE. (2002). Exposure to Teachers Smoking and Adolescent Smoking Behaviour: Analysis of Cross Sectional Data from Denmark. Tobacco Control, 11, 246–51. Rahman, MM., Karim, MJ., Ahmad, SK., Suhaili, MR., A. S. (2011). Prevalence and Determinants of Smoking Behaviour among the Secondary School Teachers in Bangladesh. Int J Public Health Res, (Special Issue), 25–32. Russo, P., Nastrucci, C., Alzetta, G., Szalai, C. (2011). Tobacco Habit: Historical, Cultural, Neurobiological, and Genetic Features of People’s Relationship with an Addictive Drug. Perspect Biol Med, 54, 557–77. Sah, SK. (2007). A Study on Patterns of Tobacco Use Among School Teachers in Mahottary District of Nepal. J Nepal Health Res Council, 5, 44–9. Savadi, P., Wantamutte, A. S., & Narasannavar, A. (2013). Pattern of Tobacco Use Among Primary School Teachers in Belgaum City , India – A Cross Sectional Study. Global Journal of Medicine and: Public Health, 2(4), 1–6. Schroeder, SA. (2012). An Update About Tobacco and Cancer: What Clinicians Should Know. J Cancer Educ, 27, 5–10. Sertoğullarından, B., Özbay, B., Ekin, S., & Yaşar, M. (2011). İlimizdeki İlköğretim Öğretmenlerinin Sigara İçimi ve Sigara Yasağı Hakkında Görüşlerinin İncelenmesi. Solunum Hastalıkları, 2(1), 11–16. Talay, F., Altın, S., Çetinkaya, E. (2005). İstanbul Eyüp İlçesi Lise Öğretmenlerine Uygulanan Sigara Anketi Sonuçları. Solunum Hastalıkları, 16, 53–9. Unger, JB., Shakib, S., Cruz, TB., Hoffman, BR., Pitney, BH., Rohrbach, LA. (2003). Smoking Behavior Among Urban and Rural Native American Adolescents in California. Am J Prev Med, 25, 251–4. Unsal, M., Hamzaceb,i H., Dabak, S., Terzi, O., Kirisoğlu, T. (2008). Smoking Status and Levels of Knowledge Regarding Cigarettes Among Primary School Teachers. South Med J, 101(12), 1227–31. Ünlü, M., Orman, A., Cirit, M., Demirel, R. (2002). Afyon'da Lise Öğretmenlerinin Sigara İçme Alışkanlığı ve Sigaraya Karşı Tutumları. Solunum Hastalıkları, 13, 203–207. WHO Report on The Global Tobacco Epidemic, 2009: Implementing Smoke-Free Environments. Available from: URL:http://www.who.int/tobacco/mpower/2009 /gtcr_download/en/ WHO Report on the Global Tobacco Epidemic, 2013. Enforcing Bans on Tobacco Advertising, Promotion and Sponsorship. Available from: URL: http://www.who.int/tobacco/global _report/2013/en/index.html Yorgancıoğlu A, Danacı AE, Çelik P, Topçu F, S. F. (2002). Attitudes of the High School Teachers and Students Towards Smoking : Two Sides of the Story. Turkish Respiratory Journal, 3(2), 43–48.

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Chapter 54 The Effect of Developing Technology on the Family Structure and Family Relations Derya ADIBELLI, Rüveyda YÜKSEL INTRODUCTION Internet is one of the most significant technological inventions that affect our daily lives in the last decade, and it doesn’t just affect the technology, science, trade, construct of government and manner of provision of service, but also social domain and thus the family and its relations which is a significant part of that domain. While the means used for social purposes was only television before 90s, it had given its place to internet today. While television was a one directional means from where the audience received notification in respect of communication, the multi-directional structure of internet through getting feedback from the other party accelerates the transformation in social relations in a manner that cannot be compared with television. The increase of computer ownership and internet connection rate at each house in Turkey is causing the people to be more online and is causing the period spent by internet to increase.  At what level the family, which is the core of the society and which is an institution that is equipped with legal rights as constitutional rights being in the first place, will be affected from such technological progress? Will technological progress provide peace and happiness to the family, or will it endanger the relations by way of increase of distrust, decrease of love and respect, and wiping out of the time that is spent together? In recent years, there have been many developments in information and communication technologies such as web sites, mobile phones, digital televisions, Ipads, tablets etc., but internet has gained the quality of being the most crucial one due to affecting social structure and relations. The entrance of internet to our lives has resulted in different consequences:  The habits of communicating and spending free times have changed,  It has been possible for the likeminded people to share their opinions as independent from time and space,  People from different cultures could be able to come together,  The people has started to express the opinions more freely,  The people, who have started to meet for hours on internet, has started to unknow their neighbors,  By contacting in virtual environment, people have started to become distanced from face-to-face meetings, and in a sense, social isolation has started to arise,  And the unlimited use of internet has started to bring along cybercrimes (pornography, communication with illegal organizations and individuals, theft and 

Assist. Prof. Dr., Akdeniz University, Kumluca Health Science Faculty, Antalya, Turkey Res.Assist., Adnan Menderes University, School of Söke Health Science, Aydın, Turkey

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abuse of personal information, fraud, easy access to addictive substances…) (Çaha, 2007). Before discussing technology and family relations, it will be beneficial to briefly review the definition and types of family from the past to present. Definition of family As per the Turkish Family Structure Research Report of 2006 prepared by General Directorate of Family and Social Researches in cooperation with Turkish Statistical Institute, family is a composition of people who are affiliated to each other through marriage, blood relation and legal means, and who lives together by mutual rights and liabilities (http://ailetoplum.aile.gov.tr). The family, in the most general sense, is being defined as the ‘smallest building block of the society’ (Yaşar Ekici, 2014). Despite the family is a universal institution, the family definition of the modern society is different from the family definition of the traditional society. And the basis of this difference is based on functions and expectations imposed on the family (Bozkurt, 2005). When it is assessed from this frame, while the family is able to be defined as a composition of people who are affiliated to each other with direct relationship by affinity and in which the adults undertake the responsibility of looking after the children (Giddens, 2000), it can also be defined as a social unit which enables the continuation of human species as the result of biological relation, in which the socialization process starts, in which mutual relations are dependent on specific rules, which conveys in between generations the material and non-material wealth that has been formed in the society until that day, and which has biological, psychological, economic, social and legal etc. aspects (Sayın, 1990). The relations among family members and the family environment is the place where the individual–improving in psychosocial aspect- encounters interaction the most. These relations make the self-confidence of the individual, his love and respect towards himself and other individuals, his creation of identity, his personality development, improvement of social skills by him and his process of adaptation to society possible (Republic of Turkey Ministry of National Education, 2011). As the place where socialization starts is the family, the education also starts within the family. Types of families The convening of people to form a family is being through marriage. But the types of families are able to show a change from society to society and in time. These are examined under various forms as per the size of the family, its place of settlement and fragmented family structure. As per sizes Traditional family: It is the family type that is generally formed in rural areas. In this family type, the relations are not equalitarian. The most significant feature of an extended family is the difference of statute within the family. The old is in higher position than the young, adolescent is in higher position than the child, and man is in higher position than the woman. And the group, whose statute is the lowest, is the individuals who join the family new such as brides. In extended families, the selection of spouse is being through the intermediacy of mother and father. The marriages by relatives and by the people from the same area are arising in very early ages. The marriage contract that is valid in marriage is often imam marriage, and the woman has no assurance. The male child is preferred. More importance is attached to the education 581

of male child. The children, who get married, prefer their father’s houses instead of opening a new house. The male child generally keeps the father’s work going. The relations of husband and wife are within a specific distance. It is not acted as excited and emotional. The wife feels frightened from his husband and also honors him. Elementary family: It is the family type in modern society. In industrialized contemporary societies, especially in the cities, the extended families have given their place to small families. The family members become independent by working outside the house as the production is being realized outside the family. There is division of labor among the members of the family. Despite determination of various roles, there is solidarity among the members of the family. The number of children is decreasing, and the interbirth interval is extending. As per settlements Rural family: At rural areas, the benefiting of woman from educational opportunities is very limited. They are generally getting married after elementary school. The family is often an economic unit in which all the individuals work together and produce together. In this type of family, the woman generally doesn’t meet with anyone except her close relatives, and she is unaware of economic independence despite substantially contributing to economic effect. Slum family: It is a family form carrying the features of extended and elementary family together. Migration from village to city has increased due to increase of population at rural area, insufficiency of land, unemployment and starting of financial difficulties. The families migrating from the village to the city appear like elementary family. But they are preserving the features extended family. The one having a voice in the house is the head of the family as it still bears the feature of extended family. The woman is having a voice in the family as she is working and as she has economic freedom. The wish of having a male child is excessive as in the extended family. Because male child is being deemed as a social assurance in cases of old age, unemployment and retirement. In addition, as the male child starts to work at small age, he is providing material contribution to the family. Excessive fertility is in subject as different from the urban elementary family. The fertility is high due to strengthening of family bonds and due to enabling continuity. Both religious and official marriage is observed. Urban family: They are worker, officer, craftsman families who have completely detached from agriculture. In families living in the cities, the woman is benefiting from educational opportunities, her social circle is expanding, and she is becoming productive. The women are knowing their legal rights better. Fragmanted family: They are families split due to death or separation. Various compliance problems may arise in children who grow up in such environments (Republic of Turkey Ministry of National Education, 2011). Change and transformation in the structure of the family In Turkish society, the family is being defined as a unit that starts with matrimony, that are being connected to each other by affinity and social bonds, that have various roles, that affect each other, that consists of members generally living in the same house, and that meets the psychological, social, cultural and economic requirements of its members (Özgüven, 2001). All political, social and economic incidents -realized by the re-establishment of 582

Turkish State after republic- have also affected the family structure. These are migration, poverty, social values, entrance of woman to work life and technology (Yaşar Ekici, 2014). Migration: As migration -that is roughly being defined as the process of geographically changing place- arises as the result of social and economic incidents, it is both a result and a cause due to being able to cause these incidents. As the result of rural migration -which has increased by the effect of industrialization-, the social and economic relations among family members coming to urban areas have decreased, elementary family type has started to be preferred, and domestic violence and child labor rates have increased also by the effect of poverty (Yenigül, 2005; Turan & Beşirli, 2008). And in respect of family structure, the external migrations have been by transnational spouse selections. These families –that are named as guest workers in Germany- have tried to keep pace with the culture of foreign countries, and they have often encountered culture conflicts among generations (Yaşar Ekici, 2014). Poverty: The increase working family members due to poverty, and separation of the individuals from the family and from their hometown due to difficulties of working, have caused changes in the family structure and relations. Social values: The continuity of social structure and social order is very important. As the institutions such as religion, law, education, economy take form under the effect of social values, they are important in respect of unity and continuity of the family and in respect of positive relations. Social values are conveyed among generations due to social institutions and groups. Entrance of woman to work life: The moving of production manner from inside the family to external environments and various professional groups after industrialization has necessitated the woman to enter the work life. This process has also caused changes in family structure, and an increase has occurred in the number of families having children in which both spouses work. But during this process, a similar change has not occurred in the roles and behaviors expected by the society from the woman. While behaviors conforming to traditional roles within the family (child care, houseworks, looking after the husband etc.) is being expected from the woman on the one hand, the opportunity of participating in work life as an equal individual has also been provided on the other hand (Eyüboğlu, Özer & Tanrıöver 2000). In today’s economy, the men -who deem the working of woman as requisite for enabling the livelihood of the family- are seeing assisting the women in houseworks and child care as a discretionary condition. And this condition has caused problems within the family (Çarkoğlu & Kalaycıoğlu, 2013). Technology: In the recent century, it is penetrating to the lives of individuals and societies rapidly and in a manner that will affect the whole world. The technological products -that most affects the family structure and relations within the family- are radio, television, computer, mobile phone and internet. These products have had negative effects on the family more than their positive effects such as facilitating our lives. While the family was the first social environment in which the individual has learned socialization, along with TV and internet, the family has become a group consisting of individuals only sharing the same house. Social and emotional sharing has decreased, and the individuals have started to seek outside the attention, love and support which should have been received from the family (Yaşar Ekici, 2014). As per the results of Household Information Technologies Usage Research, the 583

rate of houses having internet access in Turkey by April 2015 is 69.5%. This rate was 49.1% in the same month of 2013. In the first three months of 2015, 87.1% of the individuals of age group 16-74 used internet in the house environment (http://www.tuik.gov.tr). Among the media tools, the effect of especially television on the relations among family members differs as not always being positive. Watching television too much is negatively affecting the lessons, and it has a slight positive effect on general abilities and linguistic competences. Moreover, the families with high educational level are criticizing the programs more compared to ones with low educational level (Batmaz & Aksoy, 1995). In the study of Polat (2002) named “Effect of Internet on our Habits”, he has tried to determine the time allocated to internet by the internet users at internet cafes, and the habits that they give up for internet. In the study performed at the province of Edirne on 450 individuals at 40 internet cafes through the method of questionnaire, it has been observed that the internet affects the lives of people and that it had caused changes in the habits gained before starting to the internet. It has been determined that the internet users had started to allocate less time to watching television, reading newspapers, magazines and books, and chatting with their friends and families after starting to use the internet (Polat, 2002). In a research performed, as per the answers provided for the question of “From which events the technology is preventing you?”, 29% of the respondents have specified playing games, 27% of them have specified doing sports, and 8% of them have specified playing an instrument (Brant, 2003). Effect of technology on family structure Many examinations have been performed on the origin and development of family concept in the history of humanity, and various ideas have been asserted. The first scientific researches on the development of family have started by the end of 19th century. In the initial period of humanity, in which “striving to survive” was outweighing, the family was based on “living together” that is one of the basic functions of the family concept. And living together was being based on protection, security, social, economic and religious reasons, and especially production. In this respect, a firm “solidarity” among the members of the family and “responsibility” against the whole family was prevailing (Özgüven, 2001; Özdemir, 2007). The family institution, that is being qualified as being together, had encountered a big change in the industry countries by the mids of twentieth century. In parallel to the industrialization in the current era and the rapid change in the societies, significant changes have occurred in the structure of the family as the result of urbanization, and the families have become smaller. Traditionally, the “extended family type” in which three generations were living together-have gave place to widespread “elementary family” consisting of mother, father and children. The relations in the traditional type of family, which had continued its existence prominently until the mids of 20th century, were in vertical direction. There was an authority line from top to bottom and from old to young. In traditional type of family, the father had unchanging authority, and everyone younger than him (spouse, sons, brides, daughters, grandchildren…) was under his administration. There were clear rules on who will be getting heritage, and who will be getting married to whom (Lawrence, 2002; Özdemir, 2007). And today, this structure has nearly completely changed. In the modern family structure, the individuals are now getting married not 584

with the daughter or son of their neighbors or with the relatives, but with individuals with whom they no affinity. While a good spouse for a man was being defined as an individual who cooks good, who takes care of the children, who stitches socks, who feed the animal in the traditional structure, psychological gratification is being kept on the forefront among the qualifications sought in an individual to be preferred as significant other in respect of both genders in the modern family structure. Another significant result caused by social changes is the increase of marriage problems and divorces in the modern societies, and excessive increase of ones requesting help. Today’s married couples or individuals, lacking the opportunity to benefit from the experiences of older generations as in the traditional family structure, are applying to physicians, marriage consultants, social service experts, institutions relevant to public health and maternal-infant health, and other institutions as per the quality of problem relevant to marriage (Özdemir, 2007). The changes arising in the family structure may be gathered under some main headings: 1. The marriage structure has changed. The decrease being encountered in the marriage rates as in the fertility rates have dragged the individuals to coupling without marriage contract which is a new coupling type. Even if there is not sufficient statistics relevant to this subject in the whole world, some researches are indicating that many young adults are preferring this coupling type. 45% of the Danish women, 44% of the Swedish women, and 19% of the Dutch women in between ages 20-25 have preferred living together without getting married (Fukuyama, 2000). 2. For many educated people, raiding a child and having a family is not fashionable anymore. The participation of women in labor life, and their eagerness in doing a career have given rise to the opinion that the child is hindering this objective. In respect of many western women, raising a child means time spent away from work and postponement of career. 3. Divorce rates in marriages have increased. If a child had been had in a marriage, the children-who remain with a single parent-is able to raise along with economic problems, and psychological problems such as lack of love and interest. And the more tragic dimension of the problem is the children who are in adulterine position, in other words the ones who are born through a coupling without marriage contract and who don’t have the chance of knowing their fathers. As these children pass through insufficient socialization process, they are able to direct to risk behaviors in the puberty, and they are able to live their young adulthood period more problematic. 4. Number of people living alone is gradually increasing. As establishing a family with marriage contract has lost its importance and as living together is not long lasting, people are nor preferring to live alone more (Özdemir, 2007). As the reason or result of all these factors, the people are consulting to family consultancy on some significant issues. Alcohol, singleness and divorce, sex disorders, marriage and relations, homosexuality, phobias, pregnancy and abortion, HIV and AIDS, crisis, gambling, abuse, rape, families with single parent, being discharged from work, unemployment, infertility treatment, drug abuse and eating disorder are among the basic subjects (Furedi, 2000; Özdemir, 2007). The importance of parents and educational institutions is very high in enabling the behaviors of children and youth to be at socially acceptable and required standard, and in conveying them the correct values. But it wouldn’t be a correct approach to expect the fulfillment of this role only 585

from them (Özdemir, 2007). The children identify themselves with their parents at early ages, and they internalize their behavior forms through social learning. The children, who observe the family structure and the relations within the family by this way, form a repertory arising from their patterns of responding to external facts, and when they encounter similar facts in their own lives, they apply to this pool including the responses they have learned. Effect of technology on family relations In a study, by which the effect of widespread use of internet at homes on the family relations has been searched, while there is the finding that internet strengthens the family bonds through e-mail or remote contact in family structure in which healthy communication has been established, it has been informed that internet is being used as an escape in houses where more conservative family structure prevails (Kayany, 2000). Internet may cause an environment of conflict by causing uneasiness in the relations among spouses or in the relation of parent and child (Çaha, 2007). Many factors as from limiting the internet usage period, to phrases and symbols used during online communication and with whom it is contacted may be included in these group of reasons. By the effect of contemporary life, while the dinners were a time period at which the events and works performed within the day were being shared and at which the family members were able to be together, the internet use that is postponed to evening hours without being able to allocate time within the day is able to damage the common time spent with the family. On the other hand, due to its feature of enabling reciprocal communication, internet is also a significant factor strengthening the communication provided that it is used for a specific period and that it doesn’t manipulate the time required to be allocated to the family. In social relations, internet has the effect of enabling the establishment of closer relations. Such that, the subjects that are not being spoken in face-to-face communication and the words that are unable to be told are easily being able to be expressed in the internet environment. In addition, as body signals, voice tone and words-three main factors showing the quality of communication- are not being reflected on the internet environment, internal expressions, gests, mimics and facial expressions are easily able to be hidden. While it is often not possible to physically come together with many people, it is able to be contacted with many people at the same time through internet. So how are our family relations being affected while using technology at this extent in our daily lives? The conversations realized in online chat environments, and the phrases and symbols used are causing significant social changes and psychological effects especially on children and youth. Worrying, destroying psychological conditions are arising from time to time during these chats, and sometimes they are turning the lives of some people upside down. Moreover, negative reflections on real live are also occurring due to online chats. Real incidents such as abduction of girls through internet, rape and divorce arising from chat, and murders at internet cafes are painful examples of this condition (Çaha, 2007). In addition, disinformation (falsification of information), info pollution and repetition, forgery, idea piracy and performance of illegal operations over the internet are among the disadvantages of this technology (Fuchs, 2013). Today, internet is an extensive technology which the children are interested a lot in respect of facilitating the life and embodying different implementations and services. 586

Along with the effect of the new media era, the children are becoming acquainted with internet at very early ages, and they are able to get used to this technology much easier than the adults. Internet is improving the abstraction ability of the children, and it is increasing their creativeness and critical thinking potentials. On the other hand, internet has many negative aspects. Addiction and the request of the children to always be on virtual environment are often worrying the families (Rodopman Arman, Bereket & Ateş, 2011). The internet is constituting an environment of escape for the children who are always feeling alone and who are having difficulty in expressing themselves, and it is pulling them apart from the reality. Moreover, the will of navigating in social networks and of finding friends is making the child addicted to internet environment (Kırık, 2014). Besides all these effects, the progress in information technologies is playing a significant role in the development of new consumption products. Effect of technology on consumption The humanity has consumed and is consuming in each phase of social history, and will continue to do the same. But either the traditional societies or the modern and industry societies in the past were “producer” societies, the today’s society is a “consumer” society in the same deep and basic sense (Bauman, 2006). The new social order, which is being described by consumption society concept and in which the consumption desire of the people has increased as far as possible, is constituting a significant dimension of the technological revolution (Altuntuğ, 2012). By the information technologies, the convergence in between the producer and the consumer is gradually increasing. In the direction of facilities provided by scientific information and technology, performing virtual shopping, being included in consumption and spending are becoming much easier than the past. By an electronic means such as internet, directing the consumer to images–that iconizes the consumer by blessing him within popular cultureis being realized easily through providing unlimited freedom of making selection and by providing alternatives (Dolgun, 2005). The consumer, who is diving in virtual environment, is losing himself in an environment which is carefully prepared and garnished for consumption. The easy access of the environment, the multitude of opportunities provided and its attractiveness have been thought meticulously in order to increase consumption or in order to condition to consumption. New consumption tools consisting of catalogues, chain stores, stores where thousands of varieties of a product is available, gyms, electronic shopping centers, cruise ships, discount stores and casinos have turned to “consumption cathedrals” by a well metaphor. These series of new consumption tools and possibilities are making the people relax as if like they are fulfilling a holy task by making shopping (Ritzer, 2000). Credit cards are significantly accelerating consumption due to facilitating and accelerating shopping. The ease of their use and carriage has caused the credit cards to be preferred more in shopping. Credit card, which is a means of payment enabling the holder to spend his future expected income by today, is constituting the most significant factor of the consumption madness of today. Consequently, coping with the consequences arising as the result of the entrance of internet in the social life and as the result of its significant effects in the dimension of family is not a process that the family members can overcome by themselves. While taking under control by deleting specific channels of the television or by applying 587

passwords is possible at an extent, taking the internet under control as a whole is a problem exceeding the family members. Actually, the inspection of internet by the states is also technically not possible. But it seems possible for the state to adopt a guiding position by improving a policy on issues such as classification of the content of internet and raising awareness of the family members (Çaha, 2007). It should be ensured for the children to be protected against exploitation, negligence, abuse and all kinds of violence by establishing a child information network including all kinds of data relevant to children, and the inspection of such networks should be ensured by the state. In the same manner, the data that may clear up the issues covering dangers and risks towards children in cyber world should be available in the child information network to be established. In addition, as puberty –in which identity confusion is being lived intensely- is more open to risky behaviors, the awareness of the individuals in this age group should be raised by attracting their attention to aspects in which internet may be harmful (access to addictive substances, sex crimes…). For the families to minimize the negative aspects of internet and to keep its useful aspects at the forefront, it is first required for the parents to increase their knowledge regarding the content of internet and to know this new technology. In this context, the families are required to be aware of the risky conditions that may be caused by internet and of technical measures (hardware, software etc.) that will be taken against the same. It is very important for them to share with the children their ideas regarding the risk factors of internet by establishing intimate relations with their children and in a convincing manner. Instead of a repressive approach that will make the child feel that it is not being trusted to him, it should be told to him why the content is risky and what kinds of threats it bears for the present or the future. In addition, placing the computer and internet in the shared space of the family instead of the rooms of the child and youth is effective in both preventing the isolation of the child/youth, and in guiding the child regarding harmless and beneficial usage by accompanying him from time to time. Science and technology have diffused in our daily lives, and have become a part of our daily lives from banks to houses and from clothing to food. As long as technology and science has this role, it is required for the individuals and society to be equipped with sufficient foresights in this field as soon as possible. The individuals are also required to have some knowledge and skills such as being aware that the technology is closely related to tools, information, cultural requirements and economic-political decisions, and that it affects the society and it is affected by the society, and having data and decision making ability that will make logical selection possible, and having the consciousness and ability to undertake responsibility in social issues (Babaoğul & Şener, 2010). REFERENCES Altuntuğ, N. (2012). Kuşaktan kuşağa tüketim olgusu ve geleceğin tüketici profile. Organizasyon ve Tüketim Bilimleri Dergisi 4 (1): 203-212. Babaoğul, M. & Şener, A. (2010). Türkiye'de ve AB Ülkelerinde Tüketici Eğitimi. Tüketici Yazıları II s. 9-22. Batmaz, V. & Aksoy, A. (1995). T.C Başbakanlık, Aile Araştırma Kurumu. Türkiye'de Televizyon ve Aile, Ankara. Bauman, Z. (2006). Küreselleşme. 2. Basım, İstanbul: Ayrıntı Yayınları. Bozkurt, V. (2005). Sosyoloji. İstanbul: Aktüel Yayınları. Brant, M. (2003). Log on and learn. Newsweek, 25 Ağustos-1 Eylül p. 52-55. 588

Çaha, Ö. (2007). Günümüzde aile. Uluslararası Aile Sempozyumu, Ankara. p. 626-637. Çarkoğlu, A. & Kalaycıoğlu, E. (2013). Türkiye’de Aile, İş ve Toplumsal Cinsiyet. İstanbul: Koç ve Sabancı Üniversitesi, İstanbul Politikalar Merkezi. Dolgun, U. (2005). Enformasyon toplumundan gözetim toplumuna. Ekin Kitabevi, Bursa. Eyüboğlu, A.; Özer, Ş.; Tanrıöver, H.T. (2000). Kentlerde Yaşayan Kadınların İş Yaşamına Katılım Sorunlarının Sosyo-Ekonomik ve Kültürel Boyutları. Başbakanlık K.S.S.G.M. Yayınları. Ankara: Cem Web Ofset. Fuchs, C. (2013). Internet and Society: Social Theory in the Information Age. Salzburg: Routledge. Fukuyama, F. (2000). Büyük Çözülme, (Çev. Z. Avcı, A. T. Aydemir), Sabah Kitapları, İstanbul. Furedi, F. (2001). Korku Kültürü (Çev. Barış Yıldırım), Ayrıntı Yayınları, İstanbul. Giddens, A. (2000). Sosyoloji (Çev.H: Özel, C. Güzel), Ayraç Yayınevi, Ankara. http://ailetoplum.aile.gov.tr/data/54292ce0369dc32358ee2a46/aileyapısı%202006%20.pdf E rişim:24.04.2016 http://www.tuik.gov.tr/PreHaberBultenleri.do?id=18660 Erişim:24.04.2016 Kayany, J. (2000). Gauging Net's impact on society. GazetteNet Business, Monday, February 28, 2000. Kırık, A.M. (2014). Aile ve çocuk ilişkisinde internetin yeri: nitel bir araştırma. Eğitim ve Öğretim Araştırmaları Dergisi 3 (1): 337-347. Lawrence, M.F. (2002). Yatay Toplum (Çev. Ahmet Fethi), İş Bankası Kültür Yayınları, İstanbul. Özdemir, Ç. (2007). Toplumsal değişme karşısında aile ve okul. Türk Eğitim Bilimleri Dergisi 5 (2): 182-195. Özgüven, İ.E. (2000). Evlilik ve Aile Terapisi. PDREM Yayınları, Ankara. Polat, N. (2002). İnternetin Alışkanlıklarımız Üzerine Etkileri. İstanbul İletişim Fakültesi Dergisi 10; 117-131. Ritzer, G. (2000). Classical Sociological Theory, USA: McGraw Hill Inc. p.7 Rodopman Arman, A.; Bereket. A.; Ateş, E. (2011). Kim korkar ergenlikten, ergenlikle başa çıkma rehberi, Doğan Kitap. Sayın, Ö. (1990). Aile Sosyolojisi: Ailenin Toplumdaki Yeri. İzmir: Ege Üniversitesi Basımevi. T.C. Milli Eğitim Bakanlığı Aile ve Tüketici Hizmetleri, Aile Yapısı, 2011, Ankara. Turan, M.T. & Beşirli, A. (2008). Kentleşme Sürecinin Ruh Sağlığı Üzerine Etkileri. Anadolu Psikiyatri Dergisi 9, 238–243. Yaşar Ekici, F. (2014). Türk aile yapısının değişim ve dönüşümü ve bu değişim ve dönüşüme etki eden unsurların değerlendirilmesi. The Journal of Academic Social Science Studies 30: 209-224. Yenigül, S.B. (2005). The Effectcs of Migration on Urban. G.Ü. Fen Bilimleri Dergisi 18(2): 273–288.

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Chapter 55 The Rules of Requirement in the Swimming Pools Cemal GÜNDOĞDU, Evrim ÇELEBİ INTRODUCTION In wet and humid pool settings, various viral, bacterial and mycologic infections can be seen. Since it is a mass-used setting, infection of illnesses become even easier (Ertam, Ergün, Aytemur & Babür, 2003). All of the microbial illnesses infected from the pool can be prevented by chlorination, yet the risk continues since the chlorine does not kill some microbes instantly. For chlorine to kill microorganisms, time is required. Microbes which may cause to pyretic diarrhea types which can be infected via excrement like Cryptosporidium, Giardia, E. Coli and Shigella can cause to illnesses as a resulting of swallowing pool water. Therefore, unless the people who enter the pool pay attention, it is possible for illnesses to spread even in the best cared pools. Among the illnesses spread in the pool genital fungal infections, bacterial vaginitis, molluscum cantagiosum and trichomonas infections can often be seen. Additionally microbes which cause to pyretic diarrhea like cryptosporidium, coli bacillus, giardia, shigella, dysentery and paratyphoid may also cause to eye, ear, nose, throat infections and also skin diseases like fundal, mange, impetigo (www.ihsm.gov.tr). 1. HYGIENIC PROBLEMS IN SWIMMING POOLS For various health issues that people may encounter while benefiting from swimming pool, hot spring, water parks, sea, lake, river and similar places, “Recreational Water Diseases” (RHS) term is used in community health literature (Seyfried & Fraser, 1980). Limited water surface of the swimming pools should be used by a certain number of people since the users above the pool capacity pave the way for spread of microorganisms which can be infected via water. Eye, ear, respiration and digestion system function and skin rash are among this variety. Most of the microbes that causes illnesses on people have a relation with swimming (Castor&Beach, 2004). Even from the health people who use the facility, microorganisms can mix into the water with hair, dandruff, fat, sweat, nose-throat mucus, salvia, urine components, cosmetic products, sun oil and soup residuals and organic and inorganic substances like dust, soil, plant seeds from the environment. The United States of America Disease Control and Prevention Center (CDC), to be protected against Recreational Water Diseases (RSH), have suggestions like “do not swim when you have diarrhea”, “do not let children with diapers into the pool”, “do not cause to spread of microorganisms found in excrement and other people to be sick”, “do not swallow the water in which you swim”, “avoid having water into your mouth”, “be careful about health rules”, take a shower before and after swimming”, wash your hands 

Assos. Prof. Dr., İnönü University Physical Education and Sports School, Malatya Assist. Prof. Dr., Fırat University Health Science Faculty, Elazığ, Turkey

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with soup after the toilet and changing diapers”(CDC, 2002). As well as following these suggestions, precautions, to keep the pool water constantly clean, should be taken for cleaning. For instance, water of the swimming pools should allow for black-and-white disc (secchi disc) with 15cm. diameter to be seen from outside when it is placed to the deepest point of the swimming pool, and be clear and transparent enough not to contain any residue (Salvato, 1976). Additionally, a person who swims can guess the depth of the pool thanks to this disc. Foots from toilet and flow of the surface water should be prevented to mix into the swimming water pools. Temperature of the swimming pool should be stabilized to 2627 centigrade degree during summer and winter. It should be compulsory for everyone to wash their hands before entering the pool. It has been determined that each person that enter the pool leave 50ml urine and 4mg organic residue to the pool and swallow 50ml water in average (SB, 2001). Swimming pools are commonly built in either public domain or private dwelling area or tourist facility, and during the construction stage of the swimming pool, many cleaning mechanisms should be taken into consideration (Gluer, Hall, Hayes &Davis, 1979). Swimming pools should be monitored in terms of public health in accordance with eliminating bad and wrong practices or preparing even before the construction of the swimming pools to prevent, and with regulations to be made for various solutions to realize this aim. In Turkey, the purpose of Regulations of Swimming Pool Water Quality of Ministry of Environment and Forestry, to protect human health and environment, is to determine the quality of the water used for the purpose of recreation and swimming and to provide prevention of this waters, firstly as microbiological, getting dirty. Within this regulations necessary criteria are determined to be applied the waters to be used for the purpose of swimming and recreational, and decided in a way to cover technical and administrative essentials relating its monitoring, inspection and reporting (YSKY, 2006). Therefore, there should be enough number of personnel responsible for the technical and hygienic terms of pool and pool water, and this personnel should be remain at duty during the open hours of the pool. During the general cleaning at the start of the week, disinfestation should be made to lockers and changing rooms. 1.1. Occurrence of Infection Microbiologic factors caused by the water or the people entering the pool causes different types of infections. Along with eye, skin, ear, throat infections, by swallowing the water enteric infections also occur. If the chemical properties of the water are not suitable and the chemical materials used as a disinfection are in high concentration, the irritation cause by them ruins the natural body barrier and increases the susceptibility against surface infections (Güler&Çobanoğlu, 1994). Some opportunist bacteria accommodate in different areas of swimming complex and cause surface fungal infections and viral gastro enteritis. For example, pseudomonas aeruginosa folliculitis external otitis causes to corneal ulcer on contact lens users; mycobacterium marinaum causes to swimming pool granuloma; and cryptosporidium spp. Causes illnesses followed with diarrhea. This illnesses are even more serious for the people with immune system disorder (Seyfried &Fraser, 1980). In the pools without good and attentive maintenance, chances of the occurance of external 591

auditory canal infection is quite high. Depending on the infection, sometimes severe headache, swelling in external auditory canal, ear discharge, blockage and hearing problems can be observed (www.ihsm.gov.tr). If while the microbiologic or chemical evaluations of swimming pools are being done, the pool is in a sports complex, other areas of the sports complex should be evaluated in terms of microbiology (Leoni, Legagni, Guberti &Masotti, 1999). Reproduction of pseudomonas is closely related to the free remaining chlorine concentration. When the free remaining chlorine concentration drops under 0.5mg/L, within a certain period of time, speed and the seeing ratio of microorganisms increase (Seyfried &Fraser, 1980). Along with providing a significant level of protection and control against recreational water diseases via process of elimination or reducing in number and species of microorganisms like bacteria, virus, parasite which have feature of causing illnesses by using chemical materials, non-continuity of this, not doing pool maintenance well increase the risk of disease infection and in such settings even the microorganisms susceptible to chlorine are able to spread (Ceylan, 2005). No matter how clear the water seem, it may still contain colloid substances which has water-soluble matter that cannot be seen with naked eye. Colloids are almost totally organic matters, and, for bacteria and viruses, they can create protective elements that cover these and power disinfection process. If the chemical properties of the water are not suitable and the chemical materials used as disinfection are in high concentration, the possible irritation they may cause ruins the natural skin barrier of the body and increase the susceptibility against surface infections. The most important factor on the health quality control of swimming pool water is to make, when the pool is used, a sufficient disinfectant concentration continue. Particularly chlorine and bromine, iodine, cyanide salt with chlorine and ultraviolent lambs are being used against disinfection. Chlorination is a method used in disinfection in limited areas like swimming pools. Chlorine kills the microorganisms which cause to diseases in swimming pools and similar limited swimming areas. However, this takes time. When chlorine is applied with an appropriate method, RSH factor disables most of the microorganisms in less than an hour. However, some microorganisms like cryptosporidium can survive even in chlorinated water for days (CDC, 2005). If the pool water is being disinfected with chlorine, after the disinfection 0.4-0.6 ppm residual permanent chlorine should remain. This is the recommended amount for the pools for personal use and with less users. However, permanent water value of pool water in general use is recommended to be 1-1.5 ppm. According to the Turkish Standards, in the pool water, there should be at least 0.6 ppm and at most 1.5 ppm permanent chlorine or equivalent chemical substance (TSE, 2007). Especially in small pools, random chlorination by hand at night without a ratio is the most common application. However, for bigger pools a sub-structure is required to maintain the constant chlorination and necessary conditions. Chlorine in tablet or granule form is more permanent and since it is not affected by the sun rays, it does not lose its waiting activity. But for an ideal chlorination, it is more convenient to install basic mechanisms that adjust the solution amount in a unit of time. Thus, constant chlorination according to the water circulation of the pool can be provided. At first, a set of organic substances turns into chloramine by combining with chlorine. These bound chlorine compounds which is created with substances like ure found in sweat urine compound cause unwanted smells. The chlorine found freely in the water after the 592

bound chlorine is responsible for the main disinfectant effect. Sum of these two gives the total chlorine to be added to the water. On city water chlorination more or less the same mechanism is taken into consideration. Chloramines which are created with 510 times more dosage of normal chlorination are gasified and made fly. This application is the kind of application that is required to be done once a month in pools with less user and once in every 15 days in other types of swimming pools (SB, 2001). In the pumping system which provides water circulation, there are filtration systems that filters suitably to the pumping speed. For the tiny particles, by using soluble organic polymers with high molecular weight, process of collecting particles together (flocculation) should be applied. As it is in alum and some other aluminum compounds, these substances are also solved in water and later cumulated by creating pulps, and these hold the little particles in the water. Thus, these substances become in a size to be held in the filter (SB, 2001). With the regular water samples inspection of single-celled living beings which may cause to diseases and are cylindrical, frizzled, reproduced with mitosis, chlorophyll-free in pool water are required. Upon, with the samples taken from swimming pool, phenomena like general or local development and spread of a microbe that causes sickness in the organism, all of the health conditions of the pool should entirely be revised (Güler&Çobanoğlu, 1994). Bacteriologic analysis of the pool water should be duly made from by taking samples from both ends during the most crowded times of the pool once in a month, and sending the sample to the closest lab. Bacteriologic, chemical and physical properties of the pool water are determined in the publication, numbered 389, “Sample Taking Guidance from Food Substances and Water” of Ministry of Health (SB, 1980). However the properties in the mentioned publication are not sufficient, and new regulations should be made in according with the suggestions of World Health Organization (WHO, 2000). Escherichia coli, in general also known as with the abbreviation E. coli, is one of the beneficial bacteria type that lives in the large bowel of mammals. Since it normally lives in bowel, existence of the E. coli in environmental waters is a sign of pollution of excrement. E. coli is discovered by pediatrician and bacteriologist Theodore Escherich in the excrements of babies and named after him; coli means “from large bowel”. E. coli has been a commonly studied a model organism for the purpose of understanding bacteria biology in general. It can be said that it is the organism about which the most information is known. The number of E. coli bacteria that passes from the human body with excrement is between 100 billion and 10 trillion. The bacteria that creates the excrement are primarily anaerobic bacteria, and selectivee anaerobic E. coli cell numbers are one-thousandth of the other bacteria types. E. coli is among normal bowel flora, and in biological classification, they are among enteric bacteria family which is composed of the bacteria living in the bowels (SB, 1980). In all of the pool which are under good control as disinfection, spread of viral infections will be prevented or minimized. Infections in the respiration tracts occur rather in crowded pools. It is surprising that although these types of infection are sought in water, they are the infections taken by air borne viruses. Two important organisms; cryptosporidium and giardia, are resistant against all kinds of disinfection. In the results of inspecting these organisms under the microscope, it is confirmed that they are rather found in the animals. As mentioned before, these type of organisms are encountered in crowded and open-to-public pools, the pools without good disinfection. No matter how 593

much resistance these microscopic single-celled beings show, upon well-filtration of the swimming pool, it will be possible to eliminate them from the pool water (www.diproltd.com). Additionally, number of the pool users and shower-toilet number should be scaled. Therefore, additions and interventions to be made to swimming pools later on should be considered well, and expert architect and engineers should be consulted. Interventions to be made may ruin the standard and cause significant hazards (Güler &Çobanoğlu, 1994). 1.2. Skin and eye conditions There are two reasons of eye and face irritation. These are unsuitable pH and chloramines. The most suitable pH is around 7.5 for human eye. Therefore, Ph below 7.2 and above 8.0 irritates human eye. When bound chlorine level exceeds 0.2 ppm, chloramine problem can be observed. Although many people mistakenly show high chlorine level as a reason for eye condition, the main reason of eye irritation is the insufficient chlorine level or the existence of chloramine (www.promak.com). Therefore after the chlorination application, the pool should not be used before ensuring the chlorine value in the pool water is on desired level since chlorine value above 3 ppm may cause an irritating effect on the skin. Sliding of the pH value of the swimming pool water to the acidic side is on an advanced level corrosiveness. Mineral acids like sulfuric acid, nitrite acid, hypochlorite acid and soda, ammonia, hypochlorite (bleach) are from caustic alkali. Water with over alkaline feature cause deposition, reduce in disinfectant effect and irritation of skin and eye. Depending on the quality of the used chlorine substance, alkaline effect in the pool water increases. For example, in the pools where sodium hypochlorite is used, pool water will slide to the alkaline side since hydroxide comes to the light. The setting should be acidified (for a scale of liquid chlorine, a half scale is added). Hypochlorite acid carries disinfectant properties. However, with the effect of sun light, a significant decrease in disinfectant occurs. When the pH value is around 7.2-7.6, complaints about burning, reddening and deliquescence related to the eye are seen in the most minimum level and more trustable bacteriological results are obtained (Güler, 1993). 1.3. Mossing and Cloudy Water In general one of the most complaint problems in the pools is cloudy water and the other one is mossing. Moss occurs in all natural waters and lives. Mosses occurred or being occurred in swimming pools are one of the reason that causes swimming pool water to be seen cloudy. Since it also makes the surroundings of the pool slippery at the same time, it poses a danger. Since swimming pool water is on a certain temperature, unless treated appropriately, it will create an ideal settings for mosses and bacteria to develop. Although mosses are not directly harmful for swimmers, they form the basis for the feeding for bacteria and mushrooms. Upon the correct application of disinfection system, moss reproduction can be taken under control. Additionally, being ideal for chlorine and pH equilibrium when moss killer and precipitator are used increases the efficiency of the water. In another meaning, by using moss preventer or moss killer as additionally chemicals, by creating a curtain between moss creation and wall and water, moss is prevented from griping on the pool walls and grow (www.diproltd). When necessary, applications which will provide precipitation should be referred to. Accumulations like falling hair, skin, and dust should be taken and cleaned easily. 594

Moss, which can be hard to detect and remove, by reproducing rapidly, can exist with millions of moss cell that be visible with eye. Most common three colors of mosses are green, black and brown. The best way to get rid of the moss is to constantly maintain the free chlorine level of minimum 1.0 ppm and use moss preventer chemicals according to the instructions (www.promak.com.tr). Doing deep cleaning with vacuum cleaner and cleaning pool walls with brush every day in the pools have no effect in preventing mossing. Reasons of cloudy water are insufficient circulation/ filtration and insufficient and irregular chemical substance use. When flash chlorination is applied to the pool, cloudiness can be observed for a while. Upon this, the first thing to do is to check filtration system. If the filter is blocked, and circulation is weakened, backwashing should be applied and, if necessary, filter should be cleaned well by opening its cover and with the help of backwash water, and, if still needed, filter sand should be renewed. After filter system is evaluated well, pH, alkalinity, calcium hardness and TDS (Total Dissolved Solids) levels should be checked. (www.promak.com). Coloring pool water may be the cause unseen drowning. Floor of the swimming pool should be seen (Güler&Çobanoğlu, 1994). Colorful water causes an ugly view and causes pool surfaces to be dirty. Two main reasons of colorful pool water are; oxidizing metals and moss. Cloudy green pool water is usually because of moss. Green, red, brown and black colors are the situations cause by the dissolved metals. Green color occurrence is because of copper or iron, red color is because of iron and magnesium, black color is usually because of manganese. These kinds of colorful water situation are usually encountered when the pool is first filled or after flash disinfection (www.promak.com). 1.4. Calcification and Cortex Occurrence Calcium hardness and precipitation of calcification on pool cover, wall, installation tubes, filter and heaters are widely encountered and a problem that damages mechanic parts of the pool. Reasons of precipitation of calcification are; mineral occurrence arising from pool water’s being hard, high pH and cortex occurrence of cumulating of dissolved minerals. To solve these kinds of problems, use of water with low hardness, adjusting pH to 7.2-7.6 and balancing total alkalinity are preferred. White deposits on the surface of pool indicate that one or some of the water balancing factors are on a critically high level. Cortex deposits not only causes surface pollution but also causes grinding in filter and tubes. To prevent non-precipitating cortex occurrence and the blockage in tube lines, water is carried over anthracite filters. Thus, the possible blockage in tube lines are prevented. This situations weakens the circulation/ filtration. Upon realizing cortex occurrence pH, calcium hardness and total alkalinity measurement should be done and immediately adjusted. Since it is hard to reduce calcium hardness, pH and alkalinity should primarily be reduced. If the cause of the cortex is high calcium hardness or TDS, by empting a part of the pool, soft and clear water should be added (www.promak.com). Special mixtures that give dull color to the water and cause calcification-cortex are manufactured chemically and used in pool water maintenance. 2. HYGIENIC PROCESSES IN SWIMMING POOLS Mechanics installation of the swimming pools are composed of “pool circulation pumps”, “mechanics equipment”, pool water sand filters”, level control devices”, disinfection systems” and “pool water heating systems”. This installation is of 595

importance in terms of dosage of the chemicals used to make the pool water to constantly have drinking water properties, and the prevention of causing health problems of general or local development and spread of a microbe that causes sicknesses on pool users by consistently checking the properties (UHE, 1999). 2.1. Preparation of the pool water One of the most important processes in a swimming pool is the preparation of the pool water. For this; physical processes like “filtration”, “backwashing”, “pool deep cleaning”, “rarefication with clean water addition”; chemical processes like “adjusting pH value”, “precipitation”, “disinfection-oxidation”, “moss prevention”; daily maintenance processes like “measuring free chlorine, bound chlorine, pH values with test kits at least 1-2 times every day”, “adding necessary chemicals, then re-measuring with test kit”, “using moss preventer 1-2 times a week”, “cleaning leaves, insects etc.”, maintenance process, weekly or whenever needed, like “if the pool is filtered, cleaning of filter baskets once a week; if flooding, cleaning of flooding grates”, “ cleaning of walls and stairs with brush”, “removal stuck mosses”, “adding precipitator through the 8-10 hours of chlorine use”, by running pumping 3-4 hours providing circulation and homogeneous distribution”, “resting the pool water for 8-10 hours by stopping pumps”, backwashing 1-2 times a week (by checking filter pressure display)”, “adding clean water and moss preventer to the balancing storage”, “flash chlorination upon rain or seeing moss occurrence” should be done (TSE, 2007). If we were to sort these processes again, disinfestation should be made at the end of the day, after chemical use the swimming pool should be rested for 4 hours for residue and dirt to sink after filtering, and should be swept, cleaned before the operation of the swimming pool in the morning, and in each time pool water should be renewed by 10%. At maximum once in two weeks, filters should be cleaned with normal wash following backwashing. The dirt and residues gathered in the filter should be thrown away after sweeping. In the circulation system of all of the swimming pools should have equipment relating to the reducing in number, species or eliminating of microorganisms like bacteria, virus, and parasite in the water which have the capability of sickening by using chemicals via at least a pump or pumps, filter and filters. In pools, the whole water in the boat should be filtered from a filtration system every 6 hours with a special mechanism, with a device that provide water circulation (Salvato, 1976) and in small pools with less users, it is enough for pool water to make a full circulation in every 8-12 hours. In large type pools, type of the water circulation is important. Water should be filled with the shortest way. For example, in rectangular pools, water’s passing from the channels on that side and pouring into the slots on the opposite side causes water to get dirty (Vaizoğlu &Tekbaş, 2003). Water preparation technique should cover swimming pool water preparation mechanism and every stage of the measurements and methods that will meet the desired preparation purpose to work along with the related systems (TSE, 2007). Pelletizing helps the particles in the water before the filtration, especially before sand filtration, to be pelletized. In some cases, it can be constantly used according to the structure of the filter bed and particles size of the pellets. Duty of the filtration is to keeping particles away from the water by passing them from an appropriate filter setting. An increasing resistance occurs with the filter cleaning. By cleaning with suitable time periods, it should be cleansed from dirt. (Erkoç, 1997). 596

pH value of the water has an important effect on disinfection. Chemical quality of the water should always be in alkaline state; between 7.2-7.6 pH. Bacteria, mosses and algae can be killed by adding disinfection and oxidation substance, primarily chlorine and chlorine components, to the water. Facility conditions which provide the disinfection safety is virtually a determinant in terms of chemical substance use amount. It is an absolute obligation to be used in every condition. Pool water should be selfdisinfectant. The dirt that can be held by the filters should be eliminated by the oxidizer disinfectants. Organic and oxidizable substances which cannot be kept away with the filtration in the water, are eliminated with the oxidizer substances like ozone or chlorine. Request of heating the water is usually a matter for the indoor pools. In outdoor pools this request is only to extend the swimming seasons for a few months. Heating is provided with a non-corrosive and controlled heat exchanger to be placed in the circulation system. To reduce the effect of dissolved substances and salts that exceed in the water certain amount of water should be added as a precaution. Except for water decrease as a result of backwashing and other connected losses, when the water amount, which is necessity for water rarefication, is not met, water is added to the system. The need is also determined by the water parameters not corrected in the pool. On the advanced cases of the breakdown of parameters, all of the water may be required to be renewed. Additionally, the water in the pools should be renewed completely once a year. Removal of the precipitated substance in the pool floor cannot be sufficiently provided with normal circulation flow. For this, suitable pool floor cleaning devices should be used. Types which are directly connected to the pump sucking (vacuum) line or self-sucking ones can be used. The pool floor should always be clean. In indoor pools at least once a week, and in outdoor pools in every other day deep cleaning should be done (Erkoç, 1997; TSE 2007) 2.2. Water preparation equipment For water preparation and disinfection, the following chemical substances should be present at the pool in right doses. Disinfection substances which are not defined in this standard and other auxiliary materials, depending on the active substance type and amount in the concentration they created, if they are not posing risk and danger for the swimmers and personnel, and do not prevent water preparation and disinfection, and not making any opposite effect with the material in the pool, they can be used. Within the scope of correct methods for disinfection; - Chlorine gas - Sodium hypochlorite (liquid) - Calcium hypochlorite (as granule or tablet) Ca (CIO)2 solid with at least 65% purity and precipitation with 5-10% concentration - Sodium hypochlorite obtained with the NaCl electrolyze in the place of use - Chlorine gas obtained with NaCI electrolysis in place of use For pelletising and water preparation; - Aluminum sulfate - Aluminum Chloride-Hexahydrate - Sodium aluminate - Aluminumhydroxy Chloridesulfate 597

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Iron (III)-chloride-hexahydrate Ironchloridesulfate Iron (III)- sulfate Ozone Active coal powder Kieselguhr

And similar substances are dosed. To adjust pH value and acidic capacity substances like - Caustic Soda (sodium hydroxide) - Sodium Carbonate (soda) - Sodium bicarbonate - Sodium bisulfate - Hydrochloric acid - Sulfuric acid - Carbondioxyde Should be duly used (TSE, 2007). REFERENCES Castor, M.L.& Beach, M.J. (2004). Reducing illness transmission from disinfected recreational water venues: swimming, diarrhea, and the emergence of a new public health concern. The Pediatric Infectious Disease Journal. 23, 866-870. CDC (2003). Surveillance Data from Swimming Pool Inspections: Selected States and Counties. United States: May-September. MMWR 52(22), 513-516. Ceylan, S. (2005). Sağlıklı ve güvenli yüzme. TSK Koruyucu Hekimlik Bülteni. 4(4),209221. Erkoç, E. (1997). Özel Yüzme Havuzları İçin Su Hazırlanması Hakkında Talimat. Talimat No: 2. Ertam, İ.; Ergün, M.; Aytimur, D.; Babür, Y. (2003). Yüzme Sporu Yapanlarda Deri Bulgularının Havuza Devam Süresi İle İlişkisi. 37 (4), 274-277. Gluer, J.; Hall, B.; Hayes, J.; Davis, G. (1979).Coliform status of domestic swimming pools. Med J Aust. 1(5), 154-155. Güler, Ç. (1993). Plaj ve yüzme havuzları. Turist sağlığı ve hekimliği bülteni. Kasım 4,38. Güler, Ç. & Çobanoğlu, Z. (1994). Spor ve Rekreasyon (Mesire) Çevresi. Çevre Sağlığı Temel Kaynak Dizisi No.34. TC Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü, ISBN 975-7572-35-7, Birinci Baskı. Ay doğdu Ofset :Ankara Leoni, E.; Legagni, P.; Guberti, E.; Masotti, A. (1999). Risk of infection associated with microbiological quality of public swimming pools in Bologna, Italy. Public Health 113(5), 227-232. SB (2001). Turizm sağlığı eğitimi. TC Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü Yayını. 88-91, Ankara. SB (1980). Gıda maddeleri ve sulardan numune alma rehberi. TC Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü Yayını No:389. Ankara. Salvato, J.A. (1976). Guide to Sanitation in Tourist Establishments. World Health Organization:Geneva. Seyfried, P.L.& Fraser, D.J. (1980). Persistence of Pseudomonas aeroginosa in chlorinated swimming pools. Can J Microbiol. Mar 26 (3), 350-355. TSE (2007). Yüzme Havuzları-Suyun hazırlanması, teknik yapım, kontrol, bakım ve işletmesi için-genel kurallar. İkinci baskı, TSE 11899 Nisan. 598

URL: CDC (2005). http://www.cdc.gov/healthyswimming/ URL: http://www.diproltd.com/faydali/ yh_dezenfeksiyonu.html 69 URL: http://izhsl.ihsm.gov.tr/dosya/havuzsuyuhst.pdf URL: http://www.promak.com.tr/tr/ havuz_suyu_sartland.html Uygulamalı Havuz Enstitüsü (1999). Talimat no:1, Yüzme ve yıkanma suyunun hazırlanması ve dezenfeksiyonu, genel kullanımlı havuzlar için UHE Talimatı. İstanbul, 2-18. URL: http://www.uhe.org.tr/yayinlar/uhe-1_1302165552.pdf WHO (2000). Guidelines for safe recreational-water environments. August. Vaizoğlu, S.A. Tekbaş, Ö.F, (2003). Yaz Aylarında Önemi Artan Bir Sağlık Riski:Yüzme Havuzları. TSK Koruyucu Bülteni. 2(2), 21-26. Yüzme Suyu Kalitesi Yönetmeliği (YSKY). 76/160/AB), 09.01.2006 Tarih ve 26048 Sayılı Resmi Gazete.

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Chapter 56 Gender Perspective on Leadership Aslı ER KORUCU, Füsun TERZİOĞLU INTRODUCTION In social aspect, gender is role expectations of society from women and men (Şahin & Terzioğlu, 2009). Effect of social gender role starts immeadiately after birth with naming the baby and continues with determining colors of baby clothes (Çevik, 2011). In this period, growing and maturing human learns how to behave according to his gender based on society’s value judgements and starts to organize his life like that. In addition to society, also factors such as religion, customs and traditions, culture, family effect social gender role. Roles and responsibilities which are suited to individuals based on their genders, hence social gender role, turns into gender apartheid when rights and freedoms of individuals are restricted based on their social gender role. Role differentiation of women and men actually started with primitive societies and continued until today and this role differentiation, as in numerous fields, can turn into gender based applications for work-sharing selection (Şahin & Terzioğlu, 2009). Directing for professions starts in childhood, social conditioning route women to a certain type of professions (Acar et al., 1999). At present, Although remodelling of gender based work-sharing in line with socioeconomic changes and women figuring in work life more, male dominant systems still continue to exist and therefore women in general, work at mid-level positions and can’t reach for higher positions.(Çevik, 2011; Şahin & Terzioğlu, 2009). It is not right to attribute impossibility of rising and not having leading positions and falling behind men in work life only to male dominant systems. Social gender apartheid, that women undergo because of their gender and wife and mother roles which she can’t get rid of wherever they go, job alternatives may remain limited. In order for women to say “i am here too” in society, leadership skills should be improved. LEADERSHIP CONCEPT The word leader was first used in 14th century and used as “leaden” meaning “make way” and “lead way”, leadership concept has come forward in 1800’s. This word was transformed into “liderlik” in Turkish, even though words like “generalship” and “directing” were suggested, mostly “leadership” is preferred (Özer, 2007). In 20th century leadership was one of the main topics in administration field where intense scentific studies were done. In this century, both theoreticians and practitioners from different fields have showed vigorous efforts to analyze leadership. As a result, administration literature gained approximately more than 5.000 studies and more than 350 definitions (Bakan & Büyükbeşe, 2010; Bayram, 2013). According to the quotes 

MSc., Ankara University Faculty of Health Science Department of Midwifery, Ankara. Prof. Dr., Istinye University Dean of Faculty of Health Science, Director of Nursing Services MLPCare, Topkapı, Istanbul, Turkey

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that Bayram narrates (2013) some of these definitions are summarized as in Table 1. (Bayram, 2013). Table 1: Definitions of Leadership 1902 Leadership is being able to be in the center of social movements. C.H. Cooley Leadership is being able to exhibit all group’s power in its own efforts. F.W. 1911 Blackmar Leadership is the ability to make people achieve with most powerful 1921 collaboration and least conflict. E.L. Munson 1930 Leadership is art of convincing people to do what they want. C.M. Bundel Leadership is art of impressing people mentally, physically and emotionally. 1942 N.Copeland Leadership is period of influencing group to form objectives and realize them. 1950 R.M.Stogdil 1968 Leadership is being able to make decisions using authority. R.Dubin Leadership is creating surplus influence on group members to motivate them 1978 perform beyond providing a mechanical conformance for routine orientations of the organization. D.Katz & R.L.Kahn 1986 Leadership is a form of power used in affecting others’ activities. R.R.Krausz Leadership is being able to attribute different meanings to behaviors in 1994 different circumstances. R.Heifetz Leadership is period of influencing people to make effort for reaching their 1997 goals with all their potentials and willingnesses. K.Gallagher When suggested definitions of leadership concept are viewed and tried to form a synthesis, this concept may be defined as total of information and ability required in order to roundup a group of people around particular objectives and activate them to perform these objectives (Durukan, 2013). In perspective of this general definition, it is possible to see following qualities of the leader; 1. Leader is a humane person. 2. Leader has the ability to manage relations between people. 3. Leader is the person who doesn’t lose his confidence and faith in himself. 4. Leader is devoted to his job. 5. Leader, as a visionary, determines the direction. 6. Leader values improvement of democratic culture and participative management. 7. Leader is the actor of a change. 8. Leader feels glad on account of his employee’s success. 9. Leader is the owner of a message. 10. Leader is the person who creates excitement and commitment. 11. Leader does not only know to manage people, at the same time, knows to manage information (İnce et al., 2004). Writers named as Cox and Hoover (2003) tells that “ after viewing great leaders for years, summarized their most powerful qualities as ten high qualities of an efficient leader”. Indispensable honesty, high energy, good prioritizing, courage, undeterred sedulity, innovativeness and creativeness, being target-driven, genuine and catching enthusiasm, being reasonable, desire for helping others to learn and achieve are the features of an efficient leader.

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LEADERSHIP AND SOCIAL GENDER Gender is genetic, physiological and biological properties of an individual which is shown as woman or man.(Pınar et al., 2008; Vefikuluçay et al., 2007). Gender concept, divides all people in the world into two numerically equal groups. Humans are born as woman or man but while they are stepping toward womanhood or manhood, they learn their gender roles. But in terms of social structure, power, roles and responsibilities women are in a different position than men (Kahraman, 2010; Taşçı & Saruhan 2007). The culture of society which individual lives in; presents expectations regarding how a woman and man should behave, how they should think and how they should act, hence defines the features that structures woman and men socially (Akın & Demirel, 2003; Üner, 2008; Powell & Greenkouse, 2010). In another words, humans are born as female or male, but while they are being raised, within the frame of gender-specific roles that society expects, they learn to be either girl or boy (Terzioğlu & Taşkın, 2008); Girls and boys get roles appropriate to their genders and develops social gender identity with the effect of social environment that family enters into and received education. Thus, for women, doings such as housework and child care come to the fore, for men business roles are becoming more important than family roles (Acar et al., 1999). However, today social gender roles are not rigid as it was before. Within this context, for efficient leadership, aside from traditional roles, some roles and qualities of other gender are expected from women and men which are in leadership position. Leadership is a dynamic feature not constant and there are more than one factors that effects it. Different circumstances require different leadership approaches. In some instances leader should show more woman like qualities, for example should be sensitive, democratic and sometimes show manly qualities, for example should be work oriented and domineering. As a result, having only many qualities is not enough for leadership. Even though necessary leadership qualities are not depending on only one gender’s qualities, it is thought that in particular situations men and in some other particular situations women are more efficient. Effect of Social Gender on Gender Differences In all societies, inborn biological differences are commentated and valued as cultural. Thus, social expectations are developed regarding which behaviour and activities women and men may be able to do, which rights they have, who has the power, how much power they have or how much power they should have. Even though these expectations change from society to society and partially from one class of society to another class of society, there are common grounds in its substance. This substance is existence of differences and inequalities hence social gender based asymmetry (Ecevit, 2003). Social gender roles shapes both women’s and men’s lives and at the end this diversity carries more meaning than only being different (Terzioğlu & Taşkın, 2008). Today, as in whole world, there are certain role forms, which society defines for women, in Turkey (Pınar et al., 2008). Stereotypes attributed to women and men generally suggests universal features of women as; gentle, sensitive, warm, soulful, passive, dependent, submissive, shy, worried, modest, successful in verbal communication and weak, suggests opposite for men; tough, insensitive, cold, strict, active, independent, aggressive, ambitious, successful, powerful (Çevik, 2011; Şen, 2011; Turan et al., 2011; Yatağan, 2005). Because of these stereotypes attributed to men and women and social gender apartheid, women can’t benefit from educational and 602

economic resources equally, although they effect big part of social and economic development, they can’t get the intended social status (Pınar et al., 2008). In today’s conditions, even though it seems like stereotypes related to mentioned gender roles has changed, this change is happening very slowly and shows difference with respect to the size of centre of population. Also, even though it seems differences between women and men diminished in big cities, roles that are expected from women in towns and villages hasn’t changed. Child care and housework are still seen as a woman’s job to maintain, idea of woman working at a job is not supported. Besides, women are still expected to be obedient, women being self confident and defending their rights are not welcome (Yatağan, 2005). Cultural factors which effect women and men showing leadership behaviours, biological differences between woman and man brains next to social gender roles, evolutionary theories and hormonal variables may be effecting this behaviour pattern. Girls start paying attention to face and making eye contact before boys do. Baby girls like to look at face photos, baby boys like to look at object photos more. Boys run, jump, wrestle, make airplane impression; girls touch, talk, kiss,hug. Boys are interested in how toys work, competitive; girls are interested in establishing relationships. When boys get together, they tend to setup a hierarchical order, hence someone is the leader, others are aligned in respect to their powers. In girls, this behaviour is not significant (Eşel, 2005). The reason of this difference seen in girls and boys is related with the brain structure which is unisex until the eight week of fetal life but after that male fetus is attacked by testesterone. This testesterone flood, kills some of the cells in communication centre and turns unisex brain to male brain. Within same period, an increase in number of aggression and sexuality cells is observed. If this flood does not happen, female brain continues its growth without changing. At the end, as girl grows with a more developed communication center than boys, she becomes more talkative and communicates better with people around. Magnetic Resonance (MR) surveys show another difference between female and male brain; auditory centre and language centre of women has 11% more neurons than men. Furthermore, sentiment and memory centre hippocampus which processes language and observes other people’s feelings as brain circuits, is larger in women. In comparison to women, men use 2,5 times larger space for brain functions related to sexual orientation, aggression and actions. Amigdala is the center of most primitive area in the brain and it is one of the sectors that controls fear and violence tendencies of the brain. Fort his reason, while women do everything to avoid fighting, some men can suddenly come to blows without a reason (Brizendine, 2012). These particular mentioned features of girls and boys actually give an opinion about which behaviour pattern will be dominant in women and men in adulthood. As seen, girls value positive communication and conformity, whereas boys value competitive, aggressive and hierarchical order. Competitiveness and domination requires manly features such as aggression and these features are related with testesterone. Even in a same type competition, testesterone level of men significantly rises in opposition to women, it has been observed that their hormone level decreased (Kivlighan et al., 2005). Decrease of testesterone hormone, which triggers competition and struggle feelings, in women during competition when it is supposed to increase, shows as if women unconsciously avoid competition and prefer to come to an agreement in every environment. Women and men kinds showing different features and whether these different 603

features create differences in leadership status or not, has been an object of curiosity. Various studies have been done because of the thought that men are more suitable for administrator and leader position and the opinion of men being a more ideal leader and administrator started to give place to opinion of features of genders have different effects on leadership styles. Sexual roles are behaviors and roles that were formerly defined by society. Today the reason of men being seen more suitable for leadership is thought to be derived from sexual roles being different and work-sharing dependent on sexual role. WOMAN AND LEADERSHIP Historically in almost any societies, women were not represented in power, leadership and business environments which are men’s world; professionalism, authority and leadership are the features which have always been used to define men (Terzioğlu & Taşkın, 2008). A gender-based social dissolution is seen in business life, in Turkey. Girls and boys whose game and toys of differ in childhood, jobs they work when they grow up diverge (Ergün, 2013). According to yearly employment data; even though number of working women increase day by day, it is seen that women prefer jobs which they may continue to carry on their traditional roles and won’t disrupt their family responsibilities (Kuzgun & Sevim, 2004; Ergin, 2013). Women which have to balance between home life and work life due to their social role, had to incline towards feminine professions such as teaching, nursing care, secretariat that are appraised as a extension of motherhood and wife roles and become unable to compete with men, which have the same education, information, experience and skills as themself, in senior management positions in developed countries. Roles, which are attributed to women due to social gender features, limit them to show leadership behaviour in work life. Namely; when woman undertakes leadership role, the concern that is felt if their family life will be damaged, saying “there is no way i will be promoted” and not going all lengths for a job and lack of confidence because of this approach, seeing her kind, women, as first rival in work life and tendency not to compete with men, yet men see women as their rivals and compete against them. The approach of men’s world consciously limiting business life for women, the belief which was developed by men that somehow, at some point in her career she will prefer to spend more time with her family, being less skilled than men by nature, unlikely to succeed, being defined by prejudice as those who have no leadership qualities, these factors effect women showing leadership qualities (Terzioğlu & Taşkın, 2008). Apart from attributed roles in work life due to social gender features, another obstacle women come across which limits leadership behaviors of them is “glass ceiling”. Glass Ceiling was defined in 1986 by Carol Hymowitz and Timothy Schellhardt in Wall Street Journal as the invisible and unpassable barrier between administratorship and women that restrain women reaching high levels in spite of their success in business world (Başak, 2009; Longo & Clifford, 2008; Örücü et al., 2007). Glass Ceiling obstacles are not clearly seen, at the same time they are unpassable obstacles with being between women and senior management and hindering their progress regardless of their success and suitability (Aksu et al., 2013). Woman is able to set a career goal for herself in work life, but the top job they target is arbitrarily closed because she is a “woman”. These stated obstacles may hinder leadership behaviours of women; hindering their vertical activity in hierarchy of prestige, economic and political 604

power, appearing as invisible barriers in front of women. Advantages of Women for Leadership Directors should use their leadership skills in their organization or group in the best way in order to be successful. women may be able to search for success by using their own leadership features and aspects in management. These features of women directors may be exemplified as supporting employees, building effective communication, encouraging, establishing warm relationships and socializing work environment (Gökalp, 2008). Nowadays, Another factor that effects leadership is women joining workforce by bringing a business model based on feelings mostly (Uzun, 2005). Important part of leadership features of women which are admired, is based on their social roles. One of the most important features of management advantages of women is ensuring effective communication with employees. Showing interest in employees and their concerns at workplace provides women directors opportunity to be a better leader compared to men. In the long term, men give precedence to earning income, being effective in decisions and developing organization to be a successful director, whereas women give precedence and importance to working with subordinates whom they can communicate easily in their business and organization environment and promotion opportunities. Social, cultural and technological changes that are developing today and the ones already happened up today has also changed management and leadership intellection. This change, along with itself, yielded facts such as: a merciless competition environment and productivity race. In a such environment, women can play important roles in constituting a world order where social and humane value judgements are regarded. Furthermore, women can bring in their own aspects to world in respect to establishing peace, reducing poverty, valuing humane feelings in work life. In this context, the fact that world needs women directors should not be overlooked. Women staying away from rulership and power for years and not loosing their said features may yield positive results for both women and world order. In execution process of usage of rulership and power until today, pressuring or inertization features were at the forefront, politics, corporations and decision making mechanisms were vitiated with rulership games. Woman who stayed away from this rulership execution can provide to look to future more hopeful. This and suchlike attitudes of mind defend the necessity of change in intellection of management which adopts manly features. According to this mentality, in this order, the cultures of organizations needs to be changed rather than the features of women directors (Gökalp, 2008; Kutanis, 2006). Women are achieving success in business life with personal skills, personal features and value judgements they own. Women directors are effective in management using their female-specific leadership features. Leadership Features of Woman Women carried some features which were originated from their sexual roles, to management field. These features are leadership features which distinguish women from men. These are; (Gökalp, 2008; Kutanis, 2006; Uzun, 2005) Compassion For women working as director, this feature provides showing interest in employees as an individual and group. Woman leader being compassionate doesn’t 605

necessarily mean she should also be soft. After all, for women who maintain family order at home, while giving close attention to family members it is not hard to associate compassion and management. Today, management has entered into a human-centered restructuring. Woman’s compassion feature makes her important in this kind management mentality and can create her various opportunuties. Being understanding, believing to produce together, protecting each other and not exploiting, behaving people affectionate and respectful are actually management features which all leaders should adopt. Sentimentalism For years, leadership has been an element of power in the eyes of people. In fact today, feelings of people, their personalities, their inner worlds and reflection of them to organization became more important. Performances of people at work is undoubtedly related with their inner peace. Woman leaders are more sentimental than man equals. This features keep them away from behaviours such as oppressing their subordinates, being on a power trip or establishing dominance on subordinates. Even if motivations of people are high, their performances may be low in their sentimental periods. Moreover, employees, other people in organization may be in difficulties because of conditions of employment and many factors such like. Sentimentality of woman directors may be helpful in such cases with the interest and positive behaviours they show to employees. In the present methods, communicating openly and empathetical is preferable to classic organization management communication types. Woman empathizing with other’s feelings can be used as an advantage in such circumstances. In self-reviews of Women directors, on the subject of sentimality they asserted that sentimentality yields positive results and provides a effective motivation and from this aspect they are more advantageous compared to men. According to women, sentimentality is not a disadvantage, it is a beneficial feature. Drawing from this feature, relationships with subordinates may be tightened. Also logical decisions may occasionally be enhanced with this feature being supported. Being a Good Listener In order to be a efficient leader, make progress and earn attention and trust of employees; should listen to them, understand them and be sensitive with them. Most important factors of employee-management relations are good listening and being precise while telling something. This way, effective communication is established with employees. Today, valuing employees’ opinions is one one of the key elements of management. It is known that, women directors have advantages in this regard. Because listening skill of women are more developed compared to men. Women have always found time to listen and thus produced solutions to problems more easily. Women leaders bringing their listening skills which they have used in their homes for many years, to work life and thus the possibility of overcoming communication obstacles cannot be ignored. Rather than disrupt communication with square judgements, to find out people’s ideas, to understand and listen, it is an important advantage of women leaders. Sacrifice Women leaders take on their traditional roles and duties to maintain family order and at the same time they try to exhibit superior performance to be successful in 606

business life. Being superwoman with the desire to be perfect in both fields, leads to increased life stress. Today, women are leaving this abrasive thought called superwoman sydrome. Women are now applying and teaching supply systems, prioritizing and efficient use of time. Rather than chasing perfection, they are now searching balance in their lives. Despite of these changes, Woman’s social role based sacrifice feature, making her more hard working and more understanding, is an advantage for her. Intuition Power Today, it is a well accepted thought that intuitions of women are more powerful than men. Intuition is power of acquiring information which cannot be acquired by doing experiments. It is an independent information source which people forms with their instincts and intuitions. These features of women being powerful stems from embracing their own feelings and tendency of living introvert. The key of successful decision making is basing decisions on instinct without excluding logical approaches. If women associate scientific informations with the information they acquire with their intense intuition power, they gain big advantage. Because the united form of mind, logic, scientific information with intuitions, understanding ability and sensibility leads the leader to success. When women join their intuitional powers with their organizational skills, they may be able to bring their leadership features to the fore in quick decision making and taking initiative. Furthermore, women may gain an important quality in senior management by adding their ability to trust their intuitions on their experiences. When data is limited for reasoning, intuition is located in front of the logic. While making decisions which will effect the organization, on top of logic, intuition should be regarded. In our rapidly changing age, in order to be successful, leading has become important rather than following change. When woman supports her intuition power with information, she will take the opportunity to lead the future. Sense of Motherhood One of the biggest advantages of women directors is having the sense of motherhood. With the affection stemming from sense of motherhood, women directors who are approaching incidents gently and sympathetic, have brought in humane feelings to management. Also, in the environment where women directors are present, communication between male directors may be gentler. In Turkey, women exhibit more tolerant, gentle, democratic and cooperation based approach in their relations with individuals around them. As for men, they are less tolerant, gentle and democratic compared to women. Men adopted masculine management method, women adopted feminine management method. Generally women with their features different than men, gained a place in management. If women use these told advantages effectively, they will increase their success chances undoubtedly. Effect of Social Gender Perpective on Woman’s Leadership Behaviour In patriarch social order, the status of woman who has stayed in the background all the time in social living, hasn’t been different in work life; women were seen as “substitute labor force” in business life. Regardless of the fact that women constitutes half of the population in Turkey and in the world, they were not represented in economic activities and work life at the same rate as men. As well as the management 607

of companies and the management of the country, as especially climbed up to the high levels, number of women remained extremely limited alongside men (Uzun, 2005). There are a lot of factors which caused women to stay behind of men for leadership positions. Obstacles that women come across in work life; unable to escape from social gender roles, the glass ceiling which they are subjected to, sexual stereotypes and perception of woman in business life. As personal factors, motherhood and wife roles adopted by women cause indetermination of their time and limits. Therefore, from time to time, women can’t bear the responsibilities of a rise in career and leave the field to men, this situation is supported by spouses and families (Barutçugil, 2002). Women getting equal opportunities in career potentialities change according to organization’s culture. Although in some organizations conditions are equal, in some organizations they have to make more effort in order to make themselves accepted among (Rosener, 2006). Male-oriented organization cultures pose an important obstacle to women in career path. The rise of women in organization is said to be related with practices which are people oriented in organization culture, based on performance review, power distance low and based on gender equality (Ergeneli, 2004). Another factor that causes Glass Ceiling is social belief and perceptions. As per gender based socialization, society expects people to take on different roles as of their gender. As stereotypes about women hinder women’s work life, preventing formation of role models of woman in director position, they also hinder the idea that woman are suitable for these roles (Deemer, 2006). These prejudices about women are that they are sentimental, superstitious and meek-timid. For men, as opposite of this, logical, audacious, entrepreneur independent (Uzun, 2005). These believed prejudices may be blocking women’s rise for leadership positions.Another factor women come across because of their gender; most employers generally see women as temporary workers, because they think women concentrate less on work due to potential pregnancy, motherhood role, housework and for this reason it is difficult for them to get promotion, especially they are not be promoted to senior management positions. Woman are expected to own social roles first as mother and wife, professional success and career is of secondary importance (Gürol and Marşap, 2007). NURSING: SEEN AS A FEMALE PROFESSION AND LEADERSHIP Today as in all organizations, health services are in change and development too. Hospitals, which are the most important subsystem of health care system, are deemed to be one of the most difficult organizations to manage and the most complex due to complex technology and dense human relations. Nurses constitute the most important personnel group of health service sector that employs people from various occupational groups. (Vatan, 2009; Sullivan et al., 2001).Nurses that can work individually parallel to developments in technology and medicine field and in team with other occupational groups has acknowledged the importance of; giving basic health care in every environment, leading reforms in education-service field, as self-reliant and qualified practitioners directing occupational developments and developing leadership information and skills in order to fit into changes (Terzioğlu & Taşkın, 2008). Problems such as quality and accreditation practices in health services, health transformation program, performance-based salary system, ever-growing and changing legislative regulations, developments in medicine and technology regarding patient, disease and 608

health, developing creative, productive and effective methods instead of traditional healthcare and treatment, difficulties or resource constraints in covering healthcare expenses, increasing population and number of aged individuals, nurse shortage in terms of qualification and numerically, developments and fast changes as sanctions of international and national health policies, low satisfaction level of nursing personnel, exhaustion and mobbing have increased the need of nursing for powerful and equipped leader nurses, which provide well being of patient and patient’s relative and prevent unjustness, and proved nurses the importance of developing leadership skills (Öztürk et al., 2012). In addition to these, in international organizations it has been emphasized that, nurses should develop their leadership skills in order to participate in health policies and take place in decision mechanisms of health system, appointment of nurses to work at top-level leadership and executive teams should be encouraged (Duygulu & Kublay, 2008; Erkan & Abaan, 2006; Öztürk et al., 2012). Leadership is an inevitable feature that nurses have to use in all their roles. In its historical process, nursing couldn’t develop effective leaders in consequences of being a female profession, abiding by authority and the lack of risk taking behaviour (Vural, 1997). As Terzioğlu and Taşkın (2008) quoted; both internal and external factors have effect on nurses for being unable to show efficient leadership behaviours for long years and feeling powerless (Terzioğlu & Taşkın, 2008). external factors were defined as; 1) Traditional supporting role of nurse, 2) Hierarchical structure of healthcare institutions, 3) Perceiving doctors as authority or team leader, 4) Legal action threat and job loss fear. internal factors were defined as; 1) Role uncertainty, role confusion, 2) Lack of Professional confidence, 3) Timidity and shyness, 4) Lack of self respect. Most of the abovementioned factors originate from woman’s social gender role feature. The first step in efforts improve leadership in nursing is redefining of traditional caregiver role including critical thinking, leadership attitudes and professional speciality. Major responsibility for improvement of leadership is involved in nursing education. A well defined leadership profile will survive in complex healthcare system of future and help to go ahead (Terzioğlu & Taşkın, 2008). The primary reason for the existence of leadership in nursing is to determine appropriate objectives and goals for the organization. In the direction of this goals and objectives, a leader will direct nursing group, organize and activate them within the compass of a plan, find a middle ground for ideas, requests, needs of everyone in the group, disclose these co-decisions and ideas. This allows them to express themselves against the other groups. Leader nurse has to be aware of the fact that in health sector, beyond integrating activities of participants from various service disciplines, it is necessary to establish versatile relationships. Establishing connections and on the path of providing integration leader nurse has following responsibilities; identifying existing and potential collaborators, creating a vision that can be shared between employees in different conditions and in different environments, defining the value of benefits that might be of each participant to initiative, to others and to himself, providing 609

communication through sharing information, rewarding contributions and formalizing this integrated effort at the right time (Sullivan et al., 2001). Courses which will upskill leadership of nurses are undoubtedly postgraduate study and doctorate study. In this respect, importance of doctoral programs are greater. In developing the leadership skills and knowledge, importance of doctoral education is an indisputable fact. Postdoctoral training effective leader nurses depends on nurses; being able to lead others, doing positive changes in the organizations they work, in academic environments or in healthcare (Terzioğlu, 2010). Nurses with the information and skills gained in doctorate, are able to apply professional philosophy, scientific approach and various care models in clinical field; are able to undertake leader health Professional role for change in service field (Akdemir, et al., 2011). The organization having an integrated intellection and success of this intellection considerably depends on the leader nurse being efficient. Nurses carry success to top level with their creativity, their visions, developing leadership quality constantly, being courageous enough to take risk and responsibility, being learning-oriented, creating an enviroment which supports development. To be able to exist in our time, to proceed toward the desired future, to carry our profession to the future, as in every profession, we need to nurture our own leaders (Yiğit, 2002). CONCLUSION In our society, women are tried to be limited of being leader. Due to motherhood and wife images associated with women, they always have to balance between their work life and family life. For this reason, they prefer career opportunities which they can manage more comfortably with their marriage and if any, children. Therefore, women are mostly not able to approach professions which require struggling and risk, provide development and make them go ahead, thus they are not able to promote to leader positions and mostly work at service sector. Social gender role which is tasked to women and men by society, effect women in a negative way at access point of opportunities such as education, work, politics. Therefore women can’t show themselves strongly in society. Nursing, which is one of the professions where women are majority, gets its share from social gender apartheid and low status of woman in society and still couldn’t make the required development and progression. Today, it is a sad fact that nurses can’t do their leadership duties, can’t make decisions independently and constantly work according to the doctors’ or senior executives’ directives and have to submit to these directives. Empowerment of nurses and ability to say “I am here too” around the team members, will be possible with the development of strong leader nurses. SUGGESTIONS In a society, rising of women’s statuses is closely related with rising of women’s educational levels and their economic freedoms. If women can take as much part as possible in education and work life, then they will develop that much, become modernized and be able to gain aggressive features. If we expect women to show leadership skills, this will be possible with recognizing them first in education and business life. In a society, before raising their educational levels it is rather delusive to expect leadership skills from women by providing audaciousness and leadership trainings for them. Same situation is valid for nurses too. At cliched in-service trainings, 610

after giving nurses audaciousness and leadership trainings, how accurate is it to say? “preliminary test and final test results are different” or “after training nurses started to behave as a leader” The existence of wise, equipped, self confident, leader nurses of the future is possible with postgraduate programs and adding “leadership skills” trainings to these programs as a class is definitely needed. These education programs should not be limited with one semester or one year, continuing during the term of program, it should change nurses’ personalities in the direction of leader features. REFERENCES Acar, F., Ayata, A.G, Varoğlu, D. (1999). Cinsiyete Dayalı Ayrımcılık: Türkiye’de Eğitim Sektörü Örneği, Kadının Statüsü ve Sorunları Genel Müdürlüğü (KSGM, 1th Edition. Cem Web Ofset. Ankara. 5-29 Akdemir, N., Özdemir, L., Akyar, İ. (2011). Türkiye’de Mezuniyet Sonrası Eğitim Kapsamında İç Hastalıkları Hemşirelik Eğitiminin Durumu. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi, 14(1), 50-58. Akın, A., Demirel, S. (2003). Toplumsal Cinsiyet Kavramı ve Sağlığa Etkisi.Cumhuriyet Üniversitesi Tıp Fakültesi Dergisi, 25,4,73-82. Atalay, İ., Efe, R. (2008). Ecoregions of the Mediterranean Area and the Lakes Region of Turkey. First International Geography Symposium. June 5-8, 2007, Kemer, Antalya, Proceedings p. 3-23. Bakan, İ., Büyükbeşe, T. (2010). Liderlik “Türleri” ve “Güç Kaynakları” na İlişkin Mevcut gelecek Durum Karşılaştırması: Eğitim Kurumu Yöneticilerinin Algılarına Dayalı Bir Alan Araştırması. Karamanoğlu Mehmetbey Üniversitesi, Sosyal ve Ekonomik Araştırmalar Dergisi, 12, 73-84. Barutçugil, İ. (2002) Organizasyonlarda Duyguların Yönetimi, İstanbul, Kariyer Yayıncılık, p.266 Başak, S. (2009). Cam Tavanlar. Kök Araştırmalar, 11(2), 119-132. Bayram, Ş. (2013). Liderlik Kavramı ve Liderlik Türlerinin İnovasyon Üzerindeki Etkileri. Gebze İleri Teknoloji Enstitüsü, Gebze. S. 31-34 Brizendine, L. (2012). Kadın Beyni. (Çev. Zeynep Heyezan Ateş.). Say Yayınları. 11th Edition 15-55 Cox, D., John H. (2003) “Kızışan Ortamda Liderlik” (Çev. Mahmut Tuna), İstanbul, Sistem Yayıncılık, ,s.34 Çevik S.A. (2011). Atılganlık ve Kadın. Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi, 4(1),141-147. Deemer, C., Fredericks, N. (2006). Cam Tavan Üstünde Dans. (Çev. Sinem Özer). Optimist Yayınları. İstanbul. 89. Durukan, G. (2013). Liderlik Yaklaşımları Algısının İşe İlişkin Duygusal İyilik Durumu Üzerine Etkisi. Yüksek Lisans Tezi. Marmara üniversitesi. İstanbul. 24-32 Duygulu, S., Kublay, G. (2008). Yönetici Hemşirelerin ve Birlikte Çalıştıkları Hemşirelerin Liderliğe İlişkin Değerlendirmeleri ve Yönetici Hemşirelerin Sahip Oldukları Liderlik Özellikleri. Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Dergisi, 15(1): 1-14. Ecevit, Y. (2003). Toplumsal Cinsiyetle Yoksulluk İlişkisi Nasıl Kurulabilir? Bu İlişki Nasıl Çatışabilir? Cumhuriyet Üniversitesi Tıp Fakültesi Dergisi, 25,4, 83-88. Ergeneli, A., Akçamete, C. (2004). Bankacılıkta Cam Tavan: Kadın ve Erkeklerin Kadın Çalışanlar ve Kadınların Üst Yönetime Yükselmelerine Yönelik Tutumları. Ankara, Hacettepe Üniversitesi. İibf Dergisi, 22(2), 89. Erkan, E., Abaan, S. (2006). Devlete ve Özel Sektöre Bağlı Hastanelerde Çalışan Servis 611

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Chapter 57 Legislation and Mobbing in Turkey Nermin GÜRHAN, Ebru KURDAL BAŞKAYA, Çiğdem KAYA INTRODUCTION Mobbing is not only a problem of business law, it is also a phonemenon whose effects can be seen in many areas of social life and which violates lots of rights together. We can say that there are not clear legislative regulations about mobbing in Turkey. However, the real reason for that is closely related with social awareness. Although clear legislative regulations have not been created in Turkey yet, lots of articles in various laws pave the way for legal struggle against mobbing. When Legislations of Constitution, Business Law, Civil Law, Law of Obligations and Penal Law are evaluated as a whole, it can be seen that our current legal system may include some provisions on behalf of the person exposed to mobbing. It is stated by the experts that psychological abuse has been mentioned clearly especially in Law of Obligations which has come into operation recently and also employers have been charged with the task of taking precautions for the employees not to be abused psychologically in 417th article of the draft. Let’s try to explain law articles which are told to be used for mobbing in different law articles. It is clear that we will not make any comment about and evaluate the law articles. A consensus has not been created among the experts in field in the evaluation of law articles yet. Also, there are not any type of case with the name of “mobbing case” in our legal system. According to characteristics of mobbing process, action for compensation, criminal action and other legal processes are mentioned. It is observed that court and supreme court decisions derived from individual differences such as pairing up the articles in different law articles and comment them in cases for mobbing which occupy important place in judicial field recently begin to happen differently. Although it is expressed that mobbing begins to be included in legislative regulations, the fact that there is not a common language in legal platform is significant and challenging and presents negative sides in terms of mobbing sufferers. Because victims can be sometimes mistreated for the second time by laws due to these different appreciations in laws and the absence of a common language. The fact that the situations stated in many articles for the Constitution of Republic of Turkey are not violated may indeed provide the mobbing not to be experienced at all. The following articles of Turkish Constitution are internal regulations that should be cared in this aspect: The Constitution of Republic of Turkey; at the starting item of Turkish Constitution first, there is the rule of “Each Turkish citizen has the right and authority from birth to benefit from the fundamental rights and freedoms in this Constitution under equality and social justice, live an honorable life in national culture, civilization 

Assoc. Prof. Dr., Gazi University, Faculty of Health Sciences, Nursing Department. Lecturer, Uşak University, Healt Sciences Vocational School. Health Service Department.

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and legislative order, improve their material and non-material existence in this way. 10th article of the Constitution states that everybody is equal before the law without discrimination of any reasons such as language, race, colour, gender, ideology, philosophic belief, religion, sect, etc (Additional sub-article: 7.5.2004-5170/Article 1). Men and women have equal rights. The government is responsible for providing this equality to actualize (Additional sentence: 12.9.2010-5982/Article 1). Precautions to be taken for that purpose can not be appreciated against the equality principle (Additional sub-title: 12.9.2010-5982/Article 1). Precautions to be taken for children, old people, handicapped, orphan and widows of war and mission martyrs and war wounded and veterans are not regarded against equality principle. Nobody, family, party or class is granted a privilege. Government bodies and administritive authorities should act according to equality principle before the law in all procedures. Personal Immunity and material and non-material existence Article 17: Everybody has the right to protect and develop their lives, material and non-material existence. Physical integrity of a person can not be harmed except for medical obligations and the status provided by law; can not be subjected to scientific and medical experiments without approval. Nobody is tortured and tormented; nobody is sentenced or treated with a punishment incompatible with human dignity (Amendment: 7.5.2004-5170/3 Articles). Self-defence fulfillment of arrest decisions, preventing arrested or sentenced person to escape, shooting happened in quelling a riot, amrital rule or public emergency, obligatory situations in which using weapons are allowed by the law is out of the provision of first paragraph. IV. Right of privacy and its protection A. Right of privacy Article 20: Everybody has the right to claim a respect for his or her privacy and family life. The privacy and family life can not be damaged. C. Freedom of communication Article 22: (Amendment: 3.10.2001-4709/Article 7) Everybody has the right for communication. The privacy of communication is essential. VI. Freedom of thought and faith Article 24: Everybody has the fredom of thought and faith. VII. Freedom of thought and expression Article 25: Everybody has the freedom of thought and expression. Nobody is forced to express his or her thoughts and opinions in any case or reasons; nobody is condemned and accused due to the thoughts and opinions. VIII. Freedom of expression and dissemination of thoughts Article 26: Everybody has the right to express and disseminate his or her thoughts and opinions by himself/herself or with groups through statements, articles, pictures or any other ways. This freedom also includes the freedom of receiving or giving information or idea without the intervention of official authoties. The provision of this sub-article is not obstacle for the publications via radios, televisions, cinemas or etc. to be attached to permission system.

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A. Right and responsibility to work Article 49: Working is a right and responsibility for everyone. B. Working conditions and right to rest Article 50: A person can not be forced to work in jobs which are not suitable for his or her age, gender or power, small children and women and those with physical and mental handicaps are protected specially in terms of working conditions. Having a rest is the right for employees. D. Approval of international contracts Article 90: Approval of contracts which will be signed with foreign countries and international institutions on behalf of Republic of Turkey depends on the approval of Turkish Grand National Assembly with a law. International contracts brought into force in order have the force of law. Nobody can apply to the Court of Constitution about these contracts with the claim of unconstitutional law (Additional sentence: 7.5.20045170/Article 7). The provisions of international contracts are essential for the contraversies which may occur due to the fact that laws include different provisions on the same issues with the international contracts which were brought into force in order concerning fundamental rights and freedoms. Articles of Turkish Constitution above are important domestic law regulations that should be considered in this respect (Temizel, 2013). 4857 numbered business law; according to Business Law provisions Article 8, “business contract is a contract which consists of undertaking of one side (employee) to work dependently and the other side (employer) to pay salary.” Business law includes two provisions about sexual abuse. According to the first one, Article 24/11-d, if the necessary precautions are not taken although the employee is exposed to a sexual abuse by another employee or a third person and he or she informs about this event to the employer, the employee in question to terminate the business contract with valid reasons if an employee commits a sexual abuse to another employee at work. However, this handles the sexual abuse with only narrow concept. No matter how much it does not contain the psychological abuse, with the headline of “Situations and so on violating ethic and goodwill rules” article 24/II-b of the law “ if employer says words to touch the glory and honour of the employee or one the family members of the employee, acts or commits sexual abuse to the employee” and article 24/II-c “if employer annoys or threatens an employee or one of the family members or abets, provokes or hauls the employee or one of the family member against law or commits a crime to be sentenced or attribute or accuse with a groundless out of honour and dignity about the employee” enact that the employee may immediately terminate the business contract with valid reasons. The situations in question can be appreciated as behaviours containing psychological abuse. Also article 25/II-b of the law “employee’s any words to touch the glory and honour of the employer or one the family members of the employer, acts or attribute or accuse with a groundless out of honour and dignity about the employer” and article 25/II-c “ employee’s sexual abuse to any other employee of the employer and article 25/II-d employee’s annoyance to the employer or one of the family members of the employer” enacts that employer may terminate the business contract of the employee commiting abuse to the employer or one of the family members of the employer with valid reasons. According to the article 77/I with the headline of “ Business Health and Security” “Employers are responsible for taking all precautions to 616

ensure business health and security in work places and provide the equipment completely and also employees are responsible for obeying all precautions taken for business health and security.” Since health has to constitute mental and physical integrity, we can conclude that phychological health has to be protected by the employers from all types of abuse (Bayram, 2007; Süzek, 2005; Şakar, 2006). 657 numbered state personnel law; Article 10: (Amendment article: 12.05.1982 - 2670/ Article 3) State personnels are responsible for completing the tasks defined in laws, legislations and regulations in time and completely at institutions and units and having them completed, training the officers in company with them, following and controlling their attitudes and behaviors. The chiefs behave the personnel in company with them equally and in justice. They use their authority within the principles defined in laws, legislations and regulations. Chiefs can not order the personnel in company with them against laws and make a request to benefit, accept any present and take on debt. 4721 numbered Turkish civil law; 24th and 25th articles of the law include the protection of personality from the attacks of a third person. Since there is an attack on personal rights in mobbing, this 24th article for the protection of personality can be interpreted as on behalf of the victim in mobbing. It is stated in 24th article as: “ a person who attacks on personal rights against law may demand protection against the victim from the judge. Unless the approval of a person with damaged personal right is justified with one of the reasons of using higher private or public benefits or the authority by laws, the attack on person’s personel right is against the law”. However, in 25th article it is stated that “ a person whose personal right is violated may demand the attack to stop if it is still going on or the identification of illegality of this attack if the attack has stopped but its effects are still going on”. It is possible to use the articles of this law in stopping mobbing or in demanding the identification of the effects. 5237 Numbered New Turkish Penal Law; if we look at some articles of the law, it is clear that they may be associated with mobbing. Article 83: (1) In order to charge a person about the death due to the fact that the person do not perform an executive behavior that he or she is responsible for, the negliance of liability causing this result should be equivalent to the executive behaviour. (2) In order to accept that negliance and executive behaviour is equivalent, a person; a) should have a liability derived from legislative regulations or contracts about an executive behaviour, b) should jeopardize other people’s life through the behaviour that he or she performed before. (3) About a person who causes the death of a person due to the negliance of a liability, not only he or she can not be sentenced from twenty years to twenty five years instead of aggravated life sentence, from fifteen years to twenty years instead of life sentence, from ten years to fifteen years on other sitituations as fundemental punishment, but also it can not be abated. Although it is not related with mobbing at first sight, mobbing happens in work places. Then it is clear that it can not be associated with only victim’s personality. Because it can be said that violation derives from the 617

circumstances in business and work places and dangers there. Indeed empoyers have the chance to prevent the violation with the opportunities which the business law allows. Chief etc. whom employer delegates also has to act in jurisdiction. Also while a person / the people in chief position is / are responsible for preventing the actions related with the business and work places, with the reality that they have to know what will happen as a result of the actions even it is said that they are not responsible for preventing results they should have the responsibility for preventing results in fact. However, if they can prevent and save the action, then the result may be charged to him or her. For all that reasons, it is an acceptable fact that employer and chief may warn the person / people against commiting mobbing and prevent the actions causing mobbing by using some authorities and responsibilities. It is clear that if the employees apart from the victim do not prevent mobbing although they have the chance, this should bring up the criminal liability. In addition, if the mobbing adopters are chiefs or employers, they have the criminal liability since they actually commit mobbing by themselves as well as they do not fulfill their liabilities. Article 84: When we handle with the headline of leading to suicide; (1) A person who abets, encourages other people to suicide, reinforces the suicide decision of others or help the others to commit a suicide in any way is sentenced from 2 years to 5 years. (2) If the suicide happens, the person is sentenced from 4 years to 10 years. (3) The person who encourages other for suicide overtly is sentenced from 3 years to 8 years. (Former second sentence: 29.6.2005 – 5377/ article 10) (4) Those whose comprehension ability for the meaning and the result of the action is not developed or who cause the killed people to commit suicide and force the people to suicide by using power or threats are charged with the responsibility for deliberate murder crime. It is a well-known fact that the mobbing sufferer may experience depression by encountering desperation, solitude and the fear of future as a result of long lasting mobbing process and ongoing mobbing attacks and this may cause the decision of suicide. Therefore, we can use this article of TSL easily for the people commiting suicide as a result of mobbing. Article 86 -87: (1) A person who grieves other’s bodies or causes the health and comprehension ability of them to deteriorate is sentenced from one year to three years. (2) (Additional sub-article: 31.03.2005 - 5328 S.K./Article 4) If the effect of intentional injury action on person is mild as can be removed by an easy medical intervention, imprisonment from four months to one year or judicial fine are judged on victim’s complaint. The legal benefit protected from intentional injury crime is body integrity and health and the body integrity may be deteriorated through both a physical and psychological effect. However, touching on body is not required for intentional injury crime to happen. For instance, the noise causing disorders in hearing functions can also be sentenced within this aspect. In addition, it must be found that the action causes pain at the victim. Also, as we stated at other article, psychosomatic illnesses may occur in people as a result of physchological abuse and stress. Then if psychosomatic illnesses occur in person, this can be handled within suffering the body referred to intentional injury crime. Article 94: (1) About the public personnel who exhibits behaviours incomtabile with human dignity against a person causing the person to suffer physically and mentally or causing the comprehension and thinking ability to be affected and insulted 618

it is judged from three years to twelve years. Article 95: (1) If torturing actions cause the victim; a) to weaken one of the functions of senses or organs perpetually, b) continous difficulty in speaking, c) to have a permanent scarface, d) to experience a dangerous situation in life, e) to give premature birth when it is committed to a pregnant, the punishment determined according to the article above is increased at a half rate. (2) If torturing actions cause the victim; a) to fall into a vegetative state or an incurable illness, b) to lose the function of one of the senses or organs, c) to lose the ability to speak or have a child, d) to change face perpetually, e) to abort when it is commited to a pregnant, the punishment determined according to the article above is increased one times. (3) If the torturing actions cause broken bones on body the punishment from eight to fifteen years is judged according to the effect of the broken on life functions. (4) If the victim is dead as a result of the torture, aggravated life sentence is judged. Article 95: Although it is not associated directly with mobbing at first sight, in fact it is seen that evidenced stress brokens ( bones may be broken because of heavy stress on people’s body) may be appreciated within this subject. Also, if the victim is pregnant and she gives premature birth due to heavy stress, they can be used again. In addition, many situations may happen mentioned above if the victim has a heart attack as a result of heavy stress again. Also, these events may happen as a result of the suicide of a person due to heavy stress and depression even the victim is saved, then in my opinion this article in fact should be used for mobbing. Article 96: (1) A punishment from two to five years is judged about a person commiting a crime causing anybody to suffer pain. Article 105: This article considered only physical aspects of abuse by including one provision about sexual abuse. According to this regulation, a person abusing another person for sexual purpose may be judged from three months to two years of inprisonment or judicial fine on the complaints of the victim. If these actions are commited by misusing the authority derived from hierarchy and service relationship or by utilizing the ease provided by working in the same organization, the possible punishment is increased at half rate. If the victim is obliged to leave the job due to this actions, the possible punishment will not be less than a year. Article 106: (1) A person who threatens another person to attack to the life, body or sexual privacy of him or her or his or her relatives is judged by the punishment from six months to two years. A person who threatens with huge damage as assets or another bad behaviours, he or she is judged by the punishment at least six months or judicial fine. Article 107: (1) A person who forces another person to do or not to do an action against law or an inobligatory action or to provide unfair advantage is sentenced to 619

imprisonment from one ot three years or judicial fine until five thousand days. (2)(Additional sub-article: 29.06.2005-5377 S.K./Article 14) In the act of threatening that the issues about a person’s honour or prestige will be declared or attributed with the purpose of providing advantages for one’s self or others the punishment is judged according to the first sentence. Artice 108: (1) In the act of using force against a person to do something or not to do something or allow another person to do something the possible punishment is judged by increasing from one of three ot the half of it. Article 109: (1) A person who deprives another one from the freedom of going anywhere against law or stay anywhere is sentenced from one to five years. Article 117 (1) A person who violates the freedom of work or labour by using force or threat or an act against law is sentenced from six months to two years or judicial fine. (2) A person who employs another person or people without any fee or with extremely low fee through the provided service by exploiting their desparation, loneliness and dependence or exposes these person or people to a working and accomodation conditions imcompatible with human dignity is sentenced from six months to three years or judicial fine at least one hundred days. (3) A person who supplies or guide or transfer someone in order to expose him or her with the situations mentioned in the sub-article above is also sentenced to the same punishment. (4) A person who forces an employee or employer to decrease and increase fees or accept contracts under conditions apart from the accepted ones before or causes the business to stop, end or continue to stop is sentenced from six months to three years. Article 122: (1) By discriminating people against language, race, colour, gender, disability, ideology, philosophical belief, religion, sect, etc. a person who; a) prevents the sale or transfer of an estate or real estate or execution or utilization of the service or attribute employment or non-employment of a person to one of the conditions mentioned above, b) does not provide food or refuses to execute the service supplied to the public, c) prevents anybody to perform an ordinary economic activity, is sentenced from six months to one year or judicial fine. Article 123: (1) In the act of calling a person persistently, making noise just for the purpose of disrupting peace and silence or doing something againt law the agent is sentenced from three months to one year on the complaint of the victim. Article 124: (1) In the act of blocking the communication among people unlawfully the person is judged from six months to two years or judicial fine. Article 125: (1) A person who attributes a concrete action or event that may hurt homour, dignity and prestige or attacks on person’s honour, dignity and prestige by swearing is sentenced from three months to one year or judicial fine. The action should be performed by complicating at least three people so that the insult in the absence of victim may be punished. Article 126: (1) Even the name of the victim is not mentioned clearly in commiting libel or evaded implicitly if there is nothing to hesitate in its quality when it is determined for the personality of the victim, it is regarded that both the name and the insult is mentioned and explained. In addition, the articles 132- 133- 134- 257- 267 are 620

the acticles that can be used as for the content of the subject. Although it is thought that mobbing actions are unkind and non-ethic, but it does not have a value and importance legally, mobbing actions should be handled and appreciated legally since it is a matter of suffering a person deliberately and systematically as well as exceeding “abnormal” behaviour. Thus, Turkey also accepted that laws for mobbing should be created and “a commission report of psychological violance (mobbing) and recommendations for solution” was prepared by Turkish Grand National Assembly Women-Men Equality of Opportunity Commission in April 2011. Works for legislation are going on. The first regulation about this topic is Prevention of Psychological Abuse (Mobbing) at Workplaces - 2011/2 Numbered Circular published by Prime Ministry (Erdem & Parlak 2010; Bozbel & Palaz 2007; Ergin, 2009; Bayram, 2007) (Official Journal Date: 19th March, 2011 – Official Journal Number: 27879). The second regulation is Precedures and Principles About Occupational Ethic Rules of Commissioners of Audits (ARTICLE 15 – 1/e of 17th December, 2011Number: 28145 published in Official Journal) Law of obligations; the most impontant regulation about the topic is 6098 numbered Turkish Law of Obligations, in 417th article of the law. Article 417: Employer is responsible for protecting the personality of the employee and respect in service relationship and making systematic suitable for honesty principle in workplaces and taking the required precautions so that especially employees are not psychologically and sexually abused and those who were exposed to these abuse before are not damaged anymore. Employer is responsible for taking all required precautions for ensuring business health and security in workplaces, providing the equipment completely and also employees are responsible for obeying all taken precautions about business health and security. It is stated that the compensation of the damages accociated with the death, damage to the body integrity or the violation of personal rights of the employee due to employer’s behaviours against law and contracts including the provisions above depends on responsibility provisions arising from breach of the contract. With this article prevention of psychological pressure and abuse in workplace was regulated “as a liability to employers”. Also, in 421th article of the law it is stated that time for employment is given to employer in the case of release or termination of employer. Article 421: Employer is responsible for providing holiday to the employee on each Sunday of every week or if it is not possible, on a weekday fully as a rule. In the act of termination of indefinite business contract the employer is responsible for giving permission to the employee for looking for a job for two hours a day without any stoppage in fee within the notification time. In determining off-hours and off-days legal advantages of employers and employees are considered. Also 56th and 58th Articles of the law can be used in actions of compensation. Article 56:Judge may rule on the payment of a plenty amount of money as a damage for pain and suffering to the sufferer in case of the damage of body integrity of a person. In case of heavy bosy damage or death he may also rule on the payment of a plenty amount of money as a damage for pain and suffering to the sufferer or the dead. Artical 58: A person who suffers from the damage of personal right may demand a plenty amount of payment as compensation as the damage for pain and suffer. Judge may rule on another type of compensation instead of the payment or add on this 621

compensation; may especially rule on a decision denouncing the attack and may rule one this decision to be published (Demir, 2009; Gürhan, 2013). REFERENCES Bayram, F. (2007). Türk İş Hukuku Açısından İşyerinde Psikolojik Taciz (Mobbing). İş Hukuku ve Sosyal Güvenlik Hukuku Dergisi 4 (14), 551-574. Bozbel, S. & Palaz, S. (2007). “İşyerinde Psikolojik Taciz (Mobbing) ve Hukuki Sonuçları”. TİSK Akademi 2 (3), 66-81. Demir, Ş. (2009). Mobbing Olgusunun Hukuki Değerlendirmesi. Ankara Barosu Dergisi 2, 140-145. Erdem, M.R. & Parlak, B. (2010). Ceza Hukuku Boyutuyla Mobbing. TBB Dergisi 88, 261286. Ergin, H. (2009). İşyerinde Psikolojik Tacizin İş Hukukunda Ortaya Çıkışı ve Sonuçları. Ceza Hukuku Dergisi 11, 161. Gürhan, N. (2013). Adan Z ye Mobbing. Akademisyen Yayın Evi, Ankara. Resmi Gazete Tarihi: 19 Mart 2011 - Resmi Gazete Sayısı: 27879. Süzek, S. (2005). İş Hukuku Genel Esaslar Bireysel İş Hukuku. Beta Basım Yayım, İstanbul. Şakar, M. (2006). Gerekçeli ve İçtihatlı İş Kanunu Yorumu. Yaklaşım Yayıncılık Ankara. TBMM Kadın Erkek Fırsat Eşitliği Komisyonu (2011). İşyerinde Psikolojik Taciz (Mobbing) ve Çözüm Önerileri Komisyon Raporu Ankara. Temizel, Y. (2013). Mobbing ve Türk Hukuk Sistemindeki Yeri. Adalet Dergisi 45, 188223.

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Chapter 58 Hospital Management and Organization in the Ottoman Empire Bilal AK INTRODUCTION The Ottoman Empire is a Turkish Empire which dominated a large geography of 24 million square kilometers for 600 years. During 600 years it has affected the world in areas such as culture, art, economics, social, health, military and others. One of the most important reasons why the Ottoman Empire reigned the three continents, established the world order and survived 600 years is its emphasis on management and executive experience and the attention taken on to the career and merit systems of the executives. As the result of importance given to managers and administration, the world's first management school "Enderun School" was established. The graduates of this school took part in state management positions. Enderun School education and training was based upon scientific approach, specialization, leave the job to experts when necessary and professionalism. As a result, success, business growth, continuity and stability was achieved. In the Ottoman Empire, as in every part of the state, great importance was given to management in the conduction of health and hospital services (Ak, 2000: 135)b I. HEALTH MANAGEMENT IN THE OTTOMAN EMPIRE A health system and health management was applied in the Ottoman Empire which was spread throughout the whole country. Management of health services was led by the person who called "Sertibba-i Sultani" that is “Hekim Başı” (Head health administrator or head physician). Head physician, today is the equivalent of the Minister of Health, but his authority and responsibilities was wider because it also covered military health services. Head physician's office was initiated by Çelebi Sultan Mehmed (Ünver, 1950; 13, 21). During this period, Sheikh Yusuf Sinan and Ishak Pasha have been the Head physicians. Head physicians were considerable great palace officials working for the sultan. Until the 18th century, first sadrazam (the grand vizier), later Darussaade Aghas, were dressed in a fur called hil'at which were donated by the sultan. This ceremony began to be performed in the late 18th century with the presence of the sultan. The assignments of the Head physicians were made by of the Sultan according to the Grand Vizier's proposal (Ak, 2000:135,136). When the Sultan joined a war, the Head physician used to accompany him. In case the Sultan did not participate in the expedition, one of the doctors of the palace was assigned by the Head physician as army Chief physician. (Şehsuvaroğlu et al.,1984: 64). 

Assist. Prof. Dr., Toros University, School of Health Sciences, Health Management Division. [email protected]

In turn to his services this man was paid money which is called arpalik (gathered as the tax of a place). The raise in the wages of medical personnel was made under the authority of the Head physician ( Ünver, 1950: 33). Health management was conducted by the Head physician in the Ottoman Empire. Head physician authority, served as the highest authority of the health board, at the same time carrying the responsibilities of the administrative affairs. To be fair in health management, career and merit systems were emphasized. The sultan would assign whoever doctor he wants as the Head physician, since this man’s prior task was to protect the health of the monarch. Assignments of palace physicians and other important information was recorded to the notebooks called "mevacib-i cema’at-i musahere-horan". Taking into account the complaints being made, to protect the public against charlatans, incompetent and insufficient health workers, the Head physicians, checked Figure 1: Outfit head and tested those doctors from time to time and forbid them physician from profession if they did not obey the procedures (Sarı, 2000: 21-25). Head physicians were responsible from the provision, storage and protection of military medicine and supplies, preperation and submission of a calendar to the sultan every Nevruz that is the Hijra New Year, forensic medicine, the fight against epidemics, the opening of hospitals where necessary, examinations of the doctors and detention of inadequate doctors from professional application. As a person trained in the madrasas, the Head physician was also employed in the science class, which could reach the highest degrees of this class as Anatolia and Rumelia kazaskerlig rank. Head physician mission lasted 380 years and 46 Head physicians were employed during this period, and detailed records and information about them can be found in the Ottoman Empire archives (Akay, 1982:10, 21). The Head physician being a member of scientific class; was required to have a variety of features related to his personality, external appearance and the social environment. These features are: A-Personal Characteristics of the Head Physician Chief physician must have the following properties; -Honest, Merciful, Low volunteers, Abstinent, On a ground and a strong memory: Brave, Audacious, Smiling, Nice Talking and Laminar-even walk in. B-Foreign View Properties Chief physician regarding the following appearance should have the following properties: Laminar-even dress, Clean hair, beard and nails C-Environment Related Properties Chief physician must have the following envıronment related properties: Married to have children, stay away from forbidden and women, Very good 624

friends, Balanced nutrition and Entertainment (Akdeniz, 1990: 33). In the Ottoman Empire healthcare, besides the health staff such as doctors, pharmacists, after 1845 medical personnel and health managers such as the hospital director, chief physician, hospital superintendent, pharmacy inspector, health police, chief pharmacist, military chief pharmacist and forensic were employed. (Şehsuvaroğlu, et al., 1984:146). II. ORGANIZATION OF HEALTH SERVICES IN THE OTTOMAN EMPİRE Fatih Sultan Mehmed; organized the Head physician authority called "Reis-ul Etibba" inorder to manage the doctors who served in the army. During this period, Kutbettin was assigned as the first Head physician with 2000 akchas salary (Şevki, 1991: 88-89) The Head physician; although was in service of the Head lala or Kizlararasi also called Babussade Agha, was also in service of the Vizier being primarily responsible of the health of the sultan and relatives, of the health of the whole country people, of the hospitals around the country, korhanes, cuzzamhanes and of a variety of health and social welfare institutions (Şehsuvaroğlu et al.,1984: 166). Until the 19th century, the organization of health services in the Ottoman Empire was as in Fig. 2 (Ak, 2000: 138). Health organization of the Ottoman Empire has changed evolving over time. Examples include the 1839 (Fig. 3) and subsequent organizational charts from 1862 (Fig. 4) can be displayed (Ak, 2000: 143-144). III. OTTOMAN STATE HOSPITAL MANAGEMENT Hospital management is an old profession. Great Turkish scholar Mehmet Razi, has served as chief director in Baghdad hospital (Ak, 1990: 101). In the Ottoman Empire, head physicians worked on scientific labors related to medicine, but in hospital management and operation hospital managers like "Madhouse Agha", "Bimarhane Agha", "Hospital Chamberlain", "Managing Director", "Hospital Director" were assigned, which were administrators grown from people who were non-called doctors. (Ak, 1987: 13; Ak, 1997: 18). Hospital works were carried out in accordance with the foundation indentures in the hospitals. The functioning of the hospital's management and especially employee assignments, were subject to palace administrative order. There was a succession in the assignments, realized in order, which was an incorruptible trend unless compulsory. Health management was organized in a form as to distribute the tasks in top to bottom fashion. The distribution of tasks was determinative for the senior junior relationships in the hospital (Sarı, 2000:21-25). Hospital directors, were involved in the management of all administrative, financial and service affairs of the hospitals, but the Head physician was only interested in the management of activities related to patient treatment. Head physicians certainly did not deal with hospital services other than medical services.So the management of medical and administrative services were separated from each other in the hospitals. Hospital director which was the hospital manager, had a salary of 1200 akchas and food supplies for eight persons, while the head doctor had a salary of 1125 akchas and food supplies for eight persons.

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Figure 2: Until the 19th century, the Ottoman Empire Health Organization In Enderun hospitals found in Edirne and Istanbul Topkapi palaces, the administrative managers of the hospitals were callled "Madhouse Agha" who was assigned his own separate apartment in the hospital's architectural plan (Terzioğlu, 1979: 836,837). In Haseki Darushipha which was founded in 1550, managers titled hospital administrators were employed. The hospital administrator was Hacı Faik Bey (Taşkıran, 1972: 235). In Tophane hospital, which was founded in 1834, the hospital administrators titled managing directors were employed. (Şehsuvaroğlu, et al., 1984-134). In Vakif Gureba hospital which began its activities in 1845, the managers were called "Hospital minister". Hospital minister was Mehmet Tahir Bey. The first director of the hospital management Salih Efendi and hospital deputy director Hacı Derviş Efendi, have played major roles in the management of the hospital (Gürkan; 1967: 24, 25). The first Chief of Medical Staff of the hospital was the governor Ahmet Bey. In 1845, the hospital's management manual was published and internal work was scheduled. Accordingly, the Chief of medical staff was completely responsible of the patient's regime, a non-called doctor was responsible of the hospital management. In 1898, the authority called hospital management was defined in Gulhane military hospital and the first hospital director was Robert Rieder Pasha until 1904, George Deyck between 1904-1907 and Julius Weiting between 1907-1914 were hospital directors (Ataç, 2000: 259).

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Figure 3: After 1839, the Ottoman Empire Health Organization

Figure 4: Health Organization in the Ottoman Empire After 1862

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Figure 5: Health Organizations at the Beginning of the 20th Century in the Ottoman Empire (Ak, 2000: 138, 143, 144, 152).

State gave the task to the ambassador of Berlin, about finding consultatns who could do innovations in Turkish medical education and in hospital management.(1897) Berlin Ambassador asked Germany for a support about consultants. Germany charged Prof. Dr.Robert Rieder and Dr.Georg Deyeke as a consultant. Rieder, established Gülhane Seririyat Hospital and he managed the hospital as a hospital manager (Hastane Nazırı). Rieder, wanted from officials to care the hospital management. He advised about establishing a modern hospital. Then Deyeke became the manager of the hospital. He worked for hospital administration, working of nurses and calculating the cost of the hospital. Afterwards Dr. Julius Wieting was assigned as the manager of the hospital. Dr.Wieting had developed the production center at the hospital which produced drugs and dressing materials. In this center; 3000 war packages per a day, bulbs and tablets were produced. Muallim Reşit Rıza and Mustafa Bey had produced typhoid vaccine for the first time during the Balkan Wars in Anatolia. They provided spreading of the cholera vaccine all over the country. Under the command of the Doctor Fuat Kamil Bey, most of the doctors were appointed in The First Army Menzil Hospital and they worked at The Gülhane Warfare Hospital. After the war, Süleyman Numan Pasha and after him Talat Arif Bey and Tevfik Selim Bey were assigned as a hospital manager to The Gülhane Hospital (Ataç, 1996: 26, 31, 76, 80, 86). Hamidiye Etfal Children's Hospital was established in 1899 and the first hospital manager was Rifatlu Faik Efendi. The office of the hospital manager was 17 square meters and it was located on the second floor of the hospital's main building (İlker, 628

1976: 36, 37, 38). The author of this chapter, had worked in the hospital in 1975 as a deputy manager. A-Duties and Salary of Hospıtal Managers Hospital managers had activities, duties, powers and responsibilities such as hospital revenue sources, hospital site selection, hospital architectural projects, garden landscape planning, diet planning, shift planning and execution, training, assignments, supervision and inspection, medical publications, medical statistics, medical records, international relations, infection control, hospital cleaning work, specialization, institutionalization, serum and drug production, technology management, management of outstanding health care services, patient Table 1:Vakıf Gureba Hospital’s staff, their salary and other payments Roster Title Hospital director First doctors Second doctor First clerk The first surgeon First pharmacist The second surgeon The second pharmacist The second clerk The person who applied leeches Mortars also shed something for medicine person The dealer paperwork People who pay for clothes Dress-boy Head servant Square-cleaning person Chef cook Master subordinate Other Master subordinate Check the janitors Nurse TOTAL STAFF

Number of Staff

Salary (Akçe)

Rations

1 1 1 1 1 1 1 1 1

1200 1125 750 750 500 500 400 400 350

The Amount of Rations 8 people 8 people 4 people 4 people 4 people 4 people 3 people 3 people 3 people

The Mount of Forage 1 2 1 1 1 1 1

1

100

1 people

-

1

100

1 people

-

1

120

1 people

-

1

120

1 people

-

1 1 6 1 1 1 2 24 50

150 200 100 250 150 100 160 100

1 people 2 people 1 people To be allocated To be allocated To be allocated 1 people 1 people

-

In return to their jobs, hospital workers were paid money, food, coal, wood, and shoes. Following, information about the salaries and non-wage payments in the Vakif Gureba hospital can be found as an example. At the hospital, hospital director took 1200 akchas, head physician took 1125 akchas as salaries. That apart, non-wage payments called "tayinat" were made. They were necessities under the name supplies such as meat, bread, coal and barley and hay for feeding the horses given to officials for transportation. 629

Table 2: The list of supplies given to a person in the hospitals are as follows Bread 221 Meat 6 Shoe 1 Chickpea 210 Salt 195 Onion 194 Oil 20 Wood 23,385 Coal 6,300 Brass 8 Soap 30 Candle 30 (Gürkan, 1967: 159,161).

Such payments are related to the various staff titles are as follows. These payments apart, a variety of different types of meals prepared in the kitchen were served to hospital workers, separately in the morning and in the evening. The Hospital director could take 8 times the tayinat of one person, listed above. Also necessary food for the his horse was provided. Tayinat was given separately to each person in the staff list. B-Significant Hospitals in the Ottoman State The Ottomans set up hospitals by the state in places they conquered. Other than that, Sultan and important persons, set up hospitals and initiated administration via establishing foundations or organizing documents stating the terms of a foundation. Also Enderun hospitals, medical schools to train doctors and Red Crescent were established in palaces.

Hospitals served as military, civil, hijaz, minority and foreign hospitals. The education period was ten years in the Faculty of Medicine, and the courses began to be given in Turkish in 1870. (Altıntaş, 2000: 89-111). According to this classification significant hospitals in the Ottoman Empire were: 1-Civil Hospital Major civilian hospitals are located in the Ottoman Empire: 1-Bursa Yildirim Beyazit Hospital (1399) 2- Edirne Leprosy Hospital (II. Sultan Murad) (1421-1451) 3-Fatih Hospital (1470) 4-Edirne Bayezid II Hospital (1488) 5-Karacaahmet Leprosy Hospital (1514) 6-Manisa Hafza Sultan Hospital (1539) 7-Haseki Hospital (1550) 8-Sulaymaniyah Hospital and Faculty of Medicine (1556) 9-Toptaşı Atikvalide Hospital (1583) 10-Sultan Ahmet Hospital (1617) 11-Mabeyn Hospital (for palace officials) (1834) 12-Edirnekapı Mihrimah University hospital for the poor and single (1837) 13-Kızkulesi Hospital (the quarantinefor plague are) (1838) 14- Vakıf Gureba Hospital (1845) 15-Zeynep Kamil Hospital (1862) 16- Sixth Circle Female Hospital (Venereal diseases and women's Hospital) (1878) 17-Beyoğlu Municipality hospitals and first aid health center (1878) 18-Hospital Rabies (1887) 19-Nuh Kuyususu Hospital (1891) 20-Tıbbiye-i Mülkiye Hospital (1893) 21-Darülaceze home and hospital for aged and needy (1895) 22-Şişli Sultan Abdülhamit Çocuk Hastanesi (1899) 630

23-Cerrahpasa Hospitals and Municipal Health Affairs Director (1910) 24-Mekke-Cidde Quarantine Hospitals (1911) 25-Medine Red Crescent Hospital (1917) 26-Hicaz Health Agencies of Health Administration (1914-1917) - 100-bed hospital two fixed in Cidde - Jeddah, Mecca and Medina in Fully Organized 3 Temporary Hospital - Jeddah, Mecca and Medina in 3 pharmacy - Jeddah and Mecca in Guesthouse for the Poor Pilgrims - Two desalination plants for potable water in Jeddah and Yambug - An Ice Factory in Jeddah - A Hangar for 5000 People to Quarantine Administration 2-Military Hospitals During Ottoman-Russian War, mobile hospitals were established in nine battleground by Red Crescent. Hospitals were also established in other battlegrounds .Train and boat hospitals were composed for transfering the patient soldiers. New hospitals were established in Tripoli, Homs, Gary, Benghazi, Derna and Tobruk by organized Health Committees. Desert stretcher-bearers were inserted for desert areas. Hospitals were opened in areas where cholera is widespread. Red Crescent was tasked with helping hospitals and selecting hospital areas. Crescent illuminated hospitals which established in desert and modern tents with electricity. Fourth Army, established an hospital which was very well equipped with mobile X-ray machine during Desert Wars. The soldiers were undergoing health checks and vaccinated. Red Crescent had produced the needed materials, equipment, medical supplies, food, etc. For hospitals (Sarı, 2000: 233, 237). Major military hospitals are located in the Ottoman Empire: 1- Zeytinburnu Military Hospital (1794) 2- Selimiye Military Hospital (1799) 3- Levent Çiftliği Military Hospital (1799) 4- Taksim Military Artillery Hospital (1809) 5- Hassa Military Hospital (1828) 6- Maltepe Military Hospital (1828) 7- Cebehane Military Hospital (1828) 8- Military Academy Hospital (1834) 9- Tophane Military Hospital (1834) (the hospital has a managing director) 10- Humbarahane Hospital (1835) 11- Istanbul marine hospital and sanitary warehouse (1838) 12- Regiment Hospital (1838) 13- Anadolu Kavağı Militery Hospital) (1838) 14- Medical College Hospital (1839) 15- Rami Barracks Hospital (1840) 16- İstinye Hospital (1840) 17- Ahırkapı Barracks Hospital (1840) 18- Davutpaşa Hoppital (1840) 19- Toptaşı Military Hospital (1841) 20-Commander Hospital (1841) 631

21-Trabya Hospital (1844) 22- Kuleli Military High School ‘s Hospital (1844) 23-Haydar paşa Military Hospital (1845) 24- Gümüşsuyu Military Hospital (1846) 25- Demirkapı Military Hospital (1866) 26- Military Police Hospital (1866) 27-Emirgan Hospital (1872) 28- Immigrants of Hospitals for Balkan War 29- İplikhane Hospital (1877) 30-Beylerbeyi Hospital (1877) 31-Serviburnu Hospital (1877) 32-Maçka Hospital (1877) 33-Şemsi Paşa Immigrants Hospital (1877) 34-Çatalca Hospital (1877) 35-Yıldız Hospital (1896) (This hospital X-ray was used in 1897 for the first time in the history of world military) 36-Gülhane Military Hospital (1898) (In this hospital, mandatory autopsy, quinine, aspirin was manufactured drugs such as dover. War package of health tools created was diagnosed with typhus, typhoid, cholera and dysentery vaccines were administered.) 37-Haydarpaşa Military Hospital (1904) There were only 40 temporary hospitals in Istanbul and the Balkans during the First World War. 3-Beyoglu District Hospitals Istanbul Located in the Beyoglu major hospitals include: 1- Municipal Hospital 2- Bomonti Hospital 3- Emirgan Recovery Center 4- Feriköy Immigrants Hospital 5- Galatasaray Hospital 6- Gümüşsuyu Hospital 7- Halıcıoğlu Hospital 8- Military Academy Hospital 9- British Hospital 10- Italian hospital 11- Kağıthane Hospital 12- Maçka Hospital 13- Pangaaltı Hospital 14- Taksim French Hospital 15- Trabya Hospital 16- Taşkışla Hospital 17- Yeniköy Hospital 18- Zapyon Hospital 4-Istanbul Central Hospitals Major hospitals located in the center of Istanbul are: 632

1-Ağahamamı Hospital 2-Yeşilköy Hospital 3-Bakırköy Military Veterans Hospital 4-Balat Jewish Hospital 5-Cağaloğlu Emerging Associations of Women Hospital 6-Çapa Male Teacher School Hospital 7- University Hospital 8-Darüşşafaka Hospital 9-Latefat Hanım Hospital 10-Mercan Hospital 11-Yedikule Hospital 12-Yeşilköy Hospital 5-Üsküdar District Hospital Major hospitals located in Istanbul Üsküdar include: 1-Alemdağ Hospital 2-Anadolu Kavağı Kospital 3-Beylerbeyi hastanesi 4-Çengelköy Hospital 5-Fenerbahçe Hospital 6-Selimiye Hospital 7-Faculty of Medicine Hospital 8-Tuzla Hospital 9-Serviburnu Hospital 10-Zeynep Kamil Hospital. 6--Minority Hospitals Certain minority hospitals in Istanbul are: 1-Balıklı Rum Hospital 2-Yedikule Surp Birgiç Armenian Hospital 3-Taksim Surp Agop Foundation Hospital and Hospice 4-Balat Jewish Hospital 7- Foreign Hospitals Foreign hospitals in Istanbul are: 1-German Hospital (1847) 2-French Hospital (1853) 3-Senjorj Hospital (1854) 4- French Lape Hospital (1856) 5- Italian Hospital (1876) 6-Jeremya Hospital (1881) 7- Bulgarian Hospital (1902) 8- Admiral Bristol Hospital (1920) 9- Russian Hospital (Ak, 2000: 153,156). Many hospitals other than the listed above provided service in different cities of Anatolia, which are still active today. C-Hospital Organization In the Ottoman Empire, hospitals were organized, managed and operated 633

according to the rules of the foundation, since they were established mostly in due to the foundations. During the 19th century, the hospitals were institutionalized and restructured in many ways (Kahya, 2000: 17). Minority and foreign hospitals, were organized and managed according to their own procedures. In this section, information on staff and organization structure and related figures of some of the Ottoman hospitals will be given in chronological order. 1- Bursa Yıldırım Beyazıt Hospital Yildirim Beyazit Hospital is one of the first hospitals of the Ottoman Empire, in 1399 foundation document "Because of his charity and his goodness, God further glorify Almighty Majesty the Sultan Yildirim Khan" is inscribed. According to the document, the hospital staff, their daily salary and other payments were as follows Table 3: Yildirim Beyazit Hospital staff, their daily salary and other payments Title The chief Physician Physician Who Drinks Pharmacist Cook Baker TOTAL STAFF

Total Staff 1 2 2 2 1 1 9

Daily Wages 12 8 1 2 2 2

Annual Salary Wheat (Med) Rice (Med) 20 4 15 12 12 12 12 -

Note: 1 Med = 20 kg. 2,998 grams of silver per year was given to the patients' food consumption needs, etc.

Table 4: Fatih Hospital, Hospital staff, their daily salary and other payments Roster Title

Total Staff

Physician The Authorizing officer Cost Officer Ophthalmologist Surgeon Pharmacist Warehouse Officer Cooks Doorman Servants TOTAL STAFF

2 1 1 1 1 1 1 2 1 2 13

Daily Wages (Akçe) 20 4 4 8 8 6 4 3 3 3

The organizational structure of the hospital is as follows:

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Figure 6: Bursa Yildirim Beyazit Hospital Organization

Figure 7: Fatih Hospital Organization

Figure 8: Haseki Hospital Organization

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Table 5: Haseki Hospital personnel Table Title Medical staff Head Physician The second Physician Chief Surgeon Surgeon Ophthalmologist Second Ophthalmologist Pharmacists Foreman Pharmaceutical Warehouse Clerk Nurse Patients Servants

Total Staff 1 1 1 1 1 1 2 2 4

Total

16

Administrative Staff Hospital Director Editorial Clerk Purchasing officer Food Warehouses Officer Total

1 1 1 1 4

Title Auxiliary Staff Cook Washerwoman Sweeping People Doorman Gardener Scavenger Toilet Cleaner Bath Body Pouch that Person Bath Attendant Total GENERAL TOTAL

Table 6: Vakıf Gureba Hospital staff Title Hospital director Head Physician The Second Physician The First Surgeon The Second Surgeon Head Pharmacist The Second Pharmacist Assistant Surgeon (sülükçü) Pharmacists Foreman ( Havanzan) Editorial Staff (Katip ) Distributes Officer Salary Trading Officer (Vekiliharç) Cook Helpful Staff (Yamak ) Head Janitor Janitor Barber Doorman TOTAL

636

Number of Staff 1 1 1 1 1 1 1 1 1 2 1 1 4 1 1 30 1 2 55

Total Staff 2 2 1 1 1 1 1 1 1 11 31

4-Vakıf Gureba Hospital For the first time in 1845 in this hospital, "hospital" name is used. Previously the hospital "şifahane" he said. Hospital staff and organization chart is as follows

Figure 9: Vakıf Gureba Hospital Organization

5-Abdulhamit Children's Hospital Abdul Hamid of the 1899 Children's Hospital personnel and organizational chart is as follows: (İlker, 1976: 36,38). Table 7: Abdul Hamid of the 1899 Children's Hospital Personnel Table Title

Number of Staff

Medical Staff Head Physician Vice Head Physician Bacteriologist Operator Chemist Vice Operator Volunteer doctors Pharmacist Surgeon Nurse

1 1 1 1 1 1 10 4 1 2

TOTAL

23

Title Administrative Staff Hospital Director Trading Officer (Vekiliharç) Delivered people dress Cleric (İmam) Oven and Heating Officer Registrar (Mukayyıt) Male Janitor Female Janitor Gardener Doorman Cook Washerwoman Tailor Presser TOTAL GENERAL TOTAL

Number of Staff 1 1 1 1 1 1 16 12 3 2 4 2 1 1 47 70

RESULTS The Ottoman Empire affects the world for 600 years with the fields of culture, art, economics, social, military and health, etc. The most important reasons to live the Ottoman Empire for 600, is to give importance to their manager, management, careers and liyaket system. It is given great importance to the conduct of management in health and hospital services as in every part of the state in the Ottoman Empire. Ottoman Empire had the health system and health management system covering the whole 637

country. Health services were led by a person called"Head physician". 46 chief physicians were worked since 1413. There are records of them in the archives. The hospital management is an old profession. In the Ottoman Empire; chief physicians were assigned in scientific work related to medical science in management services in hospitals. Hospital managers were doing the task in hospital management and operation. They were not doctors. "Tımarhane ağası", "Bimarhane Ağası", "Minister of the hospital", "Managing Director" and "Hospital Manager" was called for Hospital Administrators.

Figure 10: Abdulhamid Children's Hospital Organization (Ak, 2000: 135,170).

Head physician, would never care medical services except of the hospital services. In hospitals, management of medical and administrative services are separated. In this chapter various examples are given for health and hospital management, personnel, and organization. As a result; Ottoman Empire which has affected the world for 600 years, would contribute to researchers and scientific community about the information and practices of management of health and hospital and the organization of the health and hospital. REFERENCES Ak, B. (2000). ”Osmanlılarda Sağlık ve Hastane Yönetimi,” Ak,B.; Ataç,A. Osmanlı Devleti’nde Sağlık Hizmetleri Sempozyumu, 6 Atralık 1999, Sağlık Bakanlığı Yayını, Ajans Türk Matbaacılık, Ankara, s.135 Ak, B. (1990). Hastane Yöneticiliği, Özkan Matbaası, Ankara,s.101 Ak, B. (1987). Hastane İdaresi ve Organizasyonu (Mimograf), Hacettepe Üniversitesi, Sağlık İdaresi Yüksekokulu, Ankara, Ak, B.(1997). Sağlık Yönetiminin Gelişimi, Modern Hastane Yönetimi Dergisi, Yıl-1,sayı2,s.18 Akay, N. (1982). Osmanlı İmparatorluğu’nda Sağlık Örgütleri ve Sosyal kuruluşlar, Hacettepe Üniversitesi Toplum Hekimliği Bölümü, Yayın no:20, Ankara,1982, s.10,21 Akdeniz, N. (1990). Osmanlılarda Hekim ve Hekimlik Ahlakı, İstanbul, s.33 638

Altıntaş, A. (2000). “Osmanlılarda Tıp Eğitimi (Tıbhane-i Amire Dönemi)”, Ak,B.; Ataç, A. Osmanlı Devletinde Sağlık Hizmetleri Sempozyumu,6 Aralık 1999,Sağlık Bakanlığı Yayını, Ankara,2000 içinde s.89,90,91,96,100,101,103, 109,111 Ataç, A. (2000). Osmanlı Devleti’nde Askeri Sağlık Hizmetleri, Ak,B.; Ataç,A. Osmanlı Devleti’nde Sağlık Hizmetleri Sempozyumu, 6 Aralık 1999, Sağlık Bakanlığı Yayını, Ajans Türk Matbaası,Ankara,s.259) Ataç, A. (1996). Gülhane Askeri Tıp Akademisinin Kuruluşu, Atatürk Kültür Merkezi Başkanlığı, Türk Tarih Kurumu Matbaası, Ankara, s.26-31, 76-80,86 Gürkan, K. İ. (1967). Gureba Hastanesi Tarihçesi, Özışık Matbaası, İstanbul, s. 159,161 İlker, F. (1976). Şişli Çocuk Hastanesi Tarihi, Nureddin Uycan Matbaası, İstanbul, s.36-38) Kahya, E. (2000). Bilim ışığında Osmanlılardaki Tıp Çalışmalarının Değerlendirilmesi, Ak,Bilal, Ataç, A. (2000). Osmanlı Devletinde Sağlık Hizmetleri Sempozyumu,6 Aralık 1999, Sağlık Bakanlığı Yayını, Ankara,s.17 Şehsuvaroğlu, N. B.: Demirhan, A.; Güreşsever, G. Ç. (1984). Türk Tıp Tarihi, Bursa, s. 166 Ünver, S. (1950). Hekimbaşı ve Hattat Katipzade Mehmed Rafi, İstanbul, s. 33) Sarı, N. (2000). ”Osmanlı Hekimliği ve Tıp Bilimi”, Ak, B.; Ataç, A. Osmanlı Devletinde Sağlık Hizmetleri Sempozyumu,6 Aralık 1999, Sağlık Bakanlığı Yayını, Ajans Türk Matbaası Ankara, s. 21,-25 Sarı, N. (2000). Osmanlı Devleti’nde Sağlık ve Sosyal Cemiyetler ve Hemşirelik, Ak,B.;, Ataç. A. Osmanlı Devleti’nde Sağlık Hizmetleri Sempozyomu 6 Aralık 1999, Sağlık Bakanlığı Yayını, Ajans Türk Matbaası, Ankara, s. 233-237 Şevki, O. (1991). (sadeleştiren; İlter Uzel), Beşbuçuk Asırlık Türk Tababeti Tarihi, Kültür Bakanlığı Yayınları, Ofset Repromat, Ankara, s.88-89) Taşkıran, N. (1972). Haseki’nin Kitabı, Yenilik Basımevi, İstanbul, 235 Terzioğlu, A. (1979). ”Alberto Bobovio’nun tarifine göre Topkapı Sarayı’ndaki Enderun Hastanesi’nin 17. Yüzyıldaki Teşkilatı”,İstanbul Üniversitesi, Edebiyat Fakültesi, Türkiyat Enstitüsü Milletlerarası Türkoloji Kongresi, Tebliğler,15-20 V, 3.Türk Sanat Tarihi, İstanbul, s.836-837 Uzunçarşılı, İ. H. (1988). Büyük Osmanlı Tarihi, 6. Cilt, Türk Tarih Kurumu Basımevi, Ankara, s.525,526

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Chapter 59 Network Analysis; Accessibility to Hospitals with Remote Sensing and Geographic Information Systems Techniques: A Case Study of Konyaaltı, Antalya-Turkey Mesut ÇOŞLU, Serdar SELİM, Namık Kemal SÖNMEZ, Dilek KOÇ-SAN INTRODUCTION Humans and / or vehicles are transported from one location to another by network systems. In general, networks connecting sites/environment is a complex system consisting of linear features. The adequacy, capacity, size and quality of this system are the factors affecting the human life. In this context, transportation as a network system that we use in our daily lives, especially to ensure the survival of people in emergency situations, is one of the important factors. Road networks usually develop as a result of a public policy for serving some purposes. Generally, the road networks development aims to raise social and economic growths by increasing linkages within a region, facilitating people movements, services, and goods (Patarasuk & Binford, 2012). Furthermore, in order to achieve optimal health services, supporting the urban infrastructure and transport network is required. Because as soon as access to patient can be provided with the most appropriate route in relevant areas. The reliability and accessibility of urban infrastructures, especially urban roads, have attracted a lot of attention since 1990s (Jenelius et al., 2006). Because, accessibility in a short time has become a priority for people. In this context, accessibility analyses can be considered as a suitable way to assess interactions between transportation and land use (Silva & Pinho, 2010; Salonen & Toivonen, 2013). It is known that geographical accessibility is a prominent variable in conceptual discussions of the multiple dimensions of health service accessibility (Love & Lindguist, 1995). The subject of transport has a complex relationship with many parameters. The complexity of this relationship is not often adequate to be analysed and managed by people. Therefore, the use of GIS to manage this complex relationship is used in widespread. Because, GIS can work with data in multiple and complex structure (Feridun, 2010). GIS software in the network module can analyse the transportation system, the selection of the most appropriate route network through spatial modelling. 

Grad. Student, Akdeniz University, Institute of Science, Department of Space Sciences and Technologies.  Assist. Prof. Dr., Akdeniz University, Faculty of Science, Department of Space Sciences and Technologies  Prof. Dr., Akdeniz University, Faculty of Science, Department of Space Sciences and Technologies  Assoc. Prof. Dr., Akdeniz University, Faculty of Science, Department of Space Sciences and Technologies

In this study, by using Geographic Information Systems (GIS) based network analysis, accessibility to the hospitals in the region selected as a research area was analysed. The accessibility was mapped on the basis of intervention services to reach in 3, 5 and 9 minutes’ time. With this principle, planning of the region for the future is aimed to guide with this work. MATERIALS and METHODS Study Area The study area is Konyaalti district of Antalya province in the Mediterranean Region in the southwest of Turkey. Its area is 562.4 km2. The population of the district is 154920 according to data from address-based population registration system (TSI, 2015). There are 39 neighbourhoods in Konyaalti district. The neighbourhoods selected as study areas are Siteler, Uncali, Molla Yusuf and Akkuyu neighbourhoods. The total area of these neighbourhoods is around 6 km2. According to TSI data in 2015 total population of the study area is 40417. In this area there are two health facilities one of which is a private hospital and the other one is Uncali District Polyclinic affiliated to Antalya Training and Research Hospital (Figure 1).

Figure 1: Study area

Material In the study, written and visual documents belonging to the selected district were used as research materials. At this stage, 1/1000 scaled master plans of the study area, current satellite data, data of the health institutions in the study area were obtained from the relevant institutions and organizations. There are two main materials one of which is particularly circulation systems in master plans used in the stage of obtaining the 641

G

analysis, and the other one is Geographic Information Systems (GIS) used in the creation stage of the analysis. GIS is a system designed to capture, store, update and query the spatial and nonspatial data in different layers, and it consists of personnel, data, software and hardware. The network analysis in GIS uses complex and intense detailed networks created by geographic object having linear property and network analysis support the decisionmaking process. In addition, in the case of temporary obstacles that can occur on the road. The route which will provide the transportation from one point to another point as quickly as is set with the help of network analysis. The shortest-path problem and sevice areas analysis are solved by means of the Dijkstra's algorithm. The algorithm obtains a junction from the set of junctions,which has the minimum shortest-path estimate, repeatedly. The service area solver can produce lines and/or polygons surrounding these lines. The polygons are obtained by placing the lines’ geometry of traversed by the Service Area solver into a triangulated irregular network data structure (Esri, 2016). Service areas analysis is the other analysis to be made with network analysis. The areas which are accessible or non-accessible around a specific location on a network in specific time intervals can be found through the service areas analysis. Method The study basically consists of 3 stages as data collection, digitization and analysis (Figure 2).

STE PI

OAL

Accessibility to Hospitals Master Plan Data Collection

STE P II

Satellite Image Processing Road Data

Relevant Documents Digitization

STEP III RE SULT

Creation of Road Processing of Attribute I f

Updating Road Data

Services Area Analysis

Hospital Data

Network Analysis

The Shortest Path Analysis

Assessment

Figure 2: Flowchart

In the first stage, 1/1000 scaled master plans of the study area were obtained. In addition, written and visual documents relating to health facilities within the boundaries of the study area were provided. Current satellite data were used in order to check the accuracy and currency of both the obtained data and master plans, and to make the necessary arrangements objectively. At the digitization stage, road center lines belonging to the study area obtained from the related state institutions and organizations were placed on the current satellite image. 642

The roads which were included on the current satellite image but not in the digital road data and master plans were updated through the screen digitization method. During the updating process, it was also provided that the required junctions were created in order to show significant connection feature of linear data. Road center lines were regarded as open to both directions, and one direction situations of the roads were not taken into account. It was determined that the speed limit was 50 km/h for emergency vehicles on all roads. At this stage, the coordinates of the private hospital and district polyclinic within the study area were transferred into GIS as vector data. Then, the attribute information of the health facillities used as emergency units in the study and current road data were created. Then, a network dataset was created with all obtained road data. In the analysis stage of the study, two basic network analysis were conducted. First of all, service areas analysis was carried out. While performing service areas analysis, it was determined to which areas the private hospital and the district polyclinic designated as emergency units could reach in 3, 5 and 9 minutes (Larsen et al., 1993; Erkal & Degerliyurt, 2013). Thus the areas outside the service areas were identified. By means of detecting the areas which are outside the service areas of the emergency units and are non-accessible within the required time, it is predicted that this analysis will be guiding in prudential physical plans of the area. After service areas analysis, the shortest path analysis computing the most appropriate route from A point to B point was conducted. While analyzing the accessibility from the shortest path, a sample accident scenario was created. Determination of the most appropriate route to this scene of the accident is crucial in terms of the first intervention to injured people.After the first invention to the injured people, it is also vital to direct them to the appropriate health facility using the shortest path. RESULTS The first analysis conducted in the study was service areas analysis. Through this analysis in the first stage it was determined to which areas the hospitals in the study area could reach the surrounding areas in 3, 5 and 9 minutes (Figure 3).

Figure 3: The accessible areas for the emergency facilities in 3, 5 and 9 minutes 643

As a result of the service areas analysis, it was detected that the ambulance from the private hospital and the district polyclinic in the study area could reach 10.83% of the study area in the first 3 minutes, 26.33% in 5 minutes and 68.00% in 9 minutes (Table 1). Table 1: The accessible and non-accessible areas in a required time Service Time (minute)

Area (km2) 0.65 1.58 4.08 4.08 1.92 6.00

3 5 9 Accessible Area Non-Accessible Area Total Area

% 10.83 26.33 68.00 68.00 32.00 100.00

Nearly over half of the non-accessible area within the study area is the district located in the west of the belt highway. This district has a location which is quite close to the health facilities. As there was no road connection between this district and the health facilities through the belt highway, this district was analysed as a non-accessible area in 9 minutes. However, by means of road connection made from two points it was detected that the accessible areas could be increased to 12.66% in 3 minutes, 36.00% in 5 minutes and 86.67% in 9 minutes (Figure 4; Table 2).

Connec tion

Connec tion

Figure 4: The accessible areas for the emergency facilities in 3, 5, ve 9. minutes after two connection

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Table 2: The accessible and non-accessible areas after two connection in a required time

Service Time (minute) 3 5 9 Accessible Area Non-Accessible area Total Area

Area (km2) 0.76 2.16 5.20 5,20 0,80 6.00

% 12.66 36.00 86,67 86,67 13,33 100.00

The second network analysis carried out in the study was the shortest path analysis which directed the emergency response vehicles to the scene of accident from the shortest and the most appropriate route. To that end, a sample accident scenario was built in a school district within the study area. Then the travel-time to the scene of accident of two health facilities (the private hospital and district polyclinic) in the study area was calculated (Table 3). As a result of the shortest path analysis, it was detected that the ambulance from Private Uncali Meydan Hospital (Route 1) could reach the scene of accident in 5.88 minutes (Figure 5). While detecting the ambulance directed to the scene of accident, the ambulance using the shortest path should be preferred because the first response to the emergency situations will be done by the health team coming with the ambulance. After this stage, it will be necessary that the injured person should be taken to the most appropriate health facility according to the condition of the injured person.

Figure 5: The nearest emergency facility to the scene of the accident

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Table 3: The arrival time to the scene of the accident

Unit Name Private Uncalı Meydan Hospital Uncali District Polyclinic

Arrival Time (minute) 5.88 6.56

CONCLUSIONS As it is unpredictable when the emergency situations will occur, GIS provides to act planly at the time of intervention. Moreover, GIS has an active role in using spatial and non-spatial data including complex and intense detail. Cities have developed and changed rapidly. Therefore it is quite important to keep up-to-date the spatial road data used in GIS and the attribute data of the emergency facilities. In GIS, network analysis contributes to planning the location of the emergency facilities and directing the emergency response vehicles to the relevant cases. This can only be possible to keep the data up-to-date constantly. It was detected that the health facilities in the study area could reach 68.00% of the area in 9 minutes but not reach 32% of the area. For the non-accessible area in the northwest of the study area, the area which could be reached in the first 9 minutes was increased to 86,67% by means of the road connection done on specific district on the belt highway. In addition, the non-accessible area was decreased from 32.00% to 13.33%. It was determined that in the shortest path analysis conducted in the study the Private Uncali Meydan Hospital was the nearest health facility to the scene of accident. The ambulance directed to the scene of accident will be able to reach the accident black spot in approximately 5.88 minutes. It is a quite important issue to intervene rapidly to the emergency situations especially in terms of human life. The roads which are basic data and used in network analysis should be arranged in an appropriate way in order to prevent the emergency response vehicles from losing time in traffic. For future work, we plan to carry out a similar study for fire stations and police stations. Acknowledgement We would like to thank Bahar ÇOŞLU for her contribution to the language editing. REFERENCES Erkal, T. & Değerliyurt, M. (2013). Eskişehir’de Acil Durum Yönetiminde Ağ (Network) Analizlerinin Kullanılması. Türk Coğrafya Dergisi 61: 11-21. Esri. (2016). Algorithms Used by the ArcGIS Network Analyst Extension. (Accessed: 23.04.2016). Feridun, D. (2010). Kırşehir’in merkez İlçesinde Acil Durumlarda İtfaiye, Sağlık Kuruluşları ve Polis Ekipleri için Network Analiz Teknikleri Kullanılarak En Uygun Güzergahların Belirlenmesi. Kahramanmaraş Sütçü İmam Üniversitesi Sosyal Bilimler Enstitüsü Coğrafya ABD, Yüksek Lisans Tezi, 62s. Jenelius, E., Peterson, T., Mattsson, L.G. (2006). Importance and Exposure in Road Network Vulnerability Analysis. Transportation Research Part A: Policy and Practice Volume 40, Issue 7, pp. 537–560. Larsen, M.P., Eisenberg, M.S., Cumminis, R.O. and Hallstrom, A.P. (1993). Predicting Survival from out-of-Hospital Cardiac Arrest: A Graphic Model. Ann. Emerg. Med. 22(11), 1652-1658. 646

Love, D. & Lindquist, P. (1995). The Geographical Accessibility of Hospitals to the Aged: a Geographic Information Systems Analysis Within Illinois. Health Services Research, 29(6): pp. 629–651. Patarasuk, R. & Binford, M.W. (2012). Longitudinal Analysis of the Road Network Development and Land-Cover Change in Lop Buri Province, Thailand, 1989–2006. Applied Geography Volume 32, Issue 2, pp. 228–239. Salonen, M. & Toivonen, T. (2013). Modelling Travel Time in Urban Networks: Comparable Measures for Private Car and Public Transport. Journal of Transport Geography Volume 31, pp 143–153. Silva, C. & Pinho, P. (2010). The Structural Accessibility Layer (SAL): Revealing How Urban Structure Constrains Travel Choice. Environment and Planning A, 42 (11), pp. 2735–2752. TÜİK. (2015). Konyaaltı İlçesi Adrese Dayalı Nüfus Kayıt Sistemi (Accessed: 01.04.2016).

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Chapter 60 The Organization of the Health Care Services in Turkey Sabahattin TEKİNGÜNDÜZ INTRODUCTION One of the important factors which determine the health care services to be useful for the people in a country is organization (Dirican, 1970). The health care services organization of the countries (finance, payment, accessible, etc.) may differ according to the economic and social conditions which they are in. When the world health care services organization is looked at, it is being seen that beside the health care services supply being provided by both the public and the private sector, the taxes, social insurance contributions, pay out of pocket and private health insurance can be present at the same time in finance too (Akdur, 1999; Tatar, 2011, WHO, 2000). While the first of the regulation studies which shaped the organization structure (central-provincial) of the Ministry of Health in Turkey is “Law on the Organization of the Ministry of Health and Social Assistance (Law No. 3017), and dated 23/06/1936, the second one is “The Decree on Organisations and Duties of the Ministry of Health” numbered 181 (Statutory Decree No. 181), and dated 14/12/1983. The third and the last regulation which radically changed the structure of the organization on the other hand is “The Decree on Organisations and Duties of the Ministry of Health and the Affiliated Institutions” numbered 663 (Statutory Decree No. 663) which was published in the Official Gazette dated 02.11.2011. With the Statutory Decree No. 663 having taken effect, the Statutory Decree No. 181 which regulated the organization structure of the Ministry of Health and the Affiliated Institutions was abolished and beside this changes were made in a lot of laws too. In this study undertaken the important regulations which changed the organization structure of The Ministry of Health in Turkey took their place. After having mentioned the regulation studies undertaken between the years of 1923 and 2003 briefly, the regulation changes and applications undertaken in the context of the Health Transformation Program (HTP) which took effect in the year of 2003, were mentioned. The organization of health care services from the year of 1923 until the year of 2003 In Turkey the studies of “Health Legislation” has taken an important place in the period of from the declaration of the Republic (1923) until the year of 1938, the central and provincial organization of the ministry has formed in this respect, the founding of the management and the applications of health have been established. Although the integration and the expansion across the country of the health care services, the bringing of all the services to a status of the duty and responsibility of the central government were aimed at in the First Ten-Year National Health Plan which took effect in the year of 1946, this plan could not be applied as required. The Social Insurances Agency 

Assist. Prof. Dr., Department of Health Care Management, School of Health, Mersin University, Turkey. [email protected].

(SIA), which began to supply health care services for the workers in the year of 1952, was provided with the ownership of the rights of establishing, managing hospitals and appointing personnel. With the hospitals connected to the special city administrations, municipalities and charities being connected to the Ministry of Health with the Law numbered 6134 in the year of 1954, the management of the hospitals belonging to the public was collected in one hand and completely brought to a status of the duty and responsibility of the central government (except for SIA, Ministry of Defence, and University Hospitals). As also can be understood from all of these applications, the general policy of the Republic from its beginning has been in the direction of the health care services being a public responsibility and duty (Akdur, 1999;Tengilimoğlu, 2012). In the new Constitution on which a referendum was held on the date of 9th July 1961 and was accepted, Turkey was described as “a social law state”, health was determined as a right and also the health care services were accepted as a duty for the state. The Law of the Socialisation of Health Care Services (SHCS) having the Law No. 224 (Law No. 224 SHCS) was published in the Official Gazette on the date of 12th January 1961 and the applications of the socialisation of the health care services was first begun to be applied in the city of Muş in the year of 1963. With the Law No. 224 SHCS; a. All the health care services in Turkey being the duty of the state, b. By expanding the Primary care services to the reach of the villages supplying everybody with the health service, c. The carrying out of the services of the preventive and curative medicine together, d. The management of the health care services in the public sector in one hand, e. The integration with the people, f. The providing of the staged health service (referral system) g. The principal of full-time working of the doctors in the public sector was brought into effect (Pala, 2007; Kurt and Şaşmaz 2012). When the Law No. 224 SHCS was accepted in the year of 1961, the socializing of the health services throughout the whole country was stated to be put into practice at the latest until the end of the year of 1992 (Law No. 224 SHCS: Article 20). Law No. 224 SHCS was successfully applied between the years of 1963-1965. However with the State Personnel Law which was accepted at The Grand National Assembly of Turkey in the year of 1965, the principle of the employment of the doctors and the other health personnel under contract was withdrawn from effect. Hence as a result of this the working full-time principle of the Law No. 224 SHCS could not be applied. This was the first important reason why the law could not be successfully applied (TTB, 1991). Hence it transformed into an unsuccessful application from the year of 1966 onwards (Pala, 2007).It is possible to enumerate the reasons of this failure as follows (Aksakoğlu, 2008; Kurt and Şaşmaz 2012): a. Some Ministers and managers did not believe in the necessity of the law and betrayed personnel's trust. b. Enough number of doctors was not appointed to the hospital and health centres. c. Education oriented service was not given to the doctors and the other workers at the schools. d. Hospital cooperation with the health centres was not established. e. The management at the level of city and group presidency proved to be 649

insufficient. Personnel allowances were not paid and no tools, instruments or medicine were given. g. The socializing application supposed to be limited with “health centres”, the hospitals were left apart. h. In time a structuring and working mode suitable for the health problems of the town could not be achieved in the urban districts. i. Single-headedness in the health care services could not be achieved. j. A mentality of scientific health management could not be institutionalized. The socialization including at the greatest extent the principles of the documents such as “The Alma-Ata Declaration -1978”, “Health for all by the year 2000–1984” and “Health21 targets–1998” which were published after itself and determined the public health policies, is an indicator of “the failure” resulting not from the system but the prevention of the socialization project (Kurt and Şaşmaz, 2012). Neoliberal restructuring began in the late 1970s (Kotz & McDonough, 2008) and spread across the developing world in the 1980s under the administrations of Reagan and Thatcher, and in 1990s, with the collapse of communism (Gamso, 2010). Neoliberal policies, in order to deregulate the ways through which the states organize themselves and perform public services, redefined the nature of the practices exercised in the field of public administration (Uluskaradağ, 2011). Public service provision began to limited, and States' role in health care began to decline. The private sector began to grow steadily. In shaping the health sector, the structural adjustment programs (funded by the World Bank and the IMF) has started to be effective. This progression has not taken long to make its impact felt also on Turkey and with the Decisions of 24th January 1980 it has achieved the qualification of the official and written government policies. As an extension of this the policy, which took the health and social security services as the services made use of under the supply and demand rules of the market, has become to be the official policy. Hence by regulating anew of The Constitution of the Republic of Turkey “The Active Privatization Period” began (Akdur, 1999). In the 1982 Constitution prepared the qualification of the state being a social state was changed. The concept of “the state founded on the human rights” which took place in the 1961 Constitution was transformed to the form of “the state respectful for the human respects” in 1982 Constitution. Beside this principal change in the providing of the health care services after the military coup in 1980 became the achievement of giving place with priority to the private sector in the providing of services. In 1987 beside the law of socialization of the health services not being withdrawn from effect, The Basic Law of Health Services which was to replace it was accepted. According to this law the main components of the studies of the Health Reform which was undertaken in the years of 1990s were those: the Social Security Institutions being collected under a single roof the establishment of the General Health Insurance, the development of the First stage health services within the framework of the family medicine, the Transformation of the hospitals to selfgoverning establishments, the providing of the Ministry of Health with a structure which plans and controls the health services giving priority to the preventive health care services. The 1990s became the years in which a rapid increase in the number of the health institutions providing private services and the development of the health field as a “Market” for the private health insurance came to life in Turkey. When the period of f.

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1980-2002 is taken into hand as a whole, the economic policies have continuity in the dimension of liberalisation named as “Structural Adjustment”. The governments taking power in this period took as a basis the policies which were compatible with the neoliberalism and produced the policies which were suitable for the suggestions of “restoration” coming from the international institutions (Pala, 2007; Mavi, 2010; The Ministry of Health, 2012a). The organization of health care services from 2003 until our day The new government taking power after the year of 2002 introduced to the society the changes and the transformations which were previously pronounced to be reform and subsequently as well to be project in health, as the “HTP” in the year of 2003. “The HTP’s objective is to make the health system more effective by improving governance, efficiency, user and provider satisfaction, and long-term fiscal sustainability (OECD, 2008)”. It has been put forward that the program, as is shown in the Figure 1, has been prepared as a structural, planned and sustainable model of Turkey which takes into account the global developments and is suitable for the socio-economic realities of the country. It was stated that the program was built upon the moral understanding aiming at all the citizens as the persons of the country owning equal rights to reach the health services in justice.

Figure 1: Health Transformation Program Model Source: The Ministry of Health, 2012a.

The Ministry of Health has put forward various arguments which will justify the starting of the “HTP” that it has put into application. Some of these arguments are as follows (The Ministry of Health, 2012a; The Ministry of Health, 2011); Finance a. There was a multiple and fragmented health finance system. b. There was no harmony and coordination between the relevant units (The Ministry of Health, Ministry of Labour and Social Security, Ministry of Finance, State Planning Organisation and Treasury) of health financing. c. The absence of a correlation between the rate of increase in the health expenditures and the rate of increase of national income. d. While performing health finance calculations, merely health care costs used to be taken into consideration; micro, macro and social welfare costs used to be ignored. e. There was neither vertical equity (distribution of burden between the rich and the poor) nor horizontal equity (equity between those who are at the same level of income) in health financing. f. The absence of a social security system encompassing the whole population. 651

Payment Fixed payment irrespective of the quantitative and qualitative a. Informality, b. Waste of resources, c. long waiting period, d. Unnecessary referrals, e. Informal payment. Organization a. Disruption in emergency services, b. Insufficiency in preventive services, c. High lack of services and imbalance in some regions, d. Widespread private practice business(obligatory payment out of pocket), e. Uncared hospitals and widespread ward type rooms, f. Insufficiency of medical device. Regulation a. Fragmentary structure in the providing of public health, b. Abandoning the health services to the conditions of the market, c. Excessive bureaucratic processes in the providing of public health, d. The insufficiency of the private sector share in the health services, e. Irregularity and imbalanced distribution in appointments and transfers, f. The determination of the medicine prices in an unsystematic manner. Behaviour a. The lack of workers’ motivation, b. The patients’ general preference of hospitals in examination, c. The absence of behaviour change programs for healthy life, d. The absence of programs oriented towards patient adaptation, e. The absence of institutional structures which protect the rights of patients, f. The absence of choice of doctor in public. The aim of HTP which was prepared on the basis of the reasons above was stated as the efficient, productive and equitable organization, the finance supply and providing of the health services. The principles determined to achieve these aims on the other hand are human-centeredness, sustainability, continual quality development, participation, agreement, voluntariness, the distinction of powers and competition in services (Sağlık Bakanlığı, 2003).When the principles, which were explained by the Ministry of Health, are investigated, it is being understood that the main approach of the “Transformation in Health” is the providing of the health finance with a insurance system, the withdrawal of the Ministry from the providing of the health service and the providing of the health services by the private health sector (Pala, 2007). With this aim a new organizational structure has been put forward. The Ministry of Health explains what kind of a method will be followed regarding the HTP as well under the topic of “The Components of the HTP”. These are (The Ministry of Health, 2008): 1. Ministry of Health as the planner and supervisor, 2. General health insurance gathering everyone under single umbrella, 3. Widespread, easily accessible and friendly health service system, a. Strengthened primary health care services and family medicine, b. Efficient and gradual referral chain, 652

c. Health facilities having administrative and financial autonomy, 4. Health manpower equipped with knowledge and skills and, working with high motivation, 5. Education and science institutions to support the system, 6. Quality and accreditation for qualified and efficient health services, 7. Institutional structuring in the rational management of medicine and supplies, 8. Access to effective information at decision making process: health information system. The Ministry of Health, proclaiming the execution of a transparent management style during the preparation and application processes of the HTP, used to point out that the studies undertaken would be announced to the public (via web site) on a continual basis. Besides this it used to be alleged that the views of the scientists, trade bodies, trade unions, industrial institutions, business world, private sector health entrepreneurs, voluntary institutions, political parties, members of the parliament and the people in the country would be taken during the process and the studies being enriched by these views optimum solutions would be produced (Sağlık Bakanlığı, 2003).The Ministry has divided the process of HTP into four stages. At the first stage the conceptualization is being mentioned about; it is being explained that the stage of the legislation will follow this. According to the Ministry afterwards the functional and dysfunctional sides of the systems will be seen with the controlled local applications; following this the program’s spreading throughout the general of Turkey will be implemented at the last stage (Pala, 2007).Before the Statutory Decree No. 663 which took effect in the year of 2011, some changes were made on both conceptual, regulation and also application subjects about the Transformation in Health. In the context of HTP with the Statutory Decree No. 663 and dated 02/11/2011,the Statutory Decree No. 181 which regulates the organizational structure of the Ministry of Health and the Affiliated Agencies, was withdrawn from effect and changes were made in a lot of laws. Below the organizational structure which was shaped by the Statutory Decree No. 663, will be mentioned about. The Central Organisation of the Ministry of Health One of the last stages of the HTP, which is shaped by the take-over of the Social Insurances Agency, General Health Insurance, Family Medicine and Full-time regulations, is the restructuring of the Ministry of Health. Restructured Organizational Structure of the Central Organisation of the Ministry of Health of Statutory Decree No. 663 is being shown below (Figure 2). As can be seen in the Figure 2 at the most top point of the central organisation there is the Minister of Health. Minister’s Private Secretary, Ministerial Advisors, Undersecretary and Deputy Undersecretaries and Deputy Minister undertake duties as being directly connected to the Minister. With the Statutory Decree No. 663 the organizational structure of the Ministry of Health has undergone a radical change under the name “Central and Provincial Organisation and the Affiliated Agencies”. A. Affiliated Agencies(Statutory Decree No. 663); 1. Public Health Agency of Turkey 2. Pharmaceuticals and Medical Devices Agency of Turkey 3. Public Hospitals Agency of Turkey 4. General Directorate of Health for the Borders and Coastal Areas of Turkey are classified in four groups. 653

Figure 2. Central Organisation of the Ministry of Health Source: The Ministry of Health, 2012b.

1. Public Health Agency of Turkey It was founded in order to execute preventive health services and first stage health services and undertake the necessary regulations. As can be seen in the Organizational Structure of Public Health Agency of Turkey (Figure 3), connected to the President of the Public Health Agency there are Legal Consulting, Audit Services, Presidencies of the Strategy Development and Internal Control Units. Besides this connected to the president, also five assistants in charge of carrying out the work and operations related with the central and provincial organizations undertake duties. 2. Pharmaceuticals and Medical Devices Agency of Turkey The duty of the Agency is to perform regulations about the medicine, the effective and contributory substances used in the production of medicine, substances subject to national and international control, medical devices, in-vitro medical diagnostic devices, traditional herbal medical products, cosmetic products, homoeopathic medical products and special purpose dietary food.

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Figure 3. The Organizational Structure of Public Health Agency of Turkey (Center) Source: http://www.thsk.gov.tr/kurumsal/organizasyon-yapisi.html.

3. Public Hospitals Agency of Turkey The duty of the Agency is the opening and operating the mouth and dental health centres of the hospitals and similar health institutions, observing, evaluating and controlling their activities in order to provide the second and the third stage health services. Besides this the agency is also in charge of providing all kinds of preventive, diagnostic, therapeutic and rehabilitative health services at these hospitals. As can be seen in the Organization Structure (Figure 4) connected to the President of the Public Hospitals Agency there are Legal Consulting, Audit Services, Presidencies of the Strategy Development and Internal Control Units.

Figure 4. The Organizational Structure of Public Hospitals Agency of Turkey (Center) Source: http://www.tkhk.gov.tr/646_teskilat-semasi

Besides this connected to the president, also five assistants in charge of carrying out the work and operations related with the central and provincial organizations undertake duties. 655

4. General Directorate of Health for the Borders and Coastal Areas of Turkey The duty of the directorate is to carry out the responsibilities resulting from the provisions of the international contract and regulations related with the Turkish channels, borders and coasts. B. Health Policy Board Its main duty is to state the policies of the Ministry and the health system. The Board consists of eleven members and the Undersecretary and undersecretary assistants. The board members are given duty by the Minister from among the ones who are the graduates of higher education of at least four year duration and have eight year of work experience. Consultative boards and commissions (universities, vocational institutes, trade unions, representatives of civil society) can be constituted within the body of the board. C. Service Units (Statutory Decree No. 663); 1. General Directorate of EU and Foreign Relations It has the duties of carrying out and developing the relations with the foreign countries and international institutions in the health field and carrying out the studies regarding the legislative and administrative regulations related with these. 2. General Directorate of Health Information Systems It has the duty of determining the country-wide policies, strategies and standards related with the information systems and communication technologies used in the health field. 3. Presidency of Strategy Development It has the duties of doing researches oriented towards the development, usage in an effective and productive manner of the financial resources of the Ministry and the affiliated agencies or having them done and taking the necessary precautions. 4. General Directorate of Health Promotion Its duty is to increase the knowledge, awareness and control abilities related with the health of the society and the individual and motivate them to take responsibility about this subject and participate in the decision processes, to generate and maintain behaviour change oriented towards the protection of individual health and the increasing of the health level. 5. General Directorate of Health Research Principally it has the duty of doing/having done and publishing researches in the fields in which there is a need for the determining, observation, evaluation of the health policies, the increasing of the health level of the country and the development of the health services. 6. Office of Legal Consultants It is in charge of and responsible for the works and operations related with legal consulting involved in the administration. 7. General Directorate of Administrative Services Its duty is carrying out studies and making proposals about the labour force planning, the development of the human resources system and the generation of the performance criteria and executing the personnel affairs of its staff.

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8. General Directorate of Emergency Health Services Its duty is the planning and the execution of the health services (on the subjects such as communication, medicine, medical and technical material), the maintaining of the cooperation and the coordination between all the parties throughout the country in the case of disasters and emergency situations. Besides this in case of the disasters and emergency situations which take place abroad, it is to participate in the health and humanitarian aid activities in cooperation with the national and international institutions and civil society organizations. 9. Audit Services Unit It has duties such as developing the methods and the techniques regarding the audit, providing the generation of the standards and principles in the audit field, preparing audit guides, taking the precautions which increase the effectivity and the productivity of the audits. 10. General Directorate of Health Investments It has duties such as carrying out the engineering services compatible with the requirement programs which are determined for the buildings that will be used in the services of the Ministry and the affiliated agencies, preparing or having its projects prepared. 11. General Directorate of Health Services It has duties such as the planning of the health services (preventive, therapeutic and rehabilitative), the planning of the health services such as organ and tissue transplantation, blood and blood and blood products, dialysis, assisted-reproduction treatment, home health care, burns, intensive care and the providing of the coordination between the related parties, carrying out the authorisation processes of the health institutions and organizations, determining or approving the price lists of the health services, determining the standards of the health occupations. Provincial Organization of the Ministry of Health With the Statutory Decree No. 663 while the central structure of the Ministry of Health changed as explained above, its provincial structure changed too. With the new regulation the health services in the city have been shaped by a triple-structure. Of these the first one is the Provincial Directorates of Health, the other the Public Hospital Union and still other the Directorates of Public Health. The organization of the Public Health Agency of Turkey in the province has been structured as the Public Hospital Union and general secretaries have been constituted for high level management. Also directorates of public health have been established in the cities from the affiliated agencies for the Public Health Agency. In Figure 5 the relationship between the Ministry of Health and this triple-structure and the relationship of the triple-structure in between themselves are being shown. Provincial Directorates of Health The Provincial Directors of Health is the representative of the Minister in the city, his/her consultant of health. He/she monitors and controls whether the services provided by the provincial organizations of the affiliated agencies are carried out according to the policies of the Ministry or not. He/she maintains with the aim of providing of the integrity of the service the coordination between the Ministry and the provincial organization of the affiliated agencies (Public Hospitals Union, Directorate of Public 657

Health).Besides this he/she also controls the private health institutions. He/she directly carries out the pre-hospital emergency health services in the cases of disaster and emergency. The number of the assistants connected to the director in the city changes according to the size of the city. Below given is the Organization Structure of the Provincial Directorates of Health (Figure 6).

Figure 5. The Relationship between the Ministry of Health and the Province Source: This figure is adapted from Ak, 2015 and Jakab et al., 2014.

Public Hospital Union As also pointed out above the World Health Organization and the World Bank have a great share in the Health policies applied in Turkey after the 1980s. Of the mentioned policies one is also the autonomization of the hospitals (Belek and Belek, 1997). As a matter of fact it was also stated in the seventh, eighth and ninth Five-Year Development Plans that the hospitals would be made to achieve administrative and financial autonomy and the legal regulations related with this would be made (URL 1). The change of regulation related with the autonomization could be realized as late as with the Statutory Decree No. 663 which took effect on the date of 02.11.2011. Statutory Decree No. 663 (related Health facilities having administrative and financial autonomy component) focuses on restructuring public hospitals as part of a new competitive environment. In the new system, all hospitals will enter into contracts with the Social Security Institution, in competition with one another, thus requiring 658

changes to their administrative and financial structures to operate in such an environment. Public hospitals finance their activities with their own revenues and will be responsible for the quality and efficiency of services (Tatar et al., 2011).

Figure 6. The Organization Structure of the Provincial Directorates of Health Source: The Ministry of Health, 2012b.

With the Statutory Decree No. 663, the second and the third stage health institutions (hospitals, the mouth and dental health centres except for the E2 and E3 group hospitals) which are connected to the Public Hospitals Agency of Turkey began to be operated as connected to the Public Hospital Unions at the level of city. The Public Hospital Union is constituted of the General Secretariat and hospital directorate. The General Secretariat is the decisive and the executive organ of the Public Hospitals Union. The General Secretary is the highest director and the executive organ of the Public Hospitals Union. Within the body of the General Secretariat the directorates of medical services, financial services and administrative services were formed. With the new regulation 89 unions were built in Turkey general. Taking the greatness of the 659

service into consideration in Istanbul 6, in Ankara 3 and in İzmir 2 unions were established. In these cities one union secretary has duty at the same time as a coordinator. The organization structure belonging to the Public Hospitals Union is being shown in Figure 7.

Figure 7. The Organization Structure of Public Hospitals Union (Provincial) Source: The Ministry of Health, 2012b.

The hospitals connected to the Public Hospitals Union are managed by the director of the hospital as being connected to the general secretary. As being connected to the director of the hospital Chief Physician, Administrative and Fiscal Affairs Director, Health Care Services Director and the Directorate of Patient Services and Health Hotel Management have been constituted. The sizes of the hospitals taken into consideration by the institution, one person may undertake the duties of hospital director and chief physician at the hospitals. In addition to this on condition that the norm and the standard put by the institution not exceeded, the general secretary determined number of chief physician assistantships and director assistantships may be generated (Tengilimoğlu, 2012).According to Statutory Decree No. 663 in the unions the workers of the general secretariat and the directors in duty at the hospitals are being employed on a contractual basis. While the President of the Public Hospitals Agency of Turkey makes contract directly with the General Secretary, the Presidents, the hospital directors, chief physician and managers make contract on offer of the General Secretary. On the offer of the Hospital President and chief physician with the assistants of the Chief Physician and on offer of the manager contract is being made with the manager assistants. Depending on the realizations in the performance targets of the contract appendix 660

contracts can be terminated before its timeline as well. In case the general secretary changes because of unsuccessfulness the contracts of the presidents and the hospital managers causing the unsuccessfulness end automatically (Statutory Decree No. 663, Article 32). The hospitals connected to the Public Hospitals Union are being made subject by the Public Hospitals Agency of Turkey or the private agencies to be determined by the ministry in six months or one year periods to evaluation according to the criteria determined. In the evaluation, i. Medical criteria, ii. Financial criteria, iii. Quality, iv. Patient/worker safety, v. Education criteria, are being used. According to the results of the evaluation the hospitals are grouped from the top to the bottom as being (A), (B), (C), (D) and (E). The group of the union is determined according to the weighted average of the hospitals. According to the results of the evaluation made, in the cases of the union’s; a. being dropped from the group, b. not being able to be carried up to the higher group in the third evaluation given its being taken over in group (D), c. not being able to be carried up to the higher group in the second evaluation given its being taken over in group (E), d. one of the hospitals within its body being dropped group in both of the evaluations executed successively, e. this hospital not being able to be carried up to the first higher group in the second evaluation given its being taken over with the group (E) hospital, the duty of the general secretary is being terminated by the Public Hospitals Agency of Turkey. In case the conditions listed in the (a), (b) and (c) articles of this clause happen on the hospital scale on the other hand, the general secretary terminates the duty of the hospital manager. The weighted average of the unions determined as a result of the evaluations made is to be taken as a basis in measuring the performance of the President of the Public Hospitals Agency of Turkey. With the Statutory Decree No. 663 the duties, rights and responsibilities of the directors who participate in the management of the union are being given below. The duties of the general secretary: a. Managing the union according to the determined targets, policies and strategies, related regulations and the performance program. b. Controlling and evaluating the activities of the union, providing the development of the management, quality and productivity. c. Undertaking the human resources planning which is required by the Agency (employment, education, etc.). d. Providing the coordination between the hospitals and the cooperation with the other agencies and institutions. e. Having budget and investment offers prepared presenting them to the Public Hospitals Agency of Turkey. f. Providing the follow-up of the statistical information related with the union, uniting the financial tables of the union, g. Providing the development of the services oriented towards the patients. h. Providing the accounting services to be carried out. Should the necessity occur the general secretary by way of determining the limits 661

in a written manner may be able to transfer some of its rights to the subunit directors. Some of the duties of the presidents to whom he/she can transfer his/her rights are stated below (Instruction, 2012). Head of Medical Services: a. Providing the medical services and health care services to be carried out in coordination and cooperation. b. Meeting the required resources timely and in accordance with the requirements, doing the requirements planning. c. Carrying out the coordination and cooperation efforts with the other agencies about the undertaking of the emergency health services. d. Having performance and activity reports prepared presenting them to the General Secretariat in monthly periods. e. Carrying out the required studies about the investments. f. Examining the reports of the infection control committee and doing the required studies. Head of Administrative Services a. Carrying out all kinds of personnel affairs of the workers according to the regulation. b. Doing effective and productive human resources planning. c. Planning the requirements such as the support services except the medical services and the equipment and consumables except the medical equipment. d. Carrying out the execution and coordination of the operations of the health information systems and the activities of communication and publicity etc. Head of Financial Services a. Carrying out and following up the bidding and after-bidding processes of the biddings of all kinds of material and service acquirements and construction works required, having the required documents related with these arranged performing the payment operations. b. Carrying out effective stock management. c. Consolidating the budgets accepted by the General Secretary and following up their realizations etc. The hospital manager undertakes duty as the top manager for the Public Hospitals Union at the hospital. The hospital manager having the duties, rights and responsibilities of the General Secretary at the hospital scale, is responsible for the management of the health facilities and the development of the services oriented towards the rights, security, satisfaction and social needs of the patients and workers. His/her duties: a. Effective and productive providing of the health service, carrying out the necessary studies on this subject, measuring, evaluating the compatibility to the standards and having planned the necessary education applying them. b. Taking the necessary precautions about the violence against the workers at the health facility. c. Meeting the necessary resources for the providing of the medical services on time and as being suitable for the requirements. d. Doing the performance evaluation in the direction of the criteria determined by the agency, providing the founding information of this evaluation to be given to 662

the General Secretariat on time, completely and correctly. Doing requirement planning related with the acquirement of medical service and medical equipment and carrying out the processes. f. Establishing the coordination with the other health facilities and agencies related with the mouth and dental health scanning services and preventive services, planning and having the activities oriented towards the development of these services carried out. g. Providing the organization of the emergency disaster plans and their coordination with the related units. h. Preparing the budget and investment offers providing them to the General Secretariat. Chief Physician In the direction of the regulation of the patient and worker rights and security, medicine based on proof, logical medicine consumption and medical ethics being fundamental, is responsible for carrying out the medical services. Administrative and Financial Services Director He/she is responsible for the services, which are provided with the aim of easing the services of the personnel providing health service at the health facilities, such as human resources, personnel affairs, general document, archive, waste services, cleaning, kitchen, security and disaster planning, technical support and in accordance with the type of the health facility budget and accounting, reporting, financial control, logical material management and supply, inspection acceptance and stock management. e.

Patient Services and Health Hotel Director He/she is responsible for cleaning, catering, security, laundry. And he/she determines the qualifications of the personnel, who work these services, is training the worker about those issues, determine the characteristics of equipment, material, and appliances, and check the materials that will be taken related to their field. Health Care Services Director In the period that passes from the acceptance of the patients applying the health facility until the completion of their leave operations, taking the directions of the doctor about the points of diagnosis, treatment and rehabilitation into consideration, he/she is responsible for the services provided in the frame of principles of patient and worker rights, security and satisfaction, the services of patient’s transfer, providing social support and the services oriented towards providing for the easing of his/her reaching to the service. Directorates of Public Health The management duty of the Public Health Agency of Turkey in the province is being carried out as being connected to the directorates of public health. The number of assistants connected to the director of public health changes according to the size of the city. It has duties such as monitoring and evaluating the activities of family medicine carried out in the city, doing the necessary studies in order to provide for the development of the health services oriented towards the society, doing studies about the struggle against cancer, doing studies about the infectious and non-infectious diseases, doing studies about the healthy nutrition, providing for the studies oriented towards the preventive psychological health services to be carried out, environmental health and 663

immunization. In Figure 8 the organizational Structure of the Directorate of Public Health is being given.

Figure 8. The Organizational Structure of the Directorate of Public Health Source: The Ministry of Health, 2012b.

CONCLUSION The neoliberal policies in the health field which were supported by the World Bank after 1980 in Turkey, were tried to be applied by the governments initially in the name of “health reform” and then of “health projects”. During this process the public resources were transferred to the therapeutic services and preventive services neglected, the share spared for health from the budget was decreased and the hospitals were forced to find their own resources. The health system of the country paralyzed, a rationale was generated by the political governments for the people and the health workers in the direction of “being saved” from the present system. The government which took power in 2002,putin the year of 2003 the afore-mentioned reform/projects with the same content again against the people with the name of “HTP”( Pala, 2007; Kurt and Şaşmaz, 2012). With the changes of regulation made, various applications were put into effect. With the new regulations the Ministry of Health was issued with the role of developing policies, determining and controlling the standards and effectively directing the resources. In the year of 2005 the hospitals of the SIA in the first place, the hospitals 664

of the other public agencies were transferred to the Ministry of Health. Again in the same year the Pilot Application of the Family Medicine was begun in the city of Düzce, at the end of the year 2010 the application of the Family Medicine was started throughout Turkey. With the general health insurance citizens have begun getting services from the private hospitals and medical centres. With the additional payment system based upon performance the doctors were encouraged to work full-time in public. For the purpose of application in the financing of the health services Global Budget system was started. Additional payment system based upon performance was brought to the workers of the Ministry of Health (Ministry of Health, 2012a). In addition to this with the Statutory Decree No. 663 which took effect in the year of 2011 the organizational structure of the centre and the province was reshaped. One of the radical changes was carried out at the public hospitals and the hospitals were transformed to an autonomous structure. The hospitals were brought to be a structure connected to the Public Hospital Unions, their directors started to be employed in a contractual style. Whether the contracts will be prolonged or not is being decided according to the performance which the agency produced. Also one of the remarkable characteristics of the Statutory Decree No. 663 is the obligation of the unions just as the agencies of development to exhibit performance in a competitive disposition. Hence the performance of the general secretary, hospital manager and agency president is determined both at the scales of the hospital and the union according to this competitive structure (Övgün and Küçük, 2013). When the regulation changes and applications done after the year of 2003 are looked at, it is being seen that the main aim is decreasing the responsibilities of the state in the fields of social state and public services and diminishing the central management in favour of the local management, the civil society and the market (Ergun, 2010). Although it has been alleged that success has been achieved in certain fields related with the HTP, the discussions on the subject of whether the system achieved the required results in the subjects such as effectivity, productivity and worker satisfaction etc. or not are continuing. Some of the criticisms done are as follows. According to the new regulation (Statutory Decree No. 663) the Ministry of Health does not have the duty of directly executing “all kinds of preventive, inspective, therapeutic and rehabilitative health service”, has the duty of managing the system and determining the health policies, has the duty of executing the health service only in cases of emergency situations and disasters. Besides this also the health directorates of city and province, which constitute the provincial organization, have except the execution of the emergency health services only the duties of coordination. In assigning to the managerial duties competence and objective criteria have not been taken into consideration. Permanent state officers execute duty under the command of the directors assigned by contract and the rights of personal benefits, wages etc. of the mentioned staff have been left to the initiative of the contracted directors (İzmir Tabip Odası, 2011). The Ministry of Health proclaiming during the preparatory and application processes of the HTP that a transparent management style would be exhibited, it used to be alleged that the studies undertaken would always be announced to the public (via the web site), the views of the shareholders and the people in the country would be taken during the process, the studies being enriched by these views optimum solutions would be produced (Sağlık Bakanlığı, 2003). However it was put forward that the contribution of 665

the shareholders taking part in the health sector in Turkey about the program was not taken, they did not have information related with the subject, a completely authoritarian regulation, being prepared with a patronizing approach, was put into effect (URL 2). Although the rate of satisfaction as of the year of 2015 was determined to be %69,8 in Turkey general (TÜİK, 2016), it was claimed that the new system brought also certain kinds of ethical problems together, effected in a negative manner the work calmness, working peace and the attitudes and the behaviours of the workers. One of the other most criticized aspects of the system is the health services, which are seen as a public policy, mainly being customer satisfaction oriented, its being built upon maximizing the institutional performance (Erdem, 2012). As a matter of fact in some of the studies done about the performance-based additional payment it has been found out that the newly founded system did not increase the productivity of the personnel, did not increase the work motivation of the personnel, did not increase the quality of the health service or decreased it, caused unnecessary examination and analyses to be requested, increased the work load of the personnel, disrupted the work calmness, effected negatively the communication between the workers, the workers were not glad about the system, could not receive the full payoff of their working, diminished the duration reserved for diagnosis, was not a just system hence caused wage inequality, caused ethical problems, did not pay attention to worker satisfaction, fore grounded patient satisfaction and increased the work stress (TTB, 2009; Erdem, 2012; Çankaya, 2013; Yüzden, 2013; Harmancı, 2013; Çakır, 2014). From the year of 2002 until our day frequent changes have been being lived through in the regulations and applications. It is being observed that the system inheres in itself inequalities. Should an example be given, the reason of the frequent changes related with the additional payment system is to overcome the inequalities between both the group of doctors and the other job groups. In the providing of the first stage health service the preventive health services oriented towards the individual being provided by family health centres and the preventive health services oriented towards the society and the environment by the society health centres, is to a great extent contrary to the approach of the integrated providing of the health service set forth by the Alma-Ata Declaration of the Main Health Services which was accepted in the year of 1978. With the last organizational structure of the Ministry of Health it is being seen that the socializing approach, which in the nearly last fifty years had been prioritizing the preventive health service for the whole people, been aiming for providing everybody with equal, reachable, qualified and free health service that is integrated, staged, financed from the general budget and been achieving great successes in this (Kurt and Şaşmaz, 2012). One of the important claims of the HTP was the “gatekeeping” function of the first stage, effective transfer system, however in the year of 2007 the transfer system was abolished and has still in our day not found application (TTB, 2011a).As a result of the transfer system not being used the hospital polyclinics have become to be the first stage which the patient applies. Because of the polyclinics also being busy, the patients apply to the emergency services where they are examined in a shorter time. This situation has caused on the one hand the usage of the hospitals outside of its aim (unnecessary use) and hence the increase of the health expenditures, the decrease of the quality of the health services. The health organization of today, in which health is not described as a right but a requirement (Hamzaoğlu, 2008),by foregrounding the providing of health service for 666

everybody as much as his/her money the fact of being healthy defined as being a matter of “individual responsibility” is fore grounded (TTB, 2011b),the indicators of health do not get better, that is, there is no macro and micro productivity(Belek, 2009) in parallel to the increase of the health expenditures, can said to be not sustainable. REFERENCES Ak, B. (2015). Sağlık Kurumları Yönetiminde Taşra Örgütlenmesi. Sağlık Kuruluşları Yönetimi-I, Lisans Ders Notu (Yayınlanmamış), Toros Üniversitesi. Akdur, R. (1999). Türkiye’de Sağlık Hizmetleri ve Avrupa Topluluğu Ülkeleri ile.Kıyaslanması.http://www.recepakdur.com/upload/ab_turkiye_kiyaslamasi.pdf, accessed 21 March 2016. Aksakoğlu, G. (2008). Sağlıkta Sosyalleştirmenin Öyküsü. http://webb.deu.edu.tr/halksagligi/doc/yazilar/ga-sagliktasosyallestirmeninoykusu.pdf., accessed 19 April 2016. Belek ,H. & Belek, İ., (1997), Sağlık Hizmetlerinde Desantralizasyon. Toplum ve Hekim Dergisi, 12(78): 44-53. Belek, İ. (2009). Sağlığın Politik Ekonomisi. 3. Baskı. Yayılama Yayınları. İstanbul. Çakır, N. (2014). Performansa Dayalı Ek Ödeme Sisteminin Sağlık Çalışanları Açısından Değerlendirilmesi: Sarayköy Devlet Hastanesi Örneği, Beykent Üniversitesi, Sosyal Bilimler Enstitüsü, Yayınlanmamış Yüksek Lisans Tezi, İstanbul. Çankaya, M. (2013). Sağlık Bakanlığı ile Birlikte Kullanım ve İşbirliği Protokolü Uygulamasına Giden Üniversite Hastanelerinde Performansa Dayalı Ek Ödeme Sisteminin Personel Verimliliğine Etkisi (Muğla Sıtkı Koçman Üniversitesi Eğitim ve Araştırma Hastanesi örneği). Muğla Sıtkı Koçman Üniversitesi, Sosyal Bilimler Enstitüsü, Yayınlanmamış Yüksek Lisans Tezi, Muğla. Dirican, M. R. (1970). Türkiye'de Sağlık Hizmetlerinin Örgütlenmesine Genel Bir Bakış. The Eurasian Journal of Medicine, 2, 25-41. Erdem, B. (2012). Kamu Yönetiminde Dönüşüm ve Sağlık Sektörü: Uzman Hekimlerin Bakış Açısıyla Performansa Dayalı Ek Ödeme Sistemi. Atılım Üniversitesi Sosyal Bilimler Enstitüsü, Yayınlanmamış Yüksek Lisans Tezi, Ankara. Ergun, A. D. (2010). Türkiye’de Neoliberal Politikalar Doğrultusunda Sağlıkta Dönüşüm: Isparta-Burdur Örnekleri, Süleyman Demirel Üniversitesi Sosyal Bilimler Enstitüsü. Yayınlanmamış Yüksek Lisans Tezi, Isparta. Gamso, J. (2010). Political economy of Ecuador in the neoliberal era of development. The University of Toledo, Master Thesis, USA. Hamzaoğlu, O. (2009). Kapitalizmde sağlık hizmetleri ve Dünya’da ve Türkiye’de Sağlık Reformu(Almanak 2008). Sosyal Araştırmalar Vakfı. Harmancı, G. (2013). Performans ve Ek Ödeme Sisteminin Sağlık Personelinin Motivasyonu Üzerine Etkileri: İzmir Buca Kadın Doğum ve Çocuk Hastalıkları Hastanesi Örneği. Beykent Üniversitesi, Sosyal Bilimler Enstitüsü, Yayınlanmamış Yüksek Lisans Tezi, İstanbul. Instruction, (2012). Türkiye Kamu Hastaneleri Kurumu Taşra Teşkilatı Çalışma Usul ve Esasları Hakkında Yönerge. 31 Ekim 2012. İzmir Tabip Odası, (2011). 663 Sayılı Sağlık Bakanlığı ve Bağlı Kuruluşlarının Teşkilat ve Görevleri Hakkında Kanun Hükmünde Kararname Değerlendirme Raporu. İzmir, http://www.izmirtabip.org.tr/userfiles/663_s_KHK.pdf, accessed 10 March 2016. Jakab, M.; Hawkins, L.; Loring, B.; Tello, J.; Ergüder, T.; & Kontas, M.; (2014). Better non-communicable disease outcomes: challenges and opportunities for health systems. No. 2, Turkey Country Assessment, World Health Organization Paris, France. 667

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Türk Tabipleri Birliği Yayınları, Ankara. TTB. (2011a). Sağlık Hizmetlerinde Piyasalaştırma Değil Kamucu, Eşitlikçi Sosyalleştirme, Rapor. Türk Tabipleri Birliği Yayınları, Ankara. TTB. (2011b). 2011 Seçimlerine Giderken Türkiye’de Sağlık. Birinci Baskı, Türk Tabipleri Birliği Yayınları, Ankara. TÜİK. (2016). Yaşam Memnuniyeti Araştırması. 2015. TÜİK Haber Bülteni, Sayı: 21518. Uluskaradağ, Ö. (2011). Health Sector Restructuring in Turkey: The Impact of Neoliberal Policies and European Union Membership Candidacy; Reasons, Results and Repercussions. Middle East Technical University, Master Thesis, Turkey. WHO. (2000). The World Health Report 2000: Health Systems: Improving Performance. Geneva,World Health Organization, ISBN 924156198X. Yüzden, G.E. (2013). Performansa Dayalı Ek Ödeme Sistemi ve Hekim Görüşlerinin Değerlendirilmesi. Gazi Üniversitesi, Sosyal Bilimler Enstitüsü, Yayınlanmamış Yüksek Lisans Tezi, Ankara.

URL 1. http://www.mod.gov.tr/Pages/DevelopmentPlans.aspx URL 2. http://www.tdb.org.tr/tdb/v2/ekler/KHK_hukuki_degerlendirme.pdf http://www.mod.gov.tr/Pages/DevelopmentPlans.aspx. Development Plans, Republic of Turkey Ministry of Development, Ankara. http://www.tdb.org.tr/tdb/v2/ekler/KHK_hukuki_degerlendirme.pdf. Sağlık Bakanlığı ve Bağlı Kuruluşların Teşkilat ve Görevleri Hakkında Kanun Hükmünde Kararname ile ilgili Değerlendirme. accessed 10 March 2016. http://www.thsk.gov.tr/kurumsal/organizasyon-yapisi.html. The Organizational Structure of Public Health Agency of Turkey (Center). Ankara, Sağlık Bakanlığı, accessed 12 May 2016. http://www.tkhk.gov.tr/646_teskilat-semasi. The Organizational Structure of Public Hospitals Agency of Turkey (Center). Ankara, Sağlık Bakanlığı, accessed 12 April 2016.

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Chapter 61 The Role of Teamwork in Patient Safety at Healthcare Institutions Şerife Didem KAYA, Aydan YÜCELER INTRODUCTION Provision of healthcare services in a more effective and quality way is an issue that has gained much more importance nowadays. In the face of the healthcare services developing thanks to the rapidly advancing environmental conditions and technology, perceptions, and in turn, expectations of patients and their relatives with regard to healthcare services have changed. Thus, the service provided in the healthcare sector should of be of higher quality and reliability compared to other services. Given that the healthcare services are directly related with the individual's health, quality and reliability of the people providing service becomes quite important. A minor error to be made by the employees might lead to such consequences which may sometimes be fatal. Therefore, the success level targeted in this sector should be "zero error". The fact that healthcare professionals already serving in very difficult conditions achieve team spirit and facilitate works of each other will bring about great opportunities in terms of both patients and themselves as well as patient safety. Moreover, healthcare sector's requiring a multitude of services are provided simultaneously brings about the necessity that all units involved in the healthcare service work in harmony with each other. Hence, it is extremely important to learn working as a team at least to put and end to man-made errors. 1. PATIENT SAFETY AT HEALTHCARE INSTITUTIONS Patient safety is a topic which has come into prominence and on which social awareness has emerged particularly in the last decade, on which quality programs intensively concentrate on. During provision of the healthcare services, patients receiving service are exposed to many hazards. Characteristics of the healthcare services, nature of the medicine science and structure of the healthcare institutions pave the way for these hazards. The risk of encountering adverse events is very high particularly at the hospitals. Financial, managerial and legal arrangements are made in order to solve the patient safety problems, which have very serious consequences for the patient, institution and the nation (Islek, 2009). 1.1. Patient Safety and Medical Error Before defining patient safety, certain concepts closely associated therewith should be mentioned of. • Adverse event defines the events including harms, injuries or complications resulting from management of healthcare, leading to death, disability and elongation of patient stay, rather than patient's condition or origin of the disease (Göktaş, 2007). • Unexpected event means those events which result in death or a serious 

Assist. Prof. Dr., Necmettin Erbakan University, Health Science, Health Management.

physical and/or psychological harm in consequence of a service provided or omitted to be provided to the patient, or which bear such risk (Yıldırım, 2005). In the literature, unexpected events and medical errors may be used in the same meaning. Unexpected event should be considered as any kind of errors, accidents and deviations (Çakır, 2007). • Harm is defined as the loss of interest or unfavorable, bad consequences caused by an event (Öğün, 2008). • Adverse event is defined as damage/harm caused by the healthcare service regardless of the underlying disease or the patient's condition (Akalın, 2007) or injury cased by a medical intervention (Yıldırım, 2005). • Error can be defined as the situation where a preplanned action does not completely yield the desired result (error in procedure) or the plan made for reaching the goal is wrong (planning error) (Aspden, Corrigan, Wolcott & Erickson, 2004) • Medical Error is defined as unexpected result caused by an unintentional disruption during the healthcare service provided to the patient; an adverse or unexpected event involving serious physical or psychological damage or risk of damage (Öğün, 2008). A medical error may lead to harm in the patient. A medical error not causing harm does not result in any adverse event (Massachusetts Coalition, 2006). Institute of Medicine (IOM) defines the medical error as "failure of an action planned to be completed or application or use of a wrong plan to reach a goal". In this definition, IOM emphasizes that the errors are due to either taking a wrong action (error of action) or a negligence in carrying out the action (error of negligence) (Altındiş, 2009). Table 1: Error Categories in Provision of Healthcare Services Diagnosis errors Errors delaying diagnosis, deficiencies of determinative tests, use of former tests, errors in monitoring the results and tests. Treatment errors Errors seen in achievement of the operation, procedure or test, errors regarding drug dose or method in treatment management, inappropriate care, responding according to abnormal test results. Prevention errors Errors seen in prophylactic treatments and insufficient follow-up or errors seen in tracking the treatment. Other errors Communication errors, equipment insufficiencies and other system deficiencies Source: (Intepeler & Dursun, 2012) Accordingly, medical errors are divided into three based on their cause of occurrence (Çakmakçı & Akalın, 2011): • Procedural errors: Conducting the wrong procedure • Negligent errors: Not conducting the right procedure • Application errors: Applying the right procedure wrongly (Akalın, 2007). • Cause of occurrence of the errors are explained with error theories. We come across the errors in three models; (Göktaş, 2007; Altındiş, 2009) • Individual model: behaviors leading to error are specific to human. Forgetfulness, inattention, distractions lead to error. • Legal model: responsible persons do not make error, negligence and reckless behaviors lead to error. • System model: latent pathologies within the system may draw one into error, 671

and lead to adverse events. 1.2. The Concept of Patient Safety Patient Safety is defined as the whole of the measures taken by the healthcare institutions and the employees in such institutions in order to prevent any possible harm to be caused by the healthcare services to the individuals (Intepeler & Dursun; 2012). According to the definition made by National Patient Safety Foundation (NPSF) in 1999 and contained in the report of IOM, it is prevention or reduction of various accidents and adverse results that may be caused by healthcare services (Kohn, Corrigan & Donaldson, 2000). The aim in patient safety is to make such designs that would prevent occurrence of the errors in all processes of healthcare institutions in such a way that they harm patients, and to take the measures that would ensure catching and correcting the errors before they reach the patient. Through the measures to be taken, it is aimed that the patients are not affected from the errors in the processes at all or that they are affected at the minimum level (Işlek, 2009). Patient safety definition incorporates the concept of avoiding causing harm in the first place. Being aware that the medicine science involves high-risk interventions, Hippocrates has firstly advised "Primum Non Nocere", meaning "First, Do No Harm", to those who will practice medicine (Sezgin, 2007). 1.3. History of Patient Safety It could be suggested that patient safety existed throughout the history of humanity in various ways and survived up to present. However, the ground-breaking study in patient safety is the report named To Err is Human: Building a Safer Health System, written by Kohn et al. and published by IOM in the USA in 1999. The report denotes that people may err in every field and that error rates may be reduced by system designs. With the research results given in the report, the topic of patient safety has gained social sensitivity and importance worldwide (Studdert, Brennan & Thomas, 2002; White, 2004). Although the report of IOM is accepted as a cornerstone in regard to patient safety, most convictions argue that this report has emerged after interest of The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in patient safety. The interest of JCAHO in patient safety could be suggested to have been started long before IOM's report, considering the year 1952, when it commenced the accreditation process. While JCAHO did not use the name patient safety, the qualitybased standards it has created have the mission of developing patient safety. Since 1990, JCAHO has started to fight against patient safety problems using more formal means, by drawing attention to the adverse events resulting in death or permanent damage, which are designated as sentinel event (Rozovsky, 2005). With the researches conducted, the concept of patient safety has come into prominence in the last decade, become the program to which most importance was attached by the quality programs, the studies conducted in this field have increased and budgets have been started to be allocated. The institutions have begun to take steps for determining, solving and taking measure for, patient safety problems (Islek; 2009). 1.4. Culture of Patient Safety Before speaking about the culture of patient safety, it would be useful to define the 672

concepts of organization culture and safety culture. In its most general definition, it is "the sum of learnt and shared values, beliefs, behavioral characteristics and symbols" (Koçel, 2005). Organization culture is generally expressed as a "system of norms, values, beliefs and habits directing behaviors of the people within an organization", or a "whole of works, values and assumptions coming into existence though interaction of the organization employees, in other words, a "set of key values, standards, norms, beliefs and understandings" (Yüceler, 2013; Çelen, 2011; Eren, 2008). The culture of safety can be defined as the "outcome of the values, attitudes, talents and behavioral patterns belonging to an individual group, which determine the style and competence of an institution in health and safety management and its commitments in this field" (Tütüncü, Küçükusta & Yağcı, 2007; Nieva & Sora, 2003). Certain researches conducted reveal the errors made in the field of healthcare are man-made. Therefore, examination of the topic of patient safety in the dimensions of specificity to human, in other words, perception, attitude and behavior, seems to be inevitable. Namely, the most important indicator of the level of patient safety could be suggested to be the cultural dimension (Çelen, 2011). It is possible to easily express the concept of "Culture of Patient Safety" through adaptation of the definition made for safety culture to the healthcare agencies and institutions (Nieva & Sora, 2003). Based on this, the Culture of Patient Safety may be defined as the "outcome of the values, attitudes, talents and behavioral patterns belonging to an individual group, which determine the style and competence of a healthcare institution in patient management and its commitments in this field" (Çelen, 2011). The culture of patient safety is one of the most important factors for prevention and correction of the errors. However, in the healthcare institutions dominated by the classic approach, people fear of that they would be interrogated and punished due to the errors they make, and therefore the errors are tried to be covered and ignored. Whereas, the errors are required to be clearly talked and discussed, main reasons should be elicited and lessons should be learnt from the errors. Such an understanding points out a contemporary approach on patient safety, and an advanced level of culture of patient safety in the institution (Ovalı, 2010). It is expected that the culture of patient safety to be established in the institutions would create an environment where the errors, processes and the problems concerning the system can be discussed clearly and without the fear of being punished, ensure success and continuity of the efforts carried out with regard to patient safety, thus, diagnosis and treatment processes and healthcare outcomes would significantly improve. Therefore, healthcare institutions are in need of evaluating the safety culture (Çelen, 2011). In the healthcare sector that sets an example for the industries with high risk factor, strong safety cultures have the potential of preventing medical mistakes that may cost people's life (Çakır, 2007). In this context, the fact that employees in the institutions providing healthcare service work in harmony with each other would make a substantial contribution in terms of establishment of the culture of patient safety. Strength of the culture to be established with a different point of view would also greatly contribute to ensuring loyalty of the individuals to their teams and institutions.

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1.5. Reasons of the Events Threatening Patient Safety Since patient safety has multiple dimensions, patient safety problems in healthcare institutions require a versatile approach. When patient safety problems are addressed with a broad approach, the sources which lead to emergence of these problems are gathered under six main headings including structure, environment, equipment and technology, system and processes, human factor, and leadership and institution culture (White, 2004):  Structure: Incorporates the basic elements of the institution. Structure is constituted by physical characteristics, supply, policy and procedures, business and management practices. Structure may be involved in the errors occurring in healthcare institutions.  Environment: Environmental conditions may lead to occurrence of such events that may threaten patient safety. The issues like lighting, flooring, heat, noise, landscaping and ergonomics are involved in occurrence of various accidents or events.  Equipment and Technology: Various tools and equipment may also lead to errors and events.  System and Processes: System and processes are the core of how the works are done and accomplished. The researches conducted reveal that the errors can be substantially reduced with the changes to be made in the system.  Human Factor: The factors stemming from human nature are also involved in the errors. Low motivation, burnout, sickness or sleeplessness greatly increase the error rate. Lack of training and knowledge are also among the important error reasons.  Leadership and Institution Culture: If a leadership style and institution culture regarding revealing and reducing the errors is not established in an institution, the occurrence rate of errors is higher. In an institution with an undeveloped culture of patient safety, errors are concealed and measures are abstained to be taken, which leads to repetition of the errors. 1.6. Patient Safety Practices The basic practices aimed at ensuring patient safety may be listed as follows:  Making Patient Identifications Correctly  Informed Consent (Taking Consent of the Patient)  Insufficient Communication between the Healthcare Professionals  Drug Administration Errors  Wrong Party, Wrong Patient, Wrong Surgical Intervention  Infection-Associated Healthcare Risks  Falling-Associated Risks 1.6.1. Making Patient Identifications Correctly First step of the practices aimed at ensuring patient safety is identifying patient information correctly and ensuring that correct diagnosis and treatment is carried out for the correct patient. Medical errors concerning wrong patient may occur in all states of diagnosis and treatment, and the error risk would increase in case the patients are sedated, disoriented or have sensory loss, service, bed or room of the patient in the hospital is changed, patient evaluation and medical record control is conducted insufficiently/deficiently, and illegible handwriting and abbreviations are used. In healthcare practices, at least two identifiers not containing the patient's room or 674

bed number is required for identification of the patient. Affixing named bracelet / wrist band to patients as soon as they are hospitalized will prevent confusion of the patient identity (Öğün, 2008). 1.6.2. Informed Consent (Taking Consent of the Patient) The requirement of respecting the patients' decision-making freedom makes it compulsory to take consent of the patients before surgical intervention. Today, informed consent has been developed and arranged as telling the information containing condition of the disease and necessity of the surgical intervention, method, benefits/harms and side effects of the surgical intervention to be performed, treatment options, if any, other than surgical intervention, course of the disease if the surgical intervention is not applied, to the patient in detail without using too many medical terms, and recording of the same in writing in a form by taking signature of the patient after the patient is fully informed about the surgical intervention (Öğün, 2008). 1.6.3. Insufficient Communication between the Healthcare Professionals Effective communication is the communication which is at the right time, definite, complete, free of uncertainty and understood by the patient, reducing the errors and resulting in improvement of patient care (Gülkaya, 2009). It is stated that the medical errors involving communication result from the patient claims notified orally, and if permitted by the laws, via telephone, that the most frequently encountered one among these is interpretation of the results wrongly when the clinical laboratory tests are learnt. While intra-team and inter-team communication are the important factors affecting course and quality of the service in the healthcare institutions, operating rooms are the spaces where this communication is carried on at the most critical points, which positively or negatively affect success of the surgical intervention and patient safety. In order to prevent these errors, JCI recommends that, while reporting a procedure/application or critical test results, the results are first noted down, read, repeated, and caused to be repeated by the recipient. The communication problems between the team members and inter-team coordination problems are shown as another reason of the medical errors (Öğün, 2008). 1.6.4. Drug Administration Errors Drug administration errors may be defines as wrong administrations occurring as a result of failure to observe the principles required to be observed in the course of administration of the drugs (Aslan & Ünal, 2005). Treatment errors include drug errors. Drug administration is fulfilled with the consecutive prescription, distribution, administration, follow-up and control processes. Drug errors may emerge in any of these processes. In patient safety programs, all these processes should be organized and managed well (Kohn et al., 2000) Drug administration errors are administering the drug at wrong time, forgetting to administer the drug, giving at wrong dose, administering a drug not prescribed, administering the wrong drug, not preparing the drug with the suitable technique, administering interacting drugs concurrently, not recording the administration. In order for prevention of these errors, the five correct principle including correct drug, correct dose, correct path, correct patient and correct patient should be observed, the drugs administered should be absolutely record, and the drugs without label should 675

be discarded (Öğün, 2008). 1.6.5. Wrong Side, Wrong Patient, Wrong Surgical Intervention Errors involving wrong-patient, wrong-side and wrong-procedure surgery result from ineffective or insufficient communication between the members of the surgical team, patient's not attending in side marking and insufficiency of the site verification procedures. Insufficient patient evaluation, insufficient review of medical records, a cultural structure not ensuring the sufficient communication among the surgical team, illegible handwriting problems and use of abbreviations are the factors contributing to these errors (Gülkaya, 2009). The Joint Commission International (JCI) uses evidence-based applications such as "Universal Protocol for Prevention of Wrong-Patient, Wrong-Side, Wrong-Procedure Surgery". The main processes incorporated in the universal protocol are (Yetkinlioğlu, 2009):  Marking of the surgical side  Pre-operation verification process, and  Break taken immediately before start of the procedure. Accordingly, the site where the surgical intervention will be applied should be marked using an understandable symbol, this procedure should be performed using active communication methods, and the patient should also be included in this process. Before starting the surgical intervention, a checklist prepared for the purpose of verifying the correct patient, correct procedure and correct body section, also, containing the information aimed at determining accuracy of all documents and equipment required for the surgical intervention (Öğün, 2008). Another factor regarding the surgical interventions is forgetting foreign object in the patient's body during operation. Forgetting in the patient's body the objects such as tools, compress or gauze used on the patient may lead to undesired results (Islek, 2009). The most essential practice that can be executed for prevention of forgetting foreign object during operation is counting the tools and materials (Aştı & Acaroğlu, 2000). All materials used in the operation such as tools, needle, scalpel and sponge should be counted and recorded before and during the surgical intervention and after closing the incision (Öğün, 2008) 1.6.6. Infection-Associated Healthcare Risks Hospital infections are the infections which do not exist in the incubation (onset) period during application to the hospital, develop after the patients are hospitalized, or which are manifested following discharge. Hospital infections affect success of the physician negatively, lead to direct or indirect patient deaths, increase treatment cost, bring a significant burden to the individual, institution and economy (Islek, 2009). Prevention of the surgical interventions corresponding to 14-16% of the hospital infections is important in prevention of infection-associated healthcare risks. In addition, aseptic technique should be observed in all invasive applications, the most important and simplest practice in prevention of hospital infections is washing hands with water and soap, and when necessary, with an antiseptic solution (Öğün, 2008). 1.6.7. Falling-Associated Risks Falling constitutes an important part of injuries of the hospitalized patients. Monitoring the situations that might lead to falling and determination and reporting of 676

the patients with falling risk beforehand would reduce falling risk (Öğün, 2008). Unfamiliar environment of the hospital, changes in body activities, individual's having physical handicap, dementia, visual and hearing loss, physical and mental insufficiencies like decrease of muscle power, or patient's using drugs like narcotics, sedatives, insulin, increases the risk of falling (Hendrich, 2006). Transfer of the patient to the operating room should be carried out by a trained patient transfer team of personnel, transfer stretchers with lock system, hanger for IV solutions, side protection and safety belt should be used for transfer, patient transfer instruction should be created, and new personnel should be trained on patient transfer. Moreover, anti-slippery floor surface, wet floor control and good lighting will prevent the falls which pose a threat for patients as well as personnel (Öğün, 2008). 1.7. Patient Safety and Accreditation The countries have established associations and institutions to ensure provision of better and more quality healthcare service at both national and international level. Provision of the healthcare service by these institutions and associations in a qualified and reliable manner is evaluated with various standards and documents. Quality certificate in healthcare services is issued according to the conformity with the standard set by the organization making the evaluation. The institutions providing healthcare service have to provide the service safely for the employee and patient. The formal process whereby conformity of a healthcare institution with the predetermined and established standards is evaluated and approved by a widely recognized legal person is called accreditation (Göktaş, 2007; Işlek, 2009). According to the definition of Joint Commission on Accreditation of Healthcare Organizations (JCAHO), accreditation is a process with three components, where the "quality", "patient safety" and "continuous development" understanding has been made the culture of institution with participation of all employees of the healthcare institutions. Accreditation of healthcare services cover a very broad field extending to evaluation, care of the patient, training of the patient and relatives influencing the treatment process, patient rights and managerial processes (Gülkaya, 2009). Accreditation is management and reduction of the risks. More than 50% of the accreditation standards involve patient safety (Islek, 2009). Accordingly, accreditation is an important element in patient safety. The standards ensure better control of the patient environment. Accreditation systems are a structure which provide objective measurements for quality management and external evaluation of quality. Accreditation plans focus on patients through the quality of the service provided to the patients, care of the patient after discharge, healthcare systems incorporating the quality of the care. A list of standards underlies these plans. The list of standards ensures comparison of the employees with performance standards and evaluation of the service systematically. This involves not only patient care, but also the training, authorization of the personnel, clinic management and research activities, ethical standards (Gülkaya, 2009). Accreditation standards in patient safety may be listed as follows (Yetkinlioğlu, 2009); • Managers and leaders should participate in planning and monitoring of the quality improvement and patient safety programs. • There should be a written plan for quality improvement and patient safety program. 677

• New systems and processes should be designed according to quality improvement principles. • Leaders of the institution should set indicators to be able to follow up their clinical and administrative structures, processes and outcomes. • Individuals with suitable experience, knowledge and skills should systematically collect and analyze the data in the institution. • Frequency of the data analysis should be appropriate for the process worked in, and meet the institution's requirements. • Improvement and safety activities should be carried for the fields of priority as determined by the institution. 2. TEAMWORK AT HEALTHCARE INSTITUTIONS 2.1. Team Concept Today, the fact that the importance placed by the individuals on health has increased, their demand for quality care in healthcare services has become widespread and they act more selectively among the relevant institutions when they are in need of healthcare service has given rise to competition. One of the factors leading to this competition is the ongoing increase in the number of the institutions providing healthcare service and the requirement of such institutions to survive (Öğüt & Kaya, 2011). In the healthcare institutions operating in this environment of competition, we come across the team as an important concept. Team refers to the small groups composed of two or more people acting in an interconnected manner in order to reach a shared valuable goal (Tepeci & Koçak, 2005). Teams are defined as two or more individuals who work together to achieve specified and shared goals, have task-specific competencies and specialized work roles, use shared resources, and communicate to coordinate and to adapt to change (Manser, 2009). According to Katzenbach and Smith, team is defined as a group composed of a small number of people who are oriented to a common goal, performance targets and an approach where they are responsible to each other, and who have skills that are complementary to each other (Katzenbach & Smith, 1998). Healthcare team is defined as a unit whose common goals are to provide a comprehensive, quality healthcare service to the individuals by considering the patient requirements, in which two or more clinicians (physician nurse, dietitian, etc.) work in cooperation, the resources are jointly used, and coordination and communication is ensured (Ulusoy & Tokgöz, 2009). 2.2. Characteristics of the Teams Team members in the healthcare institutions are professional talents who are interdependent, each of whom are different, but who complement each other. Since the mutual communications between the team members is different, each team has different structural characteristics. Structural characteristics of a team include team size, diversity of members, team norms and harmony issues (Pınar, 2011).  Team size: Two or more people are required to create a team. Number of the members of most teams is below fifteen. However, this figure may sometimes rise up to seventy five (Eren, 2008). Team size is associated with duty characteristic of the team.  Diversity of team members: This relates to the level of difference of specialization and talents of team members. Since the team members are required know each other to create a positive effect on team performance, members should have 678

different skills and specializations. Level of difference of the team members is extremely important for a creative and intellectual duty. Having different professional backgrounds creates a positive effect between the team members through the communication established by them (Pınar, 2011).  Team norms: This may be expressed as the functioning standard shared by team members and guiding their behaviors. Norms are informal standards. Norms are of importance for prescribing acceptable limits for the team members (Şimşek, 2012).  Team harmony: There should be a certain harmony between the teams. Otherwise, several difficulties might be suffered with regard to teamwork. These may be listed as personal conflicts, management, management styles, language, communication, not listening, shy persons, lack of motivation, dominant persons, lack of interest, insufficiency of technical language, participation, caste system, not respecting others, closeness, not being prioritized, being irrelevant with the subject (Kazan & Ergülen, 2008). 2.3. Characteristics of an Effective Team Effectiveness of a team is defined as the degree of performance by that team of the duties it has assumed at the set standards of quality and quantity. Distinctive characteristics of an effective team are as follows (Kavuncubaşı & Yıldırım, 2012). • A natural and relaxing atmosphere, • Participation of every member in the discussions, • Understanding and adoption of team duties by the members, • Team members' listening to each other, • Presence of the freedom of not adopting the group mindset (absence of the obligation for every member to consent to the group decision), • Making decisions by way of agreement, • Criticism that is constructive and aimed at problem solving, • Absence of leader dominance, • Team's having self-supervision awareness. 2.4. Requirement of the Teams in Healthcare Institutions The issues like rendering the healthcare institutions efficient and specialization cannot be achieved by one person alone. It is difficult for him/her to fully understand the issue, solve, decide and take action. Hence, it is required to work in teams rather than as individuals in the patient care activities. Duty segregation is made in the team and each member does his/her own part. Thus, the things are carried out faster, more effectively and efficiently (Kaya, 2004). In healthcare institutions, there are multiple teams and committees - within the scope of JCI's patient and employee safety. These may be listed as employee safety, patient safety, radiation safety, facility safety, training, infection, transfusion, cleaning, antibiotic control committee, under the responsibility of quality unit. Also listed are pink, blue, white code teams, information security teams, building tours teams, medical device teams. 2.5. Team Leadership in Healthcare Institutions Having an exciting goal based on common values which make the individuals closer to each other in teamwork is the essential condition for success. Team leader has a determinant role in this regard (Baltaş, 2001). 679

The person who assumes the leadership role in teamwork may eliminate a series of uncertainties and improve the service quality through the production process (Kavuncubaşı & Yıldırım, 2012). Therefore, the team leader is a perceived by the team members as a person who can make definite decisions, work with the senior management and guide the team when needed. Whenever possible team member should influence composition of team members and assist in their selection. Selection should be based on willingness of the individuals to take part in the team and combination of the personal and technical skills they can convey to the team. Team leader should ensure the link between the team and senior management, exhibit a fair and supportive attitude for development of the team member (Uyer, 1995). Also, both a good leader should have high ethical values individually, and such values of his/hers should match the institutional targets (Baltaş, 2001). Team leader is essential for effectiveness of the teamwork. The most important part of team leader's duty is to hold the members together while solving the problems. This means to guide the team members by asking them discussable questions, or to assist in making the decisions by providing data and basic information regarding the work. A team leader knows when to intervene in the events and when to watch from distance. Team leader refrains from putting forward solutions himself/herself for the problems and allows the team members to solve the problems assigned to them (Bateman, 1999). Among healthcare professionals, team leader may change based on the occasion. Those who support the idea that the physician should be team leader are majority. However, although it is thought that the physician may become leader in many institutions, according to some, it is more suitable that a nurse, midwife, health officer or social service specialist becomes leader according to the characteristic of the service or the topic worked on. If the work required to be done requires firstly the skills like diagnosis, medical treatment and evaluation of patient prognosis, leader of the team should undoubtedly be the physician. If the problem required to be solved requires firstly skills of specialty in healthcare consultancy, leader of the team should be the nurse or midwife. If deep family problems are in question, the social service specialist may assume the leadership responsibility. The factor most affecting the decision in teamwork is the requirements of the individual to whom care is provided. Hence, it becomes compulsory to develop such methods that would ensure identification of the patient requirements in the most effective way for selection of the most appropriately equipped member for fulfillment of the role of leadership of the team (Uyer, 1995). In short, team leader may change according to the objective of the team. 2.6. Teamwork at Healthcare Institutions The activities required for achievement of the goals at the healthcare institutions are carried out with the simultaneous efforts of the human resources with very different backgrounds and different professional orientations. It seems virtually impossible for a group of profession to direct the entire medical care process and to realize the activities contained in this process alone. The mix of knowledge and skills required for solution of the problems regarding the medical care process is so broad that a group of profession cannot possess all of those information and skills; and teamwork emerges as an inevitable obligation (Kavuncubaşı & Yıldırım, 2012). Participation in teamwork is not a preference, but a requirement in a substantial 680

part of the healthcare institutions (Pınar, 2011). Because healthcare institutions require interdisciplinary team approach. Interdisciplinary team approach is the approach that prescribes cooperation between the members of the profession of health in order to eliminate the gaps and repetitions in the services (Coşkun, 1996: 183). With this approach, both the patients receive more quality and comprehensive healthcare service and the responsibility carried by the clinician is shared (Kuyumcu, Yeşil & Cankurtaran, 2012). The requirements at the healthcare institutions are too diverse, and require a teamwork with multi-disciplinary approach to be satisfied. In a team composed of members of different disciplines such as physician, nurse, midwife, healthcare administrator, psychologist, biologist, social service specialist, dietitian, genetic consultant and physiotherapist, health technician; each member of profession is expected to provide coordinated, specific but complementary service (Coşkun, 1996). Teamwork at healthcare institutions has many advantages. These may be listed as:  Benefiting from knowledge and skills of the team members in the best way,  Ensuring communication and coordination among the healthcare professionals,  Creating synergistic action in solution of the problem with combination of the efforts,  Ensuring support, solidarity, flexibility among the members,  Developing the sense of responsibility,  Providing the opportunity for auditing with scientific advancement and feedback (Coşkun, 1996: 183). Despite the abovementioned advantages, the researches conducted state that effective teamwork cannot be attained at the healthcare institutions, there are problems in team understanding and application, which reflect on safe patient care, and in turn, on service quality (Ulusoy & Toksöz, 2009). 2.6.1. Structural Characteristics of Teamwork Structural characteristics of teamwork are relationship, social structure, goal orientedness and culture (Pınar, 2011).  Relationship: The people constituting the team are interdependent and act together. They are constantly in interaction with each other. The persons who are not in interaction with each other, for instance the persons who stand next to each other in a food line or share an elevator do not form a team (Şimşek, 2012; Eren, 2008).  The most effective way of the relationships between the employees at the healthcare institutions is attained through the communication established between each other. In a real team, the communication between the members require that the ideas are open and sincere enough to be expressed simply and briefly. One of the most important reasons of insufficiency of many teams in fulfilling their functions stems from absence of effectiveness in communication (Kesim, 1999). Because effectiveness of the intrateam and team success are directly proportional. In order to ensure effectiveness in communication, team members should have put into practice their skills such as listening, telling, interrogating, feedback, using body language and reading. Communication should be conducted sensitively in terms of ensuring the coordination in the team, carrying out the activities, enhancing the motivation, preparing team members for change, improving performance and increasing the effectiveness in extrateam relations. Ensuring an effective communication between team members increases 681

efficiency at the workplace (Kaya, 2004). Otherwise, many problems resulting from lack of communication are observed in patient safety.  Social structure: The individuals need to gather in groups. In this respect, the teams provide social interaction between the units and potential benefits for job satisfaction (Pınar, 2011).  Goal orientedness: Healthcare institutions are organizations where a multitude of teams serve jointly for a common goal. In order for a team to be effective, its goals should have been defined. The members participating in the research are aware of goal of the healthcare institution and try to fulfill requirements of their goals (Öğüt & Kaya, 2011). In this line, goal of the healthcare team is to avail of the capacity of healthcare professionals at every level to the full extent in provision of the best care possible to those in need. The healthcare team realizes this goal by means of the following. * It puts the service recipient/patient and his/her family in the center of the team. * Each officer is assigned with the duty which most matches the training he/she has received. * It constantly shares the knowledge and experiences regarding team meetings/team conferences. * It establishes close relationships between the team members and between the teams. * It ensures that the duties, powers and responsibilities are well-determined, adopted, and well known by the healthcare team members. * In duty segregation, it takes into account satisfaction of the team leader and members with the job they do (Baltaş, 2001).  Culture: A team is not composed of only the persons gathered around a common goal. The teams also have a culture. Therefore, each team member contributes something from himself/herself to the work being done and works toward success of the team. Each member in the team starts to think what he/she contributes to team rather than what the team provides to him/her. Thus, team members start to talk about not their own success, but success of the team, which creates the team culture. Creating the team culture enhances motivation and makes the individuals feel loyalty to the workplace and its future. Team culture needs to be kept alive. To do this, members within the team should be displaced from time to time. By this way, amalgamation and communication will increase among the members who better understand the problems encountered by others. Another means for keeping the team culture alive is to bring the team members and other employees together through out-of-business activities. Thanks to such activities, the dialog particularly with other employees would be advanced, it would be ensured for the team not to split from the organization (Şahin, 1996). 2.6.2. Necessary Conditions for Teamwork It is said that a series of structuring actions are necessary at individual and institutional level to create an effective teamwork environment. The individual conditions leading the teamwork to success are based substantially on success of the members constituting the team. The members constituting the team are required to have certain qualifications for success of the teamwork. These are as follows (Kavuncubaşı & Yıldırım, 2012): 682

 A strong pre-professional training: Each team member should have received a strong professional training concerning his/her field of specialty. Thus, they come into possession of professional knowledge with regard to their field of specialization. Following the professional training, the employees should continue developing themselves in line with their own professional tendencies.  By self-development following training, it is aimed to continuously develop knowledge and skills of the healthcare professionals as required by the qualifications and training standard of the personnel, which is among the organizational standards of JCI. Orientation trainings, in-service trainings, certificate (such as intensive care nursing, NRP, CPR) regarding the field of specialization should be held.  Development of professional values and norms; every employee should work towards development of professional values and norms. Norms are standards shared by the team members and guiding their behaviors. Norms are informal, they are not in written form like rules and procedures. Norms are important since they set the limits defining the acceptable behaviors. The said team norms facilitate life as they constitute references for the team members to distinguish the right from the wrong (Eren, 2008).  Predisposition to teamwork: At healthcare institutions, the teams do not compose of random people. When a team is to be established, volunteering and specialty is essential. Forcedly inclusion of the individuals in the team does not fit in participative management style. Also, in creating the team, individuals whose specialty is not proper should not be included in the team.  Being open to discussion and criticism: Occurrence of conflicts between the individuals at the healthcare institutions incorporating so many professional jobs. Each team member's being open to discussion and criticism makes the team more dynamic.  Another important factor influencing success of teamwork is suitability of institutional and managerial conditions. These are as follows (Kavuncubaşı & Yıldırım, 2012):  Democratic management understanding: Participative democratic management is to ensure participation of organization members as individuals or groups in the decisions made at various levels of the organization. Participative democratic management has become one of the primary methods of organizational change particularly in the recent years. It is a fact that people more heartfeltly adopt, and are more successful in implementing, the decisions which are made by themselves or in which they have a say (Şimşek, 2012).  Identification of powers and responsibilities: Each of the team members render service in line with their own specialty fields, the problems encountered are tried to be solved through the services instead of the physician-centered service, which is a conventional understanding (Ulusoy & Tokgöz, 2009).  Placing importance to competence in personnel selection: Personnel selection process is defined as a whole of means, proceedings and specialists ensuring making selection among the personnel candidates who will best meet what is expected from them (Can, Kavuncubaşı & Yıldırım, 2012: 172). Selection of human force of appropriate qualifications by placing importance to competence also in selection of team members is important.  A natural atmosphere: A modest institutional atmosphere should be created for being able to apply the team approach (Kavuncubaşı & Yıldırım, 2012).  Strengthening: Personnel strengthening is an understanding which allows the 683

employees to be directly involved in the organization's activities, to participate in the decisions more, and which assigns them more responsibility to increase the organization's performance (Doğan & Demirel, 2009). Strengthening is a main component of the organizational and managerial effectiveness, and plays a central role in development and continuance of team awareness (Polat, Meydan &Tokmak, 2010: ).  Creation of an environment allowing people to realize themselves: The management should create the environment where the team members can realize themselves, thus, which will increase the team effectiveness (Kavuncubaşı & Yıldırım, 2012). 3. THE ROLE OF TEAMWORK IN PATIENT SAFETY AT HEALTHCARE INSTITUTIONS Health care delivery is a complex organizational process (McNicol, Layton & Morgan, 1993). As healthcare services develop and the patients learn their rights, the aspect of diversity and quality in provision of healthcare service is increasingly coming into prominence. One of the most important of topics among these is patient safety. Patient safety is the measures taken by the institutions in order to prevent harm to the patient at the stage of provision of healthcare services (Alcan, Tekin, Civil, 2012). In this context, the healthcare institutions carrying out activities toward being accredited in order to prevent the patients from being harmed have adopted International Patient Safety Goals (IPSG) (Kaya & Yağcı, 2015). Patient is the "focus" in the accreditation philosophy. I.e., the care service provided to the patient should be optimal but accessible and the evaluation process of the service should be open to and place importance on innovation, it should be able to focus on quality and patient safety (Akyurt, 2013). The International Patient Safety Goals (IPSG) aiming to ensure safety of the system in itself by shedding light on the problematic fields in terms of health to assist the accredited institutions to address the concerns related with some of most problematic fields of the patient safety. 6 goals have been set for this purpose. These are identification of the patient correctly, improving the effective communication, improvement safety of high-risk drugs, securing of the right side - right procedure - right patient surgery, reduction of the infection risks associated with healthcare services, reduction of harm to the patients as a result of falling events. In line with these goals, efforts need to be carried out to increase awareness of the healthcare employees with the patient safety practices recommended to be prepared at the healthcare institutions (Kaya & Yağcı, 2015). The competition experienced among the healthcare institutions and the expectation arising out of aware patient profile for receiving good service now force these institutions to provide better service, in other words, to switch to an efficient management model. Thus, it is strived to be able to provide qualified healthcare service (Öğüt & Kaya, 2011). Healthcare institutions need three elements to be able to implant the quality standards of healthcare in their institutions. These are individual quality, team quality and management quality. Individual quality: Abilities, knowledge, skills and cultures of institution's employees as well as their maturity levels should develop. Team quality: The individuals constituting the institution may not be designated as qualified teams unless they develop skills of working together even if they have superior qualifications (Baltaş, 2001). Provision of good healthcare service is possible through a suitable teamwork (Öğüt & Kaya, 2011). Management quality: A qualified 684

management is expected to show such approaches that support and reinforce teamwork in the attitudes it exhibits to both its employees and its customers. It requires implementation of a performance evaluation system which values teamwork instead of individual performance and awards teamwork (Baltaş, 2001). Patient safety becomes real with a harmonized work and high performance. Success depends on the coordination of the work of all members of the team as well as on the competence of individuals. Planning care and team working are vital components of quality improvement initiatives if improvement in practice is to be achieved (McNicol et al., 1993). How teamwork is applied at healthcare institutions is of great importance for this (Kavuncubaşı & Yıldırım, 2012). Healthcare institutions are an interdisciplinary field. In all healthcare institutions, the concept of interdisciplinary team is inevitable for healthcare services. They incorporate doctors, nurses and healthcare professionals with other specialties (Manser, 2009). In provision of the healthcare service, the individuals should carry out activities in cooperation with both his/her own group of profession and other groups of health profession, as well as other supporting services. Healthcare professionals are there for the individual and for meeting his/her requirements. As insistently emphasized by World Health Organization European Regional Office in 1984 in 36 of the goals of the "Health for All" strategy, healthcare professionals place aside their professional interests and expectations and drive all their efforts towards meeting the requirements and demands of the individual, group and society (Coşkun, 1996). From the aspect of management of healthcare institutions, teamwork is the instrument to influence the medical care process (Kavuncubaşı & Yıldırım, 2012). Teamwork has become a focus of system-based interventions to improve patient safety and of medical education standards (Manser, 2009). In this respect, the objective of priority in healthcare institutions is the process of creating patient safety culture. The culture of patient safety is a multidisciplinary structure combining knowledge and communication technologies (Gündoğdu & Bahçecik, 2012). Multidisciplinary team approach in the healthcare services is the understanding that prescribes cooperation by the members of the healthcare profession to eliminate the medical errors in the services. In patient safety literature, teamwork is of vital importance (Manser, 2009). Clinical interventions which seem to be too easy result in irremediable consequences due to very simple errors (Kavuncubaşı & Yıldırım, 2012). Therefore, the responsibility with regard to minimizing the medical errors and ensuring patient safety during provision of the healthcare services mostly rests with healthcare professionals (Kaya & Yağcı, 2015). For this reason, healthcare employees are required in the first place to know the patient safety criteria in respect of the target group they will serve. For the healthcare professionals to possess the knowledge on patient safety, the culture of patient safety should be implanted in the institution. The culture of patient safety consists primarily of teamwork with management support, acting in accordance with rules, systematic reporting, training, participation, sensitivity and care of the employees, and establishment of a safe healthcare system (Gündoğdu & Bahçecik, 2012). Furthermore, the culture of patient safety expects the employees to show an approach that supports and reinforces teamwork in the behaviors they exhibit. Qualified management requires implementation of a performance evaluation system which values teamwork instead of individual performance and rewards teamwork (Baltaş, 2001). The most important factor threatening patient safety is the errors in the medical 685

practices (Cebeci, 2012). When examined the errors in the medical practices; interruption during medical practices, lack of knowledge and skills, breach of correct practices, heavy workload, lack of continuity in care and insufficient communication between team members are the factors that influence emergence of the errors (Cebeci, 2012). For instance; when root cause analysis is conducted in the sentinel events involving patient safety-correct side marking, one of the root causes is thought to stem from the lack of communication during teamwork. Therefore, all team members should absolutely be in communication in ensuring the correct side surgery. The recorded documents are highly important. Operating room nurse should check the information and records form the nurse who brings the patient, review the information together with the patient, and approve and record the obtained findings. In the operating room, the site of procedure should be verified by the surgical team (Alcan et al., 2012). Hazards can be prevented by establishment of a safe system through assumption of the responsibility of the medical errors made in the healthcare institutions and learning lesson from such errors (Gündoğdu & Bahçecik, 2012). When examined the studies emphasizing the importance of teamwork in patient safety; Manser (2009) has reviewed the methods applied in studying the relationship between teamwork and patient safety. There are Teamwork as an important contributing factor to adverse events, Healthcare providers perceptions of teamwork in dynamic medical domains, Different groups of healthcare providers perceive the quality of teamwork differently, Staff’s perceptions of teamwork are related to the quality and safety of patient care, Perceptions of teamwork and leadership style impact staff wellbeing, Teamwork behaviors related to patient safety Communication patterns supporting effective teamwork, Coordination strategies supporting effective teamwork, Leadership behaviors supporting effective teamwork. Gündoğdu and Bahçecik (2012) found in their study that, although the nurses work in harmony and carry out teamwork in cooperation in the unit they work, the fact that they attain more unfavorable outcomes in the teamwork between the units is important in terms of demonstrating that each unit has an independent culture. Moreover, in a private hospital, the highest average is seen to be in the item "we work together as a team when there is much work to be done urgently". Ulusoy and Tokgöz (2009) have determined that a great majority of the physicians have a conventional understanding in regard to teamwork. In the research conducted by Knaus et al. (1986), the relationship between the level of interaction among the physicians and nurses working in intensive care units and the mortality rates; it has been found that the level of cooperation and interaction among the physicians and nurses decreased mortality rate (Ct.: Kavuncubaşı, 2012). In the study conducted by Kim et al. (2007) with nurses; it has been found that the intra-unit teamwork where the nurses work was better compared to the inter-unit teamwork. Qualified healthcare service can be realized only by means of a teamwork which is strong, self-sufficient and high motivated. REFERENCES Akalın, E. (2007). Klinik Araştırmalar ve Hasta Güvenliği, İku , (17), 32-35. Akyurt N. (2013). Sağlık Organizasyonlarında Kalite ve Akreditasyon. Haydar Sur, Tunçay Palteki (Ed.) Hastane Yönetimi kitabı içinde (bölüm 30, sayfa 453-494). Nobel Kitapevi: Ankara. Alcan, Z.; Tekin, D.E.; Civil, S.Ö. (2012). Hasta Güvenliği: Beklenmedik Olaylarda

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Chapter 62 Theories of Play in the Context of Leisure Ali TEKİN*, Gülcan TEKİN**, Emrah AYKORA***

“A foal that does not play cannot be a horse” A proverb

1. LEISURE In English language, the word leisure, which means free time, is used to indicate ease, casualness, being in no hurry, convenience, freeness, idleness and opportunity as it derived from the Latin word licere which means being on leave, free and permitted. In Oxford English Dictionary, leisure is defined as a time when one is not working or a time of which one can be in control while it is defined in the Social Sciences Encyclopaedia as being away from any livelihood activity. In general, it is equivalent to being free from obstacles, and any time spared from work and accommodation of social responsibilities. Leisure is a time that contains common sense and benefits and that we can use according to our own judgements and preferences beyond any requirement of our existence, of what we have to do and our biological needs as well as our endeavour for a livelihood. The leisure is a spare time in which we are free to prefer anything we want without any restriction or temporal dependence for positive personal satisfaction. The leisure is a freedom to do whatever we want within a time that belongs to us and the boundaries and structure of which we do design for our personal satisfaction. Author’s definition: The leisure is a free activity of the creative capacity, free from any requirement of the work, for increased relief, entertainment, knowledge and social participation. The elements specifically underscored in definitions of leisure include “spare time”, “preference” and “benefit”. Nevertheless, it is no longer valid today to consider any time spared from work as leisure. This is because a specific time needs to be used for only an activity that would bring benefit for that time saved from accommodation of our responsibilities to be considered as leisure. Immediate positive impacts and selfrealization of individual are also realities of the leisure. Each individual has a philosophy of life. Our life philosophy fully reflects our perspective of world indeed. In other words, our perspective of world and what the reality means for us is inherent in our life philosophy. However, individuals may find it difficult to define their philosophy of life or may not be aware of the fact that they have *

Assoc. Prof. Dr., Lecturer, *** Assist. Prof. Dr. School of Physical Education and Sport, Bitlis Eren University, Bitlis, Türkiye **

a philosophy of life. Therefore, only very few individuals can realize to have leisure, to leave any undue restriction behind by leading his/her life as he/she likes, and to become the person he/she wants to be. Having the leisure is also accompanied by the responsibility to make correct choices to use it properly. The philosophy of leisure today should hinge upon culture, social and economic systems, respect for human rights, equal opportunities, human dignity, and the belief in that what is good and exclusive for the individual is also good and exclusive for the society. In a democratic society, leisure is a privilege of an individual. It is possible to have an impact on attitudes of an individual and to create desired changes in his/her behaviours through appropriate use of leisure. In this sense, leisure is important not only for individuals but also for the societies that individuals form. Establishment of a quality culture and development of good citizens are closely associated with appropriate use of leisure. The concept of leisure has such a structure to allow formation of different approaches. For instance, leisure is often considered as just the opposite of work. However, many activities may have the characteristics of both work and leisure together. Despite the fact that lack of requirement is an important criterion for leisure, most of family, social and voluntary activities contain important requirements. Thus, endeavours to define and understand the leisure have resulted in many controversies and innumerable arguments. Leisure is by no means aimless and is preferred for strengthening of the self. It is a matter of preference how and in which ways the leisure is used. Leisure is the state of having a time which an individual can spend as he/she wills and a time that is completely in his/her control. It is a moment of life for individuals in pleasure and without hurry; it is entertainment. The spirit activated gives rise to the sense of peace and liveliness. 2. PLAY 2.1. The Play Concept Leisure is based on play. The word play derived from the Anglo-Saxon word plega, which means “play, sports, fight, war and conflict”. Later, it was expressed with the word plaga, which means “blowing, flying, hitting and sticking” in Latin. The word play was given in various languages other meanings such as playing a game, doing sports and playing musical instruments. It is highly difficult to make a single and common definition of play because it can be defined in different ways from different perspectives of different scientific fields. Play can be expressed as all enjoyment-based activities that have several aims such as learning, experience, communication, preparation for adulthood and expression of the self and that contribute in overall development of a child, and that one can participate freely (Poyraz, 1999). Therefore, the play environment is a critical element in education and personal development of children; social and cognitive development, communication with the environment and emotional settlement can be naturally acquired in a play environment by itself. Play has a positive impact primarily on psychomotor development of children and facilitates development of skills. During a play, children experience their emotions (happiness, hatred, aggressiveness, disappointment and so on) and also face them (Aral et al., 2000). By doing so, children start to be aware of the world surrounding them, to 691

interpret the events and to understand himself/herself as well as others (Sevinç, 2004). Author’s definition: A play is an activity that has its aim within, that is implemented within a given place and period of time according to the rules specified and recognized by the players themselves, that activates the sense of pleasure and consciousness one cannot find during the regular life, and that we participate voluntarily. Strict adherence to the playing rules is a distinctive characteristic of play as the play rules that send the player away from the routine of the daily life are “invented” by the players themselves. Attitudes that develop owing to the play rules are transferred from the world of play into the real world. Slavson (1948) highlighted rightfully such an aspect of the play by stating “Play helps children learn the reality in the world of imagination”. From this point of view, play does not have a simple and ordinary structure but a very complex one. They contain many mysteries. Plays are completely puzzlements. Play is usually enjoyable; it may however be saddening and problematic as well. Although it is suggested that it does not have a certain structure and it provides a free environment, it may also have rules and regulations as sports do. All these are the elements that are inherent in life and that will indispensably be experienced by every individual in time. Therefore, play is inherent in the nature of human beings. If the life is a puzzle, then so is a play. According to the relevant literature, three generalizations are possible concerning the play:  Play is exhibited by particularly all young living creatures. It is a widely known and recognized reality that young living creatures often play games. Nevertheless, one should not confine plays only to children. Any activity conducted by youngsters, adults or elder people or activities that we join as a family can be considered as a play.  Play is a universal activity. Children first learn to move their bodies in line with their aims, and then to play with objects and to direct them. Plays are continuously repeated and consequently regulated by rules. This sequence of action is the same in all young people irrespective of their ethnic origin, race and culture.  Stimulation of play is a by-product of some chemical processes. It is suggested that playing has some physiological grounds and a hormonal code or a genetic program gives rise to the desire of playing. It is presented as a piece of evidence that small animals quit playing when some parts of their brain are taken out. 2.2. The Concept of Play from Past to Future Philosophies and theories of play dates back to the ancient times. Aristotle and Plato, as leading philosophers of the Ancient Greece, frequently underlined in their works the importance of play in children’s life. Despite the fact that children were often made to work in that period, their place in the society was also important. They attached importance to development of attributes as aesthetics, loyalty, dignity, honour and sense of responsibility in children while the highest value was seen to be productive citizenship. Play was therefore considered to be a method in teaching the values of the Greek society and development of positive characteristics, and became a compulsory element in education. It is not a coincidence that the word paideia, which means play, was also used in the sense of education. The hedonistic structure that emerged as a result of over-exploitation and 692

excessive consumption of leisure by the Roman culture gave damage to the balance and proportion in the play behaviour. Later, the Catholic Church extended its influence on the developing nations of the Western Europe and play started to be seen as “a social threat”. A great effort was exerted in this period of time to stop the most pleasurable types of plays that used to be highly popular in the Ancient Greece and to equip the individuals with more spiritual values. The Middle Age was an era in which children and childhood were disregarded and children were regarded as young adults with a lower statute. Deterioration in the philosophy of play was significantly restored in the 18th and th 19 Centuries owing to the contribution made by philosophers and pedagogues such as Froebel, Schiller and Rousseau. In this period, play was considered to be something important for children just as the case in the Ancient Greece. Froebel suggested that play was “the purest and most spiritual activity in childhood”. The education movement in the 19th Century helped emergence of many theories that attempted to explain and advocate play. Innovative ideas started to push the society to accept to different changes: there is a distinction between children and adults; play contains its aim within. Friedrich Wilhelm August Fröbel (1782-1852): A famous German pedagogue. His most important work is his book titled “The Education of Man”. He laid the foundations of the preschools which he called “Kindergarten”. In Froebel, the purest mental product of man in childhood is play. Play ensures development of personal motivations and skills of children in a harmonious fashion. Children should play with toys to preserve the meaning of play. Emotions, hand skills, thinking and analytical comprehension of children will develop thereby. As what develops first in children is the body movement, Froebel suggests that the first education should be for physical development. Jean Jacques Rousseau (1712-1778): A libertarian and egalitarian thinker from Geneva. His ideas are being discussed even today. He served as a source of inspiration for many thinkers and philosophers with the ideas and thoughts asserted in both the theory of politics and philosophy of education. Rousseau thinks that a new-born baby is completely innocent and there is not even a spot of stain in his/her heart. In order to preserve such an artlessness of children, we need to help them discover their skills, and we need to provide them with a well-defined area of freedom while we need to be less dominant, less oppressive and less protective over them. Suggesting that play and fun of children should be welcome, Rousseau expressed the importance of play in his words: “Never be afraid of that your children play all the day because playing warms them up for life.” 2.3. Approaches on Play The concept of play that has been a hot topic for researchers throughout the centuries was handled by scientists from various disciplines from biological, psychological, sociological and cultural aspects. 2.3.1. Biological Approach In the 18th and 19th Centuries, many ideas and thoughts were put forward suggesting that young living creatures were directed to play games by some constant biological characteristics. Some theoreticians believed that it was impossible to change 693

this innate stimulation that directs individuals to play. Although modern scientists believe that the tendency to play is based on some biological ground, they also accept that other factors stimulate to play as well. Von Schiller (1781) defined the play as “consumption of excessive energy aimlessly”. The British philosopher Herbert Spencer (1896) suggested that animals spend all their energy to find food and shelter to survive, to look after their babies and to escape other wild animals while human beings were stimulated to play because of the excessive energy that they did not use due to the fact that human beings were more sedentary than animals were. Groos (1911) and StanleyHall (1916) are among other scientists who based the play behaviour on biological factors. Johann Christoph Friedrich Von Schiller (1759-1805): German poet, philosopher, historian and a drama-writer. He suggests that “A man plays literally only when he is a human and he is a human only when he plays.” In Schiller, men have two basic drives: sensory drives and formal drives. Sensory drive originates from the physical existence of men while formal drive comes from his mental nature. However, there is a third drive to reconcile these two in human nature, which is the drive to play. Play does not go for any other aim but itself. It frees men from daily pressure and fears, and takes them to the world of freedom. Herbert Spencer (1820-1903): A British philosopher and sociologist. As his ideas on education are still highly respected even today, Spencer (1861)stated, in his book titled Education: Intellectual, Moral and Physical, that the curricula should cover five activity fields in which men needed to be developed for life, and listed these five fields: health, occupation, household, citizenship, leisure (physical education). Accordingly, education should be enjoyable and interesting. Education should navigate from simple to complex, concrete to abstract, known to unknown and experimental to rationality. Suggesting that "children should be allowed to carry out their own examinations and deductions; and we should speak to them as less as possible and they should be encouraged to discover as much as possible”, Spencer underlined that we should avoid from resorting to artificial penalties that have nothing to do with the natural consequences of their actions. Selim Sırrı (Tarcan) attempted to establish the principle of Spencer “sound minds in sound bodies” in Turkey (Ata, 2013). 2.3.2. Psychological Approach Those who attempt to explain the play behaviour of men from a psychological perspective are of the opinion that this behaviour originates from instincts of living beings. Pioneers of this opinion that suggests that the basic desires of the organism and the inner energy are associated with instincts include the British psychologist McDougall (1923) and the American psychologist James (1890). James suggested that all ordinary plays were played for the purpose of pleasure with primitive instincts. The father of psychoanalysis, Sigmund Freud, expressed that enjoyment controlled the child behaviour and suggested the “pleasure principle”. This principle is based on decreasing the tension. Energy needs to be released immediately in order to reduce the tension accumulated. Release of energy takes place through natural and automatic actions. The process of play steps in and ensures the release when such an automatic release of energy is not possible (Elis, 1973). The American psychiatrist William Menninger (1927) expressed the role of play, especially of competitive sports in reducing aggression in his words: “Competitive games are a rare way for the instinctive 694

aggressive drive to come out on a social plane.” Psychologists believe that there is an aggressive energy drive inherent in the personality that constantly waits to come out. 2.3.3. Sociological Approach In the midst of 1800s, the interest in the studies on the role played by human groups and institutions on the lives of individuals increased, which gave rise to the field of sociology. Sociology attempts to explain common behaviours, interactions, structures and developments of organized groups of people. In the very same period, the industrial revolution (transition from an agricultural economy to an industrial one) took effect in the Western Europe and North America. This strong transformation just in the eve of the 20th Century affected not only the economies but also the social structures of these regions. Poverty, crime and diseases climbed up in the settlement areas that developed around large industrial cities (suburbs). Many public and private institutions started support programs in order to cope with such problems. The role of play on socialization of youngsters and adults was examined seriously and scientifically. One of the results of these endeavours in the North America was the recreation movement. Joseph Lee (1915), as the leader of this movement, considered the play as a significant power for development of children and social life. Lee thinks that the play is not that simple to aim only at spending pleasant times. The play contributes in development of personal characteristics as it teaches attributes such as discipline, self-sacrifice and virtues. The play is a social requirement because it warms up children for the phase of adulthood. It improves physical functions and is useful for health; it prepares children first for school and then for social life. 2.3.4. Cultural Approach In cultural approach, play is examined for its relationship with the traditions and values of a certain society. Cultural researchers consider the play as a behaviour that is learnt through participation into activities approved by the society. Play helps children not only understand his/her culture but also sustain it. Play is seen as activities reflecting, maintaining and transferring to next generations the value judgements and traditions of a society. Johann Huizinga (1960) emphasized the relationship between rituals (ceremonies and customs) and play, and suggested that the play types influenced all human activities and helped men create his society since the birth of civilization. Johan Huizinga (1872-1945): “A famous Dutch historian. In his book titled Homo Ludens which he wrote in 1938, he tells: “play is older than culture. As a matter of fact, no matter how much we narrow down the concept of culture, this concept requires in any case existence of a human community and animals did not wait for men to come to teach them how to play. Undoubtedly, we can safely express that human civilization did not add any basic characteristic to the overall concept of play. Animals play just the way men do. All basic lines of play have already been realized in animal plays. It would be enough to watch carefully the joyful plays of puppies in order to observe all these lines. They invite one another to play with some attitudes and gestures that resemble a kind of ritual. Puppies follow the rule that prohibits biting the ears of your playmate. They act like they are extremely furious. However, it is obvious that they take an extreme pleasure and joy from it. Even so, such plays of these exhilarated puppies represent the most primitive form of animal enjoyment. There are high quality and extremely advanced versions of these plays: Real competitions and beautiful scenes performed for the audience. It would be worthy to note a very 695

important point here. Play is, even in its simplest forms and even in animal life, something more than a totally physiological fact or a physiologically-determined psychic response. Each play bears a meaning. If we called this active principle ascribing an abstract to the play as the intellect, then it would be going too far; if we called it as instinct, then it would be too short. Whatever aspect you take, this “deliberate” nature of the play reveals the existence of an immaterial element inherent in its abstract.” Huizinga was kept as a prisoner by Nazis in 1942 for his overall attitudes after Hitler came to power, and remained in exile in rural Ares until his death.” (Kılıçbay, 2006). 2.4. Theories of Play In the 19th Century and early 20th Century, some theories were put forward with a view to explaining the role of play in individual and social development. We can examine these theories in three sections: Classical Theories, Recent Theories, and Modern Theories. 2.4.1. Classical Theories 2.4.1.1.Surplus Energy Theory Having been influenced by Friedrich von Schiller, who suggested that animals played games with aimless actions in order to burn their surplus energy once their stomach was completely full and they had no vital need for that time, Spencer (1896) expressed in his book he wrote in the midst of the 19th Century with the title of The Principles of Psychology that play stemmed mainly from the need to burn the surplus energy. Spencer stated that game was, for children, a kind of imitation of adult behaviours displayed with an aggressive instinct such as wrestling, pursuit, imprisoning the others and so on. In this theory, content of play does not matter. 2.4.1.2.Instinct/Preparation/Pre-Exercise Theory This theory was suggested by Groos (1911) based on the Darwinist thinking. In Groos, play has a role in later survival of animals and development of their skills required in adulthood. It also applies to men. The reason why individuals conduct the activities that help them acquire skills in play environment (through exercise and drills) is completely innate. They have plenty of time to participate in these activities that are critical for them to develop the skills they will need in adulthood. This theory can also be called as “Preparation Theory” or “Pre-Exercise Theory”. Karl Groos (1861-1946): A German psychologist and philosopher. He conducted revolutionary studies particularly on the theory of play and child psychology. Based on the opinion that play is a pre-exercise of the future life, he suggested that plays of the childhood were actually a rehearsal of the real life and its impact would be observed in later times in his book titled as The Play of Man. Gross grounded his theory, as inspired by Charles Darwin, on the thought that the plays of animals with their basiclevel instincts were actually a pre-exercise for their struggle to survive. 2.4.1.3. Recapitulation Theory Stanley-Hall, who developed this theory based on the Darwinist thinking, stated that the play behaviours such as digging the sand, climbing up the trees and playing with water were instinctual and social expressions and they were the recapitulation of the primitive human activities (1916). In other words, play behaviours are a result of a 696

biological heritage. An individual go through the very same dynamic and mental development process throughout his life as his species did. Based on this theory, one cannot set any relationship between play and future behaviours. There is only a relationship between play and the past behaviours of the species. Therefore, Instinct/Preparation/Pre-Exercise Theory is contradictory. Granville Stanley Hall (1844-1924): He developed a psychological theory on adolescent development based on the ideas of Darwin on evolution. He suggests that man is born as a member of the world of animals with his egoist drives, needs and concern of survival. However, he figures out that he is a member of a civil race in his post-adolescent period with his social responsibilities, rights and concerns of others. Adolescence is a synthesis of the wild phase and civil phase of men, in other words a transition from primitiveness to civilization. An adolescent is driven by basic and simple instincts to a direction while he also figures out the other important institutions of the society for the first time in his life. In Hall, the adolescent becomes in this period a part of the culture he lives in and he may start to perceive his position within this culture. Many psychologists today think that this theory does not reflect adolescence properly because Hall dealt with adolescence only according to the American culture; studies conducted in other cultures later displayed significant differences among developmental patterns. 2.4.1.4.Relaxation Theory (Recreation Theory) Patrick put forward this theory in his book titled as Psychology of Relaxation by accepting that individuals want to conduct playful activities in order to get relaxed and to compensate the stressful adversities that come out from the tension created by the urban life and work (1916). Kraus stated that the German philosopher Moritz Lazarus considered the aim of play as “protection and regeneration” rather than burning the surplus energy. Individuals who get tired of working too hard regenerate the energy to work again owing to the play. Lazarus made a distinction between physical and mental energies and suggested that, if the current activity was substituted with physical exercise when the brain got tired, it would relax the nervous system of the individual. It is a good way for an office worker to play tennis after work in order to release the surplus energy and to increase mental energy (2001). Unlike the surplus energy theory, this theory suggests that the organism plays to increase its energy when it has a shortage of energy. As is in the surplus energy theory, the form and content of the play does not matter in the relaxation theory as well. Most of the classical theories base the play upon instinct. Nevertheless, play is considered today as something more complex than it is explained in classical theories. As all of these theories handled the play from certain angles, they fell short and too simple in explaining the play. None of these theories took personal differences into consideration. They lack experimental evidence. However, despite their simplicity, they all reflect rather optimist aspects about play. Classical theories still work today when they are blended with other play behaviour theories. 2.4.2. Recent Theories Unlike the classical theories, recent theories (theories in the 20th Century) have been in pursuit of mainly explaining the differences among the plays of individuals. Ellis (1973) compiled the recent theories under 4 headlines in his analysis on theories. 697

2.4.2.1.Choice (Alternative) Theory In this theory, leisure is both affected by and arises from work. If the work is so boring and routine and includes stress and physical effort, the individual shall start to seek a contrast in his life and may use the leisure to eliminate the stress and tension of the work. The individual attempts to escape the routine conditions through contrasting activities. An employee spending all his day indoors by working in an office would choose activities such as hunting, fishing, trekking and etc. that would take him away from the working environment (Kraus, 2001; Torkildsen, 1992). 2.4.2.2.Generalization (Maintenance) Theory This theory relies on the belief that the playing choices of an individual are a result of the nature of his work, and suggests that the leisure is a continuation of the work. It is just the opposite of the preference theory. The individual is very happy in his work from all aspects and therefore he would like to maintain his working habits in his leisure as well. A driver who drives for hours on a highway by the nature of his work may enjoy riding a motorcycle or restoring antique cars as a hobby. A painter working in an advertisement agency may maintain his occupational habits in his leisure by doing watercolour painting at his vacation (Kraus, 2001; Torkildsen, 1992). 2.4.2.3. The Cathartic Theory This theory suggests that especially competitive and active plays function as a “safety valve” for aggressive feelings that are stored to go out in a safe manner. In the Ancient Greece, Aristotle considered drama as a tool to eliminate hostile and aggressive feelings of an individual. In the first half of the 20th Century, researchers further developed this theory and expressed that play releases the stored energy that would cause anti-social tendencies and physical competitions such as football, boxing and so on alleviated fighting tendencies. The Surplus Energy Theory and the Cathartic Theory stated that children and youngsters vitally need active play in order to burn their surplus energy and release their aggressive behaviours and drives in a sociallyacceptable manner (Feshbach, 1956; Berkowitz & Green, 1962). 2.4.2.4.Psychoanalytic Development (The Learning) Theory The father of modern psychoanalysis, Sigmund Freud (1974), had different ideas about the aim and meaning of play. In psychoanalytic theory, individual behaviours are primary. Play provides an environment to resolve the contradictions that may occur in the life of a child and to give him the feeling of control and competence. Children may often encounter in their living environment complex, shocking and bothersome situations. Threatening behaviours can be taken under control and eliminated through play. In this sense, play and dreams have a therapeutic function for children. Play has a significant role in psychological and emotional development of children. Play teaches a child many things that any living being cannot teach; play is a way for children to discover themselves and to face the real world. Children learn how to live according to their personal objectives in the world of meanings and values by means of play. Freud suggests that the opposite of play is not “seriousness” but “reality”. Play is a means for children to communicate with the real world. These thoughts of Freud have been highly regarded by many researchers and pedagogues and included in curricula. Melanie Klein (1955) developed the play therapy. The child reveals his emotions and faces them and learns how to control or get 698

rid of them by playing, in other words, by role-playing. Play was studied by more social scientists and behavioural scientists in the 20th Century. The French sociologist Roger Caillois exhibited a socio-cultural approach towards play based on the theory of Huizinga and stated that the play is a cultural clue that helps discover the values, patterns and structure of a society. Caillois (1961) divided play activities into four according to their functions: agon, alea, mimicry and ilinx. Agon: It tells about the play that includes competition and winning function. Winners are defined with characteristics such as speed, stamina, memory, skills and intelligence. Agonistic games are played mutually by individuals or teams. These plays contain attentiveness, exercise, discipline, rules and boundaries. Agon can be manifested in two characters: physical (sports) or intellectual (chess). It is quite difficult in this kind of plays to achieve an absolute draw. All modern sports are examples of this type of play. Alea: Unlike Agon, effort, patience, experience or quality are not important in this type of play. These plays are therefore the ones in which the player has no influence on the result and a win depends on luck rather than the skills of players. In other words, the winner is luckier than the loser. We can list heads or tails, lotteries, pools, dices, and roulette and etc. as examples. These games are mainly for adults. Mimicry: These are the plays in imaginary or fictive universes. They cover the plays where players are made believe or make others believe. A fictive character is created and the player act as that character. It requires moving away for a while from the personality in the real life. For children, the aim is to mimic adults. They are formed by turning into toys the materials such as weapons, machines and engines used by adults and children’ using these toys to act as adults. Little girls use a toy iron, washing machine and kitchenware to play the role of a mother whereas boys believe that they are supposed to be soldiers, policemen or gunners and live in that dream world. Ilinx: It is the aspect of play that is associated with the instant dissolution of perception. Such plays are in pursuit of giving a pleasing sense of panic, creating confusion and blowing the mind by unbalancing the individual all of a sudden. Thus, settlement of perception temporarily gets lost and it creates exuberance with panic. One feels himself in a kind of spasm, attack or shock that wipes out reality. Examples include speeding, drifting, demolishment that gives pleasure, destroying a sand-castle instantly, climbing, skiing and sky-diving. Almost every child enjoys the dizziness and imbalance he creates by turning around himself. There are two opposite ends of the play behaviour. The first one is called “paideia”: it includes exuberance, freedom, naturalness, directionlessness and joy. According to Cailloise, paidia is the instinctual desire to play; cats playing with a ball of wool, dogs sniffing their masters turning around them, babies laughing when rattle is shaken and etc. The second end called “Ludus” is for men who think. It highlights the culturally-important elements of play and points to certain rules and traditions. According to Callois, plays reflect the function of societies. Therefore, if play loses its spirit, it shall mean that the society loses its spirit and it reflects the weakness and degeneration. Solitaire, cross puzzles and anagrams fall into the category of Ludus.

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2.4.3. Modern Theories Many psychologists and pedagogues studied play in terms of learning and development of children in the twentieth century. These studies led to contemporary ideas about play. Nowadays, play is considered as a blend of different elements. Modern theories emphasize the role of play on creativity, learning, problem-solving and natural expression of self. Three main theories were suggested concerning these aspects of play: 2.4.3.1. Play as Arousal-Seeking Behaviour It is based on the observation that animals and men are in search in order to accommodate their needs for information, excitement, risk, surprise and pleasure however, the expectation that a play is always fun, pleasure and humour can be misunderstood. Play can sometimes result in disappointment, and be unpleasant and boring. It may give physical pain and result in economic collapse particularly if it leads to addiction just as in the case of gambling, alcohol and drugs (Kraus, 2001). 2.4.3.2. Game as a Tool of Efficiency-Effectiveness This approach considers that individuals play with some drives such as knowledge of environment, problem-solving, mastering and the need for success. An individual in behaviour of experience and knowledge observes, tests, and effectively manages their environment. The individual tries to develop the skill to effectively communicate with his environment by repeating the same behaviour over and over again, which is defined as “efficiency”. “Effectiveness” means that the individual is able to control his environment in order to create the desired results. Skills of the individual should correspond to the level of difficulty of the mission in the play. If the play is too simple, it can be boring: it loses its attractiveness. If too hard, then it leads to disappointment and anxiety: it leads the player to quit or change the activity (Kraus, 2001). 2.4.3.3. Play as Self-Justification Play can be considered as a result of the need of self-justification. Men are active and dynamic beings in pursuit of using their skills and justifying their individualities. Activities of the individual are affected by psychological and anatomical structure, level of physical fitness, environment, family and social history. Universal desires such as new human experience, being in a group, security, recognition by others and aesthetics are decisive in shaping of play attitudes and behaviours (Huizinga, 1960). Play that is dominant in early stages of life would give its place to responsibilities at school and workplace in later times. Individuals fulfilling these responsibilities would start to look for activities that might give them entertainment and happiness. Abdurrahman Ibn-Khaldun (1332-1406): Ibn-i Khaldun, a medieval IslamicArab thinker, was a unique genius of the regression-period Islam philosophy with his versatile scientific personality. İbni Khaldun, mostly known as a historian, sociologist and political scientist, was also a scientific figure who had his distinctive philosophical and economic thoughts. His masterpiece is “Mukaddime” (The Introduction) in which he examined social, political and economic structures empirically under the field of history to draw some conclusions (Ülken, 1967). As is evident from its very name, this book was originally designed as the preface of the history book he was writing (Eliber). He interpreted his social, human and political impressions he collected from what he observed and experienced with powerful analyses in the two volumes of his 700

book “Mukaddime”. Consisting of six chapters, Mukaddime handled many subjects from civilization, nomadism, urbanity, social contradictions, and the concept of nobility to trade and arts in terms of their historical facts and sociological factors. Mukaddime covers a very wide field. Foundations of sociology, politics and political economics were first laid in this book by İbni Khaldun. He is also among the first scientists who applied psychology to history. The classification of needs was conducted by İbni Khaldun centuries before Maslow. According to İbni Khaldun, there are three types of need: Indispensible, necessary and luxurious needs. Indispensible needs are the ones concerning nutrition and safety required to survive. Necessary needs are the ones that you feel for the things which are not indispensible but give relief to people when available. Luxurious needs are the ones that accommodate the thinking concerns and aesthetic expectations of people. These needs were stated in the Hierarchy of Needs by İbni Khaldun and Maslow. İbni Khaldun points out physical needs as the primary need while he defined the need at the highest level as desires concerning the leisure (Caillois, 1961). Maslow placed basic physiological needs at the first level whereas he listed the need for selfrealization at the top. Self-realization indicates the need for leisure in addition to work and education. Abraham Maslow (1908-1970): Maslow, who was born in Brooklyn, had an unhappy childhood. His father was insensitive to his family. His mother had strong superstitions and punished little Maslow even in his minor mistakes. Maslow remembered watching how his mother killed two cats he brought home by hitting them from one wall to other. Maslow never forgave how his mother treated him. He even rejected to attend the funeral of his mother. Those years affected all his life. He stated: “All my philosophy of life and all my researches and theories stemmed from my hatred and repulsion I felt against what my mother did to me” (Hoffman, 1988). Maslow had inferiority complex in his childhood and he stated that he could not get over this inferiority complex even in his adolescence and he even tried to compensate it by developing his athletic skills. He attended first the University of Cornell and then the Winconsin University and had his PhD in 1934. According to Maslow, every man had an innate inclination for self-actualization. This situation which is the highest-level human need contains active utilization of all our skills and qualities and development and realization of our potential. In order to be an individual who has realized his self, one should first meet the needs at the lowest level among the hierarchically-listed needs. Once each need is satisfied, it activates the need that ranks just above it in the hierarchy. Research method and data of Maslow were criticized because the sample was too small to come to a generalization. Maslow accepted that his research failed to meet the requirements of scientific research but he also added that there was no other way to conduct any research on self-actualization. He considered his work just as a starting point and he added that he believed that the results he achieved would be confirmed some day (Schultz & Schultz, 2002). Play as a universal phenomenon is handled within cultural, social and psychological contexts with a view to responding to the needs of children in particular, and is affected by chemical processes. Play is a personal activity and social responsibility field for people of any age and gender. In this context, play and leisure are in interaction if it is not considered to be confined only to children. Leisure provides 701

an opportunity to play and maintain games. Play and leisure overlap to different extents conceptually and theoretically. A couple of words, ideas or themes are used to explain both concepts. These similarities suggest that the play and leisure are integrated, and they have common characteristics. That is to say that: people play freely and leisure provides freedom to choose. Self-expression is the main aim in both of them. Play tells about satisfaction and pleasure when playing. Leisure gives us this pleasure to a certain degree. Quality of experience is important for both. Experience should provide the individual with quality. Play most often starts because players feel like playing; and the leisure activity is also conducted in a similar fashion to a certain degree. One cannot play by an external pressure. That is also the case for leisure. Although play is mostly serious and tense, it is rich in joyfulness and fun. Leisure is, on the other hand, more free and non-rigid. Each one has its own internal dimensions. When playing, one faces the experience of getting caught up in the play. In leisure, experience highlights the perception of freedom. REFERENCES Aral, N.; Baran, G. (2000). Drama. Istanbul: Ya Pa Publication. Ata, B. (2013). Zihin, Ahlak ve Beden Eğitimi. Herbert Spencer (1949). Education: intellectuel, moral, and physical. Pegem Publication. Maarif Printing House, Istanbul. Berkowitz, L.A.; Green, J.A. (1962). Simple View of Aggression. Journal of Abnormal and Social Psychology. 64. pp. 293-301. Caillois, R. (1961). Man, Play, and Games. London: Thames and Hudson, p.21. Cordes, K.A.; İbrahim, H.M. (1996). Applications in Recreation and Leisure: For Today and Future. A Times Mirror Company. p.7. Ellis, M.J. (1973). Why People Play. Englewood Cliffs, N.J. s.60. Feshbach, S. (1956). The Catharsis Hyphothesis and Some Consequences of Interaction with Aggressive and Neutral Play. Journal of Personality. 24, 449-462. Freud, S. (1974). The Complete of Works of Sigmund Freud, Hogart Pres. London. Gross, K. (1911). The Play of Animals. Appleton, New York. Appleton-Century-Crofts. Hoffman, E. (1988). The Right to Be Human: A Biography of Abraham Maslow. Los Angeles: Jeremy Tarcher. p.4. Huizinga, J. (1960). Homo Ludens: A Study of the Play Element in Culture. Beacon Pres, Boston Mass, p.5. Kılıçbay, M.A. (2006). Homo Ludens: An Essay on Social Function of Play, Johan Huizinga, translated from French by Mehmet Ali Kılıçbay, pp. 16-17, Ayrıntı Publications, 2006, Istanbul. Kraus, R. (2001). Recreation and Leisure. Jones and Bartlett Publishers, p.24-27. Lee, J. (1923). Play in Education. New York, p. 452, 462-75. McDougall, W. (1923). Outline of Psychology. Newyork. Scribner’s & Sons. Menninger, W. (1927). The Psychology of Play Activities. New York. Patrick, G.T.W. (1916). The Psychology of Relaxation. Houghton Mifflin, Boston, Mass. Poyraz, H. (1999). Play and Toys in Preschool Period. Ankara: Anı Publication, Schultz D.P, Schultz S.E (2002). A History of Modern Psychology. Wadsworth, Cengage Learning. Sevinç, M. (2004). Early Childhood Development and Play in Education: Morpa Cultural Publications. Slavson, S.R. (1948). Recreation and the Total Personality. Association Press, New York, p.3. Spencer, H. (1896). The Principles of Psychology. New York: Appleton-Century-Crofts. 702

Stanley-Hall, G. (1916). Adoloscence: Its Psychology and Its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion and Education. New York Youth. Appleton, Newyork. Appleton-Century-Crofts. Torkildsen, G. (1992). Leisure and Recreation Management. Spon Pres. p.51 Ülken, H.Z (1967). İslam Felsefesi. Ankara, pp.228-229 Von Shiller, F. (1781). Versuch uber den zusammenbang der therischen naturdes menschen miltseiner geitigen. Cited in Martin H. Neumeyer & Ester S. Neumeyer (1936). Leisure and Recreation. New York: A.S Barnes, p.134.

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Chapter 63 Determining Some Physical and Physiological Parameters of Undergraduate Students Fatma ÇELİK KAYAPINAR, İlknur ÖZDEMİR INTRODUCTION In Turkey, the number of private security departments offering training under university conditions is increasing rapidly. Except for the companies and educational institutions offering private security training, universities, realizing the need of the sector, have started to open departments with two years of education under the names of defense and security, private security and protection, property protection and security programs to train qualified personnel. The reason for opening these programs at universities is; the increasing need for security, the diversification of the working areas, and the lack of qualified personnel to respond to the needs (Sayın, 2011). Additionally, the private security guards that are selected to fulfill this duty should have an effective physical appearance and physical performance standards to the next level. The sportive performance components in private security officers are expected to be on the upper limit of the normative values specified according to the age groups. However, the lack of a special status exists in the law related to the performance components, and having no physical or mental disabilities that will prevent him/her from doing his/her duty, being at least 18 years of age, and being at least 21 to receive the armed training are sufficient prerequisites to do this job (http://www.mevzuat.gov.tr). This makes it hard for those who want to be a security guard to understand the importance of physical performance components. Because there is no test battery that will allow the determination of the level of physical proficiency of private security personnel, the situation was attempted to be determined by examining the proximity of the basic motor characteristics and VO2 max values to the norm values in accordance with age groups. Private security officers can involve in a dual challenge as part of their duties. In order to be successful in a dual challenge, they need a good level of strength parameter; agility and coordination features to be able to move and change direction in a fast way; a bursting strength parameter to protect themselves and their environment in the case of sudden attacks; the flexibility parameter to prevent any injuries that may occur during duty; and good level of aerobic strength parameter to be competent enough to actively intervene in the incidents lasting for hours. Aerobic power starts to decrease with the increasing age. Aerobic exercises improve the adequacy of metabolic enzymes that regulate the exchange of energy stored not only in blood cells but also in the lungs and blood vessels. As a result of the studies on age-related changes in the cardiovascular system, it has been concluded that there is a decrease in aerobic capacity of adults, and that this capacity decreases, compared to 

Assoc. Prof. Dr., Mehmet Akif Ersoy University, School of Physical Education and Sport, Physical Education and Sport Teaching Department, Burdur, Turkey  Lecturer, Pamukkale University, Acıpayam Vocational School, Denizli-Turkey

young people, by % 30-40 in both genders from 30 to 65 years of age. It has been concluded that this decrease is limited to a small extent in adults who continue their regular exercises depending on the intensity and frequency of the exercise (Zorba, 2014). The people who will sustain their work life as private security guards are expected to do regular and continuous sport in order to develop and main their physical and physiological features. Therefore, the aim of this study is, since no similar studies were found in the literature review related to this area, to determine the physical and physiological levels of competence of the students trained at private security departments in order to make a scientific contribution. MATERIAL AND METHOD The study population included the students trained at Private Security Department of Acıpayam Vocational School, Pamukkale University in the 2015-2016 academic year, the sample of the study consisted of a total of 34 students, including 13 women and 21 men. The research sample consisted of students who participated in the study as volunteers. The height, body weight, BMI, flexibility and back strength, leg strength, jumping force, right-left hand grip, the shuttle values and aerobic capacities of the participants were measured to determine the situation. The data obtained in this study were coded in a statistics program, and the means and standard deviations were determined. The obtained data were presented in tables. Right and left hand grip strength test A Takei Physical Fitness Test T.K.K.5401 Grip D dynamometer was used. The study group was asked to clench their shoulders with maximum force bringing them in 45 ° abduction position; 3 trials were performed and the maximum values were recorded (Tamer, 2000). Back strength A Takei Physical Fitness Test T.K.K.5102 back_d dynamometer was used. The participants were asked to pull the dynamometer bar gripped by hand vertically by applying maximum strength with after placing their feet on the dynamometer stand with their knees and arms stretched, their back straight, and their bodies slightly tilted forward; after three trials, the maximum values were recorded (Tamer, 2000). Leg strength A Takei Physical Fitness Test T.K.K.5102 back_d dynamometer was used. The participants were asked to pull the dynamometer bar by using their legs vertically by applying maximum strength with after placing their feet on the dynamometer stand with their knees and arms stretched, their back straight, and their bodies slightly tilted forward; after three trials, the maximum values were recorded (Tamer, 2000). Free vertical jump test A Takei jump-meter was used. The jump-meter was attached to the abdomen of the participants, and they were asked to jump with two feet and free arms from a specified area and to land on a specified area. After three trials, the highest value was recorded in cm (Tamer, 2000). Sit-up test The athletes were asked to lie on back, join their hands on the neck, pull their 705

knees slightly towards the belly (at 90 degrees), place their soles fully on the mattress, and to do sit-ups at maximum speed for 30 seconds, and the value reached was recorded (Kamar, 2008). Flexibility test The athletes were requested to rest bare soles on the flexibility stand and to keep their knees stretched. While the practitioner were applying pressure with their hands to keep the knees at a fixed position, the participants were asked to reach forward as far as possible with their fingertips and to wait at the last point on the ruler for 3 seconds. After three trials, the highest value was recorded in cm (Tamer, 2000). Cooper The participants were asked to reach the longest distance for 12 minutes by running or walking. Each 100 meter of the 400-m running track was marked and, the test was started. Evaluation: The formula used in the Cooper test to determine the aerobic strength is as follows: VO2 max (the distance (m) -504.9) / 44.73 the values in the table can be used to determine the aerobic strength. RESULTS The right hand-left hand grip strength mean values of males were determined to be (44.78 kg and 42.73 kg), and of females (26.61 kg and 25.11 kg) respectively; the back and leg strength mean values of males were determined to be x (106.55 kg, 118, 8 kg), and of females (60.15 kg and 68.77 kg) respectively. The mean value of vertical jump distance for males was 45.80 cm, and 32.92 cm for females. Sit-up mean test result was 21,85 pieces for men and 17,30 pieces for females. The mean values of sit-stretch for males and females were respectively (24.97 cm and 28.65 cm), while VO2 max values (ml/kg/sec) were (36.88 ml/kg/min, 26.32 ml/kg/min), respectively. Table 1: Length, body weight, mean and standard deviation values of body mass index by gender Variables Gender N X±SS Gender N X±SS 164,23±0,53 13 Female 174,9±0,68 21 Male Height (cm) 56,61±7,24 13 Female 69,52±8,74 21 Male Weight (kg) 20,53±3,09 13 Female 22,33±2,53 21 BMI (kg/m2) Male Table 2: Mean and standard deviation values of the motor characteristics and maximal oxygen consumption capacity by gender Variables Right hand grip strength (kg) Left hand grip strength (kg) Leg strength (kg) Back force (kg) Vertical jump (cm) Crunch (number/sec) Sit and reach (cm) VO2 max (ml/kg/sec)

Gender N Male 21 Male 21 Male 21 Male 21 Male 21 Male 21 Male 21 Male 21

X±SS 44,78±5,74 42,73±6,83 118,8±23,06 106,55±25,93 45,80±6,88 21,85±4,01 24,97±6,26 36,88±5,21

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Gender Female Female Female Female Female Female Female Female

N 13 13 13 13 13 13 13 13

X±SS 26,61±3,28 25,11±3,93 68,77±8,77 60,15±11,69 32,92±5,69 17,30±4,57 28,65±4,23 26,63±6,88

DISCUSSION and RESULTS The average height of the sedentary working groups in the study was determined to be 174.9±0.687; average body weight, 69.52 ± 8.74; body mass index 22.33±2.53 kg/m2 for males and 20.53 ± 3.09 kg/m2 for females. The values of 18.5 to 24.9 were reported to be within the normal range (Coburn & Malek, 2012). Aslan et al., identified the strength, anaerobic strength and flexibility characteristics of athletes and sedentary individuals between the ages of 18-30, and determined whether there was a difference between the people who were at the beginning and ending of this age range. Researchers identified the physical features of the participants respectively by dividing them into two groups as younger age group (178.00±4.87cm, 19.28±0.67 years, 67.62±9.85 kg) and older age group (178.62±10.55 cm, 28.61±1.19 years, 81.37 ± 9.68 kg). According to the norms of American College of Sports Medicine (ACSM) and Canadian Society of Exercise Physiology (CSEP), the average values of right hand grip strength for men and women between 20-29 years of age must be between 48-61 kg, 25-37 kg; the average values of left hand grip strength for men and women between 4355 kg, 22-33 kg; their leg strengths between 160-213 kg, 66-113 kg, and back strengths between 126-176 kg, and 52-97 kg respectively (Heyward & Gibson, 2014). The average value of the study, the research group located in the right hand grip strength of men and women, respectively, 44.78 ± 5.74 kg, 26.61 ± 3.28 kg, left hand grip strength of 42.73 ± 6.83, 25.11 ± 3 as 93, leg strength 118.8 ± 23.06 kg and 68.77 ± 8.77 kg and 106.55 ± 25.93 kg, respectively, back strength, 60.15 ± 11.69 kg, respectively, were identified. Similar to our study results, Aslan et al., found that the leg strength in sedentary men aged 19:28 ± 0.67 years was 114.38±24.09 kg; and in sedentary men aged 28.61±1.19, 122.19±19:47 kg. Akcan and Biçer (2015) investigated the physical and physiological effects of two different 8-week strength training programmes on the athletes between ages of 18-30. Three groups were formed from the volunteers among 18-30 ages who participated in the study; Explosive Strength Group (ESG, n=12), Strength Endurance Group (SEG, n=12) and Control Group (CG, n=12). The data obtained from these three groups before and after the exercise programme are reported as follows: right hand grip strength was 43.23 ± 3.85, 43.58 ± 4.06 kg in the endurance group; 43.69 ± 6.18, 44.60 ± 5.87 kg in the Explosive Etrength Group; 42.10 ± 3.87, 42.28 ± 3.69 kg in the Control group; left hand grip strength was 40.89 ± 5.00 41.79 ± 4.92 kg in the strength endurance group; 40.79 ± 6.35, 41.40 ± 6.33 kg in the explosive strength group; 39.28 ± 4.09 39.51 ± 3.68 kg in the control group. In the same order; leg strength value was 124.21 ±11.43, 126.13 ±11.72 kg in the strength endurance group; 119.96 ±12.24 125.50 ± 9.87 kg in the explosive strength group; and 122.63 ± 6.29, 122.88 ± 6.02 kg in the control group. The back strength was reported to be 138.63 ±8.07, 142.77 ±9.24 kg in the strength endurance group; 134.04 ±11.14 139.58 ± 9.83 kg in the explosive strength group; 134.13 ± 8.36 134.46 ± 7.20 in the control group. Kılınç and Bakırcı (2014) defined the right hand grip strength as 45.6±6.2, and the left hand grip as 42.7±6.9 kg after the training they applied. Although there are similarities between the study of Akcan and Biçer and the one we conducted in terms of right-left hand grip strength and leg strength, and similarities have been identified between the study of Kılınç and Bakırcı and ours in terms of back strength. Unlike the studies conducted, in the study where some physical parameters of elite female handball players (21.60 ± 1.35 years, n = 36) and boxers (20.90 ± 2,17 years, n = 44) were 707

investigated, the left hand grip in handball players and boxers was reported as 34 70 kg ± 4.39, and 33.35 ± 4.13 kg; right hand grip as 36.79 ± 3.36 kg and 34.29 ± 3.68; back strength as 88.28 ± 17.22 kg and 94.43 ± 20.33 kg; leg strength as 123.98 ± 21.65 kg and 108.73 ± 24.16 kg, respectively (Çınar et al., 2009). As the results of the study conducted on 66 young elite wrestlers whose average age was 19.5±1.6 (years), height 1.73±0.7 (m) and body weight 76.8±14.7 (kg); dominant hand grip strength was indicated as 51.21±7.97; back strength as 155.80±27.92; leg strength as 161.61 ± 35.70 (Aydos et al., 2009). When the study conducted is compared with the study of Çınar et al (2009) and Aydos et al (2009); poor results were obtained in all the parameters; when compared with the study of Gökhan et al. (2015) better results were obtained, and when compared with Harbili et al (2005), similar results were obtained. When compared to the standard values, the male participants' hand grip strength was found to be below the mean value; and female participants' values to be within normal limits. When compared to the standard values by gender; the back and leg strength mean values of men were below the norm values. Women's back and leg strength values were within normal limits (Heyward & Gibson 2014). Vertical jump distances were found to be 45.80±6.88 cm in men and 32.92±5.69 cm in women Çınar et al (2009) reported the vertical jump values as 45.50 ± 4.65 cm in handball players and as 42.20 ± 4.76 cm in boxers. Unlike the study conducted, in the study of Sonal et al (2014) where they investigated physical and motor features of university students who were between the ages of 19 and 21 (sedentary n = 40 and athletes n = 40); they determined the vertical jump performance students as 52.57±8:20 in sedentaries and as 58.77±8.90 in athletes after three measurements. Kılınç and Bakırcı (2014) applied a combined training programme on a university men' basketball team whose ages were 21.3 ± 2.5 years, athlete ages were 9.4±4.3 years, heights were 184.6±10.1 cm. and body weights were 84±20.4 kg. The free vertical jump value was reported as 58.3±12.3 cm after training. The normal vertical jump average values stated in the literature are between 40-49 cm in men and 36-46 cm in women (Coulson & Archer 2009). According to these data; the average vertical jump distance of men in the study group was within the normal limits, while that of the women was determined to be below the normal limits. Sit-up mean test result was 21,85±4,01 pieces for men and 17,30±4,57 pieces for females. Kılınç ve Bakırcı (2014) reported the sit-up values in the basketball players as 29.6 ± 3.8 pieces after the training. The standard average values of ACSM in sit-up strength are 27-31 pieces; and 27-32 pieces for men and women aged between 20-29 years, respectively. When comparing the study data to the norm values of ACSM, test results for women and men were found to be within the normal values. The sit-stretch value mean of men and women were determined to be 24.97 ± 6.26 cm and 28.65 ± 4.23 cm, respectively; while the norm values of ACSM were indicated as 30-33cm in men and 33-36cm in women. When compared to the standard values, the average flexibility values of men and women obtained in the study can be described as rather poor. Similar to our study results, Aslan et al., found that the flexibility value in sedentary men aged 19:28 ± 0.67 years was 26.75 ± 6.39cm; and in sedentary men aged 28.61±1.19, 18.00 ± 7.99cm. Kılınç ve Bakırcı (2014) reported the flexibility values in the basketball players as 25.7±7.6 cm after the training. Akcan and Biçer (2015) reported flexibility values as 25.83 ± 3.97 cm in the explosive strength group, as 26.25 ± 4.71 cm in the strength 708

endurance group and 25.00 ± 3.91 in the control group after the 8-week strength exercises programme. Unlike the studies conducted, Çınar et al (2009) reported the flexibility values in handball players as 39.92 ± 3.54 cm and as 42.29 ± 3.30 in boxers. These values show that flexibility values decrease as one grows older, however, a special effort should be made in order for people from all sports branches and lines of work to have the optimum values and maintain the motor performance. Aerobic capacity is one of the most important indicators of physical fitness level. The VO2 max values of men and women were found to be 36.88±5.21 ml/min/kg and 26.63±6.88 ml/min/kg, respectively. While Men's value was 2154.76±233.40 m in Cooper's distance; that of women was 1696,15±307,85m. It is reported that in the literature that VO2 max value should be between 35-43 ml/min/kg and 32-38 ml/min/kg in the norm values table for adults (Reiman & Manske 2009). Akcan and Biçer (2015) reported the VO2 max values in male athletes as 51.94 ± 3.28 ml/kg/min in the explosive strength group; as 53.07 ± 2.96 ml/kg/min in the strength endurance group; and as 47.85 ± 2.68 ml/kg/min in the control group. Çınar et al (2009) reported the VO2 max values as 45.80±7.05 ml/kg/min in handball players and as 44.79±8.14 ml/kg/min in boxers. In the study conducted by Çelenk and Çumralıgil (2005), on a total of 134 elite athletes including 30 elite volleyball players(23.30 ± 3.06 years), 32 elite soccer players (22.28 ± 2.99 years), 39 elite taekwondo athletes (23.31 ± 2.88 years), the VO2 max values were reported as 50,27 ml/kg/min, 55,00 ml/kg/min, 60,52 ml/kg/min, 50,06ml/kg/min, respectively. When compared with the literature values, VO2 max values in the study were found to be far below the reported values. When comparing the aerobic values of the group involved in the study to the norm values, the values of men were determined to be within the normal limits, while women performed below the norm level. In addition, men in the 20-29 age range should perform 2400 and 2800 m, and the women in this age range should perform 1800 to 2199 m. The good performance in elite athletes has been reported as 3400-3700m in men and 2700-3000m in women (Kamar, 2003). When the study data is compared to the performance data between ages of 20-29 by gender, men and women are located in the poor category. When compared with elite level performance data, the performances for both genders are located in the poor category. This result indicates that aerobic capacity training is needed for both gender groups, especially for women. As a result, as for the values the students trained in a private security department; the values of strength, aerobic capacity, flexibility of both sexes, the values of right-left hand grip, back and leg strength in men, the values of abdominal muscle strength and vertical jump in women were found to be below standard values. The physical and physiological capacities of the male and female private security department students were determined to be below or at the lower end of the standard values. For an effective professional life, these values need to be increased and maintained. We recommend that strength, endurance and flexibility exercises be given place to in the curriculum, and training programs that will improve these values be developed and applied. REFERENCES Akcan, F.; Biçer, M. (2015).The Effect of Two Different Strength Training Programs Applied to Male Athletes in the Various Branches on Some Physical and Physiological Parameters, Turkish Journal of Sport and Exercise, 17 (2), 1-7. 709

Akkuş, H.;Harbili E.; Harbili, S.; Özergin, U. (2005). Kuvvet Antrenmanının Vücut Kompozisyonu ve Bazı Hormonlar Üzerine Etkisi, Spor Bilimleri Dergisi Hacettepe J. of Sport Sciences,16 (2), 64-76. Aktaş, Y.; Aysan, H.A.; Gökhan, İ. (2015) Amatör Futbolcuların Bacak Kuvveti ile Sürat Değerleri Arasındaki İlişkinin İncelenmesi, International Journal of Science Culture and Sport, Special Issue on the Proceedings of the 4th ISCS Conference – Part B Akyüz M.; Aydos, L.; Taş M.; Uzun A. (2009). Genç Elit Güreşçilerde Kuvvetle Bazı Antropometrik Paremetrelerin İlişkisinin İncelenmesi, Atabesbd, 11 (4) : 1-10. Archer, D.;Coulson M. (2009). Practical Fitness Testing: Analysis in Exercise and Sport, A & C Black Publishers,171. Aslan, C.S.; Koç, H.; Köklü, Y. (2011). Sporcu ve Sedanter Erkeklerde 18-30 Yaş Periyodunun Kuvvet, Anaerobik Güç ve Esneklik Üzerine Etkileri, Sağlık Bilimleri Dergisi (Journal of HealthSciences) 20:(1),48-53. Bakırcı, A;, Kılınç, F. (2014). Hazırlık Periyodunda Uygulanan Kombine Antrenmanların Üniversite Basketbol Takımının Performans Düzeyine Etkisi, İnönü Üniversitesi, Beden Eğitimi ve Spor Bilimleri Dergisi, 1(2), 48-67. Bilen Ö.; Sonala, Ç.E.; Toksöz, İ. (2014) Evaluation of the Physical Characteristics and Motoric Test Results of (Male) University Students, Procedia , Social and Behavioral Sciences 152, 1261 – 1266. Çelenk, Ç.; Çumralıgil, B. (2005) Takım sporları ile ferdi sporların bazı fiziksel ve fizyolojik özelliklerinin karşılaştırılması, 7(5). Çınar, V.; Polat, Y.; Savucu, Y.; Şahin, M. (2009). Elit Bayan Boksör ve Hentbolcuların Bazı Fiziksel Parametrelerinin İncelenmesi, e-Journal of New World Sciences Academy Sports Sciences, 4, (3), 162-170. Coburn W.J.; Malek, H.M. (2012). NSCA's Essentials of Personal Training-2nd Edition, Human Kinetics, 234. Heyward, V.H,; Gibson A. (2014).Advanced fitness assessment and exercise prescription 7th edition, Human Kinetics, 157. http://www.mevzuat.gov.tr/Metin.Aspx?MevzuatKod=7.5.7190&MevzuatIliski=0&sourceX mlSearch.Accesed(22.06.2016) Kamar, A. (2008). Sporda Yetenek Beceri ve Performans Testleri. Nobel Yayınları, 2. Basım. Ankara. Reiman P.M., Manske C. R. (2009).FunctionalTesting in Human Performance, Human Kinetics,279. Sayın, K. (2011). Retrieved from http://www.ozelguvenlikdunyasi.com/turkiye%E2%80%99de-ozel-guvenlik-okullarihakkinda.html Accesed (05.05.2016) Tamer, K. (2000). Sporda fiziksel fizyolojik performansın ölçülmesi ve değerlendirilmesi, Bağırgan Yayınevi, Ankara. Zorba E. Herkes için Spor, Canset Matbaacılık, IV Basım, 132-133.

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Chapter 64 Electrical Muscle Stimulation and Its Use for Sports Training Programs: A review Fatih KAYA, Mustafa Said ERZEYBEK INTRODUCTION Currently, there are several sport training methods that are used to increase the sportive performance. However, since the target is to obtain the effects promptly, there is a need for new and innovative methods. One of these methods is the artificial electrical muscle stimulations (EMS) which is used as the protective strength training (Pichon et al., 1995; Maffiuletti et al., 2000; Maffiuletti et al., 2002; Brocherie et al., 2005; Babault et al., 2007). The general purpose of the electrical stimulations is to develop the basic muscle properties that are related with the training (intramuscular blood flow, maximum strength, endurance) with the help of repetitive contractions (Pichon et al., 1995; Maffiuletti et al., 2000). At the beginning of the several unprompted sports activities, the central nervous system (CNS) generally activates the smallest alpha motoneurons firstly. When exercising continues and more energy is needed to be generated for the muscles, larger alpha motoneurons are increasingly activated (Porcari et al., 2002). It has been reported that the electrical muscle stimulations activate the fast twitch (FT) fibers that are generally more difficult to activate and of which the stimulation depends on the largest alpha neurons by reversing the motor unit recruitment order (Sinacore et al., 1990); that it enables more motor unit to take part in the training (Gregory and Bickel, 2005); that the indirect electrical stimulation activates almost all fibers in the given muscle group (Egginton and Hudlicka, 2000) and thus, this selective increase of the FT fibers may improve the overall strength of a muscle or a group of muscles through the electrical stimulation (Anderson, 2009). Electrical muscle stimulation may be an easy way to ‘train’ fast twitch motor units without great overall muscular effort (Komi, 2003). Currently, strengthening the muscle through the electrical stimulation is a routin procedure in the rehabilitation clinics and the studies regarding the EMS use on the healthy skeletal muscle as a training method have been increased in the last decade. The studies about the effects of the electrical muscle stimulations on the muscle performance have revealed the the high frequence impulses are efficient in terms of the strengthening (Alon and Smith, 2005; Filipovic et al., 2011; Hortobágyi 1996; Komi 2003; Matsunaga et al., 1999; Mohr et al., 1985) and the low frequence impulses are efficient in terms of the endurance (Thériault et al., 1996; Callaghan 2002; Hamada et al., 2004, Atherton et al., 2005). Also, the low frequence impulses are used for muscular recovery after the fatigue (Raymond et al., 2007; Maffiuletti et al., 2011; Babault 2011). 

Asst. Prof. Dr., Erzincan University, Education Faculty, Department of Physical Education and Sport, Erzincan, Turkey  Asst. Prof. Dr., Dumlupınar University, School of Physical Education and Sport, Kütahya, Turkey

The extensive variation of the stimulation parameters as well as the duration of the entire program and of each session affect the success of the training programs. In this research, the efficiency of EMS used in the sports training programs have been studied and discussed and suggestions have been provided for the future researches. 1. ELECTRICAL MUSCLE STIMULATION The use of EMS in sports has been started in 1960’s with Kots’ practices and it has been claimed that a new stimulation form (Russian form) strenghtens the muscles up to 40% for elite athletes (Ward and Shkuratova, 2002), and thus the use of EMS in sports became popular. In 1970’s, these studies were shared with the Western sports institutions. However, since the mechanisms involved in the EMS were not properly understood, the results were conflicting. The recent medical physiological researches have revealed precisely the adaptations of the muscle cell, blood vessels (Perez et al., 2002; Harris, 2005) and nervous system (Hortobágyi, 1996; Boerio et al., 2005; Gondin et al., 2006; Jubeau et al., 2006) caused the electrical stimulation. 1.1. Electrical Muscle Stimulation Mechanism The muscular contraction resulting from the EMS is different from the voluntary muscular contraction started by the CNS. The motor neuron excitation (action potential) started by the nervous system or by an electrical stimulus are always exactly the same (all or none principle) and each excitation causes the same basic mechanical muscular response. Thus, regardless if it is started by the nervous system or EMS, the action is similar. In this regard, the voluntary muscular action is started by the nervous system: brain → spinal cord → motor nerve → muscle (Johnston, 2004). EMS causes an artificial muscular activation by eliminating this process (Trimble and Enoka, 1991). Whereas the brain is capable to stimulate most of the muscular fibers, an EMS device can stimulate the muscular fibers up to 100%. Furthermore, unlike the human brain, an EMS device can provide high quality impulses to make the muscles work without causing cardiovascular and psychological fatigue. Compared to the voluntary training alone, this enables better and safer muscle performance results. The electrical stimulus is transferred from the EMS device to the muscles via nerve fibers or motoneurons. The role of the impulse is to provide a muscular response (twitch) upon conversion of the nerve stimulus into a mechanical activity. If the electrical impulse continues, the muscle excitation/stimulation occurs and muscular twitch is repeated. If the muscles are stimulated with the frequent impulses, the muscular fibers reach the contraction point. Thus, the muscles respond with a constant contraction (tetanization) and it depends on the summation of the basic responses. When the frequency of the stimulation impulses are increased, each individual twitch becomes less significant; until the contraction point, the appearance of the muscular contraction becomes smooth (Johnston, 2004; Starkey, 2013). The electrical impulse triggering the motor neuron excitation, the impulse frequency (number of impulses per second-Hertz), contraction duration (duration of the continous muscular contraction), rest duration (duration of the rest between the contractions), number of repetitions (repeating contraction-rest cycle) and the intensity (miliampere, mA) are the parameters that define the quantity and quality of the muscular activity (Johnston, 2004; Starkey, 2013). The number of the muscular fibers that will be recruited in the muscular activity 712

depends on the intensity of the electrical stimulus. If the stimulation comprises the intense impulse levels, more muscular fibers would be recruited to the activty. On the contrary, the lower density would cause a few number of fibers to take part in the activity (Starkey, 2013). These impulses are transferred from the EMS device to the skin through electrodes. The electrodes transmit the electrical current to the skin and motor nerve. When the electrodes are fixed on the skin and the current in the unit is turned on, the stimulation is transmitted to the muscle and thus, indirectly to the motor nerve. The appropriate electrode size and location (Forrester and Petrofsky, 2004) as well as the quality of the current are considered and the electrical current flows between the electrodes through the tissues (Johnston, 2004). 1.2. Electrical Muscle Stimulation Theory The muscular performance increasing ability of the EMS protocols with regard to both healthy and dysfunctional muscles is widely accepted and reported as a routin together with the clinical applications (Dudley et al., 1999; Belanger et al., 2000; Stevenson and Dudley, 2001; Lewek et al., 2001). However, although several researchers have reported increases in the muscular performance with EMS, there are differences in the literature with regard to the specific EMS responses compared to the voluntary contractions. The positive effects of the EMS training have been based on various mechanisms; especially the one about the voluntary muscle activation is related with the recruitment order (Kubiak, Whitman, and Johnston 1987). Henneman’s size principle (1965) defines the voluntary motor unit recruitment as the gradual recruitment of the large, typically fast motor units after recruitment of the small and typically slow motor units. There are certain facts that demonstrate the variability of the size principle (Denier et al., 1985; Nardone et al., 1989) and it has been reported that the electrical muscle stimulus is one of the factors that reverse the motor unit recruitment order (Anderson 2009, Feiereisen et al., 1997; Porcari et al., 2002; Komi, 2003; Starkey, 2013). The first of the theories claims that the EMS produces intense muscle contractions which are similar to those contractions occuring during the strength training and thus, the muscular response emanates in a similar way to the adaptations in a regular training. Another theory, the strongest claim is that the EMS reverses the voluntary motor unit recruitment order (Gregory and Bickel, 2005). Despite a statement reporting that rather than the reverse physiological voluntary recruitment order, the muscle fiber recruitment during the EMS is of the non-selective, spatially fixed and temporarily synchronised model (Gregory and Bickel, 2005; Maffiuletti et al., 2011), the EMS results support that the size principles is reversed. Compared to the voluntary contractions (6%), the reverse recruitment rate during the electrical stimulation is 28-35 % arasındadır (Feiereisen et al., 1997) and the claim that the fast motor units are ahead of the slow motor units is based on the two prevailing views: (1) the electrical resistence of the large axon motor units against the external current is much lower and they transmit their action potentials faster than the small axon motor units; (2) the data showing the increase in fatigue with EMS, compared to the voluntary contractions (Gregory and Bickel, 2005). The fact that EMS (75Hz) produces more cardiorespiratory demands compared to the voluntary contractions of the same intensity and causes more muscular fatigue in a single session, has been accepted as an indicator of the variability regarding the motor 713

unit recruitment model (Theurel et al., 2007). Another important indicator is the glycogen discharge in the FT muscle fibers, right after the electrical stimulation (Sinacore et al., 1990). It has been shown that the glucose carrying activity is higher in FT’s compared to the slow twitch (ST) fibers, when EMS is applied (Roy et al., 1997). Contrary to the motor unit recruitment order encountered during the low intensity voluntary exercising where the ST fibers are first used (Gollnick et al., 1974), the fact that large and fatigable glycolytic fiber FT motor units are first activated during EMS (Sinacore et al., 1990) supports the “reverse-size principle” regarding the motor unit recruitment with EMS. The reverse motor unit recruitment order obtained with EMS has been tested also with H-reflex (H-reflexes show the total motor unit activity) and motor responses (M-response) and it has been shown that the motor unit population activated with electrical stimulus as well as the motor unit recruitment order have changed (Trimble and Enoka, 1991). Due to this selective recruitment, an increase of up to 44% in the muscular strength has been observed (Brocherie et al., 2005; Anderson 2009). Theoretically, electrical stimulus application during a voluntary muscle movement can activate more motor units compared to the voluntary contraction alone; and it has been reported that this can led to an increase in the contraction strength and the training programs where electrical stimulus is used are much more efficient and provide more volume and muscle strength compared to the separate use of the electrical stimulus and voluntary contraction programs (Paillard et al., 2005). 1.3. Changes Related with EMS In this section, the effects of EMS on the muscle, changes in the myofibril mechanism and energy metabolism, neurophysiologic, tissular and biochemical, blood flow and capillary changes have studied in consideration of the literature. 1.3.1. Changes in Myofibril Mechanism and Energy Metabolism For the high level contractions, the basic muscular adaptations are the increases in actin and myosin (contractile proteins). Both voluntary activation and electrical stimulation may cause an increase in the contractile protein quantity of the muscle (Robinson and Snyder-Mackler, 2007). Animal testing provides useful information about the effects of EMS at the cellular level. The studies covering chronic low frequency impulses showed that the basic function elements of the muscles fibers such as (Ca2+) regulating system, myofibril system, energy metabolism and microvascular system are also affected by EMS (Callaghan, 2002). In the contraction produced by the chronic low frequency EMS, the alteration of the Ca2+ dynamics and then a change from fast to slow characteristic have been observed. These are ultra structural changes in the cross-sectional area (CSA) and the significant decreases have been observed in its weight, although the width of the band Z (this is the reason why it reminds of the ST fibers) and the number of the fibers are preserved (Pette, 2001). Also, it seems that the chronic stimulation causes the complete reorganization of the myofibrillary proteins during the conversion of the sarcomere from fast to slow (Callaghan, 2002). Furthermore, it leds to continous increase of the intracellular calcium and activates the calcium regulating enzymes such as calcineurin and calmodulin-inked protein kinase (CaMK) (Wu et al., 2000). Low frequency EMS during 48 hours may cause significant decrease in the 714

maximum Ca2+ use capacity in the sarsarcoplasmic reticulum and the initial rate. Longer stimulation causes more significant changes and accompanied with the decrease in the Ca2+ activity to reach ATPaza (Pette, 2001). Also, with chronic low frequency EMS, a significant increase in the aerobic-oxidative capacity of the FT muscles and a five times increase in the capillary density may be observed (Brown et al., 1989). There are important evidences demonstrating that when the exercising protocols are applied with low intensity, the glycolytic anaerobic metabolism is more significant in EMS compared to the voluntary exercising due to the formation of the hydrogen ions and phosphocreatine catabolism (Hultman and Spriet, 1986; Vanderthommen et al., 2003). Additionally, it has been shown that the glucose carrying activity is higher in FT fibers compared to ST fibers when EMS is applied (Roy et al., 1997). EMS may be a better approach to increase the glucose carrying activity to the skeletal muscle without intensive voluntary exercising. Also, the functional and enzymatic adaptations in the skeletal muscle response against the chronic low frequency EMS have been observed in the human subjects (Chilibeck et al., 1999; Mohr et al., 2001; Nuhr et al., 2003). 1.3.2. Neurogenic Changes Although EMS is accepted in general as a technique used to activate the muscles without activating the nervous system, the mutual transmission of the action potentials through the stimulated axones (Maffiuletti et al., 2006), the dose-response relation between the activation of the selected brain sections by quadriceps stimulation (Smith et al., 2003), the cross effects of the training at the same time (Hortobágyi et al., 1999; Maffiuletti et al., 2006) showed clearly that EMS activates the neural system. All these results demonstrate that the electrical stimulation does not completely bypass the peripheral system. However, in the recent statements about the neurophysiologic effects of EMS, it has been reported that when the normal muscles are trained through electrical stimulation, the initial rate of strength gain is fast without any change in the muscle volume, and this is an indicator showing that the adaptive mechanisms are neural. Another possible mechanism is the increasing spinal motor neuron pool activation. It has been reported that the motoneurons regulate the strength gain through the simulation of the afferent neurons and it is associated with a long term potantialization together with a snaps sensitivity due to the stimulation of the afferent nerve fibers, and thus the strength gains can be preserved for a couple of weeks even if the training is stopped and this has a long term potantialization (Hortobágyi, 1996; Gondin et al., 2006; Jubeau et al., 2006). These useful effects of the electrical muscle stimulation is accompanied by the increasing blood flow in the intramuscular and peripheral soft-wall vessels and thus, the pumping activity of the muscles increases (Hortobágyi, 1996). Various EMS studies claiming that the strength gains are associated with the neural factors rather than the changes at the muscular level covers a period of 4 weeks or less (Singer, 1986; Maffiuletti, Pensini, and Martin 2002; Malatesta et al., 2003). For example Maffiuletti, Pensini and Martin (2002) after an EMS training of 4 weeks, the significant increase in the maximum voluntary contraction (MVC) has been associated with the increase in the muscle activation and in the EMG (electromyography) activity, (Gondin et al. (2005) and upon a research where the effects of the 4 and 8 weeks EMS trainings on the neural and muscular adaptations of the knee extensor muscles, it has been reported that after a 8 weeks EMS training, quadriceps MVC tork increase is 715

associated with both muscular and neural adaptations. The first 4 weeks period being the start of the strength increase, the second 4 weeks period has led to more strength gain. Similarly, after a 5 weeks EMS training of the plantar flexor muscle, the increase in the voluntary tork has been associated with the spinal level adaptations and an increased voluntary function in the supraspinal centers (Gondin et al., 2006a). Upon the neuromuscular electrical stimulation training of fiwe weeks and then the following detraining period of five weeks, it has been observed that the neural adaptations affected by the training continue after the detraining and thus this shows that the neural changes are preserved for long term and do not affect the H-reflex elements (Gondin et al., 2006b). Maffiuletti et al. (2003), have shown in their study that the EMS training of the plantar flexor muscles (4 weeks-16 isometric EMS sessions - 75Hz) does not affect the alpha motor excitability and presynaptic inhibition as is the case with the H-reflex. Additionally, in a research where the H-reflex and M-response in the electrical stimulation are studied (Trimble and Enoka, 1991) it has been demonstrated that EMS directly activates the large afferent axones and provide cutaneous feedback that changes the motor unit population activated during the H-reflex. In a study where the central and peripheral fatigue caused by a typical EMS session (75Hz) is examined, it has been reported that the significant decrease in the maximum voluntary contraction strength after the EMS is associated with the significant decrease in the center activation and both central and peripheral factors contribute to the fatigue, and the neuromuscular propogation weakness has been demonstrated for the muscles having higher FT fiber percentage (Boerio et al., 2005). 1.3.3. Tissular and Biochemical Changes The use of muscular biopsy has provided important evidences about the cellular changes caused by EMS in human muscles and especially in the quadriceps muscle. As reported by Callaghan (2002) in the first studies (1980s), the muscle fiber area and the fiber type composition of the healthy quadriceps were not changed by 200Hz EMS; whereas in other studies, 50 Hz modulated 2500 Hz “Russian” EMS protocol caused a significant decrease in the FT fiber area, but no change has been observed in terms of the fiber type distribution. However, the post-stimulation decrease in the fiber area in the healthy subjects is the contrary to that observed in the patients with knee injury after the stimulation and this has been explained by the variations in the mechanisms covered by the strength training. Furthermore, Callaghan (2002) has indicated that the neural factors or enzymatic changes in the healthy subjects can be much more significant compared to the fiber type changes and in certain studies no significant change has been observed in the enzyme activity involved in the contraction process, whereas in certain studies, after the knee and quadriceps immobilization of 5 weeks, the decrease in the succinate dehydrogenase activity (an indicator of the mitochondrial oxidative activity) observed in the patients has been significantly slowed down after EMS. On the other hand, after the chronic low frequency EMS (8Hz, 8 hours daily) applied to the quadriceps for 8 weeks, a significant increase in the aerobic enzyme activity has been observed and no change has been seen in terms of the anaerobic indicators. It is important to note that the different results obtained from the different studies are related with the different EMS parameters. For example, in a study regarding the healthy human vastus lateralis phenotype after EMS (Perez et al., 2002), it has been 716

seen that while short periods (45-60Hz for 6 weeks, 3 days a week, 30 minutes each day, 300 µs) reduces completely the percentages of other fiber type, it increases the FTa fiber percentage. The chronic muscle weakness is related with the decrease in the muscle protein synthesis and the results obtained from the atrophic muscle studies show that EMS causes changes in the muscle physiology at the cellular level and it protects the protein synthesis in the atrophic muscles especially after the immobilization (Callaghan, 2002). 1.3.4. Changes in the Muscle Blood Flow and Capillary Structure Various studies showed that exercising with EMS can increase the blood flow in the stimulated muscles in parallel with the voluntary exercising (Currier et al., 1986; Walker et al., 1988, Levine et al., 1990). What is interesting is that Vanderthommen at al. (1997) have reported that compared to the voluntary exercising with the same work load, the blood flow is higher during EMS. Since in all of these studies (Currier et al., 1986; Walker et al., 1988; Levine et al., 1990; Vanderthommen et al., 1997) the disturbing tetanic stimulation frequencies (35-100Hz) have been used, it is likely that a vasoconstriction that resists to the expected increase in the blood flow occurs (Walker et al., 1988). Kim et al. (1995) has reported that pulmonary O2 use being same for both exercising forms, the ventilator coefficient is higher in EMS compared to the voluntary exercising; that the leg blood flow and O2 use are similar for both exercising forms and the heart rate and average blood pressure are partially higher in EMS. Other results obtained show that the lactate and ammonia flows in the leg are higher in EMS and they increase with the increasing exercising intensity; that the muscles’ glucose use is similar for both exercising forms; that the femoral venous potassium (K+) concentration increases with the exercising intensity and higher in EMS. In animals, the histochemical characteristics of the fast muscle fibers become similar to those of the slow muscle fibers after low frequency EMS and the fast muscles gain higher capillary density and more fatigue resistence (Callaghan, 2002). When these muscles are stimulated with low frequency (10 Hz continous) for 2-4 days (8 hours/day), it has been shown that the fast glycolytic transforms into fast oxidative fibers and that after 4 days of stimulation, this transformation is much higher and that the number of the capillaries is higher in the stimulated muscles (Hudlicka, 1982). It has been reported that an EMS training for 21 days regarding the human triceps surae muscles (50 Hz and 2500 Hz alternate current) develops the capillary source (Perez et al., 2002). 2. EMS IN MUSCLE STRENGHTENING The basic problem about the muscle stimulation literature is the way how EMS changes the muscular performance in the EMS or in the EMS and voluntary exercising combination as compared with the voluntary exercising. The strength response of the skeletal muscle against the stimulation depends on the intensity and frequency of the stimulation. A single shock on a muscle results in a single twitch in 200 milliseconds. If the stimulation frequency is increased 10 to 20 impulses per second, the muscle contraction is fragmental or twitch like. Unlike this, when a muscle is stimulated with high frequency, the contraction becomes smooth and the strength production peaks (tetanus). However, the muscle get tired fast (Hortobágyi, 1996; Starkey, 2013). 717

Under the natural conditions, while the motoneurons are activated unsynchronised, the artificial EMS signals are synchronised. In the natural stimulation, the motor units produce the muscular strength hierarchically (size principle). A second natural strength regulation form is the increase in the stimulation ratios of the motor units at the high contraction levels (Hortobágyi, 1996). However, in the electrical stimulation, the larger motor units are recruited first due to their low resistence. Therefore, in the artificial EMS aiming higher strength production, higher stimulation frequencies must be used. However, the muscle would get tired inevitably (Hortobágyi, 1996). The high frequency stimulation (> 70Hz) causes deficiency in the nerve-muscle intersection and the muscle get tired fastly. It has been reported that the appropriate frequency is of the similar rate to the normal motor unit discharge frequency (20-50 Hz) produced during the voluntary activity and the very low frequencies do not guarantee the muscle contraction (Petrofsky, 2004). Bickel et al. (2003) has shown that the acute EMS is sufficient to stimulate the responses at the molecular level. This kind of changes show that the hypertrophy process has started in the muscles. Therefore, after multiple EMS sessions, the changes at the muscular level can be expected. However, the effect of an EMS training program on the muscle hypertrophy is still ambigous in the literature depending on the training duration (Singer, 1986; Stevenson and Dudley, 2001; Gondin et al., 2005) and selected EMS parameters (Stevenson and Dudley, 2001). For example, in a study (Stevenson and Dudley, 2001) an impressive increase is observed in the quadriceps muscle volume after an EMS training of 8-9 weeks, whereas in the studies covering 4 weeks EMS programs, no such changes have been reported (Singer, 1986). Therefore, it has been assumed that an EMS program lasting more than 4 weeks can provide muscle hypertrophy (Obajuluwa, 1991). In all recent whole body EMS studies, it has been reported that the obtained strength gains are quite low (Filipovic, 2011). 2.1. EMS or Isometric Exercising The study results have revealed that the isometric strength can be increased up to 50% with the electrical stimulation of the knee extensor muscles (Hortobágyi, 1996). However, the studies conducted on the healthy skeletal muscles show that the strength development is not as high as in the atrophic muscles. In the publications comparing the isometric exercising and EMS (Laughman et al., 1983, Mohr et al., 1985; Robinson and Snyder-Mackler, 2007), despite the significant differences in the methodological approaches, no difference has been observed in terms of the strength/tork gains between the quadriceps isometric exercising and EMS for the healthy subjects. Only Mohr et al. (1985) have found a significant development with regard to the quadriceps muscle with the isometric exercising (14.7%). In the study that shows the voluntary isometric training is more efficient than EMS in terms of the strength increase of the elbow flexor muscles (Holcomb, 2006) the significant ineffectiveness of the EMS is associated with the exercising intensity. 2.2. EMS or Isokinetic Exercising In the studies directly comparing the EMS and isokinetic exercising for the healthy quadriceps muscles (Halbach and Straus, 1980; Nobbs and Rhodes, 1986), it has been reported that a descriptive development in the quadriceps muscle strength (42% for the exercise group, 22% for the stimulation group) can be provided. What is interesting is 718

that Nobbs and Rhodes (1986) have reported that there is no significant difference for 100°/second and 180°/second angular speeds and the strength gain is recorded at the speeds less or equal to 30°/second and 0°/second training speeds. As reported by Lloyd et al. (1986), a significant strength development in the EMS and isokinetic exercising groups is observed for each angular speeds and knee joint angles. Although there is no difference between the groups, the highest strength increase has been observed in the isokinetic group, whereas the development in the EMS group has been revealed in the isometric and slow isokinetic contractions. Similarly Halbach and Straus (1980) has found that although all of the groups have shown significant strength increase, isokinetic training have provided more strength gain compared to EMS. In this study, the isokinetic training has been applied with different speeds and tested for a single speed (120°/second). 2.3. Combination of EMS and Isometric / Isokinetic Exercising In some studies where the voluntary exercising has been combined with EMS, the objective was to define the EMS effects. All of these studies have revealed clearly that combining exercising and EMS simultaneously is much more efficient than exercising alone (Convery et al., 1994; Burkett et al., 1998). Additionally, this has been concluded regardless whether isometric or isokinetic exercising were used. Therefore, although it has been reported that the combination of these two forms do not provide any gain in the healthy quadriceps muscles (Lloyd et al., 1986) the recent studies have proved the opposite. For example, Callaghan (2002) has reported that an isometric constraction in the 45° knee flexion with or without EMS, an isotonic concentric activity from 90° to complete knee extension and a squat jump comparison; 100 Hz EMS during 0.8 seconds has improved the isometric tork for a ratio of 23% and the isotonic tork for a ratio of 4%; however squat jumps with multiple joint activities have not caused any difference. Dervisevic, Bilban and Valencic (2002) have reported that the isokinetic training combined with the low frequency EMS is a much more efficient method to develop the strength of the quadriceps, compared to the low frequency training and to the isokinetic training alone. 3. MUSCLE ENDURANCE AND EMS The limited number of the studies examining the effects of the EMS training on the muscular training shows that there is a need for studies on human. Robinson and Snyder-Mackler (2007) have indicated that EMS training does not have a significant effect on the abdominal muscle in terms of the muscular endurance. Hartsell’s (1986) study showed an increase in the quadriceps endurance upon stimulation program; however these small increases have not been more significant than those obtained by exercising alone. According to Robinson and Snyder-Mackler (2007), the basic problem for defining the effects of EMS on the muscular fatigue is the fact that the studied EMS training programs are based on the voluntary training programs and there is no clinical study showing that the voluntary endurance training principles (low intensity contractions, high numbers of repetition) were used in the EMS training to improve the muscular endurance. However, with reference to the study conducted by Thériault et al. (1994), Callaghan (2002) has reported that when much lower frequencies such as 8 Hz are used 719

on the animal models, together with an increase in the aerobic oxidative enzyme indicators of 25%, an improvement in the quadriceps endurance and a significant increase in the total quantity of the knee extension training have been observed. Callaghan (2002) who has indicated that the improvements in the endurance capacity are provided with the non uniform stimulation forms, has reported in 1995 with reference to the studies of Oldham et al. that the non uniform neuromuscular stimulation model used for the quadriceps of the old patient with osteoarthritis is better than uniform EMS. Also, the study by Lopez-Guajardo et al. (2001) has shown that low frequency (10Hz) stimulation (6 weeks, 30 minutes each day) applied to the tibialis anterior muscle of the rabbits has provided a significant increase in the endurance capacity of the muscle. Perez et al. (2003) have reported that in human, the chronic electrical stimulation sessions (a couple of hours each day) via the skin may increase the oxidative capacity and capillarization of the FT fibers of the muscle and may cause some fiber transitions among the FT subfibers. However, Perez et al. (2003) have emphasized that in several studies showing the significant effects of EMS on the human skeletal muscles, the protocols that have been applied are unrealistic and difficult to apply under sports training conditions and in clinics and that the sessions are too long (a couple of hours per day) and the used frequency currents (a duration of approximately 100 ms pulse, 50100Hz) are disturbing. The experimental results obtained from the studies involving low frequency EMS on healthy people’s muscles show that the oxidation potential of the stimulated muscles increases. For example, in the study that shows that low frequency electrical stimulation (8Hz) for 6 weeks improves the fatigue resistence of the knee extensor muscle significantly, the citrate syntasis activity, the capillary number per FT-a and FT-b fibers and the percentage of the FT-a muscle fibers in the vastus lateralis muscle have been significantly increased (Thériault et al., 1996). 4. STIMULATION PARAMETERS Nowadays, the stimulation current is transmitted by fixing the electrodes of different structure and materials on the skin covering the motor nerve (motor point). Even if the stimulation is applied on the exact motor point, the strength production of a muscle varies according to the stimulus parameters. Other factors to be considered are the stimulus waveform manipulation (rectangular, sinusoidal, triangle, symmetrical, asymmetrical, etc.) as well as its duration, intensity and frequence (Hortobágyi, 1996). One of the issues that prevents to reach a consensus about the EMS is the extensive variations in the stimulation parameters. However, it has been reported that the success of a training program depends on the allowable stimulation intensity, frequency, and the durations of the entire program and each session (Hortobágyi, 1996). The most important parameter is the frequency and generally is grouped as low, medium and high frequency (Callaghan, 2002). The conducted studies have revealed that the most appropriate program for the EMS training is three times a week, two times a day for 30 minutes and with an intensity of 0.4-30 mA (Boonyarom et al., 2009). In addition to this, while examining the efficiency of EMS with regard to various knee joint angles, several researchers use the standardized 60° knee flexion position (Laughman et al., 1983; Selkowitz, 1985; Mohr et al., 1985; Soo et al., 1988). Other researchers emphasize various knee flexions changing between 15° and 90° (Obajuluwa, 720

1991). Also, the hip flexion is constant for both application and evaluation. When multiple angles are examined, it has been seen that strength improvement occur in the closest test angle (Maffiuletti et al., 2000). The variations in the results (1-49.7%) are arisen probably from the differences in the methodological approaches and stimulation parameters. 4.1. Waveform Different waveforms (i.e. the form of impulse) are used in EMS (Laufer et al., 2001) and the improvement is determined by the nature of the waveform (Kantor et al., 1994). According to Callaghan’ın (2002), after the first trainings, during high frequency sinusoidal stimulation fatigue occurs and the strengthening effects decline. While Agrawal et al. (2008) did not find a significant strength improvement after the 2.5 kHz variable current stimulation, whereas in another study it has been reported that the improvement in the muscle strengthening was 47.7%. Similarly in the studies where 50 Hz stimulation is used without Carrier waveform, different results have been obtained. The muscle strengthening reached in these studies vary between 0% (Mohr et al., 1985) and 48.5% (Lai et al., 1988). In a study where the efficiencies of the three waveforms were compared, it has been seen that the monophasic and biphasic orthogonal waveforms are more efficient than the polyphasic waveform in terms of tork production and that these two waveforms cause less fatigue (Laufer et al., 2001). In another study, it has been reported that the bipolar interferencial current (2500 Hz carrier frequency and 80 Hz amplitude modulation frequency) and low frequency current (symmetrical biphasic) can be used to improve the quadriceps muscular strength and the sensed discomforts are similar for these two waveforms (Bircan et al., 2002). However, it has been indicated that the optimum waveform is biphasic since it produces higher muscular strength and causes less pain (Petrofsky, 2004). 4.2. Pulse Duration Although the pulse durations longer than 60 micro seconds (μs) probably activates the pain fibers, the durations over 200 – 300 μs produce a much stronger contraction (Lake, 1992) and a pulse duration of 200 to 400 μs specifically recruits motor nerves (Starkey, 2013). Also, an interval of 200 to 400 μs is applied in the human muscular trainings (Cheing et al., 2003); (Filipovic et al., 2012). It has been reported that in general, a larger electrode pad structure allows better stimulation tolerence and a current interval of 250-300 μs results in minimum pain response (Petrofsky, 2004). Currently, the clinicians and researchers generally use the symmetrical biphasic waveform and a current interval of 300 µs (Alon and Smith, 2005). Also, it has been reported that if the frequency and intensity are kept constant, the minimum frequency and maximum pulse duration would maximize the performance (Kesar and Binder-Macleod, 2006). 4.3. Duty Cycle In general, this is related with the “on/off” ratio. The “on” phase is the period when the impulse is transmitted to the muscle. The “off” phase is the period between the consecutive “on” phases (Lake, 1992). This parameter is important in terms of resisting against the early muscle fatigue and providing a rest period between the

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contractions (Binder-Macleod and Snyder-Mackler, 1993). Although the exact relationship between the fatigue and stimulated contraction duration and rest for most of the muscles (Robinson and Snyder-Mackler, 2007), Binder-Macleod and Snyder-Mackler (1993) have shown that the contraction intensity and frequency effect the fatigue directly. However, their effects are independent from each other. to reach the high strength levels while strengthening, the frequencies must be higher than the critical fusion frequency (tetani) (higher frequency, higher contraction causing more fatigue). The high contraction intensity provokes also the fatigue (Robinson and Snyder-Mackler, 2007). A training cycle comprising of the shorther “on” and longer “off” durations are useful to protect the muscle against the fatigue and thus, to increase the muscle strength (Matsunaga et al., 1999). It has been observed that longer resting periods are required to minimize the muscle fatigue in higher frequencies, compared to the medium frequencies such as 30Hz (Callaghan, 2002). Furthermore, it has been indicated that in order to avoid the fatigue, the training cycle must be at least 1:5 and for a successful muscular strengthening a training cycle of 1:1 (4 seconds on, 4 seconds off; 15 seconds on, 15 seconds off) and 1:5 (10 seconds on, 50 seconds off) is suggested (Mohr et al., 1985). 4.4. Intensity and Length Stimulation The current intensity (amplitude) is measured with various methods but defined often as miliampere (mA) (Callaghan, 2002). The strength of the contraction increases as the amplitude of the current increases and there is a linear relation between the higher contraction intensity and higher intramuscular changes (Starkey, 2013; Halbach and Straus, 1980). The stimulation intensity can be of a value corresponding to a specified voluntary isometric contraction strength or mostly of a value corresponding to the tolerence of the subject (Paavo, 2003). It has been reported in many studies that depending on the subject tolerence, the current intensity increased gradually may vary between 30-90 mA and that this current intensity does not cause a serious discomfort for the subjects (Maffiuletti, Pesini, and Martin 2002). Callaghan (2002) has reported that the maximum pain rate is experienced for the stimulus intensities corresponding to the 47.1, 70.3 and 42.8 % of the maximum voluntary isometric tork (MVIT). However, many studies covering the quadriceps stimulation application do not define higher stimulation levels (40-80% MVIT). The basic difference regarding the studies where the effects of the EMS and exercising on the muscle strength are similar (Caggiano et al., 1994; Kubiak et al., 1987) is the contraction intensity reached with EMS or exercising. This supports once again that the higher activity and stimulation levels would provide more strength gains. However, the strength gains in some other studies show that the strength gains are not always related with the contraction intensity of a muscle. While the exercising group in the Laughman et al. (1983)’s has worked at average 78% maximum voluntary ısometric contraction (MVIC), the stimulation group has worked at average 33% MVIC. Nevertheless, similar results have been obtained from both groups. In the clinical environment, the maximum comfortable intensity tends to be less than 30% of the MVIC (Starkey, 2013) and the initial level of a stimulation intensity that would provoke a reasonable contraction for affecting the intramuscular changes is 30% MVIT. Besides, the main restriction seems to be the current intensity that can be

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easily tolerated by the patient. This depends on the skin resistence and capacitive skin impedence (Lake, 1992). This is important because the patients using constant frequency stimulators with 35 Hz and higher (approximately 100Hz) would encounter problems while trying to produce strong contractions easily at higher intensities. Also, the cold application prior to treatment increaeses the maximum output tolerated by the patient, but does not translate increased torque production (Starkey, 2013). 4.4.1. Length of Treatment The examination of the application programs reveal that there are significant differences in terms of the daily stimulation quantity and the length of the experimental programs. While some of the studies are too short such as 5 days (Vinge et al., 1996) and some of them are long as 10 weeks (Obajuluwa, 1991) the common application period is 6 weeks (Draper and Ballard, 1991; Snyder-Mackler et al., 1991; SnyderMackler et al., 1995). Due to the differences in the stimulation characteristics and training protocols, the number of the electrical stimulation sessions required for providing strength gain is quite variable. While some researchers have obtained the significant strength gain after a few period of time such as 10 sessions, others reached the significant increases in the strength after 12-25 training session (Mohr et al., 1985). However, when used 4 weeks and 3 times a week, it is possible to obtain significant effects (Parker et al., 2003). In summary, regardless of the EMS method used, the analysis revealed that a stimulation period in a range of 4–6 weeks (3.2 ± 0.9 sessions per week, 17.7 ± 10.9 minutes per session, 6.0 ± 2.4 seconds per contraction with 20.3 ± 9.0% duty cycle) shows positive effects for enhancing strength parameters, jumping and sprinting ability, and power. Therefore, the results of trials using whole-body EMS methods showed that a duration of 15 minutes (2 sessions per week over a 4-week stimulation period) can be assumed to be sufficient for stimulation to activate strength adaptations and thus increasing strength abilities (Filipovic et al., 2011). 4.5. Low Frequency Stimulation Versus High Frequency Stimulation Low frequency stimulation (characteristically between 1-10 Hz) is used to improve the fatigue characteristic of a muscle. On the other hand, if the stimulation is used to provide the strength gain, it causes fatigue. A stimulation regime comprising consecutive high frequency periods together with the low frequency stimulation can be much more advantageous. (Callaghan, 2002). It has been reported that the low frequency stimulation increases the fatigue resistence during the isometric rhythmic or continous contractions of the muscles and this reaches the peak after 4 weeks (Shenkman et al., 2007). Also, it does not produce significant change in the maximum voluntary strength or may cause a slight decrease (Nuhr et al., 2003). The experimental results show that the low frequency electrical stimulation causes the oxidation potential of the stimulated muscles (Thériault et al., 1996). This is an important characteristic for keeping the activity level in the clinical applications. However, there is a significant decrease in the muscle mass (Salmons and Hendricksson, 1981), contraction speed and ability to produce strength (Jarvis, 1993). It has been accepted that 30 or 50 Hz frequency stimulation can produce higher tork value compared to the 10Hz stimulation (Lieber and Kelly, 1993). Although the high frequency stimulation improves the muscle strength theoretically, since it may cause 723

muscle fatigue if no sufficient resting period is provided, the frequency of the electrical stimulation used for the fatigued muscles are low in general and the purpose is rather the recovery of these muscles (Raymond et al., 2007; Maffiuletti et al., 2011; Babault et al., 2011). Again the low frequency is preferred for the muscular endurance trainings. Likewise, it is known that the long term low frequency electrical stimulus makes the FT fibers gain ST fibers’ characteristic. However, the evidences claiming the over stimulation causes muscular fatigue are conflicting and probably this is due to the use of different methodological approaches. For example, it has been reported that in human muscle 100 Hz uniform high frequency stimulation has a few effects on the endurance together with an increase in the contractile speed; and differently, the feline FT muscles become slower at 100 Hz stimulation (Callaghan, 2002). High frequences such as 30-50 Hz are above the natural stimulation frequency of the motor units and the regular stimulation frequencies of the motor units in daily life vary between 15Hz – 25 Hz (De Luca, 1997) and therefore, the muscle cannot cope with the extra energy demands (Callaghan, 2002). Nevertheless, it has been reported that the contraction intensity near to maximum has been reached with a stimulation of 50 Hz (Hultman, 1995). Likewise, the fast motor unit nerves in the skeletal muscle are discharged at high frequencies such as 40-60Hz (for those in the slow motor units it is 10Hz) (Bigard et al., 1991). The frequence specific stimulation studies involving nerve free animal muscles have supported the idea of using low frequency for the slow muscles and high frequency for the fast muscles (Kit-Ian, 1991). It has been confirmed that the 100 Hz frequency used for the FT fibers slows down the atrophy in the FT fibers and restores the normal contraction speed and tension. With regard to the high frequency stimulation applied to the ST fibers, it has been reported that this can reduce the fatigue resistence and cause muscle transformation from slow to fast. On the other hand, it has been reported that applying low frequency stimulation to the fast fibers may provide some beneficial effects that improve and preserve the oxidative enzyme activities and improve the endurance (Kit-Ian, 1991). In addition, it has been indicated that certain restrictions of the electromyostimulation such as random recruitment can be minimized by adding the contribution of the central pathways (reflexive recruitment of spinal motoneurons by the electrically evoked afferent volley) and that the pulse frequency should be as high as 100 Hz for this purpose (to increase the rate at which the sensory volley is sent to the spinal cord and supra-spinal centres) (Maffiuletti, et al., 2011). 5. USE IN THE SPORTS TRAINING PROGRAMS The effects of EMS on the strength gain have been tested in various training programs. For example, a stimulation period of 12 weeks has increased the muscular strength and power of the rugby players (Babault et al., 2007). However, it did not have any effect on technical rugby skills such as spurt and sprint. In another study, the combination of the EMS and plyometric training combination improved the maximum strength of the quadriceps femoris as well as the vertical jump and sprint (Herrero et al., 2006); however, EMS alone slowed down the sprint speed but did not exceed the gains obtained by the combination with the plyometric training. The current studies by Herrero et al. (2010a, 2010b) emphasize that in the endurance trainings, the superimposed electrical stimulation applied during the concentric phase of the movement is efficient on the strength improvement; however, it has been indicated that 724

when the objective is to improve the anaerobic performance, the electrical stimulation must be used isometrically. In the study by Requena et al. (2005) it has been shown that the EMS combined with fast concentric (1800/s) and eccentric training increases the maximum concentric movement. With regard to the ice hockey, while 3 weeks electrical stimulation has significantly increased the isokinetic strength of the knee extensors for the eccentric and concentric speeds, it has negatively affected the vertical jumping performance (Johnston 2004; Brocherie et al., 2005). In another study involving the volleyball players (Malatesta et al., 2003), the required level of effect in terms of the jumping performance has not been reached after 4 weeks of EMS training. On the contrary, it has been seen that a 4 weeks EMS program combined with the plyometrics is beneficial to improve the jumping skills among the volleyball players (Maffiuletti et al., 2002). In the study involving the basketball players, the EMS that has been applied as as part of the short term strength training (4 weeks) has improved the strength of the knee extensor and squat jumping ability (Maffiuletti et al., 2000). The study by Pichon et al. (1995) has shown that after an EMS program of 3 weeks, the swimming performance increases. An interesting result is that a 2 weeks complementary electrical stimulation program has positive effects on the paddling technique characterized by the power/time curve for the paddlers (Changsheng et al., 2002). However, it has been reported that most of the studies about this subject are weak methodologically (Dehail et al., 2008). With meta analysis, Bax et al. (2005) showed that the electrical stimulation is very efficient for strengthening the quadriceps femoris only compared to the control who does not exercise and that even if the stimulation is combined with the voluntary activity simultaneously, it is much more efficient. It has been reported that xcept those cases where it is combined with the eccentric training, the electrical stimulation is not significantly efficient in the classical training (Dehail et al., 2008). As summarized by Vanderthommen and Duchateau (2007), the strength gains due to the electrostimulation are not much higher than those obtained by the trainings covering the voluntary contractions. Because these gains are probably due to the intensity of the stimulation. Even if there is a standardized method, the use of the comfortable currents is very important. As a complementary element of the classical strengthening programs for the healthy individuals and athletes, especially when applied simultaneously with the voluntary contractions, EMS seems much more efficient. The basic advantages of EMS are: (1) increasing the work load of the muscle as a complementary element of the classical training and (2) causing a different contraction model than the model that occurs during the voluntary contraction (Paillard, Noe, and Edeline 2005; Vanderthommen and Duchateau, 2007). Consequently, even if the strength gains are transferrable to the sports activities, the negative results (Herrero et al., 2006) indicate that the skill training is always needed to improve the muscular coordination (Requena et al., 2005). EMS has the potential to serve as a post-exercise recovery tool for athletes, since its acute application may increase muscle blood flow and therefore metabolite washout which could in turn accelerate recovery kinetics during and after exercise (Babault et al., 2011). However, since there are studies that show different effects of EMS on the recovery process (Barnett, 2006), the relation between EMS and recovery should be further examined. Recently, the efficiency of the electrical stimulation as an exercise for preventing the muscle loss or increasing the muscle mass in gravity-free environment are studied. 725

In the studies based on the electrical stimulation of the antagonists together with the voluntary agonist muscle contractions (Ito et al., 2004; Iwasaki et al., 2006; Matsuse et al., 2006), it has been shown that the electrical stimulation can be used instead of the traditional weight training without need to the resistence equipment and stabilization. Ito et al. (2004) has reported that the hybrid training they have used during 4 weeks and 3 times a week is efficient to provide strength increase in the gravity-free environment (5000 Hz Carrier frequency and 20 Hz burst-wave stimulation frequency). Iwasaki et al. (2006) have reported that the hybrid training they have applied during 6 weeks, 3 times a week (voluntary knee extension and flexion simultaneously with the electrical stimulation) is comparable to the weight training among the healthy individuals in order to improve the knee extension strength and this method can be beneficial for the bedridden persons or space journeys. In the follow up study that gave similar results, it has been proved that the hybrid training (8 weeks / 3 times a week) provides significant strength increases and the strength gains continue longer compared to the isotonic weight training and electrical stimulation alone. It has been indicated that the increases in the muscular cross sections are comparable with the other two methods (Matsuse et al., 2006). It has been shown that in long term space journeys, as a precaution against the muscular strength and muscle mass loss, the low frequency electrical stimulation (15 Hz, 4.5 weeks, six times a week; each session lasts 6 hours) on the stretched muscles causes an insignificant decrease on the muscular strength and an increase in both types of muscular fiber cross section (Shenkman et al., 2007). 6. CONCLUSIONS The animal studies have provided detailed evidences about the chronic low frequency stimulation effects at the vascular, cellular and metabolic levels. Currently, although it has been determined that the fast muscle fibers are transformed into slow fibers upon low frequency EMS, it is still difficult to prove the transformation from fast to slow in animal models. With regard to human, it seems that there is a concensus about the benefit of the EMS regarding the functions measured by the walking analysis and some functional tests. Also, it has been accepted that the quadriceps atrophy measured with the cross sectional area can be reduced with EMS. However, with regard to the human studies, insufficient and conflicting results have been reported in terms of MVIC, MVIT, isokinetic strength, femur periphery by tape measurement, muscle protein and enzyme activity, fiber type composition, fiber type cross sectional area and fiber type ratio. Also, the literature shows that when the muscle is weak after the immobilization, the EMS will provide a medium level strengthening, however when it is applied to the healthy or strong muscles, it will not provide the required improvement. When the literature is examined, the various reasons for these differences are seen. Consequently; significant evidences demonstrating EMS’s effects on the human muscles in terms of the cellular changes have been provided and it has the potential to serve as a sport tarining tool for developing physical performance. 7. RECOMMENDATIONS FOR FUTURE RESEARCH To better understand the effect of application on sport performance, future research might consider:  Developing experimental models where the needs of the athlete and the specific 726

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Chapter 65 Prohibited Substance Use in Sports and Therapeutic Use Exemptions Halil TANIR INTRODUCTION Within today’s life style, sport is a phenomenon that becomes more important and prominent every day. Sport contributes to young peoples' acquiring a personality healthy physically and mentally, and developed socially, on the other hand it enables them to raise as model individuals, who are constructive, creative, productive, gentleman, prudent, tolerant, ethical, self-confident, and have correct behaviours and correct relationships. Rivalry and competition under certain rules form the basis of sport. Sportive activities include athletes' comparing their performances under equal conditions and using these in a rational manner. Sport should be within competition rules first, and is limited to competition relationships (Ersoy et al., 2006). It is accepted that certain negative consequences of doping use are known by many athletes. According to a previous study, the number of athletes who would use doping for money and fame without considering their health was incredibly high. The interest in and motivation for doping has become an important factor in sport, which is increasing every day, cannot be compared to anything, and is resulting from social and economic rewards. The position in the team, desire to wear the jersey, ignorance, laziness for training, or lack of preparation for competition, and accordingly athletes’ desire to achieve in quicker ways result in the increasing interest in doping. Now, international sports organizations and states try to find solutions to the problem, believing in the necessity for measures, which should be taken to prevent disastrous results of doping (Bayatlı, 2004; Yıldırım, 2001). Today, sport has become a commercial sector, and the economic opportunities coming along with achievement and the desire to win turning into greed push athletes to use adopt any ways to achieve. This case and sport becoming a profession can create a pressure that is even stronger than the desire to win that dates back to ancient times. In the last quarter-century, the greatest problem of sport has no doubt been the crime against humanity called doping (Bayatlı, 2004). International Olympic Committee (IOC) gathered in Doping in Sport World Conference in February, 1999 in Lausanne and again World Anti-Doping Agency (WADA) was established in Lausanne on November 10, 1999 (Atasü & Yücesir, 2004). In the meetings gathered by European Council, doping was defined in the broadest sense, and some reasons, even some psychological procedures, such as hypnosis were included in the definition of doping. European Council defined doping as “the administration to or use by a healthy individual of any agent or substance nor normally present in the body and/or of any physiological agent or substance when introduced in abnormal additional quantities and/or by an abnormal route and/or in an abnormal 

Assist. Prof. Dr., Adnan Menderes University, School of Physical Education and Sport, Aydın

manner, with the purpose and effect of increasing artificially and in an unfair manner the performance of that individual during the period of competition". The first official definition of doping was made in 1963 as "the use of athletes or players of any substance or methods that can artificially increase their performance and damage their physical and psychological health during competition or preparation to it in a way that doesn't fit with sport ethics" (Akgün, 1993b). Definition and History of Doping Doping is defined as “conscious or unconscious use of substances or methods that were prohibited by International Olympic Committee (IOC) in order to increase physical or mental performance during competition”. Doping is against sports ethics because it provides basis for unfair competition and damages athletes’ health in short or long terms and even results in deathly risks. For these reasons, doping has been prevented by international sports organizations such as WADA, International Olympic Committee (IOC), FIFA, UEFA, FIBA and IAAF. Doping is defined as "the conscious or unconscious use by athletes of substances or methods prohibited by International Olympic Committee (IOC)". Guiding athletes to use this kind of substances or methods or helping them is against sports ethics and is considered as a doping-related crime (URL 1). The use of various methods or substances in order to increase performance is called as “doping”. The use of “doping” substance/method in order to increase performance in sport is prohibited by International Olympic Committee and sport federations due to its negative effects on human health and fair competition in sport. Procedures carried to change “doping” test results, and avoiding giving samples are also interpreted as “doping” (www.tdkm.hacettepe.edu.tr 2016). In every period as of the primeval ages, people tried many herbal formulas to increase their strength in artificial ways (Ertaş & Petek, 2005). Throughout the history, athletes tried many methods to make their bodies strong and well working machines. The main purpose is not only increasing optimal performance, but also getting beyond that at any cost (Atasü & Yücesir, 2004). Athletes’ desires to increase their performance is a strong desire and both economic and social gaining of sportive achievement results in the deterioration of both ethic rules and health rules (Akgün, 1993b). In the last 25 years, the greatest problem of sport has been doping (Bayatlı, 2004). The word “doping” is borrowed from English, and retrieved from a South African drink obtained from the herb called “Dopa”. Dopa first stimulates that strengthens the user. English, who colonized South Africa, borrowed this word to their languages, which produced the term doping (Atasü & Yücesir, 2004). Today sport has become a commercial sector, and the economic possibilities and desire to win, which turns into ambition, make the athletes use any method to achieve. Doping was prohibited because it deteriorates fair competition in sports and affects athlete health negatively. On February, 20, 2003, World Anti-Doping Agency (WADA) stated in the definition of doping that doping was against sport ethics, and defined doping crime as “the realization of one or more of the a wide range of violations from the use of a prohibited substance or method to detection of a prohibited substance, from avoiding taking doping test to helping in attempts for doing” (Tübitak, 2008). The latest definition of doping by WADA in 2004 is “Doping is presence of a substance or a method in a sample from an athlete’s body, that has the potential to increase sportive performance or 735

threat health unnecessarily or against sports ethics; or the use of these; or the existence of a proof of using these (Yücesir, 2004). Doping is a phenomenon that is as old as sport and physical competition, and threats sport ethics and human health. In the 20th century, when modern sports became professional from amateur, and sport comes along with serious financial acquisition, doping became an ever-growing problem. Anti-doping studies started in the 1920s, when the importance of sport was comprehended, however obtaining of concrete developments was only in late 1980s. The ones who fight against doping have always been a step behind the ones who do doping, yet they never let go of the problem with an increasing effort (Atasü & Yücesir, 2004). There are two ways to reach high performance in sport. First of these is attaining high performance with doping type of substances, while the second is intense training for high performance (Göral, 2002). Throughout the history, athletes have tried to find the foods and the correct dosages of these that can turn their bodies into well-working machines (Temizer, 2000). Athletes of almost every branch believe in the benefits of substances or drugs, in addition to training and nutrition (Güner, 1996a). Table 1: The History of Doping Use in Sport

Source: (www.tdkm.hacettepe.edu.tr 2016)

Substances Prohibited in Sports Stimulants: Stimulants are drugs or substances that increase awareness or consciousness temporarily. Generally, the more effective they are, the more side effects they have. The strongest types are prescribed specially or illegal drugs. Caffeine in coffee and nicotine in cigarettes are the most commonly used stimulants. Among the most well-known stimulants are ephedrine, amphetamines, cocaine, methylphenidate, methylenedioxymethylamphetamine and modaphynile. Stimulants have such effects on the body as, awareness, total sleep time, decrease in sleep depth, delay in fatigue, 736

increase in reflexes, increase in heart beat rate, increase in blood pressure and increase in metabolic speed. Some of the substances included in stimulant classification (ephedrine, pseudoephedrine, and phenylpropanolamine) can be included in anti-flue drugs. Athletes may take these drugs unconsciously, and be imposed to penalty (Ünal &Ünal, 2003). Narcotic Analgesics: Morphine and similar substances are included in narcotic analgesics. Narcotic analgesics are used in the treatment of various types of pains. They directly affect the pain centre in the brain.Anaesthetics are drugs that slow or stop the biological functions of the cells, especially the nervous system cells. In general anaesthesy, the functions of central nervous system slow to an extent that sensitivity to pain disappears and the patient lose consciousness (ICO, 2000). Beta-2 Agonists: Beta–2 Agonists are included in the drugs used to treat asthma. These substances are not anabolic-androgenic, however, when used systematically they can provide anabolic effects like them. Beta-2 agonists like anabolic-androgenic are used by athletes in speed and strength sports. For the athletes, who were diagnosed with asthma, Beta-2 agonists, formoterol, terbutaline, salbutamol and salmeterol can be used with inhalers. For the athletes to use these substances, they need to petition to the related sport organization, and get permission. Beta-2 agonists have effects on the body, such as increase in muscle mass, decrease in body fat percentage and dilatation in airway smooth muscle cells. Long-term use of these has side effects, such as shivering, fatigue, nervousness, anger, headache, increase in blood pressure, arrhythmia and muscle cramps (Eröz, 2007; Ünal & Ünal, 2003). Peptide Hormone and Analogues: Peptide hormones are inherent hormones, and control the secretion of other hormones. Human chorionic gonadotropin, luteinising hormone, adrenocorticotrophic hormone, growth hormone, erythropoietin, insulin and insulin like growth factor are the hormones included in this group (Ünal & Ünal,2003). They regulate the normal level secretion of human chorionic gonadotropins, and androgenic steroids, and over secretion of these may result in anger, depression, fatigue and gynecomasty among male (Cicero & Q’Connor, 1990). Adrenocorticotrophic hormone (ACTH) is a polypeptide hormone that is produced in the frontal lobe of pituitary. It is an important element of hypothalamic-pituitaryadrenal axis. It is generally produced as a reaction to biological stress. Its most important effect is the stimulant effect on the secretion of corticosteroid hormones and cortisol from the adrenal cortex. Growth hormone controls growth and metabolism. It stimulates the protein synthesis and fat breakdown in the body. It has some side effects, such as skin thickness, mandibular growth, tongue growth, muscle weakness, joint and bond problems and heart diseases (Ünal & Ünal, 2003). Anabolic and Androgenic Steroids: Anabolic-androgenic steroids are the most commonly used doping substances among athletes. These are synthetic substances that have similar effects with the testosterone which is a natural steroid produced in the body. Natural testosterone has anabolic (muscle building) and androgenic (male specific attitudes and behaviours) effects. It is used in strength and speed sports in order to increase muscle strength and muscle mass. While other doping substances are used a short while ago before the competitions, anabolic steroids should be used in 10-100 times of normal treatment dosages months ago the competitions to be effective. Anabolic and androgenic steroids have serious side effects on almost every organ 737

in the body. The seriousness of the side effects depends on the dosage and duration of use. Some of these serious side effects are oedema, increased risk of tumour formation, nose bleeding, tendon injuries or breaks, increased risk of heart attacks, and hepatitis (Catlin & Hatton 1991). Diuretics: Diuretic drugs enable and increase urine disposal in order to help management of hypertension. They are used to dispose the extra fluid in the body in order to decrease blood pressure. Furosemide and hydrochlorothiazide are among the popular pharmacological agents of this group. In addition to the health risks resulting from their use, diuretics are prohibited as they can be used to dilute urine samples, and lose weight in order to compete in a lower weight class. Additionally, use of diuretics is prohibited because it is against sports ethics in a fair competition. They have some side effects, such as fluid loss, decrease in blood volume, and kidney disorders (Ünal & Ünal, 2003). Abrasives: The use of abrasives is prohibited. Abrasives are substances that accelerate drug disposal from the body or becloud the detection substances used as doping. Diuretics, epitestosterone, probenecid and plasma expanders are included in this category (Ünal & Ünal, 2003). Methods Prohibited in Sport Increasing Oxygen Carriage: The most important requirement for the conduction of muscular activities is in the oxygenation of the blood. Haemoglobin substance in the red blood cells plays the most important role in carrying oxygen to tissues. Increasing oxygen carriage to tissues is a method that increases sportive performance in sport branches that require endurance. Research reported that combination of blood doping and human erythropoietin by artificial agents develops oxygen discharge and has positive effects on aerobic exercise capacity. Due to abuse of these methods, they were prohibited by International Sport Federations (Güner, 2004b). Blood Doping: Blood doping refers to the procedure in which blood and blood products are transfused in order increase oxygen carrying capacity and accordingly develop aerobic athletic performance. In short, it refers to increasing the amount of O2carried to muscles and increasing total aerobic strength. The blood used for blood doping can be either athlete’s own blood or someone else’s blood. In medicine, blood cell transfusion is a procedure required for the treatment of immediate blood loss and advanced anaemia. Blood transfusion to athletes in order to increase athletic performance is against sport ethics. Blood doping may also result in dangerous health problems. Some of these are; allergic effects (rash, prickly heat, fever, etc.), infectious diseases, such as hepatitis, blood circulation disorders, thrombosis, metabolic shock, and AIDS if wrong type or untested blood is used (Günay & Cicioğlu, 2001). Gene Doping: Gene therapy, which is used in the treatment of some diseased, is also used by athletes to increase sportive performance and gain advantage over their competitors and with the rapid increase in knowledge of genetic therapies, the natural results of these techniques can be abused in sports and many genes can be obtained easily and affect athletes’ performance. Gene therapy refers to the proving patients with artificial genes. These artificial genes produce RNA suitable for them and provide appropriate protein synthesis (Haisma, 2006, Ünal & Ünal, 2003). Chemical and Physical Applications: These are applications that change the 738

correction of the samples taken for doping control. Use of diuretics, catheterization, changing urine samples or cheating with them, slowing down the disposal from kidneys, and preventing disposal of doping substances from kidneys with masking agents like probenecid are also considered as doping (Ünal & Ünal, 2003). Artificial Oxygen Carriers and Plasma Expanders: Due to scientific studies, new haemoglobin like chemical substances were produced to be used in serious anaemia. HB products, perfluoro-chemicals, micro capsule haemoglobin products and substances increasing oxygen intake and distribution like RSR-13 are included in this group. These substances produced to be used in the treatment of serious diseases can be used by athletes with doping purposes. The use of these by athletes was prohibited in 1999 (Güner, 2004b; Ünal & Ünal, 2003). Substances Restricted in Sports Alcohol: It is a chemical substance produced as a result of glucose fermentation. Some athletes use alcohol in order to suppress central nervous system and prevent athetosis, decrease anxiety and increase self-confidence. Long-term use of alcohol has side effects, such as addiction, imbalance, reaction time disorders, coordination disorders, aggressive behaviours and liver disorders (Ünal & Ünal, 2003). Cannabinoids: Substances like marijuana, hash, etc. are used to decrease stress before competitions. Their active matter tetrahydrocannabinol can enable the user remember and learn in short term intake, and relax. They don't have any effects on the performance. On the contrary, such effects as increasing blood pressure and heart beat rate, decreasing heart beat volume can have negative effects on sportive performance. Long-term use of these substances can deteriorate sportive performance with their negative effects on heart, liver and central nervous system. They are used to decrease stress and anxiety before competitions. It was found that in societies where the use of these are common, there has been a significant increase if the use of these by athletes. Due to their negative effects on health, and because they are against sport ethics, they have been prohibited by sport organizations sine 1989 (Güner, 2004b; Ünal & Ünal, 2003). Local Anaesthetics: Anaesthetics are drugs that slow down or stop the biological functions of cells, especially nervous system cells. They are directly applied on the pain area in order to decrease or kill the pain. In this group are bupivacaine, procaine, articaine and lidocaine. Local anaesthetics prevent the transmission of nerves and accordingly the transmission of pain. Athletes use these in order to decrease their pain and continue competing. However, these can cause serious injuries on pain decreased extremities (Kashkin, 1989). Corticosteroids: Chemical corticosteroid is a group of drugs that are like hormones and secreted from adrenal glands. Additionally, corticosteroid injections can be used as painkillers in such disorders as tennis elbow or arthritis. Corticosteroids have anti-inflammatory effects. Among patients, who use corticosteroids, chicken pox can be life threatening. These have been recently used in long period cycling races. Side effects of corticosteroids are insomnia, delay in epithelising, epigastric burning, gastric ulcer, diabetes and osteoporosis (Akgün, 1986a). Beta Blockers: Beta-blockers are drugs used for cardiac diseases in order to decrease blood pressure and heart beat rate. These drugs are also used for the 739

treatment of migraine and athetosis. The prevention of shaking arms and fingers is important in some sport branches, such as shooting and archery, and beta-blockers decrease heart beat rate and removes these problems. This is against fair competition. They have some side effects, such as insomnia, decrease in physical efficiency, nightmares, fatigue, depression, decrease in heart beat rates, decrease in blood pressure, circulation disorders, airway spasm in livers, asthma, nauseation, throwing up and low blood sugar (Ünal, 2003). International Standards forTherapeutic Use Exemptions (January 2011) International standards fortherapeutic use exemptions were first accepted in 2004 and took effect in 2005. The document below is the 5.0 new edition including the changes in the International standards fortherapeutic use exemptions, which was approved on September, 18, 2010 by World Anti-Doping Agency (WADA) administrative body. Revised International Standards for Therapeutic Use Exemptions (TUE) has been in effect as of January 1, 2011. It was published by World Anti-Doping Agency on October 1, 2010 (WADA, 2016). Terms Defined in TUE International Standards Therapeutic: Of or relating to the treatment of a medical condition by remedial agents or methods; or providing or assisting in a cure. TUE: Therapeutic Use Exemption approved by a Therapeutic Use Exemption Committee based on a documented medical file and obtained before use or possession of a substance or method that would otherwise be prohibited by the Code. TUEC: Therapeutic Use Exemption Committee is the panel established by the relevant Anti-Doping Organization to consider applications for TUEs. WADA TUEC: WADA Therapeutic Use Exemption Committee is the panel established by WADA to review the TUE decisions of other Anti-Doping Organizations. Anti-Doping Code Article 4.4 Therapeutic Use Exemptions Each International Federation shall ensure, for International-Level Athletes or any other Athlete who is entered in an International Event, that a process is in place whereby Athletes with documented medical conditions requiring the Use of a Prohibited Substance or a Prohibited Method may request a therapeutic use exemption. Athletes who have been identified as included in their International Federation’s Registered Testing Pool may only obtain therapeutic use exemptions in accordance with the rules of their International Federation. Each International Federation shall publish a list of those International Events for which a therapeutic use exemption from the International Federation is required. Each National Anti-Doping Organization shall ensure, for all Athletes within its jurisdiction that have not been included in an International Federation Registered Testing Pool, that a process is in place whereby Athletes with documented medical conditions requiring the Use of a Prohibited Substance or a Prohibited Method may request a therapeutic use exemption. Such requests shall be evaluated in accordance with the International Standard for Therapeutic Use Exemptions. International Federations and National Anti-Doping Organizations shall promptly report to WADA through ADAMS the granting of any 740

therapeutic use exemption except as regards national-level Athletes who are not included in the National Anti-Doping Organization’s Registered Testing Pool. Presence of a Prohibited Substance or its Metabolites or Markers (Article 2.1), Use or Attempted Use of a Prohibited Substance or a Prohibited Method (Article 2.2), Possession of Prohibited Substances and Prohibited Methods (Article 2.6) or Administration or Attempted Administration of a Prohibited Substance or Prohibited Method (Article 2.8) consistent with the provisions of an applicable therapeutic use exemption issued pursuant to the International Standard for Therapeutic Use Exemptions shall not be considered an anti-doping rule violation (WADA, 2016). Criteria for Granting a Therapeutic Use Exemption A Therapeutic Use Exemption (TUE) may be granted to an Athlete permitting the Use of a. The Prohibited Substance or Prohibited Method. An application for a TUE will be reviewed by a Therapeutic Use Exemption Committee (TUEC). The TUEC will be appointed by an Anti-Doping Organization (WADA, 2016). TUE will be granted only in strict accordance with the following criteria: a. The in question is needed to treat an acute or chronic medical condition, such that the Athlete would experience a significant impairment to health if the Prohibited Substance or Prohibited Method were to be withheld in the course of treating an acute or chronic medical condition. b. The Therapeutic Use of the Prohibited Substance or Prohibited Method would is highly unlikely to produce no any additional enhancement of performance other than that which beyond what might be anticipated by a return to the Athlete’s normal state of normal health following the treatment of a legitimate medical condition. The Use of any Prohibited Substance or Prohibited Method to increase “low-normal” levels of any endogenous hormone is not considered an acceptable Therapeutic intervention. The acute or chronic medical condition. c. There is no reasonable Therapeutic alternative to the Use of the otherwise Prohibited Substance or Prohibited Method. d. The necessity for the Use of the otherwise Prohibited Substance or Prohibited Method can not be not a consequence, wholly or in part, of the prior use, (without a TUE) of a substance or method which was prohibited at the time of such Use (WADA, 2016). The TUE will be cancelled, if: a. The athlete does not promptly comply with any requirements or conditions imposed by the Anti-Doping Organization granting the exemption. b. The term for which the TUE was granted has expired. c. The Athlete is advised that the TUE has been withdrawn by the Anti-Doping Organization. d. A decision granting a TUE has been reversed by WADA or CAS. An application for a TUE will not be considered for retroactive approval except in cases where: a. Emergency treatment or treatment of an acute medical condition was necessary, or b. Due to exceptional circumstances, there was insufficient time or opportunity for an applicant to submit, or a TUEC to consider, an application prior to Doping Control (WADA, 2016). 741

Therapeutic Use Exemption Committees (TUECs) TUECs shall be constituted and act in accordance with the following guidelines: a. TUECs should include at least three (3) physicians with experience in the care and treatment of Athletes and a sound knowledge of clinical, sports and exercise medicine. In order to ensure a level of independence of decisions, the majority of the members of any TUEC should be free of conflicts of interest or political responsibility in the Anti-Doping Organization. All members of a TUEC will sign a conflict of interest agreement. In applications involving Athletes with disabilities, at least one TUEC member shall possess specific experience with the care and treatment of Athletes with disabilities. b. TUECs may seek whatever medical or scientific expertise they deem appropriate in reviewing the circumstances of any application for a TUE. c. The WADA TUEC shall be composed following the criteria set out in Article 6.1. The WADA TUEC is established to review the granting or denial of TUEs for International-Level Athletes, Athletes entered in an International event as described under 7.1(b), or Athletes in their National Anti-Doping Organization’s Registered Testing Pool as set forth in Article 4.4 of the Code. In normal circumstances, the WADA TUEC shall render a decision within 30 days of receipt of all requested information (WADA, 2016). Substances Permitted for Athletes Use Table 2: For asthma Active Ingredient Name of Medicine Sodium chromoglycate Intal Salbutamol Salbulin (inhaler), Salbutol (aerosol),Ventide (aerosol), Ventalin (inhaler) Teophyphilline Afonilum SR, Talotren, Diffumal R, Theo-dur Terbutaline Bricanyl (inhaler) Salmeterol Astmerole (inhaler), Serevent (inhaler) Beclomethazone Becotide (inhaler), Becloforte (inhaler),Ventide (inhaler) Fluticasone Flixotide (inhaler), Brethal (inhaler) Source: (www.tdkm.hacettepe.edu.tr 2016) Table 3: For cold/cough Active Ingredient Name of Medicine Allantibiotics Vaporand menthol inhalations Buğuseptil Terphenadine Hisfenadin, Sanofen, Terfena Astemizole Astemin, Hismanal, Almizol Guaiphenezine (glyceryl Benzoleks, Bricanyl, Kofilin, Pertu,Vicks guaiacolate) Vaposyrup Dextromethorphan Morfan Paracetamol Panadol, Sifenol Source: (www.tdkm.hacettepe.edu.tr 2016)

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Table 4. For diarrhea Active Ingredient Diphenoxylate Loperamide HCl Oral rehydration salts (ORS)

Name of Medicine Lomotil Lorimid, Lopermid, Diadef Rehidratek, Ge-Oral

Source: (www.tdkm.hacettepe.edu.tr 2016) Table 5: For pain Active Ingredient Acetylsalicylic acid

Name of Medicine Aspirin, Alcacyl , Ataspin, Babyprin, Ecopirin, Coraspin, Dispril, Notras, Minaspin Artril, Brufen, İbufen, Dolven, Dolgit Panadol, Sifenol

Ibuprofen Paracetamol Codeine Dihydrocodeinone All nonsteroidal antiinflammatory drugs (NSAID) Source: (www.tdkm.hacettepe.edu.tr 2016)

REFERENCES Akgün, N. (1986a). Egzersiz Fizyolojisi, Ege Üniversitesi Basımevi 2. Baskı, İzmir. Akgün, N. (1993b). Egzersiz Fizyolojisi, Ege Üniversitesi Basımevi II. Cilt No.114, İzmir. Atasü, T. & Yücesir, İ. (2004). Doping ve Futbolda Performans Arttırma Yöntemleri, Form Reklam Hizmetleri No. 15, İstanbul. Bayatlı, T. (2004). Hakça Yarışma ve Doping, Form Reklam Hizmetleri No. 15, İstanbul. Cicero, T.J. & O’Connor, L.H. (1990). Abuse Liability of Anabolic Steroids and Their Possible Role in The Abuse of Alcohol, Morphine and Other Substances. In: G.C. Lin and L. Erinoffs (Eds), Anabolic Stereoid Abuse. pp. 1-28, National of Drug Abuse, Washington. Catlin, D.H. & Hatton, D.K. (1991). Use and A Buse of Anabolic and Other Drugs for Atletic Enhancement. Journal of Advances in Internal Medicine, 36:399. Ersoy, E.; Kalkavan, A.; Kalfa, A.; Özdilek, M.; Demirel, Ç.; Bişkin, M.; Eynur, H. & Baybars, R. (2006). Üniversitelerarası Türkiye Şampiyonasına Katılan Sporcuların Kendi Üniversitelerinden Beklentileri, 9. Uluslararası Spor Bilimleri Kongresi Bildiri Kitabı, Nobel Yayın Dağıtım, Muğla. Ertaş, Ş. & Petek, H. (2005). Spor Hukuku, Yetkin Yayınları, Ankara. Güner, R. (1996a). Kafeinli ve Kafeinsiz Kahvenin İzokinetik Kuvvet, Wıngate Testi ve Egzersiz Sonrası İdrar Kafein Yoğunluğu Üzerine Etkileri (Doktora tezi), Ankara Üniversitesi Tıp Fakültesi Fizyoloji Anabilim Dalı, Spor Hekimliği Bilim Dalı, Ankara. Güner, R. (2004b). Doping Madde ve Yöntemlerinin Etki ve Yan Etkileri, Form Reklâm Hizmetleri, İstanbul. Göral, M. (2002). Spor Ahlakı ve Sporcu Açısından Doping Kullanımının Etkileri ve Dopingle Mücadele Çalışmaları (Yüksek lisans tezi), Dumlupınar Üniversitesi Sosyal Bilimler Enstitüsü Beden Eğitimi ve Spor Anabilim Dalı, Kütahya. Günay, M. & Cicioğlu, İ. (2001). Spor Fizyolojisi, Baran Ofset 1. Baskı, Ankara. Haisma, H.J. (2006). Gene Doping. International Journal of Sports Medicine 27:257-266. ICO (2000). International Olympic Committee, Medical Commision, Doping Control, IN: ICO Sports Medicine Manual, Lausanne. 743

Kashkin, K.B. (1989). Hooked on Hormones An Anabolic Steroid Adiction Hypothesis. Journal of the American Medical Association, 262:3166-3170. Eröz, M.F. (2007). Milli Düzeyde, Atletizm, Güreş, Judo ve Halter Yapan Sporcuların Doping ve Ergonojik Yardım Hakkındaki Görüşlerinin ve Bilgilerinin Belirlenmesi (Yüksek lisans tezi), Dumlupınar Üniversitesi Sosyal Bilimler Enstitüsü, Beden Eğitimi ve Spor Anabilim Dalı, Kütahya. Ünal, M. & Ünal, D. (2003). Sporda Doping Kullanımı. İstanbul Tıp Fakültesi Mecmuası, 66(3):191. Temizer, A. (2000). Doping 2, Atletizm Bilim ve Teknik Dergisi, 13,7. Tübitak . (2008). Doping, Bilim ve Teknik Dergisi, 4,18. Yücesir, İ. (2004). Doping Suçu; Doping Madde ve Yöntemleri. Doping ve Futbolda Performans Arttırma Yöntemleri, Form Reklam Hizmetleri, 41s., İstanbul. URL1:TDKM (2016).http://www.tdkm.hacettepe.edu.tr/ URL: WADA (2016). http://www.wada-ama.org/ Yıldırım, E. (2001). Futbolcularda Eğitim Düzeyleri İle Doping Hakkında Bilgi Düzeyleri ve Doping Kullanım Eğilimlerinin Analizi (Yüksek lisans tezi), Fırat Üniversitesi Sağlık Bilimler Enstitüsü, Beden Eğitimi ve Spor Anabilim Dalı, Elazığ.

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Chapter 66 Exercise is Medicine Gözde ERSÖZ INTRODUCTION The industrialization and mechanization in the societies as a result of technological advancements in 20th century, while providing more time for leisure time activities, people tend to acquire a life style towards less movement (Açıl, 2006; Yan, 2007). Even though the human body is designed to move and attend physical activities, exercises do not have a place within the routine struggles of a mediocre life style and when the human body continues to live for a long time without performing the necessary movements it should do, some of the functional abilities it possesses diminish and functional inadequacies causes many illnesses (Yan, 2007). In prevention of the hypokinetic illnesses (Noncommunicable diseases) that arise in connection with immobility (Kraus & Raab, 1961), the importance of regular physical activity is determined by many researchers (Bouchard et al., 2007; Gilmour, 2007; Özer, 2001). These studies illustrated that the regular physical activity takes under control the blood pressure and blood sugar, reduces the colon cancer and coronary heart disease risks, provides weight control, prevents vein and muscle-skeleton system diseases. Besides these physiological effects, the regularly performed physical activity also affects the mental and emotional heath positively (Cindaş, 2001; Özer, 2001). Research indicated that the regular physical activity positively effects the mental health, reduces stress and anxiety symptoms, helps controlling the emotions like rage and aggression, increases the quality of sleep (Kennedy & Newton, 1997). It is said that the physical activity increases the self understanding and self respect (Gleser & Mendelberg, 1990) as it balances the health, physical structure, elasticity and weight of the individual and the increasing endorphin leads a positive emotional status (Daley, 2002). The encouragement of inclusion in physical activity is in priority targets of public health in many developed countries towards these positive influences of the physical activity (Cengiz et al., 2008). Realizing these goals is possible through increasing the inclusion in physical activity and in this regard it is important to establish all personal and social factors that are effective for providing continuity of the physical activity action and all people, from ages 3 to 93, to adopt an active life style with the slogan "sports for all". In recent times, physiological (Sevim, 2002; Bedard, 1995; Greendale et al., 1995) and psychological (Challagan, 2004; Mead et al., 2010) factors regarding the physical activity and exercise became the focal point for researchers working in the health and sport sciences fields (Biddle et al., 2000). The studies on exercise and physical activity subject indicated that it is required that the inclusion in exercise should be continuous for realizing the physical and 

Assist. Prof. Dr., Namık Kemal University, School of Physical Education and Sport, Department of Physical Education and Sport Teaching, Tekirdağ

psychological benefits of exercise. Although the benefits of exercising are known, nearly 50% of the people starting exercising quits within the first 6 months (Ntoumani & Ntoumanis, 2006). For example, Sallis et al., in their research on 1800 people who exercise, indicated that 20% of the participants quit exercise one or two times and restarted (meaning not performing exercise for 3 or more months) and 20% of them have quit the exercise for 3 or more times and restarted within the last 5 years (Sallis et al., 1990). In this paper we shall draw attention to the physiological and psychological benefits of the exercise. THE DEFINITION OF PHYSICAL ACTIVITY AND EXERCISE Physical exercise is any body movement that will result in energy consumption and defined as moving large muscle groups in a specific level, improvement of muscle performance and increasing cardiovascular resistance (Griffith, 2002; Speck, 2002). Physical exercise can be done in various levels from daily walk to intense work with apparatus. For a healthy life, in addition to mild body exercises, aerobic and anaerobic exercises are said to be performed regularly (Griffith, 2002; Kuter & Öztürk, 1997). Aerobic exercise includes exercises in which big muscle groups to be used orderly and in same tempo and which increase the speed of breathing, while anaerobic exercise provides for muscles to strengthen, increasing body resistance and strengthening of tendons without oxygen consumption (Artal & Sherman, 1998; Griffith 2002). Landers (2004) explained that in order exercise to be beneficial, the type of activity and the energy consumed during the exercise are important and aerobic exercises are more effective compared to anaerobic exercises. There are more and more findings on that the physical activity is beneficial for health and vitality. It is thought generally in the society that the physical activity carries the same meaning as "sports" and "exercise". But physical activity is the activities in the daily life that is performed by using muscles and joints and consuming energy, raising heart and breathing pace and results in different levels of tiredness, thus sport activities, exercise, games and various activities within the day are also accepted as physical activity (Bayrakçı, 2008). Physical activities like walking, cycling, playing, skating or dancing can also be included in sports (Arslan et al., 2003). Physical activity includes all of the important body movements as well as the routine activities such as (Fox & Page 2001). In addition, exercise is an event that is planned, structured and to be repeated for reaching physical form, improve or maintain it and is a subset of physical activity (Haskell & Kiernan, 2000). Exercise can be done in various levels from daily walk to intense work with apparatus. The level of the physical activity can be classified according to MET (Metabolic Equivalent) value as light, moderate and vigorous. MET is a measure related to consumed or spent oxygen per kilogram in unit time. One MET is equal to consumed oxygen amount during rest (nearly 3.5 ml/kg/minute) (Saygın, 2003; Tümer, 2007). * 1 MET is the energy used by the body while reading, talking on the phone or sitting relaxed. More the body works during the activity, more the MET value increases. * 3 to 6 MET is a moderate physical activity in all activities. * Activities with 6 and higher MET value are vigorous physical activities (Memiş, 2007). Moderate Physical Activity: These are the activities that cause a little but 746

noticeable increase in breathing and pulse. The condition of being able to talk but not sing during the performance of the activity indicates that a moderate physical activity is being performed. Moving the lawn, digging the ground, swimming or cycling are the activities in this group. Vigorous Physical Activity: These are the activities that put one out of breath and tire the individual. Football, basketball, station training, high tempo cycling or swimming are in this group (Memiş, 2007). You can determine your physical activity level by talking test: Talking Test: Talking test is one of the methods used for determining the level of the physical activity. If the individual can sing during the performed activity, that activity is a light level event. If the event is on moderate level then the person can easily talk during the performance of the activity. If the individual is out of breath and cannot talk during the activity performance then the performed activity is a vigorous level event (Marcus & Forsyth, 2003). For a healthy life, in addition to mild body exercises, aerobic and anaerobic exercises are said to be performed regularly (Griffith, 2002; Kuter & Öztürk, 1997). EXERCISE TYPES Exercise types are divided into two groups as aerobic and anaerobic according to the used energy sources (Wilmore & Costill, 1999). The physiological response of the body to the exercise differs according to the type of the exercise. While in anaerobic energy production the exercise duration shortens and intensity increases, in aerobic energy production exercise duration lengthens and intensity decreases. In exercises with high intensity level carbohydrates are used as primary fuel, while in light-moderate level exercises over 30 min. fuel usage changes from carbohydrates to fats (Rupp, 2001; Seto, 2005). Aerobic Exercise Walking, jogging, running, swimming, cycling, rowing, skiing are aerobic type exercises. Aerobic exercise is also known as endurance exercises and defined as ability to perform long periods of work and continue the effort. With regular aerobic exercise, the fat ratio of the body decreases, the body mass without fat increases, maximum oxygen consumption increases, maximum hearth minute volume increases, sinusal bradycardia develops, cavity dilatation in heart occurs, going back to normal after effort (recovery) occurs fast, endurance properties of skeletal muscles improve, hypertrophy occurs in slow contracting fibers while there can be transformation from type 2B to type 2A in fast contracting fibers, HDL - cholesterol increases in blood, LDL-cholesterol decreases, maximal voluntary ventilation in lungs increases, the distribution of the blood among tissues becomes excellent, mineral density of bones increases (Brooks & Mercier, 2000). In order to develop aerobic capacity, according to the American College of Sports Medicine (ACSM); endurance type exercises should be performed, they should not be less frequent than 3 days a week, not shorter than 20 minutes and should be in moderate and vigorous levels (Rupp, 2001). Anaerobic Exercise Anaerobic (resistance) exercise is a short and vigorous workout in which the cells provide their energy need independent of oxygen. Activities like tennis, weight lifting, short period fast runs, football, basketball, handball, sprint and jumping are governed 747

with anaerobic processes (Dunbar, 1992). Anaerobic exercise provides strengthening of the muscles, increasing of body endurance and strengthening of the tendons without oxygen consumption (Artal & Sherman, 1998; Griffith, 2002). Health has been defined as absence of disease for long years, however today the health is defined as not the absence of disease or disability, but a total wellness status of body, soul and social aspects. According to this definition, for protection of health and maintaining an active life physical activity and exercise carry great importance (Cindaş, 2001). Additionally, many of the adults are observed to perform insufficient amount of exercise for an optimal health (Bedard, 1995). THE RELATION OF PHYSICAL ACTIVITY AND EXERCISE TO PHYSICAL HEALTH The research on benefits of the regular physical exercise started to surface on the literature since the beginning of 1950s and in the studies performed in those years it is emphasized that the physical exercise is a beneficial behavior in improving health and preventing diseases (Tümer, 2007). In 1960s in parallel to the studies done to investigate the changes occur in the organism due to the non-gravity and motionless life conditions humans face during the long period space missions, the lack of movement has been accepted as a cardiovascular risk factor all over the world and the attention towards the subject increased and the studies were hastened (Sevim, 2002). In 1978, teh American College of Sports Medicine have issued a manual for those who want to do exercise. According to this manual the exercise raising the heart pace 60-90% for 15-60 minutes, 3-5 times a week was said to be improving health. Whereas World Health Organization declared that a regular and moderate physical activity for a healthy life can be achieved by preferably 30 minutes daily physical activity, at least 5 days a week (Tümer, 2007). In 1980s, however, the studies regarding that the exercise is a positive health behavior have been performed increasingly. The medical research on the term showed that the exercise reduces the risk factors in cardiovascular diseases. Again in the same period, research studying the relation between physical activity and blood pressure, cholesterol level and body mass index. Also the view that the gender, age, education status, health level and psychosocial variables affect the physical activity (Challagan, 2004; Tümer, 2007). When we arrived 2000s United States of America, developing a new vision in the scope of "Healthy Human 2000" national health goals, indicated that the exercise increases the life quality, prevent diseases and injuries and reduces death rate (Tümer, 2007). The research performed on this subject shows that the exercise positively affects the health (Ainsworth et al., 1993; Rowlands et al.,1999). With regular participation in exercise, the cardiorespiratory endurance, elasticity, muscle power, endurance, haste improvement and bone density increases (Greendale et al., 1995); obesity, depression and high anxiety probabilities decrease. Also the rate of having chronic diseases like high blood pressure, type 2 diabetes, cardiovascular diseases and colon cancer as well as death rate of individuals who perform exercise are lower compared against sedentary coevals (Longnecker et al., 1995; Haapanen et al., 1996). Insufficient physical activity is a risk factor for chronic diseases like coronary artery disease, hypertension, diabetes, osteoporosis, osteoarthritis and obesity. American Heart Association-AHA declared that the inactivity is a preventable risk factor for coronary artery disease and the exercise can reduce deaths related to coronary 748

artery disease by one third via increasing cardiovascular functional capacity (Bedard, 1995; Cindaş, 2001). It is found out that in people living previously a sedentary life and develop their form later on the total mortality by 44%, coronary artery disease death rate by 42%, and diabetes death rate decreases by 35%. (Cindaş, 2001; Kaşıkçıoğlu, 2003). In a study by Speck (2002), with 244 healthy males and 120 healthy females, individuals have performed exercises 2 times a week for 8 years and at the end of 8 years the death rates of individuals due to cardiovascular system diseases between individual who performed low and high levels of exercises were compared. Bedard (1995) indicates that the exercise maintains the bone mineral density and muscle mass in especially women with risk of osteoporosis. On the other hand an active life style is found out to be in positive correlation with reduction in some types of cancers, especially in colon cancer (Bedard, 1995). It is estimated that if all American adults have a high level active life style the death rate due to colon cancer shall be reduced by 32% (Cindaş, 2001). Despite the positive correlation between the physical activity and health, studies show that people are not exercising enough. The sedentary life style threatens the public health in all around the globe increasingly. According to the reports of the World Health Organization more than 60% of the world population lives an inactive life style in a level that can cause health problems. 90% of the 135 million diabetes patient around the world are type II diabetes patients due to lack of activity. The experts considering such a case calculated that in 2020 60% of all diseases shall be non-communicable diseases and the cause of 73% of deaths shall be lack of activity. Besides this, din parallel to the increase in the health problems the health expenditures are also increasing significantly. Research shows that the increase in number of individuals who exercise regularly shall result in economical benefits such as decrease in health expenditure and increase in efficiency, with regard to health care of which the costs are increasing steadily all around the globe. According to Bedard, in Canada, in between years 1981-1995 the increase from 21% to 37% of the rate of people doing regular physical exercises in a level that will reduce heart disease risk, caused 190 million dollars of savings in health expenditure in 1995 (Bedard, 1995). It is estimated that 37% of all deaths due to coronary heart disease is caused by physical activity insufficiency (Morgan, 2005). According to the American Heart Association (AHA) data, 250.000 people die due to physical inactivity per year in United States of America only (Burns et al., 2000; Schuit et al., 2002). World Health Organization (WHO) data presented that the lack of physical activity or a sedentary life style is among the top ten universal causes of death and disability. WHO, in order to emphasize that the physical activity is important for protecting and improving health, chose the subject of "Move for Health" in the scope of 2002 World Health Day. The main message of the “Move for Health" campaign was that increasing the physical activity is the least costly and most effective way to improve health (WHO, 2002). In 2004, Ministry of Health in Turkey chose one province form each of the 7 regions of the country in the scope of "eat healthy, protect your heart" project (Balıkesir, Muğla, Aksaray, İçel, Gaziantep, Erzincan, Ordu) and in order to detect the frequency of the coronary heart disease factors of 12.879 individuals in between ages of 30-96, also the exercising status were investigated. In this study the rate of people who perform exercises were found as 3.5 % (Kafalı, 2009). In 2014, in the study performed by the Turkey Ministry of Health on individuals of age 12 and above, the results reached as 749

that 67.6 % of males and % 76,5 of females in Turkey are physically inactive (Turkey Ministry of Health, 2014). THE RELATION OF PHYSICAL ACTIVITY AND EXERCISE TO PSYCHOLOGICAL HEALTH Exercise and Emotional Status There are many psychological benefits besides the physiological effects of the regular exercise. Researchers explained as such the mechanisms and benefits of the exercise that helps it positively affect the psychological health: Aerobic exercise increases the release of noradrenalin and dopamine, creates euphoria due to increase in levels of plasma beta endorphin and causes positive emotional status change (Bruggman & Ferguson 2002; Challagan, 2004; Daley, 2002). According to Mutrie (2002) Fox investigated 36 randomized controlled studies and found out that there is an positive correlation between the physical activity and emotional status. It is emphasized that the regularly performed exercise drops blood pressure, slows down the pulse, eases breathing that reduces stress and anxiety symptoms, decrease negative emotions like rage and aggression, provides emotion control, increas sleep quality (Artal & Sherman, 1998; Kennedy & Newton, 1997; Landers, 2004; O;Brien, 2004). In a study examining the relation between physical exercise and sleep in Finland, 1600 individuals were asked how they perceive the effects of exercise on sleep. 39% of males and 30% of females participating in the study indicated that the exercise has a significant effect on increasing sleep (O’Conner & Youngstedt, 1995). Regarding the exercise and psychological health relation, mainly the depression was focused on. The depression that affects the life quality of millions of people all around the world negatively, is an emotional status (Gelenberg, 2010). In depression therapy, although primarily the pharmacotherapy and psychological responses are used, the latest studies showed that the exercise decreases the depression as in a quality of supporting the traditional treatments (Antunes et al., 2005; Chu et al., 2011; Callaghan et al., 2011). Previous studies indicated that the exercise in treatment of depression has the same effect with the medicinal treatment (Brenes et al., 2007; Blumenthal et al., 2007) or psychological responses (Fremont & Craighead, 1987). According to Landers (2004) exercise shows an antidepressant effect right from the very beginning of the depression therapy, regulates the changes in the daily life that develop in connection with the depression and increases the individuals interaction with his/her environment. Artal and Sherman (1998) have applied 8 weeks of walking, running and fun therapies to depressive patients checked in the clinic and found out that the depression level is low only in walking and running groups. In many researches, the exercise performed 34 times in a week is shown to be able to decrease the depression symptoms like standard antidepressant drug treatments (Daley, 2002; Landers, 2004; Matthew & Wattles, 2001). National Service Framework for Mental Health (NICE) suggested to support the therapies by leading the people who are in depression therapy to exercise (Mead et al., 2010). According to the NICE depression guide, it is proposed that a light and moderate level exercise structured with a consultant, performed three times a week (45 minutes - 1 hour) for more than 10-14 weeks regulates the depression symptoms (NICE, 2009). In the guide published by the Scottish Intercollegiate Guidelines Network (SIGN), it is indicated that the depression can be handled in adults with exercising without drug therapies. An exercise driving system was established in 750

England (DOH, 2001) and people who wants to get help on exercise were supported by preparing physical activity programs but at the end of the general evaluations it was not conclusive that whether the desired results were reached regarding the effectiveness of this system and there was no suggestions for future studies (Sorensen, 2006). It is indicated that the physical exercise has positive effects on many clinical diseases like anxiety disorders, somatoform disorders among mental problems, and substance abuse. Experimental studies showed that the exercise is very efficient in decreasing anxiety. In a study with 36 patients with anxiety disorder participated, at the end of 8 weeks aerobic exercise program, in the subcategories defined other than the social phobia a significant level of drop in anxiety levels were indicated. In these patients that are followed up for a year, the recoveries were continued in agoraphobias without panic attack and general anxiety disorders, and it is observed that the frequency of panic attack and agoraphobia occurrence were decreased (Thachuk & Martin 1999). Another issue that affects the psychological status of the individuals is the "self sufficiency" concept that is defined as a person starting an action that can be effective on what is happening around and believing that it can be continued until the results are taken. Self sufficiency was defined by Bandura as a person's belief in abilities that help the person manage the situation expected form him/her (Luszczynska, Urte, & Ralf, 2005). According to Bandura the self sufficiency behavior is structured by the environmental, behavioral and cognitive factors and is defined as an ability of an individual gained to control the emotional performance that will be used in hard conditions (Bandura, 1977). Research showed that the self sufficiency concept is effective on participation in exercise (McAuley, 1992), weight control (Bernier & Avard, 1986) and developing behaviors related to health (O'Leary, 1992). Self sufficiency is also related with the depression. Having low levels of self sufficiency is one of the factors causing depression (Bandura, 1986). In general, if individuals start to doubt their abilities necessary to realize an action that is important for them, then they may fall into depression (Ahrens, 1987). In some long term studies on adults, the self sufficiency belief was among the factors that predicts depression in parenthood (Olioff & Aboud, 1991), work life (Pomaki, ter Doest, & Maes, 2006) and in important personal goals (Olioff et al., 1989). The psychological benefits are provided through participation in exercises are shown in Table 1. Another emotional status that the exercise positively affects is being well psychologically. Participants of exercise experiencing low levels of stress, worry and depression problems can be beneficial for participating in an exercise program. Also individuals being in low levels of psychological wellness can be effective on involving in exercise. For example, Muraven and Baumeister (2000) claimed that humans have limited energy to change themselves and the mental stress can reduce this energy. Also the psychological wellness being low can be related to self confidence and self sufficiency concepts. Depressive and stressed individuals can face problems in completing exercise programs and this situation affects adversely the person's psychological wellness naturally (Jones et al., 2005). The previous studies support the relation between the psychological wellness concept and the physical activity (Fox, 1999). The current studies on this field are towards understanding the physical activity behavior and 751

providing positive effects on psychological wellness by increasing this behavior (Sebire et al., 2009). Table 1. Some proposed psychological benefits of exercise in clinical and nonclinical populations (Taylor et al., 1985). Increases Decreases Academic performance Absenteeism at work Assertiveness Alcohol abuse Confidence Anger Emotional stability Anxiety Independence Confusion Cognitive performance Depression Internal locus of control Dysmenorrhoea Memory Headaches Mood Hostility Perception Phobias Popularity Psychotic behavior Positive body image Stress response Self-control Tension Sexual satisfaction Type A behavior Well-being Work errors Work efficiency Effects of Exercise on Cognitive Functions It is shown that the regularly performed aerobic exercise provides cerebrovascular integrity (reverses the disturbed cerebral circulation); improves capillary growth, dendrite connections, central nervous system functions hippocampus linked learning and memory and increases cognitive performance (Cotman & Engesser-Cesar, 2002; Swain et al., 2003). There are three hypotheses regarding the effects of exercise on cognitive functions in central nervous system (Ploughman, 2008). In the first of these, it is said that the exercise increases the oxygen saturation (Kramer et al., 1999) and angiogenesis (Kleim et al., 2002) in brain regions related to higher cognitive functions. Kramer et al. (1999) indicated that the increasing oxygen consumption rates in healthy adults via walking exercise affects the reaction time and cognitive function test performances positively (Kramer et al., 1999). The second hypothesis is that the increasing serotonin and norepinephrine like neurotransmitters in brain with exercise ease the information processing (Kubesch et al., 2003; Winter et al., 2007; McMorris et al., 2008). The third and last hypothesis indicates that the exercise increases neural survival and differentiation in developing brain and neurotrophins like brain derived neurotrophic factor (BDNF) which supports dendrite connections and synaptic mechanisms, insulin like growth factor (IGF-1), basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) that supports vascular structures (Schinder & Poo, 2000). The positive effects of exercise on cognitive functions are proved both in human and experimental animal studies. The positive effect of physical activity in cognitive performances and academic success of children at school age was also explained in a meta-analysis (Sibley & Etnier, 2003). There have been results gathered on the physical motion being less in childhood and aerobic physical conformity levels being in low effecting the academic success negatively (Castelli et 752

al., 2007; Chomitz et al., 2009). In experimental animal studies, it is shown that regular aerobic exercise in adults and adolescents increases the hippocampus derived spatial learning and memory (Chodzko-Zajko & Moore, 1994; Mello et al., 2008). Uysal et al., in a study they investigate the effects of light regular aerobic exercise on brain in rats; for the adolescent (22 days) male rats that perform light exercise for 8 weeks, 30 minutes a day, showed that the cellular density in hippocampus and dentate gyrus increases and have beneficial effects on cognitive functions (Holzschneider et al., 2012). The researchers are investigating the prevention of decrease in the cognitive properties with age for the growing elderly population. Various cross sectional studies showed that the elderly individuals that are physically active are superior than sedentary old population in visual attention (Roth et al., 2003), short term memory (Shay & Roth, 1992), computation speed (Hillman et al., 2004), administrative functions (Colcombe & Kramer, 2003) and memory (Albert et al., 1995). In a long term study examining the effects of exercise in sedentary old individuals, 124 people have exercised for 6 months and participants were divided into two groups as aerobic (walking group) and anaerobic (stretching group). After 6 months it was seen that the group performing aerobic activities showed development in tasks related to administrative functions (Kramer et al., 1999). REFERENCES Açıl, A. A. (2006). Şizofrenik hastalarda fiziksel egzersizin ruhsal durum ve yaşam kalitesi üzerine etkisi. Psikiyatri Hemşireliği Programı Yüksek Lisans Tezi, Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü. Sivas, Türkiye. Yüksek lisans tezi. Ahrens, A. H. (1987). Theories of depression: The role of goals and the self-evaluation process. Cognitive Therapy and Research.11: (6), 665-680. Ainsworth, B.E.; Haskell, W.L.; Leon, A.S.; Jacobs, D.R.; Montoye, H.J.; Sallis, J.F.; Paffenbarger, R.S. (1993). Compendium of physical activities: Classification of energy cost of human physical activities, Med. Sci. Sport Exerc. 25, 71-80. Albert, M. S.; Jones, K.; Savage, C. R.; Berkman, L.; Seeman, T.; Blazer, D. & Rowe, J. W. (1995). Predictors of cognitive change in older persons: MacArthur studies of successful aging. Psychology and aging. 10: (4), 578. Antunes H.K.; Stella S.G.; Santos R.F.; Bueno O.F.; de Mello M.T. (2005). Depression, anxiety and quality of life scores in seniors after an endurance exercise program. Rev. Bras. Psiquiatr. 27, 266–271. Arslan, C.; Koz, M.; Gür,E.; Mende, B. (2003). Üniversite öğretim üyelerinin fiziksel aktivite düzeyleri ve sağlık sorunları arasındaki ilişkinin araştırılması, Fırat Üniversitesi, Sağlık Bilimleri Dergisi. 17, 249-258. Artal, M. & Sherman C. (1998). Exercise Against Depression. The Physician and Sports Medicine, 26: (10), 57-61. Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological review, 84: (2), 191. Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. Journal of social and clinical psychology, 4: (3), 359-373. Bayrakçı, T. V. (2008). Yetişkinlerde Fiziksel Aktivite. 1.Baskı., Ankara. Sağlık Bakanlığı Yayını. Şubat, s.730. Bedard, M. (1995). Fiziksel Aktivite ve Spor Dünya Formu. (C.Açıkada, H.Turnagöl, Çev.). Bernier, M. & Avard, J. (1986). Self-efficacy, outcome, and attrition in a weight-reduction program. Cognitive Therapy and Research. 10, 319-338. 753

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Chapter 67 Muscular Endurance Training with Electromyostimulation: Is It Possible Torque Production in Fatigue?1 Fatih KAYA, Salih PINAR, Elif Sibel ATIŞ, Andrew P. LAVENDER, Mustafa Said ERZEYBEK 1. INTRODUCTION Electromyostimulation (EMS) has commonly been used to improve training outcomes for both muscle strength and fatigue resistance (Thériault et al., 1996; Brocherie, 2005). The effects of EMS have been observed in the recruitment pattern of motor units during voluntary contractions as it may reverse the order of motor unit recruitment known as Henneman’s size principle (Feiereisen et al., 1997; Porcari et al., 2002). According to the studies that support the size principle, when the muscle is stimulated using an external electrical stimulator large diameter motor units are preferentially recruited and conduct action potentials at higher speeds than axons of the smaller motor units. Electrical muscle stimulation may be an easy way to ‘train’ fast twitch motor units without great overall muscular effort (Gregory & Bickel 2005; Starkey, 2013). High frequency stimulation (>70 Hz) generates fatigue rapidly (Petrofsky, 2004). Therefore, artificial electrical stimulation of a muscle while it is conciously activated maximally, or near maximal contraction requires high frequency stimulation in order to cause fatigue (Hortobágyi, 1996). Fatigue is accompanied by a reduction in maximal force generating ability of a muscle during voluntary actions. This is due partly to compromised of the central nervous system signal pathways (Boyas & Guével, 2011) and partly metabolic factors located within the muscle fibres lead to a decline in muscle force generated over sustained periods of activity (Komi, 2003; Gandevia, 2001; Kraemer et al., 2011). However, in order to develop muscular endurance the level of training is usually low or the load used for muscular workouts is set for a low to moderate intensity (Kraemer et al., 2002). Training at this intensity for long periods over many sessions is required in order to improve muscles ability to generate force for longer periods. Nervous system adaptations to training can improve physical performance 1

This study is derived from Kaya’s (2011) doctoral dissertation, Asst. Prof. Dr., Erzincan University, Faculty of Education, Department of Physical Education and Sports, Erzincan, Turkey  Prof. Dr., Marmara University, Faculty of Sport Sciences, Istanbul, Turkey  Research Assistant/ Marmara University, Faculty of Sport Sciences, Istanbul, Turkey  Lecturer, Curtin University of Technology, Faculty of Health Sciences, School of Physiotherapy and Exercise Science, Perth, Australia  Lecturer, Curtin University of Technology, Faculty of Health Sciences, School of Physiotherapy and Exercise Science, Perth, Australia  Asst. Prof. Dr., Dumlupınar University, School of Physical Education and Sport, Kütahya, Turkey 

(Kraemer et al., 2011). Specialised, neural training sessions that improve the nervous system ability to produce sustained, high-frequency signals which allow a muscle to contract with its greatest force and physiological limit may be useful (Gandevia, 2001). The size principle of motor unit recruitment states that slow twitch (ST) fibers are preferentially recruited and larger motor units are recruited as the smaller ones are lost to fatigue at low force output contractions. Electrical stimulation of fatigued muscles may activate more motor units. Exposing fast twitch (FT) muscle fibers to continuous high frequency stimulation might decrease the stimulation threshold of the fibers causing them to be recruited earlier. Therefore, it was suggested that facilitating FT fibers recruitment with electromyostimulation would develop an ability to recruit these fibers more efficiently during a fatigue inducing contraction resulting in an improvement in the capability to maintain force output during the state of fatigue. Although electrical stimulation training of muscles with high frequency have beneficial effects on muscle strength and performance parameters little is known regarding the neuromuscular adaptations during fatigue. The aim of the present study is to investigate whether high frequency electrical stimulation incorporated into an eigth week endurance training programme could affect the capability of torque production of the fatigued quadriceps muscle. 2. MATERIALS AND METHODS 2.1 Subjects Twenty healthy male university students from the Department of Physical Education and Sports, who do not participate in any regular exercise training (age range 20-25 years) volunteered for this study. Subjects were matched according to their initial maximum voluntary torque values of quadriceps muscle and divided into electromyostimulation (EG, n=9, age 21.89±2.67 yrs, height 176.78±8.80 cm, body weight 71.00±9.10 kg) and control groups (CG, n=11, age 21.45±2.07 yrs, height 180.18±8.54 cm, body weight 79.82±10.91 kg) and assigned to one of the groups. Approval for the study was obtained from the University’s Faculty of Medicine Ethics Committee and all volunteers gave written informed consent to participate in accordance with The Declaration of Helsinki. 2.2. Experimental design and testing Training Program Before the training program, EG participated in a familiarisation session with electrical stimulation and the test protocol. During this session, each subject’s maximum exercise intensity of (load level-weight) for training sessions was defined by their 1RM, defined as the maximum weight that a full repetition can be completed but two repetitions could not. Each participant in both groups was asked to continue their regular diet and exercise routines throughout the duration of the experiment. Both groups participated in a muscular endurance training program for a period of eight weeks. EG participated in electrical stimulation sessions along with this program (Table 1). In accordance with muscular endurance training recommendations of the American College of Sports Medicine, training sessions were performed on three nonconsecutive days each week across the eight weeks (Hoeger Werner & Moore, 2002). Each training session consisted of three stages: 1) Ten minutes warm-up period 760

(cycling / treadmill / stretching exercises), 2) Three sets of muscular endurance exercise on a knee extension machine for knee extensor muscles of both legs until exhaustion at a resistance of 40% of each individual’s 1RM (10-20 min) and 3) Ten minutes cooldown period (stretching). Table 1: Training program Mode: Muscular endurance training + Electrical stimulation (only for EG) Training session: knee extension on knee extension machine Target muscle group: Quadriceps Sets: 3 sets a day The number of repetitions: until voluntary fatigue Resting: 30 sec (EG received electrical stimulation during rest) Intensity/load: % 40 1 RM-fixed Determination of voluntary fatigue: (1) subjective with feedback method (Borg scale) (2) not being able to move against resistance with appropriate range of motion. Frequency: 3 sessions per week (nonconsecutive days) Duration: 30 min- 40 min (10 min warm-up, 10-20 min training, 10 min cool-down). EMS parameters: tolerable stimulation intensity, high frequency (50 Hz) for 30 sec (knee joint angle 60°). Table 2: Parameters of Electrical Stimulation 1. Waveform: biphasic, rectangular, symmetrical 2. Intensity (amplitude): 10 mA-90 mA (subject tolerance) 3. Pulse width (pulse duration / impulse width): ≥ 200μs 4. Frequency (number of impulse every second): 50 Hz (fixed frequency). 5. Ramp up time: 0 s. 6. Ramp down time: 0 s 7. Stimulation time: 30 s. (contraction time is 1 s, relaxation time 1 s.)

When voluntary fatigue was reached, the CG were instructed to rest while the EG received electrical muscle stimulation for 30 s (Table 2). To achieve a strong muscle contraction the intensity of electrical stimulations were delivered at an intensity which was at the tolerance threshold for each individual (mean: 26.48±2.66 mA). Three sets of fifteen contractions were performed. The mean value of electrical stimulation intensity, the loads used in training (weight) and training session duration of each subject were strictly controlled and were recorded by the researchers at the end of each session. In addition, all subjects were asked to specify their subjective evaluations during stimulation (pain, muscle cramps or any other discomfort) and these comments were noted. The weights that the subjects lifted were increased according to 1RM in 2-week intervals (muscular adaptation). Application of Electrical Stimulation During the stimulation, subjects were seated on a knee extension machine with the knee joint fixed at an angle of 60°. Electrical stimulation was applied simultaneously toquadriceps muscles of both lower extremities via self-adhesive surface electrodes. Positive electrodes (5 cm×5 cm) were placed onto the motor points of the vastus medialis and vastus lateralis muscles, the negative electrodes (5 cm×10 cm) were placed on the quadriceps femoris ~ 5 cm below the inguinal ligament as described by Delitto 761

and Robinson (1989). A motor-point pen of a Compex-MI Sport electrical stimulation device (Medicompex SA, Ecublens, Switzerland) was used to determine the motor point. A four-channel EMP4 Expert device (Schwa-Medico, Ref 1040042, Germany) was used for the electical stimulation. Electrical stimulation parameters are shown in Table 2. Test Procedure All groups were tested at the pretraining session and at the end of 4 and 8 weeks of training. The test battery included measurements of: a) rested maximum voluntary torque b) maximum voluntary torque at fatigue, c) muscular endurance (fatigue indexFI). Height and weight of subjects’ were measured with a standard laboratory stadiometer and a scale at baseline and weight measurements were repeated at the end of weeks 4 and 8. 1RM measurements were taken at baseline and repeated at intervals of two-weeks. 1RM Procedure The maximum amount of weight lifted for one repetition, or 1RM, for each subject was determined by using both lower extremities with knee extention machine. Subjects initially performed 1-2 set of warm-up executing 5-10 repetitions at 40-50 % of their own estimated 1RM, they were then asked to lift progressively heavier weights to the maximum achievable level. Subjects were then asked to perform one set of knee extension at their maximum level and perform as many repetitions as possible. The following formula was used to determine a subject’s 1RM (Spanos et al., 2007): 1 RM=[(number of repetitions / 30) + 1)] X weight in kg. Isokinetic test protocol The capability of force production during the fatigue was tested using an isokinetic dynamometer, Cybex NORM dynamometer (Cybex, division of LUMEX, Inc., Ronkonkoma, New York, USA) on the dominant leg with a three-step protocol as described in Figure 1. Each test was performed at the same time of the day with a warm up period of 10 min (bicycle ergometer, ~40W, 5-7 min + stretching) and lasted 30 min. Subjects were asked to avoid caffeine drinks within one hour, large meals within two hours and excess alcohol the night before the tests. Each subject was seated with their hip angle between 75 and 90 degrees of flexion on the isokinetic dynamometer. The rotation axis of the isokinetic dynamometer was aligned with the anatomical axis of the subject's knee, and the lever arm was attached to the subject's leg at a distance of approximately 70% of the length from the medial knee joint line to the medial malleolus to allow for a standardized and comfortable position. The subject's thigh was stabilized with a canvas strap fixed to the dynamometer. While subjects were seated on the dynomometer, they performed five sub-maximal extensions and flexions for familiarization purposes (Kannus, 1994). Each participant performed the required maximal concentric knee extension repetitions through the range of motion from 90° to 0° of knee flexion at 60o/s -100o/s angular velocity, with a passive return to 90° (no quadriceps eccentric or concentric hamstring activity). During the tests, participants were continuously encouraged verbally to perform 762

with maximal effort. Each subject’s Maximum voluntary torque was measured while performing four maximal isokinetic-concentric quadriceps contractions at 60˚/sec angular velocity. This test was repeated after the muscular endurance test. Muscular endurance was measured using the fatigue protocol developed by Thorstensson and Karlsson (Brown & Weir, 2001). Each subject performed a fatigue test consisting of 50 maximal knee extensions at 1800/s angular velocity using the Cybex isokinetic dynomometer. They were paced at a rate of 50 extensions per minute by use of a metronome, the subjects were instructed to maximally extend their legs with every repetition.

Figure 1: Isokinetic test protocol

2.3 Statistical Analysis Force output data were statistically evaluated using between and within subjects comparisons with repeated measures design (Mixed-model Ax(BxS) and Ax(BxCxS) Design). Independent samples t tests were used to compare baseline data between groups. At each re-test, to assess the effects of the training on 1RM and fatigue index, values were analyzed using a two-way (training/ time) mixed analysis of variances (two-way (2x3) Mixed ANOVA). A three-way (group / time / test) mixed analysis of variance was used to evaluate peak torque scores before and after fatigue at baseline, week 4 and week 8 of training. Multiple comparisons using Bonferroni verification with checks for sphericity were carried out. The level of significance was set at p ≤ 0.05 for all procedures and statistical analyses were undertaken using the SPSS 17.0 software. 3. RESULTS There were no significant differences among baseline values of body weight (t(18)=-1.93, p>0.05; 1RM t(18)=-0.55, p>0.05; and peak torque t(18)=-0.73, p>0.05 between groups. Mean increase in duration of the training session for EG was 149.50 % (from 3.98±0.80 to 9.93±5.05) while it was 65.22% for CG (from 3.45±0.63 to 5.70±2.29) at the end of 8th week compared with the first week. Training loads of the EG increased by 32.72 % (from 36.67±6.26 to 48.67±6.12) while the increment was 19.92% (from 38.36±6.91 to 46.00±5.77) for the CG at the end of the 8th week (Table 3). 1RM scores increased for both groups at the end of the 2nd week and increased further by the end of week 8 linearly. The average change between initial and final test scores for the EG was 39.85% for 1RM (from 91.99±16.06 to 128.65±15.82), the average change for the CG was 24.50% (from 96.14±17.54 to 119.69±16.65). There were no significant differences in the average 1RM scores between EG ( = 112.32) and CG ( x = 108.32), F (1, 18) = .368, p =. 552, .020 across the eight weeks (Figure 2). 763

Table 3: Training duration and trainin loads mean values of EG and CG. EG's values higher than CG’s throughout the process. Mean (SD)

EG CG

Training duration (sec) Baseline Wk4 Wk8 3.98(0.80) 7.64(3.99) 9.93(5.05) 3.45(0.63) 3.61(0.38) 5.70(2.29)

Baseline 36.67(6.26) 38.36(6.91)

Training load (kg) Wk4 Wk8 42.33(7.27) 48.67(6.12) 41.50(6.63) 46.00(5.77)

Figure 2: 1RM changes were similar for both groups throughout the study, p>.05. (+/-1 SE).

Mean peak torque scores and the percentage changes for before and after fatigue at each test point are shown in Figure 3. Mean peak torque scores (60o/s) of both groups increased linearly from baseline through out the final testing. The mean peak torque score changes of both groups were similar at each test point before and after fatigue, F (2.36) = .352, p = .706, .019 (Figure 4) (group x time x test interaction effect). When group and test factors were ignored (time main effect) there was an increase in the mean peak torque scores of time period (F (2,36) = 22 289, p = .000, .553), and these increases were similar between the groups (F (2.36) = .032, p = .969, .002), (group x time interaction effect). At the end of 4th and 8th week the average peak torque scores were higher comparing to baseline scores (p