Compare propecia prices ukIntroduction and philosophical backgroundWork should i start propecia in the medical compare propecia prices uk humanities has noted the importance of the âÂÂmedical gazeâ and how it may âÂÂseeâ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge. To diagnosis. And to the social position of the medical profession.1 Some authors compare propecia prices uk have emphasised that vision is a distinctive modality of perception which merits its own consideration, and which may have a particular role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived. For example, commentary in this journal on the âÂÂwhite coatâ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to consider how patientsâ compare propecia prices uk clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the âÂÂmedical gazeâ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs. Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often drawn compare propecia prices uk between more reliable or less reliable knowledge. And between knowledge that is more technical or âÂÂobjectiveâÂÂ, and knowledge that is more emotionally based or more âÂÂsubjectiveâÂÂ. A frequent point of discussion is the reliability and characteristics of perception as a source of knowledge compare propecia prices uk. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the very essence of an ethical response to the world to recognise compare propecia prices uk the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways. The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchristâÂÂs The Master and His Emissary,10 where he draws on compare propecia prices uk neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchristâÂÂs arguments as well as much support. We find his work a useful compare propecia prices uk framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff to patients. In particular, it helps to illuminate the consequences of patientsâ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in compare propecia prices uk the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on GoffmanâÂÂs work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues GoffmanâÂÂs interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or compare propecia prices uk dementia, and so conversely, attention to appearance is one way of combatting the stigma associated with dementia. Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, compare propecia prices uk while also constraining and enabling elements of care within long-term community settings.16âÂÂ19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance. The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20âÂÂ22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontosâ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that compare propecia prices uk examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et alâÂÂs work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a âÂÂcertainâ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function. Its use may therefore perhaps incline us towards a âÂÂtask-basedâ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of peopleâÂÂs actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these compare propecia prices uk clinical settings that are capable of âÂÂcommunicating many messages at once, even of subverting on one level what it appears to be âÂÂsayingâ on anotherâÂÂ.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from compare propecia prices uk within each institution on the everyday work of hospital wards, their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission. It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the âÂÂanalytic incisivenessâÂÂ35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent compare propecia prices uk a range of hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital. This included one compare propecia prices uk urban, two inner city and two hospitals covering a mix of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within trauma compare propecia prices uk and orthopaedic wards (80 days) and medical assessment units (MAU. 75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, each working in clusters of 2âÂÂ4 days over a 6-week period compare propecia prices uk at each site. A single day of observation could last a minimum of 2âÂÂhours and a maximum of 12âÂÂhours. A total of 684âÂÂhours of observation were conducted for this study. This produced compare propecia prices uk approximately 600âÂÂ000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient compare propecia prices uk records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was compare propecia prices uk this advisory group that informed us of the need of a better understanding of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study. The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory compare propecia prices uk group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from our wider analysis of our ethnographic study examining ward cultures of care compare propecia prices uk and the experiences of people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to compare propecia prices uk dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing compare propecia prices uk of institutional clothing was typically connected to fewer personal items on display or within reach of the patient, with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of âÂÂget well soonâ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of patients on a compare propecia prices uk wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more âÂÂvisibleâ to staff than others. It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, and the resulting attention received favourably by the patient.A member of compare propecia prices uk the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, âÂÂWow, look at you!. àThe patient looked pleased as she sat and combed her hair [site 3âÂÂday 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly âÂÂinvisibleâÂÂ. Here, the ethnographer is observing a four-bed bay occupied by male patients living compare propecia prices uk with dementia.The man in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy team come compare propecia prices uk and see him. The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that sheâÂÂll be back later to see him again. The nurse checks on him, asks him if he compare propecia prices uk wants a pillow, and puts it behind his head explaining to him, âÂÂYou need to sit in the chair for a bitâÂÂ. She pulls his bedside trolley near to him. With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for him, and puts a blanket compare propecia prices uk over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, âÂÂThe problem is this is a really unstimulating environmentâÂÂ, then says to the patient, âÂÂAll done, letâÂÂs have a bit of a tidy up,â before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes compare propecia prices uk are open, and he is looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains. He says he doesnâÂÂt want to compare propecia prices uk sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat. The man in compare propecia prices uk bed 19 quietly sings along to the songs. ÃÂÂI am going to see my baby when I go home on victory dayâ¦âÂÂAt ten thirty, the nurse goes off on her break. The rest of the team are spread around the other bays compare propecia prices uk and side rooms. There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping his feet to the compare propecia prices uk music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents. There is a lot of paperwork in it which he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down compare propecia prices uk the chair. His head is in his hands and he suddenly looks in pain. He hasnâÂÂt compare propecia prices uk touched his tea, and is talking to himself. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasnâÂÂt come back. 18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages compare propecia prices uk to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off. It feels like a jolt to the room. She turns and looks at compare propecia prices uk me and says, âÂÂSorry were you listening to it?. àI tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have all stopped tapping their toes and stopped compare propecia prices uk singing along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it is turned back compare propecia prices uk on everyone starts tapping their toes again. The music plays on. ÃÂÂThereâÂÂll be bluebirds over the white cliffs of Dover, just you wait and seeâ¦âÂÂ[Site 3âÂÂday 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to compare propecia prices uk her awareness. Only an individual of âÂÂhigherâ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the general question of the visibility or otherwise compare propecia prices uk of patients. Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the compare propecia prices uk example below, a mother and two adult daughters visit the father of the family, who is not visible to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks very different following his admissionâÂÂhe has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hueâÂÂit is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head compare propecia prices uk is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. ÃÂÂI am like a bird I want to fly awayâ¦â plays softly in the radio in the bay. I sit with them for a bit and compare propecia prices uk we chatâÂÂhis wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it will be close because compare propecia prices uk she does not drive. He isnâÂÂt wearing his glasses and his daughter tells me that they canâÂÂt find them. We look in the bedside cabinet. She has compare propecia prices uk never seen her dad without his glasses. ÃÂÂHe doesnâÂÂt look like my dad without his glassesâ [Site 2âÂÂday 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members. Missing glasses and missing teeth were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patientâÂÂs identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of compare propecia prices uk distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence facilitates the subject of the compare propecia prices uk gaze, in gazing back, and hence helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved onesâ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing. Some older patients were clearly able to verbalise their understandings of the impacts of wearing institutional clothing. One patient compare propecia prices uk remarked to a nurse of her hospital blue tracksuit. ÃÂÂI look like an Olympian or Wentworth prison in this outfit!. The latter I expectâ¦â The staff laughed as they walked her out of the bay (site 3âÂÂday 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally. Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large compare propecia prices uk institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with his very low-necked top even when his lunch compare propecia prices uk tray was placed in front of him. He clearly felt very uncomfortable with such clothing. He continued using his hands to try to pull it up to cover his exposed chest, during and after the meal was finished (site 3âÂÂday 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to compare propecia prices uk this ward became tearful and upset after having a shower. She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.âÂÂI want my trousers, where is my bra, IâÂÂve got no bra on.â It is clear she doesnâÂÂt feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, âÂÂYour bra is dirty, do you want to wear that?. àShe replies, âÂÂNo I want compare propecia prices uk a clean one. Where are my trousers?. I want them, IâÂÂve lost them.â The healthcare assistant repeats compare propecia prices uk the explaination that her clothes are dirty, and asks her, âÂÂDo you want your dirty ones?. àShe is very teary âÂÂNo, I want my clean ones.â The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says âÂÂHelloâ to her. She is very teary and explains that she has lost her clothes. The cleaner listens sympathetically as compare propecia prices uk she continues âÂÂI am all confused. I have lost my clothes. I am all confused. How am I going compare propecia prices uk to go to the shops with no clothes on!. à(site 5âÂÂday 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may solidify staff perceptions compare propecia prices uk of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her own familiar clothing contributes significantly to her distress and disorientation. Others have argued that people with limited verbal capacity and limited cognitive comprehension will have compare propecia prices uk a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an âÂÂoptional extraâÂÂ. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of the role of personal grooming. Personal grooming was notable by its absence beyond the necessary cleaning required compare propecia prices uk for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out âÂÂself-careâ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an compare propecia prices uk acute ward. Kontosâ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates to a wider group. In Kontosâ findings, these rituals and standards compare propecia prices uk of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can impact on peopleâÂÂs appearance in ways that may mark them out as failing to achieve accepted standards of embodied personhood. The task-oriented timetabling of mealtimes may have compare propecia prices uk significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to âÂÂfeedâ a person living with dementia, when she gives up and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says âÂÂnoâÂÂ), compare propecia prices uk remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant. It signifies a task-based apparel that is demeaning to an individualâÂÂs social status. This example also contrasts poignantly with examples from Kontosâ work,20 such as that of a female who had little or no ability to compare propecia prices uk verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the âÂÂrightâ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes âÂÂplaced her hand on her chest, to prevent her blouse from touching the food as she leaned over her plateâÂÂ.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we found the âÂÂMatthew effectâ to be frequently in operation. To those who have the least, even that compare propecia prices uk which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for âÂÂlounge viewâ where visitors would see them, using residents to âÂÂcreate a visual product for othersâ sometimes to the detriment of residentsâ needs. Our observations regarding the compare propecia prices uk importance of patient appearance must therefore be considered as part of the care of the whole person and a significant feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been compare propecia prices uk observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white coats were not to be found, the dress code of medical staff did make them stand out. For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed compare propecia prices uk high levels of behaviour perceived by ward staff as people living with dementia displaying âÂÂresistanceâ to care.50 This included âÂÂresistanceâ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not see any patients removing their own clothing compare propecia prices uk. This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often interpreted by ward staff as a patientâÂÂs âÂÂresistanceâ to care. There was compare propecia prices uk some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA. The act of removal was typically interpreted by ward staff as representing compare propecia prices uk a feature of the personâÂÂs dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to further cycles of removal and replacement, leading to an escalation of distress in the person. This was important, because the recording of âÂÂrefusal of careâÂÂ, or presumed âÂÂconfusionâ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a compare propecia prices uk woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husbandâÂÂs stroke, he could no longer care for her). Across the previous evening and morning shift, she was shouting, refusing all food and care and has received assistance from the specialist dementia care worker. However, during this shift, she has become calmer following a visit from her compare propecia prices uk husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2âÂÂhours. When she does talk, she is very loud and high pitched, but this is normal for her and not a sign of distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is âÂÂon suicide watchâ and another is âÂÂrefusing their medicationâ (but compare propecia prices uk does not have a diagnosis of dementia). At 15:10 patient 1 begins to remove her sheets:15:10. The unit compare propecia prices uk seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still has not been brought more milk, which she requested from the HCA an hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff compare propecia prices uk do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge says, âÂÂHello,â when she walks past 1âÂÂs bed. 1 looks across and compare propecia prices uk smiles back at her. The nurse in charge explains to her that she needs to shuffle up the bed. 1 asks the nurse about compare propecia prices uk her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow. 1 says that he hasnâÂÂt been and she does not believe the nurse.15:25. I overhear compare propecia prices uk the nurse in charge question, under her breath to herself, âÂÂWhy 1 has been left on the unit?. à1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some jobs first and then will come and talk to her.15:30. 1 has once again compare propecia prices uk kicked her sheets off of her legs. A social worker comes onto the unit. 1 shouts, âÂÂExcuse meâ compare propecia prices uk to her. The social worker replies, âÂÂSorry IâÂÂm not staff, I donâÂÂt work hereâ and leaves the bay.15:40. 1 keeps kicking sheets off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes compare propecia prices uk her bed, which is whenever anyone comes through the unitâÂÂs door. 1 is the only elderly patient on the unit. Again, the nurse in charge is heard sympathizing that this is not the right place for her.16:30. A doctor approaches 1, tells her that she is on her compare propecia prices uk list of people to say hello to, she is quite friendly. 1 tells her that she has been here for 3 days, (the rest is inaudible because of pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses compare propecia prices uk this. The doctor responds by ending the interaction, âÂÂSee you laterâÂÂ, and leaves the unit.16:40. 1 attempts to talk to the new nurse assigned to the unit. She goes compare propecia prices uk over to 1 and says, âÂÂWhatâÂÂs up my darling?. àItâÂÂs hard to follow 1 now as she sounds very upset. The RNâÂÂs first instinct, like with the doctor and the nurse in charge, is to cover up 1âÂÂs legs with her bed sheet. When 1 reacts to this she talks to her and they agree to cover up compare propecia prices uk her knees. 1 is talking about how her husband wonâÂÂt come and visit her, and still sounds really upset about this. [Site 3, compare propecia prices uk Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure. In the compare propecia prices uk example given above, the actions were linked to the patientâÂÂs resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as âÂÂundressingâÂÂ, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So âÂÂdeviantâ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state compare propecia prices uk of undress, typically exposed from behind by their hospital gowns. This exposure in itself is of course, an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed in. This task-based compare propecia prices uk clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and BuseâÂÂs work16âÂÂ19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings. Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and compare propecia prices uk specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchristâÂÂs work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs. Focus on efficiency, pace and record keeping that measures individual task completion within a timetable of care may worsen all these effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself compare propecia prices uk be little more than a âÂÂtaskâ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearanceâÂÂself-perception and perception by othersâÂÂmay be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as âÂÂresisting careâ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patientâÂÂs alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient compare propecia prices uk. Other work has also shown how older people, and in particular people living with dementia, may be thought to be beyond concern for appearance, yet this does not accurately reflect the importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others compare propecia prices uk such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered âÂÂdignitasâ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a way of facilitating the treatment by others of a person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available. Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding compare propecia prices uk support from the NIHR.Notes1. Devan Stahl (2013). ÃÂÂLiving into the imagined body. How the diagnostic image confronts the lived body.â Medical Humanities compare propecia prices uk. Medhum-2012âÂÂ010286.2. Joyce Zazulak compare propecia prices uk et al. (2017). "The art of medicine. Arts-based training in observation and mindfulness for compare propecia prices uk fostering the empathic response in medical residents.â Medical Humanities. Medhum-2016-011180.3. E Forde (2018). "Using photography compare propecia prices uk to enhance GP traineesâ reflective practice and professional development." Medical Humanities. Medhum-2017-011203.4. Caroline Wellbery compare propecia prices uk and Melissa Chan (2014) âÂÂWhite coat, patient gown.â Medical Humanities. Medhum-2013âÂÂ0âÂÂ10âÂÂ463.5. E Goffman (1990a). Stigma. Notes on the management of spoiled identity, Penguin.6. J Bridges and C Wilkinson (2011). ÃÂÂAchieving dignity for older people with dementia in hospital.â Nursing Standard 5 (29).7. J Dancy (1985). Contemporary Epistemology, John Wiley and Sons.8. D McNaughton (1988). Moral Vision. Blackwell.9. S Weil (1953). Gravity and Grace. U of Nebraska Press.10. I McGilchrist (2009). The Master and his Emissary. The divided brain and the making of the western world. New Haven and London, Yale University Press.11. Iain McGilchrist (2011). ÃÂÂPaying attention to the bipartite brain.â The Lancet 377 (9771). 1068âÂÂ1069.12. Efrat Tseëlon (1992). ÃÂÂSelf presentation through appearance. A manipulative vs a dramaturgical approachâÂÂ. Symbolic Interaction, 15(4). 501âÂÂ514.13. E Tseëlon (1995). The masque of femininity. The presentation of woman in everyday life. London. Sage.14. E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001). ÃÂÂFashion research and its discontentsâÂÂ. Fashion Theory, 5 (4). 435âÂÂ451.16. Julia Twigg (2010a). ÃÂÂClothing and dementia. A neglected dimension?. àJournal of Ageing Studies 24(4). 223âÂÂ230.17. Julia Twigg and Christina E Buse (2013). ÃÂÂDress, dementia and the embodiment of identity.â Dementia 12(3). 326âÂÂ336.18. C. E Buse and J. Twigg (2015). ÃÂÂClothing, embodied identity and dementia. Maintaining the self through dress.â Age, Culture, Humanities (2).19. Christina Buse and Julia Twigg (2018). ÃÂÂDressing disrupted. Negotiating care through the materiality of dress in the context of dementia.â Sociology of Health &. Illness, 40(2). 340-352.20. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &. Society, 24(6). 829âÂÂ849.21. P. C Kontos (2005). ÃÂÂEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.â Dementia 4 (4). 553âÂÂ570.22. P. C Kontos and G. Naglie (2007). ÃÂÂBridging theory and practice. Imagination, the body, and person-centred dementia care.â Dementia 6 (4). 549âÂÂ569.23. Richard Ward et al. (2016a). ÃÂÂâÂÂGonna make yer gorgeousâÂÂ. Everyday transformation, resistance and belonging in the care-based hair salon.â Dementia, 15(3). 395âÂÂ413.24. Richard Ward, Sarah Campbell, and John Keady (2016b). ÃÂÂAssembling the salon. Learning from alternative forms of body work in dementia care.â Sociology of Health &. Illness, 38(8). 1287âÂÂ1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012). Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1). 49âÂÂ59.26. Päivi Topo and Sonja Iltanen-Tähkävuori (2010). ÃÂÂScripting patienthood with patient clothing.â Social Science &. Medicine, 70(11). 1682âÂÂ1689.27. Julia Twigg (2010b). ÃÂÂWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-TähkävuoriâÂÂ. Social Science and Medicine, 70(11), 1690âÂÂ1692.28. Kathleen Woodward (2006). ÃÂÂPerforming age, performing genderâ National WomenâÂÂs Studies Association (NWSA) Journal 18(1). 162âÂÂ89.29. K.M Woodward (1999). Introduction. In K.M. Woodward (ed.), Figuring Age. Women, Bodies and Generations (pp. Ix-xxix). Bloomington. Indiana University Press.30. M Hammersley and P Atkinson (1989). Ethnography. Principles in practice. London. Routledge.31. V. J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks. A mixed-method strategy. Research in the Schools, 13(1). 84âÂÂ92.32. W Housley and P Atkinson (2003). Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London. Routledge34. V Turner and E Bruner (1986). The Anthropology of Experience New York. PAJ Publications. 2435. K Charmaz and RG Mitchell (2001). ÃÂÂGrounded theory in ethnographyâ in Atkinson P. (Ed) Handbook of Ethnography, 2001. 160-174. Sage. London36. B Glaser and A Strauss (1967). The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25). 288âÂÂ30437. Juliet M. Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria. Qual. Commentary. Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39. Roy Suddaby (2006). ÃÂÂFrom the editors. What grounded theory is not.â Academy of management journal, 49(4). 633âÂÂ642.40. Elizabeth L Sampson et al. (2009). ÃÂÂDementia in the acute hospital. Prospective cohort study of prevalence and mortalityâÂÂ. British Journal of Psychiatry,195(1). 61âÂÂ66. Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012). ÃÂÂPeople with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admissionâÂÂ. Z. Gerontol. Geriatr. 45. 728âÂÂ734.42. Robert E Herriott and William A. Firestone (1983) âÂÂMultisite qualitative policy research. Optimising description and generalizabilityâÂÂ. Education Research 12:14âÂÂ1943. F Vogt (2002). ÃÂÂNo ethnography without comparison. The methodological significance of comparison in ethnographic researchâ Studies in Education Ethnography 6:23âÂÂ4244. Benjamin Saunders et al. (2018). ÃÂÂSaturation in qualitative research. Exploring its conceptualization and operationalization.â Quality and Quantity 52 (4). 1893âÂÂ1907.45. A Coffey and P Atkinson (1996). Making sense of qualitative data. Complementary research strategies. Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018). ÃÂÂThe canary in the coal mine. Continence care for people with dementia in acute hospital wards as a crisis of dehumanisationâÂÂ. Bioethics, 32(4). 251âÂÂ260.47. Christina Buse et al. (2014). ÃÂÂLooking âÂÂout of placeâÂÂ. Analysing the spatial and symbolic meanings of dementia care settings through dress.â International Journal of Ageing and Later Life 9 (1). 69âÂÂ95.48. R. K. Merton (1968). ÃÂÂThe Matthew effect in science. The reward and communication systems of science are considered.â Science 159 (3810). 56âÂÂ63.49. Geraldine Lee-Treweek (1997) âÂÂWomen, resistance and care. An ethnographic study of nursing auxiliary workâ Work, Employment and Society, 11(1). 47âÂÂ6350. Katie Featherstone et al. (2019b). ÃÂÂRefusal and resistance to care by people living with dementia being cared for within acute hospital wards. An ethnographic studyâ Health Service and Delivery Research51. Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). ÃÂÂRoutines of resistance. An ethnography of the care of people living with dementia in acute hospital wards and its consequences.â International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020). ÃÂÂUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?. àNarrative Inquiry in Bioethics53. Jeannette Pols (2013). ÃÂÂWashing the patient. Dignity and aesthetic values in nursing careâ Nursing Philosophy, 14(3). 186âÂÂ200. Does propecia work better than finasteride
Latest hair loss News By Ernie Mundell and http://www.tpsmedical.co.uk/cool-jewels-slots/ Robin does propecia work better than finasteride Foster HealthDay ReportersTHURSDAY, Aug. 5, 2021 (HealthDay News) Moderna Inc. Announced on Thursday that the potency of its treatment does not does propecia work better than finasteride dim in the first six months after the second dose. The news came in a statement that contained little actual data, but the findings may comfort the 63 million Americans who have received two doses of the Moderna treatment as the highly contagious Delta variant rips through swaths of the country where vaccination rates are low. Moderna's report came from a new analysis of its ongoing clinical trial, which started in late July 2020 and recruited 30,000 volunteers. Last November, the company does propecia work better than finasteride announced that the treatment had an impressive efficacy of 94.1 percent. That effectiveness didn't drop much after six months, the company reported Thursday. "We are pleased that our hair loss treatment is showing durable efficacy of 93 percent through six months, but recognize that the Delta variant is a significant new threat so we must remain vigilant," Moderna CEO Stéphane Bancel said in the statement. However, it wasn't clear whether the trial data extended into more recent months when the does propecia work better than finasteride Delta variant became dominant, the Times reported. In June, Moderna detailed an experiment in which its researchers tested antibodies from people who received their treatment against the Delta variant. They found the antibodies were moderately less effective at blocking the variant from does propecia work better than finasteride infecting cells. Last week, Pfizer reported that its treatment's durability also held up after six months. The treatment's efficacy started at 96.2% for the first two months after the second dose, and dropped to 83.7 percent at six months. The FDA is expected to does propecia work better than finasteride give full approval to the Pfizer treatment in September. Moderna filed for final approval of its treatment on June 1, and expects to complete its submission in August, the Times reported. Moderna said in its statement Thursday that in lab experiments of human blood cells, booster shots increased the number of hair loss antibodies, suggesting that if its treatment does weaken in future months, a booster would shore up protection. Moderna's clinical does propecia work better than finasteride trials have also shown robust antibody responses after booster shots, the company added. Full approval of Pfizer treatment could come in September The U.S. Food and Drug Administration is speeding up its timetable for full approval of the Pfizer hair loss treatment, hoping to complete the process by early September. President Joe Biden said last week that he expected a fully approved does propecia work better than finasteride treatment in early fall, but the FDA's unofficial deadline is Labor Day or sooner, according to multiple people familiar with the plan, The New York Times reported. The agency said in a statement that its leaders recognized that full approval might counter treatment hesitancy and had "taken an all-hands-on-deck approach" to completing full approval. The move could help boost vaccination rates at a moment when the highly transmissible Delta variant is does propecia work better than finasteride driving up the number of new cases across the country. A number of universities and hospitals, the Defense Department and at least one major city, San Francisco, are expected to mandate treatments once one is fully approved. Final approval could help clarify legal issues about mandates, the Times reported. Federal regulators have been under growing public pressure does propecia work better than finasteride to fully approve Pfizer's treatment ever since the company filed its application on May 7. "I just have not sensed a sense of urgency from the FDA on full approval," Dr. Ashish Jha, dean of the Brown University School of Public Health in Rhode Island, told the Times on Tuesday. "And I does propecia work better than finasteride find it baffling, given where we are as a country in terms of s, hospitalizations and deaths." Moderna, the second most widely used treatment in the United States, filed for final approval of its treatment on June 1. But the company is still submitting data and has not said when it will finish, the Times reported. Johnson & does propecia work better than finasteride. Johnson, the third treatment authorized for emergency use, has not yet applied for full approval, but plans to do so later this year. Although 192 million Americans â 58 percent of the total population and 70 percent of the nation's adults â have received at least one shot, many Americans remain vulnerable, data from the U.S Centers for Disease Control and Prevention show. The country is averaging nearly 86,000 new does propecia work better than finasteride s a day, an increase of 142 percent in just two weeks, according to a Times database. Full approval for a treatment typically requires the FDA to review hundreds of thousands of pages of documents â roughly 10 times the data required to authorize a treatment on an emergency basis. The agency can usually complete a priority review within six to eight months and was already working on an expedited timetable for the Pfizer treatment, the Times reported. What are regulators does propecia work better than finasteride looking for?. They want to see real-world data on how the treatment has been working since they authorized it for emergency use in December, the Times reported. That means verifying the company's data on treatment efficacy and immune responses, reviewing how efficacy or immunity might wane, examining new s in clinical trial participants, reviewing adverse reactions and inspecting manufacturing plants. Officials have said the government is also tracking does propecia work better than finasteride breakthrough s among tens of thousands of vaccinated people. At the same time, senior officials at the FDA and other agencies are debating whether at least some people who are already vaccinated will need booster shots. Senior administration officials does propecia work better than finasteride increasingly believe that vulnerable populations like those with compromised immune systems and older people will need them, the Times reported. A decision to fully approve Pfizer's treatment will give doctors more freedom to prescribe additional shots for certain Americans, including those with weakened immune systems, the Times reported. Roughly 3 percent of Americans â or about 10 million people â have compromised immune systems as a result of cancer, organ transplants or other medical conditions, according to the CDC. While studies indicate that the treatments work well for some, other people does propecia work better than finasteride do not produce enough of an immune response to protect them from the actual propecia. More information The U.S. Centers for Disease Control and Prevention has more on hair loss treatment. SOURCES. The New York Times. Associated Press Copyright é 2021 HealthDay. All rights reserved.Latest hair loss News THURSDAY, Aug. 5, 2021 (HealthDay News) The United States' largest operator of nursing homes said Wednesday that its workers must get vaccinated against hair loss treatment if they want to keep their jobs. The announcement from Pennsylvania-based Genesis Healthcare -- which has 70,000 employees at nearly 400 nursing homes and senior communities -- suggests the nursing home industry's reluctance to force employees to get vaccinated due to fears about losing too many workers may be shifting, the Associated Press reported. Understaffing is a major problem in the sector, but concerns about the surging Delta variant may convince nursing home owners they need to take action to quickly vaccinate the 40% of employees who still haven't received shots. Voluntary vaccination was appropriate earlier in the propecia, but only 65% of Genesis staff have received shots, according to the company. Employees have until Aug. 23 to get their first shot. "To succeed against the Delta variant is going to require much higher vaccination rates," Genesis Chief Medical Officer Richard Feifer told the AP. "Our tactics in the fight have to change." Unvaccinated staff members endanger residents, warn experts who are calling for mandatory vaccinations at nursing http://half-witpoet.com/?p=19 homes. Some workers have avoided the treatment because they think it was rushed into development and is unsafe, or they feel protected because they already had a bout of hair loss treatment, the AP reported. About 80% of nursing home residents have been vaccinated, but even vaccinated residents are at risk because many are frail and have weak immune systems, the AP reported. More than 130,000 U.S. Nursing home residents have died from hair loss treatment, according to the AP. Jennifer Moore, of Hollywood, Fla., has a husband living at a nursing home where only 35% of the staff is vaccinated. "Whenever I see a story about somebody being anti-vax, I just want to scream," said Moore, whose husband, Thomas, has Parkinson's disease. "I understand people have concerns about the treatment, but these people are working with the most vulnerable population. They have a duty to their patients." More information Visit the U.S. Centers for Disease Control and Prevention for more on hair loss treatments. SOURCE. Associated Press Robert Preidt and Robin Foster Copyright é 2021 HealthDay. All rights reserved.Latest hair loss News THURSDAY, Aug. 9, 2021 (HealthDay News) hair loss treatment hospitalizations in Florida reached a new high this week, the Florida Hospital Association (FHA) says. Hospitalizations are 13% higher than the previous peak on July 23, 2020, and 60% of the state's hospitals are expected to face a "critical staffing shortage" in the next seven days, the association said Tuesday, CNN reported. Currently, there are 11,515 hospitalized hair loss treatment patients, and 84% of in-patient beds and 86.5% of ICU beds in the state are occupied, according to the FHA. It said that 21% of hospitalized hair loss treatment patients are in the ICU and 13% are on ventilators, CNN reported. The FHA figures are from a survey of hospitals that was completed Aug. 2 and represents 82% of the state's acute care hospitals. "Current hospitalizations and the growth rate continue to be extremely troubling," Mary Mayhew, president and CEO of the Florida Hospital Association, said in a statement. "But treatments work!. The fact that less than 3% of current hospitalizations arrived from nursing homes and long-term care facilities shows the state's focus on vaccinating and protecting Florida's seniors and most vulnerable has worked." Just two states -- Florida and Texas -- accounted for one-third of all hair loss treatment cases reported in the United States in the past week, White House hair loss treatment response coordinator Jeff Zients said during a briefing Monday, CNN reported. More information Visit the U.S. Centers for Disease Control and Prevention for more on hair loss treatment hospitalizations across the country. SOURCE. CNN Robert Preidt and Robin Foster Copyright é 2021 HealthDay. All rights reserved.Latest Senior Health News By Dennis Thompson HealthDay ReporterTHURSDAY, Aug. 5, 2021 (HealthDay News) Scientists suspect that a century-old tuberculosis treatment might be able to protect older adults against the worst ravages of hair loss treatment. The Bacillus Calmette-Guérin (BCG) treatment was first used 1921, and is on the World Health Organization's list of essential medicines. More than 130 million babies worldwide receive this treatment every year. But it also is known to calm the immune system, and new research shows that the treatment might specifically blunt the severe inflammatory response that does so much damage to the body during a hair loss treatment . "Typically, older people are more susceptible to severe hair loss treatment due to their ability to make exuberant inflammatory responses," said senior researcher Dr. Subash Babu, scientific director of the National Institute for Research in Tuberculosis in Chennai, India. "Therefore, BCG might be useful by lowering this propensity." The BCG treatment already is used to modulate people's immune reaction in other diseases, most notably bladder cancer, said Dr. Waleed Javaid, director of prevention and control at Mount Sinai Downtown in New York City. Health experts in some nations with high hair loss treatment rates and little access to hair loss treatments have considered using BCG as a stopgap measure to protect older adults, researchers said in background notes. But, they said, there have been concerns that the BCG treatment might actually increase older folks' inflammation response and worsen their hair loss treatment . In this study, researchers gave the BCG treatment to 82 healthy people between 60 and 80 years old. A month after vaccination, they found decreases in biochemicals linked to inflammation. Researchers also observed a decrease in enzymes that crop up during lung inflammation, which suggested that BCG might limit lung damage during hair loss treatment . "BCG can potentially be useful as an adjuvant treatment to the hair loss-specific treatments, and it needs to be tested for its ability to function as a therapeutic treatment" that could be given as a treatment during , Babu said. "BCG is safe and well tolerated, and widely available -- it is the most widely used treatment in the world," he said. But things aren't as cut and dried as all that, said Mount Sinai's Javaid, warning that no one should mistake the BCG treatment as an alternative form of protection against hair loss treatment. This new study didn't include a single hair loss treatment patient, and so it didn't directly test the BCG treatment's effectiveness at all against the new hair loss, said Javaid, who had no role in the new research. "This cannot be an alternate in any way to the hair loss treatment. This cannot be used as a stopgap," he said. "What we see here is that it does suppress some of the immune indicators that are otherwise active during hair loss treatment , and we know that during hair loss treatment part of the damage done to our body is because of our immune reaction," Javaid continued. "A lot of studies need to be done to prove or disprove these effects." The concept is good in theory, he concluded, "but it still needs to be proven more concretely." The findings were published Aug. 4 in the journal Science Advances. More information The U.S. Centers for Disease Control and Prevention has more about the BCG treatment. SOURCES. Subash Babu, MBBS, PhD, scientific director, National Institute for Research in Tuberculosis, Chennai, India. Waleed Javaid, MD, director, prevention and control, Mount Sinai Downtown, New York City. Science Advances, Aug. 4, 2021 Copyright é 2021 HealthDay. All rights reserved.. Latest hair loss News why not check here By Ernie Mundell and Robin compare propecia prices uk Foster HealthDay ReportersTHURSDAY, Aug. 5, 2021 (HealthDay News) Moderna Inc. Announced on Thursday that compare propecia prices uk the potency of its treatment does not dim in the first six months after the second dose. The news came in a statement that contained little actual data, but the findings may comfort the 63 million Americans who have received two doses of the Moderna treatment as the highly contagious Delta variant rips through swaths of the country where vaccination rates are low. Moderna's report came from a new analysis of its ongoing clinical trial, which started in late July 2020 and recruited 30,000 volunteers. Last November, the company compare propecia prices uk announced that the treatment had an impressive efficacy of 94.1 percent. That effectiveness didn't drop much after six months, the company reported Thursday. "We are pleased that our hair loss treatment is showing durable efficacy of 93 percent through six months, but recognize that the Delta variant is a significant new threat so we must remain vigilant," Moderna CEO Stéphane Bancel said in the statement. However, it wasn't clear whether the trial data extended into more recent months when the Delta variant became dominant, compare propecia prices uk the Times reported. In June, Moderna detailed an experiment in which its researchers tested antibodies from people who received their treatment against the Delta variant. They found the antibodies compare propecia prices uk were moderately less effective at blocking the variant from infecting cells. Last week, Pfizer reported that its treatment's durability also held up after six months. The treatment's efficacy started at 96.2% for the first two months after the second dose, and dropped to 83.7 percent at six months. The FDA is expected to give full approval to the Pfizer treatment in compare propecia prices uk September. Moderna filed for final approval of its treatment on June 1, and expects to complete its submission in August, the Times reported. Moderna said in its statement Thursday that in lab experiments of human blood cells, booster shots increased the number of hair loss antibodies, suggesting that if its treatment does weaken in future months, a booster would shore up protection. Moderna's clinical trials have also shown robust antibody responses after booster shots, the compare propecia prices uk company added. Full approval of Pfizer treatment could come in September The U.S. Food and Drug Administration is speeding up its timetable for full approval of the Pfizer hair loss treatment, hoping to complete the process by early September. President Joe Biden said last week that he expected a fully approved treatment in early fall, but the FDA's unofficial deadline is Labor Day or compare propecia prices uk sooner, according to multiple people familiar with the plan, The New York Times reported. The agency said in a statement that its leaders recognized that full approval might counter treatment hesitancy and had "taken an all-hands-on-deck approach" to completing full approval. The move could help boost vaccination rates at a moment when the highly transmissible Delta variant is driving up the compare propecia prices uk number of new cases across the country. A number of universities and hospitals, the Defense Department and at least one major city, San Francisco, are expected to mandate treatments once one is fully approved. Final approval could help clarify legal issues about mandates, the Times reported. Federal regulators have been under growing public pressure compare propecia prices uk to fully approve Pfizer's treatment ever since the company filed its application on May 7. "I just have not sensed a sense of urgency from the FDA on full approval," Dr. Ashish Jha, dean of the Brown University School of Public Health in Rhode Island, told the Times on Tuesday. "And I find it baffling, given where we are as a country in terms of s, hospitalizations and deaths." Moderna, the second most widely used treatment in the compare propecia prices uk United States, filed for final approval of its treatment on June 1. But the company is still submitting data and has not said when it will finish, the Times reported. Johnson & compare propecia prices uk. Johnson, the third treatment authorized for emergency use, has not yet applied for full approval, but plans to do so later this year. Although 192 million Americans â 58 percent of the total population and 70 percent of the nation's adults â have received at least one shot, many Americans remain vulnerable, data from the U.S Centers for Disease Control and Prevention show. The country is averaging nearly 86,000 new s a day, an increase of 142 percent in just two weeks, according to a compare propecia prices uk Times database. Full approval for a treatment typically requires the FDA to review hundreds of thousands of pages of documents â roughly 10 times the data required to authorize a treatment on an emergency basis. The agency can usually complete a priority review within six to eight months and was already working on an expedited timetable for the Pfizer treatment, the Times reported. What are regulators looking for? compare propecia prices uk. They want to see real-world data on how the treatment has been working since they authorized it for emergency use in December, the Times reported. That means verifying the company's data on treatment efficacy and immune responses, reviewing how efficacy or immunity might wane, examining new s in clinical trial participants, reviewing adverse reactions and inspecting manufacturing plants. Officials have said the government is compare propecia prices uk also tracking breakthrough s among tens of thousands of vaccinated people. At the same time, senior officials at the FDA and other agencies are debating whether at least some people who are already vaccinated will need booster shots. Senior administration officials compare propecia prices uk increasingly believe that vulnerable populations like those with compromised immune systems and older people will need them, the Times reported. A decision to fully approve Pfizer's treatment will give doctors more freedom to prescribe additional shots for certain Americans, including those with weakened immune systems, the Times reported. Roughly 3 percent of Americans â or about 10 million people â have compromised immune systems as a result of cancer, organ transplants or other medical conditions, according to the CDC. While studies indicate that the treatments work well for some, other people do not produce enough of an immune response to protect them from the compare propecia prices uk actual propecia. More information The U.S. Centers for Disease Control and Prevention has more on hair loss treatment. SOURCES. The New York Times. Associated Press Copyright é 2021 HealthDay. All rights reserved.Latest hair loss News THURSDAY, Aug. 5, 2021 (HealthDay News) The United States' largest operator of nursing homes said Wednesday that its workers must get vaccinated against hair loss treatment if they want to keep their jobs. The announcement from Pennsylvania-based Genesis Healthcare -- which has 70,000 employees at nearly 400 nursing homes and senior communities -- suggests the nursing home industry's reluctance to force employees to get vaccinated due to fears about losing too many workers may be shifting, the Associated Press reported. Understaffing is a major problem in the sector, but concerns about the surging Delta variant may convince nursing home owners they need to take action to quickly vaccinate the 40% of employees who still haven't received shots. Voluntary vaccination was appropriate earlier in the propecia, but only 65% of Genesis staff have received shots, according to the company. Employees have until Aug. 23 to get their first shot. "To succeed against the Delta variant is going to require much higher vaccination rates," Genesis Chief Medical Officer Richard Feifer told the AP. "Our tactics in the http://oneworldjiujitsu.com/photos-videos/ fight have to change." Unvaccinated staff members endanger residents, warn experts who are calling for mandatory vaccinations at nursing homes. Some workers have avoided the treatment because they think it was rushed into development and is unsafe, or they feel protected because they already had a bout of hair loss treatment, the AP reported. About 80% of nursing home residents have been vaccinated, but even vaccinated residents are at risk because many are frail and have weak immune systems, the AP reported. More than 130,000 U.S. Nursing home residents have died from hair loss treatment, according to the AP. Jennifer Moore, of Hollywood, Fla., has a husband living at a nursing home where only 35% of the staff is vaccinated. "Whenever I see a story about somebody being anti-vax, I just want to scream," said Moore, whose husband, Thomas, has Parkinson's disease. "I understand people have concerns about the treatment, but these people are working with the most vulnerable population. They have a duty to their patients." More information Visit the U.S. Centers for Disease Control and Prevention for more on hair loss treatments. SOURCE. Associated Press Robert Preidt and Robin Foster Copyright é 2021 HealthDay. All rights reserved.Latest hair loss News THURSDAY, Aug. 9, 2021 (HealthDay News) hair loss treatment hospitalizations in Florida reached a new high this week, the Florida Hospital Association (FHA) says. Hospitalizations are 13% higher than the previous peak on July 23, 2020, and 60% of the state's hospitals are expected to face a "critical staffing shortage" in the next seven days, the association said Tuesday, CNN reported. Currently, there are 11,515 hospitalized hair loss treatment patients, and 84% of in-patient beds and 86.5% of ICU beds in the state are occupied, according to the FHA. It said that 21% of hospitalized hair loss treatment patients are in the ICU and 13% are on ventilators, CNN reported. The FHA figures are from a survey of hospitals that was completed Aug. 2 and represents 82% of the state's acute care hospitals. "Current hospitalizations and the growth rate continue to be extremely troubling," Mary Mayhew, president and CEO of the Florida Hospital Association, said in a statement. "But treatments work!. The fact that less than 3% of current hospitalizations arrived from nursing homes and long-term care facilities shows the state's focus on vaccinating and protecting Florida's seniors and most vulnerable has worked." Just two states -- Florida and Texas -- accounted for one-third of all hair loss treatment cases reported in the United States in the past week, White House hair loss treatment response coordinator Jeff Zients said during a briefing Monday, CNN reported. More information Visit the U.S. Centers for Disease Control and Prevention for more on hair loss treatment hospitalizations across the country. SOURCE. CNN Robert Preidt and Robin Foster Copyright é 2021 HealthDay. All rights reserved.Latest Senior Health News By Dennis Thompson HealthDay ReporterTHURSDAY, Aug. 5, 2021 (HealthDay News) Scientists suspect that a century-old tuberculosis treatment might be able to protect older adults against the worst ravages of hair loss treatment. The Bacillus Calmette-Guérin (BCG) treatment was first used 1921, and is on the World Health Organization's list of essential medicines. More than 130 million babies worldwide receive this treatment every year. But it also is known to calm the immune system, and new research shows that the treatment might specifically blunt the severe inflammatory response that does so much damage to the body during a hair loss treatment . "Typically, older people are more susceptible to severe hair loss treatment due to their ability to make exuberant inflammatory responses," said senior researcher Dr. Subash Babu, scientific director of the National Institute for Research in Tuberculosis in Chennai, India. "Therefore, BCG might be useful by lowering this propensity." The BCG treatment already is used to modulate people's immune reaction in other diseases, most notably bladder cancer, said Dr. Waleed Javaid, director of prevention and control at Mount Sinai Downtown in New York City. Health experts in some nations with high hair loss treatment rates and little access to hair loss treatments have considered using BCG as a stopgap measure to protect older adults, researchers said in background notes. But, they said, there have been concerns that the BCG treatment might actually increase older folks' inflammation response and worsen their hair loss treatment . In this study, researchers gave the BCG treatment to 82 healthy people between 60 and 80 years old. A month after vaccination, they found decreases in biochemicals linked to inflammation. Researchers also observed a decrease in enzymes that crop up during lung inflammation, which suggested that BCG might limit lung damage during hair loss treatment . "BCG can potentially be useful as an adjuvant treatment to the hair loss-specific treatments, and it needs to be tested for its ability to function as a therapeutic treatment" that could be given as a treatment during , Babu said. "BCG is safe and well tolerated, and widely available -- it is the most widely used treatment in the world," he said. But things aren't as cut and dried as all that, said Mount Sinai's Javaid, warning that no one should mistake the BCG treatment as an alternative form of protection against hair loss treatment. This new study didn't include a single hair loss treatment patient, and so it didn't directly test the BCG treatment's effectiveness at all against the new hair loss, said Javaid, who had no role in the new research. "This cannot be an alternate in any way to the hair loss treatment. This cannot be used as a stopgap," he said. "What we see here is that it does suppress some of the immune indicators that are otherwise active during hair loss treatment , and we know that during hair loss treatment part of the damage done to our body is because of our immune reaction," Javaid continued. "A lot of studies need to be done to prove or disprove these effects." The concept is good in theory, he concluded, "but it still needs to be proven more concretely." The findings were published Aug. 4 in the journal Science Advances. More information The U.S. Centers for Disease Control and Prevention has more about the BCG treatment. SOURCES. Subash Babu, MBBS, PhD, scientific director, National Institute for Research in Tuberculosis, Chennai, India. Waleed Javaid, MD, director, prevention and control, Mount Sinai Downtown, New York City. Science Advances, Aug. 4, 2021 Copyright é 2021 HealthDay. All rights reserved.. What if I miss a dose?If you miss a dose, take it as soon as you can. If you do not remember until the next day, take only that day's dose. Do not take double or extra doses. Propecia causes cancerThe premiere fundraiser for the UC Davis-affiliated student-run clinics has been canceled due to the propecia, but donors can still support the cause propecia causes cancer through an online giving campaign. The annual propecia causes cancer Silent Auction and Wine Tasting Benefit is canceled but donations can be made at. Www.ucdwineauction.comOrganizers of what would have been the 41st Annual Silent Auction and Wine Tasting Benefit are hoping to raise $50,000. The funding is crucial to maintain services and propecia causes cancer purchase supplies for the network of 12 nonprofit, free clinics that vulnerable patient populations rely on for quality care. ÃÂÂI worry that our clinics will need to limit the services or number of patients we can see if adequate funding isn't secured,â said Kayla Meadows, a second-year medical student and co-officer of the eventâÂÂs public relations team. ÃÂÂWhen so many Sacramento residents have lost their jobs, health insurance, and homes because of the propecia, the consistency of services at student-run clinics provides some security.âÂÂThe Silent Auction and Wine Tasting Benefit, held on the health campus every January, is propecia causes cancer one of the most important events connected to the School of Medicine. Students dress up, network with alumni, enjoy live entertainment and munch on appetizers, all while raising much-needed money for the clinics. The clinics are staffed by health professions student volunteers who gain propecia causes cancer valuable experience â mostly undergraduates from UC Davis, medical students from the School of Medicine and students from the Betty Irene Moore School of Nursing. They are monitored by volunteer physicians in the role of preceptors, or instructors. Although the clinics are largely propecia causes cancer closed to in-person visits because of health risks posed by the hair loss propecia, patients can still get urgent care and schedule video appointments. Still, clinics have additional expenses with new services this school year, such as care packages, home delivery of medication and medical devices and vouchers for patients to use on Uber and Lyft to get necessary blood draws and flu shots. ÃÂÂI worry that our clinics will need to limit the services or number of patients we can see if adequate funding isn't secured.âÂÂâ Kayla Meadows, a second-year medical student and co-officer of the eventâÂÂs public relations team.Once the clinics propecia causes cancer re-open, students foresee even more expenses. ÃÂÂIt's worrisome because once things start opening up and clinics go back to in-person visits, donations will be crucial for paying rent and ordering supplies,â said Irina Karashchuk, a second-year medical student who helps lead the eventâÂÂs sponsorship committee. ÃÂÂThe funding is very important because all the student-run clinics propecia causes cancer are non-profit and rely on donations and grants to stay open,â Karashchuk said. ÃÂÂFor some of the smaller clinics, the auction and wine-tasting benefit is one of the primary sources of funding.â Meadows said the propecia has a lot of people questioning what they can do to help a neighbor. ÃÂÂRest assured,â she added, âÂÂthat a donation to UC Davis student-run clinics goes a long way toward improving the health of Sacramento's community.â To donate propecia causes cancer online before the Feb. 14 deadline, or to learn more about the fundraiser and student-run clinics, visit www.ucdwineauction.com.In addition, checks may be made payable to âÂÂSilent Auction Wine Tasting Benefitâ and sent to. Darolyn Striley, 4610 X Street, Education Bldg., Suite 2101E, Sacramento, CA 95817.Two-year-old Leo Woo has propecia causes cancer already had two successful heart surgeries, thanks to UC Davis pediatric cardiothoracic surgeon Gary Raff. Leo WooLeoâÂÂs parents Sarah Ehrman and Chris Woo have entered Leo in this yearâÂÂs Rock Your Scar contest, a national contest hosted by Mended Little Hearts to raise awareness about congenital heart defects.It is a way for the family to share what they have been through and to connect with others who have also battled with congenital heart conditions. Ehrman had a normal pregnancy and did not know propecia causes cancer that Leo had any health problems until four days after he was born.âÂÂHe was turning a little bit blue. [The doctor] pulled him aside again to check him and figured out his oxygen levels in his right hand and right foot (weren't) matching up, and she heard a heart murmur,â Ehrman said.Woo was transferred to UC Davis ChildrenâÂÂs Hospital, where he was diagnosed with hypoplastic left heart syndrome (HLHS), a complex cardiac defect in which all structures on the left side of the heart are underdeveloped. Without treatment, HLHS is fatal.Woo had whatâÂÂs known as the Norwood procedure, the first in propecia causes cancer a series of three open-heart surgeries, in which Raff successfully redirected blood flow and rebuilt areas of his heart. Raff also performed the Glenn surgery on Woo, which successfully redirected blood flow from the upper body to the lungs. The third surgery in the series is still to come.Woo has also had six cardiac catheterizations from UC Davis chief propecia causes cancer of pediatric cardiology Frank Ing to improve blood flow.âÂÂWe are thankful for the care that Leo has received from UC Davis,â Ehrman said. ÃÂÂLeo is doing great.âÂÂVote for Leo Woo here. The public can propecia causes cancer vote every day until Jan. 31. Winners will be announced during Congenital Heart Defect Awareness Week, Feb propecia causes cancer. 7-14.. The premiere fundraiser for the UC Davis-affiliated student-run clinics has been canceled due to the propecia, but donors can still support the cause through an online giving compare propecia prices uk campaign. The annual Silent Auction and Wine compare propecia prices uk Tasting Benefit is canceled but donations can be made at. Www.ucdwineauction.comOrganizers of what would have been the 41st Annual Silent Auction and Wine Tasting Benefit are hoping to raise $50,000. The funding is crucial to maintain compare propecia prices uk services and purchase supplies for the network of 12 nonprofit, free clinics that vulnerable patient populations rely on for quality care. ÃÂÂI worry that our clinics will need to limit the services or number of patients we can see if adequate funding isn't secured,â said Kayla Meadows, a second-year medical student and co-officer of the eventâÂÂs public relations team. ÃÂÂWhen so many Sacramento residents have lost their jobs, health insurance, and homes because of the propecia, the consistency of services at student-run clinics compare propecia prices uk provides some security.âÂÂThe Silent Auction and Wine Tasting Benefit, held on the health campus every January, is one of the most important events connected to the School of Medicine. Students dress up, network with alumni, enjoy live entertainment and munch on appetizers, all while raising much-needed money for the clinics. The clinics compare propecia prices uk are staffed by health professions student volunteers who gain valuable experience â mostly undergraduates from UC Davis, medical students from the School of Medicine and students from the Betty Irene Moore School of Nursing. They are monitored by volunteer physicians in the role of preceptors, or instructors. Although the clinics are largely closed to in-person visits because of health risks posed compare propecia prices uk by the hair loss propecia, patients can still get urgent care and schedule video appointments. Still, clinics have additional expenses with new services this school year, such as care packages, home delivery of medication and medical devices and vouchers for patients to use on Uber and Lyft to get necessary blood draws and flu shots. ÃÂÂI worry that our clinics will need to limit the services or number of patients we can see if adequate funding isn't secured.âÂÂâ Kayla Meadows, a second-year medical compare propecia prices uk student and co-officer of the eventâÂÂs public relations team.Once the clinics re-open, students foresee even more expenses. ÃÂÂIt's worrisome because once things start opening up and clinics go back to in-person visits, donations will be crucial for paying rent and ordering supplies,â said Irina Karashchuk, a second-year medical student who helps lead the eventâÂÂs sponsorship committee. ÃÂÂThe funding is very important because all the student-run clinics are non-profit and rely on donations and grants to stay open,â compare propecia prices uk Karashchuk said. ÃÂÂFor some of the smaller clinics, the auction and wine-tasting benefit is one of the primary sources of funding.â Meadows said the propecia has a lot of people questioning what they can do to help a neighbor. ÃÂÂRest assured,â she added, âÂÂthat a donation to UC Davis student-run clinics goes a long way toward improving the health of Sacramento's community.â To donate online before compare propecia prices uk the Feb. 14 deadline, or to learn more about the fundraiser and student-run clinics, visit www.ucdwineauction.com.In addition, checks may be made payable to âÂÂSilent Auction Wine Tasting Benefitâ and sent to. Darolyn Striley, 4610 X Street, Education Bldg., Suite 2101E, Sacramento, CA 95817.Two-year-old Leo Woo compare propecia prices uk has already had two successful heart surgeries, thanks to UC Davis pediatric cardiothoracic surgeon Gary Raff. Leo WooLeoâÂÂs parents Sarah Ehrman and Chris Woo have entered Leo in this yearâÂÂs Rock Your Scar contest, a national contest hosted by Mended Little Hearts to raise awareness about congenital heart defects.It is a way for the family to share what they have been through and to connect with others who have also battled with congenital heart conditions. Ehrman had a normal pregnancy and did not know that compare propecia prices uk Leo had any health problems until four days after he was born.âÂÂHe was turning a little bit blue. [The doctor] pulled him aside again to check him and figured out his oxygen levels in his right hand and right foot (weren't) matching up, and she heard a heart murmur,â Ehrman said.Woo was transferred to UC Davis ChildrenâÂÂs Hospital, where he was diagnosed with hypoplastic left heart syndrome (HLHS), a complex cardiac defect in which all structures on the left side of the heart are underdeveloped. Without treatment, HLHS is fatal.Woo had whatâÂÂs known compare propecia prices uk as the Norwood procedure, the first in a series of three open-heart surgeries, in which Raff successfully redirected blood flow and rebuilt areas of his heart. Raff also performed the Glenn surgery on Woo, which successfully redirected blood flow from the upper body to the lungs. The third surgery in the series is still to come.Woo has also had six cardiac catheterizations from UC Davis chief of pediatric cardiology Frank Ing to improve blood flow.âÂÂWe are thankful for the care that Leo has received compare propecia prices uk from UC Davis,â Ehrman said. ÃÂÂLeo is doing great.âÂÂVote for Leo Woo here. The public can vote every day until compare propecia prices uk Jan. 31. Winners will be announced during Congenital Heart compare propecia prices uk Defect Awareness Week, Feb. Propecia withdrawalAbout This TrackerThis tracker provides the number of confirmed cases and deaths from novel hair loss by country, the propecia withdrawal trend in confirmed case and death counts by country, and a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) hair loss Resource CenterâÂÂs hair loss treatment Map and the World Health OrganizationâÂÂs (WHO) hair loss Disease (hair loss treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About hair loss treatment hair lossIn late 2019, a new hair loss emerged propecia withdrawal in central China to cause disease in humans. Cases of this disease, known as hair loss treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization propecia withdrawal (WHO) declared the propecia represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.. About This TrackerThis tracker provides the number of confirmed cases and deaths from novel hair loss by country, the trend in confirmed case and death counts by country, and a global map showing which countries have confirmed compare propecia prices uk cases and deaths. The data are drawn from the Johns Hopkins University (JHU) hair loss Resource CenterâÂÂs hair loss treatment Map and the World Health OrganizationâÂÂs (WHO) hair loss Disease (hair loss treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About hair loss treatment hair lossIn late 2019, a new hair loss compare propecia prices uk emerged in central China to cause disease in humans. Cases of this disease, known as hair loss treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the compare propecia prices uk propecia represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.. Propecia price canadaAbstractBrazil is currently home to propecia price canada the look at this website largest Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not propecia price canada always the case, however, and Japanese immigrants to Brazil endured much hardship to attain their current level of prestige. This essay explores this communityâÂÂs trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community. Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental propecia price canada health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the âÂÂmedical gazeâ and how it may âÂÂseeâ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge. To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is a distinctive modality of perception which merits its own consideration, and which may have a particular role to play in propecia price canada medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived. For example, commentary in this journal on the âÂÂwhite coatâ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to propecia price canada consider how patientsâ clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the âÂÂmedical gazeâ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs. Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often propecia price canada drawn between more reliable or less reliable knowledge. And between knowledge that is more technical or âÂÂobjectiveâÂÂ, and knowledge that is more emotionally based or more âÂÂsubjectiveâÂÂ. A frequent point of discussion is the reliability propecia price canada and characteristics of perception as a source of knowledge. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the very essence of an ethical response to the world to recognise the deep reality of others as propecia price canada separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways. The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different propecia price canada ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchristâÂÂs The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchristâÂÂs arguments as well as much support. We find his work propecia price canada a useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff to patients. In particular, it helps to illuminate the consequences of patientsâ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by propecia price canada Tseëlon,12 13 drawing on GoffmanâÂÂs work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues GoffmanâÂÂs interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 propecia price canada Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one way of combatting the stigma associated with dementia. Families and carers may also feel the importance of personal appearance. The significant propecia price canada body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, while also constraining and enabling elements of care within long-term community settings.16âÂÂ19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance. The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20âÂÂ22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontosâ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et alâÂÂs work that demonstrates the importance of hair and grooming as a key component of care.23 24 propecia price canada The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a âÂÂcertainâ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function. Its use may therefore perhaps incline us towards a âÂÂtask-basedâ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of peopleâÂÂs actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these clinical settings that are capable of âÂÂcommunicating many messages at once, even of subverting on one level what it appears to be âÂÂsayingâ on propecia price canada anotherâÂÂ.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from within each institution on the everyday work of hospital wards, their propecia price canada family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission. It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the âÂÂanalytic incisivenessâÂÂ35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent a range of hospitals types, geographies and propecia price canada socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital. This included one urban, two inner city and two hospitals covering a mix of rural and suburban catchment propecia price canada areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we propecia price canada focused observation within trauma and orthopaedic wards (80 days) and medical assessment units (MAU. 75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, each working in clusters of 2âÂÂ4 days over a propecia price canada 6-week period at each site. A single day of observation could last a minimum of 2âÂÂhours and a maximum of 12âÂÂhours. A total of 684âÂÂhours of observation were conducted for this study. This produced approximately 600âÂÂ000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN) propecia price canada. We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living propecia price canada with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group that informed us of the need of propecia price canada a better understanding of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study. The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the propecia price canada advisory group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from our wider analysis of our ethnographic study examining ward propecia price canada cultures of care and the experiences of people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all propecia price canada older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing of institutional clothing was typically connected to fewer personal items on display or within reach of the patient, propecia price canada with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of âÂÂget well soonâ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a propecia price canada certain social standing and place.Visibility of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more âÂÂvisibleâ to staff than others. It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, and the resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud propecia price canada and appreciatively, âÂÂWow, look at you!. àThe patient looked pleased as she sat and combed her hair [site 3âÂÂday 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly âÂÂinvisibleâÂÂ. Here, the propecia price canada ethnographer is observing a four-bed bay occupied by male patients living with dementia.The man in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy propecia price canada team come and see him. The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that sheâÂÂll be back later to see him again. The nurse checks on him, asks him if he wants propecia price canada a pillow, and puts it behind his head explaining to him, âÂÂYou need to sit in the chair for a bitâÂÂ. She pulls his bedside trolley near to him. With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for him, and propecia price canada puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, âÂÂThe problem is this is a really unstimulating environmentâÂÂ, then says to the patient, âÂÂAll done, letâÂÂs have a bit of a tidy up,â before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes are open, and he is propecia price canada looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains. He says he doesnâÂÂt want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is at the doorway near propecia price canada the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat. The man in propecia price canada bed 19 quietly sings along to the songs. ÃÂÂI am going to see my baby when I go home on victory dayâ¦âÂÂAt ten thirty, the nurse goes off on her break. The rest of the team are spread around the propecia price canada other bays and side rooms. There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping his feet to the propecia price canada music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents. There is a lot of paperwork propecia price canada in it which he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasnâÂÂt touched his tea, and is talking to himself propecia price canada. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasnâÂÂt come back. 18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, propecia price canada or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off. It feels like a propecia price canada jolt to the room. She turns and looks at me and says, âÂÂSorry were you listening to it?. àI tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have all stopped tapping their propecia price canada toes and stopped singing along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it propecia price canada is turned back on everyone starts tapping their toes again. The music plays on. ÃÂÂThereâÂÂll be bluebirds over the white cliffs of Dover, just you wait and seeâ¦âÂÂ[Site 3âÂÂday 3]The music was played by staff to help combat the drab and unstimulating environment of this propecia price canada hospital ward for the patients, the very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of âÂÂhigherâ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the general question of the visibility or propecia price canada otherwise of patients. Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, propecia price canada a mother and two adult daughters visit the father of the family, who is not visible to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks propecia price canada very different following his admissionâÂÂhe has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hueâÂÂit is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. ÃÂÂI am propecia price canada like a bird I want to fly awayâ¦â plays softly in the radio in the bay. I sit with them for a bit and we chatâÂÂhis wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope propecia price canada it will be close because she does not drive. He isnâÂÂt wearing his glasses and his daughter tells me that they canâÂÂt find them. We look propecia price canada in the bedside cabinet. She has never seen her dad without his glasses. ÃÂÂHe doesnâÂÂt look like my dad without his glassesâ [Site 2âÂÂday 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members. Missing glasses and propecia price canada missing teeth were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patientâÂÂs identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence facilitates the subject of propecia price canada the gaze, in gazing back, and hence helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved onesâ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing. Some older patients were clearly able propecia price canada to verbalise their understandings of the impacts of wearing institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. ÃÂÂI look like an Olympian or Wentworth prison in this outfit!. The latter I expectâ¦â The staff laughed as they walked her out of the bay propecia price canada (site 3âÂÂday 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally. Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with his very low-necked top even when his lunch tray was placed in front propecia price canada of him. He clearly felt very uncomfortable with such clothing. He continued using his hands to try to pull it up to cover his exposed chest, during and after the meal was finished (site 3âÂÂday 5).For some patients, the communication of this distress in relation propecia price canada to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower. She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.âÂÂI want my trousers, where is my bra, IâÂÂve got no bra on.â It is clear she doesnâÂÂt feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, âÂÂYour bra is dirty, propecia price canada do you want to wear that?. àShe replies, âÂÂNo I want a clean one. Where are my trousers?. I want them, IâÂÂve lost them.â The healthcare assistant repeats the explaination that her clothes are dirty, and asks her, âÂÂDo you want your dirty propecia price canada ones?. àShe is very teary âÂÂNo, I want my clean ones.â The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says âÂÂHelloâ to her. She is very teary and explains that she propecia price canada has lost her clothes. The cleaner listens sympathetically as she continues âÂÂI am all confused. I have lost my clothes. I am propecia price canada all confused. How am I going to go to the shops with no clothes on!. à(site 5âÂÂday 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may propecia price canada solidify staff perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence propecia price canada of her own familiar clothing contributes significantly to her distress and disorientation. Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an âÂÂoptional extraâÂÂ. However, for those patients most at risk of disorientation propecia price canada and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of the role of personal grooming. Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out âÂÂself-careâ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they propecia price canada prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward. Kontosâ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are propecia price canada important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates to a wider group. In Kontosâ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can impact on peopleâÂÂs appearance propecia price canada in ways that may mark them out as failing to achieve accepted standards of embodied personhood. The task-oriented timetabling of mealtimes may have significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to âÂÂfeedâ a person living with dementia, when she gives up and leave the bedside propecia price canada (this woman living with dementia has resisted her attempts and explicitly says âÂÂnoâÂÂ), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant. It signifies a task-based apparel that propecia price canada is demeaning to an individualâÂÂs social status. This example also contrasts poignantly with examples from Kontosâ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the âÂÂrightâ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes âÂÂplaced her hand on her chest, to prevent her blouse from touching the food as she leaned over her plateâÂÂ.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we found the âÂÂMatthew effectâ to be frequently propecia price canada in operation. To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for âÂÂlounge viewâ where visitors would see them, using residents to âÂÂcreate a visual product for othersâ sometimes to the detriment of residentsâ needs. Our observations regarding the importance of patient appearance must therefore be considered as part of the care of the whole person and a significant feature of the institutional propecia price canada culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may propecia price canada have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white coats were not to be found, the dress code of medical staff did propecia price canada make them stand out. For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying âÂÂresistanceâ to care.50 This included âÂÂresistanceâ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the propecia price canada removal of clothing was limited to institutional gowns and pyjamas and we did not see any patients removing their own clothing. This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often propecia price canada interpreted by ward staff as a patientâÂÂs âÂÂresistanceâ to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would always propecia price canada be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA. The act of removal was typically interpreted by ward staff as representing a feature of the personâÂÂs dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to further cycles of removal and replacement, leading to an escalation of distress in the propecia price canada person. This was important, because the recording of âÂÂrefusal of careâÂÂ, or presumed âÂÂconfusionâ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husbandâÂÂs stroke, he could no longer care for her). Across the previous evening and morning shift, she was shouting, refusing all food and care and has received assistance from the specialist dementia care propecia price canada worker. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2âÂÂhours. When she does talk, she is very loud and high pitched, but this is normal for her and not a sign of propecia price canada distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is âÂÂon suicide watchâ and another is âÂÂrefusing their medicationâ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins to propecia price canada remove her sheets:15:10. The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still has not been brought more milk, which she requested propecia price canada from the HCA an hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge says, âÂÂHello,â when she walks past 1âÂÂs propecia price canada bed. 1 looks across and smiles back at her. The nurse in charge explains to her that she needs propecia price canada to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow. 1 says that he propecia price canada hasnâÂÂt been and she does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, âÂÂWhy 1 has been left on the unit?. à1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some propecia price canada jobs first and then will come and talk to her.15:30. 1 has once again kicked her sheets off of her legs. A social worker comes onto the propecia price canada unit. 1 shouts, âÂÂExcuse meâ to her. The social worker replies, âÂÂSorry IâÂÂm not staff, I donâÂÂt work hereâ and leaves the bay.15:40. 1 keeps kicking sheets propecia price canada off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unitâÂÂs door. 1 is the only elderly patient on the unit. Again, the nurse in charge is heard sympathizing that this is not the right place for her.16:30 propecia price canada. A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells propecia price canada her that she has been here for 3 days, (the rest is inaudible because of pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, âÂÂSee you laterâÂÂ, and leaves the unit.16:40. 1 attempts to talk to propecia price canada the new nurse assigned to the unit. She goes over to 1 and says, âÂÂWhatâÂÂs up my darling?. àItâÂÂs hard to follow 1 now as she sounds very upset. The RNâÂÂs first instinct, like with the doctor and the nurse in charge, is to cover up 1âÂÂs legs propecia price canada with her bed sheet. When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking about how her husband wonâÂÂt come and visit propecia price canada her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who propecia price canada are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure. In the example given above, the actions were linked to the patientâÂÂs resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as âÂÂundressingâÂÂ, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, propecia price canada distress and disorientation. So âÂÂdeviantâ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns. This exposure in itself is of course, an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed propecia price canada in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and BuseâÂÂs work16âÂÂ19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings. Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic propecia price canada approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchristâÂÂs work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs. Focus on propecia price canada efficiency, pace and record keeping that measures individual task completion within a timetable of care may worsen all these effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a âÂÂtaskâ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearanceâÂÂself-perception and perception by othersâÂÂmay be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be propecia price canada struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as âÂÂresisting careâ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patientâÂÂs alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient. Other work has also shown how older people, propecia price canada and in particular people living with dementia, may be thought to be beyond concern for appearance, yet this does not accurately reflect the importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered âÂÂdignitasâ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a way of facilitating the treatment by propecia price canada others of a person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available. Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl propecia price canada (2013). ÃÂÂLiving into the imagined body. How the diagnostic image confronts the lived body.â Medical Humanities. Medhum-2012âÂÂ010286.2. Joyce Zazulak et al. (2017). "The art of medicine. Arts-based training in observation and mindfulness for fostering the empathic response in medical residents.â Medical Humanities. Medhum-2016-011180.3. E Forde (2018). "Using photography to enhance GP traineesâ reflective practice and professional development." Medical Humanities. Medhum-2017-011203.4. Caroline Wellbery and Melissa Chan (2014) âÂÂWhite coat, patient gown.â Medical Humanities. Medhum-2013âÂÂ0âÂÂ10âÂÂ463.5. E Goffman (1990a). Stigma. Notes on the management of spoiled identity, Penguin.6. J Bridges and C Wilkinson (2011). ÃÂÂAchieving dignity for older people with dementia in hospital.â Nursing Standard 5 (29).7. J Dancy (1985). Contemporary Epistemology, John Wiley and Sons.8. D McNaughton (1988). Moral Vision. Blackwell.9. S Weil (1953). Gravity and Grace. U of Nebraska Press.10. I McGilchrist (2009). The Master and his Emissary. The divided brain and the making of the western world. New Haven and London, Yale University Press.11. Iain McGilchrist (2011). ÃÂÂPaying attention to the bipartite brain.â The Lancet 377 (9771). 1068âÂÂ1069.12. Efrat Tseëlon (1992). ÃÂÂSelf presentation through appearance. A manipulative vs a dramaturgical approachâÂÂ. Symbolic Interaction, 15(4). 501âÂÂ514.13. E Tseëlon (1995). The masque of femininity. The presentation of woman in everyday life. London. Sage.14. E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001). ÃÂÂFashion research and its discontentsâÂÂ. Fashion Theory, 5 (4). 435âÂÂ451.16. Julia Twigg (2010a). ÃÂÂClothing and dementia. A neglected dimension?. àJournal of Ageing Studies 24(4). 223âÂÂ230.17. Julia Twigg and Christina E Buse (2013). ÃÂÂDress, dementia and the embodiment of identity.â Dementia 12(3). 326âÂÂ336.18. C. E Buse and J. Twigg (2015). ÃÂÂClothing, embodied identity and dementia. Maintaining the self through dress.â Age, Culture, Humanities (2).19. Christina Buse and Julia Twigg (2018). ÃÂÂDressing disrupted. Negotiating care through the materiality of dress in the context of dementia.â Sociology of Health &. Illness, 40(2). 340-352.20. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &. Society, 24(6). 829âÂÂ849.21. P. C Kontos (2005). ÃÂÂEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.â Dementia 4 (4). 553âÂÂ570.22. P. C Kontos and G. Naglie (2007). ÃÂÂBridging theory and practice. Imagination, the body, and person-centred dementia care.â Dementia 6 (4). 549âÂÂ569.23. Richard Ward et al. (2016a). ÃÂÂâÂÂGonna make yer gorgeousâÂÂ. Everyday transformation, resistance and belonging in the care-based hair salon.â Dementia, 15(3). 395âÂÂ413.24. Richard Ward, Sarah Campbell, and John Keady (2016b). ÃÂÂAssembling the salon. Learning from alternative forms of body work in dementia care.â Sociology of Health &. Illness, 38(8). 1287âÂÂ1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012). Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1). 49âÂÂ59.26. Päivi Topo and Sonja Iltanen-Tähkävuori (2010). ÃÂÂScripting patienthood with patient clothing.â Social Science &. Medicine, 70(11). 1682âÂÂ1689.27. Julia Twigg (2010b). ÃÂÂWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-TähkävuoriâÂÂ. Social Science and Medicine, 70(11), 1690âÂÂ1692.28. Kathleen Woodward (2006). ÃÂÂPerforming age, performing genderâ National WomenâÂÂs Studies Association (NWSA) Journal 18(1). 162âÂÂ89.29. K.M Woodward (1999). Introduction. In K.M. Woodward (ed.), Figuring Age. Women, Bodies and Generations (pp. Ix-xxix). Bloomington. Indiana University Press.30. M Hammersley and P Atkinson (1989). Ethnography. Principles in practice. London. Routledge.31. V. J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks. A mixed-method strategy. Research in the Schools, 13(1). 84âÂÂ92.32. W Housley and P Atkinson (2003). Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London. Routledge34. V Turner and E Bruner (1986). The Anthropology of Experience New York. PAJ Publications. 2435. K Charmaz and RG Mitchell (2001). ÃÂÂGrounded theory in ethnographyâ in Atkinson P. (Ed) Handbook of Ethnography, 2001. 160-174. Sage. London36. B Glaser and A Strauss (1967). The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25). 288âÂÂ30437. Juliet M. Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria. Qual. Sociol. 13. 3âÂÂ21.38. J Green (1998). Commentary. Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39. Roy Suddaby (2006). ÃÂÂFrom the editors. What grounded theory is not.â Academy of management journal, 49(4). 633âÂÂ642.40. Elizabeth L Sampson et al. (2009). ÃÂÂDementia in the acute hospital. Prospective cohort study of prevalence and mortalityâÂÂ. British Journal of Psychiatry,195(1). 61âÂÂ66. Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012). ÃÂÂPeople with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admissionâÂÂ. Z. Gerontol. Geriatr. 45. 728âÂÂ734.42. Robert E Herriott and William A. Firestone (1983) âÂÂMultisite qualitative policy research. Optimising description and generalizabilityâÂÂ. Education Research 12:14âÂÂ1943. F Vogt (2002). ÃÂÂNo ethnography without comparison. The methodological significance of comparison in ethnographic researchâ Studies in Education Ethnography 6:23âÂÂ4244. Benjamin Saunders et al. (2018). ÃÂÂSaturation in qualitative research. Exploring its conceptualization and operationalization.â Quality and Quantity 52 (4). 1893âÂÂ1907.45. A Coffey and P Atkinson (1996). Making sense of qualitative data. Complementary research strategies. Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018). ÃÂÂThe canary in the coal mine. Continence care for people with dementia in acute hospital wards as a crisis of dehumanisationâÂÂ. Bioethics, 32(4). 251âÂÂ260.47. Christina Buse et al. (2014). ÃÂÂLooking âÂÂout of placeâÂÂ. Analysing the spatial and symbolic meanings of dementia care settings through dress.â International Journal of Ageing and Later Life 9 (1). 69âÂÂ95.48. R. K. Merton (1968). ÃÂÂThe Matthew effect in science. The reward and communication systems of science are considered.â Science 159 (3810). 56âÂÂ63.49. Geraldine Lee-Treweek (1997) âÂÂWomen, resistance and care. An ethnographic study of nursing auxiliary workâ Work, Employment and Society, 11(1). 47âÂÂ6350. Katie Featherstone et al. (2019b). ÃÂÂRefusal and resistance to care by people living with dementia being cared for within acute hospital wards. An ethnographic studyâ Health Service and Delivery Research51. Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). ÃÂÂRoutines of resistance. An ethnography of the care of people living with dementia in acute hospital wards and its consequences.â International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020). ÃÂÂUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?. àNarrative Inquiry in Bioethics53. Jeannette Pols (2013). ÃÂÂWashing the patient. Dignity and aesthetic values in nursing careâ Nursing Philosophy, 14(3). 186âÂÂ200. AbstractBrazil is currently compare propecia prices uk home to the largest Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was compare propecia prices uk not always the case, however, and Japanese immigrants to Brazil endured much hardship to attain their current level of prestige. This essay explores this communityâÂÂs trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community. Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional compare propecia prices uk medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the âÂÂmedical gazeâ and how it may âÂÂseeâ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge. To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is a distinctive modality of perception which merits compare propecia prices uk its own consideration, and which may have a particular role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived. For example, commentary in this journal on the âÂÂwhite coatâ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to consider how compare propecia prices uk patientsâ clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the âÂÂmedical gazeâ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs. Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often drawn between more reliable or less reliable knowledge compare propecia prices uk. And between knowledge that is more technical or âÂÂobjectiveâÂÂ, and knowledge that is more emotionally based or more âÂÂsubjectiveâÂÂ. A frequent point of discussion is the reliability and characteristics of perception as a source of knowledge compare propecia prices uk. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the very essence of an ethical response to compare propecia prices uk the world to recognise the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways. The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchristâÂÂs The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture compare propecia prices uk. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchristâÂÂs arguments as well as much support. We find his work a useful framework for understanding important compare propecia prices uk debates in the ethics of medicine and of nursing about relationships of staff to patients. In particular, it helps to illuminate the consequences of patientsâ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by Tseëlon,12 compare propecia prices uk 13 drawing on GoffmanâÂÂs work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues GoffmanâÂÂs interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one compare propecia prices uk way of combatting the stigma associated with dementia. Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, while also constraining and enabling elements of care within long-term community settings.16âÂÂ19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt within the impersonal setting of compare propecia prices uk the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance. The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20âÂÂ22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontosâ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et alâÂÂs work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older compare propecia prices uk female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a âÂÂcertainâ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function. Its use may therefore perhaps incline us towards a âÂÂtask-basedâ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of peopleâÂÂs actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these clinical settings that are capable of âÂÂcommunicating many messages at once, even of subverting on one level what it appears to be âÂÂsayingâ on anotherâÂÂ.34 Thus, it is compare propecia prices uk important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from within each compare propecia prices uk institution on the everyday work of hospital wards, their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission. It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the âÂÂanalytic incisivenessâÂÂ35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent a range compare propecia prices uk of hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital. This included one urban, two inner city and two hospitals covering compare propecia prices uk a mix of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within trauma compare propecia prices uk and orthopaedic wards (80 days) and medical assessment units (MAU. 75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, compare propecia prices uk each working in clusters of 2âÂÂ4 days over a 6-week period at each site. A single day of observation could last a minimum of 2âÂÂhours and a maximum of 12âÂÂhours. A total of 684âÂÂhours of observation were conducted for this study. This produced approximately 600âÂÂ000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by compare propecia prices uk KF and AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover compare propecia prices uk notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group that informed us of the need of a better understanding compare propecia prices uk of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study. The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data compare propecia prices uk analysis was complete, the advisory group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from our wider analysis of our ethnographic study examining ward cultures of care and the experiences of people living with dementia compare propecia prices uk. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), compare propecia prices uk paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing of institutional clothing was typically connected to fewer personal compare propecia prices uk items on display or within reach of the patient, with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of âÂÂget well soonâ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility compare propecia prices uk of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more âÂÂvisibleâ to staff than others. It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked compare propecia prices uk on by staff, and the resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, âÂÂWow, look at you!. àThe patient looked pleased as she sat and combed her hair [site 3âÂÂday 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly âÂÂinvisibleâÂÂ. Here, the ethnographer is observing a four-bed bay occupied compare propecia prices uk by male patients living with dementia.The man in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy team come compare propecia prices uk and see him. The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that sheâÂÂll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and puts it behind his head explaining to him, compare propecia prices uk âÂÂYou need to sit in the chair for a bitâÂÂ. She pulls his bedside trolley near to him. With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for compare propecia prices uk him, and puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, âÂÂThe problem is this is a really unstimulating environmentâÂÂ, then says to the patient, âÂÂAll done, letâÂÂs have a bit of a tidy up,â before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes are open, compare propecia prices uk and he is looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains. He says he doesnâÂÂt want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is compare propecia prices uk at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat. The man in bed 19 quietly sings along to the compare propecia prices uk songs. ÃÂÂI am going to see my baby when I go home on victory dayâ¦âÂÂAt ten thirty, the nurse goes off on her break. The rest compare propecia prices uk of the team are spread around the other bays and side rooms. There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping his feet to the compare propecia prices uk music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents. There is a lot of compare propecia prices uk paperwork in it which he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasnâÂÂt touched his tea, and is talking compare propecia prices uk to himself. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasnâÂÂt come back. 18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down compare propecia prices uk on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off. It feels like a jolt to the room compare propecia prices uk. She turns and looks at me and says, âÂÂSorry were you listening to it?. àI tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have all stopped tapping their toes and stopped singing compare propecia prices uk along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it is turned back on everyone starts tapping their compare propecia prices uk toes again. The music plays on. ÃÂÂThereâÂÂll be bluebirds over the white cliffs of Dover, just you wait and seeâ¦âÂÂ[Site 3âÂÂday 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the compare propecia prices uk patients, the very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of âÂÂhigherâ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the compare propecia prices uk general question of the visibility or otherwise of patients. Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, a mother and two adult daughters visit the father of the family, who compare propecia prices uk is not visible to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks very different compare propecia prices uk following his admissionâÂÂhe has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hueâÂÂit is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. ÃÂÂI am like a bird I want to compare propecia prices uk fly awayâ¦â plays softly in the radio in the bay. I sit with them for a bit and we chatâÂÂhis wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it compare propecia prices uk will be close because she does not drive. He isnâÂÂt wearing his glasses and his daughter tells me that they canâÂÂt find them. We look in the bedside cabinet compare propecia prices uk. She has never seen her dad without his glasses. ÃÂÂHe doesnâÂÂt look like my dad without his glassesâ [Site 2âÂÂday 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members. Missing glasses and missing teeth were notable in this regard (and with compare propecia prices uk the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patientâÂÂs identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence facilitates the subject of the gaze, in gazing back, and hence compare propecia prices uk helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved onesâ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing. Some older compare propecia prices uk patients were clearly able to verbalise their understandings of the impacts of wearing institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. ÃÂÂI look like an Olympian or Wentworth prison in this outfit!. The latter I expectâ¦â The staff laughed as they walked her out of the bay (site 3âÂÂday 1).Institutional clothing may be a source of distress to patients, although they may compare propecia prices uk be unable to express this verbally. Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with his very low-necked top even when his lunch tray was placed in front of compare propecia prices uk him. He clearly felt very uncomfortable with such clothing. He continued compare propecia prices uk using his hands to try to pull it up to cover his exposed chest, during and after the meal was finished (site 3âÂÂday 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower. She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.âÂÂI want my trousers, where is my bra, IâÂÂve got no bra on.â It is clear she doesnâÂÂt feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, âÂÂYour bra is dirty, do you want to wear compare propecia prices uk that?. àShe replies, âÂÂNo I want a clean one. Where are my trousers?. I want them, IâÂÂve lost them.â The healthcare compare propecia prices uk assistant repeats the explaination that her clothes are dirty, and asks her, âÂÂDo you want your dirty ones?. àShe is very teary âÂÂNo, I want my clean ones.â The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says âÂÂHelloâ to her. She is compare propecia prices uk very teary and explains that she has lost her clothes. The cleaner listens sympathetically as she continues âÂÂI am all confused. I have lost my clothes. I am compare propecia prices uk all confused. How am I going to go to the shops with no clothes on!. à(site 5âÂÂday 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may solidify staff perceptions of her condition compare propecia prices uk. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her own familiar clothing contributes significantly to her compare propecia prices uk distress and disorientation. Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an âÂÂoptional extraâÂÂ. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed compare propecia prices uk other aspects of the role of personal grooming. Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out âÂÂself-careâ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance compare propecia prices uk and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward. Kontosâ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging compare propecia prices uk and identity, and of how an individual relates to a wider group. In Kontosâ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can impact on peopleâÂÂs appearance in ways that may mark them out compare propecia prices uk as failing to achieve accepted standards of embodied personhood. The task-oriented timetabling of mealtimes may have significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to âÂÂfeedâ a person living with dementia, when she gives up and leave the compare propecia prices uk bedside (this woman living with dementia has resisted her attempts and explicitly says âÂÂnoâÂÂ), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant. It signifies a task-based apparel that is compare propecia prices uk demeaning to an individualâÂÂs social status. This example also contrasts poignantly with examples from Kontosâ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the âÂÂrightâ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes âÂÂplaced her hand on her chest, to prevent her blouse from touching the food as she leaned over her plateâÂÂ.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we found the âÂÂMatthew effectâ to be frequently in compare propecia prices uk operation. To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for âÂÂlounge viewâ where visitors would see them, using residents to âÂÂcreate a visual product for othersâ sometimes to the detriment of residentsâ needs. Our observations regarding the importance of patient appearance compare propecia prices uk must therefore be considered as part of the care of the whole person and a significant feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the compare propecia prices uk people living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white coats were not to be found, the dress code of medical staff did make them compare propecia prices uk stand out. For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying âÂÂresistanceâ to care.50 This included âÂÂresistanceâ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the compare propecia prices uk removal of clothing was limited to institutional gowns and pyjamas and we did not see any patients removing their own clothing. This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often interpreted by compare propecia prices uk ward staff as a patientâÂÂs âÂÂresistanceâ to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would compare propecia prices uk always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA. The act of removal was typically interpreted by ward staff as representing a feature of the personâÂÂs dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to compare propecia prices uk further cycles of removal and replacement, leading to an escalation of distress in the person. This was important, because the recording of âÂÂrefusal of careâÂÂ, or presumed âÂÂconfusionâ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husbandâÂÂs stroke, he could no longer care for her). Across the compare propecia prices uk previous evening and morning shift, she was shouting, refusing all food and care and has received assistance from the specialist dementia care worker. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2âÂÂhours. When she does talk, she is very loud and high pitched, but this is normal for her compare propecia prices uk and not a sign of distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is âÂÂon suicide watchâ and another is âÂÂrefusing their medicationâ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins to remove compare propecia prices uk her sheets:15:10. The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still has not compare propecia prices uk been brought more milk, which she requested from the HCA an hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge says, âÂÂHello,â when she compare propecia prices uk walks past 1âÂÂs bed. 1 looks across and smiles back at her. The nurse in compare propecia prices uk charge explains to her that she needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow. 1 says that he hasnâÂÂt been and she does not believe compare propecia prices uk the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, âÂÂWhy 1 has been left on the unit?. à1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some jobs first and then compare propecia prices uk will come and talk to her.15:30. 1 has once again kicked her sheets off of her legs. A social worker comes onto the unit compare propecia prices uk. 1 shouts, âÂÂExcuse meâ to her. The social worker replies, âÂÂSorry IâÂÂm not staff, I donâÂÂt work hereâ and leaves the bay.15:40. 1 keeps kicking sheets off her bed, otherwise the compare propecia prices uk unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unitâÂÂs door. 1 is the only elderly patient on the unit. Again, the nurse in charge is heard sympathizing that this is not the compare propecia prices uk right place for her.16:30. A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her that she has been here for 3 days, (the rest is inaudible because compare propecia prices uk of pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, âÂÂSee you laterâÂÂ, and leaves the unit.16:40. 1 attempts to talk to the new nurse assigned to the unit compare propecia prices uk. She goes over to 1 and says, âÂÂWhatâÂÂs up my darling?. àItâÂÂs hard to follow 1 now as she sounds very upset. The RNâÂÂs first instinct, like with the doctor and the nurse in charge, is to cover up 1âÂÂs legs with compare propecia prices uk her bed sheet. When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking compare propecia prices uk about how her husband wonâÂÂt come and visit her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness compare propecia prices uk of behaviour and bodily exposure. In the example given above, the actions were linked to the patientâÂÂs resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as âÂÂundressingâÂÂ, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar clothing may be interpreted as an aspect compare propecia prices uk of confusion, yet lead to, or exacerbate, distress and disorientation. So âÂÂdeviantâ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns. This exposure in itself is of course, an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed compare propecia prices uk in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and BuseâÂÂs work16âÂÂ19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings. Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 compare propecia prices uk Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchristâÂÂs work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs. Focus on efficiency, pace and compare propecia prices uk record keeping that measures individual task completion within a timetable of care may worsen all these effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a âÂÂtaskâ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearanceâÂÂself-perception and perception by othersâÂÂmay be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled compare propecia prices uk and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as âÂÂresisting careâ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patientâÂÂs alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient. Other work has also shown how older people, and in particular people living with dementia, may be thought to be beyond concern for appearance, yet compare propecia prices uk this does not accurately reflect the importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered âÂÂdignitasâ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a way of facilitating the treatment by others of a person with humanitas, and compare propecia prices uk helping to realise dignity of patients.Data availability statementNo data are available. Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl compare propecia prices uk (2013). ÃÂÂLiving into the imagined body. How the diagnostic image confronts the lived body.â Medical Humanities. Medhum-2012âÂÂ010286.2. Joyce Zazulak et al. (2017). "The art of medicine. Arts-based training in observation and mindfulness for fostering the empathic response in medical residents.â Medical Humanities. Medhum-2016-011180.3. E Forde (2018). "Using photography to enhance GP traineesâ reflective practice and professional development." Medical Humanities. Medhum-2017-011203.4. Caroline Wellbery and Melissa Chan (2014) âÂÂWhite coat, patient gown.â Medical Humanities. Medhum-2013âÂÂ0âÂÂ10âÂÂ463.5. E Goffman (1990a). Stigma. Notes on the management of spoiled identity, Penguin.6. J Bridges and C Wilkinson (2011). ÃÂÂAchieving dignity for older people with dementia in hospital.â Nursing Standard 5 (29).7. J Dancy (1985). Contemporary Epistemology, John Wiley and Sons.8. D McNaughton (1988). Moral Vision. Blackwell.9. S Weil (1953). Gravity and Grace. U of Nebraska Press.10. I McGilchrist (2009). The Master and his Emissary. The divided brain and the making of the western world. New Haven and London, Yale University Press.11. Iain McGilchrist (2011). ÃÂÂPaying attention to the bipartite brain.â The Lancet 377 (9771). 1068âÂÂ1069.12. Efrat Tseëlon (1992). ÃÂÂSelf presentation through appearance. A manipulative vs a dramaturgical approachâÂÂ. Symbolic Interaction, 15(4). 501âÂÂ514.13. E Tseëlon (1995). The masque of femininity. The presentation of woman in everyday life. London. Sage.14. E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001). ÃÂÂFashion research and its discontentsâÂÂ. Fashion Theory, 5 (4). 435âÂÂ451.16. Julia Twigg (2010a). ÃÂÂClothing and dementia. A neglected dimension?. àJournal of Ageing Studies 24(4). 223âÂÂ230.17. Julia Twigg and Christina E Buse (2013). ÃÂÂDress, dementia and the embodiment of identity.â Dementia 12(3). 326âÂÂ336.18. C. E Buse and J. Twigg (2015). ÃÂÂClothing, embodied identity and dementia. Maintaining the self through dress.â Age, Culture, Humanities (2).19. Christina Buse and Julia Twigg (2018). ÃÂÂDressing disrupted. Negotiating care through the materiality of dress in the context of dementia.â Sociology of Health &. Illness, 40(2). 340-352.20. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &. Society, 24(6). 829âÂÂ849.21. P. C Kontos (2005). ÃÂÂEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.â Dementia 4 (4). 553âÂÂ570.22. P. C Kontos and G. Naglie (2007). ÃÂÂBridging theory and practice. Imagination, the body, and person-centred dementia care.â Dementia 6 (4). 549âÂÂ569.23. Richard Ward et al. (2016a). ÃÂÂâÂÂGonna make yer gorgeousâÂÂ. Everyday transformation, resistance and belonging in the care-based hair salon.â Dementia, 15(3). 395âÂÂ413.24. Richard Ward, Sarah Campbell, and John Keady (2016b). ÃÂÂAssembling the salon. Learning from alternative forms of body work in dementia care.â Sociology of Health &. Illness, 38(8). 1287âÂÂ1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012). Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1). 49âÂÂ59.26. Päivi Topo and Sonja Iltanen-Tähkävuori (2010). ÃÂÂScripting patienthood with patient clothing.â Social Science &. Medicine, 70(11). 1682âÂÂ1689.27. Julia Twigg (2010b). ÃÂÂWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-TähkävuoriâÂÂ. Social Science and Medicine, 70(11), 1690âÂÂ1692.28. Kathleen Woodward (2006). ÃÂÂPerforming age, performing genderâ National WomenâÂÂs Studies Association (NWSA) Journal 18(1). 162âÂÂ89.29. K.M Woodward (1999). Introduction. In K.M. Woodward (ed.), Figuring Age. Women, Bodies and Generations (pp. Ix-xxix). Bloomington. Indiana University Press.30. M Hammersley and P Atkinson (1989). Ethnography. Principles in practice. London. Routledge.31. V. J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks. A mixed-method strategy. Research in the Schools, 13(1). 84âÂÂ92.32. W Housley and P Atkinson (2003). Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London. Routledge34. V Turner and E Bruner (1986). The Anthropology of Experience New York. PAJ Publications. 2435. K Charmaz and RG Mitchell (2001). ÃÂÂGrounded theory in ethnographyâ in Atkinson P. (Ed) Handbook of Ethnography, 2001. 160-174. Sage. London36. B Glaser and A Strauss (1967). The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25). 288âÂÂ30437. Juliet M. Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria. J Green (1998). Commentary. Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39. Roy Suddaby (2006). ÃÂÂFrom the editors. What grounded theory is not.â Academy of management journal, 49(4). 633âÂÂ642.40. Elizabeth L Sampson et al. (2009). ÃÂÂDementia in the acute hospital. Prospective cohort study of prevalence and mortalityâÂÂ. British Journal of Psychiatry,195(1). 61âÂÂ66. Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012). ÃÂÂPeople with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admissionâÂÂ. Z. Gerontol. Geriatr. 45. 728âÂÂ734.42. Robert E Herriott and William A. Firestone (1983) âÂÂMultisite qualitative policy research. Optimising description and generalizabilityâÂÂ. Education Research 12:14âÂÂ1943. F Vogt (2002). ÃÂÂNo ethnography without comparison. The methodological significance of comparison in ethnographic researchâ Studies in Education Ethnography 6:23âÂÂ4244. Benjamin Saunders et al. (2018). ÃÂÂSaturation in qualitative research. Exploring its conceptualization and operationalization.â Quality and Quantity 52 (4). 1893âÂÂ1907.45. A Coffey and P Atkinson (1996). Making sense of qualitative data. Complementary research strategies. Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018). ÃÂÂThe canary in the coal mine. Continence care for people with dementia in acute hospital wards as a crisis of dehumanisationâÂÂ. Bioethics, 32(4). 251âÂÂ260.47. Christina Buse et al. (2014). ÃÂÂLooking âÂÂout of placeâÂÂ. Analysing the spatial and symbolic meanings of dementia care settings through dress.â International Journal of Ageing and Later Life 9 (1). ÃÂÂThe Matthew effect in science. The reward and communication systems of science are considered.â Science 159 (3810). 56âÂÂ63.49. Geraldine Lee-Treweek (1997) âÂÂWomen, resistance and care. An ethnographic study of nursing auxiliary workâ Work, Employment and Society, 11(1). 47âÂÂ6350. Katie Featherstone et al. (2019b). ÃÂÂRefusal and resistance to care by people living with dementia being cared for within acute hospital wards. An ethnographic studyâ Health Service and Delivery Research51. Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). ÃÂÂRoutines of resistance. An ethnography of the care of people living with dementia in acute hospital wards and its consequences.â International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020). ÃÂÂUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?. àNarrative Inquiry in Bioethics53. Jeannette Pols (2013). ÃÂÂWashing the patient. Dignity and aesthetic values in nursing careâ Nursing Philosophy, 14(3). |
Compare propecia prices uk2010.02.05 Links added 2010.02.05 Typo3 upgraded to 4.31 2010.02.01 FE added 2010.01.25 Typo3 upgraded to 4.3 Compare propecia prices ukEn rigtig god text om hvem I er som fortæller både brugerne og søgemaskinerne hvad der tilbdes.
Suspendisse aliquam, nibh a dapibus adipiscing, orci risus volutpat tortor, ut rhoncus arcu turpis ac nisl.Nulla imperdiet arcu quis libero. Ut ac pede. Curabitur fermentum tellus vel quam. In eget felis at est posuere aliquam. Donec ante. Pellentesque fermentum. Aliquam lectus ligula, euismod nec, congue nec, cursus non, quam. Donec nec risus. Suspendisse potenti. In volutpat mi nec mi. Donec eget risus. Nam tempus vehicula lorem. Proin et quam fringilla tellus fermentum dictum.Cras eu ipsum. Fusce faucibus, risus ut vestibulum semper, ante urna imperdiet eros, vel porta justo massa vitae purus. Sed aliquam hendrerit dui. Suspendisse dapibus augue at felis. Morbi velit pede, consectetuer sed, volutpat sed, ultricies in, mi. Aliquam ornare vestibulum ante. Praesent vel augue vel orci ullamcorper posuere.
Morbi ac felis et pede dictum viverra. Integer aliquam vestibulum mi. Aenean orci. Sed a lacus. Donec dui. Mauris consectetuer mauris at felis. Proin fermentum laoreet arcu. In hac habitasse platea dictumst. Nulla a mi nec quam elementum tempus. |
Compare propecia prices ukCompare propecia prices ukCompare propecia prices uk |