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There may be a risk of interactions between this herbal medicine and orthodox drugs cheap furosemide online visa. Safety of surgical and manipulative procedures The inclusion of surgical techniques adds another potential danger from non-sterile instruments and consulting environments purchase furosemide 40 mg amex, and incompetent procedures furosemide 100 mg on-line. There is also a risk from undue pressure or incorrect manipulation by inexperienced practitioners. Evidence There are difficulties in applying western methods to proving the effective- ness of traditional therapies. Data from both animal and human trials suggesting efficacy of ayurvedic interventions in managing diabetes have been published. There are some encouraging results for its effectiveness in treating various ailments, including chronic disorders associated with the ageing process. Pilot studies have also been conducted on depression, anxiety, sleep disorders, hypertension, Parkinson’s disease and Alzheimer’s disease. This group contains experts in pharmacognosy, toxicology, pharma- cology and clinical pharmacology, as well as clinicians and experts in standardisation and quality control. All trials are comparative, controlled, randomised and double blind unless there is a reason for carrying out a single-blind study. The trials are planned by the whole group but carried out at the centres of allopathic medicine with established investigators. There are over 20 clinical trial centres throughout the country for carrying out the multicentre studies. Using this network the council has shown the efficacy of several traditional medicines, including Picrorhiza kurroa in hepatitis and Pterocarpus marsupium in diabetes. The Central Council of India’s systems of medicine oversee research insti- tutes, which evaluate treatments. The government is adding 10 traditional medicines into its family welfare programme, funded by the World Bank and the Indian government. These medicines are for anaemia, oedema during pregnancy, postpartum problems such as pain, uterine and abdominal com- plications, difficulties with lactation, nutritional deficiencies and childhood diarrhoea. The regulations outline requirements for infrastructure, labour, quality control and authenticity of raw materials, and absence of contamina- tion. Of the 9000 licensed manufacturers of traditional medicines, those who qualify can immediately seek certification for good manufacturing practice. The remainders have 2 years to comply with the regulations and to obtain certification. The government has also established 10 new drug-testing laboratories for Indian systems of medicine and is upgrading existing laboratories to provide high-quality evidence to the licensing authorities of the safety and quality of herbal medicines. Randomised controlled clinical trials of selected prescriptions for Indian systems of medicine have been initiated. These will document the safety and efficacy of the prescriptions and provide the basis for their international licensing as medicines rather than simply as food supplements. Other trials have shown some promise in the treatment of bronchial asthma34,35 and angina. Most of the physicians are based in London but some of them are in areas that have a large Asian community such as Leicester, Birmingham and Bradford. However, many ayurvedic physicians use their education and knowledge in combination with their other healthcare-related licensed credentials. Integration with western medicine The Indian Medicine Central Council was established by a 1970 act to oversee the development of Indian systems of medicine and to ensure good Indian ayurvedic medicine | 215 standards of training and practice. Training for Indian medicine is given in separate colleges, which offer a basic biosciences curriculum followed by training in a traditional system. Recently the Department of Indian Systems of Medicine has expressed concern over the substandard quality of educa- tion in many colleges, which in the name of integration have produced hybrid curricula and graduates, unacceptable to either modern or tradi- tional standards. The department has made it a priority to upgrade training in Indian systems of medicine. Such clinical evaluation is essential because the remedies used in these systems will not be used in allopathic hospitals in a country such as India unless they have shown efficacy in well-controlled trials. However, carrying out randomised, double-blind, multicentre trials with standardised extracts is a slow and laborious process. Furthermore, not all herbal medicines need to undergo this rigorous trial because these preparations are already in use. The situa- tion is still further complicated because the randomised trial may not be totally appropriate for the evaluation of medicines from the traditional systems, where the prakriti (ayurveda system) or mijaj (unani system) of the individual determines the specific therapy to be used. Ayurvedic medicines Herbal drugs constitute a major share of all the officially recognised systems of health in India: ayurveda, yoga, unani, siddha, homoeopathy and natur- opathy. The metals, animals and minerals are purified by individual processes before being used for medicinal purposes. Many forms of ayurvedic medicaments may be identified including the following: • Quath: crushed herbs, used as decoction or tea for internal and external uses • Churna: fine powdered herbs, used as medicine with water or in food for internal and external uses 216 | Traditional medicine • Tail: herbs cooked in edible oil according to rules laid down for internal and external uses • Ghrat/Ghrit: herbs cooked in special butter • Asav/Arista/Sura: a kind of light wine obtained after fermentation of herbs • Arka: a distillation of herbs • Rasausadhi/Kharliya rasayan: herbs mixed with metals, minerals and animal ingredients • Bhasma: ashes • Parpaty: combinations of metals, minerals, animal ingredients and herbs • Kshar/Lavan/Salt/Drava: these are specially prepared medicaments • Medicaments based on guggula (the Indian bdellium tree Commiphora mukul Engl. Containing fruits of black pepper (Piper nigrum), Indian long pepper (Piper longum) and the rhizomes of ginger (Zingiber officinalis), it is a common combination used to stimulate and maintain the digestive and respiratory systems. This it does by reducing kapha and increasing pitta through the rejuvenation of low agni and the burning away of ama (toxins). Indian ayurvedic medicine | 217 • Triphala is a rasayana formula comprising equal parts of three fruits: amalaki (Emblica officinalis), bibhitaki (Terminalia bellirica) and haritaki (Terminalia chebula). When dissolved in the mouth, Triphala can be used to clear congestion and headaches. Other related therapies Unani The word unani derives from the Arabic word for Greece: al-Yunaan and is used to refer to medicine of Graeco-Arabic origin. Unani medicine believes that diseases can be kept at bay by the use of clean and fresh water, breathing clean air and consuming fresh food. Like- wise, a balance should be maintained between the mind and the body so that the metabolic process can take place easily and the body waste evacu- ated. According to unani the human body is composed of seven natural and basic components, called Umoor-e-Tabaiya, that are responsible for maintenance of health. These are similar to those identified in ayurveda: • Elements (arkan) • Temperament (mizaj) • Four humours (akhlaat) – blood, phlegm, yellow bile and black bile • Organs (aaza) • Vital forces or neuro (arwah) • Facultie (quwa) • Functions (afaal).

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Useful contact The Guillain Barré helpline: 0800 374803 Further reading Useful medical articles on Guillain Barré syndrome include Desforges (1992) and Fulgham & Wijdicks (1997) literature reviews generic furosemide 40mg line, Hund et al cheap furosemide 100 mg on-line. Finocchiaro and Herzfeld (1990) provide almost the only easily accessible nursing article on autonomic dysreflexia; Keely (1998) gives a useful critical care update buy furosemide with visa. Some have been published in nursing and medical journals, but can be difficult to obtain. Clinical scenario Duncan Munro, 46 years old, presented with tachypneoa (over 40 breaths/min), tachycardia (110 beats/min), hypertension (170/110 mmHg), difficulty swallowing, general fatigue with numbness in both legs and feet. During the previous three weeks, he had been travelling abroad on business and recovering from an upper respiratory tract infection. Duncan’s respiratory and motor function deteriorated a tracheotomy was performed Neurological pathologies 375 and invasive positive pressure ventilation initiated. The liver has more functions, and a wider range of functions, than any other major organ, so that hepatic failure causes many problems. Liver function tests indicate the degree of liver failure; if severe, referral to specialist centres may be necessary. The term fulminant hepatic failure (liver disease together with encephalopathy occurring within 8 weeks of onset) is still used, but it is increasingly being replaced by ■ hyperacute (0–7 days) ■ acute (8–28 days) ■ subacute (29 days-12 weeks). Although scientifically questionable (drugs are chemicals), this apparently arbitrary division is clinically useful. Symptoms of acute failure are similar from all causes, but are included here in the section on paracetamol. Many other therapeutic drugs (such as chlorpromazine) can also provoke failure (Hawker 1997a). Hepatic failure 377 Hepatic failure may be caused by hepatitis and many other viruses (e. Hepatocyte recovery is good following acute hepatic failure, and so treatment is largely a matter of system support to minimise complications (especially cerebral oedema and cardiac failure) and allow hepatocyte recovery. Progression to chronic failure usually causes ■ hyperdynamic circulation ■ portal hypertension ■ oesophageal varices and bleeding. Survivors of these complications usually progress to end-stage failure, necessitating transplantation (see Chapter 44). Most of the complications identified here occur with acute failure, but some complications of chronic failure are also specifically identified. Plasma paracetamol levels exceeding 250 mg/litre after 4 hours or 50 mg/litre at 12 hours usually result in hepatic damage (Weekes 1997), although severe symptoms may be delayed for 2–3 days, appearing only after significant, possibly fatal, damage. Human transmission is only through faeces (not blood or other body fluids), infection being endemic where sanitation is poor (Pratt 1995). Transmission can be ■ parenteral (most body fluids) ■ sexual ■ (possibly) through insect bites (Pratt 1995). Chronic carriers rarely develop infection (Raeside 1996), but can spread infection (Pratt 1995). Hepatitis C usually recurs following transplantation, but most patients remain asymptomatic. Hepatitis D complicates hepatitis B infection, making fulminant hepatic failure more likely. In Europe and North America, hepatitis D is primarily transmitted through drug injection; elsewhere infection is usually sexual (Pratt 1995). Hepatic failure 379 Complications Liver dysfunction affects most other major systems of the body. The description below is reductionist, and specific management of other systems is covered in other chapters. Cerebral oedema provokes intracranial hypertension, impairing cerebral perfusion pressure (see Chapter 22). Prolonged effects from exogenous sedation may delay recovery and make assessment difficult; debate continues on whether to avoid sedating patients with hepatic failure. Whichever medical practice is followed, nurses should actively assess the level of sedation and effects of drugs. Normal sleeping patterns may be reversed, with patients remaining awake overnight. Treatment should optimise cerebral perfusion pressure by reducing intracranial pressure while maintaining mean arterial pressure (see Chapter 22). Persistent intracranial hypertension (above 25 mmHg) may be reversed with mannitol. Chronic failure compounds dyscrasias from ■ splenatomegaly (from portal hypertension), which reduces platelet counts ■ depressed bone marrow function (from alcoholism or paracetamol) which reduces erythropoiesis. Gastrointestinal and respiratory (although not cerebral) bleeds frequently occur (Hawker 1997a). Replacement factors, such as vitamin K (Cowley & Webster 1993) or blood components, may be prescribed. Intensive care nursing 380 The liver contributes significantly to immunity through production of complements (see Chapter 23) and Kupffer cells—specialised reticuloendothelial cells in the liver which destroy any bacteria translocating from the gut. Asepsis, high standards of infection control and continuing vigilance can minimise risks to patients; early detection of infection enables early treatment. Blood from the liver soon reaches pulmonary vessels so that surviving gut bacteria readily cause pulmonary infection; increased capillary permeability enables pulmonary oedema formation, and possible shunting. As suction raises intracranial pressure, patients should be preoxygenated and duration and number of passes should be minimised (see Chapter 22). Suction may also cause trauma, so that catheters withdrawn should be observed for blood (type, amount) as well as sputum (type, colour, amount). Hepatopulmonary syndrome occurs in up to 30 per cent of patients with endstage failure (Isaac & Manji 1997). Pathology is unclear; there is no specific treatment and resolution can be spontaneous, but mortality remains high. Hepatopulmonary syndrome is an indication for liver transplantation (Isaac & Manji 1997.

Nashville: how people learn and which educational methods and Winston-Derek discount furosemide 100mg on line, 1990 discount furosemide 40 mg fast delivery. Aphasia Therapy: Historical and Contempo- field focuses on how to improve teaching cost of furosemide, solve learning rary Issues. Educational psychologists may devise achievement tests, evaluate teaching methods, develop learning aids and curricula, and investigate how children of various Applied psychology ages learn. They often serve as researchers and educators at teacher training institutions, in university psychology The area of psychology in which basic theory and departments, and on the staffs of educational research or- research are applied to the actual problems faced ganizations. Applied psychology can be best understood by com- Applied psychology has many applications in busi- paring it to the area of psychology known as basic psy- ness and industry. Organizational and industrial psychol- chology, which is concerned with answering questions ogists are concerned with the relationships between peo- about behavior through psychological theory and re- ple and their jobs. Applied psychology utilizes this knowledge to such areas as employee morale, job-related stress, job en- actively intervene in the treatment of individuals with richment, leadership qualities, and the effects of flex mental or emotional disorders, and is also employed in time in productivity. Consumer psychologists study the Approximately two-thirds of American psycholo- preferences and buying habits of consumers as well as gists work in applied fields. Many are involved in clinical their responses to advertising, often working together or counseling psychology, diagnosing and treating indi- with advertising copywriters, public relations experts, viduals with various problems of adjustment. They are employed not only by business mately one-third of the psychologists in practice in the but also by government agencies such as the Food and United States today are clinical psychologists, and most Drug Administration and the Federal Trade Commission. These professionals use a human behavior to the design of machines, tools, jobs, wide range of therapies, ranging from Freudian psycho- and work environments to provide the best possible analysis to Rogerian client-centered therapy to newer match with the abilities and limitations of the human be- cognitive approaches. It is part of a broader area private practice, either alone or in groups, or work in hos- known as human-factors engineering (also called er- pitals or clinics. They may also practice in a variety of gonomics) that has links to anatomy, anthropometry, en- other settings, including community mental-health cen- vironmental medicine, and toxicology. One very specific ters, university medical schools, centers for the mentally work environment that provides the arena for another and physically handicapped, prisons, state institutions specialization is the military. A plying psychological research to the operations of the subfield within clinical psychology is community psy- armed forces are involved in personnel selection, testing, chology, which investigates environmental factors that and training; evaluating morale; analyzing job perfor- contribute to mental and emotional disorders. Health psy- mance; studying social interaction among troops; and chologists deal with the psychological aspects of physical exploring the dynamics of combat situations. Psycholo- illness, investigating the connections between the mind gy has also contributed to the exploration of space in and a person’s physical condition. They perform individualized which involves the application of psychology to law en- assessments of each child, consult with his or her par- forcement and the judicial system. Forensic psychologists may help create personality pro- Carl Jung began to evolve his theory of archetypes files of criminals; formulate principles for jury selection; around 1910 while working with patients at the Burghölzli hypnotize victims, eyewitnesses, or defendants to en- Mental Hospital. Noting the presence of universal sym- hance their memories; or study the problems involved in bols from religion and mythology in the dreams and fan- eyewitness testimony. Yet another emerging area is pro- tasies of uneducated patients, who would have had no gram evaluation, whose practitioners evaluate the effec- conscious way of learning them, he concluded that these tiveness and cost efficiency of government programs for images belonged to a part of the unconscious not derived the Congressional Budget Office, the General Account- from personal experience. Jung proposed that universal ing Office, and other government offices and agencies. Doctoral programs generally require conscious when called forth by appropriate experiences in completion of a four- to six-year program offered by a one’s life. The course of study in- supplemented his clinical observations with a comprehen- cludes a broad overview (including courses in such areas sive study of myths and symbols that later included inves- as statistics, personality theory, and psychotherapy), as tigations into the religions and mythologies of preliterate well as specialization in a particular subfield and comple- peoples in Africa and the southwestern United States. Some Jungian archetypes are like prototypes or molds that clinical psychologists hold a Psychology Doctorate each person fills in differently depending on his or her in- (Psy. For example, although the term Illinois in 1968 and is geared exclusively toward the train- “mother” has certain universal connotations that come to ing of clinicians rather than researchers. Offered at univer- mind for most people, the details of this archetype will be sities and at independent, “free-standing” professional different for everyone. He claimed that his patients improved and eliminates the dissertation requirement. Applying Psychology: Critical and Creative ber of possible archetypes: they are as varied as human Thinking. Jung considered four archetypes, in particular, im- portant enough to form separate systems within the per- sonality. These include the persona, the anima and ani- Aptitude tests mus, the shadow, and the self. The persona is a person’s public image, the self he or she shows to others (“per- sona” is derived from the Latin word for mask). The per- See Vocational Aptitude Test sona is necessary for survival, as everyone must play cer- tain roles, both socially and professionally, to get along in society. A common problem occurs when a person comes to identify too strongly with the Archetype persona that he or she has created, a condition that Jung A central concept in the theory of personality de- called inflation. Yet, when hu- also distinguished by gender: the anima is a man’s femi- mans look at a photograph, they do so with expectations nine side, and the animus is a woman’s masculine side. We fill in the missing Jung theorized that in order for persons of both sexes to third dimension and account for other missing or incon- understand and respond to each other, each sex had to in- sistent images with our sense of what the real world corporate and be able to express elements of the other, a looks like. To program a computer to make those kinds belief that foreshadowed both the feminist and men’s of assumptions would be a gargantuan task. The human mind is capable of decod- source of spontaneity, creativity, and insight. However, rather computer is programmed to think in broader terms than ei- than combining all the other archetypes or aspects of ther/or and yes/no; expert systems, a group of program- personality, the Self has a dynamic all its own, which ming rules that describe a reasoning process allowing governs both inner harmony and harmony with the exter- computers to adapt and learn; data mining, detecting pat- nal world. It is closely related to the ability of human be- terns in stimuli and drawing conclusions from them; ge- ings to reach their highest potential, a process that Jung netic algorithm, a program that provides for random muta- called individuation, which he considered every person’s tion for the machine to improve itself; and several others. A Primer of Jungian agnoses and in looking for adverse interactions in patients Psychology. Reported in a 1995 article in Business Week, Hugo de Garis is leading a team of scientists to create a comput- ing system capable of reproducing itself. As Business Week reports, the project will attempt to “not only coax Artificial intelligence silicon circuits into giving birth to innate intelligence but imbue them with the power to design themselves—to con- Computer-based technology intended to replicate the complicated processes of human cognition, in- trol their own destiny by spawning new generations of cluding such complex tasks as reasoning, and ma- ever improving brains at electronic speeds. Art therapy can be a particularly useful treatment tool for children, who often have limited language and Chartrand, Sabra. Beyond its use in mental health treatment, art therapy is also employed as an adjunct (or complementary) thera- py to traditional medicine for the treatment of biologically based diseases and conditions. Art therapy has been used in the healing process to relieve Art therapy stress and develop coping mechanisms, in an effort to The use of art to express feelings, emotions, and treat both the physical and mental needs of the patient. Although art therapy has traditionally centered on visual mediums (paintings, sculptures, drawings, etc.

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Nursing administrators in service and academia Fourth purchase furosemide with mastercard, the theory of culture care is the only the- need to be active change leaders to use transcultural ory that searches for comprehensive and holistic nursing findings order furosemide 100mg with mastercard. Nursing faculty members need to care data relying on social structure generic furosemide 100 mg online, worldview, promote and teach ways to be effective with cul- and multiple factors in a culture in order to get a tures (Leininger, 1998). The theory is being used a lot to trism and racial biases and prejudices are being re- do culturalogical–health care assessments. Many nurses transcultural nursing concepts, findings, policies, also like to discover the differences and similarities and standards of care are being developed and used among cultures as it expands their worldviews and from findings (Leininger, 1991). Interdisciplinary deepens their appreciation of human beings of di- health personnel are finding the theory and trans- verse cultures. Learning to become immersed in a cultural nursing concepts and are finding help in culture has been a major benefit. This has been the most rewarding benefit of be used in any culture and at any time and with the theory. The consumer also likes the ethno- the theory slightly to fit their major and unique in- nursing method as they can “tell their story” and terest and goals of their discipline. Several disci- guide health researchers to discover the truths plines, including dentistry, medicine, social work, about their culture. Informants speak of being and pharmacy, are now using the culturally con- more comfortable with researchers. The goal for United States government and several theory encourages the researcher or clinician to dis- states. The concept is growing in use and will be- cover culture from the people and to let them be in come a global force. In general, the theory of culture care is a theory Tenth, nurse researchers who have been pre- of global interest and significance as we continue to pared in transcultural nursing and have used the understand cultures and their care needs and prac- theory and method commonly say things like, “I tices worldwide. It is the only theory that makes principles, theory, and findings must become fully sense to help cultures. They grow in ideas and enjoy incorporated into professional areas of teaching, discovering new knowledge of the lifeways of peo- practice, consultation, and research. Unques- Eleventh, nurses who have used the theory and tionably, the theory will continue to grow in rele- findings over time often speak of how much they vance and use as our world becomes more intensely have learned about themselves and about new cul- multicultural. Nurses dis- will be expected in the near future to function com- cover their ethnocentric tendencies as well as petently with diverse cultures. The findings are helpful to reduce with many transcultural nursing concepts, princi- cultural biases and prejudices that influence quality ples, and research findings, will be used. This was the first research method de- of Leininger’s signed to study a nursing theory and related nurs- ing phenomena. The method facilitates the discovery of people care knowledge and culturally Theory of based care related to the theory. Leininger has Leininger has defined the ethnonursing re- Culture Care search method as “a qualitative research method using naturalistic, open discovery, and largely inductively derived emic modes Diversity and and processes with diverse strategies, tech- niques, and enabling tools to document, describe, understand, and interpret the Universality people’s meanings, experience, symbols, and other related aspects bearing on Marilyn R. Qualitative Paradigm and Quantitative Paradigm The purpose of the second part of Chapter 20 is In order to understand the qualitative ethnonurs- twofold. The first part will include an overview of ing research method, it is important to understand the ethnonursing research method, which was de- the major philosophical differences between the signed to study the Theory of Culture Care qualitative and quantitative paradigms. The second part will has described qualitative paradigmatic research as present a discussion of the implications of the cul- “characterized by naturalistic and open inquiry ture care theory and related ethnonursing research methods and techniques focused on systematically findings for clinical nursing practice. Many nursing documenting, analyzing, and interpreting attri- theories are rather abstract and do not focus on butes, patterns, characteristics, and meanings of how practicing nurses might use the research find- specific domains and gestaltic (or holistic) features ings related to a theory. However, with the Culture of phenomena under study within designated Care Theory, along with the ethnonursing method, environmental or living contexts” (Leininger, 1997, there is a purposeful built-in means to discover and p. She has described quantitative research as confirm data with informants in order to make “characterized by a focus on an empirical and ob- nursing actions and decisions meaningful and jective analysis of discrete and preselected variables culturally congruent (Leininger, 2002). In viewpoints of human care, well-being, health, and qualitative research there is no control of inform- environmental contexts. The terms emic and etic ant’s ideas or manipulation of data or variables by were important concepts chosen for foci with the the researcher; open inquiry prevails to obtain data ethnonursing method. Ethnonursing focuses directly and naturally from informants in their own largely on the importance of emic (insiders’ or local homes, communities, or other natural environ- peoples’) views but does not neglect etic (the non- mental contexts. In contrast, in quantitative re- local or outsiders’) views to obtain a holistic view. Leininger has stated that the quantitative on their ideas and experiences with care but also and qualitative paradigms should not be mixed, as gathered etic data focused on the professional per- they violate the philosophy, purposes, and integrity spectives of the nursing staff (McFarland, 1997). The ethnonursing method is a The culture care theory has been developed to be unique and essential qualitative method to study congruent with the ethnonursing method and re- caring and healing practices, beliefs, and values in quires the researcher to move into familiar and nat- diverse cultural and environmental contexts and is uralistic people settings to discover human care and a major holistic method specifically designed to fit the related nursing phenomena of health (well- the culture care theory. Purpose and Philosophical Features Domain of Inquiry Leininger developed the ethnonursing research method from a nursing and cultural care perspec- A domain of inquiry is the major focus of the ethno- tive to discover largely unknown phenomena held nursing researcher’s interests. With the ethnonursing understanding and meaning of the people’s daily method, problem statements are not used because a life experiences related to human care, health, and researcher does not know whether there is a people well-being in different or similar environmental problem or more of a researcher’s problem of se- contexts” (Leininger, 1991b, p. The central pur- lected (and possibly biased) views of the people pose of the ethnonursing research method is “to es- (Leininger, 1997). For example, some domains of tablish a naturalistic and largely emic open inquiry inquiry in ethnonursing studies using the culture method to explicate and study nursing phenomena care theory have been: the care meanings and expe- especially related to the Theory of Cultural Care riences of Lebanese Muslims living in the United Diversity and Universality” (Leininger, 1991b, p. The term ethnonursing was purposefully coined the cultural care of elderly Anglo and African for this method. The prefix ethno comes from the American residents within the environmental con- Greek word ethos and refers “to the people,” while text of a long-term care institution (McFarland, the suffix nursing is essential to focus the research 1997); and the care of Mexican American women on the phenomena of nursing, particularly human during pregnancy (Berry, 1999). The ethnonursing research method has philo- Key and general informants are important in the sophical and research features that fit well with the ethnonursing research method. Philosophically, the ethnonurs- this method does not have subjects but works with ing method has been grounded with the people informants. In an ethnonursing study of the culture (Leininger, 1991b) and has supported the discovery care of Anglo and African American elderly resi- of people truths in human living contexts dents of a retirement home, the researcher worked (Leininger, 1988). The formants told the researcher about themselves and sunrise enabler (see Part 1 of this chapter by Dr.