text stringlengths 14 5.77M | meta dict | __index_level_0__ int64 0 9.97k ⌀ |
|---|---|---|
require 'puppet/provider/netapp_cmode'
Puppet::Type.type(:netapp_security_login).provide(:cmode, :parent => Puppet::Provider::NetappCmode) do
@doc = "Manage Netapp security logins. [Family: cluster]"
confine :feature => :posix
defaultfor :feature => :posix
netapp_commands :securityloginlist => {:api => 'security-login-get-iter', :iter => true, :result_element => 'attributes-list'}
netapp_commands :securitylogincreate => 'security-login-create'
netapp_commands :securitylogindestroy => 'security-login-delete'
netapp_commands :securityloginmodify => 'security-login-modify'
netapp_commands :securityloginmodifypassword => 'security-login-modify-password'
netapp_commands :securityloginlock => 'security-login-lock'
netapp_commands :securityloginunlock => 'security-login-unlock'
mk_resource_methods
def self.instances
securitylogins = []
results = securityloginlist() || []
results.each do |securitylogin|
application = securitylogin.child_get_string('application')
authentication_method = securitylogin.child_get_string('authentication-method')
username = securitylogin.child_get_string('user-name')
vserver = securitylogin.child_get_string('vserver')
securitylogin_hash = {
:name => "#{application}:#{authentication_method}:#{username}:#{vserver}",
:comment => securitylogin.child_get_string('comment'),
:role_name => securitylogin.child_get_string('role-name'),
:is_locked => securitylogin.child_get_string('is-locked'),
:ensure => :present,
}
securitylogins << new(securitylogin_hash)
end
securitylogins
end
def self.prefetch(resources)
instances.each do |prov|
if resource = resources[prov.name]
resource.provider = prov
end
end
end
def flush
application, authentication_method, username, vserver = resource[:name].split(':')
args = Array.new
args += ['user-name', username]
args += ['vserver', vserver]
case @property_hash[:ensure]
when :absent
args += ['authentication-method', authentication_method]
args += ['application', application]
securitylogindestroy(*args)
when :present
#if lock status changes, do the right thing
if @original_values[:is_locked] != is_locked
if is_locked == "true"
securityloginlock(*args)
else
securityloginunlock(*args)
end
end
securityloginmodify(*get_args)
# The security-login-modify-password api does not seem to work.
#securityloginmodifypassword('user-name',username,'new-password',resource[:password])
end
end
def create
securitylogincreate(*get_args)
@property_hash.clear
end
def destroy
@property_hash[:ensure] = :absent
end
def exists?
@property_hash[:ensure] == :present
end
def get_args
args = Array.new
application, authentication_method, username, vserver = resource[:name].split(':')
args += ['user-name', username]
args += ['password', resource[:password]] if @property_hash.empty?
args += ['authentication-method', authentication_method]
args += ['role-name', resource[:role_name]]
args += ['application', application]
args += ['vserver', vserver]
args += ['comment', resource[:comment]]
args
end
end
| {
"redpajama_set_name": "RedPajamaGithub"
} | 3,723 |
\section{Introduction}
In \cite[Theorem 3.5]{NAFA2-Kang}, we can see the following non-Archimedean
fuzzy version of the classical Mazur-Ulam theorem:
\begin{theorem}\label{NAF}
Let $X$, $Y$ be non-Archimedean fuzzy anti-2-normed spaces over a certain type of non-Archimedean field $\mathbb K$. If both $X$ and $Y$ are strictly convex, then any centred fuzzy 2-isometry $f: X \to Y$ is an additive map.
\end{theorem}
The class of strictly convex fuzzy anti-2-normed spaces was introduced in that paper (cf. \cite[Definition~2.5]{NAFA2-Kang}), although there appeared no examples there. In this note, we prove:
\begin{proposition}
There are no such strictly convex spaces at all.
\end{proposition}
As a consequence, the statement of the above Theorem is void.
Let us also point out that the situation is similar in the different non-Archimedean versions of the Mazur-Ulam theorem that have appeared in recent years (cf. \cite{PRECISION} and references in \cite{NAFA2-Kang}).
\section{Voidness of the notion of strictly convex fuzzy space}
We reflect the following definition just for the sake of completeness.
\begin{definition}\label{defNAFA2} \rm
A {\em non-Archimedean fuzzy anti-2-normed space}
is a linear space $X$ over a non-Archimedean field $( \mathbb K, |\cdot |) $ together
with a fuzzy anti-2-norm; that is to say, with a function $N:X^2\times\mathbb R\to[0,1]$
such that, for all $x,y\in X$ and all $s,t\in\mathbb R$,
\begin{enumerate}
\item[(A2N-1)] if $t\leq 0,$ then $N(x,y,t)=1$,
\item[(A2N-2)] if $t>0$, then $N(x,y,t)=0$ if and only if $x$ and $y$ are linearly dependent,
\item[(A2N-3)] $N(x,y,t)=N(y,x,t),$
\item[(A2N-4)] $N(x,cy,t)=N(x,y, t/|c|)$ for any non-zero $c \in \mathbb K$
\item[(A2N-5)] $N(x,y+z,\max\{s,t\})\leq \max\{N(x,y,s),N(x,z,t)\}$,
\item[(A2N-6)] $N(x,y,*)$ is a non-increasing function of $\mathbb R$ and $\lim_{t\to\infty}N(x,y,t)=0$.
\end{enumerate}
\end{definition}
\begin{definition}\cite[Definition 2.5]{NAFA2-Kang} \rm A non-Archimedean fuzzy anti-2-normed space $(X,N)$ is {\em strictly convex} if
\begin{equation}\label{def022}
N(x,y,s)=N(x,z,t) = N(x,y+z,\max\{s,t\}) \quad \Rightarrow \quad y=z \ \mbox{ and } \ s=t \ .
\end{equation}
\end{definition}
\begin{proposition}\label{NoHaySC}
There are no strictly convex spaces at all --in the sense of the above Definition.
\end{proposition}
\begin{proof}
Any non-Archimedean fuzzy anti-2-norm $N$ satisfies, by (A2N-2), that,
for any $x\in X$, and any $ s, t\in(0,\infty)$,
$$
N(x,-x,s)= N(x,2x,t)=N(x,x,\max\{s,t\})=0 .
$$
As these equalities are valid {\em for any} $s, t\in(0,\infty)$, it is clear that
no fuzzy anti-2-normed space $(X,N)$ may fulfil condition~(\ref{def022}) --not even the zero linear space.
\end{proof}
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 4,872 |
{"url":"https:\/\/testbook.com\/question-answer\/derivative-feedback-is-employed-in-the-control-sys--5fb4efea7d86f2546e39ce25","text":"# Derivative feedback is employed in the control system shown in the figure, to improve its damping. If the required damping factor of the system is 0.5, the value of Kd must be adjusted to:\n\nThis question was previously asked in\nESE Electronics 2013 Paper 2: Official Paper\nView all UPSC IES Papers >\n1. 4\n2. 19\n3. 0.25\n4. 6\n\nOption 2 : 19\nFree\nCT 3: Building Materials\n2962\n10 Questions 20 Marks 12 Mins\n\n## Detailed Solution\n\nConverting the blocked portion into simplified form as\n\n$${G_d}\\left( s \\right) = \\frac{1}{{\\frac{{s\\left( {4s + 1} \\right)}}{{1 + \\frac{{s{K_d}}}{{s\\left( {4s + 1} \\right)}}}}}} = \\frac{1}{{4{s^2} + s\\left( {1 + {K_d}} \\right)}}$$\n\nNow,\n\nNow, simplifying the above block diagram as\n\n$$G\\;\\left( s \\right) = \\frac{{100}}{{\\frac{{4{s^2} + s\\left( {1 + {K_d}} \\right)}}{{1 + \\frac{{100}}{{4{s^2} + s\\left( {1 + {K_d}} \\right)}}}}}}$$\n\n$$= \\frac{{100}}{{4{s^2} + s\\left( {1 + {K_d}} \\right) + 100}}$$\n\n$$= \\frac{{25}}{{{s^2} + \\frac{{s\\left( {1 + {K_d}} \\right)}}{4} + 25}}$$\n\nComparing it with the standard equation as\n\n$$2{{\\xi }}{{{\\omega }}_n} = \\left( {\\frac{{1 + {K_d}}}{4}} \\right)$$\n$$5 = \\frac{{1 + {K_d}}}{4}$$","date":"2021-10-20 01:27:50","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 1, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.7833991050720215, \"perplexity\": 5606.723531912979}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2021-43\/segments\/1634323585290.83\/warc\/CC-MAIN-20211019233130-20211020023130-00515.warc.gz\"}"} | null | null |
//question object we are going to use as a test object in the following series of tests.
var question1 = {
'question':'test question 1',
'votes':5
}
var question1id = 1;
var firebaseid1 = 1;
//Test if a question HTML is rendered correctly on the moderator's panel page.
var output = renderAdminIndividualQuestion(question1id, question1, firebaseid1);
var expectedoutput = "<div class=\"row\">\
<div class=\"col-md-12\">\
<div class=\"question\" id=\"question1\"><h3>test question 1</h3></div>\
</div>\
</div>\
<div class=\"row\">\
<div class=\"col-sm-2 col-md-2\">\
<h3 class=\"votes\"><label class=\"label "+"label-danger"+"\" id=\"votes1\">5 votes</label></h3>\
</div>\
<div class=\"col-sm-10 col-md-10\">\
<button class=\"btn btn-primary btn-md admin-meeting-btn\" id=answerbtn1 onclick=\"answerQuestion('1','1')\">Answer Question</button>\
<button class=\"btn btn-danger btn-md admin-meeting-btn\" onclick=\"deleteQuestion('1')\">Delete Question</button>\
</div>\
</div>\
<hr>";
test( "test renderAdminIndividualQuestion", function() {
ok( output == expectedoutput, "Passed!" );
});
//Test if a question HTML is rendered correctly on the participant's page.
var output2 = renderIndividualQuestion(question1id, question1);
var expectedoutput2 = "<div class=\"row\">\
<div class=\"col-md-12\">\
<div class=\"row\">\
<div class=\"col-sm-12 col-md-12\">\
<div class=\"question\" id=\"question1\"><h3>test question 1</h3></div>\
</div>\
</div>\
<div class=\"row\">\
<div class=\"col-sm-12 col-md-12\">\
<div class=\"alert alert-danger error-notification\" id=\"error1\"></div>\
</div>\
</div>\
</div>\
</div>\
<div class=\"row\">\
<div class=\"col-sm-12 col-md-12\">\
<h3 class=\"votes\"><label class=\"label label-danger\" id=\"votes1\">5 votes</label></h3>\
<button class=\"btn btn-primary btn-md upvote-btn\" onclick=\"upvote('1')\">Upvote</button>\
</div>\
</div>\
<hr>";
test( "test renderIndividualQuestion", function() {
ok( output2 == expectedoutput2, "Passed!" );
});
/*Test if a question HTML is rendered correctly on the projection page. A question is rendered left or right based on its
*index in the array. An odd indexed question will be on the left of the screen, an even indexed question will be on the right.
****renderProjQuestion1 tests if the question is positioned on the left of the screen.
*/
var expectedoutput3 = "<div class=\"row\">\
<div class=\"col-md-6\">\
<div class=\"row individual-qn\">\
<div class=\"col-md-9\"><h4 class=\"question-wrapper\" id=\"question1\">test question 1</h4></div>\
<div class=\"col-md-3\"><h3><label class=\"label label-danger\">5 votes</label></h3></div>\
</div>\
</div>";
var output3 = renderProjQuestion(question1id, question1, 2);
test( "test renderProjQuestion1", function() {
ok( output3 == expectedoutput3, "Passed!" );
});
/*Test if a question HTML is rendered correctly on the projection page. A question is rendered left or right based on its
*index in the array. An odd indexed question will be on the left of the screen, an even indexed question will be on the right.
****renderProjQuestion2 tests if the question is positioned on the right of the screen.
*/
var expectedoutput4 = "<div class=\"col-md-6\">\
<div class=\"row individual-qn\">\
<div class=\"col-sm-9 col-md-9\"><h4 class=\"question-wrapper\" id=\"question1\">test question 1</h4></div>\
<div class=\"col-md-3\"><h3><label class=\"label label-danger\">5 votes</label></h3></div>\
</div>\
</div>\
</div>";
var output4 = renderProjQuestion(question1id, question1, 3);
test( "test renderProjQuestion2", function() {
ok( output4 == expectedoutput4, "Passed!" );
}); | {
"redpajama_set_name": "RedPajamaGithub"
} | 8,390 |
Q: Origin of "forecast" According to Dictionary.com
forecast[fawr-kast, -kahst, fohr-]
verb (used with object), forecast or forecasted, forecasting.
*
*to predict (a future condition or occurrence); calculate in advance
to forecast a heavy snowfall; to forecast lower interest rates.
*to serve as a prediction of; foreshadow.
*to contrive or plan beforehand; prearrange.
verb (used without object), forecast or forecasted, forecasting.
4.to conjecture beforehand; make a prediction.
5.to plan or arrange beforehand.
noun
6.a prediction, especially as to the weather.
7.a conjecture as to something in the future.
8.the act, practice, or faculty of forecasting.
9.Archaic. foresight in planning.
According to Online Etymology dictionary, fore- has an etymology of Middle-English but Cast doesn't have a known origin. Forecast doesn't have a known origin either.
So what is the origin of the word forecast?
A: Etymonline derives forecast from two English words, fore- and cast.
Fore- is derived by the American Heritage Dictionary of Indo-European Roots from the conjecturally reconstructed PIE per,
Base of prepositions with the basic meanings of "forward", "through"
via conjecturally reconstructed Germanic, *fura, before.
Etymonline identifies cast as cognate with Swedish kasta, Danish kaste, North Frisian kastin, "of uncertain origin". OED 1 provides a few more apparent cognates from North Germanic and invites comparison with
kös (kasu),köstr (:—kastuz), pile, heap thrown up, which has been compared with L. gerĕre (ges-) gestus.
Wiktionary offers a conjecturally reconstructed verb from Proto-Germanic:
from Proto-Germanic *kastōną ("to throw, cast"), of unknown origin.
AHDIER does not index cast, and the online database to Pokorny appears to offer no term from which cast is derived, suggesting that no one has convincingly pushed the origin of cast farther back than common Germanic.
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 2,075 |
Codeline 40E is membrane housing series of 4" diameter with end entry design. This is used for commercial and industrial RO applications. Vessel models are available in operating pressure of 300 PSI, 600 PSI and 1000 PSI. They are made up of epoxy/ glass composite to meet the demands of long term and continuous use in RO processes. Codeline 40E vessels can accommodate any standard 4" membrane element.
The membrane housing of the 40E series is shown in the exploded view below. The parts table contains an explanation of the numbers. Clicking on the enlargement opens a PDF file containing both the exploded view and the parts table.
Quality: read more about our quality certificates.
Multiporting: learn more about multiporting with Codeline pressure vessels.
Older products: click here for more information about older Codeline products.
User Guides: click here for all the Codeline User Guides. | {
"redpajama_set_name": "RedPajamaC4"
} | 1,793 |
Q: Do translation functions like __e() have to take strings in English in themes? I'm developing a theme and curious if strings could be written in a language different from English and still be properly translatable?
What I mean is when using translation functions in a custom theme, e.g. __('string','textdomain') or __e('string','textdomain') can I use language different from English to write the string, for example: __e('строчка','textdomain')?
Or do I have to write everything in English and then provide a translation files for other languages (presumably because theme's default language defaults to the WPLANG setting in wp-config.php)?
Hope someone can clarify this.
A: Yes, you can use any language you want. But if you want your theme to be translated by everyone, you should pick a language that people are likely to know, like English.
If you, for example, care only about former USSR countries, Russian might be as good.
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 245 |
using UnityEngine;
using System.Collections;
public class GazeScaleTo : GazeBehaviour
{
[SerializeField] private Vector3 scale;
[SerializeField] private float speed;
[SerializeField] private Space space;
[SerializeField] private iTween.EaseType easeType;
[SerializeField] private GameObject scaleObject;
private bool hasGaze;
private Vector3 startScale;
void Awake()
{
if ( scaleObject == null ) { scaleObject = gameObject; }
startScale = scaleObject.transform.localScale;
}
protected override void DoGazeEnter( GazeHit hit )
{
iTween.ScaleTo( scaleObject, iTween.Hash(
"name", "gazeScaleTo",
"scale", scale,
"speed", speed
)
);
}
protected override void DoGazeExit( GazeHit hit )
{
iTween.ScaleTo( scaleObject, iTween.Hash(
"scale", startScale,
"speed", speed
)
);
}
protected override void DoGazeStop( GazeHit hit )
{
iTween.StopByName( "gazeScaleTo" );
}
}
| {
"redpajama_set_name": "RedPajamaGithub"
} | 9,127 |
{"url":"http:\/\/www.mathnet.ru\/php\/archive.phtml?wshow=paper&jrnid=mais&paperid=630&option_lang=eng","text":"RUS\u00a0 ENG JOURNALS \u00a0 PEOPLE \u00a0 ORGANISATIONS \u00a0 CONFERENCES \u00a0 SEMINARS \u00a0 VIDEO LIBRARY \u00a0 PACKAGE AMSBIB\n General information Latest issue Archive Impact factor Search papers Search references RSS Latest issue Current issues Archive issues What is RSS\n\n Model. Anal. Inform. Sist.: Year: Volume: Issue: Page: Find\n\n Model. Anal. Inform. Sist., 2018, Volume\u00a025, Number\u00a03, Pages\u00a0312\u2013322 (Mi mais630)\n\nComputational Geometry\n\nOn the Hodge, Tate and Mumford\u2013Tate conjectures for fibre products of families of regular surfaces with geometric genus\u00a01\n\nO.\u00a0V.\u00a0Oreshkina (Nikol'skaya)\n\nA.G. and N.G. Stoletov Vladimir State University, 87 Gorky str., Vladimir, 600000, Russia\n\nAbstract: The Hodge, Tate and Mumford\u2013Tate conjectures are proved for the fibre product of two non-isotrivial 1-parameter families of regular surfaces with geometric genus 1 under some conditions on degenerated fibres, the ranks of the Ne\u0301ron\u2013Severi groups of generic geometric fibres and representations of Hodge groups in transcendental parts of rational cohomology.\nLet $\\pi_i:X_i\\to C\\quad (i = 1, 2)$ be a projective non-isotrivial family (possibly with degeneracies) over a smooth projective curve $C$. Assume that the discriminant loci $\\Delta_i=\\{\\delta\\in C \\vert \\mathrm{Sing}(X_{i\\delta})\\neq\\varnothing\\} \\quad (i = 1, 2)$ are disjoint, $h^{2,0}(X_{ks})=1,\\quad h^{1,0}(X_{ks}) = 0$ for any smooth fibre $X_{ks}$, and the following conditions hold:\n$(i)$ for any point $\\delta \\in \\Delta_i$ and the Picard\u2013Lefschetz transformation $\\gamma \\in \\mathrm{GL}(H^2 (X_{is}, \\mathbb{Q}))$, associated with a smooth part $\\pi'_i: X'_i\\to C\\setminus\\Delta_i$ of the morphism $\\pi_i$ and with a loop around the point $\\delta \\in C$, we have $(\\log(\\gamma))^2\\neq0$;\n$(ii)$ the variety $X_i (i = 1, 2)$, the curve $C$ and the structure morphisms $\\pi_i:X_i\\to C$ are defined over a finitely generated subfield $k \\hookrightarrow \\mathbb{C}$.\nIf for generic geometric fibres $X_{1s}$ and $X_{2s}$ at least one of the following conditions holds:\n$(a)$ $b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s})$ is an odd prime number, $\\quad$ $b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s})\\neq b_2(X_{2s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{2s})$;\n$(b)$ the ring ${\\mathrm{End}}_{\\mathrm{Hg}(X_{1s})} {\\mathrm{NS}}_{\\mathbb{Q}}(X_{1s})^\\perp$ is an imaginary quadratic field, $\\quad b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s})\\neq 4$,\n${\\mathrm{End}}_{\\mathrm{Hg}(X_{2s})} {\\mathrm{NS}}_{\\mathbb{Q}}(X_{2s})^\\perp$ is a totally real field or $b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s}) > b_2(X_{2s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{2s})$;\n$(c)$ $[b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s})\\neq 4, {\\mathrm{End}}_{\\mathrm{Hg}(X_{1s})} {\\mathrm{NS}}_{\\mathbb{Q}}(X_{1s})^\\perp= \\mathbb{Q}$; $b_2(X_{1s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{1s})\\neq b_2(X_{2s})-{\\mathrm{rank}} {\\mathrm{NS}}(X_{2s})$, then for the fibre product $X_1 \\times_C X_2$ the Hodge conjecture is true, for any smooth projective $k$-variety $X_0$ with the condition $X_1 \\times_C X_2$ $\\widetilde{\\rightarrow}$ $X_0 \\otimes_k \\mathbb{C}$ the Tate conjecture on algebraic cycles and the Mumford\u2013Tate conjecture for cohomology of even degree are true.\n\nKeywords: Hodge, Tate and Mumford\u2013Tate conjectures, fibre product, Mumford\u2013Tate group, $l$-adic representation.\n\n Funding Agency Grant Number Russian Foundation for Basic Research 16-31-00266_\u00ec\u00ee\u00eb_\u00e0 This work was supported by the Russian Foundation for Basic Research under the Grant No 16-31-00266.\n\nDOI: https:\/\/doi.org\/10.18255\/1818-1015-2018-3-312-322\n\nFull text: PDF file (698\u00a0kB)\nReferences: PDF file \u00a0 HTML file\n\nUDC: 512.7\n\nCitation: O.\u00a0V.\u00a0Oreshkina (Nikol'skaya), \u201cOn the Hodge, Tate and Mumford\u2013Tate conjectures for fibre products of families of regular surfaces with geometric genus\u00a01\u201d, Model. Anal. Inform. Sist., 25:3 (2018), 312\u2013322\n\nCitation in format AMSBIB\n\\Bibitem{Ore18} \\by O.~V.~Oreshkina (Nikol'skaya) \\paper On the Hodge, Tate and Mumford--Tate conjectures for fibre products of families of regular surfaces with geometric genus~1 \\jour Model. Anal. Inform. Sist. \\yr 2018 \\vol 25 \\issue 3 \\pages 312--322 \\mathnet{http:\/\/mi.mathnet.ru\/mais630} \\crossref{https:\/\/doi.org\/10.18255\/1818-1015-2018-3-312-322} \\elib{http:\/\/elibrary.ru\/item.asp?id=35144413}","date":"2020-01-28 01:15:28","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 1, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 1, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.4100813567638397, \"perplexity\": 1593.1042073713616}, \"config\": {\"markdown_headings\": false, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2020-05\/segments\/1579251737572.61\/warc\/CC-MAIN-20200127235617-20200128025617-00441.warc.gz\"}"} | null | null |
Remembering Jae Scharlin, activist, childbirth educator, private investigator
Crook Sells Access to Data Tool Used by Private Investigators
Private Investigator and TV Personality Craig Case Accused of Conspiracy and Fraud – The Santa Barbara Independent
Family hires private investigator to take over search for missing Lake Carolina kayaker
Private Investigator and TV Personality Craig Case Accused of Conspiracy and Fraud
State Licensure
How to Become a Private Investigator in New Mexico
License Requirements
Private investigators are hired to perform many different types of investigations in New Mexico. A private investigator, for example, may research suspected fraud for a business, find out who is sending criminal threats to a client, and can locate and recover stolen property. It is even possible for private investigators to gather evidence that will be used in courts or by law enforcement officers.
If you're someone interested in a career as a private investigator and live in New Mexico, you will first need to become licensed by the New Mexico Private Investigations Board. Licensure is important as it insures investigators in the state are of the highest quality.
Find schools and get information on the program that's
right for you.
(It's fast and free!)
New Mexico Private Investigator License Requirements
Age: Over the age of 18.
Provisional Requirements: You must be a US citizen with at least a high school diploma.
Criminal Background Check: Applicants will have to submit to, and be able to pass, a background check. For this purpose, you will supply a full fingerprint set to the New Mexico board of commissions.
Discharge from Military: A dishonorable discharge from any of the armed services will not preclude you from being a private investigator.
Financial History: New Mexico does not require a check of your financial standing before receiving a private investigator license.
Mental Health Check/Mental Disease or Defect: A mental health examination is not part of the licensing process in New Mexico.
Insurance Needed: Private investigators in this state must be able to secure a surety bond of at least $10,000.
Automatic Disqualifications: Felony convictions or convictions involving violence or the illegal use/possession of a firearm will prevent you from earning a PI license.
Degree and/or Accepted Experience: New Mexico does not require private investigators to be educated about the high school level. It does, however, mandate work experience. You should have 6,000 hours of work experience in the last five years. This work experience should include investigating crimes and threats, people, stolen property, and evidence that will be used in court.
Written Exams: You will need to pass an exam offered by the New Mexico Regulations and Licensing Department. The exam covers jurisprudence and is twenty-five questions.
New Mexico Private Investigator Training
Although New Mexico requires security managers to undergo certified training, it has no such requirements for private investigators. Instead of a state-certified course, you should consider a degree in a related field from an accredited university. Associate and bachelor's degree programs that serve as a good base for a private investigation careers include criminal justice, forensics, political science, law and investigation techniques.
Forms Needed for a Private Detective License in New Mexico
Fees Required: You will need to pay the New Mexico Private Investigations Board a $400 non-refundable fee. In addition, you will need to pay $44 for the fingerprint set to be used in your background check.
Registration Needed: After earning a passing grade with the jurisprudence exam, you will fill out an application and submit it to the Investigations Board. With your application, the Board needs to receive proof of work experience, two passport-style photos, proof of your age and a copy of your surety bond. Fingerprints will be sent to the Department of Safety.
Maintenance Required for PI License: Private investigator licenses expire on the last day of your birth month. You will need to pay a $300 renewal fee to prevent your license from expiring.
New Mexico Private Investigator Salary
The data provide by the Bureau of Labor Statistics shows that 330 private investigators were working in New Mexico in 2015, which was the last time data was made available. Across the state of New Mexico, the average pay for a private investigator in 2015 was $33,680.
Links to New Mexico State Government Pages or Other State Resources
New Mexico Private Investigations Board
Jurisprudence Exam Sample
BLS Salaries and Employment Information
Private Investigator Programs and Schools in New Mexico
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PrivateInvestigatorLicense.Org is rated 4.8 out of 5 stars based on 2 ratings and 2 user reviews. | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 9,127 |
Q: flutter weather api is'nt work the snapshot.data is showing error Main.dart
import 'package:flutter/material.dart';
import 'package:flutter_application_1/currentWeather.dart';
void main() {
runApp(MyApp());
}
class MyApp extends StatelessWidget {
// This widget is the root of your application.
@override
Widget build(BuildContext context) {
return MaterialApp(
title: 'Flutter Demo',
theme: ThemeData(
primarySwatch: Colors.blue,
),
home: CurrentWeatherPage(),
);
}
}
models/weather.dart
class Weather {
final double temp;
final double feelslike;
final double low;
final double high;
final double description;
Weather({ required this.temp, required this.feelslike, required this.low, required this.high, required this.description});
factory Weather.fromjson(Map<String, dynamic>json) {
return Weather(
temp: json['main']['temp'].toDouble(),
feelslike: json['main']['feels_like'].toDouble(),
low: json['main']['temp_min'].toDouble(),
high: json['main']['temp_max'].toDouble(),
description: json['weather'][0]['description'],
);
}
}
currentWeather.dart
import 'dart:convert';
import 'package:http/http.dart' as http;
import 'package:flutter/material.dart';
import 'package:flutter_application_1/models/weather.dart';
class CurrentWeatherPage extends StatefulWidget{
@override
_CurrentWeatherPageState createState() => _CurrentWeatherPageState();
}
class _CurrentWeatherPageState extends State<CurrentWeatherPage> {
@override
Widget build(BuildContext context) {
return Scaffold(
body: Center(
child: FutureBuilder(
builder: (context, snapshot){
// ignore: unnecessary_null_comparison
if (snapshot != null){
Weather _weather = snapshot.data;
// ignore: unnecessary_null_comparison
if (_weather == null){
return Text("ERROR GETING WEATHER");
} else {
return weatherBox(_weather);
}
} else{
return CircularProgressIndicator();
}
},
future: getCurrentWeather(),
),
),
);
}
Widget weatherBox(Weather _weather){
return Column(
children: <Widget>[
Text("${_weather.temp}°c"),
Text("${_weather.description}"),
Text("${_weather.feelslike}°c"),
Text("H:${_weather.high}°c L:${_weather.low}°c"),
],
);
}
}
Future getCurrentWeather() async {
Weather weather;
String city = "chennai";
String apikey = "safdgfdsgvf";
var url = Uri.parse("api.openweathermap.org/data/2.5/weather?q=$city&appid=$apikey");
final response = await http.get(url);
if (response.statusCode == 200) {
weather = Weather.fromjson(jsonDecode(response.body));
}else {
weather = Weather.fromjson(jsonDecode(response.body));
}
return weather;
}
in currentWeather.dart
Weather _weather = snapshot.data;
snapshot.data is showing error:A value of type 'Object?' can't be assigned to a variable of type 'Weather'.
Try changing the type of the variable, or casting the right-hand type to 'Weather'.dart(invalid_assignment)
how can I solve this error
A: You should convert snapshot.data which is Map<String,String> object to Weather object.
Weather _weatherl = Weather.fromjson(snapshot.data!.data());
// Output of this code is depend on how is your data structured in the database and Weather model you have defined here.
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 9,489 |
Recent statistics from the World Health Organization, WHO, shows that no fewer than a million people die annually from suicide, which represents a global mortality rate of 16 people per 100,000 or one death every 40 seconds. More disturbing also is the fact that there are an estimated 10 to 20 million attempted suicides every year.
This is a menace we must pay attention to. Let us come together and SAY NO TO SUICIDE. Join us this Saturday 7th January 2017.
If you are in Lagos you can be part of the purpose driven generation, a life changing conference for youths and teenagers.
Come and discover what it takes to live a fulfilling year in 2017. | {
"redpajama_set_name": "RedPajamaC4"
} | 5,272 |
Layouts have been carefully thought out to maintain the original colonial structure and spaces allowing for oversize suites and bathrooms.
Restorations have been passionately conducted by the owners using only local craftmen and the finest finishes for the interiors.
Original cotto tiles, walls, fireplaces, porticos and wood burning ovens have been saved and complemented with the highest quality fixtures for bathrooms and kitchens.
The exteriors are a careful mix of environmental and historical awareness; courts and Bisazza design infinity pools allow for a magical dive into the Tuscan countryside. | {
"redpajama_set_name": "RedPajamaC4"
} | 2,968 |
American actor and director
Patricia Bauer
Last Updated: Jul 11, 2019 See Article History
Alternative Title: Forest Steven Whitaker
Forest Whitaker, in full Forest Steven Whitaker, (born July 15, 1961, Longview, Texas, U.S.), American actor and director who was known for his riveting and deeply nuanced portrayals of a wide variety of characters in movies and on television, whether he was in a leading role or playing a minor character.
Whitaker grew up in Los Angeles. He played football in high school and attended California State Polytechnic University, Pomona, on a football scholarship. He later transferred to the University of Southern California, where he studied music and acting. Whitaker first gained wide notice in a small part in the hit teen comedy Fast Times at Ridgemont High (1982). He spent the next several years making guest appearances on TV shows, including Cagney & Lacey and Hill Street Blues, before playing a pool shark who demolishes Fast Eddie Felson (Paul Newman) in Martin Scorsese's film The Color of Money (1986) in what film critic Pauline Kael described as a "brief, startling performance." Whitaker also portrayed the soldier Big Harold in Oliver Stone's harrowing Vietnam War movie Platoon (1986), and he appeared with Robin Williams in Good Morning, Vietnam (1987).
In 1988 Whitaker won the award for best actor at the Cannes film festival for his starring role as jazz great Charlie Parker in Clint Eastwood's biopic Bird. His other notable roles included the captured British soldier who persuades his Irish Republican Army captor to look after his enigmatic girlfriend Dil in The Crying Game (1992), a gay fashion designer in Robert Altman's Prêt-à-Porter (Ready to Wear; 1994), the best friend of the protagonist (played by John Travolta) in Phenomenon (1996), and the unsettling title hit man in Jim Jarmusch's Ghost Dog: The Way of the Samurai (1999).
In the 21st century Whitaker played a police captain in the thriller Phone Booth (2002). He won an Academy Award for best actor in a leading role for his portrayal of the charismatic and brutal Ugandan dictator Idi Amin in The Last King of Scotland (2006). Whitaker was nominated for an Emmy Award for his extended guest role in 2006 as a stroke patient on the TV medical drama series ER. He also was a cast member (2006–07) on the show The Shield and starred in the short-lived series Criminal Minds: Suspect Behavior (2011). Whitaker was praised for his portrayal of White House butler Cecil Gaines in the film Lee Daniels' The Butler (2013), and he later played Colonel Weber in the science fiction movie Arrival (2016), as well as the rebel militant Saw Gerrera in the Star Wars spinoff Rogue One: A Star Wars Story (2016). In 2017 he assumed a recurring role in the TV series Empire, and the following year he appeared in the movies Black Panther, Sorry to Bother You, and Burden.
Get unlimited access to all of Britannica's trusted content. Start Your Free Trial Today
Whitaker also began working as a director in the 1990s. His credits included Waiting to Exhale (1995), based on the 1992 novel by Terry McMillan; Hope Floats (1998); and First Daughter (2004). In addition, he played Erie in a brief 2016 Broadway revival of the short Eugene O'Neill play Hughie.
Patricia Bauer The Editors of Encyclopaedia Britannica
Los Angeles , city, seat of Los Angeles county, southern California, U.S. It is the second most populous city and metropolitan area (after New York City) in the United States. The city sprawls across a broad coastal plain situated between mountains and the Pacific Ocean; the much larger Los Angeles…
Pomona, city, Los Angeles county, southern California, U.S. It lies in the Pomona Valley at the base of the San Gabriel Mountains. Originally inhabited by Gabrielino (Tongva) Indians, the area became the site of the Rancho San José Spanish land grant in the 18th century. Founded in 1875 and promoted…
University of Southern California, private coeducational institution of higher education in Los Angeles, California, U.S. It comprises the College of Letters, Arts, and Sciences, the Graduate School, and 19 professional schools. The university offers undergraduate degrees in about 75 fields and graduate and professional degrees in about 125 disciplines. It…
Cuba Gooding, Jr.
Cuba Gooding, Jr., American actor who was perhaps best known for his scene-stealing performance as a professional football player who is the only loyal client of a sports agent played by Tom Cruise in the blockbuster film Jerry Maguire (1996). Gooding earned an Academy Award for best supporting…
Denzel Washington, American actor celebrated for his engaging and powerful performances. Throughout his career he has been regularly praised by critics, and his consistent success at the box office helped to dispel the perception that African American actors could not draw mainstream white…
July 15, 1961 (age 58)
Academy Award (2007)
related facts and data
Janet Leigh - Facts
Black Panther - Facts
Gene Wilder - Facts
View Facts & Data
directing (movie and theater)
awards - Oscar
AllMovie - Biography of Forest Whitaker
Bruce Springsteen, American singer, songwriter, and bandleader who became the archetypal rock performer…
Walt Disney, American motion-picture and television producer and showman, famous as a pioneer of animated…
Clint Eastwood, American motion-picture actor who emerged as one of the most popular Hollywood stars…
Article Facts & Data Media | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 3,044 |
Q: Upgraded to phonegap 1.1 on Android - now half the screen is half black, half white I've written a simple hello world in PhoneGap 0.9.5.1 for Android which works fine. Recently, I upgraded to 1.1. and I get a half white half black screen (divided horizontally).
Any suggestions?
A: I resolved this by removing
super.init();
from the droidgap activity's onCreate method.
Odd, I read somewhere you needed this for 1.1 to work.
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 742 |
Yesterday, Thursday 23 June 2016, the majority of Slough voters - together with the majority of people in England & Wales - voted to turn their backs on the world's most successful co-operation venture, the European Union.
It was a protest vote against conditions in Britain, fuelled by the semi-drunken rhetoric of Nigel Farrage and by Buffoon Boris' desire to become Prime Minister. They unfairly blamed the EU for everything they could think-of.
Who will they blame next time?
They never cared what 'doubtful-truths' they spoke, deliberate distortions they made and, just like many other (but certainly not all) politicians, they stopped caring as soon as the public had casted their votes.
Hate-the-EU campaign leaders shrug-off all responsibility for the tragedy they knowingly caused. Like most wreckers they optimistically expect someone else will pay the high financial costs, the higher mortgages, the higher bills for food and the other goods we import.
It's doubtful whether the jubilant fanatics will commiserate with those going to loose their jobs, as their organisations relocate to the EU, and those going to loose their homes. It's a bleak prospect but please don't worry, 'cos Hate-the-EU leaders repeatedly said, it should be alright by 2030.
Inevitably one wonders who has the spare cash to hold-out for another 14 years in the forlorn hope that things should be better ?
The weather should be dry tomorrow but often it is not. Hate-the-EU fanatics deceived their gullible supporters whilst knowing their fantasy delusions of a far-away should can never be guaranteed for the deserving masses of this country, England.
Scotland overwhelmingly (62%) voted to remain in the EU. Northern Ireland did too (55.7%) but neither could exceed Gibraltar's 95.91% pro-EU demand.
The tip of the iceberg . . . .
This, Ladies and Gentlemen, is only the tip of the gigantic iceberg going to hit us severely. The damage will be widespread and long-lasting.
It could encourage northern England to join Independent Scotland for prosperity and EU Single Market access.
From Holyrood Parliament to Westminster Parliament = 332 miles.
From Newcastle-upon-Tyne to Westminster = 248 miles but only a tantalising 91 miles from Holyrood.
Halfway between Holyrood and Westminster are Manchester and Leeds.
The break-up of the United Kingdom and Great Britain was inevitable but now the fragmentation of England could be the next surprise.
Why, many people ask, did that calamitous clown David Cameron voluntarily inflict this disaster on the UK when his task was to protect it and nurture it.
Increasingly regarded as a weak coward, Cameron, a glorified Spin Doctor (his only experience outside politics), appeared scared of UKIP before the 2015 parliamentary election. After that election UKIP was nothing and was fading away. There was no compelling need for a UKIP approved referendum yet Cameron gleefully inflicted it on the UK's 4 countries and Gibraltar.
Aloof from people's ordinary lives, our politicians entrusted to defend our nations interest - perhaps befuddled by cheap tax-payers funded booze copiously flowing in the House of Commons bars - failed to contemplate the inevitable consequences when voting to introduce Cameron's referendum.
Why should MPs over the drunk-driving limited be allowed to vote ?
As usual, we - not them - will pay the heavy costs of the politicians' latest mess. | {
"redpajama_set_name": "RedPajamaC4"
} | 7,626 |
package com.helger.photon.tinymce4.supplementary.tools;
import java.io.File;
import java.util.Locale;
import org.slf4j.Logger;
import org.slf4j.LoggerFactory;
import com.helger.commons.io.file.FileSystemIterator;
import com.helger.commons.io.file.FilenameHelper;
import com.helger.commons.io.file.IFileFilter;
public final class MainCreateTinyMCEThemeEnum
{
private static final Logger LOGGER = LoggerFactory.getLogger (MainCreateTinyMCEThemeEnum.class);
public static void main (final String [] args)
{
final StringBuilder aSB = new StringBuilder ();
// Last update: 2013-11-22
for (final File aFile : new FileSystemIterator ("src/main/resources/tinymce-dev/themes").withFilter (IFileFilter.directoryPublic ()))
{
final String sID = FilenameHelper.getBaseName (aFile);
aSB.append (sID.toUpperCase (Locale.US)).append (" (\"").append (sID).append ("\"),\n");
}
LOGGER.info (aSB.toString ());
}
}
| {
"redpajama_set_name": "RedPajamaGithub"
} | 4,707 |
\section{Introduction}\label{sec:intro}
The circular velocity, $V_c(r)= \sqrt{GM(r)/r}$, of a test particle
at a radial distance $r$ from the center of a mass distribution gives a
direct measure of the total gravitational mass, $M(r)$, contained
within that
radius. A measured profile of $V_c$ as a function of $r$ for a spiral
galaxy --- often simply called its Rotation Curve (RC) --- is therefore a
direct probe of the spatial distribution of the total gravitating mass
inside the galaxy including its dark matter (DM) content;
see, e.g., \citet{Sofue_Rubin_RC_rev_2001},
\citet{Trimble_rev_1987} for reviews. Recent comprehensive discussions
of the RC and mass models for our Galaxy, the Milky way, can be found,
e.g., in
\citet{Weber_deBoer_2010,Sofue_GrandRC_2012,Nesti_Salucci_2013}.
Recently, it has been shown that the RC of the Milky Way can be directly
used to derive not only the local density of DM, but also the velocity
distribution of the DM particles in the Galaxy~\citep{BCKM_PRD_2013},
which are crucial for analyzing the results of both direct as well as
indirect DM search experiments \citep{Jungman_etal_PhysRep_1996}; see
also
\citet{CRBM_NewA_2007,CBC_King_JCAP_2010,KB_King_PRD_2012,Burch_Cowsik_2013}.
For this purpose, it is essential to derive the RC of the Galaxy to as
large a galactocentric distance as possible without referring to any
specific model of the DM halo of the Galaxy. In this paper we derive the
RC of the Galaxy spanning a large range of galactocentric distances
starting from its inner regions ($\sim 0.2\,{\rm kpc}$) out to $\sim 200\,{\rm kpc}$
using kinematical data on a variety of tracer objects moving in the
gravitational potential of the Galaxy, without assuming any model of the
DM halo of the Galaxy.
The circular velocity of a test particle in the Galaxy is, of course,
not a directly measured quantity. The RC of the Galaxy has to be
derived from the kinematical as well as positional data
for an appropriate set of tracer objects moving in the gravitational
field of the Galaxy. Except in few cases, the full 3-D velocity
information of the tracers is not available, and the RC has to be
reconstructed from only the measured line-of-sight ({\it los}) velocity and
positional information of various tracer objects in the Galaxy.
For deriving the RC in the disk region of the Galaxy, one usually makes
the reasonable assumption that the disk tracer objects move in circular
orbits around the Galactic center. From the observed
heliocentric {\it los}\ velocities, $v_{\rm h}$, of the tracers and their position
coordinates in the Galaxy, and with an assumed set of
values of the Galactic Constants (GCs), [$R_0, V_0$], where $R_0$
and $V_0$ are the sun's distance from and circular rotation speed
around the Galactic center, respectively, that define the Local
Standard of Rest (LSR) frame, and applying corrections for
the peculiar motion of the sun with respect to the LSR, one can
obtain the circular velocities around the Galactic center, $V_c$, in a
fairly straightforward manner~\citep{Binney_Merrifield_1998}.
Observations on
a variety of tracers such as HI regions, CO emission associated with HII
regions, compact objects like Carbon stars (C stars), Cepheids,
planetary nebulae (PNe), masers, and so on, have been used to derive the
RC of the Galaxy in the disk region. Some recent compilations of RC data
for the disk region of the Galaxy can be found, e.g., in
\citet{Sofue_etal_2009} and \citet{Burch_Cowsik_2013}.
To derive the RC in the outer regions of the Galaxy beyond the Galactic
disk, one has to rely on distant tracers like Blue Horizontal Branch
(BHB) stars, K Giant (KG) stars and relatively rare tracer objects like
Globular Clusters (GCl), dwarf spheroidal (dSph) galaxies and so forth
which populate the Milky Way's extended DM halo out to
galactocentric distances of several hundreds of kpc. Unlike the disk
tracers, these non-disk tracers do
not exhibit any systematic motion, and move about in the Galaxy along
various different orbits. The standard approach then is to assume that
the tracer population under consideration is isotropically
distributed in the halo of the Galaxy and then use the Jeans
equation~\citep{Binney_Tremaine_2008} for spherical systems relating the
circular velocity $V_c$ at radius $r$ to the number density and
galactocentric radial as well as transverse velocity dispersions of the
tracers at that radius. Of course, in absence of full 3-D velocity
information, with only the observed radial velocity dispersion
available, the RC constructed using Jeans equation depends on the
unknown velocity anisotropy parameter $\beta\equiv
1-\sigma_t^2/2\sigma_r^2$ ($\sigma_r$ and $\sigma_t$ being the radial and
transverse velocity dispersions of the tracers, respectively; see
section \ref{sec:nondisk} below).
The Jeans equation approach has been used in several recent studies to
extend the RC of the Galaxy to distances beyond the extent of the
Galaxy's stellar disk. Accurate measurements of {\it los}\ velocities of a
sample of 2401 BHB stars drawn from SDSS DR6
\citep{SDSS-DR6} were used by \citet{Xue_etal_2008} to derive the RC
of the Galaxy to $\sim 60\,{\rm kpc}$ for two constant ($r$-independent) values
of $\beta$, namely $\beta=0$ (isotropic velocity distribution) and
$\beta=0.37$, the
latter derived from results of numerical simulations. More recently, the
Jeans equation has also been employed, together with certain analytical
models of the phase-space distribution
function of the tracer population, to construct the RC of the Galaxy to
various distances of $\sim$ 25 to $\sim$ 80 kpc
\citep{Gnedin_etal_2010,Deason_etal_2012a,Kafle_etal_2012}.
A crucial ingredient in the derivation of the distant RC using
Jeans equation is the measured radial velocity dispersion of the tracers
as a function of their galactocentric distance $r$. An important finding
in this regard is the result, first shown by
\citet{Battaglia_etal_2005_2006}, that the radial
velocity dispersion remains almost constant at a value of $\sim
120\km\s^{-1}$ out to $\sim 30\,{\rm kpc}$ and then steadily {\it declines} down to
a value of $\sim 50\km\s^{-1}$ at $r\sim120\,{\rm kpc}$. In
their work \citet{Battaglia_etal_2005_2006} used a heterogeneous sample
of about 240 halo objects consisting of field blue horizontal branch
stars, red giant stars, globular clusters and distant
satellite galaxies. Similar trend of the radial
velocity dispersion profile has been found in several subsequent studies
using different samples of tracers, e.g., by
\citet{Xue_etal_2008,Brown_etal_2010,Gnedin_etal_2010,Deason_etal_2012a,Deason_etal_coldveil_2012b},
and most recently in large cosmological simulations by
\citet{Rashkov_etal_eris_2013}.
In this paper we consider a combination of currently available
largest samples of a variety of both disk and non-disk tracers to
construct the RC of the Galaxy from $\sim 0.2\,{\rm kpc}$ to $\sim200\,{\rm kpc}$. We
perform detailed analysis of the dependence of the RC on
the choice of the GCs and also the dependence on the anisotropy parameter
$\beta$ of the non-disk tracers. We find that, while the RC in the disk
region is significantly influenced by the choice of the GCs, the dominant
uncertainty in the RC at large distances beyond the stellar disk comes
from the uncertainty in the value of $\beta$. Since currently not much
reliable observational information on $\beta$ is available, in this
paper we calculate the circular velocities using Jeans equation
with the velocity anisotropy $\beta$ of the tracers taken as (a) a
radially constant free parameter varying over a possible range of values
from $\beta=0$ (corresponding to complete isotropy of the tracers'
orbits) to $\beta=1$ (corresponding to completely radial orbits of the
tracers), (b) a radially varying $\beta$ of the Osipkov-Merritt (OM) form
\citep[see][p.297-298]{Binney_Tremaine_2008} given by
$\beta(r)=(1+r_a^2/r^2)^{-1}$, with $r_a$ the ``anisotropy radius", and
(c) a radial profile of $\beta$
obtained from a recent large high resolution
hydrodynamical simulations of formation of late-type spirals like our
Galaxy~\citep{Rashkov_etal_eris_2013}.
We find that, irrespective of the value of $\beta$, the mean RC steadily
declines with $r$ beyond $r\sim 60\,{\rm kpc}$. The circular speed
at a given radius decreases as $\beta$ is increased (i.e., as the
tracers' orbits are made more radially biased). Thus, the lowest value
of the rotation speed at any $r$ obtains for the case of complete radial
anisotropy ($\beta=1$) of the non-disk tracers. This fact allows us to
set a lower limit on the total mass of the Galaxy, $M(r)$, within
a radius $r$, giving $M(200\,{\rm kpc})\geq
(6.8\pm4.1)\times10^{11}M_\odot$. In this context, it may be noted
that the recent numerical simulation study of
\citet{Rashkov_etal_eris_2013} indicates
an increasingly radially biased velocity ellipsoid of the Galaxy's
stellar population at large distances, with stellar orbits tending to be
purely
radial ($\beta\to 1$) beyond $\sim 100\,{\rm kpc}$. If this behavior of
$\beta$ is confirmed by future observational data, then the above lower
limit on the Galaxy's mass (obtained from our results with $\beta=1$) may
in fact be a good estimate of the actual mass of the Galaxy out to
$\sim 200\,{\rm kpc}$.
The rest of this paper is arranged as follows. In Section
\ref{sec:disk} we derive the RC on the disk of the Galaxy up to a
distance of $\sim20\,{\rm kpc}$ from the Galactic center. We specify the
various tracer samples used in our derivation of the RC and study
the dependence of the RC on the chosen set of values of the GCs,
[$R_0, V_0$]. In Section \ref{sec:nondisk} we extend the RC to
larger
distances (up to $\sim 200 \,{\rm kpc}$) by an extensive analysis of various
non-disk tracer samples discussed there in details. Finally, in
Section \ref{sec:combined_vc}, we present our unified RC and our
estimates of the total mass of the Galaxy within $\sim 200\,{\rm kpc}$
and conclude by summarizing our main results in Section
\ref{sec:summary}.
\section{Rotation curve from disk tracers}\label{sec:disk}
Let us consider a tracer object with Galactic coordinates ($l,~b$) at a
heliocentric distance $r_{\rm h}$ and observed heliocentric {\it los}\ velocity
$v_{\rm h}$ (see Figure \ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}).
\input{Fig_coordinates_a_axes_b_TPM_clr.txt}
We shall assume that the tracer follows a nearly circular orbit about
the Galactic center. The velocity of the tracer as would be measured by
an observer stationary with respect to the LSR, $v_{\rm LSR}$, can be obtained
from the measured $v_{\rm h}$ through the relation
\begin{equation}
v_{\rm LSR}=v_{\rm h}+U_\odot\cos b \cos l + V_\odot\cos b \sin l + W_\odot \sin b\,,
\label{eq:vh2vlsr}
\end{equation}
where $(U_\odot, V_\odot, W_\odot)$ denote the peculiar motion of the
sun with respect to LSR; see Figure \ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}.
In our calculations below we shall take $(U_\odot, V_\odot, W_\odot) =
(11.1,~12.24,~7.25)$ ($\km\s^{-1}$) \citep{Schonrich_etal_pecvel_2010}.
Simple algebraic steps then allow us to relate the desired circular
velocity with respect to Galactic center rest frame, $V_c$, to $v_{\rm LSR}$
as \citep{Binney_Merrifield_1998}
\begin{equation}
V_c(R)=\frac{R}{R_0}~\left[\frac{v_{\rm LSR}}{\sin l \cos b} +
V_0\right]\,,
\label{eq:vlsr2vc}
\end{equation}
where, $R$ is the projection of the galactocentric distance $r$ onto the
equatorial plane,
\begin{equation}
R=\sqrt{R_0^2 + r_{\rm h}^2 \cos^2 b - 2 R_0 ~r_{\rm h} \cos b \cos l}\,.
\label{eq:rh2R}
\end{equation}
For a given set of GCs, $[R_0,V_0]$, the Cartesian coordinates of the
tracer are given by
\begin{eqnarray}
x & = & r_{\rm h} ~\cos b ~\sin l \,,\nonumber \\
y & = &R_0-r_{\rm h}~\cos b~\cos l\,, \label{xyz_general}
\\
z &= &r_{\rm h}~\sin b\,,\nonumber
\end{eqnarray}
with Galactic center at the origin and sun lying on the Galactic
mid-plane ($z=0$) with coordinates $(x,y,z) = (0,R_0, 0)$ as
illustrated in the left panel of Figure
\ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}.
Hence, for known ($l,~b,~r_{\rm h},~v_{\rm h}$) one can
solve for $V_c$ from Equation (\ref{eq:vlsr2vc}) for a given set of GCs.
{\it Tangent Point Method} (TPM) : For $R<R_0$, one can calculate
$V_c$ by the simple tangent point method \citep{Binney_Merrifield_1998}
as follows: Along a given {\it los},\ the maximum {\it los}\ velocity will occur
for the tracer closest to the Galactic center, with the {\it los}\ tangent to
the circular orbit of the tracer at that point (see right panel of
Figure \ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}). This maximum {\it los}\
velocity, called the terminal velocity ($v_t$), is easily seen to be
related to $V_c$ through the relation
\begin{equation}
V_c(R_t)= \left|v_{t, {\rm LSR}}(R_t)+V_0 \sin l\right|\,, ~~~(b=0)\,,
\label{eq:vc_tangent}
\end{equation}
where
\begin{equation}
R_t = |R_0~\sin l|
\label{eq:R_tangent}
\end{equation}
is the distance of the tangent point from the Galactic center, and
$v_{t, {\rm LSR}}$ is the $v_t$ corrected for the sun's peculiar motion as in
Equation (\ref{eq:vh2vlsr}).
For non zero galactic latitude ($b$), Equation (\ref{eq:vc_tangent})
generalizes to:
\begin{equation}
V_c(R_t)= \left|\frac{v_{t, {\rm LSR}}(R_t)}{\cos b} + V_0~\sin l\right|\,,
\label{eq:vc_tangent_b}
\end{equation}
and in this case the Cartesian coordinates of the tracer are given by
\begin{eqnarray}
x &=&R_0~\sin l~\cos l \,, \nonumber \\
y &=& R_0~\sin^2 l\,, \label{eq:vc_tangent_xyz}
\\
z &=& R_0 ~\cos l ~\tan b\,.\nonumber
\end{eqnarray}
Hence the circular velocity $V_c$ can be calculated
directly from the measured terminal velocity by using
Equation (\ref{eq:vc_tangent_b}).
The details of the disk tracer samples used in this paper along with
references to
the corresponding data sources for each tracer genre are given in
the Appendix (Table \ref{Table:Disk_samples}).
The cuts on $l$ and $b$ are adopted from
the published source papers. Towards the Galactic center ($l\to
0\textdegree$) or
anti-center ($l\to180\textdegree$), we expect $v_{\rm LSR}$ to approach zero
to prevent unphysical $V_c$ values there [see
Equation (\ref{eq:vlsr2vc})]. However, $v_{\rm LSR}$ observations in practice
have finite values due to contamination from non circular motions
dominant there. Therefore, additional restrictions have been applied on
$l$ ranges so as to ensure that we avoid observations too close to
Galactic center (anti-center) regions. We further impose a cut to
keep only the tracers whose $|z| \leq 2 \,{\rm kpc}$ and $ R \leq 25 \,{\rm kpc}$ so
as to ensure that the selected tracers `belong' to the stellar disk of
the Galaxy. The $x$--$y$ and $l$--$z$ scatter plots for the selected
disk tracers listed in Table \ref{Table:Disk_samples} are shown in
the Appendix (Figures \ref{Fig:Fig_disk_xy_scatter_clr} and
\ref{Fig:Fig_disk_lz_scatter_clr}, respectively).
It is clear from Equations (\ref{eq:vlsr2vc}) --
(\ref{eq:vc_tangent_xyz})
that the RC depends on the set of values of the GCs
([$R_0, V_0$]) adopted in the calculation. Values of $R_0$ in the
range $\sim (7 - 9)
\,{\rm kpc}$ and $V_0$ in the range $\sim (180 - 250)\km\s^{-1}$ exist in
literature \citep[see,
e.g.,][]{Reid_1993_r0_8,Olling_M_1998_GC_range,Ghez_etal_2008_r0,Reid_etal_2009_VLBI_maser,MB_2010,Sofue_etal_2011_GC,Brunthaler_etal_2011_r0_v0,Schonrich_2012_r0_v0}.
Actually, the ratio $V_0/R_0 = (A - B)$, $A$ and $B$ being the
Oort constants \citep[see, e.g.,][]{Binney_Merrifield_1998}, is
considerably better constrained. Maser observations and
measurements of stellar orbits around SgrA* near the Galactic center
report values of $(A-B)$ in the range from about 29 to 32
$\km\s^{-1}\,{\rm kpc}^{-1}$
\citep{Reid_Brunthaler_2004_GC_ratio_sgA_pm,Reid_etal_2009_VLBI_maser,MB_2010}.
RCs have been traditionally presented with the IAU
recommended set of values, $\GCset_{\rm IAU} = [8.5, 220]$, for which,
however, the ratio $V_0/R_0 = 25.9$ is outside the range of values
of this ratio mentioned above. A recently suggested set of
values of $[R_0, V_0]$, consistent with observations of
masers and stellar orbits around SgrA* mentioned above, is $\GCset =
[8.3, 244]$ \citep[see, e.g.,][]{Bovy_etal_2009,Gillessen_etal_2009}.
In general, as easily seen from Equation (\ref{eq:vlsr2vc}), given a RC,
$V_c(R)$, for a certain set of values of $[R_0, V_0]$, one can
obtain the new RC, $\tilde{V}_c(R)$, for another set of values of the GCs
denoted by $[\tilde{R}_0, \tilde{V}_0]$ through the relation
\begin{equation}
\tilde{V}_c(R) =
\frac{R_0}{\tilde{R}_0} \left[V_c(R) -
\frac{R}{R_0}\left(V_0 - \tilde{V}_0\right)\right]\,.
\label{eq:v_rescale}
\end{equation}
In order to illustrate the dependence of the RC on the
choice of the GCs, in this paper we shall calculate RCs with three
different sets
of values of $\GCset$, namely the set [8.3, 244] mentioned above as well
as two other sets, the IAU recommended set [8.5, 220] and
the set [8.0, 200] \citep{Sofue_GrandRC_2012}.
\input{Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr.txt}
Figure \ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr} shows our
calculated RCs for the disk region of the Galaxy. The left panel of
Figure \ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr} shows the
RCs for each of the different tracer samples listed in
Table \ref{Table:Disk_samples} for the GCs set $\GCset = [8.3, 244]$, and
the right panel shows the RCs obtained by taking the weighted averages
of the combined $V_c$ data from all the samples shown in the left panel,
for three different sets of values of the GCs as indicated.
The circular velocities and their errors for
individual disk tracer samples displayed in the
left panel of Figure \ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr} are
obtained in the following way: For each tracer object in a given sample
we calculate $V_c$ and $R$ for the object from the known position
coordinates of the object and its measured {\it los}\ velocity as
described above. We then bin the resulting data ($V_c$ vs.~$R$) in $R$,
and in each $R$ bin calculate the mean of all the $V_c$ values of all
the objects contained within that bin and assign it to the mean $R$
value of the objects in that bin. The error bars on $V_c$
correspond simply to the standard deviation (s.d.) of the $V_c$ values
in that bin~\footnote{Note that the {\it los}\ velocities $v_{\rm h}$ of
individual tracer objects are measured fairly accurately and
their measurement errors contribute negligibly little to the final
errors on the $V_c$ values.}. We have taken a bin size of 0.25 kpc for
$0<R\leq 1\,{\rm kpc}$, 1.0 kpc for $1<R\leq 15\,{\rm kpc}$, and
2.5 kpc for $15<R\leq 17.5\,{\rm kpc}$. The objects with $R> 17.5\,{\rm kpc}$ are
few in number and are placed in one single bin. The above choices
of the bin widths in $R$ for various ranges of $R$, arrived
at by trial and error, are ``optimal" in the sense that the bin widths
are large enough so that there are sufficient number of objects
in each bin (to allow the mean value of $V_c$ in the bin to be a
reasonably good representative of the true value of $V_c$ at the value
of $R$ under consideration), while at the same time being not too large
as to miss the fine features of the RC. The RCs
in the right panel of Figure
\ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr} are obtained by
combining the $V_c$ data from all the samples shown in the left
panel in the same $R$ bins as above and then calculating the mean
circular speed ($V_c$) and its $1 \sigma$ uncertainty ($\Delta V_c$)
within each bin by the standard weighted average method
\citep{Bevington_3rdEd_2003}:
\begin{equation}
V_c = \frac{\sum_i w_i V_{c,i}}{\sum_i w_i}\,, {\rm \hskip 0.5cm
and
\hskip 0.5cm}
\, \Delta V_c = \sqrt{\frac{1}{\sum_i w_i}}\,,
\label{eq:weighted_av}
\end{equation}
with $w_i = 1/(\Delta V_{c,i})^2$, where $V_{c,i}$ and $\Delta V_{c,i}$
are the $V_c$ value and its $1\sigma$ error, respectively, of the
$i$-th data point within the bin.
As seen from Figure \ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr}, the
RC in the disk region depends significantly on the choice of GCs. As
expected, at any given $R$ the circular velocity is higher for higher
value of $V_0$.
\section{Rotation curve from non-disk tracers}
\label{sec:nondisk}
In order to extend the RC beyond the Galactic disk we next consider
tracer objects populating the stellar halo of the Galaxy. Unlike the
nearly circularly rotating disk tracers the non-disk tracers do not
exhibit any systematic circular motion. Hence the formalism described
in the previous section cannot be used to derive the RC at large
galactocentric distances beyond the Galactic disk. Instead,
we use the Jeans equation~\citep[see,
e.g.,][p.349]{Binney_Tremaine_2008} for spherical systems relating the
number density and radial as well as transverse velocity
dispersions of the tracers at radius $r$ to the circular velocity $V_c$
at that radius:
\begin{equation}
V_c^2(r) = \frac{GM(r)}{r} = - \sigma^2_r
\left(\frac{d\lnn_{\rm tr}}{d\ln r}
+ \frac{d\ln\sigma^2_r}{d\ln r} + 2\beta\right)\,.
\label{eq:Jeans_eqn}
\end{equation}
Here $r=\left(R_0^2 + r_{\rm h}^2 - 2 R_0 ~r_{\rm h} \cos b \cos
l\right)^{1/2}$ is the galactocentric radial distance of a tracer (see
Figure \ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}), and $n_{\rm tr}$, $\sigma_r$
and $\beta$ are, respectively, the number density of the tracer
population, their galactocentric radial velocity dispersion, and the
velocity anisotropy parameter, at $r$. The velocity anisotropy $\beta$
is defined as
\begin{equation}
\beta=1-\frac{\sigma_t^2}{2\sigma_r^2}\,,
\label{eq:beta_anisotropy_parameter}
\end{equation}
where $\sigma_t$ is the galactocentric transverse velocity
dispersion of the tracers.
In this work we have chosen two independent classes of
non-disk stellar tracers, namely, a sample of 4985 Blue Horizontal
Branch (BHB) stars from SDSS-DR8 compiled
by \citet{Xue_etal_BHB_SDSS_DR8_2011} and a set
of 4781 K Giant (KG) stars from SDSS-DR9
\citep{Xue_etal_KGiants_SDSS_DR9_2012}. These two samples allow us to
probe the Galactic halo up to a galactocentric distance of $\sim 100
\,{\rm kpc}$. In order to reach out further we
consider an additional heterogeneous (Hg) sample of 430
objects comprising of 143 Globular Clusters (GCl)
\citep{Harris_GCl_2010_1996}, 118 red halo giants (RHG)
\citep{Carney_etal_2003_2008}, 108 field blue horizontal branch (FHB) stars
\citep{Clewley_etal_2004}, 38 RR-Lyrae stars (RRL)
\citep{Kinman_etal_2012}, and 23 dwarf spheroidals (dSph)
\citep{McConnachie_DG_2012}. To ensure that the sample comprises of
only halo objects, we apply a cut on the $z$ and $R$ coordinates of the
tracers, leaving out objects with $r<25\,{\rm kpc}$ in all the non-disk tracer
samples mentioned above. After these cuts, we are left with a ``BHB"
sample of 1457 blue horizontal branch stars, a ``KG" sample of 2227
K-giant stars and a ``Hg" sample of 65 objects comprising of 16 GCls,
28 FHB stars and 21 dSphs, with which we shall
construct our RC for the non-disk region. The last sample allows us to
extend the RC to a galactocentric distance of 190 kpc, the mean $r$ of
the objects in the furthest radial bin in the Hg sample. The spatial
distributions of the three final non-disk tracer samples (after position
cuts mentioned above) in terms of
$x$-$z$, $y$-$z$ and $x$-$y$ scatter plots are shown in the Appendix
(Figure \ref{Fig:Fig_nondisk_scatter_BHB_KG_HS_clr}).
The number density of the tracers, $n_{\rm tr}$, appearing in the Jeans
equation (\ref{eq:Jeans_eqn}) is estimated in the following way. We
radially bin the objects in a given sample and estimate the
tracer density from the star counts in the annular volume of each bin
and assign it at the mean radius of the objects contained within
that bin. In order to ensure a reasonably good number of objects per bin
we adopt a variable bin size increasing with distance. For the BHB
sample, a uniform bin size of 2 kpc is used over its entire range of $r$
from 25 to 55 kpc. For the KG samples, the bin widths are 2 kpc for
$25\,{\rm kpc} < r \leq 55\,{\rm kpc}$ and 4 kpc for $55\,{\rm kpc} < r \leq 103\,{\rm kpc}$;
objects with $r > 103\,{\rm kpc}$ (up to 110 kpc) are all placed in one single
bin. For the Hg sample, because of the relatively small total number
(65) of objects, we adopt the following optimal, ``object wise" binning
in increasing order of the galactocentric distance $r$ of the objects:
the first 6 radial bins contain 8 objects in each bin; the next 2 bins
contain 6 objects in each bin; and, finally, the remaining 5 objects are
placed in one single bin. Uncertainties in the number density estimates
are obtained from Poissonian errors on the tracer counts in each bin.
The resulting density estimates for the three
samples mentioned above with the GCs set $\GCset=[8.3,244]$ are shown in
Figure \ref{Fig:Fig_ntr_8.3_a_compare_bcd_powfits_clr}, where we also show
for comparison (see the top left panel of Figure
\ref{Fig:Fig_ntr_8.3_a_compare_bcd_powfits_clr}) the tracer densities from
some earlier studies that used different tracer samples. Our results are
seen to be in reasonably good agreement with those obtained in the
previous studies.
\input{Fig_ntr_8.3_a_compare_bcd_powfits_clr.txt}
We then perform power-law fits ($n_{\rm tr} (r) \propto r^{-\gamma}$) to
the radial profile of the tracer number density for each of the three
samples separately. The resulting best power-law fits are also shown in
Figure \ref{Fig:Fig_ntr_8.3_a_compare_bcd_powfits_clr}. The values of the
parameters of the best power-law fit for each tracer sample are given
in Table \ref{Table:nd_n_sigma_fit_params_bf}. Within
each sample, there is no significant difference in the values of
$n_{\rm tr}$ for the three different sets of GCs, as also seen from the
values of the power-law fit parameters given in Table
\ref{Table:nd_n_sigma_fit_params_bf}.
Next, we have to calculate the galactocentric radial velocity
dispersion, $\sigma_r$, that appears in the Jeans equation
(\ref{eq:Jeans_eqn}), for our non-disk samples. To do this we first
transform the observed heliocentric {\it los}\ velocity, $v_{\rm h}$, of each
individual tracer object to $v_{\rm GSR}$, the velocity that would be measured
in the Galactic Standard of Rest (GSR) frame. This is
easily done by correcting for the circular motion of the LSR
$(V_0)$ and
solar peculiar motion with respect to LSR, $(U_\odot, V_\odot, W_\odot)$
(see Figure \ref{Fig:Fig_coordinates_a_axes_b_TPM_clr}):
\begin{eqnarray}
v_{\rm GSR} & = & v_{\rm h}+ U_\odot\cos b \cos l + V_\odot \cos b \sin l
\nonumber \\
& \, \, & + W_\odot
\sin b +V_0~\cos b ~\sin l\,.
\label{eq:vh2vgsr_nd}
\end{eqnarray}
For large samples like the BHB and KG stars described above, we
calculate the $v_{\rm GSR}$ for all the individual tracers in the same radial
bins as used in the estimation of the tracers' number density described
above, calculate their dispersion, $\sigma_{\rm GSR}$, and assign it to the
mean radius of all the tracers contained within that bin. The
corresponding uncertainty, $\Delta\sigma_{\rm GSR}$, in our estimate of
$\sigma_{\rm GSR}$ in each bin is calculated by using the standard formula
$\Delta\sigma_{\rm GSR} = \sqrt{1/[2(N-1)]}\sigma_{\rm GSR}$
\citep{LC_sigma_error_1998,EHP_sigma_error_1993,GKP_sigma_error_1994},
where $N$ is the number of objects in the bin.
For the Hg sample, however, owing to its small size, we follow a
different method, similar to that used in
\citet{Battaglia_etal_2005_2006}, for calculating the $\sigma_{\rm GSR}$ and
its uncertainty in each radial bin: we
randomly generate a sample of 10,000 mock values of $v_{\rm h}$ for each
tracer object in a radial bin using a Gaussian centered at the observed
value of $v_{\rm h}$ and a width of typically $\sim (10 - 20)\%$ of this $v_{\rm h}$
value. We then transform these 10,000 $v_{\rm h}$ values for
each tracer in the bin to get the corresponding 10,000 values of $v_{\rm GSR}$
using equation (\ref{eq:vh2vgsr_nd}), and calculate the associated
dispersions $\sigma_{\rm GSR}$ in that bin. We assign the mean
value of the $\sigma_{\rm GSR}$ values for all the
objects in a given bin to the mean radius of all the objects
in the bin. The corresponding uncertainty in $\sigma_{\rm GSR}$ is taken
to be the r.m.s. deviation of the $\sigma_{\rm GSR}$ values in that bin.
Our results for $\sigma_{\rm GSR}$ for the three tracer samples are shown in
Figure~\ref{Fig:Fig_sigmatr_8.3_a_compare_bcd_powfits_clr} in which
we also show for comparison (see the top left panel of Figure
\ref{Fig:Fig_sigmatr_8.3_a_compare_bcd_powfits_clr}) the $\sigma_{\rm GSR}$ values
obtained in some earlier studies using different samples, which, again,
are seen to be in reasonably good agreement with our results.
\input{Fig_sigmatr_8.3_a_compare_bcd_powfits_clr.txt}
The other three panels of
Figure~\ref{Fig:Fig_sigmatr_8.3_a_compare_bcd_powfits_clr}
show the best power-law fits ($\sigma_{\rm GSR} (r) \propto r^{-\alpha}$)
to the radial profiles of $\sigma_{\rm GSR}$ for each of the three non-disk
samples. The values of the parameters of the best power-law fits for the
three tracer samples are given in Table
\ref{Table:nd_n_sigma_fit_params_bf}.
Again, as in the case of $n_{\rm tr}$, the effect of variation of the
Galactic Constants on $\sigma_{\rm GSR}$ is negligible.
Finally, the galactocentric radial velocity dispersion, $\sigma_r$, can
be obtained from $\sigma_{\rm GSR}$ by using the relation
\citep{Battaglia_etal_2005_2006}
\begin{equation}
\sigma_r=\frac{\sigma_{\rm GSR}}{\sqrt{1-\beta H(r)}}\,,
\label{eq:sigmagsr2sigmar}
\end{equation}
where
\begin{equation}
H(r) = \frac{r^2+R_0^2}{4r^2}
-\frac{\left(r^2-R_0^2\right)^2}{8r^3R_0}
\ln\frac{r+R_0}{r-R_0}\,,
\quad \quad (r>R_0)
\label{eq:H_r}
\end{equation}
and $\beta$ is the velocity anisotropy of the tracers defined in
equation (\ref{eq:beta_anisotropy_parameter}). Equation
(\ref{eq:sigmagsr2sigmar})
is derived by decomposing the $v_{\rm GSR}$'s into their galactocentric
radial and transverse components and taking the averages of the squares
of the velocity components.\footnote{Note that equation (3) given in
the 2005 paper of \citet{Battaglia_etal_2005_2006} is incorrect. The
correct equation, same as equation (\ref{eq:sigmagsr2sigmar}) above, is
given in the 2006 (Erratum) paper of \citet{Battaglia_etal_2005_2006}
and also in \citet{Dehnen_etal_2006}.}
The last quantity that remains to be specified before we can solve the
Jeans equation (\ref{eq:Jeans_eqn}) is the velocity anisotropy
parameter, $\beta$, of the tracers. There is not much definite
observational information available on the value of $\beta$ of the
tracers because of the lack of availability of proper motion
measurements on sufficiently large number of tracer objects. In
general $\beta$ can be a function of $r$. A recent maximum
likelihood analysis \citep{Deason_etal_2012a} of radial velocity data of
a large sample of halo stars, performed within the context of a model
for the (in general anisotropic) velocity distribution function of the
halo stars, indicates the stellar velocity anisotropy being radially biased
with a value of $\beta\sim 0.5$ for $r$ from $\sim$ 16 kpc up to $r\sim
48 \,{\rm kpc}$. This is also indicated by the recent results
from the large numerical simulation study of
\citet{Rashkov_etal_eris_2013},
which finds the velocity distribution of the Galaxy's stellar
population at large $r$ to be radially biased ($\beta > 0$) with
stellar orbits tending to purely radial ($\beta \to 1$) at $r\mbox{\raisebox{-.6ex}{~$\stackrel{>}{\sim}$~}}
100\,{\rm kpc}$. Based on these considerations, to explore various
possibilities for $\beta$, in this paper we shall
calculate our RCs for (a) three representative constant
values of $\beta$, namely, $\beta=0$ (isotropic), 0.5 (mildly radially
biased anisotropy), and 1 (fully radially anisotropic), (b) a radially
varying $\beta$ of the OM form
\citep[see][p.297-298]{Binney_Tremaine_2008} given by
$\beta(r)=(1+r_a^2/r^2)^{-1}$, $r_a$ being the ``anisotropy radius",
and (c) a radial profile of $\beta$
obtained from the recent large high resolution
hydrodynamical simulations done by \citet{Rashkov_etal_eris_2013}. In
principle, $\beta$ and its radial profile may be different for
different tracer samples. But since
currently no reliable measurements of
$\beta$ for the different samples extending to large galactocentric
distances are available, any choice of different $\beta$ for different
samples would be necessarily arbitrary. For simplicity, therefore, we
assume the same values of $\beta$ and its radial profile for our
three tracer samples.
\input{Table_nd_n_sigma_fit_params_bf.txt}
With $n_{\rm tr}$, $\sigma_r$ and $\beta$ thus specified, we can now
proceed to solve the Jeans equation (\ref{eq:Jeans_eqn}) to obtain
the $V_c$
profiles for the three different tracer samples described above. For
each tracer sample we calculate the $V_c$'s in the same radial bins as
used in calculating the $n_{\rm tr}$'s and $\sigma_{\rm GSR}$'s, and the best-fit
power-law forms of $n_{\rm tr}$ and $\sigma_{\rm GSR}$ described above are used
for calculating the radial derivatives appearing in the Jeans equation
(\ref{eq:Jeans_eqn}). The corresponding $1\sigma$ error, $\Delta V_c$,
on $V_c$ within each radial bin is calculated from those of $n_{\rm tr}$
and $\sigma_{\rm GSR}$ in the bin by standard quadrature.
\newpage
\input{Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr.txt}
\newpage
The resulting RCs for the three tracer samples are shown in Figure
\ref{Fig:Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr}.
As clear from the left panels of Figure
\ref{Fig:Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr}
the RCs for
different choices of GCs almost overlap, thus indicating that the
RC at large galactocentric distances beyond a few tens of
kpc is fairly insensitive to the precise values of the GCs.
Instead, the main uncertainty in the RC comes from the unknown value of
the tracers' velocity anisotropy parameter $\beta$, as evident from the
right panels of Figure
\ref{Fig:Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr}.
As expected,
the lowest rotation speeds obtain for the most radially biased velocity
anisotropy ($\beta=1$).
\section{Combined rotation curves to $r\sim200\,{\rm kpc}$}
\label{sec:combined_vc}
\input{Fig_vcfull_samplecollapse_a_dgc_0.0_log_b_8.0_0.0_log_sofue12_clr.txt}
\noindent We now combine the rotation curves obtained from disk and
non-disk tracers (Figures
\ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr}
and \ref{Fig:Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr}) to
construct the rotation curve of the Galaxy up to $\sim 200
\,{\rm kpc}$.
\input{Fig_vcfull_8.3_dbeta_linear_bm_a_below50kpc_b_above50kpc_clr.txt}
For the disk region ($r<25 \,{\rm kpc}$) we take the averaged $V_c$ data
for a chosen set of GCs from the
right panel of Figure \ref{Fig:Fig_vc_disk_a_samples_8.3_b_coll_dgc_clr}.
For the non-disk region ($r\geq 25\,{\rm kpc}$), we combine the $V_c$ data from
Figure
\ref{Fig:Fig_vc_nd_diff_samples_leftcol_dgc_beta0_rightcol_8.3_dbeta_clr}
for the
three tracer samples in every 2 kpc radial bins and calculate the
resulting mean circular speed ($V_c$) and its $1 \sigma$ uncertainty
($\Delta V_c$) within a bin by weighted averaging
as described in section \ref{sec:disk} [see equation
(\ref{eq:weighted_av})].
The resulting rotation curves for $\beta=0$ and three sets of values
of the GCs are shown in Figure
\ref{Fig:Fig_vcfull_samplecollapse_a_dgc_0.0_log_b_8.0_0.0_log_sofue12_clr},
and
those for different values of $\beta$, for one particular set of GCs,
$\GCset=[8.3,244]$, are shown in Figure
\ref{Fig:Fig_vcfull_8.3_dbeta_linear_bm_a_below50kpc_b_above50kpc_clr}.
For comparison,
we also show in Figure
\ref{Fig:Fig_vcfull_8.3_dbeta_linear_bm_a_below50kpc_b_above50kpc_clr}
estimates of circular velocities at specific values of $r$
obtained from a variety of independent considerations in some earlier
studies by various authors.
The $\beta$ dependence of the radial profile of the cumulative mass,
$M(r)=r V_c^2(r)/G$, is shown in Figure
\ref{Fig:Fig_mr_8.3_dbeta_bm_clr}. Again, estimates of $M(r)$ from
various independent considerations and given at
certain specific values of $r$ in some earlier works, are also shown in
Figure \ref{Fig:Fig_mr_8.3_dbeta_bm_clr} for comparison.
Note that the lowest mass of the
Galaxy corresponds to $\beta=1$, which
allows us to set a lower limit on the mass of the Galaxy,
$M(\sim200\,{\rm kpc})\geq (6.8\pm4.1)\times 10^{11}M_\odot$.
\input{Fig_mr_8.3_dbeta_bm_clr.txt}
In Figure
\ref{Fig:Fig_vcfull_grand_8.3_a_linear_R13_OM_inset_b_log_R13_NScomp_clr}
we show the full rotation curve of the Galaxy out to $\sim 200\,{\rm kpc}$ for
$\GCset=[8.3,244]$ and for a radial profile of the non-disk tracers'
velocity anisotropy parameter $\beta$ of the OM form,
$\beta(r)=(1+r_a^2/r^2)^{-1}$, for two different values of
$r_a=$ 15 kpc and 70 kpc. In addition, we show the RC generated with a
$\beta$ profile extracted from Figure 2 of
\citet{Rashkov_etal_eris_2013} with the corresponding numerical data in
tabular form given in Table
\ref{Table:RC_data_Rashkov_beta_8.3_244}. The inset in the left panel of
Figure
\ref{Fig:Fig_vcfull_grand_8.3_a_linear_R13_OM_inset_b_log_R13_NScomp_clr}
shows the OM $\beta$ profile for various values of $r_a$ as well as the
$\beta$ profile obtained in \citet{Rashkov_etal_eris_2013}. The latter
is seen to roughly follow the OM form and is
reasonably well bracketed within OM $\beta$ profiles with $r_a=15\,{\rm kpc}$
and $r_a=70\,{\rm kpc}$. In Figure
\ref{Fig:Fig_vcfull_grand_8.3_a_linear_R13_OM_inset_b_log_R13_NScomp_clr}
we also show the circular
velocity data from terminal velocities and rotation curve
fits for the Burkert and NFW models of the DM halo of the Galaxy given
in \citet{Nesti_Salucci_2013} (up to $\sim 100\,{\rm kpc}$) in comparison with
our RC generated with the $\beta$ profile
of \citet{Rashkov_etal_eris_2013}.
\input{Fig_vcfull_grand_8.3_a_linear_R13_OM_inset_b_log_R13_NScomp_clr.txt}
\input{Table_RC_data_Rashkov_beta_8.3_244.txt}
As already mentioned, a noticeable feature of the
rotation curve, irrespective of the velocity anisotropy of the
tracer objects, is its clearly declining nature beyond about $\sim$60
kpc, as would be expected of an effectively finite size of the dark
matter halo of the Galaxy.
We emphasize that, for any given $\beta$, the rotation curve and
mass profile of the Galaxy shown in
Figures
\ref{Fig:Fig_vcfull_8.3_dbeta_linear_bm_a_below50kpc_b_above50kpc_clr}
and
\ref{Fig:Fig_mr_8.3_dbeta_bm_clr}, respectively, are based entirely
on
observational data, and are obtained without making any models of the
mass distributions of the various components (the bulge, disk and dark
matter halo) of the Galaxy.
\section{Summary}
\label{sec:summary}
In this paper, we have constructed the rotation curve (RC) of the Galaxy
from a galactocentric distance of $\sim 0.2\,{\rm kpc}$ out to $\sim200\,{\rm kpc}$ by
using kinematical data on a variety of both disk and non-disk objects
that trace the gravitational potential of the Galaxy,
without assuming any theoretical models of the visible and dark
matter components of the Galaxy. We have studied
the dependence of the RC on the choice of the Galactic
constants (GCs) and also studied the dependence on the velocity
anisotropy parameter $\beta$ of the non-disk tracers. The RC in the
disk region is found to depend significantly on the choice of values
of the GCs. The rotation curve at large distances beyond
the stellar disk, however, depends more significantly on the parameter
$\beta$ than on the values of the GCs. In general, the
mean RC is found to steadily decline beyond $r\sim 60\,{\rm kpc}$, irrespective
of the value of $\beta$. At any given galactocentric distance $r$, the
circular speed is lower for larger values of $\beta$. Considering that
the largest allowed value of $\beta$ is unity (complete radial
anisotropy), this allows us to set a model-independent lower limit on
the total mass
of the Galaxy, giving $M(\mbox{\raisebox{-.6ex}{~$\stackrel{<}{\sim}$~}} 200\,{\rm kpc})\geq
(6.8\pm4.1)\times10^{11}M_\odot$. We have also noted
that recent results from high resolution hydrodynamical simulations of
formation of galaxies like Milky Way \citep{Rashkov_etal_eris_2013}
indicate an increasingly radially biased velocity ellipsoid of the
Galaxy's stellar population at large distances, with stellar orbits
tending to be almost purely radial ($\beta\to 1$) beyond $\sim
100\,{\rm kpc}$. This implies that the above lower
limit on the Galaxy's mass (obtained from our results with $\beta=1$) may
in fact be a good estimate of the actual mass of the Galaxy out to
$\sim 200\,{\rm kpc}$.
\acknowledgements We thank G.~Battaglia, W.~Brown, A.~Deason,
O.~Gnedin, P.~Kafle, S.~Sharma, Y.~Sofue, M.~Weber, and X.~Xue for
useful communications. PB thanks R.~Cowsik for discussions
and for support under a Clark Way Harrison Visiting Professorship at the
McDonnell Center for the Space Sciences and Physics Department at
Washington University in St. Louis. We thank the anonymous referee for
useful comments and suggestions.
\vfill\eject
\newpage
\input{refs.txt}
\vfill\eject
\newpage
\vskip2cm
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 1,111 |
\section{Introduction}
\label{sec:intro}
Deep Learning has had great impact across a broad variety of areas such as computer vision, natural language processing and automatic speech recognition (ASR) over the past several years. It is also the driving force behind the current Artificial Intelligence (AI) technologies that have achieved unprecedented success in a wide spectrum of applications. ASR is one of the first areas that witnessed performance breakthroughs using deep learning techniques \cite{Hinton_DNNSPM}. Models that employ deep architectures are dominant in today's ASR systems that are ubiquitous in our everyday life, for instance, Google's voice search, Amazon's Alexa, Apple's Siri and IBM's Watson speech-to-text service. On some datasets, the word error rates (WERs) of high-performance ASR can even achieve human parity \cite{Saon_2017HumanParity}\cite{Xiong_ASRParity}.
The high performance of deep learning heavily relies upon large amounts of training data and high computational power. For instance, the amount of training speech data for ASR nowadays can easily reach thousands of hours, is often tens of thousands of hours, and some tasks even utilize as much as one million hours \cite{Parthasarathi_PetaAM}. Moreover, deep neural networks (DNNs) can have tens of millions of parameters or more. Without an appropriate distributed training strategy, training such models with deep architectures using this order of magnitude of data may take months to finish on a single GPU. Therefore, it is critical to investigate strategies that can speed up the training and reduce the turn-around time to an acceptable level. In this context, distributed learning has been demonstrated to be a very effective approach for training speedup. Over the years, various distributed machine learning strategies have been proposed and applied to different tasks. Distributed training of acoustic models as a branch of distributed machine learning has a lot in common with other domains such as computer vision in terms of algorithmic and system design. However, it also has characteristics unique to the ASR domain. Therefore, directly borrowing techniques from other domains may not give the best training performance for ASR. In the speech community, distributed acoustic modeling has been an active research topic. Notable work includes parameter server (PS) based synchronous training \cite{Seide_ParaSGD}\cite{Chen_BMUF}, PS based asynchronous training \cite{Heigold_DistDNN}\cite{Heigold_DistSeq} and decentralized asynchronous training \cite{Zhang_ADPSGDSWB}\cite{Zhang_DDLASR}.
This tutorial will review commonly-used techniques for distributed training of acoustic models. We will first walk through some fundamentals of parallel stochastic gradient descent (SGD), high performance computing (HPC) architectures and deep acoustic modeling which are the foundation of the current large-scale distributed training. We will then present an in-depth investigation of several distributed strategies including synchronous/asynchronous and centralized/decentralized schemes and discuss their pros and cons. In particular, an emphasis is put on the interplay between computation and communication, which is the most important factor to design a successful distributed training strategy. Experiments are carried out on the 2000-hour Switchboard (SWB2000) dataset \cite{Godfrey_SWB}\cite{Cieri_Fisher}, one of the most widely-used public benchmark datasets in the speech community \cite{Saon_2017HumanParity}\cite{Xiong_ASRParity}. We will conclude by analyzing the performance of various strategies. In particular, we will show that the asynchronous decentralized parallel SGD (AD-PSGD) algorithm recently proposed by IBM has achieved one of the best speedup performance to date on this dataset.
\vspace{-0.2cm}
\section{Optimization with SGD}
\label{sec:sgd}
\vspace{-0.1cm}
\subsection{Algorithm}
\label{sec:alg}
Most of the machine learning problems that employ DNNs are optimized using SGD. Suppose $\mathcal{X} \subseteq \mathbb{R}^{d_{x}}$ is the input space and $\mathcal{Y} \subseteq \mathbb{R}^{d_{y}}$ is the output space of a supervised learning problem. We want to estimate a function $h$ with parameters $w$ that maps the input to the output
\vspace{-0.1cm}
\begin{align}
h(w;x): \mathcal{X} \rightarrow \mathcal{Y}. \vspace{-0.3cm}
\end{align}
A loss function $f(h(w;x),y)$ is used to measure the closeness between the prediction $h(w;x)$ and label $y$ where $x \in \mathcal{X}$ and $y \in \mathcal{Y}$. A risk function $F(w)$ given parameters $w$ is defined as the expected loss over the underlying joint distribution $p(x,y)$:
\vspace{-0.2cm}
\begin{align}
F(w) = \mathbb{E}_{(x,y)}[f(h(w;x),y)] \triangleq \mathbb{E}_{\xi}[f(w,\xi)] \label{eqn:risk} \vspace{-0.3cm}
\end{align}
where $\xi \thicksim p(x,y)$ is a random variable on data $(x,y)$. We want to choose parameters $w$ that minimize $F(w)$
\vspace{-0.2cm}
\begin{align}
w^{*} = \operatornamewithlimits{argmin}_{w} F(w). \label{eqn:minrisk} \vspace{-0.3cm}
\end{align}
In practice, we only have access to a set of $n$ training samples $\{(x_{i},y_{i})\}_{i=1}^{n}$. Accordingly, we minimize the following empirical risk
\vspace{-0.2cm}
\begin{align}
F(w) = \frac{1}{n} \sum_{i=1}^{n}f(w,(x_{i},y_{i})) \label{eqn:emprisk} \vspace{-0.3cm}
\end{align}
where $\xi$ assumes the empirical data distribution.
When it comes down to large-scale optimization of DNNs in Eq.\ref{eqn:minrisk}, SGD is the dominant technique in deep learning due to its computational efficiency and competitive performance over other more complex optimization algorithms \cite{Bottou_SGD}. SGD solves the optimization problem of Eq.\ref{eqn:minrisk} iteratively. A basic SGD update formula is given by Eq.\ref{eqn:mbsgd}
\begin{align}
w_{k+1} & = w_{k} - \alpha_{k}\cdot\left[\frac{1}{M}\sum_{m=1}^{M} \nabla f(w_{k};\xi_{k,m})\right] \label{eqn:mbsgd}
\end{align}
where $w_{k}$ are the parameters after iteration $k$, $\alpha_{k}$ the learning rate and $\nabla f(w_{k};\xi_{k,m})$ the gradient evaluated at $w_{k}$ using the data samples denoted by the random variable $\xi_{k,m}$. There are $M$ samples randomly drawn from the whole $n$ training samples to form a so-called mini-batch. Their aggregated gradient is considered a ``noisy'' version of the true gradient $\nabla F(w)$ and hence a stochastic approximation \cite{Robbins_SA} of the deterministic gradient descent method. Therefore it is often referred to as the mini-batch based SGD and $M$ is the batch size. Besides the basic SGD algorithm given in Eq.\ref{eqn:mbsgd}, a variety of variants have been proposed in literature to improve its convergence properties where Adagrad \cite{Duchi_adagrad}, Adam \cite{Kingma_adam} and Nesterov acceleration \cite{Nesterov_NAG} are among the most notable ones. These SGD variants have found varied degrees of success in different applications. In this paper, for the tutorial purpose and for the ease of discussion, we will focus on the basic SGD form in Eq.\ref{eqn:mbsgd}.
\vspace{-0.3cm}
\subsection{Training Strategies}
\label{sec:strageties}
Strategies of distributed machine learning can be broadly categorized into the follow families:
\paragraph{data parallel vs. model parallel}
Data parallelism distributes mini-batches of data onto a number of learners (e.g. a GPU or CPU) with each learner having a copy of the model. The computation is carried out on each learner in parallel using the data before the system aggregates the statistics in some fashion. Sometimes, the model is too large to fit into the memory of one single learner. Under this condition, model parallelism is used to split the model across the learners with each learner only having a partial model. The output of one learner is used as the input of another learner to conduct the computation of the full model. Although model parallelism is used in some scenarios \cite{Seide_ParaSGD}, data parallelism is the dominant distributed strategy in practice in today's distributed learning community \cite{Jia_ImageNet4mins}\cite{Chen_BMUF}\cite{Heigold_DistDNN}.
\paragraph{single node vs. multiple nodes}
A node refers to a physical device (e.g. a server) in a computer network. Distributed training on a single node is a straightforward setup where all learners (e.g. GPUs) stay within one machine with a shared memory. The communication among the learners is reliable and it can give a moderate speedup. Therefore, it is still a reasonable option for distributed training of DNNs. Obviously it has the limitation of the capability of scaling out and the number of learners is limited to the hardware configuration of the machines. Multiple-node distributed training has a number of machines (nodes) to form a cloud or cluster where learners use shared memory for local communication within the node and message passing over the network for internode communication. It has become the norm for recent large-scale distributed training.
\paragraph{centralized vs. decentralized}
Centralized distributed training relies on a central PS and all learners only communicate with the PS for model updates. Decentralized setting has no PS and all learners form a network of certain topology (e.g. a ring). All learners are in an equal position in terms of computation and communication. Centralized distributed training is commonly used in practice in many of the machine learning applications. However, it imposes a large communication bottleneck to the PS as the hub when the number of learners is large. Decentralized distributed training, on the other hand, has an advantage on the communication bandwidth and is becoming more and more popular.
\paragraph{synchronous vs. asynchronous}
Distributed training algorithms can be run in synchronous or asynchronous mode. Under synchronous mode, gradient computation and model update are synchronized with each other. Model update is carried out after all learners finish local gradient computation. Under asynchronous mode, however, the synchronization between the gradient computation and model update is removed and learners receive their mini-batches as needed depending on their computation and communication speed, which significantly reduces the idle time relative to the synchronous mode.
In what follows, we will focus on data-parallel multiple-node distributed acoustic modeling since it is the most popular distributed setting nowadays. We will present an in-depth investigation of its behavior in centralized/decentralized configurations under synchronous/asynchronous modes.
\vspace{-0.3cm}
\subsection{HPC Architecture}
\label{sec:hpc}
Distributed computing aims at parallelizing execution among independent computational resources (e.g. processors). A parallel program consists of three components: (1) The parallel part that can be carried out in parallel, for example, gradient computation. (2) The sequential part that can not be parallelized. For example, the summation of gradients or models can only be accomplished after the gradients or models are in place. (3) The communication portion that passes information between computational resources, for instance, gradient/weight transfer among learners. Assuming communication cost is zero, Amdahl's law states that the speedup of a parallel program is bounded by $\frac{1}{1-p}$, where $p$ is the portion of the parallelizable part of the program. For the SGD algorithm, the parallel part dominates the sequential part. Hence $p$ is very close to 1 and very high speedups can be achieved in principle. As a result, the fundamental limiting factor to achieve linear speedup in this case is the communication cost.
A typical distributed training system, as depicted in Fig.\ref{fig:hpc}, has the following hardware components: data storage, memory, processing units (CPU/GPU) and the network. Data communication follows this path: Each learner loads input data from data storage under storage bandwidth constraint to main memory. It conducts data-preprocessing using the CPU before sending it to GPU via CPU-GPU databus for model training. When the gradient computation is finished, the gradients are sent to the PS or other learners under the constraint of network bandwidth. Typical bandwidth of storage systems ranges from 1-10 MB/s (network file system) to 100MBs/s (hard disk drives, HDD), to 300-500MB/s (solid state drive, SSD), to several GB/s (non-volatile memory express (NVMe) SSDs). Typical main memory bandwidth is of several tens of GB/s. Typical CPU-GPU databus bandwidth ranges from 16GB/s one way (e.g. PCI-e 3rd gen) to 50GB/s one way (e.g. IBM Power 9 Nvlink). Typical network bandwidth ranges from 100MB/s (e.g. 1Gb Ethernet) to 10GB/s (e.g. 100Gb Ethernet, RDMA). A high-end HPC cluster (e.g. SUMMIT supercomputer) usually is equipped with NVMe SSDs, NVlinks and 100Gb Ethernet (or higher) to enable fast communication. On the computation side, the key deciding factor is FLOPS. Typical high-end CPUs run at hundreds of GFLOPS to 1 TFLOPS and typical high-end GPUs run at 10 TFLOPs or higher. System programmers use concurrent programming, usually achieved by multi-threading, to overlap communication with computation. In synchronous mode, data-loading and data-processing can be overlapped with gradient computation. In asynchronous mode, all communication paths (i.e. data-loading, data preprocessing, CPU-GPU data transfer, and gradients/weights transfer) can be overlapped with gradient computation. Ideally, we wish to pursue perfect overlap between communication and computation. In practice, the communication that cannot be overlapped by computation is the limiting factor in achieving linear speedup. One of the important tasks in designing distributed learning is to maximize the overlap between the two. \vspace{-0.5cm}
\begin{figure}[tbh]
\centering
\includegraphics[width=6cm, height=5cm]{fig1_hpc.png}
\caption{Components and data flow in an HPC environment for distributed training.}\label{fig:hpc}\vspace{-0.7cm}
\end{figure}
\section{Acoustic Modeling in ASR}
\label{sec:am}
Suppose $X = \{x_{1}, x_{2}, \cdots, x_{m}\}$ is a sequence of acoustic features and $W = \{w_{1}, w_{2}, \cdots, w_{n}\}$ is a sequence of words. ASR systems find the most likely word sequence $W$ given the observed acoustic feature sequence $X$:
\begin{align}
W^{*} = \operatornamewithlimits{argmax}_{W} P(W|X) = \operatornamewithlimits{argmax}_{W} \frac{P(X|W)P(W)}{P(X)} \label{eqn:asr}
\end{align}
This is illustrated in Fig.\ref{fig:asr}. There are four major components in an ASR system. A feature extractor converts a speech waveform into a sequence of acoustic feature vectors (e.g. logMel features). An acoustic model computes the probability that a particular word sequence can produce the observed acoustic features, $P(X|W) = P(x_{1}, x_{2}, \cdots, x_{m} | w_{1}, w_{2}, \cdots, w_{n})$. A language model computes the probability of a particular word sequence, $P(W)= P(w_{1}, w_{2}, \cdots, w_{n})$. Finally, there is a decoder which searches for the best word sequence $W^{*}$ that maximizes Eq.\ref{eqn:asr}.
\begin{figure}[tbh]
\centering
\includegraphics[width=9.5cm, height=2.2cm]{fig2_asr.png}
\caption{Components of an ASR system.}\label{fig:asr}\vspace{-0.7cm}
\end{figure}
In this article, we consider DNN acoustic models based on a hidden Markov model (HMM) structure, often referred to as DNN-HMM. HMMs are probabilistic automata that are commonly used for modeling sequences of variable length such as speech. Under this structure, words are represented as strings of speech sounds, called "phones". Each phone is represented by an HMM with numerous states. Since a phone can be affected by its context (i.e. phones immediately before and after it), modern ASR systems use the so-called context-dependent (CD) phones. The HMM states of each CD phone are clustered using a decision tree based on their acoustic similarity. This gives rise to a large number of CD HMM states as fine-grained phone classes for acoustic modeling. In DNN-HMMs, the output of the DNNs after the topmost softmax represents a set of posterior probabilities corresponding to each of the CD HMM states \cite{Dahl_CDDNN}. Modern acoustic models use either CNNs or recurrent networks the most popular of which are LSTMs \cite{Saon_2017HumanParity}\cite{Xiong_ASRParity}. Training of acoustic models involves optimizing the DNNs under an appropriate objective function. In ASR, frame-based cross-entropy (CE) \cite{Hinton_DNNSPM} and sequence-based loss functions such as state-level minimum Bayes error (sMBR) \cite{Kingsbury_Seqtrain} are commonly used for optimization. In recent years, end-to-end (E2E) ASR systems based on connectionist temporal classification (CTC) \cite{Graves_CTC} or encoder-decoder \cite{Chan_LAS} structures are also drawing attention in the speech community. This tutorial will use the LSTM-based DNN-HMM acoustic models trained with the CE criterion to investigate the distributed training strategies in ASR as they are most representative. But the techniques presented are applicable in principle to other models and training criteria as well.
\section{Distributed Training of Acoustic Models}
\label{sec:dist_am}
\subsection{Unique Characteristics}
\label{sec:char}
DNN acoustic models have distinct characteristics from other domains (e.g. computer vision) in terms of distributed training. A DNN-HMM acoustic model typically has a softmax layer with a large number of output CD phone classes \cite{Xiong_ASRParity}\cite{Saon_2017HumanParity}\cite{Dahl_CDDNN} which are usually on the order of magnitude of 10,000. Moreover, the distribution of speech samples across phone classes is hugely uneven. In addition, the input feature space is relatively more structured for speech signals. Therefore, the DNN acoustic models are usually shallower than those in vision. Table \ref{tab:modelcomp} shows the configurations of two representative DNN models for speech and vision tasks, a 50-layer ResNet model for the ImageNet image recognition task and a 6-layer LSTM model for the Switchboard ASR task. The ResNet model has a smaller model size even with more convolutional layers due to parameter sharing and local connectivity. However, the convolutional operation is computationally expensive, which results in a longer computing time for each batch. On the other hand, the LSTM model for the speech task has a bigger model but the computation is faster. Overall, the optimization of an acoustic model has a lighter computational load but a heavier communication load relative to the vision models. This \textbf{high communication/computation ratio} imposes a major challenge for distributed training of DNN acoustic models.
\begin{table}[tbh]
\centering
\begin{tabular}{l|c|c|c|c|c} \hline
& model & layers & output & size & computation/batch \\ \hline\hline
vision & ResNet & 50 & 1,000 & $\sim$ 100MB & $\sim$ 0.18 sec \\ \hline
speech & LSTM & 8 & 32,000 & $\sim$ 165MB & $\sim$ 0.07 sec \\ \hline
\end{tabular}\vspace{0.2cm}
\caption{Model comparison between speech and computer vision. A ResNet model is used for the ImageNet task and an LSTM model is used for the SWB2000 task. The last column shows the seconds used to compute a batch of size 32 on a P100 GPU.}\label{tab:modelcomp}\vspace{-0.7cm}
\end{table}
\subsection{Centralized Distributed Training}
\label{sec:centralized}
Centralized distributed training has a PS serving as a hub in the network, as illustrated in Fig.\ref{fig:csgd}. The PS has the global view of the model and all learners only communicate with the PS. Each learner pulls the model from the PS. The computation of gradients is carried out local on each learner, after which the gradients are pushed back to the PS. The PS collects the statistics from the learners and updates the model accordingly, depending on whether the implementation is synchronous or asynchronous.
\begin{figure}[ht]
\centering
\begin{subfigure}{.4\textwidth}
\centering
\includegraphics[width=5cm, height=4.5cm]{fig3a_csgd.png}
\caption{centralized}\label{fig:csgd}
\end{subfigure}
\hspace{1cm}
\begin{subfigure}{.4\textwidth}
\centering
\includegraphics[width=5cm, height=4.5cm]{fig3b_dsgd.png}
\caption{decentralized}\label{fig:dsgd}
\end{subfigure}
\caption{Centralized distributed training with a parameter server (left) and decentralized distributed training without a parameter server where communication takes place among the learners (right).}\vspace{-0.7cm}
\end{figure}
Consider the SGD iteration given in Eq.\ref{eqn:mbsgd}. Suppose each mini-batch $M$ is evenly split onto $L$ learners with each learner $l$ having a batch size of $M_{l}=M/L$.
\subsubsection{Synchronous Parallel SGD}
Under synchronous parallel SGD, each learner $l$ pulls model $w_{k}$ from the PS, computes the local gradient \vspace{-0.2cm}
\begin{align}
g^{(l)}(w_{k}, \xi_{k}) = \frac{1}{M_{l}}\sum_{m=1}^{M_{l}} \nabla f(w_{k};\xi_{k,m}) \label{eqn:ccsgd_g} \vspace{-0.2cm}
\end{align}
and then pushes $g^{(l)}(w_{k}, \xi_{k})$ back to the PS.
The PS will wait until all $L$ learners finish their local gradient computation to aggregate them up for model update \vspace{-0.2cm}
\begin{align}
w_{k+1} = w_{k} - \alpha_{k} \cdot \left[\frac{1}{L}\sum_{l=1}^{L} g^{(l)}(w_{k}, \xi_{k})\right] \label{eqn:ccsgd_w} \vspace{-0.2cm}
\end{align}
Note that all learners use the same copy of the model $w_{k}$ for the computation of $g^{(l)}(w_{k}, \xi_{k})$ which is consistent with the global copy of the model residing on the PS. Eqs. \ref{eqn:ccsgd_g} and \ref{eqn:ccsgd_w} give the same update as Eq.\ref{eqn:mbsgd}. Synchronous parallel SGD is the most reliable implementation of SGD in a distributed setting and shares the same convergence property. Synchronous SGD may suffer from the well-known ``straggler" problem because the PS has to wait for the slowest learner. This synchronization cost limits the overall speedup. Nevertheless, because of its simplicity, centralized synchronous distributed training of acoustic models is still popular in the speech community. Representative work includes \cite{Seide_ParaSGD}\cite{Chen_BMUF} form Microsoft, \cite{Parthasarathi_PetaAM} from Amazon, \cite{Hannun_Deepspeech} from Baidu. The global model updates can be conducted either through gradient aggregation \cite{Seide_ParaSGD}\cite{Hannun_Deepspeech} or model averaging \cite{Chen_BMUF}. One of the notable work among them is a strategy based on blockwise model-update filtering (BMUF) \cite{Chen_BMUF} proposed by Microsoft, which is a variant of synchronous SGD. Under BMUF, data is partitioned into blocks. Each worker updates its local model in parallel using SGD. Instead of performing direct model averaging, the global model is updated using block-level stochastic optimization by synchronizing local models from all learners based on the block momentum. Good performance has been reported by Microsoft on large-scale distributed acoustic modeling and has also been used by Amazon to train DNN acoustic models using one million hours of data \cite{Parthasarathi_PetaAM}.
\subsubsection{Asynchronous Parallel SGD}
Under asynchronous parallel SGD, each learner $l$ pulls model $\hat{w}_{k}$ from the PS and computes the local gradient \vspace{-0.2cm}
\begin{align}
g^{(l)}(\hat{w}_{k}, \xi_{k}) = \frac{1}{M_{l}}\sum_{m=1}^{M_{l}} \nabla f(\hat{w}_{k};\xi_{k,m}) \label{eqn:casgd_g} \vspace{-0.2cm}
\end{align}
then pushes $g^{(l)}(\hat{w}_{k}, \xi_{k})$ back to the PS.
The PS will update the model right after receiving the gradient from learner $l$ \vspace{-0.2cm}
\begin{align}
w_{k+1} = w_{k} - \alpha_{k} \cdot g^{(l)}(\hat{w}_{k}, \xi_{k}) \label{eqn:casgd_w} \vspace{-0.2cm}
\end{align}
In this case there may exist inconsistency between the model $w_{k}$ on the PS and the model $\hat{w}_{k}$ pulled by learner $l$ for the computation of its local gradient \vspace{-0.2cm}
\begin{align}
\hat{w}_{k} = w_{k-\tau}, \ \ \ \ \tau \geq 0 \vspace{-0.2cm}
\end{align}
This is because the model on the PS may have been updated by other learners while learner $l$ is still computing its local gradients. This inconsistency is often referred to as staleness. Asynchronous parallel SGD, with the synchronization removed between the learner and server, can significantly reduce the idle time and improve the speedup. It does not have the ``straggler" problem and can automatically balance the workload among the fast and slow learners. Nevertheless, the incurred staleness may hurt convergence and eventually the learning performance.
In the speech community, centralized asynchronous distributed training of acoustic models has also been being used \cite{Heigold_DistDNN}\cite{Heigold_DistSeq}. Downpour SGD based on the DistBelief framework \cite{Dean_LargeDistNN}, proposed by Google, is a representative application. Distributed training ranging from multilingual acoustic modeling \cite{Heigold_DistDNN} to sequence acoustic modeling \cite{Heigold_DistSeq} has been reported using this strategy to deliver good performance. Downpour SGD is a variant of asynchronous SGD. It divides the data into blocks and distributes them onto multiple learners. Each learner keeps a local copy of the model and uses it to carry out computation in parallel. They independently push the updates to the PS, which keeps the current state of model, and then pull the updated model from PS. The PS itself is sharded across multiple machines and each shard is only responsible for updating part of the model. Downpour SGD introduces asynchrony to both local learners and PS shards and has been shown to be robust to machine failure during training. But centralized asynchronous distributed training may be bothered by the potential large staleness issue in general and it is challenging to have a good parallelization efficiency and convergence behavior.
\subsection{Decentralized Distributed Training}
\label{sec:decentralized}
Centralized distributed training relies on a PS to communicate with all the learners. All the communication takes place between the server and the learners and there is no communication among the learners. This introduces a high communication cost at the PS, which is proportional to the number of learners, and will eventually hurt the scaling of the training. A PS does not necessarily need to be realized as a physical server or sharded servers \cite{Dean_LargeDistNN}. It can also be conceptually realized via the allreduce operation \cite{Patarasuk_Allreduce} based on message passing. In HPC terminology, an operation is a ``reduce" operation if it is commutative and associative (e.g. summation). Allreduce is the operation that reduces all the elements and broadcasts the reduction results to each participant. Decentralized distributed training does not require a centralized server to support the communication. Fig.\ref{fig:dsgd} shows how decentralized SGD works. The learners form a network by connecting with each other following some topology (e.g. a ring). Each learner keeps a local copy of the model and carries out gradient computation and model updates locally. The updated local model is then propagated to other learners in the network typically via model averaging.
Consider the centralized data parallel SGD setting of Eq.\ref{eqn:mbsgd} under synchronous mode. Suppose each learner pulls the model from the PS, evaluates the gradient using batch size $M_{l}$ and updates the model locally \vspace{-0.2cm}
\begin{align}
w^{(l)}_{k+1} & = w_{k} - \alpha_{k}\cdot\left[\frac{1}{M_{l}}\sum_{m=1}^{M_{l}} \nabla f(w_{k};\xi_{k,m})\right] \vspace{-0.2cm}
\end{align}
Then we average models across all the learners \vspace{-0.2cm}
\begin{align}
w_{k+1} = \frac{1}{L}\sum_{l=1}^{L}w^{(l)}_{k+1} = w_{k} - \alpha_{k}\cdot\left[\frac{1}{M}\sum_{m=1}^{M} \nabla f(w_{k};\xi_{k,m})\right] \label{eqn:c2de} \vspace{-0.2cm}
\end{align}
which shows that given the basic SGD in Eq.\ref{eqn:mbsgd} one-step model averaging and gradient averaging are equivalent. Eq.\ref{eqn:c2de} also provides a way to create a decentralized implementation of centralized SGD where all learners form a ring and the PS is replaced by a global model averaging carried out by the allreduce operation using reduction (sum) followed by broadcast.
In general, the mathematical model of data parallel decentralized SGD is given by Eq.\ref{eqn:dsgd}: \vspace{-0.2cm}
\begin{align}
\mathbf{W}_{k+1} = \mathbf{W}_{k} \cdot \mathbf{T} - \alpha_{k} \cdot g(\mathbf{\Phi}_{k},\bm{\xi}_{k}) \label{eqn:dsgd} \vspace{-0.2cm}
\end{align}
where, for $l = 1, \dots, L$, \vspace{-0.2cm}
\begin{itemize}
\item $\mathbf{W}_{k} = [w^{\scriptit{(1)}}_{k}, \dots, w^{\scriptit{(l)}}_{k}, \dots, w^{\scriptit{(L)}}_{k}]$ is a matrix with each column containing model parameters in each learner $l$ at iteration $k$
\item $\mathbf{T}$ is a mixing matrix for the model averaging pattern among learners given a network topology
\item $\mathbf{\Phi}_{k} = [\hat{w}^{\scriptit{(1)}}_{k}, \dots, \hat{w}^{\scriptit{(l)}}_{k}, \dots, \hat{w}^{\scriptit{(L)}}_{k}]$ is a matrix with each column containing model parameters used for computing gradient in each learner $l$ at iteration $k$
\item $\bm{\xi}_{k} = [\xi^{\scriptit{(1)}}_{k}, \dots, \xi^{\scriptit{(l)}}_{k}, \dots, \xi^{\scriptit{(L)}}_{k}]$ is a matrix with each column containing indexing random variables for mini-batch samples used for computing gradients in each learner $l$ at iteration $k$
\item $g(\mathbf{\Phi}_{k},\bm{\xi}_{k}) = [\frac{1}{M_{1}}\sum_{m=1}^{M_{1}} \nabla f(\hat{w}^{\scriptit{(1)}}_{k};\xi^{\scriptit{(1)}}_{k,m}), \dots, \frac{1}{M_{L}}\sum_{m=1}^{M_{L}} \nabla f(\hat{w}^{\scriptit{(L)}}_{k};\xi^{\scriptit{(L)}}_{k,m})]$ is a matrix with each column containing gradients computed in each learner $l$ at iteration $k$
\end{itemize}
The first term on the right in Eq.\ref{eqn:dsgd} describes the communication pattern among learners while the second term depends on gradient computation on each learner. The two terms can be evaluated concurrently. Each learner keeps a local model and computes the gradients locally. Meanwhile, the local model is also averaged with other learners in the network through the mixing matrix. If the computation takes a longer time than the communication, the first term can be entirely overlapped by the second term. Eq.\ref{eqn:dsgd} can also be carried out in synchronous \cite{Lian_DecentSGD}\cite{Zhang_ADPSGDSWB} or asynchronous \cite{Lian_ADPSGD}\cite{Zhang_ADPSGDSWB} mode. In synchronous mode, the model update has to hold until the two terms are both in place. In asynchronous mode, the model update takes place whenever a learner finishes its local computation. By introducing various synchronization mechanisms between the two terms, Eq.\ref{eqn:dsgd} can cover a broad variety of decentralized training strategies.
It is also worth pointing out that although it is suitable for theoretical analysis of convergence behaviors of a training strategy, Eq.\ref{eqn:dsgd} does not reflect its communication cost which mainly includes the time of data transfer from storage and memory, model/gradient transfer between CPU and GPU and model/gradient averaging among learners.
Model averaging in the decentralized SGD is indicated by the mixing matrix $\mathbf{T}$ which is typically chosen as \textbf{doubly stochastic matrices}. A matrix $\mathbf{T}=(t_{ij})$ is called a doubly stochastic matrix if $t_{ij} \in [0,1]$ and $\sum_{i}t_{ij}=\sum_{j}t_{ij}=1$. For instance,
\[
\mathbf{T}_{1} = \begin{bmatrix}
\frac{1}{3} & \frac{1}{3} & 0 & 0 & 0 & 0 & \frac{1}{3} \\
\frac{1}{3} & \frac{1}{3} & \frac{1}{3} & 0 & 0 & 0 & 0 \\
0 & \frac{1}{3} & \frac{1}{3} & \frac{1}{3} & 0 & 0 & 0 \\
\cdots & \cdots & \cdots & \cdots & \cdots & \cdots & \cdots \\
\frac{1}{3} & 0 & 0 & 0 & 0 & \frac{1}{3} & \frac{1}{3}
\end{bmatrix} \ \ \ \
\mathbf{T}_{u} = \begin{bmatrix}
\frac{1}{L} & \frac{1}{L} & \cdots & \cdots & \cdots & \frac{1}{L} & \frac{1}{L} \\
\frac{1}{L} & \frac{1}{L} & \cdots & \cdots & \cdots & \frac{1}{L} & \frac{1}{L} \\
\frac{1}{L} & \frac{1}{L} & \cdots & \cdots & \cdots & \frac{1}{L} & \frac{1}{L} \\
\cdots & \cdots & \cdots & \cdots & \cdots & \cdots & \cdots \\
\frac{1}{L} & \frac{1}{L} & \cdots & \cdots & \cdots & \frac{1}{L} & \frac{1}{L}
\end{bmatrix}
\]
where $\mathbf{T}_{1}$ represents a model averaging scheme in which each learner averages its local models with its immediate left and right neighbors in a ring. $\mathbf{T}_{u}$ represents the scheme where local models of all learners are averaged. Treating $\mathbf{T}$ as a transition matrix of a Markov chain, if its represented chain is irreducible and aperiodic, it has a stationary uniform distribution $\mathbf{T}_{u}$: $\mathbf{T}^{n} \rightarrow \mathbf{T}_{u}$ when $n \rightarrow \infty$. It indicates that with sufficient rounds of model averaging under $\mathbf{T}$, local models of all learners will reach consensus, which is the average of all local models.
In recent years, decentralized parallel SGD has been theoretically shown to be equally good in terms of convergence rate as the conventional SGD \cite{Lian_DecentSGD}\cite{Lian_ADPSGD}. Communication-wise, decentralized parallel SGD is advantageous over the centralized strategies as it removes the communication barrier on the PS. Recent work from IBM \cite{Zhang_ADPSGDSWB}\cite{Zhang_DDLASR} has demonstrated good performance in both speedup and WER using asynchronous decentralized strategies in large-scale acoustic modeling. In particular, a hybrid distributed setting was proposed in \cite{Zhang_DDLASR} that combines synchronous and asynchronous modes under the same decentralized parallel SGD framework. Asynchronous decentralized strategies are also found to tolerate larger batch sizes relative to the centralized strategies.
\subsection{Improving Training Efficiency}
\label{sec:eff}
When designing a distributed training strategy based on SGD, batch size and communication bandwidth are two critical factors to consider in practice for training efficiency.
For data parallel SGD, the speedup is roughly proportional to the batch size under the constraints of GPU memory and model size. The more data we can parallelize in each batch the faster the training is. It is difficult to increase the number of learners while maintaining a high percentage GPU usage if the batch size is not sufficiently large. However, it is often observed that too large a batch size may hurt the convergence of SGD and eventually the performance of the model \cite{Zhang_DDLASR}. Therefore, effectively increasing the batch size without compromising performance has been actively investigated over the years in the distributed training community \cite{Jia_ImageNet4mins}\cite{Zhang_ADPSGDSWB}. To deal with the batch size issue, learning rate warm-up is often used. A common practice is that a large batch is learned with a large learning rate, which are roughly in proportion, but the large learning rate is achieved by gradually scaling up from a small learning rate. This strategy usually gives good performance in practice. It is also observed that larger batch sizes are possible in decentralized asynchronous SGD with partial model averaging \cite{Zhang_DDLASR}.
Bandwidth indicates how much data can be communicated per second. In parallel SGD, we always hope for a perfect overlap between communication and computation to minimize the training time. The communication takes place when data is copied from storage to memory, models/gradients are transferred between CPU and GPU and models/gradients are averaged among learners. The computation mainly involves gradient evaluation. We want to push computation-heavy operations to GPUs while reducing the communication cost. DNN models with large number of parameters require high communication bandwidth and may become the eventual bottleneck of the whole distributed training. Specialized to distributed acoustic modeling, the issue may become even more severe due to its high communication/computation ratio. First of all, loading features and labels from storage to memory may affect the training efficiency given the low bandwidth between the two. A typical way to deal with it is to run data loaders in multiple processes in parallel to pipeline data loading and perform online feature expansion if necessary. In terms of model/graident transfer, a broad variety of communication-reduction techniques have been proposed. Gradient compression approaches such as gradient quantization \cite{Seide_1bit}\cite{Alistarh_QSGD} and gradient sparsification \cite{Aji_SparseSGD} are used to reduce the required communication bandwidth. Partial model averaging instead of global model averaging is another way to reduce the communication cost \cite{Lian_DecentSGD}\cite{Zhang_ADPSGDSWB}.
When training acoustic models under discriminative sequence criteria, additional care needs to be taken with issues on storage, communication and computation in terms of training efficiency. The hypothesis space in the discriminative objective function is represented by lattices \cite{Kingsbury_Seqtrain} which take significant amount of storage space. As a result, the data loading is more time-consuming compared to the CE training. On the computation side, the gradient evaluation involves the forward and backward algorithm running on lattices, which typically takes place on CPUs as it is nontrivial to express it in an efficient form of matrix multiplication suitable for GPUs. For large-scale distributed training, shallow lattices of low density are usually used to reduce the required storage space and speed up the communication and computation \cite{Parthasarathi_PetaAM}.
\section{Experiments}
\label{sec:exp}
In this section, we evaluate various distributed deep acoustic model training strategies on SWB2000. The first set of experiments are designed to compare their performance in convergence, speedup and WER for the pedagogical purpose.
\textbf{Dataset} \ \ SWB2000 is a well-established public benchmark for ASR evaluation \cite{Hinton_DNNSPM}\cite{Saon_2017HumanParity}\cite{Xiong_ASRParity}. The dataset consists of 1,975 hours of audio data among which 10 hours of audio is used for the heldout set for training. WERs are evaluated on the Hub5 2000 evaluation set which is composed of two parts: One is the 2.1-hour switchboard (SWB) data and the other is the 1.6-hour callhome (CH) data.
\textbf{Model} \ \ The acoustic model is a DNN-HMM with a bi-directional LSTM architecture. There are 6 LSTM layers and each LSTM layer contains 1,024 cells with 512 in each direction. On top of the LSTM layers, there is a linear bottleneck layer with 256 hidden units followed by a softmax output layer with 32,000 units corresponding to the CD-HMM states. The LSTM is unrolled 21 frames and trained with non-overlapping feature subsequences of that length. The input is a 260-dimensional vector consisting of a speaker-adapted acoustic feature based on perceptual linear prediction (PLP) \cite{Hermansky_PLP} (40-dim), a speaker embedding vector \cite{Dehak_ivec} (100-dim) and a logMel feature with its delta and double-delta \cite{Saon_2017HumanParity} ($3\!\times\!40$-dim). The language model is trained using publicly available text data from a wide variety of sources. The final LM used for decoding has 36M 4-grams with a vocabulary of 85,000 words.
\textbf{Baseline} \ \ We establish the baseline by training the acoustic model using SGD on a single P100 GPU without parallelization. The batch size is 256. Following the input dimensionality and LSTM unroll length, a batch is a tensor of size $260\!\times\!21\!\times\!256$. The initial learning rate is 0.1 which is annealed by $\frac{1}{\sqrt{2}}$ every epoch after 10th epoch. The training finishes after 16 epochs. The WERs are 7.5\% on SWB and 13.0\% on CH, one of the best results under CE training on this dataset. This is a well-tuned training recipe where the learning rate scheduling and batch size are optimized towards the best WERs.
\textbf{HPC Setting} \ \ We use a cluster of 4 x86 servers with 2 7-core Intel Xeon E5-2680 2.40GHz CPUs and 1TB main memory per server. Each server has 4 P100 GPUs. Therefore, there are 16 GPUs in total. Servers are connected with 100 Gbit/s Ethernet. On each server, CPU and GPU communicate via PCI-e Gen3 bus with a 16GB/s peak bandwidth in each direction. The audio data is first converted to input features and labels in the HDF5 format and stored locally on NVMe on each server. The connection among learners has a ring topology. In case of allreduce, it is implemented using NCCL \cite{NCCL}. Each learner has 2 concurrent processes on CPUs to load the input features and labels. The data loader generates 21-frame subsequences for unrolled LSTM and expands the delta and double delta of logMel features on the fly, which overlaps with the gradient evaluation on GPUs. No gradient compression is used in communication.
\textbf{Training Strategies} \ \ We implement and compare three distributed training strategies. (1) \textbf{SC-PSGD}: synchronous decentralized parallel SGD with allreduce for model averaging (mixing matrix $\mathbf{T}_{u}$). This is equivalent to a synchronous centralized parallel SGD where the PS operations are replaced with a reduction-then-broadcast allreduce operation. (2) \textbf{SD-PSGD}: synchronous decentralized parallel SGD in which each learner averages its model with its left and right neighbors (mixing matrix $\mathbf{T}_{1}$). This model averaging pattern can reduce the communication cost compared to allreduce. (3) \textbf{AD-PSGD}: asynchronous decentralized parallel SGD where local gradient computation and model update running concurrently with model averaging with its left and right neighbors (mixing matrix $\mathbf{T}_{1}$). Asynchronous centralized parallel SGD is not included in the experiments as it is known to be hard to train and gradually loses popularity to other strategies.
Fig.\ref{fig:loss_speedup} shows the heldout loss of the distributed strategies using 16 GPUs in the left panel. The total batch size is 2560 and therefore each learner has a local batch size of 160. The batch size 2560 is determined based on WERs. The initial learning rate is 0.1 which is the same as that of the baseline. In the first 10 epochs, it linearly warmed up to 1.0 after which it is annealed by $\frac{1}{\sqrt{2}}$ every epoch. All three distributed training strategies converge to similar loss close to that of the baseline. Their WERs are also close to those of the baseline. Specifically, WERs are 7.6\% on SWB and 13.1\% on CH under \textbf{SC-PSGD}, 7.6\% on SWB and 13.3\% on CH under \textbf{SD-PSGD} and 7.6\% on SWB and 13.2\% on CH under \textbf{AD-PSGD}. On the other hand, their speedup performance differs significantly, which is presented in the right panel of Fig.\ref{fig:loss_speedup} as a function of the number of GPUs. The synchronous SGD (\textbf{SC-PSGD} and \textbf{SD-PSGD}) has a smaller speedup than the asynchronous SGD (\textbf{AD-PSGD}) due to the idle time of the learners in the synchronization. We also compare the impact of two implementations of allreduce on \textbf{SC-PSGD}: one is the open-source MPI allreduce (SC-PSGD-OpenMPI) and the other is the NCCL allreduce (SC-PSGD-NCCL). The latter is a faster allreduce implementation than the former, which improves the speedup for synchronous SGD. Since \textbf{SD-PSGD} uses partial model averaging, it is implemented with OpenMPI. The partial model averaging reduces the communication cost and therefore gives better speedup over SC-PSGD-OpenMPI. Among these strategies, the best speedup performance is given by \textbf{AD-PSGD} which achieves 11x speedup over 16 GPUs.
\begin{figure}[ht]
\centering
\begin{subfigure}{.4\textwidth}
\centering
\includegraphics[width=\textwidth, height=5cm]{fig4a_heldout_loss.png}
\caption{heldout loss}
\end{subfigure}
\hspace{0.5cm}
\begin{subfigure}{.4\textwidth}
\centering
\includegraphics[width=\textwidth, height=5cm]{fig4b_speedup.png}
\caption{speedup}
\end{subfigure}
\caption{Heldout loss and speedup of investigated strategies.}\label{fig:loss_speedup}\vspace{-0.7cm}
\end{figure}
One of the advantages of asynchronous SGD over synchronous SGD is its automatic load balancing. It allows a faster learner to consume more computation than a slow learner. To demonstrate this, we design a scenario in which 8 of the 16 GPUs in the cluster share running jobs from other tasks, which results in slow learners. Fig.\ref{fig:load} shows the distribution of the workload under $\textbf{AD-PSGD}$ across 16 GPUs in terms of the processed mini-batches in one epoch. It clearly shows the pattern that faster learners pick up higher workload during the training to create faster overall training. Furthermore asynchronous SGD can eliminate the ``straggler" problem that limits synchronous SGD. To show this effect, we design another scenario in Table \ref{tab:speedup_slow_learner} where we purposely slow down one GPU learner by 2x, 10x and 100x to make it a ``straggler". As can be seen from the table, this ``straggler" leads to significant prolonged training time in one epoch in synchronous SGD while not affecting asynchronous SGD. $\textbf{AD-PSGD}$ in this case delivers consistent speedup.
\begin{figure}[tbh]
\centering
\includegraphics[width=7cm, height=5cm]{fig5_load_adpsgd.png}
\caption{Distribution of workload on 16 GPUs for asynchronous decentralized parallel SGD.}\label{fig:load}\vspace{-0.7cm}
\end{figure}
\begin{table}[tbh]
\centering
\begin{tabular}{l|c|c|c|c} \hline
\multirow{2}{*}{slow GPU learner} & \multicolumn{2}{c|}{\textbf{SC-PSGD}} & \multicolumn{2}{c}{\textbf{AD-PSGD}} \\ \cline{2-5}
& hr/epoch & speedup & hr/epoch & speedup \\ \hline\hline
no slowdown & 1.09 & 8.70 & 0.87 & 10.88 \\ \hline
2x & 1.67 & 5.71 & 0.89 & 10.63 \\ \hline
10x & 6.24 & 1.52 & 0.91 & 10.42 \\ \hline
100x & 57.73 & 0.16 & 0.92 & 10.38 \\ \hline
\end{tabular}
\caption{Runtime and speedup comparison on 16 GPUs when one GPU slows down by 2x-100x.}\label{tab:speedup_slow_learner} \vspace{-0.7cm}
\end{table}
In the second set of experiments, we try to show how the discussed training stategies can substantially help to shorten the training time on SWB2000 without sacrificing recognition accuracy, especially their scaling-out capability when increasing the number of GPUs. To maximize the parallelization performance it is critically important to increase the batch size while sustaining a good convergence. It was found that \textbf{AD-PSGD} can tolerate much larger batch size than its synchronous centralized counterpart \cite{Zhang_DDLASR}.
\textbf{HPC Setting} \ \ We use a 8-server cluster equipped with 1TB main memory and 8 V100 GPUs on each server. Each server has 2 9-core Intel Xeon E5-2697 2.3GHz CPUs. Between servers are 100Gbit/s Ethernet connections. GPUs and CPUs are connected via PCIe Gen3 bus, which has a 16GB/s peak bandwidth in each direction. In order to maximize the feasible batch size and meanwhile effectively reduce the required communication bandwidth, we employ a hierarchical-ring (H-ring) configuration following \cite{Zhang_DDLASR}. In this configuration, GPU learners on the same computing node run \textbf{SC-PSGD} with a local ring by NCCL allreduce. They are called a super learner. All the super learners then form another ring running \textbf{AD-PSGD}. Therefore, it is a hierarchical implementation of synchronous and asynchronous SGD in one configuration.
Table \ref{tab:adpsgd_scaleout} shows the speedup and recognition performance.\footnote{In order to make the speedup comparable, we optimize the batch size against WER on 64 GPUs and then scale down to 32 and 16 GPUs with the same local batch size on each learner (128 per learner). Therefore, the batch sizes on 16 and 32 GPUs may not be optimal under these two conditions.} While training the LSTM acoustic model on SWB2000 with a single V100 GPU takes 195 hours, it takes 20 hours on 16 V100 GPUs, 9.9 hours on 32 V100 GPUs and 5.2 hours on 64 V100 GPUs. This is equivalent to about 38x speedup with similar WERs. To the best of our knowledge, this is the best speedup reported on SWB2000 with this level of recognition accuracy by the time of submission of this paper.
\begin{table}[tbh]
\centering
\begin{tabular}{l|c|c|c|c|c} \hline
\multirow{2}{*}{GPUs} & \multirow{2}{*}{batch size} & \multirow{2}{*}{training time} & \multirow{2}{*}{speedup} & \multicolumn{2}{c}{WER} \\ \cline{5-6}
& & & & SWB & CH \\ \hline\hline
single V100 GPU & 256 & 195 hr & - & 7.5 & 13.0 \\ \hline
16 V100 GPUs & 2048 & 20.0 hr & 9.8 & 7.5 & 13.2 \\ \hline
32 V100 GPUs & 4096 & 9.9 hr & 19.7 & 7.5 & 13.2 \\ \hline
64 V100 GPUs & 8192 & 5.2 hr & 37.5 & 7.6 & 13.2 \\ \hline
\end{tabular}
\caption{Scaling-out performance on SWB2000 using the H-ring configuration with various numbers of GPUs.}\label{tab:adpsgd_scaleout}\vspace{-0.7cm}
\end{table}
\section{Summary}
\label{sec:sum}
In this article, we walked through the distributed training of DNN acoustic models using mini-batch based data parallel SGD. We gave an overview of existing distributed training strategies (synchronous vs. asynchronous, centralized vs. decentralized) in the speech community and analyzed their advantages and disadvantages. We also studied their convergence and speedup performance on the popular public benchmark SWB2000 dataset. For distributed training using data parallel SGD, a batch size that is sufficiently large is a necessary condition for good speedup. It depends on optimization algorithms and a careful design of learning schedules. In addition, handling the interplay between communication and computation is crucial for high-performance distributed training. In practice, we strive for the maximum overlap between communication and computation when designing and implementing a distributed training strategy from both algorithmic and HPC architectural perspectives.
\bibliographystyle{IEEETran}
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 8,113 |
\section{Introduction}\label{sec0}
\par
In the paper we investigate conjugation with the Bargmann
transformation of pseudo-differential and Toeplitz
operators on $\rr d$ with isotropic symbols, and we
explore relations between Wick and anti-Wick operators.
Particularly we consider
Shubin operators and operators of infinite order.
This gives rise to analytic type pseudo-differential operators on $\cc d$
that are called Wick or Berezin operators
because of the fundamental contributions
by F. Berezin \cite{Berezin71,Berezin72}, which in turns goes back to
some ideas in \cite{Wi} by G. C. Wick.
\par
Let $a$ be a suitable locally bounded function on $\cc {2d}$ such that
$z\mapsto a(z,w)$ is analytic, $z,w\in \cc d$. Then the Wick operator
$\operatorname{Op} _{\mathfrak V}(a)$ with symbol $a$ is the operator which takes an
appropriate entire function $F$ on $\cc d$ into the entire function
\begin{equation}\label{Eq:AnalPseudoIntro}
\operatorname{Op} _{\mathfrak V}(a)F (z) = \pi ^{-d}
\int _{\cc d} a(z,w)F(w)e^{(z-w,w)}\, d\lambda (w),
\end{equation}
where $d\lambda$ is the Lebesgue measure
and $(\, \cdot \, ,\, \cdot \, )$ is the scalar product on $\cc d$.
(See \cite{Ho1} and Section \ref{sec1}
for notation.) Wick operators appear naturally in
several problems in analysis and its applications, e.{\,}g.
in quantum mechanics.
For example, the harmonic oscillator, the creation
and annihilation operators take the simple forms
$$
F\mapsto \scal z{\nabla _z}F +cF,
\quad
F\mapsto z_jF
\quad \text{and}\quad
F\mapsto \partial _{z_j}F,
$$
respectively, for some constant $c$, in the Wick formulation (see \cite{B1}).
\par
An advantage of the Wick calculus compared to corresponding
operators on functions and distributions defined on $\rr d$
is that in almost all situations, the involved functions are entire,
which admits the use of the powerful techniques of complex analysis.
(A more general approach is studied in \cite{Teofanov2}, where the
Wick calculus is formulated in terms of spaces of
formal power series expansions instead of spaces of entire functions.)
The possible lack of analyticity of $a(z,w)$
in \eqref{Eq:AnalPseudoIntro} with respect to the $w$ variable
is removable in the sense
that for any Wick symbol $a$, there is a unique $a_0$ such that
$(z,w)\mapsto a_0(z,\overline w)$ is entire, and
$\operatorname{Op} _{\mathfrak V}(a)=\operatorname{Op} _{\mathfrak V}(a_0)$. Consequently it is no restriction
to assume that $a(z,w)$ in \eqref{Eq:AnalPseudoIntro} is analytic in $z$ and
conjugate analytic in $w$, which we do in the introduction henceforth.
Any linear and continuous operator from the Schwartz space,
a Fourier invariant Gelfand-Shilov space or Pilipovi{\'c} space, to
the corresponding distribution spaces, respectively, is in a unique way transformed
into a Wick operator by the Bargmann transform (see \cite{Teofanov2}).
\par
Several operators in quantum mechanics are so-called Shubin operators, i.{\,}e.
pseudo-differential operators
$$
\operatorname{Op} (\mathfrak a )f(x) = (2\pi )^{-\frac d2}\int _{\rr d}\mathfrak a (x,\xi )
\widehat f(\xi )e^{i\scal x\xi}\, d\xi ,
\qquad f\in \mathscr S (\rr d),
$$
where the symbol $\mathfrak a$ belongs to the Shubin class
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$, the set of all $\mathfrak a \in C^\infty (\rr {2d})$
such that
$$
|\partial _x^\alpha \partial _\xi ^\beta \mathfrak a (x,\xi )|
\lesssim
\omega (x,\xi )(1+|x|+|\xi |)^{-\rho |\alpha +\beta |},\quad \alpha ,\beta \in \nn d.
$$
Here $\omega$ is a suitable weight function on $\rr {2d}$ and $0 \le \rho \le 1$.
Partial differential operators with polynomial coefficients,
e.{\,}g. the creation and annihilation operators or the harmonic oscillator
mentioned above, are examples of Shubin operators.
In Section \ref{sec2} we prove that the Bargmann image of Shubin
operators with symbols in
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ is the set of all
Wick operators in \eqref{Eq:AnalPseudoIntro} such that
$a$ belongs to $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$.
This means that $\cc {2d} \ni (z,w)\mapsto a(z,\overline w)$
is an entire function that satisfies
\begin{equation}\label{Eq:AnalShubinIntro}
|\partial _z^\beta \overline \partial _w^\gamma a(z,w)|
\lesssim
e^{\frac 12|z-w|^2}\omega (\sqrt 2 \overline z)
\eabs {z+w}^{-\rho |\beta +\gamma |} \eabs {z-w}^{-N}
\end{equation}
for every $N\ge 0$.
\par
An important subclass of Wick operators are the
anti-Wick operators, which are
Wick operators where the symbol
$a(z,w)$ does not depend on $z$. That is, for an appropriate
measurable function $a_0$ on $\cc d$, its anti-Wick operator is given by
\begin{equation}\tag*{(\ref{Eq:AnalPseudoIntro})$'$}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F (z) = \pi ^{-d}
\int _{\cc d} a_0(w)F(w)e^{(z-w,w)}\, d\lambda (w).
\end{equation}
Again $F$ is a suitable entire function on $\cc d$. The anti-Wick
operators can also be described as the Bargmann image of
Toeplitz operators on $\rr d$. (See e.{\,}g. \cite{LieSol,Shubin1,To11} for the definition
of Toeplitz operators.)
\par
A feature of Toeplitz operators and anti-Wick operators, useful for energy
estimates in quantum mechanics and
time-frequency analysis, is that non-negative symbols give rise to
non-negative operators. (Cf. e.{\,}g. \cite{LieSol,Lieb1,Lieb2}.)
An operator $T=\operatorname{Op} _{\mathfrak V}(a)$
with $a$ satisfying \eqref{Eq:AnalShubinIntro} for every $N\ge 0$, is called
\emph{positive} (\emph{non-negative}), if there is a constant
$C> 0$ ($C\ge 0$) such that
$$
(TF,F)_{A^2} \ge C\nm F{A^2}^2,
$$
for every analytic polynomial $F$ on $\cc d$, where $(\, \cdot \, ,\, \cdot \, )_{A^2}$
is the scalar product induced by the Hilbert norm
$$
\nm F{A^2} =\pi ^{-\frac d2}
\left ( \int _{\cc d} |F(z)|^2e^{-|z|^2}\, d\lambda (z) \right )^{\frac 12}.
$$
\par
The implication from non-negative symbols to non-negative operators
is not relevant for Wick operators in \eqref{Eq:AnalPseudoIntro}
when $a(z,w)$ is not constant with respect to $z$, since
the analyticity of the map $z\mapsto a(z,w)$ implies that
$a(z,w)$ is non-real almost everywhere. For such symbols it is
instead natural to check whether positivity of the map
$w\mapsto a(w,w)$ leads to positive operators (see e.{\,}g.
\cite{Berezin71,Berezin72,Fo}). By choosing
$$
d=1,\quad a(z,w) = 1-2z\overline w +2z^2\overline w^2
\quad \text{and}\quad
F(z)=z
$$
we obtain
$$
a(w,w)=(1-|w|^2)^2+|w|^4> 0
\quad \text{but}\quad
(\operatorname{Op} _{\mathfrak V}(a)F,F)_{A^2} =-1<0.
$$
Consequently
$\operatorname{Op} _{\mathfrak V}(a)$
may fail to be a non-negative operator even though $a(w,w)$ is positive.
\par
On the other hand, for certain conditions on $a$, we deduce in Section \ref{sec3}
a weaker positivity result for Wick operators, which is equivalent to the
sharp G{\aa}rding inequality in isotropic pseudo-differential calculus on $\rr d$
(see Theorem 18.6.7 and the proof of Theorem 18.6.8 in \cite{Ho1}). That is
for $a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$
with
$\omega (z)=\eabs z^{2\rho}$ and $\rho > 0$ we prove
\begin{align}
{\operatorname{Re}} (\operatorname{Op} _{\mathfrak V}(a)F,F)_{A^2}
&\ge -C\nm F{A^2}^2
\label{Eq:SharpGardingIntro}
\intertext{and}
|{\operatorname{Im}} (\operatorname{Op} _{\mathfrak V}(a)F,F)_{A^2}|
&\le C\nm F{A^2}^2,
\quad \text{when}\quad
a(w,w) \ge 0
\label{Eq:SharpGardingIntroImPart}
\end{align}
(cf. Theorem \ref{Thm:ShGarding}).
In particular we obtain energy estimates also for
Wick operators with symbols that are non-negative on the diagonal.
\par
The latter result is obtained by approximating Wick operators by
anti-Wick operators, using for the Wick operator \eqref{Eq:AnalPseudoIntro} with
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$
the remarkable identity
\begin{equation}\label{Eq:WickToAntiWickIntro}
\operatorname{Op} _{\mathfrak V}(a)
=
\sum _{|\alpha |<N} \frac {(-1)^{|\alpha |}}{\alpha !}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_\alpha ) + \operatorname{Op} _{\mathfrak V}(c_N)
\quad \text{where} \quad
b_\alpha (w)
=
\partial _z^\alpha \overline \partial _{w}^\alpha a(w,w),
\end{equation}
for some $c_N\in \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega _N)}(\cc {2d})$
with $\omega _N(z)= \omega (z)\eabs z^{-2N\rho}$.
Here we again assume $\rho > 0$.
The decay conditions on $b_\alpha$ and $c_N$ are, respectively,
\begin{align}
|\partial _w^\beta \overline \partial _w^\gamma b_\alpha (w)|
& \lesssim
\omega (\sqrt 2 \overline w)\eabs {w}^{-\rho |2\alpha +\beta +\gamma |},
\qquad
\alpha, \beta, \gamma \in \nn d,
\label{Eq:WickAntiWickbalphaIntro}
\intertext{and}
|\partial _z^\beta \overline \partial _w^\gamma c_N(z,w)|
& \lesssim
e^{\frac 12|z-w|^2}\omega (\sqrt 2 \overline z)\eabs z^{-2N\rho}
\eabs {z+w}^{-\rho |\beta +\gamma |} \eabs {z-w}^{-N}.
\end{align}
Consequently, many Wick operators can essentially be expressed
as linear combinations of anti-Wick operators. The expansion
\eqref{Eq:WickToAntiWickIntro} is deduced in Section \ref{sec3} using
Taylor expansion and integration by parts, see Proposition
\ref{Prop:WickToAntiWick} and Remark \ref{Rem:WickToAntiWick2}.
\par
The conditions on $b_\alpha$ are the same as the conditions on $a$
\eqref{Eq:AnalShubinIntro}, restricted to the diagonal $z=w$, and with improved decay.
On the diagonal, the growth term $e^{\frac 12|z-w|^2}$ disappears, which dominates in
\eqref{Eq:AnalShubinIntro} when $|z-w|\gtrsim |z|$ or $|z-w|\gtrsim |w|$.
The right-hand side of \eqref{Eq:WickAntiWickbalphaIntro}
becomes as large as possible when
$\alpha =\beta =\gamma =0$, that is $b_0$
is the dominating term in the sum \eqref{Eq:WickToAntiWickIntro}.
\par
The conditions on $c_N$ are the same as the estimates \eqref{Eq:AnalShubinIntro}
again with improved decay due to the factor $\eabs z^{-2N\rho}$.
\par
For polynomial symbols, \eqref{Eq:WickToAntiWickIntro}
agree with the integral formula \cite[Theorem 3]{Berezin71} due to Berezin
which carry over Wick operators into anti-Wick operators. For
the general case, \eqref{Eq:WickToAntiWickIntro} is analogous to the
approximation technique of pseudo-differential operators on $\rr d$
in terms of Toeplitz operators given in \cite[Theorem 24.1]{Shubin1}
and its proof, by Shubin.
\par
The anti-Wick symbols in \eqref{Eq:WickToAntiWickIntro}
$b_\alpha (w)=\partial _z^\alpha \overline \partial _w^\alpha a (w,w)$ extend to have the property that
$\partial _z^\alpha \overline \partial _w^\alpha a (z,w)$ is entire in
$z$ and conjugate entire in $w$.
Note that restriction to the diagonal also appears in the positivity condition
\eqref{Eq:SharpGardingIntro} on Wick symbols.
\par
The sharp G{\aa}rding inequality \eqref{Eq:SharpGardingIntro} is
reached by using the fact that $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_0)$
is non-negative,
and that
if $T$ is either $\operatorname{Op} ^{\operatorname{aw}}_{\mathfrak V}(b_\alpha )$
or $\operatorname{Op} _{\mathfrak V}(c_N)$ for $\alpha \neq 0$, then
$\nm {TF}{A^2}\lesssim \nm F{A^2}$ when $F\in A(\cc d)$ is a polynomial.
\par
In Section \ref{sec5} we deduce links concerning ellipticity, hypoellipticity
(in Shubin's sense) and weak ellipticity between Shubin and Wick symbols.
The notion of hypoelliptic symbol resembles hypoelliptic symbols
in Shubin's sense (see \cite{Shubin1}).
More specifically, we say that the symbol $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ is
hypoelliptic of order $\rho _0\ge 0$, whenever there is an $R>0$ such that
$$
|\mathfrak a (x,\xi )|\gtrsim \omega (x,\xi )\eabs {(x,\xi )}^{-\rho _0}
\quad \text{and}\quad |\partial ^\alpha \mathfrak a (x,\xi )|
\lesssim |\mathfrak a (x,\xi )|\eabs {(x,\xi )}^{-\rho |\alpha |}
$$
when $|(x,\xi )|\ge R$.
\par
A linear operator $T$ from $\mathscr S '(\rr d)$ to $\mathscr S '(\rr d)$
is called globally hypoelliptic if
$$
Tf=g,\ f\in \mathscr S '(\rr d),\ g\in \mathscr S (\rr d)
\quad \Rightarrow \quad
f\in \mathscr S (\rr d).
$$
(See e.{\,}g. \cite{BogBuzRod}.)
It can be proved that a pseudo-differential operator with hypoelliptic
symbol in Shubin's sense is globally hypoelliptic as operator (see e.{\,}g.
\cite[Corollary 25.1]{Shubin1}).
\par
We show, similarly to our investigations of
the sharp G{\aa}rding
inequality and for expansion \eqref{Eq:WickToAntiWickIntro}, that ellipticity, hypoellipticity
and to some degree weak ellipticity for the Shubin symbol $\mathfrak a$
can be characterized by certain conditions for the corresponding Wick symbol
$a(z,w)$ along the diagonal $z=w$. For example, let
$\mathfrak a$ be a polynomial on $\rr d$ with principal symbol $\mathfrak a _p$, and let $a(z,w)$
be a polynomial in $z, \overline w \in \cc d$ with principal part
$a_p$. Then $\mathfrak a$ is elliptic means that
$\mathfrak a _p(x,\xi )\neq 0$ when $(x,\xi )\neq (0,0)$, and
$a$ is elliptic means that $a_p(z,z)\neq 0$ when $z\neq 0$.
For such $\mathfrak a$ we prove
$$
\mathfrak a \ \text{is elliptic}
\quad \Leftrightarrow \quad
a\ \text{is elliptic},
$$
when $a(z,w)$ is the Wick symbol corresponding to $\mathfrak a$
(which must be a polynomial in $z$ and $\overline w$).
\medspace
Our investigations include the Bargmann transform of certain
operators of infinite order, i.{\,}e. pseudo-differential operators
with ultra-differentiable symbols that are permitted to grow faster
than polynomially at infinity together with their derivatives. Particularly
we consider Wick operators of infinite order, i.{\,}e. the Bargmann
images $\operatorname{Op} _{\mathfrak V}(a)$ of operators $\operatorname{Op} (\mathfrak a )$ of infinite order
in \cite{AbCaTo},
and characterize their images under the Bargmann transform
(see Theorem \ref{Thm:GevreySymbolsBargmTransfer}).
Then we deduce in Subsections
\ref{subsec3.2} and \ref{subsec3.3} continuity results for anti-Wick operators
which holds for the symbols $b_\alpha$ in \eqref{Eq:WickToAntiWickIntro} when
$\operatorname{Op} _{\mathfrak V}(a)$ is the Bargmann image of an
operator of infinite order.
\par
In fact, in Subsection \ref{subsec3.2}
we show that $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_\alpha )$ possess several
other continuity properties than what is valid for $\operatorname{Op} _{\mathfrak V}(a)$
in the expansion \eqref{Eq:WickToAntiWickIntro}
(see Propositions \ref {prop:contAW} and \ref{prop:contAW2}). In Subsection
\ref{subsec3.3} we deduce estimates of the Wick symbol $b_{\alpha}^{\operatorname{aw}}$
to the anti-Wick operator $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_\alpha )$, i.{\,}e. the unique element
$b_{\alpha}^{\operatorname{aw}}\in \wideparen A(\cc {2d})$ such that $\operatorname{Op} _{\mathfrak V}(b_{\alpha}^{\operatorname{aw}})
=\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_\alpha )$. We show that usually, $b_{\alpha}^{\operatorname{aw}}$
satisfies stronger conditions than $a$ when $\operatorname{Op} _{\mathfrak V}(a)$
is a Wick operator of infinite order (see Theorems \ref{Thm:WickSymbolAntiWickOpFolland},
\ref{Thm:WickSymbolAntiWickOpGS} and \ref{Thm:WickSymbolAntiWickOpSOmega}).
\par
The paper is organized as follows. In Section \ref{sec1} we
recall useful properties for weight functions, Gelfand-Shilov spaces, the Bargmann
transform, pseudo-differential operators, Wick and anti-Wick operators.
Thereafter we characterize in Section \ref{sec2} Shubin operators
and operators of infinite order in terms of appropriate classes of
Wick operators on the Bargmann side.
These considerations are based on a formula for the Wick symbol expressed
in terms of a short-time Fourier transform of the Weyl symbol, and
admits characterization of the Wick symbols corresponding to
Shubin Weyl symbols and symbols for operators of infinite order
(see Proposition \ref{Prop:SBaTaRel}).
\par
In Section \ref{sec2} we also study composition and show for example
that the well-known closure under composition of Shubin operators
and operators of infinite orders have simple and natural proofs on the Wick symbol side.
\par
In Section \ref{sec3} we deduce series expansions of Wick operators
in terms of anti-Wick operators, and between Wick symbols and symbols
to corresponding Shubin operators.
We also consider anti-Wick operators, and
show continuity results for them. We show
that the upper bounds for the Wick symbols of anti-Wick operators
are stricter than for general Wick symbols.
\par
In Section \ref{sec4} we discuss lower bounds for Wick operators
and deduce the sharp G{\aa}rding's inequality.
Section \ref{sec5} concerns ellipticity, hypoellipticity and weak ellipticity.
\par
Finally we observe in Section \ref{sec6} that a polynomial bound of a Wick symbol implies
that the symbol is a polynomial. For pseudo-differential operators this
corresponds to partial differential operators with polynomial coefficients.
This gives a characterization of such operators as those having
polynomially bounded Wick symbols.
\par
\section{Preliminaries}\label{sec1}
\par
In this section we recall some facts on function and distribution
spaces as well as on pseudo-differential operators, Wick and anti-Wick operators.
Subsection \ref{subsec1.1} concerns weight functions and
Subsection \ref{subsec1.2} treats Gelfand-Shilov spaces.
In Subsection \ref{subsec1.3} we introduce the Bargmann transform and
topological spaces of entire functions on $\cc d$, and
in Subsection \ref{subsec1.4} we recall the definitions
and some facts on pseudo-differential operators on $\rr d$ as well
as Wick and anti-Wick operators on $\cc d$.
Subsection \ref{subsec1.5} defines certain symbol classes for pseudo-differential
operators on $\rr d$.
\par
\subsection{Weight functions}\label{subsec1.1}
A \emph{weight} on $\rr d$ is a positive function $\omega \in L^\infty _{loc}(\rr d)$
such that $1/\omega \in L^\infty _{loc}(\rr d)$. The weight $\omega$
is called \emph{moderate} if there is a positive locally bounded function
$v$ such that
\begin{equation}\label{eq:2}
\omega(x+y)\le C\omega(x)v(y),\quad x,y\in\rr{d},
\end{equation}
for some constant $C\ge 1$. If $\omega$ and $v$ are weights such
that \eqref{eq:2} holds, then $\omega$ is also called \emph{$v$-moderate}.
The set of all moderate weights on $\rr d$ is denoted by $\mathscr P _E(\rr d)$.
The set $\mathscr P (\rr d)$ consists of weights that are $v$-moderate for
a polynomially bounded weight, that is a weight of the form $v(x) = {\eabs x}^s$
where $\eabs x = (1+|x|^2)^{\frac 12}$ and $s \ge 0$.
The bracket notation is also used for complex arguments as
$\eabs z=(1+|z|^2)^{\frac 12}$ when $z\in \cc d$.
If $s\in \mathbf R$ then $x\mapsto \eabs x^s$ belongs to $\mathscr P (\rr d)$,
due to Peetre's inequality
\begin{equation}\label{eq:Peetre}
\eabs{x+y}^s \leqslant 2^{|s|} \eabs{x}^s\eabs{y}^{|s|}\qquad x,y\in\rr{d},
\qquad s \in \mathbf R.
\end{equation}
\par
The weight $v$ is called \emph{submultiplicative}
if it is even and \eqref{eq:2}
holds for $\omega =v$.
If \eqref{eq:2} holds and $v$ is submultiplicative then
\begin{equation}\label{eq:2Next}
\begin{gathered}
\frac {\omega (x)}{v(y)} \lesssim \omega(x+y) \lesssim \omega(x)v(y),
\\[1ex]
\quad
v(x+y) \lesssim v(x)v(y)
\quad \text{and}\quad v(x)=v(-x),
\quad x,y\in\rr{d}.
\end{gathered}
\end{equation}
The notation
$A(\theta )\lesssim B(\theta )$, $\theta \in \Omega$,
means that there is a constant $c>0$ such that $A(\theta )\le cB(\theta )$
for all $\theta \in \Omega$.
\par
If $\omega$ is a moderate weight then by \cite{To11} there is a
submultiplicative weight
$v$ such that \eqref{eq:2} and \eqref{eq:2Next}
hold. If $v$ is submultiplicative then
\begin{equation}\label{Eq:CondSubWeights}
1\lesssim v(x) \lesssim e^{r|x|}
\end{equation}
for some constant $r>0$ (cf. \cite{Groch}). In particular, if $\omega$ is moderate, then
\begin{equation}\label{Eq:ModWeightProp}
\omega (x+y)\lesssim \omega (x)e^{r|y|}
\quad \text{and}\quad
e^{-r|x|}\lesssim \omega (x)\lesssim e^{r|x|},\quad
x,y\in \rr d
\end{equation}
for some $r>0$.
If not otherwise specified the symbol $v$ always denote a submultiplicative weight.
\par
\subsection{Gelfand-Shilov spaces}\label{subsec1.2}
Let $s ,\sigma > 0$. The
Gelfand-Shilov space $\mathcal S _s^\sigma (\rr d)$ ($\Sigma _s^\sigma (\rr d)$) of
Roumieu (Beurling) type consists of all $f\in C^\infty (\rr d)$
such that
\begin{equation}\label{gfseminorm}
\nm f{\mathcal S _{s,h}^\sigma}\equiv \sup \frac {|x^\alpha \partial ^\beta
f(x)|}{h^{|\alpha + \beta |}\alpha !^s \, \beta !^\sigma}
\end{equation}
is finite for some (every) $h>0$. The supremum refers to all
$\alpha ,\beta \in \mathbf N^d$ and $x\in \rr d$.
The seminorms
$\nm \, \cdot \, {\mathcal S _{s,h}^\sigma}$ induce an inductive limit topology for the
space $\mathcal S _s^\sigma (\rr d)$ and a projective limit topology for
$\Sigma _s^\sigma (\rr d)$. The latter space is a Fr{\'e}chet space under this topology.
The space $\mathcal S _s^\sigma (\rr d)\neq \{ 0\}$ ($\Sigma _s^\sigma (\rr d)\neq \{0\}$),
if and only if $s+\sigma \ge 1$ ($s+\sigma \ge 1$ and $(s,\sigma) \neq (\frac 12, \frac 12)$).
We write $\mathcal S _s (\rr d) = \mathcal S _s^s (\rr d)$ and $\Sigma _s (\rr d) = \Sigma _s^s (\rr d)$.
\par
The \emph{Gelfand-Shilov distribution spaces} $(\mathcal S _s^\sigma )'(\rr d)$
and $(\Sigma _s^\sigma )'(\rr d)$ are the dual spaces of $\mathcal S _s^\sigma (\rr d)$
and $\Sigma _s^\sigma (\rr d)$, respectively.
\par
The embeddings
\begin{multline}\label{GSembeddings}
\mathcal S _{s_1}^{\sigma _1} (\rr d) \hookrightarrow \Sigma _{s_2}^{\sigma _2}(\rr d)
\hookrightarrow
\mathcal S _{s_2}^{\sigma _2} (\rr d)
\hookrightarrow
\mathscr S (\rr d)
\\[1ex]
\hookrightarrow \mathscr S '(\rr d)
\hookrightarrow (\mathcal S _{s_2}^{\sigma _2})'(\rr d)
\hookrightarrow (\Sigma _{s_2}^{\sigma _2})'(\rr d)
\hookrightarrow (\mathcal S _{s_1}^{\sigma _1}) '(\rr d),
\\[1ex]
s_1+\sigma _1 \ge 1,\ s_1<s_2,\ \sigma _1<\sigma _2,
\end{multline}
are dense.
For topological spaces $A$ and $B$, $A\hookrightarrow B$ means that the inclusion $A\subseteq B$ is continuous.
\par
The spaces $\mathcal S _s$ and $\Sigma_s$, and their duals spaces, admit
characterizations in terms of coefficients with respect to expansions with respect to
the Hermite functions
$$
h_\alpha (x) = \pi ^{-\frac d4}(-1)^{|\alpha |}
(2^{|\alpha |}\alpha !)^{-\frac 12}e^{\frac {|x|^2}2}
(\partial ^\alpha e^{-|x|^2}),\quad \alpha \in \nn d.
$$
The set of Hermite functions on $\rr d$ is an orthonormal basis for
$L^2(\rr d)$.
We use $\mathcal H _0(\rr d)$ to denote the space of finite linear combinations
of Hermite functions.
Then $\mathcal H _0(\rr d)$ is dense in the Schwartz space $\mathscr S (\rr d)$,
as well as in $\mathscr S '(\rr d)$, with respect to its weak$^*$ topology.
The same conclusion is true for $\Sigma _s(\rr d)$ when $s>\frac 12$,
$\mathcal S _s(\rr d)$ when $s\ge \frac 12$ and their distribution dual
spaces $\Sigma _s'(\rr d)$ and $\mathcal S _s'(\rr d)$.
An $f$ in any of these spaces possess an expansion of the form
\begin{equation}\label{Eq:HermiteExpansions}
f=\sum _{\alpha \in \nn d}c(f,\alpha )h_\alpha ,
\quad
c (f,\alpha )=(f,h_\alpha ), \quad \alpha \in \nn d.
\end{equation}
Here $(\, \cdot \, , \, \cdot \, )$ denotes the unique extensions of the $L^2$ form,
which is linear in the first variable and conjugate linear in the second variable,
from $\mathcal H _0(\rr d)\times \mathcal H _0(\rr d)$ to
$\mathcal S _s'(\rr d)\times \mathcal S _s(\rr d)$ or
$\Sigma _s'(\rr d)\times \Sigma _s(\rr d)$.
We recall that (cf. \cite[Chapter V.3 ]{RS})
\begin{equation}
\begin{alignedat}{5}
f&\in \mathscr S (\rr d) & \quad &\Leftrightarrow &\quad
|c(f,\alpha )| &\lesssim \eabs \alpha ^{-N} &
\ &\text{for every}& \ N&\ge 0 ,
\\[1ex]
f&\in \mathscr S '(\rr d) & \quad &\Leftrightarrow &\quad
|c(f,\alpha )| &\lesssim \eabs \alpha ^{N} &
\ &\text{for some}& \ N&\ge 0.
\end{alignedat}
\end{equation}
The topology on $\mathscr S (\rr d)$ is equivalent to the Fr\'echet space
topology defined by the sequence space seminorms
\begin{equation*}
\mathscr S (\rr d) \ni f \mapsto \sum_{\alpha \in \nn d}
\eabs \alpha ^{2N} |c(f,\alpha )|^2, \quad N \ge 0.
\end{equation*}
For $f \in \mathscr S '(\rr d)$ the sum in \eqref{Eq:HermiteExpansions}
converges in the weak$^*$ topology.
\par
The Hermite functions are eigenfunctions to the harmonic
oscillator $H=H_d\equiv |x|^2-\Delta$ and to the Fourier transform
$\mathscr F$, given by
$$
\mathscr Ff (\xi )= \widehat f(\xi ) \equiv (2\pi )^{-\frac d2}\int _{\rr
{d}} f(x)e^{-i\scal x\xi }\, dx, \quad \xi \in \rr d,
$$
when $f\in L^1(\rr d)$. Here $\scal \, \cdot \, \, \cdot \, $ denotes the
scalar product on $\rr d$. In fact
$$
H_dh_\alpha = (2|\alpha |+d)h_\alpha, \quad \alpha \in \nn d.
$$
\par
The Fourier transform $\mathscr F$ extends
uniquely to homeomorphisms on $\mathscr S'(\rr d)$,
from $(\mathcal S _s^\sigma )'(\rr d)$ to $(\mathcal S ^s_\sigma )'(\rr d)$ and
from $(\Sigma _s^\sigma )'(\rr d)$ to $(\Sigma ^s_\sigma )'(\rr d)$.
It also restricts to
homeomorphisms on $\mathscr S(\rr d)$, from
$\mathcal S _s^\sigma (\rr d)$ to $\mathcal S ^s_\sigma (\rr d)$, from
$\Sigma _s^\sigma (\rr d)$ to $\Sigma ^s_\sigma (\rr d)$,
and to a unitary operator on $L^2(\rr d)$. Similar facts hold true
when the Fourier transform is replaced by a partial
Fourier transform.
\par
Let $\phi \in \mathscr S (\rr d) \setminus 0$ be
fixed. We use the transform
\begin{equation}\label{eq:cTdef}
\begin{aligned}
\mathcal{T}_\phi f(x,\xi) &= (2\pi)^{-\frac d2}e^{i \langle x, \xi \rangle}
(f,e^{i\scal \, \cdot \, \xi}\phi (\, \cdot \, -x))
\\[1ex]
&=
e^{i \langle x, \xi \rangle}\mathscr F (f\cdot \overline {\phi (\, \cdot \, -x)})(\xi )
=
\mathscr F (f(\, \cdot \, +x)\overline \phi )(\xi ), \quad x, \xi \in \rr d,
\end{aligned}
\end{equation}
where $f \in \mathscr S '(\rr d)$ and $\phi \in \mathscr S (\rr d) \setminus 0$
(cf. \cite{Cappiello1}). If $f ,\phi \in \mathscr S (\rr d)$ then
\begin{align*}
\mathcal{T} _\phi f(x,\xi )
&=
(2\pi )^{-\frac d2}e^{i \langle x, \xi \rangle}
\int _{\rr d} f(y)\overline {\phi
(y-x)}e^{-i\scal y\xi}\, dy
\\[1ex]
&=
(2\pi )^{-\frac d2}
\int _{\rr d} f(y+x)\overline {\phi
(y)}e^{-i\scal y\xi}\, dy, \quad x,\xi \in \rr d.
\end{align*}
\par
We notice that the short-time Fourier transform $V_{\phi}f$
of $f$ is given by
\begin{equation}\label{Eq:LinkSTFTandTmap}
V_{\phi}f(x,\xi) = e^{-i \langle x, \xi \rangle} \mathcal{T}_\phi f(x,\xi).
\end{equation}
Thus by \cite[Theorem 2.3]{To11} it follows that the definition of the map
$(f,\phi)\mapsto \mathcal{T} _{\phi} f$ from $\mathscr S (\rr d) \times \mathscr S (\rr d)$
to $\mathscr S(\rr {2d})$ is uniquely extendable to a continuous map from
$\mathcal S _s'(\rr d)\times \mathcal S_s'(\rr d)$
to $\mathcal S_s'(\rr {2d})$, and restricts to a continuous map
from $\mathcal S _s (\rr d)\times \mathcal S _s (\rr d)$
to $\mathcal S _s(\rr {2d})$.
The same conclusion holds with $\Sigma _s$ in place of
$\mathcal S_s$, at each place.
\par
The adjoint $\mathcal{T} _\phi ^*$ is given by
$$
(\mathcal{T} _\phi^* F, g)_{L^2(\rr d)}
=
(F, \mathcal{T} _\phi g)_{L^2(\rr {2d})}
$$
for $F \in \mathcal S _s'(\rr {2d})$ and $g \in \mathcal S _s(\rr d)$,
and similarly with $\Sigma _s$ or with $\mathscr S$ in place of
$\mathcal S _s$ at each occurrence.
When $F$ is a polynomially bounded measurable function we
write
\begin{equation}\label{Eq:Moyalsformula}
\mathcal{T} _\phi^* F(y) = (2\pi)^{-\frac d2} \iint _{\rr {2d}}
F(x,\xi) \, e^{i\scal {y-x}\xi}\phi (y-x)
\, d x d \xi ,
\end{equation}
where the integral is defined weakly so that
$(\mathcal{T} _\phi^* F, g)_{L^2(\rr d)}
=
(F, \mathcal{T} _\phi g)_{L^2(\rr {2d})}$
for $g \in \mathscr{S}(\rr d)$.
The identity \eqref{Eq:Moyalsformula} is called Moyal's formula.
\par
We have
\begin{equation}\label{eq:reproducing}
(\mathcal{T}_\psi ^*\circ \mathcal{T} _\phi )f
=(\psi ,\phi ) f, \qquad f \in \mathcal S _s'(\rr d),\ \phi ,\psi \in \mathcal S _s(\rr d),
\end{equation}
and similarly with $\Sigma _s$ or with $\mathscr S$ in place of
$\mathcal S _s$ at each occurrence.
\par
Two important features of $\mathcal{T} _\phi$ which distinguish
it from the short-time Fourier transform are the differential identities
\begin{align}
\label{eq:diffident}
\partial_x^\alpha \mathcal{T} _\phi f (x,\xi) & = \mathcal{T} _\phi (\partial^\alpha f) (x,\xi),
\qquad \alpha \in \nn d
\intertext{and}
\label{eq:diffidentstar}
D_{\xi}^\beta \mathcal{T} _\phi f (x,\xi) & = \mathcal{T}_{g_\beta} f(x,\xi), \qquad \beta \in \nn d, \qquad
\phi _\beta (x) = (-x)^\beta \phi (x).
\end{align}
\par
By \eqref{Eq:LinkSTFTandTmap} it follows that
characterizations of Gelfand-Shilov spaces and their distribution spaces
in terms of estimates of their short-time Fourier transforms
carry over to estimates on $\mathcal{T} _\phi$
in place of $V_\phi$. For example we have
the following (see e.{\,}g. \cite{GZ,Teof} for the proof of (1)
and \cite{Toft18} for the proof of (2)).
See also \cite{CPRT10} for related results.
\par
\begin{prop}\label{stftGelfand2}
Let $s,\sigma >0$,
$\phi \in \mathcal S _s^\sigma (\rr d)\setminus 0$
($\phi \in \Sigma _s^\sigma (\rr d)\setminus 0$) and let
$f\in (\mathcal S _s^\sigma )'(\rr d)$ ($f\in (\Sigma _s^\sigma )'(\rr d)$).
Then the following is true:
\begin{enumerate}
\item $f\in \mathcal S _s^\sigma (\rr d)$ ($f\in \Sigma _s^\sigma (\rr d)$) if and only if
\begin{equation}\label{stftexpest2}
|\mathcal{T} _\phi f(x,\xi )| \lesssim e^{-r (|x|^{\frac 1s}+|\xi |^{\frac 1\sigma})}, \quad x,\xi \in \rr d,
\end{equation}
for some (every) $r > 0$.
\item $f\in (\mathcal S _s^\sigma )'(\rr d)$ ($f\in (\Sigma _s^\sigma )'(\rr d)$) if and only if
\begin{equation}\label{stftexpest2Dist}
|\mathcal{T} _\phi f(x,\xi )| \lesssim e^{r(|x|^{\frac 1s}+|\xi |^{\frac 1\sigma})}, \quad
x,\xi \in \rr d,
\end{equation}
for every (some) $r > 0$.
\end{enumerate}
\end{prop}
\par
\subsection{The Bargmann transform and spaces of analytic
functions}\label{subsec1.3}
\par
If $\Omega \subseteq \cc d$ is open then $A(\Omega)$
consists of all (complex-valued) analytic functions on $\Omega$.
Complex derivatives are denoted, with $z = x+iy \in \Omega$,
\begin{equation*}
\partial_{z_j} = \frac{1}{2} \left( \partial_{x_j} - i \partial_{y_j} \right), \quad
\overline{\partial}_{z_j} = \frac{1}{2} \left( \partial_{x_j} + i \partial_{y_j} \right)
\end{equation*}
for $1 \le j \le d$, which admits the Cauchy-Riemann equations to be written as
$\overline{\partial}_{z_j} f = 0$, $1 \le j \le d$.
\par
The Bargmann kernel is defined by
$$
\mathfrak A_d(z,y)=\pi ^{-\frac d4} \exp \Big ( -\frac 12(\scal
zz+|y|^2)+2^{1/2}\scal zy\Big ), \quad z \in \cc d, \quad y \in \rr d,
$$
where
$$
\scal zw = \sum _{j=1}^dz_jw_j\quad \text{and} \quad
(z,w)= \scal z{\overline w}
$$
when
$$
z=(z_1,\dots ,z_d) \in \cc d\quad \text{and} \quad w=(w_1,\dots ,w_d)\in \cc d.
$$
Sometimes $\scal \, \cdot \, \, \cdot \, $ denotes the duality between a test function
space and its dual. The context precludes confusion between its double use.
The Bargmann transform $\mathfrak V_df$ of $f\in \mathcal S _{1/2}'(\rr d)$
is the entire function
\begin{equation}\label{bargdistrform}
\mathfrak V_d f (z) =\scal f{\mathfrak A_d(z,\, \cdot \, )},
\quad z \in \cc d.
\end{equation}
The right-hand side is a well defined element in $A(\cc d)$,
since $y\mapsto \mathfrak A_d(z,y)$ belongs to
$\mathcal S _{1/2} (\rr d)$ for $z \in \cc d$ fixed, and
$\mathfrak A_d(\, \cdot \, ,y)$ is entire for all $y \in \rr d$.
Let $p\in [1,\infty ]$ and $\omega \in \mathscr P _E(\rr d)$. Then
$L^p_{(\omega )}(\rr d)$ consists of all $f\in L^1_{loc}(\rr d)$ such
that $\nm f{L^p_{(\omega )}}\equiv \nm {f\cdot \omega }{L^p}$
is finite. If $f\in L^p_{(\omega )}(\rr d)$, then
\begin{multline}
\mathfrak V_d f (z) =\int_{\rr d} \mathfrak A_d(z,y)f(y)\, dy
\\[1ex]
=
\pi ^{-\frac d4}\int _{\rr d}\exp \Big ( -\frac 12(\scal
z z+|y|^2)+2^{1/2}\scal zy \Big )f(y)\, dy,\quad z \in \cc d.
\end{multline}
(Cf. \cite{B1,B2,To11,Toft18}.)
\par
For $p\in (0,\infty]$, $\omega \in \mathscr P _E(\cc d)$ and
$\omega _0(z)=\omega (\sqrt 2\overline z)$, let
$A^p_{(\omega )}(\cc d)$ be the set of all $F\in A(\cc d)$
such that
\begin{equation*}
\nm F{A^p_{(\omega )}}
\equiv \pi ^{-\frac dp}
\nm {F\cdot e^{-\frac 12|\, \cdot \, |^2}\cdot \omega _0}{L^p},
\end{equation*}
and set $A^p=A^p_{(\omega )}$ when $\omega =1$.
It was proved by Bargmann \cite{B1} that
\begin{equation}\label{Eq:L2A2Isometry}
\mathfrak V_d : L^2(\rr d) \to A^2(\cc d)
\end{equation}
is bijective and isometric. The space $A^2(\cc d)$ is the Hilbert space
of entire functions with scalar product
\begin{equation*}
(F,G)_{A^2}\equiv \int _{\cc d} F(z)\overline {G(z)}\, d\mu (z),\quad F,G\in A^2(\cc d),
\end{equation*}
where $d\mu (z)=\pi ^{-d} e^{-|z|^2}\, d\lambda (z)$ and $d\lambda (z)$ is
the Lebesgue measure on $\cc d$. The space $A^2(\cc d)$ is known as the
Fock space in quantum mechanics (see\cite{Fo}).
\par
In \cite{B1} it was proved that the Bargmann transform maps the Hermite functions
to monomials as
\begin{equation}\label{Eq:BargmannHermiteMap}
\mathfrak V_dh_\alpha = e_\alpha ,\qquad e_\alpha (z)= \frac {z^\alpha}{\alpha !^{\frac 12}},
\quad z\in \cc d,\quad \alpha \in \nn d.
\end{equation}
The orthonormal basis
$\{ h_\alpha \}_{\alpha \in \nn d} \subseteq L^2(\rr d)$
is thus mapped to the orthonormal basis
$\{ e_\alpha \} _{\alpha \in \nn d}\subseteq A^2(\cc d)$.
Bargmann also proved that there is a reproducing formula for
$A^2(\cc d)$. Let $\Pi _A$ be the operator from $L^2(d\mu )$
to $A(\cc d)$, given by
\begin{equation}\label{eq:projection}
\Pi _A F (z)= \int _{\cc d} F(w)e^{(z,w)}\, d\mu (w),
\quad z \in \cc d.
\end{equation}
Then $\Pi _A$ is the orthogonal projection from
$L^2(d\mu)$ to
$A^2(\cc d)$ (cf. \cite{B1}).
\par
When we discuss extensions and restrictions of the
Bargmann transform to Gelfand-Shilov spaces and their
distribution spaces, we use
\begin{equation}\label{Eq:GevreyQuasinormMIxed}
|z|_{s,\sigma} = |\operatorname{Re} z|^{\frac 1s}
+
|\operatorname{Im} z|^{\frac 1\sigma},
\qquad
z\in \cc d,
\end{equation}
and consider the seminorms
\begin{alignat*}{2}
\nm F{\mathcal A _{\mathscr S ;r}}
&\equiv
\nm {F\cdot e^{-\frac 12|\, \cdot \, |^2}\eabs \, \cdot \,
^{r}}{L^\infty},&
\quad
\nm F{\mathcal A _{\mathscr S ;r}'}
&\equiv
\nm {F\cdot e^{-\frac 12|\, \cdot \, |^2}\eabs \, \cdot \,
^{-r}}{L^\infty}
\intertext{and}
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}}
&\equiv
\nm {F\cdot e^{-\frac 12|\, \cdot \, |^2+r|\, \cdot \,
|_{s,\sigma}}}{L^\infty}, &
\quad
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}'}
&\equiv
\nm {F\cdot e^{-\frac 12|\, \cdot \, |^2-r|\, \cdot \,
|_{s,\sigma}}}{L^\infty}
\end{alignat*}
when $F\in A(\cc d)$, $r>0$ and $s,\sigma \ge \frac 12$. Then
$\mathcal A _{0,s}^\sigma (\cc d)$ for
$s, \sigma > \frac 12$,
$\mathcal A _{\mathscr S} (\cc d)$ and
$(\mathcal A _s^\sigma )' (\cc d)$ for
$s,\sigma \ge \frac 12$
are the sets of all
$F\in A(\cc d)$ such that
\begin{equation*}
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}}<\infty,
\quad
\nm F{\mathcal A _{\mathscr S ;r}}<\infty
\quad \text{and}\quad
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}'}<\infty,
\end{equation*}
respectively, for every $r>0$.
The spaces are equipped with the
projective limit topology with respect to $r>0$,
defined by each class of seminorms, respectively.
\par
In the same way we
let $\mathcal A _{s}^\sigma (\cc d)$ for
$s,\sigma \ge \frac 12$,
$\mathcal A _{\mathscr S}' (\cc d)$ and
$(\mathcal A _{0,s}^\sigma )' (\cc d)$ for $s,\sigma >\frac 12$
be the sets of all
$F\in A(\cc d)$ such that
\begin{equation*}
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}}<\infty,
\quad
\nm F{\mathcal A _{\mathscr S ;r}'}<\infty
\quad \text{and}\quad
\nm F{\mathcal A _{\mathcal S _{s;r}^\sigma}'}<\infty ,
\end{equation*}
respectively, for some $r>0$.
Their topologies are the inductive limit
topologies with respect to $r>0$,
defined by each class of seminorms, respectively.
We also set
$$
\mathcal A _{0,s} =\mathcal A _{0,s}^s
\quad \text{and}\quad
\mathcal A _{s} =\mathcal A _{s}^s.
$$
Then
\begin{alignat*}{5}
{\mathfrak V}_d \, &: &\,
\mathscr S (\rr d) &\to \mathcal A _{\mathscr S}(\cc d), &
\qquad
{\mathfrak V}_d \, &: &\,
\mathscr S '(\rr d) &\to \mathcal A _{\mathscr S}'(\cc d), & &
\\[1ex]
\mathfrak V_d \, &: &\,
\mathcal S _s^\sigma (\rr d) &\to \mathcal A _s^\sigma (\cc d), &
\qquad
\mathfrak V_d \, &: &\,
(\mathcal S _s^\sigma )'(\rr d)
&\to (\mathcal A _s^\sigma )' (\cc d) &
\quad
s,\sigma &\ge \frac 12
\intertext{and}
\mathfrak V_d \, &: &\,
\Sigma _s^\sigma (\rr d)
&\to
\mathcal A _{0,s}^\sigma (\cc d), &
\qquad
\mathfrak V_d \, &: &\,
(\Sigma _s^\sigma )'(\rr d)
&\to (\mathcal A _{0,s}^\sigma )' (\cc d), &
\quad
s,\sigma &> \frac 12
\end{alignat*}
are homeomorphisms \cite{Toft18}.
\par
From these homeomorphisms, the fact that the map
\eqref{Eq:L2A2Isometry} is a homeomorphism and
duality properties for Gelfand-Shilov spaces, it follows that
$(\, \cdot \, ,\, \cdot \, )_{A^2}$ on $\mathcal A _{1/2}(\cc d)\times
\mathcal A _{1/2}(\cc d)$ is uniquely extendable to
a continuous sesqui-linear form on
$(\mathcal A _s^\sigma )'(\cc d)\times \mathcal A _s^\sigma (\cc d)$.
The dual of $\mathcal A _s^\sigma (\cc d)$
can be identified with $(\mathcal A _s^\sigma )'(\cc d)$ through
this form. Similar facts hold for $\mathcal A _{0,s}^\sigma$
in place of $\mathcal A _s^\sigma$ at each occurrence.
(Cf. e.{\,}g. \cite{To11,Toft18}.)
\par
Finally let $\mathcal A _{\flat _1;r}(\cc d)$ and $\mathcal A _{\flat _\infty ;r}(\cc d)$
for $r > 0$ be the Banach spaces which consist
of all $F\in A(\cc d)$ such that
$$
\nm F{\mathcal A _{\flat _1;r}}\equiv \nm {F\cdot e^{-r|\, \cdot \, |}}{L^\infty}
\quad \text{respectively}\quad
\nm F{\mathcal A _{\flat _\infty ;r}}\equiv \nm {F\cdot e^{-r|\, \cdot \, |^2}}{L^\infty}
$$
is finite, and let $\mathcal A _{\flat _1}(\cc d)$ be the inductive limit
of $\mathcal A _{\flat _1;r}(\cc d)$ with respect to $r>0$. Also let
$\mathcal A _{0,\flat _\infty}(\cc d)$ and $\mathcal A _{0,\flat _\infty}'(\cc d)$
be the projective respectively inductive limit topologies of
$\mathcal A _{\flat _\infty ;r}(\cc d)$ with respect to $r>0$.
\par
It is evident that
$\mathcal A _{\flat _1}(\cc d)$ is densely embedded in $\mathcal A _s^\sigma (\cc d)$
for every $s,\sigma \ge \frac 12$, as well as in $\mathcal A _{0,s}^\sigma (\cc d)$
for every $s,\sigma > \frac 12$. The form
$(\, \cdot \, ,\, \cdot \, )_{A^2}$ on $\mathcal A _{\flat _1}(\cc d)\times
\mathcal A _{\flat _1}(\cc d)$ is uniquely extendable to
a continuous sesqui-linear form on
$A(\cc d)\times \mathcal A _{\flat _1} (\cc d)$ and the dual
of $\mathcal A _{\flat _1} (\cc d)$ can be identified with $A(\cc d)$.
The Fr{\'e}chet space topology of $A(\cc d)$
can be defined by the seminorms
$$
F\mapsto \sup _{|z|\le N}|F(z)|,\qquad N=1,2,\dots .
$$
(Cf. \cite{Toft18}.)
\par
\begin{rem}\label{Rem:BargmannPilipovicSpaces}
The spaces $\mathcal A _{\flat _1}(\cc d)$ and $\mathcal A _{0,\flat _\infty}(\cc d)$
are examples of Bargmann images of special Pilipovi{\'c} spaces, a family
of Fourier invariant topological vector spaces which are smaller than any Fourier
invariant Gelfand-Shilov space, and which were introduced
and investigated in \cite{Toft18}. For any $\sigma >0$, the Bargmann image
of the Pilipovi{\'c} spaces $\mathcal H _{\flat _\sigma}(\rr d)$ and
$\mathcal H _{0,\flat _\sigma}(\rr d)$ are given by
\begin{align*}
\mathcal A _{\flat _\sigma}(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^{\frac {2\sigma}{\sigma +1}}}
\ \text {for some}\ r>0 }
\intertext{respectively}
\mathcal A _{0,\flat _\sigma}(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^{\frac {2\sigma}{\sigma +1}}}
\ \text {for every}\ r>0 }.
\end{align*}
\par
If $\sigma >1$, then the (strong) duals of $\mathcal A _{\flat _\sigma}(\cc d)$ and
$\mathcal A _{0,\flat _\sigma}(\cc d)$ are given by
\begin{align*}
\mathcal A _{\flat _\sigma}'(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^{\frac {2\sigma}{\sigma -1}}}
\ \text {for every}\ r>0 }
\intertext{respectively}
\mathcal A _{0,\flat _\sigma}'(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^{\frac {2\sigma}{\sigma -1}}}
\ \text {for some}\ r>0 }
\end{align*}
through a unique extension of the $A^2$ scalar product on
$\mathcal A _{\flat _1}(\cc d)\times \mathcal A _{\flat _1}(\cc d)$.
In particular, if $\sigma$ tends to $\infty$, it follows that some of
these conditions tend to
\begin{align*}
\mathcal A _{0,\flat _\infty}(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^2}
\ \text {for every}\ r>0 }
\intertext{respectively}
\mathcal A _{0,\flat _\infty}'(\cc d)
& \equiv
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{r|z|^2}
\ \text {for some}\ r>0 }.
\end{align*}
Note that in \cite{Toft18,Teofanov2}, the set $\mathcal A _{0,\flat _\infty}(\cc d)$
is denoted by $\mathcal A _{0,\frac 12}(\cc d)$, and its dual
$\mathcal A _{0,\flat _\infty}'(\cc d)$ is denoted by $\mathcal A _{0,\frac 12}'(\cc d)$.
\end{rem}
\par
At many places it will be crucial to use the Gaussian window
\begin{equation}\label{Eq:phidef}
\phi (x)=\pi ^{-\frac d4}e^{-\frac 12|x|^2}, \quad x\in \rr d,
\end{equation}
in the transform $\mathcal{T}_\phi$.
For this $\phi$ the relationship between
the Bargmann transform and $\mathcal{T} _\phi$ is
\begin{equation}\label{bargstft1}
\mathfrak V_d = U_{\mathfrak V}\circ \mathcal{T} _\phi ,\quad \text{and}\quad
U_{\mathfrak V}^{-1} \circ \mathfrak V_d = \mathcal{T} _\phi ,
\end{equation}
where $U_{\mathfrak V}$ is the linear, continuous and bijective operator on
$\mathscr D'(\rr {2d})\simeq \mathscr D'(\cc d)$, given by
\begin{equation}\label{UVdef}
U_{\mathfrak V} F (x+i\xi ) = (2\pi )^{\frac d2} e^{\frac 12(|x|^2+|\xi |^2)}e^{i\scal x\xi}
F(\sqrt 2\, x,-\sqrt 2\, \xi ), \quad x,\xi \in \rr d,
\end{equation}
cf. \cite{To11} in combination with \eqref{Eq:LinkSTFTandTmap}.
\par
In analytic operator theory we need subspaces of
$$
\wideparen A(\cc {2d})
\equiv
\Sets {\Theta K}
{K\in A(\cc {2d})},
$$
where the semi-conjugation operator is
\begin{equation}\label{Eq:ThetaOpDef}
(\Theta K) (z,w) = K(z,\overline w),\qquad z,w\in \cc d.
\end{equation}
If $T$ is a linear and continuous operator
from $\mathcal S _{1/2}(\rr d)$ to $\mathcal S _{1/2}'(\rr d)$,
then there is a unique $K\in \wideparen A(\cc {2d})$
such that $\Theta K\in \mathcal A _{1/2}'(\cc {2d})$
and $\mathfrak V_d \circ T \circ \mathfrak V_d^{-1}$
is given by
\begin{equation}\label{Eq:CompIntOp}
F(z)\mapsto \int _{\cc d}K(z,w)F(w)\, d\mu (w).
\end{equation}
(See e.{\,}g. \cite{Teofanov2}.) For these reasons we let
$$
\wideparen \mathcal A _{0,s}(\cc {2d}),
\quad
\wideparen \mathcal A _s(\cc {2d}),
\quad
\wideparen \mathcal A _{\mathscr S}(\cc {2d}),
\quad
\wideparen \mathcal A _{\mathscr S}'(\cc {2d}),
\quad
\wideparen \mathcal A _s'(\cc {2d})
\quad \text{and}\quad
\wideparen \mathcal A _{0,s}'(\cc {2d})
$$
be the images of
$$
\mathcal A _{0,s}(\cc {2d}),
\quad
\mathcal A _s(\cc {2d}),
\quad
\mathcal A _{\mathscr S}(\cc {2d}),
\quad
\mathcal A _{\mathscr S}'(\cc {2d}),
\quad
\mathcal A _s'(\cc {2d})
\quad \text{and}\quad
\mathcal A _{0,s}'(\cc {2d})
$$
respectively, under the map $\Theta$. We also let $\wideparen A^p(\cc {2d})$
and $\wideparen \mathcal A _{\flat _1}(\cc {2d})$
be the images of $A^p(\cc {2d})$ and $\mathcal A _{\flat _1}(\cc {2d})$,
respectively, under the map $\Theta$.
The topologies of the former spaces are
inherited from the corresponding latter spaces.
\par
The semi-conjugated
Bargmann (SCB) transform is defined as
$$
\mathfrak V_{\Theta ,d}
=
\Theta \circ \mathfrak V_{2d}.
$$
All properties of the Bargmann transform
carry over naturally to analogous properties for the SCB transform.
\par
\subsection{Pseudo-differential operators}\label{subsec1.4}
\par
Let $A$ be a real $d\times d$ matrix.
The \emph{pseudo-differential operator}
$\operatorname{Op} _A(\mathfrak a)$ with \emph{symbol}
$\mathfrak a \in \mathcal S _{1/2} (\rr {2d})$ is the linear and continuous operator on
$\mathcal S _{1/2} (\rr d)$ given by
\begin{equation}\label{e0.5}
\operatorname{Op} _A(\mathfrak a )f (x)
=
(2\pi ) ^{-d}\iint \mathfrak a (x-A(x-y),\xi )
f(y)e^{i\scal {x-y}\xi }\,
dyd\xi, \quad x\in \rr d.
\end{equation}
For $\mathfrak a \in \mathcal S _{1/2}'(\rr {2d})$ the
pseudo-differential operator $\operatorname{Op} _A(\mathfrak a )$
is defined as the continuous
operator from $\mathcal S _{1/2}(\rr d)$ to $\mathcal S _{1/2}'(\rr d)$ with
distribution kernel
\begin{equation}\label{atkernel}
K_{\mathfrak a ,A}(x,y)
=
(2\pi )^{-\frac d2} \mathscr F _2^{-1}\mathfrak a (x-A(x-y),x-y), \quad
x,y \in \rr d,
\end{equation}
where $\mathscr F _2F$ is the partial Fourier
transform of $F(x,y)\in
\mathcal S _{1/2}'(\rr {2d})$ with respect to the $y$
variable. This definition makes sense since the
mappings
\begin{equation}\label{homeoF2tmap}
\mathscr F _2\quad \text{and}\quad F(x,y)\mapsto F(x,x-y)
\end{equation}
are homeomorphisms on $\mathcal S _{1/2}'(\rr {2d})$.
The map $a\mapsto K_{\mathfrak a ,A}$ is
hence a homeomorphism on $\mathcal S _{1/2}'(\rr {2d})$.
\par
If $A$ and $B$ are real $d\times d$ matrices and
$\mathfrak a \in \mathcal S _{1/2}'(\rr {2d})$,
then there is a unique $\mathfrak b \in \mathcal S _{1/2}'(\rr {2d})$ such that
$\operatorname{Op} _A(\mathfrak a )= \operatorname{Op} _B(\mathfrak b )$, and that $\mathfrak b$ can be obtained by
\begin{equation}\label{Eq:RealPseudoCalculiTransfer}
\operatorname{Op} _A(\mathfrak a )= \operatorname{Op} _B(\mathfrak b )
\quad \Leftrightarrow \quad
e^{i\scal {AD_\xi }{D_x}}\mathfrak a (x,\xi )
=
e^{i\scal {BD_\xi }{D_x}}\mathfrak b (x,\xi )
\end{equation}
(see \cite{Ho1,CaTo}).
\par
\begin{rem}\label{BijKernelsOps}
By Fourier's inversion formula, \eqref{atkernel} and the
kernel theorem
\cite[Theorem 2.2]{LozPer}, \cite[Theorem 2.5]{Teof2} for
operators from
Gelfand-Shilov spaces to their duals,
it follows that the map $\mathfrak a \mapsto \operatorname{Op} _A(\mathfrak a )$
is bijective from $\mathcal S _{1/2}'(\rr {2d})$
to the set of all linear and continuous operators from
$\mathcal S _{1/2}(\rr d)$ to $\mathcal S _{1/2}'(\rr {2d})$.
\end{rem}
\par
If $A=0$ then
$\operatorname{Op} _A(\mathfrak a ) = \operatorname{Op} _0(\mathfrak a ) = \operatorname{Op} (\mathfrak a ) = \mathfrak a (x,D)$
is the Kohn-Nirenberg or standard representation.
If $A=\frac 12 I_d$
where $I_d$ is the $d\times d$ identity matrix
then $\operatorname{Op} _A(\mathfrak a ) = \operatorname{Op} ^w(\mathfrak a )$ is the Weyl quantization.
In this paper we use mainly the Weyl quantization and we put
\begin{equation*}
K_{\mathfrak a }^w = K_{\mathfrak a ,I_d/2} \ .
\end{equation*}
\par
The Weyl product $\mathfrak a {\text{\footnotesize $\#$}} \mathfrak b$ of two Weyl symbols $\mathfrak a ,\mathfrak b
\in \mathcal S _{1/2}(\rr {2d})$ is defined
as the product of symbols corresponding to operator composition. Thus
\begin{equation*}
\operatorname{Op} ^w(\mathfrak a {\text{\footnotesize $\#$}} \mathfrak b ) = \operatorname{Op} ^w(\mathfrak a ) \circ \operatorname{Op} ^w(\mathfrak b )
\end{equation*}
and the Weyl product can be extended to larger spaces as long as
composition is well defined.
\medspace
Next we recall the definition of Wick operators. Suppose that
$a\in \wideparen A(\cc {2d})$ satisfies
\begin{equation}\label{Eq:AntiWickL1Cond}
w\mapsto a(z,w)e^{r|w|-|w|^2} \in L^1(\cc d)
\end{equation}
locally uniformly with respect to $z\in \cc d$ for every $r>0$. Then the
\emph{analytic pseudo-differential operator},
or \emph{Wick operator} $\operatorname{Op} _{\mathfrak V}(a)$ with symbol $a$
and acting on $F\in \mathcal A _{\flat _1}(\cc d)$, is defined by
\begin{align}
\operatorname{Op} _{\mathfrak V}(a)F(z) &= \int _{\cc d} a(z,w)F(w)e^{(z,w)}\, d\mu (w),
\quad z \in \cc d.
\label{Eq:AnalPseudo}
\end{align}
(Cf. e.{\,}g. \cite{Berezin71,Fo,Teofanov2,To11, Toft18}.)
The condition \eqref{Eq:AntiWickL1Cond} and
$F\in \mathcal A _{\flat _1}(\cc d)$ imply that the integrand on
the right-hand side of \eqref{Eq:AnalPseudo} is well defined.
The locally uniform
condition \eqref{Eq:AntiWickL1Cond} with respect to $z\in \cc d$
implies that $\operatorname{Op} _{\mathfrak V}(a)F \in A(\cc d)$.
\par
In \cite{Teofanov2} several extensions and restrictions of
$\operatorname{Op} _{\mathfrak V}(a)$ are given.
The following result follows
from \cite[Theorems 2.7 and 2.8]{Teofanov2}. Here
$\mathcal L(\mathcal A _{\flat _1}(\cc d),A(\cc d))$
is the space of all linear and continuous operators from
$\mathcal A _{\flat _1}(\cc d)$ to $A(\cc d)$.
\par
\begin{prop}\label{Prop:ContAnalPseudo}
The map $a\mapsto \operatorname{Op} _{\mathfrak V}(a)$
from $\wideparen \mathcal A _{\flat _1}(\cc {2d})$ to
$\mathcal L(\mathcal A _{\flat _1}(\cc d),A(\cc d))$ is uniquely
extendable to a bijective map from
$\wideparen A(\cc {2d})$ to
$\mathcal L(\mathcal A _{\flat _1}(\cc d),A(\cc d))$.
\end{prop}
\par
Let $L_A(\cc {2d})$ be the set of all $a \in L^1_{\rm loc}(\cc {2d})$ such that
$z\mapsto a(z,w)$ is entire for almost every $w\in \cc d$ and
\begin{equation}\label{Eq:LACond}
w \mapsto
\sup _{\alpha \in \nn d}
\left |
\frac { \partial _z^\alpha a(z,w)\cdot e^{r|w|-|w|^2}}{h^{|\alpha |}\alpha !}
\right |
\in L^1(\cc d)
\end{equation}
for every $h,r>0$ and $z\in \cc d$.
If $a\in \wideparen A(\cc {2d})$ satisfies \eqref{Eq:AntiWickL1Cond} then
$a\in L_A(\cc {2d})$ as a consequence of Cauchy's integral formula.
Thus $L_A(\cc {2d})$ is a relaxation of the former condition.
\par
If $a\in L_A(\cc {2d})$ then $\operatorname{Op} _{\mathfrak V}(a):
\mathcal A _{\flat _1}(\cc d) \to \mathcal A _{\flat _1}'(\cc d)=A(\cc d)$
is continuous.
Hence the following result is a straight-forward consequence of Proposition
\ref{Prop:ContAnalPseudo} and the fact that
$\wideparen {\mathcal A} _{\flat _1}'(\cc {2d})=\wideparen A(\cc {2d})$.
\par
\begin{prop}\label{Prop:LAOpsIdent}
Let $a\in L_A(\cc {2d})$. Then there is a unique $a_0\in \wideparen A(\cc {2d})$
such that $\operatorname{Op} _{\mathfrak V}(a) = \operatorname{Op} _{\mathfrak V}(a_0)$ as mappings
from $\mathcal A _{\flat _1}(\cc d)$ to $\mathcal A _{\flat _1}'(\cc d)$. It holds
\begin{multline}\label{Eq:AntiWickAnalPseudoRel}
\operatorname{Op} _{\mathfrak V}(a) = \operatorname{Op} _{\mathfrak V}(a_0)
\\[1ex]
\text{where}\quad
a_0(z,w) = \pi ^{-d} \int _{\cc d}a(z,w_1)e^{-(z-w_1,w-w_1)}\, d\lambda (w_1).
\end{multline}
\end{prop}
\par
\begin{proof}
The operator $\Pi _A$ defined in \eqref{eq:projection} is the orthogonal
projection from $L^2(d\mu)$ to $A^2(\cc d)$ which is uniquely extendable
to a continuous
map from
\begin{equation}\label{Eq:AntiWickL1SymbClass}
L_{0,A}(\cc d) \equiv
\sets {a_0 \in L^1_{\rm loc}(\cc d)}{w \mapsto a_0(w)e^{r|w|-|w|^2} \in L^1(\cc d)
\ \text{for every}\ r>0}
\end{equation}
to $A(\cc d)$ (see e.{\,}g. \cite{To11}). Hence, if $F,G\in \mathcal A _{\flat _1}(\cc d)$ and $a_0$ is
given by \eqref{Eq:AntiWickAnalPseudoRel} then
\begin{multline*}
(\operatorname{Op} _{\mathfrak V}(a)F,G)_{A^2}
=
((\operatorname{Op} _{\mathfrak V}(a)\circ \Pi _A)F,G)_{A^2}
\\[1ex]
= \left (
\int _{\cc d} \left ( \int _{\cc d}
a(\, \cdot \, ,w_1)e^{(\, \cdot \, ,w_1)}e^{(w_1,w)}\, d\mu (w_1)
\right )
F(w)\, d\mu (w),G \right )_{\!\! A^2}
\\[1ex]
=
\left (
\int _{\cc d} a_0(\, \cdot \, ,w)e^{(\, \cdot \, ,w)} F(w)\, d\mu (w),G
\right )_{\!\! A^2}
=
(\operatorname{Op} _{\mathfrak V}(a_0)F,G)_{A^2},
\end{multline*}
and thus $\operatorname{Op} _{\mathfrak V}(a) = \operatorname{Op} _{\mathfrak V}(a_0)$ follows. The assertion
now follows from Proposition \ref{Prop:ContAnalPseudo} and the fact that $a_0$ in
the integral formula of \eqref{Eq:AntiWickAnalPseudoRel} defines an element in
$\wideparen A(\cc {2d})$.
\end{proof}
\par
We will also consider \emph{anti-Wick operators} \cite{Fo,Berezin71,Berezin72}
defined by
\begin{equation}\label{Eq:AntiWick}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F(z) = \int _{\cc d} a_0(w)F(w)e^{(z,w)}
\, d\mu (w),\quad z \in \cc d,
\end{equation}
when $a_0\in L_{0,A}(\cc d)$ and $F$ belongs to $\mathcal A _0(\cc d)$, the space of
analytic polynomials on $\cc d$.
Then $a_0\in L_{0,A}(\cc d)$ if and only if $a(z,w)\equiv a_0(w)$ belongs to
$L_A(\cc {2d})$, and then $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) = \operatorname{Op} _{\mathfrak V}(a)$.
Consequently, all results for Wick operators with symbols in
$L_A(\cc {2d})$ hold for anti-Wick operators. In particular, if
$a_0\in L_{0,A}(\cc d)$, then $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0):
\mathcal A _{\flat _1}(\cc d) \to A(\cc d)$ is continuous.
We denote
the Wick symbol of the anti-Wick operator $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)$
by $a_0^{\operatorname{aw}}$. Then \eqref{Eq:AntiWickAnalPseudoRel} takes the form
\begin{multline}\tag*{(\ref{Eq:AntiWickAnalPseudoRel})$'$}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) = \operatorname{Op} _{\mathfrak V}(a_0^{\operatorname{aw}})
\\[1ex]
\text{where}\quad
a_0^{\operatorname{aw}} (z,w) = \pi ^{-d} \int _{\cc d}a_0(w_1)e^{-(z-w_1,w-w_1)}\, d\lambda (w_1).
\end{multline}
\par
Pseudo-differential operators on $\rr d$ may be transferred to
Wick operators on $\cc d$ by means of the Bargmann transform.
\par
\begin{defn}\label{Def:AnalPseudo}
Let $\mathfrak a \in \mathcal S _{1/2}'(\rr {2d})$.
\begin{enumerate}
\item the \emph{Bargmann assignment} $\mathsf S_{\mathfrak V}\mathfrak a$ of $\mathfrak a$ is
the unique element $a\in \wideparen A (\cc {2d})$ which fulfills
\begin{equation}\label{Eq:BargmannAssignment}
\operatorname{Op} _{\mathfrak V}(a) = \mathfrak V_d \circ \operatorname{Op}^w (\mathfrak a )\circ \mathfrak V_d^*
\quad \Leftrightarrow \quad a = \mathsf S_{\mathfrak V}\mathfrak a \text ;
\end{equation}
\vspace{0.2cm}
\item the \emph{Bargmann kernel assignment} $K_{\mathfrak V,\mathfrak a}$ of $\mathfrak a$ is
the unique element $K \in \wideparen A (\cc {2d})$, which is the kernel of
the map $\mathfrak V_d \circ \operatorname{Op}^w (\mathfrak a )\circ \mathfrak V_d^*$ with respect to
the sesquilinear $A^2$ form.
\end{enumerate}
\end{defn}
\par
By the definitions we have
\begin{equation}\label{SVandSVK}
K_{\mathfrak V,\mathfrak a}(z,w) = e^{(z,w)}\mathsf S_{\mathfrak V}\mathfrak a (z,w).
\end{equation}
\par
\begin{example}\label{Ex:BargAssignment}
The creation and annihilation operators
$$
2^{-\frac 12}(x_j-\partial _{x_j})
\quad \text{and}\quad
2^{-\frac 12}(x_j+\partial _{x_j}),
$$
are transfered to the operators
\begin{equation}\label{Eq:LinearWickOps}
F\mapsto z_jF
\quad \text{and}\quad
F\mapsto \partial _{z_j}F,
\end{equation}
by the Bargmann transform (see \cite{B1}).
The Wick symbols of the operators in \eqref{Eq:LinearWickOps}
are $z_j$ and $\overline w_j$, respectively \cite{Berezin71,To11}. By combining these identities
with the fact that the Weyl symbol of $i^{-1}\partial _{x_j}$ equals $\xi _j$
we get
\begin{equation}\label{Eq:BargmannAssignBasicMaps}
\begin{gathered}
\mathsf S_{\mathfrak V}(2^{-\frac 12}(x_j-i\xi _j)) = z_j,
\qquad
\mathsf S_{\mathfrak V}(2^{-\frac 12}(x_j+i\xi _j)) = \overline w_j,
\\[1ex]
\mathsf S_{\mathfrak V}(x_j) = 2^{-\frac 12}(z_j+\overline w_j)
\qquad \text{and}\qquad
\mathsf S_{\mathfrak V}(\xi _j) = 2^{-\frac 12}i(z_j-\overline w_j).
\end{gathered}
\end{equation}
\end{example}
\par
We need to compare $K_{\mathfrak a}^w$ and $K_{\mathfrak V,\mathfrak a}$.
On the one hand we have for $f,g \in \mathscr S (\rr d)$
\begin{equation*}
(\operatorname{Op}^w (\mathfrak a ) f, g)_{L^2(\rr d)}
= (K_{\mathfrak a}^w, g \otimes \overline f)_{L^2(\rr {2d})}
= (\mathfrak V_{2d} K_{\mathfrak a}^w, \mathfrak V_{2d} (g \otimes \overline f)_{A^2(\cc {2d})}
\end{equation*}
and on the other hand
\begin{align*}
(\operatorname{Op}^w (\mathfrak a ) f, g)_{L^2(\rr d)}
& = (\operatorname{Op} _{\mathfrak V}(a) \mathfrak V_d f, \mathfrak V_d g)_{A^2(\cc d)}
\\[1ex]
& = ( K_{\mathfrak V,\mathfrak a}, \mathfrak V_d g \otimes \overline{\mathfrak V_d f})_{A^2 (\cc {2d})}
\\[1ex]
& = ( \Theta K_{\mathfrak V,\mathfrak a},
\Theta (\mathfrak V_d g \otimes \overline{\mathfrak V_d f} ))_{A^2 (\cc {2d})}.
\end{align*}
Since
\begin{align*}
\Theta (\mathfrak V_d g \otimes \overline{\mathfrak V_d f} )(z,w)
= \mathfrak V_d g(z) \overline{\mathfrak V_d f(\overline w)}
= \mathfrak V_{2d} (g \otimes \overline f) (z,w)
\end{align*}
we obtain
\begin{equation}\label{eq:kernelreal2complex}
K_{\mathfrak V,\mathfrak a} = \Theta \mathfrak V_{2d} K_{\mathfrak a}^w
= \mathfrak V_{\Theta,d} K_{\mathfrak a}^w.
\end{equation}
\par
\subsection{Symbol classes for pseudo-differential
operators on $\rr d$}\label{subsec1.5}
\par
In order to define a generalized family of Shubin symbol classes
\cite{Shubin1}, we
need to add a restriction of the involved weights. Let $\rho \in [0,1]$, and let
$\mathscr P _{\operatorname{Sh} ,\rho }(\rr d)$
be the set of all $\omega \in \mathscr P (\rr d)\cap C^\infty (\rr d)$ such that
for every multi-index $\alpha \in \nn d$,
$$
|\partial ^\alpha \omega (x)|\lesssim \omega (x)\eabs x^{-\rho |\alpha |},
\quad x\in \rr d.
$$
For $\omega \in \mathscr P _{\operatorname{Sh} ,\rho }(\rr {d})$ the Shubin symbol class
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {d})$ is the set of all $f \in C^\infty (\rr {d})$
such that for every $\alpha \in \nn {2d}$,
$$
|\partial ^\alpha f(x)|\lesssim \omega (x) \eabs x^{-\rho |\alpha |},
\qquad x\in \rr {d}.
$$
\par
Let $\rho \in [0,1]$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho }(\rr {2d})$ and
$A$ be a real $d\times d$ matrix.
Then it follows from \cite{Shubin1} or \cite[Section 18.5]{Ho1}
that $e^{i\scal {AD_\xi }{D_x}}$ is a homeomorphism on
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$, which implies that the set
$$
\sets {\operatorname{Op} _A(\mathfrak a )}{\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})}
$$
is independent of the choice of $A$, in view of
\eqref{Eq:RealPseudoCalculiTransfer}. If $B$ is another
real $d\times d$ matrix and
$\mathfrak a ,\mathfrak b \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ satisfy
\eqref{Eq:RealPseudoCalculiTransfer}, then it follows from
\cite[Section 18.5]{Ho1} that
\begin{gather}
\mathfrak a - \mathfrak b \in \operatorname{Sh} _\rho ^{(\omega _\rho)}(\rr {2d}),
\quad \text{where}\quad
\omega _\rho (x,\xi )= \omega (x,\xi )\eabs {(x,\xi )}^{-2\rho}.
\label{Eq:DifferencesShubinSymbols}
\intertext{In particular}
|\mathfrak a (x,\xi ) - \mathfrak b (x,\xi ) |
\lesssim \omega (x,\xi )\eabs {(x,\xi )}^{-2\rho}.
\label{Eq:DifferencesShubinSymbols2}
\end{gather}
\par
We also need the symbol classes defined in \cite[Definition~1.8]{AbCaTo}
with symbols satisfying estimates of the form
\begin{equation}\label{eq:symbolgevrey}
|\partial _x^\alpha \partial _\xi^\beta \mathfrak a (x,\xi )|
\lesssim h^{|\alpha +\beta |} \alpha !^\sigma \beta !^s
e^{r (|x|^{\frac1{s}}+|\xi |^{\frac1{\sigma}})}, \qquad x,\xi \in \rr d.
\end{equation}
(See also \cite{CaTo} for the restricted case when $s=\sigma$.)
\par
\begin{defn}\label{Def:GevreyGSSymbols}
Let $s,\sigma >0$. Then
\begin{enumerate}
\item $\Gamma ^{\sigma ,s;0}_{s,\sigma}(\rr {2d})$ consists of all
$\mathfrak a \in C^\infty (\rr d)$ such that
\eqref{eq:symbolgevrey} holds for every $h > 0$ and some $r > 0$;
\vspace{0.2cm}
\item $\Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d})$ consists of all
$\mathfrak a \in C^\infty (\rr d)$ such that
\eqref{eq:symbolgevrey} holds for some $h > 0$ and every $r > 0$;
\vspace{0.2cm}
\item $\Gamma ^{\sigma ,s}_{s,\sigma}(\rr {2d})$ consists of all
$\mathfrak a \in C^\infty (\rr d)$ such that
\eqref{eq:symbolgevrey} holds for some $h > 0$ and some $r > 0$.
\end{enumerate}
\end{defn}
\par
\begin{rem}
The symbol classes $\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ have isotropic
behaviour with respect to phase space $T^* \rr d\simeq \rr {2d}$,
and the same holds for the symbol classes in Definition
\ref{Def:GevreyGSSymbols} when $\sigma = s$.
See also \cite{CaTo} for the restricted case when $s=\sigma$,
and \cite{AbCoTe} for a bilinear extension.
Important classes similar to those given by Definition
\ref{Def:GevreyGSSymbols} are considered in \cite{Prangoski}.
\end{rem}
\par
Pseudo-differential operators with symbols in the classes in
Definition \ref{Def:GevreyGSSymbols} are examples of so called
operators of infinite order.
These operators are continuous on appropriate Gelfand-Shilov (distribution)
spaces \cite{AbCaTo,CaTo}.
The next result characterizes the symbol classes in
Definition \ref{Def:GevreyGSSymbols} by means of estimates of form
\begin{equation}\label{Eq:STFTgevrey}
|\mathcal{T}_\psi \mathfrak a (x,\xi , \eta ,y)|
\lesssim
e^{r_1(|x|^{\frac1{s}}+|\xi|^{\frac1{\sigma}}) - r_2(|\eta |^{\frac1{\sigma}} + |y|^{\frac1{s}}) },
\quad x,\xi ,y, \eta \in \rr d.
\end{equation}
We omit the proof since the result is a special case of
\cite[Proposition~2.1$'$]{AbCaTo}.
We refer to
\cite[Subsection~1.1]{AbCaTo} for the definition of the Gelfand-Shilov spaces
$\mathcal S _{s,\sigma}^{\sigma ,s}(\rr {2d})$,
$\Sigma _{s,\sigma}^{\sigma ,s}(\rr {2d})$ and their distribution spaces.
\par
\begin{prop}\label{Prop:GSclassesChar}
Let $s,\sigma >0$ and let $\mathfrak a \in C^\infty (\rr {2d})$.
Then the following is true:
\begin{enumerate}
\item if $\psi \in \mathcal S _{s,\sigma}^{\sigma ,s} (\rr {2d})\setminus 0$, then
$\mathfrak a \in \Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d})$
if and only if \eqref{Eq:STFTgevrey} holds for every
$r_1 > 0$ and some $r_2 > 0$;
\vspace{0.2cm}
\item if $\psi \in \Sigma _{s,\sigma}^{\sigma ,s} (\rr {2d})\setminus 0$, then
$\mathfrak a \in \Gamma ^{\sigma ,s;0}_{s,\sigma }(\rr {2d})$ if and only if
\eqref{Eq:STFTgevrey} holds for some $r_1 > 0$ and all $r_2 > 0$;
\vspace{0.2cm}
\item if $\psi \in \Sigma _{s,\sigma}^{\sigma ,s} (\rr {2d})\setminus 0$, then
$\mathfrak a \in \Gamma ^{\sigma ,s}_{s,\sigma}(\rr {2d})$
if and only if \eqref{Eq:STFTgevrey} holds for some $r_1 > 0$ and some $r_2 > 0$.
\end{enumerate}
\end{prop}
\par
\subsection{Elliptic, weakly elliptic and hypoelliptic elements in $\operatorname{Sh} ^{(\omega )}_\rho (\rr d)$}
\par
Let $\rho \ge 0$ and $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr d)$. Then
$f\in \operatorname{Sh} ^{(\omega )}_\rho (\rr d)$ is called
\emph{weakly elliptic} of order $\rho _0\ge 0$,
(in $\operatorname{Sh} ^{(\omega )}_\rho (\rr d)$),
or \emph{$\rho _0$-weakly elliptic},
if there is an $R>0$ such that
$$
|f(x)| \gtrsim \eabs x^{-\rho _0}\omega (x),\qquad |x|\ge R.
$$
A weakly elliptic function of order $0$ is called \emph{elliptic}.
\par
Let $A$ and $B$ be real $d\times d$ matrices, $\rho >0$, $\rho _0\in [0,2\rho )$,
$\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})$ and suppose that $\mathfrak a ,\mathfrak b \in
\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ satisfy \eqref{Eq:RealPseudoCalculiTransfer}.
It follows from \eqref{Eq:DifferencesShubinSymbols}
that $\mathfrak a$ is weakly elliptic of order $\rho _0$, if and only if
$\mathfrak b$ is weakly elliptic of order $\rho _0$. In particular,
$\mathfrak a$ is elliptic, if and only if $\mathfrak b$ is elliptic.
\par
Next we define Shubin hypoelliptic symbols (cf. Definitions 5.1 and 25.1 in \cite{Shubin1}).
\par
\begin{defn}\label{Def:Hypoelliptic}
Let $\rho >0$, $\rho _0 \ge 0$, $\omega _0\in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {d})$
and $f\in \operatorname{Sh} _\rho ^{(\omega _0)}(\rr {d})$. Then
$f$ is called \emph{hypoelliptic} (in \emph{Shubin's sense}
in $\operatorname{Sh} _\rho ^{(\omega _0)}(\rr {d})$) of order $\rho _0$,
if there is an $R>0$
such that for every $\alpha \in \nn d$, it holds
\begin{alignat*}{2}
|\partial ^\alpha f(x)| &\lesssim |f(x)|\eabs x^{-\rho |\alpha |}, &
\qquad |x|&\ge R,
\intertext{and}
|f(x)| &\gtrsim \omega _0(x)\eabs x^{-\rho _0}, &
\qquad |x| &\ge R .
\end{alignat*}
\end{defn}
\par
Elliptic and hypoelliptic symbols are important since they give rise to parametrices.
For $\rho$, $\omega$ as above and $\mathfrak a \in \operatorname{Sh} ^{(\omega )}_\rho (\rr {2d})$ elliptic,
there is an elliptic symbol $\mathfrak b \in \operatorname{Sh} ^{(1/\omega )}_\rho (\rr {2d})$
such that
$$
\operatorname{Op} _A(\mathfrak a )\circ \operatorname{Op} _A(\mathfrak b ) =I+\operatorname{Op} _A(\mathfrak c _1)
\quad \text{and}\quad
\operatorname{Op} _A(\mathfrak b )\circ \operatorname{Op} _A(\mathfrak a ) =I+\operatorname{Op} _A(\mathfrak c _2)
$$
for some $\mathfrak c _1,\mathfrak c _2\in \mathscr S (\rr {2d})$.
An operator $\operatorname{Op} (\mathfrak c )$ with $c\in \mathscr S (\rr {2d})$
is regularizing in the sense that $\operatorname{Op} (\mathfrak c )$ is continuous from $\mathscr S '(\rr d)$
to $\mathscr S (\rr d)$. (Cf. e.{\,}g. \cite{BonChe,Shubin1}.)
\par
\section{Reformulation of pseudo-differential calculus
using the Bargmann transform}\label{sec2}
\par
In this section we characterize the Bargmann assignment of
pseudo-diffe\-ren\-ti\-al operator symbols from Subsection \ref{subsec1.5},
using estimates of complex derivatives.
In Subsection \ref{subsec2.1}
we show how pseudo-diffe\-ren\-ti\-al operators on $\rr d$ with Shubin symbols
are transformed to Wick operators by the Bargmann transform.
In Subsection \ref{subsec2.2}
we deduce similar links between pseudo-diffe\-ren\-ti\-al operators
of infinite order, given in the second part of Subsection \ref{subsec1.5},
and suitable classes of Wick operators.
Subsection \ref{subsec2.3} treats composition formulae for symbols
of Wick operators, which leads to algebraic
properties for operators in Subsection \ref{subsec2.1} and \ref{subsec2.2}.
As an application we obtain short proofs of composition results for
pseudo-differential operators on $\rr d$ from Subsection \ref{subsec1.5}.
\par
\subsection{Wick symbols of Shubin pseudo-differential
operators}\label{subsec2.1}
\par
The following proposition is essential in the characterization of Shubin
type pseudo-differential operators on $\rr d$ by means of the corresponding
Wick symbols. The Shubin classes can be characterized using the
transform $\mathcal{T}_\phi$ by means of estimates of the form
\begin{align}
|\partial_x^\alpha \partial_\xi^\beta \mathcal{T} _\phi f(x,\xi)|
&\lesssim
\omega(x) \eabs{x}^{- \rho |\alpha|} \eabs{\xi}^{-N},
\label{eq:Gineq1}
\\[1ex]
|\partial_x^\alpha\mathcal{T} _\phi f(x,\xi)|
&\lesssim
\omega(x) \eabs{x}^{- \rho |\alpha|} \eabs{\xi}^{-N}
\label{eq:Gineq2}
\intertext{and}
|\mathcal{T} _\phi f(x,\xi)|
&\lesssim
\omega(x) \eabs{\xi}^{-N}.
\label{eq:Gineq3}
\end{align}
The proof of the following result is similar to the proof of
\cite[Proposition~3.2]{Cappiello1}.
\par
\begin{prop}
\label{prop:symbchar1}
Let $0 \le \rho \leqslant 1$, let $\omega \in \mathscr P _{\operatorname{Sh} ,\rho }(\rr {d})$,
and suppose $f\in \mathscr{S} '(\rr d)$ and $\phi \in\mathscr{S} (\rr d) \setminus 0$.
The following conditions are equivalent:
\begin{enumerate}
\item $f \in \operatorname{Sh} _\rho^{(\omega )}(\rr d)$,
\vspace{0.2cm}
\item \eqref{eq:Gineq1} holds true for any $N \geqslant 0$ and
$\alpha, \beta \in \nn d$,
\vspace{0.2cm}
\item \eqref{eq:Gineq2} holds true for any $N \geqslant 0$ and
$\alpha \in \nn d$,
\end{enumerate}
\medspace
and the following conditions are equivalent:
\begin{enumerate}
\item[{(1)$'$}] $f \in \operatorname{Sh} _0^{(\omega )}(\rr d)$,
\vspace{0.2cm}
\item[{(2)$'$}] \eqref{eq:Gineq3} holds true for any $N \geqslant 0$.
\end{enumerate}
\end{prop}
\par
\begin{proof}
First we prove that (1) implies (2).
Suppose $f \in \operatorname{Sh} _\rho^{(\omega )}(\rr d)$ and let
$\alpha,\beta, \gamma \in \nn d$ be arbitrary. We will show
\begin{equation*}
|\xi^\gamma \partial_x^\alpha \partial_\xi^\beta \mathcal{T} _\phi f(x,\xi)|
\lesssim
\omega(x) \eabs{x}^{-\rho|\alpha|}.
\end{equation*}
\par
By \eqref{eq:diffident}, \eqref{eq:diffidentstar} and integration by parts we get
\begin{multline*}
|\xi^\gamma \partial_x^\alpha \partial_\xi^\beta \mathcal{T} _\phi f(x,\xi)|
=
\left
| \xi^\gamma \mathcal{T}_{\phi _\beta}(\partial^\alpha f)(x,\xi)
\right |
\\[1ex]
=
(2 \pi)^{-\frac d2} \left| \int_{\rr d} \left((i\partial_{y})^\gamma e^{- i \langle \xi,y \rangle }\right)
\overline{\phi _\beta(y)} \, \partial^\alpha f(x+y)\, dy \right |
\\[1ex]
\lesssim
\int_{\rr{d}} \left| \partial_{y}^\gamma \left[\overline{\phi _\beta(y)} \,
\partial^\alpha f(x+y)\right] \right|\, dy
\\[1ex]
=
\int_{\rr{d}} \left| \sum_{\kappa \leqslant \gamma} \binom{\gamma}{\kappa}
\partial^{\gamma-\kappa}
\overline{\phi _\beta(y)} \, \partial^{\alpha+\kappa} f(x+y)\right|\, dy
\\[1ex]
\lesssim
\sum_{\kappa \leqslant \gamma} \binom{\gamma}{\kappa} \int_{\rr d} \left |
\partial^{\gamma-\kappa}
\phi _\beta(y) \right| \, \omega(x+y) \eabs{x+y}^{-\rho|\alpha+\kappa|}\, dy.
\end{multline*}
Since $\omega$ is polynomially moderate, Peetre's inequality
\eqref{eq:Peetre} and the fact that $\phi \in \mathscr{S}$ give
\begin{multline*}
|\xi^\gamma \partial_x^\alpha \partial_\xi^\beta \mathcal{T} _\phi f(x,\xi)|
\\[1ex]
\lesssim
\omega(x) \eabs{x}^{-\rho |\alpha |} \sum_{\kappa \leqslant \gamma}
\binom{\gamma}{\kappa}
\int_{\rr d} \left| \partial^{\gamma-\kappa} \phi _\beta(y) \right| \, \omega (y)
\, \eabs{y}^{|m|+\rho |\alpha+\kappa|}\, dy
\\[1ex]
\asymp \omega(x) \eabs{x}^{- \rho |\alpha|}.
\end{multline*}
Thus $f\in \operatorname{Sh} _\rho^{(\omega )}(\rr d)$ implies
implies \eqref{eq:Gineq1}, and as a special case \eqref{eq:Gineq2},
and $f \in \operatorname{Sh} _0^{(\omega )}(\rr d)$ implies \eqref{eq:Gineq3}.
We have proved that (1) implies (2) which in turn implies (3),
and that (1)$'$ implies (2)$'$.
\par
Conversely, suppose (3), that is $f \in \mathscr{S}'(\rr d)$ and \eqref{eq:Gineq2}
holds for all $ N \ge 0$ and all $\alpha \in \nn d$,
which is a weaker assumption than (2).
We obtain from \eqref{eq:reproducing}
\begin{align*}
f(x)
& = \|\phi \|_{L^2}^{-2} \, \mathcal{T} _\phi^* \mathcal{T} _\phi f(x)
\\[1ex]
& = \|\phi \|_{L^2}^{-2} \, (2 \pi)^{-\frac d2} \iint _{\rr {2d}}
\mathcal{T} _\phi f(y,\xi) \, e^{i \langle \xi,x-y \rangle} \, \phi (x-y) \, dyd\xi
\end{align*}
which is an absolutely convergent integral due to \eqref{eq:Gineq2}
and the fact that $\phi \in\mathscr{S}(\rr d)$. We may differentiate under the
integral, so integration by parts, \eqref{eq:Gineq2} and Peetre's
inequality give for some $N_0 \ge 0$, any $\alpha \in \nn d$ and any $x \in \rr d$
\begin{multline*}
\left |
\partial^\alpha f(x)
\right |
=
\|\phi \|_{L^2}^{-2} \, (2 \pi)^{-\frac d2} \left| \iint _{\rr {2d}} \mathcal{T} _\phi f(y,\xi)
\, \partial_y^\alpha
\left ( e^{i \langle \xi,x-y \rangle} \, \phi (x-y) \right ) \, dyd\xi
\right |
\\[1ex]
=
\|\phi \|_{L^2}^{-2} \, (2 \pi)^{-\frac d2} \left| \iint _{\rr {2d}} \partial_y^\alpha
\mathcal{T} _\phi f(y,\xi) \, e^{i \langle \xi,x-y \rangle} \, \phi (x-y) \, dyd\xi \right |
\\[1ex]
=
\|\phi \|_{L^2}^{-2} \, (2 \pi)^{-\frac d2} \left| \iint _{\rr {2d}} \partial_y^\alpha
\mathcal{T} _\phi f(x-y,\xi) \, e^{i \langle \xi,y \rangle} \, \phi (y) \, dyd\xi \right |
\\[1ex]
\lesssim
\iint _{\rr {2d}} \omega(x-y) \eabs{x-y}^{- \rho |\alpha|} \,
\eabs{\xi}^{-d-1} \, |\phi (y)| \, dyd\xi
\\[1ex]
\lesssim
\omega (x) \eabs {x}^{- \rho |\alpha|} \iint _{\rr {2d}} \eabs{\xi}^{-d-1}
\eabs{y}^{N_0+\rho |\alpha|} \, |\phi (y)| \, dyd\xi
\\[1ex]
\asymp
\omega(x) \eabs{x}^{- \rho |\alpha|}.
\end{multline*}
Thus $f \in \operatorname{Sh} _\rho^{(\omega )}(\rr d)$ and we have proved the
equivalence of (1), (2) and (3).
\par
It remains to show that (2)$'$ implies (1)$'$, that is
\eqref{eq:Gineq3} for all $N \ge 0$ implies
$f \in \operatorname{Sh} _0^{(\omega )}(\rr d)$.
We have for some $N_0 \geqslant 0$, any $\alpha \in \nn d$, $x \in \rr d$ and $N \geqslant 0$,
\begin{align*}
\left |
\partial^\alpha f(x)
\right |
& =
\|\phi \|_{L^2}^{-2} \, (2 \pi)^{-\frac d2} \left| \iint _{\rr {2d}} \mathcal{T} _\phi f(y,\xi) \, \partial _x^\alpha
\left ( e^{i \langle \xi,x-y \rangle} \, \phi (x-y) \right ) \, dyd\xi
\right |
\\[1ex]
& \lesssim
\sum_{\beta \leqslant \alpha}
\binom{\alpha}{\beta}
\iint _{\rr {2d}} \left| \mathcal{T} _\phi f(y,\xi) \right| \eabs{\xi}^{|\beta|}
\left| \partial^{\alpha-\beta} \phi (x-y) \right| \, dyd\xi
\\[1ex]
& \lesssim
\sum_{\beta \leqslant \alpha}
\binom{\alpha}{\beta}
\iint _{\rr {2d}} \omega(y) \eabs{\xi}^{|\alpha|-N}
\left| \partial^{\alpha-\beta} \phi (x-y) \right| \, dyd\xi
\\[1ex]
& \lesssim
\omega (x) \sum_{\beta \leqslant \alpha}
\binom{\alpha}{\beta}
\iint _{\rr {2d}} \eabs{\xi}^{|\alpha|-N}
\eabs{x-y}^{N_0} \left| \partial^{\alpha-\beta} \phi (x-y) \right| \, dyd\xi
\\[1ex]
& \lesssim
\omega(x)
\end{align*}
provided $N$ is sufficiently large, since $\phi \in \mathscr{S}$.
This shows that $f \in \operatorname{Sh} _0^{(\omega )}(\rr d)$.
\end{proof}
\par
We may now characterize the Shubin classes $\operatorname{Sh} _\rho^{(\omega )}(\rr {2d})$
by estimates on their Bargmann (kernel) assignments of the forms
\begin{align}
\big |
( \partial_z + \overline \partial _w)^\alpha (\partial _z- \overline \partial _w)
^\beta & {\mathsf S}_{\mathfrak V} \mathfrak a (z,w)
\big |
\notag
\\[1ex]
&\lesssim
e^{\frac1{2} |z-w|^2}\omega (\sqrt 2\, \overline z)
\eabs{z+w}^{- \rho |\alpha + \beta|} \eabs{z-w}^{-N} ,
\label{eq:characShubinBargmann}
\\[1ex]
\left| \partial_z^\alpha \overline \partial _w
^\beta \mathsf S_{\mathfrak V} \mathfrak a (z,w) \right |
&\lesssim
e^{ \frac1{2} |z-w|^2}\omega (\sqrt 2\, \overline z)\eabs{z+w}^{- \rho |\alpha + \beta|}
\eabs{z-w}^{-N} ,
\label{eq:characShubinBargmann2}
\\[1ex]
\left | \mathsf S_{\mathfrak V} \mathfrak a (z,w) \right|
&\lesssim
e^{ \frac1{2} |z-w|^2} \omega (\sqrt 2\, \overline z)
\eabs{z-w}^{-N}
\label{eq:characShubinBargmann0}
\intertext{and}
\left | K_{\mathfrak V,\mathfrak a} (z,w) \right|
&\lesssim
\omega (\sqrt 2\, \overline z)
\eabs{z-w}^{-N} e^{ \frac1{2} \left( |z|^2 + |w|^2 \right)}.
\label{eq:characShubinBargmannkernel0}
\end{align}
\par
\begin{thm}\label{Thm:ShubinAnalChar}
Let $0 \le \rho \leqslant 1$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})$ and
$\mathfrak a \in \mathscr S '(\rr {2d})$.
The following conditions are equivalent:
\begin{enumerate}
\item $\mathfrak a \in \operatorname{Sh} ^{(\omega )}_\rho (\rr {2d})$,
\vspace{0.2cm}
\item \eqref{eq:characShubinBargmann} holds true for every $N\ge 0$, $z,w\in \cc d$ and $\alpha,\beta \in \nn d$,
\vspace{0.2cm}
\item \eqref{eq:characShubinBargmann2} holds true for every $N\ge 0$, $z,w\in \cc d$ and $\alpha,\beta \in \nn d$,
\end{enumerate}
\medspace
and the following conditions are equivalent:
\begin{enumerate}
\item[(1)$'$] $\mathfrak a \in \operatorname{Sh} ^{(\omega )}_0 (\rr {2d})$,
\vspace{0.2cm}
\item[(2)$'$] \eqref{eq:characShubinBargmann0} holds true for any $N \in \mathbf N$
and $z,w\in \cc d$,
\vspace{0.2cm}
\item[(3)$'$] \eqref{eq:characShubinBargmannkernel0} holds true for any $N \in \mathbf N$
and $z,w\in \cc d$.
\end{enumerate}
\end{thm}
\par
For the proof we need the following proposition of independent interest. Here
we recall that $\mathsf S_{\mathfrak V}$ is bijective from $\mathcal S _{1/2}'(\rr {2d})$
to the set
\begin{equation}\label{Eq:SBGelfandShilovLargeDist}
\sets{a\in \wideparen A(\cc {2d})}
{|a(z,w)|\lesssim e^{(\frac 12+r)|z-w|^2}\ \text{for every}\ r>0 }.
\end{equation}
\par
\begin{prop}\label{Prop:SBaTaRel}
Let $\psi (x,\xi ) = (\frac 2\pi )^{\frac d2} e^{-(|x|^2+|\xi |^2)}$, $x,\xi \in \rr d$,
$\mathfrak a \in \mathcal S _{1/2}'(\rr {2d})$ and $a$ belongs to the set in
\eqref{Eq:SBGelfandShilovLargeDist}. Then
\begin{align}
\mathsf S_{\mathfrak V} \mathfrak a (z,w)
&=
(2 \pi)^{\frac d2} e^{\frac1{2} |z-w|^2}
\mathcal{T}_\psi \mathfrak a \left( \frac{x+y}{\sqrt{2}}, - \frac{\xi+\eta}{\sqrt{2}},
\sqrt{2}(\eta-\xi), \sqrt{2} (y-x) \right),
\label{eq:BargmannsymbolSTFT}
\intertext{and}
(\mathsf S_{\mathfrak V}^{-1}a)(x,-\xi )
&=
\left( \frac{2}{\pi} \right)^d \int _{\cc {d}}
a \left( \frac z{\sqrt 2} - w, \frac z{\sqrt 2} + w \right)
e^{- 2 |w|^2}\, d\lambda (w),
\label{eq:InvBargmannsymbolSTFT}
\end{align}
with $z=x+i\xi $, $w=y+i\eta$ and $x,y,\xi ,\eta \in \rr d$.
\end{prop}
\par
\begin{proof}
Let
$\phi (x,y) = \pi^{-\frac d2} e^{-\frac1{2}(|x|^2+|y|^2)}$ for $x,y \in \rr {d}$,
and let $K_{\mathfrak a}^w$ be the kernel of $\operatorname{Op}^w (\mathfrak a )$. Then
$\psi =\mathscr F _2(\phi \circ \kappa)$, where $\kappa (x,y)=(x+y/2,x-y/2)$.
By \eqref{bargstft1} (or \cite[Eq.~(1.35)]{Teofanov2})
and \cite[Lemma~4.1]{Cappiello1}
we have
\begin{align*}
& \mathfrak V _{\Theta ,d} K_{\mathfrak a}^w (z,w)
= \mathfrak V _{2d} K_{\mathfrak a}^w (z,\overline w)
= \mathfrak V _{2d} K_{\mathfrak a}^w ( (x,y) + i (\xi,-\eta))
\\[1ex]
& = (2 \pi)^d e^{\frac1{2} \left( |z|^2 + |w|^2 \right) + i \left( \langle x, \xi \rangle
- \langle y, \eta \rangle \right)}
\mathcal{T}_\phi K_{\mathfrak a}^w \left( \sqrt{2} (x,y), - \sqrt{2} (\xi,-\eta) \right)
\\[1ex]
& = (2 \pi)^{\frac d2} e^{\frac1{2} \left( |z|^2 + |w|^2 \right) + i \left( \langle y, \xi \rangle -
\langle x, \eta \rangle \right)}
\mathcal{T}_\psi \mathfrak a \left( \frac{x+y}{\sqrt{2}}, - \frac{\xi+\eta}{\sqrt{2}}, \sqrt{2}(\eta-\xi),
\sqrt{2} (y-x) \right),
\\[1ex]
& = (2 \pi)^{\frac d2} e^{\frac1{2} \left( |z|^2 + |w|^2 \right) + i \, {\operatorname{Im}} (z,w)}
\mathcal{T}_\psi \mathfrak a \left( \frac{x+y}{\sqrt{2}}, - \frac{\xi+\eta}{\sqrt{2}}, \sqrt{2}(\eta-\xi),
\sqrt{2} (y-x) \right).
\end{align*}
Together with the identity
$$
|z|^2 + |w|^2 + 2i \, {\operatorname{Im}} (z,w) = |z-w|^2 +2(z,w)
$$
this gives
\begin{multline}
\mathfrak V _{\Theta ,d} K_{\mathfrak a}^w (z,w)
\\[1ex]
= (2 \pi)^{\frac d2} e^{\frac1{2}|z-w|^2 + (z,w)}
\mathcal{T}_\psi \mathfrak a \left( \frac{x+y}{\sqrt{2}}, - \frac{\xi+\eta}{\sqrt{2}}, \sqrt{2}(\eta-\xi),
\sqrt{2} (y-x) \right ).
\end{multline}
A combination of this identity with \eqref{SVandSVK} and \eqref{eq:kernelreal2complex}
gives \eqref{eq:BargmannsymbolSTFT}.
\par
In order to prove \eqref{eq:InvBargmannsymbolSTFT}, we use
Moyal's formula \eqref{Eq:Moyalsformula}, \eqref{eq:reproducing} and the fact that $\nm \psi {L^2}=1$.
This implies that the inverse of $\mathcal{T} _\psi$ is given by
\begin{multline*}
(\mathcal{T} _\psi ^{-1}F) (x,\xi ) = (\mathcal{T} _\psi ^*F) (x,\xi )
\\[1ex]
=
(2\pi )^{-d}\iiiint _{\rr {4d}}
F(x_1,\xi _1,\eta _1,y_1)\psi (x-x_1,\xi -\xi _1)
e^{i(\scal {x-x_1}{\eta _1}+\scal {y_1}{\xi -\xi _1}}\, dx_1d\xi _1d\eta _1dy_1.
\end{multline*}
Writing
$$
G(z,w) = F(x,\xi ,\eta ,y),\qquad z=x+i\xi ,\ w=y+i\eta,
$$
we obtain
\begin{equation}\label{Eq:TInvOp1}
\mathcal{T} _\psi ^*F(x,\xi )
=
2^d(2\pi )^{-\frac {3d}2}\iint _{\cc {2d}} G(w_1,w_2)e^{-|z-w_1|^2}
e^{i{\operatorname{Im}} \scal {z-w_1}{w_2}}\, d\lambda (w_1)d\lambda (w_2).
\end{equation}
\par
If $\mathfrak a = \mathcal{T} _\psi ^*F$ and $a=\mathsf S_{\mathfrak V} \mathfrak a$,
then \eqref{eq:BargmannsymbolSTFT} shows that
$$
a(z,w)
=
(2\pi )^{\frac d2}e^{\frac 12|z-w|^2}G \left( \frac {\overline z+\overline w}{\sqrt 2},\sqrt 2(w-z) \right)
$$
which gives
$$
G(z,w)
=
(2\pi )^{-\frac d2}e^{-\frac 14|w|^2}
a \left( \frac {2\overline z -w}{2\sqrt 2},\frac {2\overline z +w}{2\sqrt 2} \right).
$$
\par
Inserting this into \eqref{Eq:TInvOp1} we get
\begin{multline*}
\mathcal{T} _\psi ^*F (x,-\xi )
\\[1ex]
=
\frac 1{2^d\pi ^{2d}}\iint _{\cc {2d}}
a \left( \frac {2\overline w_1 -w_2}{2\sqrt 2},\frac {2\overline w_1 +w_2}{2\sqrt 2} \right)
e^{-|\overline z-w_1|^2}e^{-\frac 14|w_2|^2}
e^{i{\operatorname{Im}} \scal {\overline z-w_1}{w_2}}\, d\lambda (w_1)d\lambda (w_2),
\end{multline*}
and by taking
$$
\frac {2\overline w_1 -w_2}{2\sqrt 2}-\frac z{\sqrt 2}
\quad \text{and}\quad
\frac {2\overline w_1 +w_2}{2\sqrt 2}-\frac z{\sqrt 2}
$$
as new variables of integration, we obtain using \eqref{eq:projection}
\begin{align*}
& \mathcal{T} _\psi ^*F (x,-\xi )
\\[1ex]
& =
\frac {2^d}{\pi ^{2d}}\iint _{\cc {2d}}
a \left( w_1+\frac z{\sqrt 2},w_2+\frac z{\sqrt 2} \right)
e^{-(|w_1|^2+|w_2|^2)}
e^{2i{\operatorname{Im}} ({w_1},{w_2})}\, d\lambda (w_1)d\lambda (w_2)
\\[1ex]
& =
2^d \iint _{\cc {2d}}
a \left( w_1+\frac z{\sqrt 2},w_2+\frac z{\sqrt 2} \right)
e^{2i{\operatorname{Im}} ({w_1},{w_2})}\, d\mu (w_1)d\mu (w_2)
\\[1ex]
& =
2^d \int _{\cc {d}} \left( \int _{\cc {d}}
a \left( w_1+\frac z{\sqrt 2},w_2+\frac z{\sqrt 2} \right)
e^{ (w_1,w_2)} \, e^{ (-w_2,w_1)} \, d\mu (w_1) \right) d\mu (w_2)
\\[1ex]
& =
2^d \int _{\cc {d}}
a \left( -w_2+\frac z{\sqrt 2},w_2+\frac z{\sqrt 2} \right)
e^{ -|w_2|^2} \, d\mu (w_2)
\\[1ex]
& =
\left( \frac{2}{\pi} \right)^d \int _{\cc {d}}
a \left(\frac z{\sqrt 2} - w,\frac z{\sqrt 2} + w \right)
e^{ -2 |w|^2} \, d\lambda (w).
\end{align*}
\end{proof}
\par
\begin{proof}[Proof of Theorem \ref{Thm:ShubinAnalChar}]
Combining Propositions \ref{prop:symbchar1} and \ref{Prop:SBaTaRel},
writing $z + w = 2 z + w - z$, we obtain that
$\mathfrak a \in \operatorname{Sh} _\rho^{(\omega )}(\rr {2d})$ if and only if for all $\alpha,\beta \in \nn d$
and $N \in \mathbf N$ we have
\begin{multline*}
\left | (\partial_x + \partial_y)^\alpha (\partial_\xi + \partial_\eta)^\beta
\left( e^{ - \frac1{2} |z-w|^2} \mathsf S_{\mathfrak V} \mathfrak a (z,w) \right)\right |
\\[1ex]
\lesssim
\omega \left( \frac{\overline{z+w}}{\sqrt{2}} \right)
\eabs{z+w}^{- \rho |\alpha + \beta|} \eabs{z-w}^{-N}
\\[1ex]
\lesssim
\omega (\sqrt 2\, \overline z)\eabs{z+w}^{- \rho |\alpha + \beta|} \eabs{z-w}^{-N+k}
\end{multline*}
for some $k \in \mathbf N$ that can be absorbed into $N$.
\par
Note that multi-index powers of the differential operators $\partial_x + \partial_y$ and
$\partial_\xi + \partial_\eta$ acting on the factor $e^{ - \frac1{2} |z-w|^2} = e^{- \frac1{2}
\left( |x-y|^2 + |\xi-\eta|^2 \right)}$ are zero.
Thus we obtain the equivalent condition
\begin{multline*}
\left| (\partial_x + \partial_y)^\alpha (\partial_\xi + \partial_\eta)^\beta
\mathsf S_{\mathfrak V} \mathfrak a (z,w) \right |
\\[1ex]
\lesssim
\omega (\sqrt 2\, \overline z)\eabs{z+w}^{- \rho |\alpha + \beta|}
\eabs{z-w}^{-N} e^{ \frac1{2} |z-w|^2} .
\end{multline*}
\par
Using the (conjugate) analyticity of $\mathsf S_{\mathfrak V} \mathfrak a (z,w)$
with respect to $z \in \cc d$ ($w \in \cc d$)
we can formulate this as \eqref{eq:characShubinBargmann}.
We have now shown the equivalence between (1) and (2).
\par
The equivalence between (2) and (3)
follows from the binomial formulae
\begin{align*}
(\partial _z+ t\overline \partial _w)^\alpha
&=
\sum _{\gamma \le \alpha}
{\alpha \choose \gamma}t^{|\gamma|}\partial _z^{\alpha -\gamma}
\overline \partial _w^{\gamma},\qquad t\in \{ -1,1\} ,
\\[1ex]
\partial _z^\alpha
&=
2^{-|\alpha |}
\sum _{\gamma \le \alpha}
{\alpha \choose \gamma}
(\partial _z+ \overline \partial _w)^{\alpha -\gamma}
(\partial _z- \overline \partial _w)^{\gamma}
\intertext{and}
\overline \partial _w^\beta
&=
2^{-|\beta |}
\sum _{\gamma \le \beta}
{\beta \choose \gamma} (-1)^{|\gamma |}
(\partial _z+ \overline \partial _w)^{\beta -\gamma}
(\partial _z- \overline \partial _w)^{\gamma}.
\end{align*}
\par
It remains to consider the case $\rho = 0$.
We obtain from
Propositions \ref{prop:symbchar1} and \ref{Prop:SBaTaRel}
that $\mathfrak a \in \operatorname{Sh} _0^{(\omega )}(\rr {2d})$ if and only if for all $N \in \mathbf N$ we have
\begin{equation*}
\left | \mathsf S_{\mathfrak V} \mathfrak a (z,w) \right|
\lesssim
\omega (\sqrt 2\, \overline z)
\eabs{z-w}^{-N} e^{ \frac1{2} |z-w|^2}, \quad z, \zeta \in \cc d.
\end{equation*}
This shows the equivalence between (1)$'$ and (2)$'$.
\par
Finally the equivalence of (2)$'$ and (3)$'$
is an immediate consequence of
\eqref{SVandSVK} and
$$
|e^{(|z|^2+|w|^2)/2} e^{-(z,w)}| = e^{(|z|^2-2 \, {\operatorname{Re}} (z,w)+|w|^2)/2}= e^{|z-w|^2/2}.
\qquad \qedhere
$$
\end{proof}
\par
Let $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$,
be the set of all $a\in \wideparen A(\cc {2d})$ such that
\begin{equation}\label{Eq:ShubinWickEstimates}
\left| \partial_z^\alpha \overline \partial _w
^\beta a(z,w) \right |
\le C
e^{ \frac1{2} |z-w|^2}\omega (\sqrt 2\, \overline z)\eabs{z+w}^{- \rho |\alpha + \beta|}
\eabs{z-w}^{-N} ,\quad N\ge 0.
\end{equation}
The smallest constant $C\ge 0$ defines a semi-norm parameterized by $\alpha$,
$\beta$ and $N$,
and we equip $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ with
the Fr{\'e}chet space topology defined by these semi-norms.
The following result is an immediate consequence of Theorem
\ref{Thm:ShubinAnalChar} and its proof.
\par
\begin{prop}
Let $0 \le \rho \leqslant 1$ and $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})$. Then
${\mathsf S}_{\mathfrak V}$ is a homeomorphism from
$\operatorname{Sh} ^{(\omega )}_\rho (\rr {2d})$ to $\wideparen
\mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$.
\end{prop}
\par
\subsection{Wick operators corresponding to Gevrey
type pseudo-differential operators}\label{subsec2.2}
\par
Using \eqref{eq:BargmannsymbolSTFT} and \eqref{Eq:GevreyQuasinormMIxed}
we obtain the following theorem expressed with estimates of the form
\begin{equation}\label{Eq:BargmannSTFT}
|a(z,w)|
\lesssim \exp \left( \frac1{2} |z-w|^2 + r_1 |z+w|_{s,\sigma} - r_2 |z-w|_{s,\sigma} \right)
\end{equation}
(cf. Definition \ref{Def:GevreyGSSymbols}). The verification is left for the reader.
\par
\begin{thm}\label{Thm:GevreySymbolsBargmTransfer}
The following is true:
\begin{enumerate}
\item if $s,\sigma \ge \frac 12$, then $\mathsf S_{\mathfrak V}$ is homeomorphic
from $\Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d})$ to the set of all
$a\in \wideparen A(\cc {2d})$ such that \eqref{Eq:BargmannSTFT} holds for all
$r_1 > 0$ and some $r_2 > 0$;
\vspace{0.2cm}
\item if $s,\sigma > \frac 12$, then $\mathsf S_{\mathfrak V}$ is homeomorphic
from $\Gamma ^{\sigma ,s ;0}_{s,\sigma}(\rr {2d})$ to the set of all
$a\in \wideparen A(\cc {2d})$ such that
\eqref{Eq:BargmannSTFT} holds for some $r_1 > 0$ and every $r_2 > 0$;
\vspace{0.2cm}
\item if $s,\sigma >\frac 12$, then $\mathsf S_{\mathfrak V}$ is homeomorphic
from $\Gamma ^{\sigma ,s}_{s,\sigma}(\rr {2d})$ to the set of all
$a\in \wideparen A(\cc {2d})$ such that
\eqref{Eq:BargmannSTFT} holds for some $r_1 > 0$ and some $r_2 > 0$.
\end{enumerate}
\end{thm}
\par
\begin{rem}
The restrictions on $s$ and $\sigma$ in Theorem
\ref{Thm:GevreySymbolsBargmTransfer} are needed since
we must choose $\psi$ in \eqref{Eq:STFTgevrey} as
the Gauss function in Proposition \ref{Prop:SBaTaRel}.
According to the proof of Theorem \ref{Thm:ShubinAnalChar}
this is necessary for the use of
the formula \eqref{bargstft1}
that relates $\mathcal{T} _\phi K_{\mathfrak a}^w$ and the Bargmann transform
$\mathfrak V _{2d} K_{\mathfrak a}^w$.
For this $\psi$ we have $\psi \in \mathcal S _s^\sigma (\rr d)$
($\psi \in \Sigma _s^\sigma (\rr d)$),
if and only if $s,\sigma \ge \frac 12$ ($s,\sigma > \frac 12$).
\end{rem}
\par
Theorem \ref{Thm:GevreySymbolsBargmTransfer} can
be combined
with continuity results in \cite{AbCaTo} to deduce
continuity of Wick operators
acting on the Bargmann images
of $\Sigma _s^\sigma (\rr d)$, $\mathcal S _s^\sigma (\rr d)$,
$(\mathcal S _s^\sigma )'(\rr d)$
and $(\Sigma _s^\sigma )'(\rr d)$, respectively.
The following result follows by a straight-forward combination of
Theorems 3.8, 3.15 and 3.16 in \cite{AbCaTo},
\eqref{Eq:BargmannAssignment} and Theorem
\ref{Thm:GevreySymbolsBargmTransfer}.
\par
\begin{prop}
Let $a\in \wideparen A(\cc {2d})$. Then the following
is true:
\begin{enumerate}
\item if $s,\sigma \ge \frac 12$ and
\eqref{Eq:BargmannSTFT} holds for all
$r_1 > 0$ and some $r_2 > 0$, then
$\operatorname{Op} _{\mathfrak V}(a)$ is continuous
on $\mathcal A _s^\sigma (\cc d)$ and on
$(\mathcal A _s^\sigma )'(\cc d)$;
\vspace{0.2cm}
\item if $s,\sigma > \frac 12$ and \eqref{Eq:BargmannSTFT}
holds for
some $r_1 > 0$ and all $r_2 > 0$, then
$\operatorname{Op} _{\mathfrak V}(a)$ is continuous
on $\mathcal A _{0,s}^\sigma (\cc d)$ and on $(\mathcal A _{0,s}^\sigma )'(\cc d)$;
\vspace{0.2cm}
\item if $s,\sigma >\frac 12$ and \eqref{Eq:BargmannSTFT} holds for some
$r_1 > 0$ and some $r_2 > 0$, then $\operatorname{Op} _{\mathfrak V}(a)$ is continuous
from $\mathcal A _{0,s}^\sigma (\cc d)$ to $\mathcal A _{s}^\sigma (\cc d)$, and from
$(\mathcal A _{s}^\sigma )'(\cc d)$ to $(\mathcal A _{0,s}^\sigma )'(\cc d)$.
\end{enumerate}
\end{prop}
\par
\subsection{Composition of Wick operators}\label{subsec2.3}
\par
Let $a_1,a_2 \in \wideparen A(\cc {2d})$. If composition is well defined then
the complex twisted product $a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2$ is defined by
$$
\operatorname{Op} _{\mathfrak V}(a_1)\circ \operatorname{Op} _{\mathfrak V}(a_2) =
\operatorname{Op} _{\mathfrak V}(a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2).
$$
By straight-forward computations it follows that
the product ${\text{\footnotesize $\#$}} _{\mathfrak V}$ is given by
\begin{equation}\label{Eq:DefCompTwistProd}
a_1 {\text{\footnotesize $\#$}} _{\mathfrak V} a_2 (z,w)
= \pi ^{-d}\int_{\cc d} a_1(z,u) a_2 (u,w) e^{-(z-u,w-u)}\, d \lambda (u),
\quad z,w \in \cc d,
\end{equation}
provided the integral is well defined. Inserting derivatives,
\eqref{Eq:DefCompTwistProd} takes the form
\begin{multline}\tag*{(\ref{Eq:DefCompTwistProd})$'$}
(\partial _z^{\alpha _1} \overline \partial _w^{\beta _1} a_1) {\text{\footnotesize $\#$}} _{\mathfrak V}
(\partial _z^{\alpha _2} \overline \partial _w^{\beta _2}a_2) (z,w)
\\[1ex]
= \pi ^{-d}\int_{\cc d} (\partial _z^{\alpha _1} \overline \partial _u^{\beta _1} a_1)(z,u)
(\partial _u^{\alpha _2} \overline \partial _w^{\beta _2} a_2)(u,w) e^{-(z-u,w-u)}
\, d \lambda (u), \quad z,w \in \cc d.
\end{multline}
\par
The following lemma is a product rule
for the complex twisted product.
\par
\begin{lemma}\label{Lemma:DiffCompTwistProd}
Let $a_1,a_2\in \wideparen A(\cc {2d})$ and suppose
the integral in \eqref{Eq:DefCompTwistProd}$'$ is well defined for all $z,w\in \cc d$
and all $\alpha _1,\alpha _2,\beta _1,\beta _2\in \nn d$ such that
$$
|\alpha _1+\alpha _2+\beta _1+\beta _2|\le 1.
$$
Suppose also that the integrand in \eqref{Eq:DefCompTwistProd} is zero at infinity.
Then
\begin{alignat}{2}
\partial _{z_j}(a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2)
&=
(\partial _{z_j}a_1) {\text{\footnotesize $\#$}} _{\mathfrak V}a_2
+
a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}(\partial _{z_j}a_2), &
\quad
j &= 1,\dots ,d
\label{Eq:DiffCompTwistProd1}
\intertext{and}
\overline \partial _{w_j}(a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2)
&=
(\overline \partial _{w_j}a_1) {\text{\footnotesize $\#$}} _{\mathfrak V}a_2
+
a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}(\overline \partial _{w_j}a_2), &
\quad
j &= 1,\dots ,d.
\label{Eq:DiffCompTwistProd2}
\end{alignat}
\end{lemma}
\par
\begin{proof}
If
$$
F_{a_1,a_2}(z,w,u)
=
a_1(z,u) a_2 (u,w) e^{(z,u-w) + (u,w)}
$$
then
$$
\pi ^d(a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2)(z,w)
= \int_{\cc d}F_{a_1,a_2}(z,w,u)e^{-|u|^2}\, d\lambda (u).
$$
This gives
$$
\pi ^d \partial _{z_j}(a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2) (z,w) = b_1(z,w)
+b_2(z,w)-b_3(z,w),
$$
where
\begin{align*}
b_1(z,w)
&=
\int_{\cc d} F_{\partial _{z_j}a_1,a_2}(z,w,u)e^{-|u|^2}\, d\lambda (u),
\\[1ex]
b_2(z,w)
&=
\int_{\cc d} F_{a_1,a_2}(z,w,u)\overline u_je^{-|u|^2}\, d\lambda (u)
\intertext{and}
b_3(z,w)
&=
\overline w_j\int_{\cc d} F_{a_1,a_2}(z,w,u)e^{-|u|^2}\, d\lambda (u)
\\[1ex]
&=
\overline w_j \pi^d (a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2)(z,w).
\end{align*}
\par
The conjugate analyticity of $u \mapsto a_1(z,u)$ and $u \mapsto e^{(z,u-w)}$ implies
$\partial _{u_j}a_1(z,u) = \partial _{u_j}e^{(z,u-w)} = 0$ which gives
\begin{multline*}
\partial _{u_j}F_{a_1,a_2}(z,w,u)
\\[1ex]
=
\left( a_1(z,u) \partial _{u_j}a_2 (u,w)
+
\overline w_ja_1(z,u) a_2 (u,w) \right) e^{(z,u-w) + (u,w)}
\\[1ex]
=
F_{a_1,\partial _{z_j}a_2}(z,w,u) + \overline w_jF_{a_1,a_2}(z,w,u).
\end{multline*}
Consider $b_2(z,w)$. Integration by parts gives
\begin{multline*}
b_2(z,w)
=
\int_{\cc d} F_{a_1,a_2}(z,w,u)\overline u_je^{-|u|^2}\, d\lambda (u)
\\[1ex]
= - \int_{\cc d} F_{a_1,a_2}(z,w,u) \, \partial _{u_j}e^{-|u|^2} \, d\lambda (u)
\\[1ex]
=
\int_{\cc d} \partial _{u_j}F_{a_1,a_2}(z,w,u) e^{-|u|^2}\, d\lambda (u)
\\[1ex]
=
\int_{\cc d} F_{a_1,\partial _{z_j}a_2}(z,w,u)
e^{-|u|^2}\, d\lambda (u)
+
\overline w_j \int_{\cc d} F_{a_1,a_2}(z,w,u)
e^{-|u|^2}\, d\lambda (u)
\\[1ex]
=
\int_{\cc d} F_{a_1,\partial _{z_j}a_2}(z,w,u)
e^{-|u|^2}\, d\lambda (u)
+
b_3(z,w).
\end{multline*}
\par
A combination of these identities now gives
\begin{multline*}
\pi ^d \partial _{z_j} (a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}a_2) (z,w)
\\[1ex]
=
\int_{\cc d} (
F_{\partial _{z_j}a_1,a_2}(z,w,u)
+
F_{a_1,\partial _{z_j}a_2}(z,w,u)
)e^{-|u|^2}\, d\lambda (u)
\\[1ex]
=\pi ^d(\partial _{z_j}a_1) {\text{\footnotesize $\#$}} _{\mathfrak V}a_2(z,w)
+
\pi ^d a_1 {\text{\footnotesize $\#$}} _{\mathfrak V}(\partial _{z_j}a_2) (z,w),
\end{multline*}
and \eqref{Eq:DiffCompTwistProd1} follows.
\par
The assertion \eqref{Eq:DiffCompTwistProd2} is proved by similar arguments.
\end{proof}
\par
The characterization
in Theorem \ref{Thm:ShubinAnalChar} (3)
can be applied
to prove the following composition result,
which is a generalization of \cite[Theorem~23.6]{Shubin1} to include
the case when $\rho = 0$.
\par
\begin{prop}\label{prop:composition}
Let $0 \le \rho \leqslant 1$ and $\omega_j \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})$ for $j = 1,2$.
If $\mathfrak a _j \in \operatorname{Sh}_\rho^{(\omega _j)}(\rr {2d})$ for $j = 1,2$, then $\mathfrak a _1 {\text{\footnotesize $\#$}} \mathfrak a _2
\in \operatorname{Sh} _\rho^{(\omega _1\omega _2)}(\rr {2d})$.
\end{prop}
\par
\begin{proof}
If $\mathfrak a _0 = \mathfrak a _1 {\text{\footnotesize $\#$}} \mathfrak a _2$ and $a_j = \mathsf S_{\mathfrak V} \mathfrak a _j$, $j=0,1,2$, then
$a_0 = a_1 {\text{\footnotesize $\#$}} _{\mathfrak V} a_2$.
From Lemma \ref{Lemma:DiffCompTwistProd} and \eqref{Eq:DefCompTwistProd}
we obtain for $\alpha, \beta \in \nn d$,
\begin{align*}
& \partial_z ^\alpha \overline \partial _w
^\beta a_0 (z,w)
\\[1ex]
& = \sum_{\gamma \leqslant \alpha} \sum_{\kappa \leqslant \beta}
\binom{\alpha}{\gamma} \binom{\beta}{\kappa}
\left( (\partial _z^{\alpha - \gamma} \overline \partial _w^{\beta-\kappa}
a_1) {\text{\footnotesize $\#$}} _{\mathfrak V}
(\partial _z^{\gamma} \overline \partial _w^{\kappa}a_2) \right)(z,w)
\\[1ex]
& = \pi^{-d} \sum_{\gamma \leqslant \alpha} \sum_{\kappa \leqslant \beta}
\binom{\alpha}{\gamma} \binom{\beta}{\kappa}
\int_{\cc d} \partial _z^{\alpha-\gamma} {\overline \partial} _u^{\beta-\kappa} a_1(z,u)
\partial _u^{\gamma} \overline \partial _w^{\kappa} a_2 (u,w) e^{(z,u-w) + (u,w)} d \mu (u).
\end{align*}
\par
Since $\omega _2 \in \mathscr P (\rr {2d})\simeq \mathscr P (\cc {d})$ is moderate,
Theorem \ref{Thm:ShubinAnalChar} gives for some $N_0 \ge 0$ and any $N_1, N_2 \geqslant 0$
\begin{align*}
|\partial _u^{\alpha-\gamma} \overline \partial _w^{\beta-\kappa} a_1(z,u)|
& \lesssim
\omega _1(\sqrt 2\, \overline z)\eabs {z+u}^{-\rho |\alpha+\beta-\gamma -\kappa |}
\eabs {z-u}^{-N_1} e^{\frac1{2} | z - u |^2}
\intertext{and}
|\partial _u^\gamma \overline \partial _w^\kappa a_2(u,w)|
& \lesssim
\omega _2(\sqrt 2\, \overline z)\eabs {z-u}^{N_0}\eabs {u+w}^{-\rho |\gamma +\kappa |}
\eabs {u-w}^{-N_2} e^{\frac1{2} | u - w |^2}.
\end{align*}
\par
This gives
\begin{multline}\label{Eq:Derb0Est}
\left | \partial _z^\alpha \overline \partial _w
^\beta a_0 (z,w) \right|
\\[1ex]
\lesssim
\omega _1(\sqrt 2\, \overline z)\omega _2(\sqrt 2\, \overline z) e^{\frac 12|z-w|^2}
\int_{\cc d}
F(z,w,u)e^{\Phi (z,w,u)}\, d \lambda (u)
\end{multline}
where for any $N_1 \geqslant 0$
\begin{align*}
F(z,w,u)
&=
\eabs{z+u}^{-\rho|\alpha+\beta-\gamma-\kappa|} \eabs{z-u}^{N_0-N_1}
\eabs{u+w}^{-\rho|\gamma+\kappa|} \eabs{u-w}^{-N_2}
\intertext{and}
\Phi (z,w,u)
&=
- \frac1{2} |z-w|^2 + \frac1{2} |z-u|^2 + \frac1{2} |u-w|^2 - |u|^2
\\[1ex]
& \qquad \qquad \qquad \qquad \qquad \qquad \qquad
+ {\operatorname{Re}} (z,u-w) + {\operatorname{Re}} (u,w) = 0.
\end{align*}
By Peetre's inequality and the facts that $\gamma \le \alpha$ and $\kappa \le \beta$
we get
\begin{multline*}
\eabs {z+u}^{\rho |\gamma +\kappa|}\eabs{u+w}^{-\rho|\gamma+\kappa|}
\lesssim
\eabs {z-w}^{\rho |\gamma +\kappa|}
\\[1ex]
\lesssim
\eabs {z-u}^{\rho |\gamma +\kappa|}\eabs {u-w}^{\rho |\gamma +\kappa|}
\\[1ex]
\le
\eabs {z-u}^{\rho |\alpha +\beta|}\eabs {u-w}^{\rho |\alpha +\beta|}
\end{multline*}
and
\begin{equation*}
\eabs {z+u}^{-\rho |\alpha +\beta |}
\lesssim
\eabs {z+w}^{-\rho |\alpha +\beta |}\eabs {u-w}^{\rho |\alpha +\beta |}
\end{equation*}
wherefrom
\begin{equation}\label{Eq:FuncFEst}
F(z,w,u)
\le
\eabs{z+w}^{-\rho |\alpha +\beta|}
\eabs{z-u}^{\rho |\alpha +\beta| +N_0-N_1}
\eabs{u-w}^{2\rho |\alpha +\beta |-N_2}.
\end{equation}
Hence a combination of \eqref{Eq:Derb0Est} and \eqref{Eq:FuncFEst}
gives for any $N \geqslant 0$
\begin{align*}
& (\omega _1(\sqrt 2\, \overline z)\omega _2(\sqrt 2\, \overline z))^{-1}
\eabs{z+w}^{\rho|\alpha+\beta|}
\left| \partial _z^\alpha \overline \partial _w
^\beta a_0 (z,w) \right|
\\[1ex]
& \lesssim
e^{\frac1{2} |z-w|^2}
\int_{\cc d} \eabs{z-u}^{\rho|\alpha+\beta| + N_0 - N_1} \eabs{u-w}
^{2\rho|\alpha+\beta| - N_2}\, d \lambda (u)
\\[1ex]
& \lesssim
\eabs{z-w}^{-N} e^{\frac1{2} |z-w|^2}
\int_{\cc d} \eabs{z-u}^{\rho|\alpha+\beta| + N_0+N - N_1} \eabs{u-w}
^{2\rho|\alpha+\beta| + N - N_2}\, d \lambda (u).
\end{align*}
By letting
$$
N_1 \geqslant \rho|\alpha+\beta| + N_0 + N
\quad \text{and}\quad
N_2 > 2\rho|\alpha+\beta| + N + 2 d
$$
we obtain
\begin{equation*}
\left| \partial _z^\alpha \overline \partial _w^\beta
a_0 (z,w) \right|
\lesssim
\omega _1(\sqrt 2\, \overline z)\omega _2(\sqrt 2\, \overline z)
\eabs{z+w}^{-\rho|\alpha+\beta|}
\eabs{z-w}^{-N} e^{\frac1{2} |z-w|^2}.
\end{equation*}
According to
Theorem \ref{Thm:ShubinAnalChar} (3)
this estimate
implies that $\mathfrak a _0 \in \operatorname{Sh} _\rho^{(\omega _1\omega _2)}(\rr {2d})$.
\end{proof}
\par
\begin{rem}
Eq. \eqref{Eq:DefCompTwistProd}
combined with Theorem \ref{Thm:GevreySymbolsBargmTransfer}
can be used to show composition results for pseudo-differential
operators with symbols in $\Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d})$.
In fact we may use an argument similar to the proof of Proposition
\ref{prop:composition}, but simpler since derivatives can be avoided.
We obtain
\begin{alignat*}{3}
\mathfrak a _1 {\text{\footnotesize $\#$}} \mathfrak a _2 \in \Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d})
\quad \text{when}\quad
\mathfrak a _1,\mathfrak a _2 \in \Gamma ^{\sigma ,s}_{s,\sigma ;0}(\rr {2d}),
\quad s,\sigma \ge \frac 12,
\end{alignat*}
and similarly with $\Gamma ^{\sigma ,s;0}_{s,\sigma}$
in place of
$\Gamma ^{\sigma ,s}_{s,\sigma ;0}$, provided $\sigma >\frac 12$.
Thereby we regain parts of \cite[Theorem~3.18]{AbCaTo} for certain
restrictions on $s$ and $\sigma$.
\end{rem}
\par
\section{Relations and estimates for Wick and
anti-Wick operators}\label{sec3}
\par
In this section we first show how to approximate a Wick operator by means of
a sum of anti-Wick operators.
Then we prove continuity results for anti-Wick operators with symbols having
exponential type bounds. Finally we deduce estimates for the Wick symbol
of these anti-Wick operators.
\subsection{Expansion of Shubin type Wick operators with respect to
anti-Wick operators}\label{subsec3.1}
\par
The first result can be stated for semi-conjugate analytic symbols on $\cc {2d}$.
\begin{prop}\label{Prop:WickToAntiWick}
Suppose $s\ge \frac 12$, $a \in \wideparen \mathcal A _s'(\cc {2d})$,
let $N\ge 0$ be an integer, and let
\begin{align*}
a_\alpha (w) &= \partial _z^\alpha \overline \partial _w^\alpha a (w,w), \quad \alpha \in \nn d,
\intertext{and}
b_\alpha (z,w) &= |\alpha |
\int _0^1 (1-t)^{|\alpha |-1} \partial _z^\alpha \overline \partial _w^\alpha a
(w+t(z-w),w)\, dt, \quad \alpha \in \nn d\setminus 0.
\end{align*}
Then
\begin{equation}\label{Eq:WickToAntiWick}
\operatorname{Op} _{\mathfrak V}(a)
=
\sum _{|\alpha |\le N}
\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_\alpha )}{\alpha !}
+
\sum _{|\alpha | = N+1}\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}(b_\alpha )}{\alpha !}.
\end{equation}
\end{prop}
\par
\begin{proof}
Taylor expansion gives
\begin{align*}
a(z,w) & = \sum _{|\alpha |\le N} \frac {(-1)^{|\alpha |} c_{\alpha}(z,w)} {\alpha !}
+
\sum _{|\alpha | = N+1}\frac {(-1)^{|\alpha |}c_{0,\alpha}(z,w)} {\alpha !},
\intertext{where}
c_{\alpha} (z,w) &= (-1)^{|\alpha |} (z-w)^\alpha \partial _z^\alpha a (w,w)
\intertext{and}
c_{0,\alpha} (z,w) &= (-1)^{|\alpha |} |\alpha |(z-w)^\alpha
\int _0^1 (1-t)^{|\alpha |-1} \partial _z^\alpha a (w+t(z-w),w)\, dt.
\end{align*}
Hence
$$
\operatorname{Op} _{\mathfrak V}(a)
=
\sum _{|\alpha |\le N}\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}(c_{\alpha} )}{\alpha !}
+
\sum _{|\alpha | = N+1}\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}(c_{0,\alpha} )}{\alpha !},
$$
and the result follows if we prove
\begin{equation}\label{Eq:WickAntiWickExpIdent}
\operatorname{Op} _{\mathfrak V}(c_{\alpha} )
=
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_\alpha )
\quad \text{and}\quad
\operatorname{Op} _{\mathfrak V}(c_{0,\alpha} )
=
\operatorname{Op} _{\mathfrak V}(b_\alpha ) .
\end{equation}
\par
It follows from \eqref{Eq:AntiWickAnalPseudoRel} that
$$
\operatorname{Op} _{\mathfrak V}(b_\alpha ) = \operatorname{Op} _{\mathfrak V}(c_{1,\alpha} )
\quad \text{and}\quad
\operatorname{Op} _{\mathfrak V}(c_{0,\alpha} ) = \operatorname{Op} _{\mathfrak V}(c_{2,\alpha} )
$$
where
\begin{align}
c_{j,\alpha}(z,w)
&=
(-1)^{|\alpha |} \pi ^{-d} |\alpha |
\int _0^1 (1-t)^{|\alpha |-1} h_{j,\alpha}(a;t,z,w)\, dt, \label{eq:cjdef}
\intertext{$j=1,2$, with}
h_{1,\alpha}(a;t,z,w)
&=
(-1)^{|\alpha |} \int _{\cc d}
\partial _z^\alpha \overline \partial _w^\alpha a
(w_1+t(z-w_1),w_1)
e^{-(z-w_1,w-w_1)}\, d\lambda (w_1) \label{eq:h1def}
\intertext{and}
h_{2,\alpha}(a;t,z,w)
&=
\int _{\cc d}(z-w_1)^\alpha
\partial _z^\alpha a
(w_1+t(z-w_1),w_1)
e^{-(z-w_1,w-w_1)}\, d\lambda (w_1). \nonumber
\end{align}
Since
$$
(z-w_1)^\alpha e^{-(z-w_1,w-w_1)}
=
\overline \partial _{w_1}^\alpha e^{-(z-w_1,w-w_1)}
$$
integration by parts yields
\begin{multline*}
h_{2,\alpha}(a;t,z,w)
=
\int _{\cc d}
\partial _z^\alpha a
(w_1+t(z-w_1),w_1)
\overline \partial _{w_1}^\alpha e^{-(z-w_1,w-w_1)} \, d\lambda (w_1)
\\[1ex]
=
(-1)^{|\alpha |}
\int _{\cc d}
\partial _z^\alpha \overline \partial _{w}^\alpha a
(w_1+t(z-w_1),w_1)
e^{-(z-w_1,w-w_1)}\, d\lambda (w_1)
=
h_{1,\alpha}(a;t,z,w),
\end{multline*}
and the second equality in \eqref{Eq:WickAntiWickExpIdent}
follows. The first equality in \eqref{Eq:WickAntiWickExpIdent}
follows by similar arguments. The details are left for the reader.
\end{proof}
\par
\par
\begin{rem}\label{Rem:WickToAntiWick2}
Proposition \ref{Prop:WickToAntiWick} and its proof
show that
\begin{equation}\tag*{(\ref{Eq:WickToAntiWick})$'$}
\operatorname{Op} _{\mathfrak V}(a)
=
\sum _{|\alpha |\le N}
\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_{\alpha})}{\alpha !}
+
\sum _{|\alpha | = N+1}\frac {(-1)^{|\alpha |}\operatorname{Op} _{\mathfrak V}(c_{1,\alpha})}{\alpha !}
\end{equation}
where $c_{1,\alpha}$ is defined by \eqref{eq:cjdef} and \eqref{eq:h1def}.
\end{rem}
\par
In the following result we estimate $a_\alpha$ in Proposition \ref{Prop:WickToAntiWick}
and $c_{1,\alpha}$ in \eqref{eq:cjdef}
when $a =\mathsf S_{\mathfrak V} \mathfrak a$ satisfies
\eqref{eq:characShubinBargmann2} for every $N\ge 0$ and $\alpha,\beta \in \nn d$.
By Theorem \ref{Thm:ShubinAnalChar} this means
that $\operatorname{Op} _{\mathfrak V}(a)$
is the Bargmann transform of a Shubin type operator.
\par
\begin{prop}\label{Prop:ShubinWickExpEst}
Let $0 \le \rho \le 1$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})$,
$a \in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$,
and let $a_\alpha$ and $b_\alpha$
be as in Proposition \ref{Prop:WickToAntiWick} for $\alpha \in \nn d$.
Then $\operatorname{Op} _{\mathfrak V}(b_\alpha)
= \operatorname{Op} _{\mathfrak V}(c_{1,\alpha})$ for
a unique $c_{1,\alpha}\in \wideparen A(\cc {2d})$,
\begin{align}
|\partial _w^\beta \overline \partial _w^\gamma a_\alpha (w)|
&\lesssim
\omega (\sqrt 2\overline {w}) \eabs {w}^{-\rho (2 |\alpha| +|\beta +\gamma |)},
\quad
\alpha ,\beta ,\gamma \in \nn d,
\label{Eq:ShubinWickExpEst1}
\intertext{and}
|\partial _z^\beta \overline \partial _w^\gamma c_{1,\alpha} (z,w)|
&\lesssim
e^{\frac{1}{2} |z-w|^2}
\omega (\sqrt 2\overline {z}) \eabs {z+w}^{-\rho (2 |\alpha| + |\beta +\gamma|)}
\eabs {z-w}^{-N},
\quad
\alpha ,\beta ,\gamma \in \nn d.
\label{Eq:ShubinWickExpEst2}
\end{align}
\end{prop}
\par
\begin{rem}\label{Rem:UniquenessIdentRemainderTerm}
The Wick symbol $c_{1,\alpha}$ in Proposition \ref{Prop:ShubinWickExpEst} is
uniquely defined and given by \eqref{eq:cjdef} in view of
Proposition \ref{Prop:LAOpsIdent}, when $h_{1,\alpha}$ is
defined by \eqref{eq:h1def}.
The conditions in Proposition \ref{Prop:ShubinWickExpEst}
imply that $c_{1,\alpha} \in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega _\alpha )} (\cc {2d})$
where $\omega _\alpha =\eabs \, \cdot \, ^{-2\rho |\alpha |}\cdot \omega$.
\end{rem}
\par
\begin{proof}[Proof of Proposition \ref{Prop:ShubinWickExpEst}]
The estimate \eqref{Eq:ShubinWickExpEst1} is an immediate consequence of
\begin{equation*}
\partial _w^\beta \overline \partial _w^\gamma a_\alpha (w)
= \partial _w^{\alpha+\beta} \overline \partial _w^{\alpha +\gamma} a (w,w)
\end{equation*}
and \eqref{eq:characShubinBargmann2}.
\par
In order to prove \eqref{Eq:ShubinWickExpEst2} we first note that
the uniqueness assertion for $c_{1,\alpha}$ is a consequence of
Remark \ref{Rem:UniquenessIdentRemainderTerm}.
Let $h_{1,\alpha}(a;z,w)$
be the same as in the proof of Proposition \ref{Prop:WickToAntiWick}.
Integration by parts gives
$$
\partial _z^\beta \overline \partial _w^\gamma h_{1,\alpha}(a;t,z,w)
=
h_{1,\alpha}(\partial _z^\beta \overline \partial _w^\gamma a;t,z,w),
$$
which reduce the problem to prove that \eqref{Eq:ShubinWickExpEst2}
holds for $\beta =\gamma =0$.
\par
The assumption $a \in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$
combined with $\omega$
and $\eabs \, \cdot \, ^{-|\alpha |}$ being moderate imply
$$
| \partial_z^\alpha \overline \partial_w^\beta a(z,w) |
\lesssim
e^{\frac1{2} |z-w|^2}
\omega (\sqrt 2\, \overline w)\eabs{w}^{- \rho |\alpha +\beta |}
\eabs{z-w}^{-N}
$$
for every $N\ge 0$. This gives
\begin{multline*}
e^{{\operatorname{Re}} (z,w)} |h_{1,\alpha} (a;t,z,w)|
\\[1ex]
\lesssim
\int _{\cc d}
\omega (\sqrt 2\overline {w_1})
e^{\frac{t^2}{2} |z-w_1|^2}\eabs {w_1}^{-2\rho |\alpha |}\eabs {t(z-w_1)}^{-N}
e^{{\operatorname{Re}} (z+w-w_1,w_1)}\, d\lambda (w_1),
\end{multline*}
that is
\begin{multline}\label{Eq:LongEsthalpha}
e^{-\frac 14|z-w|^2} |h_{1,\alpha} (a;t,z,w)|
\\[1ex]
\lesssim
\int _{\cc d}
\omega (\sqrt 2\overline {w_1})
e^{\frac{t^2}{2} |z-w_1|^2}\eabs {w_1}^{-2\rho |\alpha |}\eabs {t(z-w_1)}^{-N}
e^{-|w_1-z_2|^2}\, d\lambda (w_1)
\\[1ex]
=
\int _{\cc d}
\omega (\sqrt 2(\overline {z_2+w_1}))
e^{\frac{t^2}{2} |z_1-w_1|^2}\eabs {z_2+w_1}^{-2\rho |\alpha |}\eabs {t(z_1-w_1)}^{-N}
e^{-|w_1|^2}\, d\lambda (w_1)
\end{multline}
for every $N\ge 0$, where $z_1=\frac 12(z-w)$ and $z_2=\frac 12(z+w)$.
\par
If $t\in [0,\frac 12]$, then the last estimate together with the
moderateness of $\omega$ give
\begin{multline*}
e^{-|z_1|^2} |h_{1,\alpha} (a;t,z,w)|
\lesssim
\omega (\sqrt 2\overline {z_2})\eabs {z_2}^{-2\rho |\alpha |}
\int _{\cc d}
e^{\frac 18|w_1|^2}
e^{\frac{1}{8} |z_1-w_1|^2}
e^{-|w_1|^2}\, d\lambda (w_1)
\\[1ex]
\lesssim
\omega (\sqrt 2\overline {z_2})\eabs {z_2}^{-2\rho |\alpha |} e^{\frac{1}{4} |z_1|^2}\int _{\cc d}
e^{\frac{1}{4} |w_1|^2}
e^{-\frac 78|w_1|^2}\, d\lambda (w_1)
\\[1ex]
\lesssim
\omega (\sqrt 2\overline {z_2})\eabs {z_2}^{-2\rho |\alpha |} e^{\frac{1}{2} |z_1|^2}
\eabs {z_1}^{-N},
\end{multline*}
for every $N\ge 0$.
The moderateness of $\omega$ again gives
\begin{equation}\label{Eq:halphaEst}
|h_{1,\alpha} (a;t,z,w)|\lesssim e^{\frac{1}{2} |z-w|^2}
\omega (\sqrt 2\overline {z}) \eabs {z+w}^{-2\rho |\alpha |}\eabs {z-w}^{-N}
\end{equation}
or every $N\ge 0$, when $t\in [0,\frac 12]$.
\par
Suppose instead $t\in [\frac 12,1]$. Then
$\eabs {t(z_1-w_1)}^{-N}\asymp \eabs {z_1-w_1}^{-N}$.
Moderateness again gives
$$
\omega (\sqrt 2(\overline {z_2+w_1}))
\eabs {z_2+w_1}^{-2\rho |\alpha |}\eabs {z_1-w_1}^{-N_0}
\lesssim
\omega (\sqrt 2\overline z)
\eabs {z}^{-2\rho |\alpha |}
$$
for some $N_0$. Hence \eqref{Eq:LongEsthalpha} gives
\begin{multline*}
e^{-|z_1|^2} \omega (\sqrt 2\overline z)^{-1}\eabs {z}^{2\rho |\alpha |}
| h_{1,\alpha} (a;t,z,w)|
\\[1ex]
\lesssim
\int _{\cc d}
e^{\frac{1}{2} |z_1-w_1|^2}\eabs {z_1-w_1}^{-N}
e^{-|w_1|^2}\, d\lambda (w_1)
\\[1ex]
=
e^{|z_1|^2}\int _{\cc d}
\eabs {z_1-w_1}^{-N}
e^{- \frac{1}{2} |w_1+z_1|^2}\, d\lambda (w_1)
\asymp
e^{|z_1|^2}\eabs {z_1}^{-N}
\end{multline*}
for every $N\ge 0$. This gives \eqref{Eq:halphaEst} also for $t\in [\frac 12,1]$.
\par
The result now follows by using \eqref{Eq:halphaEst} when estimating
$|c_{1,\alpha}(z,w)|$ in \eqref{eq:cjdef}
and evaluating the arising integral.
\end{proof}
\par
The next result, analogous to Proposition \ref{Prop:ShubinWickExpEst},
will be useful in Section \ref{sec5} when we discuss hypoellipticity
for Shubin operators in the Wick setting.
\par
\begin{prop}\label{Prop:AsymptoticExpansion1}
Let $\rho \ge 0$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\cc d)$,
$\omega _t=\omega \cdot \eabs \, \cdot \, ^{-2\rho t}$ when $t\ge 0$,
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$,
$\mathfrak a = \mathsf S_{\mathfrak V}^{-1}a$ and $N\ge 0$ be an integer.
Then
\begin{equation}\label{Eq:ExpansionWickTaylor}
\mathfrak a (x,-\xi ) = \sum _{|\alpha |\le N}
\frac {(-1)^{|\alpha |}
(\partial _z^\alpha \overline \partial _w^\alpha a)(2^{-\frac 12}z,2^{-\frac 12}z)}
{2^{|\alpha |}\alpha !} +c_N(z), \quad z = x + i \xi,
\end{equation}
where
\begin{equation}\label{Eq:EstExpansionWickTaylor}
\begin{alignedat}{2}
\partial _z^\alpha \overline \partial _w^\alpha a
\in
\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega _{|\alpha |})}(\cc {2d})
\quad &\text{and} &\quad
(x,\xi )\mapsto c_N(x-i\xi ) \in \operatorname{Sh} _{\rho}^{(\omega _{N+1})}(\rr {2d}).
\end{alignedat}
\end{equation}
\end{prop}
\par
\begin{proof}
The first claim in \eqref{Eq:EstExpansionWickTaylor} $\partial _z^\alpha \overline \partial _w^\alpha a \in
\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega _{|\alpha |})}(\cc {2d})$ is an immediate consequence
of the definition \eqref{Eq:ShubinWickEstimates} and Peetre's inequality.
\par
By Taylor expanding the right-hand side of
\eqref{eq:InvBargmannsymbolSTFT}
we obtain
\begin{equation}\label{Eq:ExpansionWickTaylor1}
\mathfrak a (x,-\xi ) = \sum _{|\alpha +\beta |\le 2N+1}
\frac {(2/\pi)^d I_{\alpha ,\beta}\cdot
(\partial _z^\alpha \overline \partial _w^\beta a)(2^{-\frac 12}z,2^{-\frac 12}z)}
{\alpha !\beta !} +c_N(z),
\end{equation}
where
\begin{equation*}
I_{\alpha ,\beta}
=
\int _{\cc {d}}(-w)^\alpha \overline w^\beta e^{- 2 |w|^2}
\, d\lambda (w),
\end{equation*}
and
\begin{equation}\label{Eq:cNdef}
c_N(z)
=
2(N+1)
\sum _{|\alpha +\beta |= 2N+2}
\frac {(-1)^{|\beta |}}{\alpha !\beta !}
\int _0^1(1-\theta )^{2N+1}
H_{\alpha ,\beta } (z ,\theta )\, d\theta
\end{equation}
with
\begin{equation}\label{Eq:Hdef}
H_{\alpha ,\beta } (z ,\theta ) =
\left ( \frac 2\pi \right )^d \int _{\cc {d}}
(\partial _z^\alpha \overline \partial _w^\beta a)
\left ( \frac z{\sqrt 2}- \theta w,\frac z{\sqrt 2}+\theta w \right )
w^\alpha \overline w^\beta
e^{- 2 |w|^2 }\, d\lambda (w).
\end{equation}
\par
The orthonormality of $\{ e_\alpha \} _{\alpha \in \nn d}\subseteq A^2(\cc d)$
(cf. \eqref{Eq:BargmannHermiteMap})
yields $I_{\alpha,\beta} = 0$ if $\alpha \neq \beta$ and
\begin{align*}
I_{\alpha,\alpha}
& = \int _{\cc {d}}(-w)^\alpha \overline w^\alpha e^{- 2 |w|^2} \, d\lambda (w)
\\[1ex]
& = (-1)^{|\alpha|} 2^{-d -|\alpha|} \alpha! \pi^d \int _{\cc {d}} |e_\alpha(w) |^2
\, d\mu (w)
\\[1ex]
& = (-1)^{|\alpha|} 2^{-d -|\alpha|} \alpha! \pi^d.
\end{align*}
Comparing \eqref{Eq:ExpansionWickTaylor1} with \eqref{Eq:ExpansionWickTaylor}
we see that the sum in the latter formula has been proven correct.
It remains to study the remainder $c_N$.
We need to prove that $\mathfrak c (x,\xi )=c_N(x-i\xi )$ belongs to
$\operatorname{Sh} _{\rho}^{(\omega _{N+1})}(\rr {2d})$. If
$$
h_{\alpha ,\beta } (z ,w,\theta ) =
(\partial _z^\alpha \overline \partial _w^\beta a)
\left ( \frac z{\sqrt 2}- \theta w,\frac z{\sqrt 2}+\theta w \right )
w^\alpha \overline w^\beta e^{- 2 |w|^2 }
$$
then
$$
H_{\alpha ,\beta } (z ,\theta )
=
\left ( \frac 2\pi \right )^d \int _{\cc {d}}
h_{\alpha ,\beta } (z ,w,\theta )
\, d\lambda (w).
$$
\par
First we notice that
\begin{align*}
\partial _z^\alpha \overline \partial _z^\beta c_N(z)
&=
2(N+1)
\sum _{|\gamma +\delta |= 2N+2}
\frac {(-1)^{|\delta |}}{\gamma !\delta !}
\int _0^1(1-\theta )^{2N+1}
\partial _z^{\alpha}\overline \partial _z^{\beta}
H_{\gamma ,\delta } (z ,\theta )\, d\theta,
\\[1ex]
\partial _z^\alpha \overline \partial _z^\beta H_{\gamma ,\delta} (z,\theta )
&=
\left ( \frac 2\pi \right )^d
\int _{\cc {d}} \partial _z^\alpha \overline \partial _z^\beta h_{\gamma ,\delta}
(z,w,\theta ) \, d\lambda (w)
\intertext{and}
\partial _z^\alpha \overline \partial _z^\beta h_{\gamma ,\delta}
(z,w,\theta )
&=
2^{-\frac {|\alpha +\beta |}2}(\partial _z^{\alpha +\gamma}
\overline \partial _z^{\beta +\delta}
a)\left( \frac z{\sqrt 2} - \theta w,\frac z{\sqrt 2} + \theta w \right )w^\gamma
\overline w^\delta e^{- 2 |w|^2 }.
\end{align*}
From the definition \eqref{Eq:ShubinWickEstimates} this implies that
for every $M\ge 0$ and some $M_0\ge 0$ we have
\begin{multline*
|\partial _z^\alpha \overline \partial _z^\beta h_{\gamma ,\delta}
(z,w,\theta )|
\\[1ex]
\lesssim
e^{-2(1-\theta ^2)|w|^2}\omega (\overline z-\sqrt 2\theta \overline w)
\eabs {z}^{-\rho (|\alpha +\beta |+2N+2)}\eabs {\theta w}^{-M-M_0}|w|^{2N+2}
\\[1ex]
\lesssim
e^{-2(1-\theta )|w|^2}\omega (\overline z)
\eabs {z}^{-\rho (|\alpha +\beta |+2N+2)}\eabs {\theta w}^{-M}|w|^{2N+2}.
\end{multline*}
This gives
$$
|\partial _z^\alpha \overline \partial _z^\beta H_{\gamma ,\delta} (z,\theta )|
\lesssim
\omega (\overline z)
\eabs {z}^{-\rho (|\alpha +\beta |+2N+2)}\cdot J(\theta ),
$$
where
$$
J(\theta ) = \int _{\cc d} e^{-2(1-\theta )|w|^2}\eabs {\theta w}^{-M}|w|^{2N+2}
\, d\lambda (w).
$$
\par
For $\theta \in [0,\frac 12]$ we get
$$
J(\theta ) = \int _{\cc d} e^{-|w|^2}|w|^{2N+2}\, d\lambda (w),
$$
which is finite and independent of $\theta$. If instead $\theta \in [\frac 12,1]$,
and choosing $M>2d+2N+2$, then
$$
J(\theta ) \le
\int _{\cc d} \eabs {\theta w}^{-M}|w|^{2N+2}\, d\lambda (w),
$$
which is again finite and independent of $\theta$.
\par
A combination of these estimates give
$$
|\partial _z^\alpha \overline \partial _z^\beta H_{\gamma ,\delta} (z,\theta )|
\lesssim
\omega (\overline z)
\eabs {z}^{-\rho (|\alpha +\beta |+2N+2)},
$$
which in turn implies
$$
|\partial _z^\alpha \overline \partial _z^\beta c_N(z)|
\lesssim
\omega (\overline z)
\eabs {z}^{-\rho (|\alpha +\beta |+2N+2)}.
$$
This means that $\mathfrak c \in \operatorname{Sh} _{\rho}^{(\omega _{N+1})}(\rr {2d})$.
\end{proof}
\par
\subsection{Continuity of anti-Wick operators with exponentially
bounded symbols}\label{subsec3.2}
\par
Next we consider anti-Wick symbols that satisfy
exponential bounds of the form
\begin{align}
|a_0 (w)|
&\lesssim
e^{-r_0 |w|^{\frac 1s}},
\label{Eq:NonAWGSEst1}
\intertext{or}
|a_0 (w)|
&\lesssim
e^{r_0 |w|^{\frac 1s}}.
\label{Eq:NonAWGSEst2}
\end{align}
\par
In order to formulate our results we introduce new spaces of entire functions.
Let $s > \frac{1}{2}$, $t_0, r > 0$, and
let $\mathcal A _{s, t_0,r}(\cc d)$ be the Banach space of all $F \in A(\cc d)$ such that
\begin{equation*}
\nm F{\mathcal A _{s, t_0,r}} \equiv
\nm {F\cdot e^{- t_0 |\, \cdot \, |^2 + r |\, \cdot \, |^{\frac{1}{s}}}}{L^\infty}
< \infty.
\end{equation*}
Set
\begin{equation*}
\mathcal A _{0,(s, t_0)}(\cc d) = \bigcap_{r > 0} \mathcal A _{s, t_0,r} (\cc d)
\quad \text{and}\quad
\mathcal A _{(s, t_0)}'(\cc d) = \bigcap_{r > 0} \mathcal A _{s, t_0,-r} (\cc d)
\end{equation*}
equipped with the projective limit topology.
Likewise we set
\begin{equation*}
\mathcal A _{(s, t_0)}(\cc d) = \bigcup_{r > 0} \mathcal A _{s, t_0,r} (\cc d)
\quad \text{and}\quad
\mathcal A _{0,(s, t_0)}'(\cc d) = \bigcup_{r > 0} \mathcal A _{s, t_0,-r} (\cc d)
\end{equation*}
equipped with the inductive limit topology.
\par
Referring to Section \ref{subsec1.3} it is clear that
the spaces $\mathcal A _{0,(s, t_0)}(\cc d)$, $\mathcal A _{(s, t_0)}(\cc d)$, $\mathcal A _{(s, t_0)}'(\cc d)$
and $\mathcal A _{0,(s, t_0)}'(\cc d)$ are generalizations of
\begin{align*}
\mathcal A _{0,(s, \frac{1}{2})}(\cc d) &= \mathfrak V_d ( \Sigma_s (\rr d) ) = \mathcal A _{0,s}(\cc d)
\\[1ex]
\mathcal A _{(s, \frac{1}{2})}(\cc d) &= \mathfrak V_d ( \mathcal S _s (\rr d) ) = \mathcal A _{s}(\cc d)
\\[1ex]
\mathcal A _{(s, \frac{1}{2})}'(\cc d) &= \mathfrak V_d ( \mathcal S _s '(\rr d) ) = \mathcal A _{s}'(\cc d)
\intertext{and}
\mathcal A _{0,(s, \frac{1}{2})}'(\cc d) &= \mathfrak V_d ( \Sigma_s' (\rr d) ) = \mathcal A _{0,s}'(\cc d),
\end{align*}
respectively.
\par
\begin{prop}\label{prop:contAW}
Let $a_0\in L^\infty _{loc}(\cc d)$, $0 < t_0 < 1$ and
\begin{equation}\label{eq:t0t1}
t_1 = \frac{1}{4(1-t_0)}.
\end{equation}
Then the following is true:
\begin{enumerate}
\item if \eqref{Eq:NonAWGSEst2} holds for some $r_0 > 0$ then
\begin{equation}\label{Eq:ContAW1}
\begin{alignedat}{2}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) &: & \mathcal A _{0,(s, t_0)}(\cc d) &\to \mathcal A _{0,(s, t_1)}(\cc d),
\\[1ex]
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) &: & \mathcal A _{0,(s, t_0)}'(\cc d) &\to \mathcal A _{0,(s, t_1)}'(\cc d)
\end{alignedat}
\end{equation}
are continuous;
\vspace{0.2cm}
\item if \eqref{Eq:NonAWGSEst2} holds for every $r_0 > 0$ then
\begin{equation}\label{Eq:ContAW2}
\begin{alignedat}{2}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) &: &\mathcal A _{(s, t_0)}(\cc d) &\to \mathcal A _{(s, t_1)}(\cc d),
\\[1ex]
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) &: &\mathcal A _{(s, t_0)}'(\cc d) &\to \mathcal A _{(s, t_1)}'(\cc d)
\end{alignedat}
\end{equation}
are continuous.
\end{enumerate}
\end{prop}
\par
\begin{proof}
We only prove that the first map in \eqref{Eq:ContAW1} is continuous. The
other continuity assertions follow by similar arguments and are left
for the reader.
\par
Let $r_2 > 0$ be given, $r_1 > r_0$ and $F\in \mathcal A _{0,(s, t_0)}(\cc d)$.
We have for $z \in \cc d$
\begin{align*}
& |\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F(z)| e^{- t_1 |z |^2 + r_2 |z|^{\frac{1}{s}}}
\\[1ex]
& \lesssim e^{- t_1 |z |^2 + r_2 |z|^{\frac{1}{s}}}
\int_{\cc d} |a_0 (w)| \, |F(w)| \, e^{{\operatorname{Re}} (z,w) - |w|^2}\, d\lambda (w)
\\[1ex]
& \lesssim e^{- t_1 |z |^2 + r_2 |z|^{\frac{1}{s}}} \nm F{\mathcal A _{s, t_0,r_1}}
\int_{\cc d} e^{r_0 |w|^{\frac{1}{s}}
+ t_0 |w|^2 - r_1 |w|^{\frac{1}{s}} + {\operatorname{Re}} (z,w) - |w|^2}\, d\lambda (w)
\\[1ex]
& = e^{r_2 |z|^{\frac{1}{s}}} \nm F{\mathcal A _{s, t_0,r_1}}
\int_{\cc d} e^{-(r_1-r_0) |w|^{\frac{1}{s}} -(1- t_0) |w|^2 +
{\operatorname{Re}} (z,w) - t_1 |z |^2 }\, d\lambda (w)
\\[1ex]
& = e^{r_2 |z|^{\frac{1}{s}}} \nm F{\mathcal A _{s, t_0,r_1}}
\int_{\cc d} e^{-(r_1-r_0)
|w|^{\frac{1}{s}} - \left | \sqrt{1- t_0} w - \frac{1}{2 \sqrt{1- t_0} } z \right|^2 }
\, d\lambda (w)
\\[1ex]
& = e^{r_2 |z|^{\frac{1}{s}}} \nm F{\mathcal A _{s, t_0,r_1}}
\int_{\cc d} e^{-(r_1-r_0) \left| w + \frac{1}{2 (1- t_0) } z \right |
^{\frac{1}{s}} - (1- t_0)\left| w \right|^2 }\, d\lambda (w)
\\[1ex]
& \le
e^{(r_2 - c_1(r_1 - r_0)) |z|^{\frac{1}{s}}}
\nm F{\mathcal A _{s, t_0,r_1}}
\int_{\cc d} e^{ c_2 (r_1-r_0) | w |^{\frac{1}{s}} - (1- t_0)\left| w \right|^2 }\, d\lambda (w)
\\[1ex]
&\asymp
\nm F{\mathcal A _{s, t_0,r_1}}
e^{(r_2 - c_1(r_1 - r_0)) |z|^{\frac{1}{s}}}
\end{align*}
for some constants $c_1, c_2>0$. By choosing $r_1$ sufficiently large we
get
\begin{equation*}
\nm {\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0) F} {\mathcal A _{s, t_1,r_2}}
\lesssim
\nm F{\mathcal A _{s, t_0,r_1}}.
\end{equation*}
The estimates and \eqref{Eq:AntiWick} imply $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F \in A(\cc d)$.
\end{proof}
\par
\begin{rem}
Note that \eqref{eq:t0t1} implies $t_1 > \frac{1}{4}$
and $t_0 \le t_1$ with equality if and only if $t_0 = \frac{1}{2}$.
Hence $\mathcal A _{0,(s, t_0)}(\cc d) \subseteq \mathcal A _{0,(s, t_1)}(\cc d)$,
and similarly for the other spaces.
\end{rem}
\par
The particular case $t_0 = \frac{1}{2}$ gives
\par
\begin{cor}\label{cor:contBargmannGS}
Let $a_0\in L^\infty _{loc}(\cc d)$.
If \eqref{Eq:NonAWGSEst2} holds for some (every) $r_0 > 0$
then $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)$ is continuous on $\mathcal A _{0,s}(\cc d)$
(on $\mathcal A _{s}(\cc d)$).
\end{cor}
\par
With a technique similar to the proof of Proposition \ref{prop:contAW}
one shows the following result.
\par
\begin{prop}\label{prop:contAW2}
Let $a_0\in L^\infty _{loc}(\cc d)$, $0 < t_0 < 1$ and suppose \eqref{eq:t0t1} holds.
Then the following is true:
\begin{enumerate}
\item if \eqref{Eq:NonAWGSEst1} holds for all $r_0 > 0$ then
\begin{equation}\label{Eq:RegAW1}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0): \mathcal A _{0,(s, t_0)}'(\cc d) \to \mathcal A _{0,(s, t_1)}(\cc d)
\end{equation}
is continuous;
\vspace{0.2cm}
\item if \eqref{Eq:NonAWGSEst1} holds for some $r_0 > 0$ then
\begin{equation}\label{Eq:RegAW2}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0): \mathcal A _{(s, t_0)}'(\cc d) \to \mathcal A _{(s, t_1)}(\cc d)
\end{equation}
is continuous.
\end{enumerate}
\end{prop}
\par
Again the particular case $t_0 = \frac{1}{2}$ gives
\par
\begin{cor}\label{cor:regBargmannGS}
Let $a_0\in L^\infty _{loc}(\cc d)$. Then the following is true:
\begin{enumerate}
\item if \eqref{Eq:NonAWGSEst1} holds for all $r_0 > 0$
then
\begin{equation*}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0): \mathcal A _{0,s}'(\cc d) \to \mathcal A _{0,s}(\cc d)
\end{equation*}
is continuous;
\item if \eqref{Eq:NonAWGSEst1} holds for some $r_0 > 0$
then
\begin{equation*}
\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0): \mathcal A _{s}'(\cc d) \to \mathcal A _{s}(\cc d)
\end{equation*}
is continuous.
\end{enumerate}
\end{cor}
\par
\subsection{Estimates of Wick symbols of anti-Wick operators with
exponentially bounded symbols}\label{subsec3.3}
\par
For anti-Wick operators in \cite[Eq.~(2.94)]{Fo} we have the following result.
\par
\begin{thm}\label{Thm:WickSymbolAntiWickOpFolland}
If $a_0\in L^\infty _{loc}(\cc d)$ satisfies
\begin{equation}\label{Eq:ExpQuadratic}
|a_0(w)| \lesssim e^{r|w|^2}, \quad w \in \cc d, \quad \text{for some} \quad r < 1,
\end{equation}
then $a_0\in L_{0,A}(\cc d)$ and \eqref{Eq:AntiWickAnalPseudoRel}$'$ holds for some
$a_0^{\operatorname{aw}}\in \wideparen A(\cc {2d})$ with
\begin{equation*}
|a_0^{\operatorname{aw}}(z,w)|\lesssim e^{r_0 |z+w|^2-\operatorname{Re}(z,w)},
\qquad
r_0=4^{-1}(1-r)^{-1}.
\end{equation*}
\end{thm}
\par
\begin{proof}
The claim $a_0\in L_{0,A}(\cc d)$ is an immediate consequence of the assumption \eqref{Eq:ExpQuadratic}
and the definition \eqref{Eq:AntiWickL1SymbClass}.
The integral in \eqref{Eq:AntiWickAnalPseudoRel}$'$ can be estimated as
\begin{multline*}
\left |
\int _{\cc d}a_0(w_1)e^{-(z-w_1,w-w_1)}\, d\lambda (w_1)
\right |
\\[1ex]
\lesssim
\int _{\cc d} e^{r|w_1|^2} \left | e^{-(z-w_1,w-w_1)} \right |
\, d\lambda (w_1)
\\[1ex]
=
e^{-\operatorname{Re}(z,w)}
\int _{\cc d} e^{-(1-r)|w_1|^2} e^{\operatorname{Re}(z+w,w_1)}
\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 1{4(1-r)}|z+w|^2-\operatorname{Re}(z,w)}
\int _{\cc d} e^{-(1-r)|w_1-(z+w)/(2(1-r))|^2}
\, d\lambda (w_1)
\\[1ex]
\asymp e^{r_0|z+w|^2-\operatorname{Re}(z,w)} .\qedhere
\end{multline*}
\end{proof}
\par
\begin{rem}
The condition on $a_0^{\operatorname{aw}}$ in Theorem \ref{Thm:WickSymbolAntiWickOpFolland}
implies that $a_0^{\operatorname{aw}}$ belongs to
$\wideparen {\mathcal A} _{0,\frac 12}^\prime (\cc {2d})$
(see \cite{Teofanov2}).
In particular it follows that $\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)=\operatorname{Op} _{\mathfrak V}(a_0^{\operatorname{aw}})$
is continuous from $\mathcal A _{0,\frac 12}(\cc d)$ to $\mathcal A _{0,\frac 12}'(\cc d)$
(cf. \cite[Theorem 2.10]{Teofanov2} and
Remark \ref{Rem:BargmannPilipovicSpaces}).
\end{rem}
\par
The following result concerns exponentially moderate weight functions.
\par
\begin{thm}\label{Thm:WickSymbolAntiWickOpSOmega}
Let $a_0\in L_{0,A}(\cc d)$, $a_0^{\operatorname{aw}} \in \wideparen A(\cc {2d})$
is given by \eqref{Eq:AntiWickAnalPseudoRel}$'$
and $\omega \in \mathscr P _E(\cc d)$. If
\begin{equation*}
|a_0(w)|\lesssim \omega (2w), \quad w \in \cc d,
\end{equation*}
then
\begin{equation*}
|a_0^{\operatorname{aw}}(z,w)|\lesssim e^{\frac 14|z-w|^2} \omega (z+w), \quad z,w \in \cc d.
\end{equation*}
\end{thm}
\par
\begin{proof}
Let $r\ge 0$ be chosen such that $\omega (z+w)\lesssim \omega (z)e^{r|w|}$,
$z,w\in \cc d$. From \eqref{Eq:AntiWickAnalPseudoRel}$'$ we get
\begin{multline*}
|a_0^{\operatorname{aw}}(z,w)|
\lesssim
\int _{\cc d} \omega (2w_1)
e^{-\operatorname{Re}(z-w_1,w-w_1)}\, d\lambda (w_1)
\\[1ex]
=
e^{-\operatorname{Re}(z,w)}
\int _{\cc d}
\omega (2w_1)
e^{\operatorname{Re}(z+w,w_1)-|w_1|^2}\, d\lambda (w_1)
\\[1ex]
=
e^{-\operatorname{Re}(z,w)+\frac 14|z+w|^2}
\int _{\cc d}
\omega (2w_1)
e^{-|w_1-(z+w)/2|^2}\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 14|z-w|^2}
\int _{\cc d}
\omega (2w_1+z+w)
e^{-|w_1|^2}\, d\lambda (w_1)
\\[1ex]
\lesssim
e^{\frac 14|z-w|^2}
\omega (z+w)\int _{\cc d} e^{2r|w_1|-|w_1|^2}\, d\lambda (w_1)
\asymp
e^{\frac 14|z-w|^2}
\omega (z+w). \qedhere
\end{multline*}
\end{proof}
\par
The anti-Wick operators in Propositions \ref{prop:contAW} and
\ref{prop:contAW2} can also be described as Wick operators
with symbols that have smaller growth bounds than
$\wideparen \mathcal A _s(\cc {2d})$ and its dual.
The following result extends Theorem \ref{Thm:WickSymbolAntiWickOpSOmega}
for weights of the form $e^{c |z|^{\frac1s}}$ with $c \in \mathbf R$
from $s \ge 1$ to $s \ge \frac 12$.
\par
\begin{thm}\label{Thm:WickSymbolAntiWickOpGS}
Let $s\ge \frac 12$ ($s> \frac 12$), $a_0\in L_{0,A}(\cc {d})$ and
let $a_0^{\operatorname{aw}}$ be given by \eqref{Eq:AntiWickAnalPseudoRel}$'$.
Then the following is true:
\begin{enumerate}
\item if \eqref{Eq:NonAWGSEst1} holds for
some (every) $r_0 > 0$ then
\begin{equation}\label{Eq:AWGSEst1}
|a_0^{\operatorname{aw}} (z,w)|
\lesssim
e^{\frac 14|z-w|^2-r |z+w|^{\frac 1s}}
\end{equation}
for some (every) $r>0$;
\vspace{0.2cm}
\item if \eqref{Eq:NonAWGSEst2} holds for every (some) $r_0>0$ then
\begin{equation}\label{Eq:AWGSEst2}
|a_0^{\operatorname{aw}} (z,w)|
\lesssim
e^{\frac 14|z-w|^2+r |z+w|^{\frac 1s}}
\end{equation}
for every (some) $r>0$.
\end{enumerate}
\end{thm}
\par
\begin{rem}
Thanks to the parameter $\frac 14$ in the factor $e^{\frac 14|z-w|^2}$
rather than $\frac 12$, the estimates \eqref{Eq:AWGSEst2} are much stronger
than the estimates \eqref{Eq:BargmannSTFT} with $\sigma = s$.
Corollary \ref{cor:contBargmannGS} can thus be seen as a
consequence of Theorems \ref{Thm:GevreySymbolsBargmTransfer}
and \ref{Thm:WickSymbolAntiWickOpGS}, and \cite[Definition~2.4,
and Theorems~4.10 and 4.11]{CaTo}.
\end{rem}
\par
\begin{rem}\label{Rem:WickSymbolAntiWickOpGS}
The estimates for $a_0^{\operatorname{aw}}$ in Theorem
\ref{Thm:WickSymbolAntiWickOpGS} may seem
weak since the dominating factor $e^{\frac 14|z-w|^2}$
is present in \eqref{Eq:AWGSEst1} and \eqref{Eq:AWGSEst2}
but absent in the original estimates \eqref{Eq:NonAWGSEst1}
and \eqref{Eq:NonAWGSEst2} for $a_0$.
\par
On the other hand, Wick symbols for operators with
continuity involving the spaces $\mathcal A _s(\cc d)$ and
$\mathcal A _s'(\cc d)$, as well as $\mathcal A _{0,s}(\cc d)$ and
$\mathcal A _{0,s}'(\cc d)$, usually satisfies conditions of the
form
$$
|a(z,w)| \lesssim e^{\frac 12|z-w|^2 \pm r_1|z+w|^{\frac 12}\pm |z-w|^{\frac 1s}}
$$
in view of \cite[Theorems~2.9 and 2.10]{Teofanov2},
and Theorem \ref{Thm:GevreySymbolsBargmTransfer}. Here
the dominating factor is $e^{\frac 12|z-w|^2}$, which is larger
than the factor $e^{\frac 14|z-w|^2}$ in Theorem
\ref{Thm:WickSymbolAntiWickOpGS}.
\par
This factor has a large impact on functions on $\rr d$ that are transformed back
by the inverse of the Bargmann transform.
For instance, if $\varepsilon >0$, then the Bargmann image of any
non-trivial Gelfand-Shilov space and its distribution space
contain
\begin{equation*}
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{(\frac 12-\varepsilon )|z|^2}}
\end{equation*}
and are contained in
\begin{equation*}
\sets {F\in A(\cc d)}{|F(z)|\lesssim e^{(\frac 12+\varepsilon )|z|^2}}.
\end{equation*}
The same holds true for the Bargmann images of
$\mathscr S (\rr d)$ and $\mathscr S '(\rr d)$.
\end{rem}
\par
Theorem \ref{Thm:WickSymbolAntiWickOpGS} is
a straight-forward consequence of the following two
propositions, which give more details on the relationships between
$r$ and $r_0$ in
\eqref{Eq:NonAWGSEst1}, \eqref{Eq:NonAWGSEst2}, \eqref{Eq:AWGSEst1}
and \eqref{Eq:AWGSEst2}.
\par
\begin{prop}\label{Prop:WickSymbolAntiWickOpGS1}
Let $s\ge \frac 12$ and let $r_0,r\in (0,\infty )$ be
such that
\begin{alignat}{5}
r_0&\in (0,\infty ) &
\quad &\text{and} & \quad
r&<\frac {r_0}{4(1+r_0)}, &
\quad
\quad &\text{when} & \quad
s &={\textstyle{\frac 12}},
\label{Eq:CondAntiWickOpGS1}
\intertext{and}
r_0&\in (0,\infty ) &
\quad &\text{and} & \quad
r &\le 2^{-\frac 1s}r_0, &
\quad
\quad &\text{when} & \quad
s&\in (\textstyle{\frac 12},\infty ),
\label{Eq:CondAntiWickOpGS2}
\end{alignat}
with strict inequality in \eqref{Eq:CondAntiWickOpGS2}
when $s<1$.
If $a_0\in L^\infty _{loc}(\cc {d})$ satisfies
\eqref{Eq:NonAWGSEst1} and $a_0^{\operatorname{aw}} \in \wideparen A(\cc {2d})$
is given by \eqref{Eq:AntiWickAnalPseudoRel}$'$, then
\eqref{Eq:AWGSEst1} holds.
\end{prop}
\par
\begin{prop}\label{Prop:WickSymbolAntiWickOpGS2}
Let $s\ge \frac 12$ and $r_0,r\in (0,\infty )$ be
such that
\begin{alignat}{5}
r_0&\in (0,1) &
\quad &\text{and} & \quad
r&>\frac {r_0}{4(1-r_0)}, &
\quad
\quad &\text{when} & \quad
s &={\textstyle{\frac 12}},
\tag*{(\ref{Eq:CondAntiWickOpGS1})$'$}
\intertext{and}
r_0&\in (0,\infty ) &
\quad &\text{and} & \quad
r &\ge 2^{-\frac 1s}r_0, &
\quad
\quad &\text{when} & \quad
s&\in (\textstyle{\frac 12},\infty ),
\tag*{(\ref{Eq:CondAntiWickOpGS2})$'$}
\end{alignat}
with strict inequality in \eqref{Eq:CondAntiWickOpGS2}$'$
when $s<1$.
If $a_0\in L^\infty _{loc}(\cc {d})$ satisfies
\eqref{Eq:NonAWGSEst2} and $a_0^{\operatorname{aw}} \in \wideparen A(\cc {2d})$
is given by \eqref{Eq:AntiWickAnalPseudoRel}$'$, then
\eqref{Eq:AWGSEst2} holds.
\end{prop}
\par
For the proofs of Propositions \ref{Prop:WickSymbolAntiWickOpGS1}
and \ref{Prop:WickSymbolAntiWickOpGS2}
we use the inequalities
\begin{alignat}{3}
|z|^\theta -|w|^\theta
&\le
|z+w|^\theta
\le
|z|^\theta +|w|^\theta ,&
\qquad
\theta &\in (0,1], &\ z,w &\in \cc d
\label{Eq:TriangPowIneq1}
\\[1ex]
|z+w|^\theta
&\le
(1+\varepsilon )|z|^\theta +(1+\varepsilon ^{-1})|w|^\theta ,&
\qquad
\theta &\in [1,2], &\ z,w &\in \cc d,
\label{Eq:TriangPowIneq2}
\intertext{and}
|z+w|^\theta
&\ge
(1-\varepsilon )|z|^\theta +(1-\varepsilon ^{-1})|w|^\theta ,&
\qquad
\theta &\in [1,2], &\ z,w &\in \cc d,
\label{Eq:TriangPowIneq3}
\end{alignat}
for every $\varepsilon >0$.
\par
\begin{proof}[Proof of Proposition \ref{Prop:WickSymbolAntiWickOpGS1}]
Suppose that $a_0$ satisfies
\eqref{Eq:NonAWGSEst1} for some $r_0 >0$.
First we consider the case $s>\frac 12$.
If $s < 1$ let $\varepsilon _1 > 0$ and $\varepsilon _2 = \varepsilon_1^{-1}$,
and if $s \ge 1$ let $\varepsilon _1 = 0$ and $\varepsilon _2 = 2$,
and let $c=2^{-\frac 1s}$.
Then \eqref{Eq:AntiWickAnalPseudoRel}$'$,
\eqref{Eq:TriangPowIneq1}
and \eqref{Eq:TriangPowIneq3} give
\begin{multline}\label{Eq:WickAWickComp1}
|a_0^{\operatorname{aw}}(z,w)|
\lesssim
\int _{\cc d} e^{-r_0 |w_1|^{\frac 1s}}
e^{-\operatorname{Re}(z-w_1,w-w_1)}\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 14|z+w|^2-\operatorname{Re}(z,w)}
\int _{\cc d} e^{-r_0 |w_1|^{\frac 1s} -|w_1-(z+w)/2|^2}
\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 14|z-w|^2}
\int _{\cc d} e^{-r_0 |w_1+(z+w)/2|^{\frac 1s} -|w_1|^2}
\, d\lambda (w_1)
\\[1ex]
\le
e^{\frac 14|z-w|^2}e^{-cr_0(1-\varepsilon _1) |z+w|^{\frac 1s}}
\int _{\cc d} e^{-r_0(1-\varepsilon _2) |w_1|^{\frac 1s} -|w_1|^2}
\, d\lambda (w_1)
\\[1ex]
\asymp
e^{\frac 14|z-w|^2}e^{-cr_0(1-\varepsilon _1) |z+w|^{\frac 1s}}.
\end{multline}
If $s\ge 1$, then $\varepsilon _1=0$ and $\varepsilon _2=2$,
and the result follows from \eqref{Eq:WickAWickComp1}.
If instead $s<1$, then
the result follows by choosing $\varepsilon _1>0$ small enough,
and we have proved the result in the case $s>\frac 12$.
\par
Next suppose that $s=\frac 12$.
For $\varepsilon _1 > 0$ and $\varepsilon _2 = \varepsilon_1^{-1}$
\eqref{Eq:WickAWickComp1} gives
\begin{equation*}
|a_0^{\operatorname{aw}}(z,w)|
\lesssim
e^{\frac 14|z-w|^2}
e^{-\frac 14r_0(1-\varepsilon _1) |z+w|^2}
\int _{\cc d} e^{-(r_0(1-\varepsilon _2)+1) |w_1|^2}
\, d\lambda (w_1).
\end{equation*}
For any $\varepsilon _2<\frac {1+r_0}{r_0}$ it follows that the integral
converges, and
$$
1-\varepsilon _1=1-\varepsilon _2^{-1}<(1+r_0)^{-1}.
$$
By the assumptions there is $\delta > 0$ such that
\begin{equation*}
r = \frac{r_0(1-\delta)}{4 (1+r_0)}.
\end{equation*}
Since
$$
1-\varepsilon _1 \nearrow (1+r_0)^{-1}
\quad \text{as}\quad
\varepsilon _2 \nearrow \frac {1+r_0}{r_0}
$$
we may pick $0 < \varepsilon _2<\frac {1+r_0}{r_0}$ such that
\begin{equation*}
\frac{1-\delta}{1+r_0} \le 1-\varepsilon _1
\end{equation*}
and the result follows in the case $s=\frac 12$.
\end{proof}
\par
\begin{proof}[Proof of Proposition \ref{Prop:WickSymbolAntiWickOpGS2}]
First we consider the case when
$s>\frac 12$.
Suppose that $a_0$ satisfies \eqref{Eq:NonAWGSEst2}
for some $r_0 >0$, let $\varepsilon _1,\varepsilon _2\ge 0$ be
such that $\varepsilon _1=\varepsilon _2=0$ when $s\ge 1$ and
$\varepsilon_1\varepsilon _2=1$ when $s<1$, and let $c=2^{-\frac 1s}$. Then
\eqref{Eq:AntiWickAnalPseudoRel}$'$, \eqref{Eq:TriangPowIneq1}
and \eqref{Eq:TriangPowIneq2} give
\begin{multline}\label{Eq:WickAWickComp3}
|a_0^{\operatorname{aw}}(z,w)|
\lesssim
\int _{\cc d} e^{r_0 |w_1|^{\frac 1s}}
e^{-\operatorname{Re}(z-w_1,w-w_1)}\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 14|z+w|^2-\operatorname{Re}(z,w)}
\int _{\cc d} e^{r_0 |w_1|^{\frac 1s} -|w_1-(z+w)/2|^2}
\, d\lambda (w_1)
\\[1ex]
=
e^{\frac 14|z-w|^2}
\int _{\cc d} e^{r_0 |w_1+(z+w)/2|^{\frac 1s} -|w_1|^2}
\, d\lambda (w_1)
\\[1ex]
\le
e^{\frac 14|z-w|^2}e^{cr_0(1+\varepsilon _1) |z+w|^{\frac 1s}}
\int _{\cc d} e^{r_0(1+\varepsilon _2) |w_1|^{\frac 1s} -|w_1|^2}
\, d\lambda (w_1)
\\[1ex]
\asymp
e^{\frac 14|z-w|^2}e^{cr_0(1+\varepsilon _1) |z+w|^{\frac 1s}}.
\end{multline}
If $s\ge 1$, then $\varepsilon _1=\varepsilon _2=0$, and the result follows
from \eqref{Eq:WickAWickComp3}. If instead $s<1$, then
the result follows by choosing $\varepsilon _1>0$ small enough,
and the result follows in the case $s>\frac 12$.
\par
Next suppose that $s=\frac 12$. Then
\eqref{Eq:WickAWickComp3} gives
\begin{equation*}
|a_0^{\operatorname{aw}}(z,w)|
\lesssim
e^{\frac 14|z-w|^2}
e^{\frac 14r_0(1+\varepsilon _1) |z+w|^2}
\int _{\cc d} e^{r_0(1+\varepsilon _2) |w_1|^2 -|w_1|^2}
\, d\lambda (w_1).
\end{equation*}
For any $\varepsilon _2<\frac {1-r_0}{r_0}$ the integral converges, and
$$
1+\varepsilon _1=1+\varepsilon _2^{-1}>(1-r_0)^{-1}.
$$
Since
$$
1+\varepsilon _1 \searrow (1-r_0)^{-1}
\quad \text{as}\quad
\varepsilon _2 \nearrow \frac {1-r_0}{r_0},
$$
the result follows in the case $s=\frac 12$
by letting $r=\frac {r_0(1+\varepsilon _1)}4$.
\end{proof}
\par
\section{A lower bound for Wick operators}\label{sec4}
\par
In this section we apply the asymptotic expansions in the previous section
for Shubin-Wick operators to deduce a sharp G{\aa}rding inequality.
\par
First we have the following result. We put
$\wideparen \mathcal A _{\operatorname{Sh} ,\rho}(\cc {2d})
=
\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ when $\omega =1$.
\par
\begin{prop}\label{Prop:ContApSpaces}
Let $\omega \in \mathscr P (\cc d)$, $p\in [1,\infty]$,
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,0}(\cc {2d})$
and $a_0\in L^\infty (\cc d)$. Then $\operatorname{Op} _{\mathfrak V}(a)$ and
$\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)$ are both continuous on
$A^p_{(\omega )}(\cc d)$.
\end{prop}
\par
The claimed continuity of $\operatorname{Op} _{\mathfrak V}(a)$
is a straight-forward consequence of
\cite[Theorem 3.3]{Teofanov2}, in combination with
Proposition \ref{prop:symbchar1} and the relationship
$ K(z,w)=a(z,w) e^{(z,w)} $ between the kernel and symbol of a
Wick operator (cf. \eqref{Eq:AnalPseudoIntro}). In order to be
self-contained we include an alternative and shorter proof.
\par
\begin{proof}
Let $F\in A^p_{(\omega )}(\cc d)$, $G(z)
=
e^{-\frac 12|z|^2}|F(z)\omega (\sqrt 2\overline z)|$,
\begin{align*}
H_1(z) & = e^{-\frac 12|z|^2}|\operatorname{Op} _{\mathfrak V}(a)F(z)\omega (\sqrt 2\overline z)|
\quad \text{and}\quad \\
H_2(z) & = e^{-\frac 12|z|^2}|\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F(z)\omega (\sqrt 2\overline z)|.
\end{align*}
We have
$$
\omega (\sqrt 2\overline z) \lesssim \omega (\sqrt 2\overline w)\eabs {z-w}^{N_0}
$$
for some $N_0\ge 0$. By Theorem \ref{Thm:ShubinAnalChar} and \eqref{eq:characShubinBargmann0} we get
\begin{multline*}
H_1(z) \lesssim e^{-\frac 12|z|^2}\int _{\cc d} e^{\frac 12|z-w|^2}
\eabs {z-w}^{-N}|F(w)\omega (\sqrt 2\overline z)|
e^{{\operatorname{Re}} (z,w)-|w|^2}\, d\lambda (w)
\\[1ex]
= (\eabs \, \cdot \, ^{N_0-N}*G)(z),
\end{multline*}
for every $N\ge 0$. By choosing $N>2d+N_0$ and using Young's inequality we get
$\nm {H_1}{L^p}\lesssim \nm {G}{L^p}$ which means
$\nm {\operatorname{Op} _{\mathfrak V}(a)F}{A^p_{(\omega )}}\lesssim \nm F{A^p_{(\omega )}}$,
and the asserted continuity for $\operatorname{Op} _{\mathfrak V}(a)$ follows.
\par
In the same way we get
\begin{multline*}
H_2(z) \lesssim \nm {a_0} {L^\infty} e^{-\frac 12|z|^2}
\int _{\cc d} |F(w)\omega (\sqrt 2\overline w)|\eabs {z-w}^{N_0}
e^{{\operatorname{Re}} (z,w)-|w|^2}\, d\lambda (w)
\\[1ex]
\asymp ((\eabs \, \cdot \, ^{N_0}e^{-\frac 12|\, \cdot \, |^2})*G)(z),
\end{multline*}
and another application of Young's inequality shows that
$\nm {H_2}{L^p_{(\omega )}}\lesssim \nm {G}{L^p_{(\omega )}}$ that is
$\nm {\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(a_0)F}{A^p_{(\omega )}}\lesssim \nm F{A^p_{(\omega )}}$.
\end{proof}
\par
We have finally a version of the sharp G{\aa}rding inequality.
\par
\begin{thm}\label{Thm:ShGarding}
Let $\rho >0$, $\omega (z) = \eabs z ^{2\rho}$ and let
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ be such that
$a(w,w)\ge -C_0$ for all $w \in \cc d$, for some constant $C_0\ge 0$. Then
\begin{alignat}{2}
{\operatorname{Re}} \big ( (\operatorname{Op} _{\mathfrak V}(a)F,F)_{A^2} \big )
&\ge
-C\nm F{A^2}^2, &
\qquad
F &\in \mathcal A _{\mathscr S}(\cc d)
\label{Eq:ShGarding1}
\intertext{and}
\big | \operatorname{Im} \big ( (\operatorname{Op} _{\mathfrak V}(a)F,F)_{A^2} \big ) \big |
&\le
C\nm F{A^2}^2, &
\qquad
F &\in \mathcal A _{\mathscr S}(\cc d)
\label{Eq:ShGarding2}
\end{alignat}
for some constant $C\ge 0$.
\end{thm}
\par
\begin{proof}
Let $b_0(w)=a(w,w)$. Then
$\operatorname{Op} _{\mathfrak V}(a) = \operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_0)+\operatorname{Op} _{\mathfrak V}(a_1)$
for some $a_1\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}(\cc {2d})
\subseteq \wideparen \mathcal A _{\operatorname{Sh} ,0}(\cc {2d})$, in view of Proposition
\ref{Prop:ShubinWickExpEst}.
Since $\Pi_A F = F$ for $F \in A^2(\cc d)$ (cf. \eqref{eq:projection}),
the assumption $b_0\ge - C_0$ implies
$(\operatorname{Op} _{\mathfrak V}^{\operatorname{aw}}(b_0)F,F)_{A^2}\ge - C_0
\| F \|_{A^2}^2 $ for every $F\in \mathcal A _{\mathscr S}(\cc d)$.
The operator $\operatorname{Op} _{\mathfrak V}(a_1)$ is continuous on $A^2(\cc d)$
in view of Proposition \ref{Prop:ContApSpaces}. A combination of these facts
gives the result.
\end{proof}
\par
\section{Ellipticity and hypoellipticity for Shubin and
Wick operators}\label{sec5}
\par
In this section we show that the Bargmann assignment
$\mathsf S_{\mathfrak V}$ maps the sets of hypoelliptic symbols and
weakly elliptic symbols
in the Shubin class $\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$
bijectively into the sets of hypoelliptic symbols and
weakly elliptic Wick symbols
in $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$, respectively.
Then we explain some consequences for polynomial symbols.
\par
\subsection{Transition of weakly elliptic symbols}\label{subsec4.1}
For symbols in
$\wideparen \mathcal A _{\operatorname{Sh} ,\rho} ^{(\omega )}(\cc {2d})$
we define ellipticity and weak ellipticity as follows.
\par
\begin{defn}\label{Def:WickShubinEllipticity}
Let $\rho >0$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\cc d)$ and
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho} ^{(\omega)}(\cc {2d})$.
Then $a$ is called \emph{weakly elliptic}
of order $\rho _0\ge 0$, or \emph{$\rho _0$-weakly elliptic}, if for some $R > 0$
$$
|a(z,z)|\gtrsim \eabs z^{-\rho _0}\omega (\sqrt 2\overline z), \quad |z| \ge R.
$$
If $a$ is weakly elliptic of order $0$ then $a$ is called \emph{elliptic}.
\end{defn}
\par
\begin{thm}\label{Thm:ElliptEquiv}
Let $\omega \in \mathscr P (\rr {2d})\simeq \mathscr P (\cc d)$,
$\rho >0$ and $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$.
Then the following is true:
\begin{enumerate}
\item if $z=x+i\xi$, $x,\xi \in \rr d$, then
\begin{equation}\label{Eq:RelAssignDiag}
| \mathsf S_{\mathfrak V} \mathfrak a (z ,z) -\mathfrak a (\sqrt 2\, x,-\sqrt 2\, \xi )|
\lesssim
\omega (\sqrt 2\, \overline z)
\eabs z^{-2\rho}\text ;
\end{equation}
\vspace{0.2cm}
\item if $\rho _0\in [0,2\rho )$, then $\mathsf S_{\mathfrak V}$ is
bijective from the set of weakly elliptic symbols in
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ of order $\rho _0$ to the set of
weakly elliptic symbols in
$\wideparen A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ of order $\rho _0$.
\end{enumerate}
\end{thm}
\par
As a consequence of (2) in the previous theorem we get the following.
\par
\begin{cor}\label{Cor:ElliptEquiv}
Let $\mathfrak a$ be as in Theorem \ref{Thm:ElliptEquiv}. Then
the following is true:
\begin{enumerate}
\item if $\rho _0\in [0,2\rho )$, then $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ is weakly elliptic of order
$\rho _0$, if and only if
$\mathsf S_{\mathfrak V}\mathfrak a \in \wideparen A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ is weakly elliptic of order $\rho _0$;
\vspace{0.2cm}
\item $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ is elliptic if and only if
$\mathsf S_{\mathfrak V}\mathfrak a \in \wideparen A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$ is elliptic.
\end{enumerate}
\end{cor}
\par
For the proof of Theorem \ref{Thm:ElliptEquiv} we need the following proposition,
related to Propositions \ref{Prop:WickToAntiWick} and
\ref{Prop:AsymptoticExpansion1}.
\par
\begin{prop}\label{Prop:WickShubinTaylorExp}
Let $N\ge 0$ be an integer, $\rho \ge 0$, $\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})\simeq
\mathscr P _{\operatorname{Sh} ,\rho}(\cc d)$, $\omega _k(x,\xi )=\omega (x,\xi )\eabs {(x,\xi )}^{-2\rho k}$
and $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$. Then for some
$\mathfrak c _N\in \operatorname{Sh} _\rho ^{(\omega _{N+1})}(\rr {2d})$ and
constants $\{ c_{\alpha} \}_{|\alpha| \le 2N}$ with $c_{0}=1$, it holds
\begin{equation}\label{Eq:WickShubinTaylorExp}
\mathsf S_{\mathfrak V}\mathfrak a (2^{-\frac 12}z ,2^{-\frac 12}z)
=
\sum _{k=0}^N\mathfrak a _k(x,-\xi ) + \mathfrak c _N(x,-\xi ),
\qquad
\mathfrak a _k = \sum _{|\alpha |=2k} c_{\alpha} \partial ^\alpha \mathfrak a .
\end{equation}
\end{prop}
\par
\begin{proof}
Let $\psi$ be as in Proposition \ref{Prop:SBaTaRel}.
If we put $z=w$, then \eqref{eq:BargmannsymbolSTFT} and
Taylor's formula give
\begin{multline}\label{Eq:TaylorNonWick}
(2\pi )^{d} \mathsf S_{\mathfrak V}\mathfrak a (2^{-\frac 12}z ,2^{-\frac 12}z)
=
(2\pi )^{\frac {3d}2} \mathcal{T} _\psi \mathfrak a (x,-\xi ,0,0)
\\[1ex]
=
2^d\iint _{\rr {2d}} \mathfrak a (t+x,\tau -\xi )e^{-(|t|^2+|\tau |^2)}\, dtd\tau
=
\sum _{k=0}^{2N+1} \mathfrak b _k(x,-\xi ) +\mathfrak c (x,-\xi )
\end{multline}
where
\begin{align*}
\mathfrak b _k(x,\xi ) &= \frac {2^d}{k!}\iint _{\rr {2d}}
\eabs {\mathfrak a ^{(k)}(x,\xi);(t,\tau ),\dots ,(t,\tau )}
e^{-(|t|^2+|\tau |^2)}\, dtd\tau
\intertext{and}
\mathfrak c (x,\xi )&=
\frac 1{(2N+1)!}\int _0^1 (1-\theta )^{2N+1} \mathfrak c _\theta (x,\xi )\, d\theta ,
\intertext{with}
\mathfrak c _\theta (x,\xi ) &= 2^d\iint _{\rr {2d}}
\eabs {\mathfrak a ^{(2N+2)}(x+\theta t,\xi +\theta \tau );(t,\tau ),\dots ,(t,\tau )}
e^{-(|t|^2+|\tau |^2)}\, dtd\tau .
\end{align*}
\par
If $k$ is odd, then
$$
(t,\tau )\mapsto \eabs {\mathfrak a ^{(k)}(x,\xi);(t,\tau ),\dots ,(t,\tau )}
e^{-(|t|^2+|\tau |^2)}
$$
is odd which implies that the integral is zero. Hence $\mathfrak b _k(x,\xi )=0$ when
$k$ is odd. For $k=0$ we observe that the integral for $\mathfrak b _0$ becomes
$$
2^d\iint _{\rr {2d}} e^{-(|t|^2+|\tau |^2)}\, dtd\tau
=
(2\pi )^d,
$$
and it follows from these relations that
$$
(2\pi )^{-d}\sum _{k=0}^{2N+1}\mathfrak b _k = \sum _{k=0}^N\mathfrak a _k,
$$
with $\mathfrak a _k$ as in \eqref{Eq:WickShubinTaylorExp} and $c_{0}=1$. Hence
the result follows if we prove that the last term in \eqref{Eq:TaylorNonWick} satisfies $\mathfrak c _N \in \operatorname{Sh} _\rho ^{(\omega _{N+1})}(\rr {2d})$.
\par
For $\theta \in [0,1]$ and $\alpha \in \nn {2d}$ we have
\begin{multline*}
|\partial ^\alpha \mathfrak c _\theta (x,\xi )|
\lesssim
\iint _{\rr {2d}} |\partial^\alpha \mathfrak a ^{(2N+2)}(x+\theta t,\xi +\theta \tau )|
\eabs {(t,\tau )}^{2N+2} e^{-(|t|^2+|\tau |^2)}\, dtd\tau
\\[1ex]
\lesssim
\iint _{\rr {2d}} \omega (x+\theta t,\xi +\theta \tau )
\eabs {(x+\theta t,\xi +\theta \tau )}^{-(2N+2+|\alpha |)\rho}
\eabs {(t,\tau )}^{2N+2}
e^{-(|t|^2+|\tau |^2)}\, dtd\tau
\\[1ex]
\lesssim
\omega (x,\xi)
\eabs {(x,\xi )}^{-(2N+2+|\alpha |)\rho}
\iint _{\rr {2d}}
\eabs {(t,\tau )}^{N_0}
e^{-(|t|^2+|\tau |^2)}\, dtd\tau
\\[1ex]
\asymp
\omega (x,\xi)
\eabs {(x,\xi )}^{-(2N+2+|\alpha |)\rho}
\end{multline*}
for some $N_0>0$. In the last inequality we have used the fact that $\omega$
is polynomially moderate.
\par
This implies
$$
|\partial ^\alpha \mathfrak c (x,\xi )|\lesssim \int _0^1 |\partial ^\alpha \mathfrak c _\theta (x,\xi )|
\, d\theta
\lesssim
\omega (x,\xi)
\eabs {(x,\xi )}^{-(2N+2+|\alpha |)\rho},
$$
which shows that $\mathfrak c, \mathfrak c _N \in \operatorname{Sh} _\rho ^{(\omega _{N+1})}(\rr {2d})$.
\end{proof}
\par
\begin{proof}[Proof of Theorem \ref{Thm:ElliptEquiv}]
Let $\psi$ be as in Proposition \ref{Prop:SBaTaRel} and $N=0$
in Proposition \ref{Prop:WickShubinTaylorExp}. Then
\begin{equation}\tag*{(\ref{Eq:RelAssignDiag})$'$}
| \mathsf S_{\mathfrak V}\mathfrak a (2^{-\frac 12}z ,2^{-\frac 12}z) -\mathfrak a (x,-\xi )|
\lesssim
\omega (x,-\xi)
\eabs {(x,-\xi )}^{-2\rho},
\end{equation}
and (1) follows.
\par
Suppose $\rho _0\in [0,2\rho)$. Then it follows from the latter inequality that
$$
| \mathsf S_{\mathfrak V}\mathfrak a (z ,z)|
\gtrsim \eabs z^{-\rho _0}\omega (\sqrt 2\, \overline z),
\qquad |z|\ge R
$$
for some $R>0$, if and only if
$$
|\mathfrak a (x,\xi )|\gtrsim \eabs {(x,\xi )}^{-\rho _0}\omega (x,\xi ), \qquad |z|\ge R
$$
for some $R>0$, and the asserted equivalence in (2) follows.
\end{proof}
\par
\subsection{Shubin hypoellipticity in a Wick setting}
\par
\par
\begin{defn}\label{Def:ShubinWickHypoelliptic}
Let $\rho >0$, $\rho _0\ge 0$,
$\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\cc d)$ and
$a\in \wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$.
Then $a$ is called \emph{hypoelliptic} (in the \emph{Shubin-Wick sense}
in $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$) of order $\rho _0$,
if there is an $R>0$
such that for every $\alpha ,\beta \in \nn d$, it holds
\begin{alignat}{2}
|\partial _z^\alpha \overline \partial _w^\beta a(z,z)|
&\lesssim
|a(z,z)|\eabs z^{-\rho |\alpha +\beta |}, &
\qquad |z| &\ge R \text .
\label{Eq:ShubinWickHypoelliptic1}
\intertext{and}
|a(z,z)| &\gtrsim \omega _0(\sqrt 2 \overline z)
\eabs z^{-\rho _0}, &
\qquad |z| &\ge R.
\label{Eq:ShubinWickHypoelliptic2}
\end{alignat}
\end{defn}
\par
According to Definition \ref{Def:Hypoelliptic},
if $\omega$, $\rho$ and $\rho _0$ are as in
the definition, then $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$
is hypoelliptic
of order $\rho _0$
means that
there is an $R>0$ such that for every $\alpha \in \nn {2d}$, it holds
\begin{alignat}{2}
|\partial ^\alpha \mathfrak a (x,\xi )|
&\lesssim
|\mathfrak a (x,\xi )|\eabs {(x,\xi )}^{-\rho |\alpha |}, &
\qquad |(x,\xi )| &\ge R \text .
\label{Eq:ShubinWickHypoellipticReal1}
\intertext{and}
|\mathfrak a (x,\xi )| &\gtrsim \omega (x,\xi )
\eabs {(x,\xi )}^{-\rho _0}, &
\qquad |(x,\xi )| &\ge R.
\label{Eq:ShubinWickHypoellipticReal2}
\end{alignat}
\par
Similar to Theorem \ref{Thm:ElliptEquiv} we have the following.
\par
\begin{thm}\label{Thm:HypoelliptShubinEquiv}
Let $\rho >0$, $\rho _0\ge 0$,
$\omega \in \mathscr P _{\operatorname{Sh} ,\rho}(\rr {2d})\simeq
\mathscr P _{\operatorname{Sh} ,\rho}(\cc d)$,
$\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ and $a=\mathsf S_{\mathfrak V}\mathfrak a$.
Then $\mathfrak a$ is hypoelliptic of order $\rho _0$ in
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$, if and only if
$a$ is \emph{hypoelliptic} of order $\rho _0$
in $\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$.
\end{thm}
\par
\begin{proof}
Suppose that $\mathfrak a \in \operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ is hypoelliptic of order $\rho _0$, and choose $N\ge 0$ such that
$2N\rho >\rho _0$. Suppose that
$R>0$ is chosen such that \eqref{Eq:ShubinWickHypoellipticReal1}
and \eqref{Eq:ShubinWickHypoellipticReal2} are fulfilled.
Then Proposition \ref{Prop:WickShubinTaylorExp} gives for $z=x+i\xi$ with
$|z|\ge R$ where $R > 0$ is sufficiently large
\begin{multline*}
|a(2^{-\frac 12}z,2^{-\frac 12}z)|
\gtrsim
|\mathfrak a (x,-\xi )|-
\sum _{k=1}^N\sum _{|\alpha |=2k}
(|\partial ^\alpha \mathfrak a (x,-\xi )| +
|\mathfrak c (x,-\xi )| )
\\[1ex]
\gtrsim
|\mathfrak a (x,-\xi )| -|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-2\rho}-
\omega (x,-\xi )\eabs {(x,-\xi )}^{-\rho (2N+2)}
\\[1ex]
\gtrsim
|\mathfrak a (x,-\xi )| -|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-2\rho}
\\[1ex]
\gtrsim
|\mathfrak a (x,-\xi )| \gtrsim \omega (x,-\xi )\eabs {(x,-\xi )}^{-\rho _0},
\end{multline*}
and \eqref{Eq:ShubinWickHypoelliptic2} follows. In particular
it follows from the previous estimates that
\begin{equation}\label{Eq:IneqHypoShubinHypoWick}
|a(2^{-\frac 12}z,2^{-\frac 12}z)|
\gtrsim
|\mathfrak a (x,-\xi )|,
\qquad |z|\ge R.
\end{equation}
\par
For fixed $\alpha ,\beta \in \nn d$, let
$\Omega _k$ be the set of all $(\gamma ,\delta )\in \nn {2d}\times \nn {2d}$
such that $|\gamma |=2k$ and $|\delta |=|\alpha +\beta |$. By Proposition \ref{Prop:WickShubinTaylorExp} and
\eqref{Eq:IneqHypoShubinHypoWick} we have for
some $R$ large enough and $|z|\ge R$,
\begin{multline*}
|(\partial _z^\alpha \overline \partial _w^\beta a)(2^{-\frac 12}z,2^{-\frac 12}z)|
\lesssim
\sum _{k=0}^N\sum _{(\gamma ,\delta )\in \Omega _k}
(|\partial ^{\gamma +\delta}\mathfrak a (x,-\xi )| +
|\partial ^\delta \mathfrak c (x,-\xi )| )
\\[1ex]
\lesssim
\sum _{k=0}^N\sum _{(\gamma ,\delta )\in \Omega _k}
\big ( |\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-\rho (2k+|\alpha +\beta |)} +
\omega (x,-\xi )\eabs {(x,-\xi )}^{-\rho (2N+|\alpha +\beta |)} \big )
\\[1ex]
\asymp
|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-\rho |\alpha +\beta |} +
\omega (x,-\xi )\eabs {(x,-\xi )}^{-\rho (2N+|\alpha +\beta |)}
\\[1ex]
\lesssim
|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-\rho |\alpha +\beta |} +
|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{\rho _0-\rho (2N+|\alpha +\beta |)}
\\[1ex]
\asymp
|\mathfrak a (x,-\xi )|\eabs {(x,-\xi )}^{-\rho |\alpha +\beta |}
\lesssim
|a(2^{-\frac 12}z,2^{-\frac 12}z)|\eabs {(x,-\xi )}^{-\rho |\alpha +\beta |},
\end{multline*}
which implies that \eqref{Eq:ShubinWickHypoelliptic1} holds.
\par
This shows that
$a$ is hypoelliptic of order $\rho _0$ in
$\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$
when $\mathfrak a$ is hypoelliptic of order $\rho _0$ in
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$.
\par
Suppose instead that $a$ is hypoelliptic of order $\rho _0$ in
$\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$. By using
Proposition \ref{Prop:AsymptoticExpansion1},
\eqref{Eq:cNdef} and \eqref{Eq:Hdef}
instead of Proposition
\ref{Prop:WickShubinTaylorExp}, similar
computations as in the first part of the proof shows that
\eqref{Eq:ShubinWickHypoellipticReal1} and \eqref{Eq:ShubinWickHypoellipticReal2}
hold for some $R>0$. This shows that
$\mathfrak a$ is hypoelliptic of order $\rho _0$ in
$\operatorname{Sh} _\rho ^{(\omega )}(\rr {2d})$ when
$a$ is hypoelliptic of order $\rho _0$ in
$\wideparen \mathcal A _{\operatorname{Sh} ,\rho}^{(\omega )}(\cc {2d})$, and the result follows.
\end{proof}
\par
\subsection{Ellipticity in the case of polynomial symbols}
\par
Next we discuss ellipticity for polynomial symbols, i.{\,}e.
\begin{alignat}{2}
\mathfrak a (x,\xi ) &= \sum _{|\alpha +\beta | \le N}c(\alpha ,\beta )
x^\alpha \xi ^\beta , &
\quad
x,\xi &\in \rr d,
\label{Eq:RealPolSymbol}
\intertext{and}
a(z,w) &= \sum _{|\alpha +\beta | \le N}c(\alpha ,\beta )z^\alpha {\overline w}^\beta ,
&
\quad
z,w &\in \cc d.
\label{Eq:ComplexPolSymbol}
\intertext{The corresponding principal symbols are}
\mathfrak a _p (x,\xi ) &= \sum _{|\alpha +\beta | = N}c(\alpha ,\beta )x^\alpha \xi ^\beta , &
\quad
x,\xi &\in \rr d,
\label{Eq:RealPrincipalPolSymbol}
\intertext{and}
a_p (z,w ) &= \sum _{|\alpha +\beta | = N}c(\alpha ,\beta )
z^\alpha {\overline w} ^\beta , &
\quad
z,w &\in \cc d,
\label{Eq:ComplexPrincipalPolSymbol}
\end{alignat}
respectively.
\par
First we relate polynomials on $\rr {2d}$ to Shubin classes.
\par
\begin{prop}\label{Prop:DiffOpShubin}
Let $\mathfrak a$ and $\mathfrak a _p$ be as in \eqref{Eq:RealPolSymbol}
and \eqref{Eq:RealPrincipalPolSymbol}
for some $c(\alpha ,\beta )\in \mathbf C$, $\alpha ,\beta \in \nn d$
and $N\ge 0$, and let $\omega _{N}(x,\xi )=\eabs {(x,\xi )}^{N}$,
$x,\xi \in \rr d$. Then the following is true:
\begin{enumerate}
\item $\mathfrak a \in \operatorname{Sh} _1^{(\omega _{N})}(\rr {2d})$;
\vspace{0.2cm}
\item $\mathfrak a$ is elliptic with respect to $\omega _{N}$, if and only if
$\mathfrak a _p(x,\xi )\neq 0$ when $(x,\xi )\neq 0$.
\end{enumerate}
\end{prop}
\par
The result can be considered folklore. In order to be self-contained we present
the arguments.
\par
\begin{proof}
First we prove (1). Let $t=\max (|x_1|,\dots ,|x_d|,|\xi _1|,\dots ,|\xi _d|)$ when
$x=(x_1,\dots ,x_d)\in \rr d$ and $\xi =(\xi _1,\dots ,\xi _d)\in \rr d$. Then
$$
|\mathfrak a (x,\xi )| \le \sum _{|\alpha +\beta | \le N_0}|c(\alpha ,\beta )| t^{|\alpha +\beta |}
\lesssim 1+t^{N}
\le \eabs {(x,\xi )}^{N},
$$
which gives the desired bound for $|\mathfrak a (x,\xi)|$. Since the degree of a polynomial
is lowered by at least one for every differentiation we get
$$
|\partial^\alpha \mathfrak a (x,\xi )| \lesssim \eabs {(x,\xi )}^{N-|\alpha |}
$$
for every $\alpha \in \nn {2d}$, which gives (1).
\par
In order to prove (2) we let $\mathfrak a _p$ be as in \eqref{Eq:RealPrincipalPolSymbol}.
First suppose that $\mathfrak a _p(x,\xi )\neq 0$ when $(x,\xi )\neq (0,0)$, and let $g$ be the continuous
function on $\rr {2d}\setminus 0$ given by
$$
g(x,\xi ) =\frac {|\mathfrak a _p(x,\xi )|}{|(x,\xi )|^{N}},\qquad (x,\xi )\neq (0,0).
$$
Since $g$ is continuous and positive, and the sphere
$$
\mathbf S^{2d-1}=\sets {(x,\xi )\in \rr {2d}}{|x|^2+|\xi |^2 = 1}
$$
is compact, it follows that there are constants $c_1,c_2>0$ such that
$$
c_1\le g(x,\xi )\le c_2,\qquad (x,\xi )\in \mathbf S^{2d-1}.
$$
By homogeneity it now follows
$$
c_1|(x,\xi )|^{N} \le |\mathfrak a _p(x,\xi )| \le c_2|(x,\xi )|^{N},\qquad x,\xi \in \rr d.
$$
Hence, if
$$
\mathfrak b (x,\xi )= \mathfrak a (x,\xi )-\mathfrak a _p(x,\xi )
= \sum _{|\alpha +\beta | \le N-1}c(\alpha ,\beta )x^\alpha \xi ^\beta ,
$$
then the first part of the proof implies that for some constants $C>0$ and $R>0$
we have
\begin{equation*}
|\mathfrak a (x,\xi )| \ge |\mathfrak a _p(x,\xi )| -|\mathfrak b (x,\xi )| \ge c_1|(x,\xi )|^{N_0} - C\eabs {(x,\xi )}^{N-1}
\gtrsim \eabs {(x,\xi )}^{N}
\end{equation*}
when $|(x,\xi )|\ge R$. Hence $\mathfrak a$ is elliptic with respect to $\omega _{N_0}$.
\par
Suppose instead $\mathfrak a _p(x_0,\xi _0)=0$ for some $(x_0,\xi _0)\neq (0,0)$. For any
$(x,\xi )=(tx_0,t\xi _0)$ we have
\begin{multline*}
|\mathfrak a (x,\xi )| \le |\mathfrak a _p(x,\xi )| +|\mathfrak b (x,\xi )|
=
|t^N\mathfrak a _p(x_0,\xi _0)| +|\mathfrak b (x,\xi )|
\\[1ex]
=
|\mathfrak b (x,\xi )| \lesssim \eabs {(x,\xi )}^{N-1},
\end{multline*}
giving that $|\mathfrak a (x,\xi )|\gtrsim \eabs {(x,\xi )}^{N}$, $|(x,\xi )|\ge R$,
cannot hold for any $R>0$.
\end{proof}
\par
By Theorems \ref{Thm:ElliptEquiv}, \ref{Thm:HypoelliptShubinEquiv}
and Proposition \ref{Prop:DiffOpShubin} we get the following.
The details are left for the reader.
\par
\begin{prop}\label{Prop:DiffOpBargmannShubin}
Let $a$ and $a_p$ be as in \eqref{Eq:ComplexPolSymbol}
and \eqref{Eq:ComplexPrincipalPolSymbol}
for some $c(\alpha ,\beta )\in \mathbf C$, $\alpha ,\beta \in \nn d$
and $N\ge 0$, and let $\omega _{N}(x,\xi )=\eabs {(x,\xi )}^{N}$,
$x,\xi \in \rr d$.
Then the following is true:
\begin{enumerate}
\item $a\in \mathcal A _{\operatorname{Sh} ,1}^{(\omega _{N})}(\cc {2d})$;
\vspace{0.2cm}
\item $a$ is elliptic in $\mathcal A _{\operatorname{Sh} ,1}^{(\omega _{N})}(\cc {2d})$ if and only if $a_p(z,z)\neq 0$
when $z\neq 0$.
\end{enumerate}
\end{prop}
\par
\begin{rem}\label{Rem:Elliptic}
Let $\mathfrak a$, $\mathfrak a _p$, $a$ and $a_p$ be as in
\eqref{Eq:RealPolSymbol}--\eqref{Eq:ComplexPrincipalPolSymbol}.
Then it follows from Propositions \ref{Prop:DiffOpShubin} and
Proposition \ref{Prop:DiffOpBargmannShubin} that $\mathfrak a$ is elliptic, if
and only if $\mathfrak a _p$ is elliptic, and that $a$ is elliptic, if and only if $a_p$
is elliptic.
\end{rem}
\par
We have now the following.
\par
\begin{thm}\label{Thm:Ellipticity}
Let $\mathfrak a \in \operatorname{Sh} _1^{(\omega _{N})}(\rr {2d})$ and $\mathfrak a _p$ be as in \eqref{Eq:RealPolSymbol}
and \eqref{Eq:RealPrincipalPolSymbol}
for some $c(\alpha ,\beta )\in \mathbf C$, $\alpha ,\beta \in \nn d$
and $N\ge 0$.
Then the following is true:
\begin{enumerate}
\item the principal symbol $a_p(z,w)$ of $\mathsf S_{\mathfrak V}\mathfrak a$
is given by
\begin{equation}
\label{Eq:ComplexPrincipalSymb}
a_p(z,w) = 2^{-\frac N2}
\sum _{|\alpha +\beta |= N}
c(\alpha ,\beta )i^{|\beta |}
(z+\overline w)^\alpha (z-\overline w)^\beta
\text ;
\end{equation}
\vspace{0.2cm}
\item $\mathfrak a$ is elliptic in $\operatorname{Sh} _1^{(\omega _{N})}(\rr {2d})$ if and only if
$a_p$ is elliptic in $\mathcal A _{\operatorname{Sh} ,1}^{(\omega _{N})}(\cc {2d})$;
\vspace{0.2cm}
\item $\mathfrak a _p(x,\xi )> 0$ for every $(x,\xi )\neq (0,0)$,
if and only if
$a_p(z,z)> 0$ for every $z\neq 0$.
\end{enumerate}
\end{thm}
\par
\begin{proof}
Let $z=x+i\xi$, $x,\xi \in \rr d$, i.{\,} e. $x=\frac 12(z+\overline z)$ and
$\xi =\frac 1{2i}(z-\overline z)$. By Theorem \ref{Thm:ElliptEquiv} we
get
\begin{equation}\label{Eq:PrincipalSymbolShubinWickIdent}
a_p(2^{-\frac 12}z,2^{-\frac 12}z) = \mathfrak a _p(x,-\xi ).
\end{equation}
This implies
\begin{multline*}
a_p(z,z) = 2^\frac N2\sum _{|\alpha +\beta | = N}c(\alpha ,\beta )x^\alpha (-\xi )^\beta
\\[1ex]
= 2^\frac N2\sum _{|\alpha +\beta | = N}c(\alpha ,\beta )2^{-|\alpha |}
(z+\overline z)^\alpha (2i)^{-|\beta |}(-(z-\overline z) )^\beta ,
\end{multline*}
which gives
\begin{equation}
\tag*{(\ref{Eq:ComplexPrincipalSymb})$'$}
a_p(z,z) = 2^{-\frac N2}
\sum _{|\alpha +\beta |= N}
c(\alpha ,\beta )i^{|\beta |}
(z+\overline z)^\alpha (z-\overline z)^\beta .
\end{equation}
The formula \eqref{Eq:ComplexPrincipalSymb} now follows from
\eqref{Eq:ComplexPrincipalSymb}$'$ and analytic continuation, using the
fact that $a_p(z,w)$ is analytic in $z$ and conjugate analytic in $w$.
\par
The assertion (2) follows by a combination of Corollary \ref{Cor:ElliptEquiv},
Propositions \ref{Prop:DiffOpShubin} and \ref{Prop:DiffOpBargmannShubin},
and the assertion (3) is a direct consequence of
\eqref{Eq:PrincipalSymbolShubinWickIdent}.
\end{proof}
\par
\section{A necessary condition for polynomially bounded
Wick symbols}\label{sec6}
\par
In \cite[Section~2.7]{Fo} Folland shows that polynomial symbols for
pseudo-differential operators correspond
to polynomial Wick and anti-Wick symbols.
Thus partial differential operators with polynomial coefficients
corresponds to polynomial Wick symbols.
Here we show that a Wick symbol that is polynomially bounded
must be a polynomial. This gives a characterization of Wick
symbols corresponding to polynomial symbols for pseudo-differential
operators.
\par
Cauchy's integral formula implies that an entire function
which is polynomially bounded must
be a polynomial:
\par
\begin{prop}\label{Prop:PolynomialSymbol}
Let $F\in A(\cc d)$ have Maclaurin series
$$
F(z) = \sum _{\alpha \in \nn d} c(\alpha )e_\alpha (z),\quad z\in \cc d.
$$
Suppose that for some $j\in \{ 1,\dots ,d\}$, $C>0$, $N \ge 0$, and an open neighbourhood
$I\subseteq \mathbf C$ of the origin we have
$$
|F(z)|\le C \eabs {z_j}^N,\quad z_j\in \mathbf C,
$$
provided $z_k\in I$, $k\in \{ 1,\dots ,d\} \setminus \{ j\}$. Then $c(\alpha ) = 0$
when $\alpha _j > N$.
\end{prop}
\par
\begin{proof}
By interchanging the variables, we may assume that $j=d$. Let
$R\ge 1$ and $\varepsilon >0$ be chosen such that
$$
D_\varepsilon \equiv \sets {z_0\in \mathbf C}{|z_0|\le \varepsilon} \subseteq I.
$$
Take $\alpha \in \nn d$ such that $\alpha _d>N$, let
$\beta =(\alpha _1+1,\dots ,\alpha _d+1)\in \nn d$ and
$\gamma _\varepsilon \subseteq \mathbf C$ be the
boundary circle of $D_\varepsilon$. Then Cauchy's integral formula gives
\begin{multline*}
\frac {|c(\alpha )|}{\alpha !^{\frac 12}}
=
\left |
\frac { \partial^\alpha F (0) }{\alpha !}
\right |
= (2\pi )^{-d}
\left |
\idotsint _{\gamma_\varepsilon ^{d-1}}
\left (
\int _{|z_d|=R}
\frac { F(z)}{z^\beta}\, dz_d
\right )
\, dz_1\cdots dz_{d-1}
\right |
\\[1ex]
\le
(2\pi )^{-d}
\idotsint _{\gamma_\varepsilon ^{d-1}}
\left (
\int _{|z_d|=R}
\frac {| F(z)|}{|z^\beta |}\, |dz_d |
\right )
\, |dz_1|\cdots |dz_{d-1}|
\\[1ex]
\lesssim
R^{-\alpha _d} \eabs R^N\varepsilon ^{-(\alpha _1+\dots +\alpha _{d-1})}
\to 0
\end{multline*}
as $R\to \infty$.
\end{proof}
\par
\begin{cor}
Let $a\in \wideparen A(\cc {2d})$ and suppose
\begin{equation}\label{Eq:GlobPolEst}
|a(z,w)|\lesssim \eabs{(z,w)} ^N
\end{equation}
for some $N\ge 0$. Then $a$ is a polynomial in $z\in \cc d$ and $\overline w\in \cc d$
of degree at most $N$.
\end{cor}
\par
\begin{proof}
By Proposition \ref{Prop:PolynomialSymbol} it follows that $a$ is a
polynomial of degree at most $2dN$. We need to prove that the degree
is at most $N$. In order to do this we may assume that $a$ has degree
at least one.
\par
For some integer $M\ge 1$ we have
$$
a(z,w) = a_M(z,w) +a_{M-1}(z,w),
$$
where
\begin{align*}
a_M(z,w)
&=
\sum _{|\alpha +\beta |=M}c(\alpha ,\beta )z^\alpha \overline w^\beta
\intertext{is non-trivial and}
a_{M-1}(z,w)
&=
\sum _{|\alpha +\beta |\le M-1}c(\alpha ,\beta )z^\alpha \overline w^\beta .
\end{align*}
Since $a_M$ is non-trivial, there are $z_0,w_0\in \cc d$ such that
$|z_0|^2+|w_0|^2=1$ and $|a_M(z_0,w_0)|=c_0\neq 0$. By
homogeneity we get
$$
|a_M(tz_0,tw_0)| = c_0|t|^M,\qquad t \in \mathbf R.
$$
In the same way we get
$$
|a_{M-1}(tz_0,tw_0)| \le C(1+|t|)^{M-1},\qquad t\in \mathbf R
$$
for some constant $C$ which is independent of $t$.
\par
Suppose contrary to the assumption that $M>N$. For $t\in \mathbf R$ with
$|t|\ge 1$ we have
\begin{multline*}
\left |
\frac {a(tz_0,tw_0)}{\eabs {(tz_0,tw_0)}^N}
\right |
\gtrsim
|t|^{-N}\left (|a_M(tz_0,tw_0)| - |a_{M-1}(tz_0,tw_0)| \right )
\\[1ex]
\ge
|t|^{-N}\left (c_0|t|^M - C(1+|t|)^{M-1} \right ) \to \infty
\quad \text{as}\quad
|t|\to \infty .
\end{multline*}
This contradicts \eqref{Eq:GlobPolEst}, and the hence our assumption
that $M>N$ must be false.
\end{proof}
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 3,392 |
\section{Introduction}
\label{sec:intro}
The text in an image is an important source of information in our daily life, which can be extracted and interpreted for different purposes. However, scene text images often encounter various quality degradation during the imaging process, resulting in low resolution and blurry structures. This problem significantly impairs the performance of the downstream high-level recognition tasks, including scene text detection~\cite{zhou2017east,ma2018arbitrary}, optical character recognition (OCR) and scene text recognition~\cite{shi2016end,shi2018aster,luo2019moran}. Thus, it is necessary to increase the resolution as well as enhance the visual quality of scene text images.
\begin{figure}[t]
\centering
\includegraphics[width=\linewidth]{TATT_tissue.pdf}
%
\caption{SR recovery of different models on rotated and curve-shaped text images. `R', `P' and `S' stand for recognition, PSNR and SSIM results. Characters in red are missing or wrong.}
\label{fig:SR_recovery}
\vspace{-0.5cm}
\end{figure}
In the past few years, many scene text image super-resolution (STISR) methods have been developed to improve the image quality of text images, with notable progress obtained by deep-learning-based methods~\cite{dong2015boosting ,zhang2017cnn,wang2019textsr,wang2020scene,chen2021scene}. By using a dataset of degraded and original text image pairs, a deep convolutional neural network (CNN) can be trained to super-resolve the text image. With strong expressive capability, CNNs can learn various priors from data and demonstrate much strong performance. A recent advance is the TPGSR model~\cite{ma2021text}, where the semantics of the text are firstly recognized as prior information and then used to guide the text reconstruction process. With the high-level prior information, TPGSR can restore the semantically correct text image with compelling visual quality.
Despite the great progress, many CNN-based methods still have difficulty in dealing with spatially-deformed text images, including those with rotation and curved shape. Two examples are shown in Fig.~\ref{fig:SR_recovery}, where the text in the left image has rotation and the right one has a curved shape. One can see that the current representative methods, including TSRN~\cite{wang2020scene} and TPGSR~\cite{ma2021text}, produce blurry texts with semantically incorrect characters. This is because the architectures in current works mainly employ locality-based operations like convolution, which are not effective in capturing the large position variation caused by the deformations. In particular, the TPGSR model adopts a simplistic approach to utilize the text prior: it merely merges text prior with image feature by convolutions. This arrangement can only let the text prior interact with the image feature within a small local range, which limits the effect of text prior on the text reconstruction process. Based on the this observation, some globality-based operations (\eg, attention) should be employed to capture long range correlation in the text image for better STISR performance.
In this paper, we propose a novel architecture, termed Text ATTention network (TATT), for spatial deformation robust text super resolution. Similar to TPGSR, we first employ a text recognition module to recognize the character semantics as text prior (TP). Then we design a transformer-based module termed TP Interpreter to enforce global interaction between the text prior and the image feature. Specifically, the TP Interpreter operates cross attention between the text prior and the image feature to capture long-range correlation between them. The image feature can then receive rich semantic guidance in spite of the spatial deformation, leading to improved text reconstruction. To further refine the text appearance under spatial deformation, we design a text structure consistency loss, which measures the structural distance between the regular and deformed texts. As can be seen in Fig.~\ref{fig:SR_recovery}, the characters recovered by our method show better visual quality with correct semantics.
Overall, our contributions can be summarized as follows:
\begin{itemize}[topsep=2pt]
\setlength{\topsep}{0pt}
\setlength{\itemsep}{0pt}
\setlength{\parsep}{0pt}
\setlength{\parskip}{0pt}
\item We propose a novel method to align the text prior with the spatially-deformed text image for better SR recovery by using CNN and Transformer.
\item We propose a text structure consistency loss to enhance the robustness of text structure recovery from spatially-deformed low-resolution text images.
\item Our proposed model not only achieves state-of-the-art performance on the TextZoom dataset in various evaluation metrics, but also exhibits outstanding generalization performance in recovering orientation-distorted and curve-shaped low-resolution text images.
\end{itemize}
\section{Related Works}
\subsection{Single Image Super Resolution}
Single image super resolution (SISR) aims at recovering a high-resolution (HR) image from a given low-resolution (LR) input image. The traditional methods design hand-crafted image priors for this task, including statistical prior~\cite{GunturkAM04}, self-similarity prior~\cite{MairalBPSZ09} and sparsity prior~\cite{YangWHM10}. The recent deep-learning-based methods train convolutional neural networks (CNNs) to address the SISR task and achieve leading performance. The seminal work SRCNN~\cite{dong2015image} adopts a three-layer CNN to learn the SR recovery. Later on, more complex CNN architectures have been developed to upgrade the SISR performance, \eg, residual block~\cite{lim2017enhanced}, Laplacian pyramid~\cite{lai2017deep}, dense connections~\cite{zhang2018residual} and channel attention mechanism~\cite{zhang2018image}. Recently, generative adversarial networks have been employed in SISR to achieve photo-realistic results~\cite{ledig2017photo,wang2018recovering,chen2018fsrnet}.
\subsection{Scene Text Image Super Resolution (STISR)}
Different from the general purposed SISR that works on natural scene images, STISR focuses on scene text images. It aims to not only increase the resolution of text image, but also reconstruct semantically correct texts that can benefit the down-stream recognition task. The early methods directly adopt the CNN architectures from SISR for the task of STISR. In~\cite{dong2015boosting}, Dong \etal~extended SRCNN~\cite{dong2015image} to text images, and obtained the best performance in ICDAR 2015 competition~\cite{peyrard2015icdar2015}. PlugNet~\cite{mouplugnet} adopts a pluggable super-resolution unit to deal with LR images in feature domain. TextSR~\cite{wang2019textsr} utilizes the text perceptual loss to generate the desired HR images to benefit the text recognition.
To address the problem of STISR on real-world scenes, Wang~\etal \cite{wang2020scene}~built a real-world STISR image dataset, namely the TextZoom, where the LR and HR text image pairs were cropped from real-world SISR datasets~\cite{zhang2019zoom,cai2019toward}. They also proposed TSRN~\cite{wang2020scene} to use the sequential residual block to exploit the semantic information in internal features. SCGAN~\cite{xu2017learning} employs a multi-class GAN loss to supervise the STISR model for more perceptual-friendly face and text images. Further, Quan \etal~\cite{quan2020collaborative} proposed a cascading model for recovering blurry text images in high-frequency domain and image domain collaboratively. Chen \etal~\cite{chen2021scene} and Zhao~\etal~\cite{zhao2021scene} enhanced the network block structures to improve the STISR performance by self-attending the image features and attending channels.
\begin{figure*}[t]
\centering
\includegraphics[width=0.9\linewidth]{TATT_pipeline_v2.pdf}
\caption{Architecture of our proposed TATT network for STISR. TPGB, TPG and SRB are short for text prior guided blocks, TP Generator and Sequential-Recurrent Blocks, respectively, while $\oplus$ means the element-wise addition.}
\label{fig:TP-Framework}
\vspace{-0.3cm}
\end{figure*}
\subsection{Scene Text Recognition}
Scene text recognition aims to extract text content from the input images.
Some early approaches tend to recognize each character first and then interpret the whole word\cite{jaderberg2014deep,he2015reading}, while some others regard the text image as a whole and performing word-level classification~\cite{jaderberg2016reading}. Considering text recognition as an image-to-sequence problem, CRNN~\cite{shi2016end} extracts image features and uses the recurrent neural networks to model the semantic information. It is trained with CTC~\cite{graves2006connectionist} loss to align the predicted sequence and the target sequence.
Recently, attention-based methods achieve a great progress due to the robustness in extracting text against shape variance of text images~\cite{cheng2017focusing,cheng2018aon}. Despite the great performance achieved by the recent methods, it is still difficult to recognize the text in low-resolution images. Therefore, we aim to solve the problem of high-resolution text image restoration for better recognition in this paper.
\section{Methodology}
\begin{figure*}[t]
\centering
\includegraphics[width=0.85\linewidth]{TATT-TP_Interpreter.pdf}
\caption{Architecture of TP Interpreter. `MSA', `LN', `MCA' and `FFN' namely mean the Multi-head Self-Attention, Layer-Norm, Multi-head Cross-Attention and Feed-Forward Network layers, while `FPE' and `RPE' refer to the Fixed Positional Encoding and Recurrent Positional Encoding. While $\oplus$ means the element-wise addition.}
\label{fig:TP-Interpreter}
\vspace{-0.3cm}
\end{figure*}
\subsection{Overall Architecture}
The pipeline of our TATT network is shown in Fig.~\ref{fig:TP-Framework}. It takes low-resolution (LR) text images $Y \in \mathbb{R}^{h \times w \times 3}$ as input, which is processed in the following two paths. In the first path, the input images are sent into a TP Generator (TPG) to predict the recognition probability sequence as text prior $f_p$ (similar to ~\cite{ma2021text}). This process can be denoted as $f_P = \textit{TPG}(Y)$. $f_P \in \mathbb{R}^{l \times |\mathcal{A}|}$ is an $l$-length sequence composed of categorical probability vectors with size $|\mathcal{A}|$. $\mathcal{A}$ denotes the character set which is composed of `0' to `9', `a' to `z' and a blank class~($37$ in total). The second path extracts image features $f_I \in \mathbb{R}^{h \times w \times c}$ from the input LR image $Y$ by a $9 \times 9$ convolution layer (we denote this process as $f_I = \textit{Conv}(Y)$).
Then, the text prior $f_P$ and the image feature $f_I$ are passed to the TP Interpreter $\textit{TPI}(\cdot)$ to calculate a TP map $f_{TM} \in \mathbb{R}^{h \times w \times c}$, which is denoted as $f_{TM} = \textit{TPI}(f_P, f_I)$. The TP Interpreter computes the correlation between the text prior $f_P$ and image feature $f_I$, and assigns the semantic guidance in $f_P$ to the corresponding location in the spatial domain to guide the final SR text recovery. The resultant TP map $f_{TM}$ is a modulating map which can be use to enhance the semantics-specific part of the image feature .
Finally, the TP map $f_{TM}$ and the image feature $f_I$ are passed into a reconstruction module. This module includes $5$ Text-Prior Guided Blocks (TPGBs) that progressively fuse $f_{TM}$ and $f_I$, and a final Pixel-Shuffle layer to increase the resolution. Each of the 5 TPGBs firstly merges $f_{TM}$ and $f_I$ by element-wise addition, followed by a Sequential-Recurrent Block~(SRB)~\cite{wang2020scene} to reconstruct the high-resolution image feature. The output of this module is the super-resolved (SR) text image.
\subsection{TP Interpreter}
In the proposed architecture, the crucial part lies in the design of TP Interpreter (TPI). The TP Interpreter aims to interpret the text prior $f_P$ to the image feature $f_I$ so that the influence of the semantics guidance can be exerted to the correlated spatial position in the image feature domain. One intuitive idea is to enlarge $f_P$ to the shape of $f_I$ and then merge them by convolution. Since the convolution operation has a small effective range, the semantics of $f_P$ cannot be assigned to the distant spatial location in $f_I$, especially in the case of spatially-deformed text. Thus, we turn to design a Transformer-based TP Interpreter with attention mechanism to enforce global correlation between text prior $f_P$ and the image feature $f_I$.
As shown in Fig.~\ref{fig:TP-Interpreter}, the proposed TP Interpreter consists of an Encoder part and a Decoder part. The Encoder encodes the text prior $f_P$ by performing correlation between the semantics of each character in $f_P$ and outputs the context-enhanced feature $f_E$. The decoder performs cross attention between $f_E$ and $f_I$ to interpret the semantic information to the image feature.
\textbf{Encoder.}
The Encoder takes the text prior $f_P$ as input and project it to $C$ channels to match the image feature channel. Since the input text prior is processed in parallel in the encoder, the model is not aware of the semantic order in TP. We thus encode the position by adding the Fixed Positional Encoding (FPE) to $f_P$ in an element-wise manner before feeding it into the encoder. Note that we adopt Sinusoidal Positional Encoding~\cite{vaswani2017attention} as our FPE in this paper.
After encoding the position, the text prior is passed into the encoder module. The encoder has a Multi-head Self Attention (MSA) layer and a FeedForward Network (FFN) layer~\cite{vaswani2017attention}. Skip connection is deployed between the current layer and the previous layer to enable residual learning. The MSA layer performs global correlation between the semantic elements in text prior $f_P$, resulting in a contextually enhanced TP feature $f_E \in \mathbb{R}^{l \times c}$ for later computation. Due to the space limit, the description of MSA and FFN is omitted. One can refer to \cite{vaswani2017attention} for details.
\textbf{Decoder.} The decoder module accepts the output from the encoder module $f_E$ and image feature $f_I$ to perform global cross attention. Similar to the setting in encoder, we firstly add a position encoding to $f_I$ to incorporate position information. We design a recurrent positional encoding (RPE) to better encode the bias contained in sequential dependency of image feature in horizontal direction, and better help the model look up the text semantic features in the subsequent cross attention~\cite{shiv2019novel,liutkus2021relative}.
In RPE, we maintain the learnable parameter with the same shape as image feature and encode the sequential dependency in horizontal direction to help the model better learn the neighboring context.
See \textbf{supplementary file} for more details.
The position-encoded image feature, denoted by $f_I^{'}$, and the encoder output $f_E$ are then delivered to the decoder module for correlation computation.
We process the two inputs with a Multi-head Cross Attention ($\textit{MCA}$) layer, which performs cross attention operation between $f_E$ and $f_I^{'}$. Firstly, the features of $f_E$ and $f_I^{'}$ are divided into $n$ subgroups in the channel dimension. Then a cross attention operation $\textit{CA}_i$ is performed on the $i$-th group of $f_E$ and $f_I^{'}$:
\begin{equation}
\textit{CA}_i(f_{Ei}, f_{Ii}^{'}) = \textit{SM}(\frac{(f_{Ii}^{'}W_i^{\alpha}) (f_{Ei}W_i^{\beta})^{T}}{\sqrt{d_k}})(f_{Ei}W_i^{\gamma})
\label{equCA}
\end{equation}
\noindent where $f_{Ei}\in\mathbb{R}^{l\times\frac{c}{n}}$ and $f_{Ii}^{'}\in\mathbb{R}^{hw\times\frac{c}{n}}$ denote the $i$-th group of $f_E$ and $f_I^{'}$, respectively. $W_i^{\alpha} \in \mathbb{R}^{\frac{c}{n} \times d_k}$, $W_i^{\beta} \in \mathbb{R}^{\frac{c}{n} \times d_k}$ and $ W_i^{\gamma} \in \mathbb{R}^{\frac{c}{n} \times d_k}$ are the parameters of linear projections. $SM$ refers to the Softmax operation.
We process the results ${\textit{CA}}_i$~($i \in \{0,1,...,n-1\}$) with a channel-wise concatenation $\odot(\cdot)$ and a linear projection $W^o$, described as
\begin{equation}
\textit{MCA} = \odot(\textit{CA}_0, \textit{CA}_1, ..., \textit{CA}_{n-1})W^o
\label{equDecoder}
\end{equation}
\noindent The output of MCA is passed to a FFN for feature refinement, and then reshaped to obtain the TP map $f_{TM}$.
By using the MCA operation, the text prior $f_E$ can effectively interact with the image feature $f_I^{'}$ by correlating every element in semantic domain to the position in spatial domain. Thus, the semantically meaningful regions in the spatial domain are strengthened in the TP map $f_{TM}$, which can be used to modulate the image feature for semantic-specific text reconstruction.
\subsection{Text Structure Consistency Loss}
While the proposed TATT network can attain a good performance, the reconstructed text image still needs some refinement to improve the visual appearance. This is because it is a bit difficult for a CNN model to represent the deformed text features as it does for regular text features, and the reconstructed text image has weaker character structures with relatively low contrast. As a remedy, we simulate deformed text images and design a text structure consistency (TSC) loss to train the proposed TATT network.
We consider minimizing the distance of three images, \ie, the deformed version of the SR text image $\mathbf{D}\mathcal{F}(Y)$, the SR version of the deformed LR text image $\mathcal{F}(\mathbf{D}Y)$ and the deformed ground truth $\mathbf{D}(X)$, where $\mathbf{D}$ denotes the random deformation\footnote{We consider rotation, shearing and resizing in this paper.}. By increasing the similarity among the three items, we can encourage the CNN model to reduce the performance drop when encountering spatial deformations. The proposed TSC loss firstly measures the structural similarity between the above triplet. For this purpose, we extend the Structure-Similarity Index Measure (SSIM)~\cite{wang2004image} to a triplex SSIM (TSSIM), described as
\begin{equation}
\begin{array}{l}
\begin{split}
&\textit{TSSIM}(x, y, z) =\\ &\frac{(\mu_{x}\mu_{y} + \mu_{y}\mu_{z} + \mu_{x}\mu_{z} + C_1)(\sigma_{xy} + \sigma_{yz} + \sigma_{xz} + C_2)}{(\mu_{x}^2 + \mu_{y}^2 + \mu_{z}^2 + C_1)(\sigma_{x}^2 + \sigma_{y}^2 + \sigma_{z}^2 + C_2)}
\end{split}
\end{array}
\label{equ:TRI_SSIM}
\end{equation}
\noindent where $\mu_x$, $\mu_y$, $\mu_z$ and $\sigma_x$, $\sigma_y$, $\sigma_z$ represent the mean and standard deviation of the triplet $x$, $y$ and $z$, respectively. $\sigma_{xy}$, $\sigma_{yz}$ and $\sigma_{xz}$ denote the correlation coefficients between $(x, y)$, $(y, z)$ and $(x, z)$, respectively. $C_1$ and $C_2$ are small constants to avoid instability for dividing values close to zero. The derivation is in the \textbf{supplementary file}.
Lastly, TSC loss $L_{TSC}$ is designed to measure the mutual structure difference among $\mathbf{D}\mathcal{F}(Y)$, $\mathcal{F}(\mathbf{D}Y)$ and $\mathbf{D}X$:
\begin{equation}
\begin{array}{l}
\begin{split}
&{L}_{TSC}(X, Y;\mathbf{D}) = \\
&1 - \textit{TSSIM}(\mathbf{D}\mathcal{F}(Y), \mathcal{F}(\mathbf{D}Y), \mathbf{D}X)
\end{split}
\end{array}
\label{equ:TSCLoss}
\end{equation}
\subsection{Overall Loss Function}
In the training, the overall loss function includes a super resolution loss $L_{SR}$, a text prior loss $L_{TP}$ and the proposed TSC loss $L_{TSC}$. The SR loss $L_{SR}$ measures the difference between our SR output $\mathcal{F}(Y)$ and the ground-truth HR image $X$. We adopt $L_2$ norm for this computation. The TP loss measures the $L_1$ norm and KL Divergence between the text prior extracted from the LR image and those from the ground truth. Together with TSC loss $L_{TSC}$, the overall loss function is described as follows:
\begin{equation}
{L} = L_{SR} + \alpha L_{TP} + \beta L_{TSC}
\label{equ_AllLoss}
\end{equation}
where the $\alpha$ and $\beta$ are the balancing parameters.
\section{Experiments}
\subsection{Implementation Details}
TATT is trained and tested on a single RTX 3090 GPU.
We adopt Adam~\cite{kingma2014adam} optimizer to train the model with batch size $64$. The training lasts for $500$ epochs with learning rate $10^{-3}$. The input image of our model is of width $64$ and height $16$, while the output is the $2 \times$ SR result. We set the $\alpha$ and $\beta$ in (\ref{equ_AllLoss}) to $1$ and $0.1$, respectively~(see \textbf{supplementary file} for ablations). The deformation operation $\mathbf{D}$ in $L_{TSC}$ is implemented by applying random rotation in a range of $[-10, 10]$ degree, shearing and aspect ratio in a range of $[0.5, 2.0]$. The head numbers of MSA and MCA layers are both set to $4$ (following the best settings in ~\cite{carion2020end}). The number of image feature channels $c$, $d_k$ in MSA, MCA and FFN calculation are all set to $64$. The model size of TATT is $14.9$M in total. When training, the TPG is initialized with pretrained weights derived from ~\cite{crnnpytorch}, while other parts are randomly initialized. When testing, TATT will occupy 6.5GB of GPU memory with batch size $50$
\subsection{Datasets}
\textbf{TextZoom.} TextZoom~\cite{wang2020scene} has $21,740$ LR-HR text image pairs collected by changing the focal length of the camera in real-world scenarios, in which $17,367$ samples are used for training. The rest samples are divided into three subsets, based on the camera focal length, for testing , namely easy ($1,619$ samples), medium ($1,411$ samples) and hard ($1,343$ samples). Text label is provided in TextZoom.
\textbf{Scene Text Recognition Datasets.} Besides experiments conducted in TextZoom, we also adopt ICDAR2015~\cite{karatzas2015icdar}, CUTE80~\cite{risnumawan2014robust} and SVTP~\cite{phan2013recognizing} to evaluate the robustness of our model in recovering spatially-deformed LR text images. ICDAR2015 has $2,077$ scene text images for testing. Most text images suffer from both low quality and perspective-distortion, making the recognition extremely challenging. CUTE80 is also collected in the wild. The test set has $288$ samples in total. Samples in SVTP are mostly curve-shaped text. The total size of the test set is $649$. Besides evaluating our model on the original samples, we further degrade the image quality to test the model generalization against unpredicted bad conditions.
\subsection{Ablation Studies}
\label{sec:AblationStudy}
In this section, we investigate the impact of TP Interpreter, the TSC loss function and the effectiveness of positional encoding. All evaluations in this section are performed on the real-world STISR dataset TextZoom~\cite{wang2020scene}. The text recognition is peformed by CRNN~\cite{shi2016end}.
\textbf{Impact of TP Interpreter in SR recovery.}
Since our TP Interpreter aims at providing better alignment between TP and the image feature and use text semantics to guide SR recovery, we compare it with other guiding strategies, \eg, first upsampling the TP to match the image feature with deconvolution layers~\cite{ma2021text} or pixel shuffle to align text prior to image feature, and then fusing them to perform guidance with element-wise addition or SFT layers~\cite{wang2018recovering}\footnote{The SFT layer merges the semantics of image feature with channel-wise affine transformation.}. The results are shown in Tab.~\ref{table:Fusion_ablation}. One can see that the proposed TP interpreter obtains that highest PSNR/SSIM, which also indicates the best SR performance.
Referring to the SR text image recognition, one can see that using Pixel-Shuffle and deconvolution strategies provides inferior guidance ($46.2\%$ and $49.8\%$). There is no stable improvement by combining them with the SFT layers ($47.9\%$ and $48.6\%$). This is because none of the competing strategies performs global correlation between the text semantics and the image feature, resulting in inferior semantic guidance for SR recovery. In contrast, our TP Interpreter can obtain a good semantics context and accurate alignment to the text region. It thus strengthens the guidance in image feature and improves the text recognition result to $52.6\%$. This validates that using TP Interpreter is an effective way to utilize TP semantics for SR recovery. Some visual comparisons are shown in Fig.~\ref{fig:TPI_COM}. One can see that the setting with TP interpreter can lead to the highest quality SR text image with correct semantics.
\begin{table}
\small
\centering
\begin{tabular}{l|ccc}
\hline
Strategy & avg & PSNR & SSIM \\\hline
w/o TP & 41.4\% & 21.42 & 0.7690\\\hline
PS + A & 46.2\% & 20.58 & 0.7683\\
PS + S~\cite{wang2018recovering} & 47.9\% & 20.72 & 0.7560\\
D~\cite{ma2018arbitrary} + A & 50.6\% & 21.10 & 0.7819\\
D~\cite{ma2018arbitrary} + S~\cite{wang2018recovering} & 49.6\% & 20.87 & 0.7783 \\
TPI & \textbf{52.6\%}& \textbf{21.52}& \textbf{0.7930}\\\hline
\end{tabular}
\caption{Modules adopted in aligning and guiding the TP sequence to the image feature. D and PS refer to aligning operations Deconvolution and Pixel-Shuffle, respectively. A and S refer to guidance fusion operations by element-wise Addition and SFT Layers~\cite{wang2018recovering}, respectively. TPI is the TP Interpreter.}
\label{table:Fusion_ablation}
\vspace{-0.3cm}
\end{table}%
\begin{figure}[t]
\centering
\includegraphics[width=\linewidth]{TATT-TPI_com.pdf}
\caption{SR recovery by different guiding strategies.}
\label{fig:TPI_COM}
\vspace{-0.3cm}
\end{figure}
\begin{figure}[t]
\centering
\includegraphics[width=\linewidth]{TATT-heatmap.pdf}
\caption{Attention heatmap of the foreground characters.}
\label{fig:AttentionHeatmap}
\vspace{-0.3cm}
\end{figure}
To demonstrate how the TP Interpreter provides global context, we visualize the attention heatmap provided by our MCA (the outputs from the $SM$ layer in (\ref{equCA})) in Fig.~\ref{fig:AttentionHeatmap}. One can see that the region of the corresponding foreground character has the highest weight (highlighted). It thus proves that the ability of TP Interpreter in finding semantics in image features. Some other highlighted regions in the neighborhood also demonstrate that the TP Interpreter can be aware of the neighboring context, which can provide better guidance for final SR recovery.
\textbf{Impact of training with TSC loss.} To validate the effectiveness of the TSC loss in refining text structure, we compare the results of $4$ models trained with and without the TSC loss, including non-TP based TSRN~\cite{wang2020scene}, TBSRN~\cite{chen2021scene}, TP based TPGSR~\cite{ma2021text} and TATT. From the results in Tab.~\ref{table:LossImpact_1}, one can see that all models lead to a performance gain ($4.3\%$ for TSRN, $1.3\%$ for TBSRN, $0.8\%$ for TPGSR, and $1.0\%$ for TATT) in SR text recognition when adopting our TSC loss. Notably, though TBSRN~\cite{chen2021scene} is claimed to be robust for multi-oriented text, it can still be improved with our TSC loss, indicating that training with the TSC loss can improve the robustness of reconstructing the character structure against various spatial deformations.
\textbf{Effectiveness of the RPE.}
We evaluate the impact of recurrent positional encoding in learning text prior guidance. We deploy different combinations of fixed positional encoding (FPE), learnable positional encoding~\cite{carion2020end} and the proposed recurrent positional encoding (RPE) in the encoder and decoder modules, and compare the corresponding text recognition results on the SR text images. From Tab.~\ref{table:RPE}, we observe that using LPE or FPE in decoder shows limited performance because they are weak in learning the sequential information. By adopting RPE in the decoder, the SR recognition is increased by $1.8\%$, indicating that RPE is beneficial to text sequential semantics learning.
\begin{table}
\small
\centering
\setlength\tabcolsep{4pt}
\begin{tabular}{l|c|cccc}
\hline
Approach & $L_{\textit{TSC}}$ & easy & medium & hard & avg \\\hline
\multirow{2}{*}{TSRN~\cite{wang2020scene}} & $\times$ & 52.5\% & 38.2\% & 31.4\% & 41.4\%\\
& $\checkmark$ & \textbf{58.0\%} & \textbf{43.2\%} & \textbf{33.4\%} & \textbf{45.7\%}\\\hline
\multirow{2}{*}{TBSRN~\cite{chen2021scene}} & $\times$ & 59.6\% & 47.1\% & 35.3\% & 48.1\%\\
& $\checkmark$ & \textbf{60.8\%} & \textbf{49.6\%} & \textbf{36.1\%} & \textbf{49.4\%}\\\hline
\multirow{2}{*}{TPGSR~\cite{ma2021text}} & $\times$ & 61.0\% & \textbf{49.9\%} & 36.7\% & 49.8\%\\
& $\checkmark$ & \textbf{62.0\%} & 49.8\% & \textbf{37.4\%} & \textbf{50.6\%} \\\hline
\multirow{2}{*}{ours} & $\times$ & 62.1\% & 52.1\% & 37.8\% & 51.6\%\\
& $\checkmark$ & \textbf{62.6\%} & \textbf{53.4\%} & \textbf{39.8\%} & \textbf{52.6\%} \\\hline
\end{tabular}
\caption{TextZoom results of models with and without TSC loss.}
\label{table:LossImpact_1}
\end{table}%
\begin{table}
\small
\centering
\begin{tabular}{c|ccc}
\hline
Approach & Enc & Dec & avg \\\hline
\multirow{3}{*}{Ours} & FPE & FPE & 50.5\% \\
& FPE & LPE & 50.8\% \\
& FPE & RPE & \textbf{52.6\%} \\\hline
\end{tabular}
\caption{SR text image recognition results of different positional encoding ablations on TextZoom. The Enc and Dec refer to the encoder and decoder of the TP Interpreter.}
\label{table:RPE}
\vspace{-0.3cm}
\end{table}%
\begin{table*}
\small
\centering
\begin{tabular}{l|c|cccc|cccc}
\hline
~ & ~ & \multicolumn{4}{c|}{PSNR} & \multicolumn{4}{c}{SSIM}\\\hline
Method & Loss & easy & medium & hard & \textbf{avg} & easy & medium & hard & \textbf{avg} \\\hline
Bicubic & $\times$ & 22.35 & 18.98 & 19.39 & 20.35 & 0.7884 & 0.6254 & 0.6592 & 0.6961 \\\hline
SRCNN~\cite{dong2015image} & $L_2$ & 23.48 & 19.06 & 19.34 & 20.78 & 0.8379 & 0.6323 & 0.6791 & 0.7227 \\
SRResNet~\cite{ledig2017photo} & $L_2$+$L_{\textit{tv}}$+$L_p$ & 24.36 & 18,88 & 19.29 & 21.03 & 0.8681 & 0.6406 & 0.6911 & 0.7403 \\
HAN~\cite{niu2020single} & $L_2$ & 23.30 & 19.02 & 20.16 & 20.95 & 0.8691 & 0.6537 & 0.7387 & 0.7596\\
TSRN~\cite{wang2020scene} & $ L_2$+$L_{\textit{GP}}$ & \textbf{25.07} & 18.86 & 19.71 & 21.42 & 0.8897 & 0.6676 & 0.7302 & 0.7690 \\
TBSRN~\cite{ma2021text} & $L_{\textit{POS}}$+$L_{\textit{CON}}$ & 23.46 & \textbf{19.17} & 19.68 & 20.91 & 0.8729 & 0.6455 & 0.7452 & 0.7603 \\
PCAN~\cite{zhao2021scene} & $L_2$+$L_{\textit{EG}}$ & 24.57 & 19.14 & 20.26 & 21.49 & 0.8830 & 0.6781 & 0.7475 & 0.7752\\
TPGSR~\cite{ma2021text} & $L_2$+$L_{\textit{TP}}$ & 23.73 & 18.68 & 20.06 & 20.97 & 0.8805 & 0.6738 & 0.7440 & 0.7719 \\
TPGSR-3~\cite{ma2021text} & $L_2$+$L_{\textit{TP}}$ & 24.35 & 18.73 & 19.93 & 21.18 & 0.8860 & 0.6784 & 0.7507 & 0.7774 \\
TATT & $L_2$+$L_{\textit{TP}}$+$L_{\textit{TSC}}$ & 24.72 & 19.02 & \textbf{20.31} & \textbf{21.52} & \textbf{0.9006} & \textbf{0.6911} & \textbf{0.7703} & \textbf{0.7930} \\\hline
\end{tabular}
\caption{PSNR/SSIM indices for competing SISR and STISR methods. `-3' means multi-stage settings in~\cite{ma2021text}.}
\label{table:PSNRSSIM}
\end{table*}%
\begin{table*}
\centering
\setlength\tabcolsep{4pt}
\scalebox{0.98}{
\footnotesize
\begin{tabular}{l|c|cccc|cccc|cccc}
\hline
~ & ~ & \multicolumn{4}{c|}{ASTER~\cite{shi2018aster}} & \multicolumn{4}{c|}{MORAN~\cite{luo2019moran}} & \multicolumn{4}{c}{CRNN~\cite{shi2016end}}\\\hline
Method & Loss & easy & medium & hard & \textbf{avg} & easy & medium & hard & \textbf{avg} & easy & medium & hard & \textbf{avg}\\\hline
Bicubic & $\times$ & 64.7\% & 42.4\% & 31.2\% & 47.2\% & 60.6\% & 37.9\% & 30.8\% & 44.1\% & 36.4\% & 21.1\% & 21.1\% & 26.8\%\\\hline
SRCNN~\cite{dong2015image} & $L_2$ & 69.4\% & 43.4\% & 32.2\% & 49.5\% & 63.2\% & 39.0\% & 30.2\% & 45.3\% & 38.7\% & 21.6\% & 20.9\% & 27.7\%\\
SRResNet~\cite{ledig2017photo} & $L_2$+$L_{\textit{tv}}$+$L_p$ & 69.4\% & 47.3\% & 34.3\% & 51.3\% & 60.7\% & 42.9\% & 32.6\% & 46.3\% & 39.7\% & 27.6\% & 22.7\% & 30.6\%\\
HAN~\cite{niu2020single} & $L_2$ & 71.1\% & 52.8\% & 39.0\% & 55.3\% & 67.4\% & 48.5\% & 35.4\% & 51.5\% & 51.6\% & 35.8\% & 29.0\% & 39.6\%\\
TSRN~\cite{wang2020scene} & $ L_2$+$L_{\textit{GP}}$ & 75.1\% & 56.3\% & 40.1\% & 58.3\% & 70.1\% & 53.3\% & 37.9\% & 54.8\% & 52.5\% & 38.2\% & 31.4\% & 41.4\%\\
TBSRN~\cite{ma2021text} & $L_{\textit{POS}}$+$L_{\textit{CON}}$ & 75.7\% & 59.9\% & 41.6\% & 60.0\% & 74.1\% & 57.0\% & 40.8\% & 58.4\% & 59.6\% & 47.1\% & 35.3\% & 48.1\%\\
PCAN~\cite{zhao2021scene} & $L_2$+$L_{\textit{EG}}$ & 77.5\% & 60.7\% & 43.1\% & 61.5\% & 73.7\% & 57.6\% & 41.0\% & 58.5\% & 59.6\% & 45.4\% & 34.8\% & 47.4\%\\
TPGSR~\cite{ma2021text} & $L_2$+$L_{\textit{TP}}$ & 77.0\% & 60.9\% & 42.4\% & 60.9\% & 72.2\% & 57.8\% & 41.3\% & 57.8\% & 61.0\% & 49.9\% & 36.7\% & 49.8\%\\
TPGSR-3~\cite{ma2021text} & $L_2$+$L_{\textit{TP}}$ & \textbf{78.9\%} & 62.7\% & 44.5\% & 62.8\% & \textbf{74.9\%} & \textbf{60.5\%} & \textbf{44.1\%} & \textbf{60.5\%} & \textbf{63.1\%} & 52.0\% & 38.6\% & 51.8\%\\
TATT & $L_2$+$L_{\textit{TP}}$+$L_{\textit{TSC}}$ & \textbf{78.9\%} & \textbf{63.4\%} & \textbf{45.4\%} & \textbf{63.6\%} & 72.5\% & 60.2\% & 43.1\% & 59.5\% & 62.6\% & \textbf{53.4\%} & \textbf{39.8\%} & \textbf{52.6\%} \\\hline
HR & - & 94.2\% & 87.7\% & 76.2\% & 86.6\% & 91.2\% & 85.3\% & 74.2\% & 84.1\% & 76.4\% & 75.1\% & 64.6\% & 72.4\%\\\hline
\end{tabular}}
\caption{SR text recognition for competing SISR and STISR methods. `-3' means multi-stage settings in~\cite{ma2021text}.}
\label{table:SR_text_recognition}
\vspace{-0.3cm}
\end{table*}%
\begin{table}
\centering
\footnotesize
\begin{tabular}{l|ccc|cc}
\hline
Method & AS~\cite{shi2018aster} & MO~\cite{luo2019moran} & CR~\cite{shi2016end} & PSNR & SSIM \\\hline
Bicubic~\cite{wang2020scene} & 36.1\% & 32.2\% & 19.5\% & 19.68 & 0.6658\\
TSRN~\cite{wang2020scene} & 46.6\%& 43.8\% & 35.2\% &19.70 & 0.7157\\
TBSRN~\cite{chen2021scene} & 48.5\%& 45.1\% & 37.3\% & 19.10 & 0.7066 \\
TPGSR~\cite{ma2018arbitrary} & 46.6\% & 45.3\% & 40.2\% &19.79 & 0.7293\\
Ours & \textbf{51.7\%} & \textbf{47.3\%} & \textbf{43.8\%} & \textbf{20.20} & \textbf{ 0.7535}\\\hline
HR & 80.8\% & 75.7\% & 68.8\% & - & -\\\hline
\end{tabular}
\caption{Evaluation of competitive STISR models on spatially-deformed samples picked in TextZoom in terms of recognition, PSNR and SSIM. `AS', `MO' and `CR' refer to ASTER~\cite{shi2018aster}, MORAN~\cite{luo2019moran} and CRNN~\cite{shi2016end}, respectively.}
\label{table:DistortedTextZoom}
\vspace{-0.3cm}
\end{table}%
\begin{figure*}[t]
\centering
\includegraphics[width=\linewidth]{TATT-vis.pdf}
\caption{Visualization of regular and spatially-deformed samples from TextZoom recovered by state-of-the-art STISR models and the SR text recognition results. Characters in red are missing or wrong. `w TSC' means that the model is trained with our TSC loss.}
\label{fig:TextZoomVis}
\vspace{-0.3cm}
\end{figure*}
\begin{table}
\footnotesize
\centering
\begin{tabular}{c|l|ccc}
\hline
& super-resolver & AS~\cite{shi2018aster} & MO~\cite{luo2019moran} & CR~\cite{shi2016end}\\\hline
\multirow{5}{*}{O} & Bicubic & 38.1\% & 29.1\% & 18.1\% \\
& TSRN~\cite{wang2020scene} & 41.5\% & 33.8\% & 26.6\% \\
& TBSRN~\cite{chen2021scene} & 46.8\% & 45.3\% & 38.3\% \\
& TPGSR~\cite{ma2021text} & 53.1\% & 52.3\% & 42.5\% \\
& Ours & \textbf{53.4\%} & \textbf{59.1\%} & \textbf{47.2\%} \\\hline
\multirow{5}{*}{CO} & Bicubic&33.2\%&28.1\%&23.6\%\\
&TSRN~\cite{wang2020scene}&46.4\%&42.1\%&29.1\%\\
&TBSRN~\cite{chen2021scene}&45.5\%&44.7\%&31.9\%\\
&TPGSR~\cite{ma2021text}&48.3\%&52.8\%&38.3\%\\
&Ours&\textbf{54.7\%}&\textbf{54.0\%}&\textbf{45.1\%}\\\hline
\multirow{5}{*}{GN} & Bicubic&29.4\%&25.8\%&7.5\%\\
&TSRN~\cite{wang2020scene}&31.3\%&27.5\%&11.5\%\\
&TBSRN~\cite{chen2021scene}&40.2\%&\textbf{33.4\%}&15.8\%\\
&TPGSR~\cite{ma2021text}&35.7\%&31.7\%&18.1\%\\
&Ours&\textbf{43.0\%}&\textbf{33.4\%}&\textbf{21.1\%}\\\hline
\multirow{5}{*}{GB} &Bicubic&27.0\%&22.3\%&5.5\%\\
&TSRN~\cite{wang2020scene}&39.2\%&35.8\%&20.4\%\\
&TBSRN~\cite{chen2021scene}&42.6\%&42.8\%&20.8\%\\
&TPGSR~\cite{ma2021text}&45.9\%&\textbf{43.8\%}&29.6\%\\
&Ours&\textbf{47.4\%}&\textbf{43.8\%}&\textbf{35.7\%}\\\hline
\end{tabular}
\caption{Impact of using different STISR models as super-resolver against degradation. `O', `CO', `GB' and `GN' refer to original images and image degradation in terms of contrast, Guassian blurring and Gaussian noise. `AS', `MO' and `CR' refer to ASTER~\cite{shi2018aster}, MORAN~\cite{luo2019moran} and CRNN~\cite{shi2016end}, respectively.}
\label{table:SynLR_Ablations}
\vspace{-0.3cm}
\end{table}%
\subsection{Comparison with State-of-the-Arts}
\textbf{Results on TextZoom.} We conduct experiments on the real-world STISR dataset TextZoom~\cite{wang2020scene} to compare the proposed TATT network with state-of-the-art SISR models, including SRCNN~\cite{dong2015image} and SRResNet~\cite{ledig2017photo} and HAN~\cite{niu2020single}, and STISR models, including TSRN~\cite{wang2020scene}, TPGSR~\cite{ma2021text}, PCAN~\cite{zhao2021scene} and TBSRN~\cite{chen2021scene}. For TPGSR, we compare two models of it, \ie, 1-stage and 3-stage (TPGSR-3). The evaluation metrics are SSIM/PSNR and text recognition accuracy. The comparison results are shown in Tab.~\ref{table:PSNRSSIM} and Tab.~\ref{table:SR_text_recognition}.
One can see that our model trained with $L_{TSC}$ achieves the best PSNR ($21.52$) and SSIM ($0.7930$) overall performance. This verifies the superiority of our method in improving the image quality.
As for the SR text recognition, our method achieves new state-of-the-art accuracy under all settings by using the text recognition models of ASTER~\cite{shi2018aster} and CRNN~\cite{shi2016end}. It even surpasses the 3-stage model TPGSR-3 by using only a single stage.
We also test the inference speed of the three most competitive STISR methods, \ie, TBSRN~($982$ fps), TPGSR~($1,085$ fps) and our TATT model~($960$ fps). TATT has comparable speed with TPGSR and TBSRN, while surpasses them by $2.7\%$ and $3.6\%$ in SR image text recognition by using ASTER as the recognizer.
To further investigate the performance on spatially deformed text images, we manually pick $804$ rotated and curve-shaped samples from TextZoom test set to evaluate the compared models. Results in Tab.~\ref{table:DistortedTextZoom} indicate that our TATT model obtains the best performance, and the average gap over models like TPGSR and TBSRN becomes larger when encountering spatially deformed text.
We also visualize the recovery results of both regular samples and spatially-deformed samples of TextZoom in Fig.~\ref{fig:TextZoomVis}. Without TP guidance, TSRN and TBSRN perform far from readable and they are visually unacceptable. With the TP guidance, TPGSR is still unstable in recovering spatially-deformed images. In contrast, our TATT network performs much better in recovering text semantics in samples of all cases compared to all the competitors. With TSC loss, our model further upgrades the visual quality of the samples with better-refined character structure.
\begin{figure}[t]
\centering
\includegraphics[width=\linewidth]{TATT-FalureCase.pdf}
\caption{Visualization of the STISR and text recognition results on extremely compressed and blurred text samples.}
\label{fig:FailureCases}
\vspace{-0.3cm}
\end{figure}
\textbf{Generalization to recognition dataset.} We evaluate the generalization performance of our TATT network to other real-world text image datasets, including ICDAR15~\cite{karatzas2015icdar}, CUTE80~\cite{risnumawan2014robust} and SVTP~\cite{phan2013recognizing}. These datasets are built for text recognition purpose and contain spatially deformed text image in natural scenes. Since some of the images in these datasets have good quality, we only pick the low-resolution images (\ie, lower than $16 \times 64$) to form our test set with $533$ samples ($391$ from ICDAR15, $3$ from CUTE80 and $139$ from SVTP). Since the degradation is relatively small, we manually add some degradation on them, including contrast variation, Gaussian noise and Gaussian blurring (see details in \textbf{supplementary file}). We compare with TSRN~\cite{wang2020scene}, TBSRN~\cite{chen2021scene} and TPGSR~\cite{ma2021text} in this test and evaluate the recognition accuracy on the SR results. All models are trained on TextZoom and tested on the picked low-quality images.
The results are illustrated in Tab.~\ref{table:SynLR_Ablations}, we can see that the proposed TATT network achieves the highest recognition accuracy across all types of degradations. This indicates that our TATT network, though trained on TextZoom, can be well generalized to images in other datasets. The reconstructed high-quality text images by TATT can benefit the downstream tasks such as text recognition.
\section{Conclusion and Discussions}
In this paper, we proposed a Text ATTention network for single text image super-resolution. We leveraged a text prior, which is the semantic information extracted from the text image, to guide the text image reconstruction process. To tackle with the spatially-deformed text recovery, we developed a transformer-based module, called TP Interpreter, to globally correlate the text prior in the semantic domain to the character region in image feature domain. Moreover, we proposed a text structure consistency loss to refine the text structure by imposing structural consistency between the recovered regular and deformed texts. Our model achieved state-of-the-art performance in not only the text super resolution task but the downstream text recognition task.
Though recording state-of-the-art results, the proposed TATT network has limitation on recovering extremely blurry texts, as shown in Fig.~\ref{fig:FailureCases}. In such cases, the strokes of the characters in the text are mixed together, which are difficult to separate. In addition, the computational complexity of our TATT network grows exponentially with the length of the text in the image due to the global attention adopted in our model. It is expected to reduce the computational complexity and improve run-time efficiency of TATT, which will be our future work.
\section{Acknowledgements}
This work is supported by the Hong Kong RGC RIF grant (R5001-18). We thank Dr. Lida Li for the useful discussion on this project.
{\small
\bibliographystyle{ieee_fullname}
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 7,847 |
Lamprophis fuscus – gatunek węża z rodziny Lamprophiidae.
Osobniki tego gatunku osiągają rozmiary od 40 do 60 centymetrów. Ciało w kolorze oliwkowo-zielonym. Większość życia spędza pod ziemią w starych termitierach.
Węże te występują endemicznie w Republice Południowej Afryki.
Przypisy
Bibliografia
Lamprophiidae
Łuskonośne Afryki
Gatunki i podgatunki zwierząt nazwane w 1893 roku | {
"redpajama_set_name": "RedPajamaWikipedia"
} | 6,811 |
\section{Introduction}
Imagine a situation that adding roads to a road network in order to reduce traffic congestion results in, on contrary to one's expectation, slowing down overall traffic flow (called Braess's paradox \cite{Braess:paradox}). Random walks on graphs can also exhibit a version of this paradox. The family of random walks on undirected graphs is a special type of Markov chain: the transition probability from an initial state to another is given by the inverse of the degree of the vertex corresponding to the initial state. The parameter known as Kemeny's constant can be used to measure the average time for travel of a Markov chain between two randomly chosen states; so, in the context of random walks, it can be interpreted as a measure of how
well-connected the vertices of a graph are. Related applications can be found in \cite{Emma:Kemeny} for detecting potential super-spreaders of COVID-19, and in \cite{Crisostomi:Google} for determining `critical' roads in vehicle traffic networks based on Markov chains.
Kemeny's constant can serve as a proxy for identifying an edge exhibiting the version of the paradox \cite{KirklandZeng}, by examining an edge whose insertion into an undirected graph corresponding to a road network increases Kemeny's constant for random walks on the graph (such an edge is called a \textit{Braess edge}) that corresponds to travel times on the network. In the present paper, we study under what circumstances graphs can have a Braess edge in order to see what type of graphs exhibit the version of the paradox.
The term `Braess edge' is introduced in \cite{KirklandZeng}, and acknowledges Dietrich Braess who studies Braess's paradox for traffic networks \cite{Braess:paradox}. Kirkland and Zeng \cite{KirklandZeng} provides a particular family of trees, with a vertex adjacent to two pendent vertices (such two vertices are called \textit{twin pendent vertices}), such that inserting an edge between the twin pendent vertices causes Kemeny's constant to increase. Furthermore, Ciardo \cite{CiardoparadoxicalTwins} extends the result to all connected graphs with twin pendent vertices. Unlike the works \cite{KirklandZeng} and \cite{CiardoparadoxicalTwins}, Hu and Kirkland \cite{HuKirkland} establishes equivalent conditions for complete multipartite graphs and complete split graphs to have every non-edge as a Braess edge.
Our work is to generalise the circumstances in \cite{KirklandZeng,CiardoparadoxicalTwins} where graphs have a pair of twin pendent vertices; so, we consider graphs that can be constructed from a connected graph and two paths by identifying a vertex of the graph and a pendent vertex of each path. We call the two paths \textit{twin pendent paths} in the constructed graph. In Section \ref{Section:Braess edges on pendent}, a formula is derived that identifies a graph with twin pendent paths in which the non-edge between the pendent vertices of the twin pendent paths is a Braess edge. In Section \ref{Section: Asymptotic}, a combinatorial expression is provided in order to investigate asymptotic behaviour of a family of graphs with twin pendent paths regarding the tendency to have the non-edge, between the pendent vertices of the twin pendent paths, as a Braess edge. Furthermore, several families of graphs are discussed throughout Sections \ref{Section:Braess edges on pendent}, \ref{Section: Asymptotic}, and \ref{Section:Asymptotic for trees}. In particular, asymptotic behaviours of families of trees are characterized in Section \ref{Section:Asymptotic for trees}.
\section{Preliminaries}
Throughout the paper, we assume all graphs to be simple and undirected.
We shall introduce necessary terminology and notation in graph theory. Let $G$ be a graph of order $n$ with vertex set $V(G)$ and edge set $E(G)$ where $n=|V(G)|$. An edge joining vertices $v$ and $w$ of $G$ is denoted by $v\sim w$. Let $m_G$ be defined as $|E(G)|$. The subgraph of $G$ \textit{induced} by a subset $S$ of $V(G)$ is the graph with vertex set $S$, where two vertices in $S$ are adjacent if and only if they are adjacent in $G$. For $v\in V(G)$, we denote by $\mathrm{deg}_G(v)$ the degree of $v$. A vertex $v$ of a graph $G$ is said to be \textit{pendent} if $\mathrm{deg}_G(v)=1$. Given a labelling of $V(G)$, we define $\mathbf{d}_G$ to be the column vector whose $i^\text{th}$ component is $\mathrm{deg}_G(v_i)$ for $1\leq i\leq n$, where $v_i$ is the $i^\text{th}$ vertex in $V(G)$. For $v,w\in V(G)$, the distance between $v$ and $w$ in $G$ is denoted by $\mathrm{dist}_G(v,w)$. For a connected graph $G$ with a vertex $v$, the \textit{eccentricity} $e_G(v)$ of $v$ in $G$ is $e_G(v)=\mathrm{max}\{\mathrm{dist}_G(v,w)|w\in V(G)\}$. The \textit{diameter}, denoted $\mathrm{diam}(G)$, of $G$ is $\mathrm{diam}(G)=\mathrm{max}\{e_G(v)|v\in V(G)\}$.
The \textit{trivial} graph is the graph of order $1$. A \textit{tree} is a connected graph that has no cycles. A \textit{forest} is a graph whose connected components are trees. A \textit{spanning tree} (resp. a \textit{spanning forest}) of $G$ is a subgraph that is a tree (resp. a forest) and includes all of the vertices of $G$. A \textit{$k$-tree spanning forest} of $G$ is a spanning forest that consists of $k$ trees. For $v\in V(G)$, we use $G-v$ to denote the graph obtained from $G$ by the deletion of $v$. A vertex $v$ of a connected graph $G$ is called a \textit{cut-vertex} of $G$ if $G-v$ is disconnected. If $G-v$ has $k$ connected components $G_1,\dots,G_k$ for some $k\geq 2$, then the subgraph induced by $V(G_i)\cup\{v\}$ for $1\leq i\leq k$ is called a \textit{branch} of $G$ at $v$.
Let us introduce several types of connected graphs. We denote the complete graph of order $n$ by $K_n$, the cycle of length $n$ by $C_n$, and the path on $n$ vertices by $P_n$. If we need to specify the ordering of vertices of a cycle or a path, then we use $C_n=(v_1,v_2,\dots,v_n,v_1)$ to denote the cycle whose vertices are labelled by $v_1,\dots,v_n$, and whose edges are $v_1\sim v_n$ and $v_i\sim v_{i+1}$ for $i=1,\dots,n-1$; similarly, $P_n=(v_1,v_2,\dots,v_n)$ denotes the path whose vertices are labelled by $v_1,\dots,v_n$ and whose edges are $v_i\sim v_{i+1}$ for $i=1,\dots,n-1$. A \textit{star} $S_n$ is a tree on $n$ vertices with one vertex of degree $n-1$. For $n\geq 3$, $v$ is called the \textit{centre} vertex of $S_n$ if $\mathrm{deg}_{S_n}(v)=n-1$. For $n>k\geq 1$, a \textit{broom} $\mathcal{B}_{n,k}$ is a tree constructed from the path on $k$ vertices by adding $n-k$ pendent vertices to one pendent vertex on the path.
Let $k\geq 2$, and let $G_i$ be a graph with $v_i\in V(G_i)$ for $i=1,\dots,k$. Suppose that $V(G_1),\dots,V(G_k)$ are disjoint. Let $v\notin V(G_i)$ for $i=1,\dots,k$. We consider a graph $G$ with vertex set $V(G)=\{v\}\cup\left(\bigcup_{i=1}^k \left(V(G_i)-v_i\right)\right)$, where two vertices $x$ and $y$ in $G$ are adjacent if and only if it satisfies one of the following: \begin{enumerate*}[label=(\roman*)]
\item $x\sim y\in \bigcup_{i=1}^kE(G_i)$; and
\item one of $x$ and $y$ is $v$, and the other is a vertex adjacent to $v_j$ in $G_j$ for some $1\leq j\leq k$.
\end{enumerate*}
Then, we say that the graph $G$ is obtained from $G_1,\dots, G_k$ by \textit{identifying} vertices $v_1,\dots,v_k$ as $v$.
\iffalse
Let $k\geq 2$, and let $G_i$ be a graph with $v_i\in V(G_i)$ for $i=1,\dots,k$. Suppose that $V(G_1),\dots,V(G_k)$ are disjoint. Let $v\notin V(G_i)$ for $i=1,\dots,k$. Consider a graph $H$ where $V(H)=\{v\}\cup\left(\bigcup_{i=1}^k V(G_i)\right)$ and $E(H)=\{v\sim v_i|i=1,\dots k\}\cup\left(\bigcup_{i=1}^k V(G_i)\right)$.
\fi
Let $G$ be a graph. Let $P_{k_1+1}=(v_1,\dots,v_{k_1+1})$ and $P_{k_2+1}=(w_1,\dots,w_{k_2+1})$ where $k_1$ and $k_2$ are non-negative integers with $k_1+k_2\geq 2$. Suppose that $\widetilde{G}$ is the graph obtained from $G$, $P_{k_1+1}$, and $P_{k_2+1}$ by identifying a vertex $v$ of $G$, $v_1$, and $w_1$ as $v$. We say that the paths $(v,v_2,\dots,v_{k_1+1})$ and $(v,w_2\dots,w_{k_2+1})$ in $\widetilde{G}$ are \textit{twin pendent paths}. Then, the pendent vertices of the twin pendent paths in $\widetilde{G}$ are $v_{k_1+1}$ and $w_{k_2+1}$. We remark that considering the construction of $\widetilde{G}$, it is reasonable to assume that $k_1$ and $k_2$ are permitted to be zero (we consider it throughout this paper), as opposed to one's anticipation from the word `twin pendent paths', in that $P_{k_1+1}$ and $P_{k_2+1}$ both are of length at least $1$.
\begin{figure}[t!]
\begin{center}
\begin{tikzpicture}
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\draw plot [smooth cycle] coordinates {(0.3,.3)(1.3,.3)(2.2,.5) (2.3,1.5)(2.1,2.2)(0.6,2.1)(0.1,0.8)} node at (0.5,0.7) {$G$};
\node[label={below, yshift=0cm: $\widetilde{G}$}] (tilG) at (2.3,0) {};
\begin{scriptsize}
\node[enclosed, label={above, yshift=0cm: $v$}] (v) at (1.8,1.5) {};
\node[enclosed, label={above, yshift=0cm: $v_2$}] (v1) at (2.8,2) {};
\node[enclosed, label={above, yshift=0cm: $v_{k_1}$}] (v2) at (3.8,2.3) {};
\node[enclosed, label={above, yshift=0cm: $v_{k_1+1}$}] (v3) at (4.7,2.6) {};
\node[enclosed, label={below, yshift=0cm: $w_2$}] (w1) at (2.8,1) {};
\node[enclosed, label={below, yshift=0cm: $w_{k_2}$}] (w2) at (3.8,0.7) {};
\node[enclosed, label={below, yshift=0cm: $w_{k_2+1}$}] (w3) at (4.8,0.5) {};
\end{scriptsize}
\draw (v) -- (v1);
\draw[thick, loosely dotted] (v1) -- (v2);
\draw (v2) -- (v3);
\draw (v) -- (w1);
\draw[thick, loosely dotted] (w1) -- (w2);
\draw (w2) -- (w3);
\end{tikzpicture}
\end{center}
\caption{An illustration of twin pendent paths in $\widetilde{G}$.}\label{Figure:twinpendentpaths}
\end{figure}
Consider a discrete, finite, time-homogeneous Markov chain whose finite state space is $\{1,\dots,n\}$. The Markov chain can be represented by the transition matrix $M$. (We refer the interested reader to \cite{Seneta:Markov} for the necessary background for Markov chains.) Then, Kemeny's constant $\kappa(M)$ is defined as $\sum_{j\neq i}^n m_{i,j}w_j$, where $m_{i,j}$ is the mean first passage time from state $i$ to state $j$, and $w_j$ is the $j^\text{th}$ entry of the stationary distribution. Note that Kemeny's constant is independent of $i$. It is found in \cite{Levene:KemenyInterpre} that $\kappa(M)+1=\sum_{i=1}^n\sum_{j=1}^n w_im_{i,j}w_j$. This admits the interpretation of Kemeny's constant in terms of the expected number of steps from a randomly-chosen initial state to a randomly-chosen final state. Alternatively, $\kappa(M)$ can be expressed as $\kappa(M)=\sum_{j=2}^{n}\frac{1}{1-\lambda_j}$ where $1,\lambda_2,\dots,\lambda_n$ are the eigenvalues of $M$. For the details, the reader may refer to \cite{KemenySnell}.
For our work, we use the combinatorial expression for Kemeny's constant for a random walk on a connected graph in \cite{KirklandZeng}. In order to emphasize that we are dealing with random walks on connected graphs, given a connected graph $G$, we use $\kappa(G)$ to denote Kemeny's constant for the transition matrix of the random walk on $G$. We denote by $\tau_{G}$ the number of spanning trees of $G$, and by $\mathcal{F}_{G}(i;j)$ the set of $2$-tree spanning forests of $G$ such that one of the two trees contains a vertex $i$ of $G$, and the other has a vertex $j$ of $G$. We define $F_{G}$ to be the matrix given by $F_{G}=[f_{i,j}^{G}]$ where $f_{i,j}^{G}=|\mathcal{F}_{G}(i;j)|$. Note that $f_{i,i}^{G}=0$, that is, the diagonal entries of $F_G$ are zero. Recall that $m_G$ is the number of edges of $G$. Then, Kemeny's constant for the transition matrix of the random walk on $G$ is given by
\begin{equation*}
\kappa(G)=\frac{\mathbf{d}_G^T F_G\mathbf{d}_G}{4m_G\tau_G}.
\end{equation*}
A non-edge $e$ of $G$ is said to be a \textit{Braess edge} for $G$ if $\kappa(G)<\kappa(G\cup e)$ where $G\cup e$ is the graph obtained from $G$ by adding $e$ to $G$. A connected graph $G$ is said to be \textit{paradoxical} \cite{CiardoparadoxicalTwins} if there exists a Braess edge for $G$.
We also introduce some useful notation. We denote by $\mathbf{1}_k$ the all ones vector of size $k$, by $\mathbf{0}_k$ the all zeros vector of size $k$, and by $J_{p,q}$ the all ones matrix of size $p\times q$. If $k=p=q$, we write $J_{p,q}$ as $J_k$. The subscripts $k$ and a pair of $p$ and $q$ are omitted if their sizes are clear from the context. We denote by $\mathbf e_v$ the column vector whose component in $v^\text{th}$ position is $1$ and zeros elsewhere, and denote by $\mathbf{f}_G^v$ the $v^{\text{th}}$ column of $F_{G}$. Then, the $i^{\text{th}}$ entry of $\mathbf{f}_G^v$ is $f_{i,v}^{G}$. Moreover, $\mathbf{f}_G^v$ can be written as $\mathbf{f}^v$ if $G$ is clear from the context.
We assume familiarity with basic material on graph theory. We refer the reader to \cite{book:GraphAndDigraphs} for the necessary background. In what follows, we omit $G$ that is a subscript or a superscript in the notation described in this section when no confusion arises, and we use boldface lowercase letters to denote column vectors.
\section{Graphs with twin pendent paths and the Braess edge}\label{Section:Braess edges on pendent}
In this section, for a connected graph with twin pendent paths, we provide an equivalent condition for the non-edge between the pendent vertices of the twin pendent paths to be a Braess edge. Moreover, we examine several families of graphs through the equivalent condition.
We begin with investigating the components in the expression for Kemeny's constant $\kappa(G)$ where $G$ is a connected graph with a cut-vertex---a connected graph with twin pendent paths has a cut-vertex.
\begin{proposition}\label{gen:H1andH2}
Let $H_1$ and $H_2$ be connected graphs, and let $v_1\in V(H_1)$ and $v_2\in V(H_2)$. Assume that $G$ is obtained from $H_1$ and $H_2$ by identifying $v_1$ and $v_2$ as a vertex $v$. Suppose that $\widetilde{H}_1=H_1-v_1$ and $\widetilde{H}_2=H_2-v_2$. Then, labelling the vertices of $G$ in order of $V(\widetilde{H}_1)$, $v$, and $V(\widetilde{H}_2)$, we have:
\begin{align}\nonumber
\mathbf{d}_{G}^T&=[\mathbf{d}_{H_1}^T\;\mathbf{0}^T_{|V(\widetilde{H}_2)|}]+[\mathbf{0}^T_{|V(\widetilde{H}_1)|}\;\mathbf{d}_{H_2}^T],\\\nonumber
m_{G}&=m_{H_1}+m_{H_2},\\\nonumber
\tau_{G}&=\tau_{H_1}\tau_{H_2},\\\label{F_G}
F_{G}&=\left[\begin{array}{c|c|c}
\tau_{H_2}F_{\widetilde{H}_1} & \tau_{H_2}\mathbf{f}_1 & \tau_{H_2}\mathbf{f}_1\mathbf{1}^T+\tau_{H_1}\mathbf{1}\mathbf{f}_2^T \\\hline
\tau_{H_2}\mathbf{f}^T_1 & 0 & \tau_{H_1}\mathbf{f}^T_2\\\hline
\tau_{H_1}\mathbf{f}_2\mathbf{1}^T+\tau_{H_2}\mathbf{1}\mathbf{f}_2^T & \tau_{H_1}\mathbf{f}_2 & \tau_{H_1}F_{\widetilde{H}_2}
\end{array}\right],
\end{align}
where $\mathbf{f}_1$ and $\mathbf{f}_2$ are the column vectors obtained from $\mathbf{f}_{H_1}^v$ and $\mathbf{f}_{H_2}^v$ by deleting the $v^\text{th}$ component (which is $0$), respectively. Furthermore, we obtain
\begin{align}\label{dfd:expression}
\mathbf{d}_G^TF_G\mathbf{d}_G
=\tau_{H_2}\mathbf{d}_{H_1}^TF_{H_1}\mathbf{d}_{H_1}+\tau_{H_1}\mathbf{d}_{H_2}^TF_{H_2}\mathbf{d}_{H_2}+4\tau_{H_2}m_{H_2}\mathbf{d}_{H_1}^T\mathbf{f}_{H_1}^v+4\tau_{H_1}m_{H_1}\mathbf{d}_{H_2}^T\mathbf{f}_{H_2}^v.
\end{align}
\end{proposition}
\begin{proof}
The conclusions for $\mathbf{d}_G$ and $m_G$ are readily established. We shall consider $F_G$ and $\tau_G$. Since $f_{i,j}^G=f_{j,i}^G$ for all $i,j\in V(G)$, $F_G$ is symmetric. Hence, we only need to verify the entries above the main diagonal. Note that $v$ is a cut-vertex of $G$. Since all spanning trees of $G$ can be obtained from spanning trees of $H_1$ and of $H_2$ by identifying $v_1$ and $v_2$ as $v$, we have $\tau_G=\tau_{H_1}\tau_{H_2}$. Let $i,j\in V(H_1)$. For each spanning forest of $H_1$ in $\mathcal{F}_{H_1}(i;j)$, we can obtain $\tau_{H_2}$ spanning forests of $G$ in $\mathcal{F}_{G}(i;j)$ from the forest of $H_1$ and each of $\tau_{H_2}$ spanning trees of $H_2$ by identifying $v_1$ and $v_2$. Therefore, $f_{i,j}^{G}=\tau_{H_2}f_{i,j}^{H_1}$ for $i,j\in V(H_1)$. Similarly, for $i,j\in V(H_2)$, we have $f_{i,j}^{G}=\tau_{H_1}f_{i,j}^{H_2}$. Let $i\in V(\widetilde{H}_1)$ and $j\in V(\widetilde{H}_2)$. The set $\mathcal{F}_{G}(i;j)$ is a disjoint union of $A_i$ and $A_j$, where $A_i$ is the set of spanning forests of $G$ in $\mathcal{F}_{G}(i;j)$ such that the tree having the vertex $i$ among the two trees contains $v$, and $A_j=\mathcal{F}_G(i;j)\backslash A_i$. Since for each spanning forest in $A_i$ the tree with $i$ has $v$, the tree contains a spanning tree of $H_1$ as a subtree. So, any forest in $A_i$ can be constructed from a spanning tree of $H_1$ and a spanning forest in $\mathcal{F}_{H_2}(v_2;j)$ with $v_1$ and $v_2$ identified as $v$. Hence, we have $|A_i|=\tau_{H_1}f_{v_2,j}^{H_2}$. Note that $f_{i,v_1}^{H_1}=f_{v_1,i}^{H_1}$. Applying an analogous argument to the case $|A_j|$, we have $|A_j|=\tau_{H_2}f_{i,v_1}^{H_1}$. Thus, $f_{i,j}^{G}=\tau_{H_2}f_{i,v}^{H_1}+\tau_{H_1}f_{v,j}^{H_2}$ for $i\in V(\widetilde{H}_1)$ and $j\in V(\widetilde{H}_2)$. Therefore, our desired results for $F_G$ and $\tau_G$ are obtained.
Now, we shall prove \eqref{dfd:expression}. Labelling the vertices of $H_1$ (resp. $H_2$) in order of $V(\widetilde{H}_1)$ and $v$ (resp. $v$ and $V(\widetilde{H}_2)$), we have
$$
\tau_{H_2}F_{H_1}=\left[\begin{array}{cc}
\tau_{H_2}F_{\widetilde{H}_1} & \tau_{H_2}\mathbf{f}_1 \\
\tau_{H_2}\mathbf{f}^T_1 & 0
\end{array}\right],\;\tau_{H_1}F_{H_2}=\left[\begin{array}{cc}
0 & \tau_{H_1}\mathbf{f}^T_2\\
\tau_{H_1}\mathbf{f}_2 & \tau_{H_1}F_{\widetilde{H}_2}
\end{array}\right].
$$
Note that $(\mathbf{f}_{H_1}^v)^T=\begin{bmatrix}
\mathbf{f}_1^T & 0
\end{bmatrix}$ and $(\mathbf{f}_{H_2}^v)^T=\begin{bmatrix}
0 & \mathbf{f}_2^T
\end{bmatrix}$. Then,
$$
\begin{bmatrix}
\tau_{H_2}\mathbf{f}_1 & \tau_{H_2}\mathbf{f}_1\mathbf{1}_{|V(\widetilde{H}_2)|}^T+\tau_{H_1}\mathbf{1}_{|V(\widetilde{H}_1)|}\mathbf{f}_2^T\\
0 & \tau_{H_1}\mathbf{f}^T_2
\end{bmatrix}=\tau_{H_2}\mathbf{f}_{H_1}^v\mathbf{1}_{|V(H_2)|}^T+\tau_{H_1}\mathbf{1}_{|V(H_1)|}(\mathbf{f}_{H_2}^v)^T.
$$
Considering $\mathbf{d}_{G}^T=[\mathbf{d}_{H_1}^T\;\mathbf{0}^T_{|V(\widetilde{H}_2)|}]+[\mathbf{0}^T_{|V(\widetilde{H}_1)|}\;\mathbf{d}_{H_2}^T]$ with $F_G$ in \eqref{F_G}, we have
\begin{align*}\nonumber
&\mathbf{d}_G^TF_G\mathbf{d}_G\\\nonumber=&\tau_{H_2}\mathbf{d}^T_{H_1}F_{H_1}\mathbf{d}_{H_1}+\tau_{H_1}\mathbf{d}^T_{H_2}F_{H_2}\mathbf{d}_{H_2}+2\mathbf{d}^T_{H_1}\begin{bmatrix}
\tau_{H_2}\mathbf{f}_1 & \tau_{H_2}\mathbf{f}_1\mathbf{1}^T+\tau_{H_1}\mathbf{1}\mathbf{f}_2^T\\
0 & \tau_{H_1}\mathbf{f}^T_2
\end{bmatrix}\mathbf{d}_{H_2}
\\\nonumber=&\tau_{H_2}\mathbf{d}_{H_1}^TF_{H_1}\mathbf{d}_{H_1}+\tau_{H_1}\mathbf{d}_{H_2}^TF_{H_2}\mathbf{d}_{H_2}+2\mathbf{d}_{H_1}^T\left(\tau_{H_2}\mathbf{f}_{H_1}^v\mathbf{1}_{|V(H_2)|}^T+\tau_{H_1}\mathbf{1}_{|V(H_1)|}(\mathbf{f}_{H_2}^v)^T\right)\mathbf{d}_{H_2}
\\
=&\tau_{H_2}\mathbf{d}_{H_1}^TF_{H_1}\mathbf{d}_{H_1}+\tau_{H_1}\mathbf{d}_{H_2}^TF_{H_2}\mathbf{d}_{H_2}+4\tau_{H_2}m_{H_2}\mathbf{d}_{H_1}^T\mathbf{f}_{H_1}^v+4\tau_{H_1}m_{H_1}\mathbf{d}_{H_2}^T\mathbf{f}_{H_2}^v.
\end{align*}
\end{proof}
We can see from Proposition \ref{gen:H1andH2} that given $m_{H_i}$ and $\tau_{H_i}$ for $i=1,2$, $\mathbf{d}_G^TF_G\mathbf{d}_G$ can be computed from $\mathbf{d}_{H_i}^TF_{H_i}\mathbf{d}_{H_i}$ and $\mathbf{d}_{H_i}^T\mathbf{f}_{H_i}^v$ for $i=1,2$. The following examples regarding $K_n$, $C_n$, $P_n$ and $S_n$ present the corresponding quantities $\mathbf{d}^TF\mathbf{d}$ and $\mathbf{d}^T\mathbf{f}^v$, and assist us later to obtain several results and related examples.
\begin{example}\label{ex:K_n}
{\rm Consider a complete graph $K_n$ on $n$ vertices. Then, $m=\binom{n}{2}$ and $\tau=n^{n-2}$ by Cayley's formula (see \cite{book:GraphAndDigraphs}). Note that $K_n$ is symmetric (see \cite{Godsil:AlgebraicGraph}), \textit{i.e.,} for any pair of edges of $K_n$, there is an automorphism that maps one edge to the other. So, $F_{K_n}=\alpha(J-I)$ where $\alpha=f_{i,j}^{K_n}$ for all $i,j\in V(K_n)$. Then, $\alpha$ is the determinant of the submatrix obtained from the Laplacian matrix of $K_n$ by deleting $i^\text{th}$ and $j^\text{th}$ rows and columns where $i\neq j$ (see \cite{Seth:MatrixTreeTheorem}). It can be seen that $\alpha=2n^{n-3}$. Therefore, for any vertex $v$ in $K_n$, we have}
\begin{align*}
&\mathbf{d}^TF\mathbf{d}=\alpha(n-1)^2\mathbf{1}^T(J-I)\mathbf{1}=2n^{n-2}(n-1)^3,\\
&\mathbf{d}^T\mathbf{f}^v=\alpha(n-1)\mathbf{1}^T(\mathbf{1}-\mathbf e_v)=2n^{n-3}(n-1)^2.
\end{align*}
\end{example}
\begin{example}\label{ex:C_n}
{\rm Consider the cycle $C_n=(1,2,\dots,n,1)$ where $n\geq 3$. For $1\leq v \leq n$, we obtain
\begin{align*}
&F_{C_n}=\begin{bmatrix}
\mathrm{dist}(i,j)(n-\mathrm{dist}(i,j))
\end{bmatrix}_{1\leq i,j\leq n},\; \mathbf{d}=2\mathbf{1},\\
&(\mathbf{f}^v)^T=\begin{bmatrix}
(v-1)(n-(v-1)) & \cdots & 1\cdot(n-1) & 0 & 1\cdot(n-1) & \cdots & (n-v)v
\end{bmatrix}.
\end{align*}
It can be checked that for $v=1,\dots,n$,
\begin{align*}
\mathbf{d}^TF\mathbf{d}=\frac{2}{3}(n-1)n^2(n+1)\;\text{and}\;\mathbf{d}^T\mathbf{f}^v=\frac{1}{3}(n-1)n(n+1).
\end{align*}}
\end{example}
Note that for any tree $\mathcal T$, $F_{\mathcal T}$ is the distance matrix of $\mathcal T$ (see \cite{KirklandZeng}), which is the matrix whose $(i,j)$-entry is the distance between $i$ and $j$.
\begin{example}\label{ex:P_n}
{\rm Consider the path $P_n=(1,2,\dots,n)$ where $n\geq 2$. Let $v$ be a vertex of $P_n$. For $1\leq v \leq n$, we have \begin{align*}
&F_{P_n}=\begin{bmatrix}
|i-j|
\end{bmatrix}_{1\leq i,j\leq n},\; \mathbf{d}=2\mathbf{1}_{n}-\mathbf{e}_1-\mathbf{e}_{n},\\
&(\mathbf{f}^v)^T=\begin{bmatrix}
v-1 & \cdots & 1 & 0 & 1 & \cdots & n-v
\end{bmatrix}.
\end{align*}
One can verify that for $v=1,\dots,n$,
\begin{align*}
&\mathbf{d}^TF_{}\mathbf{d}=4\mathbf{1}^TF\mathbf{1}-4\mathbf{1}^TF\mathbf e_1-4\mathbf{1}^TF\mathbf e_n+2\mathbf e_1^TF\mathbf e_n=\frac{4}{3}(n-1)^3+\frac{2}{3}(n-1),\\
&\mathbf{d}^T\mathbf{f}^v=(v-1)^2+(n-v)^2.
\end{align*}}
\end{example}
\begin{example}
{\rm Consider a star $S_n$ of order $n$ where $n\geq 3$. Suppose that $n$ is the centre vertex. Then, we have
\begin{align*}
\mathbf{d}^T=\begin{bmatrix}
\mathbf{1}_{n-1}^T & 0
\end{bmatrix}+(n-1)\mathbf e_n,\;F_{S_n}=\begin{bmatrix}
2(J-I) & \mathbf{1}_{n-1}\\
\mathbf{1}_{n-1}^T & 0
\end{bmatrix}.
\end{align*}
Hence, we have that for $v=1,\dots,n$,
\begin{align*}
&\mathbf{d}^TF\mathbf{d}=2\mathbf{1}_{n-1}^T(J-I)\mathbf{1}_{n-1}+2(n-1)^2=2(n-1)(2n-3),\\
&\mathbf{d}^T\mathbf{f}^v=\begin{cases*}
n-1, & \text{if $v=n$}\\
3n-5, & \text{if $v\neq n$.}
\end{cases*}
\end{align*}}
\end{example}
We consider the following definition for clarity of exposition regarding our work in this paper.
\begin{definition}\label{Def:paradoxical}
{\rm Let $G$ be a connected graph on $n$ vertices, and $v\in V(G)$. Fix two non-negative integers $k_1,k_2$ with $k_1+k_2\geq 2$. Let $\widetilde G(v,k_1,k_2)$ denote the graph obtained from $G$, $P_{k_1+1}=(v_1,\dots,v_{k_1+1})$ and $P_{k_2+1}=(w_1,\dots, w_{k_2+1})$ by identifying the vertices $v$, $v_1$ and $w_1$. Also, we denote by $\widehat G(v,k_1,k_2)$ the graph obtained from $\widetilde G(v,k_1,k_2)$ by inserting the edge $v_{k_1+1}\sim w_{k_2+1}$. We say that $G$ is {\em $(v,k_1,k_2)$-paradoxical} if $\kappa(\widehat G(v,k_1,k_2))>\kappa(\widetilde G(v,k_1,k_2))$. If $G$ is $(v,k_1,k_2)$-paradoxical for every $v\in V(G)$, then we say that $G$ is {\em $(k_1,k_2)$-paradoxical}.}
\end{definition}
Our main goal stated in the beginning of this section can be rephrased in terms of Definition \ref{Def:paradoxical}: given a connected graph $G$ with a vertex $v$, we shall find an equivalent condition for $G$ to be $(v,k_1,k_2)$-paradoxical.
\begin{example}\label{Ex:paradoxical}
{\rm Consider the following graphs:
\begin{center}
\begin{tikzpicture}[scale=0.80]
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={left, yshift=0cm: }] (v_1) at (-1,0.5) {};
\node[enclosed, label={left, yshift=0cm: }] (v_2) at (0,-1) {};
\node[enclosed, label={below, yshift=0cm:}] (v_3) at (0,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_4) at (0,1) {};
\node[enclosed, label={right, yshift=0cm: }] (v_5) at (-1,-0.5) {};
\node[enclosed, label={above, yshift=0cm: $v$}] (v_6) at (1,0) {};
\node[label={below, yshift=0cm: $G$}] (G) at (0,-1.2) {};
\draw (v_2) -- (v_3);
\draw (v_1) -- (v_3);
\draw (v_3) -- (v_4);
\draw (v_3) -- (v_5);
\draw (v_3) -- (v_6);
\begin{scope}[xshift=6cm]
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={left, yshift=0cm: }] (v_1) at (-1,0.5) {};
\node[enclosed, label={left, yshift=0cm: }] (v_2) at (0,-1) {};
\node[enclosed, label={below, yshift=0cm:}] (v_3) at (0,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_4) at (0,1) {};
\node[enclosed, label={right, yshift=0cm: }] (v_5) at (-1,-0.5) {};
\node[enclosed, label={above, yshift=0cm: $v$}] (v_6) at (1,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_9) at (2,0.6) {};
\node[enclosed, label={right, yshift=0cm: }] (v_10) at (1.7,-0.6) {};
\node[enclosed, label={right, yshift=0cm: }] (v_11) at (2.4,-1.2) {};
\node[label={below, yshift=0cm: $\widetilde{G}(v,1,2)$}] (G) at (0,-1.2) {};
\draw (v_2) -- (v_3);
\draw (v_1) -- (v_3);
\draw (v_3) -- (v_4);
\draw (v_3) -- (v_5);
\draw (v_3) -- (v_6);
\draw (v_6) -- (v_9);
\draw (v_6) -- (v_10);
\draw (v_10) -- (v_11);
\end{scope}
\begin{scope}[xshift=12cm]
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={left, yshift=0cm: }] (v_1) at (-1,0.5) {};
\node[enclosed, label={left, yshift=0cm: }] (v_2) at (0,-1) {};
\node[enclosed, label={below, yshift=0cm:}] (v_3) at (0,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_4) at (0,1) {};
\node[enclosed, label={right, yshift=0cm: }] (v_5) at (-1,-0.5) {};
\node[enclosed, label={above, yshift=0cm: $v$}] (v_6) at (1,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_9) at (2,0.6) {};
\node[enclosed, label={right, yshift=0cm: }] (v_10) at (1.7,-0.6) {};
\node[enclosed, label={right, yshift=0cm: }] (v_11) at (2.4,-1.2) {};
\node[label={below, yshift=0cm: $\widehat{G}(v,1,2)$}] (G) at (0,-1.2) {};
\draw (v_2) -- (v_3);
\draw (v_1) -- (v_3);
\draw (v_3) -- (v_4);
\draw (v_3) -- (v_5);
\draw (v_3) -- (v_6);
\draw (v_6) -- (v_9);
\draw (v_6) -- (v_10);
\draw (v_10) -- (v_11);
\draw (v_9) -- (v_11);
\end{scope}
\end{tikzpicture}
\end{center}
With the aid of MATLAB\textsuperscript{\textregistered}, $\kappa(\widehat{G}(v,1,2))-\kappa(\widetilde{G}(v,1,2))\approx 0.1667$. Further, it is shown in Example \ref{Ex:asymp for star} that $G$ is $(v,1,2)$-paradoxical.}
\end{example}
Let us continue with the hypothesis and notation of Definition \ref{Def:paradoxical}. To see if $G$ is $(v,k_1,k_2)$-paradoxical, we need to investigate $\kappa(\widehat G(v,k_1,k_2))-\kappa(\widetilde G(v,k_1,k_2))$. So, we shall find formulae for $\mathbf{d}_{\widetilde{G}}^TF_{\widetilde{G}}\mathbf{d}_{\widetilde{G}}$ and $\mathbf{d}_{\widehat G}^TF_{\widehat G}\mathbf{d}_{\widehat G}$ in Lemmas \ref{lem:P_k} and \ref{lem:C_k}, respectively.
\begin{lemma}\label{lem:P_k}
Let $P_k$ be a path with two pendent vertices $x$ and $y$ where $k\geq 2$, and $H$ be a connected graph. Suppose that $G$ is the graph obtained from $P_k$ and $H$ by identifying a vertex of $P_k$ and a vertex of $H$, say $v$. Let $\mathrm{dist}_G(v,x)=k_1$ and $\mathrm{dist}_G(v,y)=k_2$. Then,
\begin{align*}
\hspace{-0.25cm}\mathbf{d}_{G}^TF_{G}\mathbf{d}_{G}=\mathbf{d}_{H}^TF_{H}\mathbf{d}_{H}+4(k-1)\mathbf{d}_H^T\mathbf{f}_H^v+\tau_{H}\left(\frac{4}{3}(k-1)^3+\frac{2}{3}(k-1)+4m_{H}(k_1^2+k_2^2)\right).
\end{align*}
\end{lemma}
\begin{proof}
The conclusion is straightforward from \eqref{dfd:expression} and Example \ref{ex:P_n}.
\end{proof}
\begin{lemma}\label{lem:C_k}
Let $C_k$ be a cycle of length $k$ where $k\geq 3$, and $H$ be a connected graph. Suppose that $G$ is the graph obtained from $C_k$ and $H$ by identifying a vertex of $C_k$ and a vertex of $H$, say $v$. Then,
\begin{align*}
\mathbf{d}_{G}^TF_{G}\mathbf{d}_{G}=k\mathbf{d}_H^TF_H\mathbf{d}_H+4k^2\mathbf{d}_{H}^T\mathbf{f}_{H}^v+\frac{2\tau_H}{3}(k+2m_H)(k-1)k(k+1).
\end{align*}
\end{lemma}
\begin{proof}
The conclusion is readily established from \eqref{dfd:expression} and Example \ref{ex:C_n}.
\end{proof}
Using Lemmas \ref{lem:P_k} and \ref{lem:C_k}, we establish our desired equivalent condition as follows.
\begin{theorem}\label{Theorem:brass for general twin pendent path}
Let $G$ be a connected graph with a vertex $v$. Suppose that $k_1,k_2\geq0$, $k_1+k_2\geq 2$ and $k-1=k_1+k_2$. Then, $G$ is $(v,k_1,k_2)$-paradoxical if and only if
\begin{align}\label{inequality: paradoxical if and only if >0}
\hspace{-0.3cm}\begin{split}
&k\mathbf{d}_G^T(2\mathbf{f}_G^v\mathbf{1}^T-F_G)\mathbf{d}_G+4m_G^2\tau_Gk\left(-\frac{2}{3}(k_1+k_2)(k_1+k_2-1)+2k_1k_2)\right)\\
+&\frac{2m_G\tau_Gk}{3}\left(-5(k_1+k_2)^3+(k_1+k_2)^2+(k_1+k_2)+12k_1k_2(k_1+k_2+1)\right)\\
-&\frac{2\tau_Gk}{3}(k_1+k_2+1)(k_1+k_2)(k_1+k_2-1)^2>0.
\end{split}
\end{align}
\end{theorem}
\begin{proof}
Evidently, $m_{\widetilde{G}}=m_G+k-1$, $m_{\widehat{G}}=m_G+k$ and $\tau_{\widetilde{G}}=\tau_G$. Since $v$ is a cut-vertex in $\widehat{G}$, we have $\tau_{\widehat{G}}=k\tau_G$. Then,
\begin{align}\nonumber
\kappa(\widehat G(v,k_1,k_2))-\kappa(\widetilde G(v,k_1,k_2))&=\frac{\mathbf{d}_{\widehat G}^TF_{\widehat G}\mathbf{d}_{\widehat G}}{4m_{\widehat{G}}\tau_{\widehat{G}}}-\frac{\mathbf{d}_{\widetilde{G}}^TF_{\widetilde{G}}\mathbf{d}_{\widetilde{G}}}{4m_{\widetilde{G}}\tau_{\widetilde{G}}}\\\label{diff:Ghat Gtil}
&=\frac{(m_G+k-1)\mathbf{d}_{\widehat G}^TF_{\widehat G}\mathbf{d}_{\widehat G}-k(m_G+k)\mathbf{d}_{\widetilde{G}}^TF_{\widetilde{G}}\mathbf{d}_{\widetilde{G}}}{4k(m_G+k)(m_G+k-1)\tau_G}.
\end{align}
Then, $G$ is $(v,k_1,k_2)$-paradoxical if and only if $$(m_G+k-1)\mathbf{d}_{\widehat G}^TF_{\widehat G}\mathbf{d}_{\widehat G}-k(m_G+k)\mathbf{d}_{\widetilde{G}}^TF_{\widetilde{G}}\mathbf{d}_{\widetilde{G}}>0.$$
For simplicity, let $\mathbf{d}=\mathbf{d}_G$, $\mathbf{f}^v=\mathbf{f}_G^v$, $F=F_G$, $m=m_G$ and $\tau=\tau_G$. Using Lemmas \ref{lem:P_k} and \ref{lem:C_k}, we have
\begin{align}\label{temp:eqn11}
\begin{split}
&(m+k-1)\mathbf{d}_{\widehat G}^TF_{\widehat G}\mathbf{d}_{\widehat G}-k(m+k)\mathbf{d}_{\widetilde{G}}^TF_{\widetilde{G}}\mathbf{d}_{\widetilde{G}}\\
=&(m+k-1)\left(k\mathbf{d}^TF\mathbf{d}+4k^2\mathbf{d}^T\mathbf{f}^v+\frac{2\tau}{3}(k+2m)(k-1)k(k+1)\right)\\
&-k(m+k)\left(\mathbf{d}^TF\mathbf{d}+4(k-1)\mathbf{d}^T\mathbf{f}^v+\frac{4}{3}\tau(k-1)^3+\frac{2}{3}\tau(k-1)+4m\tau(k_1^2+k_2^2)\right)\\
=&-k\mathbf{d}^TF\mathbf{d}+4mk\mathbf{d}^T\mathbf{f}^v+4m^2\tau k\left(\frac{1}{3}(k-1)(k+1)-k_1^2-k_2^2\right)\\
+&\frac{2m\tau k}{3}\left((k-1)k(k+1)+2(k-1)^2(k+1)-2(k-1)^3-(k-1)-6k(k_1^2+k_2^2)\right)\\
+&\frac{2\tau k}{3}\left((k-1)^2k(k+1)-2k(k-1)^3-k(k-1)\right).
\end{split}
\end{align}
Since $\mathbf{1}^T\mathbf{d}=2m$, we have $4mk\mathbf{d}^T\mathbf{f}^v=2k\mathbf{d}^T\mathbf{f}^v\mathbf{1}^T\mathbf{d}$. Then, one can check from $k-1=k_1+k_2$ that the last expression in \eqref{temp:eqn11} can be recast as the left side of the inequality \eqref{inequality: paradoxical if and only if >0}.
\end{proof}
Now, we shall introduce the following notation to easily analyse the expression in \eqref{inequality: paradoxical if and only if >0}. Let $G$ be a connected graph of order $n$ with $V(G)=\{1,\dots,n\}$, and let
\begin{align*}
\phi_G(v)&:=\mathbf{d}_G^T(2\mathbf{f}_G^v\mathbf{1}^T-F_G)\mathbf{d}_G,\\
\phi_1(k_1,k_2)&:=-\frac{2}{3}(k_1+k_2)(k_1+k_2-1)+2k_1k_2,\\
\phi_2(k_1,k_2)&:=-(k_1+k_2)(5(k_1+k_2)^2-(k_1+k_2)-1)+12k_1k_2(k_1+k_2+1),\\
\phi_3(k_1,k_2)&:=-(k_1+k_2+1)(k_1+k_2)(k_1+k_2-1)^2,
\end{align*}
where $v$, $k_1$ and $k_2$ are integers such that $1\leq v\leq n$, $k_1, k_2\geq 0$ and $k_1+k_2\geq 2$. Furthermore, let
\begin{align}\label{Formula: Phi_G}
\hspace{-0.1cm}\Phi_G(v,k_1,k_2):=k\phi_G(v)+4m_G^2\tau_Gk\phi_1(k_1,k_2)+\frac{2m_G\tau_Gk}{3}\phi_2(k_1,k_2)+\frac{2\tau_G k}{3}\phi_3(k_1,k_2).
\end{align}
By Theorem \ref{Theorem:brass for general twin pendent path}, $G$ is $(v,k_1,k_2)$-paradoxical if and only if $\Phi_G(v,k_1,k_2)>0$. We simply write $\Phi_G(v,k_1,k_2)$ and $\phi_G(v)$ as $\Phi(v,k_1,k_2)$ and $\phi(v)$, respectively, if $G$ is clear from the context. Note that $\phi_i(k_1,k_2)=\phi_i(k_2,k_1)$ for $i=1,2,3$. So, $\Phi_G(v,k_1,k_2)=\Phi_G(v,k_2,k_1)$.
\begin{remark}
{\rm A connected graph $G$ is $(v,k_1,k_2)$-paradoxical if and only if $G$ is $(v,k_2,k_1)$-paradoxical. Furthermore, $G$ is $(k_1,k_2)$-paradoxical if and only if $G$ is $(k_2,k_1)$-paradoxical.}
\end{remark}
\subsection*{Signs of $\phi_i(k_1,k_2)$ for $i=1,2,3$ and $\phi_G(v)$}
We shall consider the signs of $\phi_i(k_1,k_2)$ for $i=1,2,3$ in terms of $k_1$ and $k_2$, and consider an upper bound for each $\phi_i(k_1,k_2)$. Evidently, $\phi_3(k_1,k_2)$ decreases as $k_1+k_2$ increases, and so
\begin{align}\label{minimum of phi_3}
\phi_3(k_1,k_2)\leq -6\;\text{for any $k_1, k_2\geq 0$ where $k_1+k_2\geq 2$}
\end{align}
with equality if and only if $k_1+k_2=2$. Next, $\phi_1(k_1,k_2)$ can be written as
$$\phi_1(k_1,k_2)=-\frac{2}{3}(k_1^2-(k_2+1)k_1+k_2^2-k_2).$$
Setting $\phi_1(k_1,k_2)=0$, we have
$$
k_1=\frac{1}{2}\left((k_2+1)\pm\sqrt{-3k_2^2+6k_2+1}\right).
$$
Since $\phi_1(k_1,k_2)$ is symmetric, without loss of generality, we shall fix $k_2$ first. It follows from $-3k_2^2+6k_2+1<0$ that if $k_2<1-\frac{2\sqrt{3}}{3}<0$ or $k_2>1+\frac{2\sqrt{3}}{3}>2$, then $\phi_1(k_1,k_2)<0$ for any $k_1\geq 0$. Furthermore, if $k_2=1$, then $\phi_1(1,1)=\frac{2}{3}$, $\phi_1(2,1)=0$ and $\phi_1(k_1,1)<0$ for $k_1>2$. Finally, for $k_2=2$, we have $\phi_1(0,2)=-\frac{4}{3}$, $\phi_1(1,2)=\phi_1(2,2)=0$ and $\phi_1(k_1,2)<0$ for $k_1>2$. Therefore, $\phi_1(k_1,k_2)>0$ if and only if $(k_1,k_2)=(1,1)$; $\phi_1(k_1,k_2)=0$ if and only if $(k_1,k_2)\in\{(1,2),(2,1),(2,2)\}$; and $\phi_1(k_1,k_2)<0$ for any $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$ and $(k_1,k_2)\notin\{(1,1),(1,2),(2,1),(2,2)\}$.
\begin{remark}\label{Remark:phi_1 decrease}
{\rm We have $\frac{\partial \phi_1}{\partial k_1}=-\frac{4}{3}k_1+\frac{2}{3}(k_2+1)$. Then, $\phi_1(2,0)=-\frac{4}{3}$ and $\frac{\partial \phi_1}{\partial k_1}\Bigr|_{\substack{k_2=0}}<0$ for $k_1\geq 2$; $\phi_1(3,1)=-2$ and $\frac{\partial \phi_1}{\partial k_1}\Bigr|_{\substack{k_2=1}}<0$ for $k_1\geq 3$; $\phi_1(3,2)=-\frac{4}{3}$ and $\frac{\partial \phi_1}{\partial k_1}\Bigr|_{\substack{k_2=2}}<0$ for $k_1\geq 3$; finally, $\phi_1(k_2,k_2)=-\frac{2}{3}(k_2^2-2k_2)\leq -2$ for $k_2\geq 3$ and $\frac{\partial \phi_1}{\partial k_1}<0$ for $k_1\geq k_2\geq 3$. Hence, since $\phi_1(k_1,k_2)$ is symmetric, $\phi_1(k_1,k_2)\leq -\frac{4}{3}$ for integers $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$ and $(k_1,k_2)\notin\{(1,1),(1,2),(2,1),(2,2)\}$. Furthermore, by computation, we have $\phi_1(3,0)=\phi_1(4,2)=-4$. Therefore, $\phi_1(k_1,k_2)\leq -2$ for integers $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$ and $(k_1,k_2)\notin\{(0,2),(2,0),(1,1),(1,2),(2,1),(2,2),(2,3),(3,2)\}$.}
\end{remark}
Putting $k-1=k_1+k_2\geq 2$, $\phi_2(k_1,k_2)$ can be written as
$$
\phi_2(k_1,k_2)=-12kk_1^2+12k(k-1)k_1-(k-1)(5k^2-11k+5).
$$
Setting $\phi_2(k_1,k_2)=0$, we have
$$
k_1=\frac{1}{12k}\left(6k(k-1)\pm\sqrt{-12k(k-1)(2k^2-8k+5)}\right).
$$
Since $2k^2-8k+5>0$ for all $k\geq 4$, $\phi_2(k_1,k_2)<0$ for any $k_1,k_2\geq 0$ with $k_1+k_2\geq 3$. For $k=3$, we have $\phi_2(1,1)=2>0$ and $\phi_2(2,0)=-34<0$. Let $f(t)=-(t-1)(2t^2-8t+5)$ where $t$ is real number. Then, for fixed $t\geq 3$, the maximum of $\phi_2(t_1,t_2)$ for nonnegative numbers $t_1$ and $t_2$ with $t_1+t_2=t-1$ is attained as $f(t)$ at $t_1=\frac{t-1}{2}$. We can find that $f(3)>0$, $f(4)=-15$ and $f'(t)<0$ for $t\geq 4$. From computation, we have $\phi_2(0,3)=-123$ and $\phi_2(1,2)=-27$. Hence,
\begin{align}\label{minimum of phi_2 for k}
\phi_2(k_1,k_2)<-15\; \text{for any $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$ and $(k_1,k_2)\neq(1,1)$.}
\end{align}
We claim that for a non-trivial connected graph $G$, $\phi(v)=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}>0$ for $v=1,\dots,n$. In order to establish our claim, we first show that $f_{i,j}^G$ is a metric on the vertex set of $G$ by using the resistance distance (see \cite{Klein:resistance} for an introduction). Let $L$ be the Laplacian matrix of $G$, and let $L^\dagger=[\ell^\dagger_{i,j}]_{n\times n}$ be the Moore--Penrose inverse of $L$. Then, the resistance distance $\Omega_{i,j}$ between vertices $i$ and $j$ of $G$ is represented (see \cite{Klein:sum}) as:
$$
\Omega_{i,j}=\ell^\dagger_{i,i}+\ell^\dagger_{j,j}-\ell^\dagger_{i,j}-\ell^\dagger_{j,i}.
$$
Moreover, the resistance distance is a metric on $V(G)$ (see \cite{Bapat:graphs}). As proved in \cite{Pavel:resistance}, the number $f_{i,j}^G$ of $2$-tree spanning forests of $G$ having $i$ and $j$ in different trees is
$$
f_{i,j}^G=\tau_G\Omega_{i,j}.
$$
Therefore, we have the following properties endowed by the metric $\Omega_{i,j}$:
\begin{enumerate}[label=(\roman*)]
\item $f_{i,j}^G\geq 0$, with equality if and only if $i=j$;
\item $f_{i,j}^G=f_{j,i}^G$ for all $i$, $j$;
\item for any $i,j,k$, $f_{i,j}^G\leq f_{i,k}^G+f_{k,j}^G$, with equality \cite{Kirkland:CombinatorialBook} if and only if either all paths in $G$ from $i$ to $j$ pass through $k$ or $k$ is one of $i$ and $j$.
\end{enumerate}
Let $X=2\mathbf{f}^v\mathbf{1}^T-F$, and $Q=[q_{i,j}]=\frac{X+X^T}{4}$. Then,
$$\mathbf{d}^TX\mathbf{d}=\frac{1}{2}(\mathbf{d}^TX\mathbf{d}+\mathbf{d}^TX^T\mathbf{d})=2\mathbf{d}^TQ\mathbf{d}.$$
Since $2Q=\mathbf{f}^v\mathbf{1}^T+\mathbf{1}(\mathbf{f}^v)^T-F$, we have $2q_{i,j}=f_{i,v}+f_{v,j}-f_{i,j}\geq 0$. Since $G$ is connected, if $i\neq v$, then there exists a $2$-tree spanning forest having $i$ and $v$ in different trees, \textit{i.e.,} $f_{i,v}>0$. For a non-trivial connected graph $G$, there exists a vertex $i$ with $i\neq v$ such that $2q_{i,i}=f_{i,v}+f_{v,i}>0$. Hence, $Q$ is a non-negative symmetric matrix with $Q\neq 0$. Since $\mathbf{d}>0$, we have $\mathbf{d}^TQ\mathbf{d}>0$. Therefore, $\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}>0$.
Recall that given a connected graph $G$ of order $n$ where $n\geq 2$, $G$ is $(v,k_1,k_2)$-paradoxical if and only if $\Phi(v,k_1,k_2)>0$, where $1\leq v\leq n$ and integers $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$. We have seen that $\phi(v)>0$ for any $1\leq v\leq n$ regardless of $k_1$ and $k_2$; $\phi_1(k_1,k_2)\geq 0$ if and only if $(k_1,k_2)\in\{(1,1),(1,2),(2,1),(2,2)\}$; $\phi_2(k_1,k_2)<0$ for any $k_1,k_2$ with $(k_1,k_2)\neq(1,1)$; and $\phi_3(k_1,k_2)<0$ for any $k_1,k_2$. Hence, $\phi(v)$ must have a relatively larger quantity in order for $G$ to be $(v,k_1,k_2)$-paradoxical.
Consider the case $k_1=k_2=1$. Then, $\Phi(v,1,1)=3\phi(v)+8m_G^2\tau_G+4m_G\tau_G-12\tau_G$. Clearly, $\Phi(v,1,1)>0$ for any non-trivial connected graph $G$ and any vertex $v$ of $G$. Hence, we have the following result.
\begin{theorem}\cite{CiardoparadoxicalTwins}\label{Theorem: (v,1,1)-paradoxical}
Let $G$ be a connected graph of order $n$ where $n\geq 2$. Then, $G$ is $(1,1)$-paradoxical.
\end{theorem}
\subsection*{Combinatorial interpretation for $\mathbf{f}^v_G\mathbf{1}^T+\mathbf{1}(\mathbf{f}^v_G)^T-F_G$}
Let $G$ be a non-trivial connected graph with a vertex $v$. We now discuss a combinatorial interpretation for $q_{i,j}$ where $q_{i,j}=\frac{1}{2}(f_{i,v}^G+f_{v,j}^G-f_{i,j}^G)$. Denote by $\mathcal{F}_{G}(i,j;v)$ (or equivalently $\mathcal{F}_{G}(v;i,j)$) the set of all spanning forests consisting of two trees in $G$, one of which contains vertices $i$ and $j$ and the other of which contains a vertex $v$. Then, we have
\begin{align*}
|\mathcal{F}_{G}(i;j)|&=|\mathcal{F}_{G}(i;v,j)|+|\mathcal{F}_{G}(i,v;j)|,\\
|\mathcal{F}_{G}(i;v)|&=|\mathcal{F}_{G}(i,j;v)|+|\mathcal{F}_{G}(i;v,j)|,\\
|\mathcal{F}_{G}(v;j)|&=|\mathcal{F}_{G}(i,v;j)|+|\mathcal{F}_{G}(v;i,j)|.
\end{align*}
It follows that $2q_{i,j}=f_{i,v}+f_{v,j}-f_{i,j}=2|\mathcal{F}_{G}(i,j;v)|$, that is, $q_{i,j}$ is the number of $2$-tree spanning forests of $G$ having $i$, $j$ in one tree and $v$ in the other. Thus, we define $Q_{G,v}$ as the matrix $Q_{G,v}=[q_{i,j}]$ associated to $G$ and $v$. Then,
\begin{align*}
Q_{G,v}=\frac{1}{2}(\mathbf{f}^v\mathbf{1}^T+\mathbf{1}(\mathbf{f}^v)^T-F),\;\;\phi_G(v)=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}=2\mathbf{d}^TQ_{G,v}\mathbf{d}.
\end{align*}
\begin{remark}\label{Remark:entries r}
{\rm Let $G$ be a connected graph with a vertex $v$. Let $Q_{G,v}=[q_{i,j}]$. Since $2q_{i,j}=f_{i,v}+f_{v,j}-f_{i,j}$, we have $q_{i,j}=0$ whenever $v=i$ or $v=j$. Suppose that $v$ is a cut-vertex. If there is no path from $i$ to $j$ with $i\neq v$ and $j\neq v$ in $G-v$, then by the combinatorial interpretation for $q_{i,j}$, we obtain $q_{i,j}=0$. Consider a branch $B$ of $G$ at $v$. Let $i,j\in V(B)$. For each forest in $\mathcal{F}_{G}(i,j;v)$, the subtree with the vertex $v$ in the forest must contain all vertices of $V(G)\backslash V(B)$. Thus, for the subgraph $G'$ induced by $V(G)\backslash (V(B)-\{v\})$, we have $|\mathcal{F}_{G}(i,j;v)|=\tau_{G'}|\mathcal{F}_{B}(i,j;v)|$. This implies that $G'$ is a tree if and only if $|\mathcal{F}_{G}(i,j;v)|=|\mathcal{F}_{B}(i,j;v)|$.
Given a tree $\mathcal T$ with a vertex $v$, let $Q_{\mathcal T,v}=[q_{i,j}]$. Consider two vertices $i$ and $j$ in $\mathcal T$ with $i\neq v$ and $j\neq v$. For each forest in $\mathcal{F}_{\mathcal T}(i,j;v)$, there is a subtree of the forest having $i$ and $j$. Then, all vertices $w_0,w_1,\dots,w_{\mathrm{dist}(i,j)}$ on the subpath with pendent vertices $i$ and $j$ must be contained in the subtree. Therefore, $q_{i,j}=\mathrm{min}\{\mathrm{dist}(v,w_p)|p=0,\dots,\mathrm{dist}(i,j)\}$. In particular, if $i=j$ then $q_{i,j}=\mathrm{dist}(i,v)$.}
\end{remark}
Based on Remark \ref{Remark:entries r}, let us consider the following example.
\begin{example}\label{Example:R_Pn v}
{\rm Consider the path $P_6=(1,\dots,6)$. Let $Q_{P_n,v}=[q_{i,j}]$ where $v=3$. Evidently, $q_{3,i}=q_{i,3}=0$ for $1\leq i\leq 6$. Since $v$ is a cut vertex, we have $q_{i,j}=0$ for $i\in\{1,2\}$ and $j\in\{4,5,6\}$. By the argument in the second paragraph of Remark \ref{Remark:entries r}, we have
\begin{align*}
Q_{P_n,v}=\begin{bmatrix}
2 & 1 & 0 & 0 & 0 & 0\\
1 & 1 & 0 & 0 & 0 & 0\\
0 & 0 & 0 & 0 & 0 & 0\\
0 & 0 & 0 & 1 & 1 & 1\\
0 & 0 & 0 & 1 & 2 & 2\\
0 & 0 & 0 & 1 & 3 & 3\\
\end{bmatrix}.
\end{align*}}
\end{example}
While the combinatorial interpretation for entries of $Q_{G,v}$ is given, we mainly focus on the computation of $\mathbf{d}^TQ_{G,v}\mathbf{d}$ in the rest of this section; but the combinatorial interpretation is used more in Section \ref{Section:Asymptotic for trees}.
\subsection*{Several examples} We now find conditions for $K_n$, $C_n$, $P_n$ or $S_n$ to be $(v,k_1,k_2)$-paradoxical or $(k_1,k_2)$-paradoxical. For simplicity, set $k-1=k_1+k_2$ and $\phi_i=\phi_i(k_1,k_2)$ for $i=1,2,3$. Note that $\phi_G(v)=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}=2\mathbf{d}^TQ_{G,v}\mathbf{d}$ and $\phi_i(k_1,k_2)=\phi_i(k_2,k_1)$ for $i=1,2,3$. We compute $\phi_G(v)$ by using $F$ and $\mathbf{f}^v$ for $G=K_n$ or $G=C_n$, and by directly finding $Q_{G,v}$ for $G=P_n$ or $G=S_n$. For convenience, the following quantities are computed in advance: $\phi_2(1,2)=-27$, $\phi_3(1,2)=-48$, $\phi_2(2,2)=-60$ and $\phi_3(2,2)=-180$.
\begin{example}\label{Ex:asymp for K_n}
{\rm Consider a complete graph $K_n$ on $n$ vertices. Let $v$ be a vertex of $K_n$. Then, from $\phi(v)=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}$ and Example \ref{ex:K_n}, it is readily seen that
$$
\phi(v)=2n^{n-2}(n-1)^3=2\tau(n-1)^3.
$$
Using \eqref{Formula: Phi_G} with $m=\frac{n(n-1)}{2}$, we obtain
\begin{align*}
\Phi_{K_n}(v,k_1,k_2)=\tau k\left(2(n-1)^3+n^2(n-1)^2\phi_1+\frac{1}{3}n(n-1)\phi_2+\frac{2}{3}\phi_3\right).
\end{align*}
Suppose that $(k_1,k_2)\notin \{(1,1),(1,2),(2,1),(2,2)\}$. By Remark \ref{Remark:phi_1 decrease}, $\phi_1\leq -\frac{4}{3}$. From \eqref{minimum of phi_2 for k}, we have $\phi_2<-15$. By \eqref{minimum of phi_3}, $\phi_3\leq -6$. Hence,
\begin{align*}
\Phi(v,k_1,k_2)<\tau k\left(-\frac{4}{3}n^4 + \frac{14}{3}n^3-\frac{37}{3}n^2 +11n-6\right).
\end{align*}
One can verify that $-\frac{4}{3}n^4 + \frac{14}{3}n^3-\frac{37}{3}n^2 +11n-6<0$ for $n\geq 1$. Thus, if $(k_1,k_2)\notin\{(1,1),(1,2),(2,1),(2,2)\}$, then $K_n$ is not $(v,k_1,k_2)$-paradoxical for any $n\geq 1$.
Consider $(k_1,k_2)=(1,2)$ and $(k_1,k_2)=(2,2)$. Then,
\begin{align*}
&\Phi(v,1,2)=4\tau\left(2(n-1)^3-9n(n-1)-32\right),\\
&\Phi(v,2,2)=5\tau\left(2(n-1)^3-20n(n-1)-120\right).
\end{align*}
Using the derivatives of $\frac{\Phi(v,1,2)}{4\tau}$ and $\frac{\Phi(v,2,2)}{10\tau}$ with respect to $n$, it can be checked that $\Phi(v,1,2)>0$ if and only if $n\geq 7$; $\Phi(v,2,2)>0$ if and only if $n\geq 13$. Hence, $K_n$ is $(1,2)$-paradoxical for $n\geq 7$, and $(2,2)$-paradoxical for $n\geq 13$.}
\end{example}
\begin{example}\label{Ex:asymp for C_n}
{\rm Given a cycle $C_n$ with a vertex $v$, from $\phi(v)=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F)\mathbf{d}$ and Example \ref{ex:C_n}, we have $\phi(v)=\frac{2}{3}(n-1)n^2(n+1)=\frac{2\tau}{3}(n-1)n(n+1)$. Using \eqref{Formula: Phi_G}, we find
\begin{align*}
\Phi_{C_n}(v,k_1,k_2)=\tau k\left(\frac{2}{3}(n-1)n(n+1)+4n^2\phi_1+\frac{2}{3}n\phi_2+\frac{2}{3}\phi_3\right).
\end{align*}
We observe that the term of the highest degree about $n$ in $\frac{\Phi(v,k_1,k_2)}{\tau k}$ has a positive coefficient. This implies that given $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$, $C_n$ is $(k_1,k_2)$-paradoxical for sufficiently large $n$. Consider $(k_1,k_2)=(1,2)$ and $(k_1,k_2)=(2,2)$. Then,
\begin{align*}
&\Phi(v,1,2)=4\tau\left(\frac{2}{3}(n-1)n(n+1)-18n-32\right),\\
&\Phi(v,2,2)=5\tau\left(\frac{2}{3}(n-1)n(n+1)-40n-120\right).
\end{align*}
One can verify that $\Phi(v,1,2)\geq 0$ for $n\geq 6$ with equality if and only if $n=6$; $\Phi(v,2,2)\geq 0$ for $n\geq 9$ with equality if and only if $n=9$. Hence, $C_n$ is $(1,2)$-paradoxical for $n\geq 7$, and $(2,2)$-paradoxical for $n\geq 10$.}
\end{example}
\begin{example}\label{Ex:asymp for P_n}
{\rm Consider the path $P_n=(1,\dots,n)$ with a vertex $v$. By Remark \ref{Remark:entries r} and Example \ref{Example:R_Pn v}, we have
\begin{align*}
Q_{P_n,v}=\begin{bmatrix}
M_1 & 0 \\
0 & M_2
\end{bmatrix}
\end{align*}
where $M_1=\begin{bmatrix}
\mathrm{min}\{v-i,v-j\}
\end{bmatrix}_{1\leq i,j\leq v}$ and $M_2=\begin{bmatrix}
\mathrm{min}\{i,j\}
\end{bmatrix}_{1\leq i,j\leq n-v}$. We have $\mathbf{d}_{P_n}=2\mathbf{1}_{n}-\mathbf{e}_1-\mathbf{e}_{n}$. Then,
\begin{align*}
\mathbf{d}^TQ_{P_n,v}\mathbf{d}&=4\mathbf{1}^TQ_{P_n,v}\mathbf{1}+(M_1)_{1,1}+(M_2)_{n-v,n-v}-4\mathbf{1}^TQ_{P_n,v}\mathbf e_1-4\mathbf{1}^TQ_{P_n,v}\mathbf e_n\\
&=4\left(\sum_{k=1}^{v-1}k^2+\sum_{k=1}^{n-v}k^2\right)+n-1-2v(v-1)-2(n-v)(n-v+1)\\
&=4(n-1)v^2-4(n^2-1)v+\frac{4}{3}n^3-\frac{1}{3}n-1.
\end{align*}
The minimum of $\mathbf{d}^TQ_{P_n,v}\mathbf{d}$ is attained as $\frac{1}{3}n(n-1)(n-2)$ if $n$ is odd, and as $\frac{1}{3}n^3-n^2+\frac{5}{3}n-1$ if $n$ is even. The maximum of $\mathbf{d}^TQ_{P_n,v}\mathbf{d}$ is $\frac{1}{3}(n-1)(2n-1)(2n-3)$ at $v=1$ or $v=n$.
By \eqref{Formula: Phi_G} and the minimum of $\phi(v)=2\mathbf{d}^TQ_{P_n,v}\mathbf{d}$, we have
$$\Phi_{P_n}(v,k_1,k_2)\geq k\left(\frac{2}{3}n(n-1)(n-2)+4(n-1)^2\phi_1+\frac{2}{3}(n-1)\phi_2+\frac{2}{3}\phi_3\right).$$
By a similar argument as in Example \ref{Ex:asymp for C_n}, given $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$, $P_n$ is $(k_1,k_2)$-paradoxical for sufficiently large $n$.}
\end{example}
\begin{example}\label{Ex:asymp for star}
{\rm Consider a star $S_n$ of order $n$ with a vertex $v$. Using Remark \ref{Remark:entries r}, it can be checked that
\begin{align*}
Q_{S_n,v}=\begin{cases*}
J+\begin{bmatrix}
I_{n-1} & 0\\
0 & 0
\end{bmatrix}-\mathbf e_v\mathbf{1}^T-\mathbf{1}\mathbf e_v^T, & \text{if $\mathrm{deg}(v)=1$,}\\
\begin{bmatrix}
I_{n-1} & 0\\
0 & 0
\end{bmatrix}, & \text{if $\mathrm{deg}(v)=n-1$}.
\end{cases*}
\end{align*}
Hence,
$$\mathbf{d}^TQ_{S_n,v}\mathbf{d}=\begin{cases*}
(n-1)(4n-7), & \text{if $\mathrm{deg}(v)=1$,}\\
n-1, & \text{if $\mathrm{deg}(v)=n-1$}.
\end{cases*}$$
Suppose that $v$ is the centre vertex. Then, $n\geq 3$. By \eqref{Formula: Phi_G} and $\phi(v)=2\mathbf{d}^TQ_{S_n,v}\mathbf{d}$, we have
\begin{align*}
\Phi_{S_n}(v,k_1,k_2)=k\left(2(n-1)+4(n-1)^2\phi_1+\frac{2}{3}(n-1)\phi_2+\frac{2}{3}\phi_3\right).
\end{align*}
Let $(k_1,k_2)\neq (1,1)$. Clearly, $\phi_1\leq 0$. By \eqref{minimum of phi_2 for k} and \eqref{minimum of phi_3}, we have $\phi_2<-15$ and $\phi_3\leq -6$, respectively. So, $\Phi(v,k_1,k_2)<-4k(2n-1)$. Hence, if $S_n$ is $(v,k_1,k_2)$-paradoxical where $v$ is the centre vertex of $S_n$, then $(k_1,k_2)=(1,1)$ and $n\geq 3$.
Suppose that $v$ is a pendent vertex. Then,
\begin{align*}
\Phi_{S_n}(v,k_1,k_2)=k\left(2(n-1)(4n-7)+4(n-1)^2\phi_1+\frac{2}{3}(n-1)\phi_2+\frac{2}{3}\phi_3\right).
\end{align*}
We have $\phi_1(2,0)=-\frac{4}{3}$, $\phi_2(2,0)=-34$ and $\phi_3(2,0)=-6$; $\phi_1(3,2)=-\frac{4}{3}$, $\phi_2(3,2)=-163$ and $\phi_3(3,2)=-480$. One can check that $\Phi(v,2,0)=8n^2-102n+82>0$ for $n\geq 12$; $\Phi(v,2,1)=32n^2-160n>0$ for $n\geq 6$; $\Phi(v,2,2)=40n^2-310n-330>0$ for $n\geq 9$; and $\Phi(v,3,2)=16n^2-720n-1216>0$ for $n\geq 47$. Let $$A=\{(0,2),(2,0),(1,1),(1,2),(2,1),(2,2),(2,3),(3,2)\}.$$
Suppose that $(k_1,k_2)\notin A$. By Remark \ref{Remark:phi_1 decrease}, we have $\phi_1(k_1,k_2)\leq -2$. From \eqref{minimum of phi_2 for k} and \eqref{minimum of phi_3}, $\phi_2< -15$ and $\phi_3\leq -6$, respectively. Hence, $\Phi(v,k_1,k_2)< -k(16n-12)$. Therefore, if $S_n$ is $(v,k_1,k_2)$-paradoxical for a pendent vertex $v$, then $k_1$, $k_2$ and $n$ satisfy one of the following: \begin{enumerate*}[label=(\roman*)]
\item $(k_1,k_2)=(1,1)$, $n\geq 2$; \item $(k_1,k_2)\in\{(0,2),(2,0)\}$, $n\geq 12$; \item $(k_1,k_2)\in\{(1,2),(2,1)\}$, $n\geq 6$; \item $(k_1,k_2)=(2,2)$, $n\geq 9$; and \item $(k_1,k_2)\in\{(2,3),(3,2)\}$, $n\geq 47$.
\end{enumerate*}}
\end{example}
\iffalse
We now compute $\mathbf{d}^TQ_{G,v}\mathbf{d}$ where $G$ is one of $K_n$, $C_n$, $P_n$, and $S_n$, with some vertex $v$ of $G$.
\begin{example}\label{Ex:Kn drd}
{\rm Given a complete graph $K_n$ of order $n$ and a vertex $v$ of $K_n$, from $2\mathbf{d}^TQ_{K_n,v}\mathbf{d}=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F_{K_n})\mathbf{d}$ and Example \ref{ex:K_n}, it is readily seen that
$$
\mathbf{d}^TQ_{K_n,v}\mathbf{d}=n^{n-2}(n-1)^3.
$$}
\end{example}
\begin{example}\label{Ex:Cn drd}
{\rm Given a cycle $C_n$ of length $n$ with a vertex $v$, from $2\mathbf{d}^TQ_{C_n,v}\mathbf{d}=\mathbf{d}^T(2\mathbf{f}^v\mathbf{1}^T-F_{C_n})\mathbf{d}$ and Example \ref{ex:C_n}, we have
$$
\mathbf{d}^TQ_{C_n,v}\mathbf{d}=\frac{1}{3}(n-1)n^2(n+1).
$$}
\end{example}
Let us compute $\mathbf{d}^TQ_{G,v}\mathbf{d}$, where $G$ is one of $P_n$ and $S_n$ with some vertex $v$ of $G$, by finding $Q_{G,v}$ instead of using $F$ and $\mathbf{f}^v$.
\begin{example}\label{Ex:P_n drd}
{\rm Given the path $P_n=(1,2,\dots,n)$ and a vertex $v$ for $1\leq v\leq n$, considering Remark \ref{Remark:entries r} and Example \ref{Example:R_Pn v}, we have
\begin{align*}
Q_{P_n,v}=\begin{bmatrix}
M_1 & 0 \\
0 & M_2
\end{bmatrix}
\end{align*}
where $M_1=\begin{bmatrix}
\mathrm{min}\{v-i,v-j\}
\end{bmatrix}_{1\leq i,j\leq v}$ and $M_2=\begin{bmatrix}
\mathrm{min}\{i,j\}
\end{bmatrix}_{1\leq i,j\leq n-v}$. We have $\mathbf{d}_{P_n}=2\mathbf{1}_{n}-\mathbf{e}_1-\mathbf{e}_{n}$. Then,
\begin{align*}
\mathbf{d}^TQ_{P_n,v}\mathbf{d}&=4\mathbf{1}^TQ_{P_n,v}\mathbf{1}+(M_1)_{1,1}+(M_2)_{n-v,n-v}-4\mathbf{1}^TQ_{P_n,v}\mathbf e_1-4\mathbf{1}^TQ_{P_n,v}\mathbf e_n\\
&=4\left(\sum_{k=1}^{v-1}k^2+\sum_{k=1}^{n-v}k^2\right)+n-1-2v(v-1)-2(n-v)(n-v+1)\\
&=4(n-1)v^2-4(n^2-1)v+\frac{4}{3}n^3-\frac{1}{3}n-1.
\end{align*}
The minimum of $\mathbf{d}^TQ_{P_n,v}\mathbf{d}$ is attained as $\frac{1}{3}n(n-1)(n-2)$ if $n$ is odd, and as $\frac{1}{3}n^3-n^2+\frac{5}{3}n-1$ if $n$ is even. The maximum of $\mathbf{d}^TQ_{P_n,v}\mathbf{d}$ is $\frac{1}{3}(n-1)(2n-1)(2n-3)$ at $v=1$ or $v=n$.}
\end{example}
\begin{example}\label{Ex:S_n drd}
{\rm Consider a star $S_n$ of order $n$. Suppose that $n$ is the centre vertex. Using Remark \ref{Remark:entries r}, it can be checked that
\begin{align*}
Q_{S_n,v}=\begin{cases*}
J+\begin{bmatrix}
I_{n-1} & 0\\
0 & 0
\end{bmatrix}-\mathbf e_v\mathbf{1}^T-\mathbf{1}\mathbf e_v^T, & \text{if $\mathrm{deg}(v)=1$,}\\
\begin{bmatrix}
I_{n-1} & 0\\
0 & 0
\end{bmatrix}, & \text{if $\mathrm{deg}(v)=n-1$}.
\end{cases*}
\end{align*}
Hence,
$$\mathbf{d}^TQ_{S_n,v}\mathbf{d}=\begin{cases*}
(n-1)(4n-7), & \text{if $\mathrm{deg}(v)=1$,}\\
n-1, & \text{if $\mathrm{deg}(v)=n-1$}.
\end{cases*}$$}
\end{example}
\fi
\section{Asymptotic behaviour of a sequence of graphs with twin pendent paths regarding the Braess edge}\label{Section: Asymptotic}
We have seen the families of complete graphs, cycles, stars, and paths in the previous section, and we have observed their asymptotic behaviours with respect to the property of being $(v,k_1,k_2)$-paradoxical as the orders of graphs increase. In particular, from Examples \ref{Ex:asymp for C_n} and \ref{Ex:asymp for P_n}, if for any non-negative integers $k_1$ and $k_2$ with $k_1+k_2\geq 2$, any graph in a family of cycles or paths has sufficiently large order relative to $k_1$ and $k_2$, then it is $(k_1,k_2)$-paradoxical. This idea is formalized for a specified vertex, and a tool for finding such families is described in this section.
\begin{definition}\label{Def:asymptotically}
{\rm Let $\mathcal G^v$ be a sequence of graphs $G_1,G_2,\dots$ where for each $n\geq 1$, $G_n$ is a connected graph of order $n$ with a {\em specified} vertex $v$. Fix integers $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$. The sequence $\mathcal G^v$ is {\em asymptotically $(k_1,k_2)$-paradoxical} if there exists $N>0$ such that $G_n$ is $(v,k_1,k_2)$-paradoxical for all $n\geq N$. The sequence $\mathcal G^v$ is {\em asymptotically paradoxical} if for any integers $l_1,l_2\geq 0$ with $l_1+l_2\geq 2$, $\mathcal G^v$ is asymptotically $(l_1,l_2)$-paradoxical.}
\end{definition}
In what follows, $\mathcal G^v=(G_n)^v$ denotes a sequence of connected graphs $G_1,G_2,\dots$ where for each $n\geq 1$, $|V(G_n)|=n$ and $v\in V(G_n)$.
\begin{example}
{\rm From Theorem \ref{Theorem: (v,1,1)-paradoxical}, any sequence $\mathcal G^v=(G_n)^v$ is asymptotically $(1,1)$-paradoxical.}
\end{example}
\begin{example}
{\rm Let $\mathcal G_1^v=(K_n)^v$, $\mathcal G_2^v=(C_n)^v$, $\mathcal G_3^v=(P_n)^v$ and $\mathcal G_4^v=(S_n)^v$. From Examples \ref{Ex:asymp for K_n}--\ref{Ex:asymp for star}, $\mathcal G_2^v$ and $\mathcal G_3^v$ are asymptotically paradoxical, but $\mathcal G_1^v$ and $\mathcal G_4^v$ are not. In particular, $\mathcal G_1^v$ is asymptotically $(k_1,k_2)$-paradoxical if and only if $(k_1,k_2)\in\{(1,1),(1,2),(2,1),(2,2)\}$. Consider $\mathcal G_4^v=(S_n)^v$. Suppose that there exists $N>0$ such that $v$ is a pendent vertex of $S_n$ for all $n\geq N$. Then, $\mathcal G_4^v$ is asymptotically $(k_1,k_2)$-paradoxical if and only if $(k_1,k_2)$ is in the set $A$ described in Example \ref{Ex:asymp for star}. If there exists $N>0$ such that $v$ is the centre vertex of $S_n$ for all $n\geq N$, then $\mathcal G_4^v$ is asymptotically $(k_1,k_2)$-paradoxical if and only if $(k_1,k_2)=(1,1)$.}
\end{example}
Consider a sequence $\mathcal G^v=(G_n)^v$. Examining the proof of Theorem \ref{Theorem:brass for general twin pendent path} with \eqref{diff:Ghat Gtil}, we find from \eqref{Formula: Phi_G} that
\begin{align}\nonumber
&\kappa(\widehat{G}_n(v,k_1,k_2))-\kappa(\widetilde{G}_n(v,k_1,k_2))\\\nonumber
=&\frac{\Phi_{G_n}(v,k_1,k_2)}{4k(m_{G_n}+k)(m_{G_n}+k-1)\tau_{G_n}}\\\label{Tempeqn}
=&\frac{\phi_{G_n}(v)+4m_{G_n}^2\tau_{G_n}\phi_1(k_1,k_2)+\frac{2m_{G_n}\tau_{G_n}}{3}\phi_2(k_1,k_2)+\frac{2\tau_{G_n}}{3}\phi_3(k_1,k_2)}{4(m_{G_n}+k)(m_{G_n}+k-1)\tau_{G_n}}.
\end{align}
Note that since $\phi_{G_n}(v)>0$ for all $n\geq 2$, we have $\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}>0$.
We introduce a sufficient condition for $\mathcal G^v=(G_n)^v$ to be asymptotically $(k_1,k_2)$-paradoxical. Moreover, the following result can be used for minimizing $N_0>0$ such that $G_n$ is $(v,k_1,k_2)$-paradoxical for all $n\geq N_0$.
\begin{proposition}\label{Proposition:monotone}
Let $k_1,k_2$ be non-negative integers with $k_1+k_2\geq 2$ and $(k_1,k_2)\neq(1,1)$. Given a sequence $\mathcal G^v=(G_n)^v$, suppose that $\frac{\phi_{G_{N+1}}(v)}{4m_{G_{N+1}}^2\tau_{G_{N+1}}}\geq\frac{\phi_{G_N}(v)}{4m_{G_N}^2\tau_{G_N}}$ for some $N>0$. If $G_N$ is $(v,k_1,k_2)$-paradoxical, then $G_{N+1}$ is $(v,k_1,k_2)$-paradoxical. This implies that if $G_{N_0}$ is $(v,k_1,k_2)$-paradoxical for some $N_0>0$, and if $\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}$ is non-decreasing for $n\geq N_0$, then $G_n$ is $(v,k_1,k_2)$-paradoxical for all $n\geq N_0$---that is, $\mathcal G^v=(G_n)^v$ is asymptotically $(k_1,k_2)$-paradoxical.
\end{proposition}
\begin{proof}
We only need to show that if $\Phi_{G_{N}}(v,k_1,k_2)>0$ then $\Phi_{G_{N+1}}(v,k_1,k_2)>0$. We note that $m_{G_{N+1}}>m_{G_n}$. From the numerator in \eqref{Tempeqn}, it follows that
\begin{align*}
\Phi_{G_{N+1}}(v,k_1,k_2)&=4m_{G_{N+1}}^2\tau_{G_{N+1}}\left(\frac{\phi_{G_{N+1}}(v)}{4m_{G_{N+1}}^2\tau_{G_{N+1}}}+\phi_1(k_1,k_2)+\frac{\phi_2(k_1,k_2)}{6m_{G_{N+1}}}+\frac{\phi_3(k_1,k_2)}{6m_{G_{N+1}}^2}\right)\\
&> 4m_{G_{N+1}}^2\tau_{G_{N+1}}\left(\frac{\phi_{G_{N+1}}(v)}{4m_{G_{N+1}}^2\tau_{G_{N+1}}}+\phi_1(k_1,k_2)+\frac{\phi_2(k_1,k_2)}{6m_{G_{N}}}+\frac{\phi_3(k_1,k_2)}{6m_{G_{N}}^2}\right)\\
&\geq 4m_{G_{N+1}}^2\tau_{G_{N+1}}\left(\frac{\phi_{G_{N}}(v)}{4m_{G_{N}}^2\tau_{G_{N}}}+\phi_1(k_1,k_2)+\frac{\phi_2(k_1,k_2)}{6m_{G_{N}}}+\frac{\phi_3(k_1,k_2)}{6m_{G_{N}}^2}\right)\\
&=4m_{G_{N+1}}^2\tau_{G_{N+1}}\frac{\Phi_{G_{N}}(v,k_1,k_2)}{4m_{G_{N}}^2\tau_{G_{N}}}>0.
\end{align*}
Note that the first inequality is obtained by \eqref{minimum of phi_2 for k} and \eqref{minimum of phi_3}.
\end{proof}
\begin{example}
{\rm Let $(k_1,k_2)=(1,2)$. Consider $\mathcal G^v=(P_n)^v$ where for each $n\geq 2$, $v$ is a pendent vertex of $P_n$. Examining Example \ref{Ex:asymp for P_n}, it can be seen that $\Phi_{P_{4}}(v,1,2)<0$ and $\Phi_{P_{5}}(v,1,2)>0$; and $\frac{\phi_{P_n}(v)}{4m_{P_n}^2\tau_{P_n}}$ is strictly increasing for $n\geq 2$. Therefore, by Proposition \ref{Proposition:monotone}, $P_n$ is $(v,1,2)$-paradoxical for $n\geq 5$.
}
\end{example}
Here is the main result in this section.
\begin{theorem}\label{Theorem:asymtotically paradoxical}
Given a sequence $\mathcal G^v=(G_n)^v$, $\mathcal G^v$ is asymptotically paradoxical if and only if $\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}\rightarrow\infty$ as $n\rightarrow\infty$.
\end{theorem}
\begin{proof}
We shall prove the sufficiency by contrapositive. Suppose that $\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}$ is bounded, say $0<\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}\leq L$ for any $n\geq 2$ and for some $L>0$. Then, from \eqref{Tempeqn}, we have
\begin{align*}
&\kappa(\widehat{G}_n(v,k_1,k_2))-\kappa(\widetilde{G}_n(v,k_1,k_2))\\
<&\frac{\phi_{G_n}(v)+4m_{G_n}^2\tau_{G_n}\phi_1(k_1,k_2)+\frac{2m_{G_n}\tau_{G_n}}{3}\phi_2(k_1,k_2)+\frac{2\tau_{G_n}}{3}\phi_3(k_1,k_2)}{4m_{G_n}^2\tau_{G_n}}\\
\leq&L+\phi_1(k_1,k_2)+\frac{\phi_2(k_1,k_2)}{6m_{G_n}}+\frac{\phi_3(k_1,k_2)}{6m_{G_n}^2}.
\end{align*}
Considering Remark \ref{Remark:phi_1 decrease}, \eqref{minimum of phi_2 for k}, and \eqref{minimum of phi_3}, there exist integers $K_1\geq 0$ and $K_2\geq 0$ with $K_1+K_2\geq 2$ such that $\kappa(\widehat{G}_n(v,K_1,K_2))-\kappa(\widetilde{G}_n(v,K_1,K_2))<0$ for all $n\geq 2$---that is, $\mathcal G^v$ is not asymptotically paradoxical.
Suppose that $\frac{\phi_{G_n}(v)}{4m_{G_n}^2\tau_{G_n}}$ diverges to infinity. Fix $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$. Since $G_n$ is connected for all $n\geq 1$, $m_{G_n}$ goes to infinity as $n\rightarrow\infty$. It follows from \eqref{Tempeqn} that
\begin{align*}
\lim_{n\rightarrow\infty}\left(\kappa(\widehat{G}_n(v,k_1,k_2))-\kappa(\widetilde{G}_n(v,k_1,k_2))\right)=\infty.
\end{align*}
Therefore, $\mathcal G^v$ is asymptotically paradoxical.
\end{proof}
\begin{example}\label{Example:asymp. paradoxical}
{\rm Revisit Examples \ref{Ex:asymp for K_n}--\ref{Ex:asymp for star}. One can verify that as $n\rightarrow\infty$, we have $\frac{\phi_{K_n}(v)}{4m_{K_n}^2\tau_{K_n}}\rightarrow0$; $\frac{\phi_{C_n}(v)}{4m_{C_n}^2\tau_{C_n}}\rightarrow\infty$; $\frac{\phi_{P_n}(v)}{4m_{P_n}^2\tau_{P_n}}\rightarrow\infty$; $\frac{\phi_{S_n}(v)}{4m_{S_n}^2\tau_{S_n}}\rightarrow 2$ where $v$ is a pendent vertex of $S_n$; and $\frac{\phi_{S_n}(v)}{4m_{S_n}^2\tau_{S_n}}\rightarrow 0$ where $v$ is the centre vertex of $S_n$. By Theorem \ref{Theorem:asymtotically paradoxical}, the sequences $(C_n)^v$ and $(P_n)^v$ are asymptotically paradoxical.}
\end{example}
Now we shall construct $(v,k_1,k_2)$-paradoxical graphs from a connected graph that is not $(v,k_1,k_2)$-paradoxical, by using an asymptotically paradoxical sequence. Given a connected graph $G$ with a vertex $v$, suppose that $G$ is not $(v,k_1,k_2)$-paradoxical. Adding new vertices and edges to $G$, we shall make the resulting graph $(v,k_1,k_2)$-paradoxical.
Note that the case of the equality in the following proposition is used in Section \ref{Section:Asymptotic for trees}.
\begin{proposition}\label{Proposition:dRd with cut vertex}
Let $G$ be a connected graph, and $v$ be a cut-vertex. Suppose that there are $\ell$ branches $B_1,\dots,B_\ell$ of $G$ at $v$. Then,
\begin{align}\label{drd:branches}
\mathbf{d}_G^TQ_{G,v}\mathbf{d}_G=\sum_{k=1}^{\ell}\tau_{G'_k}\mathbf{d}_{B_k}^TQ_{B_k,v}\mathbf{d}_{B_k}\geq \sum_{k=1}^{\ell}\mathbf{d}_{B_k}^TQ_{B_k,v}\mathbf{d}_{B_k}
\end{align}
where $G'_k$ is the subgraph induced by $V(G)\backslash (V(B_k)-\{v\})$. This implies that $\phi_G(v)\geq\sum_{k=1}^{\ell}\phi_{B_k}(v)$. Moreover, the two sides are equal if and only if $G$ is a tree.
\end{proposition}
\begin{proof}
Let $Q_{G,v}=[q_{i,j}]$. By Remark \ref{Remark:entries r}, if $i=v$ or $j=v$, then $q_{i,j}=0$. Consider $i\neq v$ and $j\neq v$. Suppose that $i\in V(B_{k_1})$ and $j\in V(B_{k_2})$ for $k_1\neq k_2$. Since $v$ is a cut-vertex of $G$, we find from Remark \ref{Remark:entries r} that $q_{i,j}=0$. Hence, for $k=1,\dots,\ell$, the submatrix of $Q_{G,v}$ whose rows and columns are indexed by $V(B_k)$ and $V(G)\backslash V(B_k)$, respectively, is the zero matrix. For $k=1,\dots,\ell$, assume $i,j\in V(B_k)$. Since $v$ is a cut-vertex, by Remark \ref{Remark:entries r}, we have $|\mathcal{F}_{G}(i,j;v)|=\tau_{G'_k}|\mathcal{F}_{B_k}(i,j;v)|$ where $G'_k$ is the subgraph induced by $V(G)\backslash (V(B_k)-\{v\})$, with equality if and only if $G'_k$ is a tree. Therefore, the submatrix of $Q_{G,v}$ whose rows and columns are indexed by the vertex set $V(B_k)$ is $\tau_{G'_k}Q_{B_k,v}$.
Let $1\leq k \leq \ell$. For $\mathbf{d}_{B_k}=(d_i)_{i\in V(B_k)}$, let $\widehat{\mathbf{d}}_{B_k}=(\hat{d}_i)_{i\in V(G)}$ where $\hat{d}_i=d_i$ if $i\in V(B_k)$, and $\hat{d}_i=0$ if $i\in V(G)\backslash V(B_k)$. Then, for $1\leq k_1,k_2\leq \ell$,
\begin{align*}
\widehat{\mathbf{d}}_{B_{k_1}}^TQ_{G,v}\widehat{\mathbf{d}}_{B_{k_2}}=\mathbf{d}_{B_{k_1}}^T\widetilde{Q}_{G,v}\mathbf{d}_{B_{k_2}}
\end{align*}
where $\widetilde{Q}_{G,v}$ is the submatrix of $Q_{G,v}$ whose rows and columns are indexed by $V(B_{k_1})$ and $V(B_{k_2})$, respectively. If $k_1\neq k_2$ then $\mathbf{d}_{B_{k_1}}^T\widetilde{Q}_{G,v}\mathbf{d}_{B_{k_2}}=0$. Furthermore, $\mathbf{d}_{B_{k_1}}^T\widetilde{Q}_{G,v}\mathbf{d}_{B_{k_1}}=\tau_{G'_{k_1}}\mathbf{d}_{B_{k_1}}^TQ_{B_{k_1},v}\mathbf{d}_{B_{k_1}}$. Evidently, $\mathbf{d}_G=\sum_{k=1}^{\ell}\widehat{\mathbf{d}}_{B_k}$. Therefore, the desired result follows.
\end{proof}
\begin{proposition}\label{Proposition:contruction of paradoxical graphs}
Let $H_i$ be a connected graph with a vertex $v_i$ for $i=1,\dots,\ell$. Suppose that a sequence $\mathcal G^v=(G_n)^v$ is asymptotically paradoxical. Consider a sequence $(\mathcal G')^v=(G'_n)^v$ where for $1\leq n \leq \sum_{i=1}^{\ell}|V(H_i)|$, $G'_n=G_n$, and for $n>\sum_{i=1}^{\ell}|V(H_i)|$, $G'_n$ is the graph obtained from $H_1,\dots,H_\ell$ and $G_{n-\sum_{i=1}^{\ell}|V(H_i)|}$ by identifying the vertices $v_1,\dots,v_\ell,v$. Then, $(\mathcal G')^v$ is asymptotically paradoxical.
\end{proposition}
\begin{proof}
Suppose that $n>\sum_{i=1}^{\ell}|V(H_i)|$. Let $n_0=n-\sum_{i=1}^{\ell}|V(H_i)|$. Since $v$ is a cut-vertex in $G'_n$, we have $\tau_{G'_n}=\tau_{G_{n_0}}\tau_{H_1}\cdots\tau_{H_\ell}$. Using Proposition \ref{Proposition:dRd with cut vertex}, we obtain
\begin{align*}
\frac{\phi_{G'_n}(v)}{4m_{G'_n}^2\tau_{G'_n}}\geq\frac{\phi_{G_{n_0}}(v)+\sum_{i=1}^{\ell}\phi_{H_i}(v_i)}{4(m_{G_{n_0}}+\sum_{i=1}^{\ell}m_{H_i})^2\tau_{G_{n_0}}\tau_{H_1}\cdots\tau_{H_\ell}}.
\end{align*}
As $n\rightarrow \infty$, we have $n_0\rightarrow\infty$. Since $(\mathcal G)^v$ is asymptotically paradoxical, by Theorem \ref{Theorem:asymtotically paradoxical} we obtain $\frac{\phi_{G_{n_0}}(v)}{4m_{G_{n_0}}^2\tau_{G_{n_0}}}\rightarrow\infty$ as $n\rightarrow\infty$. It follows that $\frac{\phi_{G'_n}(v)}{4m_{G'_n}^2\tau_{G'_n}}\rightarrow\infty$ as $n\rightarrow\infty$. Therefore, $(\mathcal G')^v$ is asymptotically paradoxical.
\end{proof}
\begin{remark}\label{Remark:discussion for construction}
{\rm Let a sequence $\mathcal G^v=(G_n)^v$ be asymptotically paradoxical. Suppose that a connected graph $H$ with a vertex $w$ is not $(w,k_1,k_2)$-paradoxical for some integers $k_1$ and $k_2$ with $k_1+k_2\geq 2$. Proposition \ref{Proposition:contruction of paradoxical graphs} tells that regardless of the number of branches of $H$ at $w$, we can obtain a $(v,k_1,k_2)$-paradoxical graph from $H$ by identifying $w$ and the vertex $v$ of $G_n$ for sufficiently large order $n$.}
\end{remark}
\begin{example}
{\rm Adopting the notation in Remark \ref{Remark:discussion for construction}, consider the following graph $H$:
\begin{center}
\begin{tikzpicture}[scale=0.80]
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={left, yshift=0cm: }] (v_1) at (-1,1) {};
\node[enclosed, label={left, yshift=0cm: }] (v_2) at (-1,-1) {};
\node[enclosed, label={right, yshift=0cm: $w$}] (v_3) at (0.3,0) {};
\node[enclosed, label={right, yshift=0cm: }] (v_4) at (-2.5,-1) {};
\node[label={below, yshift=0cm: $H$}] (G) at (0,-1.2) {};
\draw (v_1) -- (v_2);
\draw (v_2) -- (v_3);
\draw (v_1) -- (v_3);
\draw (v_2) -- (v_4);
\end{tikzpicture}
\end{center}
One can check from computation that $\phi_{H}(w)=2\mathbf{d}_{H}^TQ_{H,w}\mathbf{d}_{H}=118$ and $\Phi_{H}(w,1,2)<0$. So, $H$ is not $(w,1,2)$-paradoxical. From Example \ref{Example:asymp. paradoxical}, $\mathcal G^v=(P_n)^v$ is asymptotically paradoxical. For ease of exposition, we assume that for each $n\geq 2$, $v$ is a pendent vertex of $P_n$. Suppose that $G'_{n}$ is the graph obtained from $H$ and $P_n$ by identifying $w$ and $v$ as $v$. As discussed in Remark \ref{Remark:discussion for construction}, there must be some $N_0>0$ such that $G'_n$ is $(v,1,2)$-paradoxical for all $n\geq N_0$. We shall minimize such an $N_0$. Using Proposition \ref{Proposition:dRd with cut vertex} and Example \ref{Example:asymp. paradoxical}, we have
$$
\phi_{G'_n}(v)=2\mathbf{d}_{G'_n}^TQ_{G'_n,v}\mathbf{d}_{G'_n}=2\mathbf{d}_{H}^TQ_{H,w}\mathbf{d}_{H}+6\mathbf{d}_{P_n}^TQ_{P_n,v}\mathbf{d}_{P_n}=118+2(n-1)(2n-1)(2n-3).
$$
By computation of $\Phi_{G'_n}(v,1,2)$ for $n=2,\dots,5$, $G'_2$, $G'_3$, and $G'_4$ are not $(v,1,2)$-paradoxical, and $G'_5$ is $(v,1,2)$-paradoxical. Furthermore, it can be checked that $\frac{\phi_{G'_n}(v)}{4m_{G'_n}^2\tau_{G'_n}}$ is strictly increasing for $n\geq 5$. Hence, by Proposition \ref{Proposition:monotone}, $G'_n$ is $(v,1,2)$-paradoxical for all $n\geq 5$. In other words, we can construct a $(v,1,2)$-paradoxical graph from $H$ and a path of length at least $4$ by identifying $w$ and a pendent vertex of the path.}
\end{example}
\section{Asymptotically paradoxical sequences of trees}\label{Section:Asymptotic for trees}
We begin with presenting an outline of this section. Throughout this section, we shall consider sequences $\mathcal G^v=(\mathcal T_n)^v$ of trees, where for each $n\geq 2$, $\mathcal T_n$ is obtained from $\mathcal T_{n-1}$ by an addition of a new pendent vertex or a subdivision of an edge. Then, we examine asymptotic behaviour of such trees upon the addition of twin pendent paths; specifically, we investigate under what circumstances the sequences are asymptotically paradoxical. Considering Theorem \ref{Theorem:asymtotically paradoxical}, we need to understand $\frac{\phi_{\mathcal T_n}(v)}{4m_{\mathcal T_n}^2\tau_{\mathcal T_n}}$. Recall that $\phi_{\mathcal T_n}(v)=2\mathbf{d}_{\mathcal T_n}^TQ_{\mathcal T_n,v}\mathbf{d}_{\mathcal T_n}$. To consider conditions for $\frac{\phi_{\mathcal T_n}(v)}{4m_{\mathcal T_n}^2\tau_{\mathcal T_n}}$ to diverge to infinity, we shall find the minimum of $\mathbf{d}_{\mathcal T_n}^TQ_{\mathcal T_n,v}\mathbf{d}_{\mathcal T_n}$, provided the number of branches of $\mathcal T_n$ at $v$ and the eccentricity of $v$ in each branch are given (Proposition \ref{Proposition:lowest bound of drd for tree}). With the minimum, we provide some condition in terms of the eccentricity of $v$ in $\mathcal T_n$ and the number of branches of $T_n$ at $v$ satisfying some property, in order for the sequences to be asymptotically paradoxical (Theorem \ref{Theorem: asymp. l_n and e(v) growing}).
Here is a sketch of two steps to find the minimum of $\mathbf{d}_{\mathcal T_n}^TQ_{\mathcal T_n,v}\mathbf{d}_{\mathcal T_n}$. By Proposition \ref{Proposition:dRd with cut vertex}, we only need to understand the minimum of $\mathbf{d}_{B}^TQ_{B,v}\mathbf{d}_{B}$ where $B$ is a branch of $\mathcal T_n$ at $v$---that is, the minimum of $\mathbf{d}_{\mathcal T}^TQ_{\mathcal T,v}\mathbf{d}_{\mathcal T}$ where $\mathcal T$ is a tree with a pendent vertex $v$ and the eccentricity of $v$ is given. This minimum is provided in \eqref{lowest bound of dRd for tree} at the end of Step 1. By Proposition \ref{Proposition:dRd with cut vertex}, we establish our desired result in Proposition \ref{Proposition:lowest bound of drd for tree} in Step 2.
\subsection*{Step 1}\label{Subsec:step1}
\begin{figure}[h!]
\begin{center}
\begin{tikzpicture}
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={below, yshift=0cm: $v$}] (v_1) at (0,1) {};
\node[enclosed, label={below, yshift=0cm: $v_1$}] (v_2) at (1.5,1) {};
\node[enclosed, label={below, yshift=0cm: $v_2$}] (v_3) at (3,1) {};
\node[enclosed, label={below, yshift=0cm: $v_3$}] (v_4) at (4.5,1) {};
\node[enclosed, label={below, yshift=0cm: $v_4$}] (v_5) at (6,1) {};
\node[enclosed] (v_6) at (1,1.5) {};
\node[enclosed] (v_10) at (1.5,1.5) {};
\node[enclosed] (v_7) at (2,1.5) {};
\node[enclosed] (v_8) at (3,1.5) {};
\node[enclosed] (v_9) at (3,2) {};
\draw (v_1) -- (v_2);
\draw (v_2) -- (v_3);
\draw (v_3) -- (v_4);
\draw (v_4) -- (v_5);
\draw (v_2) -- (v_6);
\draw (v_2) -- (v_7);
\draw (v_2) -- (v_10);
\draw (v_3) -- (v_8);
\draw (v_8) -- (v_9);
\end{tikzpicture}
\end{center}
\caption{}\label{Figure:Example splitting tree}
\end{figure}
Let $\mathcal{T}$ be a tree of order $n$, and $v$ be a pendent vertex in $\mathcal{T}$. Suppose that $\alpha$ is the eccentricity $e_{\mathcal T}(v)$ of $v$ in $\mathcal T$. Then, there exists the path $P=(v_0,v_1,\dots,v_\alpha)$ of length $\alpha$ in $\mathcal T$ where $v_0=v$. Evidently, $v_0$ and $v_\alpha$ are pendent vertices in $\mathcal T$. Let $\mathcal{T}_0$ and $\mathcal{T}_\alpha$ be the trees where $V(\mathcal{T}_0)=\{v_0\}$ and $V(\mathcal{T}_\alpha)=\{v_\alpha\}$. For $k=1,\dots,\alpha-1$, if there are more than two branches of $\mathcal T$ at $v_k$, then we define $\mathcal{T}_k$ to be the tree obtained from $\mathcal{T}$ by deleting two branches except $v_k$ where one contains $v_{k-1}$ and the other $v_{k+1}$; if there are exactly two branches of $\mathcal T$ at $v_k$, then we define $\mathcal T_k$ to be the tree with $V(\mathcal T_k)=\{v_k\}$. Then, $V(\mathcal T_0),\dots,V(\mathcal T_\alpha)$ are mutually disjoint sets. Moreover, for each $k=0,\dots,\alpha$, we have $e_{\mathcal{T}_k}(v_k)\leq \alpha-k$. As an example, if $\mathcal T$ is the tree in Figure \ref{Figure:Example splitting tree}, then $V(\mathcal T_0)=\{v\}$, $V(\mathcal T_3)=\{v_3\}$, and $V(\mathcal T_4)=\{v_4\}$; furthermore, $\mathcal T_1$ and $\mathcal T_2$ are $S_4$ and $P_3$, respectively.
Let $Q_{\mathcal{T},v}=[q_{i,j}]$. Recall that $q_{i,j}=|\mathcal{F}_{\mathcal T}(i,j;v)|$ is the number of $2$-tree spanning forests of $\mathcal T$ having $i$, $j$ in one tree and $v$ in the other. Note that $v=v_0$. In order to understand the structure of $Q_{\mathcal{T},v}$, we shall consider two cases: \begin{enumerate*}[label=(\roman*)]
\item $i$ and $j$ are in different subtrees; and
\item $i$ and $j$ are in the same subtree.
\end{enumerate*} Suppose that $i\in V(\mathcal{T}_{k_1})$ and $j\in V(\mathcal{T}_{k_2})$ where $0\leq k_1< k_2\leq \alpha$. For each forest in $\mathcal{F}_{\mathcal T}(i,j;v)$, since $i$ and $j$ belong to the same subtree in the forest, the subtree must contain $v_{k_1}$ and $v_{k_2}$. For any vertex $w$ on the subpath of $\mathcal T$ with $i$ and $j$ as the pendent vertices, we have $\mathrm{dist}_{\mathcal{T}}(v,v_{k_1})\leq \mathrm{dist}_{\mathcal{T}}(v,w)$. Hence, by Remark \ref{Remark:entries r}, $q_{i,j}=k_1$ for $i\in V(\mathcal{T}_{k_1})$ and $j\in V(\mathcal{T}_{k_2})$ with $0\leq k_1<k_2\leq \alpha$.
Assume that $i,j$ are in $V(\mathcal T_k)$ for some $1\leq k\leq \alpha$. Consider the subpath $P'$ of $\mathcal T_k$ with $i$ and $j$ as the pendent vertices. Suppose that $w_0$ is the vertex on $P'$ such that $\mathrm{dist}_{\mathcal{T}_k}(v_k,w_0)\leq \mathrm{dist}_{\mathcal{T}_k}(v_k,w)$ for $w\in V(P')$. Then, $\mathrm{dist}_{\mathcal{T}}(v,w_0)=k+\mathrm{dist}_{\mathcal{T}_k}(v_k,w_0)$. Let $Q_{\mathcal{T}_k,v_k}=[\tilde{q}_{i,j}]$. By Remark \ref{Remark:entries r}, we have $q_{i,j}=k+\tilde{q}_{i,j}$.
Labelling the rows and columns of $Q_{\mathcal{T},v}$ in order of $v,V(\mathcal{T}_1),\dots,V(\mathcal{T}_\alpha)$, we obtain the following structure:
$$
Q_{\mathcal{T},v}=
\left[\begin{array}{c|c|c|c|c|c}
0 & 0 & 0 & 0 & \cdots & 0\\\hline
0 & J+Q_{\mathcal{T}_1,v_1} & J & J & \cdots & J\\\hline
0 & J & 2J+Q_{\mathcal{T}_2,v_2} & 2J & \cdots & 2J\\\hline
0 & J & 2J & 3J+Q_{\mathcal{T}_3,v_3} & \cdots & \vdots\\\hline
\vdots & \vdots & \vdots & \vdots & \ddots & (\alpha-1)J\\\hline
0 & J & 2J & 3J & \cdots & \alpha J+Q_{\mathcal{T}_\alpha,v_\alpha}
\end{array}\right]
$$
where the $J$s in the blocks of $Q_{\mathcal T,v}$ are appropriately sized. Let $n_k=|V(\mathcal{T}_k)|$ for $k=0,\dots,\alpha$. Note that $n_0=n_\alpha=1$. Then, $Q_{\mathcal{T},v}$ can be recast as
\begin{align*}
Q_{\mathcal{T},v}&=\sum_{i=0}^{\alpha-1}\begin{bmatrix}
0 & 0 \\
0 & J_{n-(n_0+\cdots+n_i)}
\end{bmatrix}+\mathrm{diag}(0,Q_{\mathcal{T}_1,v_1},\dots,Q_{\mathcal{T}_\alpha,v_\alpha})\\
&=\sum_{i=0}^{\alpha-1}\begin{bmatrix}
\mathbf{0}_{n_0+\cdots+n_i}\\
\mathbf{1}_{n-(n_0+\cdots+n_i)}
\end{bmatrix}\begin{bmatrix}
\mathbf{0}_{n_0+\cdots+n_i}^T & \mathbf{1}_{n-(n_0+\cdots+n_i)}^T
\end{bmatrix}+\mathrm{diag}(0,Q_{\mathcal{T}_1,v_1},\dots,Q_{\mathcal{T}_\alpha,v_\alpha})
\end{align*}
where $n=n_0+n_1+\dots+n_\alpha$.
Now, we shall compute $\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}$. Let $\mathbf x^T=\begin{bmatrix}
0 & \mathbf{d}_{\mathcal{T}_1}^T & \cdots & \mathbf{d}_{\mathcal{T}_{\alpha-1}}^T & 0
\end{bmatrix}$ and $\mathbf y=\mathbf{e}_{v}+\sum_{i=1}^{\alpha-1}2\mathbf{e}_{v_i}+\mathbf{e}_{v_\alpha}$. Then,
\begin{align*}
\mathbf x^T Q_{\mathcal{T},v}\mathbf x&=\sum_{i=0}^{\alpha-2}\left(\mathbf{d}_{\mathcal T_{i+1}}^T\mathbf{1}+\cdots +\mathbf{d}_{\mathcal T_{\alpha-1}}^T\mathbf{1}\right)^2+\sum_{i=1}^{\alpha-1}\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}\\
&=4\sum_{i=0}^{\alpha-2}\left(\sum_{j=i+1}^{\alpha-1}(n_j-1)\right)^2+\sum_{i=1}^{\alpha-1}\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}=4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)^2+\sum_{i=1}^{\alpha-1}\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}.
\end{align*}
We can find that the submatrix of $Q_{\mathcal T,v}$ whose rows and columns are indexed by $\{v_0,\dots,v_\alpha\}$ is $[\mathrm{min}(i,j)]_{0\leq i,j\leq \alpha}$. So, $\left(\sum_{k=0}^\alpha\mathbf e_{v_k}\right)^TQ_{\mathcal T,v}\left(\sum_{k=0}^\alpha\mathbf e_{v_k}\right)$ is the sum of all entries in $[\mathrm{min}(i,j)]_{0\leq i,j\leq \alpha}$. Thus, from $\mathbf y=2\left(\sum_{k=0}^\alpha\mathbf e_{v_k}\right)-(\mathbf e_v+\mathbf e_\alpha)$, we have
\begin{align*}
\mathbf y^TQ_{\mathcal{T},v}\mathbf y&=4\mathbf{1}^T[\mathrm{min}(i,j)]_{0\leq i,j\leq \alpha}\mathbf{1}-4(\mathbf e_v+\mathbf e_\alpha)^TQ_{\mathcal{T},v}\left(\sum_{k=0}^\alpha\mathbf e_{v_k}\right)+(\mathbf e_v+\mathbf e_\alpha)^TQ_{\mathcal{T},v}(\mathbf e_v+\mathbf e_\alpha)\\
&=\frac{2}{3}\alpha(\alpha+1)(2\alpha+1)-2\alpha(\alpha+1)+\alpha=\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1).
\end{align*}
Finally, we find
\begin{align*}
&\sum_{i=0}^{\alpha-1}\mathbf x^T\begin{bmatrix}
0 & 0 \\
0 & J_{n-(n_0+\cdots+n_i)}
\end{bmatrix}\mathbf y\\
=&\sum_{i=0}^{\alpha-2}\left(\mathbf{d}_{\mathcal T_{i+1}}^T\mathbf{1}+\cdots +\mathbf{d}_{\mathcal T_{\alpha-1}}^T\mathbf{1}\right)\left(2(\alpha-i)-1\right)\\
=&2\sum_{i=0}^{\alpha-2}\left(\sum_{j=i+1}^{\alpha-1}(n_j-1)\right)\left(2(\alpha-i)-1\right)=2\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)\left(2(\alpha-i)+1\right).
\end{align*}
From Remark \ref{Remark:entries r}, for each $k=0,\dots,\alpha$, we have $|\mathcal{F}_{\mathcal T_k}(l,v_k;v_k)|=0$ for $l\in V(\mathcal T_k)$. So, the $v_k^\text{th}$ column of $\mathrm{diag}(0,Q_{\mathcal{T}_1,v_1},\dots,Q_{\mathcal{T}_\alpha,v_\alpha})$ is the zero vector. This implies $\mathbf x^T\mathrm{diag}(0,Q_{\mathcal{T}_1,v_1},\dots,Q_{\mathcal{T}_\alpha,v_\alpha})\mathbf y=0$. Hence,
\begin{align*}
2\mathbf x^TQ_{\mathcal{T},v}\mathbf y&=4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)(2(\alpha-i)+1).
\end{align*}
Note that $\mathbf d_\mathcal T=\mathbf x+\mathbf y$. Therefore, for a tree $\mathcal T$ with a pendent vertex $v$,
\begin{align}\label{identity:dRd for tree with v}
\begin{split}
\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}=&\mathbf x^T Q_{\mathcal{T},v}\mathbf x+2\mathbf x^TQ_{\mathcal{T},v}\mathbf y+\mathbf y^TQ_{\mathcal{T},v}\mathbf y\\
=&4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)^2+\sum_{i=1}^{\alpha-1}\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}\\
&+4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)(2(\alpha-i)+1)+\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1).
\end{split}
\end{align}
\begin{figure}[h!]
\begin{center}
\begin{tikzpicture}
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={below, yshift=0cm: $v$}] (v_1) at (0,1) {};
\node[enclosed, label={below, yshift=0cm: $v_1$}] (v_2) at (1,1) {};
\node[enclosed, label={below, yshift=0cm: $v_2$}] (v_3) at (2,1) {};
\node[enclosed, label={below, yshift=0cm: $v_{\alpha-1}$}] (v_4) at (3,1) {};
\node[enclosed, label={below, yshift=0cm: $v_\alpha$}] (v_5) at (4,1) {};
\node[enclosed] (v_6) at (2.1340,1.5) {};
\node[enclosed] (v_7) at (2.5,1.8660) {};
\node[enclosed] (v_8) at (3.5,1.8660) {};
\node[enclosed] (v_9) at (3.8660,1.5) {};
\node[label={center, yshift=0cm: $\dots$}] (v_10) at (3,2) {};
\draw (v_1) -- (v_2);
\draw (v_2) -- (v_3);
\draw[thick, loosely dotted] (v_3) -- (v_4);
\draw (v_4) -- (v_5);
\draw (v_4) -- (v_6);
\draw (v_4) -- (v_7);
\draw (v_4) -- (v_8);
\draw (v_4) -- (v_9);
\end{tikzpicture}
\end{center}
\caption{A broom on $n$ vertices with exactly $(n-\alpha)$ pendent vertices having a common neighbour.}\label{Figure:Broom}
\end{figure}
\begin{example}\label{Ex:Broom dRd}
{\rm Let $n\geq\alpha\geq 1$, and $\mathcal{B}_{n,\alpha}$ be the broom with vertices $v,v_1,\dots,v_\alpha$ in Figure \ref{Figure:Broom}. Let $v_0=v$, and $X=\{0,\dots,\alpha\}\backslash\{\alpha-1\}$. Suppose that for $i\in X$, $\mathcal T_i$ is the tree with $V(\mathcal T_i)=\{v_i\}$, and $\mathcal T_{\alpha-1}$ is the subtree induced by $V(\mathcal{B}_{n,\alpha})\backslash \{v_1,\dots,v_{\alpha-2},v_\alpha\}$. Then, $\mathcal T_{\alpha-1}$ is a star of order $n-\alpha$ with the centre vertex $v_{\alpha-1}$. Let $n_i=|V(\mathcal T_i)|$ for $i=0,\dots,\alpha$. By \eqref{identity:dRd for tree with v} and Example \ref{Ex:asymp for star}, we obtain
\begin{align*}
\mathbf{d}_{\mathcal{B}_{n,\alpha},v}^TQ_{\mathcal{B}_{n,\alpha},v}\mathbf{d}_{\mathcal{B}_{n,\alpha},v}=&4\sum_{i=1}^{\alpha-1}(n-\alpha-1)^2+\mathbf{d}^T_{S_{n-\alpha}}Q_{S_{n-\alpha},v_{\alpha-1}}\mathbf{d}_{S_{n-\alpha}}\\
&+4\sum_{i=1}^{\alpha-1}(n-\alpha-1)(2(\alpha-i)+1)+\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1)\\
=&4(\alpha-1)(n-\alpha-1)^2+(n-\alpha-1)(4\alpha^2-3)+\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1).
\end{align*}}
\end{example}
We continue \eqref{identity:dRd for tree with v} with the same hypotheses and notation. We consider $\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}$ for $i=1,\dots,\alpha-1$ in \eqref{identity:dRd for tree with v}. Note that for $i=1,\dots,\alpha-1$, $v_i$ is not necessarily a pendent vertex in $\mathcal T_{v_i}$. The result for the minimum of $\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}$ appears in the paper \cite{KirklandZeng} as the minimum of $\mathbf{d}^T_{\mathcal{T}_i}(2\mathbf{f}_{\mathcal T_i}^v\mathbf{1}^T-F_{\mathcal T_i})\mathbf{d}_{\mathcal{T}_i}$. We shall introduce the result, which is proved by induction in \cite{KirklandZeng}, with a different proof by using the combinatorial interpretation for entries in $Q_{\mathcal{T}_i,v_i}$.
\begin{lemma}\cite{KirklandZeng}\label{Lemma:lower bound of dRd for tree}
Let $\mathcal T$ be a tree of order $n\geq 2$ with a vertex $v$. Then,
\begin{align*}
\mathbf{d}^T Q_{\mathcal T,v} \mathbf{d}\geq n-1
\end{align*}
with equality if and only if for $n=2$, $\mathcal T=P_2$ and for $n\geq 3$, $\mathcal T=S_n$ and $v$ is the centre vertex.
\end{lemma}
\begin{proof}
Let $Q_{\mathcal T,v}=[q_{i,j}]$. By Remark \ref{Remark:entries r}, we have $q_{ii}=\mathrm{dist}(i,v)\geq 1$ whenever $i\neq v$. The degree of each vertex is at least $1$. So, we have $\mathbf{d}^T Q_{\mathcal T,v} \mathbf{d}\geq (n-1)$. To attain the equality, $q_{i,j}=0$ if $i\neq j$. From Remark \ref{Remark:entries r}, we can find that $v$ is a cut-vertex so that $\mathcal T-v$ consists of $n-1$ isolated vertices. Therefore, our desired result is obtained.
\end{proof}
Applying Lemma \ref{Lemma:lower bound of dRd for tree} to $\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}$ in \eqref{identity:dRd for tree with v} for each $i=1,\dots,\alpha-1$, we obtain $\sum_{i=1}^{\alpha-1}\mathbf{d}^T_{\mathcal{T}_i}Q_{\mathcal{T}_i,v_i}\mathbf{d}_{\mathcal{T}_i}\geq n-\alpha-1$. Thus, $\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}$ in \eqref{identity:dRd for tree with v} is bounded below as follows:
\begin{align*}
\begin{split}
\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}
\geq& 4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)^2+4\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)(2(\alpha-i)+1)\\
&+(n-\alpha-1)+\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1).
\end{split}
\end{align*}
Consider
\begin{align}\label{temp:iden}
&\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)^2+\sum_{i=1}^{\alpha-1}\left(\sum_{j=i}^{\alpha-1}(n_j-1)\right)(2(\alpha-i)+1)\\\nonumber
=&\left[(n_1+\cdots+n_{\alpha-1}-(\alpha-1))^2+(n_1+\cdots+n_{\alpha-1}-(\alpha-1))(2\alpha-1)\right]\\\nonumber
&+\left[(n_2+\cdots+n_{\alpha-1}-(\alpha-2))^2+(n_2+\cdots+n_{\alpha-1}-(\alpha-2))(2\alpha-3)\right]\\\nonumber
&+\cdots+\left[(n_{\alpha-1}-1)^2+(n_{\alpha-1}-1)3\right].
\end{align}
Since $n_1+\cdots+n_{\alpha-1}$ is constant, we find that the minimum of \eqref{temp:iden} is attained as $(n-\alpha-1)(n+\alpha-2)$ at $n_1=n-\alpha$ and $n_2=\cdots=n_{\alpha-1}=1$. Therefore, when $v$ is a pendent vertex, we have
\begin{align}\label{lowest bound of dRd for tree}
\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}\geq (n-\alpha-1)(4n+4\alpha-7)+\frac{1}{3}\alpha(2\alpha-1)(2\alpha+1)
\end{align}
where equality holds if and only if $\mathcal T$ is a broom $\mathcal{B}_{n,\alpha}$ with $v,v_1,\dots,v_\alpha$ described below:
\begin{center}
\begin{tikzpicture}
\tikzset{enclosed/.style={draw, circle, inner sep=0pt, minimum size=.10cm, fill=black}}
\node[enclosed, label={below, yshift=0cm: $v$}] (v_1) at (0,1) {};
\node[enclosed, label={below, yshift=0cm: $v_1$}] (v_2) at (1,1) {};
\node[enclosed, label={below, yshift=0cm: $v_2$}] (v_3) at (2,1) {};
\node[enclosed, label={below, yshift=0cm: $v_{\alpha-1}$}] (v_4) at (3,1) {};
\node[enclosed, label={below, yshift=0cm: $v_{\alpha}$}] (v_5) at (4,1) {};
\node[enclosed] (v_6) at (0.1340,1.5) {};
\node[enclosed] (v_7) at (0.5,1.8660) {};
\node[enclosed] (v_8) at (1.5,1.8660) {};
\node[enclosed] (v_9) at (1.8660,1.5) {};
\node[label={center, yshift=0cm: $\dots$}] (v_10) at (1,2) {};
\draw (v_1) -- (v_2);
\draw (v_2) -- (v_3);
\draw[thick, loosely dotted] (v_3) -- (v_4);
\draw (v_4) -- (v_5);
\draw (v_2) -- (v_6);
\draw (v_2) -- (v_7);
\draw (v_2) -- (v_8);
\draw (v_2) -- (v_9);
\end{tikzpicture}
\end{center}
\subsection*{Step 2}
The following is the result for the minimum of $\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}$ where $\mathcal T$ is a tree with a vertex $v$. (The vertex $v$ is not necessarily a pendent vertex.)
\begin{proposition}\label{Proposition:lowest bound of drd for tree}
Let $\mathcal T$ be a tree with a vertex $v$. Suppose that $B_1,\dots,B_\ell$ are the branches of $\mathcal T$ at $v$ for some $\ell\geq 1$. Let $n_i=|V(B_i)|$, and let $e_i=e_{B_i}(v)$ for $i=1,\dots,\ell$. Then,
\begin{align*}
\mathbf{d}^T_\mathcal{T}Q_{\mathcal{T},v}\mathbf{d}_\mathcal{T}\geq \sum_{i=1}^{\ell}\left[(n_i-e_i-1)(4n_i+4e_i-7)+\frac{1}{3}e_i(2e_i-1)(2e_i+1)\right]
\end{align*}
where equality holds if and only if for $i=1,\dots,\ell$, each branch $B_i$ is a broom $\mathcal{B}_{n_i,e_i}$ such that if $n_i>e_i+1$, then $v$ is one of the $(n_i-e_i)$ pendent vertices having a common neighbour; if $n_i=e_i+1$, then $v$ is a pendent vertex in $\mathcal{B}_{n_i,e_i}$ (which is a path).
\end{proposition}
\begin{proof}
The conclusions can be readily established by Proposition \ref{Proposition:dRd with cut vertex} and \eqref{lowest bound of dRd for tree}.
\end{proof}
Hereafter, the symbols $\omega$, $\mathcal{O}$ and $\Theta$ stand for the small Omega notation, the big O notation and the big Theta notation, respectively (see \cite{Arora:Complexity}).
As mentioned in the beginning of this section, we consider the following sequence $\mathcal G^v=(\mathcal T_n)^v$ of trees, where $V(\mathcal T_1)=\{v\}$ and for each $n\geq 2$, $\mathcal T_n$ is obtained from $\mathcal T_{n-1}$ by adding a new pendent vertex to $\mathcal T_{n-1}$, or by subdividing an edge in $\mathcal T_{n-1}$ into two edges connecting to a new vertex. We denote by $\alpha_n(x)$ and $\ell_n(x)$ the eccentricity of $x$ in $\mathcal T_n$ and the number of branches of $\mathcal T_n$ at $x$, respectively. For the rest of this section, we use $\alpha_n(\cdot)$ and $\ell_n(\cdot)$ only for the specified vertex $v$ of the trees in the sequence, so we simply write $\alpha_n(v)$ and $\ell_n(v)$ as $\alpha_n$ and $\ell_n$.
Define $B_1^{(1)}=\mathcal T_1$ and $\ell_1=1$. Assume that for $n\geq 2$, $B_1^{(n-1)},\dots,B_{\ell_{n-1}}^{(n-1)}$ are the branches of $\mathcal T_{n-1}$ at $v$. Let $\{w\}=V(\mathcal T_n)\backslash V(\mathcal T_{n-1})$. Consider the case $\ell_n-\ell_{n-1}=1$. Then, $w$ must be added to the vertex $v$ in $\mathcal T_{n-1}$ to form $\mathcal T_n$. For this case, we define $B_i^{(n)}$ as $B_i^{(n-1)}$ for $i=1,\dots,\ell_n-1$, and define $B_{\ell_n}^{(n)}$ as the path $(v,w)$. Suppose $\ell_n=\ell_{n-1}$. Then, there exists exactly one branch $B_k^{(n-1)}$ for some $k\in\{1,\dots,\ell_{n-1}\}$ such that $w$ is adjacent to at least a vertex of $B_k^{(n-1)}$ in $\mathcal T_n$. We define $B_i^{(n)}$ as $B_i^{(n-1)}$ for $1\leq i\leq \ell_{n-1}$ with $i\neq k$, and define $B_k^{(n)}$ as the induced subtree of $\mathcal T_n$ by $V\left(B_k^{(n-1)}\right)\cup\{w\}$. Hence, we may define $$\beta_{n}=|\{i|e_{B_i^{(k)}}(v)=\Theta(\alpha_k),i=1,\dots,\ell_{n}\}|.$$
Note that $\beta_{n}$ is the number of branches of $\mathcal T_{n}$ at $v$ such that the eccentricity of $v$ in a branch is asymptotically bounded above and below by the eccentricity of $v$ in $\mathcal T_k$.
\begin{example}
{\rm If $\mathcal G^v=(P_n)^v$ where $v$ is a pendent vertex for $n\geq 2$, then $\alpha_n=n-1$ and $\ell_n=\beta_n=1$. If $\mathcal G^v=(S_n)^v$ where $v$ is the centre vertex for $n\geq 3$, then $\alpha_n=1$ and $\ell_n=\beta_n=n-1$.}
\end{example}
\begin{remark}
{\rm Consider a sequence $\mathcal G^v=(\mathcal T_n)^v$ of trees. Evidently, $\beta_n\leq \ell_n=\mathcal{O}(n)$ and $\alpha_n=\mathcal{O}(n)$. Since $\alpha_n=\mathrm{max}\{e_{B_i^{(n)}}(v)|1\leq i\leq \ell_n\}$, we have $\beta_n\geq 1$.}
\end{remark}
Here is the main result in this section.
\begin{theorem}\label{Theorem: asymp. l_n and e(v) growing}
Let $\mathcal G^v=(\mathcal T_n)^v$ be a sequence of trees. If $\beta_n\alpha_n^3=\omega(n^2)$, then $\mathcal G^v$ is asymptotically paradoxical.
\end{theorem}
\begin{proof}
Suppose that $\beta_n\alpha_n^3=\omega(n^2)$. For $n\geq 2$, suppose that $B_1^{(n)},\dots,B_{\ell_n}^{(n)}$ are the branches of $\mathcal T_n$ at $v$. Let $e_i^{(n)}=e_{B_i^{(n)}}(v)$ and $k_i^{(n)}=\left|V\left(B_i^{(n)}\right)\right|$ for $i=1,\dots,\ell_n$. We may assume that $e_j^{(n)}=\Theta(\alpha_n)$ for $j=1,\dots,\beta_n$. Then, for each $j=1,\dots,\beta_n$, there exist $C_j>0$ and $N_j>0$ such that $e_j^{(n)}\geq C_j \alpha_n$ for all $n\geq N_j$. Choose $C_0=\mathrm{min}\{C_j|j=1,\dots,\beta_n\}$ and $N_0=\mathrm{max}\{N_j|j=1,\dots,\beta_n\}$. Then, $e_j^{(n)}\geq C_0 \alpha_n$ for all $n\geq N_0$ and $1\leq j\leq \beta_n$. By Proposition \ref{Proposition:lowest bound of drd for tree}, for $n\geq N_0$, we have
\begin{align*}
\frac{\phi_{\mathcal T_n}(v)}{4m_{\mathcal T_n}^2\tau_{\mathcal T_n}}&=\frac{2\mathbf{d}^T_{\mathcal T_n}Q_{\mathcal{T}_n,v}\mathbf{d}_{\mathcal T_n}}{4(n-1)^2}\\
&\geq \frac{\sum_{i=1}^{\ell_n}\left[\left(k_i^{(n)}-e_i^{(n)}-1\right)\left(4k_i^{(n)}+4e_i^{(n)}-7\right)+\frac{1}{3}e_i^{(n)}\left(2e_i^{(n)}-1\right)\left(2e_i^{(n)}+1\right)\right]}{2(n-1)^2}\\
&\geq \frac{\beta_nC_0\alpha_n(2C_0\alpha_n-1)(2C_0\alpha_n+1)}{6(n-1)^2}.
\end{align*}
Since $\beta_n\alpha_n^3=\omega(n^2)$, we have $\frac{\phi_{\mathcal T_n}(v)}{4m_{\mathcal T_n}^2\tau_{\mathcal T_n}}\rightarrow\infty$ as $n$ goes to infinity. Therefore, the conclusion follows.
\end{proof}
\begin{corollary}\label{Corollary:eccentricity and asymp paradoxical}
Suppose that $\mathcal G^v=(\mathcal T_n)^v$ is a sequence of trees $\mathcal T_n$ such that $\alpha_n=\omega(n^\frac{2}{3})$. Then, $\mathcal G^v$ is asymptotically paradoxical.
\end{corollary}
\begin{proof}
It is straightforward from Theorem \ref{Theorem: asymp. l_n and e(v) growing}.
\end{proof}
\begin{corollary}\label{Corollary:diameter and asymp paradoxical}
Suppose that $\mathcal G^v=(\mathcal T_n)^v$ is a sequence of trees $\mathcal T_n$ such that $\mathrm{diam}(\mathcal T_n)=\omega(n^\frac{2}{3})$. Then, $\mathcal G^v$ is asymptotically paradoxical.
\end{corollary}
\begin{proof}
Let $P$ be a longest path in $\mathcal T_n$. Suppose that $w_0$ is the vertex on $P$ such that $\mathrm{dist}(v,w_0)\leq \mathrm{dist}(v,w)$ for all vertices $w$ on $P$. Then, $\alpha_n\geq \mathrm{dist}(v,w_0)+\frac{1}{2}\mathrm{diam}(\mathcal T_n)$. By Corollary \ref{Corollary:eccentricity and asymp paradoxical}, our desired result follows.
\end{proof}
A \textit{rooted} tree is a tree with a vertex designated as the root such that every edge is directed away from the root. A \textit{leaf} in a rooted tree is a vertex whose degree is $1$. The \textit{depth} of a vertex $v$ in a rooted tree is the distance between $v$ and the root. The \textit{height} of a rooted tree is the maximum distance from the root to all leaves.
\begin{figure}[h!]
\hfill
\adjustbox{valign=c}{
\begin{forest}
[$v$
[]
]
\node at (current bounding box.south)
[below=6.5ex]
{$\mathcal T_2$};
\end{forest}}
\hfill
\adjustbox{valign=c}{
\begin{forest}
[$v$
[$z$[$x$]]
]
\node at (current bounding box.south)
[below=1ex]
{$\mathcal T_3$};
\end{forest}}
\hfill
\adjustbox{valign=c}{
\begin{forest}
[$v(w)$
[[]]
[$x$]
]
\node at (current bounding box.south)
[below=1ex]
{$\mathcal T_4$};
\end{forest}}
\hfill
\adjustbox{valign=c}{
\begin{forest}
[$v$
[[$z$[$x$]]]
[]
]
\node at (current bounding box.south)
[below=1ex]
{$\mathcal T_5$};
\end{forest}}
\hfill
\adjustbox{valign=c}{
\begin{forest}
[$v$
[$w$[[]][$x$]]
[]
]
\node at (current bounding box.south)
[below=1ex]
{$\mathcal T_6$};
\end{forest}}
\hfill\mbox{}
\caption{A sequence of rooted trees considered in Example \ref{Example:a sequence of rooted trees}.}\label{Figure:a seq of rooted}
\end{figure}
\begin{example}\label{Example:a sequence of rooted trees}
{\rm Let $\mathcal G^v=(\mathcal T_n)^v$ be a sequence of trees. For each $n\geq 1$, $\mathcal T_n$ can be considered as a rooted tree at $v$. We may also regard branches $B_1^{(n)},\dots,B_{\ell_n}^{(n)}$ of $\mathcal T_n$ at $v$ as rooted trees at $v$. For each $n\geq 3$, let $\mathcal T_n$ be obtained from $\mathcal T_{n-1}$ as follows: if $e_{B_1^{(n-1)}}(v)=\lfloor n^{c_0}\rfloor-1$, then a new vertex $x$ is added to a leaf $z$ of $B_1^{(n-1)}$ such that the depth of $z$ is the height of $B_1^{(n-1)}$; if $e_{B_1^{(n-1)}}(v)=\lfloor n^{c_0}\rfloor$, then a new vertex $x$ is added to a vertex $w$ in $\mathcal T_{n-1}$ such that $\mathrm{dist}(v,w)<e_{B_1^{(n-1)}}(v)$. Assume that $c_0=0.7$. Considering $\lfloor 3^{c_0}\rfloor=\lfloor 4^{c_0}\rfloor=2$ and $\lfloor 5^{c_0}\rfloor=\lfloor 6^{c_0}\rfloor=3$, one of all possible sequences can be obtained as in Figure \ref{Figure:a seq of rooted}. Note that the very left branch of each rooted tree at $v$ in that figure is $B_1^{(n)}$ for $n=2,\dots,6$. Then, $e_{B_1^{(n)}}(v)\geq e_{B_k^{(n)}}(v)$ for all $n\geq 2$ and $2\leq k\leq\ell_n$. Moreover, $e_{B_1^{(n)}}(v)\geq n^{c_0}-1$ for all $n\geq 2$. By Corollary \ref{Corollary:eccentricity and asymp paradoxical}, $\mathcal G^v$ is asymptotically paradoxical---that is, for integers $k_1,k_2\geq 0$ with $k_1+k_2\geq 2$, $\mathcal T_n$ is $(v,k_1,k_2)$-paradoxical for sufficiently large $n$.}
\end{example}
From the following example, the converses of Theorem \ref{Theorem: asymp. l_n and e(v) growing}, Corollaries \ref{Corollary:eccentricity and asymp paradoxical} and \ref{Corollary:diameter and asymp paradoxical} do not hold.
\begin{example}\label{Example:Counter example broom}
{\rm Consider a sequence $\mathcal G^v=(\mathcal T_n)^v$ where for $n\geq 4$, $\mathcal T_n$ is a broom $\mathcal{B}_{n,\alpha_n}$ with $\alpha_n\geq 3$. Suppose that for each $n\geq 4$, $v$ is the pendent vertex of $\mathcal{B}_{n,\alpha_n}$ that does not have any common neighbour with other pendent vertices in $\mathcal{B}_{n,\alpha_n}$. Clearly, $\beta_n=1$. Suppose that $\alpha_n=\omega(1)$. By Example \ref{Ex:Broom dRd}, we obtain
\begin{align*}
\frac{\phi_{\mathcal{B}_{n,\alpha_n}}(v)}{4m_{\mathcal{B}_{n,\alpha_n}}^2\tau_{\mathcal{B}_{n,\alpha_n}}}=&\frac{4(\alpha_n-1)(n-\alpha_n-1)^2+(n-\alpha_n-1)(4\alpha_n^2-3)+\frac{1}{3}\alpha_n(2\alpha_n-1)(2\alpha_n+1)}{2(n-1)^2}\\
\geq&\frac{2(\alpha_n-1)(n-\alpha_n-1)^2}{(n-1)^2}
\end{align*}
for $n\geq 4$. Since $n^2\alpha_n=\omega(n^2)$, we have $\frac{\phi_{\mathcal T_n}(v)}{4m_{\mathcal T_n}^2\tau_{\mathcal T_n}}\rightarrow\infty$ as $n$ goes to infinity. Therefore, $\mathcal G^v$ is asymptotically paradoxical. Moreover, we have $\beta_n\alpha_n^3=\omega(1)$.}
\end{example}
\bigskip
{\bf Acknowledgment.} The author is grateful to Lorenzo Ciardo at the University of Oslo for discussions that initiated this study, and Steve Kirkland at the University of Manitoba for his encouragement, reviews, and comments.
{\bf Post-acknowledgment.} This article was submitted for publication in the Electronic Journal of Linear Algebra on February 5, 2021. The author later noticed that Proposition \ref{gen:H1andH2} of this manuscript is equivalent to Theorem 2.1 in the article `arXiv:2108.01061' and its publication: N. Faught, M. Kempton, and A. Knudson, A 1-separation formula for the graph Kemeny constant and Braess edges, \textit{Journal of Mathematical Chemistry}, 1--21, 2021.
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 4,934 |
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<licenses>
<license>
<name>Apache License Version 2.0</name>
<url>LICENSE.txt</url>
</license>
</licenses>
</dependency>
</dependencies>
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| {
"redpajama_set_name": "RedPajamaGithub"
} | 4,902 |
function hs = gui_multiedit(maintext, opts, optval)
% GUI_MULTIEDIT creates a simple gui with multiple
% edit boxes.
%
% hs = gui_multiedit(maintext, opts, optval)
%
% input:
% maintext - string; title text visible on top of the gui
% opts - cell array of strings; each string is a title
% corresponding to one edit box
% optval - cell array of strings; each string is the
% starting value for the edit box
%
% output:
% hs - structure of handles; contains handles to all
% elements of the figure
% hs.hf - handle; handle to the figure
% hs.maintxt - handle; handle to the title text
% hs.txt - array of handles; handles to consecutive
% text boxes (serve as titles to edit boxes)
% hs.edit - array of handles; handles to consecutive
% edit boxes
% hs.ok - handle; handle to the OK button
% hs.cancel - handle; handle to the cancel button
% this gui is useful for gathering options
% also one needs to specify: text options on one side
% (and on the second something else?)
if nargin == 0 || isempty(maintext)
maintext = 'Please fill the fileds below';
end
if nargin < 2 || isempty(opts)
opts = {'option 1'; 'option 2'; 'option 3'};
end
if nargin < 3 || isempty(optval)
optval = cell(size(opts));
end
nopt = length(opts);
% width options
desl = 200;
editl = 120;
descdist = 10;
wg = 3 * descdist + editl + desl;
% button sizes
buth = 40; butdh = 5; butdrest = 15;
butdw = 10;
butw = round((wg - 3 * butdw)/2); % two buttons
abvbut = buth + butdh + butdrest;
% main text options
distt = [10 5];
maintxth = 35;
% height options
opth = 30;
optsep = 15;
hg = nopt * opth + (nopt + 1) * optsep + (buth+butdh+butdrest) + ...
sum(distt) + maintxth;
hs.hf = figure('Units', 'pixels', 'Position', [350, 350, wg, hg],...
'Visible', 'off', 'menubar', 'none');
% main text
hs.maintxt = uicontrol('Style', 'text',...
'Units', 'pixels', 'Position', ...
[descdist, hg - (maintxth + distt(2)), ...
wg - descdist*2, maintxth], ...
'String', maintext, 'FontSize', 16, ...
'Parent', hs.hf);
for o = 1:nopt
myh = (nopt - o) * opth + (nopt - o) * optsep + abvbut;
% text
hs.txt(o) = uicontrol('Style', 'text',...
'Units', 'pixels', 'Position', [descdist, myh, ...
desl, opth], 'String', opts{o},...
'FontSize', 12, 'Parent', hs.hf);
% edit
hs.edit(o) = uicontrol('Style', 'edit',...
'Units', 'pixels', 'Position', [descdist*2 + desl,...
myh, editl, opth], 'String', optval{o},...
'FontSize', 12, 'Parent', hs.hf);
end
% add buttons
hs.ok = uicontrol('Style', 'pushbutton', 'Units', 'pixels',...
'Position', [butdw, butdh, butw, buth], 'String', 'OK',...
'FontSize', 14, 'Parent', hs.hf);
hs.cancel = uicontrol('Style', 'pushbutton', 'Units', 'pixels',...
'Position', [butdw*2 + butw, butdh, butw, buth], 'String', 'Cancel',...
'FontSize', 14, 'Parent', hs.hf);
set(hs.hf, 'Visible', 'on');
| {
"redpajama_set_name": "RedPajamaGithub"
} | 2,129 |
{"url":"https:\/\/forum.bebac.at\/mix_entry.php?id=21893&view=mix","text":"Pharma_88\n\u2606\n\nIndia,\n2020-08-27 16:07\n(426\u00a0d\u00a013:53\u00a0ago)\n\nPosting: #\u00a021893\nViews: 2,903\n\n## Design\u00a0[Regulatives\u00a0\/ Guidelines]\n\nDear All,\n\nWe are thinking to perform steady state BE study for XXX submission where Test product is ER formulation and Reference product is IR formulation. Further, Its HVD product. So, question is whether is this feasible to conduct replicate BE IR vs ER and if yes then what are the parameters for conclusion?\n\nThanks.\nHelmut\n\u2605\u2605\u2605\n\nVienna, Austria,\n2020-08-27 17:32\n(426\u00a0d\u00a012:28\u00a0ago)\n\n@\u00a0Pharma_88\nPosting: #\u00a021894\nViews: 2,400\n\n## Jurisdiction?\n\nHi Pharma_88,\n\n\u00bb We are thinking to perform steady state BE study for XXX submission\u2026\n\nUnfortunately my crystal ball is in the laundry and reading tea leaves turned out to be an insufficient substitute.\nHence, which XXX?\n\n\u00bb \u2026 where Test product is ER formulation and Reference product is IR formulation.\n\n<nitpick>\n\nNot BE, but comparative BA. You can only hope for similar extent of absorption but never for rate of absorption in a comparison of ER vs IR. Furthermore, BE means similarity in PK metrics of interest if equimolar doses are administered. Sometimes one has to increase the ER dose to get similar AUCs\u2026 Whatever is applicable in your case, BE is the wrong term.\n\n<\/nitpick>\n\n\u00bb Further, Its HVD product. So, question is whether is this feasible to conduct replicate BE IR vs ER and if yes\u2026\n\nIs it a highly variable drug\u00a01 or are one\u00a0\u2013 or both\u00a0\u2013 products\u00a02 highly variable? But, in principle, yes.\n\n\u00bb \u2026 then what are the parameters for conclusion?\n\nOnce you tell us what XXX is, we can possibly help.\n\n1. HVDs exhibit highly variable clearances (CVwR \u226530% if administered as a solution).\n2. HVDPs may additionally\u00a0\u2013 or solely\u00a0\u2013 show highly variable absorption.\n\nDif-tor heh smusma\u00a0\ud83d\udd96\nHelmut Sch\u00fctz\n\nThe quality of responses received is directly proportional to the quality of the question asked.\u00a0\ud83d\udeae\nScience Quotes\nPharma_88\n\u2606\n\nIndia,\n2020-08-31 10:26\n(422\u00a0d\u00a019:34\u00a0ago)\n\n@\u00a0Helmut\nPosting: #\u00a021898\nViews: 2,298\n\n## Jurisdiction?\n\n\u00bb \u00bb We are thinking to perform steady state BE study for XXX submission\u2026\n\u00bb\n\u00bb Hence, which XXX?\n\nIts for EMEA.\n\n\u00bb \u00bb \u2026 where Test product is ER formulation and Reference product is IR formulation.\n\u00bb\n\u00bb <nitpick>\n\nNot BE, but comparative BA. You can only hope for similar extent of absorption but never for rate of absorption in a comparison of ER vs IR. Furthermore, BE means similarity in PK metrics of interest if equimolar doses are administered. Sometimes one has to increase the ER dose to get similar AUCs\u2026 Whatever is applicable in your case, BE is the wrong term.\n\n<\/nitpick>\n\nCan you please elaborate to understand. If you can provide me any supportive literature to go in detail its really helps me.\n\n\u00bb \u00bb Further, Its HVD product. So, question is whether is this feasible to conduct replicate BE IR vs ER and if yes\u2026\n\u00bb\n\u00bb Is it a highly variable drug or are one\u00a0\u2013 or both\u00a0\u2013 products highly variable? But, in principle, yes.\n\u00bb\n\u00bb \u00bb \u2026 then what are the parameters for conclusion?\n\u00bb\n\u00bb Once you tell us what XXX is, we can possibly help.\n\nEMEA\nHelmut\n\u2605\u2605\u2605\n\nVienna, Austria,\n2020-08-31 12:21\n(422\u00a0d\u00a017:39\u00a0ago)\n\n@\u00a0Pharma_88\nPosting: #\u00a021901\nViews: 2,364\n\n## EMA: ABEL for HVD(P)s, PK metrics\n\nHi Pharma_88!\n\n\u00bb Its for EMEA.\n\nThe EMEA (European Agency for the Evaluation of Medicinal Products) was renamed to EMA (European Medicines Agency) fifteen years ago.\n\n\u00bb \u00bb <nitpick>\n\nNot BE, but comparative BA. You can only hope for similar extent of absorption but never for rate of absorption in a comparison of ER vs IR. Furthermore, BE means similarity in PK metrics of interest if equimolar doses are administered. Sometimes one has to increase the ER dose to get similar AUCs\u2026 Whatever is applicable in your case, BE is the wrong term.\n\n<\/nitpick>\n\u00bb\n\u00bb Can you please elaborate to understand. If you can provide me any supportive literature to go in detail its really helps me.\n\nVery nitpicking: Even if release characteristics of products are identical (say, IR vs IR, MR vs MR) there are no \u201cBE studies\u201d. Bioequivalence is the desired outcome of a comparative BA study. One assessor of Poland regularly did not accept study protocols which mentioned BE in the title. His response was essentially:\n\n\u201cIf you already know the outcome, why do you want to perform a study at all?\u201d\n\nBut to reiterate: Bioequivalence means similar rate and extent of absorption after equimolar doses. The PK metrics for rate are generally Cmax and for extent AUC0\u2013t. For modified release products AUC0\u2013\u221e is required as well (contrary to the FDA where all three are always required). Depending on the product characteristics additional PK metrics are required.\u00a01\nWhen comparing MR to IR, the rate of absorption might be similar (i.e., for delayed release products, where only tmax will be different) or different (i.e., for prolonged\u00a0\/ controlled \/ extended \/ sustained release products).\nIn the latter case, this is a desired property:\n\u2022 Less fluctuations in steady state (which was called \u00bbthe flatter is better\u00ab\u00a02 in the late 1980s).\n\u2022 Enhanced compliance (o.a.d. instead of b.i.d. or even t.a.d.).\n\n\u00bb \u00bb \u00bb \u2026 then what are the parameters for conclusion?\n\nSee the applicable MR guideline, Section\u00a05. Note that if you want to compare a new MR product to an established IR product, this is not a generic application acc. to Directive 2001\/83\/EC, Article\u00a010(2)(b) but a hybrid application. For the required PK studies 3 see Section\u00a05.1 and for the therapeutic studies Section\u00a05.2 (only if you are extremely lucky, they might be waived). For the required PK metrics see Section\u00a06.8.2.\nIn case of high variability, reference-scaling according to the EMA\u2019s ABEL (Average Bioequivalence with Expanding Limits) is acceptable for the following PK metrics:\n\u2022 Single dose studies\nCmax and C\u03c4.\n\n\u2022 Multiple dose studies\nCmax,ss and C\u03c4,ss. 4,5\nIn case of multiphasic release products additionally partial AUCs, Cmax, and Cmax,ss in all phases (where the cut-off times have to be pre-specified).\n\nFor details about ABEL see the IR-GL Section 4.1.10 and the Q&A document Section\u00a08. Note that in order to plan for ABEL, you have to give a sound justification that expanding the common BE limits is clinically not relevant (contrary to RSABE for the U.S. FDA and China\u2019s CDE\/NMPA; don\u2019t forget this step).\nI recommend a full replicate design (4 periods TRTR|RTRT or 3 periods TRT|RTR\u00a06) and not the partial replicate design (TRR|RTR|RRT). For the pros and cons see this post.\n\n1. Prolonged release products\nSince quite often we have flip-flop PK (ka\u00a0< kel) the late part of the profile represents absorption. For the same reason the truncated AUC0\u201372 (as for IR products) is not acceptable.\nForget the \u201coption\u201d to waive the multiple dose study if AUC0\u2013\u03c4 \u226410% of AUC0\u2013\u221e. I didn\u2019t see a single case where it worked.\n2. Delayed release products\nMultiple dose study not required.\n3. Multiphasic modified release products\nPartial AUCs and Cmax in all phases.\nIf t\u00bd is short (say, \u22644\u00a0h), waiving the multiple dose study based on AUC0\u2013\u03c4 \u226410% of AUC0\u2013\u221e generally works.\n1. Not that simple. Sometimes rapid onset of effect is important as well, which lead to development of multiphasic products with IR- and prolonged release-components (zolpidem, methylphenidate, dexamfetamine).\n2. A lot. Not only comparative BA but food-effect, dose proportionality,\nAdditionally between-subject variability of the MR product should be compared with that of the IR product by a one-sided test (non-superiority).\n3. If you want to expand the limits only for C\u03c4,ss (which is more variable than Cmax,ss), it is not necessary to sample two profiles. Since you are in (pseudo-) steady state, use the concentrations pre-dose and at \u03c4.\n4. Instead of testing Cmax,ss and C\u03c4,ss for equivalence, you can also use \u201cbracketing\u201d, i.e., one-sided tests: Cmax,ss for safety (non-inferiority) and C\u03c4,ss for efficacy (non-superiority). For examples see the respective vignette of the R-package PowerTOST.\n5. Although only the 4 period full replicate and the partial replicate designs are given as examples in Section 8 of the Q&A document, Section\u00a019 made clear that the 3 period full replicate design is acceptable as long as at least twelve eligible subjects are in sequence RTR. However, that\u2019s not relevant in practice (see this post).\n\nDif-tor heh smusma\u00a0\ud83d\udd96\nHelmut Sch\u00fctz\n\nThe quality of responses received is directly proportional to the quality of the question asked.\u00a0\ud83d\udeae\nScience Quotes\nPharma_88\n\u2606\n\nIndia,\n2020-09-08 09:05\n(414\u00a0d\u00a020:55\u00a0ago)\n\n@\u00a0Helmut\nPosting: #\u00a021910\nViews: 2,122\n\n## EMA: ABEL for HVD(P)s, PK metrics\n\nThanks For your detailed response.\n\nI have a few questions and need your suggestion in this regards.\n\nI have kept following parameters in SS study (IR VS ER).\n\nPrimary pharmacokinetic parameters: AUC0-\u03c4,ss\nSecondary pharmacokinetic parameters:\nDay 01 to 04-Morning dose: Cpd\nDay 04 (Morning dose): C\u03c4,ss, Cmax,ss, Cmin,ss, Tmax,ss, accumulation index, %Fluctuation and Cav\n\nand also want to know for Cpd and C\u03c4,ss:\n\nCpd: All pre-dose samples needs to be considered including profiling day sample or only samples before profiling day?\n\nC\u03c4,ss: How to calculate it? Whether morning dose of Day 04 is also need to be taken in to account to calculate.\n\nThanks.\nHelmut\n\u2605\u2605\u2605\n\nVienna, Austria,\n2020-09-08 17:25\n(414\u00a0d\u00a012:35\u00a0ago)\n\n@\u00a0Pharma_88\nPosting: #\u00a021911\nViews: 2,089\n\n## EMA: MD PK metrics\n\nHi Pharma_88,\n\n\u00bb I have kept following parameters in SS study (IR VS ER).\n\nPK metrics, pleeze.\n\n\u00bb Primary pharmacokinetic parameters: AUC0-\u03c4,ss\n\nOK.\n\n\u00bb Secondary pharmacokinetic parameters:\n\u00bb Day 01 to 04-Morning dose: Cpd\n\nOK. No comparison\u00a0\u2013 just report them.\n\n\u00bb Day 04 (Morning dose): C\u03c4,ss, Cmax,ss, Cmin,ss, Tmax,ss, accumulation index, %Fluctuation and Cav\n\u00bb\n\u00bb Please correct me.\n\nIf you don\u2019t have a lag-time, Cmin,ss (the \u2018true\u2019 minimum concentration) should be very similar to both Cpd and C\u03c4,ss. Cmin,ss is required only for originators. Since a hybrid application is closer to a generic, you could drop it.\n\nAFAIK, the accumulation index $$\\frac{1}{1-\\exp (-\\lambda_\\textrm{z}\\cdot \\tau)}$$ is not required by any agency.\nYou would need a reliable estimate of $$\\small{\\lambda_\\textrm{z}}$$, which you may not obtain for the ER formulation in all subjects. As long as you don\u2019t have flip-flop PK (see below), $$\\small{\\lambda_\\textrm{z}}$$ is a property of the drug and therefore, not relevant for comparing products.\nCav is not informative because it is simply AUC0\u2013\u03c4\/\u03c4. If you want you can report it though without a statistical comparison. The outcome will be exactly the same as for AUC0\u2013\u03c4. Cav is only needed for the calculation of fluctuation.\n\n\u00bb Cpd: All pre-dose samples needs to be considered including profiling day sample or only samples before profiling day?\n\nYou have to collect at least three pre-dose samples in order to demonstrate achievement of steady-state. In your case mornings of days 2\u20134. See also this presentation (slide 14).\n\n\u00bb C\u03c4,ss: How to calculate it? Whether morning dose of Day 04 is also need to be taken in to account to calculate.\n\nNope. It\u2019s the concentration at the end of the (last) dosing interval or in your case at 96\u00a0hours. Too lazy to search but the EMA states somewhere that this sample should be collected with a time deviation of \u226410\u00a0minutes. In my studies I always used the estimated concentration at \u03c4.\n\nLet\u2019s explore three examples. One-compartment model, no lag-time, D\u00a0100, V\u00a05, t\u00bd,el\u00a014\u00a0h, t\u00bd,abs\u00a01\u00a0h (IR). Pseudo-steady-state reached after 5\u00a0\u00d7\u00a014\u00a0=\u00a070\u00a0h, results for the profile day 4.\n1. \u00a0 \u00a0 \u00a0 Cpd\u00a0 Ctau\u00a0 AUCtau\u00a0 %PTF\u00a0 Cmax\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nIR\u00a0 \u00a0 9.2\u00a0 \u00a09.4\u00a0 \u00a0400.0\u00a0 \u00a0 87\u00a0 23.9\nER\u00a0 \u00a011.5\u00a0 11.7\u00a0 \u00a0399.0\u00a0 \u00a0 48\u00a0 19.8\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nT\/R\u00a0 125%\u00a0 125%\u00a0 \u00a0 100%\u00a0 \u00a056%\u00a0 \u00a083%\n\nC\u03c4,ss\u00a0> Cpd. In practice this difference likely will not be evident due to variability. If you prefer a belt plus suspenders, dose for another day. As expected the AUCs are practically identical and the ER produces less fluctuation.\nEven for a moderately slower rate of absorption it is not possible to waive the MD study because the extrapolated AUC is 45% of AUC0\u2013\u221e.\n\n2. \u00a0 \u00a0 \u00a0 Cpd\u00a0 Ctau\u00a0 AUCtau\u00a0 %PTF\u00a0 Cmax\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nIR\u00a0 \u00a0 9.2\u00a0 \u00a09.4\u00a0 \u00a0400.0\u00a0 \u00a0 87\u00a0 23.9\nER\u00a0 \u00a013.2\u00a0 13.6\u00a0 \u00a0395.9\u00a0 \u00a0 28\u00a0 18.2\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nT\/R\u00a0 144%\u00a0 145%\u00a0 \u00a0 \u00a099%\u00a0 \u00a032%\u00a0 \u00a076%\n\nSimilar but a further reduction in fluctuation.\n\n3. \u00a0 \u00a0 \u00a0 Cpd\u00a0 Ctau\u00a0 AUCtau\u00a0 %PTF\u00a0 Cmax\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nIR\u00a0 \u00a0 9.2\u00a0 \u00a09.4\u00a0 \u00a0400.0\u00a0 \u00a0 87\u00a0 23.9\nER\u00a0 \u00a013.6\u00a0 14.5\u00a0 \u00a0377.8\u00a0 \u00a0 13\u00a0 16.6\n\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\u2500\nT\/R\u00a0 144%\u00a0 145%\u00a0 \u00a0 \u00a094%\u00a0 \u00a015%\u00a0 \u00a069%\n\nNow we crossed the border of flip-flop PK (kabs\u00a0\u2264\u00a0kel) which leads to trouble. Absorption of the ER is the slowest process and hence, steady-state is not reached.\nIn any case to hope to demonstrate equivalence of Cmax and C\u03c4 is futile. Either concentrate on PTF (one-sided test for non-superiority) and\/or consider a bracketing approach (see this post).\n\nSince you mentioned before that you have to deal with a HVD(P), you can expand the limits for some PK metrics (see this post) if the study will be performed in a replicate design. You don\u2019t need a treatment-free washout, i.e., the built-up of a subsequent steady states can overlap with the washout from the previous one. Example for a full replicate design, where T\u00a0= ER and R\u00a0= IR. Profile days in red.\n\nSequence\/Day\u00a0 1\u00a0 2\u00a0 3\u00a0 4\u00a0 5\u00a0 6\u00a0 7\u00a0 8\u00a0 9 10 11 12 13 14 15\n1\u00a0 \u00a0 \u00a0 \u00a0 T\u00a0 T\u00a0 T\u00a0 T\u00a0 T\u00a0 R\u00a0 R\u00a0 R\u00a0 R\u00a0 R\u00a0 T\u00a0 T\u00a0 T\u00a0 T\u00a0 T\n2\u00a0 \u00a0 \u00a0 \u00a0 R\u00a0 R\u00a0 R\u00a0 R\u00a0 R\u00a0 T\u00a0 T\u00a0 T\u00a0 T\u00a0 T\u00a0 R\u00a0 R\u00a0 R\u00a0 R\u00a0 R\n\nNo fun.\n\nDif-tor heh smusma\u00a0\ud83d\udd96\nHelmut Sch\u00fctz\n\nThe quality of responses received is directly proportional to the quality of the question asked.\u00a0\ud83d\udeae\nScience Quotes\n21,760 posts in 4,550 threads, 1,545 registered users;\nonline 5 (0 registered, 5 guests [including 2 identified bots]).\nForum time: Thursday 06:01 CEST\u00a0(Europe\/Vienna)\n\nAlways remember that you are absolutely unique.\nJust like everyone else. \u00a0 \u00a0Margaret Mead\n\nThe Bioequivalence and Bioavailability Forum is hosted by\nIng. Helmut Sch\u00fctz","date":"2021-10-28 04:01:07","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 1, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.583972692489624, \"perplexity\": 7152.394791188535}, \"config\": {\"markdown_headings\": true, \"markdown_code\": false, \"boilerplate_config\": {\"ratio_threshold\": 0.3, \"absolute_threshold\": 10, \"end_threshold\": 5, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2021-43\/segments\/1634323588257.34\/warc\/CC-MAIN-20211028034828-20211028064828-00449.warc.gz\"}"} | null | null |
{"url":"https:\/\/gateoverflow.in\/368464\/slow-start-phase-self-doubt","text":"175 views\nwhen no of RTT \u00a0is asked ,\n\ni am confused when will start from 1 \u00a0\u00a0AND \u00a0when will start from 2\n\nrest part i known \u00a0folow until thresold size and then increse with given MSS\n\nLET SUPPOSE THRESOLD 20\n\nFOR EX ::: \u00a0\u00a0\u00a01 2 4 8 16 20 22 24 26\n\nOR \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a02 4 8 16 20 22 24 26\n\nin ex 1 no of rtt is \u00a09 \u00a0while in ex 2 \u00a0\u00a0no of rtt is 8\n\ncan anyone tell me when we will start 1 and when we will start with 2\n\nCheck for the MSS given if it is not mentioned take 1 as default otherwise take the mentioned one.\n\nLike refer this problem :- https:\/\/gateoverflow.in\/1794\/Gate-cse-2014-set-1-question-27 it is mentioned MSS = 2KB so we start from that size only.\n\nby\n\nand what happened if the given AIMD\/MIMD\u00a0 formate\n\nwhat is the use of AIMD AND MIMD\n\nAIMD is Additive Increase Multiplicative decrease it is the algorithm that is widely popular for congestion control it is same what we have learnt that window size will increase linearly if congestion is not detected and it will reduce to half if congestion is detected.\n\nI don\u2019t think GATE has ever asked about MIMD","date":"2023-02-07 12:15:54","metadata":"{\"extraction_info\": {\"found_math\": false, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.8738279938697815, \"perplexity\": 3032.9040587335144}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.3, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2023-06\/segments\/1674764500456.61\/warc\/CC-MAIN-20230207102930-20230207132930-00747.warc.gz\"}"} | null | null |
While you might be thinking that you are saving money now, pesticides are a major contributor to poor health later.
•They block hormone receptor sites in the cells of your body.
Hormones such as insulin, leptin, and thyroid hormones can all get clogged with pesticide chemicals. Once a hormone receptor site gets clogged, you'll become weight-loss resistant, your thyroid will malfunction, and you'll put yourself on a fast path to cancers such as breast cancer. | {
"redpajama_set_name": "RedPajamaC4"
} | 1,360 |
{"url":"https:\/\/wiki.cosmos.esa.int\/planckpla2015\/index.php\/HFI\/LFI_joint_data_processing","text":"# HFI\/LFI joint data processing\n\nJump to: navigation, search\n\nThe HFI(Planck) High Frequency Instrument \/ LFI(Planck) Low Frequency Instrument common processing uses as basic input the maps at the nine frequencies covered by the two instruments.\n\nThe goal is to obtain various catalogues, identify the different astrophysical components whose superposition leads to the observed sky, and provide a statistical characterisation of the CMBCosmic Microwave background, in particular through a likelihood code (of a particular theoretical given Planck data).","date":"2018-09-23 09:57:50","metadata":"{\"extraction_info\": {\"found_math\": false, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.8482205271720886, \"perplexity\": 5199.119131524676}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": false}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2018-39\/segments\/1537267159193.49\/warc\/CC-MAIN-20180923095108-20180923115508-00130.warc.gz\"}"} | null | null |
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"redpajama_set_name": "RedPajamaCommonCrawl"
} | 8,343 |
{"url":"https:\/\/www.effortlessmath.com\/math-topics\/sbac-math-grade-6-practice-test-questions\/","text":"# 6th Grade SBAC Math Practice Test Questions\n\nIt may be difficult to pass the 6th Grade SBAC Math test, but we will make it easy for your student by providing the 6th Grade SBAC Math practice test questions. After a lot of research, our experts have collected 10 of the best common 6th Grade SBAC Math test questions. Detailed and step-by-step solutions to each question also are provided at the end of the post to help your 6th Grade student identify areas of weakness.\n\nMake sure to follow some of the related links at the bottom of this post to get a better idea of what kind of mathematics questions students need to practice.\n\n## The Absolute Best Book to Ace 6th Grade SBAC Math Test\n\n$18.99 Satisfied 139 Students ## 10 Sample 6th Grade SBAC Math Practice Questions 1- What is the missing prime factor of number 420? $$420=2^2\u00d73^1\u00d7\u2026$$ A. $$2^2\u00d73^1\u00d75^1\u00d77^1$$ B. $$2^2\u00d73^1\u00d77^1\u00d79^1$$ C. $$1^2\u00d72^3\u00d72^1\u00d73^1$$ D. $$3^2\u00d75^1\u00d77^1\u00d79^1$$ 2- If the area of the following trapezoid is equal to $$A$$, which equation represents $$x$$? A. $$x = \\frac{13}{A}$$ B. $$x = \\frac{A}{13}$$ C. $$x=A+13$$ D. $$x=A-13$$ 3- By what factor did the number below change from the first to the fourth number? $$8, 104, 1352, 17576$$ A. 13 B. 96 C. 1456 D. 17568 4- 170 is equal to \u2026 A. $$-20-(3\u00d710)+(6\u00d740)$$ B. $$((\\frac{15}{8})\u00d772 )+ (\\frac{125}{5})$$ C. $$((\\frac{30}{4} + \\frac{15}{2})\u00d78) \u2013 \\frac{11}{2} + \\frac{222}{4}$$ D. $$\\frac{481}{6} + \\frac{121}{3}+50$$ 5- The distance between the two cities is 3,768 feet. What is the distance between the two cities in yards? A. 1,256 yd B. 11,304 yd C. 45,216 yd D. 3,768 yd 6- Mr. Jones saves$3,400 out of his monthly family income of $74,800. What fractional part of his income does Mr. Jones save? A. $$\\frac{1}{22}$$ B. $$\\frac{1}{11}$$ C. $$\\frac{3}{25}$$ D. $$\\frac{2}{15}$$ 7- What is the lowest common multiple of 12 and 20? A. 60 B. 40 C. 20 D. 12 8- Based on the table below, which expression represents any value of f in term of its corresponding value of $$x$$? A. $$f=2x-\\frac{3}{10}$$ B. $$f=x+\\frac{3}{10}$$ C. $$f=2x+2 \\frac{2}{5}$$ D. $$2x+\\frac{3}{10}$$ 9- 96 kg $$=$$\u2026 ? A. 96 mg B. 9,600 mg C. 960,000 mg D. 96,000,000 mg 10- Calculate the approximate area of the following circle? (the diameter is 25) A. 78 B. 491 C. 157 D. 1963 ## Best 6th Grade SBAC Math Prep Resource for 2022 ## Answers: 1- A $$420=2^2\u00d73^1\u00d75^1\u00d77^1$$ 2- B The area of the trapezoid is: area= $$\\frac{(base 1+base 2)}{2})\u00d7height= ((\\frac{10 + 16}{2})x = A$$ $$\u219213x = A\u2192x = \\frac{A}{13}$$ 3- A $$\\frac{104}{8}=13, \\frac{1352}{104}=13, \\frac{17576}{1352}=13$$ Therefore, the factor is 13 4- C Simplify each option provided. $$A. -20-(3\u00d710)+(6\u00d740)=-20-30+240=190$$ $$B. (\\frac{15}{8})\u00d772 + (\\frac{125}{5}) =135+25=160$$ $$C. ((\\frac{30}{4} + \\frac{15}{2})\u00d78) \u2013 \\frac{11}{2} + \\frac{222}{4} = ((\\frac{30 + 30}{4})\u00d78)- \\frac{11}{2}+ \\frac{111}{2}=(\\frac{60}{4})\u00d78) + \\frac{100}{2}= 120 + 50 = 170$$this is the answer $$D. \\frac{481}{6} + \\frac{121}{3}+50= \\frac{481+242}{6}+50=120.5+50=170.5$$ 5- A 1 yard $$=$$3 feet Therefore, $$3,768 ft \u00d7 \\frac{1 \\space yd }{3 \\space ft}=1,256 \\space yd$$ 6- A 3,400 out of 74,800 equals to $$\\frac{3,400}{74,800}=\\frac{17}{374}=\\frac{1}{22}$$ 7- A Prime factorizing of $$20=2\u00d72\u00d75$$ Prime factorizing of $$12=2\u00d72\u00d73$$ LCM$$=2\u00d72\u00d73\u00d75=60$$ 8- C Plug in the value of $$x$$ into the function f. First, plug in 3.1 for $$x$$. $$A. f=2x-\\frac{3}{10}=2(3.1)-\\frac{3}{10}=5.9\u22608.6$$ $$B. f=x+\\frac{3}{10}=3.1+\\frac{3}{10}=3.4\u226010.8$$ $$C. f=2x+2 \\frac{2}{5}=2(3.1)+2 \\frac{2}{5}=6.2+2.4=8.6$$ This is correct! Plug in other values of $$x. x=4.2$$ $$f=2x+2\\frac{2}{5} =2(4.2)+2.4=10.8$$ This one is also correct. $$x=5.9$$ $$f=2x+2 \\frac{2}{5}=2(5.9)+2.4=14.2$$ This one works too! $$D. 2x+\\frac{3}{10}=2(3.1)+\\frac{3}{10}=6.5\u22608.6$$ 9- D 1 kg$$=$$ 1000 g and 1 g $$=$$ 1000 mg 96 kg$$=$$ 96 $$\u00d7$$ 1000 g $$=$$96 $$\u00d7$$ 1000 $$\u00d7$$ 1000 $$=$$96,000,000 mg 10- B The diameter of a circle is twice the radius. Radius of the circle is $$\\frac{25}{2}$$. Area of a circle = $$\u03c0r^2=\u03c0(\\frac{25}{2})^2=156.25\u03c0=156.25\u00d73.14=490.625\u2245491$$ Looking for the best resource to help you succeed on the SBAC Math Grade 6 Math test? ## The Best Books to Ace 6th Grade SBAC Math Test ## Related to This Article ### More math articles ### What people say about \"6th Grade SBAC Math Practice Test Questions\"? No one replied yet. X 21% OFF Limited time only! Save Over 21% SAVE$5\n\nIt was $23.99 now it is$18.99","date":"2023-04-01 11:08:34","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 1, \"mathjax_display_tex\": 1, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.510714054107666, \"perplexity\": 9593.311640897913}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2023-14\/segments\/1679296949958.54\/warc\/CC-MAIN-20230401094611-20230401124611-00143.warc.gz\"}"} | null | null |
Fighting mandatory data retention: CITIZENFOUR to screen at Parliament House
Posted by Nsw Council for Civil Liberties 1168.60sc on February 05, 2015
"The New South Wales Council for Civil Liberties is taking an unusual route in the fight to stop data retention, swapping out Twitter for the silver screen... [The council] aims to screen the film for politicians and media in Canberra, raising money to rent a viewing space in Parliament House for a February 9 screening, presented in conjunction with Madman Entertainment and Electronic Frontiers Australia."
Article: CITIZENFOUR to Screen at Parliament House
Source: 4:3 Film, 23/01/2015
"In an effort to persuade MPs of the bill's danger, the NSW Council for Civil Liberties is currently hosting screenings of Laura Poitras' documentary film CitizenFour, an insider look at the Edward Snowden affair which exposed the global scale of the National Security Agency's data gathering operations... All federal MPs have been invited to the film's Canberra screening, to be held Monday night, which the organisation is currently fundraising for."
Article: Abbott 'Bullying' Labor On Data Retention Laws, Says Ludlam
Source: New Matilda, 05/02/15 | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 8,260 |
from rest_framework import serializers
from users.models import Users
class UsersSerializer(serializers.ModelSerializer):
class Meta:
model = Users
fields = ('id','userName','userPassword','created','lastLoginTime','state') | {
"redpajama_set_name": "RedPajamaGithub"
} | 6,129 |
Q: Image on the page by drag and drop According to MDN Using files from web applications
i can use drag and drop to upload images and if i am right understand get that images on page.
So i take that code
html:
<html>
<head>
<title></title>
</head>
<style>
.box{
width:200px;
height: 200px;
background-color: lightgray;
}
</style>
<body>
<div class="box" id="dropbox">drop here</div>
<div id="qq"></div>
</body>
</html>
And javascript after last <div>:
<script>
var dropbox;
dropbox = document.getElementById("dropbox");
dropbox.addEventListener("dragover", dragover, false);
dropbox.addEventListener("drop", drop, false);
function dragover(e) {
e.preventDefault();
}
function drop(e) {
e.preventDefault();
var dt = e.dataTransfer.files;
function handleFiles(files){
for (var i = 0; i < files.length; i++) {
var file = files[i];
var imageType = /^image\//;
if (!imageType.test(file.type)) {
continue;
}
var img = document.createElement("img");
// img.classList.add("obj");
img.file = file;
var qq = document.getElementById("qq");
qq.appendChild(img);
var reader = new FileReader();
reader.onload = (function(aImg) { return function(e) { aImg.src = e.target.result; }; })(img);
reader.readAsDataURL(file);
}
}
}
</script>
And no image happened on the page. What i am doing wrong?
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 8,840 |
Raves for the GRASSHOPPER JUNGLE and ANDREW SMITH!
_Boston Globe-Horn Book_ winner
A _Publishers Weekly_ Best Book of the Year
A _Kirkus Reviews_ Best Book of the Year
A _SLJ_ Best Book of the Year
" _Grasshopper Jungle_ , in many ways, is a book about how there might be **a manual for defeating monsters** that have invaded town, but there's not going to be an easy manual for everything else that weighs on the mind."
—A.V. Club
"The end of the world comes with neither a bang nor a whimper but with a dark chuckle and the ominous click-click of giant insect mandibles in this **irreverent, strangely tender new novel**."
— _The Washington Post_
" **A literary joy to behold** . . . reminds me of Kurt Vonnegut's _Slaughterhouse_ _Five_ , in the best sense."
— _The New York Times Book Review_
"Nuanced, gross, funny and poignant, it's **wildly origina** **l**."
— _The San Francisco Chronicle_
" **An absurdist** Middlesex . . . **and is all the better for it**. A-"
— _Entertainment Weekly_
"I found myself saying over and over again 'Where in the heck is he going with this?' All the while turning the pages as fast as I could. Mostly I kept thinking, This was a brave book to write _."_
—Terry Brooks, author of the Shannara series
"Original, weird, sexy, thought-provoking and guaranteed to stir controversy. _Grasshopper Jungle_ is a **cool/passionate, gay/straight, male/female, absurd/real, funny/moving, past/present, breezy/profound masterpiece of a book**. **One hell of a book**."
—Michael Grant, _New York Times_ bestselling author of the Gone series
"Andrew Smith is the bravest storyteller I know. _Grasshopper Jungle_ is the most intelligent and gripping book I've read in over a decade. I didn't move for two days until I had it finished. **Trust me. Pick it up right now. It's a masterpiece.** "
—A. S. King, Printz Honor–winning author of _Ask the Passengers_ and _Please Ignore Vera Dietz_
" **It's sexy, gory, hilarious, and refreshingly amoral.** I wish I'd had this book when I was fifteen. It almost makes me sad that it took twenty years to finally find what I'd been looking for."
—Jake Shears, lead singer of Scissor Sisters
" **Once you get lost in** Grasshopper Jungle **you won't want to be found.** "
—Geekdad.com
"Raunchy, **bizarre** , smart and **compelling**."
— _Rolling Stone_
" **Bold, bizarre, and beautiful.** "
— _The Boston Globe_
"In _Grasshopper Jungle_ it's as if Andrew Smith is somehow possessed by the ghost of Kurt Vonnegut. This book is nothing short of a **brilliant, hilarious thrill-ride that is instantly infectious**. But, the most beautiful thing about _Grasshopper Jungle_ is the deft hand by which Smith explores teenage love and sexuality that is truly breathtaking."
—John Corey Whaley, Printz Award–winning author of _Where Things Come Back_
" _Grasshopper Jungle_ is about the end of the world. And everything in between."
—Alex London, author of _Proxy_
"A meanderingly funny, weirdly compelling and **thoroughly brilliant** chronicle of 'the end of the world, and shit like that' . . . **a mighty good book."**
— _Kirkus Reviews_ , starred review
"Filled with gonzo black humor, Smith's outrageous tale makes serious points about scientific research done in the name of patriotism and profit, the intersections between the personal and the global, the weight of history on the present, and the often out-of-control sexuality of 16-year-old boys."
— _PW_ , starred review
" **Original, honest,** and **extraordinary** . . . pushes the boundaries of young adult literature."
— _SLJ_ , starred review
"No author writing for teens today can match Andrew Smith's mastery of the grotesque, the authentic experiences of teenage boys or the way one seamlessly becomes a metaphor for the other."
— _BookPage_ , Top Teen Pick
BY ANDREW SMITH
_The Alex Crow_
_Grasshopper Jungle_
_The Marbury Lens_
_100 Sideways Miles_
_Winger_
GRASSHOPPER JUNGLE
A HISTORY
by
andrew smith
DUTTON BOOKS
AN IMPRINT OF PENGUIN GROUP (USA), LLC
DUTTON BOOKS
An imprint of Penguin Group (USA), LLC
Published by the Penguin Group
Penguin Group (USA) LLC, 375 Hudson Street, New York, New York 10014, USA
USA • Canada • UK • Ireland • Australia
New Zealand • India • South Africa • China
penguin.com
A Penguin Random House Company
Copyright © 2014 by Andrew Smith
Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader.
Library of Congress Cataloging-in-Publication Data
Smith, Andrew (Andrew Anselmo), date.
Grasshopper jungle : a history / by Andrew Smith.
pages cm
Summary: "Austin Szerba narrates the end of humanity as he and his best friend Robby accidentally unleash an army of giant, unstoppable bugs and uncover the secrets of a decades-old experiment gone terribly wrong"—Provided by publisher.
ISBN 978-1-101-59006-5
[1. Survival—Fiction. 2. Friendship—Fiction. 3. Genderidentity—Fiction. 4. Family life—Iowa—Fiction.
5. Insects—Fiction.6. Iowa—Fiction. 7. Science fiction. 8. Humorous stories.]
I. Title.
PZ7.S64257Gr 2014
[Fic]—dc23
2013030265
The publisher does not have any control over and does not assume any responsibility for author or third-party websites or their content.
Version_2
# Contents
Raves for the _Grasshopper Jungle_ and Andrew Smith!
By Andrew Smith
Title Page
Copyright
Dedication
Note to the reader
PART 1: EALING
Kimber Drive • Fixing Feet • Louis Asks a Rhetorical Question • There's Blood on Your Spam • Grant Wallace Murdered Me • What Made This Country Great • Shann's New Old House • Going Somewhere You Shouldn't Go • Robby's Volcano • Doors That Go Somewhere; Doors That Go Nowhere • Curfew • Stupid People Should Never Read Books • The Death-ray Gun • Robby Could Have Been a Preacher • Never Name a Pizza Joint Stan's • If You Ever Want to Get Shot In Ealing • The Trapdoor • Hungry Jack • Johnny's Things • Two-headed Boy • Blue Light • Priorities • Hell Breaks Loose • History is Full Of Shit
PART 2: WATERLOO CORNFIELD
Palindromes • A Bath, a Shave, and Modesty • Johnny And Ollie • The Patch Job • Say Please • A snapshot • Haggled • The Boy In The Glass • Skating And Kayaking • Eden Five Needs You • An Awful lot Of math • Tally-ho! • The Inner Tomb • And Here's Number Five • Taking Drags • A Visitor Comes And Goes • The Thing In The Cornfield
PART 3: THE SILO
A Tough Day At Curtis Crane Lutheran Academy • Bugs Do Two Things • A Gift From Johnny Mckeon • Shann Calls • My Mom's Little Blue Kayaks • Pages From History • School Prayers • The Vice president's Balls • Modern-day Nightingales • Shann, The Horny Polish Kid, And Satan • Four Photographs • the president's sperm • The Virgin Saint And His Ward • The Diving Bell • The Popular Girl • Welcome To Eden • Some Kind Of Sign • Gimme Shelter • The Dragon Parade • Soup From paint Cans • Gideon's Breeding rights • The Queen Of The Universe • The Library and The new tally-ho! • Ventilator Blues • Something Always Happens While Someone Else Dances • Lucky, In polish Boy names • Movie Night in Eden • The Good doctor Accounts for history • Unstoppable Corn! unstoppable Corn! • Three Of Five • The Orphan Felek
PART 4: THE END OF THE WORLD
We, The New Humans • Last Legs • Davy Crockett And Daniel Boone Never Wore Coonskin Caps • Garlic, Dr Pepper, And Crystal Meth • Clickety Clickety • On The Roof Again • Denny Drayton Has A Gun, Motherfucker • Exile In Eden • A Chance Meeting Under A Portrait Of A Presbyterian, Or, Calvin Coolidge's Canoe • A Most Soothing Showerhead • Infinita Milites! Infinita Milites! • Robby The Theologian • Satan And The Pastor • Serial Killer Usa • Looking For Wiggles • Concerning The Bison, And Free Will • Population Explosion • Everything A Guy Could Need, And The Two Best Rock Albums Ever Made • The Blood Of God • Wanda Mae's Pink Bowling Ball • Rules Are Rules, But The Brain Room Is Not Particularly Brainy • Never Look For Ice Cream In A Sperm Freezer • A Real Concrete Iowa Thinker • Nighttime In Eden • The Finale Of Seem • The Sunshine Bores The Daylights Out Of Me • The Right Kind Of Cigarettes To Smoke Just Before You Kill Something • There Are No Cup-O-Noodles In Eden • Rat Boys From Mars, And An Unfortunate Incident Involving An Inflatable Whale • The Battle Of The Del Vista Arms • The End Of The World • Pictures Of Robby And Shann • The Intergalactic Bug Cops • Enola Gay And Beau Barton's Boner • The Battle Of Kelsey Creek Bridge
Great Big Jar
EPILOGUE: LUCKY, A CIGARETTE RUN, AND THE BISON
Acknowledgments
Excerpt from _The Alex Crow_
For Michael Bourret, who would not allow me to quit
Ealing, Iowa, is a fictional town. None of the characters and places in this book actually exist. Any similarities between events and characters to actual history only occur in the true portions of this book, which aren't that many.
# PART 1:
EALING
I READ SOMEWHERE that human beings are genetically predisposed to record history.
We believe it will prevent us from doing stupid things in the future.
But even though we dutifully archived elaborate records of everything we've ever done, we also managed to keep on doing dumber and dumber shit.
This is my history.
There are things in here: babies with two heads, insects as big as refrigerators, God, the devil, limbless warriors, rocket ships, sex, diving bells, theft, wars, monsters, internal combustion engines, love, cigarettes, joy, bomb shelters, pizza, and cruelty.
Just like it's always been.
## KIMBER DRIVE
ROBBY BREES AND I made the road the Ealing Mall is built on.
Before we outgrew our devotion to BMX bicycles, the constant back-and-forth ruts we cut through the field we named Grasshopper Jungle became the natural sweep of Kimber Drive, as though the dirt graders and street engineers who paved it couldn't help but follow the tracks Robby and I had laid.
Robby and I were the gods of concrete rivers, and history does prove to us that wherever boys ride bicycles, paved roadways ribbon along afterward like intestinal tapeworms.
So the mall went up—built like a row of happy lower teeth—grinned for a while, and then about a year ago some of the shops there began shutting down, blackening out like cavities when people left our town for other, better places.
BMX riding was for middle-school kids.
We still had our bikes, and I believe that there were times Robby and I thought about digging them out from the cobwebbed corners of our families' garages. But now that we were in high school—or at least in high school classes, because we'd attended Curtis Crane Lutheran Academy since kindergarten—we rode skateboards, and also managed to sneak away in Robby's old car.
We were in tenth grade, and Robby could drive, which was very convenient for me and my girlfriend, Shann Collins.
We could always depend on Robby. And I counted on the hope—the erotic plan I fantasized over—that one night he'd drive us out along the needle-straight roads cutting through the seas of cornfields surrounding Ealing, and Robby wouldn't say anything at all as I climbed on top of Shann and had sex with her right there on the piles of Robby's laundry that always seemed to lie scattered and unwashed in the dirty old Ford Explorer his dad left behind.
## FIXING FEET
ON THE FRIDAY that ended our painfully slow first week after spring break, Robby and I took our boards and skated through the filthy back alley of Grasshopper Jungle.
Nobody cared about skaters anymore.
Well, at least nobody cared among the four remaining businesses that managed to stay open in the Ealing Mall after the McKeon plant closed down: The laundromat Robby never quite made it to, The Pancake House, and the liquor and thrift stores owned by Shann's stepdad.
So we could skate there, and did pretty much whatever we wanted to do.
Judging from the empty beer cans, the mysterious floral sleeper sofa we were certain was infested with pubic lice, and the pungent smell of piss in the alley, it was clear everyone else in Ealing was similarly okay with the no-limits code of conduct in Grasshopper Jungle, too.
And that proved to be an unfortunate fact for me and Robby on that Friday.
We had built ramps from sagging flaps of plywood that we laid across a flight of concrete steps behind a vacant unit that used to be a foot doctor's office.
"Bad business plan," Robby said.
"What?"
"Fixing people's feet in a town everyone's dying to run away from."
Robby was so smart it hurt my head to think about how sad he could be sometimes.
"We should go into business," I said.
"Want to have a fag?"
Robby liked calling cigarettes fags.
"Okay."
There was no way we'd ever sit down on that couch. We upended blue plastic milk crates and sat with forearms resting across our knees while we propped our feet on our boards and rocked them back and forth like we floated over invisible and soothing waves.
Robby was a better smoker. He could inhale thick, deep clouds of cigarette smoke and blow life-sized ghost models of both of us when he'd casually lean back and exhale.
I liked cigarettes, but I'd never smoke if Robby didn't.
"What kind of business?" Robby said.
"I don't know. I could write stuff. Maybe comic books."
"And you could draw me." Robby took a big drag from his cigarette. "I'd be like your spokesmodel or something."
I have to explain.
I have that obsession with history, too.
In one corner of my closet, stacked from the floor to the middle of my thigh, sits a pile of notebooks and composition binders filled with all the dumb shit I've ever done. My hope was that, one day, my dumb history would serve as the source for countless fictional accounts of, well, shit.
And I drew, too. There were thousands of sketches of me, of Shann and Robby, in those books.
I consider it my job to tell the truth.
"What, exactly, does a spokesmodel do?"
"We speak. And look good at the same time. It's a tough job, so I'd expect to make decent money."
"Multitasking."
"The shit out of it, Porcupine."
Robby called me Porcupine because of how I wore my hair. I didn't mind. Everyone else called me Austin.
Austin Szerba.
It is Polish.
Sometimes, in wonder, I can marvel at the connections that spiderweb through time and place; how a dying bull in Tsarist Russia may have been responsible for the end of the world in Ealing, Iowa.
It is the truth.
When he was a young man, Andrzej Szczerba, who was my great-great-great-grandfather, was exiled from his home in a small farming village called Kowale. Andrzej Szczerba had been involved in a radical movement to resist the imposition of Russian language and culture on Poles. Andrzej, like many Polish boys, hoped that one day his country, which had been treated like a sausage between the dog jaws of selfish neighboring empires, would be able to stand on its own.
It was a good idea, but it was not going to happen in Andrzej's lifetime.
So Andrzej was forced to leave Kowale—and travel to Siberia.
He did not get very far.
The train carrying the exiled Andrzej derailed when it struck a dying bull that had collapsed on the tracks. It was a terrible accident. Andrzej was left, presumed dead, abandoned in the middle of a snowy field.
Andrzej Szczerba wore a silver medallion with an image of Saint Casimir, who was the patron saint of Poland, on a chain around his neck. He believed Saint Casimir had saved his life in the train wreck, and every day for the rest of his life, Andrzej would kiss the medal and say a prayer, thanking Saint Casimir.
It was a fortunate thing for me that Andrzej Szczerba did not die in that snowy field. Wounded, he walked for two days until he came to the town of Hrodna, where he hid from the Russians and ultimately married a Polish girl named Aniela Masulka, who was my great-great-great-grandmother.
Andrzej's healthy Polish semen made four Catholic children with Aniela—two boys and two girls.
Only one of them, his youngest son, Krzys, would ever end up near Ealing, Iowa.
This is my history.
## LOUIS ASKS A RHETORICAL QUESTION
WE LEANED OUR backs against the cinder-block wall, smoking in the cut of shade from a green rolling dumpster, and at just about the same time I talked Robby into taking his car to drive us over to Shann Collin's new old house, I looked up and noticed the population of Grasshopper Jungle had increased uncomfortably.
Four boys from Herbert Hoover High, the public school, had been watching us while they leaned against the galvanized steel railing along the edge of the stairway we had been using for a ramp.
"Candy Cane faggots, getting ready to make out with each other in Piss Alley."
The Candy Cane thing—that was what Hoover Boys enjoyed calling boys from Curtis Crane Lutheran Academy. Not just because it kind of rhymed. We had to wear ties to school. Whoever invented the uniform could have planned better to avoid the striped red-and-white design of them. Because when we'd wear our ties, white shirts, and blue sweaters with the little embroidered crosses inside bloodred hearts, you couldn't help but think we looked like, well, patriotic, Christian-boy candy canes.
But Robby and I weren't big enough losers to still be wearing our uniforms while skating.
Well, we weren't so much skating as smoking cigarettes, actually.
Robby wore a Hormel Spam T-shirt and baggy jeans with holes in them he sagged so low you could see half his citrus-motif boxers. They had oranges and lemons on them.
Citrus does not grow in Iowa.
I wore yellow-and-green basketball shorts and a black Orwells tee. So we didn't look like candy cane boys.
The Orwells are a punk band from Illinois.
The other part—the faggot part—well, let's just say Robby got picked on.
A lot.
I only knew one of the boys: Grant Wallace. It's hard not to know pretty much every kid in a town the size of Ealing, even if you didn't pay too much attention to people as a rule.
However, I did know this: Grant and his friends were there for no other reason than to start crap.
It was bound to be historic, too.
And two 140-pound Candy Cane faggot sophomores with cigarettes and skateboards were not likely to stop anything four bored and corn-fed twelfth-graders from Hoover had in mind.
Robby just sat back casually against the wall, puffing away on his cigarette.
I couldn't help but think he looked like a guy in one of those old black-and-white movies about firing squads and blindfolds and the Foreign Legion and shit like that.
One of Grant's friends, a pudgy guy with a face full of whiteheads and only one eyebrow, took his cell phone out from his pocket and began recording video of us.
Consult history: Nothing good ever happens when cell phones are used to record video.
And I guess that was as good as Grant's directorial cue to begin.
"Let me and Tyler borrow you guys' skateboards for a few minutes. We'll bring them back."
Tyler must have been the mule-faced kid on Grant's right, because he nodded, all excited, an encouragement for us to be cooperative Candy Cane faggots.
But Robby said no before the question was entirely out of Grant's mouth.
The truth is—and history will back me up on this, too—that when kids like Grant ask kids like me and Robby if they can borrow stuff like skateboards, the boards are either going to get stolen, or the kids like me and Robby are going to be beaten up and then the boards are going to get stolen.
The way kids like me and Robby get beaten up first is when one of them says no.
History class is over for today.
We got beaten up by Grant Wallace, Tyler, and some other kid who smelled like he had barf on his sleeves, while the fourth kid filmed it with his cell phone.
Oh, and extra credit in history: You should never wear loose mesh basketball shorts and boxer underwear if you're going to get kneed in the balls. Just so you know for the future.
I don't even think either one of us made it all the way to his feet before the kicks and punches started. Robby got a bloody nose.
Grant took our boards and chucked them up onto the roof of The Pancake House.
Then the four Hoover Boys took our shoes off and threw them on the roof, too.
And if the boards didn't make such a racket when they landed, Grant and his friends would have taken Robby's and my pants and sent them up to shoe-and-skateboard heaven, too. But the Chinese guy named Louis who worked in the kitchen of The Pancake House stuck his face out the back door, and asked, politely, what we thought we were doing.
I do not know what I thought I was doing.
But that question, in itself, when asked by a Chinese pancake chef named Louis, was enough to make Grant and his friends call an end to their diversion.
I was curled up on my side, cupping my nuts, while the sleeve of my black Orwells T-shirt adhered to some gooey piss stain on Grasshopper Jungle's asphalt.
Grant and the Hoover Boys left, and Louis, apparently satisfied with the lack of an answer to his rhetorical question about what we boys thought we were doing, shut the door.
For a moment, I found myself wondering, too, why guys like Grant Wallace, who called guys like me and Robby Brees faggots, always seemed to take pleasure in removing the trousers of littler guys.
That would be a good question for the books, I thought.
## THERE'S BLOOD ON YOUR SPAM
##
"ARE YOU HURT?"
"Balls. Knee. Boxers."
"Oh. Um."
"There's blood on your Spam."
"Shit."
## GRANT WALLACE MURDERED ME
##
ROBBY FELT BAD, not because of his bloody nose. Because he blamed himself when things like this happened. He cried a little, and that made me sad.
We recovered.
History shows, after things like that, you either get up and have a cigarette, in your socks, with your bloody friend, or you don't.
Since it wasn't time for Robby and me to die, we decided to have a smoke.
I believe Andrzej Szczerba would have wanted a smoke when he pulled himself, bloodied, up from the wreckage in that snowy field in Poland.
There are as many theories on how to deal with a bloody nose as there are ears of corn in all the combined silos of Iowa.
Robby's approach was artistic.
Propping himself dog-like on his hands and knees, he hung his head down, depositing thick crimson coins of blood from his nostrils and simultaneously puffing a cigarette, while he drip-drip-dripped a pointillist message on the blacktop: GRANT WALLACE MURDERED ME
I watched and smoked and wondered how our shoes and skateboards were getting along, up there on the roof.
Unfortunately, as funny as it was to both of us, Robby stopped bleeding after forming the second A, so he only got as far as GRANT WA
"Nobody's going to know what that means," I said.
"I should have used lowercase."
"Lowercase does use less blood. And a smaller font. Everyone knows that."
"Maybe you should punch me again."
I realized I'd never punched anyone in my life.
"I don't think so, Robby. You got any quarters on you?"
"Why?"
"Let's go throw our shirts in the laundry place. You need to learn how to use those things anyway."
So Robby and I limped around to the front of the mall and went inside Ealing Coin Wash Launderette, where, maximizing the return on our investment, we not only washed our T-shirts, but the socks we had on as well.
"This is boring," Robby observed while we waited for the fifth dime we slotted into the dryer to magically warm the dampness and detergent from our clothes. "No wonder I never come here."
"Doesn't your apartment building have a laundry room?"
"It's nasty."
"Worse than this?"
"This? This is like Hawaii, Porcupine. Sitting here with you, barefoot, with no shirts on, watching socks and shit go around."
Robby lived alone with his mom in a tiny two-bedroom at a place called the Del Vista Arms, a cheap stucco apartment building only three blocks from Grasshopper Jungle. We walked there, in our damp laundered socks and T-shirts.
Two of the apartments on Robby's floor had Pay or Quit notices taped to their doors.
"Wait here," he said, and he quietly snuck inside.
It meant his mother was home. Robby usually didn't like people to come over when his mom was there. I knew that. He was just going to get the keys to the Ford and take me for a ride, anyway.
So I waited.
"The blood didn't come out of your Spam shirt," I said.
We drove west, down Mercantile Street toward my house, and I noticed the diffused brown splotches of post-laundered blood that dotted Robby's chest. And he was still in his socks, too.
"I'll loan you a pair of shoes when we get to my house," I offered. "Then let's go get Shann and do something."
I glanced over my shoulder and checked out the backseat.
I wondered if I would ever not be horny, or confused about my horniness, or confused about why I got horny at stuff I wasn't supposed to get horny at.
As history is my judge, probably not.
"I think we should go up on the roof and get our shit back. Tonight, when no one will see us. Those were my best shoes."
Actually, those were Robby's only non-Lutheran-boy school shoes.
I was willing.
"I bet there's some cool shit up on that roof," I said.
"Oh yeah. No doubt everyone in Ealing hides their cool shit up on the roof of The Pancake House."
"Or maybe not."
## WHAT MADE THIS COUNTRY GREAT
ROBBY HAD AN older sister named Sheila.
Sheila was married and lived with her husband and Robby's six-year-old nephew in Cedar Falls.
I had a brother named Eric.
Eric was in Afghanistan, shooting at people and shit like that.
As bad as Cedar Falls is, even the Del Vista Arms for that matter, Eric could have gone somewhere better than Afghanistan.
Both our moms took little blue pills to make them feel not so anxious. My mom took them because of Eric, and Robby's mom needed pills because when we were in seventh grade, Robby's dad left and didn't come back. My dad was a history teacher at Curtis Crane Lutheran Academy, and my mom was a bookkeeper at the Hy-Vee, so we had a house and a dog, and shit like that.
Hy-Vee sells groceries and shit.
My parents were predictable and ominous. They also weren't home yet when Robby and I got there in our still-wet socks and T-shirts.
"Watch out for dog shit," I said as we walked across the yard.
"Austin, you should mow your lawn."
"Then it would make the dog shit too easy to see and my dad would tell me to pick it up. So I'd have to mow the lawn and pick up dog shit."
"It's thinking like that that made this country great," Robby said. "You know, if they ever gave a Nobel Prize for avoiding work, every year some white guy in Iowa would get a million bucks and a trip to Sweden."
Thinking about me and Robby going to Sweden made me horny.
## SHANN'S NEW OLD HOUSE
FIRST THING, NATURALLY: We got food from the kitchen.
We also made dirt tracks on the floor because socks are notoriously effective when it comes to redistributing filth from sidewalks, lawns, the Del Vista Arms, and Robby's untidy old Ford Explorer.
I boiled water, and we took Cups-O-Noodles and Doritos into my room.
Robby sat on my bed and ate, waiting patiently while I recorded the last little bit of the day's history in my notebook.
"Here." I tossed my cell phone over to the bed. "Call Shann."
"Have you ever smelled a Dorito?"
"Mmmm . . ." I had to think about it. I wrote. "Probably not."
"Just checking," he said, "'Cause they smell like my nephew's feet."
"Why did you smell a six-year-old kid's feet?"
"Good question."
As usual, Shann got mad because I had Robby call her using my phone, and when she answered, she thought it was me. This, quite naturally, made me horny. But Robby explained to her I was writing, and he told her that something terrible had happened to us. He asked if it would be okay that we came over to her new old house as soon as we finished eating.
Robby was such a suave communicator when it came to relaying messages to Shann. In fact, I believed it was the biggest component of why she was so much in love with me. Sometimes, I wished I could cut off Robby's head and attach it to my body, but there were more than a couple things wrong with that idea: First, uncomfortably enough, it kind of made me horny to think about a hybridized Robby/Austin having sex with Shann; and, second, decapitation was a sensitive topic in Ealing.
Well, anywhere, really. But, in Ealing during the late 1960s there was this weird string of serial murders that went unsolved. And they all involved headlessness.
History is full of decapitations, and Iowa is no exception.
So, after we finished eating, I outfitted Robby with some clean socks, a Titus Andronicus T-shirt (I changed into an Animal Collective shirt—all my tees are bands), and gave him my nicest pair of Adidas.
And both of us tried to pretend we didn't notice my dad's truck pulling up the drive just as we took off for Shann's.
"Perfect timing," I said.
Robby answered by pushing in the dashboard cigarette lighter.
Besides all the head-cutting-off shit that went on fifty years ago, Ealing was also known for Dr. Grady McKeon, founder of McKeon Industries, which, up until about six months ago, employed over half the town's labor force. Grady McKeon was some kind of scientist, and he made a fortune from defense programs during the Cold War. When the fight against Communism went south on McKeon, the factory retooled and started manufacturing sonic-pulse shower-heads and toothbrushes, which ultimately became far more profitable when made in Malaysia or somewhere like that. So the factory shut down, and that's also why most of the Ealing strip mall was deserted, and why every time I visited Robby at the Del Vista Arms, there were more and more Pay or Quit notices hanging on doors.
And that's a half century of an Iowa town's history in four sentences.
Grady McKeon was gone, but his much younger brother still lived and ran businesses in Ealing. Johnny McKeon owned Tipsy Cricket Liquors and the From Attic to Seller thrift store, both of which were big crowd-pleasers at the strip mall.
Johnny, who was responsible for thinking up the names of those two establishments entirely on his own, was also Shann's stepfather.
And Shannon Collins, whom Robby and I called Shann, her mother (the relatively brand-new Mrs. McKeon), and Johnny had just taken ownership of the McKeon House, a decrepit old wooden monstrosity that was on the registry of historic homes in Ealing.
Well, actually, it was the only historic home in Ealing.
It took Robby and me two cigarettes to get to Shann's new old house.
It had already been a rough day.
We were going to need another pack.
## GOING SOMEWHERE YOU SHOULDN'T GO
SHANNON KISSED ME on the lips at the door of her new old house.
She kissed Robby on the lips, too.
Shann always kissed Robby on the mouth after she kissed me.
It made me horny.
I wondered what she would say if I asked her to have a threesome with us in her new old, unfurnished bedroom.
I knew what Robby would say.
Duh.
I wondered if it made me homosexual to even think about having a threesome with Robby and Shann. And I hated knowing that it would be easier for me to ask Robby to do it than to ask my own girlfriend.
I felt myself turning red and starting to sweat uncomfortably in my Animal Collective shirt.
And I realized that for a good three and a half minutes, I stood there at the doorway to a big empty house that smelled like old people's skin, thinking about three-ways involving my friends.
So I wondered if that meant I was gay.
I hadn't been listening to anything Shann and Robby were talking about, and while I was pondering my sexuality, they were probably thinking about how I was an idiot.
I might just as well have been a blowup doll.
These are the things I don't write down in the history books, but probably should.
I don't think any historians ever wrote shit like that.
"You have to excuse him. He got kneed in the balls."
"Huh?"
Robby nudged me with his shoulder and said it again, louder, because idiots always understand English when you yell it at them: "YOU HAVE TO EXCUSE HIM. HE GOT KNEED IN THE BALLS."
Shann put her hand flat on the side of my face, the way that real moms, who don't take lots of drugs every day, do to little boys they think might be sick. Real moms have sensors or some kind of shit like that in their hands.
Shann's mom, Mrs. McKeon, was a real mom. She also used to be a nurse, before she married Johnny McKeon.
"Are you okay, Austin?"
"Huh? Yeah. Oh. I'm sorry, Shann. I was kind of tripping out about something."
Having a three-way in Sweden with Robby and her was what I was tripping out about.
But I didn't tell her.
Shann's room was empty.
The entire house was mostly empty, so our footsteps and voices echoed like sound effects in horror films about three kids who are going somewhere they shouldn't go.
Thinking about things like that definitely did not make me horny.
In fact, just about the only things I noticed in that musty mausoleum of a house were unopened boxes—brand-new ones—containing McKeon Pulse-O-Matic® showerheads and toothbrushes.
"The moving van's going to be here this afternoon. They just finished at the house," Shann explained as the three of us stood awkwardly in her empty, echoey room.
Because, in an empty bedroom with creaky old wood floors, it is a natural human response to just stand there and shift your weight from foot to foot, and think about sex.
## ROBBY'S VOLCANO
SHANN AND I started going out with each other in seventh grade.
When I think about it, a lot of stuff happened to us that year.
There are nine filled, double-sided-paged volumes of Austin Szerba's Unexpurgated History of Ealing, Iowa for that year alone.
That year, Eric went into the Marines and left me at home, brotherless, with our dog named Ingrid, a rusty golden retriever with a real dynamo of an excretory tract.
People in Ealing use expressions like real dynamo whenever something moves faster than a growing stalk of corn.
It was also the same year Robby's dad went to Guatemala to film a documentary about a volcanic eruption. Lots of stuff erupted that year, because Mr. Brees met a woman, got her pregnant, and expatriated to Guatemala.
And, just like a lot of boys in seventh grade, I started erupting quite frequently then, too.
A real dynamo.
And, that year Shannon Collins's mom moved to Ealing, enrolled her daughter at Curtis Crane Lutheran Academy (where we were all good, non-smoking, non-erupting Christians), and married Johnny McKeon, the owner of From Attic to Seller Consignment Store and Tipsy Cricket Liquors.
And I fell in love with Shann Collins.
It was a very confusing time. I didn't realize then, in seventh grade as I was, that the time, and the eruptions, and everything else that happened to me would only keep getting more and more confusing through grades 8, 9, and 10.
I will tell you how it was I managed to get Shann Collins to fall in love with me, too: My best friend, Robby Brees, taught me how to dance.
I was infatuated with Shann from the moment I saw her. But, being the new kid at school, and new in Ealing, Shann kept pretty much to herself, especially when it came to such things as eruptive, real dynamo, horny thirteen-year-old boys.
Robby noticed how deeply smitten I was by Shann, so he selflessly taught me how to dance, just in time for the Curtis Crane Lutheran Academy End-of-Year Mixed-Gender Mixer. Normally, genders were not something that were permitted to mix at Curtis Crane Lutheran Academy.
So I went over to Robby's apartment every night for two and a half weeks, and we played vinyl records in his room and he taught me how to dance. This was just after Robby and his mother had to move out of their house and into the Del Vista Arms.
Robby was always the best dancer of any guy I ever knew, and girls like Shann love boys who can dance.
History does show that boys who dance are far more likely to pass along their genes than boys who don't.
Boys who dance are genetic volcanoes.
It made me feel confused, though, dancing alone with Robby in his bedroom, because it was kind of, well, fun and exceptional, in the same way that smoking cigarettes made me feel horny.
Seventh grade was also when Robby and I stole a pack of cigarettes from Robby's mom. By the time we got into tenth grade, Robby's mom started buying them for us. She might take drugs and not have one of those sensor things in the palm of her hand like real moms do, but Mrs. Brees doesn't mind when teenage boys smoke cigarettes in her house and dance with each other, alone in the bedroom, and that's saying something.
That year, at the end of seventh grade, Robby confessed that he'd rather dance with me than with any girl. He didn't just mean dance. It was very confusing to me. It made me wonder more about myself, whom I doubted, than about Robby, whom I suppose I love.
At first, I thought Robby would grow out of it—you know, start erupting like everyone else.
But there was nothing wrong with Robby's volcano, and he never did grow out of it.
So it was at the Curtis Crane Lutheran Academy End-of-Year Mixed-Gender Mixer that Robby casually and bravely walked up to the new girl, Shann Collins, and announced to her:
"My friend Austin Szerba is shy. That's him over there. He is good-looking, don't you think? He's also a nice guy, he writes poetry, he's a really fantastic dancer. He would like very much if you would agree to dance with him."
And everything, confusing as it was, worked out beautifully for me and Shann and Robby after that.
## DOORS THAT GO SOMEWHERE;
DOORS THAT GO NOWHERE
"OKAY. SO, BASICALLY this house is, like, infested with demons or something," Shann told us.
Demonic infestations have a way of making guys feel not so horny.
"It's in the Ealing Registry of Historical Homes," I pointed out.
"People died here."
"You should get that kind of air freshener shit that you plug into outlets so it masks the scent of death and decay with springtime potpourri," Robby offered.
"Look at this," she said. "There are doors that go nowhere, and I swear I heard something ticking and rattling inside my wall a moment ago."
Shann used words like moment.
She wasn't from Ealing.
One of the walls in her creaky room had two doors set into it. The wall itself was kind of creepy. It had wallpaper with flowers that seemed to float like stemless clones between wide red stripes. If I pictured a room where I was going to murder someone, aside from the instruments of torture and shit like that, it would have this wallpaper. If I was on death row, awaiting electrocution, I'd be wearing pajamas with the same pattern on them.
Shann went to the door on the left and pulled it open.
When she opened it, there was only the jamb and frame of the door, and then a wall of bricks behind it.
"See?"
I could only imagine what was on the other side of the bricks.
Robby, naturally, felt compelled to say something less than comforting.
"I suggest you don't liberate whatever's imprisoned back there," he said.
Shann was getting angry. I knew I should intervene, but I didn't know what to say.
"Nowadays, people spend a lot of money for distressed bricks like those," I said.
It was probably for the best that Shann wasn't paying attention to me.
"And look at this," she said.
When she opened the second door, a long, narrow stairway extended down into darkness on the other side. The chasm was at least twenty feet deep, but it dead-ended at another distressed brick wall, and there were no other doorways leading off in any direction that I could see.
"What can you expect from a house this old?" I asked.
It was a good question.
Ghosts and shit like that, was what I was thinking, though. You wouldn't expect miniature ponies and trained talking peacocks that dispensed Sugar Babies and gumballs from their asses, would you?
"I don't want to stay in this room by myself," Shann said.
And that made me very horny again.
I also wanted candy.
Shann, obviously stressed, looked at Robby, then at me.
"I need to talk to you, Austin," she said, and motioned for me to go with her down the candyless staircase of death and decay.
Robby took the hint. "Uh. I need to go to the bathroom. Maybe Pulse-O-Matic® my teeth. Or take a shower. Or something."
He made a tentative, weight-shifting creak onto one leg and I followed Shann behind door number two.
We sat beside each other on the staircase.
Our bare legs touched.
Shann had a perfect body, a Friday-after-school body that was mostly visible because she was barefoot, and wore tight, cuffed shorts with a cantaloupe-colored halter top. A boy could go insane, I thought, just being this close to Shann's uncovered shoulders, wheat hair, and heavy breasts.
This staircase to nothing was a fitting dungeon for constantly erupting, real-dynamo sixteen-year-old boys like me.
"Why is Robby wearing your clothes, and what happened to you and him?"
While we sat there, three important things struck me about Shann: First, I realized that, like most girls I knew, Shann could ask questions in machine-gun bursts that peppered the male brain with entirely unrelated projectiles of interrogation. Second, it was often unstated, but clear by her tone, that Shann was jealous of Robby, possibly to the point of being a little curious about my sexuality. I know, maybe that was also my confusion, as well. Because, third, what was most troubling to me, was that despite all the fantasies, all the intricately structured if/then scenarios I concocted involving Shann Collins and me, whenever an opportunity to take action presented itself—like being alone with her in a nearly sealed dungeon—I became timid and restrained.
I couldn't understand it at all.
History chews up sexually uncertain boys, and spits us out as recycled, generic greeting cards for lonely old men.
Dr. Grady McKeon was a lonely old man. I can only conclude he must have also at one time been a sexually confused, unexplainably horny teenage boy who erupted all over everything at the least opportune times. He was twenty-five years old, and well on his way to building an empire of profits when his younger brother, Johnny, was born. I once heard a tobacco-chewing hog farmer say that, in Iowa, folks liked to spread out their children like dog shit on a dance floor.
Dr. Grady McKeon would be Shann's stepuncle, if there is such a thing, and if he weren't dead. He was the last person to live in the historic McKeon house. He died when his private jet went down in the Gulf of Mexico. Its engines choked to death on ash from Mount Huacamochtli, the same erupting volcano in Guatemala that Robert Brees Sr. was filming a documentary on. And it also happened the same year Robby Brees and I smoked our first cigarette, danced together, and I fell in love with Shannon Collins.
Johnny McKeon never wanted to live in his dead brother's old house. It took Shann's mother about four years of badgering to get him to finally break down and take the place out of mothballs.
I held Shann's hand, and we sat there in the dungeon with our legs pressed together, and I was so frustrated I felt like I could explode. But I concentrated, and methodically went through the entire account of what happened to me and Robby at Grasshopper Jungle. I told her about our plan to climb up onto the roof of the Ealing Mall to get our stuff back.
"I'm coming with you," she decided.
"Not up on the roof," I said, so authoritatively my voice lowered an octave.
Sounding father-like to Shann in the echoing darkness of the staircase that led nowhere made me feel horny, demons or not. I scooted closer and put my arm around her so that my fingers relaxed and splayed across the little swath of exposed skin above the waist of her shorts.
"I'll wait in Robby's car. I'll be your lookout."
"Shann?" I said.
I almost had myself convinced to ask her if didn't she think it was time we had sex, and the thought made me feel dizzy. I would force myself to no longer have any doubt or confusion, to not wind up recycled by history.
"What?"
"This staircase really is creepy."
And just as I pushed her firmly against the distressed brick wall and put my open mouth over hers, Robby swung the door wide above us and said, "The moving van's here."
## CURFEW
WHILE SHANN'S MOM, the movers, and Johnny McKeon worked at unloading and organizing the houseful of furniture they'd shipped over from their old-but-much-newer house, the three of us stole away in Robby's Ford Explorer on our mission to reclaim our shoes and skateboards.
Friday nights in Ealing, Iowa, rarely got more thrilling than climbing up on the roof of a three-quarters abandoned mall, and we were up for the excitement.
On Fridays, my curfew came at midnight, which meant that if I was quiet enough I could stay out until just before my mother served breakfast on Saturday morning.
I had to check in with my dad and mom, so they'd know I was still alive.
I told them I was going out for pizza with Robby and Shann.
It wasn't a lie; it was an abbreviation.
I was not concerned about going to hell.
Nobody who was born and raised in Ealing, Iowa, was afraid of hell, or Afghanistan, or living at the Del Vista Arms.
Checking in for Robby meant swinging by his two-bedroom deluxe apartment at the Del Vista Arms and asking his mom for five dollars and a fresh pack of cigarettes, while Shann and I waited in the parking lot.
Shann did not smoke.
She was smarter than Robby and me, but she didn't complain about our habit.
## STUPID PEOPLE SHOULD NEVER READ BOOKS
IT TOOK ME a very long time to work up the nerve to kiss Shann Collins, who was the first and only girl I had ever kissed.
There was a possibility that I'd never have kissed her, too, because she was the one who actually initiated the kiss.
It happened nearly one full year after the Curtis Crane Lutheran Academy End-of-Year Mixed-Gender Mixer.
Like Robby explained to her: I was shy.
I was on the conveyor belt toward the paper shredder of history with countless scores of other sexually confused boys.
After the Curtis Crane Lutheran Academy End-of-Year Mixed-Gender Mixer, I tried to get Shann to pay more serious attention to me.
I tried any reasonable method I could think of. I joined the archery club when I found out she was a member, and I offered multiple times to do homework with her. Sadly, nothing seemed to result in serious progress.
At last, all I could do was let Shann Collins know that I would be there for her if she ever needed a friend or a favor. I do not believe I had any ulterior motives in telling her such a thing. Well, to be honest, I probably did.
I'd leave notes for Shann tucked inside her schoolbooks; I would compliment her on her outfit. She laughed at such things. Shann knew it was a ridiculous thing to write, since all the girls at Curtis Crane Lutheran Academy dressed exactly the same way. Still, history will show that patient boys with a sense of humor, who can also dance, tend to have more opportunities to participate in the evolution of the species than boys who give up and mope quietly on the sidelines.
But I began to worry. Rumors were spreading around Curtis Crane Lutheran Academy about me and Robby, even though I never heard anything directly.
Then, in the second semester of eighth grade, I was called in to the headmaster's office for something I wrote in a book report. Even though the book I read was in Curtis Crane's library, as well as the Ealing Public Library, apparently nobody other than kids had bothered to read the book until I wrote my report on it.
The book was called The Chocolate War, and the copy I read belonged to my brother, Eric. Mrs. Edith Mitchell, who was the eighth-grade English teacher, assumed the book was about a candy kingdom or something. She probably thought there were magical talking peacocks in the book that shot gumballs and Sugar Babies out of their asses.
But there were teenage boys in the book—Catholic boys—who masturbated.
Boys who attend Curtis Crane Lutheran Academy are not allowed to masturbate.
My father nearly lost his job because I wrote a report on a book that had Catholic boys and masturbation in it.
Pastor Roland Duff, the headmaster at Curtis Crane Lutheran Academy, was very distraught.
He had the school's only copy of The Chocolate War resting on his desk when I came to his office.
There, he counseled me about masturbation and Catholicism.
"My fear is that when boys read books such as this," he said, "they will assume there is nothing at all wrong with masturbation, and may, out of curiosity, attempt to masturbate. In fact, Austin, it is true that masturbation has serious harmful effects. It makes boys spiritually and physically weak."
The headmaster patted his forehead, which was damp, with a handkerchief that had the Curtis Crane Lutheran Academy logo—a black cross surrounded by a bloodred heart—embroidered on its corner. I wondered if they had prepared him in his religious training for giving teenage boys talks about masturbating.
He went on, "In history, entire armies have been defeated because their soldiers masturbated too frequently. It happened to the Italians in Ethiopia."
When he said the words too frequently, I wondered if there was some number higher than once or twice per day that would get me off the hook to hell and military failure.
In any event, I hoped he was right. I hoped the bad guys in Afghanistan—where my brother, Eric, whose book got me into trouble, was fighting—were also excessive masturbators like the Italians.
Pastor Roland Duff continued, "Masturbation can also turn boys into homosexuals."
When he said homosexuals, he waved his hands emphatically like he was shaping a big blob of dough into a homosexual so I could see what he was talking about.
That frightened me, and made me feel ashamed and confused.
Then he called my mother into the office and he talked to her about masturbation, too.
Up until that day, I was certain my mother didn't know there was such a thing as masturbation.
As I stood there, shifting my weight awkwardly from one foot to the other, Pastor Roland Duff told my mother about the Warning Signs of Masturbation, so she could keep a better watch over me.
Then he sent me home with my mother and suspended me from classes for one day.
When I came back to school, Mrs. Edith Mitchell made all the girls leave the classroom while Pastor Roland Duff explained the guidelines for books we boys were not allowed to read at Curtis Crane Lutheran Academy. We were no longer permitted to read any books that had masturbation, Catholics, or penises in them. Pastor Roland Duff gave the entire class of boys the same speech he'd given me about masturbation, weakness, and homosexuality.
Once again, he blamed masturbation for Italy losing wars.
That kind of shit never made it into history books, either.
Sometimes, during his speech, he would remark, "As I was explaining to Austin Szerba . . ."
And he would wave his hands as though he were shaping a doughy Austin Szerba in the air, so all the other boys could see what a boy who wrote a book report about masturbation and Catholics looked like.
Then he led the boys in prayer and excused us so Mrs. Edith Mitchell could have a similar talk with the girls.
Robby and I whispered outside that after all that masturbation talk, a cigarette would be nice.
It was the worst day of my life since Eric left home.
Everyone knew that I was the one to blame for all the trouble about masturbating. At Curtis Crane Lutheran Academy, you couldn't hear the name Austin Szerba and not think about masturbating.
I didn't speak in class again for the rest of the year.
Robby thought it was funny and told me I was brave.
Best friends do that kind of stuff.
When the boys were taken out of the room, I wondered if Mrs. Edith Mitchell was telling the girls about Austin Szerba, and how teenage boys masturbate, or if maybe she had found a book with girls who masturbated in it. Thinking about a book like that made me very horny.
The library was quieter and emptier than usual for a long time after that day.
But when the boys came back into the classroom, Shann deftly slipped a note onto my lap beneath our desks. I thought she was going to tease me about masturbating, but the note said this:
Okay, I'll admit it, Austin Szerba, you have finally won me over. I read The Chocolate War, too. I love that book. This school is full of shit. Let's go get a Coke after class and hang out. By the way, I like what you're wearing today.
I was dressed exactly like every other boy at Curtis Crane Lutheran Academy.
Later that day, Shann Collins and I kissed for the first time.
It happened right after I said to her, "Stupid people should never read books."
## THE DEATH-RAY GUN
AT ONE HOUR before midnight, Shann and I waited inside an old Ford Explorer parked behind the Del Vista Arms. Robby Brees, dressed in a pair of my clean white socks, best Adidas skate shoes, and Titus Andronicus T-shirt, dashed into his apartment to get us more cigarettes and wave, in passing, at his mother.
Events that night were going to set in motion a disaster that would probably wipe out human life on the planet. That night, I was going to say something to Shann I had never said to anyone. I was going to do something I'd never done, and see things I could not understand and never believed existed.
This is history, and it is also the truth.
I sat in the front seat.
Robby refused to chauffeur us around like he was some kind of limo driver, he said, so either Shann or I always had to sit up front with him. This rule increased the degree of difficulty in actually fulfilling my fantasy regarding Shann Collins and Robby's backseat.
But now, Robby was gone.
"What are you doing?" Shann said as I shimmied my way between the front seats, over the center console where there was still an assortment of cassette tapes that had belonged to Robby's dad.
I thought what I was doing was obvious enough, so I said, "I'm looking for my death-ray gun."
"Well, if your ray gun doesn't look like a pair of Robby's underwear or socks, it isn't back here."
Robby needed to stop accumulating so much laundry this way, but it did keep the floor of his room tidy.
My foot got stuck between the passenger seat and console. My shoe came off. I left it there.
"I'm coming back there with you till Robby comes out."
"Robby came out in the seventh grade," Shann said.
A lot of things happened in seventh grade.
"There." I said, "I've never been back here alone with you, Shann. It's rather sexy."
I thought using the word rather would make me seem mature and like I was not from Ealing.
"I've never heard you say anything like that before, Austin," she said.
"Rather?"
"No. Sexy," Shann explained. And she was right about that. I never had spoken about sex with Shann. I was too afraid to.
"Well, it is sexy," I said. I kicked off my other shoe and scooted myself against her.
I put my arms around Shann. I leaned into her and brought my feet up onto the bench seat. I put my lips on her neck and licked her. She gasped.
"Shann, I want to tell you that I'm in love with you. I love you, Shann."
I had never said that before, either.
"Oh, Austin. I love you."
It was the first time Shann said it, too.
Then the dome light in the Explorer blinked on. Robby opened the driver's door.
"You are not having sex in my car—on top of my clothes!" Robby said.
I don't remember exactly how it happened, but the basketball shorts I'd been wearing that day were halfway down to my knees.
"Um. No. Robby. No."
Shann coughed nervously and straightened up, while I pulled my shorts back over my hips.
"One of you," Robby said sternly, "up front now. Let's go get our shit."
I squeezed my way back into the front seat.
Robby gave me an intense, scolding stare.
He shook his head and laughed at me. Robby wasn't angry. Robby was as shocked as I was. He and I both knew what probably would have happened if he had waited about one more minute before coming back to the car.
I extracted my shoe from the center console. Somehow my socks had come off, too. I tried to find them. Clothing has a way of abandoning ship sometimes.
Then Robby dropped a pack of cigarettes in my lap and pushed in the dashboard lighter.
He started the car.
"Light one for me, Porcupine," he said.
## ROBBY COULD HAVE BEEN A PREACHER
WE CASED THE Ealing Mall.
We sat across the street at Stan's Pizza, where we ate and watched through the window.
Stan's closed at midnight. Stan was visibly angry that we came in and ordered. There was nobody in the place, and Stan wanted to go home.
I ordered a large Stan-preme in an attempt to cheer Stan up.
"We'll have a large Stanpreme, please. For here," I said.
In the same way that Johnny McKeon was proud for coming up with the names Tipsy Cricket Liquors and From Attic to Seller Consignment Store entirely on his own, and just as Dr. Grady McKeon was considered a genius for inventing the brand Pulse-O-Matic®, Stan must have been very pleased with himself for creating the concept of the Stanpreme.
People from Ealing were very creative.
We didn't know for certain that Stan's real name was Stan. We never asked him.
Stan was Mexican, so probably not.
We sat, ate, and watched.
Stan watched us.
Everything was dark at the Ealing Mall across the street, except the sign over the Ealing Coin Wash Launderette. The launderette never closed. There was no need to. Between the hours of 2:00 and 6:00 a.m., it was more of a public bathroom, a hash den, or a place to have sex than a launderette, though.
Thinking about having sex on the floor of the Ealing Coin Wash Launderette suddenly made me horny.
Nobody was out there.
This was Ealing at nighttime.
Nobody ever had any reason to be out, unless they were standing on the curb watching their house burn down.
I wondered if Ollie Jungfrau had gone home. Ollie worked at Johnny McKeon's liquor store. Tipsy Cricket closed at midnight, too, but it was already completely dark by the time Stan scooted the tin pizza disk containing his eponymous creation down on our table by the window.
That was the first time in history anyone from Ealing, Iowa, used the word eponymous. You could get beaten up in Ealing for using words like that.
Just like Robby and I got beaten up for sitting there smoking cigarettes and being queers. But I don't know if I'm really queer. Just some people think so.
We ate.
Robby asked Stan for three ice waters, please.
Stan was not a happy man.
We couldn't finish the Stanpreme. It was too big. Stan brought us a box for the three slices we had left on his tin disk.
"Do you think we should make a plan or something?" I asked.
Robby said, "This is Ealing. There's some kind of prohibition against making plans."
If we didn't hate being Lutherans so much, Robby could easily have been a preacher.
## NEVER NAME A PIZZA JOINT STAN'S
ROBBY PARKED THE Explorer at the end of Grasshopper Jungle.
He positioned the vehicle facing Kimber Drive, so we could make a quick getaway if we had to.
Like real dynamos.
The pretense of doing something daring and wrong made the rescue of our shoes and skateboards a more thrilling mission to us. Nobody, ultimately, would give a shit about two teenage boys who'd been embarrassed and beaten up by some assholes from Hoover, who climbed up on an insignificant strip mall to get their shoes back.
Shann waited in the backseat.
When we were about ten feet from the car, Robby got an idea.
"Wait," he said. "We should leave our shoes in the Explorer."
It made sense, like most of the shit Robby told me. Once we got up on the roof, it would be easier if we didn't have to carry so much stuff back down. We could wear our roof shoes to make our descent.
It was really good that Grant Wallace and those dipshits didn't throw our pants up there, too, I thought.
We went back to the car.
Shann was already asleep on top of Robby's underwear and shit.
We took off our shoes and left them on the front seat.
Robby grabbed his pack of cigarettes and a book of matches and said, "Now we can do this."
A narrow steel ladder hung about six feet down from the roof's edge. It was impossible to reach the bottom of it, so Robby and I rolled the heavy green dumpster across the alley and lined it up below the ladder.
Then we climbed on top of the dumpster in our socks.
I didn't believe the garbage collectors ever emptied the thing anymore. The dumpster was sticky, and leaked a trail of dribbling fluid that smelled like piss and vomit when we rolled it away from the cinder-block wall beside the pubic-lice-infested couch.
From the top of the dumpster, we could barely reach the lowest rung on the ladder. I gave Robby a boost. His socks, which were actually my socks, felt wet and gooey in the stirrup of my palms.
I felt especially virile doing a pull-up to get myself onto the ladder after him.
Soon, we were up on the roof, where we could stand and look down at the dismal, cancerous sprawl of Ealing.
We lit cigarettes.
Robby said, "You should never name a pizza joint Stan's."
We stood, looking directly across Kimber Drive at the yellowed plastic lens that fronted the long fluorescent tubes illuminating the lettered sign for Stan's Pizza.
Someone had painted an A between the S and T, so the sign read: Satan's Pizza
People were always doing that to Stan.
They did it so many times that Stan simply gave up on cleaning the paint, and allowed the sign to say what the good people of Ealing wanted it to say:
Satan's Pizza
People from Ealing had a good sense of humor, too.
"I have seen Pastor Roland Duff eating there," I said.
"Did he order a Satanpreme?"
It was difficult to find our shoes and skateboards up on the roof at night. As I had originally theorized, there was plenty of cool shit up there, so Robby and I kept getting distracted. It didn't matter much, since Shann had fallen asleep, anyway.
We found a plastic flamingo with a long metal spike descending from its ass, so you could stick it in your lawn and fool passersby into thinking that flamingos were indigenous to Iowa.
Robby discovered two bottles of screw-top wine, full and sealed, and he placed them on the roof beside the top of the ladder.
We theorized that maybe back in the days when Ollie was thinner, he may have climbed up here to get drunk and talk to the flamingo. Ollie Jungfrau weighed more than four hundred pounds now.
Satan's delivered to Tipsy Cricket Liquors.
"Have you ever been drunk, Porcupine?" Robby said.
"No."
"One of these days, let's get drunk together."
"Okay," I said.
Like considering most things that were against some well-intended list of rules, thinking about getting drunk for the first time with Robby made me feel horny.
We found two round aluminum canisters that had reels of 16 mm film in them. Nobody watched 16 mm movies anymore. There was an old projector at Curtis Crane Lutheran Academy, but we decided not to take the films, just in case they were pornos or something.
We did want to take the flamingo, though.
Robby placed the plastic pink flamingo next to the bottles of wine.
"One of us can climb down first, then the other can toss down the bird and the wine," Robby said.
Robby also found a Halloween mask. It was covered in fur and looked like the face of a grimacing lemur. It was the face a lemur in an electric chair would make. That had to come home with us, too, we decided.
"If you ever want to get shot in Ealing, walk through someone's backyard at night with a lemur mask on," Robby said.
## IF YOU EVER WANT TO GET SHOT IN EALING
WE FINALLY FOUND our shoes and put them on.
I was embarrassed to admit it, but it was kind of emotional for us being reunited with our stuff after that very long day.
I could see how Robby felt the same.
We put our skateboards down with the rest of the things we'd gathered, and then we sat beside the rooftop air ventilation unit to relax and have another cigarette.
"It feels good to have my shoes back," Robby said.
"If we didn't find them, I was going to let you have those Adidas of mine."
"Thanks."
We both exhaled smoke at the same time.
"Austin?"
"What?"
"Do you realize that today we got beaten up for being queers?"
"I know."
"But you're not a queer," Robby offered.
"I don't think so."
"Well, I apologize."
"You didn't do anything, Rob."
Sometimes, I called him Rob.
"I've never done anything," he said. "I've never even been kissed or anything, but I still get beaten up."
"Shann kisses you all the time."
"That isn't what I mean."
"I know."
"Well, if I'm going to get beat up for being queer, at least I'd like to know one time what it feels like to be kissed."
"Um. I guess you deserve that. You know. Everyone deserves to not feel alone."
"Can I kiss you, Austin?"
The air suddenly became unbreathably thin.
I thought about it. I shook my head.
"That would be too weird."
"Sorry."
"Don't be."
We sat there, smoking.
Everything was shitty and confusing.
Robby felt terrible.
I said, "I guess I would kiss you, Robby."
"Don't feel like you have to."
"I don't feel that way."
So Robby Brees, my best friend, and the guy who taught me how to dance so I could set into motion Shann Collins's falling in love with me, scooted around with his shoulders turned toward mine.
He was nervous.
I was terrified.
I watched him swallow a couple times.
Then Robby placed his cigarette carefully down on the gravel beside his foot. He put his hand behind my neck and kissed me.
He kissed me the way I kiss Shann, but it felt different, intense, scary.
Robby's tongue tasted like cigarettes when he slid it inside my mouth. I liked the taste, but it made me more confused. Our teeth bumped together. It made a sound like chimes in my head. I never bumped teeth with Shann when I kissed her.
When we finished kissing, Robby pulled his face away and I watched him lick his lips and swallow.
Robby's eyes were wet, like he was going to cry or something.
He looked away and wiped his eyes.
Robby said, "I'm sorry."
"No. It's okay. I said you could. I said let's do it."
"Is it okay?"
"I said so, Robby. It was weird. Really. Are you okay?"
"I think that was the best moment of time in my entire life, Austin." Robby wiped his eyes and said, "Thank you. I've wanted to ask you to do that forever."
"You could have asked me."
"I didn't want you to hate me."
"How could I hate you?"
"For wanting to do that to you."
"Oh. Well. I am sorry if it was clumsy. I didn't know if I was supposed to act like the man or the woman."
Robby picked up his cigarette.
"You weren't supposed to act at all."
"Good. Because I'm pretty sure I was just being . . . um . . . Porcupine."
Robby puffed.
"You know what, Robby?"
"What?"
"If you ever want to get shot in Ealing, do that in someone's yard at night."
## THE TRAPDOOR
WE SAT THERE without saying anything else until we'd smoked our cigarettes down.
I tried not to think about what Robby and I did.
What Robby and I just did was the only thing I could think about.
If I was confused and torn before going up on the roof with Robby, I was pulp, ready to be spit out by history, after we spent a few minutes there.
I tried to think like we didn't actually do it, but I could still taste Robby's mouth in mine. I tried to listen for Shann moving around below us in Grasshopper Jungle, so I wouldn't hear my mind telling me how it would be all right if Robby asked if he could kiss me again sometime.
It would be thrilling and daring.
After midnight, Ealing is quieter than a stone coffin.
Robby could tell I was confused—tripping out, we would say.
"Are you mad at me?" he said.
"Shit. I'm not mad."
"Okay. Look."
I hadn't been looking at Robby. Until he'd said that, I didn't even notice that I was staring at my shoelaces, tracing the zigzag path of them up, down, back, forth with the tip of my finger, like a train on a white switchback track, from one shoe to the other, over and over.
Around the loop, crossover, back and forth.
I raised my eyes.
Robby scooted through the gravel away from me.
He had lifted a square metal door in the roof, propped it open. I hadn't even realized it was there.
"Roof access ladder," Robby said. "It goes down into the secondhand store."
"It was left unlocked?" I said.
"Nobody ever comes up here."
"Up here has a watch-flamingo, and a lemur head."
"No one wants to mess with shit like that."
Robby lowered his face down below the rim of the trapdoor.
He said, "Do you want to go down there?"
I had already done something with Robby I never believed I would do. Climbing down inside Johnny McKeon's secondhand store in the middle of the night was meaningless shit in comparison.
I said, "That would be cool."
When I stood up, I was dizzy.
I was like the tip of my finger, zigging and zagging from eye to eye, following a string, making history.
Robby watched me get up. I caught his eyes looking at me. I knew we'd never look at each other the same, and I didn't know how I felt about that. I caught him trying to see if I had an erection. I tried to pull my T-shirt down to cover it.
The basketball shorts and boxers I'd been wearing that day revealed yet another strategic flaw for the history books.
History shows that erections happen at the worst possible times, and they stick around until someone else notices them. Often, it is either a librarian or an English teacher, like Mrs. Edith Mitchell.
I went to the edge of the roof, to the top of the small ladder we'd used to get up there.
"Shann," I said. "I just want to make sure she's okay."
Robby didn't answer.
Words like okay can mean all kinds of things.
Robby knew enough that saying anything might nail down a definition of okay that wasn't what either one of us wanted to hear.
The Explorer was dark and quiet.
Shann was still asleep.
We hadn't been gone for more than twenty minutes, even if time seemed to slow to a crawl now.
Across the street, Satan's Pizza winked. The fluorescent tubes inside the sign made an audible hiss like a dying wasp when it went dark.
Robby climbed down the trapdoor.
I followed him.
## HUNGRY JACK
ON WEEKENDS AND over the summers I earned money doing jobs for Johnny McKeon at his From Attic to Seller Consignment Store. Johnny felt obligated to me because I was Shann's boyfriend.
Usually, the jobs required cleaning the store.
Secondhand stores are like vacuum cleaners to the world: They suck in everybody's shit.
History shows that, like Ealing, when towns are dying, the last things to catch the plague are the secondhand and liquor stores.
Johnny McKeon was on top of the world.
Sometimes, Johnny would receive new consignments out in Grasshopper Jungle, and then leave me to go through and sort boxes, unroll and sweep off rugs, and clean out the drawers in dressers and nightstands.
I found a lot of condoms and Bibles in them.
Johnny told me I could do whatever I wanted with those things.
I threw the Bibles in the dumpster.
Robby and I climbed down the ladder. It deposited us, like visiting aliens, into a common back room that connected Tipsy Cricket Liquors with From Attic to Seller.
The ladder was attached by metal brackets to a plasterboard wall where the electrical panel box for the store was located. I'd seen the ladder there plenty of times. I had even noticed the Roof Access sign posted on the wall with an arrow pointing up, as though you might not know where a roof could be, direction-wise.
I never thought about going up on the roof of the mall before I went there with Robby.
On the other side of the wall was the shop's toilet. It was such a small space that you would be looking straight across at your own face in the mirror, and could reach the soap and paper towel dispensers and wash your hands in the sink while you were sitting on the toilet.
Ollie Jungfrau could never take a shit in there.
There was a sign on the door that said: No Public Restroom
Everyone knew the public restroom was at the launderette, or between the dumpster and the couch in Grasshopper Jungle if you couldn't hold it that far.
There was a homeless guy who'd come riding through on his rickety old bicycle about once per week or so. His bicycle was always teetering, precisely and ridiculously balanced with huge bundles and bags strapped to any available rusted crossbar. Robby and I called him Hungry Jack, but we never asked him his name.
Hungry Jack didn't have any front teeth.
Hungry Jack fought in Vietnam.
When he came through, Hungry Jack would stop and climb into the dumpster, dig around for things.
Robby and I caught him taking a shit one time, between the dumpster and the couch.
I have read that the human memory for smells is one of the most powerful bits of data that can be etched into our brains. Although it seemed so foreign to me, being inside From Attic to Seller in the middle of the night, the smell of the place was entirely familiar. The shop had this constant, perfumed odor of sorrow, death, abandonment, condoms, and Bible verses; that was like nothing I'd ever smelled anywhere else.
I felt as at home there as you'd have to feel, lying in your own coffin.
## JOHNNY'S THINGS
"THIS WAY," I whispered.
Robby had never set foot inside the secondhand store until that night. I'd told him about it enough times.
"This is rather scary," Robby said.
Now Robby was speaking like a non-Ealingite.
"Do you want to get out?"
"No."
Robby put his hand on my shoulder so he wouldn't trip on anything. I led him out around the back counter, which was a rectangular glass case where Johnny McKeon displayed watches, jewelry, cameras, guns, and three framed insect collections.
There were only a few things in From Attic to Seller that I favored. The insects were among my most appreciated abandoned items.
One of the frames contained only butterflies. For some reason, I always found the butterflies to be boring. But the other two frames were wonders: One displayed forty-one beetles. I counted them. There were all kinds of oddities in the frame, including beetles with horns, and some nearly as large as my clenched fist. The beetles in the center were posed so their shells were open and their glassine wings spread wide.
The last frame had fifteen bugs in it. An enormous centipede curled around the bend at one corner, and a glossy black scorpion raised its stinging tail in the other. Centered against the white backing board was a vampire bat with little beaded eyes, frozen with its mouth snarled open.
"Isn't that the coolest shit?" I asked.
Robby said, "No."
Robby remained attached to my shoulder and I took him along the circular path around the main floor of the store.
Johnny McKeon arranged From Attic to Seller Consignment Store so that shoppers, or even people coming in to inquire about using the toilet, would have to walk a serpentine path from the front door to the back counter. His path led past every stack of clutter Johnny offered up for sale. Tipsy Cricket was different. At the liquor store, the counter was right up front, a deterrent to booze and cigarette thieves.
Johnny McKeon was a good marketer.
"I've never seen so much shit in my life," Robby said.
There were nightstands on top of end tables stacked perilously on dinner tables. And every flat surface of every item of furniture was covered in figurines, place settings, ashtrays, silverware, toys, picture frames, clocks, crucifixes, candles, rock collections, pocketknives, and too many other things for me to list.
I put the price tags on almost every one of them for Johnny, too.
Johnny McKeon made a lot of money.
As soon as one corner of the shop would empty out, it quickly filled back up again. A lot of the things came from realtors and loan agents. Some people in Ealing left behind what they couldn't fit in the trunks and backseats of their cars when the banks took their homes.
Abandoned stuff from defeated Iowans had a way of migrating into Johnny McKeon's hands.
Robby's hand slipped from my shoulder.
He said, "Oops."
Objects clinked together in the dark. Figurines fell.
"Be careful," I said.
"Where are we going?"
"I want to see what Johnny's hiding," I said.
That scared Robby.
Robby grabbed my hand.
"Don't be such a baby," I said. "You wanted to come down here. I know where I'm going."
Robby started to let go of my hand.
"It's okay," I said. I pulled Robby along by the hand like a little kid.
Johnny McKeon kept things in his private office. He never let me go in there. Johnny never let anyone go in there.
There were things Johnny wouldn't sell. One of them was a sealed glass globe he kept on a shelf beside the office door. I was fascinated by the globe. It had been made by some of the scientists in the lab at McKeon Industries, and contained a perfectly balanced universe.
There was water, land, plants, bacteria, a species of tiny shrimp, worms, and even some translucent fish in there.
It was perfect.
It was sealed and self-sustaining.
Nothing got in and nothing got out.
My hand was wet and hot.
"You're sweating all over me," I said to Robby.
"Sorry."
I turned the knob to Johnny's office.
Of course, it was locked.
Robby bumped into me. He wasn't paying attention and he pinned me flat against the office door with his chest.
"No go," Robby said. "I guess we should get out of here."
"I know where Johnny keeps the key. It isn't very smart," I said.
Despite his creativity at naming businesses, and his eye for marketing strategies, Johnny McKeon wasn't that careful when it came to trusting teenage boys.
History lesson: Teenage boys watch you, even when they pretend they don't give a shit about your life.
Johnny kept the key resting flat on the lip of the molding at the top of the door.
I pulled it down and unlocked our way into Johnny McKeon's office, where he kept his secrets.
Robby said, "I really need a cigarette."
## TWO-HEADED BOY
WE STOOD INSIDE Johnny McKeon's private office.
There were no windows. It was impossible to see anything in the dark.
Robby threw the switch for the office lights. I jumped when they came on.
You don't expect things to get all bright on you when you're nervous about doing something you're not supposed to be doing.
Robby shrugged apologetically.
He said, "We may as well turn on the light in here. Nobody can see us."
My heart raced, but Robby was right: Nobody could see us.
Robby shut the door to the office, which closed us in with Johnny's things.
Johnny McKeon's real-life horror show.
Johnny McKeon's office smelled the same as the rest of the shop, but wasn't nearly as cluttered. In fact, the office was rather tidy.
Rather.
I said it again.
The three walls boxing the office behind the door were lined with dark wooden shelves. Johnny had salvaged the shelves from the Ealing Public Library when it was remodeled three years before: the year we were in seventh grade.
"Holy shit," Robby said.
Here's why he said it: Johnny McKeon's shelves were full of horrible, grotesque things. They were the kinds of things that no sixteen-year-old boy could tear his eyes from. And there were four sixteen-year-old-boy eyes in Johnny's office.
One of the cases displayed another of the McKeon sealed glass globes, but this was different from the peaceful and pleasant nature-ball Johnny kept outside in the shop. The globe was about the size of a basketball, and it was propped steady atop a black lacquered stand with a brass plaque on front, as though it was some kind of trophy or shit like that. But this could not have been a trophy.
The plaque read:
MCKEON INDUSTRIES 1969
CONTAINED MI PLAGUE STRAIN 412E
Inside the globe was a festering universe.
The globe Robby and I studied held something resembling a black, folded, and coiled brain. The thing clearly was not a brain, but the wrinkled patterns on its surface made me think of one.
"This has to be like some kind of movie prop or something," Robby said.
"Look around, Rob. All the shit in here looks real," I said.
In fact, everything inside Johnny's office was real, we came to find out later. It didn't matter. Neither of us actually believed Johnny McKeon was hiding away props for horror films.
The black thing inside the globe pulsed and twitched like a beating heart. It seemed to become more animated the longer we stared at it. It was almost like a gelatinous cauliflower. Here and there on its velvet surface, a mound would rise up, like a mosquito bite, a black pimple, and then burst open at its peak.
Little volcanoes erupting.
When the pimples burst open, strands of oval globules, pale yellow pearls, coiled and twisted over the surface of the blob, then turned black and sprouted velvet hairs, dissolving back into the surface of the brain thing.
Where the glass globe with the fish, shrimp, plants, and worms outside in Johnny McKeon's shop emanated a placid, almost hopeful aura, this thing whispered of rot and death, disease.
Robby and I could have stared at Johnny's secret collection of things all night.
On another case was an assortment of large specimen jars.
All of them had a common etched label:
MCKEON INDUSTRIES 1969
HUMAN REPLICATION STRAND 4-VG-03
One of them contained a human head. It was a man's head. His eyes were squinted, half open, and although they were clouded, his pupils and irises were plainly visible. He had pale blue eyes. I could even see small blood vessels in the whites of his eyes. He had a mustache. His lips were tightly pursed and frowning.
"He doesn't look too happy," I said.
"This has to be fake," Robby said. "Who would keep shit like this?"
"Johnny McKeon would," I answered. "He probably found it when the plant shut down and thought it was cool."
"He could charge admission," Robby said.
Another jar on the rack held a pair of human hands.
The palms were pressed together. It reminded me of the trite framed artwork depicting disembodied praying hands that hung at teenager eye level above the long urinal in the boys' toilet at Curtis Crane Lutheran Academy.
The pictures were there to remind us what good teenage boys do with their hands.
The jar beside the hands contained a penis and testicles.
The position of the jars made an artistic statement about what happened to boys who masturbate.
"That guy probably went to Curtis Crane," Robby said.
His voice shook with nervousness.
There is nothing more deeply frightening to a sixteen-year-old boy than confronting the possibility of losing his penis.
We had to leave, but we were mesmerized.
But the thing on that particular rack that was most compelling was the jar containing a two-headed boy. It was a whole fetus, bluish in color and clay-like, tiny but fully developed.
Robby reached up and spun the jar around, making the boy pirouette for us as he floated in the zero gravity of his vacuum jar. His little legs were bowed and folded beneath him. A knotted umbilical strand corkscrewed from his round belly. One hand, its fingers so perfect, rested opened, palm up in front of the knob of his penis. The other hand was clenched in a defiant fist beside his hip. And from the boy's shoulders sprouted two perfect heads, one tilted to the side, resting. Both mouths were open, small black caverns that exposed the ridge of gums and the small rounded mounds of the boy's tongues. The eyes were open and hollow. Each plum-sized head was rimmed with a floating tuft of iron-colored hair.
There was something overwhelmingly sad about the boy.
I couldn't identify what it was.
Robby said, "This isn't right."
I said, "I think I know exactly what it would be like to have two heads like that."
The last wall contained specimens of bugs. But these weren't any bugs I'd ever seen. They also floated inside sealed rectangular glass cases filled with preserving fluid. They looked almost like aquariums with alien creatures in them.
Some of the bugs in the tanks were as big as middle-school kids.
They looked like praying mantises, or grasshoppers maybe.
The larger tanks only contained parts of bugs: heads, appendages, thoraxes.
The heads were as large as mine and Robby's.
The tanks were also labeled:
MCKEON INDUSTRIES 1969
UNSTOPPABLE SOLDIER—STRAND 4-VG-12
"We need to get out of here," Robby said.
I agreed.
It was too late, though. Robby and I were trapped in Johnny McKeon's office. Somebody was outside, in the main room of the shop.
They weren't making any attempt to be quiet, either.
## BLUE LIGHT
"OH, SHIT, AUSTIN."
"Get the light," I whispered.
Robby flicked the switch, but Johnny McKeon's office didn't go dark.
The glass globe with the pulsating black shit in it wriggled and burned with a blue light. It was like writhing cobalt embers trapped inside the sphere of the glass. The thing in the sphere, whatever it was, obviously responded to light.
Hiding was our only option, but there was no place inside Johnny's office that was very suitable. Robby pointed at the desk. We pulled Johnny's chair out and huddled together, hugging each other in the small rectangular space below the desk.
We were just like that poor two-headed boy floating in fluid in the jar.
We didn't even think to lock Johnny's office door behind us.
Why would anyone have thought to do such a thing?
Because it would have been smart, I told myself.
The knob on the door squeaked and turned. There were footsteps. Someone came into the office. I put my face down on the floor and looked from under the desk. There were several sets of feet there.
Someone said, "What the crap is that?"
The shoes were positioned so whoever was inside with me and Robby was looking at the mysterious globe.
"It's alive," another voice concluded.
"People always said Johnny McKeon kept weird shit in here. Maybe it's an alien or something."
Robby's fingers squeezed around my arm. We both knew the voice. It was Grant Wallace. He and his boys had somehow gotten into From Attic to Seller.
"Let's take that shit," the kid named Tyler said.
"You're carrying it. It looks heavy," Grant said. "I don't want that shit. I came for the booze. Let's go."
The Hoover Boys apparently found their way into the back room connecting Tipsy Cricket with the secondhand store. They probably broke into the abandoned foot doctor's office to do it.
It was a simple matter.
For all anyone knew, Grant and his boys may have been planning their theft from Tipsy Cricket for a long time. It probably had everything to do with why we ran into them in Grasshopper Jungle earlier that day.
Technically, our encounter with Grant Wallace happened the day before, since it was solidly past midnight in our time zone, which was located under the desk in Johnny McKeon's office.
"Is that a dick?" one of the boys asked.
"It's a dick," another concluded.
"Johnny Mack has a dick in a bottle in his office," Grant affirmed.
"Maybe it's his," one of Grant's friends said.
"Let's take it," another of them said.
"I'm not touching it. It's a jar with a dick in it." I think Tyler said that.
"Oh yeah," someone else said. "And balls, too."
"That's sick. I'm not touching it. Hang on. I'm going to take a picture of that dick in a jar with my phone," the videographer decided.
"Text it to me." One of the Hoover Boys laughed.
I desperately wished they'd stop talking about the penis in the jar, but Grant and his friends were like lonely parakeets in front of a mirror.
Finally, after they'd exhausted all speculation and conversational rhetoric on the topic of penises in jars, the boys stood there numbly for a moment, apparently unable to detach their eyes. I heard the sound of something heavy and solid sliding on one of the shelves.
The blue shadows in the room swirled.
Tyler had lifted the globe.
It was not a good idea.
"Let's go. I'm thirsty," he said.
They left the door to Johnny's office standing open.
The blue light danced away into the darkness of the back room, and then faded entirely.
I grabbed Robby's wrist and pulled him out from our hiding place. Then I led him back through the shop and up the ladder to the roof.
## PRIORITIES
ROBBY BREES AND I had our priorities.
As soon as we closed the hatch and were outside on the roof again, we lit cigarettes.
Smoking dynamos.
"Shit," Robby said.
"Shit," I agreed.
Shit, like the word okay, can mean any number of things. In fact, in the history I recorded in my book for that one Friday in Ealing, Iowa, I believe I used the word shit in every possible context.
I will have to go back through the history and check.
Robby and I said shit—nothing else—approximately eleven more times as we smoked our cigarettes up on the roof.
"What do you think that shit in the ball was?" Robby said.
"I don't know. You read the nameplate on it. It said Contained Plague."
"Nothing good is ever called Plague," Robby said.
"Maybe it was just some glow-in-the-dark experimental stuff," I said.
"I've done an experiment. We made a battery out of a lemon. Remember that?" Robby asked.
"Yes. It was a good experiment," I agreed. I nodded like a scientist would. "We knew what was supposed to happen before we even started it. And it worked."
"But I don't think things called Plague are the subject of the kinds of experiments we do in the lab at Curtis Crane," Robby said.
That's what it was—what Robby and I had done up there on the roof at Grasshopper Jungle—I thought.
An experiment.
It is perfectly normal for boys to experiment. I read it somewhere that was definitely not in a book at Curtis Crane Lutheran Academy. Or if it was in a book, it would certainly no longer be part of Curtis Crane Lutheran Academy's library collection. Not after the shit I did in eighth grade.
Maybe I heard some psychologist who specialized in Teen Sexuality say shit about things like Boys experimenting on one of those afternoon talk shows that are only on television for the fulfillment of depressed and lonely women.
Depressed and lonely women need to know about Teen Sexuality and how it's normal for boys to experiment. Normal. That's what the psychologist would say. The psychologist also would have been a slim woman with nicely trimmed hair, a sincere and calming smile, and modest jewelry.
That was bullshit.
History shows that real experiments, like the one we did with the lemon, always involve some reasonable expectation ahead of time about the outcome. About how things will work out.
Robby slid the pack of cigarettes into the back pocket on his sagging jeans and we gathered up our flamingo, wine, grimacing lemur, and skateboards. We made our way down the ladder and onto the dumpster we'd rolled across Grasshopper Jungle.
"Don't say anything to Shann," I cautioned.
I didn't need to tell Robby that. It was just one of those things boys do sometimes to confirm that there are secrets that shall be protected.
Robby said, "You mean about what we saw in her stepdad's office, or what we did up on the roof?"
I said, "Shit."
I imagined I had two arguing and confused heads sprouting up from my shoulders.
I felt sadness for that other boy inside the jar in Johnny McKeon's office.
## HELL BREAKS LOOSE
SHANN WAS SLEEPING soundly in the backseat of Robby's Ford Explorer when we came back to the car. She stretched out comfortably, with her head lying on some crumpled socks and a pair of Robby's boxers that had fire trucks and Dalmatians on them.
Watching Shann sleep made me horny.
I was all messed up.
I thought I probably needed to talk to someone about how sexually confused I felt. I couldn't talk to Robby about it, not after what we did on the roof. I thought, but only for half a second, about talking to Pastor Roland Duff. But I already felt guilty as it was.
I thought I could talk to my father.
It scared me to think about doing that, but my father would know what to tell me. He could help me sort things out. I just needed to work up the courage to start the conversation. Then everything would fall into place.
Everything always falls into place that way.
"Shann?" I whispered.
I ran my hand up her leg to wake her.
Shann opened her eyes slowly. She smiled at me.
I felt guilty and sad.
"Did you and Robby already go?" she asked.
I said yes, but didn't tell her we'd been gone for over an hour. It was nearly 2:00 a.m.
Robby opened the Explorer's rear gate and deposited our flamingo, the grimacing lemur head, skateboards, and wine bottles.
He already held an unlit cigarette in his mouth when he got behind the wheel.
Robby passed the pack to me and started the engine. We lit both our cigarettes on the same orange coiled moon burning at the end of the car's lighter. Our faces were so close our cheeks touched. I looked Robby straight in the eye as we leaned in to get the cigarettes going. It was awkward. I felt sad for Robby.
I turned around and reached back between the seats. I held Shann's hand.
Behind her, I saw a glowing blue ball floating down the steps in back of the vacant podiatrist's office. Grant and the Hoover Boys were coming out from the mall.
I glanced at Robby.
I was certain he saw the same thing in the rearview mirror. We both knew better than to say anything and have Shann turn around. She would only start asking questions. Maybe she'd want to confront those punks.
In a lot of ways, Shann was tougher than Robby and me.
Maybe the boys were already drunk. I can't be certain of it. But something happened to cause Tyler to let go of the glass globe. I watched the circle of blue light drop like a falling moon.
Robby coughed.
Back in Grasshopper Jungle, blue light splattered everywhere.
"I'm ready to go home," I said.
"Um. Yeah," Robby agreed.
Robby's hands gripped the wheel, but his eyes were pinned to the rearview mirror.
Grant and his friends were the first victims of Contained MI Plague Strain 412E.
Nobody knew anything about it.
Travis Pope and his wife, Eileen, had been hired by the association management of the Ealing Mall to clean the common areas every week. They drove through the lot Saturday mornings before sunrise, rarely doing anything about the debris that accumulated in the back alley of a soon-to-be abandoned mall.
That Saturday, Travis and Eileen stopped in Grasshopper Jungle and picked up large chunks of broken glass from the alley. Travis Pope tossed the shards into the dumpster somebody had pushed against the rear wall of The Pancake House. Travis cursed the winos and delinquent kids in the town for getting drunk and fucking in public.
Travis and Eileen Pope were the fifth and sixth victims of Contained MI Plague Strain 412E.
Nobody knew anything about it.
And later that morning, an old man Robby Brees and I called Hungry Jack, who was missing his front teeth and had served in the United States Army in Vietnam, climbed into the dumpster we rolled across Grasshopper Jungle. The dumpster had pieces of Johnny McKeon's sick broken universe inside it.
Hungry Jack became the seventh victim of Contained MI Plague Strain 412E.
All hell had broken loose. It splattered across the piss-soaked pavement of Grasshopper Jungle.
Nobody knew anything about it.
## HISTORY IS FULL OF SHIT
EVERY DAY I wrote in my books.
I drew pictures, too.
That night, I drew a plastic flamingo with a spike coming out of its ass, a grimacing lemur, bottles of wine, and a picture of me with my shorts pulled down around my knees. In my drawing, I was in the backseat of Robby's Ford Explorer, lying on Shann Collins and some socks and a pair of my best friend's boxers that were printed with red fire trucks and spotted Dalmatian dogs.
I drew a two-headed baby boy trapped inside a pickle jar.
That night, I sat at my desk until the sky outside began to get light.
I took off my shoes and socks, and my Orwells T-shirt, too. I always write more accurate accounts of history when wearing as little as possible.
It's difficult to avoid the truth when you're undressed.
My armpits reeked. I had serious B.O.
That was also true.
Ingrid, my golden retriever, was in my bedroom. She liked to lie down beneath my desk so I could keep my bare feet in her fur. Ingrid, although she could shit better than any dog I knew—a real dynamo—never barked. When she was a puppy, she had a tumor on her neck. It made it so she couldn't bark, which helped me sneak into the house past curfew countless times.
Our house got robbed twice, too.
"You're a good dog, Ingrid," I said. I wriggled my toes in her fur.
I wrote.
Even when I tried to tell everything that happened, I knew my accounts were ultimately nothing more than an abbreviation. It's not that I neglected to write details—I told the truth about Shann's room, the staircase leading down to nothing, what the main ingredients of a Stanpreme pizza are. I wrote what it felt like to have my bare penis pressing upward against the cool skin of Shann Collins's thigh.
That was also true.
I told about Robby kissing me. I described it in detail, down to the taste and feel of his tongue. I kept accurate count of the cigarettes we smoked, and described the things trapped inside the jars we found locked up in Johnny McKeon's office.
But no historian could ever put everything that happened in a book.
The book would be as big as the universe, and it would take multiple countless lifetimes to read.
History necessarily had to be an abbreviation.
Even those first men—obsessed with recording their history—who painted on cave walls in Lascaux and Altamira, only put the important details down.
We killed this big hairy thing and that big hairy thing. And that was our day. You know what I mean.
My name is an abbreviation.
Three grandfathers back, a man named Krzys Szczerba came to the United States from Poland.
People in America did not know what to do with all those consonants and shit in Krzys Szczerba's name. They decided to swap some out for vowels, and to take others away from Krzys Szczerba, so my three-grandfathers-back grandfather became Christopher Szerba.
I imagined. Sometimes I drew this picture: An official stone building, a repository for all the consonants and shit taken from refugees' names when they arrived on the doorstep of the United States of America. It is piled high everywhere with the letters we don't find useful: Cs and Zs in great heaping mounds that looked so much like the black-and-white photographs of luggage or shoes from World War 2.
Krzys Szczerba.
History, and the United States of America, can call him Chris.
History is full of shit like that.
Krzys Szczerba came to America when he was seventeen years old.
In 1905, being seventeen years old made you a man. In 1969, when Hungry Jack fought in Vietnam, seventeen years old was a man. Now, I wasn't so sure. My brother, Eric, who was somewhere in Afghanistan, was twenty-two.
Krzys Szczerba came across the Atlantic with his father. They planned on working and earning enough money so Krzys's mother, brother, and two sisters could come to the United States, too. People who did that were called Bread Polacks. They came here to make money.
Krzys Szczerba's father died on the boat in the middle of the ocean.
His body was sent down naked into the water with prayers and a medallion of Saint Casimir.
Krzys Szczerba's family never came to their son.
Chris Szerba ended up in southern Minnesota, where he met a grocer's daughter named Eva Nightingale. Eva had breasts like frosted cupcakes and skin the color of homemade peach ice cream. Her body was a soft and generous pillow of endless desserts. Chris Szerba's semen found its way into Eva Nightingale's tummy, where it produced a good, cigarette-smoking, Catholic Polish boy named Andrzej.
Sometimes when I wrote my history, I would slip in pages I drew about Krzys Szczerba and his lonely and sad life in the United States.
It was hard for me, at times, to separate out the connections that crisscrossed like intersecting highways through and around my life in Ealing.
It was the truth, and I had to get it down.
And that was our day. You know what I mean.
I took off my boxers and went to bed.
It was 6:01 a.m.
The end of the world was about four hours old. Just a baby.
Johnny McKeon was picking up two dozen donuts at that moment.
Ollie Jungfrau was waking up, trying to decide if he should masturbate or not.
It was just after three in the afternoon in Afghanistan.
Louis, the Chinese cook at The Pancake House, whose real name was Ah Wong Sing, was taking a shit in the public restroom at the Ealing Coin Wash Launderette.
History never tells about people taking shits. I can't for a moment believe that guys like Theodore Roosevelt or Winston Churchill never took a shit. History always abbreviates out the shit-taking and excess consonants.
In about a week, the pieces started coming together.
In a week, we figured out history.
Eventually, we would learn this:
The thing inside the globe, the Contained MI Plague Strain 412E, wasn't anything remarkable unless it came into contact with human blood.
Contained MI Plague Strain 412E really was contained and harmless inside Johnny McKeon's glass universe.
Tyler dropped that universe directly onto the spot where earlier that day Robby Brees began spelling out GRANT WALLACE MURDERED ME in his own blood.
The Contained MI Plague Strain 412E was happy to meet Robby Brees's blood.
Robby Brees was my best friend. He taught me how to dance. We smoked cigarettes. He kissed me. To be honest, I kissed him back. Robby was homosexual. I didn't know if I was anything.
I wondered what I was. None of that mattered. Nobody knew anything about it except for me and Robby.
The man whose scientific company invented the Contained MI Plague Strain 412E died when his plane crashed into the ocean. The plane's engines were destroyed by billowing plumes of caustic ash. The ash came from a volcano in Guatemala. It was called Huacamochtli. Robby Brees's dad was filming the Huacamochtli eruption at precisely the same moment that Dr. Grady McKeon's jet disintegrated on impact with the surface of the Gulf of Mexico.
Water is unyielding when you're moving at 500 mph.
We were in seventh grade then. My brother, Eric Christopher Szerba, joined the United States Marines that year. At the same moment Huacamochtli was being filmed by Robby's father and Dr. Grady McKeon's body was being torn apart by the force of impact, my brother, Eric, was on his way to boot camp. Robby Brees's dad never came back to Ealing, Iowa. He didn't want to see Robby's mom ever again.
We found this out later:
The Contained MI Plague Strain 412E said hello to Robby Brees's blood on the asphalt in Grasshopper Jungle.
And the end of the world began at about 2:00 a.m., around three and a half feet away from a discarded floral-print sleeper sofa infested with pubic lice in Ealing, Iowa. One time, Travis Pope unfolded the sofa and fucked his wife, Eileen, on it.
Both of them had pubic lice.
It didn't matter.
History is my compulsion.
I see the connections.
# PART 2:
WATERLOO CORNFIELD
## PALINDROMES
KRZYS SZCZERBA WAS Catholic.
He smoked cigarettes.
Christopher Szerba was Catholic.
He did not give up smoking cigarettes when he gave up the excess consonants.
All the Szerba boys were cigarette-smoking Catholics until my father fell in love with my mother and married her. He quit smoking, converted, and as a result, his semen created two strong Lutheran sons inside her body.
Their names were Eric Christopher and Austin Andrzej Szerba.
My dad picked up some discarded consonants from the wastepile of history.
It is pronounced Uhnn-zhay.
Don't ask me why. It's Polish and shit.
I smoke cigarettes. I hate church. But one day, after I talk to my father about my confusing sexual impulses, I will change my name back to Szczerba.
My father's name was Eric Andrew Szerba. My mother was Connie Kenney before she married him.
People from Iowa like vowels and rhymes.
Lutherans in Iowa like John Deere tractors and big breakfasts on Saturdays.
Usually, my dad would only have to stand outside my door and speak my name to get me out of bed for our Saturday breakfast. That morning, the morning after Robby and I went up on the roof of the Ealing Mall to find some shit, my father had to come into my room and shake my shoulder.
"You stink, Austin," my father, whose name was Eric, told me.
"I have B.O.," I agreed.
"Ingrid needs to shit," my father said.
That was how we told each other good morning that day.
I sat up.
I would have gotten out of bed, but I realized I was naked under the sheet. I'd taken everything off when I finished writing, when I went to bed.
No sixteen-year-old boy wants to stand up naked in front of his father.
I thought about my decision to talk to him. I wanted to ask him if maybe he was confused about sexual attraction when he was my age. Or if maybe he was still confused about sexual attraction. Experimenting. Things falling into place. Where else would things fall, if not a place? It's not like things are just going to float away. Gravity works. Dr. Grady McKeon certainly knew that when he was watching the Gulf of Mexico get closer and closer and closer.
Maybe the guys who painted the caves in Lascaux and Altamira were sexually confused, too.
I could not bring myself to talk to my father about sexuality while I was naked.
I decided it could wait.
Things would have to float a little while longer.
My father could tell I was naked. He watched me, like he was testing to see if I would get out from under the sheet.
But I was naked. I wasn't going anywhere.
We watched each other, both of us caught up in eyeballing the palindrome of each other's lives.
My mother took an antianxiety drug called Xanax. It was a little blue pill that looked like a tiny kayak. Robbie's mother took it, too. Our moms were like Xanax sisters, except they didn't know much more about each other than first names, who their baby boys' best friends were, and Ealing gossip.
Kayak and Xanax are palindromes.
Robby's mother was named Connie, too.
It was always fascinating to me how perfect things could be if you just let all the connections happen. My history showed how everything connected in Ealing, Iowa.
You could never get everything in a book.
Good books are always about everything.
My mother would take her antianxiety drug when she felt stress or panic setting in. Saturday mornings usually meant no drugs. She took her drugs in the afternoons, on holidays, and whenever we had visiting human beings at the house.
"Um. Dad?"
"Yes, Austin?"
"Would you please let Ingrid outside for me so she can shit?"
"No problem, son."
I got out of bed and pulled on some shorts.
I stunk.
My phone was lying on the floor, under the rumpled boxers I wore the day before. No fire trucks and dogs. They were blue plaid. Iowa was blue plaid. That is the truth.
The battery in my phone was nearly dead.
At 3:45 a.m. I received a text message from Robby. It said:
I'm sorry, Austin.
Robby and I always used punctuation and spelling in text messages.
We both despised abbreviations.
I sent him a message in reply:
Don't be dumb, Robby.
I was certain Robby was asleep at that precise moment. I felt bad for calling him dumb, like maybe he would take it the wrong way and not know if I meant dumb for asking to kiss me or dumb for being sorry, which is what I meant.
So I sent him another message:
You shouldn't worry about me, Rob. Let's talk and have a fag later. Ha-ha. Now relax, and come meet me at SATAN'S after I get off at 5. Bring boards.
I was so confused.
That was true.
## A BATH, A SHAVE, AND MODESTY
I AM POLISH.
My hair is the color of potato peels and I have skin the shade of boxed oatmeal.
Food descriptions work well in Iowa.
Polish kids have natural and persistent bags under their eyes. I think we evolved through a lot of sleepless nights or shit like that. If you read the history of Poland, which I have done, you'd probably just shake your head and say, That is full of shit.
I am Krzys Szczerba's great-great-grandson.
That is the only thing I know about myself with absolute certainty.
I think I would like to smoke a cigarette with him. I have a feeling Krzys Szczerba could cuss, had hair the color of russet potatoes, and Quaker Oats skin, just like me. I feel like I could ask him anything. He would tell me what to do.
He came to America when Theodore Roosevelt, a man who apparently never took a shit in his life, was president.
Connie, my mother, drove me to work at Johnny McKeon's From Attic to Seller Consignment Store that morning.
I did not have a big Lutheran Saturday breakfast with my mother and father because I needed a bath more.
On Saturdays I shave.
I did not actually need to shave. It was something that boys in Iowa start doing when they are sixteen, regardless of necessity. I ran the tip of my finger around my lips before applying the shaving cream. Robby's lips had some spiny little whiskers around them. I felt them when we kissed. I found the feeling to be a little unexpected. Also, his lips were thinner, not as heavy, as Shann's. I never thought about it before, how maybe Shann felt spiny little whiskers around my thin, un-meaty lips when we kissed.
I was disgusted with myself.
I called Shann while the bathtub was filling and I sat on the toilet, locked inside the bathroom. My mother and father ate their big Lutheran Saturday breakfast downstairs.
I told Shann I loved her.
She said she loved me.
I was naked, so I knew I was telling the truth.
Also, Shann did not say I love you, too.
Everyone knows I love you, too does not mean I love you.
The too makes it a concession, a gesture, an instinct of politeness.
History lesson for the morning.
I turned the water off and slid into the tub. My face began to sweat.
"I am in the bathtub, Shann," I said.
"Are you naked?" she asked.
"Well, I would be normally," I said, "but since I knew I would be talking to you, I went out and slipped into a modest bathing suit."
She knew I was kidding. It made me very horny to admit to her that I was, indeed, fully naked.
"I am totally naked," I admitted.
Shann told me that she slept well, that she was not scared in her new old bedroom as she thought she would be. But, she said, at exactly 6:00 a.m. there came a ticking sound from inside her wall. Shann explained that it sounded like a typewriter.
Nobody uses typewriters anymore, I told her.
At exactly 6:01 a.m. I was taking off all my clothes and going to bed.
Johnny McKeon was buying donuts.
The Contained MI Plague Strain 412E was dying off, but managed to wriggle around on three slices of Stanpreme pizza we threw in the dumpster, where it wormed its way down the esophagus of its last initial carrier, a homeless man named Hungry Jack, who participated in the killing of an entire village of women, elderly people, and children in Vietnam.
Ollie Jungfrau was probably masturbating.
Ah Wong Sing was taking a shit.
Something was ticking inside Shann Collins's wall.
She said the ticking stopped after a moment. Shann used words like moment. The way she talked made me horny. I told her if the ticking came again, maybe she could record it on her phone because I'd like to hear it.
She told me she would do that.
I shaved.
"The Pancake House is busy this morning," my mother said when she pulled into the front lot of the Ealing Mall. Then she said, "We should eat breakfast there sometime."
"Okay, Mom," I said. "If you want a donut, Johnny always brings coffee and donuts in for me and Ollie Jungfrau on Saturdays."
"Johnny McKeon is such a nice man," my mother said.
"Yes," I agreed, "Johnny takes good care of us."
She parked almost as far away from the secondhand store as you could get and still be on Kimber Drive. My mother was not very steady-handed at squeezing our Chevrolet between slotted cars in parking lots.
I wore a Modest Mouse T-shirt, the shoes we salvaged from the roof of the mall the night before, clean boxers—Iowa plaid—and loose 501s with a belt. I smelled good. My hair was still wet from the bath I took. I did not like my jeans to droop like Robby did. Boys at Curtis Crane Lutheran Academy were required to wear belts and matching socks. We would be called in to Pastor Roland Duff's office if our underwear showed.
Lutherans in Iowa are very modest.
"What is a Modest Mouse?" my mother asked.
She had a stretchy thing on her hair. It was green and looked like the waistband from a pair of fat guy's underwear. I didn't know what those things were called. You know, women from Iowa wear them. In their hair. Her nails needed a new coat of paint. They were chipped or grown out around the edges. Apparently, my mother's nails grew much faster than mine did. Real dynamos. She wore a green velour tracksuit with a zip-up top. I guessed it would be called a tracksuit. I'd never seen my mother run one time in my life. Who wants to run when you can kayak everywhere?
"Nothing," I said. "I don't know."
She parked the Suburban facing out toward the street, directly across from Satan's Pizza.
My mother was very calm that morning.
Maybe all I needed was a tiny blue kayak, to get things to fall into place for me.
I decided I would ask Robby if he'd ever gone kayaking on one of his mother's Xanax before. Probably not. Like me, Robby never even got drunk before.
But we could smoke cigarettes like real dynamos.
"Do you need one of us to come pick you up, Sweetie?" she asked.
My mother called me Sweetie when she was calm.
When she said one of us, it meant that she anticipated being drugged out by five, and my dad could come get me.
History does show that more of what we actually say is not contained in words, anyway. It's why those cave guys simply stuck to the pictures of big hairy things and shit like that.
"Robby and I are going skating," I said. "I'll call if I'm going to be late for dinner."
My mother leaned over and kissed me.
## JOHNNY AND OLLIE
IT'S ABOUT TIME you met these two:
Ollie Jungfrau lifted half a maple bar to me when I walked through the door to From Attic to Seller Consignment Store. It was the kind of gesture drunken soldiers at a bar would make when weary battlefield comrades came in from the war looking for a drink.
But it was with half a donut.
"Hey, Dynamo," Ollie said, winking at me.
Ollie Jungfrau called me Dynamo. The first time he said it, I had to look it up. Who says Dynamo? People in Ealing, Iowa, do, that's who.
That's another word I'm going to try to erase from history, never say it again. But it is a challenging redirection. I'm from Ealing, Iowa, after all.
I rather wished Robby was there, so we could go have a cigarette.
"Hey, Ollie," I said.
Ollie panted contemplatively between bites of his donut. He had red stuff on his chin. The front lines of jelly donuts had already been decimated by the panzer division of Ollie's appetite.
"Coffee." Ollie waved his hand gracefully between a tall paper cup and me, as though he were introducing blind dates at a barn dance.
"Thanks," I said, appreciative of my date's quiet demeanor.
Coffee is a girl who never tells boys no. The idea of such a compliant partner normally would have made me horny, but I was too hungry, still sleepy, and I was also watching Ollie Jungfrau eat a donut at the exact moment sexual thoughts involving a quiet girl at an Iowa barn dance occurred to me.
I liked coffee. And cigarettes. Neither of these truths were welcome at my home. I did not like jelly donuts, however. All the more for Ollie and the customers. Jelly only belongs in one place. Two, if you have decent toast, I suppose.
History.
"John-nnnny!" Ollie called out in the direction of Johnny McKeon's office, "The kid's here!"
I heard Johnny moving things around in the back of the shop. I had already confirmed to myself that I did not feel guilty about being in the shop at night. I was an employee. Robby and I didn't do anything wrong. Well, we didn't do anything wrong inside the store, at least. What Grant Wallace and those other boys did would have happened whether or not Robby and I were there to see it.
So I did not feel guilty about the below-the-roof part of the night.
I sat down across the display counter from Ollie and selected a white-frosted cake donut with blue and yellow Iowa plaid sprinkles that scattered a candy galaxy over its surface.
Ollie nodded. He had an expression on his face like a saint receiving a vision of a bloodied Jesus. Ollie Jungfrau would have been the patron saint of donuts. Not that I'm allowed to believe in saints.
I did not believe in Jesus, either, even if he was good at picking donuts. I was not allowed to say that, either.
I might not put that shit down in the book.
"Good choice," Ollie said.
"It was calling my name, Ollie," I said.
"A voice like an angel."
Ollie took his donuts seriously.
Johnny McKeon looked agitated. He stood beside Ollie at the counter, with his palms flat on the glass and his elbows locked straight. Johnny was a giraffe of a man, and his hands looked like twin octopi. I had never seen anyone with fingers as long as Johnny McKeon's.
If Johnny McKeon ever gave you the thumb-and-index-finger international gesture for OK, trained poodles could jump through it.
Maybe even dolphins.
I looked past his fingers at the vampire bat and bugs in the collections below our donuts. Most people would probably not want to eat donuts here.
"Good morning, Johnny," I said. Sometimes I would say something corny, like "Hey-ho, Johnny."
But not today.
Johnny McKeon said, "Is it still morning?"
That was what Johnny always said to me.
Johnny McKeon was a mover. He was out of bed every day by five. He got things done. I liked him very much, and he knew that. Johnny was aware I smoked cigarettes, too. He'd get mad at me for it, but he'd also sometimes give me free smokes when he broke up vendor multi-pack specials at Tipsy Cricket.
"If your dad or mom tells me anything about this, I'm saying you stole them," is what he always said to me, too.
That morning, Johnny McKeon said to me:
"I'm going to leave you in charge of the store this morning, Austin. You can handle it. I need to run in to Waterloo and pick up some plywood and stuff. Some a-hole broke in through the podiatrist's last night."
Johnny never cussed. He had to be pretty mad to say something as daring as a-hole.
"Someone broke in?" I echoed.
"Yeah," Johnny said. "Right through the dang wall."
I looked at Ollie Jungfrau. He was eating a glazed bow tie and nodding. Apparently, he knew all the details. Naturally he would. It was Saturday, donut day, and Ollie always showed up first, before Tipsy Cricket was supposed to open.
"Sign of the times," Ollie analyzed, shaking his head in a grim I-saw-this-coming rhythm.
"Did you call the police?" I asked. My heartbeat accelerated. The coffee made me sweat. Under my armpits, the chemical beads of my deodorant stick began to erupt like miniature laboratory volcanoes. Outside in Grasshopper Jungle, the Contained MI Plague Strain 412E was now completely dead, having moved into the bodies of seven hosts. Robby Brees was asleep in his bed at the Del Vista Arms. Ingrid was taking a shit.
"They were here all morning. What can you do?" Johnny said. "'You should have a video system. You should have an alarm,' they said. But this is Ealing."
There never was anything worth filming in Ealing, unless you were one of Grant Wallace's buddies watching him kick the shit out of a couple Candy Cane faggots.
In Iowa, there are cameras trained on cornfields. So you can watch corn grow.
"My house has been robbed," I said. "Because my dog can't bark. I should teach her to shit on people."
Ollie chewed thoughtfully. "My uncle has a German shepherd who will do that. He only takes commands in German. Scheiß, Dieter, scheiß! And he'll toast a brownie on the spot."
Ollie Jungfrau was full of Scheiße.
"Did they take anything?" I asked.
Johnny said, "A case of Gilbey's Gin. And the sons of guns got into my office, too. They took a display I had in there."
I sipped my coffee and looked at the candy galaxy on my donut. It hovered on a perfect plane of glass above a rhinoceros beetle.
Johnny went on without any prodding, "I had one of those glass globes the scientists at M.I. made. It had this photoluminescent mold sealed up inside it. I really liked that thing. It made the nicest blue glow if I'd turn the lights on it at nighttime."
"Whoa, whoa, whoa," Ollie objected. "What kind of mold?"
"Photoluminescent," Johnny repeated.
Ollie took a bite of donut and shook his head rapidly. "Nope. No such word," he decided.
Ollie graduated from Herbert Hoover High School, third in his class.
Ollie Jungfrau was a tool.
"I think it means glow in the dark," I said.
Ollie unrolled his glazed fingers. He was counting something. "Then why wouldn't you just say glow in the dark, Johnny? It has less syllables."
"Was it . . . um . . . valuable?" I asked.
"Nah," Johnny said. "I don't think so. How would I know? It was just part of the crazy stuff from boxes that got delivered to me after M.I. shut down. I don't know anything about it."
Johnny reached below the counter and found a metal-cased Stanley tape measure. He placed this and a pencil on top of a pad of lined paper and slid the pile across the display case toward my cup of coffee.
Johnny said, "Bring this stuff, Austin. I need you to come back and help me take measurements so I can fix the danged wall. So they won't ever do something like that again."
They weren't ever going to do it again, plywood or not.
Nobody knew that, either.
## THE PATCH JOB
THIS IS HOW history works: It is omniscient.
Everyone trusts history.
Think about it—when we read history books—nobody ever asks, How did you find this out if it happened before you were born?
History is unimpeachable, sublime.
It is my job.
I can tell you things that nobody could possibly know because I am the recorder. I found out everything in time, but I'm abbreviating. Cutting out the shit.
You have to trust me.
This is history.
You know what I mean.
Why wouldn't you trust me? I admitted everything. Think of how embarrassing these truths are to me.
Most of what I found out came to me much later, after the end of the world, when Robby and I would go out on cigarette runs. You will see. I did the work of history, what I am supposed to do. I found clues and artifacts everywhere, put them together. And I found out exactly what happened.
This is why you can trust me.
I couldn't begin to explain why things happened. Why isn't my job.
I would love to talk to Krzys Szczerba, or even my own father. They might know. They could tell me why I am the way I am.
All I can do is keep my lists of what happened.
That's what I do.
And that was our day. You know what I mean.
I considered telling Johnny McKeon about Grant Wallace and the Hoover Boys. It scared me to imagine what could possibly happen. Nothing good might come of it, I thought. Shann would ask why Robby and I didn't say anything to her when we left Grasshopper Jungle. She would know something was wrong with me. I would spill my guts. Spilling my guts is how history gets recorded. Shann would find shit out.
When I thought about bad things happening between me and Robby and Shann, I could feel my balls shriveling up inside my body.
That's the truth.
History lesson for the day: My balls are barometers to emotional storms.
So I helped Johnny McKeon measure the wall at the spot the Hoover Boys dug through so they could get inside the back room. I held the zero end of the measure and Johnny pulled out the tape and called off numbers to me, which I recorded in pencil on my pad of paper. Like cave painters in France.
"What kind of crazy stuff?" I asked.
I suppose I'd been having an imaginary conversation in my head.
Johnny said, "What?"
"I mean, what kind of crazy stuff came in the boxes from M.I. after they closed down?"
"Oh." Johnny made another mark on the wall. "I can't believe they actually knocked out a stud just to get to some cheap gin. It was mostly things from experiments they were doing, I guess, from my brother's storage unit. It was a bunch of junk of his I inherited, I guess, but never looked at until the place got all packed up. To be honest, I didn't know what to do with the stuff. There was so much of it, I threw some away. I put stuff in the office. I even put some of it on the roof. I don't know what I was thinking, but it was my brother's, you know? Go figure. So. Eh."
"Oh." I said, "Um. I. Um . . . like experiments. Do you think I could see them sometime?"
I felt like asking Johnny McKeon how the little boy with two heads was getting on.
Johnny shrugged. "Eh. Maybe sometime, Austin. It's kind of . . . well . . . morbid stuff, if you ask me."
"Sounds like it could be cool," I said.
"Eh," Johnny said.
We measured. Johnny recited numbers and items, like half-inch plywood, studs, drywall mud, and tape, and shit like that. It sounded incredibly manly. My balls felt bigger just writing that shit down.
I printed in uppercase. It was manly.
"Hey, Johnny." I said, "Tonight, I'd like to take Shann out to dinner and a movie. Maybe to Waterloo. Would that be okay?"
"What are you? Asking permission to take your girlfriend on a date?" Johnny said.
"No. I'm asking for a ride. Do you think you could give us a ride?"
"Do I get to go to the show, too? I could sit in the middle," Johnny said.
He was teasing.
"Um."
"Don't you think it's about time you get your driver's license?"
I turned sixteen in February. It was a week until the beginning of May.
"My mom and dad don't want me to drive yet."
"That should do it," Johnny said, and rolled up the tape measure. "Sure. I'll take you kids. Only not too late. I don't want to have to come pick you up in Waterloo after midnight."
"I'll be at your house around six." I said, "Thanks, Johnny."
## SAY PLEASE
WATERLOO, IOWA, SPRAWLED along the Cedar River, twenty miles away from Ealing.
Johnny McKeon took my notes and the shopping list he'd dictated and put me in charge of From Attic to Seller.
It made me feel like something—something with big balls—to know that Johnny trusted me, even if I did intend to go back and see if he still kept his office key on the trim molding above the door.
I was also planning on smoking at least one cigarette, too.
I rarely smoked alone, but I needed one.
In truth, until that day, I never smoked alone.
I'd just have to toughen up and go buy a pack from the tool in the liquor store.
Ollie Jungfrau left when it was time to open Tipsy Cricket, which didn't have a fixed schedule. Opening the liquor store happened once there were two or three people waiting outside the door. Usually, they'd tap on the glass with quarters or car keys to let Ollie and Johnny know there were thirsty Iowans with money who needed to spend it on alcohol.
The secondhand store, as always, smelled like insecticide, condoms, and despair, with a little sweet hint of unanswered prayers, formaldehyde, cardboard donut boxes, and chicory, all mixed in. I waited a few minutes, just to be sure Johnny wouldn't double back after something he'd forgotten, then I slipped through the back room to the pale green linoleum and fluorescent lights of Tipsy Cricket Liquors.
I made plenty of noise tracking my way through the back room.
I did not want to startle Ollie Jungfrau, or catch him looking at computer porn or masturbating behind the counter.
Making noise was the polite thing to do.
"Scared to be alone, Dynamo?" Ollie grinned at me sympathetically when he saw my intentionally clumsy entrance near the beer cooler in back.
"No," I said, with efficient curtness.
I was all business and could not waste time. I did not want to let Johnny down.
Ollie Jungfrau played games on a laptop computer tapped in to the wireless network from Johnny's office. He played all day long while he sat behind the counter at Tipsy Cricket. I did not see the allure of that particular pastime. But for a guy like Ollie, having his ego sucked into the fantasy of being a muscular soldier in tight clothing, trapped aboard a space station infested by aliens, was preferable to rooting his identity in the here and now.
Ollie Jungfrau killed thousands of aliens, every day.
It made him horny.
"By the way," Ollie said, "I looked up photoluminescent on the computer. It means glow in the dark."
"Okay," I agreed.
"That's stupid," Ollie decided.
Ollie Jungfrau never took his eyes from his laptop screen while we talked. He shot something with a spastic swipe at the space bar, or some shit like that. The thing on Ollie's screen howled in pain. Its leg came off.
Ollie laughed and put his game on pause.
He was sweating.
"I came over to buy some cigarettes," I said.
"For whom?" Ollie asked.
"Me."
"I think it's I."
"Me."
"What would your parents say?"
That was a pointless question, I thought. Why would Ollie Jungfrau ever want to insinuate himself into a conversation between me and my parents regarding cigarettes?
So I said, "They would tell I to say please."
## A SNAPSHOT
OLLIE SOLD ME the cigarettes I asked for. I wanted to show Robby how brave and independent I could be. I bought two packs and a disposable lighter, then went back to the shop.
My balls were big.
I called Shann minutes before noon.
I asked her if she'd like to see a movie and have dinner with me in Waterloo that night.
"What about Robby?" she asked.
"Robby's fine," I answered. "Um. And how's your mom?"
"Fine," Shann said. "What are you talking about?"
"I thought you were just making small talk about other townsfolk we know," I said.
"No. I mean, are we all three hanging out tonight?"
"This isn't about Robby. I was planning on just me and you having a date, Shann," I said. "Johnny told me he'd drive us and everything."
Johnny McKeon wouldn't mind if Shann and I sat together in the backseat for the drive. It was a long, straight road to Waterloo.
The thought of having sex with Shann in the car while her stepfather drove us to Waterloo made me very horny.
Then the shop's front door opened. A family of tourists—a man, woman, and their identically clothed, identical twin boys who looked to be about six years old and undoubtedly had identically stinky feet, as Robby would confirm—came in and began their family expedition along Johnny's path of wonder and despair.
They marched through the maze in parade fashion. The mother, up front, regulated the speed. She stopped from time to time to admire a cow creamer or an iron trivet shaped like a squashed rooster. She pulled out drawers on dressers and nightstands.
She wasn't going to find any condoms.
A couple drawers still had Bibles in them.
The twin boys followed, shoulder to shoulder, holding hands. If they got a little closer to each other, they would look just like the boy in the jar Johnny McKeon kept inside the office. The father held up the rear of the parade. He had a canvas satchel, a man-purse, Robby and I called them, strapped diagonally across his shoulders.
They definitely were not from Iowa, I thought.
Maybe Minneapolis.
It wasn't unusual for tourists to stop at From Attic to Seller on Saturdays.
This family was probably on their way to the ocean, and found themselves trapped in the center of an enormous continent. They may have been looking for postcards so they could mail out desperate messages like:
Send help now! And that was our day. You know what I mean.
But Johnny McKeon did not sell postcards at From Attic to Seller Consignment Store. He did, however, sell condoms at Tipsy Cricket Liquors. I think most of the condoms he sold ended up stuck to the floor of the Ealing Coin Wash Launderette, or in dresser drawers and nightstands that I cleaned out when their owners lost homes and hope.
And that is an economic snapshot of the United States of America, and a dying Iowa town.
"It would be so nice to go out on a date, just you and me, Austin," Shann said.
"It's not like we never do that, Shann," I explained.
The family snaked their way closer to me at the counter. Along the way, the mother had picked up some objects.
"I know," Shann said, "but it's . . . well . . . different now, don't you think?"
My heart beat faster.
"Oh," I said. "Yes."
I didn't know what she meant. I suddenly felt guilty again, like Shann knew everything.
"I love you, Austin," Shann said.
Then I got it. I understood.
I was relieved and stupid at the same time.
"I love you, Shann." I did not say too. But I was fully clothed, anyway. "Did I tell you I am alone at the shop? Johnny needed to go to Waterloo to pick up some things. There are customers here."
I eyeballed the two packs of cigarettes I stacked on the glass case above my favorite insect collection.
"Austin?"
"What?"
"That ticking noise is happening again," she said. She sounded a little frightened.
It was exactly noon.
"Let me hear it."
Shann held her phone up to her wall. She had described the sound perfectly—typing. There was nothing else I could think of when I heard it. But the typing noise stopped in a matter of seconds.
It was exactly noon.
Ten hours in to the end of the world.
Nobody knew anything about it.
## HAGGLED
"I WILL PAY five dollars for the snow globe from Iowa City, this corkscrew, and the porcelain corncobs salt-and-pepper shakers."
Mom, the drum major at the head of the tourist parade, placed her spoils on top of the counter beside my cigarettes. The two-headed boy with four arms and legs pressed its noses against the face of the glass case and left dual unpointed exclamation marks in clear snot directly in front of the bug collections. Dad, at the rear, slid his hand down into his purse and extracted a billfold.
"Um."
Johnny McKeon haggled with customers. Price tags, in stores such as From Attic to Seller, may just as well been written as fill-in-the-blank forms, as far as most shoppers were concerned.
Johnny knew what to do.
I did not.
"Um," I said again.
"Well?" she asked. She thought I was stupid. I knew the look. "Five dollars."
"I . . . I'm only taking care of the counter for my girlfriend's dad," I said. I suddenly felt virile, capable of breeding, horny. The twins frightened me, though. Their noses pointed upward on the glass, distorting into two peaked snot volcanoes.
My job included keeping the glass cases clean.
"I am not permitted to haggle," I pointed out.
"Pfft!" The mother, obviously used to getting her way, was exasperated. She had to do math.
Nobody likes math.
I took the items and tallied up the prices while the silent husband thumbed through bills.
"Eleven dollars and fifty cents," I said.
I increased the price by one dollar, just because I could, and because I was going to have to clean up a pair of snot streaks left behind by the Friendship League of Minnesota.
The man paid what I asked. I bagged my first sale.
Then the man with the purse asked, "Is this Ealing?"
"I know. A lot of people just can't believe they've finally arrived when they get to Ealing," I said. "But this is it."
"This is it . . . heh-heh," the man said. He pulled a small glossy guidebook from his purse and continued, "Ealing, Iowa. Seven unsolved decapitations in 1969."
"Uh."
He proudly held his book up so I could see the cover. It read:
Serial Killer America
"We're on a road trip!" The man with the purse twittered like a gleeful bird.
The twins snarfled and snotted against the glass.
"Cross another one off the list," the mother decided. Then she added, "Please be careful with my corncobs."
I needed a cigarette.
## THE BOY IN THE GLASS
I STOOD OUTSIDE in the parking lot and smoked. I watched the traffic of people who came and went and came and went at The Pancake House, the launderette, Tipsy Cricket Liquors, and, across the street, at Satan's Pizza, too.
At 12:45, I phoned Robby.
I lit another cigarette. I was in charge.
Robby was impressed, maybe jealous, that I was alone and having a cigarette without him. He was still in his bed when I called. I heard him light one up over the phone as we talked. So Robby and I had a cigarette together by cell phone.
It's good to have a cigarette with your best friend.
I told him everything that happened—the history of the morning—even about the snot-faced twin kids from Minneapolis who smeared up the glass case, and how I overcharged them a dollar just because I didn't like them. He asked if I'd gone back into the alley at Grasshopper Jungle. I said no. I wasn't going to go back there.
Everything seemed okay.
It was just another Saturday afternoon in Ealing, Iowa.
But I couldn't shake the feeling that something impossibly huge had happened in the past twenty-four hours. Maybe that's just the omniscience of the recorder who looks back on history as he's painting the walls of his cave. Shit like that.
There is a blissful haze that quietly flies into your head like a swarm of anesthetized butterflies after you smoke a couple fags. Buzzing from nicotine, I went back inside From Attic to Seller Consignment Store, wandered my way along the parade route of Johnny McKeon's display maze, and found myself standing once again in front of Johnny's locked office door.
Johnny McKeon obviously didn't really care to hide the things he kept inside his office. Maybe they were an embarrassment. Maybe he just didn't know what to do with the things that once belonged to his dead brother. I thought I might ask Johnny about that if he ever showed me his experiments.
I wanted to know why.
As my fingers felt along the groove of the molding, I thought about what I would do with Eric's things if he never came home again.
I would probably keep them in my room and not let anyone else look at them.
I understood Johnny McKeon.
The key was still there, where Johnny always hid it.
I went inside his office.
Johnny McKeon did not say anything about the missing globe to the policemen who came out that morning. If he had, he'd have to have shown them the rest of the things inside the office. Johnny would not want to do that.
There were smears on the old library shelf where Tyler's fingers had tracked through the dust at the base of the globe. He didn't even bother to take the stand. It was still there, still announcing the Contained MI Plague Strain 412E.
Not so much contained any longer.
That was the first time I'd considered the possibility that maybe those four boys were going to end up getting sick.
But I figured all that shit was from 1969, according to the dates on the labels. Nothing incurable could ever come from 1969.
The Beatles and the Stones came from 1969.
And like Johnny McKeon said, it was only photoluminescent mold, after all.
The two-headed boy, although hardly bigger than a cantaloupe, was older than me. I talked to him.
"You're nearing middle age, my man. You must be tired of being inside that jar."
I put my face close to the glass, resting my chin on the shelf so I could look directly into the little dark sockets of the boy's eyes.
I placed my palm on the cool curve of the glass.
The boy inside twitched.
The movement was so slight. Just a jittering spasm of the fingers. But I saw it.
I snapped my hand away from the glass and took a step back.
I bumped into Johnny McKeon's desk so hard it felt like I ripped a hole in my jeans.
## SKATING AND KAYAKING
THE ALLEYWAY BEHIND Satan's Pizza wasn't nearly as long or accommodating for skaters as Grasshopper Jungle. The pizza place was a stand-alone business, so all we could really do there was goof around in small circles. Goofing around in small circles was how Robby and I usually skated, anyway.
When I showed up, Robby had on the grimacing lemur mask and the Titus Andronicus T-shirt I loaned him the night before.
After what happened to me in Johnny McKeon's office, everything I saw that day seemed like it oozed out of some twisted nightmare. I kept telling myself that maybe I was only imagining things as a result of too much nicotine and too little oxygen in my brain.
There was no way that little boy could have moved his fingers at me.
"Hey-ho, Lemur Boy," I said.
Robby raised his arms, twisting his fingers into claws above his hairy lemur head. He froze there like that, not saying anything. He stood with one foot on the deck of his skateboard. My board was right beside his.
Grimacing lemurs are a little unnerving.
"Amazingly lifelike," I said.
Robby remained silent and motionless, a taxidermist's display of a lemur-Lutheran-boy-crossbreed experiment.
I shrugged and slid my skateboard away from him. I got on it and pushed off.
"Hey, wait up," Robby said. He followed after me.
When he rolled up alongside me, still wearing the mask, Robby said, "I went through the jungle, Porcupine."
"Did you see anything?" I asked.
"Nah." Robby said, "Somebody pushed the dumpster back. Everything was just like it's always been."
"Are the pubic lice happy and well?" I asked.
"Thriving," Robby said. "I picked up a few hitchhikers who wanted to hang out with you. Let's have a fag."
"Okay. Can you smoke in that thing?"
"I haven't tried yet," Robby answered. "It's probably not flame retardant. Or else it's carcinogenic, or will mess up your sperm and make you have two-headed babies and shit."
"Yeah," I agreed. "You wouldn't want to smoke cigarettes wearing a carcinogenic grimacing lemur mask that's capable of messing up your sperm."
"Nobody wants messed-up sperm."
"Messed-up sperm is the evolutionary slot machine that will destroy mankind."
Robby and I were having a conversation about sperm.
Robby said, "How long are we going to talk about sperm?"
I answered, "I don't know. Talking about sperm is something that people just don't do enough of. It does make me feel a little weird, though."
Robby took off the mask. His face was pink and damp with sweat.
We looked at each other. Robby smiled and nodded. I knew everything between us was okay. He stuck his hand out, and I took it.
It was a real Lutheran-minister-kind-of-awkward-and-sweaty Iowa handshake.
"What is this shit?" I said, "We are shaking hands. We never shake hands."
Robby said, "I know. Well, I just, um, wanted to tell you . . ."
"You don't need to say anything, Rob."
I patted his shoulder.
"I guess not," Robby said. I took out one of the packs of cigarettes Ollie Jungfrau sold me, and Robby added, "I think it is always appropriate to end a conversation about sperm with a sweaty handshake."
"Yeah," I said.
We sat down on our skateboards right next to each other and smoked.
Every Saturday, Robby asked me how many donuts Ollie Jungfrau ate. I could not be certain, but that day I think I counted nine. Robby asked me to swear I would take pictures with my cell phone if Ollie Jungfrau ever exploded.
Then I told Robby about going back inside Johnny McKeon's office, and how scared I was because I believed I saw the two-headed boy inside the jar twitch his fingers at me when I talked to him.
Robby shook his head dismissively. "Last night, after all the shit that happened, we are both probably traumatized. You were seeing things."
"I don't think I'm traumatized, Robby," I said.
"I think the inside of this lemur mask made my face stink," Robby said. He blew out a big gaseous cloud of smoke.
"You're still wearing the T-shirt I loaned you," I said.
"I'll give it back after I wash it."
"Oh. Sure thing, Rob." I asked, "How's the flamingo?"
"Fine. Just fine." Robby rocked sideways on his board. "On Monday night, my mom's working a double shift. You should come over and get drunk with me."
"Maybe we should do that," I said. "I was thinking. Have you ever popped one of your mom's little blue relaxers?"
"Zannies?" Robby asked.
"Yeah. Ever taken one?" I said, "I was just wondering. They look like little boats, don't they? Kayaks. I just figured they make you all calm and shit. Sailing away. Like you don't have any problems and everything is figured out."
Robby said, "I never tried one. Anyway, you don't have any problems, or anything to figure out, either."
"Sure. Sure I don't," I said.
"Like what?" Robby asked.
"Okay," I said.
Okay, at times, can effectively serve as the closing curtain to difficult teenage conversations.
Then I said, "I will come over on Monday and get drunk with you."
"I'll let you wear the lemur mask."
"I don't want my face to stink."
"Yeah. Probably not."
By the time we'd gotten on to our second cigarette, I worked up the nerve to tell Robby about the date I made with Shann. Feeling awkward and guilty about it was stupid, too, but it was just another element of my confusion about things. Robby didn't seem to mind. I was more confused. I thought he'd feel left out, like we were ditching him.
He offered to drive me to Shann's house so I wouldn't have to skate all the way out there. Robby said it would give me B.O., and I probably did not want to have B.O. on a date with Shann.
"You're right," I said. "I don't want to have B.O."
Robby said, "If you have B.O., you might as well have messed-up sperm, too."
"I'll shake to that," I said.
Robby picked up the grimacing lemur mask and sniffed the inside of it.
"This is nasty," he said.
"I thought you'd be disappointed," I said. "Because we're going out on Saturday night without you."
"But it's Shann," Robby said. "She's your girlfriend. You need to go out together. That's what boyfriends and girlfriends do."
"Yeah. Well, I feel bad."
"Why?"
I said, "I don't really know, Robby. What are you going to do tonight?"
Robby said, "Me? Laundry, I guess. Shit like that."
"Right."
"Come on," Robby said, "let's head out and pick up the Explorer."
"Maybe tomorrow we could do something," I said. "Just me and you."
"We could fold my laundry," Robby offered.
## EDEN FIVE NEEDS YOU
SHANN COLLINS AND I ate burgers and onion rings at Jackie's Country Kitchen in Waterloo, Iowa, after the movie.
People in Iowa are real dynamos at naming businesses.
Movies came to Waterloo about a month after they began showing on other parts of the continent. The movie Shann and I sat through was one that all the kids at Curtis Crane Lutheran Academy had seen on opening day, which happened weeks earlier, just so they could tell everyone who hadn't seen it what it was about and how good it was.
The kids at Curtis Crane Lutheran Academy all agreed the movie was terrific.
It was probably the dumbest movie I'd ever seen in my life.
But since I was with Shann, I didn't actually pay attention to much of it.
It is difficult for any movie to keep my attention. That's something else wrong with me, I think. It's all part of the big confusing history behind Austin Andrzej Szerba. I don't know why I am the way I am. I knew I should talk to my father about things. I just needed to find a way to get that conversation to start.
Shann and I sat in the corner of the back row.
The movie was called Eden Five Needs You 4. I had not seen the first three parts, but it didn't matter since everyone at Curtis Crane Lutheran Academy had, and had told everything about what happened. It also didn't matter because apparently the plot of the movie was not an essential element to the experience.
Eden Five Needs You 4 was a very loud, visually assaulting science-fiction movie about a teenager who was abducted by benevolent aliens and taken to a planet called Eden Five.
The first four Edens were probably shitholes.
The benevolent aliens abducted the teen because Earth was dying, due to all the wars and environmental destruction humans had inflicted on their planet and shit like that. So the benevolent aliens chose the teen because they wanted his sperm to start a new population of human beings on this other, nice planet called Eden Five. Well, the teen didn't want his sperm to be the sole genesis of a new race of mankind on Eden Five, because he did not want to be responsible for all the shitty things human beings are genetically driven to do: War, crucifixions, genocide, religion, television.
He paid attention to history enough to know that Adam should have used a condom.
So the teen stole one of the benevolent aliens' spacecrafts and returned to Earth to get his best friend, another teen, so he could go back to Eden Five with him, and both of their sperm could be used to start a new race of mankind. That way, neither one of them would have to take full responsibility for all the shit human beings are naturally driven to do.
You know, friends blaming friends for the other guy's sperm being messed up.
That's what history's all about.
In the meantime, the president of the United States, who had formerly been director of the Central Intelligence Agency, learned of the plan to start a new world on Eden Five. The president was unhappy that it was not going to be his sperm that started an entire new race. He ordered the United States Space Agency to send rockets up and destroy the craft with (now) the two teenagers aboard. The United States spaceships were also loaded with frozen embryos that had all been created from the president's sperm.
The United States spacecrafts also looked like gigantic flying pairs of balls.
Hollywood is good at subtlety.
Like I said, it was the dumbest movie I ever saw.
The actor who played the teenager was thirty years old in real life, but nobody in the paying audience seemed to mind because he was very handsome and well groomed.
I don't really know how the movie ended, or if there was a clear conclusion to the story. While we waited in line for our tickets, I did hear some boys ahead of us talking about next summer's release of Eden Five Needs You 5, so the movie probably had a real cliffhanger of an ending.
The boys in front of us chewed tobacco. They carried paper coffee cups that were halfway filled with sticky brown saliva. They left these on the floor of the theater, for the future. If you were ever going to start a new planet and needed some sperm, these boys would not be on your list.
During the big in-space fight scene between the flying American testicles and the teens whose sperm was going to create a new race of blameless humans, Shann and I had our tongues in each other's mouths.
It's not that the movie made us particularly horny. If we actually paid attention to it, we might likely have been anesthetized. I read a popular myth somewhere about how schools in Iowa used to put a chemical called saltpeter in their cafeteria food. People believed that saltpeter made it so boys would not get erections.
It was all a bunch of shit, of course.
Nothing, except possibly paying attention to Eden Five Needs You 4, could ever make boys not get erections.
I slid my hand up inside the loose sweater Shann was wearing and played with her perfect breasts.
The movie was very loud.
I had never touched Shann's naked breasts before. She liked it.
I liked it more, I think.
In fact, Shann dropped her hand between my legs and rubbed me. Shann had never put her hand there before. This caused a very sudden and accidental eruption of Mount Austin Andrzej Szerba inside my jeans.
I gasped and gulped.
It happened exactly at a moment where the dumb movie went absolutely quiet.
I was mortified. I nearly passed out.
Shann knew what happened. It was obvious.
The tobacco-chewing yahoos in front of us could probably tell what happened.
I slumped down in my seat.
I wondered if it was possible to die from embarrassment.
"Oh," Shann said.
"Uh," I said.
And Shann whispered, "Eden Five needs you."
So, while we eyed each other over our burgers and onion rings, I slipped my foot out of my shoe and caressed Shann's leg with my toes under the table at Jackie's Country Kitchen. I was somewhere in the middle of telling her the story about Ollie Jungfrau's uncle's German shepherd that can toast a brownie on demand, and how damaged sperm was probably responsible for every great man-made calamity in history, when Shann said to me:
"You know what I really love about you, Austin?"
I did not know what she really loved about me. Probably not my endurance.
I said, "No. Tell me."
Shann said, "I love how you tell stories. I love how, whenever you tell me a story, you go backwards and forwards and tell me everything else that could possibly be happening in every direction, like an explosion. Like a flower blooming."
"Really?" I asked. "I . . . Hmm . . . I never noticed that about me before."
I felt myself getting embarrassed again, but not nearly to the degree I had been when we encountered an accidental spill during the painfully quiet post–epic battle scene in Eden Five Needs You 4.
Shann said, "I think you're irresistibly cute, Austin Szerba."
"Thank you, Shannon Collins." I said, "I will shake to that."
Here is what happened that night:
Seven people in Ealing, Iowa, stopped eating food. They began bumping into walls and shit. They were very sick.
Ollie Jungfrau was constipated. He'd eaten too many donuts that day and had a dinner whose principal ingredient was cheese.
There were only six houses on the street where I lived. Two of them had been repossessed by the bank. Their windows and doors were posted with notices printed in very small type. At exactly the same moment Eden Five Needs You 4 got embarrassingly silent and I erupted, a third home on my street went empty as the owners were ordered out by grim-faced officers of the court who waved official papers.
And in that house, tucked away inside the drawer of an abandoned nightstand were four unopened condoms and a Book of Mormon that had been taken from a room at a Marriott Hotel in San Diego, California.
The family had been to Sea World.
Pastor Roland Duff ate a personal-sized Stanpreme pizza at Satan's Pizza. While he sat alone, Roland Duff read the Waterloo paper and looked up movie listings. He thought he might enjoy seeing Eden Five Needs You 4. Pastor Roland Duff had never seen the Pacific Ocean.
Shann's stepfather, Johnny McKeon, who was also my employer, drove out to Waterloo to pick us up at Jackie's Country Kitchen at 10:30.
On the drive back to Ealing, Shann sat next to me with her head resting on my shoulder.
It was a quiet ride.
Most of the way home, I was trying to decide if what happened to me could technically be considered having sex; if that was the first time I actually had sex with someone else. I decided it was close enough. Close enough to repopulate Eden Five. Close enough to be a forbidden subject in the library at Curtis Crane Lutheran Academy.
Thinking about what happened in the movie theater made me hope Shann would touch me like that again.
I also desperately wanted to change out of my soggy Iowa plaid boxers.
"So, how was the movie?" Johnny asked.
"Huh?" I said.
Sweaty, damp, and oddly energized, I got home at 11:15. My predictable parents were already asleep at that time. The house was dark. Ingrid waggled and quivered excitedly. She stuck her bowling-pin nose into my crotch when I opened the door.
"Go toast some brownies, Ingrid," I said.
I stood on our front step and waited for Ingrid to shit. Then we both went upstairs into my room, where, at last, I could peel myself out of my ruined clothes.
At 12:04 I slipped between the coolness of my sheets just as my phone rang.
I thought it was Robby, but it was Shann.
She told me the typing-ticking sound had come back and she was scared.
"Tomorrow, after church, me and Robby are coming over," I said. "We're going to find out what's inside the wall."
"Okay," Shann said. "I love you, Austin."
"Eden Five needs me," I said.
I was very horny again.
## AN AWFUL LOT OF MATH
WENDY MCKEON LOOKED so much like her daughter, Shann, that people sometimes assumed they might be sisters.
Robby and I went directly to Shann's house after church. Johnny and Wendy didn't take Shann to services that week. They made the excuse that they were settling in to their new old house. When you didn't go to church in Ealing, sometimes it was almost necessary to stick a sign in your yard asking forgiveness from your neighbors.
God cuts slack to people who need to settle in, but your neighbors might not.
Students from Curtis Crane Lutheran Academy were required to wear our ties and sweaters at church, even though most people in Ealing did not dress up on Sundays.
"Don't you two look handsome?" Wendy McKeon said when she greeted us at her door.
Robby and I hadn't changed into our non-Lutheran-boy clothes yet.
"Like candy canes," I said.
"Kind of makes you want to beat us up, doesn't it?" Robby asked.
"Oh, you," Wendy said and put her hand flat on Robby's chest.
Robby was so much funnier and better looking than I was. I believed Wendy sometimes wondered why Shann wasn't his girlfriend, instead of the Polish kid's. Robby wasn't out to anyone but me and Shann. Wendy McKeon didn't know anything about teenage boys unless she learned it from one of those daytime television talk programs.
Wendy McKeon would have thought it was not normal for Robby and me to experiment.
There was an exterminator service van parked in front of the McKeon House. Shann had told her mother about the noises coming from the wall, and Johnny and Wendy decided it was most likely rats.
"Old houses like this do often have rats inside them," I said to Shann when Robby and I were in her room. I couldn't help but play with the idea of asking Shann for an Eden Five Needs You 4 threesome with me and Robby. The amount of math in that thought made my head ache.
"Rats with typewriters," Robby added.
"These rats type every six hours," Shann said, continuing the numerical assault on my head. "At exactly six and twelve. I've been keeping track."
"So they're obsessive-compulsive rats with typewriters," Robby said.
"Just wait a moment," Shann said. She looked at her wristwatch. It was 11:50.
I was horny and mathematically confused.
The exterminator men crawled all around the floor, looking for holes rats could use to get inside the walls. When they didn't find any, they crawled up into the attic and around the perimeter of the home's foundation, setting traps and putting out attractive dishes of poison that looked like candy corn.
They did not find any rats because there weren't any.
At exactly noon, the noise inside Shann's wall came again. This time, all three of us were there, and all three of us heard it. The sound went silent in less than a minute, but we triangulated with our ears the precise spot in the wall where it originated.
"Do you kids want some lunch?" Wendy called from deep in the house somewhere.
I nodded at Shann and she yelled back at her mother. The house was so big it wouldn't have been too outrageous to actually use cell phones. In houses, teenagers tend to communicate with their parents by screaming across distances.
"It's some kind of a machine," I said.
The wall there was made from top-to-bottom tongue-and-groove wood plank. Some of the slats were loose and could wiggle. I felt certain we'd be able to pry a board or two up without inflicting any permanent damage to Shann's bedroom wall. I asked Shann to bring us some butter knives or flathead screwdrivers—anything Robby and I could use to get at the boards.
And just when Wendy McKeon hollered up to us that lunch was served, Robby and I peeled back a six-inch-wide slat and found the source of Shann's four-times-per-day haunting.
The ghost in Shann's wall was a machine.
The thing was set back between the wall of Shann's room and a bathroom on the other side. It sat on a low, dust-covered pine shelf. Thick rubberized wires ran from its back, following the roadways of wall studs and joists up and down, out of sight.
The machine was also covered in dust, made of Bakelite and blue rounded metal that had the same aesthetic style of a toaster or an automobile designed fifty years ago. At the front was a keyboard, like a typewriter's, but the thing was much bigger than a simple typewriter.
This was what was called a teletype machine.
From the back of the platen cylinder, a yellowed scroll of perforated paper had been spitting out the same repeated message, typed out in black-ink capital letters that formed ladder-like rungs over several feet:
THE FLAMINGO ALERTS ON ENVIRONMENTAL PRESENCE OF 412-E. SILO GENERATORS NOW ACTIVATED. REPORT TO THE SILO WITH PROPER HASTE.
THE FLAMINGO ALERTS ON ENVIRONMENTAL PRESENCE OF 412-E. SILO GENERATORS NOW ACTIVATED. REPORT TO THE SILO WITH PROPER HASTE.
THE FLAMINGO ALERTS ON ENVIRONMENTAL PRESENCE OF 412-E. SILO GENERATORS NOW ACTIVATED. REPORT TO THE SILO WITH PROPER HASTE.
I looked at Robby.
He looked at me.
Both of us, at the same time, said, "Oh."
And Robby said, "Nobody says 'with proper haste.'"
"Who would ever say something like that?" I added.
Shann said, "What's going on, Austin?"
I said, "Uh."
## TALLY-HO!
"I DON'T THINK I'll need to eat again before Guy Fawkes Day," I said.
"Tallyho to that," Robby said.
"Chip chip and all that," I said.
That night, Robby drove his car east along the flat straight highway that linked Ealing to Waterloo. We were hanging out together, like I'd promised.
Robby said we would be traveling through time, and it might be ugly.
I did not know why Robby wanted to go to Waterloo, or why he wanted to travel through time. I only hoped he did not want to sit through Eden Five Needs You 4.
Wendy McKeon was raised in southern Indiana. Regionalists sometimes referred to that area as Northern Kentucky. Lunch, for a person raised in that part of the continent, consisted of the following: fried chicken, potato salad, mashed potatoes, creamed corn, deviled eggs, canned fruit cocktail, sweet pickles, American cheese slices, white bread, softened margarine, milk, cake, and peanut butter.
After the orgy of Wendy McKeon's lunch, we unplugged the teletype machine before we left. Robby and I took the printout of the repeating message with us, and we replaced the wobbly board to the wall in Shann's bedroom.
Having a teletype machine built into your wall was not so strange, I offered, considering Shann's room also included a door that went nowhere and a staircase descending to a dungeon for horny Lutheran boys.
Shann agreed. It was just a weird house.
"But it is on the Ealing Registry of Historical Homes," Robby reminded us.
"An abundance of distressed bricks," I commented.
"Who knows what other crazy stuff the McKeons did in this house?" Shann said.
"Yes," I said. "Who knows?"
There was some figuring out that had to be done.
Figuring out meant a sort of confession to Shann would be involved if Robby and I were not careful. I did not want to tell Shann about the things that happened in Johnny McKeon's office, and I did not want to say to her what Robby and I did when we were up on the roof of the Ealing Mall.
But I do not lie. If Shann ever asked about it, I would tell her.
So Robby and I opted for a waiting period of quiet consideration before exploring the possibilities of what the teletype message actually could mean.
Robby and I went back to my house and changed out of our Lutheran Boy superhero costumes. I loaned him another Austin Szerba outfit from my closet. Soon, I thought, all my clothes as well as Robby's would be scattered, unwashed, over the backseat of his Ford Explorer.
"There is no silo at the McKeon House," I said. "I looked."
I pulled on a pair of jeans and slipped my feet into some loose skate shoes.
"So did I," Robby said. I gave him some Levis and my Pink Floyd T-shirt to wear. Mine said LCD Soundsystem.
"You're not planning on taking me to see Eden Five Needs You 4, are you?"
"No," Robby answered. "I'm going to see something I always wondered about, but was too chicken to go by myself."
"Sounds like what I'd say about Eden Five," I said.
Eventually, I was relieved. I was grateful that Robby truly was not interested in the film I'd seen with Shann the night before.
Robby didn't even slow the car when we drove past the Waterloo Cinezaar.
Another brilliant job of name branding by an Iowa entrepreneur.
Finally, Robby pulled the Explorer into the parking lot of a squat and dim strip mall. The place was dismal, but not nearly as run-down and left in abandon as the Ealing Mall at Grasshopper Jungle. The signs above each of the businesses were lit up, despite the fact that the majority of places were closed on Sunday nights.
There was a launderette, and it appeared to be clean and condom-free. Naturally, there was a liquor store, another business called Cheap Smokes that had a decal of a marijuana leaf in the corner of its front window, a barbershop, and an indoor shooting range and gun shop called Fire at Will's.
Waterloo was definitely the place.
And at the end of the mall, in an area where four or five cars had parked beneath a lonely overhead light facing the unit's front door, was a bar called the Tally-Ho!
The Tally-Ho! was widely known in the area as being a secret place for homosexual men to hang out and meet.
The secret was not well kept.
People in Ealing just didn't talk about the Tally-Ho!, or if they did, it was in a very low register, so other ears would not perk up at mention of the name.
The Tally-Ho! was Waterloo, Iowa's one and only gay bar.
"Uh," I said.
"What?" said Robby.
"Why did you come to the Tally-Ho!, Robby?"
"I wanted to see what it looked like," Robby explained.
"We can't go inside," I argued. "People might think we're . . . Um. Prostitutes, or something."
"Did you actually just say prostitute?" Robby asked.
"I can't be certain," I said. "I think I did."
"We can't go inside because we're only sixteen," Robby said.
"Do you want to go inside?" I asked.
"Are you asking me on a date, Austin?" Robby said.
"No."
I was so confused.
Robby went on, "I wanted to come here just so I could see what the future is like. What if I end up here, with nowhere else to go? What will I look like?"
"You could wear the grimacing lemur mask," I offered.
"I always wondered who came to this place," Robby said.
"I guess everyone kind of wonders that, but they're just too afraid to admit it," I said.
Robby shook out some cigarettes, held the pack so I could take one. I pressed the lighter into the dash. I thought I knew why Robby came here. It was sad.
We smoked.
"Do you want to go look?" Robby said.
"What? Like, inside?"
"No. Maybe we could just poke our faces in the door and say something like we're lost and need to know how to get back to Ealing."
"Nobody would believe it," I said. "Nobody ever wants to get back to Ealing."
"You may be right," Robby said. "Still, what would they do to us?"
"What if they think we're gay or something?"
"What are you trying to say, Austin?"
"Um. Sorry, Rob." I took a drag off my cigarette. "I guess I better just shut up."
Robby got out of the car.
Robby wasn't angry or upset at what I'd said. Real friends know what they mean when one of them says clumsy or stupid things. History shows that.
History also shows there aren't an awful lot of real friends on the record.
So I got out of the car, too.
## THE INNER TOMB
IT WAS FRIGHTENING and thrilling, following Robby to the door of the Tally-Ho!
It seemed as though hidden eyes were out there in the dark of the parking lot, and they were watching us and constructing stories—histories—about what these two boys from Curtis Crane Lutheran Academy might be up to.
The Tally-Ho!, as it turned out, was not a vibrant, happening scene at all.
It was exactly what Robby expected.
He stood with his hand on the door's pull bar. A sign hung from metal S-hooks beneath clear plastic suction cups on the inside of the glass. It said:
NO PERSONS UNDER 21 ALLOWED
I expected to hear happy music seeping out from the door, the sound of laughter and boisterous barroom conversations, but the Tally-Ho! let no such atmosphere leak out from its small, encapsulated world.
The place was as quiet as a cemetery in a morning snowfall.
Robby took a deep breath, pulled open the door, and stepped inside.
And, like a sedated Chihuahua on a jeweled leash, I followed him.
I was so nervous I thought my knees would buckle. My head swam in agitated seas of conflict and confusion: What if people thought we were gay? Why did I care what people thought? What if I really was gay? I kissed Robby, after all. What would Shann say about us being here? What if someone started hitting on me or Robby? What if we got in trouble for walking into the place? What if we got beat up again by some assholes like Grant Wallace and his friends?
Robby Brees was much braver than I could ever be.
We stood there, dumb and quiet in the dark alcove just inside the front door of the Tally-Ho!
The place was as tired and mournful as the library at Curtis Crane Lutheran Academy after the masturbation scandal. Nobody so much as turned to glance at the two nervous kids who stood at the door.
I hid behind Robby.
The bartender washed glasses. He wore a T-shirt that was too tight. It accentuated the roll of his belly. He was balding and showed a blurring tattoo of Bettie Page, blanketed beneath the swirling shrubbery of black hair on his forearm. Two other men sat at the bar. They both appeared to be tired, in their forties. They stared straight ahead as though watching something other than their own reflections in the mirror behind the bartender.
They were separated by three barstools.
The closer of the two had dirty hands. He bit his fingernails, too.
At the back of the room sat an undersized pool table with worn felt. It was tucked too near a corner to actually be playable. A man with a Royals ball cap shot pool by himself. He scratched the cue ball while we watched him. After he took another shot, he glanced up at me and Robby. He smiled.
I whispered, "Aren't you going to ask them? You know . . . say we're lost or shit?"
Robby shook his head and backed himself into me.
He said, "No. Let's get out of here, Austin."
Robby leaned on me, pushing me back.
We quietly slid out the door.
Nobody even watched us leave.
## AND HERE'S NUMBER FIVE
ROBBY AND I sat against the tailgate of the Explorer. We smoked cigarettes and watched cars on the highway. Robby said he wished we'd have brought our skateboards with us.
"Skating would be good," I said.
The alley behind Tally-Ho! looked like a real clean place to skate.
"I never knew there were four gay guys in Waterloo," I said.
That number involved making an assumption about the bartender.
"It's Sunday," Robby said. "I bet when this place gets really busy, there might be five or six."
"You're not going to be like that, Rob," I said. "I mean, all lonely and shit."
"Is that what you think?" Robby asked.
"I'm pretty sure that is what I think," I said.
Out on the highway, a car slowed and then pulled into the parking lot at the opposite end, near Fire at Will's Indoor Shooting Range. It was a newer Honda Accord. The car drove along the front aisle of parking stalls and then turned left into a slot beside the other vehicles lined up near the Tally-Ho!
Robby and I watched from our hidden spot behind his old Ford.
"And here's number five," I said.
The Honda's door opened. Freshly pressed slacks and shiny black loafers with dangly tassels that flapped from their insteps like beagle ears lowered mechanically from the bottom of the driver's door. Then Pastor Roland Duff got out, straightened and brushed off his trousers, shut the door, and entered the Tally-Ho!
"Uh," I said.
"Uh," Robby answered.
"I wonder what Pastor Roland Duff is doing here," I said.
"Do you really wonder?" Robby asked.
"I guess not," I said.
"He must be lonely," Robby said.
"I'll buy that, Robby," I said. "But if Pastor Roland Duff is lonely, it isn't because he's gay. It's because he's a shitspoon."
Robby nodded thoughtfully and smoked.
Then he said, "I'll buy that, too, Austin."
"I would like another cigarette, Robby," I said.
Robby pulled the crumpled pack from his back pocket and handed it to me.
He said, "Where did you get that word from? I admire it."
"What?" I said, "Shitspoon?"
"Uh-huh," Robby said.
"It was the name of the alien's spacecraft in Eden Five Needs You 4," I said.
"You're making that up," Robby said.
"I know. I didn't pay attention to that shitspoon flick at all, Rob."
## TAKING DRAGS
"WERE YOU SCARED in there?" I asked.
"I wasn't scared," Robby said.
"I was," I said.
"I could feel your heartbeat through the floorboards. I thought it was because you found the bartender to be attractive."
"Uh. Was he attractive?" I asked.
"Kind of," Robby said.
I smoked.
"Do you think I'm queer, Rob?" I asked.
"I don't care if you're queer," Robby said. "Queer is just a word. Like orange. I know who you are. There's no one word for that."
I believed him.
"I know I'm not orange," I said.
"Kind of oatmealy," Robby said.
I always let Robby read the books. He was the only one allowed inside Austin Andrzej Szerba's history department.
"Sometimes I'm confused," I said. "Actually, pretty much all the time I am. I wonder if I'm normal. I think I might ask my dad about it. You know, if he ever felt this way. Or if maybe he still does sometimes. Because I feel . . . Uh . . . I wonder if I am queer or shit."
"You should ask your dad, Porcupine," Robby said.
"Would you ask your dad?"
"My dad doesn't give a shit about me," Robby said.
"Uh."
I took another drag. "It made me feel weird. The other night. But I keep thinking about you, and I think doing that means there is something wrong about me."
"I'm sorry. I won't do what I did ever again. You know. Sorry, Austin."
"Nuh." I said, "It's not something to be sorry about. I just don't know what to do, Rob."
"You worry too much," Robby said.
"I know."
And then Robby said, "I do love you, though."
"Yeah, Rob. I know." I blew out a cloud of smoke. I tried to make it all perfect and cool like Robby could, but it didn't work.
So I said, "I love you, Robby."
I did not say too.
Robby said, "I know that, Austin. It is nice to hear you say it, though."
"I wish we brought our skateboards."
"Uh-huh."
I didn't know what to do.
## A VISITOR COMES AND GOES
SO WE STOOD there and smoked our cigarettes down.
In the paralytic coma that is a Sunday night in a strip mall parking lot paved atop the scraps of a cornfield somewhere imprecisely located on the outskirts of Waterloo, Iowa, the whooshing excitement of passing cars came once or twice, every five minutes or so.
And that was our day. You know what I mean.
The Tally-Ho! turned out to be not so much a disappointment for Robby as the sad realization of everything he expected to see.
That is, except for Pastor Roland Duff showing up.
But history does consistently prove that whenever guys go out to visit someplace they've never been before, they're going to see shit they did not expect to see.
The Age of Discovery had come to Ealing, Iowa.
Experiments and shit like that.
Krzys Szczerba never expected to see the frosted cupcake breasts on Eva Nightingale's pillowed mounds of peach ice cream body. He never thought he would see his father, who was also named Andrzej, slipping down into the cold, green-black Atlantic with nothing more than a silver chain for Saint Casimir jingling upon the Quaker Oats whiteness of his still and empty chest.
And as strange and discomforting as it was to watch the headmaster from Curtis Crane Lutheran Academy pull up in freshly pressed attire and then casually step inside the Tally-Ho! with the carriage of a man entering the most familiar place on his planet, what we saw next was even stranger.
Out from the darkness in back of us, loaded down with plastic bags, bundles of clothing, suitcases, and a cardboard box lashed by three bungee cords to a broken saddlebag frame that vibrated over a half-flat back tire, a squeaking and tottering rusted old bicycle wobbled and creaked its way into the lamplight.
Hungry Jack had come to pay a visit.
Hungry Jack got around for an old guy on a crooked bicycle.
"He's a real dynamo on the two-wheeler," I observed.
"I don't think he's a Tally-Ho! kind of guy," Robby said.
"You never know," I offered.
Robby took another puff and shook his head. "You never do, Porcupine."
It was Robby who'd spoken to Hungry Jack in the past.
I was afraid of the toothless old war criminal.
Robby was much braver than I was, except when it came to shit like breaking into From Attic to Seller Consignment Store in the middle of the night.
Robby had given Hungry Jack cigarettes in the past, and, on occasion, the two of them smoked together in Grasshopper Jungle while I worked inside Johnny McKeon's store. That was how Robby found out all the history about Hungry Jack and the things he'd done in Vietnam.
"You want to know what happens?" Hungry Jack had said to Robby.
"What happens?" Robby said.
Hungry Jack said, "You could do whatever you wanted to do over there."
"What I would want to do is get on a boat and come home," Robby told him.
"No boats!" Hungry Jack jumped up and down and repeated himself, "No boats! No fucking boats home! What are you, a crybaby?"
"I suppose I am a crybaby," Robby said to him.
"You could do whatever you want," Hungry Jack said. "Any kind of drug you like. Heroin. Pot. Heroin. Heroin. You could fuck anything you wanted. All the time. Drugs and fucks. I bet you'd like to fuck anything, wouldn't you? Wouldn't you?"
"Uh," Robby told him, "I don't think I would like to fuck anything."
"Yes you would fuck anything," Hungry Jack told him.
"No I wouldn't," Robby affirmed.
"You would, too," Hungry Jack argued.
Robby told me this back-and-forth rally of counter-shot verbal tennis balls continued for several rounds.
"Well, that's what we did," Hungry Jack said. "Fucked everything. Fucked everyone who'd hold still long enough. We fucked the planet if we wanted to. And no boats! But you know what happened?"
"I suppose you cooked your brain on dope and a little while later your penis scabbed up and fell off from all the dirty shit you fucked," Robby ventured.
"As soon as one boy shoots, everyone starts shooting," Hungry Jack told Robby.
And then Hungry Jack said, "Then, it's time to come home."
Then Hungry Jack told Robby about all the people who died in the village.
Robby told me.
But I never talked to Hungry Jack before or since that day Robby told me the old man's stories.
So that night, Robby Brees and I stood there in the parking lot of the Tally-Ho!, which was Waterloo, Iowa's one and only gay bar.
I thought about fucking things.
And while I thought about fucking things, and Robby and I smoked cigarettes, we witnessed firsthand what happens to a person who swallowed a mouthful of Stanpreme pizza that had been contaminated by Contained MI Plague Strain 412E.
Here is what happened:
Hungry Jack tottered toward us. The front tire of his bicycle jerked this way and that, but somehow the man kept rolling. Hungry Jack's eyes were fixed directly on Robby and me.
When he stopped his bicycle, Hungry Jack was ten feet away from us. He stood at the edge of the dark near a low easement that separated the blacktop of the parking lot from the blacktop of the highway.
At first, the old man was motionless, straddling the top tube of the bike frame with his feet planted on either side. Hungry Jack's chin was slick with drool, but that wasn't uncommon for him.
Hungry Jack had no front teeth.
He stared at Robby. Hungry Jack knew Robby. For all I could tell, I was invisible to the man.
Robby took a big drag from his cigarette.
Robby said, "Hey, Jack. You want a cigarette?"
Jack stared and drooled.
"He's freaking out on you, Rob," I whispered. "Let's just leave."
"Maybe he's exhausted from the long ride," Robby said. Then he asked again, "Want to smoke, Jack?"
Hungry Jack wobbled. He raised his right knee and got off the bicycle.
Hungry Jack released his grasp on the handlebars and his bicycle crashed in a noisy heap. A thermos bottle with a small amount of gasoline in it rolled away toward the curb.
Robby smoked.
Hungry Jack looked at Robby. He took two steps toward us and stopped. The whole time I never saw the man blink once.
He also never said anything to Robby.
Then Hungry Jack turned around and stepped over the low hedge that bordered the parking lot. He lumbered like a sleepwalker, out onto the highway.
Hungry Jack walked directly into the path of a Dodge pickup that was speeding in the direction headed away from Ealing.
The truck never slowed, even after the concussive thud the old man's body made when Hungry Jack went spinning and cartwheeling down the road.
Things like that happened in Iowa all the time, but Robby and I never saw it right in front of our faces.
"Holy shit, Rob," I said.
Robby said, "Holy shit."
## THE THING IN THE CORNFIELD
SOMETHING ELSE HAPPENED, too.
We did not talk about it at school.
Shann wondered why Robby and I were both so sullen that next day. We told her we were tired. I asked if the noise in her wall had come back, but our unplugging the teletype machine had put an end to the typing rats problem in the McKeon House.
"What are we going to say, Rob?" I had asked him. "Are we going to tell Shann we were hanging out in the parking lot of a gay bar smoking cigarettes and we saw Pastor Roland Duff out cruising just before some homeless guy stepped in front of a Dodge truck? Are we going to tell her what happened after that?"
And Robby said, "What did happen after that, Austin? I still don't believe we saw that shit."
Because what happened was this:
We ran out onto the highway to see if we could help Hungry Jack.
It was terrible.
It took us several minutes to find him.
The truck had thrown the old man's body more than a hundred feet through the air. We found Hungry Jack lying in a field of waist-high corn on the opposite side of the highway from the Tally-Ho!
He had been knocked completely out of his shoes, and his dirty pants had been pulled down, turned entirely inside out, and twisted around his broken legs.
Hungry Jack wasn't just dead. He was destroyed.
I had never seen anyone dead before. Neither had Robby. I thought about Krzys Szczerba saying good-bye to his father on the boat in the middle of the ocean, how scared and alone he must have felt. I thought about Saint Casimir, and Pastor Roland Duff across the street from us.
"Holy shit, Rob," I said again.
I stepped closer to the mangled wreckage of the old man.
Robby said, "Don't touch him."
"He just walked right out in front of that shit," I said.
"We need to call someone," Robby said.
I took my phone out of my pocket and turned it on.
Then Hungry Jack moved his arms. His chest heaved and collapsed, and he wriggled around in the dirt between the young cornstalks that had been mowed down when he tumbled and tumbled through the field.
"Stay still!" I tried to tell him.
Robby and I stood back, afraid to get too close. From the light on my cell phone's screen I could see how there was blood all over the place. Pieces of Hungry Jack were sticking out from his belly and from the top of his head.
But the old man wheezed and writhed around in the dirt.
It looked like he was breaking apart.
He was coming apart like a soft-boiled egg oozing thick, yolky blood.
"Let's get somebody," Robby said.
My hand shook so bad I could not even punch three emergency digits on my phone. I also could not look away from the thrashing heap in the cornfield.
Hungry Jack split entirely in half, the same way you'd cleave the husk of a roasted peanut, all the way from his skull to the fork of his crotch. Then he began turning inside out.
That is exactly what happened.
It wasn't that Hungry Jack was actually turning, but something was coming out of the peanut shell of the old man's body. The thing flopped and crawled stiffly, like a newborn calf, all slick and covered with blood and slippery goo.
"Holy shit," we both said, over and over.
Robby grabbed my shoulder.
I grabbed him back.
We stood there, shaking and holding each other, and we watched as a six-legged bug the size of a small man crawled like some kind of windup mechanized toy out of the hollowed remains of Hungry Jack.
It wiped itself clean with four of its appendages, bringing its spiny hands up to its mandibles, licking itself clean and dry with crackling, smacking bug-mouth sounds.
The thing's head was triangular. It looked like a praying mantis, only it was as tall as we were.
It was identical to those things—pieces of giant bugs—Robby and I had seen floating inside sealed aquarium displays in Johnny McKeon's office two nights before.
Those things were not alive.
This one was.
And it came out of Hungry Jack's body.
The thing hissed and moved toward us. Its head pivoted and turned in a near-complete circle. It froze the point of its chin directly at Robby, looking, looking, and then it backed away.
I pulled Robby's shirt so hard, it nearly came off over the top of his head.
We took off running.
We did not look back.
# PART 3:
THE SILO
SAINT CASIMIR'S REAL name was Kazimierz.
He died very young, in his twenties.
Kazimierz refused to be married, even though his father had arranged for a princess as the boy's bride. Because of that, Kazimierz is revered for his chastity and purity. He is considered the patron saint of Poland, and also patron saint of the young.
Maybe Saint Kazimierz was considered the patron for the young because he refused to do what his father told him to do.
History shows that all teenage boys can empathize with that.
But maybe Kazimierz did not get married to the princess because he was confused about what he wanted and what was expected of him, just like me.
Among the wonders credited to Kazimierz is an account of how the young prince somehow miraculously contributed to a victory of the Polish Army over the Russians.
Apparently, the Russians masturbated excessively.
## A TOUGH DAY AT CURTIS CRANE LUTHERAN ACADEMY
HISTORY LESSON FOR the day: The more time you wait before telling somebody the truth about a secret you've been keeping, the longer your path out of the woods gets.
"What am I going to do, Ingrid?" I said.
I came straight home from school that day. I threw my Lutheran Boy patriotic candy cane outfit on the floor of my bedroom and sat down at my desk. I tried to figure things out as I drew pictures and wrote my stories, but everything only became more muddled and confused.
It had been a tough day at school.
I did not know what to say to Robby. I tried all day to come up with some coherent story to tell Shann. The story would have been an abbreviation, naturally, but I would have to go back to the moment Robby and I left her alone in the backseat of his Ford Explorer on Friday night in Grasshopper Jungle.
I would not tell her about experiments or what was, and was not, normal for teenage boys to do, according to the popular psychologist who, although a middle-aged female with cosmetic lip surgery, was a foremost authority on teenage boys. I thought about how I would describe the things Robby and I saw inside her stepfather's office, and I could only hope Shann would not ask me why I'd taken Robby down there in the first place.
Because I was not sure why Robby and I did go down there. All I knew was that I liked doing things with Robby that we were not supposed to do, normal or not.
I curled my bare toes in Ingrid's fur.
She let out a big, contented breath, like she was exhaling a billowing puff of soothing cigarette smoke.
"What am I going to say to Shann, Ingrid?"
Robby phoned after that. He asked if I was mad at him, and I told him of course not. That was a dumb thing for him to ask.
Then he said, "Okay, Porcupine. I was just scared about it since you wouldn't talk to me at school. Can you skate down to Grasshopper Jungle? I need to show you something."
I needed a cigarette, too.
So I said, "Okay, Rob. Give me fifteen minutes."
I kicked around through my scattered wardrobe.
I was running out of non-Lutheran-boy clothes.
I slipped on my basketball shorts. I closed my eyes and imagined a prayer to Saint Kazimierz to protect me against getting hit in the balls or having an erection in front of anyone. I pulled on a black Shins T-shirt, found some socks under my bed, got my skate shoes and board, and went out into the hallway.
I said to Ingrid, "Don't toast any brownies till Dad lets you out."
Ingrid made a dog sigh and put her chin down between her paws.
## BUGS DO TWO THINGS
AND ON THAT Monday night, Robby Brees and I were going to get drunk together for the first time in our lives.
We had already planned it out. I had obtained permission from my mother and father to spend the night at the Del Vista Arms Luxury Apartments and go to school with Robby in the morning.
It was not like I could back out now.
I had spent the night at the Del Vista Arms before. My father trusted Robby. Robby was never late to class at Curtis Crane Lutheran Academy. Robby never caused school-wide controversies by doing such things as reading books about Catholic boys who masturbate. Also, there was no reason for anybody to ever not trust Robby Brees.
I trusted Robby enough to stay at the Del Vista Arms.
Two of the people who lived on Robby's floor smoked meth.
The night before, on Sunday, Robby and I stood in a young cornfield and watched Hungry Jack's body split apart. We saw a bug the size of a small bear climb out of him.
The other six victims of Contained MI Plague Strain 412E had not hatched yet.
Bugs do two things.
They eat and they fuck.
Bugs are soldiers, machines, just like Hungry Jack was.
Bug One—the bug that hatched from Hungry Jack—wanted to eat and fuck. It ate most of what was left of Hungry Jack. It wanted to find Eileen Pope, Travis Pope's wife. It wanted to make more bugs with her.
Ealing, Iowa, was just like Eden Five for a new planet of horny soldiers.
Robby was already in the alley when I got to Grasshopper Jungle. He waited for me behind Tipsy Cricket Liquors. When I skated up to him, he held an unlit cigarette in his mouth.
Robby always waited for me. It made smoking better.
Louis, the cook from The Pancake House whose real name was Ah Wong Sing, had just thrown a cardboard box full of potato peelings, empty milk cartons, and eggshells into the dumpster. He spilled some peelings onto the sleeper sofa. He brushed them away with his hands.
"I wonder if he knows what pubic lice are," Robby said.
"I have seen Louis take a nap on that couch before," I said.
Louis smiled and nodded at us as he walked across the alleyway.
Louis did not speak English very well, so when Robby asked me if I wanted a fag, Louis got embarrassed. He made it obvious that he was trying not to listen to us, which made it obvious that he was listening to us.
"Hello, Louis," I said.
Robby struck a match for me and I got my cigarette going.
Louis said, "Hello, Dynamo."
Ah Wong Sing believed that Dynamo was my real name.
Louis hung out with Ollie Jungfrau. They played online alien hunter games and looked at porn together. I thought maybe if I did more shit like that with Robby it might make me feel normal and not so confused.
Louis kept smiling nervously and disappeared through the back door to The Pancake House's kitchen.
We smoked.
"You're still coming over to get drunk with me, right?" Robby said.
"I don't know about getting drunk, Rob. It's been a weird couple days. Maybe I'll just watch you do it. You know, like keep you safe and shit." I said, "Like in the sixties, guys used to do that for their buddies when they dropped acid."
"I'm not dropping acid, and I'm not going to get drunk if you don't," Robby said.
I felt guilty about my attempt to back down.
We skated through the alley without saying anything.
When we were down by the dumpster, I stopped and asked Robby what it was he wanted to show me. He carried the rolled-up front section of the Waterloo News and Gazette in his back pocket. When he unrolled it, I already had a premonition that there would be something about the accident outside Waterloo, about what had happened to Hungry Jack.
"Look at this," Robby said.
There was a photograph of Hungry Jack's dirty and laceless shoes lying beside the highway. In the grainy background, I saw the Tally-Ho! and Fire at Will's Indoor Shooting Range and Gun Shop. The photograph was like staring through a portal in time.
The short article said that a transient had been struck and killed by a motorist and there were no witnesses.
Transient is a nice way of saying homeless. Homeless makes people think of despair. It makes you think that the United States of America doesn't care about people.
Transient sounds like you have a case of wanderlust.
Wanderlust is part of the American Spirit.
The transient in the article had been carrying a military I.D. card that gave his name as Charles R. Hoofard.
Hungry Jack's real name was Charles R. Hoofard.
He was born in Indianapolis in 1950.
In 1950, Harry S. Truman was president of the United States.
Harry Truman, as far as I can tell, also never took a shit in his life.
In 1950, the same year that a boy named Charles R. Hoofard was born in Indianapolis, President Harry S. Truman sent military assistance to the French. They were trying to maintain their French Catholic colony in Vietnam. That military aid would grow and blossom to the point that a boy with wanderlust from Indiana named Charles R. Hoofard ultimately took time out from fucking whatever he wanted to fuck to participate in the killing of an entire village of women, elderly people, and children.
History is full of shit like that.
All roads intersect on pages on my desk.
All roads spring up along trails worn down by boys on bikes.
All roads lead past shooting ranges, liquor stores, and gay bars.
Wanderlust is part of the American Spirit.
The article went on to say that Charles R. Hoofard's body had been brutalized by coyotes before being discovered by a farmer Monday morning.
It asked for anyone with information to phone the Iowa State Patrol.
"Uh," I said.
I rolled the newspaper up and handed it back to Robby.
We never called anyone about what happened to Hungry Jack.
We had been uncharacteristically silent back inside Robby's Explorer in the lot outside the Tally-Ho!
Robby sped all the way home to Ealing.
We smoked and smoked.
I think Robby was crying, too.
Robby and I were in shock.
That is a poor excuse for someone who feels obligated to record history, but that's what happened.
It was our day, and you do know what I mean.
"We did see the same thing, Rob. People would think we were dropping acid," I said.
"Shit like that isn't supposed to happen," Robby said.
"But it did," I said. "Maybe we should get drunk."
Then Robby said, "That bug. It was the same thing we saw inside Johnny's office."
"Like I said. We saw the same thing, Robby."
It was getting on to evening. We decided to take Robby's car and pick up my school clothes and sleeping bag.
I always slept on the floor at Robby's apartment. If I put my ear to the floor, I sometimes could hear the meth smokers down the hall fighting with each other.
But as we were skating back through the alley, just when we came to the spot where Grant Wallace and the Hoover Boys had beaten us up three days earlier, Robby and I noticed something on the piss-covered blacktop of the alley:
GRANT WA
It was the message Robby started spelling out in the blood that dripped from his nose.
The letters gave off a pale blue glow in the dimming light of evening.
"Um," Robby said.
I said, "Yes. I see that, too, Robby."
## A GIFT FROM JOHNNY MCKEON
JOHNNY MCKEON WAS just locking up the front door of From Attic to Seller Consignment Store when Robby and I skated past.
He frowned at me, shook his head, and made a two-fingered gesture to his lips as a kind of sign language reproach about Robby and me skating around in front of his place of business with cigarettes in our mouths.
I was embarrassed.
"Sorry, Johnny," I said. I dropped my cigarette onto the blacktop.
Robby did, too.
Johnny said it was a great coincidence that I happened by, because he'd gotten something that afternoon that he meant to bring home for me. I felt guilty and scared because Johnny McKeon had never given me anything more than a paycheck and a couple free packs of cigarettes in the past. I'd never asked for anything more from Johnny McKeon, either.
"Wait up," Johnny said, and he went back inside his store.
Robby and I waited.
"I found this today in a jewelry box," Johnny said when he came back. He locked the door to the secondhand store and held out his hand to me. His hand was cupped closed, the way a kid might hold on to a bug or something.
"I thought you might get a kick out of this, Austin," Johnny said.
Robby was curious. He leaned in closer to see what Johnny McKeon was offering me. When Johnny unfolded his tentacle fingers, I saw a coiled silver chain with an oval medallion strung on its links. In the center of the pendant was the image of a man with a halo, his chin turned downward in an attitude of something that looked like modesty. The bauble was worn, but the man held what looked like a tree branch in his hand. Around the rim of the outside, in raised letters, was the inscription: SAINT KAZIMIERZ
And Johnny McKeon said, "Isn't that a kick? You were just telling me about that guy, and I never heard of him before. Ever. Isn't that a kick?"
"That's a kick, Johnny," I said.
"Anyway," Johnny said, "it's for you, Austin. What would I want with something like that, anyway?"
"I don't know," I said. "Thank you, Johnny."
Robby watched me slip the chain around my neck.
"This is the nicest thing in the world," I said.
I meant it, too.
"You're welcome," Johnny said.
It felt cool and powerful against my skin. The thought of wearing the medal under my Lutheran Boy clothes, against my naked body at Curtis Crane Lutheran Academy made me feel wicked and daring. It also made me very horny to think about breaking such a long list of theoretically unbreakable and ancient Lutheran Boy rules.
I decided I would never take it off.
"Thank you so much, Johnny," I said again. "What a kick."
"That's what I was thinking," Johnny said. "It's a real kick, ain't it?"
Johnny McKeon was in a generous mood. He offered to drive Robby and me to my house so I could pick up the clothes and things I needed to spend the night at the Del Vista Arms.
He and Robby even waited in Johnny's car while I let Ingrid out to take a shit.
I kept playing with the medallion inside my T-shirt. I pressed it against my bare chest. I took it out at least a dozen times to look at Saint Kazimierz.
It made me feel magic.
## SHANN CALLS
I IMAGINED A SILVER chain washing up on the cold shoreline in Massachusetts or Maine. Somehow the thing had slipped away from Andrzej Szczerba's body, and had been carried slowly for a century until being discovered in a tangled mass of seaweed and fishing line.
It had to come to Ealing.
It had to end up around Austin Andrzej Szerba's neck.
I sat in the front seat and Johnny McKeon drove us to the Del Vista Arms from my house. Shann called when we were about halfway there.
"I found something out," Shann said.
"What?" I wondered.
There were an awful lot of things I thought Shann might be talking about, but none of them was correct.
"I found the silo," she said.
"Uh," I said.
There were also an awful lot of silos in Iowa. I did not know what Shann was talking about.
"You know," she went on, "the message from the machine in the wall? Well, today after school I went down to City Hall and looked up the Ealing Registry of Historical Homes."
"You did? They actually have that?" I asked.
Now there was a book that could have absolutely everything about its subject fully contained within its bindings.
"I saw photos of my house. Old ones. There used to be a silo on the property. I found the silo," she said.
But there was no silo on the property now.
I pointed that out to Shann.
Shann said, "We have to go look, Austin."
"But it's dark and shit," I said. "Do you think someone is hiding the McKeon silo?"
You can't hide a silo in Iowa.
The best you could do is maybe disguise it to look like someone else's silo, or maybe something like a penis.
People in Iowa were generally too reserved for such antics.
"No," Shann chided. "I don't think someone's hiding our silo. But there was one here at one time."
"Uh," I said.
"Tomorrow. After school. You, Robby, and me. We'll go see if there's anything left of it. I have a copy of the picture."
"Uh," I said again. I glanced back at Robby.
Shann knew we were going to get drunk. We told her. She didn't approve of it. What can you do?
Somewhere, there was a middle-aged, nice-looking woman psychologist with voluptuous, artificially induced lips who, as a foremost expert on teenage boys, could serenely explain to Shann that boys sometimes need to be boys and do dumb things that can get boys in lots and lots of trouble and shit like that.
But Shann did not watch much television.
"Okay, Shann," I said. "I think we can do that. Maybe there is something there, after all."
"I just know we're going to find some other weird stuff that Grady McKeon was doing here," Shann said.
I agreed, and said, "There's probably more than anyone will ever know."
Then Shann said, "I love you, Austin."
I looked at Robby in the backseat, then at Johnny behind the wheel, and I said, "Um. Me too, Shann."
In my defense, and with plenty of history to back me up, it was a perfectly acceptable response considering the environmental realities I had to contend with.
Shann certainly understood the translation: I am sitting next to your stepfather and my best friend.
You know what I mean.
## MY MOM'S LITTLE BLUE KAYAKS
I HAD TWO of my mother's little blue kayaks.
They were hidden inside a matching pair of clean gray Curtis Crane Lutheran Academy regular boys' socks I brought with me to Robby's apartment for school the next day.
Robby did not know I had them.
I unrolled my sleeping bag on the floor in Robby's room and left my stack of Lutheran Boy clothes on top of his dresser. Robby brought in a bottle of wine he'd hidden in the back of his refrigerator.
His mother never knew anything about it.
The bottle was so cold the glass fogged and dripped.
Then I showed Robby the Xanax pills I'd stolen. He was not happy about what I did.
Robby said, "I'd never take one of those, Porcupine."
"Uh," I said. "Why not? Everyone else does."
History lesson for the early evening: When a teenage boy says everyone else does, he's usually not being mathematically precise. Robby knew that. We spoke the same language.
Robby said, "I just don't want to ever do shit like that."
I came to my own defense, rationalizing, "I always thought they'd make me feel better."
"Better than what?" Robby asked.
"I don't know," I said. "Better than shitty and scared all the time."
"Don't be dumb, Austin," Robby said.
Robby unscrewed the cap on the wine. I watched him swallow. He liked it.
"Well, I'm taking one anyway," I said.
"Go ahead," Robby said.
Robby would not take one. He looked unhappy when I put the tiny blue pill on my tongue. But it was something I always wondered about. I hoped my mother's little kayak would help me figure things out.
Get things to fall right into place.
I washed it down with some wine.
The wine tasted sweet, and it burned at the same time.
Robby kept the grimacing lemur mask and the plastic yard flamingo in his bedroom. I tried the lemur mask on. It did make my face stink, and the lenses in the eyes made everything look strange. There was some kind of refractive prism on the lenses of the mask that made Robby look blue. I took it off.
"Yes," I confirmed, "now my face really does stink."
"I told you," Robby said. "Did that Xanax do anything to you?"
"Uh. I don't think so," I said. "But it's only been a minute."
I picked up the flamingo. I shook it.
"What are you doing?" Robby said.
"Shaking the plastic lawn flamingo," I explained.
"Why?" Robby asked.
"I want to see if candy will come out of its ass," I answered.
Maybe I was starting to feel different.
We shared more wine. We drank straight from the bottle. I was kind of messy. The wine ran down my neck. It baptized Saint Kazimierz. But it also made my face not stink so bad.
"Maybe the message was about this flamingo," I said.
I was somewhat impressed by my brilliance.
"Uh," Robby said.
Robby wasn't really paying attention. He opened up his record player and was flipping through a bookcase of vinyl LPs that used to belong to his dad.
"Yeah," I went on, "maybe it's like a smoke detector for that shit in the globe Tyler dropped. McKeon Industries did used to make Pulse-O-Matic® brand smoke detectors."
"I think you're high, Porcupine," Robby said.
He shook his head and carefully grooved the stylus onto the edge of the spinning record.
I don't know exactly what the Xanax did to me. All I can remember is how relaxed and not-uptight I felt. I did not care about anything.
Everything was nice, very nice.
As I sat there on the corner of Robby's bed, I was aware that nothing at all mattered anymore, and I wasn't confused about feeling happy.
I was floating away.
We finally could forget about everything.
Robby played a crackling vinyl recording of Exile on Main Street, and we got drunk on screw-top wine and smoked cigarettes and took off our T-shirts.
I opened my notebook and drew sketches of Robby as he reclined, bare chested, on the floor in the slate-colored streetlight that came through the apartment's open window.
It was warm, and outside the sound of insects in the night was electric.
The music sounded better than anything I'd ever heard.
I had never been so happy in my life.
I played with the little silver medal against my bare chest.
I wrote poetry while we sat there like that in the dark and talked about our favorite poems and books and laughed and smoked.
And Mick Jagger sang to us:
Tryin' to stop the waves behind your eyeballs,
Drop your reds, drop your greens and blues.
## PAGES FROM HISTORY
IN THE MORNING, Robby's alarm clock buzzed like an air-raid warning.
We had to get up to go to school.
When I opened my eyes, I was lying next to Robby on his bed. My arm stretched across the space between us, and my open hand lay flat in the middle of Robby's chest. I had my legs pressed up against his leg. One of my feet was completely underneath Robby's calf.
The covers of Robby's bed had been thrown down on the floor around his footboard, and we were sprawled out on top of the bottom sheet.
At that moment, all I had on were some boxers, my left sock, and the silver chain Johnny McKeon gave me with Saint Kazimierz on it around my neck.
I sat up, still drunk and woozy from the pill.
I felt drained and rushed, like my brain had just flushed itself down the toilet of my throat.
I was vaguely aware that Robby sat up in the bed. He turned off his alarm and watched me while I rolled my legs over the edge of his bed. It was all I could do to will myself not to vomit until I staggered and tripped in my drooping boxers out of Robby's bedroom.
I needed to find the toilet.
Robby's favorite poem is Dulce Et Decorum Est by Wilfred Owen. It is a poem about war and lies, youth and thievery.
It begins:
Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge.
Robby has very good taste for words.
My favorite poem is The Emperor of Ice-Cream by Wallace Stevens. It is a poem about everything else: sex, lust, pleasure, loneliness, and death.
It begins:
Call the roller of big cigars,
The muscular one, and bid him whip
In kitchen cups concupiscent curds.
Robby recited his poem from memory that night, and I fumbled over some of the last lines in my poem, but finally got it right.
They were both so beautiful, and their sound, as we said them to each other above the music, made our chests fill up with something electric and buzzing, like love and magic.
When I finished throwing up, I flushed the toilet and turned on Robby's shower.
I dropped my orphaned sock and Iowa plaid boxers onto the floor below the sink. I climbed into the tub and got under the water.
It was cold, and there was a grimy ring of brown that had accumulated around the bottom of Robby's bathtub. The apartment had only the one bathroom. It was right in the middle of a T-shaped hallway that separated Robby's bedroom from his mother's.
Connie Brees was not home from work yet.
I put my face under the water. I felt terrible. My eyes blurred and I fingered the medal of Saint Kazimierz and looked at his modest eyes and little upside-down halo. I put the thing in my mouth.
I heard the bathroom door open.
Robby said, "Austin? Are you okay, Austin?"
"I'm okay," I said. There was an edge in my voice.
And I said, "Can you just let me have five minutes, Robby? Okay?"
Robby said, "Sure. I brought your school clothes in for you."
Robby was sad because I was being an asshole.
I did not want to go to school.
I never wanted to get out of that dirty shower.
I did not want to look at Robby Brees.
I said, "Okay. Thank you."
But I said it in such a tone that it meant: Get out of here and leave me alone.
At exactly that moment, Shann was eating a toasted bagel and looking at a black-and-white photograph of the McKeon House.
And while I was standing under the shower in Robby's apartment, Travis Pope passed out behind the wheel of his Nissan truck and crashed into a shallow drainage ditch on the practice fields at Herbert Hoover High School. His wife, Eileen, was sitting beside him. She was not wearing her seat belt. They were hatching.
Someone down the hall from Robby's apartment at the Del Vista Arms was holding a torch lighter below a glass pipe and cooking methamphetamine smoke into his face.
Ollie Jungfrau was finally taking a shit. He was going to be late for work.
Johnny McKeon was driving to the Ealing Mall. He was in a good mood. Johnny was always in a good mood.
Ah Wong Sing was looking at video from a porn site in the Netherlands. He was going to be late for work.
I was combing Robby's conditioner with my fingers through my hair. It smelled like bubble gum.
My brother, Eric Christopher Szerba, was on his way to a hospital in Germany. He had lost both of his testicles and his right leg from the knee down. Two other boys died in the same explosion. We would not learn this until the following day.
Robby Brees was in his underwear, sitting on his bed. He put his face into his palms and cried.
## SCHOOL PRAYERS
EVERYTHING FELL INTO place, all right.
But things dropped so hard the entire world broke.
I learned this:
My mother's little blue kayaks were perfectly seaworthy. Her Xanax did make me feel not stressed out. They took away my confusion and worry. They made me believe that I only had one head on my shoulders, and that head had everything all figured out. Everything is nicely, sweetly normal when you are floating on the kayak.
But I would need to take them forever if I wanted things to stay that way.
There was one Xanax left.
It was inside the matching, clean gray Curtis Crane Lutheran Academy regular boys' socks Robby carried into the bathroom for me while I was under the shower.
I flushed it down the toilet with the last of my vomit.
While Robby showered, I quietly left his apartment at the Del Vista Arms. I counted three yellow Pay or Quit notices taped to doors on Robby's floor. I walked to Curtis Crane Lutheran Academy alone.
I was not late to class.
I did not say anything to Robby.
Every morning began with a prayer. Robby came in to class. He was almost tardy for the first time in his life. He was flustered and his cheeks were red. Robby's tie was crooked and his shirttail hung down in back of his sweater like he'd been running. He'd obviously been looking for me. Robby would have to fix his appearance or Pastor Roland Duff would call him in for counseling about proper grooming for Lutheran boys.
I prayed with the other students in the classroom, but I only thought about Robby Brees and the chain around my neck.
I did not talk to Robby for days after that.
I needed to talk to my father.
I did not have any idea what I would say.
I told Shann I was sick.
She thought it was from drinking wine with Robby the night before. That may have been true. I had no way of figuring out if anything was true or not true on that Tuesday after I spent the night with Robby.
So I told her we would have to go searching for her invisible silo after school on Wednesday. I needed to go home and let Ingrid out and then go to bed and shit like that, I told her. Shann understood.
It was already getting too late to do anything about the entire world falling off the cliff that opened at our feet in Grasshopper Jungle. All I could think about was how the pull of gravity was screwing with one particular Polish kid from Ealing, Iowa.
Shann said, "I think you're both hung over. Robby looks sicker than you."
"Uh," I said.
"I hope this teaches you something," Shann scolded.
"So do I," I said.
"Tell Robby to come over tomorrow," Shann said.
"Uh. Robby can do whatever he wants."
Shann and I walked out of Curtis Crane Lutheran Academy at the end of the day. Robby had already gone home without saying anything to either one of us.
"What's the matter with you?" she asked.
"I'm not sure," I said.
It was the truth.
Shann repeated her history lesson for the day: "I hope you learned your lesson, is all I can say."
"I'm sorry, Shann," I said. Then I added, "I love you, Shann."
Shann looked around to see if anyone was paying attention to us.
We were alone.
She pressed up against me. It was a very daring move for a pair of Lutheran kids in eyeshot of the front doors of Curtis Crane.
For some reason, the medallion of Saint Kazimierz seemed to get heavy and burn against my bare chest. And I thought about Robby again.
Shann whispered, "I love you, Austin."
I rubbed my hips into her. I had to say it: "Shann, do you think . . . Um. Maybe . . . if I got some condoms . . ."
She cut me off. "No! Go home, Austin Szerba. You're sick. You're not even thinking like a normal boy."
I thought that was what normal boys did think about.
I tried to prove something, but my experiment failed.
"Sorry, Shann. Um. Are you sure?"
She said, "Can you for one moment stop being silly, Austin?"
She said moment again. I was horny, and scared, and so confused about everything.
"I will," I said. "I need to go lie down. I'm sorry."
I was not thinking like a normal boy.
What was I going to do?
## THE VICE PRESIDENT'S BALLS
SOME NIGHTS MY mother stayed at work at the Hy-Vee until late, so my dad and I would have to prepare dinner for ourselves.
There was once a time when it was against the law in Iowa for women to allow boys and dads to cook dinner for themselves.
Now, kids like Robby Brees and me often had to survive on our wits and by eating shit like Cup-O-Noodles and Doritos.
Most of all, I wanted to go to bed and mope, but that evening I cooked fish sticks and frozen french fries for my dad. I waited for him to come home from school, so we could talk.
The fish in the sticks claimed to come from Alaska.
The fries were not from France. The package said they were grown in Oregon and Idaho.
If there's one thing America can do well, it's freeze shit.
I waited.
I was nearly asleep with my head on the table when my father came in.
"You stayed up too late with Robby last night, didn't you?" my father, whose name was Eric, said.
"Uh," I answered. I picked my head up and rubbed my eyes.
I was still wearing my Lutheran Boy tie and sweater.
For the first time I realized I'd left my sleeping bag, underwear, socks, toothbrush, sneakers, and cell phone in Robby's bedroom. At least I had the foresight to stuff my history notebooks into my Lutheran Boy school backpack.
"Yes," I said. "I think I'm not feeling well, Dad."
My father sat at the table and began eating. I got up and went to the refrigerator and took out a bottle of ketchup. My dad was a ketchup man. Not me.
The ketchup was made in Nebraska.
So they do something there, after all.
I watched him.
He ate.
I was getting ready to say something. I just needed to know what words to start with.
My dad said, "Is something wrong, Austin?"
"Uh," I said. I was determined to do it. So I said, "Dad, when you were about my age . . . Did you ever . . . Um . . . experience a . . . I mean, did you ever get a . . . have guy friends who you . . . Um . . . did you ever experiment with another . . . Um . . ."
It was a mess.
That is exactly how it came out.
My father stopped chewing. Fish sticks are not things that require any degree of jaw strength.
I wished my brother, Eric, was still at home.
He had been gone so long that it was as though I were an only child. Having a brother there would help. Eric was someone I could have talked to about things like erections and sex and making mistakes and accidental spills and being confused and all that kind of shit.
At exactly that moment, Eric Christopher Szerba was in a morphine-induced coma.
As I sat there nervously watching my father, there was a small earthquake in Guatemala. Robert Brees Sr. was sleeping naked in a queen-sized bed with his new Guatemalan wife. Her name was Greta. Robert Brees Sr.'s two-year-old son, whose name was Hector, was lying on Robert's chest. In the sky above them, hot ash from a volcano named Huacamochtli began billowing soundlessly into the atmosphere.
And at that precise moment, there were three bugs in Ealing, Iowa: Hungry Jack, Travis Pope, and Travis's wife, Eileen. They all wanted to do only two things.
The four Hoover Boys had not yet hatched. They were sick. Young people don't break down as fast.
Robby Brees was lying in his bed at the Del Vista Arms Luxury Apartments. He was wearing my T-shirt and the boxers that I'd taken off and dropped on his bathroom floor. Robby was listening to the Rolling Stones.
Shann Collins was writing in a diary she kept locked in the nightstand beside her bed. She theorized how she might get away with her wish to have sex with her boyfriend, who sensitively promised her he would use a condom.
When my father and mother did learn about what happened to Eric, they left Iowa and flew to the military hospital in Germany where my brother was undergoing treatment. At first, they tried to arrange for me to stay at the Del Vista Arms with Robby and his mother. I begged them to leave me home alone because I was old enough, and somebody needed to let Ingrid out to shit, after all.
It was really only that I was afraid to face Robby Brees. I knew I would have to face him eventually, but I did not want to do it yet.
My parents would not take me with them.
They said I should stay in school, and they would call me twice per day.
When Eric Christopher Szerba was recovering from his wounds, the vice president of the United States of America came to the hospital and visited him.
The vice president was from Delaware.
I never knew anyone who'd even been to Delaware.
The vice president of the United States of America took a shit that day in the men's toilet of the cafeteria at the military hospital before visiting my brother's room. The vice president of the United States of America had two testicles that he liked very much, and neither one of his legs had been blown off.
When the vice president of the United States of America was a teenager, he also experimented.
My father stopped chewing and stared at me. I could see in his eyes that he knew exactly what I was trying to talk about. There is a certain dark and faraway look that fathers get in their eyes when their sons uncomfortably venture toward asking them questions about their penises and shit like that.
I could see that look right away.
"Um," he said. "You mean, like in chemistry class?"
"Uh," I said.
For the last few days in chemistry class at Curtis Crane Lutheran Academy, we had been making a slippery, gooey, milky white polymer from borax and some other shit.
A polymer is something that is heavy and thick, made up of lots of small molecules. The word polymer came from Greece.
The Greeks were good at making up words for shit.
Robby Brees was my partner in the lab.
Robby said the polymer we made in chemistry class looked and felt exactly like sperm. Everyone else in the class also thought it was exactly like sperm.
Actually, not everyone. Only the physically and spiritually weak boys who masturbated thought our polymer looked and felt exactly like sperm. That was every boy in the class, considering we were all in tenth grade and fifteen or sixteen years old, which made all us boys physically and spiritually weak masturbators who could never be relied on to effectively defend the United States against foreign invasions. Only a couple of the girls thought our borax polymer looked and felt exactly like sperm.
Shann did. But she sat beside me during the awkward eruption at Eden Five Needs You 4.
Mr. Duane Coventry, our chemistry teacher, got mad and embarrassed by the behavior of the boys in the class. He obviously thought the stuff was exactly like sperm, too. So Mr. Duane Coventry brought in small vials of blue food coloring and made us tint our borax-polymer sperm experiments, so they wouldn't look so much like sperm.
"Yeah, Dad. In chemistry," I said.
"I once made a battery with a lemon," my father said.
"Uh. I did that, too, Dad," I said. "Everyone does that shit when they're kids."
My father swabbed his Alaska fish stick through his puddle of Nebraska ketchup.
"Yes, Austin," he said. "I did do experiments when I was your age."
He said it with finality and relief.
That was the end of the history lesson about my dad and what he did when he was a teenager.
"Uh. Thanks, Dad. Well, good night."
"Good night, son," my father said.
I went to bed.
I realized that was the last time in my life I would ever attempt to speak to my father about sperm, or about my sexual curiosity and confused feelings. I'd be just as well served watching daytime television programs for women, or speaking to Ollie Jungfrau about those kinds of things. Or to any complete stranger sitting on a bus bench, for that matter.
In the morning chaos before school, my parents were up and speaking with two liaison officers in the kitchen when I came downstairs. That was the day they left Ealing to go to Germany and see my brother, Eric, who no longer had any balls. My mother and father both agreed it would be all right if I stayed in bed that day.
So I did not go to school.
## MODERN-DAY NIGHTINGALES
KRZYS SZCZERBA STARTED a factory in Minnesota.
He manufactured urinals.
There is something grandly American in the story.
Krzys Szczerba came to America and earned a living by making things for guys to piss on. The urinals he made were big. They were shoulder height, spanning entire walls with thick porcelain backs and drainage gutters all along the floor where you would carefully distance the toes of your shoes.
Americans like big things to piss on.
In those days, guys didn't feel the need for seclusion or personal space when they pissed. American men and boys lined up shoulder to shoulder and unashamedly pissed like a choreographed army on everything in front of them.
That was our day.
Krzys Szczerba's urinals were big enough so a dozen or more guys could all piss on the same wall together, all at the same time.
We had a similarly designed group urinal at Curtis Crane Lutheran Academy. It was the one with images of disembodied praying hands hanging above it at eye level to remind us boys not to get any experimental ideas with our hands while they were holding our penises.
But the urinal at Curtis Crane Lutheran Academy was stainless steel and shaped like a knee-high watering trough for livestock. The urinal chimed a musical song whenever boys would piss down onto its flat metal bottom. And only four boys at a time could use it. More than that, and there would be some uneasy trespassing into your neighbor's personal space.
We kept our eyes on the praying hands.
Besides freezing shit and making it food, pissing on things was something American boys have always been real dynamos at.
Krzys Szczerba called his urinals Nightingales, after his wife, Eva Nightingale, who, like the urinals Krzys made, was big, accommodating, and perfectly white.
There were birds with ribbons streaming from their happy beaks etched along the top rail of Krzys Szczerba's Nightingale urinals.
It was a good name for a urinal, I thought.
Krzys Szczerba's urinal factory went out of business during the Great Depression.
During the Great Depression, I think American boys pretty much pissed wherever they wanted to.
There was also a stainless steel trough urinal at Satan's Pizza, but it was only wide enough for two guys to use at once. It was extremely awkward, being paired up with a complete stranger like that at a pizza place.
It was like being on a blind date.
Worse yet would be if I was standing there peeing, and then one other guy would come into the men's room and stand beside me, unzip, and when I glanced over, it would be Louis, the cook from The Pancake House, or maybe Ollie Jungfrau or Pastor Roland Duff.
I always tried to hold my pee whenever I ate at Satan's Pizza.
Sometimes, a guy just can't, though.
There were old color photographs of Italy that hung behind glass-faced frames above the urinal at Satan's Pizza. One of them showed the Coliseum in Rome, and the other showed Michelangelo's statue of David.
You know what I mean.
What guy doesn't like to think about Italy and civilization and shit like that when he is holding his penis and pissing into a steel trough?
I am the great-great-grandson of Krzys Szczerba, a man who made things for other guys to piss on.
My brother, Eric Christopher Szerba, got pissed on, too.
In a way, Krzys Szczerba made me and my brother. When you think about it, Krzys Szczerba's factory was still in full operation, and we were his modern-day Nightingales.
Everyone at Curtis Crane Lutheran Academy heard about what happened to Mr. Szerba's son, Eric Szerba, who was in Afghanistan.
Robby did not go to school that day, either.
There was something wrong with both of us, but it was not something like what was happening to those Hoover Boys, although there was equally little Robby Brees or I could do about it.
## SHANN, THE HORNY POLISH KID, AND SATAN
JOHNNY MCKEON CAME over to my house that afternoon. He said he wanted to check on me and see if I needed anything. There were lots of things I needed, but Johnny couldn't give any of them to me.
I certainly couldn't talk to Johnny McKeon about my confusion, or about what was happening between me and Robby; and between me and Shann.
"I came to see if you needed anything," Johnny said when I opened the front door. He added, "You know, if I could do anything for you, Austin."
I was still in my boxers. I had not gotten out of bed all day. Ingrid squeezed between my legs and wriggled past Johnny out into the yard. The poor dog was about to explode.
I combed my fingers through my messed-up hair. I said, "Thanks, Johnny. I think I'm okay. I could use a cigarette, I think."
"I brought some for you." Johnny said, "They're in my car. Hang on."
"Watch out for dog shit, Johnny," I said. "And, thank you."
"If your mom or dad says anything about this, I'm telling them you stole them."
Johnny always said that.
So Johnny McKeon stayed there with me on my front porch while I smoked a cigarette and talked to him. I'd forgotten all about my plan to look for the missing invisible McKeon silo with Shann. Everything had been such a nightmarish blur since Robby Brees and I had gotten beaten up for being queers by those four assholes in the alley at Grasshopper Jungle.
It was like swimming through a big bowl of alphabet soup, where all the letters are alive and flash little dancing horror shows for you: grimacing lemurs, two-headed baby boys, accidental eruptions at the Waterloo Cinezaar, little blue kayaks, enormous green praying mantises, praying hands, the Tally-Ho!, my pissed-on brother, Eric Christopher Szerba, and my best friend, Robert Brees Jr., whom I loved very much and felt a terrible sadness for at the same time.
"You're a good dog, Ingrid," I said.
Ingrid lay beneath my bare feet and I sat on a wicker chair in my boxers and smoked a cigarette with Johnny McKeon in front of my house.
At that moment, my parents were on an airplane flying over Scotland.
"Why don't you put some clothes on and I'll take you and Shann out and get you pizza or something?" Johnny McKeon asked.
"You mean you don't want to just take me to dinner in my underwear, Johnny?" I said.
Johnny shook his head gravely. For someone who was always in a good mood, Johnny McKeon never really knew when people were joking around with him.
"No, kid," he said. "Put some trousers and a shirt on or I ain't taking you anywhere."
I waggled my Saint Kazimierz medal at Johnny and told him thanks, but I hoped he wasn't planning on sitting in the middle, considering he was going to be chauffeuring his stepdaughter and me out on another date.
He didn't get that, either.
Johnny said, "I'll drop you two off, and come pick you up. But in Ealing, not Waterloo. Now go put some britches on, Austin."
I found some 501s that weren't too dirty. They were lying on my bedroom floor. I slipped into Robby's Spam T-shirt. He'd left it there at my house the day we went up on the roof of the Ealing Mall. It still had a few faded bloodstains and it smelled like Robby, which kind of made me a little sad. I didn't bother putting on any socks. I got the Adidas I'd loaned to Robby a few days earlier and slipped them on.
It made me feel lonely to wear Robby's shirt.
I went to pee in the men's room at Satan's Pizza before our Stanpreme arrived at the table. It was taking a chance because the pizza place was unusually busy for a Wednesday evening.
Nobody came in to share the trough with me and the photos of Rome and naked David.
I sat beside Shann and we looked out the window, across Kimber Drive to Grasshopper Jungle, the Ealing Mall.
We talked.
At first it was almost as uncomfortable as standing next to Ollie Jungfrau at the little trough urinal in the back of Satan's Pizza. I kept thinking about Robby. I felt so guilty about the things we did.
I do not lie, but I did not want to tell Shann about Robby, and I did not want to tell Robby about Shann, either.
So I sat there and thought about how I was ripping my own heart in half, ghettoizing it like Warsaw during the Second World War—this area for Shann; the other area for queer kids only—and wondering how it was possible to be sexually attracted and in love with my best friend, a boy, and my other best friend, a girl—two completely different people, at the same time.
I was so confused.
There had to be something wrong with me. I envied Shann and Robby both so much for being confident in who they were and what they felt, and for knowing what part of my ghettoized heart they lived in.
Eventually, Shann worked up the courage to talk to me about Eric.
We were eating our pizza by that time, and I had pushed all those thoughts about my brother into a dark place in my head. The pissed-on Polish boys' ghetto. Now a light shined on them.
So I told her this:
Eric Christopher Szerba and I got pissed on. I could not remember any image of my brother where we were not boys together. Eric Christopher Szerba was still a boy. Eric Christopher Szerba was my big brother. Now he was ruined, destroyed. He would be somebody else the next time we talked. It would be awkward, like peeing next to a stranger. We got pissed on, Eric and me. Everyone did. Nobody was better off anywhere. Nobody learned a lesson. Nobody got saved.
I could not eat any more pizza after that.
I think I might have been crying.
I have to be honest. This is history. I was crying while I sat there at Satan's Pizza, looking out the window at Grasshopper Jungle. I was crying, and it wasn't only for Eric Christopher Szerba. It was for Robby Brees, my mother, my father, Robby's mother, Krzys Szczerba, and for Saint Kazimierz, too.
Shann was crying. She put her face against my neck.
Shann said, "I've always been in love with you for how you say things, Austin. Ever since that day in eighth grade when we sat together and had Cokes and talked about The Chocolate War. Do you remember that?"
"Yes," I said. "It's that book about the peacock who shits gumballs and Sugar Babies out of its ass, right?"
Shann laughed a little and we kissed.
And I told her: "Shann, sometimes I do really dumb things and I don't think about the people I might be hurting. I want you to know that I love you, no matter how dumb I am. No matter what I do."
I was trying to tell her the truth—my abbreviated truth—about me and Robby. Shann thought I was talking about the day before, at school, when I attempted to start a conversation involving the use of condoms.
Shann said, "You are not dumb, Austin. I love you very much. I was thinking about what you said, about . . . Um. You know. If you used a condom."
I nearly fell off the bench at Satan's Pizza when she said that.
I said, "You mean you would?"
I tried to devise a means of getting Shann Collins over to my empty house that night.
"Maybe we could try to do that sometime. When the time is right," Shann said.
I thought the time was right.
Hearing her say the words do that made me very horny.
Shann tried changing the subject. She placed her purse on the table beside the remains of our Stanpreme. When she opened the purse, I hoped she was going to show me how she'd brought along a pack of condoms or shit like that. Not that I needed any. I had dozens of condoms from cleaning out the furniture for Johnny McKeon at From Attic to Seller Consignment Store.
I fought with myself.
There was rioting in the ghetto.
That is the truth.
I was being such an asshole to my two best friends.
I decided to shut up. Like Shann told me, she'd let me know when the time was right to try to do that, and that was much closer to a yes than a no.
Eden Five needed me.
Maybe I could prove something to myself, eventually, and watch how everything might fall perfectly into place for me.
Shann pulled a small black-and-white photograph out from her purse. It was the picture she'd gotten from the Ealing Registry of Historic Homes.
And, yes, I was disappointed, and very horny, too.
## FOUR PHOTOGRAPHS
Here, our history looks at four photographs:
1. THIS IS THE MCKEON SILO.
In grainy black and white it looks like a galvanized steel penis with Saturn booster rockets, sitting on a launch pad a quarter mile behind Shann's historic home, preparing to blast off for Eden Five.
"I found it," Shann said.
2. THIS IS A PHOTOGRAPH OF ME AND MY BROTHER, ERIC Christopher Szerba. The picture was taken when Eric was twelve years old. That would make me about five or six. In the picture, we are standing on the shore of Lake Minnewonka, in Canada. The sun is setting into our eyes. Our mother, Connie Szerba, was morbidly obsessed with having the sun shine in our white Polish faces whenever we posed for pictures.
In the photograph, my hair is messy, sticking up unevenly. It is also much lighter in color than my hair is now. I am wearing Velcro-laced Teenage Mutant Ninja Turtles sneakers. They had lights along their soles and flashed when I walked. I loved those shoes.
Eric is tall and skinny. He wears a red plaid shirt, untucked, an Iowa boy after all. Eric also has on brand-new cuffed Levis. I can almost feel their stiffness in the photograph. His legs are like matchsticks in them. The jeans have not been washed yet. Eric Christopher Szerba has his arm around my shoulder, but the way he is standing is not the uncomfortable posture of a boy about to turn teenager who is coerced into hugging his little brother to falsely freeze a peaceful moment for a family snapshot while on vacation.
Both of us have those Polish Boy bags under our eyes.
Eric is very handsome. His hair is the color of maple syrup and he has a spray of freckles on his cheeks. The way he smiles, you can see his two big front teeth. His lips are wet. The shadow of my father stretches all the way past our ankles. You can see, in silhouette on the ground, how my father's elbows point out like wings on a nightingale where he holds the camera up to his eyes.
3. NEITHER OF THE OTHER BOYS killed in the same explosion that removed both of Eric Christopher Szerba's balls and one of his legs were younger than my brother. But they were boys, too. Julio Arguelles was thirty-four years old. There is a snapshot of him that was taken when he was six years old. He grew up in Brooklyn, and in the photograph he is standing in the driveway beside his family's home. There is a low redbrick wall at the end of the driveway. On the other side of the wall, you can see the white T of a wood-framed laundry post sticking up. There are some white T-shirts and underwear hanging from the clotheslines. It appears there is no wind blowing. Julio is wearing a Superman T-shirt with a red-rimmed collar, the triangular S, and there are fierce abdominal muscles drawn onto the fabric that loosely drapes over Julio's six-year-old chest. At the very bottom of the T-shirt is a band of yellow—Superman's belt—and the red swath that marks the upper waist of his briefs. It is a funny shirt. I would have worn it when I was a kid. Julio Arguelles's dark chocolate hair sweeps down over his forehead, and Julio is holding up a hand in a permanent Number One gesture. I can't guess what question Julio was answering when that photograph was taken. Julio Arguelles has a faint orange Kool-Aid mustache. He is wearing blue sweat pants, but the legs are pulled up to his knees. He has black sneakers and no socks. Julio Arguelles had three daughters. The oldest of his girls was nine.
4. PAAVI SEPPANEN'S FAMILY came from Finland. Paavi means small. Paavi also died in the explosion that took my brother's right leg below his knee and obliterated both of Eric Christopher Szerba's testicles. Paavi Seppanen was twenty-six years old when he died in Afghanistan. There is a photograph of Paavi that was taken at Easter when Paavi Seppanen was ten years old. Paavi has airy, thin red-blond hair the color of clover honey. He is wearing a collared, white long-sleeve shirt that is tucked into belted black slacks. He has a black clip-on necktie and is standing between his younger brother and sister. He looks like their protector. You can see they believe that about Paavi. Paavi has his arms around his brother and sister and they are all smiling. The younger boy and girl are holding empty woven baskets in their hands. The egg hunt has not started yet. The girl is maybe three in the photograph, and Paavi's younger brother is wearing gray pants, a necktie, and suspenders. Paavi was homosexual. Nobody knew anything about it.
## THE PRESIDENT'S SPERM
"I FOUND IT," Shann said.
"It's difficult to miss, I suppose," I agreed. "Maybe it's painted like the sky, instead of a penis, and so we just don't notice it nowadays."
Shann bumped me with her shoulder.
Johnny McKeon could not tell when people were messing around with him, but his stepdaughter could.
"I mean, I really found it," Shann insisted. "I hiked out along the old service roads. There are some broken-down henhouses there and old troughs for the milk cows."
"Maybe those are urinals," I offered.
"Be serious," Shann said.
"Uh. Okay." I decided to be serious.
Shann said, "I found the old foundation to the silo. It's concrete, and there's a circular hatch in the middle of it. It looks like something you'd climb through to get into a diving bell or something."
"Uh," I said. "Nobody uses diving bells in Iowa. It's not natural. Besides, there's nothing to see beneath the surface of Iowa."
"I couldn't open it," Shann said.
"You tried?" I was impressed.
"Well . . . no. I was actually afraid to do it alone," Shann admitted.
"That was probably wise of you, Shann. There could be lost Russian sailors down there," I offered. "They would be very horny if they'd been down there ever since Iowa was last covered by a vast sea. Or maybe it's full of the president's sperm."
That made Shann laugh.
I was horny.
I felt like I scored points toward getting her to come over to my lonely house with me. I desperately wanted her to, but I was not going to ask her to please do that. Johnny would probably say no, anyway, in spite of the condoms.
But Johnny McKeon waited in his car and pretended not to watch us when Shann walked me to my front door and we kissed good night.
## THE VIRGIN SAINT AND HIS WARD
I WROTE.
At the bottom of the first page, I penciled in a picture of a big galvanized steel silo that towered in the distance behind the McKeon House, which was Ealing, Iowa's solitary listing on the Registry of Historic Homes.
Ingrid squirmed beneath my bare feet. She perked her ears up. If she hadn't been stricken by cancer when she was a puppy, she may have barked. She looked like she wanted to bark. So I thought maybe she wanted to bark at me because she needed to shit, which was the most predictable quality Ingrid possessed.
She was a quiet fountain of shit and reliability.
Outside, in the distance, a police siren wailed like a plaintive coyote.
We never heard sirens in Ealing. It's not that bad things never happened here, it's just that nobody ever bothered to complain about it when they did.
A few miles away from my house, Ollie Jungfrau was locking up Tipsy Cricket Liquors. He had called the Iowa State Patrol, reporting that some kind of wild animal had attacked Wayne DeLong in the parking lot after Wayne left Tipsy Cricket Liquors. Wayne was carrying a paper sack with a bottle of El Capitan Vodka and a twelve-pack of Dura-Flex Extra-Sensitive Condoms.
The wild animal that attacked Wayne DeLong was Hungry Jack.
Wayne's friends called him Wayne-O. Wayne-O was a pilot. He didn't drink too much on nights before he flew, he said. He was supposed to fly a commuter plane from Cedar Rapids to Omaha in six hours.
Wayne-O wasn't going to make that flight.
Ollie Jungfrau told the Iowa State Patrol officers the animal he'd seen attacking Wayne DeLong looked like a six-foot-tall grasshopper. The troopers requested that Ollie Jungfrau breathe into a machine.
Wayne DeLong was eaten right in front of the Ealing Coin Wash Launderette. The only thing left of Wayne-O was his belt buckle, eyeglasses, and the Tipsy Cricket paper sack containing the twelve-pack of condoms Wayne-O would never get to use, and the bottle of El Capitan Vodka that Wayne-O would also never drink.
"Okay, Ingrid," I said. "Come on."
I stood up from my seat at the desk. Ingrid raced ahead of me and ran downstairs to the front door, wagging her tail and panting.
"Uh. Wait, girl," I said. I turned back. I'd forgotten the cigarettes Johnny McKeon brought for me in my bedroom.
It was a nice night.
I sat on the front porch in nothing but my boxers and Robby Brees's Spam T-shirt. I put my bare feet up on the railing while Ingrid sniffed around in the yard. I lit a cigarette and considered staying home from school for a second consecutive day.
I thought Robby was right. I would surprise my dad by cleaning up all the dog shit and mowing the lawn before my parents came back home from Germany.
"There goes my Nobel Prize and my trip to Sweden with Robby Brees," I said.
I was talking to Saint Kazimierz.
I smoked.
Saint Kazimierz chose to maintain his virginity until his death.
I could not comfortably wrap my head around that thought.
Saint Kazimierz must have been a real dynamo at saying no to his penis.
After he died a virgin boy in his twenties, Saint Kazimierz's body was wrapped in silk. Saint Kazimierz's corpse reportedly cured all kinds of people who were afflicted with untreatable illnesses. He even brought a dead girl back to life.
This is all true.
The maintenance of his virginity was more remarkable than any of that shit, as far as I was concerned.
I couldn't see how a Polish boy could do that.
I wondered if, in the 1400s in Poland, being a virgin boy meant you were still technically permitted to experiment, or at least allowed to produce a little polymer from time to time. Otherwise, it had to be some kind of hoax or, perhaps, a genuine miracle.
Saints, like Kazimierz, I decided, truly were superhuman.
When his original tomb crumbled, the clergy decided to transport the boy's body to a new crypt. When the priests opened his tomb, Saint Kazimierz's body was miraculously preserved, and smelled like flowers.
Maybe shit like that will happen to any Polish boy who can actually fight off the urge to lose his virginity.
It was hopeless for me.
I was destined to be a stinky Polish corpse that would never cure diseases or shit like that.
A gray fog of headlights came sweeping like a sandstorm down the middle of our street.
Nobody ever drove out this way in the middle of the night.
Then Robby Brees's old Ford Explorer pulled up and parked along the curb in front of my house.
I was scared, but also very happy to see Robby.
I had been a ridiculous asshole to Robby Brees over the past two days. And now, here I was: caught red-handed smoking on my porch, alone, in my underwear and Robby's Spam shirt that he'd been wearing when we got called queers and beaten up by the Hoover Boys.
Seeing Robby Brees get out of the car made me feel guilty and nervous. It was the same way I'd felt the day Pastor Roland Duff called me in to the headmaster's office at Curtis Crane Lutheran Academy to counsel me on the history and consequences of masturbation.
Robby did not expect to see me sitting there on the front porch, smoking in my boxers. In fact, he did not see me at all, which is why he let out a little startled squeal when I said, "Hi, Robby. It's really good to see you."
Nobody ever expects to be cheerfully greeted at midnight by a kid smoking in his underwear on a deserted street in Ealing, Iowa.
I may just as well have been a six-foot-tall praying mantis, or shit like that.
Robby regained his composure.
He said, "Hey, Porcupine."
"Want a cigarette?" I asked.
Robby said, "Uh."
He looked around, like he was trying to see if there was some kind of joke being played on him. Ingrid came up and sniffed his hand and then transformed herself into a doggy rug beneath my chair.
I took my bare feet down from the porch rail and curled my toes in her fur.
She sighed contentedly.
I said, "You're a good dog, Ingrid."
The sirens in the distance went silent.
Robby said, "I didn't mean to bother you, Austin. I just came to drop off some things on your porch. I didn't think you'd be out here."
He went back to get what he'd brought from his car.
"Watch out for dog shit," I warned.
"I am watching out," he confirmed.
It must have been the end of the world or some shit like that. Robby Brees, who never did his laundry, had been washing laundry all day, which is why he did not go to school. It was part of the reason why Robby did not go to school. Most of the reason was that his Polish-kid best friend had been acting like a complete asshole.
He carried a neatly folded stack of half my entire non-Lutheran-Boy wardrobe in his arms.
On top of it were two pairs of sneakers, my toothbrush, and cell phone.
"Sorry it took so long to get all this stuff back," Robby said. "Your sleeping bag's in the Explorer, too."
I took the bundle from Robby. Our hands touched.
Everything smelled really good.
"This stuff smells good," I said.
Robby said, "Thanks. I tried."
Robby shrugged.
"You actually did all your laundry today?" I asked.
"Yeah," Robby said. "It's not too bad. I couldn't find one of your socks, though."
Socks and underwear have a way of disappearing with me.
"Maybe it's under your bed," I said.
I immediately felt the flush of embarrassment. I silently prayed to Saint Kazimierz to make me not say anything else that was as stupid as the shit I just said to Robby.
"Your dad's been calling," Robby said.
"Uh."
"I talked to him. He said everything is going to be okay. I hope you don't mind that I answered your phone." Robby said, "Austin, I'm really sorry about Eric."
Robby was such a good person.
"You are such a good friend, Rob," I said.
I gave Robby a cigarette. Then we went to his car to get my sleeping bag. I could hardly believe my eyes: Robby Brees's backseat was completely cleaned out. All the dirty clothes were gone. It was like there was a new Robby.
"The new Robby," I said.
"Yeah," Robby agreed.
"Uh." I said, "Now I feel guilty about wearing your Spam shirt. I think I might have B.O. I've been lying in bed all day."
"Austin, you do have B.O.," Robby confirmed. "I can smell it from here. You smell like leftover pizza in a locker room."
Robby, who swore that Doritos smelled like a six-year-old boy's feet, had an acute sense for smells.
"Uh. I will do laundry tomorrow, too," I said. "We'll be, like, laundry buddies, or shit like that, and we can chat about how we manage to get our things to smell so fresh."
We sat on the porch, next to the stack of all my clean-smelling laundry that was missing at least one sock, and Ingrid, my golden retriever, who was missing her vocal cords, and smoked together.
I tried making small talk.
I said, "I ate a Stanpreme tonight with Shann."
"Oh," Robby said.
"It always tastes better when you're there. I think Satan dislikes you," I said.
"He hates everyone who asks for ice water. What do you expect? He's Satan," Robby theorized.
"Oh yeah," I said. Robby was very smart about theology, too.
"Look, I wanted to say something, Porcupine," Robby began.
"Don't say anything, Rob. I don't want you to."
I waved my hand in the air between us like I was erasing words from an invisible blackboard.
"Okay," Robby said.
## THE DIVING BELL
THE THREE OF US marched through waist-high weeds and brambles, across fields that at one time were forests of corn, out to Shann's launch pad.
Shann Collins found the invisible McKeon silo.
The silo was just as Shann had described it to me: A circular pad of concrete thirty feet in diameter. Around the circumference, corroded anchor bolts that used to support the structure's cylindrical outer wall poked up like a mummy's rusted fingers. In the exact center was a steel hatch, tightened shut by a spoked metal wheel that looked entirely like something you'd find on top of an old diving bell.
I was nervous.
"We should have brought flashlights," I said.
And then I added, "Let's go back and get some flashlights."
Robby, who was never scared of anything unless we were breaking in to Johnny McKeon's museum of horrors in the middle of the night, said, "Let's have a cigarette and then open this shit up, Porcupine."
"You boys smoke too much," Shann said.
So Robby and I lit cigarettes, and before he'd taken the second drag on his, Robby squatted down above the hatch wheel and began forcing it counterclockwise.
As soon as the wheel rotated a quarter turn, we heard a low buzzing sound coming up from beneath the hatch.
"Um," I said. "Robby? That thing's full of bugs or shit."
"It's not full of bugs," Robby argued.
"If it's full of bugs, I'm going to be mad," Shann offered.
"If it's the kind of bugs I'm thinking of, you won't be mad for too long," I said.
"He is thinking of butterflies that shit raspberry cupcakes on your head," Robby said.
That made me hungry for cupcakes.
"No," I said. "No, I am not thinking of butterflies that shit raspberry cupcakes, Rob."
Robby knew what kind of bugs I was thinking about, but Robby was not afraid.
Finally, the wheel would turn no more. The hatch came loose, and Robby stood up and lifted it open.
The hole was three feet across. As soon as the hatch raised up, the inside of the lower chamber illuminated in a flickering greenish fluorescent light. The buzzing noise was louder now, but it was fairly obvious that it was being produced by some kind of power generator, as opposed to six-foot-tall, man-eating praying mantises.
I took a drag, exhaled, and said, "Roof access, Rob."
## THE POPULAR GIRL
AT EXACTLY THE same moment Robby Brees opened the hatch to the McKeon silo, my mother and father stood at the bedside of Eric Christopher Szerba. It was nearly midnight in Germany. My parents were trying to talk Eric into speaking with his younger brother on their cell phone. My father held his phone above Eric's bed like it was a fragile baby bird. Eric did not want to talk to his younger brother. Eric Christopher Szerba told my father to get out of his goddamned room and leave him alone.
At that moment, my cell phone was sitting on the coffee table in our living room beside an empty container of chicken-flavored Cup-O-Noodles.
I often forgot to carry my phone with me.
At that moment, Grant Wallace fell down in his bathroom while taking a piss. Grant hit his head on the rim of his toilet. It was not a Nightingale. Grant Wallace's head broke open. It didn't matter. Grant was hatching. The bug that came out of Grant was young and powerful. He was hungry and also very horny. He needed to eat, and he needed to find Eileen Pope. He could smell and hear Eileen Pope, even though she was four miles away from the Wallace home.
Grant Wallace made a terrible mess in his bathroom. There was nothing that was not covered by spatters of blood after he finished eating. But Grant was still hungry, and he also wanted to fuck and make more bugs with Eileen Pope.
When he came out of the bathroom, Grant Wallace ate his two younger brothers, his mother, and the family's Yorkshire terrier, which was named Butterfly.
Grant Wallace's father, Will Wallace, was not home from his job in Waterloo yet.
Will Wallace owned Fire at Will's Indoor Shooting Range and Gun Shop.
At that moment, Will Wallace was selling a 9mm Ruger over the counter to a drunk man who claimed he was going to use it to shoot his ex-wife's cat.
Will Wallace had a sign behind his counter. The sign displayed Will Wallace's two favorite mottos. It looked like this:
A GUN IS NOT A TOY
ALL SALES FINAL
The three Hoover Boys Grant Wallace enjoyed hanging out with hatched within minutes of one another. Like Grant, Travis Pope, and Hungry Jack, they wanted to do only two things.
Now there were seven bugs in Ealing, Iowa: Eileen Pope and her six suitors—Hungry Jack, Travis Pope, Grant Wallace, Tyler Jacobson, Devin Stoddard, and Roger Baird. Eileen Pope was going to be very popular.
Eileen's dance card was full.
At that moment, the vice president of the United States of America was performing his monthly testicular self-exam. His balls felt perfectly fine. The vice president of the United States of America named his balls Theodore and Franklin. Theodore was a little bigger than Franklin.
And Johnny McKeon was inside his office. He watched the little two-headed baby boy inside the jar. Johnny had seen the boy move before. The two-headed boy was moving his hands now: open and closed, open and closed, open and closed.
Johnny said, "Ain't that a kick?"
Johnny thought the thing inside the jar was some sort of deranged toy.
Two-Headed Boys Are Not Toys.
Ollie Jungfrau was lying in his bed. He lived in a bachelor apartment at the Del Vista Arms. He needed to take the day off after the stressful ordeal with Wayne DeLong in the parking lot at Grasshopper Jungle the night before. Ollie Jungfrau thought masturbating would make him feel more cheerful. He also phoned out for pizza delivery from Satan's Pizza.
Customers for Tipsy Cricket Liquors had to bother Johnny McKeon at the secondhand store if they needed booze, cigarettes, or condoms. Johnny didn't mind. Johnny McKeon never minded much of anything.
Louis, the Chinese cook at The Pancake House, whose real name was Ah Wong Sing, met Connie Brees in the alley at Grasshopper Jungle.
They went back to the Del Vista Arms together.
At exactly the same moment the hatch on the McKeon silo came up into the Iowa sky for the first time in forty years, Connie Brees was making certain her son, Robert Brees Jr., was not at home. She went through Robby's room, looking for a box of condoms she found on the floor of Robby's bedroom on Tuesday afternoon when Robby was at school. Ah Wong Sing sat naked, waiting for Connie Brees in her bedroom, which was just on the other side of the little bathroom where I'd vomited and taken a shower on Tuesday morning.
And, at exactly the moment Robby lifted open the old hatch and the subterranean chamber below our feet lit up in pale fluorescent-green light, I was thinking about having an underground threesome with Shann and Robby, and feeling myself turn red and hot with my sweating, embarrassed horniness.
I also wanted cupcakes.
## WELCOME TO EDEN
IF DRIVING OUT to the Tally-Ho! with Robby Brees was like traveling forward in time, then climbing down into the belly of the McKeon silo with him was like going backwards.
First: Robby climbed down the rounded steel ladder, and Shann and I followed. As soon as Robby was halfway down to the floor, which was fifteen feet below the hatch opening, a welcoming sound chimed us into the silo.
It was a recording of a very sterile, anesthetized-sounding woman's voice that said:
Welcome to Eden. Please secure the hatch upon entry.
Welcome to Eden. Please secure the hatch upon entry.
Welcome to Eden. Please secure the hatch upon entry.
"Uh," I said. The message kept repeating without any indication that it would stop. I added, "Shann, if this place ends up being full of sperm, I'm leaving."
The place did have sperm in it. We found it later.
You will see.
"It's just like our mothers or something," Shann said. "I bet she won't shut up till one of us closes the front door."
Shann pointed up to the hatch and the disc of blue Iowa sky above our heads.
Shann was very smart.
I thought it was like our mothers because the voice sounded like the two Connies—Connie Brees and Connie Szerba—when they were floating along on little blue kayaks.
Welcome to Eden. Please secure the hatch upon entry.
Welcome to Eden. Please secure the hatch upon entry.
"Okay," I said. "I can't take it anymore."
But before I could do anything, Robby was back up the ladder, sealing shut the hatch above us.
The welcome announcement stopped.
Robby looked down at us from the top of the ladder.
"Uh," I said. "What if we can't get out, Rob, and this chamber suddenly begins filling up with sperm or shit like that?"
Robby said, "Eden Five needs us, Porcupine."
"Uh," I repeated.
"You worry too much," Robby said.
That was very true.
Everyone knew I worried too much.
Absentmindedly, I fiddled with the silver Saint Kazimierz bauble dangling from the chain around my neck.
## SOME KIND OF SIGN
THE DIVING BELL turned out to be much more than a diving bell. It was a bunker fortress, a preserved glimpse, like Paleolithic cave art, at the paranoia that gripped Cold War Ealing, Iowa, and the United States of America.
It was everything in the entire world down there.
You will see.
The first room below the hatch was something like a mudroom. There were benches all along its circular wall, with coat and hat hooks positioned at even distances above them. The wall was painted an industrial shade of gray with bold yellow block letters that said:
MCKEON INDUSTRIES INFESTATION COMPLEX
EDEN PROJECT • EALING, IOWA
There was a pair of scuffed wingtip shoes left beneath one of the benches, as well as a powder-blue windbreaker hanging from a hook. There was also a matching set of three of the same plastic pink lawn flamingos with the wire stakes coming out of their asses. The wire stakes were fed through perfectly drilled holes in the benches. The flamingos were turned with their beaks toward the center of the mudroom, like they were watching us.
"This must be some kind of nuke shelter," Robby said.
"Nuh," I said. "It has something to do with that shit Tyler dropped."
Shann said, "What are you talking about?"
"Let's see what's down here," I said.
A single metal door led out of the entry room. The fact that this door also had a sealing airlock mechanism convinced me that the silo had been created for some anticipated disaster. A reasonable observer might conclude that Dr. Grady McKeon had prepared the structure, as many Americans did during the 1960s, as a type of bomb shelter for his family. But I knew after what I'd seen inside Johnny McKeon's office at From Attic to Seller Consignment Store that there was something much more to this silo and to Grady McKeon's creations.
I was certain Robby believed it, too.
None of us had any way of knowing it at the time, but Robby Brees and the bloody message he left on the pavement at Grasshopper Jungle had just as much to do with the end of the world as old, dead Dr. Grady McKeon ever did.
We went through the first door.
Robby said, "I don't mind telling you this, Shann, but I think you should keep this place secret from your parents, so we can have a raging party down here."
"Like an orgy," I whispered.
"Uh," Shann said.
"We could rule the world from this place," Robby offered.
I wasn't really listening to them. I was nervous about being there, and I was silently communicating to Saint Kazimierz, asking him if he could make me stop thinking about having an orgy.
In the early 1970s, among the last times anyone had ever been down inside the McKeon silo, which was technically called the Eden Project, scientists and workers from McKeon Industries actually did come down here to have sex parties.
We would find this out later, much to Shann's embarrassment.
The doorway led us into a vast tiled hallway of lockers, which in turn opened on either side to a wide shower room on our right, sinks and mirrors to our left, with gleaming stainless fixtures and hospital-clean floors and walls. I went inside the shower room. The showerheads were arranged like sunflowers blooming outward from the tops of central posts that looked like columnar periscopes in old submarines. Twenty people could shower in there at the same time. The place was obviously designed with the idea of not segregating shower-takers and clothes-changers by gender.
I opened one of the spigots.
The water came out hot.
The place was suitable for an army, and it was also ready to be used.
"Too bad I already took a bath today," I said.
"Yeah. Too bad," Shann said.
She was joking.
In the shower chamber, at the end of the room where there were polished redwood benches and cubbies for towels and clothes, there were three doored stalls to toilets, and an enormous twenty-foot-long porcelain communal wall urinal. I examined the top of the urinal. There were birds on it with ribbons coiled around their happy beaks. The urinal was an antique Nightingale.
I knew I would have to pee in that thing.
My destiny was calling.
Once again, every highway that had ever been laid was intersecting right at my feet. I rubbed the Saint Kazimierz medal against my chest and thanked the virgin boy.
Robby had opened some of the lockers. They all contained identical sets of supplies: clean towels and shower kits with soap and razors, fresh white-and-blue nylon jumpsuits that zipped up the front, sealed packages of white socks, and cloth caps, all of which had been embroidered in blue and gold thread with the McKeon Industries Scientific Labs Department logo.
All the jumpsuits were numbered and said Eden on their chests.
"I wonder if we should change our clothes or shit," Robby said.
"If there's one in there that says Eden 5, I am putting it on," I decided.
Robby waved a hanger like a banner in front of me. On the left chest, the jumpsuit said this:
EDEN
5
"This is like some kind of sign or shit," I said.
## GIMME SHELTER
THE UNIFORM MADE me look like someone who worked at a place that sold hot dogs and ice cream cones.
I stripped down to my boxers and slipped myself hurriedly inside the jumpsuit. Shann and Robby gave in to their desire to conform. All teenagers really want to be exactly alike, so why wouldn't they?
Shann and Robby put on uniform jumpsuits as well.
Watching Shann and Robby take off their clothes made me realize that nylon jumpsuits were also not very good at hiding erections. Saint Kazimierz kept me strong.
I wanted a cigarette.
Shann Collins was Eden 49.
Robby Brees became Eden 133.
We put on our white caps and socks. We were an army now.
There were a lot of lockers down there, enough to find suits that fit us perfectly. Enough to last forever.
"Do you think this place would explode or shit if we smoked down here?" I asked.
Robby said, "I was wondering the same thing, Porcupine."
The place did not explode.
I noticed there were ashtrays built into the walls of the locker room. Everyone smoked in the 1970s, especially in Iowa. Who wouldn't smoke if you were sealed underground and the world above was going down a cosmic shithole?
Walking silently over the cool, slick floor in our brand-new McKeon Industries Scientific Labs Department white socks, we left the locker room through the only hatched doorway at the opposite end from the entry.
We came out into a massive auditorium with rows of cushioned seats that all faced a podium and rolling blackboards at the front of the room.
It was like a lecture hall.
The stage area was lit up in track lights that pointed down at the lectern, so the audience's attention would be focused on whoever might be up there telling them all the important shit they needed to know.
On one of the chalkboards behind the speaker's podium, a diagram had been drawn.
It looked like this:
412E HUMAN BLOOD HOST LARVAL STAGE METAMORPHOSIS SEXUAL REPRODUCTION INFESTATION
It was just like biology class with pollywogs.
I hated biology, and as far as I know, pollywogs cannot destroy the world. Then again, I never paid attention in biology class unless the teacher was talking about sexual reproduction with humans.
Our ninth-grade biology teacher at Curtis Crane Lutheran Academy was named Mrs. Edna Fitzmaurice. She had a mustache and would not tolerate nervous giggling when she said a word like penis or vagina. Edna Fitzmaurice's main function at Curtis Crane Lutheran Academy was to make teenagers morbidly terrified of sex.
History lesson: Over the course of centuries in the history of education, although fought valiantly by endless armies of pedagogues, the attempt to frighten teenagers away from sex has proven to be a losing battle.
The lecture hall had multiple sets of doorways leading out from each of its three curved walls. There was so much for us to explore. The place was easily five times larger than the McKeon House where Shann lived, maybe bigger than that.
The first door we opened took us into a type of lounge. It looked like a television set from a 1960s-era family comedy, with low, straight-backed sofas perched on narrowly tapered birchwood peg legs, shag carpeting, and coffee tables shaped like kidney beans. On one of the tables was an assortment of magazines. They were perfectly unwrinkled, dustless, hardly touched. The most recent date on any of the magazines was 1971.
There were framed photographs on the walls: an image of the flag of the United States of America planted on the surface of the moon, the faces of presidents carved into Mount Rushmore, a herd of longhorn cattle, what apparently were Iowa cornfields, Willie Stargell swinging at home plate in the 1971 World Series, and a black-and-white picture of President Richard Nixon and his family, taken in the White House in front of a fireplace, and a painting of President George Washington. It was everything that made America worth living in an underground cave for, while the rest of the world went entirely to shit.
That was our day. You know what I mean.
And there was a cigarette machine in the lounge.
Discovering it had an almost religious impact on Robby and me.
"Thank you, Saint Kazimierz," I said.
I pulled my medal out from my jumpsuit and kissed the saint.
"You're going to go to hell for turning Catholic," Robby said.
Robby pulled one of the levers on the machine. Out popped a red pack of Pall Mall cigarettes and a book of matches that advertised how you could get into art school by drawing a cute little fawn named Winky.
You did not need to put money into the machine to get cigarettes out of it.
It was a miracle.
Robby said, "Thank you, Saint Kazimierz."
We sat on one of the couches and smoked.
The Pall Mall cigarettes were a little stale, but they were free.
I had read somewhere that cigarette manufacturers during the 1970s also put saltpeter in their tobacco. I wondered if Americans had fewer erections during the 1970s than during other decades. Apparently, the saltpeter in my Pall Mall was not having much of an effect on my penis. I sat beside Shann and rubbed her leg with mine. The jumpsuits felt very nice. I put my hand on her neck. We kissed, and I slipped my tongue into Shann's mouth.
I believed Robby was a better kisser than me. I tried to kiss Shann like Robby would.
Robby watched us. He was not bothered at all by what I was doing with Shann.
He got up from the couch and went over to the wall, where a built-in shelf surrounded an old reel-to-reel tape recorder. There was a big spool of tape that had been left threaded across the machine's playheads.
Robby pressed the power button and the two level-meter windows on the bottom of the machine flickered with yellow light. There were red needles that looked as fine as strands of horsehair, and they pricked up inside each window. Robby flipped a switch. It made a soft click, and the reels jerked and spun.
Music came from everywhere around us.
It was a recording of the Rolling Stones's album, Let It Bleed.
Robby said, "Oh, hell yes."
Robby danced and smoked.
He was such a great dancer. It was just like when he taught me how to dance in his room at the Del Vista Arms so I could win Shann's attention when we were in seventh grade. I wanted to dance with Robby, too.
Robby said, "I never want to leave Shann's silo."
Mick Jagger sang Gimme Shelter.
History will show that Gimme Shelter is one of the greatest songs ever recorded. It sounded so beautiful down inside Shann's silo. Robby danced in his jumpsuit, which he had unzipped all the way past his belly button, so you could see his brightly colored, non-plaid, non-Iowa boxers. They had pictures of ice cream cones with rounded scoops of colorful ice cream melting down the diamond-patterned waffle cones in suggestive drips.
Robby always had the coolest boxers.
He waved his hands around and tilted his cigarette daringly from his lips.
Oh, a storm is threatening
My very life today.
I got up and danced with Robby there in my jumpsuit and socks on the thick shag carpeting in the lounge room. It all felt very good. Shann joined us. The three of us danced together. It made me very horny.
I said, "I never want to leave Shann's silo."
Shann smiled and danced between Robby and me.
We were in Eden.
Eden needed us.
All roads crossed on our dance floor.
## THE DRAGON PARADE
WE DANCED AND DANCED.
The tape played. We were sweaty and hypnotized, and we lost ourselves as the music fell all around, washing over us.
I said, "I love you, Shann. I love you, Robby."
What was I going to do?
Shann and Robby smiled at me.
Shann combed her fingers through my wet hair. Robby touched my hand with his.
We danced and danced.
And while I danced with Robby and Shann below the ground, things happened in the world above.
Ingrid, my golden retriever that could not bark, was exhausted from being outside and watching me mow the lawn and scoop up dog shit all day. She was curled up beneath my desk, asleep and content, waiting for me to come home.
Ah Wong Sing and Connie Brees were lying naked together in bed. They had had sex three times in one hour.
Ah Wong Sing was a real dynamo for such a quiet guy.
The Pancake House cook and Connie Brees smoked a marijuana cigarette that Ah Wong Sing had rolled before coming over to the Del Vista Arms. They also used up the last of the condoms Connie Brees had found on the floor of Robby's bedroom.
The family from Minnesota who had come through Ealing the previous Saturday on their serial-killer road trip were heading back home to Minneapolis. They bought a Stanpreme pizza to go and had a picnic on the benches at Amelia Jenks Bloomer Park.
It was not a good idea.
Nobody in Ealing, Iowa, ever went to Amelia Jenks Bloomer Park.
Some parks are unexplainably like that: Unused, as though there is some unspoken recognition there might be a sort of toxic pall hanging over them. In fact, Amelia Jenks Bloomer Park was built on the site of an old chemical milling and etching plant. The tanks there had corrupted, and poisonous metals from them seeped into the ground. Swallowing water from the drinking fountains at Amelia Jenks Bloomer Park was just a little safer than sucking on a nozzle of unleaded premium at the Arco on Kimber Drive. Nobody knew anything about that. The twin boys drank and drank from the fountains at Amelia Jenks Bloomer Park in Ealing, Iowa. They filled squirt guns again and again with Amelia Jenks Bloomer Park's drinking water.
It did not matter.
The family sat and looked over their memories in their guidebook. Before Amelia Jenks Bloomer Park was an abandoned park, United Chem-Etch Incorporated's parking lot occupied the exact spot where the picnic tables were located. In 1969, the decapitated head of an adult white male had been discovered in that parking lot. It was a perfect place to have a family picnic. The father remarked how fresh the sausage meat was on the Stanpreme pizza they had bought.
The Hoover Boys—at least the bugs that hatched from the Hoover Boys—Tyler, Devin, and Roger, scampered with clicking, mechanical jerkiness across the Little League field adjacent to the picnic area.
They audibly buzzed with horniness and hunger.
One of the twin boys saw them. He said, "Look! A dragon parade!"
It was not a dragon parade.
Mantises are very quick. It's not that the bugs that hatched from the Hoover Boys and the other victims of Contained MI Plague Strain 412E were precisely mantises, but they were close enough in physiology, with their triangular heads and viciously barbed trisegmented striking arms. And they also stood six feet tall.
In battle, a six-foot-tall praying mantis could easily destroy a six-foot-tall grizzly bear. They were like grizzly bears with steel plating and lightning-fast arms studded with row upon row of shark's teeth.
The bugs that hatched out from the victims of Contained MI Plague Strain 412E liked to snatch their prey up by the head, and then commence eating their thrashing victims straight down to their shoes.
The dragon parade made a bloody mess at Amelia Jenks Bloomer Park.
They were very quick.
They even ate what was left of the tourist family's Stanpreme pizza before scurrying off to look for more food and also for Eileen Pope, who they could hear and smell and wanted to fuck.
And while we danced and danced, my mother swallowed another of her little blue kayaks. She had gone back to the hotel with my father. My father was leaving a voicemail message on my cell phone at exactly the same moment that Shann and Robby danced with me.
The message was this:
Hey, Austin. We've been sitting with Eric, and he looks good. Real good. He is going to be fine, son, so there's no need to worry about your big brother. He is a hero. Call me and let me know how things are going at school. I hope you're eating okay, and not just Cup-O-Noodles and shit like that. And don't forget to let Ingrid out. I love you, son.
Happy hour was beginning at the Tally-Ho!
Thursdays were good days there for men to meet new men who were daring enough to finally try their luck at the Tally-Ho! Will Wallace was drinking a beer at the bar while Shann ran her fingers through my hair and Robby brushed my sweaty hand softly with his.
Will Wallace was not homosexual. The Tally-Ho! sold beer for seventy cents per glass during Thursday happy hours. Will Wallace also enjoyed the attention he got from men who showed up at Waterloo, Iowa's one and only gay bar for the first time.
Will Wallace had no idea he was spending his last evening on earth in a bar for homosexual men.
At the same time Will Wallace was finishing his second glass of beer at the Tally-Ho!, Mr. Duane Coventry, our chemistry teacher at Curtis Crane Lutheran Academy, was tapping on the front door at Tipsy Cricket Liquors. He needed a bottle of whiskey. Duane was single, and he drank a lot. Nobody opened the door for him, so he got back into his car and drove to the Hy-Vee, where Connie Szerba worked as a bookkeeper.
At the Hy-Vee, Duane Coventry purchased two boxes of antihistamine tablets for his allergies. He did not have allergies. The chemistry teacher from Curtis Crane Lutheran Academy was a real dynamo when it came to cooking methamphetamine in his kitchen. Duane Coventry was very lonely. He should have tried hanging out at the Tally-Ho!
Hungry Jack, whose real name was Charles R. Hoofard, but was now a massive green bug that looked like a praying mantis, and Travis Pope, who was also a massive green bug that looked like a praying mantis, were back in the alley at Grasshopper Jungle. They were fighting over mating privileges with Travis's wife, Eileen Pope, who was also a massive green bug that looked like a praying mantis.
It didn't matter. Travis had already inseminated her a dozen times that day, and now he was more hungry than horny. There was plenty of Eileen Pope to go around.
Eileen Pope was about to become queen of a new world.
Once her six suitors got to her, they would collectively fertilize millions of eggs inside Eileen Pope's burgeoning abdomen. It would take her several days to produce and hide her egg mass, but then in a matter of hours there would be more hatchlings from those first seven victims of the Contained MI Plague Strain 412E than there were people in the entire state of Iowa.
The world would have just about seven days before the bugs started taking over.
And bugs only want two things.
So Travis Pope submitted to Hungry Jack and scuttled away down the alley behind the Ealing Mall.
Travis Pope hunted for someone to eat.
Hungry Jack joined himself to Eileen Pope as she clamped four of her arms onto the dirty convertible sofa in Grasshopper Jungle and buzzed with contented, fizzling coos like a short-circuiting wall socket.
We danced until the entire tape played through and flapped its disconnected end over and over around the receiving spool in an unending counterclockwise loop.
Shann and Robby and I were soaked with sweat. The three of us collapsed onto the thick shag carpeting, panting and staring up at the high ceiling overhead.
Shann said, "Let's try to find something besides shower water to drink."
I said, "I want to go piss in my great-great-grandfather's urinal."
"So do I," said Robby.
History often loops around into complete circles.
The spool of tape spun and spun.
## SOUP FROM PAINT CANS
ANDRZEJ SZCZERBA'S AMERICAN name, the one with swapped-out consonants and shit, was Andrew Szerba. Andrzej Szczerba was my great-grandfather. His mother was Eva Nightingale, and his father was Krzys Szczerba, who Americans renamed Christopher Szerba, manufacturer of palatial urinals.
Robby and I peed all over the gleaming receiving wall of Krzys Szczerba's beautiful urinal.
"This is the greatest urinal ever made," I said.
Robby stared at the spot on the wall where the disembodied praying hands would be hanging if this were Curtis Crane Lutheran Academy.
"Very accommodating and unoppressive," Robby offered.
"If the act of urination had self-esteem, it could not help but feel better about itself after occurring in such a splendid location," I said.
Robby said, "Without a doubt, this is the nicest thing I have ever urinated on, with the possible exception of Sheila's husband's new Harley-Davidson."
Sheila was Robby's sister, who lived in Cedar Falls.
"You peed on your brother-in-law's Harley-Davidson?" I asked.
"He wasn't my brother-in-law at the time, but, yes, Porcupine, I peed all over the seat," Robby explained.
"Why?" I asked.
"I'm not really sure," Robby said. "Something inside me just told me that motorcycle needed a good peeing-on."
"Well, I have never peed on anything that was particularly nice. Except for maybe the grass on the football field at Curtis Crane Lutheran Academy," I said.
"You peed on our school?" Robby asked.
"Yes," I said. And then I asked, "Robby? Are we done talking about peeing yet?"
"I'm pretty sure we've said everything that needed to be said, Austin," Robby answered.
"We probably should shake hands," I said.
"Meet me at the hand soap dispenser," Robby answered.
Andrzej was seventeen years old when he left home, the same age his father was when Krzys Szczerba found himself entirely alone in the middle of the Atlantic Ocean. The Great Depression had arrived in the United States of America, and urinals—even beautiful ones with names that sang—were no longer in high demand.
Growing up, Andrew—Andrzej—always felt there was something quiet and troubling that made him different from other boys.
You know what I mean.
Krzys Szczerba's boy was often afraid and confused, just like another Andrzej who was going to be his great-grandson. Since he was born, his father, Krzys, only spoke to his son in Polish.
Andrzej Szczerba rescued an injured bird when he was thirteen. That would have been about the same year he was in seventh grade in Minnesota, where his father ran the Nightingale Convenience Works.
History shows that lots of shit happens to Polish boys when they are in seventh grade.
I do not know why, but that is not my job. My job is saying what. The shit that happens to us Polish boys is causally related to the bags under our eyes.
The bird Andrzej found was a European starling. Andrzej kept it and raised the bird as a pet. He named the bird Baby.
By the time Andrzej was seventeen and left home, Baby could talk. Baby spoke English as well as Polish, which displeased Eva Nightingale, who believed that Krzys and his son frequently conspired against her will, and plotted in their anarchists' tongue. She thought the bird was in on the Polish conspiracy, too.
Whether or not Baby actually understood the things he said was always a matter to be decided by the person listening to Baby speak.
Andrzej loved Baby. He never kept the bird in a cage, either. In fact, Andrzej tried to encourage the bird to fly away and find a suitable mate or a more natural place to live, but Baby would not leave Andrzej. Baby preferred to stay inside Andrzej's coat, or perched near his collar at all times.
People in southern Minnesota, where Andrzej was a boy, thought Andrzej was crazy. You must be crazy, after all, if a bird loves you.
In 1933, when Andrzej was seventeen years old, he and Baby found themselves at the very center of a vast continent. They were somewhere in the state of Iowa, in a place called Boatman's Bluff. Andrzej, like a lot of young men during the Great Depression, was more or less a hobo.
I also do not know why people say more or less. Everything is more or less of anything you can think of. Iowa is more or less the French Riviera. The French Riviera has the largest per-capita consumption of Spam in the world, more or less.
That is more or less the truth.
Andrzej was a hobo.
On a frozen morning in April, Andrzej arrived at a farm foreclosure auction. Sometimes, he went to these auctions just to stand in the midst of the people, where he could stay warm. Often, when auction-goers saw how young Andrzej was, and what a beautiful face the boy had, they would invite Andrzej home and feed him and allow him to take a warm bath or sleep for a while in their outbuildings.
It was natural for kindhearted people to feel a sense of sadness or obligation when they looked at young Andrzej, all alone and helpless. He looked like an angel, or like an injured bird.
Perhaps it was that people were also attracted to the strange talking bird that stayed inside Andrzej's collar and nuzzled against the boy's neck, which was the color of hominy grits.
That kindness people sometimes showed him was what Andrzej was looking for on the morning in April at the farm foreclosure auction. Andrzej was very hungry, and the ground of the dead farm was frozen in such deep black ruts that it hurt his feet when he walked through the crowd.
Andrzej ran into another drifter among the people at the auction: a nineteen-year-old boy named Herman Weinbach, who had come from Michigan. Herman Weinbach's straight hair, which was the color of pot roast gravy, hung down across one eye. His skin was the color of soda-and-flour biscuits.
Herman Weinbach had been a member of the American Communist Party, but he quit all political activities due to hunger, he explained. People were leaving the American Communist Party in the early 1930s, and Herman simply didn't believe anything was ever going to change, whether it was destined to, as Karl Marx said, or not.
Herman Weinbach was also homosexual, but nobody knew anything about it.
When Herman Weinbach saw Andrzej Szczerba at the auction, he asked Andrzej if he was a Jew. Andrzej told him no, that he was Catholic, and Herman said that would have been his next guess, after Quaker.
Herman Weinbach was a Jew, but nobody knew anything about that, either. He told Andrzej he was an atheist.
Andrzej Szczerba had never met an atheist before. At least, he had never met anyone daring enough to say they were atheists. Just the thought of denying God frightened Andrzej, who, like me, frequently touched a silver medallion of Saint Kazimierz he constantly wore on a chain around his neck.
Before Herman Weinbach died, he told Andrzej Szczerba that being a Communist homosexual Jew in Iowa in 1933 was like being a European starling that spoke two languages.
Andrzej did not know what Herman meant when he said that, but I believe he meant it was something beautiful and wonderful.
The boys found a man in the crowd who was smoking. He gave Herman and Andrzej some tobacco, and he let them roll cigarettes. Cigarettes were a good way to not feel so hungry.
That day Andrzej and Herman became great friends and traveling companions. They shared their hunger, and Andrzej showed Herman the tricks he could do with Baby.
The boys had to go to a soup kitchen in Ames to get a meal that day. They had to wait for other boys to finish eating, so they could borrow something to hold soup for themselves. Herman and Andrzej had nothing except a talking bird named Baby.
They ate out of borrowed paint cans.
The boys who loaned them their paint cans waited for Herman Weinbach and Andrzej Szczerba to finish their meal.
You just don't give away empty paint cans when there's soup that needs to be ladled out.
This is the truth. It was America, and America had very little to spare for boys like Herman Weinbach and Andrzej Szczerba.
Herman was going to California, he said. He told Andrzej about his uncle, a man named Bruno Wojner, who had trained an amazing dog act for a circus.
The name of the circus act was Bruno's Amazing and Incredible Dogs. Herman said his uncle, Bruno Wojner, would be very excited about Andrzej's talking bird, and maybe they could go to work at Bruno's circus in California.
Andrzej thought California would be much better than Iowa, even if it was only a different place to starve and be cold, so the boys decided to try to go to California together, and find Uncle Bruno and his amazing dogs.
They made a pact to stay together—Herman, Andrzej, and Baby.
Of course, Andrzej never managed to leave Iowa, but the idea was good and romantic. That's what all Polish boys like when they are seventeen years old: Romantic ideas and somewhere to go.
Andrzej and Herman ate their soup from paint cans and saved half of their bread for later, and also to feed to Baby.
Things like this were what made America great: romance, talking birds, eating dinner from paint cans, and setting off with your friend to see the world.
There was an entire world inside Shann's silo, which was actually called Eden.
The world was frozen in time from around 1971.
That world included telephones wired into the walls. The phones were made from heavy plastic. Their mouthpieces were connected to the machinery of the telephone with tightly corkscrewed rubber cables. The phones had rotary dials on them and illuminated square buttons along their bottoms that were labeled with the names of other extensions within the silo called Eden.
Not one of us had ever used a phone like the ones we found in the silo.
I could hear a dial tone in them, and I'm certain I could have figured out how to place a call, but we decided there was no one any of us wanted to talk to, anyway.
We found out that Shann's and Robby's cell phones did not work inside the silo.
We discovered Eden's cafeteria, a museum piece in stainless steel and formica.
There were soda taps behind the buffet lines, with machines that must have been producing ice cubes for several days. The only soda brand I recognized was Coca-Cola. There was also something called Nesbitt's, which was orange, and another, piss-colored beverage named Vernors. The taps worked. The sodas came out cold and carbonated.
It was another miracle.
Free sodas.
And there was a warehouse filled with food. The food was all boxed in cardboard and contained green cans of just about every imaginable concoction you could eat. There were green foil pouches of peanut butter, and every one of the boxes contained small packs of cigarettes. This was the same kind of stuff the United States of America sent to its troops fighting in Vietnam, cigarettes and all.
"Thank you, Saint Kazimierz," I said.
"Thank you, Saint Kazimierz," Robby repeated.
Shann would not compromise her unsteady Lutheranism, most likely because she did not smoke.
"Robby and I both went to church on Sunday," I pointed out.
"I was moving in," Shann explained. "No one expects you to go to church when you're unpacking boxes."
There were enough boxes in Eden for us to unpack that we'd never have to go to church again.
## GIDEON'S BREEDING RIGHTS
SHANN'S BEDROOM HAD a door that led into a brick wall and another that dead-ended at the foot of a stairwell. It was what I called a dungeon for horny Polish boys.
In truth, the silo called Eden went all the way into the foundation of the McKeon House, and the doorways in Shann's room had been bricked off when the Eden Project work crews finished construction on Dr. Grady McKeon's subterranean shelter.
Just as those McKeon Industries scientists back in the 1960s had been playing with self-sustaining universes they trapped inside globes of glass, the bigger enclosed bubble project they'd been working on lay beneath the ground under Shann's bedroom and stretched beyond the derelict cornfields on Dr. Grady McKeon's own property.
Here is what we found: Eden had a gymnasium, a fitness center with polished wood floors and weightlifting equipment, a sauna, and another shower room. There was a small facility for laundry that put the Ealing Coin Wash Launderette to shame in terms of its cleanliness and lack of discarded condoms and cigarette butts on the floor.
There was even a salon with those old-fashioned hair dryers that looked like brainwashing torture machines from science fiction movies, barber chairs, and haircutting tools.
Shann looked at her hair in the mirror. As always, it was beautiful, the color of mature wheat in late August. Her skin was perfect and unblemished.
I said, "Would you like us to do something with your hair?"
Shann said, "Do either of you guys know anything about hairstyles?"
And Robby continued our string of unanswered questions with, "Why are you both looking at me? Do you think it's just natural that I'd be, like, into doing hair and shit?"
Later, we found Eden's dormitories. Naturally, I was incapable of wandering through the bedrooms with Shann and Robby without feeling horny and guilty. I wondered if there had ever been threesomes inside Shann's silo.
Each room had two double beds. They looked, in style, like hotel rooms, except they lacked bathrooms and toilets, which were all located at the center of a hub of hallways that connected the fitness center and the lecture hall and entry room where we had changed out of our Iowa surface-dweller clothing.
There wasn't much room for argument in the discussion we had as we explored the bedrooms: Eden was built to house survivors for the end of the world. We could say the idea was to protect a few human specimens in the event of a nuclear war, but Robby and I knew Eden was probably built for something else entirely.
The idea that Robby and Shann and I were inside some kind of breeding compound for the genesis of an entire new species of humans was particularly thrilling and attractive.
"If we never came out of Eden, the three of us would be able to start an entire new race of underground Iowans," I said.
"Uh." Robby was unenthusiastic.
"Well. If we had to," I offered. "Between you, me, and Shann, we would have enough genetic diversity to not breed two-headed boys and shit like that."
I was somehow working into a long-range threesome strategy.
"Uh," Robby repeated.
Shann said, "I bet that's what Grady McKeon had in mind with the whole idea of Eden: starting everything over."
"Everyone who eventually came out would just end up doing the same stupid shit that always happened up there," I said, and pointed my thumb at the world above us.
"We should leave a copy of Porcupine's History of the World down here, just to save mankind the trouble," Robby said.
"That would be a good strategy," I said. "When do you two suppose we might start working on the new species?"
Shann rolled her eyes and pushed my chest.
I liked that.
She also changed the subject: "There must be books or stuff like that down here," Shann said.
Robby jumped on one of the beds like it was a trampoline. He said we should all do that, so Shann and I joined him. It was fun. We made a mess of that room. It was ours, anyway. Nobody could stop us.
I pulled out my little medal of Saint Kazimierz and looked at him and thought about how difficult the boy-saint's life must have been.
I hopped down onto the floor. I pulled open the drawers on the nightstands at the head of the double bed Shann and Robby were jumping on. There was a Gideon's Bible inside, but, naturally, there would be no condoms in Eden.
Every room had a Gideon's Bible in it.
Grady McKeon must have worked some kind of deal with those Gideon people. Maybe he promised to let them leave some sperm down here, besides just a bunch of Bibles, I thought.
We had no idea of the time when we were down in Eden.
We also had no idea about what was beginning to happen up above us in Ealing.
Nobody did.
## THE QUEEN OF THE UNIVERSE
WE FOUND EDEN'S library at exactly the same time the Hoover Boys and Grant Wallace found Eileen Pope and Hungry Jack in the alley at Grasshopper Jungle.
Now Eileen was very busy. She was getting filled up with the seeds of a new apex species for Planet Earth. She was happy. Eileen was the queen of the new universe. But she was hungry, too.
While Devin Stoddard, the same Hoover Boy who had kneed me in the balls the Friday before and was now a lumbering six-foot-tall mantis beast, pumped future generations of little Devin bugs into Eileen Pope's swelling abdomen, she pivoted her thoracic midsection around clockwise and clamped Devin's head in the toothy mace of her grasping arms. Devin Stoddard did not resist. He pumped and pumped and pumped. Devin Stoddard continued pumping semen into Eileen Pope even after she had eaten his entire head.
Eileen Pope was doing the two things bugs like to do.
The other bugs watched and waited. They wanted more turns on Eileen Pope, even if she was still hungry after eating Devin Stoddard. When Eileen Pope finished eating, the only thing left of Devin Stoddard was a gooey smear across the floral sofa in Grasshopper Jungle.
And, at the exact moment we found Eden's library and Eileen Pope was crunching her way through Devin Stoddard's exoskeleton to get to the slick and nourishing goodness inside her mate, Johnny McKeon was locking up From Attic to Seller Consignment Store for the night.
Johnny decided to take a box of garbage out to the dumpster in the alley of Grasshopper Jungle.
It was not a good idea.
## THE LIBRARY AND THE NEW TALLY-HO!
HISTORY SHOWS THAT an examination of the personal collection of titles in any man's library will provide something of a glimpse into his soul.
Such was the case with Dr. Grady McKeon's library beneath the ground.
Here was Dr. Grady McKeon's collection of books: There was a wall of novels. And every one of the novels in Dr. Grady McKeon's library was an American work. Also, every novel had been written by a man.
Before going down into Eden, I never knew that American men had written so many books and shit. The men who wrote the books in Dr. Grady McKeon's library weren't just guys, they were monuments, and had names like Melville, Hawthorne, Twain, Fitzgerald, Faulkner, Dreiser, and on and on. The most recent novel, if you could call it that, was The Old Man and the Sea, by Ernest Hemingway.
There was not a copy of The Chocolate War, however, but that stood to reason.
Another wall in Dr. Grady McKeon's library was filled with books on all kinds of scientific subjects: botany, evolution, taxonomy, genetics, and reproduction. The books on reproduction caught my eye. They were very old and conservatively worded, however.
But the most wonderful feature of Dr. Grady McKeon's library were the rows of desks, each of which had been furnished with supplies for writing and drawing.
It was meant to be that Eden would have its historian.
"This is meant to be," I said.
I sat down at one of the desks and looked through the assortment of pens and empty leather-bound logbooks. I felt around with my feet in the carpeting beneath where I sat. It was difficult for me to adequately concentrate on writing without Ingrid sighing under my toes.
So I said, "What am I going to do, Shann?"
Shann said, "I don't know, Austin."
Shann was smart. She knew I was troubled about things. She always let me have room. In some ways, Shann was like Ingrid.
"This is where I will write the history of the end of the world," I said.
Shann said, "Uh."
Then I picked up some thick permanent markers and opened their caps. Naturally, I smelled them. I do not know why, because that is not my job, but history shows that every time a teenage boy opens a permanent marker, he will first sniff it before deciding how to go about defacing the planet.
That is what I did.
On the empty wall above the desk where I sat, I drew a big hairy thing—a bison—in as close a likeness as I could manage to the figure that had been drawn so many centuries before on the wall of a cave at a place called Altamira. Maybe it was my great-times-one-thousand-grandfather who'd drawn the Altamira bison. It would have been back when the world was like this: messed-up and poisonous, and a few scared and confused specimens found their way inside a cave called Altamira that may just as well have been a silo called Eden.
They would have gone down in that cave to start things over again. Perhaps my great-times-one-thousand-grandfather also smoked cigarettes and wore a medallion of a virgin Polish saint around his neck. He would have experimented, too. Maybe he was also confused about the people he was in love with, and whether or not there was something wrong with him for frequently finding himself sexually attracted to the guy he grew up with.
You know what I mean.
Thinking about being inside a cave with Robby and Shann made me feel very horny.
Robby said, "Nice cow, Austin."
"It is a bison," I pointed out.
"Oh," Robby said. And he added, "Nice buff, Porcupine."
Robby and Shann were great friends, true friends. They both allowed me the space that I needed. While I wrote the history of our day inside Eden, Shann and Robby sat and waited quietly. But there was still much of the silo we had to explore, so I rushed and abbreviated, and when I was satisfied that I had gotten down the important details of our discovery, I tucked the logbook under my arm and led the way out of the library and deeper into the mysteries of Dr. Grady McKeon's sealed-in universe.
Just across the hallway from Eden's library was a bar.
An actual bar, inside a compound designed to resurrect mankind.
Robby said, "I christen this bar New Tally-Ho!"
"Eden Five needs a gay bar," Shann said.
"Everywhere needs gay bars, Shann," I pointed out.
This was true.
We went inside the New Tally-Ho!
In the same way the Eden No Coins Required Launderette put to shame the dirty laundry joint at Grasshopper Jungle, the New TallyHo! was immeasurably more luxurious than Waterloo, Iowa's one and only gay bar.
There were built-in wine coolers and every kind of liquor I had ever heard of in my life, and some others that I had not.
There was a bottle of something called Krupnik, which came from Poland.
Once again, all roads crossed where I stood.
The New Tally-Ho! was impressively furnished, with a wide mahogany serving bar and a floor-to-ceiling mirror behind racks of immaculately arranged bottles and crystal ware. There was a pool table with a perfect felt surface. It sat in the middle of the floor with plenty of space around for proper play. A dart board hung on one wall. The chalkboard beside it still recorded a match from four decades back, between someone named Doc and another player named Virgil. Doc, apparently, was not such a good dart player.
We killed this big hairy thing. We played darts. And that was our day.
None of us was in the mood to try drinking alcohol. Drinking was reckless, and made us unconcerned about doing stupid shit.
"Um," I said. "Let's not get drunk, Robby."
We agreed to save that experiment for some other time.
Robby knew what I meant.
After our trip through the bar, we found a medical clinic that looked like it was equipped to do surgery.
"Lots of drugs in here," Shann said.
"An entire navy of kayaks," I added.
Eden was built like a starfish. Its arms radiated outward from the room we called the lecture hall, which was just beyond the mudroom and lockers and showers, where Dr. Grady McKeon had somehow managed to install a salvaged antique Nightingale urinal.
At the end of the arm that housed the medical clinic, there was a full-sized bowling alley with two complete lanes and a rack of balls and shoes, all of which had been personalized with the names of their owners.
Seeing those relics, as well as the scoreboard that had been kept for darts in the bar, made me suddenly aware that all the first people who had ever been down inside Eden were most likely dead.
"This is kind of creepy," Shann said. She stared at a swirling pink bowling ball with dainty finger holes and a gold-etched name on it that said Wanda Mae.
Wanda Mae was the first Queen of Eden.
She was fertile, left-handed, and enjoyed having sex with multiple partners in Eden. Wanda Mae also liked to bowl.
People in Iowa liked to bowl.
Robby said, "Bowling creeps me out, too, Shann. Except for the fact that it is the only sport that encourages its participants to smoke cigarettes."
I wanted a cigarette.
I tapped Robby's shoulder. I did not have to say anything to him. Robby Brees always knew what I was thinking, even when I was thinking about something other than smoking.
We lit cigarettes and backtracked to the final unexplored arm of the place called Eden.
And there we found the most important treasure the silo had yet to offer up: Eden's Movie Theater.
I will tell you.
## VENTILATOR BLUES
BACK IN THE lounge, Robby uncovered a cache of reel-to-reel tapes in the cupboard below the tape machine.
"I would be happy to stay down here forever," Robby said.
"The future of mankind is . . . Um. Inside our jumpsuits," I said.
"I wonder what time it is," Shann said.
"It is time to begin the rebuilding of the universe with hybrid Austin-Shann-Robby offspring," I answered. I did not want Shann to think about leaving the silo.
Robby held up a box with a glossy black-and-white photo printed on its cover. It held a reel copy of Exile on Main Street.
"It's a miracle. This is like heaven," Robby said.
"Eden," I corrected.
Exile on Main Street, according to Robert Brees Jr., was the most brilliant rock album ever created.
"In Eden, it is permanently the nineteen-seventies," Robby affirmed.
"I never want to go home again," I said.
Robby wanted us to spend the night in Shann's silo.
He said, "Let's sleep here tonight."
"I'll cook dinner," I offered.
The opportunity was daring and thrilling to me. My heart raced with the thought of an Eden slumber party.
Shann said, "I can't spend the night with two boys. What would my mom say?"
I said, "She will probably say for you to use condoms."
"Shut up!" Shann answered.
"You are right, Shann. Eden needs us to not use condoms. It is our duty to repopulate Planet Earth with our handsome Iowan children," I said.
Robby threaded the new tape onto the machine.
Robby and I smoked. The three of us were having a beautiful time in Eden. We laughed, and I drew pictures of Shann and Robby in their jumpsuits, dancing together.
I asked Robby to recite Dulce Et Decorum Est, and he did. It was beautiful. I wanted to watch Robby kiss Shann. I wanted Robby to kiss her the real way, like I would, but there was no way Robby would just do something like that.
The song that played was called Ventilator Blues.
Everybody walking 'round
Everybody trying to step on their Creator
## SOMETHING ALWAYS HAPPENS WHILE SOMEONE ELSE DANCES
HERE IS WHAT happened while Shann and Robby danced together, and I fantasized about watching Robby put his tongue in Shann's mouth:
Johnny McKeon stepped out into the alley at Grasshopper Jungle. Johnny carried a cardboard banana box someone had left behind in the garage of a foreclosed home in Ealing.
Johnny McKeon intended to toss the garbage into the same dumpster that Hungry Jack ate from at least once per week.
Hungry Jack's real name was Charles R. Hoofard. Charles R. Hoofard was born in Indiana and had served in the United States Army in Vietnam, where he participated in the extermination of an entire village of women, children, and elderly people. Hungry Jack was now a claw-armed six-foot-tall praying mantis thing, and he was waiting in line to fuck Eileen Pope.
Eileen Pope had been breeding all day and she was near exhaustion. Eileen Pope was also a claw-armed six-foot-tall praying mantis that had just eaten her most recent sexual partner, the Hoover Boy named Devin Stoddard. Devin Stoddard kneed me in the balls on the previous Friday when he and his friends beat me and Robby Brees up for being queers.
I was pretty sure I was not exactly queer.
But I was not certain.
Devin Stoddard was born in Crete, Nebraska. He once got fired from a part-time job bagging groceries at the Hy-Vee for smoking marijuana in a parked car when he was supposed to be gathering shopping carts.
At that moment, Eileen Pope's husband, Travis Pope, was inside The Pancake House, which looked as though it had been fire-hosed with blood and ground meat.
Travis Pope ate nine people inside The Pancake House.
It was a terrible mess.
Travis Pope had been very hungry after fucking Eileen all day long, ever since they had hatched out in the wreckage of Travis's Nissan truck. Travis Pope also enjoyed the sugary taste of spilled imitation-maple-flavored syrup on raw human beings.
Travis Pope had never been a blueberry syrup man.
The imitation-maple-flavored syrup served by The Pancake House was made in New Jersey.
At the same time, Johnny McKeon opened the back door to From Attic to Seller Consignment Store, Eileen Pope clamped her four bristly upper arms into the woven fabric on the sofa in Grasshopper Jungle while Grant Wallace impregnated her over and over and over.
Hungry Jack and the two remaining Hoover Boys, who were also now claw-armed six-foot-tall praying mantises, postured and hissed with their toothy arms erect, sparring over who would get to deposit his semen inside Eileen Pope next.
Eileen Pope was nearly finished getting pregnant. She was as fertilized as a genetically modified cornfield in Kansas, and was getting ready to lay millions of squirming eggs. Eileen Pope was still hungry, too.
Eileen Pope decided she would eat Grant Wallace soon, and then she could go find a dark, protected place to build her foaming mass of eggs.
Johnny McKeon did not notice the breeding swarm of bugs as he walked out into Grasshopper Jungle carrying his box of refuse.
The box Johnny carried was full of VHS porno movies.
The movies were made in a place called the San Fernando Valley, which is near Los Angeles, California.
Johnny McKeon did not enjoy watching pornography anymore. He had grown out of that preoccupation. Johnny would have given the tapes to Ollie Jungfrau, but Ollie stayed home from work at Tipsy Cricket Liquors that day.
Ollie was lucky.
Ollie Jungfrau would have wanted those movies. Ollie was a connoisseur of porn, and he especially enjoyed sex films from the 1980s, which was when these particular ones had been made.
It was just past 8:00 on Thursday evening.
Ingrid was still sleeping beneath the desk in my bedroom.
Will Wallace was driving home from the Tally-Ho! in Waterloo. Will Wallace was drunk. He glanced at himself repeatedly in his rearview mirror, and he thought about the young man from Vinton, Iowa, who had been hitting on him during happy hour at the Tally-Ho!
The man who'd been hitting on Will Wallace was a paramedic. He was handsome and lonely. Will Wallace wondered what it would be like if he tried being queer. He had never experimented when he was a teenager, but he tried to imagine himself doing something sexual with the handsome young paramedic from Vinton. Will Wallace was drunk and excited by the thought. He was very horny by the time he got to Ealing. Will knew what he would do to his wife as soon as he got the chance.
Will Wallace had a vasectomy.
He thought about buying some condoms at Tipsy Cricket Liquors, just in case he ever got especially drunk and daring with anyone in Waterloo.
Will Wallace tried calling home on his cell phone, but there was no answer. Sometimes his wife got angry at him for coming home drunk after hanging out at Waterloo, Iowa's one and only gay bar. Will assumed his wife was not answering her phone because she was mad at him. The actual reason she was not picking up her phone was that she had been eaten by Grant Wallace, who was at one time Will's son.
Will Wallace decided to make amends for flirting with a gay man. He stopped off at Satan's Pizza and ordered a surprise Stanpreme for his wife and children. For dessert, he thought his wife, whose name was Dorothy, would like something sweet and alcoholic. So Will Wallace drove across the street to Tipsy Cricket Liquors, where he planned to buy some condoms for himself, and coffee liqueur and vanilla ice cream for Dorothy Wallace.
It was not such a good idea.
Here is what happened at Grasshopper Jungle while I watched and dreamed about Shann and Robby dancing together:
Johnny McKeon dropped his box of VHS pornos at his feet. He said something like What the hey? or Ain't that strange? when he saw the six-foot-tall bugs that buzzed and vibrated around the abandoned sofa in the alley.
Johnny McKeon never cussed.
Eileen Pope was crunching her way down through Grant Wallace's triangular head. Grant was still pumping his semen into her oviduct and his pinchers clamped rigidly into Eileen's thorax. One of Grant Wallace's arms broke off and it flexed, opened and closed, opened and closed, wriggling in the stew of piss and insect semen on the asphalt of Grasshopper Jungle.
Tyler Jacobson, one of the other Hoover Boys who was now a six-foot-tall, tooth-armed monster, picked up Grant Wallace's twitching arm and began eating it like a massive stalk of celery. Roger Baird, the remaining Hoover Boy bug, attempted to mount Eileen Pope and impregnate her as she ate Grant Wallace, who was also still joined with Eileen in the final act of making future clusters of little Grant Wallace larvae inside her.
Hungry Jack rotated his head toward the sound of the crashing box of porno tapes. His arms spiked high and his useless wings flared out from the carapace coverings along his backside. It was an impressive and threatening pose for a large male mantis. Then Hungry Jack came scuttling straight across the alley at Johnny McKeon.
Johnny probably said What the hey? again and fell back through the open door to From Attic to Seller Consignment Store.
Will Wallace was just pulling up to the front of Tipsy Cricket Liquors. He was horny and drunk, and the inside of his Volvo smelled like a Stanpreme. He did not even notice Travis Pope standing in front of The Pancake House. Will Wallace just took Travis Pope for someone having a cigarette break, as opposed to someone who had been transformed by Contained MI Plague Strain 412E into a gigantic carnivorous bug that was more powerful than a wild tiger.
By the time Will Wallace's eye caught hold of the unnatural form of Travis Pope, he was already within striking range of Travis's lightning-fast barbed arms. Travis Pope wasn't exactly hungry, but prey excited him as much as Eileen Pope's oviduct did.
Travis fired his clawed arms at Will Wallace and crushed Will's rib cage between them. Will Wallace did not even have time to gasp.
Travis carried Will Wallace, who thrashed and kicked uselessly, into The Pancake House. Travis Pope smeared Will Wallace's hair through a puddle of imitation-maple-flavored syrup. Then Travis ate him like a piece of French toast.
Johnny McKeon managed to slam shut the thick, solid-core door that opened from his secondhand store onto the back alley at Grasshopper Jungle. Johnny had stumbled upon the scene of cannibalistic bugs as big as grizzly bears that fucked and ate at the same time, which were the two things that bugs like to do.
Hungry Jack was a mere half second too slow to catch Johnny McKeon. As Johnny bolted shut the door, Hungry Jack punched his spiked arms into the wood. The barbs on Hungry Jack's arms bored two-thirds of the way through the door.
Bugs are not smart.
Hungry Jack could have easily hammered the door into toothpicks.
As soon as the door was shut, Hungry Jack forgot all about Johnny McKeon. Although he knew he was still hungry, Hungry Jack went back to wait on another turn with Eileen Pope.
Eileen Pope and the two surviving Hoover Boys were gone.
Hungry Jack sniffed and sniffed at the air, trying to smell her, but Eileen Pope was no longer emitting the powerful hormones that had attracted him and the other males in the first place.
Johnny McKeon was smart.
Since the break-in at Tipsy Cricket Liquors the previous Friday, Johnny had installed an alarm system that connected his businesses to the Iowa State Patrol.
Johnny McKeon activated his alarm.
The Iowa State Patrol, which operated from a substation in Waterloo, was alerted to an emergency at the Ealing Mall. A patrol car with a state trooper from Waterloo was on its way.
It was not a good idea.
At that moment, it was early morning in Germany. My brother, Eric Szerba, was lying on his back in a hospital bed. An intravenous needle pumped drugs and fluids into his arm, and other things had been taped to his body to tell whether or not Eric Szerba was still alive.
A thin plastic tube had been inserted into the opening of Eric Szerba's penis so he could urinate.
The tube was manufactured in Ohio.
It was called a catheter, as opposed to a Nightingale.
Eric pushed numbers on the display of a cell phone. Eric Szerba was calling me, but I left my phone inside my house. Eric Szerba would not have known that cell phones do not work in Eden.
Eric Szerba was also crying.
Ingrid rolled herself out from her place at my desk. She went across the room and pulled a pair of my discarded blue Iowa plaid boxers out from under the bed. She sniffed the boxers and rested her damp nose in them. This is what Ingrid did sometimes when she was lonely, or when she needed to take her mind off shitting.
It was Ingrid's silent way of kissing me.
Ah Wong Sing, who most people called Louis, kissed Connie Brees one last time before leaving the Del Vista Arms. Connie was in the shower. She was standing naked in the same grimy tub where I took a shower Tuesday before school. I had also vomited in that same bathroom.
Louis pulled the yellowed curtain back and looked at Connie Brees. He wanted to have sex again, but Connie told him no because her son would probably be home any minute now.
Connie Brees had to get ready for work.
She took two Xanax as soon as Ah Wong Sing left the apartment.
When the song finished playing, Shann kissed Robby and told him thank you for dancing.
It was not the kind of kiss I hoped to see. Shann kissed the side of Robby's cheek. I stared at Robby's perfect neck and jaw. Shann's breasts looked especially full and heavy beneath the shimmer of her jumpsuit. Robby was a little embarrassed. He knew what I was thinking.
Robby always knew what I was thinking.
Robby Brees turned red when Shann kissed him.
I lit a cigarette.
## LUCKY, IN POLISH BOY NAMES
GOOD BOOKS ARE about everything.
This is my history.
Andrzej Szczerba and Herman Weinbach became great friends.
Andrzej Szczerba was also my great-grandfather.
After they left the soup kitchen in Ames, Andrzej Szczerba and Herman Weinbach walked through the night. They tried to find a place where they could sleep and stay warm. They fed bread crumbs to Baby, who almost immediately began to impersonate Herman Weinbach.
Herman habitually used expressions like Ach! And Nu?
Baby began saying Ach and Nu, too. Andrzej thought it was funny.
The boys believed they were headed toward California, but the following day they took a ride from a family whose pickup truck had been loaded with all their household belongings, and Herman Weinbach and Andrzej Szczerba ended up at an abandoned farm outside of a place called Midvale, which was also in Iowa.
Nobody even knew the boys had moved themselves into the place.
They lived there together, with Baby, a talking European starling, for nearly a year. On their third night in the abandoned farmhouse, Andrzej Szczerba and Herman Weinbach slept together.
Herman Weinbach was homosexual.
At first, Andrzej found the situation to be awkward and frustrating.
What Herman Weinbach and Andrzej Szczerba did together evolved into something substantially more than an experiment. So Andrzej was confused, very much like his great-grandson, who would also be named Andrzej. But Andrzej Szczerba also enjoyed the closeness of sleeping with Herman Weinbach.
Andrzej had never kissed any person other than his mother, Eva Nightingale, and his father, Krzys Szczerba, in his entire life. Young Andrzej enjoyed kissing Herman Weinbach very much. Herman Weinbach was experienced, and Andrzej felt tremendous pleasure and satisfaction in sharing the sex the two of them enjoyed together.
Nobody knew anything about Andrzej and Herman.
They fell as deeply in love with each other as anyone in the entire history of mankind.
That is the truth.
Andrzej loved Herman, but he told him he would never become a Communist.
Herman Weinbach laughed about that.
Baby imitated everything the boys said to each other.
Baby said, Ach! Being a Communist homosexual Jew in Iowa is like being a bird that speaks Polish. And Baby also said, I believe I am in love with you, Herman Weinbach and I love you with all of my heart, Andrzej Szczerba.
The boys hunted and scrounged, sometimes begging for food to stay alive. They were very happy together in Midvale. Nobody bothered them at all. Baby flew around the house with them, and every night Andrzej and Herman slept together in their lovers' bed. They had found the bed in the home's attic on the morning after their initial experiment. They had pulled the bed down to the home's living room so they could sleep beside the fireplace, where they burned furniture and sometimes even the doors from kitchen cupboards to stay warm.
They loved each other.
In January of 1934, Herman Weinbach became ill with pneumonia. He died while Andrzej held him in bed.
Andrzej Szczerba was completely lost without Herman.
Andrzej asked the bird, What am I going to do, Baby?
Andrzej cried for days and days without leaving the house. Finally, Andrzej Szczerba wrapped Herman Weinbach's gray body in their bedclothes and he carried his friend out into the frozen winter.
Baby flitted around Andrzej Szczerba and lit on his collar or atop his head as the boy toiled at digging Herman Weinbach's grave.
All the while the bird sang out about how much Herman loved Andrzej, and vice versa. Baby said things that were sexual and suggestive, too—things the boys sometimes said to each other openly in the solitude of their squatter's home.
Andrzej Szczerba was like me in many ways. He was confused and troubled by things, and he loved his friend as much as it was possible to love anyone. But there were those things that set Andrzej Szerba apart from me, too.
This is what happened:
Andrzej knew he had to leave Midvale after he buried Herman Weinbach on the old farm. Maybe it was that he was crazy with grief. I believe that is the truth. Andrzej knew he could not keep Baby with him any longer. Baby said too many things that could make problems for a young man in Iowa in 1934. Andrzej Szczerba was eighteen years old in 1934.
Andrzej Szczerba killed his bird and left the farmhouse in Midvale, Iowa, on the same evening he buried Herman Weinbach's body in a ruined cornfield.
That spring, Andrzej Szczerba found himself in Iowa City. He was still greatly tormented over the things he had done with Herman Weinbach, and about losing everything he had ever loved.
Andrzej Szczerba needed to prove something to himself.
In this way, he was very much like me.
He found a job cleaning up at a butcher's shop. There, Andrzej met a young woman named Phoebe Hildebrandt. Phoebe Hildebrandt was plain and uninteresting at seventeen years of age. Her father was the butcher who had hired Andrzej to clean.
They knew my great-grandfather as Andrew Szerba.
Phoebe Hildebrandt and her father, whose name was Edmund, both took pity on Andrew because of his age, the softness of his features, and how quiet and sad the boy was. They never knew anything about Andrew's love for a boy named Herman Weinbach.
Andrew Szerba, whose Polish name was my name, Andrzej, also had bags under his eyes.
Andrzej means man in Polish boy names.
One night in June, Andrzej Szczerba and Phoebe Hildebrandt went for a walk. Andrzej forced himself sexually onto Phoebe. Phoebe Hildebrandt did not resist his advances.
Phoebe cried. Sexual intercourse was painful. She lay on her back in the dirt, wondering how long it would take for him to finish. But she also allowed Andrzej Szczerba to insert his erect penis into her vagina. The act hurt Phoebe Hildebrandt, who was a virgin.
Andrzej Szczerba wanted to find something out about himself, which he did. He found out he thought only about Herman Weinbach while he engaged in sexual intercourse with Phoebe Hildebrandt.
Afterward, Andrzej Szczerba was disgusted in himself, and he was disgusted by Phoebe and her uninteresting personality, too.
But Andrzej Szczerba's semen found its way deep into Phoebe Hildebrandt's body from that unloving sexual act in June of 1934 outside a place called Iowa City, Iowa.
Phoebe Hildebrandt was my great-grandmother.
In 1935, a boy named Felek Szczerba was born. This happened only two months after Andrzej and Phoebe were married.
Andrzej Szczerba never put his penis inside Phoebe Hildebrandt again after that first time beside a dirt road in Iowa City.
And that was our day. You know what I mean.
Andrzej loved Felek, his son, as much as he had ever loved anything, but Andrzej Szczerba was very unhappy.
Felek means lucky in Polish boy names.
Felek Szczerba's American name was Felix Szerba.
Felix Szerba was my grandfather.
## MOVIE NIGHT IN EDEN
THE THEATER IN Eden had half as many seats as the Cinezaar in Waterloo.
It was comfortable and clean. Like everything in Eden, the theater sat unused, brand-new, and at the same time it had been preserved like some kind of fossil.
This was where we learned the most about the history of McKeon Industries, and about the things that started happening up above us in Ealing after the unfortunate coincidence of Tyler Jacobson dropping the globe of Contained MI Plague Strain 412E directly onto Robby Brees's blood.
The screen of the Edenzaar was a bit smaller than the screen in Waterloo. The projector sat on a stand, atop a raised platform behind the rows of crushed velvet seats. But all things considered, it was one of the nicer movie venues in this part of Iowa.
Growing up, Robby Brees had always been projector monitor in our classes at Curtis Crane Lutheran Academy. He knew everything about how to operate a 16 mm film projector. It took no effort to get him to volunteer to see what had been left behind in Eden for our viewing pleasure.
As he searched through the cabinets behind us, Shann and I took seats in the back row. I slid my hand into the warm spot between Shann's thighs.
I said, "Eden Five needs you."
Shann said, "Eden Five has to wait until Eden Five grows up."
Robby held up a big steel canister of film and told us the movie inside was called Five Easy Pieces.
I thought it was a funny name, especially since I was Eden 5. I was waiting, too. I thought I was grown up. I wished Shann would ask me to go back to one of the dorm rooms with her while Robby experimented with the projector.
"Never heard of it," I said.
"It's from 1970. And it's probably the greatest movie ever made," Robby answered.
Robby missed being born at the right time by four decades.
My father, Eric Andrew Szerba, was ten years old in 1970.
Eric Andrew Szerba's Polish name would be Arek Andrzej Szczerba.
His father, Felek, who everyone called Felix, was thirty-five when Five Easy Pieces was made.
"You should have been alive in the seventies, Rob," I said.
"Hell yes," Robby affirmed.
We did not watch Five Easy Pieces that night. Robby found another stack of canisters that were labeled Eden Orientation Series. It felt like we were being indoctrinated into an army or some shit like that. And I hoped it was an army for repopulating the planet, so it made me very horny to think about my mission down here in Eden with Shann and Robby.
"Duty calls," I said.
Shann said, "Huh?"
I told Robby it was our duty to get oriented.
"We owe it to the world, and to history, to watch Eden Orientation Series, Robby," I pointed out.
There were three film reels in all. Robby and I noticed they were numbered One of Five, Two of Five, and Three of Five.
Two canisters of the five films were missing.
Robby also found reels of a film called A Clockwork Orange, but Reels Four and Five of Eden Orientation Series were nowhere in the theater.
That was because those particular reels were up on the roof at Grasshopper Jungle. They were there when we found a plastic flamingo with a steel spike coming out of its ass, a grimacing lemur mask that makes your face stink, and two bottles of wine, one of which Robby and I drank on Monday night in his bedroom at the Del Vista Arms.
It took me and Robby a while to figure that part out.
Not too long, though. We were probably a little more intelligent than most cave people.
You know what I mean.
Robby Brees fed the leader of Reel One into the projector, and a grainy numbered countdown squiggled and danced on the screen in front of us.
Robby hopped over the seats and sat beside me.
I was in the middle of Shann and Robby. I was always in the middle of them. It made me feel horny and awkward, too.
Most boys would have sat next to Shann.
Boys from Curtis Crane Lutheran Academy would never sit without an empty seat between them at a movie theater. That's what Lutheran boys do. They project their fear of being thought of as homosexual, so they do uncomfortable things like sit with empty seats between them, and then end up wondering if they or their friend on the other side of their sexual buffer zone might be curious about being gay. The uptight straight-kid Lutheran Boy Code of Conduct mandates the maintenance of THE EMPTY SEAT between boys in a movie theater, so you don't get any funny ideas about your friend, and nobody looking at you will think you're queer, either.
Lutheran Boys in Iowa know those rules and follow them like lemmings on a springtime jog.
But not Robby Brees. He sat so close to me, our knees rubbed against each other.
Shann knew Robby was in love with me.
How could she not know it?
She probably knew I loved Robby, too. I said it when we danced, after all. And I meant it. Shann definitely knew I was in love with her, too.
What was I going to do?
I felt nervous and guilty when Shann held my hand and Robby's knee pressed so comfortably against mine.
"I wonder if they have any popcorn in the cafeteria," Shann said.
"Or ice cream," Robby added. He touched my hand with his fingers. It electrified me.
"Call the roller of big cigars," I said.
That was the first line from my favorite poem, The Emperor of Ice-Cream.
The line sounded so sexually suggestive. It was like something Herman Weinbach might have said to his lover, Andrzej Szczerba. I felt myself turning a brilliant, heated red.
The film's sound came on just then.
And there was the face of Dr. Grady McKeon.
## THE GOOD DOCTOR ACCOUNTS FOR HISTORY
DR. GRADY MCKEON looked like an old movie star.
Well, he looked like an old movie star with a slight twitch in his right eye, which was magnified through the thick lenses of his black-framed glasses. Dr. Grady McKeon looked like an old movie star with a psychopath's twitch in his eye. He looked calm and reassuring, how you might imagine a serial killer to look at you while he was sharpening his knives and discussing which parts of your body produce the best-tasting sausage meat.
Dr. Grady McKeon also had a very small L-shaped scar between his eyebrows. When he was twelve years old, Grady McKeon was struck in the head by an unoccupied wooden swing. The swing was unoccupied because he had just pushed his younger sister, whose name was Arlene, onto her face.
Grady McKeon did not want his sister to be on the swing.
Arlene was not very talented when it came to sitting on things like bench seats on swings. In 1974, she fell from a ski lift in Jackson Hole and died.
Jackson Hole is in Wyoming.
Arlene was a real dynamo on snow skis. Not so much on ski lifts.
Dr. Grady McKeon was comfortable narrating the filmed history of his life's accomplishments. Grady McKeon's hair was perfect. He carried a strong resemblance to Shann's stepfather, Johnny McKeon, who was Grady McKeon's decades-younger and immensely less talented brother. Also, Grady McKeon had never physically abused Johnny the way he had inflicted harm on their sister, Arlene.
Arlene McKeon was also Miss Iowa in 1969.
Iowans love shapely young women with names that have lots of long rhyming vowels, even if their brothers are psychopaths.
The film was in black and white, but I feel safe making the claim that Dr. Grady McKeon's hair was the color of Smith Brothers licorice cough drops, and his skin was the same color as French vanilla non-dairy creamer.
Dr. Grady McKeon wore a blue-and-white Eden jumpsuit, too.
His jumpsuit was monogrammed, the same way a doctor's smock at a hospital would be. The monogram said:
DR. GRADY
EDEN
1
Reel One opened with Dr. Grady McKeon's personal message to the audience. It was a frighteningly sober introduction, despite the fact that Dr. Grady McKeon maintained a comforting butcher's smile while he spoke.
Dr. Grady McKeon looked like he was floating on a fistful of little blue kayaks. He could have easily been sitting across from us at a desk, selling us his top-of-the-line casket for our departed loved ones. Whoever that might be.
After his introduction, the film went through a history of McKeon Industries from its founding in 1957 through 1971, which was the year the Eden Orientation Series films were produced.
In 1971, a film called The French Connection won the Academy Award for Best Picture. Voting members of the Academy probably did not get a chance to see Eden Orientation Series.
This is exactly what Dr. Grady McKeon said at the beginning of his film:
Welcome to the Eden Project, my friends.
Welcome, welcome.
If there are any McKeon family members in the audience, would you please stand and make your presence known?
This is where Dr. Grady McKeon smiled and nodded and panned his head from one side of the screen to the other, as though he could somehow look out at us from his black-and-white celluloid universe.
"Stand up, Shann," I said.
"Stand up," Robby urged.
"This is so dumb," Shann said.
Shann stood up. Robby and I clapped for her.
Shann said, "Shut up."
Then Dr. Grady McKeon nodded and continued:
Thank you.
Each of you is fortunate to be part of the Eden Project. You are fortunate to have survived, but you also bear a tremendous responsibility to mankind.
You must breed, my friends. You must breed.
"You heard the man," I blurted out.
Shann said, "Shhh—"
Dr. Grady McKeon seemed to pause, anticipating the instructions he delivered might cause nervous comments among his audience.
Robby said, "Uh."
And Grady McKeon continued:
The event that brought you here today was one of two things.
First, if there has been nuclear fallout detected in the atmosphere, you would have been directed into the showers upon arrival. The world above is no longer habitable. You will be alerted as to when it will be appropriate to return to the surface. Until that time, this is the New World, my friends, and you all are the New Men and Women. The men and women of the future.
You have a responsibility to breed.
Do not despair.
I was not despairing.
Here, Dr. Grady McKeon looked very serious and clinical. The camera zoomed in so Dr. Grady McKeon's face occupied the entire screen. Grady McKeon's twitching right eyeball was as big as an Ozark watermelon. Dr. Grady McKeon stared directly out from the screen with the same expression a doctor performing a physical gets just as he grabs your balls and tells you to cough.
When a doctor grabs your balls, how can you think about coughing?
Coughing when someone is grabbing your balls requires as much concentration as riding a unicycle while carrying an Ozark watermelon.
History shows that when your balls are being grabbed, you can only think about your balls and nothing else.
"See? I told you that's why we're here," I said. "Eden Five needs us."
Shann pointed out that there was no nuclear war taking place at the moment.
"Nobody's dropped any bombs," Shann said.
It was something of a disappointment to me.
"Oh," I said.
Robby said, "Um."
Then Dr. Grady McKeon went on:
Second, in the event of a 412E alert, the world aboveground will unfortunately become an interspecies battlefield, tremendously dangerous for human beings. You must pay close attention to all the training films we have prepared. Your survival—and the future of humanity—depend on this.
Pay attention and breed, my friends.
Breed.
If the flamingo at the entry chamber did not activate a warning signal upon your arrival, then you are all safe and free from 412E contamination.
Make note: If the 412E event is more than twenty-four hours into its cycle, you must not return to the surface unless you have prepared the appropriate tools.
You will be instructed, my friends.
This is your new world, and you are the new race.
You are Unstoppable.
Please, do not despair my friends. I think you will enjoy living in this most remarkable world.
Live in love. Live in love.
Eden is love, my friends.
In Eden, a new human race will begin. It is your duty to do this. You will find the Eden Project Compound to have sufficient resources for years, perhaps decades. You must prepare to recapture the world from the mantid armies above. If you have arrived within the window of infestation, then you may be able to halt what will invariably be the end of the world.
But you must act.
Pay careful attention, my friends.
Pay careful attention and breed.
Then Dr. Grady McKeon smiled a very creepy smile, like he was imagining pornos from Eden. I happened to be imagining pornos from Eden, too, and they involved the three of us: me, Shann, and Robby.
The introduction shot lap-dissolved into old newsreel clips that took us through the history of Ealing, Iowa, and its most notorious scientist, Dr. Grady McKeon, founder of McKeon Industries.
Robby said, "What a fucking psycho."
Robby and I never dropped f-bombs.
Obviously, he was as impacted by Dr. Grady McKeon as I was, even if I did appreciate the frequent directive to have sex down there in our new world.
Shann squirmed in her seat. She said, "Uh. Am I wrong about something, or do you two boys actually know something more than I do about what he's talking about?"
I said, "Uh."
Robby said, "Uh."
## UNSTOPPABLE CORN! UNSTOPPABLE CORN!
ALL ROADS INTERSECTED at our feet.
We watched the first three reels of Eden Orientation Series.
This is what we learned:
Dr. Grady McKeon's original business venture, which he founded in Ealing, Iowa, in 1957, which was the same year that his little baby brother, Johnny, came into the world, initially developed fertilizers aimed at increasing corn yields. At that time, McKeon Industries had a workforce of three scientists, one secretary, and a man who drove packages in his pickup truck and swept the floors of the old service station Grady McKeon had taken out on lease. The fertilizer produced was a tremendous hit throughout the Corn Belt, and McKeon Industries expanded rapidly.
In 1961, which was the year after my father, Eric Andrew Szerba, was born, McKeon Industries moved into its main plant, the one that recently shut down in Ealing. At the new facility, Dr. Grady McKeon unveiled the redesigned company symbol.
The Great Seal of McKeon Industries looked like something you might find in an Ayn Rand novel.
Ayn Rand was an author who had no books at all on the shelves of Dr. Grady McKeon's library in Eden.
The new symbol for McKeon Industries depicted a gigantic woman, sitting calmly with her legs folded beneath her, apparently gazing out from her two-hundred-foot-high face upon the beautiful and fruitful fields of Iowa. She had an expression like she had just swallowed some blue kayaks.
They would have naturally been full-sized kayaks, since the woman was as tall as an oil derrick.
Arranged before her bare knees (she was wearing a modestly styled dress that adequately covered her perfect thighs), like a child's toys at Christmas, were hand-sized factories with smokestacks, a gleaming and modern steel locomotive, and, for whatever reason, a trio of bare-chested men in overalls working behind what looked like yoked teams of oxen.
Ahead of the unnaturally enormous woman, perfect rows of sequoia-sized cornstalks grew, stretching off forever into the Iowa horizon. And inscribed around the curving edge at the bottom of the McKeon Seal were the words:
INFINITA FRUMENTA! INFINITA FRUMENTA!
Infinita frumenta! is Latin for Unstoppable Corn! or some shit like that.
You could pretty much put anything you wanted to in Latin at the bottom of a picture and people in Iowa would either beat you up, or think you were a messenger from God.
Dr. Grady McKeon believed he was God.
He preached the gospel of infinita frumenta.
History provides evidence that infinita frumenta made Dr. Grady McKeon one of the Cold War's largest profiteers. His success entirely resulted from an accident of nature.
In Reel Two of Eden Orientation Series, Dr. Grady McKeon narrated from off-camera as we saw clips of hardworking scientists in perfectly clean white lab coats, while they peered into microscopes and tilted their cigarettes with smirking intelligence and engaged in academic discussions with one another.
Scientists loved a good smoke back in the 1960s.
There were also ashtrays built in to the armrests of the Eden theater. When Robby and I saw those smart, hardworking scientists lighting up their fags, we couldn't resist the urge to join them.
It was our duty to smoke along with the Eden Orientation Series.
"Ahhh . . . ," I said, after I took a drag.
"Ahhh . . . ," Robby said.
In the 1960s, infinita frumenta meant that McKeon Industries was working toward the development of corn plants that could not be eaten by insects.
Unstoppable Corn.
Like smoking cigarettes on the job, they probably thought Unstoppable Corn was a good idea at the time.
Scientists working for Dr. Grady McKeon experimented with corn.
I know that's an oddly funny thing to say, and I may have to strike that line from my history book, but that's what they did.
They experimented with corn.
Scientists at McKeon Industries, like Robby Brees and I, had no idea what the results of their experiment would be, but they did it anyway.
Dr. Grady McKeon and his colleagues attempted to blend genetic material from the semen of grasshoppers into the pollen from corn plants.
Pollen is plant sperm.
It was not a good idea.
The corn they produced from their plant-sperm-and-grasshopper-semen experiment was lively and strong. It was also true that, as hoped, bugs would not eat it. It was unstoppable. Dr. Grady McKeon was very happy. His company's stock was worth an incalculable fortune.
Fortune is also an odd word.
Unfortunately, the corn that was produced by the plant-sperm-and-grasshopper-semen experiment at McKeon Industries also caused an undesirable side effect in teenage boys: Their balls dissolved.
Testicular dissolution among developing adolescent males, is how Dr. Grady McKeon described it.
That sounded nicer.
If a doctor told me, "You are merely experiencing testicular dissolution," it would not frighten me nearly as much as if he said, "Your balls are going to dissolve, Austin."
Actually, the scientists from McKeon Industries at first concluded that their Unstoppable Corn only caused boys undergoing puberty to have their balls dissolve. That was because the slightest amount of Unstoppable Corn affected adolescent boys that way. Ultimately it was discovered that Unstoppable Corn would pretty much dissolve anyone's balls if you ate enough of it, and if you also had balls.
Enough of it turned out to be about an ear and a half.
The corn that was harvested in all the McKeon farms across Iowa that year was shipped as a goodwill gesture from the United States of America to the people of Canada.
That was the end of Reel Two.
Robby and I both squirmed at the thought of eating some of the McKeon plant-sperm-and-grasshopper-semen corn. We also felt sorry for Canada.
"I am never eating anything with corn in it again," Robby said.
"Do they even make food that doesn't have corn in it in Iowa?" Shann asked.
"Uh," Robby said.
I wondered, "Did Dr. Grady McKeon ever get married?"
"It seems like he probably practiced breeding a lot," Robby said.
"He never was married," Shann answered.
"Maybe he ate some of his own corn," I suggested.
"I need a cigarette," Robby said.
We found out later that Dr. Grady McKeon, indeed, did not eat his own corn and experience testicular dissolution. You will see.
INFINITA FRUMENTA! INFINITA FRUMENTA!
## THREE OF FIVE
REEL THREE, WHICH was the final part of the film we saw that night, ended on a cliffhanger.
Dr. Grady McKeon's Eden Orientation Series Part Three was a true corker.
At the end of it, all I could say at first was, "Holy shit."
Robby said, "Holy shit."
Here is what happened in Reel Three:
Fortunately for Dr. Grady McKeon and his company, it turned out that during the 1960s anything that could look like corn and make your balls dissolve was of tremendous interest to the Department of Defense. McKeon Industries received its first of many lucrative contracts to develop Unstoppable Weapons and, later, Unstoppable Soldiers.
That was how the six-foot-tall, tooth-armed mantises that were more powerful than grizzly bears came about. But that was through an accident of nature, too.
By 1965, McKeon Industries employed 2,700 people in Ealing, Iowa.
In 1965, Ealing, Iowa, was a Cold War boomtown.
That year, my father, Eric Andrew Szerba, who had been baptized in the Catholic Church, enrolled in kindergarten.
After the mishap with the grasshopper-semen-and-plant-sperm experiment, McKeon Industries went to work on a variety of theoretical methods aimed at stopping the global spread of Communism. There were multiple units within the scientific department at McKeon Industries, each of which was developing its own creative anti-Communist ideas.
One of the units worked with the Unstoppable Corn material. In that particular lab, scientists attempted to invent some type of delivery system that would result in the testicular dissolution of enemy armies.
Nobody would ever take an army of Communists without balls seriously.
Another of the units worked on a human replication project. It was a first attempt to actually clone soldiers. That was where the human head, penis, and the praying hands in the jars came from. Robby and I found those when we broke into Johnny McKeon's office the night we climbed up on the roof at Grasshopper Jungle. The Human Replication Unit was also where the little two-headed boy was created.
We found this out later.
Reel Three of Eden Orientation Series involved Robby and me in ways we never anticipated.
This was how it happened:
The film showed how the Unstoppable Corn lab team had been extracting cellular material from crop yields that had been stored in a silo on one of the remaining McKeon Industries Unstoppable Corn farms.
Their goal was to dissolve Russian balls around the world.
Later, I did find out by researching archived records in Eden that President Richard Nixon also brought some of Dr. Grady McKeon's Unstoppable Corn to China as a gift. In what was called Eden's Brain Room, I discovered a black-and-white photograph that showed the prime minister of China, a man whose name was Chou En-lai, eating some of Dr. Grady McKeon's Unstoppable Corn while the president of the United States of America looked on and smiled warmly.
Prime Minister Chou En-lai's balls dissolved.
When the Unstoppable Corn team began off-loading silos of Unstoppable Corn in Iowa, they discovered the corn, when decaying, produced a new variety of mold that they had never seen before. They had never seen it before because the mold was an accident of nature. The mold gave off a blue photoluminescent glow.
This second accident of nature became known as Plague Strain 412E.
There was no significance to the 412E part of the name. The marketing division of McKeon Industries believed the name sounded good for a sales pitch to the Defense Department, as though it came about after hundreds of trials and tests. In reality, 412E was just an accident of nature that occurred when scientists attempted to splice together the genetic material from grasshopper semen with plant sperm and fertilize corn with it.
Scientists at McKeon Industries took the mold into their labs, where they grew great heaps of the stuff inside long glass boxes that looked like massive aquariums. They didn't know what to do with the mold, but they were fascinated by the sponge-like form of the mold, and how it moved and pulsated, and gave off light.
Despite seeing it in the black-and-white film, Robby and I recognized the familiar glow of the 412E mold when the camera captured its luminescence after the scientists in the film turned off the laboratory's lights.
Dr. Grady McKeon, the film's narrator, said this:
Behold the wondrous glow of a new being!
I said, "Uh."
Shann said, "He's a little overly impressed by something that looks like rotten cauliflower."
"That's the same shit Johnny had in his office," Robby said.
"What is?" Shann asked.
"That shit," I said.
Robby added, "Um. Yeah."
Robby Brees and I had some explaining to do.
"Your stepfather," I said. "He had some of that stuff inside his office at From Attic to Seller Consignment Store. Robby and I saw it."
"When were you inside Johnny's office?" Shann asked.
"Shh—" Robby said, playing the part of the irritated moviegoer who is distracted by talkers in the theater. "Be quiet and listen to the film."
Here was where Eden Orientation Series turned into a horror show.
It turned into a horror show for two reasons.
First, the scientists who were working on the Unstoppable Corn/Unstoppable Soldier project decided to try mixing the genetic material from the mold with a fresh sample of human blood.
They decided to use Dr. Grady McKeon's own blood.
Dr. Grady McKeon thought of himself as a kind of God. So he drew his own blood to mix with the genetic material from the photoluminescent mold.
It was not a good idea.
The idea to mix human blood material with the 412E mold was even less reasonable than laboratory scientists deciding it was a good idea to smoke on the job and screw around with grasshopper semen by grafting it into plant sperm and injecting it into corn seeds.
Dr. Grady McKeon's blood made the 412E mold very happy.
Here was the beginning of the end of the world, and it took place in the 1960s.
"This is the shit that was drawn on the blackboard in the lecture hall," I said.
"Huh?" Shann said.
Robby said, "Uh-oh."
It was all starting to come together.
The roads were intersecting.
But it got worse, too.
I said, "Robby, hop back there and freeze the film on that part."
Robby, who was our projector monitor, said, "What?"
I said, "Back up to that part where the scientist is adding blood to the petri dish and stop it on that frame."
Robby did what I asked him to do.
And here was the second reason Eden Orientation Series truly turned into a horror show right before my eyes: The scientist who was feeding the human blood host to 412E, who also happened to be starting an initial infestation event, looked exactly like my father, Eric Andrew Szerba.
Of course, the scientist in the film could not be my father because Eric Andrew Szerba would have been a kindergartner at exactly the same time that portion of the film was shot.
"Hey, Porcupine," Robby said, "that guy looks exactly like your dad."
I said, "Uh."
Shann agreed, "He does look exactly like your dad, Austin."
The film was grainy, but we all could see how the scientist's lab coat had been monogrammed with a name: FELIX SZERBA
It was my grandfather, Felek Szczerba, whose father, like me, had been born with the name Andrzej.
Felek Szczerba, whose American name was Felix Szerba, was the first victim of McKeon Industries Plague Strain 412E.
Nobody knew anything about it.
They sure found out fast, though.
As we let the film play through, Dr. Grady McKeon's voice spoke over a series of frozen pictures. The pictures showed the faces of the scientists and secretaries who worked with Felix Szerba at McKeon Industries. Dr. Grady McKeon explained how these brave patriots lost their lives while developing an Unstoppable Soldier to fight against Communism.
Unfortunately, the Unstoppable Soldiers McKeon Industries created were nothing more than accidents of nature resembling six-foot-tall praying mantises with lightning-fast arms that were studded with rows and rows of needle-sharp, barbed teeth.
Unstoppable Soldiers liked doing only two things: fucking and eating.
They were also nearly impossible to stop.
Dr. Grady McKeon said that, through research, scientists at McKeon Industries did find one way to stop his Unstoppable Soldiers.
And that was exactly when Reel Three of Five ended.
"We need to go back," I said.
Robby said, "Uh."
Shann said, "Back where?"
"We need to go back to Grasshopper Jungle. Robby and I need to go back up on the roof. We left something there," I said.
"What did you two leave up there?" Shann said.
I could have said a lot of things about what Robby Brees and I left behind up on the roof of Grasshopper Jungle.
I said, "The rest of this film is up there. Shann, we need to see the rest of this film."
Shann said, "Oh."
And Robby said, "And I think we need to hurry."
## THE ORPHAN FELEK
FELEK SZCZERBA WAS nine years old when his father was killed.
It happened at a place called Cisterna.
Cisterna is in Italy.
Andrzej Szerba had joined the United States Army in 1942. He enlisted in the Army because he wanted to fight against Hitler, and because he was so unhappy living in Iowa with Phoebe Hildebrandt.
Andrzej Szczerba was homosexual, but nobody knew anything about that.
The only person who ever knew about Andrzej Szczerba's homosexuality was Herman Weinbach.
Herman Weinbach died from pneumonia in Midvale, Iowa, in 1934.
Andrzej Szczerba never got to meet Herman Weinbach's uncle, a man named Bruno Wojner, who performed with Bruno's Amazing and Incredible Dogs with a circus in California.
In the summer of 1944, Andrzej Szczerba was shot through the back of his head while he was crouching down to take a shit in a little place called Cisterna, Italy. He received a medal for getting killed while shitting.
Andrzej Szczerba's great-grandson, Eric Christopher Szerba, also received a medal for having his balls torn off by an unstoppable homemade bomb.
Dulce Et Decorum Est.
Felix Szerba was very intelligent. He graduated from high school in Iowa City at the age of fourteen. His mother, Phoebe Hildebrandt, remarried when Felek was ten years old.
Phoebe Hildebrandt began having sexual intercourse after the long lonely spell that followed the time Andrzej Szczerba stole her virginity and gave her his son, Felek.
Phoebe Hildebrandt hated Felek's name.
Against Felek's will, Phoebe Hildebrandt had her new husband, whose name was Daniel Barton, adopt the boy and change his name to Felix Barton. It is a little-known fact of history that I was nearly named Austin Barton, a name that has the kind of ringing sound Iowans appreciate.
Daniel Barton owned a radio station in Iowa City. He was fifty-two years old when he married Phoebe Hildebrandt in 1945.
Daniel Barton also had defective semen. He had a low sperm count, but Daniel Barton never knew anything about it. He never knew because his wife, Phoebe, became pregnant three times from three different men before Felix graduated from high school.
Daniel Barton was convinced he had very powerful sperm.
Phoebe Barton was a real dynamo at having sexual intercourse with numerous men in Iowa City.
Phoebe Barton was unstoppable. She liked doing exactly the same two things that bugs like to do.
Phoebe Barton never knew how much she would enjoy sexual intercourse until Andrzej Szczerba was shot in the head while taking a shit. Before that, Phoebe only believed that sexual intercourse was painful, interminably long, and sad—and that it would make you bleed. Phoebe Barton's three new children—a boy named Eldon Wayne and two girls, Chastity and Linda—were presumed by everyone to be full-blooded Bartons. Daniel Barton believed it, too.
Phoebe Barton's youngest daughter, whose name was Linda, was a product of semen that was produced in the testicles of Felix's high school physics teacher.
After Felix Barton, whose real name was Felek Szczerba but was called Felix Szerba by American people, graduated high school at the very young age of fourteen, Daniel Barton and his wife, Phoebe, enrolled the boy into Stanford University.
Stanford University is in a place called Palo Alto, California.
Palo Alto means tall stick in Spanish.
There are big trees near Stanford University.
Spanish missionaries were real good at naming shit.
Felix Barton was very lonely and unhappy in California. At Stanford, Felix tried to kill himself once by mixing chemicals that created a poisonous cloud of gas.
It was not a good idea.
Felix Barton only ended up burning the lining of his airways. As a result, Felix Barton, who had been born Felek Szczerba, had a chronic cough for the rest of his life.
After he graduated the university, Felix had his name legally changed back to Felek Andrzej Szczerba. He sometimes went by Felix Szerba, because Americans get so uptight about all those bunched-up consonants and shit like that.
Felek married a Catholic Polish girl he met in California. His wife was named Ksenia. She was very beautiful. Ksenia Szczerba was my grandmother.
Unlike his adoptive father, Daniel Barton, Felek Szczerba did not have any problems at all with his sperm.
In 1960, when Felek was twenty-five years old, his first son, Arek Andrzej Szczerba, was born. Arek Andrzej Szczerba was my father, Eric Szerba.
Felek and Ksenia Szczerba had four more strong Polish sons together. Their names were Krzys, Mieszko, Gabrysz, and Jacek.
In 1965, Felek Szczerba and his family moved back to Iowa, to Ealing, where Felek accepted a position in the research laboratories at McKeon Industries.
In 1968, Felek Szczerba was killed in a motorcycle accident. The history recorded in the Waterloo paper described how Felek Szczerba apparently lost control of his motorcycle and ran himself beneath the wheels of a freight car that was carrying liquid fertilizer.
The fertilizer was made in Ealing, Iowa.
What actually happened to Felek Andrzej Szczerba that day was this: Felek Andrzej Szczerba hatched out.
Felek means lucky.
Felek Szczerba was the first Unstoppable Soldier.
# PART 4:
THE END OF THE WORLD
SAINT KAZIMIERZ WAS not an Unstoppable Soldier.
When he was a teenager, his father ordered Kazimierz to lead the army of Poland to conquer Hungary. Some Catholic scholars claim Kazimierz refused to do it. They say Kazimierz did not refuse because he was afraid. Kazimierz refused because he thought it was unjust to go to war against Hungary. Some historians claim Kazimierz, who was only thirteen at the time, went to war, but was defeated.
Hungarians may have masturbated less often than Polish boys. This is probably true.
Kazimierz's father punished him for not going to war. It is difficult to imagine how you could punish a boy for not going to war. It is kind of like punishing a boy for skipping dinner by giving him cake.
In order to resist sexual temptation, Kazimierz wore a hair shirt, which was something coarse and irritating that was made from goats' hair. Devout people like Kazimierz would wear this garment as underwear so it would rub against their skin. The only purpose of a hair shirt is to cause injury and pain. Some historians claim that Saint Kazimierz may have worn his hair shirt in direct contact with his penis.
Hair shirts work like dynamos.
Nobody makes hair shirts nowadays.
## WE, THE NEW HUMANS
I TOLD SHANN Collins everything that night.
I told her about what happened at Grasshopper Jungle. I said Grant Wallace and the Hoover Boys had broken into the place looking for alcohol, and that Robby Brees and I should not have been there, but we were. I told Shann Collins what we found inside Johnny McKeon's office, and how Tyler Jacobson dropped the glass universe and splattered what we knew was 412E all over the alley behind From Attic to Seller Consignment Store.
This is what I said to Shann Collins: Robby Brees drove me out to Waterloo, so we could look into the future. We went to the Tally-Ho!, where a homeless man we called Hungry Jack stepped in front of the path of a speeding Dodge truck, and then this horrible creature hatched out of his body and ate him.
Shann had to go home. It was late.
Shann changed out of her Eden Project jumpsuit. She could not go home dressed in a strange uniform. Wendy McKeon, Shann Collins's mother, was one of those types of mothers who paid attention to things like what their children were wearing when they left the house. Wendy McKeon would ask questions, and we did not want anyone to know about Shann's silo.
Nobody knew anything at all about Eden.
Robby Brees and I kept our Eden Project jumpsuits on. We left all our clothes, except for our shoes, down inside the silo. Wearing the jumpsuits made us feel like we were an Army or something. It made us feel like we belonged together.
Anyway, Robby Brees and I had some shit to do.
Nobody would ever know if Robby and I didn't go home that night.
It was 8:30. Shann had missed dinner with her family. Her cell phone hadn't worked when we were down inside Eden. She was going to be in trouble. Good Lutheran kids in Iowa do not forget to come home for dinner with their families.
Coming up out of Eden under a big, black, star-filled Iowa sky made us feel like we were climbing from a spaceship and onto the surface of some alien world. Everything was different.
We were the New Humans.
That was exactly what Dr. Grady McKeon told us we were.
Robby waited for me in his old Ford Explorer, so I could walk Shann to the front door of the McKeon House. I asked her if she wanted me to say something to her mom or to Johnny McKeon, but Shann said no, that she was going to be in trouble and I couldn't possibly make things better.
So I hugged Shann. It felt really good squeezing my body against hers in my jumpsuit, like I wasn't wearing anything but my boxers. I kissed her for a long time and ran my hands up and down from her butt to her shoulders. I was trying to get her to accept Dr. Grady McKeon's advice about our mission. I had forgotten all about Robby waiting in his car and about big monstrous bugs. I pressed my hips into Shann's.
That was exactly when Shann whispered, "I think Robby is in love with you, Austin."
I felt a lump in my throat, and I asked Saint Kazimierz to make things okay.
"Uh," I said.
"I can tell he is," Shann said.
I said, "Is there something wrong with that?"
Shann backed away from me a half step. Her eyes tracked up and down, up and down, all over my body. Jumpsuits are no good for hiding erections. I tried to adjust myself.
Shann said, "Is there something wrong with that? Don't you think there's something wrong with that, Austin?"
"Uh," I said.
I honestly did not think there was anything wrong with Robby Brees being in love with me.
I was probably wrong about that.
Shann said, "Have you guys ever done anything?"
I felt all the blood draining out from every part of my body. It felt cold and wiggly.
"What do you mean? Like skate? We do lots of things," I said.
I do not lie. It is my job not to ever lie.
I wanted a cigarette.
"Have you ever kissed Robby?" Shann said.
I had to tell her. I loved Shann, and I do not lie.
"Um. Yes," I said.
"Oh," Shann said. "Like, I mean, a real kiss?"
"Yes, I did," I said.
I looked away. I was suddenly aware that Robby was waiting. I could hear the clunk-clunk-clunk of the old Ford's engine.
Shann backed up against the front door.
Then Shann said, "Have you and Robby ever had sex with each other?"
"Uh. Um," I said, "no."
I did not lie to her.
"Come on, Shann. Please." I said, "You know I am totally in love with you."
Shann looked as though I'd just kicked her in the stomach. She did not say another word. She went inside and closed the door behind her. I heard the sound of the deadbolt turning within the door's locking mechanism.
And that was my day. You know what I mean.
What was I going to do?
The end of the world was nearly one week old.
The end of the world was nearly one week old and only three people in Ealing knew about it: Me, Robby Brees, and Shann Collins.
## LAST LEGS
ROBBY SLID A PACK of cigarettes across the top of the dashboard toward me when I climbed into his car.
He did not say anything.
I did not say anything.
Robby could tell something else had gone wrong. Another something else. Robby always knew everything about me.
I lit a cigarette.
The engine clunked and clunked.
"This car's on its last legs," I said.
## DAVY CROCKETT AND DANIEL BOONE NEVER WORE COONSKIN CAPS
ROBBY TOOK ME home. I needed to get my history books, and Ingrid, too.
I wanted to take Ingrid with us to Eden.
Maybe I was crazy with grief. Maybe all the shit—thinking about my brother, Eric, my grandfather, Felek, and his lost and sad father, Andrzej, poor Herman Weinbach who loved him, Saint Kazimierz, Shann Collins, and the talking European starling named Baby—playing all of those thoughts through the reel-to-reel between my ears made me feel like I was all alone and standing on the edge of a razor blade.
Robby played one of his father's old cassette tapes in the Explorer.
We listened to Exile on Main Street.
And the car shuddered past Curtis Crane Lutheran Academy, which was located in Ealing, Iowa, on Main Street.
"So. You want to tell me about it, Porcupine?" Robby said.
I knew what Robby was talking about. I played dumb, anyway.
I said, "Tell you about what, Rob?"
"What happened between you and Shann back there. That's what," Robby said.
"Oh." I said, "Nothing."
History does show that nothing means a hell of a lot more than nothing when teenagers talk. In this case, Robby knew it meant that I did not want to talk about it, so he left me alone.
Robby Brees was such a good friend.
It was awkwardly quiet inside my empty house with Robby Brees that night. It was one of those exceedingly dumb moments where I did not know whether I was supposed to actually say something to him. I felt myself wanting to act like an asshole to Robby again, so I closed my eyes and asked Saint Kazimierz to help me shut the hell up.
Ingrid came bounding for the door as soon as we were inside. She ran out into the nicely mowed front yard.
I left the door standing open, a kind of message to anyone passing by that Robby Brees and I were not conducting experiments inside my house while my parents were gone.
Robby knew what I was doing.
Leaving the door open like that was the kind of thing an uptight asshole would do.
I grabbed my cell phone from the coffee table where it had been sitting all day. I saw that I'd missed a phone call from Eric, my brother. Eric left a message. I sat on the sofa and listened to my brother's voice. Robby stood by the door and watched me. He knew what was happening. We were soldiers in this together, wearing our Grasshopper Jungle uniforms.
Robby Brees and I could be unstoppable, too, if we told ourselves to be.
This is the message Eric left for me on my phone:
Hey, Booney. I miss you and I hope you're out having fun and smoking cigarettes and shit like that. I wish you were here instead of Dad and Mom. I'm sorry if I scared you or anything. I'm going to be okay, Booney. I promise. You be okay, too. I'll see you soon.
When I was nine years old and Eric was fifteen, my family took a trip to Nashville, Tennessee. I still do not understand why we went to Nashville, but I do remember that my mother and father enjoyed the trip quite a bit.
Because Eric was a teenager, my father and mother would go out at night and listen to music. They felt comfortable leaving my brother and me alone at our hotel.
Eric was mature and sensible enough at fifteen to take care of me.
These days, mothers and fathers end up in jail for doing shit like that. At least, you frequently hear terrible stories about what happens to kids left alone in hotel rooms, even if the kids happen to be sensible and mature.
While we were in Tennessee, my father bought me a fake coonskin cap, which I wore for so many continuous days and nights I began to develop a bald spot on the back of my scalp. My bald spot was right below the place on the cap where a plastic button had been stitched to the inside, in order to secure the fake raccoon tail.
The coonskin cap was a souvenir from a place called Crockett-Land.
The coonskin cap was made in China.
Richard M. Nixon, president of the United States of America, brought some Unstoppable Corn to China in 1972. He used the Unstoppable Corn to dissolve Prime Minister Chou En-lai's balls.
To my knowledge, my fake coonskin cap did not adversely affect my balls.
CrockettLand sold souvenirs that cashed in on a man named Davy Crockett, who was a frontiersman from Tennessee.
Eric started calling me Booney that summer when I was nine and he was fifteen because he said I looked like Daniel Boone, who was also a frontiersman from Pennsylvania.
History shows that neither Davy Crockett nor Daniel Boone ever wore coonskin caps, but movies made people believe they did. Meriwether Lewis wore coonskin caps, however.
I was happy my brother did not start calling me Meriwether.
I do not know if movies ever showed Meriwether Lewis wearing a coonskin cap. When you think of exciting movies about frontiersmen, you tend to think about Daniel Boone and Davy Crockett, as opposed to some guy named Meriwether.
Movies made people believe a lot of shit about history.
Robby Brees and I believed what we saw in Eden Orientation Series.
It was the truth.
There were two prostitutes who lived in the same hotel in Nashville where we stayed.
One night, Eric and I were playing catch with a foam rubber football out on the balcony that connected all the rooms on the third floor, which was the floor our room was on. We said hello to the prostitutes.
The prostitutes were named Tiffany and Rhonda.
I do not know their last names.
History shows that a lot of prostitutes do not necessarily need last names.
Tiffany had hair the color of whipped sweet potatoes and skin like creamy hot cocoa. Rhonda had lemon meringue hair and always wore lipstick the color of cotton candy.
Eric knew what Tiffany and Rhonda were doing. I thought it was curious how my brother would watch Tiffany and Rhonda come and go, and come and go, and how Eric always acted so nice and proper toward them. The girls winked at us both, and sometimes Tiffany, who was quite fat, would comb her hands through Eric's hair and flirt with him suggestively, and rub the back of my neck with her thick warm fingers.
Tiffany and Rhonda were very nice.
On the third night, Eric went into Tiffany and Rhonda's room with them.
Eric left me alone on the balcony for nearly an hour. It may have been more or less than an hour. When you are nine years old, five minutes can seem like a week, more or less.
When he came out of Tiffany and Rhonda's room, Eric looked pale, like he was sick or something. Eric's hair was sweaty around his ears and along the back of his neck, and somehow his T-shirt had been turned backwards and inside out. Eric's eyes were funny, too, like he was sleepy and startled at the same time.
I asked him why he left me alone, and Eric told me that Tiffany and Rhonda gave him a blow job.
To me, hearing that those girls gave my brother Eric a blow job sounded very nice.
History shows that all boys consider blow job to be a nice-sounding set of words.
I thought a blow job was putting your face in front of an air conditioner, which is something all nine-year-old boys love to do, even though Eric did not look like he had been cooled off very much.
I asked Eric if Tiffany and Rhonda would give me a blow job, too.
Eric laughed and laughed.
Then he told me what a blow job was.
Eric lifted up his shirt and showed me how there were perfect kisses of cotton candy lipstick all down below his freckled, cream of wheat belly and over both of his nipples.
At that time, being nine years old and dressed in a coonskin cap in Nashville, Tennessee, as I was, I could not understand at all why anyone would ever let someone give them a blow job.
I listened to my brother's message a second time. I realized I'd almost forgotten how Eric liked to call me Booney.
Sometimes, when I teased Eric afterward, during that summer when he was fifteen, I would call him Cotton Candy and Eric would get embarrassed in front of my mother and father, and tell me to shut up, too.
While I listened to my brother's voice, a text message came in from Shann Collins. It said this:
You are disgusting.
I did not even know that I was sitting there on my sofa in my living room crying.
I don't cry.
I suppose I was tired, and disappointed, too, for what I had done to Shann and Robby, and especially because I missed my brother and I wanted him to get better, even if I knew nothing would ever be better than it was for Eric and me on those summer nights when we played catch and shit like that, all alone in that hotel in Nashville.
Robby put his hand on my shoulder and shook me.
He said, "Hey. Hey. Don't do that, Austin."
I wiped my face and told Robby I was sorry for crying.
Then I went back into my room and grabbed my history books.
It was a heavy stack.
## GARLIC, DR PEPPER, AND CRYSTAL METH
WE WERE NOT heading toward Grasshopper Jungle.
I said, "Robby, where are you going?"
Robby said, "I need to go to my house. I need to grab some shit, too."
Ingrid curled up on the backseat. I reached between Robby and me and stroked her fur.
"You're a good dog, Ingrid," I said.
There was something unnaturally still and menacing about the night. Maybe I was only working myself up, getting too emotional.
Ealing would always be a ghost town. It just felt like more of a ghost town that night, after Robby parked the Explorer along the curb in front of the Del Vista Arms.
Robby said, "You want to come in with me, Austin?"
I said, "I better wait here with Ingrid. You wouldn't want her to shit in your car, or shit like that."
Robby shrugged.
We both knew what we were thinking about.
Robby said, "I'll be right back."
I turned around and patted Ingrid again. I tried not to be nervous about things, but my head was swimming, drowning actually, in uncertainty. I unzipped the top of my jumpsuit and played with the Saint Kazimierz medal that hung from my neck.
And then I whispered, "What am I going to do, Ingrid?"
Robby ran around the front of the car and disappeared inside the Del Vista Arms.
I thought about Shann Collins, and how she told me I was disgusting.
At exactly that moment, Ollie Jungfrau was killing aliens in an online space-shooter game. He was sitting up in his bed, in his underwear, with his laptop resting on his thighs. Ollie had eaten a large pizza and drank five cans from a six-pack of Dr Pepper. Tiny speckles of pizza sauce dotted Ollie's swollen breasts. Ollie Jungfrau needed to piss, but he did not want to get up from bed. He tried to calculate whether he could get away with peeing in his empty Dr Pepper cans. Ollie Jungfrau decided trying to do that might cut his penis, which he could not actually see due to the roll of his belly, or it might cause him to piss in his own bed. Ollie had pissed in his bed before, when he was too tired to get up and walk to the toilet. Ollie Jungfrau got up. He walked past his window and looked down at the street.
Ollie Jungfrau saw Robby Brees running around the front of a Ford Explorer parked in front of their apartment building. Ollie hated Robby Brees because Robby was gay, and Ollie knew it, and also because Robby was so young and good-looking. Ollie wished Robby Brees would fall down, trip on the curb or shit like that, but Robby was also coordinated and balanced.
Ollie Jungfrau hated young, good-looking, coordinated kids. Especially ones like Robby Brees, who were gay.
Ollie Jungfrau's eye caught the movement of something farther down the street in the dark. Ollie Jungfrau's eyes were good at noticing quick movements. That was how he killed so many aliens in the game he played every day. The motion Ollie detected was not caused by an alien, however.
Ollie Jungfrau saw the dark form of an Unstoppable Soldier crossing the street ahead of Robby Brees's Ford Explorer. He saw the creature just as Robby disappeared into the foyer at the Del Vista Arms.
The Unstoppable Soldier, a six-foot-tall mantis thing with spike-studded arms, was Hungry Jack.
Hungry Jack was hungry again.
I sat inside Robby Brees's Ford Explorer. I was turned toward the backseat, stroking Ingrid's fur and flipping the silver Saint Kazimierz medallion with my left hand. Ollie Jungfrau did not know the Polish kid he sold cigarettes to and called Dynamo was down there in the gay kid's car on the street.
Ollie Jungfrau stood at his window, frozen in fright. He was in his boxers and socks, and he was standing in a puddle of his own steaming piss.
Ollie's piss had the slight smell of garlic and Dr Pepper.
And at the same time that Ollie Jungfrau was urinating down his bread dough thighs, watching in horror as Hungry Jack scampered like a metal windup puppet through the dark toward me and Ingrid while we sat in Robby's car, Duane Coventry, the chemistry teacher from Curtis Crane Lutheran Academy, put down his glass meth pipe after smoking three peanut-sized rocks of crystal.
Duane Coventry sat completely naked at his computer. The chemistry teacher from Curtis Crane Lutheran Academy could look at pornography for endless hours when he smoked meth. The only thing that sometimes interfered with viewing pornography, which frequently lasted until daybreak, was if Duane Coventry turned the computer's camera on himself. Then Duane Coventry used his monitor as a mirror, so he could study his face, scratch at it, pick spots out of his skin that were not there, until he made them real with his own yellowed fingernails.
That was what Duane Coventry was doing at the exact moment Ollie Jungfrau was pissing himself, and Hungry Jack was click-stepping toward the smell of Robby Brees and the food-meat things that sat inside Robby's car. Duane Coventry was picking his face, naked, seated at his computer, picking and picking and picking.
Duane Coventry thought he left his doors and windows open. Duane Coventry always had to check his doors and windows whenever he smoked his meth. He stood up, took a step toward the front door of his small Iowa house. Then Duane Coventry turned around and grabbed his pipe. He burned the amber residue inside the little glass globe and inhaled deeply.
Duane Coventry forgot why he'd been standing up. He sat down again and began picking his face.
Every night Duane Coventry smoked methamphetamine was exactly like this.
Nobody knew anything about Duane Coventry.
Duane Coventry wanted to look at pornography and masturbate, but he needed to check his doors and windows. Duane believed people were always outside, always watching him.
Duane Coventry went into his kitchen, where he'd been cooking methamphetamine for over a year without anyone knowing about it.
Duane Coventry loved methamphetamine more than he could ever love anything else.
He checked the door that opened onto the kitchen porch.
It was locked.
Duane Coventry walked through the small living room and checked the windows behind his sofa. The windows were latched secure. Then he checked his front door. The front door had not been closed all the way.
Scrawled into the plasterboard wall, all down along both sides of Duane Coventry's front door were letters and numbers. They were license plate tags from cars Duane Coventry saw outside his house whenever he smoked meth.
There were exactly 464 different license plate numbers etched into Duane Coventry's living room wall. Duane Coventry knew there was always someone out there watching him, waiting for him.
When Duane Coventry opened the front door, he stepped outside. As soon as Duane Coventry went outside his little Iowa house, he strained to think about why he was going out into the night. He had forgotten what he needed to do, but Duane Coventry, our chemistry teacher from Curtis Crane Lutheran Academy, did realize he was completely naked.
He thought that maybe he was supposed to check to be certain his car doors had been locked.
Duane Coventry's car was parked in the driveway beside a hedge of rosebushes.
Duane walked across the yard toward his car.
It was not a good idea.
Tyler Jacobson and Roger Baird had caught up to the exhausted Eileen Pope, who was trying to find something as big as an empty house or a garage in which to lay her millions of fertilized eggs. Roger Baird had Eileen Pope pinned down. He was fucking her on the lawn just beyond Duane Coventry's rose hedge. Roger Baird was doing one of the only two things Unstoppable Soldiers ever want to do. Eileen Pope was too tired to eat Roger Baird. Tyler Jacobson was tired and hungry. Tyler Jacobson smelled Duane Coventry's sweat as soon as the meth smoker opened his front door.
Duane Coventry looked over the hedge and saw the three monstrous things in the grass of his lawn.
Duane Coventry said, "Big fucking bugs."
That is exactly what they were.
Tyler Jacobson, Roger Baird, and Eileen Pope were the materialization of a meth smoker's most horrible delusion: gigantic bugs with jagged bear-trap mandibles and folded claw-arms prickled with mountain ranges of knife-blade, triangular teeth.
In the last second of his life, Duane Coventry felt a sort of jubilant vindication: He had been right after all this time. There really were horrible things waiting to get him outside his house.
Duane Coventry was right.
Tyler Jacobson left little more than a few dime-sized bloodstains from the meal he made of the chemistry teacher from Curtis Crane Lutheran Academy.
Tyler Jacobson was unstoppable.
And at exactly that moment, Ingrid's ears perked up.
If Ingrid were a normal dog that hadn't lost her throat's barking mechanism to cancer, Ingrid would have barked and barked.
Ingrid heard and smelled the monster named Hungry Jack as he got right up next to Robby's old Ford.
I scratched Ingrid's ears.
I said, "What's wrong, Ingrid?"
I turned away from her and I saw the triangular, glistening head of the giant bug that stared at me, fascinated, watching me through the windshield of my best friend's car.
"Holy shit," I said.
I am not certain that is exactly what I said, but I did say something.
Sometimes historians need to fill in the blanks on their own. It is part of our job.
You trust us because we are historians.
Historians are reliable blank-fillers.
It is my job.
Hungry Jack's mandibles yawned open. A gooey string of bug saliva hammocked between his jagged side-hinged jaws. The mandibles opened and closed, opened and closed. Hungry Jack wanted to eat me and Ingrid. Hungry Jack pressed his head into the windshield of Robby's Explorer. He tried to bite me through the glass, but he could not figure out what was keeping him from getting me into his mouth.
He bit and bit at the windshield, each time leaving streaks of milky bug spit on the glass.
Ingrid squeezed her way up between the front seats, into my lap, and also tried to bite Hungry Jack through the unyielding windshield.
Bugs are not very smart, but Hungry Jack was persistent.
I reached over to the steering column, but Robby had taken the car keys with him. Of course Robby would have taken the keys. He would have no way to enter the Del Vista Arms without his keys.
I pressed down into the car's horn.
Robby's Ford Explorer was exactly like Ingrid: barkless. The horn did not work.
I pushed Ingrid back and scooted my way deeper into the rear cargo compartment of the car. Hungry Jack whipped his arms up and struck them into the windshield. He was figuring out the puzzle. Cracks starred outward from the impact, fracturing the windshield in every direction, all the way to the rubber gasket frame.
At exactly that moment, Robby Brees stepped out from the foyer at the Del Vista Arms. When I saw Robby, he was standing on the sidewalk with some objects under one arm, only a few feet away from Hungry Jack.
It was not a good idea.
"Robby!" I screamed, but it was too late.
## CLICKETY CLICKETY
THE COMPOUND EYES on an Unstoppable Soldier take up approximately three-fourths of his head.
Hungry Jack could see the entire world around him at all times, even when he was focused on getting to me and Ingrid, who were hiding inside Robby Brees's Ford Explorer.
The poor old car took a beating from Hungry Jack's tooth-spiked arms.
Hungry Jack's head swiveled entirely around when he detected the movement of Robby Brees outside the doorway to the Del Vista Arms.
Robby Brees was going to be easy prey.
Robby stood, frozen. I screamed for him to run, but Robby was not paying attention to me.
I realized I was going to sit there and watch my best friend get killed if I did not do something about it. I crawled up from the rear compartment and grabbed the latch on the rear passenger door. I was not even thinking at that moment about how Robby and I were going to die together.
All I knew is I had to do something for the person I loved.
I opened the door and screamed at Robby again.
Hungry Jack sprang down from the hood of the Explorer and landed squarely on his four rear feet. Hungry Jack was so close to Robby that his folded and spiked arms were practically touching Robby's shoulders.
Then Hungry Jack backed away from Robby. The monster butted up into the fender of Robby's Explorer without ever looking toward me or Ingrid again.
Hungry Jack ran, clickety clickety, down the street and disappeared into the night.
Unstoppable Soldiers could run at speeds exceeding forty miles per hour.
Hungry Jack was afraid of Robby Brees.
I had seen it before. The first night—when Hungry Jack hatched out in that cornfield across from the Tally-Ho!—he did the same thing. He ran away from Robby Brees.
It was because Robby Brees was God to the Unstoppable Soldiers.
We found this out later.
"Holy shit," I said.
"Uh," Robby said.
Robby Brees had still not moved from the spot I thought he was going to die in.
"Holy shit, Rob."
I grabbed Robby and hugged him. We stood there on the street holding each other. Ingrid curled her body around our legs, wagging her tail.
Above us, Ollie Jungfrau looked down from his window. He had regained his composure, but was still standing, soaked, in a puddle of his own piss.
Ollie Jungfrau said, "I might have known little Dynamo was a queer, too. Dumb stupid lucky queer kids."
Robby and I had to get out of there.
Robby Brees and I had shit to do, and monsters to kill.
## ON THE ROOF AGAIN
ROBBY SPED ALL the way to Grasshopper Jungle.
It turned out the things Robby wanted to get from his apartment at the Del Vista Arms were these: some clean underwear and socks, his toothpaste, the plastic lawn flamingo with the steel spike coming out of its ass, and the grimacing lemur mask.
"I should have gotten some underwear, too," I said. "What if we end up having to stay down there?"
"I don't know, Austin," Robby said.
"Neither do I," I agreed.
Nobody knew anything about what we should do.
It was why we needed to get those last two reels of film from the roof of Grasshopper Jungle.
Dr. Grady McKeon told us to get those films.
We had to get the films and go back to Eden. Robby and I both knew that it was not too late, that the infestation was still in its first stage. We still had time, and Dr. Grady McKeon said there would be instructions for what to do on the last reels of the Eden Orientation Series.
Maybe Robby and I could stop the Unstoppable Soldiers.
Maybe Shann Collins would forgive me.
Maybe that plastic flamingo would start shitting candy bars and vanilla ice cream out of its ass, too.
When Robby rounded the turn onto Kimber Drive, his phone chimed.
It was a text message from Shann Collins.
Shann's text message to Robby Brees said this:
I hate you.
Robby glanced at the message on the screen of his phone. I watched him. He did not show any reaction at all. Robby knew it was not a joke message, though. Then he handed his phone over to me so I could see what Shann had written, too.
"I had a feeling you told her about me and you," Robby said.
I said, "I never lie, Rob. Shann asked me about it. I don't know what I am going to do."
Robby sighed.
I answered Shann's text message using Robby's phone:
Shann, it is me, Austin. Please do not make this about Robby. I love you both too much. Can we talk?
Shann's answer came to my phone:
You are disgusting. I hate you both.
Robby pulled the Explorer into the alley at Grasshopper Jungle.
If we had gone around to the front of the mall, we might have seen the mess Travis Pope had made at The Pancake House.
Robby and I had no idea what had been going on at Grasshopper Jungle.
He eased the Explorer along the back of the mall and parked beneath the metal ladder that came down from the roof behind From Attic to Seller Consignment Store.
Robby and I left Ingrid inside the car and climbed up onto the roof racks of the Explorer. From there, it was an easy reach to the bottom of the ladder.
"Um," Robby said, "that creature-thing really messed the shit out of my car."
"Sorry, Rob," I said. "We might as well call them what they are: Unstoppable Soldiers, created from the sicko brains at McKeon Industries who thought it was a good idea to mix bug sperm and blood with anything that happened to show up in their petri dish."
"Who would think it wasn't a good idea to mix bug sperm and blood with shit?" Robby said.
I said, "Uh."
Robby said, "I wonder what a can of bug spray would do to them."
"Uh," I said. "I think Eden One Thirty-Three and Eden Five better get their butts onto the roof and find the rest of that movie."
"I do hate stopping a film right in the middle," Eden 133 said. "Just when it was getting good."
Actually, we stopped the film just when my grandfather, Felek Andrzej Szczerba, became McKeon Industries's first Unstoppable Soldier.
We climbed up onto the roof of the Ealing Mall.
Johnny McKeon was hiding inside, just waiting for somebody to respond to his emergency alarm. Johnny McKeon was also going through the stock of handguns he had on display in the glass case at From Attic to Seller Consignment Store.
Johnny McKeon had a lot of guns for sale.
Robby and I had no way of knowing Johnny McKeon was directly below our feet.
"Smoke?" I said.
"Fags," Robby agreed.
"I guess so," I said.
We lit up.
The steel film canisters were right where we had left them. I bent down and picked up both canisters. What we hadn't noticed the first time we were up on the roof became strikingly obvious now. The film cans were wrapped with tape and marked with a thick black pen: Four of Five, and Five of Five.
Robby said, "Can I ask you something, Austin?"
I said, "Sure."
"Was it hard for you to tell Shann the truth?" Robby asked.
I shook my head.
"No," I said.
It was the truth.
"Oh." Robby said, "And you really don't know what you're going to do?"
I took a drag and exhaled.
"No," I said. "I think I should just leave you both alone before I ruin everyone's life."
"You wouldn't ruin my life," Robby said.
"I don't want to hurt you or Shann, Rob," I said.
I was ruining Robby's and Shann's lives, even if Robby told me I wasn't.
I was disgusted with myself.
We threw our cigarette butts down and stamped them out on the grit of the roof.
A police siren wailed. We could see the pulse of red lights coming closer through the night toward Kimber Drive.
"Do you think someone saw us come up the ladder?" Robby said.
"I don't know," I answered. "We should get out of here before we get arrested, or shit like that."
## DENNY DRAYTON HAS A GUN, MOTHERFUCKER
JOHNNY MCKEON TURNED off all the lights.
He was inside From Attic to Seller Consignment Store, waiting for the coyote cry of the Iowa State Patrol car that had been dispatched from Waterloo.
The State Patrol was responding to an emergency alarm Johnny McKeon rang when he saw Hungry Jack and the other Unstoppable Soldiers in the alley at Grasshopper Jungle.
There was only one bored trooper in the patrol car. He sat behind the wheel. He was bored because he was coming to Ealing. Nothing ever happened in Ealing, and he figured it was going to be another pile of Ealing nothing crap from a false alarm at an abandoned business in a loser town.
Ealing, Iowa, was the elephants' graveyard for American entrepreneurism.
The trooper was named Denny Drayton.
It was a good Iowa name.
Denny Drayton's skin was nearly translucent white, the sickly color of the coconut center in a Mounds bar. He had absolutely no hair.
Denny Drayton needed to take a shit. He hoped wherever he was heading to had a shitter that worked, and toilet paper, too. Denny Drayton carried a pack of baby wipes in his patrol car for emergencies, like when he'd pull off to the side of the road and shit in someone's yard.
The baby wipes in Denny Drayton's patrol car were made in a place called Eden Prairie, Minnesota.
That is the truth.
Denny Drayton chewed tobacco while he was on patrol. He held a plastic liter Diet Coke bottle between his thighs as he drove. The Diet Coke bottle was three-fourths full of hot tobacco spit. Iowa State Troopers were not supposed to chew tobacco on the job, but Denny Drayton had a motto for just about every situation he encountered.
His motto was this: Fuck that shit. I have a gun, motherfucker.
Denny Drayton's motto was tattooed in an arc of Old English lettering that made a semicircle like a rising sun over his white and hairless belly button.
Fuck that shit. I have a gun, motherfucker.
Denny Drayton shaved his entire body every morning. He shaved all his hair off, even his eyebrows and pubic hair.
Trooper Drayton also had a tattoo of the flag for the Confederate States of America. The stars and bars flag was tattooed directly on the front of Denny Drayton's hairless scrotum.
Denny Drayton was most likely insane.
Denny liked to show off his hairless body and the tattoos of his motto and the Confederate flag in the shower room at the police station in Waterloo. Denny Drayton told his police officer friends that he got the tattoo of his motto for reading material, just in case he ever hooked up with a bitch who was smart enough to read and give blow jobs at the same time.
Denny Drayton had one joke, and that was it.
It wasn't a particularly good joke, and everyone knew it. But Denny Drayton had a gun, motherfucker.
The six-foot-tall praying mantis beast that used to be named Travis Pope lumbered out of The Pancake House on his four clicking lower legs. He was a little groggy. Will Wallace had been exceedingly drunk, and Unstoppable Soldiers are sensitive to eating drunk people and people who smoke meth and shit like that.
Travis Pope only wanted to find the swarm and go dormant with them overnight.
Denny Drayton was just pulling into the parking lot.
Johnny McKeon noticed the flashing red lights through the glass front of his secondhand store. Johnny McKeon had a gun—a Smith & Wesson .500 magnum.
The gun weighed six pounds.
A Smith & Wesson .500 magnum could blow a man's head off.
Pastor Roland Duff saw the lights on Trooper Denny Drayton's patrol car, too. Roland Duff had come back from Waterloo, where he had met a nice Christian man at the Tally-Ho!
Roland Duff sat alone inside Satan's Pizza. He was eating a small Stanpreme. Roland Duff was exchanging text messages with his new friend. Roland Duff was very excited. He had an erection. Pastor Roland Duff and his new friend were flirting suggestively, and arranging a date for Saturday evening.
Roland Duff's new friend was named Shaun Doherty.
Shaun Doherty owned a septic pumping business. He lived in a town called West Bazine, which was in Iowa. East Bazine did not exist at all.
Shaun Doherty and Pastor Roland Duff planned on meeting at the Waterloo Cinezaar on Saturday evening.
They were going to see Eden Five Needs You 4.
That was the plan, at least.
Denny Drayton turned his spotlight onto the dark front of The Pancake House. His keen sense of Iowan normalcy alerted Denny Drayton that something was not right. Windows were shattered, the front door had been torn from its hinges, and it looked like there were some bloody shoes and a belt lying on the sidewalk in front of the mall.
"Something's not right here," Denny Drayton said.
Denny Drayton spit into his Coke bottle and pinched another wad of black, moist tobacco from a can of Copenhagen he kept pinned behind the patrol car's sun visor.
He farted. Denny Drayton admired the smell of his own farts.
"I really need to take a shit," Denny Drayton said.
Then the Iowa trooper saw Travis Pope, an Unstoppable Soldier, moving with mechanical jerkiness through the debris field of blood, glass, clothing, and imitation-maple-flavored pancake syrup.
Denny Drayton opened the door on his patrol car. He spit onto the asphalt of the Ealing Mall's parking lot and then stood up, angling his spotlight so it would fully illuminate the strange creature in front of The Pancake House.
It was not a good idea.
Denny Drayton thought it must have been some kind of prank. Maybe somebody was making a movie or something. Denny Drayton wished he could be in a movie.
"What the heck is that shit?" Denny Drayton said.
Denny Drayton drew his pistol. His gun was a 9mm Sig Sauer model P250.
Denny Drayton's pistol was made in New Hampshire.
Compared to Johnny McKeon's Smith & Wesson .500 magnum, Denny Drayton's weapon was a rubber band gun.
Travis Pope's attention was riveted to all the lights blazing from the patrol car. He was not hungry, but he decided to kill the man making all the noise and light, anyway. Unstoppable Soldiers do that kind of shit.
Johnny McKeon came outside just then. Johnny pointed his powerful pistol in the direction of Travis Pope. Johnny McKeon was not a good shot. He knew he would miss hitting the creature unless he got very, very close.
Pastor Roland Duff had never had sex with another person in his entire life. He believed he was ready to have sex with his new friend, Shaun Doherty. Roland Duff imagined the thrill of experimenting with another man after all his lonely years. He was very excited about it. Roland Duff adjusted his uncomfortable erection and sat watching the police lights from across the street. He was curious. Pastor Roland Duff could not tell what was going on.
Sometimes, Pastor Roland Duff counseled himself over his own doubts and weaknesses. He could not decide whether he was a virgin or not. Pastor Roland Duff did believe that masturbation was immoral and compromising. Roland Duff was frequently wracked by guilt. He was uncertain if he could still be a virgin and masturbate as often as he did. Pastor Roland Duff thought he would masturbate when he got back home that night.
Pastor Roland Duff did not really get the chance.
At exactly that moment, ash flakes fell like snow in Guatemala on the home of Robert Brees Sr. For some strange reason, Robert Brees Sr. thought about the son he'd left behind in Iowa. Robby would be sixteen now, he thought. Robert Brees Sr. watched the ashes falling and falling. He had not thought about his son in years.
Eric Christopher Szerba was lying awake in a hospital bed. Eric was looking at the tubes and medications near the head of his bed, and wondering if anything there could be useful to him in committing suicide.
Robby Brees and I were driving out from Ealing toward the McKeon House. We were going back to Eden to watch the last reels from Eden Orientation Series. Robby played Let It Bleed in the tape deck.
And Robby sang along with Love In Vain.
Robby Brees reached across the center console and put his hand on top of mine.
The wife of the vice president of the United States of America was performing oral sex on the vice president. It was the vice president's birthday, and the vice president of the United States of America was getting a blow job. Franklin and Theodore were very happy.
I had not named my balls.
Robby Brees had not named his balls, either. I asked him about it.
And Robby said to me, "Who would ever name his balls?"
I said, "I would like to, but once you give your balls names, there is no going back."
"Well, if you do think up names for your balls, let me know what they are. I would hate for us to have balls with the same names in such a small town as Ealing," Robby decided.
Robby was always so smart about small town social blunders and shit like that.
"Having balls with the same name as your best friend's is a serious social blunder," I said.
That is the truth.
"Get down on the ground!" Trooper Denny Drayton said to Travis Pope.
Johnny McKeon was very scared. He crept across the parking lot. The Smith & Wesson .500 magnum was so heavy, it hurt Johnny McKeon's wrist just to hold it.
Travis Pope got closer and closer to Denny Drayton.
The last thing Denny Drayton said was his motto. He said, "Fuck this shit. I have a gun, motherfucker."
Then Denny Drayton began shooting at Travis Pope.
Johnny McKeon ducked.
Across the street, Pastor Roland Duff ducked.
Denny Drayton fired and fired and fired.
Unstoppable Soldiers do not like being shot at. They also have exoskeletons that are as bulletproof as the hull of an aircraft carrier.
They are unstoppable.
Denny Drayton emptied his gun. He was in the process of reloading when Travis Pope unhinged his barbed arms and picked Denny Drayton up by his head. Travis Pope bit most of the trooper's head off and let Denny Drayton's hairless and tattooed body fall down onto the blacktop.
Johnny McKeon whispered, "Well, I'll be danged."
Johnny was smart. He did not fire his pistol at the monster. Johnny McKeon quietly went around to the driver's side of his truck, got behind the wheel, and drove off.
Stan, the owner of Satan's Pizza, and Pastor Roland Duff, the headmaster from Curtis Crane Lutheran Academy, were not so smart.
But they were curious. Pastor Roland Duff was curious about a lot of things. He was still fantasizing about Shaun Doherty.
Nothing exciting ever happened in Ealing. Pastor Roland Duff and Stan, the owner of Satan's Pizza, who had come from behind the counter when he heard what sounded like gunfire, stepped out onto the street to see what was causing all the commotion across Kimber Drive at Grasshopper Jungle.
It was not a good idea.
## EXILE IN EDEN
ROBBY DROVE THE Ford Explorer through the fields of weeds and brambles behind Shann's house.
He parked beside the dilapidated chicken coops where the hatch into Eden sat nearly unnoticeable in the center of an old concrete pad.
Ingrid was excited. She had found a new place to shit.
Robby opened the hatch. The welcome recording began again and the room below us lit up.
I took my phone out of the pocket of my Eden 5 jumpsuit. I did not need to explain to Robby that I was calling Shann Collins. Robby knew what I was doing. I wanted to try to get Shann to listen to me.
We all needed to be safe now, and the Unstoppable Soldiers had come out in Ealing.
Shann would not answer my call. I knew she was not asleep. It was 11:00. No teenager in the world goes to sleep before 11:00. I left a voice message as Robby stood near and listened. There was no need to hide anything from Robby Brees.
I had no secrets with him.
I had no secrets with Shann Collins, either.
This is what I said:
"Shann, I am sorry. I told you I do stupid shit without thinking about who I might hurt. But the truth is, I think you need to come to Eden. Me and Robby are going back inside now, so my phone won't work, just in case you want to tell me I am disgusting again. We have the rest of the film. I think something terrible is happening in Ealing, and maybe we are the only ones who can stop it. Well. Uh. I love you, Shann. I really do love you. You have to know that, Shann. Please come to Eden with me and Robby. Hurry."
I put the phone back inside my jumpsuit. I rubbed the silver medallion of Saint Kazimierz between my thumb and finger.
I said, "Saint Kazimierz, I am Polish. I am a kid. I'm not sure if I'm technically a virgin or not. But a solid two out of three gives me hope you might look out for me and Robby and Ingrid."
Robby stood, watching me.
And I said, "I really do love you, Robby. How can I be in love with two people at the same time?"
Robby said, "I don't know how you can do that, Austin."
It was very difficult carrying Ingrid down the ladder.
Not only did I fail to think about bringing clean underwear and shit like that, I never even thought about how I would get a sixty-pound golden retriever down a very tall ladder.
Robby had to help. We sandwiched Ingrid between us and climbed down. We must have looked like a reject hybridization of two boys and a barkless dog. That was probably some kind of shit they pulled at McKeon Industries back in the sixties, too.
By the time we finally got down into the mudroom, we were both damp with sweat, we smelled like dog fur, and the repeated welcoming tape was driving us crazy.
"I have B.O.," I said.
"I know," Robby agreed.
Robby and I went back up one final time to get my history books and the things Robby had brought from the Del Vista Arms. Then we sealed the three of us—me, Ingrid, and Robby—inside the Eden Project.
Robby and I put on clean pairs of white Eden scientist socks in the locker room. I thought about changing into a clean jumpsuit, but I did not want to give up the number 5. I wanted to take a shower, but we had too much shit to do.
Robby Brees left his bundle of things on the bench we'd been sitting on. I carried the two final reels of film, and Robby followed me into the theater room.
## A CHANCE MEETING UNDER A PORTRAIT OF A PRESBYTERIAN, OR, CALVIN COOLIDGE'S CANOE
MY FATHER'S NAME is Eric Andrew Szerba.
His Polish name was Arek Andrzej Szczerba.
His father, Felek, was a scientist at McKeon Industries.
Felek Andrzej Szczerba was the world's first Unstoppable Soldier.
All roads cross here on my desk. As a historian, I realize, too, that we are all on the same road, all the time.
Sometimes we drive in circles or the wrong way, because we are stupid like that.
And that was my day. You know what I mean.
Eric Szerba, my father, was only a little boy when Felek was killed.
Raising five fatherless Polish boys in Ealing, Iowa, was a tremendous challenge for my grandmother, Ksenia Szczerba. Dr. Grady McKeon saw to it that the family was provided for, so Ksenia never had to go to work, and McKeon Industries subsidized the five brothers' education.
All the Szczerbas moved far away from Iowa after my grandmother died. Ksenia Szczerba died of exhaustion in 1992, several years before I was born. Only my father, Eric, stayed in Ealing, where he became a teacher after graduating college.
Eric Szerba's first teaching assignment was at Herbert Hoover High School, Ealing's public school. He began teaching when he was twenty-two years old.
In his first year of teaching World History, Eric Szerba met a fifteen-year-old boy named Kelly Kenney.
Kelly Kenney is a true Iowa kind of name for a boy. It is a name that almost tastes like buttermilk biscuits and honey.
Kelly Kenney was not such a good student. But Kelly Kenney was persistent. At least once per week, Kelly Kenney would say this to Eric Szerba:
"Hey, Mister Szerba. You should meet my sister, Connie. She is twenty years old and a real dynamo. You are single, right, Mister Szerba? You should go out with Connie. Here is our phone number. Connie likes going to the movies, and you would make a nice couple. Connie is not a slut, either. Ha-ha. You should call on her, Mister Szerba. That would be neat!"
Eric Szerba was not the kind of young man who would ever call a girl based on urgent pleading from a fifteen-year-old boy. Eric and Connie would never have met solely as a result of Kelly Kenney's persistent prodding.
It was Connie Kenney who came in to Eric Szerba's classroom on behalf of her parents, at Herbert Hoover High School's Open House in the fall semester of 1982.
In 1982, every classroom at Herbert Hoover High School had a portrait of Ronald Reagan hanging above the blackboard. Ronald Reagan was president of the United States of America in 1982. I can find no historical records anywhere that detail whether Ronald Reagan ever took a shit, or if he named his balls.
I believe Ronald Reagan most likely did name his balls.
I believe that Ronald Reagan, the president of the United States of America, named both of his balls the same thing: Calvin Coolidge. Ronald Reagan would have named both of his balls Calvin Coolidge just to avoid any confusion on his part.
It may have been a social blunder, but it made remembering your balls much easier. No one wants to be caught in the embarrassing situation of forgetting the name of only one of your balls.
Connie Kenney, who was Lutheran, met my father, Arek Andrzej Szczerba, a Catholic who smoked cigarettes, beneath a portrait of Ronald Reagan.
Ronald Reagan was Presbyterian.
Kelly Kenney claims to have been responsible for Eric and Connie's eventual marriage, but history shows that it was the result of a meeting of the two in a classroom at a public school, beneath a portrait of a Presbyterian who never took a shit and named his balls Calvin Coolidge.
I once saw a photograph of Calvin Coolidge in an exhibit at the Library of Congress. Calvin Coolidge was riding in a canoe.
The canoe was named Beaver Dick.
I could not make that up if I tried.
That is the truth.
Eric Andrew Szerba changed his life for Connie Kenney. He quit smoking cigarettes and he converted to Lutheranism. In exchange for Eric Szerba's devotion to her, Connie Kenney allowed Eric Andrew Szerba to put his penis inside her vagina. This happened several times before the two were actually married, although it was an act that good Lutherans in Iowa look askance at.
After they were married, Eric Andrew Szerba, a non-smoking Lutheran teacher of history, took a position at Ealing's private school, Curtis Crane Lutheran Academy. Eric Andrew Szerba's non-smoking Lutheran Polish semen created a son named Eric Christopher, who was born in 1989, and a second son named Austin Andrzej, who was born in 1995.
This is my history.
## A MOST SOOTHING SHOWERHEAD
"YOU ARE A GOOD dog, Ingrid," I said.
Ingrid curled up beneath my feet. I sat in the back row of Eden's theater.
Behind us, Robby Brees fed the leader strip for Reel Four of Eden Orientation Series into the toothy cogs of the theater's projector. Then Robby jumped over the seat back and sat down right next to me, like he always did when we went to the movies together.
Robby Brees put his hand on the armrest, so he was touching me.
The final two reels of film in Eden Orientation Series contained some of the most horrible things either one of us had ever seen.
We lit cigarettes and watched.
This is what we found out:
McKeon Industries worked frantically toward the development of Unstoppable Weapons and Unstoppable Soldiers during the second half of the 1960s.
McKeon Industries wanted to make Unstoppable Anything. They would have made Unstoppable Cup-O-Noodles if they could. The scientists who worked for Dr. Grady McKeon didn't seem to be overly concerned about consequences, like how to stop shit once they made it unstoppable, and shit like that.
Reel Four of Eden Orientation Series opened with a headshot of the insane Dr. Grady McKeon himself. Dr. Grady McKeon sat behind his mahogany desk in what was called Eden's Brain Room, wearing a thin white, V-neck T-shirt.
"I'll bet you anything he wasn't wearing any pants when they filmed that," Robby said.
I had been thinking exactly the same thing.
Dr. Grady McKeon rambled on about his projects, and bragged about corn and the dissolved balls of Maoist thugs, while he smoked a cigarette and his eye twitched like a strand of Christmas tree tinsel during a springtime Iowa thunderstorm.
Robby Brees and I found the Brain Room later that night.
Dr. Grady McKeon licked his lips and began:
Ah. My friends. Tell me, are you breeding?
Are you? Hmmm?
Breed, my friends. Breed and love. You are the New Humans.
It's a lovely place, our Eden, don't you agree?
Robby said, "Thinking about that guy kind of has a damping effect on the drive to conjugate."
I said, "Uh."
McKeon Industries experimented with several methods for creating an Unstoppable Soldier.
Dr. Grady McKeon's Human Replication Unit actually grew human body parts that floated in polymer suspensions. The polymer suspensions created their own electrical charges, like jellied batteries. This was where the praying hands, the penis, and the little two-headed boy came from. They were all created from Dr. Grady McKeon's own tissue samples.
So each jar actually was Dr. Grady McKeon, more or less.
Apparently, all of the things inside the jars filled with electrical polymers were more or less alive, too, according to Dr. Grady McKeon.
More or less.
Johnny McKeon didn't know anything about the somewhat-living penis, hands, and baby boy he'd been keeping inside his office at From Attic to Seller Consignment Store.
Dr. Grady McKeon had been a sick monster.
"Well, he did develop a most soothing showerhead," Robby pointed out.
"I will give him that. There is nothing quite like showering beneath a Pulse-O-Matic® showerhead," I agreed.
I could not help but feel sad about the poor little boy with two heads. I really did see his hand move that day when I was alone inside Johnny McKeon's office. The two-headed boy had been imprisoned within that glass container, more or less alive, for over forty years.
But the man's head in the jar came from something else entirely.
We found out about that in Reel Five.
The Human Replication Unit at McKeon Industries also collected and experimented with sperm. Dr. Grady McKeon had no apparent difficulty obtaining sperm samples from very powerful and important American men. Dr. Grady McKeon's power sperm had been frozen and stored in a cryogenic vault inside Eden's Brain Room.
It was exactly like Eden Five.
On the door of the freezer vault were framed photographs of men, including President Richard Nixon, Vice President Spiro Agnew, the Director of the Central Intelligence Agency, whose real name was Richard Helms, and, of course, Dr. Grady McKeon.
Each of them had donated multiple samples of their Unstoppable Sperm.
The Unstoppable Sperm was intended as the beginning of a New Universe.
Robby said, "Um."
I said, "This place really is full of sperm, Robby."
Dr. Grady McKeon explained that the vault full of Unstoppable Sperm was a precaution. What if, he postulated, only women managed to escape to the Eden Project, or if there was a depletion of desirability among male breeders? Dr. Grady McKeon confidently answered his hypothetical question: Unstoppable Sperm would become the genetic seed bank for the New Universe.
It was most likely something that Dr. Grady McKeon had intended all along.
Much later, in conducting further analysis inside the Brain Room, and through reading Dr. Grady McKeon's barely legible and ranting diaries, I did discover that in 1975, McKeon thawed out the sperm from CIA Director Richard Helms, President Richard Nixon, and Vice President Spiro Agnew.
Dr. Grady McKeon discarded that sperm unceremoniously into his prized Nightingale Urinal.
Dr. Grady McKeon replaced the Unstoppable Sperm with his own.
The Brain Room was pretty much full of Dr. Grady McKeon's sperm.
From the Unstoppable Sperm experiments, Reel Four jumped across the McKeon Industries Complex to the Unstoppable Corn Unit, where a series of catastrophic accidents of nature sprang up like milkweed in well-watered fields of Iowa corn.
## INFINITA MILITES! INFINITA MILITES!
HERE WAS REEL FIVE:
Felek Szczerba was the first Unstoppable Soldier.
The end of the world began in Ealing, Iowa, in 1968. Nobody knew anything about it. The scientists at McKeon Industries were crazy and drunk on money. Dr. Grady McKeon would have done anything to be the man responsible for creating an unstoppable force in the universe.
He nearly got away with it, too.
Initially, there were five people infected by Dr. Grady McKeon's 412E: three scientists and two secretaries. The five victims made a mess of McKeon Industries in 1968.
They were Unstoppable Soldiers. All they wanted to do was fuck and eat.
Because McKeon Industries maintained such extreme levels of security during the Cold War, the Unstoppable Soldiers that had been accidentally created there never got a chance to step outside into the Iowa daylight. If they had ever gotten outside, the world would have certainly come to an end, and there would have been a new apex species in charge of Planet Earth—one that wanted only to fuck and eat.
Besides fucking and eating, a few of us human beings are driven to paint on the walls of caves. Other than that, and the fact that we die relatively easily when you shoot at us, I think human beings are very much like Dr. Grady McKeon's Unstoppable Soldiers.
INFINITA MILITES! INFINITA MILITES!
Despite images of all the dead people inside the lab building, the destruction of an entire research wing of the facility, and shit like that, Dr. Grady McKeon's voice had a gleeful chime to it as he narrated over grainy black-and-white surveillance footage of the beasts, while cameras caught them unreservedly engaged in the two things that Unstoppable Soldiers like to do.
There were several unfortunate clips of the Unstoppable Soldiers eating a few of their co-workers, but what can you do?
It was all in the name of science and anti-Communism.
A commercial had been spliced directly into the middle of Reel Five. The commercial was a sales pitch to the Defense Department for McKeon Industries's Unstoppable Soldiers. It suggested exposing prison inmates, the unemployed, welfare recipients, and hippies to 412E, and then dropping them off in sunny Havana, or possibly deep inside Red China.
Bulletproof, tireless machines of conquest. McKeon Industries presents to the world our Unstoppable Soldiers!
The commercial footage kept replaying the image of Felek Szczerba in the process of hatching out.
As soon as an Unstoppable Soldier hatches out, he is a bit puffy and wilted, kind of like a butterfly when it sheds the husk of its chrysalis. But as soon as the Unstoppable Soldier ate what remained of Felek Szczerba's corpse, it also ate two attending nurses and a physician.
All of this was captured on camera.
Bulletproof, tireless machines of conquest. McKeon Industries presents to the world our Unstoppable Soldiers!
The Unstoppable Soldier that hatched out of Felek Szczerba ate the cameraman, too.
Apparently, the scientists at McKeon Industries did not have any ideas for what to do about the Unstoppable Soldiers that had taken over their Unstoppable Corn Research Unit. They only knew that they wanted to sell the Unstoppable Soldiers, and that they were unsuccessful at shooting them. So the leaders of McKeon Industries did the worst possible thing you could do with an Unstoppable Soldier infestation: They waited to see if the Unstoppable Soldiers would simply die, or go away on their own.
Unstoppable Soldiers do not just go away.
Unstoppable Soldiers can live a very long time between meals.
McKeon Industries eventually learned these two details. Unfortunately for an entire crew of McKeon Industries scientists, they also learned that Unstoppable Soldiers were bulletproof.
Dr. Grady McKeon narrated:
In the spring of 1968, tireless scientists at McKeon Labs kept round-the-clock vigil on our formidable troops, observing carefully while the burgeoning females deposited egg masses as large as a high school basketball court!
Imagine the reproductive and growth potential of such an army, my friends!
Robby said, "Uh. Those egg things look exactly like the shit inside the globes."
He was right.
The third stage in the infestation of Unstoppable Soldiers—the breeding and egg-laying phase—reverted back in appearance to the original black-pulsing and cauliflowered mass of the 412E mold; but on a much grander scale.
Like the contained mold specimen Robby and I first saw inside Johnny McKeon's office the night we climbed down the Roof Access ladder and into From Attic to Seller Consignment Store, the egg masses laid by the two female Unstoppable Soldiers quivered and writhed, radiating an obviously powerful light.
The egg masses swelled with small volcanic bulges that would rise up and spit globules of snot-like eruptions, only to be reabsorbed into the pulsating blob. And the female Unstoppable Soldiers never moved from their guardian positions over their rookeries. They stayed with their spiked arms spring-loaded, just waiting for anything to get near enough to become a next meal.
Dr. Grady McKeon appeared once again in the role of on-screen narrator before the end of Reel Five.
Dr. Grady McKeon had aged considerably between the filming of the first reels and the reel that showed the siege of the Unstoppable Soldiers. His hair was thinner, and behind the thick distortion of Dr. Grady McKeon's eyeglasses, his eye twitch fired and fired like an inexhaustible machine pistol.
Dr. Grady McKeon said:
It was merely by blind chance, my friends, that we at McKeon Industries ultimately discovered the secret to demobilizing our Unstoppable Soldiers. Pay attention, my friends, for you may be able to affect a similar salvation if the conditions are favorable in your situation.
If not, then take heart. Enjoy your lives here in Eden. And, by all means breed, my friends. Breed and live in love. The New Universe depends on your success.
I love you. I do love you all.
Then Grady McKeon began to weep on camera.
Robby said, "He is fucking insane."
"Uh," I said. "Let's have another cigarette."
Scientists at the lab dared to enter the sealed-off Unstoppable Corn Unit where the eggs had been laid. The McKeon Industries scientists formed an armed phalanx in their Eden jumpsuits. Dr. Grady McKeon himself led the entry of the scientist army into the secure laboratory.
Dr. Grady McKeon and his scientists were armed with flamethrowers.
History provides a compelling argument that every scientist who tinkers around with unstoppable shit needs a reliable flamethrower.
When Dr. Grady McKeon entered the lab, however, the Unstoppable Soldiers reacted to him in exactly the same manner I had seen Hungry Jack respond to Robby: The Unstoppable Soldiers were afraid of Dr. Grady McKeon.
They tried to get away from him.
Dr. Grady McKeon was clearly the God of Unstoppable Soldiers.
So McKeon Industries reasoned that since Dr. Grady McKeon had brought the Unstoppable Soldiers into being, it was he that could erase their existence as well.
So they experimented.
The notable characteristics of McKeon Industries experimentation entailed two prominent features: First, scientists working alongside Dr. Grady McKeon seemed to have no logical expectation for any particular outcome. They simply randomly selected any convenient biological agents and threw them into the paint cans of their soup kettle.
Second, for whatever reasons, the McKeon labs seemed a bit overly obsessed with blood or sperm as their default catalysts.
## ROBBY THE THEOLOGIAN
UNSTOPPABLE SOLDIERS WERE ridiculously easy to kill.
It cost McKeon Industries a few more scientist-meals to figure that simple fact out, but eventually the problem of the first infestation had been clearly put to rest.
They started, naturally, with sperm.
Scientists at McKeon Industries's Unstoppable Soldier Unit used Dr. Grady McKeon's sperm. They loaded plastic capsules filled with sperm into ink-marker guns and shot the capsules at the Unstoppable Soldiers.
Unstoppable Soldiers do not appreciate being shot with somebody's sperm.
One Unstoppable Soldier snatched the unfortunate scientist with the plastic-capsule-sperm-pistol, and picked him up by his head, while the other two males played wishbone with his legs.
It was a gruesome spectacle.
"You can't really blame them for doing that," Robby said.
"No," I agreed. "Can't blame them at all. Who wouldn't get ticked off if you shot them with plastic capsules filled with Dr. Grady McKeon's sperm?"
"Even Saint Kazimierz would get mad at a guy over shit like that," Robby said.
Robby Brees was such a gifted theologian.
The two female Unstoppable Soldiers remained, poised motionless in their guarding positions over their pulsating mountains of eggs.
The scientist who lost his life in the failed sperm attack was named Heinrich Fuchs. It was an unfortunate surname, by Iowa standards.
Heinrich Fuchs was born in a place called Splugen, which is in Switzerland.
I researched Heinrich Fuchs. There were a lot of Fuchs in Splugen.
Splugen was full of dumb Fuchs.
The Swiss are famous for maintaining neutrality, except, apparently, when it comes to shooting at monstrous bugs with someone else's sperm.
Dulce Et Decorum Est.
If McKeon Industries ever reworked its motto following infinita frumenta!, which basically means Unstoppable Corn, and its successor, infinita milites!, which means something like Unstoppable Soldiers, or shit like that, they might have considered a slogan along the lines of post sperma sanguine conantur!
I believe, from Latin, the phrase might be translatable to something like this: After sperm, try blood!
It rings nicely, but it is not nearly as melodious as a good old rhyming Iowa name.
"I'm glad it didn't work," Robby decided. "I would hate to have to fill up little bullets with my sperm just so we could go out and kill Hungry Jack."
"Uh," I said.
We realized that in the same way the 1968 Unstoppable Soldiers cowered away from Dr. Grady McKeon because it was his blood that created them, the Unstoppable Soldiers in Ealing today would only be stopped by Robby Brees.
That was what the insane Dr. Grady McKeon meant when he told us, "Pay attention, my friends, for you may be able to affect a similar salvation if the conditions are favorable in your situation."
It was the blood that did the trick, and Robby Brees was God to Ealing's newest crop of Unstoppable Soldiers.
The scientists at McKeon Industries, none of whom had ever received a Nobel Prize and its accompanying million dollars and trip to Sweden for a threesome with Robby Brees and Shann Collins, nearly drained Dr. Grady McKeon dry collecting blood from the twitching man. Once they did, their initial method of delivery was less sophisticated than the plastic capsules filled with sperm: One of the scientists went into the lab where the Unstoppable Soldiers had taken over, and he squirted them with Dr. Grady McKeon's blood from a large plastic hypodermic.
That particular scientist lost his right arm from the elbow down.
"That is a really dumb way to lose an arm," I pointed out.
"Those guys actually went to college and shit," Robby said.
"I think a lot of colleges in the sixties offered degrees in taking LSD, Rob," I said.
"It is fortunate you were not born with two heads," Robby concluded.
But a remarkable thing happened once the targeted Unstoppable Soldier had come into contact with the blood of his God. The Unstoppable Soldier stopped, and fell to pieces.
The six-foot-tall praying mantis with tooth-spiked arms simply broke apart, segment by segment.
That was the first Unstoppable Soldier. It was the one that hatched out of Felek Szczerba.
At that exact moment, as Robby and I sat watching Reel Five of Eden Orientation Series, the disconnected pieces of Felek Szczerba's Unstoppable Soldier body were floating in a brine of preservatives, sealed within large glass cases resembling aquariums, inside Johnny McKeon's private office.
So McKeon Industries was able to clean up the first infestation of Unstoppable Soldiers in Ealing, Iowa, during 1968. They let the eggs begin to hatch, unfortunate as it was. Film images captured the black creatures as they began bursting out from the gooey egg masses. The miniaturized Unstoppables were about as large as third-graders as soon as they hatched, and the first ones immediately began feasting on their brothers and sisters.
They were, after all, Unstoppable Soldiers. Actually, until they'd eaten and molted several times, the hatchlings were more like Unstoppable Cub Scouts.
Unstoppable Cub Scouts only want to do one thing, at least until they enter Unstoppable Puberty, which happens in about four hours.
Within days, the sealed-off McKeon Industries lab facility was completely packed—from attic to cellar—with full-grown, hungry Unstoppable Soldiers, all of which engaged in a round-the-clock unstoppable orgy of sex and cannibalism.
The experiment had to be halted.
More blood was drawn. Dr. Grady McKeon became frail and anemic. But finally, all the Unstoppable Soldiers had been erased.
It was not the end of the film, however.
The worst was yet to come.
Robby Brees and I did not know anything about it.
## SATAN AND THE PASTOR
"UM, ROBBY," I said, "I just thought of something."
"I don't like the idea of draining my blood, Porcupine," Robby said.
"Not that. I was thinking, what if Ingrid needs to shit?" I said.
Neither one of us considered the fact that getting Ingrid up the ladder to the entry hatch was likely going to be far more difficult than getting her down.
Robby said, "You might just have to put her inside the Nightingale."
I shook my head.
"I could never do that to a genuine Nightingale," I said.
The movie played on.
And, at that exact moment as Robby and I sat next to each other inside Eden's theater, Pastor Roland Duff and Stan, the Mexican man who owned and operated Satan's Pizza, cautiously made their way across Kimber Drive toward the red and blue flashing lights of the Iowa State Patrol car.
It was not a good idea.
Stan, whose real name was Sevastián Hernandez, walked one step in front of Pastor Roland Duff. The two men saw Johnny McKeon driving away from the Ealing Mall.
Grasshopper Jungle was eerily quiet. The shops were all dark. This was normal for the most part because so much of the mall had shut down. But even the Ealing Coin Wash Launderette was lightless; and that was unusual.
Pastor Roland Duff assumed the power on the south side of Kimber Drive must have gone out. The lights were still on at Satan's Pizza.
Roland Duff glanced nervously at Stan Hernandez illuminated by the silent flickering lights from the patrol car. The alternating washes of blue and red made it seem like the men were standing on the dance floor at a discotheque. Pastor Roland Duff realized he had never actually looked at Stan Hernandez before.
Stan Hernandez was very handsome.
Too bad Stan Hernandez was Catholic, thought Roland Duff.
Roland Duff, who had never had sex with anyone, was very aroused.
Unfortunately for Pastor Roland Duff and Stan Hernandez, so was Travis Pope.
Stan Hernandez and Pastor Roland Duff got right up alongside Denny Drayton's abandoned patrol vehicle. The driver-side door had been left fully open, and the vehicle's motor was idling. The two men saw the sideways Diet Coke bottle that leaked its viscous contents of tobacco spit all over the cushioned upholstery of the driver's seat.
Denny Drayton's emptied Sig Sauer was on the ground next to the rear tire.
Trooper Drayton's mostly headless and entirely hairless corpse lay in the parking lot in front of the car.
The Unstoppable Soldier that had been Travis Pope flitted up to the roof of Denny Drayton's patrol car. He perched like an obscene living gargoyle atop the rack of flashing colorful lights.
Stan Hernandez looked up and said, "Holy shit."
Those were the last words Pastor Roland Duff, who was mostly a virgin, ever heard in his life.
Holy shit.
Excrementum Sanctum.
Travis Pope killed Stan Hernandez and Pastor Roland Duff. Travis Pope also ate Pastor Roland Duff's entire aroused body. The headmaster from Curtis Crane Lutheran Academy was very tender and moist. Travis Pope made bug shit all over the Iowa State Patrol car, then he scampered away, sniffing the air, trying to find where Eileen and the other bugs had gone.
And at exactly that moment, Ollie Jungfrau opened the door to his Dodge Caravan minivan. He put his laptop and a plastic Walmart bag, into which he'd stuffed some clean clothes, onto the passenger seat.
Ollie Jungfrau was going to get the hell out of Ealing if it was the last thing he'd ever do.
It was.
As Ollie Jungfrau made his way toward the east-west highway that connected Ealing to Waterloo and Dubuque, he noticed a figure running along the side of the road.
Ollie Jungfrau imagined he was stuck inside a video game.
He imagined he was in charge of driving a Dodge Caravan minivan, and the object of the game was to run down big fucking bugs.
"Suck on the front end of a Dodge fucking Caravan, you big fucking alien bugs," Ollie Jungfrau said.
Ollie Jungfrau's penis was hard.
Ollie Jungfrau got erections whenever he killed aliens in video games.
The thing Ollie Jungfrau saw running along the roadside was not a big fucking alien bug, however. The thing Ollie Jungfrau saw was Louis, the cook from The Pancake House, whose real name was Ah Wong Sing.
Louis was five foot four inches tall.
Louis had fucked Connie Brees three times that day, using condoms that Connie Brees found on the floor of Robby's bedroom.
Ollie Jungfrau nearly ran his friend over before he realized it was not a big fucking alien bug.
And running next to Louis was another person Ollie Jungfrau recognized: It was the eighth-grade English teacher from Curtis Crane Lutheran Academy. Her name was Mrs. Edith Mitchell.
Mrs. Edith Mitchell sometimes shopped at Tipsy Cricket Liquors. However, Mrs. Edith Mitchell did not purchase condoms there. Mrs. Edith Mitchell smoked Marlboro menthol cigarettes and drank white wine from cardboard boxes.
Ollie Jungfrau pulled his Dodge Caravan over to the side of the road.
"Hey, you two," Ollie Jungfrau said, "I think Ealing's being invaded by aliens or something. I'm not joking, you better get in."
Ah Wong Sing and Mrs. Edith Mitchell were frantic.
They had seen the bugs, too.
Ah Wong Sing slid open the rear side door on Ollie Jungfrau's Dodge Caravan.
"Thank God," Ah Wong Sing said.
"Thank God," Mrs. Edith Mitchell echoed.
They got inside Ollie Jungfrau's minivan. Ollie accelerated as fast as a Dodge Caravan carrying three Iowans could go. He headed toward the bridge that led out of town, just on the other side of Amelia Jenks Bloomer Park.
It was not a good idea.
## SERIAL KILLER USA
I KNEW HOW to kill the Unstoppable Soldiers.
"We could use my paintball gun," I said.
Paintball is a game teenage boys like to play. We dress up in old clothes and shoot one another with mushy plastic balls filled with paint. The balls are about the size of a nickel. They burst open and leave a splatter mark upon impact, like blood.
"Uh," Robby said.
"We could take some of your blood and inject it with a hypodermic into paintballs." I said, "That's how we can kill the Unstoppable Soldiers. I am certain they have the needles and shit to do it in the clinic."
"You are insane, Austin," Robby said.
Robby crossed his arms tightly in front of his chest. He did not want me to take any of his blood.
"Do you want to stay down here forever?" I asked.
"Yes," Robby said. "I do want to stay down here forever. As long as the Rolling Stones are here, it's fine with me."
The film continued:
From mid-1968 until early 1970, there were a series of unsolved beheadings in Ealing, Iowa.
Robby Brees and I solved them that night, as we watched Reel Five of Eden Orientation Series.
Newspapers, and even the few books that had been written about the Monster of Ealing serial killings put the number of victims at seven. There were actually a lot more than that.
A head belonging to one of the victims was floating inside a large glass jar that sat on a shelf in Johnny McKeon's office in From Attic to Seller Consignment Store at the exact moment Robby Brees and I sat and watched our film play out.
Dr. Grady McKeon got his contract for Unstoppable Soldiers.
What engineer of warfare could possibly pass up a chance to set free a breeding, self-regenerating horde of horny and hungry Unstoppable Soldiers inside enemy territory? The Defense Department of the United States of America wanted Unstoppable Soldiers very much.
McKeon Industries tested their 412E strain on prison inmates. The prison inmates had all volunteered for the program. They had been told it would be an opportunity to leave the country and kill Communists.
Offering the possibility of such an experience to an incarcerated prisoner in the Iowa Men's Reformatory, which is now called Anamosa State Penitentiary, is kind of like offering a lazy white kid one million dollars, a trip to Sweden, and a threesome with Shann Collins and Robby Brees.
Sign me up.
So the scientists at McKeon Industries exposed the inmate volunteers to their 412E plague mold, strapped them down naked to hospital beds, pumped them full of liquid sedatives, and filmed the volunteers while McKeon Industries teams waited for the hatching to begin.
Monsters were making monsters.
At first, Dr. Grady McKeon's staff assumed the Unstoppable Soldiers that hatched would be placid and sedated from all the drugs, too.
It was not a good idea.
History shows that, as a group, scientists tend to not be very aggressive when it comes to physical attacks. The scientists who worked for Dr. Grady McKeon were like good-morning breakfasts for the first hatchling Unstoppable Soldiers.
It also became apparent to the McKeon Industries scientists that the Unstoppable Soldiers are always very horny. The Unstoppable Soldiers needed females, but, unfortunately, there were no female volunteers for the Unstoppable Soldiers Project, Phase 2. This made the Unstoppable Soldiers very edgy.
Six-foot-tall praying mantises with jagged rows of serrated teeth on their arms are not very good at masturbating. This made them even angrier.
Dr. Grady McKeon decided to halt the experiment a second time.
Again, the Unstoppable Soldiers proved difficult to stop. Ultimately it was discovered that the only way to prevent hatching-out among the exposed inmate volunteers was by removing their heads.
This is what the scientists at McKeon Industries did.
And they cleaned up their failures as sloppily as they did everything else, which accounts for the discovery of headless corpses in fields around Ealing, Iowa, in 1969.
Robby posed a question: "Austin, is it just me, or do you feel dumber, too, after spending the last couple hours watching those McKeon scientists experiment with shit?"
"No doubt, Rob, we have lost some brain cells," I answered.
And Robby said, "What are we going to do, Austin?"
Ingrid sighed beneath my feet.
That was usually Ingrid's question.
The film ended with footage of the McKeon Industries Family Picnic Day: happy scientist families eating corn on the cob and playing softball or running three-legged races. It was all very creepy, made more so by Dr. Grady McKeon's voiced-over exhortations:
Breed, my friends, breed. Breed and be the New Human Race.
"I wonder if that corn they're feeding the kids is Unstoppable," Robby said.
I said, "Uh."
Fuck corn.
I never wanted to eat corn again.
Just as the film ran its last strip of leader through the projector, Robby and I heard another sound coming through Eden's speaker system:
Welcome to Eden. Please secure the hatch upon entry.
Welcome to Eden. Please secure the hatch upon entry.
Someone had opened the hatch from outside.
Someone was coming down the entry ladder.
Welcome to Eden. Please secure the hatch upon entry.
## LOOKING FOR WIGGLES
THE MOVIE MADE quite an impression on Robby Brees and me.
We were terrified.
Robby and I stared at each other, both of us uncertain as to which course of action to take: Run and hide, prepare to fight, or go out to the mudroom and see who might be calling on us so late at night.
It was past midnight, Friday morning.
The end of the world was one week old and it was getting out of hand.
"What are we going to do, Ingrid?" I said.
I pinched the silver medallion of Saint Kazimierz between my finger and thumb, raised it to my lips, and kissed it.
At exactly that moment, Eric Andrew Szerba, my father, and Connie May Kenney Szerba, my mother, were drinking cups of strong German coffee. They sat at my brother's bedside in a military hospital, where he was not recovering very well from losing the lower half of his right leg and both of his testicles to a shrapnel bomb in Afghanistan.
On the other side of Ealing, on Onondaga Street, the Unstoppable Soldier that hatched out of Eileen Pope entered Duane Coventry's house through the open front door. Eileen Pope began filling the rooms of the small house with jellied clusters of translucent gray eggs. In a few hours, the house would be entirely filled with Eileen Pope's egg mass, which would turn black and boil with mountainous eruptions of oily unstoppable goo.
The males would have to leave Eileen Pope alone now. Tyler Jacobson and Roger Baird perched alongside each other, up on the roof of the house. Unstoppable Soldiers do not sleep; they rest.
Unstoppable Soldiers cannot close their massive compound eyes.
The Unstoppable Soldier that hatched out of Tyler Jacobson would not have slept even if he could shut his massive, lidless eyes. Tyler Jacobson was hopped up on all the crystal meth that had been coursing through Duane Coventry's body. The crystal meth made Tyler Jacobson very edgy and extremely horny. Tyler Jacobson scrambled on top of Roger Baird, who was also an Unstoppable Soldier, and attempted to copulate with him.
Roger Baird had been in a resting state.
Roger Baird was not very happy after being disturbed from his rest by another male Unstoppable Soldier that was in the act of copulating with him. Tyler Jacobson was confused. The two six-foot-tall praying mantis monsters fought.
Roger Baird was pinned. Tyler Jacobson bit Roger's head completely off. Roger Baird's head rolled down the slope of Duane Coventry's roof like a noisy pinecone felled by a gust of wind.
Clop clop! Clop clop! Thud! went Roger's triangular head as it tumbled unevenly down the shingled pitch of the roof, dropped, and landed below the front porch.
Undeterred, Tyler Jacobson continued doing the two things that Unstoppable Soldiers on crystal meth like to do.
Tyler Jacobson was very confused.
Connie Brees was very tired. She worked on the night staff at the FedEx facility outside Waterloo. She sorted and scanned flats and packages. While she worked, Connie Brees's brain floated along on little blue kayaks.
She floated and floated.
Connie Brees thought about Ah Wong Sing, the man she'd had sex with all afternoon long. Connie Brees wanted to have sex with Ah Wong Sing again. She thought about the ocean, volcanoes in Guatemala, and her son, Robert Brees Jr.
Connie Brees had never actually seen the ocean in her entire life.
Connie Brees wondered if her son, Robert, and the Polish kid he constantly hung around with were gay. Connie Brees glanced at the clock to see if it was time to go outside and have a cigarette. She decided that her son, Robert Brees Jr., and the Polish kid he always hung around with were most likely homosexual for each other. It did not matter, Connie thought. She wanted Robert Brees Jr. to be happy.
The Polish kid seemed nice.
Connie Brees would rather Robert be happy than grow up and float around on little blue kayaks going nowhere.
Connie Brees looked up at the clock again.
Travis Pope made his way through the pitch dark at Amelia Jenks Bloomer Park. Unstoppable Soldiers can see very well at night. Travis Pope sniffed and sniffed at the air. He could smell Eileen Pope, and he was making his way out of the park toward an older neighborhood of small homes along Onondaga Street.
Travis Pope scurried out onto the highway behind Amelia Jenks Bloomer Park. A two-lane, steel Warren truss bridge crossed Kelsey Creek there.
Kelsey Creek is a tributary of the Cedar River, which runs through Waterloo.
Travis Pope stood in the center of the highway at the threshold of the Kelsey Creek Bridge.
The headlights from Ollie Jungfrau's Dodge Caravan minivan washed over Travis Pope, making him glow like a pale green ghost. Everyone inside Ollie Jungfrau's Dodge Caravan minivan could see the six-foot-tall, spike-armed Unstoppable Soldier that stood in the middle of the bridge.
Ollie Jungfrau laughed.
"Ha-ha," Ollie said.
Ollie Jungfrau was in a video game, and he had two passengers who were watching him play from the backseat of his Dodge Caravan.
"Suck on my fat Dodge Caravan cock, you sonofabitch fucking alien bug," Ollie Jungfrau said. Then he added, "Welcome to Earth, motherfucker. Next stop: Hell."
Ollie Jungfrau was a tool.
Ollie Jungfrau jammed the accelerator all the way down to the floor.
Ollie Jungfrau had an erection.
Louis, whose real name was Ah Wong Sing, knew that Ollie Jungfrau regularly used obscene language when he became caught up inside his video games. Mrs. Edith Mitchell, on the other hand, was disgusted by what she heard and saw.
It did not matter. Mrs. Edith Mitchell was in shock, anyway.
Earlier that evening, Mrs. Edith Mitchell had been outside in her neighborhood, which was just west of the Del Vista Arms. She had been looking for her blue Maine coon cat. The cat had not been home in two days.
Edith Mitchell's blue Maine coon cat was named Wiggles.
Wiggles had no balls, but this was neither a result of having eaten Unstoppable Corn, nor because Wiggles had ever been in the blast pattern of a roadside bomb in Afghanistan.
Wiggles's balls had never been named, as far as I can tell.
Mrs. Edith Mitchell did not find Wiggles.
When she returned to her home, the Unstoppable Soldier that had hatched out from Hungry Jack in the middle of a cornfield across from a Waterloo gay bar was inside her living room eating her husband.
Tally-Ho!
It was a mess.
Edith Mitchell's husband was named Leslie Mitchell. Leslie Mitchell was a retired veterinarian. Leslie Mitchell cut Wiggles's balls off.
Wiggles's balls ended up in a trash can, which is what animal doctors tend to do with all the testicles they cut off things. Wiggles's balls ended up in the same trash can that contained a thumb-sized tumor that had been cut from the throat of Ingrid, my golden retriever.
Ingrid never barked after that.
When Mrs. Edith Mitchell came home and saw an enormous bug devouring her husband inside her living room, she ran off screaming down the street.
The television was on. Leslie Mitchell had been watching a program about how to cook lamb when Hungry Jack came in and started eating him.
Now Mrs. Edith Mitchell was staring through the windshield of a Dodge Caravan minivan, while Ollie Jungfrau zeroed in on one of the monsters poised motionless in the road directly ahead.
"Suck this dick, bitch," Ollie Jungfrau said.
Ollie Jungfrau dripped sweat that smelled of garlic and urine. His arms locked straight on the steering wheel.
The Dodge Caravan minivan impacted squarely with the Unstoppable Soldier that had been standing in the roadway at the Kelsey Creek Bridge.
Dodge Caravan minivans do not hold up so well against Unstoppable Soldiers with exoskeletons as tough as the exterior hull of an aircraft carrier.
It was like an Ozark watermelon throwing itself onto the cutting edge of a samurai sword.
The front end of Ollie Jungfrau's Dodge Caravan minivan shattered. The impact of the collision with Travis Pope drove the Dodge's motor all the way back to the front seat. Ollie Jungfrau's right foot was severed in the crash. Travis Pope's enormous head slapped through the Dodge Caravan's windshield and crushed Ollie Jungfrau's rib cage.
The crumpled Dodge Caravan grinded and scraped its way to the center of the Kelsey Creek Bridge before coming to rest against the steel trusses. Before the van stopped moving, Travis Pope had climbed in through the broken windshield.
Travis Pope, who was not very hungry, began picking disinterestedly at Ollie Jungfrau's fleshy corpse.
In the backseat, Ah Wong Sing and Mrs. Edith Mitchell had been dusted with gems of safety glass and flecked by Ollie Jungfrau's blood, but they were still very much alive. They were also trapped inside a crumpled Dodge Caravan minivan.
Ah Wong Sing attempted to open the side door, but it would not move. The frame of Ollie Jungfrau's Dodge Caravan minivan had twisted inward on itself, so nothing would open.
Mrs. Edith Mitchell covered her face with her hands.
The Unstoppable Soldier that hatched out from Travis Pope sat up front, watching the two frightened humans in back while he chewed and chewed at Ollie Jungfrau.
Kelsey Creek Bridge is a good spot for walleye fishing.
The vice president of the United States of America once caught an eleven-pound walleye in the Allegheny Reservoir in Pennsylvania.
One female walleye can lay 500,000 eggs during a spawn.
Travis Pope made shit all over the front seats. Then Travis Pope climbed out through the van's shattered windshield and scampered off into the Iowa night, sniffing the air, looking for Eileen Pope.
The vice president of the United States of America was asleep. He dozed off after receiving a blow job. Blow jobs always made the vice president drowsy. The vice president of the United States of America was scheduled to fly to Germany early the following morning, to visit in the afternoon with American soldiers who had been wounded in Afghanistan.
The vice president's wife, who has no formal title, was having a glass of Scotch whisky.
And at that exact moment, Wiggles, Mrs. Edith Mitchell's wayward blue Maine coon cat, came back home looking for food.
## CONCERNING THE BISON, AND FREE WILL
LATER, AFTER ROBBY and I left Eden, I came to a sudden realization about history.
Here is what I concluded:
All this time, I have been devoting too much thought to the guys who painted the bison on the wall of the cave, and too little attention to the bison itself.
I mean, the bison is the important member of the team, isn't he?
But once the historians put the thing on the wall, it was almost as though every bison for all eternity became doomed to face the hunter's interminable slaughter.
We killed this big hairy thing and this big hairy thing. And that was our day. You know what I mean.
I began to consider the fact that maybe history is actually the great destroyer of free will. After all, if what we blindly believe about history is true—the old cliché admonishing us to learn how not to repeat the same shit over and over again—then why do the same shitty things keep happening and happening and happening?
I felt guilty for ever having written anything at all about me, about Robby or Shann, Johnny McKeon, Pastor Roland Duff, Unstoppable Corn, Saint Kazimierz, Krzys Szczerba, Contained MI Plague Strain 412E, Andrzej Szczerba, Herman Weinbach, a talking European starling named Baby, Felek Szczerba, Phoebe Hildebrandt, Eva Nightingale, my brother, Eric, and two prostitutes named Tiffany and Rhonda, whom we met on the third-floor balcony at a hotel in Nashville, Tennessee.
Each of us became a bison on the wall of my own cave.
Paavi Seppanen.
Julio Arguelles.
Everyone on every road that crossed beneath the point of my pen was always going to do the same things over and over and over.
I was confused.
How could I be in love with a girl and a boy, at the same time?
I was trapped forever.
You know what I mean.
## POPULATION EXPLOSION
WELCOME TO EDEN. Please secure the hatch upon entry.
The repeating message finally stopped.
Whoever had joined Robby and me in Eden closed the hatch after they came inside.
But it was no six-foot-tall praying mantis army of spike-armed killers, nor was it some crazed hermit McKeon Industries Unstoppable Scientist. Our new arrivals in Eden were Shann Collins, her stepfather, Johnny McKeon, and her mother, Wendy McKeon.
Johnny McKeon was carrying the biggest handgun I had ever seen.
Johnny McKeon's Smith & Wesson .500 magnum was made in Massachusetts. A bullet fired from the pistol travels at nearly two thousand feet per second.
"I wonder if Johnny kills queers," Robby whispered.
"Uh," I said.
Johnny McKeon did not come down into Eden to kill Robby Brees and me.
Shann and her family had come down to Eden because they knew the Unstoppable Soldiers were running wild in Ealing, Iowa.
Robby and I stood in the doorway to the locker room. Ingrid, never one to get too worked up about such things as late-night visitors, sat on the floor between us and yawned.
To Johnny McKeon and his wife, Robby Brees and I must have looked like players in a science fiction movie, dressed as we were in our matching and numbered Eden Project jumpsuits.
Shann Collins, who now officially hated me and Robby Brees, avoided my eyes when I tried to look at her.
"Welcome to Eden, Johnny," I said. "I think you are safe down here."
"Uh," Johnny McKeon said.
Johnny McKeon was pale and shaken. He looked at the gun in his hand, then back at me with an apologetic expression like Johnny McKeon wasn't aware that a gun the size of a small bazooka had somehow attached itself to the palm of his right hand.
"You can't shoot them, anyway," I said.
"Uh. I know that, Austin," Johnny McKeon said.
And then Johnny asked, "Are you okay?"
I caught Shann's eye.
Shann Collins had been looking at my face. She turned pale and immediately lowered her gaze. Shann Collins was confused. She was in love with the Polish kid who was also confused.
I said, "Yes. We are okay, Johnny."
Johnny McKeon walked across the floor of the mudroom and placed his Smith & Wesson .500 magnum on the bench just below the scientist's old windbreaker that had been hanging from a hook on the wall for nearly half a century.
I said, "I suppose it's time for me and Robby to show you what has been going on."
Shann coughed nervously.
You know what I mean.
## EVERYTHING A GUY COULD NEED, AND THE TWO BEST ROCK ALBUMS EVER MADE
WE WERE THE New Humans.
Johnny McKeon, Shann Collins, and her mother, Wendy Collins McKeon, changed into Eden Project jumpsuits and white scientist socks. Robby and I did not stay in the locker room and watch them change their clothes. Things were weird enough without doing shit like that.
When the newest New Humans joined us in the lecture hall, I pointed out the chalkboard diagram of the development from 412E, the Unstoppable Corn mold, to the creatures Johnny McKeon had seen fucking and eating earlier that evening in the alley at Grasshopper Jungle.
Although we suspected it, Robby and I did not know for certain that there were several more Unstoppable Soldiers up above us in Ealing until we heard it from Johnny McKeon.
Up until that moment, Robby and I had only seen one Unstoppable Soldier, the one that came out of Hungry Jack. Despite that, we did believe the Hoover Boys and Grant Wallace had to have hatched out as well.
Johnny McKeon also confirmed the Unstoppable Soldiers were spawning.
Robby Brees and I had watched all five reels of Eden Orientation Series. We knew the world had less than twenty-four hours before every human being on the planet dropped to a lower level on the food chain.
It was not a good level to be on.
"Uh, Rob," I said. "You still against the paintball idea?"
Robby said, "Uh."
Johnny McKeon drank Scotch, and Wendy made herself a vodka gimlet at Eden's Tally-Ho!, which was the nicest bar in a thirty-mile radius for this part of Iowa.
Things would be better for Johnny and Wendy McKeon if they were drunk.
Robby Brees reached across the bar and nonchalantly grabbed the bottle of Scotch whisky and poured some out into two glasses.
Nobody said anything about it.
Robby said, "Tally-Ho!"
Robby Brees and I drank the Scotch whisky. It tasted like hot cinnamon and dried fruit.
Johnny McKeon said, "This Scotch must be sixty years old."
Johnny McKeon appreciated good Scotch whisky.
"It is like drinking history," I said.
Johnny said, "Cheers."
Robby Brees and I got drunk with Johnny McKeon and Shann Collins's mom in Eden. It only took two small glasses of Scotch whisky to make me feel like everything was funny, and I wanted to dance with Robby Brees again.
We lit cigarettes.
Wendy McKeon might have known Robby and I smoked cigarettes, but we had never done it in front of her. She was distant and unaffected by what was going on. Johnny and Shann must have scared the shit out of her with the stories about what they knew was happening in Ealing.
And Johnny and Shann didn't know half of it.
Wendy McKeon was very pretty. Her breasts were tight and sharp beneath the shimmering fabric of her jumpsuit. I wanted to touch them.
Wendy McKeon was Eden 93.
Johnny McKeon was Eden 7.
Wendy McKeon's hair was the color of ground coriander.
I fantasized that somebody would suggest we all have an orgy when we got to the parts of the film where Dr. Grady McKeon commanded us to breed. The Scotch whisky made me feel very horny and confused. I would be the first one to volunteer to strip naked out of my clothes, but Johnny McKeon kind of made me feel nervous.
I could not imagine Johnny McKeon ever having sexual intercourse with Wendy Collins McKeon.
Johnny McKeon was the only person in Eden I did not want to take a shower with at that exact moment.
I realized I was getting a Scotch whisky–fueled erection. I did not believe anyone would approve of my erection at that moment. So I sat at the bar and asked Robby for another cigarette.
Robby knew what I was thinking. He always did.
"Tally-Ho! Porcupine," Robby said.
Robby Brees was drunk. He lit a cigarette for me and passed it to me.
The filter end was just a little bit wet with Robby's spit.
"I'll be danged if they don't have everything you'd ever need down in this place," Johnny McKeon said.
Johnny McKeon got up from the barstool. He threw a dart at the board that hung on the other side of the pool table.
"I'll be double-danged," Johnny said, daringly.
"A proper Eden will always have everything a guy could ever need or want, Johnny," I said.
"That, and the two best rock albums ever made in the history of humankind," Robby added.
## THE BLOOD OF GOD
WE TOOK JOHNNY McKeon and his family on a tour of the silo.
We did not show them the entire Eden Orientation Series. Johnny McKeon only wanted to see a portion of the final film. He wanted his wife to know what the creatures he saw at Grasshopper Jungle looked like.
It did not matter. You could not watch five minutes of Eden Orientation Series and not witness some experiment with sperm, or shit like that, or hear Dr. Grady McKeon telling us that it was our duty to start having sex.
"My big brother was a nut case," Johnny McKeon concluded.
"Isn't there television down here?" Wendy McKeon asked. "Maybe there would be something on the news about what's going on."
It was a good question.
The lack of televisions did not register with me until Wendy McKeon asked about it. We hadn't seen one television set in Eden. I imagined Dr. Grady McKeon concluded that when the Eden Project became a necessary sanctuary for humanity, there would be nothing at all worth watching on any broadcast stations.
New Humans would be without commercial television.
Maybe there was hope, after all.
Dr. Grady McKeon was probably correct about post-apocalyptic television broadcasts, although we eventually did find a bank of five side-by-side televisions that night in Eden's Brain Room.
Here is what happened:
We were all very tired after watching the final few moments of corn eating and three-legged-race running in Reel Five. Shann would neither speak to me nor sit near me inside Eden's theater. I thought Johnny McKeon or Wendy might have seen Shann's behavior as cold or unexpected, but if they did, I could not tell.
I began to think guilty thoughts that maybe Shann had said something to her parents about me. I was confused and frustrated, and I desperately wanted to have an opportunity to speak to Shann.
Robby Brees and I were also drunk. The Scotch whisky made us brave and reckless.
I admitted to Johnny McKeon that we had come up with a plan to kill the Unstoppable Soldiers—a plan involving Robby Brees's blood and the paintball guns that had been stored inside my garage ever since my brother, Eric, went away to join the Marines and have his testicles blown off.
Robby announced that if he could have one more drink of Scotch whisky he would let me take blood from him.
It was all a very ghastly proposition.
I did not think I could actually do something like stick a needle into Robby Brees's arm. The thought of inflicting pain on Robby nearly made me cry. With everything that had been going on in my life that past week, and now with Shann treating me like an enemy, I was an emotional disaster.
Shann's mother, Wendy McKeon, had been a registered nurse before marrying Johnny McKeon and moving to Ealing. She said if she could have one more vodka gimlet, she would draw a few vials of blood from Robby Brees.
I went pale.
Robby went pale.
It was all very ghastly.
The clinic filled with the steaming smell of alcohol breath. There is something about the sterility of clinics that repels everything, as though they are vacuums unto themselves, like the glass globes into which the McKeon scientists trapped all kinds of shit. As soon as the five of us entered the Eden Project clinic, the place absorbed the odors of booze, sweat, cigarettes, and golden retriever.
"I have B.O.," I said.
Ingrid sighed and curled up on the floor beneath the flat, padded examination table.
"Saint Kazimierz brought a dead girl back to life, and he also made a blind boy see," I said. I unzipped the top of my jumpsuit and slipped the silver chain over my head. I told Robby he should wear the Saint Kazimierz medal while Wendy McKeon drew blood from him. I put my chain on Robby. He looked scared.
Wendy McKeon told Robby to lie down on the table and strip to his waist. Wendy began opening cupboards and drawers in the clinic, gathering the things she would use to collect blood from Robby Brees.
Robby undid the top of his jumpsuit and slid it down around his hips. He lay there, half naked on the operating table.
"I wonder if those McKeon sickos ever operated on teenagers here," I said.
Robby said, "Uh."
I touched the Saint Kazimierz medal and pressed it against Robby's heart.
Wendy put two wadded balls of gauze into Robby's palm and told him to squeeze them.
"I bet that's the first time you ever squeezed someone else's balls in a doctor's office," I joked.
Robby said, "Shut up, Austin."
"Okay," I agreed.
Shann was exasperated. She said, "I can't watch this."
Shann thud-thudded in her padded scientist socks out into the hallway.
I wanted to follow her, but I was stuck. I could not just leave Robby alone in the clinic. I looked back and forth, from the door to Robby's pale chest as Wendy McKeon tightened a rubber tube around my best friend's bicep.
Robby gripped the wads of gauze in his hand. He was scared. I didn't want to see Robby Brees scared and hurt.
Robby's skin was the color of the insides of sweet Babcock peaches.
He knew what I was thinking.
Robby Brees whispered, "You should go talk to her, Porcupine."
Robby Brees always knew what was going on.
I wanted to ask Ingrid what was I going to do, but I did not want Johnny McKeon and Shann's mom to think I was an insane kid who talked to his non-barking dog and shit like that.
"Uh . . . Um . . . ," I said.
Wendy McKeon stabbed a thick needle right into the bend of Robby's arm.
"Gee whiz, babe," Johnny McKeon said.
Thick maroon blood began filling up the cylinder on the syringe.
Blub-blub! went Robby's blood.
Robby winced.
I felt my knees buckle.
"Uh. I better step outside," I said.
## WANDA MAE'S PINK BOWLING BALL
SHANN COLLINS HAD gone down to the end of the hallway. She stood outside the doorway to Eden's bowling alley. Shann faced away from me, but I could tell she was crying.
I felt like shit.
"Please don't cry, Shann," I said.
I put my hand on her shoulder and slid it up beneath the soft warm fluffs of her perfect hair. She did not pull away from me. That was progress, I thought.
History is all about progress.
"And please don't hate Robby. Uh. Or me. I would never lie to you, Shann. I love you too much." I said, "And, uh, be honest: How many boys do you know who actually have the ability to save the entire world? Robby Brees is like a superhero."
Shann laughed and cried at the same time.
History does show that Shann Collins was a complex person, capable of doing such things simultaneously.
All my best friends were very complex.
"Why didn't you ever tell me, Austin?" Shann said.
I nearly gave Shann Collins the automated teenage boy response, which would have been I don't know. I stopped myself.
"Do you really want to hear about Robby? Because I will tell you everything I know about him, Shann," I said.
Shann said, "No."
I said, "I love you, Shann Collins."
She wiped at her face. It was my fault Shann was crying.
"Tell me the truth. Are you gay, Austin?" Shann Collins said.
"I really don't think so. Uh. I don't know, Shann." I said, "Maybe there is something wrong with me."
"But I love you, Austin," Shann said.
"I know that. I'm sorry for hurting you, Shann." I said, "I can't even begin to tell you how much I love you."
Then Shann turned around and put her arms around me. We kissed, more deeply and passionately than we had ever kissed in our lives. I pressed my hips into hers. She did not back away from me at all.
Shann Collins clearly approved of my erection.
She said, "I'm scared, Austin."
I whispered, "I guess I am, too."
"Okay."
"I'm sorry."
We moved like tangled dancers through the doorway and into the bowling alley.
That was a lot of progress.
The world was turning, and mankind was marching onward, doing the same stupid shit over and over and over.
I unzipped Shann Collins's jumpsuit and did the same to mine, so I could press my bare chest against her full breasts. My throat tightened. My heart felt like it was squirming up inside my neck, just like a fat walleye forcing its way through a shallow creek during the spring spawn.
Eden 5 needed to spawn.
We went deeper into the bowling alley.
I imagined being inside a cave, fifteen thousand years in the past.
Shann Collins and I threw off all our clothing. Naked, we went down onto the floor together.
"Do you think this is the end of the world, Austin?"
"We'll be okay. We'll be okay."
Shann kissed me. She put her mouth everywhere on my body.
It was electric.
But I could not stop myself from thinking about my brother, Eric, and the two prostitutes named Tiffany and Rhonda. I thought about Saint Kazimierz and his hair shirt, about Krzys Szczerba, and all the Szczerba men after him. I thought about Robby in the clinic.
I thought about naming my balls.
Shann Collins helped me put my penis inside her vagina, and we had sexual intercourse right there on the floor of Eden's bowling alley, below a pair of shoes and a pink ball that had Wanda Mae embossed in gold on it.
Our sex was noisy and urgent and wet. I rubbed my kneecaps raw, scraping them on the rough carpeting at the shoe-changing station. I pushed Shann along on her butt until her head and mine bumped against the rattling rack of bowling shoes.
I did not care about anything at that exact moment.
No one knew anything about it.
Dr. Grady McKeon would be proud of Shann Collins and me.
We were unstoppable.
At exactly that moment, Louis, the cook from The Pancake House, whose real name was Ah Wong Sing, climbed over the bloody, shitty mess in the front seat of Ollie Jungfrau's Dodge Caravan minivan. He got out of the van through the shattered window, the same way the Unstoppable Soldier that once had been Travis Pope did.
Ah Wong Sing wanted to help Mrs. Edith Mitchell get out, too.
"Climb over the seat," he said to her.
Mrs. Edith Mitchell shook her head and said no.
Ah Wong Sing tried all the doors on the Dodge Caravan. He could not open any of them.
"Climb over the front seat," Ah Wong Sing repeated.
But Mrs. Edith Mitchell would not move.
Ah Wong Sing said he would get somebody to help. He ran off, across the Kelsey Creek Bridge toward Amelia Jenks Bloomer Park, which was the opposite direction from where he had seen the Unstoppable Soldier going.
Ah Wong Sing was smart.
Mrs. Edith Mitchell waited in the crumpled Dodge Caravan minivan.
It was not a good idea.
At exactly that moment, Robby Brees was lying back, dizzy. Robby stared up at the soft fluorescent lights inside the clinic while Wendy McKeon smoothed a plastic bandage across the small dark hole she had left in Robby's arm.
"Just lie there for a few minutes," Wendy McKeon told him.
Then Wendy McKeon put the three large syringes she had filled with Robby Brees's blood inside a small steel clinical refrigerator.
Johnny McKeon was asleep on a wheeled doctor's chair with the back of his head propped against the wall.
In the bowling alley, Shann Collins and I hurried to put our clothes on. We were both sticky and smeared all over with semen and saliva. I wanted to take a shower.
Neither of us said a word.
I was more confused than ever.
I felt terrible for all the things I had selfishly done to Shann and Robby. I shut my eyes and asked Saint Kazimierz to help me.
Outside, I heard Wendy McKeon calling for us in the hallway.
I stuttered guiltily, offering something shitty about bowling a few frames when I saw Robby Brees, Ingrid, and Shann's parents looking for us in the hallway.
I do not lie, and now I was a liar, too.
Shann and I were mortified with embarrassment.
Robby's mouth tightened in a disappointed frown. He looked drained and tired.
Robby knew what we did. He could tell.
Robby Brees always knew everything about me.
Robby Brees slipped my silver chain over his head and handed the medallion with Saint Kazimierz back to me.
Robby said, "Thanks for this, Austin. You probably need it more than me now."
A cigarette was what I needed, but I did not have the guts to say anything to Robby Brees.
I looked at Ingrid and said, "What am I going to do, Ingrid?"
Ingrid yawned, which is what Ingrid always does when she is confused.
I was confused, too.
Johnny McKeon said, "Dang. A dog who understands English. Ain't that a kick?"
## RULES ARE RULES, BUT THE BRAIN ROOM IS NOT PARTICULARLY BRAINY
JOHNNY MCKEON DID not have to try very hard to convince me and Robby that we should wait until daylight before going back to my house for the paintball guns.
Robby Brees and I were going to use my paintball guns and Robby's blood to kill the Unstoppable Soldiers and save the world.
Nobody wants to go out in the dark with Unstoppable Soldiers on the loose, even if you happen to be hanging around with their God, who is armed with a paintball gun, or shit like that.
I hoped the God of Unstoppable Soldiers was not too upset with me for sneaking away while his blood was being drained so I could have sexual intercourse with Shann Collins on the floor of a bowling alley.
Unlike my great-grandfather, Andrzej Szczerba, I was not testing myself or trying to prove anything.
That was what I told myself, at least.
I was probably wrong.
I mumbled something about wanting to take a shower. I stunk.
Wendy McKeon said that if we had to stay in Eden for a while, we would have to make some kind of rules about when boys could shower and when girls could shower.
It was a ridiculous thing to make a rule about. Wendy McKeon may just as well have made a rule about the rotational speed of the earth.
History shows that as long as there have been human beings on this planet, once you put two of them together, rulemaking will start up before you know it.
"I sometimes take showers with Ingrid," I confessed.
Ingrid yawned.
We made this stupid rule and this stupid rule.
Boys are not allowed to love each other.
Then we painted a bison on the wall.
I wanted to take a shower. I was sticky and scratchy between my legs. I felt like the abrasive acrylic carpet fibers from the bowling alley were boring into my balls. I had B.O., and I needed to pee really bad.
Everyone else wanted to go to sleep. It was very awkward and nerve-wracking for me, talking about going to bed. I wanted Shann and Robby to sleep in the same room with me. I wanted to hold them both and tell them how sorry I was.
I knew that would not happen. You know, rules, and shit like that.
It was on our way through the hallway of Eden's dorms that we discovered the Brain Room.
Here is how we discovered it: The door had a brass plaque with etched banker-font letters that said this:
BRAIN ROOM
Robby, Shann, and I did not notice it before when we were running crazy through the sleeping compartments, jumping on beds and not making rules, and shit like that.
"What the heck?" Johnny McKeon said.
"Maybe it's some kind of command post," Wendy, Johnny's wife, offered.
"Uh," I said. "After watching and listening to Dr. Grady McKeon for about three and a half hours tonight, I would not be surprised if the room on the other side of this door was filled with actual brains."
"Or sperm," Robby added.
"Uh," I said.
I turned red.
Shann was absolutely silent.
Nobody wanted to hear about sperm at that exact moment.
But Robby was actually closer to winning the guess-what-is-inside-the-Brain-Room game.
It turned out there was quite a bit of sperm inside the Brain Room.
Robby Brees, the God of all Unstoppable Soldiers, pushed his way between Johnny McKeon and me. Robby turned the knob on the door.
We went inside Dr. Grady McKeon's Brain Room.
To be more precise, we went into the receptionist's office of the Brain Room.
Dr. Grady McKeon kept a secretary. History will verify that his secretary was highly involved in Dr. Grady McKeon's mission to breed. Dr. Grady McKeon attempted to breed with his secretary on top of her desk, on the floor of the reception area, on the pool table in Eden's Tally-Ho!, and even on the stainless steel tray caddy in the cafeteria.
Dr. Grady McKeon's sperm was not very lively. Dr. Grady McKeon's sperm was not unstoppable. In fact, Dr. Grady McKeon's sperm never got started.
Dr. Grady McKeon's secretary's name was Wanda Mae Rutkowski.
She had a nameplate on her desk that said so.
Moments earlier, Shann Collins and I had sexual intercourse below Wanda Mae Rutkowski's pink bowling ball and tricolor bowling shoes. Wanda Mae Rutkowski had feet like Godzilla. While my penis was inside Shann Collin's vagina, I noticed that Wanda Mae Rutkowski's shoes were women's size 11.
It is my job to notice accurate details, no matter what is going on.
Wanda Mae Rutkowski's desk was frozen in time.
"Hey! Gum!" I said.
Wanda Mae Rutkowski left an opened, pale green rectangular package of Wrigley's Doublemint gum on her desk. There were three sticks left inside the pack. I took one and began chewing it. The texture at first was cardboard-like and somewhat disappointing, but there was still a remarkable double-mintiness locked within the sugary gum.
"Unstoppable Chewing Gum," I said.
Robby said, "Um."
I prayed to Saint Kazimierz that he would see to it my balls would not dissolve.
Wanda Mae Rutkowski also had a pack of cigarettes called Virginia Slims. I wanted to smoke one of them. There were two cigarette butts in an ashtray that came from Clement's Motor Inn in Cedar Rapids. Wanda Mae Rutkowski had cotton candy lipstick. It made me horny thinking about Wanda Mae's lips. My penis was a real dynamo. I finally settled on names for my balls.
My balls deserved names.
The Virginia Slims cigarettes were menthol, and very thin. They looked like candy.
Wanda Mae Rutkowski obviously enjoyed minty pleasures.
A rotary-dial phone sat on her desk, too. Like the others we had seen in Eden, it had a row of clear plastic buttons across its base.
## NEVER LOOK FOR ICE CREAM IN A SPERM FREEZER
"WELL, I'LL BE a monkey's uncle," Johnny McKeon said.
I never knew what that meant, but in Dr. Grady McKeon's case, it would have to mean that someone's sperm got inside a monkey.
Ingrid yawned.
Johnny McKeon picked up the handset for the phone. "I haven't seen one of these beauties in a coon's age."
In the wild, North American raccoons live approximately three years.
Doublemint gum was invented in 1914.
Krzys Szczerba was twenty-six years old in 1914.
I stuck my stale Doublemint chewing gum under Wanda Mae Rutkowski's desk.
Johnny McKeon dialed Ollie Jungfrau's phone number. Ollie Jungfrau could not answer his phone at the Del Vista Arms because Ollie Jungfrau had been eaten by Travis Pope on the Kelsey Creek Bridge.
It didn't matter because the Brain Room's phone did not connect to phones on the surface of the planet Earth.
"This is only an internal line, I guess," Johnny McKeon said.
Who would you call after the end of the world, anyway?
"Satan's Pizza does not deliver in the event of global cataclysm," I said, adding, "It says so right at the bottom of the placemat menus."
"I never noticed that," Johnny McKeon, who had absolutely no sense of humor, said.
Satan's Pizza would no longer be delivering because Stan, the owner, whose real name was Sevastián Hernandez, had his head removed by Travis Pope's crushing mandibles earlier that evening.
On the wall behind Wanda Mae Rutkowski's desk hovered the sun-like golden shield of McKeon Industries's infinita frumenta! seal. On either side of the seal hung black-and-white, framed photographs of Dr. Grady McKeon with President Richard M. Nixon, Vice President Spiro T. Agnew, and CIA Director Richard Helms. There were two other photographs hanging on the wall. The first was a photograph of a man named James Arness, who was a television star in a program about the Wild West. The second was a photograph of Dr. Grady McKeon standing with Pope Paul VI. The inscription on James Arness's photograph said:
To Grady—Thanks for the Corn!!!
The pope wrote a message across his picture in blue ink:
Dear Grady, This corn is sublime.
Dr. Grady McKeon dissolved the pope's balls.
Excrementum Sanctum.
Below the Great Seal of McKeon Industries was a small brass plate that read:
SPERM VAULT
IN EDEN, MANKIND IS UNSTOPPABLE!
The seal was actually a door cover to Dr. Grady McKeon's bank of frozen sperm.
Robby opened the seal door. Behind the door was a heavy steel freezer.
"They have the president's sperm in there," Robby said.
"Uh," I said. "They have the pope's sperm in there."
"And James Arness's," Johnny McKeon added.
"Oh my!" Wendy McKeon said.
"James Arness was a handsome man. Handsome. My favorite actor, too," Johnny McKeon offered.
"Maybe there's some ice cream in there," Robby suggested.
"Uh," I repeated. I pushed the Great Seal shut. "Let's not look for ice cream in a sperm freezer, Rob."
To the side of Wanda Mae Rutkowski's desk was a windowless door marked:
PRIVATE
It led to Dr. Grady McKeon's Brain Room.
## A REAL CONCRETE IOWA THINKER
TWO HEADS, WITH four gaping eyes, sat on Dr. Grady McKeon's desk, staring directly at us when Robby opened the door marked Private.
Shann gasped.
Wendy squeaked.
Johnny McKeon said, "Ain't that a kick?"
There were two identical grimacing lemur masks inside the Brain Room.
They were the first things we noticed, simply because they looked like severed monster heads resting atop Dr. Grady McKeon's desk, poised to defend the room against intruders. They were exact matches to the one Robby and I took from the roof of Grasshopper Jungle, only these were cleaner and appeared to be brand-new.
"Grady McKeon must have owned the world's finest collection of grimacing lemur masks and sperm," Robby theorized.
"Holy shit," I said.
"I wonder if they make your face stink," Robby said.
Shann finally spoke. She was not looking at the grimacing lemur masks. She stared in shocked wonder at the cases along the wall behind her dead stepuncle's desk.
"What is this stuff?" Shann said.
Johnny McKeon sighed and leaned against his brother's desk.
Johnny said, "It looks like the same boatload of oddities McKeon Industries had delivered to the store when they packed up and closed down the plant."
Robby and I tried to play dumb. Johnny McKeon never found out that Robby Brees and I had been inside his office at From Attic to Seller Consignment Store the night Grant Wallace and the Hoover Boys broke in and robbed Tipsy Cricket Liquors. We were not about to tell him, either.
I said, "What is it, Johnny?"
And Robby said, "Uh."
Here is what we found inside the Brain Room:
There were ten perfect globes of pulsating black Contained MI Plague Strain 412E—more than one for every continent on Earth—enough to ensure the annihilation of the entire human species. And all along the other shelves sat rows of bottles and bottles of deformed, clay-like body parts that had been cultivated from Dr. Grady McKeon's inadequate sperm in the Human Replication Unit labs. I noticed a foot inside one of the polymer-electric cells. It sprouted long nails that grew all the way to the glass barrier and its toes twitched, which made faint tick-tick! tick-tick! sounds against the jar. And there were oblong cases that contained some of the segmented parts of the first Unstoppable Soldiers that'd been dissolved with Dr. Grady McKeon's own blood.
It was a deranged carnival sideshow.
Against one of the Brain Room's walls was a bank of five television sets.
The televisions were absolutely useless, as primitive as kerosene lanterns. Each of them had a numbered dial that went from channel 2 to 13. Johnny McKeon explained to me, Shann, and Robby that at one time, televisions had to be calibrated and tuned by hand. Johnny McKeon told us that people stopped having so many children in Iowa after the invention of the remote control. Johnny said when he was a kid in Iowa, there were only five channels broadcasting, and that none of them was on the air twenty-four hours per day.
"Wow," I said. "Did they have programs instructing you on how to paint bisons on your walls?"
Johnny said, "I don't think they had any art classes on TV in those days, Austin."
Johnny McKeon was a real concrete Iowa thinker.
Johnny turned on one of the televisions. It took the picture tube nearly a minute to light up. There was nothing but monochromatic electric sandpaper on every one of the ratchet-knob channels Johnny McKeon clicked through.
"This is a real beauty," Johnny said.
"Oh," I said.
"It sure is," Robby agreed.
The real prize of the Brain Room was Dr. Grady McKeon's personal logbook.
The logbook looked like it had been written by a seven-year-old with a dull pencil. Dr. Grady McKeon's scientific record included undiluted details of every time Dr. Grady McKeon masturbated for one of his experiments, or engaged in coitus with other Eden Project volunteers.
In the frenetic scrawl of a crazed disciple of unstoppability, Dr. Grady McKeon also confessed to flushing Pope Paul VI's sperm down his Nightingale. The other contributors' samples soon followed.
Dr. Grady McKeon saw himself as the future King of a New Universe.
Too bad his sperm never worked for anything.
But the logbook also provided relevant pieces of information about the upside-down universe of McKeon Industries Labs.
"It says here," I said, flipping through the book, "that the lemur masks are detection devices that cause people to glow bright red if they are contaminated with the 412E."
"That's cracker-jack science, right there," Johnny said.
Scotch whisky made Johnny McKeon talkative and enthusiastic, even at the end of the world.
Robby slipped one of the masks over his face and looked around at each of us.
"Red balls," he said.
"What?" I said. I cupped my hands over my balls.
"On the wall. All the balls look red," Robby said, pointing to the globes of 412E. "But we are all a boring shade of blue."
I remembered how, the night I slipped away on my mother's blue kayaks in Robby Brees's bedroom at the Del Vista Arms, when I put his lemur mask on my face, it made Robby appear to turn blue.
I would not say that it was a boring shade, however. Robby Brees could never be a boring blue.
"And the best part is," Robby continued, "this one does not make my face stink!"
## NIGHTTIME IN EDEN
SHANN COLLINS, HER mother, Wendy McKeon, and stepfather, Johnny, all stayed in one room together.
We said good night in the hallway. I tried to catch Shann's eye, but she was nervous and shy—not like Shann at all.
We should not have had sexual intercourse.
It was an unstoppable mistake.
History will show that teenagers are unstoppable horny dynamos once the jumpsuits come off. I knew that well enough after living through the week when the world ended in Ealing, Iowa.
The Collins-McKeons slipped into their room and shut the door.
Then Robby quietly said good night to me and went inside one of the rooms by himself.
"Hey—" I said.
Robby did not want to talk to me.
"What am I going to do, Ingrid?"
I did not know what to do. Everything was a mess. I was in love with my two best friends, and I was making them both miserable at the same time. And there were big horny bugs up above us that were eating the whole planet.
I walked away from the dormitory rooms, carrying Dr. Grady McKeon's logbook.
Ingrid followed me into the locker room.
Ingrid lay on the tile floor and watched me while I took a shower.
Afterward, I put my boxers on and dropped my jumpsuit into the Eden Launderette. I sat on the washing machine while it ran, and I remembered how Robby Brees had told me the Ealing Coin Wash Launderette was like a vacation in Hawaii compared to the Del Vista Arms's laundry room.
I left my Eden 5 jumpsuit there, tumbling and tumbling in the dryer, then found my way into my own, lonely sleeping compartment, which happened to be the messy one—the room where Robby, Shann, and I had jumped on the beds.
I sighed and sat down.
I wrote until I fell asleep with the lights on.
Tucked inside Dr. Grady McKeon's personal logbook, I found a 1971 brochure that featured Cypress Gardens's water ski team and a creased glossy photograph of Wanda Mae Rutkowski.
Wanda Mae Rutkowski was the very image of the two-hundred-foot-tall woman on the great seal of McKeon Industries.
At the bottom of the picture, a message that had nothing to do with corn or sperm had been scrawled in smeared blue ink and curling, candy-sweet script. It said:
Grady, I hope you can someday forgive me. We will always have Eden, Wanda Mae
In her photograph, Wanda Mae Rutkowski is wearing knee-high lemon yellow vinyl boots. Although people in the 1970s did not recycle plastics, those boots could likely have been converted into at least three complete shower curtains; perhaps a full-size Slip 'N Slide, or one of those inflatable bouncy houses parents rent for their kid's birthday. Her dress, low-cut to showcase the perfect V separating her breasts, has long belled sleeves and a wild floral print in pinks and violets. Wanda Mae is wearing a matching headband that spans her forehead from eyebrows to hairline. The hem on the dress barely covers her panties, which I imagine would be a pale lavender. Her hair falls in loose globular curls over her shoulders. It is the color of tangerine marmalade, and Wanda Mae's flawless skin looks like home-churned Indiana butter.
I can't be certain, but I believe Dr. Grady McKeon did not hire Wanda Mae Rutkowski for her stenographic abilities.
Wanda Mae Rutkowski performed in a barefoot water ski show in Florida throughout the 1970s, after Dr. Grady McKeon sealed up his subterranean sexual pleasure dome in Ealing, Iowa, for the last time.
Dr. Grady McKeon became a recluse in his old historic house when Wanda Mae Rutkowski left him. Wanda Mae married a dog trainer who made a fortune racing greyhounds in Florida. The dog trainer's name was Jan Wojner. Jan Wojner learned everything he knew about dogs from his grandfather Bruno, who survived the Great Depression by performing with circus dogs in California.
Unstoppable dogs!
Wanda Mae Wojner won the Women's National Barefoot Water Ski Championship, which was held in Waco, Texas, in 1978.
In 1978, Pope Paul VI died without ever knowing that Dr. Grady McKeon had unceremoniously discarded his sperm in my great-great-grandfather's urinal.
In 1978, McKeon Industries presented four sealed globes of Contained MI Plague Strain 412E to the United States Department of Defense.
Nobody knew anything about it.
In his abandonment, Dr. Grady McKeon, who had gone about as far off the deep end as anyone could go following the gruesome disasters of his Unstoppable Soldier experiments, got crazier and crazier. He forgot all about Unstoppable Soldiers and his Eden Project.
In 1978, Dr. Grady McKeon bought a small palace in Costa Rica and boarded up the old McKeon House in Ealing, Iowa.
I could only find evidence of one recorded trip he made back to Ealing to attend a shareholders' meeting, which happened when Robby Brees and I were in seventh grade.
It was not a good time to fly.
## THE FINALE OF SEEM
IT IS THE STRANGEST MACHINE: pencil and paper, paint and wall; medium, surface, and man. The machine stitches all roads into one, weaves every life together, everything.
All good books are about everything, abbreviated.
The final lines of the opening stanza of my favorite poem are these:
Let be be finale of seem.
The only emperor is the emperor of ice-cream.
By the time Krzys Szczerba was a middle-aged man, he had grown tired of struggling and feeling so isolated from his identity in the United States of America.
Krzys Szczerba could never stop being the Polish boy who lost his father on the crossing to America. Every day, Krzys Szczerba could shut his eyes and see the gray, wooden body of his father as it slipped into the cold water of the slate sea.
Krzys Szczerba's son, Andrzej, had gone away to Iowa City. Krzys Szczerba never knew anything about how much his son loved Herman Weinbach. Krzys knew something about his grandson, a boy named Felek, which means lucky. But Krzys Szczerba had never seen the child, nor the mother—a butcher's daughter named Phoebe Hildebrandt.
Eva Nightingale, Krzys's wife and the inspiration for his Nightingale urinal, was killed by a street trolley in Saint Louis in 1936, when Krzys was forty-eight years old. Things like that happened all the time, and nobody knew anything about it.
Without the creamy white pillows of Eva's body to enfold him at night, Krzys Szczerba became cold. Krzys Szczerba froze inside. Krzys Szczerba still had brothers and sisters in Poland whom he had not seen since 1905, when Theodore Roosevelt was president.
In 1937, Krzys left the United States of America to return to Poland.
It was not a good idea.
In September 1939, Krzys Szczerba was killed as he walked in a marching column of refugees along a muddy farm road in western Poland.
In September 1939, Germany was unstoppable, and Russia shared in the spoils of Polish conquest. Nobody needed Polish boys.
Too bad for Poland.
Too bad for boys like me.
This was just one of those things in history that gave us Polish boys sleepy bags under our watchful eyes. We see everything. It is our job to pay attention to details.
Wanda Mae Rutkowski had size 11 feet.
One day, I will go to Poland. I will ask Robby Brees to go to Poland with me. I know I will find the same country road where Krzys Szczerba died, and I will bring flowers in last month's newspaper and place them there.
With my finger I will draw the image of a bison in the dirt, and Robby Brees and I will smoke cigarettes and I will tell him all the stories I know, about everything.
This is the truth.
## THE SUNSHINE BORES THE DAYLIGHTS OUT OF ME
"I DECIDED ON Orville and Wilbur," I said.
Robby said, "Huh?"
"My balls," I said. "I have decided to name my balls Orville and Wilbur."
I named my balls after the Wright brothers.
Orville and Wilbur Wright were from Ohio, although Wilbur was born in Indiana. They invented an airplane.
Orville and Wilbur Wright never married anyone in their entire lives. They must have masturbated a lot, which, according to Pastor Roland Duff, would have made them highly stoppable soldiers.
Maybe they wore hair shirts.
"Which one's which?" Robby said.
"Wilbur Wright did not have a mustache and was bald on top. So Wilbur is on the left," I answered. "The left side is . . . Uh . . . kind of bald."
"Um. That makes sense," Robby decided.
Robby Brees nodded appreciatively and took a long drag from his cigarette.
We drove in Robby's old Ford Explorer, away from the McKeon House, which was the only house on Ealing, Iowa's Registry of Historic Homes.
It was morning, and it was time for Robby Brees and me to go kill some monsters.
I wore my fresh-laundered Eden 5 jumpsuit. It smelled like detergent and brand-new underwear. We had Ingrid, three syringes full of Robby Brees's blood, six packs of cigarettes from the free Eden vending machines, and the two grimacing lemur masks with us.
Robby looked like he slept well. He had showered and his hair was wet. Robby looked good.
Robby always looked good.
Robby said, "I am relieved to announce we are safe from committing the worst imaginable social blunder, which is giving your balls the same names as another guy in the same town's balls."
"I am thankful for that," I said.
I took a drag from my cigarette.
Robby said, "My balls are named Mick and Keith."
"Those are probably the best names anyone has ever given their balls in the history of naming your balls," I said.
Robby said, "Thank you, Austin."
He pushed a cassette into the tape player in the Explorer's dashboard.
It was Exile on Main Street.
That cassette was so old, all the printing had completely worn off it. Robby knew the difference between Exile on Main Street and Let It Bleed only because of the smudge patterns on the plastic shell casings.
The first song on Exile on Main Street is called Rocks Off. Some of the lyrics go like this: The sunshine bores the daylights out of me.
Sometimes I understood Robby Brees better than other times. I knew he was mad at me for leaving him there in the clinic the night before, even if he selflessly encouraged me to do it. That was Robby, and I loved him.
I believed Robby was jealous of Shann Collins.
And, looking at the sky and all the light, I also agreed that the sunshine was boring.
I wished we could go back underground and be alone in the dayless and nightless world of Eden, so we could play music and dance together—just me, Robby, and Shann.
And Ingrid, too.
Ingrid does not dance or bark.
I have tried to dance with Ingrid. It makes her nervous.
We headed off toward the town of Ealing, in the direction of my house. After that, who could possibly know? It wasn't like there were any specific instructions on how to hunt down and kill wild Unstoppable Soldiers. Even the lunatics who ran the labs at McKeon Industries only had to deal with bugs in a jar, so to speak.
The state of Iowa is a pretty big jar.
Johnny McKeon urged us to take his gun. We did not. Despite being Iowa boys, neither Robby nor I had ever fired a real gun in our lives. I was afraid one of us would accidentally kill the other. That would be worse than being eaten by an Unstoppable Soldier.
Paintballs are just paintballs, unless they're filled with the blood of your God and you are an Unstoppable Soldier, but a Smith & Wesson .500 magnum could bring down a helicopter.
So we left Johnny McKeon's Smith & Wesson .500 magnum in Eden.
Johnny McKeon made a sling from two Eden Project jumpsuits, and I carried Ingrid up the ladder with me and Robby when we left the silo. Johnny offered to come with us, but I convinced him the Unstoppable Soldiers would leave Robby—and hopefully me—alone.
Johnny McKeon knew he did not want to leave Shann and Wendy by themselves, anyway. He was just doing the Iowa-right thing by offering us his gun and company.
Iowa-right is the same thing as blue plaid on your boxers.
Johnny McKeon was a humorless, but good, man.
That morning, we had eaten breakfast in the Eden cafeteria. Wendy McKeon cooked pancakes and brewed coffee. I did not sleep well. Neither did Shann. Her eyes were red and her hair was uncombed. It was a look I had never seen before. Shann Collins looked nervous. She looked like Ingrid when I danced with her.
Shann and I managed to have a few moments alone that morning while Robby showered and Johnny McKeon visited the toilet.
It was awkward and embarrassing. We held hands, but it somehow was not like the us we used to be.
"Are you okay?" I asked.
Shann said, "I suppose so. Are you?"
Nobody from Iowa ever says I suppose so.
"My knees are scuffed up," I admitted.
It made me feel horny to think about my knees.
"I never did that with anyone before," Shann said.
"I. Uh." I did not know what to say. What could I say? Was I supposed to apologize or something?
I said, "I thought it was amazing. The best thing ever. I love you so much, Shann. Did you . . . Uh . . . Did you like it? Shann?"
"It hurt," Shann said. "And you told me you would use a condom."
That was an unfair thing for Shann to say to me. It was cold, too. We never talked about condoms or anything the night before at our little End of the World Party; we just did it because it was what we wanted, the one thing we needed to do. But Shann sounded like someone at a butcher shop rejecting a cut of meat for having too much fat, or shit like that.
"Uh. I must have left my condoms in my other jumpsuit, Shann," I said.
Shann was angry. She was sorry for what we did.
I felt like shit.
Ingrid was happy to get out of Eden. She shit for a solid ten minutes.
Edens are made for humans, not for animals.
And Dr. Grady McKeon was no Noah. Noah would not have flushed the pope's sperm down a urinal, not to mention James Arness's.
"What am I going to do, Robby?"
Robby drove with both hands on the wheel, a cigarette angled daringly from his lips. He looked cool, like a tough guy in a movie, or maybe someone who was about to save the world, but had to think things over first.
I mean, what if the world was not worth saving, after all? What if, in some twisted way, Dr. Grady McKeon really had the right idea about starting over in a well-stocked Eden with stacks and stacks of blank books just waiting to be filled up by New Humans writing a New History where we did not do the same shitty things over and over and over?
"Why do you want me to tell you what to do, Austin? I have a tough enough time figuring out what I'm going to do," Robby said.
"Uh."
Robby was right.
"I am sorry for what I did last night, Rob," I said.
"Why do you have to apologize to me for anything?" Robby said.
"You know," I said. "I had sexual intercourse with Shann Collins in the bowling alley while you were lying in the clinic having your blood taken out, so we . . . uh . . . you . . . could save the world."
"The bowling alley sounds like a romantic spot for you and Shann Collins to have sexual intercourse," Robby said.
"Uh," I said.
"It's not like I would have traded places with you," Robby offered.
"Um."
Naturally, that made me think again about having a threesome with Shann and Robby. Normally, the thought would make me feel very horny. Too bad Shann Collins did not seem to like me anymore. Too bad Robby Brees did not seem to like me very much, either.
I reached back and stroked Ingrid's fur.
I did not like myself, but at least Ingrid did.
Dogs are good for that kind of shit.
We drove along Kelsey Creek.
The largest walleye ever caught in Kelsey Creek weighed six pounds, four ounces.
Looking across to the opposite bank, I noticed the streets of Ealing that surrounded Amelia Jenks Bloomer Park were completely deserted. Ealing had become even more of a ghost town than it usually was. Fat, twisting columns of smoke coiled upward into the morning sky. Homes and buildings were burning.
War had come to Iowa.
Robby and I both saw it. We knew what was going on.
It was unstoppable.
"I feel like shit," I said.
"Was it good? Did you like having sexual intercourse in the bowling alley with Shann Collins?" Robby asked. He glanced at me with an inspector's no-bullshit appraisal. He shook another cigarette out and tossed the pack across the center console, onto my lap. I lit one and passed the lighter over to Robby Brees.
"I guess so," I said. "Uh. I skinned my knees on the carpet."
"I have heard that can happen. You have to be careful with that indoor-outdoor shit they made in the 1970s." Robby said, "It's like sandpaper on naked knees when you are trying to put your penis inside someone."
Robby was really smart about carpet burns and sex, and shit like that.
I took a deep drag from my cigarette. It was a brand called Benson & Hedges. The name made me feel rich or something. A name like Benson & Hedges says I spend a lot of money on my cigarettes.
"So, I am sorry, Rob," I said.
Robby shrugged. "They have a name for guys like you, you know, Austin?"
"Um. Bisexual?" I guessed. I did not think I was bisexual. I was only guessing.
I was always only guessing.
I was trying to talk to Robby and make him not think about things like me betraying my friends; hurting their feelings. But Robby Brees was too smart for that shit.
"No," Robby said. "The word is selfish. You don't really care about me or Shann."
I slumped down in my seat and stared at the columns of smoke across the creek.
It was like bombs had been dropped, and the biggest one just landed on my chest.
Robby turned right to cross the Kelsey Creek Bridge.
He stopped the car.
I was not looking.
I was not looking because I felt like I was going to start crying or shit if Robby said one more thing to me.
Robby Brees said, "Holy shit."
## THE RIGHT KIND OF CIGARETTES TO SMOKE JUST BEFORE YOU KILL SOMETHING
OLLIE JUNGFRAU'S DODGE Caravan minivan sat crumpled against the steel trusses of the Kelsey Creek Bridge.
The nose of the van was folded in on itself, as though it had run head on into an unbendable pole. The front wheels sat in a stew of antifreeze, transmission fluid, and motor oil. There was blood, too. The windshield had been caved in, and dripping smears of blood streaked everywhere, over the shelf of the van's dashboard, the steering wheel, and both front seats.
I slipped one of the grimacing lemur masks over my head.
"Um," Robby said.
I wanted to see if any red lights would show up. I wanted to hide my face from Robby Brees.
Ingrid did not like the mask.
If she were a normal dog, Ingrid would have barked at me.
"Do not get out of the car, Robby," I said from inside my mask.
Robby said, "That's Ollie Jungfrau's van."
I did not say anything. Of course I knew whose van it was.
Robby inched the Ford Explorer slowly past the wrecked vehicle.
I smoked.
The mouth of the grimacing lemur mask served as a kind of cigarette holder. I could easily wedge the filter end of my Benson & Hedges cigarette tightly between two of the grimacing lemur's lower teeth.
It was very convenient.
"Uh," Robby said. "What if smoking a cigarette in that mask messes up your sperm, Austin?"
I did not care if my sperm got messed up. I wanted my sperm to get messed up.
I did not say anything to Robby. I kept smoking with the mask on.
Robby stopped the Explorer and slipped the second mask over his head.
He smoked, too.
And Robby said, "I'm sorry if I hurt your feelings, Austin."
"It's okay." I said, "You are right, Robby. I deserved it. I deserve to have messed-up sperm."
"Nobody deserves messed-up sperm," Robby said.
He drove around Ollie Jungfrau's ruined Dodge Caravan minivan.
Unfortunately, at exactly that moment, Mrs. Edith Mitchell woke up. Mrs. Edith Mitchell was still hiding in the backseat of Ollie Jungfrau's Dodge Caravan. She had fallen asleep, wedged down between the seats and the floorboard of the van. When she poked her head up to see if she was being rescued, what Mrs. Edith Mitchell saw drove her beyond the brink of her sanity.
What she saw were two monsters with rat-like heads in blue-and-white jumpsuits driving a Ford Explorer while they smoked cigarettes.
Mrs. Edith Mitchell thought Ollie Jungfrau was correct: That aliens from outer space had landed in Iowa, for whatever reason.
Mrs. Edith Mitchell believed the end of the world had come to Ealing, Iowa.
She was probably correct.
Robby Brees and I did not see Mrs. Edith Mitchell looking out at us through the dark rear windows of the crumpled Dodge Caravan. As we passed, Mrs. Edith Mitchell finally mustered enough courage to climb through the bloody muck in the front seat and get out of the van.
Mrs. Edith Mitchell removed her shoes and all of her clothing. She jumped, naked and white, like a fluffy marshmallow schoolmarm, from the side of the Kelsey Creek Bridge into Kelsey Creek.
It was not a good idea.
Mrs. Edith Mitchell did not know how to swim.
Beneath the surface of Kelsey Creek, a cluster of walleyes was engaged in the spring spawn.
On the other side of the bridge, past the parking lot for Amelia Jenks Bloomer Park, as Robby drove into the neighborhood where I lived we saw a television news van that had come all the way from Des Moines. The van was painted with a bold design that said Eyewitness News. The van sat on its side in the middle of the street. The radar antenna had been deployed and was stretched out across the road like a big broken arm.
The doors on the Eyewitness News van were left open. We caught quick, passing glimpses of a bloody mess inside the vehicle. There was one black high-top Converse basketball shoe sitting in the road beside the tipped-over van.
Unstoppable Soldiers do not like to be filmed by television news crews from Des Moines.
The first Converse Chuck Taylor signature basketball shoes were made in Massachusetts in 1932. In 1932, Krzys Szczerba's Nightingale Convenience Works manufactured the last Nightingale urinal.
That particular urinal, Krzys Szczerba's final, grand porcelain monolith, ended up beneath the ground in an Iowa sanctuary constructed by a madman. Robby Brees and I urinated into it together, in Eden.
We drove past three houses that were engulfed in flames, and two others that had already burned to the ground. Apparently, the people of Ealing tried to come up with some method for fighting the Unstoppable Soldiers.
Their ideas did not appear to have been effective.
There were dozens of dead Iowans, and mere parts of others, scattered like Halloween decorations across yards, on fence posts and mailboxes, or lying in the streets.
Robby said, "When we get to your house, we have to get the guns loaded quick. Then we need to go back to the Del Vista Arms."
I said, "Why?"
"My mom," Robby said. "I have to try to get my mom."
"Oh."
Despite Connie Brees's obvious shortcomings as a single parent, her son, Robert Brees Jr., was a good boy.
Robby Brees really was a superhero.
I did not even think about my mother and father until Robby told me he wanted to rescue his mother. My cell phone was with my clothes inside the locker room in Eden. I hoped my parents, and Eric, my brother who had lost half his right leg and both of his testicles in Afghanistan nearly a week before, were not planning on returning to the continent of North America anytime soon.
"You are a superhero or shit like that, Rob," I said.
"A gay superhero," Robby added.
Robby blew a big cloud of smoke out from the mouth of his grimacing lemur mask. It was just about the coolest thing I had ever seen.
"I just realized that the Unstoppable Soldiers' God is gay," I said.
"I told you I was—in seventh grade," Robby corrected.
I smiled and nodded. The grimacing lemur mask on my head only grimaced and smoked.
"I am sorry, Rob," I said. I squeezed Robby's hand.
"There's nothing you can do about me being gay," Robby said.
Readers of history may decide that joking while two guys are driving around through a town that has recently been slaughtered by six-foot-tall praying mantis beasts with shark-tooth-studded arms is in poor taste.
It is.
But that is exactly what real boys have always done when confronted with the brutal aftermath of warfare.
Dulce Et Decorum Est.
I said, "I am going to try to be a better person. Not so selfish and shit. And maybe one day you will tell me if I have done it."
"Uh. Let's have another fag before we get out," Robby said. He maneuvered the Explorer as close to my garage as he could get it. Then Robby said, "And then let's go kill some big fucking bugs, Porcupine."
"I think Benson & Hedges are the right kind of cigarettes to smoke just before you kill something," I said.
## THERE ARE NO CUP-O-NOODLES IN EDEN
EDEN'S ARMY OF grimacing lemurs landed in Ealing, and it was time for them to go to war.
Robby Brees and I charged up the paintball guns. We injected small amounts of Robby's blood into dozens of grape-sized jellied projectiles.
When we finished, we left three bloodstained hypodermic needles on the white tiled countertop in my kitchen. It looked like a heroin den.
It was disgusting.
The smell of blood made me want to vomit. I had been smelling it all day.
We smoked and smoked to cover up the defeated odor that hung everywhere over Ealing, Iowa.
Before we left my house, I grabbed an armload of clean underwear and T-shirts and the razor and shaving cream from my bathroom. Tomorrow would be Saturday. Saturdays were shaving days. I did not take my bottle of bubble bath with me. I would miss taking baths. There had to be a bathtub somewhere in Eden.
There were no Cup-O-Noodles in Eden, so I also filled a paper sack with as many of the paper and Styrofoam containers of the miracle food I could find in the pantry.
All houses in Iowa have pantries.
Cup-O-Noodles are unstoppable food.
Before we left my house, the telephone in the kitchen began ringing and ringing. It was my father calling. He wanted to know what the hell was happening. He wanted to know why the hell I had not called him. And he asked, how the hell did Ealing, Iowa, end up on news broadcasts in Germany, telling stories of enormous bugs that were devouring every man, woman, and child in the town? What the hell was all this about?
"It is a lot of hell, Dad," I said.
At exactly that moment, all the power cut out everywhere in Ealing, Iowa.
The wireless phone in our kitchen went dead.
Robby and I heard gunfire in the distance.
Ealing, Iowa, had gone to hell.
## RAT BOYS FROM MARS, AND AN UNFORTUNATE INCIDENT INVOLVING AN INFLATABLE WHALE
PICTURE THIS IF YOU CAN:
Robby Brees and I, wearing fur-covered, full-head grimacing lemur masks that helped identify Unstoppables, smoking cigarettes and dressed in matching form-fitting blue-and-white Eden Project jumpsuits, as we carried fully automatic paintball rifles slung over our shoulders. And we were accompanied by a sixty-pound golden retriever that could not bark.
If we had thought everything out more clearly, we probably would have anticipated the likelihood of being fired upon by real guns and real bullets from my next-door neighbors, Earl Elgin and his teenage son, whose name was Earl Elgin Jr.
Earl Elgin Jr. was fifteen years old; a redheaded Lutheran boy who attended Curtis Crane Lutheran Academy, and fortunately for me and Robby, he and his father were both terrible shots. They were especially terrible shots because they were scared out of their minds after enduring a night-long rampage of six-foot-tall praying mantis beasts with spike-armed claws. And now they had come face-to-face with what they believed could only be alien invader rat boys from Mars.
We knew Earl Elgin Jr. as EJ.
EJ Elgin had skin the color of cottage cheese.
He also had a real dynamo of an Iowa name—EJ Elgin.
In the same way that Benson & Hedges says I spend a lot of money on my cigarettes, EJ Elgin says Sperm met egg in Iowa.
EJ Elgin only had one ball.
EJ Elgin lost one of his testicles when he was nine years old. EJ's father, Earl Elgin Sr., hired a giant inflatable whale-shaped bouncer house for EJ's birthday party. One of EJ's balls got stuck inside a plastic-rimmed ventilation hole near what was supposed to be the big inflatable whale's spout. It is painful to recall, but I am only doing my job. I was there. I recorded the history of EJ Elgin's detached ball.
Nothing puts a damper on a boy's ninth birthday party like the loss of one of the guest of honor's guests of honor.
EJ had to be taken to the hospital in Waterloo after having one of his balls detached when it became lodged in the plastic vent on a giant inflatable whale. He came home the following day with an excess of unoccupied space inside his scrotum. I do not know if doctors discard detached human balls in the trash can or not.
The boys at Curtis Crane pestered EJ for a while.
After his ninth birthday party and the horrible incident with the enormous inflatable whale, all of us, to a boy, were horrified and curious. All the boys at Curtis Crane Lutheran Academy wanted to see EJ's ball sack, now that one of EJ's balls had been lost to a whale attack.
By the time the boys at Curtis Crane Lutheran Academy entered puberty, which is an epiphany, a kind of religious awakening as to the true magnificence of our balls, and shit like that, we all felt mournfully afraid of EJ Elgin, the boy with only one ball.
EJ Elgin, to my knowledge, never named his solitary ball.
The one he lost might have been appropriately named Jonah.
Perhaps Ahab.
"Stay right there and don't move, you motherfucking rat boys from Mars," Earl Elgin Sr. said.
He nervously pointed his emptied assault rifle directly at my belly.
"Dad, we caught us some alien rat fucks from outer space," EJ added. "Let's shoot them in the balls."
EJ plinked a shot level with Robby's crotch. Robby flinched and whined. EJ only had a BB gun.
The Elgin males were not especially brilliant, but they had been through a lot. I had to give them that.
"Uh," I said.
Robby raised his open hand in the intergalactic gesture of peace, and said, "Please do not shoot us in the balls, EJ Elgin. It is only me, Robby Brees, and my friend, Austin Szerba, who is your next-door neighbor, and we are not rat boys from Mars. We come in peace, and smoking cigarettes."
"Benson and Hedges," I said.
Earl Elgin squinted and tilted his head. The weapon he held was a Colt AR15-A3 Tactical Carbine. It looked exactly like the paintball rifles Robby and I carried, except if Earl Elgin had actually shot us with it, Robby and I would both be dead, gory messes. EJ Elgin had a Daisy .177 pellet rifle. If he had actually shot us with it, Robby and I would have stinging welts on our skin, possibly on our ball sacks.
He missed Robby's ball sack.
A Rat Boy from Mars definitely would not want to get shot in the balls with a Daisy .177.
My next-door neighbors, EJ Elgin and his father, had been packing camping equipment into the bed of a pickup truck. They were planning on taking the rest of their family, which consisted of EJ's mother, who was named Rosemary, and his two younger sisters, Edie and Donna, as far away from Ealing and the monster invasion as they could get. When Robby and I came outside of my house, carrying armloads of underwear, shaving stuff, and Cup-O-Noodles, Earl Elgin Sr. and his son, EJ, saw us and grabbed their weapons.
Earl Elgin Sr. let loose a burst of rifle fire that shattered nearly every window on my house, as well as one on the driver's side of Robby's old Ford Explorer—which had really taken a beating since the attack by Hungry Jack the night before.
"Holy shit!" I said.
Boxers, T-shirts, and Styrofoam containers of dehydrated ramen noodles flew everywhere.
Ingrid, who was not particularly startled by the gunfire, was shitting in the front yard when it happened.
That was exactly when Earl Elgin Sr. told us to put our hands up and surrender, because he and his boy were going to become some kind of national heroes for capturing the invading Rat Boys from Mars.
"Shoot them in the balls, Dad," EJ Elgin urged.
"Uh," Robby said.
Both of us had our hands raised in the intergalactic gesture of Please do not shoot us in the balls.
"Earl Elgin, you shot my goddamned house!" I said.
Earl Elgin Sr. looked confused.
Earl Elgin Sr. said, "What the fuck did you creatures do with the Szerba boy?"
Robby Brees and I did not get killed that day by Earl Elgin Sr. and his one-balled son, EJ.
But it took some dramatic pleading from me to stop Earl Elgin Sr. from shooting me and allow me to take my head off so I might show him who was actually inside the clinging and form-fitting Rat Boy from Mars jumpsuit.
"Thank you, Saint Kazimierz," I said.
I felt like the virgin saint was looking out for me and Robby.
There was no other way I could explain not being shot in the balls.
We left Earl and EJ to their hurried departure preparations and got into Robby's battered Ford Explorer.
And Robby said, "Holy shit, Austin," as we drove away from my house and headed toward the Del Vista Arms.
What could I do?
## THE BATTLE OF THE DEL VISTA ARMS
I ASKED MYSELF THIS:
What could I do?
Just one week earlier, everything was perfect. Everything was Iowa blue plaid. Robby and I skated in Grasshopper Jungle. Shann Collins made me very horny. There were no books mentioning Catholics or masturbation available in the library at Curtis Crane Lutheran Academy. Ollie Jungfrau dreamed of internet porn and Saturday morning donuts with me and Johnny McKeon.
All of that equaled normal.
Then Grant Wallace and the Hoover Boys beat the shit out of Robby Brees and me. They threw our shoes up on the roof at Grasshopper Jungle because they said we were queers from Curtis Crane Lutheran Academy, and after that, the whole world went to shit.
So, what could I do?
Robby played Let It Bleed.
Although it had been made more than forty years before, it seemed like every song on that Rolling Stones album was precisely about Robby and me, or Unstoppable Soldiers, Ealing, Iowa, and McKeon Industries.
Robby sang, "We all need someone we can feed on. And if you want it, you can feed on me . . ."
"Uh," I said.
We smoked cigarettes.
Ingrid sighed and yawned in the backseat.
And at the exact moment we pulled up to Robby Brees's apartment, the cook from the destroyed Pancake House, Louis, whose real name was Ah Wong Sing, happened to be hiding inside a cinder-block cubicle where dumpsters were stored at the Del Vista Arms.
Louis's clothes were ripped. He was missing one shoe and his shirt hung open. Dried blood stippled his torn cook's trousers. But he was very, very happy to see us.
He also did not glow red when I looked at him through the eyes of my grimacing lemur mask.
But Louis was so psychologically worn from what he had seen and been through that he did not even seem startled by the Rat Boy from Mars with the fully automatic AR15-A3 Tactical Carbine replica paintball gun.
"Good morning, Louis," I said.
I waved my open hand in the intergalactic Rat Boy from Mars gesture of This is the end of the world, but I am politely greeting you anyway.
"Um," Robby said.
Robby Brees was not wearing his grimacing lemur mask. "It's just us, Louis. Me, and Austin from the secondhand store. You know? Austin Szerba? The dynamo kid?"
Robby Brees held up a lit cigarette in the intergalactic gesture of We are the skater kids who smoke in the alley, and shit like that.
Louis had not slept in two days. He was spent. He'd had sexual intercourse with Robby Brees's mother three times in the previous twenty-four hours. After he ran away from the carnage at the Kelsey Creek Bridge, Louis came back to the Del Vista Arms, thinking he would find safety and Connie Brees.
Instead, Louis found the Unstoppable Soldier called Hungry Jack.
The end of the world was one week old, and people everywhere were finding out about it. And the Battle of Ealing began that morning at the Del Vista Arms Luxury Apartments.
Here is what happened:
Hungry Jack was confused, and Louis was a very motivated runner when being chased by Unstoppable Soldiers. Hungry Jack had been huddling beneath the aluminum roof that covered a row of cars at the Del Vista Arms when Louis ran through the parking lot.
Unstoppable Soldiers are like cats in that they are stimulated by movement. They are also like walleyes in that they only want to do two things. The two things walleyes and Unstoppable Soldiers want to do is fuck and eat.
Unstoppable Soldiers are not as intelligent as either cats or fish.
So when Louis managed to slip inside the dumpster corral, Hungry Jack looked around for a while and then forgot what he had been looking for.
Unfortunately for Robby and me, Hungry Jack became stimulated by the movement of a Rat Boy from Mars in a tight blue-and-white jumpsuit. The Unstoppable Soldier that had hatched out from Hungry Jack's body in a cornfield outside of Waterloo while Robby and I stood in horrified amazement and watched it happen became very aroused by the motion around Robby Brees's Ford Explorer.
Hungry Jack flitted down to the lot from the rooftop of the car park.
I saw him first.
Through the lenses on my grimacing lemur mask, a brilliant flash of red caused me to momentarily consider that I had indeed ignited the flammable, carcinogenic, messed-up-sperm-causing mask with my Benson & Hedges cigarette.
Hungry Jack looked like a ball of flame as he flew down from the awning above the car park.
"Holy shit," I said. "These things really do work."
I was impressed by the technology of the grimacing lemur mask.
Unfortunately, I should have been more impressed by the speed with which Hungry Jack closed the distance between us.
It was also impressive how Hungry Jack picked me up by my head. Until that moment, I had never in my life been picked up by my head. I did find myself marveling for an instant at how well the grimacing lemur mask protected my skull from the piercing barbs of the studded spikes all along Hungry Jack's tri-segmented pincers.
But it was only an instant.
Then I screamed.
And while I was screaming, Hungry Jack unhinged his bear-trap mandibles in order to crush my Rat Boy skull. I looked over at Robby, thinking my beautiful friend, a person I loved very much but had also inflicted a great deal of pain upon, was going to be the last image burned into the screens of my dying eyes.
Robby Brees stood there, looking more cool and superhero-ish than any Lutheran boy from Iowa ever did, calmly smoking a cigarette while his eyes, which were the color of robin egg Cadbury chocolate Easter treats, focused directly on the monster that was just about to eat my head.
Robby raised his paintball gun and let go a burst of three rounds that splattered into Hungry Jack's mouth and compound eyes.
Pop! Pop! Pop!
The paintballs gushed.
The Unstoppable Soldier received a faceful of the blood of his God.
Fortunately, this caused Hungry Jack to release his vise clamp on my head. I hit the ground, and Hungry Jack reeled away from the concussion of the blast.
"Shit! Shit! Shit! Holy shit!" was all I could say.
Excrementum Sanctum.
And while Unstoppable Soldiers' exoskeletons are as impenetrable as the hull on an aircraft carrier, the blood of their God rusts every rivet in their construction, and sinks them on the spot.
"Glad we didn't have to use my sperm," Robby said.
"Uh," I said, dazed, on my hands and knees in the parking lot at the Del Vista Arms. "Thank you, Saint Kazimierz. And thank you, Robby Brees."
Louis, whose real name was Ah Wong Sing, cowered in the doorway to the dumpster corral.
Hungry Jack hissed and gurgled.
The Unstoppable Soldier looked confused, if such an expression could manifest itself on the face of a six-foot-tall beast that looked like a praying mantis. Hungry Jack's left arm fell off first. The right arm disjointed and plunked down onto the ground seconds later. The tooth-spiked claw arms rattled around on the pavement of the parking lot, spastically opening and closing, opening and closing, as they scraped along the ground with no coherent mission.
Where the claw arms had detached from Hungry Jack's thorax, a gooey stream of slick yellow fluid burbled like twin pots of boiling unstoppable cornmeal mush. Then Hungry Jack's chin lowered and his head rolled away from his body, landing on the ground between the two flailing arms.
What was left of Hungry Jack scampered away on four gangly legs, which soon became three, then two, and the entire Unstoppable Soldier collapsed in puddles of oily mush.
Robby Brees saved my life.
Being a historian naturally has its dangers, but this is my job.
I tell the truth.
## THE END OF THE WORLD
AT THE CONCLUSION of the First Battle of Ealing, which took place in a parking lot at the Del Vista Arms Luxury Apartments, the Unstoppable Soldier that had once been growing inside a homeless man named Hungry Jack lay in a soupy yellow mess of jumbled bug parts.
At that moment, there were only three Unstoppable Soldiers remaining on the surface of the planet called Earth. They were Tyler Jacobson, Travis Pope, and Travis Pope's wife, Eileen, who had filled Duane Coventry's house on Onondaga Street with a jellied, pulsating black goo of fertilized eggs.
Robby Brees and I, the two Rat Boys from Mars who were the only people capable of saving the planet called Earth, had no way of calculating how many other Unstoppable Soldiers there were, and no way of knowing where to look for them.
So Robby put on his grimacing lemur mask and the two of us entered the hallway of the Del Vista Arms Luxury Apartments. Ingrid, my silent golden retriever, and Louis, the equally silent cook from the most certainly closed-down Pancake House, cautiously followed.
We were there to save Robbie's mom, Connie Brees.
"Aaah!" screamed Eunice Mayhew when Robby Brees and I entered the hallway of the Del Vista Arms.
Eunice Mayhew was the manager of the Del Vista Arms. At the exact moment Robby and I stepped through the entrance that led in from the parking lot, Eunice Mayhew was posting two more Pay or Quit notices on locked doors to silent apartments.
Eunice Mayhew did not glow red.
Eunice Mayhew was fifty-three years old. She had a figure like an upended pickle barrel, and was just about the same height. Her hair was the color of cigarette ash, and her skin had a similar hue to the gritty waterline around Robby Brees's bathtub, where I'd showered after spending the night with Robby earlier that week. I know that you would not eat either one of those things: cigarette ash or the ring inside Robby Brees's bathtub.
I also do not believe an Unstoppable Soldier would eat Eunice Mayhew.
"Aaah!" Eunice Mayhew screamed again. She threw her hands up, in what I suppose was the intergalactic gesture of I surrender to the conquering Rat Boys from Mars.
If somewhere there existed entire planets of Eunice Mayhews, Robby Brees and I could rule the cosmos.
Eunice Mayhew is also a very solid Iowa name.
A name like Eunice Mayhew says Sperm met egg in Iowa, and zygote grew up to become a bingo-playing, quilting square-dancer with a body like an upended pickle barrel.
At the exact moment Eunice Mayhew screamed and two Rat Boys from Mars occupied the hallway at the Del Vista Arms, Shann Collins was lying down on her bed inside the Eden Project silo.
Shann was scared, and she was crying, too.
Wendy and Johnny McKeon assumed their daughter was crying because Shann was scared about the monsters, and worried about her friends who had gone out hunting the beasts.
It was not exactly why Shann Collins was crying.
Earlier, Shann and Johnny had crawled up to the surface in order to use their cell phones.
There was no more cellular service at all in Ealing, Iowa.
Shann and Johnny saw the forest-like columns of smoke that ringed the horizon.
They had gone back inside Eden, and Shann slipped into her bedroom, where she lay down on her bed and cried.
The night before, Shann Collins and I had sexual intercourse on the floor of the Eden bowling alley while I stared at a pair of shoes that had belonged to Wanda Mae Rutkowski.
The healthy Polish sperm I deposited inside Shann Collins's vagina found its way to a receptive egg.
Shann Collins was already pregnant, and she did not know anything about it.
The New Universe began in Eden one week after the end of the world began in Ealing.
Eden Five needed us, and Shann Collins and I were Adam and Eve to every New Human.
I had Unstoppable Sperm.
Dr. Grady McKeon would have been very pleased.
As Shann Collins, who was pregnant with a strong Polish boy who was going to be named Arek Andrzej Szczerba, cried on her bed, a volcano called Huacamochtli in Guatemala exploded in a massive eruption that blacked out the sun.
Everything in the village of Poqomchi rattled and shook. Rocks and burning ash from the angry sky bombarded the little village. Robby's father, Robert Brees Sr., his wife, Greta, and two-year-old son, Hector, tried to leave their small home. Robert Brees Sr. could not start his car. The car's motor was strangled in the steaming ash that turned everything into a dead gray night. Robert, Greta, and Hector Brees choked in the noxious smoke. They covered their faces with damp cloths and began walking away from their small house.
It was not a good idea.
In a cave in Spain, at a place called Altamira, a painted bison lay folded in death, his nose pressed to the ground, mouth open, one tired and defiant eye staring and staring and staring. He had been staring that way for fifteen thousand years, neither dead nor alive, trapped by history with his nameless balls pressed down into the ground between his curled hind legs.
Altamira means high view.
At exactly that moment, the vice president of the United States of America was being escorted through Eric Christopher Szerba's hospital room in Germany. The vice president of the United States of America patted my brother's shoulder and said to him, "The United States of America thanks you, son."
The vice president of the United States of America did not know anything at all about what was happening in Iowa, but he did know that Eric Christopher Szerba had lost his balls.
It made the vice president of the United States of America uncomfortable to think about a healthy young boy like Eric Christopher Szerba losing his balls to a bomb blast in Afghanistan. The vice president did not know exactly what to say to Eric.
What can you say to a kid who lost his balls?
All the boys at Curtis Crane Lutheran Academy already knew there was no good answer to that. We all learned that lesson when EJ Elgin's ball was torn off by a whale.
The vice president of the United States of America was very pleased that his own balls, which he had named Theodore and Franklin, were just fine.
At exactly that moment, three massive National Guard helicopters flew at very low altitude directly over the Del Vista Arms Luxury Apartments.
The darkened hallway where we stood rattled and shook.
"Don't be afraid, Mrs. Mayhew," Robby said. "It's just me. Robby Brees."
Eunice Mayhew kept her hands up. She recognized Robby's voice.
Anyone who knew Robby Brees would recognize his voice. Robby's voice was perfect and smooth. Robby Brees's voice sounded the way soft vanilla ice cream feels and tastes inside your mouth on a blistering summer day, and when he sang, Robby Brees could make a lump form in my throat.
Eunice Mayhew cocked her head like a confused, barrel-shaped Orpington hen.
She said, "Something crazy is going on around here, Robby. Was that you and your friend dressed up like giant bugs this morning?"
"No, ma'am," Robby answered. "Uh. My friend . . . uh . . . Austin and me were only dressed up like lemurs."
"Rat Boys from Mars," I corrected.
Robby left the key to his apartment hanging from the ignition switch in his Ford Explorer. He knocked and knocked on the door to his apartment.
"Mom," Robby said to the door, "wake up! I left my keys in the car! Mom! You need to let me in!"
Connie Brees was asleep.
She did not expect her son, Robby, to be dressed as a Rat Boy from Mars. It was Friday morning, and Robby was supposed to be dressed up as a Curtis Crane Lutheran Academy Boy from Iowa. Connie Brees also did not expect her son to be accompanied by a second Lutheran Rat Boy from Mars, a golden retriever that could not bark, and Louis, the cook from The Pancake House, with whom she had sexual intercourse using condoms she found on the floor of her sixteen-year-old son's bedroom just the day before.
It was obvious Connie Brees did not expect any of this because she was wearing nothing but low-cut silk panties and a pale violet plunge bra.
Connie Brees had very large tits and fine golden strands of silky fuzz that lay smooth and flat between her navel and the waistband on her panties.
Connie Brees's skin was the color of perfectly prepared, soft and warm buttered toast. Her eyes matched Robby's, and her hair, which fell softly over her bare shoulders, was the color of apple spice cake.
"Uh," I said.
Robby's mother made me very horny. I definitely wanted to invite her to Eden.
I was not so sure about taking Louis, though.
Wendy McKeon's pancakes were just fine.
I wondered if Robby Brees would disapprove if I had sexual intercourse with his mother. I already knew how much it hurt his feelings that I had done it with Shann Collins.
I sighed. I was very confused.
Robby Brees was a good son. He did not have to be a good son. Nobody would expect it of him, unless you really knew Robby, and maybe loved him, too.
Connie Brees did not glow red.
Robby took off his grimacing lemur mask and kissed his mother. They held each other like they knew everything that had ever happened on every road that crossed beneath our feet.
I was happy for Robby and Connie Brees.
## PICTURES OF ROBBY AND SHANN
HERE ARE TWO pictures I drew the week the world ended:
Robby Brees is sitting on the floor of his bedroom. He leans back on his elbows and there is a half-empty bottle of sweet white wine standing open beside his hip.
Robby is not wearing a shirt. In the picture, which was drawn on Monday night, Robby Brees is wearing nothing but some tight, white cotton underwear with colorful tigers printed on them.
His chest is square and flat, and his belly relaxed and soft. The perspective of the picture is from where I sit, cross-legged and in my socks, on top of Robby's bed.
I am floating.
We are laughing.
There is a cigarette held between the first two fingers of Robby's right hand, which comfortably rests on his belly.
The paper I draw on in my history book still smells of our cigarettes and wine.
Robby's skin reminds me of the warm insides of a late-summer white peach. Those peaches are named Babcock. Robby's hair is the color of graham cracker piecrust.
I can almost hear the music playing from Robby's stereo.
Robby is smiling, and we are reciting our favorite poems above the jangling vocals on a song called Live With Me.
The picture makes me feel like I am floating again.
Shann Collins sits on the staircase that leads to nowhere from her bedroom in the McKeon House. She is framed in an open doorway above, and narrow walls of distressed brick to either side of her.
The perspective is from below, looking up at Shann Collins from her dungeon for horny Lutheran boys. I draw it so her shorts, as they did, gap open just a bit, and there is a mysterious centering to the warm spot between Shann Collins's legs. I think about her pubic hair and the moistness in that perfect locus.
It is history.
It is the truth.
Shann's blouse opens slightly between the third and fourth button. I can almost smell the ginger and orange blossom lotion she smooths on her skin. Her hair is summer wheat and her skin is the color of a perfect October butternut squash. Shann Collins is smiling and her eyes are scolding.
I imagine I am explaining to her every wrong I have ever committed.
There is nothing I can do.
It is my job to tell the truth.
The picture makes me feel like the luckiest boy at the Curtis Crane Lutheran Academy End-of-Year Mixed-Gender Mixer, and it is the first time Shann Collins has ever danced with me. It makes me feel like seventh-grade Austin Szerba, whose best friend, Robby Brees, teaches him in secret how to dance with someone you love.
History will show that eighth-grade boys are never aware of the roads they have built, nor the ones they are standing on.
I love Shann Collins so much I am afraid it is killing me.
I love Robby Brees the same way.
I am an unstoppable train wreck to their lives.
## THE INTERGALACTIC BUG COPS
ROBBY'S FORD EXPLORER was running out of gas.
It was a matter of reasonable debate, which would happen first: Would the gas run out, or would the old car simply give up and die?
Bang! Bang! Bang! Bang! Bang! went the thrown rod inside the Ford's crankcase.
We left the Del Vista Arms with two new citizens for Eden: Connie Brees and Louis, whose real name was Ah Wong Sing.
I thought Eden would be too crowded now. I did not want any more boys down there. Eden was only big enough for me and Robby Brees. I could make allowances for Johnny. It was selfish, I know, but it was how I felt.
That is the truth.
While Robby drove away from the Del Vista Arms, I plucked up my Saint Kazimierz medallion and put it into my mouth.
We'd found a chapel in Eden. It was little more than a small broom closet, but it had a church-like appearance. There is a particular kind of angle and aesthetic to all churches. The same quality is exhibited by coffins and urinals—you know what function they serve as soon as you see them.
These are the things that require neither signs nor labels.
Churches, coffins, and urinals all proclaim, This is what I am.
No questions asked.
At the exact moment Robby and I drove away with Louis, Connie Brees, and Ingrid, my golden retriever, in the backseat, I decided that I was going to become a Catholic, like I was always supposed to be—like all the Szczerba men always had been.
Saint Kazimierz's blood was in me, even if he did die a virgin.
Saint Kazimierz brought a dead girl to life, and he saved me from having my skull crushed by Hungry Jack.
"Thank you, Saint Kazimierz," I said.
Near Amelia Jenks Bloomer Park, two National Guard soldiers stood in the road beside an armored vehicle. They waved their hands at us, palms forward in the intergalactic gesture of We have guns, so you better stop, motherfucker.
We should have known the intergalactic bug cops would show up.
"Um," Robby said.
"Uh," I said.
"I wonder if they are going to give us tickets for underage smoking of cigarettes," Robby offered.
"I wonder if they are going to shoot us for being Truant Rat Boys from Mars," I said.
The truth is, the two National Guardsmen nearly did shoot Robby and me for being Rat Boys from Mars who were also ditching school.
We had no way of knowing that school, like everything else in Ealing, Iowa, had ceased to operate, due to the end of the world, and shit like that.
Coincidentally, Robby Brees and I were both wearing our grimacing lemur masks as we sat in the front seat of the dying Ford Explorer.
One of the guardsmen glowed red.
"Holy shit, Rob," I said.
"I see it," Robby concurred.
"What's wrong?" Connie Brees asked from the backseat.
"Nothing," I said, in the intergalactic teenage response to any question ever asked.
Robby corrected me, "That stocky guy on the left is going to turn into one of those bugs."
And, from the backseat of Robby's Ford Explorer, Louis finally spoke.
He said, "Shit."
"How could that happen?" I said.
"Those McKeon guys didn't know shit about what they were doing. Their experiment never got outside their lab," Robby said.
"You deserve a Nobel Prize, Rob," I said.
I dreamed of going to Sweden with Robby. I hoped he would let Shann come, too.
Connie Brees reached over the seat back and touched Robby's shoulder.
Connie said, "Do you know what's going on, Robert?"
She liked to call her son Robert.
I liked the way it sounded, too.
Robby said, "It would take hours to explain, Mom. Austin and I will tell you everything."
"Uh," I said.
I did not want Robby and me to tell his mother everything.
Robby stopped the car in the middle of the road.
Both of the National Guardsmen showed edgy, wide-eyed alertness. They were obviously uncertain as to how to respond to the two monsters in blue-and-white jumpsuits driving a beat-up Ford Explorer through the ruined town of Ealing, Iowa.
History will show that it is exactly times like these that having a grown-up and a golden retriever in the backseat of your Ford Explorer when you are also dressed as a Truant Rat Boy from Mars has potentially lifesaving benefits. The guardsmen, who were armed with M-16s, also thought Connie Brees was very sexy, which provided a considerable anesthetizing influence over our detainers.
An M-16 rifle is the military equivalent of a Colt AR-15. The difference is that the guardsmen's M-16s had thirty-round clips and were fully automatic. Also, unlike Earl Elgin, I did not believe the soldiers would miss Robby and me if they decided to shoot.
## ENOLA GAY AND BEAU BARTON'S BONER
CONNIE BREES SHOWED the soldiers her breasts and FedEx identification badge.
She explained she was taking her "sons" and "husband" to safety in Waterloo.
Robby's mother did not actually expose herself in front of her teenage sons, but she did elevate her chest, the way that some women do, as though she were hoisting a battle flag before a lesser enemy.
It made me happy to think of Robby as my brother, but I was not comfortable with the idea of Ah Wong Sing being my father. It was quite obvious that he would have had to be our stepfather, and no son ever likes his stepfather.
That is a fact of history.
The guards' names were Beau Barton and Florencio Villegas.
Beau Barton had a real dynamo of an Iowa name.
Florencio Villegas did not.
Also, Florencio Villegas had somehow been infected by Contained MI Plague Strain 412E.
Nobody had any way of knowing how that came to be.
Later, when Robby Brees and I discussed poetry, science, and history one evening in the library of Eden, we concluded that, somehow, the dead Unstoppable Soldiers may have developed Unstoppable Mold; or perhaps the mold grew on the egg masses that were deposited in Duane Coventry's home on Onondaga Street. Maybe, we conjectured, Florencio Villegas happened to pass through the alley where we skated in Grasshopper Jungle when Robby's blood was fresh on the pavement, after Tyler Jacobson dropped the moldy blue universe from inside Johnny McKeon's office to splatter over everything.
Whatever the origin, it did not matter.
We would never know with absolute certainty.
Histories are actually full of conjectures. Those conjectures become so accepted by descendants and readers that time itself is forced to rearrange its own furniture. This is a new history, and I cannot do such a thing.
The end of the world was fully one week old, and the only human being on the entire planet called Earth with the capacity to stop it was my best friend, a sixteen-year-old homosexual Lutheran boy from Iowa named Robert Brees Jr.
Florencio Villegas was born in Topeka, Kansas.
Florencio Villegas was a diesel mechanic in Cedar Rapids.
He would be dead within thirty minutes.
Beau Barton worked as a bagger at a grocery store in Boone County. He would also be dead within thirty minutes.
Beau Barton was twenty-four years old and smelled like mouthwash and chewing tobacco. Beau Barton was actually related to me in a distant and illegitimate, Iowa-by-marriage way.
Beau Barton, like me, was Phoebe Hildebrandt's great-grandson. Nobody ever knew Beau Barton's actual great-grandfather was the Catholic priest who counseled Phoebe for years following the death of her first husband, Andrzej Szczerba. Everyone in Iowa City assumed the semen that created Beau's grandfather, a man named Eldon Wayne Barton, came from the balls of Daniel Barton, whose balls did not work so well. Daniel Barton was the radio station owner Phoebe Hildebrandt married after her husband, Andrzej Szczerba, was shot in the head while taking a shit during the Battle of Cisterna in Italy during World War 2.
All roads keep crossing and crossing at the point of my pen.
Nobody ever knew anything about Beau Barton and me.
Beau Barton adjusted his penis conspicuously as he leaned his face through my window. He was attempting to assess the threat level of the smoking Rat Boys from Mars and the woman with the large tits in the backseat.
Beau Barton, my cousin, had an obvious erection. He stared and smiled, practically drooling at Connie Brees.
Beau Barton thought he would most likely masturbate in the trees by the creek later that day if nothing was happening. He would not get that opportunity.
Beau Barton was sweating. He showed obvious embarrassment when he became aware that I was looking directly at the camouflaged bulge caused by his swelling erection.
Beau Barton was an idiot.
When Beau Barton was fourteen years old, he unintentionally burned down his family's garage in Boone County, Iowa. It happened when Beau Barton set fire to a plastic model of the Enola Gay. Beau Barton, the teenager, loved to build models and then set fire to them. Fires and big tits gave Beau Barton, the twenty-four-year-old National Guardsman, unstoppable hard-ons.
Louis and Ingrid may just as well have been invisible to Beau Barton from Boone County. He probably might have noticed them had they been engulfed in flames.
The Enola Gay was a plane named after the mother of Paul Tibbets, who was its pilot.
History will show that Enola Gay Haggard Tibbets is the only mother who ever shared her name with an airplane that killed at least one-tenth of one million human beings.
Paul Tibbets was covered for Mother's Day gifts after naming a plane with such a reputation after his mom.
Paul Tibbets grew up in Cedar Rapids, Iowa, which is also where Florencio Villegas repaired diesel engines.
Orville and Wilbur Wright invented the airplane.
All roads converged at Kelsey Creek Bridge.
At that exact moment, Beau Barton, the very aroused National Guardsman, wanted to do only two things: He wanted to put his penis between Connie Brees's breasts, and he wanted to go back home to Boone County, Iowa.
Boone County, Iowa, is named for Nathan Boone, who was the youngest son of Daniel Boone. As far as I know, neither Nathan Boone nor his father ever wore coonskin caps. They also never killed more than a hundred thousand people. I wore an artificial coonskin cap that had been made in China on the day my fifteen-year-old brother, Eric Christopher Szerba, got his first blow job in a Nashville hotel from two prostitutes named Tiffany and Rhonda. Eric liked his blow job. Eric also started calling me Booney ever since that trip we took to Nashville when I was only nine and Eric got a blow job.
When I was nine years old, I could not understand why my fifteen-year-old brother, Eric, would let Tiffany and Rhonda talk him into putting his penis inside their mouths, but when I was nine, I also could have just as easily lost my balls in a whaling accident and never known the difference.
Boys' attitudes about their balls and putting their penises in someone else's mouth change significantly sometime after the age of nine.
The soldiers wore the kind of camouflaged battle dress issues that troops used in Afghanistan, which is where my brother lost the lower portion of his right leg and both of his testicles. With those uniforms, the National Guardsmen did not blend in so well among things like Iowa cornfields and rivers with spawning walleyes, and shit like that.
Robby and I took off our masks so Beau Barton and Florencio Villegas would not kill us, and so they could see we were just normal-looking sixteen-year-old Iowa brothers who happened to be wearing matching blue-and-white jumpsuits, which also did not blend in so well.
Beau Barton was mad at me for staring at his erection.
He said, "Are you boys in some kind of dance club or something?"
"Uh," I said.
Robby answered, "We work at a car wash in Waterloo. These are our car wash uniforms."
Robby truly deserved a Nobel Prize, a million dollars, and a trip to Sweden with me and Shann, if he would let her come along.
Beau Barton said, "Those are some real humdinger outfits they make you boys wear."
People in Boone County, Iowa, used words like humdinger.
## THE BATTLE OF KELSEY CREEK BRIDGE
EALING, IOWA, WAS being evacuated by the National Guard.
Beau Barton and Florencio Villegas had been posted on the road to Kelsey Creek Bridge. Their job was to ensure traffic moved in one direction only.
That direction was away from Ealing.
Beau Barton and Florencio Villegas instructed us to follow them across Kelsey Creek Bridge. They drove ahead of Robbie's Ford Explorer in their armored vehicle. They decided to escort us around the wreck of Ollie Jungfrau's Dodge Caravan minivan. Beau Barton and Florencio Villegas wanted to be certain we made it safely to the highway that connected Ealing to Waterloo.
It was very kind of them to do that, but it was not a good idea.
Someone had already placed a yellow tarp over the smashed front end of Ollie Jungfrau's Dodge Caravan minivan. There was also a dripping black X spray-painted on the tarp. The National Guard were real dynamos at covering dead things with plastic.
We had seen dozens of tarps in Ealing on our drive away from the Del Vista Arms. The tipped-over Eyewitness News van was entirely blanketed with them. It looked like an inflatable bouncer house you might rent for a kid's birthday party.
Watch your balls.
Ealing had become the plastic tarp capital of Iowa.
Unstoppable Tarps! Unstoppable Tarps!
No one at all knew what the hell was going on in Ealing, Iowa, except for me and Robby Brees.
Unfortunately for Beau Barton and Florencio Villegas, just as their vehicle crept past the wreckage of Ollie Jungfrau's van, the Unstoppable Soldier that used to be a Hoover High School punk named Tyler Jacobson, still hopped up on meth and confused after his first sexual experiment, appeared, standing in the middle of the road at the end of the bridge.
And just behind Tyler Jacobson was the Unstoppable Soldier that had hatched out of Travis Pope.
They only wanted to do one thing at that exact moment.
Tyler Jacobson and Travis Pope had also molted during the night. They were now eight feet tall, with abdomens as thick as telephone poles.
Louis whimpered in the backseat.
Louis knew all about Unstoppable Soldiers and the things they liked to do.
The armored vehicle stopped.
Robby said, "Holy shit."
I said, "They . . . um . . . got bigger."
Robby Brees's sputtering Ford Explorer chose that exact moment to die.
We were stuck on Kelsey Creek Bridge.
"Um," I said.
The doors of the National Guard vehicle opened on either side. Beau Barton and Florencio Villegas popped out of the cab, their M-16s raised and ready. It looked like a scene from an action movie.
Beau Barton and Florencio Villegas had guns, motherfuckers.
It was a very bad idea.
Connie Brees said, "Oh my God."
Ingrid yawned.
Louis threw his arms around Connie Brees. He buried his face in Connie Brees's hair and turned away from the spectacle that unfolded on the bridge ahead of us, through the windshield of Robby's dead Ford Explorer.
In the creek below us, walleyes spawned and spawned. Carried on Kelsey Creek's steady current, Mrs. Edith Mitchell's body had already drifted into the Cedar River.
I found myself thinking about Saint Kazimierz, and contemplating why people said things like Oh my God at times like these. If there really was a God, I thought, why would Connie Brees want to lay her claim to a deity that unleashed Unstoppable Soldiers on human beings caught on a bridge above Kelsey Creek in Iowa?
Johnny McKeon had one tattoo on his entire body. On his right forearm, in blurry blue-green ink, which is how all tattoos look on men as old as Johnny McKeon who had also served in the United States Navy, was the image of Sputnik. Beneath the satellite was an inscription that read Oh My God!
Johnny McKeon told me that his father, who was also Dr. Grady McKeon's father, looked up into the starlit sky above Iowa the night the Soviet Union launched Sputnik, and said those three exact words.
Oh my God!
Johnny McKeon's father believed it was the end of the world in 1957.
Johnny McKeon's father had a heart attack as soon as he said those three words.
He died when Johnny was an infant.
Oh my God.
History will probably verify that Oh my God was among the first idiomatic exclamations uttered by human beings. The phrase has persisted for at least twenty thousand years.
We killed this big hairy thing, and this big hairy thing, and then we did a little experiment.
Oh my God.
You know what I mean.
If God had satellite TV, he was probably tuned in to the Battle of Kelsey Creek Bridge. Maybe he and Saint Kazimierz were sitting on a cloud couch together, nibbling unstoppable popcorn and watching what happened to us, and to Beau Barton and Florencio Villegas, too.
The National Guardsmen's machine guns spit bursts of metal-jacketed bullets at the Unstoppable Soldiers. The sound was electric and terrifying. The bullets may just as well have been candy sprinkles on unstoppable frosted cupcakes, because they had absolutely no effect at all on the monstrous praying mantis beasts with blade-spiked arms.
Tyler Jacobson and Travis Pope walked through the spray of bullets like they were cats walking through darkness; like beauty pageant queens parading through swirling showers of glitter.
If the Unstoppable Soldiers even noticed the bullets careening off their exoskeletons, they did not show it.
Tyler Jacobson snatched Florencio Villegas between the pointed blades that ridged his crushing arms. Tyler Jacobson began devouring the soldier, boots, helmet, body armor, and all. Some of Florencio Villegas's blood splashed over the metal hood of the armored vehicle he'd been driving just moments earlier.
Tyler Jacobson even tried to eat Florencio Villegas's M-16.
He spit it out.
Travis Pope attempted to fight with Tyler Jacobson over the meal he was making of Florencio Villegas. Beau Barton bravely fired and fired at both of the Unstoppable Soldiers while they ate and sparred over Florencio Villegas's right leg.
That was exactly when Travis Pope noticed the other, as-yet-uneaten National Guardsman.
It was not a good thing for my second- or third-cousin, or whatever sharing a great-grandmother made Beau Barton to me.
I got out of Robby's car first.
For a moment, stunned, Robby Brees and I had sat there, watching what was happening on the bridge ahead of us. Then I realized we were all stuck anyway, and Robby and I still had our paintball guns that were loaded with the blood of a real, cigarette-smoking, homosexual teenage God.
As soon as my feet hit the tarmac of the bridge span, Robby shouted, "Austin! Hey! What the hell are you doing?"
Tyler Jacobson was covered with blood and bug spit. He also had a foot-long length of Florencio Villegas's webbed belt dangling from his left mandible like a strand of bloody spaghetti. Tyler Jacobson was aroused by the motion I made as I ran from Robby's Ford Explorer. He watched me for a moment while he excreted a foamy white meringue of bug shit onto the blacktop between his two hind legs.
Tyler Jacobson was already hungry again.
Beau Barton emptied his M-16 on the Unstoppable Soldiers. He tried to run back toward Ollie Jungfrau's van when his gun stopped firing.
Unstoppable Soldiers are very, very fast.
Travis Pope sprang with a single jump over the armored vehicle the guardsmen had been driving. Travis Pope landed directly on top of Beau Barton. It was like a cat playing with a very small mouse.
Travis Pope pinned Beau Barton with his two middle legs.
Beau Barton wriggled and squirmed.
Travis Pope lowered his triangular face, opened his massive jaws, and bit off everything that had once been Beau Barton from the armpits up. Travis Pope chewed and chewed.
The sound was like a starved barbershop quartet engaged in a buffalo-wing-eating contest.
I raised my paintball gun.
I thought about saying something dramatic.
History, when told truthfully, will show that boys never really do make heroic statements while engaged in battle. Historians craftily pen those things in after the fact.
I had nothing to say.
But I did think about Saint Kazimierz. I thought about my brother, Eric Christopher Szerba. I wished he could watch what was happening here on the Kelsey Creek Bridge on satellite television. I thought about my mother and father, too, and I was convinced I would never see them again. And I thought about my balls—Orville and Wilbur.
I cannot say why I thought about my balls, only that I did.
All of that ran through my mind in the exact span of time it took for me to pull the trigger on my paintball gun.
That is the truth.
Bap! Bap! went the paintballs.
At that exact moment, Tyler Jacobson sprang toward me.
Pop! Pop! Pop! went Robby Brees's paintball gun.
Robby, naturally, chased after me when I ran from the car. Robby Brees truly was a superhero.
If Unstoppable Soldiers are capable of showing expressions with their mechanical faces and massive compound eyes, then both Tyler Jacobson and Travis Pope looked at each other in confusion and stunned defeat, possibly horror.
I shot Travis Pope a third time, a direct hit into his thoracic joint.
The Unstoppable Soldier broke completely in half.
"Fuck yeah!" I said.
I had never killed anything bigger than a freshwater perch in my entire life. There was something exhilarating and pure that rushed through me in that moment. I am almost embarrassed to say that it felt somewhat sexual, and made me kind of horny.
It is the truth.
This is why assholes in charge of shit convince boys to go to war, I believe.
"Fuck yeah!" Robby said.
Robby Brees felt the same thing.
Tyler Jacobson staggered away from the front of the guards' vehicle. As he stumbled backward, he began disassembling—clop! clop! clop!—in detached segments that looked like goat-sized green lobsters flailing around in puddles of cheesy, shimmering yellow goo.
"Robby?" I said.
"Yeah?" Robby answered.
"Are you okay?" I said.
Robby Brees said, "Yep."
And I said, "That was probably one of the top-three most bitchin' things I have ever done in my life."
Robby said, "The only way it could have been better, Porcupine, is if we were on our skateboards when it happened."
Robby Brees was the brightest boy on the planet called Earth.
At that exact moment, in a small house across Ealing, on Onondaga Street, the Unstoppable Soldier that had once been Eileen Pope came out into the blue plaid Iowa afternoon.
She was very horny and very hungry.
And her eggs were hatching.
## GREAT BIG JAR
WE TRANSFERRED OUR belongings from Robby's dead Ford Explorer into the National Guard armored vehicle.
Robby drove.
The armored vehicle did not have a cassette tape deck.
It would have been a perfect time to listen to Exile on Main Street.
"They should put tape decks in this shit," Robby said.
"They don't even have a lighter for our fags," I pointed out.
"What could they possibly have been thinking?" Robby offered. "Anyone knows boys are better soldiers when they can smoke cigarettes and listen to the Rolling Stones."
"We are unstoppable," I said.
It was just as well. I had matches, and half a pack remained of my Benson & Hedges cigarettes. I lit one for Robby and then reached across and put it into his mouth. I touched his lips. I was still very confused about everything. I cared so much for Robby Brees. I would do anything for him. But at that exact moment, I was worried about Shann Collins, and I needed to get back to Eden.
What was I going to do?
I caught Connie Brees watching me when I put a lit cigarette into Robby's mouth and my fingers touched his lips. Connie Brees smiled.
"Um," I said.
Robby said, "Thanks, Austin."
I lit a cigarette for myself and passed the pack and matches to Robby's mom. Louis did not smoke.
Ingrid yawned.
Robby and I explained as much as we could. It was really too much to fit inside one car ride, and who could ever expect Connie Brees and Louis Ah Wong Sing to make any sense of what had been happening in Ealing, anyway?
It would take time.
Robby and I smoked.
Robby Brees sang Let It Loose. I had to be quiet when he sang because the sound of it made me want to cry, in a good way.
"I ain't in love, I ain't in luck . . ."
After he finished, Robby said, "There are other Unstoppable Soldiers out there somewhere."
I nodded.
I said, "Uh. What can we do, Rob?"
Robby said, "It is a big jar we're in, Austin."
"It's a great big jar," I said.
Here is what the end of the world looks like:
It looks like a child running out into the road, eyes focused only on some destination ahead—the future, which is on the other side—and the child fails to notice the speeding truck that is there, on that same road, in the present.
This is what the end of the world looks like.
All roads cross here.
Thu-Thump!
Robby slammed on the brakes.
The armored vehicle completely ran over the small pedestrian, front wheels and back wheels.
"Shit!" Robby said.
"Uh," I said.
We sat there for a moment, not really knowing what to do.
What do you do when it is the end of the world and you run over some dumb kid who jumps out in front of your armored vehicle?
"I will go look," I said.
I climbed down from the cab.
In truth, I was afraid to look at the road behind us and come face-to-face with the bloody mess that would be there. This is history. I was standing in the present, looking back at the past with the empty road ahead of us.
What could I do?
And in the road behind us, stiffly clambering up onto shaky legs was a dark, confused Unstoppable Soldier that stood no taller than shoulder height to me.
And it was hungry.
I ran before the thing realized I was food.
"Holy shit! Holy shit! Holy shit!"
Excrementum Sanctum.
I slammed the door shut just as the hungry beast crumpled its arms against the side of the cab.
"What the—" Robby began. Then he saw the folded, spiked arms of the Unstoppable Soldier as they scraped against the bulletproof window on my door.
"Gun it, Rob," I said.
This is what the end of the world looks like.
Leaping and skittering over the strands of barbwire that lined the highway out toward the old McKeon House came dozens and dozens—hundreds and hundreds—of little, hungry and horny Unstoppable Soldiers.
"Holy shit," Rob said.
"Holy shit," I agreed.
We drove.
I lit another cigarette.
# EPILOGUE:
LUCKY,
A CIGARETTE RUN, AND THE BISON
I call the boy Lucky.
It is only a nickname for the kid.
In the dead of a bitter Iowa winter when he was born, inside the same examination room where Wendy McKeon filled syringes with Robby Brees's blood, I gave him the name Arek Andrzej Szczerba.
I also reclaimed my stolen consonants.
I write in the library. The walls have been adorned with every imaginable beast and totem: a bison, a two-headed boy, an Unstoppable Soldier, a volcano in Guatemala, praying hands, a Stanpreme pizza, a sign that says Roof Access .
You know what I mean.
Today is March 29, but spring has not taken hold above us yet.
It is also Robby Brees's twenty-first birthday. We are going out on a cigarette run today.
I will explain.
Lucky—Arek—is four years old. We have been living in Eden for a long time. Wendy McKeon made rules about things like when boys and girls can take showers, and there is a new history. The new history is Eden's.
What I have written here is not the history of Eden. It is the history of the end of the world. All real histories will be about everything, and they will stretch to the end of the world.
The end of the world started when Andrzej Szczerba slid into the cold sea as his boy, Krzys, watched and wept and drifted closer and closer to the United States of America.
Nobody knew anything about it.
There are more of us now. The citizens of the New Universe include Robby Brees, Shann Collins, Johnny and Wendy McKeon, Connie Brees, Louis Ah Wong Sing, and my son, Arek. Connie Brees also gave birth to a baby—a girl named Amelie.
Amelie Sing Brees is a real dynamo of an Eden name.
We did what Dr. Grady McKeon told us we needed to do.
And Ingrid is here. She lies beneath my feet as I write.
I continue to be torn between my love for Shann Collins and Robby Brees. But I no longer care to ask the question, What am I going to do?
Sometimes it is perfectly acceptable to decide not to decide, to remain confused and wide-eyed about the next thing that will pop up in the road you build. Shann does not like it. Robby Brees asks me to live with him. I stay in my own room, which I share with my strong Polish son, Arek, and we are very happy.
Robby Brees and I ventured out into the world above during a snowstorm, in the first winter after the end of the world. We were correct in assuming the Unstoppable Soldiers would either leave Iowa or hibernate during wintertime.
We armed ourselves with the blood of God, in any event.
It was reckless and wild, going out with Robby. It was just like everything Robby Brees and I ever did together for our entire lives. Nobody else would come with us. We began to call these trips our Cigarette Runs.
Nobody knew anything about them.
Of course, we had enough cigarettes in Eden to last us for years and years.
We would be gone for days. It frightened the others, so we came back one time with battery-powered walkie-talkies that had a range of fifteen miles.
Robby and I always went much farther than fifteen miles.
One time, we'd gone all the way to Minneapolis.
Robby and I never found a single human being on the surface of the planet called Earth. I do not believe Robby and I wanted to find anyone else, but we never said that aloud. We did not need to say such things.
On our Cigarette Runs, we have killed a few Unstoppable Soldiers that stubbornly scavenged during wintertime, and Robby Brees and I always spend our nights together in the nicest abandoned hotels, penthouses, and mansions.
It is fun and daring.
It is on these Cigarette Runs that I have uncovered much of the history included in this book. It is the truth. It is my job. From hand-scrawled calendars, newspapers, appointment books, pocket-sized digital voice recorders, bones, cast-off clothing, and inflatable whales, I have put things together the best that I can, and I know that you trust me.
I have no reason to lie.
Animals have come back in tremendous numbers. On our last Cigarette Run, just after Arek's fourth birthday in February, Robby and I ran into a herd of deer standing across the I-35. There were thousands of them. The deer had already forgotten why they should be afraid of human beings. When we got out of the car we'd been driving, Robby and I could walk right up to the animals and pet them.
Robby Brees and I are the kings of the world when we are out on our runs.
When we come back to Eden, tired and exhilarated at the same time, Robby and I bring gifts home for the women and babies: new clothes and underwear, diapers, toys, food that does not come in army-issue cans, even sports cars and motor homes.
I always bring back books for the library. Books have everything in them. After the end of the world, you cannot learn a goddamned thing from a computer or a television screen.
Nobody ever thought about that—how humanity could only be preserved by paintings on cave walls, or books, and vinyl recordings. Robby Brees always brings vinyl records home to Eden.
I found an autographed copy of The Chocolate War.
We own everything in the world, and Robby and I stockpile whatever we might need if Eden breaks down. It is going to happen eventually. Things break down. History tells us that, even if we do not want to listen.
Shann is quietly pouting; no doubt hiding inside her bedroom. She does not like it when Robby and I go out on our runs. But it is Robby's birthday.
We need to do it.
There is something inside all boys that drives us to go away again and again and again.
Again is now.
We have not been out all month, and soon it will be too warm and too dangerous for Robby and me to leave. The Unstoppable Soldiers will come back. They always do.
Robby Brees and I found a two-man ultralight aircraft in the hangar at Cedar Falls airfield. Just like Orville and Wilbur Wright. Robby swears he is brave enough to try taking the thing up for a flight. We have checked the motor, and it runs fine. I think if I get drunk enough today, or shit like that, I will let Robby Brees talk me into sitting in that goddamned airplane with him and going up for his twenty-first birthday, as long as I can have a cigarette or two.
He promises we will fly over Grasshopper Jungle in our own airplane, and Robby will sing Rolling Stones songs and I will smoke cigarettes and spit on the planet called Earth and we will shout the names of our balls from the sky.
Johnny McKeon has never given up trying to contact other human beings. I believe there are others somewhere on the planet Earth. I cannot calculate how long an Unstoppable Diaspora could overrun every continent. I fantasize that my mother, father, and brother are all fat and speak German fluently.
Maybe Polish.
Johnny McKeon hooked up spools of flat, twin-channeled wires to the antenna posts on the television sets in the Brain Room. Every day he sits, watching nothing and listening to static, twisting and turning the knobs on the UHF and VHF adjustments. One morning, last summer, Johnny McKeon came running from the Brain Room, shouting, "I'll be danged! I'll be danged! I found someone!"
Naturally, we all ran to see what Johnny McKeon had found on the televisions in the Brain Room. When we got there, there was nothing. Johnny McKeon swore he'd seen a portion of an old episode of a program called Gunsmoke.
James Arness was the star of Gunsmoke.
Johnny McKeon has been losing his mind down here in Eden.
He watches the televisions every day.
Wendy McKeon makes rules. Robby and I do not follow Wendy McKeon's rules very well.
Ah Wong Sing cooks. He is a real dynamo at cooking.
Connie Brees has a 230 bowling average.
Before we leave, Robby, Arek, and I take a piss together in the giant Nightingale urinal. It is what we do. One day, I will tell Arek about Krzys Szczerba and Eva Nightingale, and all the rest of our history.
Arek is a good boy.
"I will look for a coonskin cap for you when Robby and I are out, Lucky," I say.
Arek looks up from where he is peeing and says, "What's that, Tata?"
Arek calls me Tata.
"You will see," I say.
Ingrid is up above, shitting in the snow.
Robby and I make several trips up and down, transporting things we want to take with us on our run. This trip we are driving a BMW X5. We took it, brand-new, from a dealership in Peoria, Illinois, where if anybody was still alive, Robby Brees and I would be wanted outlaws.
Once the car is loaded, Robby and I say good-bye to the other New Humans.
Shann is tough. She kisses us both and tells Robby to be careful.
I still enjoy watching Shann kiss Robby Brees.
Robby tells her that he will bring her back a Rolex wristwatch.
Shann Collins has four Rolex wristwatches. It is a joke. I would have a difficult time imagining anything as useless in Eden as a Rolex wristwatch.
I say we will bring back cases of Cup-O-Noodles.
That makes everyone happy.
Cup-O-Noodles is Arek's favorite meal.
Arek gets to climb up the ladder with us. The boy has only been outside a handful of times in his entire life.
Robby is warming up the BMW. I still do not drive very well, although Robby has taught me how to do it.
Arek forms an icy snowball in his little pink hands. It is a game. All boys do this, just as all boys build roads that crisscross and carry us away.
"Pow! Tata! You are dead!" Arek says.
Tata is Polish for Daddy.
The snowball hits my thigh and I feign injury. I scoop a handful of snow and return fire, purposely missing the boy.
The hatch is open. Louis and Shann poke their heads above the rim, like timid gophers.
I light a cigarette.
Robby gets out of the car and trudges across the snow to say a last good-bye to Arek. Like his father, Arek also loves Robby Brees very much.
In the swirling fog of smoke that rises in front of my face, I notice a large figure moving in the field beyond a row of parked motor homes and Cadillacs.
"Holy shit!" I say.
Robby has a paintball gun at his side. We never go out without one.
"Holy shit!" Robby says.
"Austin?" Shann calls nervously.
Shann cannot see what the three of us are looking at.
"What is that, Tata?" Arek, who I call Lucky, asks.
Across the field, I can see them. There are three of them, at first, and then I realize it is an entire herd: massive, dark, horned, and humpbacked. North American bison. The buffaloes have come to Iowa, to Eden.
"It is a big hairy thing," I say.
And that was our day.
You know what I mean.
## ACKNOWLEDGMENTS
I have been writing all my life. I never for a moment considered the idea of publication until my dear friend, author Kelly Milner Halls, challenged me into doing it.
It was a good idea, even if I never actually wanted anyone to read what I wrote.
Thank you, Kelly.
About two years ago, I decided to stop writing. Well, to be honest, not the verb writing, but I decided to get out of the business aspect of it, for which I have absolutely no backbone. I never felt so free as when I wrote things that I believed nobody would ever see. Grasshopper Jungle was one of those things. It was more-or-less fortune, then, that I happened to show the first portion of the novel to my friend Michael Bourret. He talked me into not quitting. Michael is, after all, a magical agent. I think when he walks into offices and shit like that, people believe they are looking at a baby harp seal. Nobody says no to a baby harp seal. Michael wanted to represent me and this novel that nobody was supposed to see.
It was a good idea. Thank you, Michael.
We made a list: Who did I want to show Grasshopper Jungle to, well . . . besides nobody? And on that list was Julie Strauss-Gabel. I never thought I'd hear from her, much less get the chance to work with her, but Julie gave me a phone call. We wanted to work together.
It was a good idea.
In fact, I have to say that working with Julie Strauss-Gabel as my editor and publisher on Grasshopper Jungle has been one of the most rewarding experiences in my writing career. Thank you, Julie.
Most writers never know the name of the person who copyedits their books. Copy editors are the people who tell writers they don't know the difference between restrictive and nonrestrictive clauses, or between Latin dance steps and dessert toppings.
I suppose it is a good idea to know these things.
My copy editor, museum date, and Hell's Kitchen dining partner whenever I go to New York, Anne Heausler, is simply the best; and she is so gentle when battering my self-esteem with her Chicago Manual of Style or Webster's Dictionary. Thank you, Anne.
And finally, I don't know if having a writer in the family is such a good idea. But I must give thanks and love to my wife, Jocelyn; my son, Trevin; and daughter, Chiara, for being such dynamos at putting up with me.
Turn the page to read a preview of Andrew Smith's
prologue:
HERE IS A PINWHEEL
"Here, kitty-kitty."
The cat had a name—Alex—but General Parviz always called him in the same generic manner.
General Parviz, all gilded epaulets and clinking medals, a breathing propaganda poster, repeated, cooing, "Here, kitty-kitty."
The Alex cat, a six-toed Manx, an official gift from the Hemingway estate and the people of the United States of America, swept its head from side to side, walking slow like a drowsy lion. The cat paused at the general's slippered feet as though considering whether or not it actually wanted to jump up into General Parviz's lap.
The general patted his thigh softly, beckoning.
"Kitty-kitty."
The cat leapt soundlessly.
Then cat, general, palace, bodyguards, and approximately one-third the territory of the capital city blew up.
Here, kitty-kitty.
\- - -
Here is a handful of dirt.
As far as its use as a medium for sustaining life—nourishing roots—it is perhaps the least capable dirt that can be found anywhere on the planet. To call it sand would be to give it some unwarranted windswept and oceanic dignity.
It is simply dead dirt, and it fills my hand.
I will tell you everything, Max, and we will carry these stories on our small shoulders.
• • •
On my fourteenth birthday, Marden and I played outside the village in one of Mr. Antonio's fields with Sahar, Marden's sister. We would have been in trouble if we had been discovered. There was a funeral that day for Mr. Antonio's cousin who had been killed fighting against the rebels, so it was expected that everyone attend.
At school that morning, we performed a play. I had the role of Pierrot, Sahar my Columbine. One of the boys in our class played a joke on me: At the end of the day when we went to change out of our costumes to prepare for the funeral, somebody had taken all my clothes—everything—so I had to stay dressed as the mute white clown. I didn't mind so much; the costume was loose and soft and made me feel disconnected, like a ghost drifting above the dead fields we played in.
"This is Mr. Barbar's ram," Marden said.
Mr. Barbar's ram had been missing for more than a week.
Sahar and I grabbed small handfuls of dirt. We poured our dirt into the eye sockets on the rotting skull. What else would kids do? Playing with dirt and horned carcasses was a good way to have fun.
The thing looked like a caricature of the devil himself.
When the FDJA came to the village that day—it was just after the mourners arrived back from the funeral—four of them took all the boys and made us go up to the third floor of the school building. I was still dressed as Pierrot; nobody would confess as to who the thief of Ariel's clothing was.
Of course, we all knew what was going to happen next, once the rebels got us into the upstairs classroom. We could already hear gunfire and cries coming from outside the school.
The rebels bribed us with cigarettes and guns.
What boy doesn't want cigarettes and a gun?
One of the men, his face hidden behind a red scarf, said to me, "What are you supposed to be?"
"Pierrot," I answered.
He shook his head, confused.
"You look like a boy-whore."
Ivan, a ten-year-old, puffed on his first cigarette and glared at me. I wanted to slap him. One of the FDJA men patted the boy's head. We were all goners at this point.
Everyone knew. It had been this way all our lives. Here, the deliberate cruelty of violence was a matter of fact, controlling, constraining, and understandable. Not so much in some of my other stories, Max.
The rebels targeted the older boys, many of whom were approaching conscription age for the Republican Army. They taunted the boys with insults about patriotism and loyalty to capitalist puppet masters. One boy, Jean-Pierre, pissed himself when the man whose face was covered with the red snot-stiffened rag prodded his belly with a gun barrel. Naturally, this was very funny to the FDJA men. Who wouldn't laugh at a sixteen-year-old boy who pissed his pants as he was about to be kidnapped by thugs with guns?
I felt bad for Jean-Pierre, who, like the other chosen boys in the schoolroom, recited a robotic pledge of allegiance to the FDJA. He would have done the same thing on his eighteenth birthday to the Republican Army, anyway. So, who cared?
We were all going to go with the FDJA now, or we would never leave this third-floor schoolroom. They promised us that we were old enough to make our way as men, even though some of the youngest boys were barely ten years old.
My friend Marden was sixteen.
When one of the men tried wrapping the red scarf of the FDJA around Marden's neck, my friend swatted his hand away. Marden was always defiant like that—impulsive—and everyone knew it was a mistake. But what could we do?
To make an example of him to the other boys, two of the FDJA men picked up Marden by his feet and threw him headfirst out the window as he kicked and scratched at them. But Marden didn't scream or cry. I heard the impact of his body against the paving stones that lined the street below.
I desperately wished I had my proper school clothes. I felt so isolated and noticeable in my thin white clown suit.
Two of my schoolmates ran for the doorway that led to the stairs. The man with the hidden face fired at them and they tumbled down in a heap across the threshold.
"Let's go!" he said.
I could only see his eyes peering out from a slit on the covering. He waved his gun to goad the remaining boys—there were five of us—over our friends' bodies and out the door.
One of the men videoed the slaughter in the schoolroom with his cell phone, sweeping it around and around until he focused directly on my face. Most of the white makeup I'd worn earlier had been wiped away, but I was still pale and painted. And I was crying. The video would be uploaded with the usual descriptions blaming all this on the Republican Army. People naturally believe things they see. Nobody argues with the irrefutable postings on YouTube.
I was told that in America, many people believed FDJA stood for Freedom Democracy Jesus Army.
They sent money.
I stood by the open window, thinking about Marden and how we'd been playing in Mr. Antonio's field just moments before. What could I do? I was frozen at the edge of the floor, with the fingers of one of my hands resting on the windowsill where my friend had left the room that smelled of sweat and gunpowder.
The man with the red mask, his eyes wild and white, turned toward me. The other boys made their way out into the hallway, tramping through blood. He raised his rifle. The barrel was so slender and short. I was as familiar with these guns as anything in the world—how they smelled, the sound of their report. When he pointed the thing at the center of my chest, I thought it would be a better end than to be thrown after Marden—but when the man pulled the trigger, the thing jammed—dead—and the two remaining FDJA men stared at me as though I were dead, as though the gun had functioned properly and I was done for—I believe they could not accept anything other than this—the wide white staring eyes of them, whiter than the soft clown suit that seemed to flutter around my body.
Then they left and I heard their footsteps clattering downstairs as the others ahead of them yelled at the boys and told them to form a line and get out onto the street.
Happy birthday to me.
Later, I thought, this was the first miracle I had seen. Perhaps my survival was nothing more than an accident. Accident, miracle—I suppose the storyteller retains the right to determine such things.
Picture this, Max: I waited in the classroom for a while, wondering if maybe I really was dead—that this is what being dead is, just a dream that continues on and on—and now I truly was the ghost I'd imagined myself to be when Sahar and Marden and I played that afternoon.
When I was certain the men and their new conscripts had gone, I went downstairs into the school's kitchen and hid inside a walk-in refrigerator.
\- - -
Here is nothing but ice.
It is more than ice, more than anyone on the steamer had ever seen. It is the blue-white fist of God, curling calloused fingers to grasp the protesting wooden hull. It is an infinity field of jaws with countless rows of teeth; absolute control and the concurrent absence of control. The hungry ice creaks and moans, stretching forever to become horizon, ceiling, and cemetery; and the ship, frozen and moving, trapped in this relentless vise, is slowly dragged along, endlessly northwest into more and more ice.
TUESDAY, FEBRUARY 10, 1880—A _LEX CROW_
Today is our fifth month in the ice. The ship is held fast. The readings calculated by Mr. Piedmont, ship's navigator, measure the distance the ice has taken us at more than one hundred miles!
It is the cruel reversal of our intent. The men of the Alex Crow expedition set off with the expectation that it would be us—the first voyagers here to absolute north—who might inflict our will upon the planet; instead we face the grim truth that nature's will is uncontestable.
I keep such daily accounts as no measure of optimistic entertainment. My overwhelming sense is that the end of our story will not be written by my hand.
I don't think I can endure this imprisonment much longer; I am beginning to wonder if I'll go as insane as Murdoch.
After breakfast, a party of seven men took a team of dogs and one of the sleds out onto the pack to hunt for seal and bear. I stood at the rail and watched in amazement as the men and dogs clambered over the unyielding hummocks of ice that had once been the ocean.
Twenty-five of us remained behind on the Alex Crow, including the newspaperman, Mr. Warren, who had crushed his hand three days ago between the ice and forefoot of the hull and is currently under my care. Today, the majority of the men busy themselves with the drudgery of routine maintenance.
Some watch and record wildlife sightings. Wildlife!
In the afternoon we heard rifle fire but could not determine its direction due to the blinding whiteness that smothered everything.
It was then that Murdoch, who has taken to following me around, said, "Doctor, Doctor, I do believe our men have found something."
\- - -
Here we see a two-quart jar of Mason-Dixon-brand sauerkraut.
I believe sauerkraut, along with guns, is some type of national symbol in the Land of Nonsense. Everyone in Sunday, West Virginia, eats sauerkraut and also shoots things. So it isn't a casual act by which I begin a story with the examination of a jar of sauerkraut—the sauerkraut has a purpose; it shapes one of my clearest initial memories since coming to America, as though when the contents of that particular two-quart jar of Mason-Dixon-brand sauerkraut spilled, something began to fill me up after all my emptying and emptying.
I arrived here in Sunday little more than one week after my fifteenth birthday.
A year had passed since the miracle in the schoolhouse.
Happy birthday to me, once again.
Mother—my American mother, Natalie Burgess—has the most confusing habit of making everything seem insignificant and small. My brother Max calls her the Incredible Shrinking Machine.
Here is what happened: When the top jar tumbled from its eye-level placement, it caught the edge of the metal cage basket on the shopping cart and exploded in a fetid shower of cabbage and knife-shards of glass.
Mother was dressed in salmon-colored shorts and pale yellow sandals.
One of the glass shards slashed across her leg, mid-calf.
She said, "Oh."
I had only been here four days, but the way she said it sounded like an apology to me, as though it were her fault for being in that precise spot inside the Sunday Walk-In Grocery Store at the exact moment the jar slipped from the shelf.
We had dropped Max off at school earlier. I was not enrolled yet, because the officials at William E. Shuck High School insisted on testing and testing me to determine whether or not I was an idiot, or could speak English, which I could do perfectly well despite my aversion to talking.
"Oh," Mother said again.
I shifted my weight from foot to foot. I didn't have any idea what I was supposed to do. Maybe I was an idiot of some kind. But here I was in this grocery store, which may just as well have been some gleaming palace or gilded mosque, watching in confused silence while Mother bled all over the speckled linoleum floor.
It was a nauseating scene; so much so that I vomited, which made everything just that much more repulsive, and Mother said "Oh" again because we were making such a mess on aisle number seven.
Mother reached into her purse and gave me a handkerchief so I could wipe my face. The handkerchief smelled like perfume and mint chewing gum. Then she pressed some wadded napkins into the cut on her leg.
A clerk wearing a brown apron came running up the aisle toward us. I thought he was mad because of all the mess we'd made, but he was most concerned about the injury to Mother's leg.
"We're calling an ambulance!" he said. "Please sit down!"
And he flailed his arms as though he were swimming toward us.
But Mother said, "No. No. I'll be fine! I'm so sorry for all this."
And while the man pleaded with her, bent forward so she could press her soaked napkins against the wound, she grabbed my clammy hand in hers and led me out to the car.
"I'm sorry. This is so embarrassing, Ariel," she said as we climbed in.
We did not make it home. Mother passed out behind the wheel less than a mile from the Sunday Walk-In Grocery, due to all the blood she'd lost.
She was like that.
\- - -
Here is Joseph Stalin telling the melting man what he had to do.
Joseph Stalin's voice came from the air vents on the dashboard of the melting man's recycled U-Haul moving van. Joseph Stalin also spoke to the melting man through the radio.
The melting man tried to do anything he could to make Joseph Stalin shut up.
He removed the radio at a rest stop near Amarillo, Texas, and left its dangling wires atop the hand dryer in the men's toilet, but Joseph Stalin's voice still came through the old speakers.
At the same time Leonard Fountain—the melting man—crossed the border between Oklahoma and Arkansas, Joseph Stalin told him this: "They are coming to get you, Leonard. You know that. You must not let them catch you."
Leonard Fountain drove his recycled U-Haul truck all the way from Mexico City, where he'd assembled the biggest bomb he'd ever seen at a rented flat on the top floor of an apartment house across the street from one of the sixteen Holiday Inns in the city.
Leonard Fountain believed he had to stop the Beaver King. The Beaver King was hiding somewhere near a shopping mall called Little America. He knew that, because Joseph Stalin told him all about the Beaver King. The Little America Mall had an animated Statue of Liberty in the center of its welcoming gates. The statue could spin its crowned head around in a full circle, and its torch-bearing arm could lower and flash colorful beams of lights at the dazzled shoppers.
No doubt, had the French been more technologically advanced, the original Statue of Liberty would perform the exact same tricks.
Leonard Fountain had a fascination with bombs. He grew up in Idaho, where kids were naturally expected to blow things up.
What else would you do?
When he was thirteen years old, although he spent the majority of his waking hours playing video games or masturbating, Leonard Fountain helped out his neighbors by blowing up beaver dams.
On his fifteenth birthday, Leonard Fountain, who hadn't started melting yet, made a remote-controlled bomb from three sticks of dynamite and lashed it to the neck of a dairy cow.
They never found the cow's head.
Leonard Fountain loved blowing things up.
"They are coming for you, Leonard," Joseph Stalin said. "There is a drone flying directly above our truck. You can see it. When you look at it, it will disappear."
Outside Arkadelphia, the melting man pulled the truck onto the shoulder of the highway. He knew what to do. He pretended to be distracted, and then looked up into the sky behind the rear gate on the U-Haul.
Leonard Fountain saw something in the sky.
What he saw was a perfect rectangular prism that hovered soundlessly, fifty feet above his head. The thing was metallic and shiny, about four feet long, and as soon as the melting man focused on it, the thing rotated diagonally and vanished—became invisible.
They were watching Leonard Fountain. Leonard Fountain knew it all along.
From time to time, when he'd get out of the van to pee or sometimes vomit alongside the road, the melting man would suddenly jerk his head around and glance up into the sky, and the little floating box—it resembled a package of tinfoil—would always be there, and then it would turn slightly and disappear.
And it was while the melting man drove through Arkansas, in the direction of Tennessee, that Joseph Stalin became particularly nasty.
"Look at you," Joseph Stalin scolded. "You're disgusting. You better get this done before you dissolve into a puddle of pus and goo. Now pay attention."
Leonard Fountain did not want to pay attention. He drove with an old Hohner Special 20 harmonica in his mouth, and he'd blow the loudest noise through it every time Joseph Stalin said anything about what he wanted the melting man to do. But the harmonica didn't work. So Leonard Fountain bought two spring-winding kitchen timers at a drugstore and he taped them over his ears with medical gauze, hoping the metallic tick-tick-ticking of them would stop the Communist dictator's voice.
He thought Joseph Stalin's voice must have been beamed into his head from a government satellite. What other explanation could there be?
Actually, there was another explanation, but Leonard Fountain never figured it out.
Leonard Fountain was insane and melting, and he needed to blow something up.
\- - -
Here we see the family pet—a crow we call Alex.
The bird is named after a barkentine steamer commissioned by the U.S. Navy in the late nineteenth century. The ship became icebound—trapped—during an expedition to discover a fabled open seaway to the North Pole in 1879.
Alex is a product of my American father's research.
I don't think the research turned out very well for Alex.
What my father does, I believe, is less research, and perhaps more appropriately called "aimless scientific wandering."
And he finds things you'd never know were out there.
Alex is a morbid being, obsessed with his own death, and gruesomely despondent. I know that's an odd set of qualities for a bird, but Alex should not have been saved to begin with. He is a member of a species that has been extinct for more than a century, and I think all Alex really wants to do is go back to where he'd been pulled from.
My father, and the company he works for, are tireless in their obsession with saving things from nonexistence, and by doing so, controlling the course of life itself. Unfortunately, sometimes paths and directions can't be so easily controlled, as the men on the ill-fated steamer Alex Crow found out. And sometimes things don't want to be saved or brought back from where they'd been trapped.
**Looking for more?**
Visit Penguin.com for more about this author and a complete list of their books.
**Discover your next great read!**
| {
"redpajama_set_name": "RedPajamaBook"
} | 2,184 |
Q: Use ityped init with useRef and useEffect in React with TypeScript Trying to implement ityped in a React app. The code shown below should work in JSX; however, this React app is written in Typescript (TSX), which is why it fails with a type error.
"Intro.tsx" component:
import React, { useEffect, useRef } from 'react';
import { init } from 'ityped';
import "./intro.scss";
export default function Intro() {
const textRef = useRef(null);
useEffect(() => {
init(textRef.current, {
showCursor: false,
strings: ['Web developer', 'Logo designer']
})
}, []);
return (
<div className="intro" id="intro">
<div className="left">
<div className="imgContainer">
<img src="assets/man.png" alt="" />
</div>
</div>
<div className="right">
<div className="wrapper">
<h2>Hi there, I'm</h2>
<h1>Andreas Petersen</h1>
<h3>A <span ref={textRef}></span> </h3>
</div>
<a href="#portfolio">
<img src="assets/down.png" alt="" />
</a>
</div>
</div>
)
}
The error is as follows:
My guess is that const textRef = useRef(null); needs to be defined in a way, so that init() from ityped can understand it correctly.
A: You'll need to do two things. First, like you guessed, you'll need to specify what sort of ref this is:
const textRef = useRef<HTMLSpanElement>(null);
Secondly, even with that type, textRef.current can still be null as far as the types are concerned. So you either need to add code to your use effect to check for null:
useEffect(() => {
if (!textRef.current) {
return;
}
init(textRef.current, {
showCursor: false,
strings: ['Web developer', 'Logo designer']
})
}, []);
Or if you're confidant that you've made it impossible for it to be null after the first render (ie, you're unconditionally passing it into a component that will use it), you can use a non-null assertion (!) to insist to typescript that you know it's not null:
useEffect(() => {
init(textRef.current!, {
showCursor: false,
strings: ['Web developer', 'Logo designer']
})
}, []);
Be aware that this second option means you're telling typescript not to check your work. If you make a mistake and it actually can be null, typescript can't tell you that, and you may get unexpected behavior at runtime.
A: Yes, you need to add type to your useRef so Typescript can understand that the ref is for a span element.
Try this: const textRef = useRef<HTMLSpanElement>(null);
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 6,181 |
Fårhus (dänisch auch: Faarhuus; deutsch: Faarhuus und Schafhaus) ist ein dänischer Ort, der zur Kirchspielsgemeinde (dän.: Sogn) Bov Sogn an der deutsch-dänischen Grenze gehört.
Geschichte
Auf der Karte der dänischen Landesaufnahme von 1857/58 war der Ort, der damals schon aus mehreren Gebäuden bestand, unter dem Namen "Schafhaus" eingezeichnet. Auf der Karte der Preußischen Landesaufnahme von 1879 war der Ort ebenfalls unter dem Namen "Schafhaus" eingetragen. Im 19. Jahrhundert wurde die Bahnstrecke Fredericia–Flensburg erbaut. Bereits 1879 besaß Fårhus einen eigenen Bahnhof.
Der Ort Fårhus fand nur selten eine geschichtliche Erwähnung. Während des Zweiten Weltkrieges wurde die südlich gelegene Stadt Flensburg mehrfach von alliierten Bombern angegriffen. Im Jahr 1942 wurden bei Kragelund Flugabwehrgeschütze für die Luftverteidigung Flensburgs aufgestellt. 1942 und 1943 wurden außerdem Scheinwerferpositionen hinter dem Versammlungshaus von Fårhus () und am Skyttehusvej (der bei Fårhus beginnt ()) eingerichtet. 1944 legte schließlich die deutsche Luftwaffe südöstlich von Fårhus (unweit von Kragelund) auf Feldern am Waldrand einen Militärflugplatz für Jagdflugzeuge an, der den Namen Feldflugplatz Schafhaus (dänisch: Fårhus Feltflyveplads) erhielt (). Der neue Flugplatz lag 9,5 Kilometer vom Flensburger Flugplatz Schäferhaus entfernt. Schrittweise wurden offenbar weitere Gebäude und Anlagen dem Flugplatz hinzufügt. Der Feldflugplatz Schafhaus wurde in der Kriegszeit selten genutzt. Hin und wieder landeten dort deutsche Kampfjets, die aber kurz danach wieder verschwanden. Zum Kriegsende befanden sich wohl lediglich fünf deutsche Flugzeuge vom Typ Junkers Ju 88 sowie möglicherweise noch eine Heinkel He 219 auf dem Flugplatz. 1944 wurde des Weiteren 600 Meter südlich von Fårhus im Wald von der deutschen Sicherheitspolizei in Dänemark das Internierungslager Frøslev als Gefangenenlager für dänische Widerstandskämpfer eingerichtet.
Am 5. Mai 1945 wurde vom Sonderbereich Mürwik aus die Teilkapitulation der deutschen Truppenteile in Dänemark angeordnet. Danach zogen die deutschen Soldaten aus Dänemark ab (vgl. Dänemark unter deutscher Besatzung). Nach dem Krieg wurde das Internierungslager Frøslev unter dem Namen Faarhuslager von den Dänen weiterbetrieben. Angehörige der deutschen Minderheit sowie Personen, die mit den Deutschen kollaboriert hatten, wurden dort inhaftiert. Das Flugplatzgelände von Fårhus wurde nach dem Krieg von den dänischen Landstreitkräften als Übungsplatz genutzt. In dieser Zeit existierte dort ein Schießstand mit einem Granatwerfer sowie eine Teststrecke für Fahrzeuge. Von 1959 bis 1967 nutzte auch ein Segelflugverein das Gelände. Die militärische Nutzung endete im Jahr 1967. Von 1968 bis 1990 diente das Gelände als Flugplatz für Kleinflugzeuge und Ultraleichtflugzeuge. Seitdem wird das Gelände wieder landwirtschaftlich genutzt.
2020 lebten 230 Einwohner im Ort Fårhus.
Verschiedenes
In der Zeit des Zweiten Weltkrieges wurde am nördlichen Rand der Fårhus-Plantage ein Militärfriedhof angelegt, der offenbar aber nicht genutzt wurde.
Eine militärisch genutzte Baracke, die unweit der Scheinwerferposition beim Versammlungshaus stand, wurde um 1946 vom Polizeiassistenten (dänisch: Politiassistenten) Willemoes-Petersen aus Padborg gekauft, der sie in Padborg in der Nygade 8 neu aufbaute (). Die Baracke blieb so bis heute erhalten.
Der Feldflugplatz Schafhaus ist heute der am besten erhaltene Feldflugplatz aus dem 2. Weltkrieg in Dänemark. Ganze Teile der Anlage sind heute noch erkennbar.
Der nördliche Siedlungsbereich bei Fårhus, wo sich die Straße Frydendalvej und Tøndervej kreuzen, wird "Frydendal" genannt ().
Einzelnachweise
Ort in der Region Syddanmark
Geographie (Aabenraa Kommune)
Geographie (Nordschleswig) | {
"redpajama_set_name": "RedPajamaWikipedia"
} | 6,485 |
Zoe's Ghana Kitchen are on a mission to warm you up this winter, starting with the brilliantly named It's Ghana Be Meze on Saturday 2nd of February at Carlton London Cafe in E3. It's a celebration of Ghanaian streetfood, and there are two sittings.
"Happy New Year! It's cold. It's really cold. So come and get warmed up with us.
Tropical Fruits and Peppercorn Syrup"
I am creating a weekly newsletter to feature news about all of the latest and best pop-up and temporary things in London. Please sign up below! | {
"redpajama_set_name": "RedPajamaC4"
} | 9,225 |
using System.Linq;
using AutoMapper;
using Newtonsoft.Json;
using Search.Api.Models.Request;
using Search.Api.Models.Soe;
namespace Search.Api.Config {
/// <summary>
/// Contains the automapper maps.
/// </summary>
public static class AutoMapperConfig {
/// <summary>
/// Registers the maps.
/// </summary>
public static void RegisterMaps() {
Mapper.CreateMap<SearchRequest, SoeSearchRequest>()
.ForMember(dest => dest.DefinitionQueries,
option => option.MapFrom(src => src.QueryLayers.Select(x => x.DefQuery).ToArray()))
.ForMember(dest => dest.F, option => option.Ignore())
.ForMember(dest => dest.Geometry, o => o.Ignore())
.ForMember(dest => dest.IncludeAll, option => option.Ignore())
.ForMember(dest => dest.LayerIds,
option => option.MapFrom(src => src.QueryLayers.Select(x => x.Id).ToArray()))
.ForMember(dest => dest.ProgramId, option => option.Ignore())
.ForMember(dest => dest.SearchMethod, option => option.Ignore())
.ForMember(dest => dest.SiteName, option => option.Ignore())
.ForMember(dest => dest.DefQuery, option => option.Ignore())
.ForMember(dest => dest.Token, options => options.Ignore())
.ForMember(dest => dest.AccessRules, options => options.Ignore())
.AfterMap((src, dest) => {
dest.SearchMethod = "";
if (src.SiteName != null) {
dest.SiteName = string.Join(",", src.SiteName.Terms);
dest.IncludeAll = src.SiteName.IncludeAll;
dest.SearchMethod = "site";
} else if (src.Geometry != null) {
dest.Geometry = JsonConvert.SerializeObject(src.Geometry);
dest.SearchMethod = "geometry";
} else if (!string.IsNullOrEmpty(src.ProgramId)) {
dest.ProgramId = src.ProgramId;
dest.SearchMethod = "program";
}
else if (!string.IsNullOrEmpty(src.DefQuery))
{
dest.DefQuery = src.DefQuery;
dest.SearchMethod = "defQuery";
}
});
#if DEBUG
Mapper.AssertConfigurationIsValid();
#endif
}
}
}
| {
"redpajama_set_name": "RedPajamaGithub"
} | 5,970 |
package com.example.thomas.tapin;
import android.content.DialogInterface;
import android.content.Intent;
import android.graphics.Color;
import android.graphics.PorterDuff;
import android.os.Bundle;
import android.support.v7.app.AlertDialog;
import android.support.v7.app.AppCompatActivity;
import android.view.View;
import android.widget.AdapterView;
import android.widget.ListView;
import android.widget.ProgressBar;
import android.widget.Toast;
import java.text.SimpleDateFormat;
import java.util.ArrayList;
import java.util.Date;
/**
* Created by Thomas on 21/04/2017.
*/
public class view extends AppCompatActivity
{
private ListView listView;
private EmployeeScroll scroll;
private ArrayList<Employee> currentEmployees;
private ProgressBar spinner;
String cid = "";
Date currentDate;
@Override
protected void onCreate(Bundle savedInstanceState)
{
super.onCreate(savedInstanceState);
setContentView(R.layout.activity_view);
spinner = (ProgressBar)findViewById(R.id.progressBar2);
spinner.setVisibility(View.VISIBLE);
spinner.getIndeterminateDrawable().setColorFilter(Color.WHITE, PorterDuff.Mode.MULTIPLY);
cid = getIntent().getExtras().getString("cid");
listView = (ListView)findViewById(R.id.employeeList);
currentDate = new Date();
setTitle("Schedule for Today: "+new SimpleDateFormat("dd/MM/yyy").format(currentDate));
currentEmployees = new ArrayList<Employee>();
getCurrentEmployees();
}
public void getCurrentEmployees()
{
final ArrayList<String> info = new ArrayList<String>();
BackgroundTask backgroundTask = new BackgroundTask(new BackgroundTask.AsyncResponse()
{
@Override
public void processFinish(String output)
{
if (output.equals("null"))
{
spinner.setVisibility(View.INVISIBLE);
AlertDialog alertDialog = new AlertDialog.Builder(view.this).create();
alertDialog.setTitle("Sorry");
alertDialog.setMessage("There are No Employees Working Today");
alertDialog.setButton(AlertDialog.BUTTON_NEUTRAL, "Okay",
new DialogInterface.OnClickListener()
{
public void onClick(DialogInterface dialog, int which)
{
Intent intent2 = new Intent(getApplicationContext(), EmployerMain.class);
intent2.addFlags(Intent.FLAG_ACTIVITY_CLEAR_TOP);
startActivity(intent2);
finish();
}
});
alertDialog.show();
}
else
{
String[] tokens = output.split("-");
for (String t : tokens)
{
info.add(t);
}
for (int i = 0; i < info.size(); i++)
{
String employee = info.get(i);
String[] splitInfo = employee.split(",");
Employee n = new Employee(i, splitInfo[0], splitInfo[1], splitInfo[2], splitInfo[3]);
currentEmployees.add(n);
}
spinner.setVisibility(View.INVISIBLE);
scroll = new EmployeeScroll(getApplicationContext(), currentEmployees, 0);
listView.setAdapter(scroll);
listView.setOnItemClickListener(new AdapterView.OnItemClickListener() {
@Override
public void onItemClick(AdapterView<?> parent, View view, int position, long id)
{
final AlertDialog alertDialog = new AlertDialog.Builder(view.this).create();
Employee e = currentEmployees.get((int)view.getTag());
alertDialog.setTitle(e.getName());
if (!e.isCheckedIn())
{
alertDialog.setMessage("Should Clock in at "+e.getTime1());
}
else
{
alertDialog.setMessage("Clocked in at "+e.getTime1()+" and will Clock out at "+e.getTime2());
}
alertDialog.setButton(AlertDialog.BUTTON_NEUTRAL, "Okay",
new DialogInterface.OnClickListener()
{
public void onClick(DialogInterface dialog, int which)
{
alertDialog.cancel();
}
});
alertDialog.show();
}
});
}
}
});
if( BackgroundTask.isNetworkAvailable(view.this))
{
backgroundTask.execute("getCheckedIn", cid, new SimpleDateFormat("d").format(currentDate), new SimpleDateFormat("M").format(currentDate));
}
else
{
finish();
Toast.makeText(view.this,"No internet connection", Toast.LENGTH_LONG ).show();
}
}
}
| {
"redpajama_set_name": "RedPajamaGithub"
} | 3,207 |
Rumored Buzz on Matthew McConaughey Exposed
You don't have to go to the gym every single day and lift heavy weights. If you want to keep match, it is about breaking a sweat every single day. 1 of the primary regions of focus for Matthew McConaughey is his diet regime. As an actor, he demands to be in shape and constantly moderate his physique based on the function he's taking on. In "Greenlights," McConaughey also recalled turning down a $14.5 million rom-com offer you — one of the largest of his career — because he wanted to take his operate in a new direction. The actor also said his dad died of a heart attack whilst possessing sex with his mom.
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Matthew McConaughey speaks June 7 in the White Property briefing space about the recent college shooting in his Texas hometown.
The way the film pits the behaviorx of Andie and Michelle against a single a different is a masterclass in internalized misogyny.
Can McConaughey, with no earlier political knowledge, tackle problems like abortion and climate transform with the gravity they deserve?
Stepping in shit is inevitable, so let's either see it as superior luck, or figure out how to do it less normally. Emiko Tamagawaproduced and edited this interview for broadcast withTodd Mundt.Allison Haganadapted it for the internet. Think about eulogies — the stories people today tell when somebody is gone, he says. Asking himself what stories will outlive him aids McConaughey reside a lot more earnestly, he says. Gazing back at all of the greenlights he's passed in his life, McConaughey acknowledges that maybe not absolutely everyone witnesses really so a lot of. The concept is relative, he says, and he chases eternal greenlights rather than battery-powered ones that won't last.
We enjoy how Alba is here to show us all the moments — even when they're not fairly picture ideal. The Honest Beauty founder has been open about the challenges that come along with getting a mom and that she's proper there with you when it comes to navigating it all. Lay out what you can get accomplished now and what will take longer," Alba told Parents Latina Magazinein 2020. Just before joining the group, Hepsev played in distinct projects in Istanbul where she performed Ottoman, Central Asian and Turkish Sufi music.
Longbranch McConaughey joined Wild Turkey as inventive director in 2016, and Longbranch hit U.S. shelves in 2018 immediately after years of close improvement and almost 90 tastings by McConaughey and Wild Turkey Master Distiller Eddie Russell. Although the score was tied with just 36 seconds left on the clock, soon check here the Coyotes would make history with their initially home win and the 600th win in program history. "They bowed their heads for 21 seconds of silence just before the game.
Before You are Left Behind what You Must Do To Find Out About Matthew McConaughey
It expenses money to make indie queer media, and frankly, we have to have extra members to survive 2023As thanks for Literally keeping us alive, A+ members get access to bonus content, added Saturday puzzles, and extra! Winner of Finest Initially Function at the 2007 Berlin Film Festival, lesbian filmmaker Chou Zero's romantic drama is a striking film. Years following a sudden tragedy, a cam girl and a tattoo artist — and former childhood sweethearts — navigate their conflicting boundaries and familial obligations as they attempt to reconnect. Chou's style is poetic and dreamlike generally turning back to her heroines' interior lives.
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Matthew McConaughey Could Be Fun For Anyone
"In retrospect, I wish I would've questioned issues extra, I wish I wasn't so naïve but becoming naïve is not an excuse for what I did and the part I played in this," she mentioned. "Once again, in no way was I trying to gain sympathy and I fully realize I am not the victim in this. I am not the one particular who's seriously acquiring hurt here, it really is Behati and her kids and for that I am so so sorry." Later in the TikTok video, Stroh—who toldPage Sixthe affair occurred "final year"—shared an image of an alleged DM exchange with Levine on the screen behind her. "Maroon 5 is practically elevator music at this point, so I am certain you know who Adam Levine is," Stroh, 23, continued.
Charming English bachelor Charles is unlucky in love, but senses his luck might have changed when he meets a beautiful American woman, Carrie, at a wedding. They spend one particular magical night together just before Carrie heads back to the states (ah, do not you hate missed connections?). Nonetheless, these two just preserve crossing paths—at four weddings and 1 funeral—pushing them to believe that, by fate, they're meant to be despite the timing often getting, effectively, off. To catch a break from her suffocating touring schedule, Princess Ann spends a night out in Rome…while on a sedative prescribed by her medical professional . When American reporter, Joe Bradley finds her sleeping on a park bench, he takes her back to his apartment for her safety .
At the time, he had shared a photo on Instagram with McConaughey, Chris Rock, Sasha Baron Cohen and Isla Fisher, Baron Cohen's wife, at Bono's South of France home. Kate Hudson appeared as a singer on the well known Tv series, Glee,and performed Carly Simon's "You're So Vain" with Matthew McConaughey in 2003's How To Lose A Guy In 10 Days. She also had a singing function in the film adaptation of the Broadway musical, Nine, during which she performed "Cinema Italiano" as a main cast member.
His investment in sports teams and pickles during what he labeled a consequential period of consideration regarding the gubernatorial election suggests otherwise. Undoubtedly, as 1 of the most well-known folks in the United States, his anti-vaccination rhetoric is problematic. The image of a parent justifying their choice not to vaccinate their kid with a Matthew McConaughey interview in hand is not a delighted a single, despite the fact that the sensible level of danger attached to his words could possibly appear minimal. McConauaghey's image as an actor has proven itself shockingly dynamic.
The outing comes as the pair recently celebrated Liam's 33rd birthday on Jan. 13, which Gabriella commemorated on Instagram with a photo of Liam amongst blue waves in a tropical location. The couple—who've been romantically linked considering the fact that December 2019—were photographed on Dec. 16 in Sydney, Australia as they strolled by means of an airport. Texas' sixth man has come to his team's rescue in the last two residence games in the second half with most of the harm becoming carried out at the cost-free-throw line. Rice has knocked down 16-of-19 absolutely free throws in the second half of the last two residence games, which has given him the unofficial title as The Closer. Guard Jabari Rice has made 16-of-19 absolutely free throws in the second halves of the last two property games. Prior to joining SiriusXM, Watford oversaw customer operations of Dow Jones, including all aspects of marketing and subscription acquisition for the Wall Street Journal, Barron's and MarketWatch.
This entry was posted in an actress and tagged celebrity, film, movie on January 19, 2023 by vrheadphones.
← 5 Closely-Guarded 먹튀검증카지노 Secrets Explained in Explicit Aspect Tom Hardy Explained → | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 3,202 |
\section{Introduction}
\label{introduction}
Brownian motors, quantum ratchets or molecular pumps, all these machines
operate under the same principle: The chaos of the micro-world cannot be
avoided, but one can take advantage of it \cite{reimann02}.
Nanoscale ratchet devices have been designed with the surprising
property that they can extract work from the noise of thermal
and quantum fluctuations~\cite{zapata96}.
Ratcheting is the mechanism behind molecular motors, which can use the
chaotic Brownian motion to turn directionless energy into directed motion
\cite{howard97}. These lilliputian motors seem to be
responsible for many biological process, such as mechanical
transport~\cite{svoboda93} or muscle contraction~\cite{kitamura99}.
Apart from these fascinating
machines, the ratchet effect has been used to describe economical or
sociological processes where the intrinsic asymmetry in
the system allow to rectify an unbiased input \cite{dybvig95}.
A ratchet-like effect is also the major cause of material deterioration due to cyclic stress loading, thermal or mechanical
fluctuations \cite{lekarp00, royer04, sou00}.
Asymmetries in foundations can produce tilting and eventual collapse
of any structure due to ratcheting \cite{england95}.
The tower of Pisa is a well documented case, where
the tilt was observed from its construction in 1173~\cite{burland94}. Pavement design is another important field in which graded soils are used
as supportive roadbed \cite{lekarp98,lekarp00,sharp84,werkmeister01}.
The excitations that traffic imposes on the sub-layer
produce deformations in the granular material. These deformations are
transmitted to the upper layers of the pavements, causing its degradation or
even its breakage. Cyclic loading tests are extensively used in the
investigation of the plastic response of unbound granular matter \cite{lekarp98} . In these experiments, the material is subjected to a certain cyclic stress condition mimicking traffic. From a practical point of view, the main question is whether the material accumulates plastic deformation in each cycle, or
whether it adapts to the excitation reaching a shakedown state. Only materials in which the excitations {\it shake down} should be consequently used in pavement design.
The use of simple models of granular materials allows the numerical solution
of the dynamics. Discrete Element Methods (DEM) such as
Molecular Dynamics (MD) \cite{cundall89,luding04,oda97} and
Contact Dynamics (CD) \cite{radjai96,moreau94} have been in fact often successfully applied to the investigation of the elasto-plastic behavior of granular matter. Specially interesting from the physical point of view, is how the contact modelization affects the overall response \cite{coste04,farkas02}. Recent MD results have shown the key role that sliding plays on the plastic deformation of a granular packing subjected to cyclic loading, and the existence of a range of values of the excitations for which a simple visco-elastic model of disks subjected to cyclic loading attains shakedown \cite{alonso04, garcia-rojo04}. Beyond the shakedown limit, two other possible responses have also been identified;
For very high loads, the material accumulates deformations at a relatively
high constant rate, leading to an incremental collapse of the structure.
For moderate loading intensities, the system undergoes an adaptation
process in which the accumulation of deformation gradually decreases to
a very low constant value. This
post-compaction is associated to a relaxation of the dissipated energy per
cycle, that progressively decreases to a constant value dependent on the
imposed loading. In this final stage, there is a small but persistent
accumulation of permanent strain, associated to a periodic behavior of the
sliding contacts \cite{alonso04}, which is called ratcheting regime.
Due to the non-lineality and the irreversibility of the behavior, cyclic
loading is a rather complicated problem from the theoretical point of view.
Elasto-plastic and hypoplastic theories can account for the change in the
incremental stiffness during loading and unloading phases, only if basic
modifications are undertaken \cite{kolymbas99,tatsuoka03}. In the case of
elastoplasticity, the overall plastic behavior in the loading-unloading
is obtained as the result of a combination of several {\it yield surfaces}
\cite{mroz81}.
In the hypoplastic theory the {\it inter-granular strain} is introduced to take into account the dependence of the response on the deformation history~\cite{niemunis96}. Interestingly, a point of convergence of both theories has been established by the {\it bounding surface elasto-plasticity} \cite{dafalias86a}. This theory introduces a tiny elastic nucleus changing with the deformation, and describe the hysteresis by means of internal variables taking into account the evolution of the microstructure. The characterization of such internal variables has been traditionally done using structure tensors, measuring the fabric properties of the contact network \cite{thornton86}. There is numerical evidence that a single fabric tensor, measuring the anisotropy of the contact network can be used to characterize the resilient response \cite{cowin85}. But the description of the plastic deformation requires to take into account the inherent decomposition of the contact network in sliding and non-sliding contacts \cite{alonso05c}. The role of kinematical modes such as sliding and rolling has been also investigated to some extent for monotonic deformation, but not for cyclic loading \cite{astrom00,cundall89,latzel03}.
The final aim of this paper is the characterization of ratcheting response of a granular packing under cyclic loading. For this purpose, three macroscopic variables will be introduced. A simple DEM model will then be used to investigate the dependence of the material response on different macroscopic and microscopic variables. From this investigation, we have found that our simple model is able to reproduce several behaviors observed in the experience, and microscopically justifies the use of popular empirical laws, like the $k- \theta$ model. The main parameters of our model and the details of the MD simulations are
presented in Section~\ref{model}.
The ratcheting regime resulting in the biaxial test is described in Sect.
\ref{ratcheting}. In Sect.~\ref{material} we decompose the
strain response in its permanent and resilient components. We continue with an analysis of hysteresis in the plastic response, establishing in Sect.~\ref{hysteresis}, a direct relation between the particular shape of the stress-strain cycle and the dissipated energy per cycle. From this relationship it will be easy to explain the observed dependence of the dissipated energy per cycle on the deviatoric stress. Results on
the permanent strain and the resilient parameters are presented for the
different cases studied in Secs. \ref{plastic} \& \ref{resilient}. The approach proposed here is basically empirical.
The resilient parameters will be therefore conveniently defined in terms of the recoverable deformation, as is usually done by experimentalists
\cite{lekarpb00}. The dependence on the imposed stress is investigated, and
the results are compared to predictions of resilient response models
\cite{hicks71, allen74, uzan85, tam88}. The influence of the friction and the stiffness at the contacts, main micro-mechanical parameters of the model, will also be determined. We finish in Section \ref{discussion} with a discussion of the main conclusions of this work.
\section{model}
\label{model}
In our visco-elastic 2D model, the grains are modeled by soft disks. The
deformation that two grains suffer during the interaction is reproduced by
letting the disks overlap. During the overlapping, a certain force $f^c$ is exerted at the contact point. This force can be decomposed in the following parts:
\begin{equation}
\vec{f}^c=\vec{f}^e+\vec{f}^v,
\label{eq:contact force}
\end{equation}
\noindent
where $\vec{f}^e$ and $\vec{f}^v$ are the elastic and viscous
contribution. The elastic part of the contact force is also decomposed
as
\begin{equation}
\vec{f^e}= f^e_n \hat{n}^c + f^e_t \hat{t}^c.
\label{eq:elastic force}
\end{equation}
\noindent
The unit normal vector $\hat{n}^c$ points in the direction of the vector
connecting the center of mass of the two disks. The tangential vector
$\hat{t}^c$ is perpendicular to $\hat{n}^c$.
The normal elastic force is calculated as
\begin{equation}
f^e_n= -k_n A/L_c,
\label{eq:normal force}
\end{equation}
\noindent
where $k_n$ is the normal stiffness, $A$ is the overlapping area and
$L_c$ is a characteristic length of the contact.
Our choice is $L_c=R_i+R_j$. This normalization is necessary to
be consistent in the units of force.
The frictional force is calculated using an extension of the method
proposed by Cundall-Strack \cite{cundall79}. An elastic force
proportional to the elastic displacement is included at each contact
\begin{equation}
f^e_t= -k_t \Delta x^e_t,
\label{eq:tangential force}
\end{equation}
\noindent
where $k_t$ is the tangential stiffness. The elastic displacement
$\Delta x_t $ is calculated as the time
integral of the tangential velocity of the contact during the
time where the elastic condition $|f^e_t|<\mu f^e_n$ is satisfied.
The sliding condition is imposed, keeping this force constant when
$|f^e_t|=\mu f^e_n$. The straightforward calculation of this elastic
displacement is given by the time integral starting at the beginning
of the contact:
\begin{equation}
\Delta x^e_t=\int_{0}^{t}v^c_t(t')\Theta(\mu f^e_n-|f^e_t|)dt',
\label{friction}
\end{equation}
\noindent
where $\Theta$ is the Heaviside step function and $\vec{v}^c_t$
denotes the tangential component of the relative velocity $\vec{v}^c$
at the contact:
\begin{equation}
\vec{v}^c=\vec{v}_{i}-\vec{v}_{j}+\vec{\omega}_{i}\times\vec{R}_{i}
-\vec{\omega}_{j}\times\vec{R}_{j}.
\end{equation}
\noindent
Here $\vec{v}_i$ is the velocity and $\vec{\omega}_i$ is the
angular velocity of the particles in contact. The branch vector
$\vec{R}_i$ connects the center of mass of particle $i$ to
the point of application of the contact force. Replacing Eqs.
(\ref{eq:normal force}) and (\ref{eq:tangential force}) into
(\ref{eq:elastic force}) one obtains:
\begin{equation}
\vec{f^e}= - k_n \frac{A}{L_c} \hat{n}^c - k_t \Delta x^e_t \hat{t}^c.
\label{eq:elastic force2}
\end{equation}
Damping forces are included in order to allow rapid relaxation
during the preparation of the sample, and to reduce the acoustic
waves produced during the loading. These forces are calculated as
\begin{equation}
\vec{f}^v = -m(\gamma_n v^c_n \hat{n}^c + \gamma_t v^c_t \hat{t}^c),
\label{eq:viscous force}
\end{equation}
\noindent
being $m=(1/m_i+1/m_j)^{-1}$ the effective mass of the disks
in contact. $\hat{n}^c$ and $\hat{t}^c$ are the normal and tangential
unit vectors defined before, and $\gamma_n$ and $\gamma_t$ are the
coefficients of viscosity. These forces introduce time dependent effects
during the loading. However, these effects can be arbitrarily reduced by
increasing the loading time, as corresponds to the quasi-static approximation.
The interaction of the disks with the walls is modeled by using a simple
visco-elastic force: First, we allow the disks to penetrate the walls.
Then we include a force
\begin{equation}
\label{box}
\vec{f}^b= - \left ( k_n\delta + \gamma_b m_\alpha v^b \right ) \vec{n},
\end{equation}
\noindent
where $\delta$ is the penetration length of the disk, $\vec{n}$ is
the unit normal vector to the wall, and $v^b$ is the relative
velocity of the disk with respect to the wall.
The evolution of the position $\vec{x}_i$ and the orientation
$\varphi_i$ of the particle $i$ is governed by the equations of motion:
\begin{eqnarray}
m_i\ddot{\vec{x}}_i &=&\sum_{c}\vec{f^c_i}
+\sum_{b}\vec{f}^b_i, \nonumber\\
I_i\ddot{\varphi}_{i} &=&\sum_{c}\vec{R}^c_i\times\vec{f^c_i}
+\sum_{b}\vec{R}^b_i\times\vec{f}^b_i.
\label{eq:newton}
\end{eqnarray}
Here $m_i$ and $I_i$ are the mass and moment of inertia of the disk.
The first sum goes over all those particles in contact with this particle;
the second one over all the forces given by the walls.
The interparticle contact forces $\vec{f^c}$ are given
by replacing Eqs. (\ref{eq:elastic force2}) and (\ref{eq:viscous force}) in
Eq. (\ref{eq:contact force}).
We use a fifth-order Gear predictor-corrector method for solving
the equation of motion \cite{allen87a}. This algorithm consists of
three steps. The first step predicts position and velocity of
the particles by means of a Taylor expansion. The second step
calculates the forces as a function of the predicted positions
and velocities. The third step corrects the positions and
velocities in order to optimize the stability of the algorithm.
This method is much more efficient than the simple Euler approach
or the Runge-Kutta method, especially for cyclic loading, where very high
accuracy is required.
The relevant contact parameters of this model are the normal stiffness at the contacts $k_n$, the ratio of tangential and normal stiffness
$k_t/k_n$, the normal and tangential damping frequencies and the friction
coefficient. In the quasi-static approximation, the results are independent
of the frequency of the cyclic loading. The system is polydisperse, being the radii
of the grains Gaussian distributed with mean value of $1.0cm$ and variance
of $0.36$.
\section{Onset of granular ratcheting}
\label{ratcheting}
In a biaxial experiment, the sample is subjected to a certain stress state
characterized by the principal stresses $\sigma_1$ and $\sigma_2$.
In this case the stress space is therefore a plane,
since the third component is zero, $\sigma_3 \equiv 0$.
In our simulations, the system is first homogeneously compressed with
$\sigma_1=\sigma_2$. After an equilibrium state under the pressure
$P_0=\frac{\sigma_1+\sigma_2}{2}=\sigma_1$ has been
reached, the vertical stress is quasi-statically changed:
\begin{equation}
\sigma_2(t) = P_0 \left[ 1 + \frac{\Delta \sigma}{2} \left( 1- \cos \left(
\frac{2 \pi t}{t_0} \right) \right) \right],
\end{equation}
where $t$ is the simulation time and $t_0$ is the period of the loading. Note that $\Delta \sigma$, introduced in the last equation, is the maximum deviatoric stress measured in units of $P_0$. In our approximation, it fully characterizes the intensity of the cyclic load imposed on the walls.
Deformation appears in the sample due to the imposed
excitations. The strain is the magnitude that characterizes the
accumulation of permanent deformation in the sample. Among the different
practical definitions of strain available
\cite{desai84}, we have chosen here Cauchy's
definition, which is basically the ratio of the new and the original
length of the system. Let $L^i_0$ be the original
length of the sample in the principal direction $i$ ($i={x,y}$). The
principal component of the strain tensor $\epsilon_{ij}$ on this direction
will then be:
\begin{equation}
\epsilon_i (t)\equiv \epsilon_{ii}(t) =\frac{L_i (t)-L^i_0}{L^i_0},
\label{eq:defstrain}
\end{equation}
where $L_i$ is the length of the system in the principal direction $i$ at the
moment of the measurement.
Different loading intensities will be exerted on the sample by changing the
value of $\Delta \sigma$. The reaction of the system will be characterized by
the deviatoric permanent strain, $\gamma$, that is the
difference between the strains in the principal directions:
\begin{equation}
\gamma=\epsilon_2-\epsilon_1.
\label{eq:gamma}
\end{equation}
\begin{figure} [t]
\begin{center}
\epsfig{file=FIGURES/shear.eps,width=1.0\linewidth}
\caption{Typical stress-strain relation during cyclic loading. In the
long-time behavior the response is given by a limit hysteresis loop. This
is shown by the dashed line ( the loop here corresponds to $N=1000$). In this simulation $\Delta \sigma = 0.14 P_0$ and $P_0=10^{-4} k_n$, where the normal contact stiffness is $k_n= 2 \cdot 10^6 N/m$. The damping constants are defined in terms of the
characteristic oscillation period $t_s=\sqrt{k_n/\rho \lambda^2}$ (in our case $t_s=0.1414$), where $\rho$ is the density of the grains and $\lambda$ the mean radius of the disks composing the sample. The period of oscillation was taken long enough ($t_0=10^5 t_s$), to be sure that we are in the quasi-static limit).}
\label{fig:shear}
\end{center}
\end{figure}
The typical evolution of the permanent strain during the cyclic
loading is shown in Fig. \ref{fig:shear}. The stress-strain relation
consists of hysteresis loops. This hysteresis produces an accumulation of
deviatoric strain with the number of cycles in addition to a progressive
compaction, which is not shown there. After some decades of cycles,
the accumulation of permanent deformation becomes linear, as shown in
Fig. \ref{fig:ratcheting}. This strain rate remains constant for very large
number of cycles, even when the volume ratio is very close to the saturation
level.
A micro-mechanical explanation of this linear accumulation of strain
is provided by following the dynamics of the contact network.
Although most of the contact forces of this network satisfy the elastic
condition $|f_t| < \mu f_n$, the strong heterogeneities produce a
considerable amount of contacts reaching the sliding condition
$|f_t| = \mu f_n$ during the compression. After a number of loading
cycles, the contact network reaches a quasi-periodic behavior. In this
regime, a fraction of the contacts reaches almost periodically the sliding
condition, as shown in the inset of Fig. \ref{fig:ratcheting}. In each load-unload transition there is an abrupt reduction of sliding contacts, which induces the typical discontinuity of the stiffness upon reversal of the loading. The load-unload asymmetry at each sliding contact makes it to slip the same amount and in the same direction during each loading cycle, leading to an overall ratcheting response.
The contact behavior can be observed by embedding two
points at each particle near to the contact area, and following their translation during each cycle. Their relative displacements are calculated as $\vec s^{i} = \vec s_0 - \vec s_{rb}$, where $\vec s_0$ is the displacement of
the embedded point $i$ and $\vec s_{rd}$ is the rigid body motion. This latter
is given by the vector connecting the initial to the final position of
the contact point. Note that $\vec s = 0$ when the two particles move as a
rigid body.
Figure \ref{fig:cosserat} shows the displacement at the contacts during cycle $N=1000$. Simulations show that, in this regime, this displacement field is almost constant after each cycle. There are two deformation modes resembling the mechanical ratchets:
(i) At the sliding contacts the displacement vectors do not agree, so that
there is a systematic slip during each cycle which also leads to a
constant frictional dissipation per cycle.
(ii) At the non-sliding contacts the displacement vectors are almost the same for the two particles.
\begin{figure} [b]
\begin{center}
\epsfig{file=FIGURES/rojito_ratcheting.eps,width=1.0\linewidth}
\caption{Cumulative permanent deformation against the number of
cycles (N). After the post-compaction regime the system accumulates permanent strain at a constant strain-rate. This is the so-called ratcheting regime,
which emerges as a result of the periodicity of the sliding contacts.
The inset precisely shows the fraction of the sliding contact versus time in this state.}
\label{fig:ratcheting}
\end{center}
\end{figure}
Note from Fig.~\ref{fig:cosserat} that the distribution of this ratchets
are not uniform, but they are localized in layers resembling shear bands. This kind of strain localization with intense rolling is typical in sheared granular materials \cite{vardoulakis95,astrom00}. Fundamental differences are however observed between the cyclic loading response and the behavior under monotonic shear: The translation of each particle during the ratcheting regime is given by an almost constant displacement per cycle. On the other hand, the displacement of the particle during monotonic shear is rather chaotic, well described by an anomalous diffusion \cite{radjai02}.
Such systematic translation per cycle of the individual grains in the ratcheting regime has a strong spatial correlation. This is shown in the displacement field of Fig. ~\ref{fig:disfield}. The most salient feature here is the formation of vorticity cells, where a cluster of particles rotates as a whole. These vorticities survive during several hundred of cycles. This is contrary to the case of the simple shear, where the vorticities have a very short life-time ~\cite{radjai02}. It is interesting to see from Figures ~\ref{fig:cosserat} and ~\ref{fig:disfield} the kinematic phase separation of the grains: (a) Grains organized in large vorticity cells, and (b) grains which accommodate the cells to make them more compatible with the imposed boundary conditions. Since such kinematical modes are linked with the a non-vanishing antisymmetric part of the displacement gradient, the strain tensor is not sufficient to provide a complete description of this convective motion during cyclic loading. An appropriate continuum description of ratcheting would require additional continuum variables taking into account the vorticity and the gearing between the contacts. As in the case of the shear band formation, the Cosserat theory may be a good alternative \cite{vardoulakis89}
\begin{figure} [t]
\begin{center}
\epsfig{file=FIGURES/cosserat.eps,width=1.0\linewidth}
\caption{Displacement at the contacts during one cycle in the ratcheting. The arrows are proportional to the displacements $s$ of the two material points at the contacts referred to the contact point. More details are found in the text. The figure is a snapshot of the simulation of Figure \ref{fig:shear} for $N=1000$.}
\label{fig:cosserat}
\end{center}
\end{figure}
\begin{figure} [htt]
\begin{center}
\epsfig{file=FIGURES/disfield.eps,width=1.0\linewidth}
\caption{Vortex formation as a consequence of the ratcheting of the particles. The arrows are proportional to the displacement of the particle after one cycle in the ratcheting regime. They are plotted at the center of the disks. The cycle is the same as the one shown in Figure \ref{fig:cosserat}.}
\label{fig:disfield}
\end{center}
\end{figure}
\section{Material response to cyclic loading}
\label{material}
The existence of an elastic region in the deformation of granular
materials implies that there is a finite region in the space of stress-states around the origin, in which the system reacts reversibly. Experiments and simulations show, however, that there is not such pure elastic behavior in a granular sample. Note, that this is not in contradiction with the existence of shakedown: A granular system may not accumulate any systematic
permanent deformation after one loading cycle, but will always dissipate some
energy because grain interactions are inherently inelastic. This is possible
thanks to the additional energy supplied to the system by the external
loading. In the particular case of our model, the system reaches a
visco-elastic shakedown. In this limit state, the system dissipates some energy in each cycle and the overall behavior is not elastic, but the stress-strain cycle is still hysteretic (see Figure $\ref{fig:cycle}$). Therefore we differentiate in cyclic loading between an elastic and a resilient deformation of the sample. The latter implying that no permanent deformation has been accumulated after one cycle, while the first also implies the total absence of hysteresis or memory effects in the response.
It has been recently shown that there is a broad range of values of $\Delta \sigma$ for which a granular packing reacts to the imposed cyclic
excitations by slowly deforming in a ratcheting regime
\cite{alonso04,garcia-rojo04}.
This is a quasi-periodic state, macroscopically characterized by a constant
strain rate and a conservation
of the shape of the stress-strain cycle (see Figure $\ref{fig:shear}$). At
the beginning of the loading process, the system suffers a re-arrangement of
the sliding contacts, after which they start to behave periodically within
the loading cycles. This {\it post-compaction} process is associated to a relaxation of the strain rate and also of the dissipated energy per cycle towards a
constant value \cite{garcia-rojo04}. This stationary value of the strain
rate fully determines the macroscopic plastic response of the system in the ratcheting regime. At any stage of the experiment, the strain can therefore be decomposed in two well differentiated components. The irreversible plastic strain accumulated after the
end of the current cycle $\gamma_P$, and the recoverable resilient strain, $\gamma_R$, accumulated along the cycle. In the ratcheting regime, the strain rate ($\Delta \gamma/ \Delta N$) is approximately constant, while the latter deformation is well characterized by the resilient parameters: resilient modulus, $M_R$ and the Poisson ratio $\zeta$. The first parameter, as it appears in Figure $\ref{fig:cycle}$, is the ratio of the maximum deviatoric stress and the corresponding deviatoric resilient strain:
\begin{equation}
M_R=\frac{\Delta \sigma}{\gamma_R},
\label{eq:MR}
\end{equation}
and quantifies the overall stiffness of the material. The Poisson ratio, correspondingly, is the ratio of the horizontal ($\epsilon^R_1$) and axial ($\epsilon^R_2$) resilient strains:
\begin{equation}
\zeta=- \frac{\epsilon^R_1}{\epsilon^R_2}.
\end{equation}
It is a measure for the isotropy of the deformation. The definition of
$\epsilon^R_1$ and $\epsilon^R_2$ is similar to that in Eq.
($\ref{eq:defstrain}$). They are both measured at the final stage of the
loading, just before unloading starts. Similarly to Eq. ($\ref{eq:gamma}$), the resilient deviatoric strain is defined in terms of the resilient strains as
$\gamma^R=\epsilon_2^R-\epsilon_1^R$.
\begin{figure} [ht]
\begin{center}
\psfig{file=FIGURES/cycles.eps,width=1.0\linewidth}
\caption{Sketch of the typical material reaction to cyclic loading in
the granular ratcheting. After a post-compaction stage, the system accumulates permanent strain, $\gamma_P$, at a constant strain-rate $\Delta \gamma / \Delta N$. The resilient modulus $M_R$ is also indicated, as defined in Eq. ($\ref{eq:MR}$).}
\label{fig:cycle}
\end{center}
\end{figure}
\begin{figure} [ht]
\begin{tabular}{cc}
\psfig{file=FIGURES/figure45a.eps,width=\linewidth,angle=0}\\
\psfig{file=FIGURES/figure45b.eps,width=\linewidth,angle=0}
\end{tabular}
\caption{Evolution of the resilient parameters with the number of
cycles: Resilient modulus $M_R$ (top) and Poisson ratio $\zeta$ (bottom). The curves show the measures of these magnitudes for different values of the deviatoric stress $\Delta \sigma$. The data in the figure correspond to the simulation of a system with friction coefficient $\mu=0.1$, normal stiffness $k_n=2 \cdot 10^6 N/m$, normal damping $1/\gamma_n=4 \cdot 10^2 t_s$, and tangential damping $1/\gamma_t=8 \cdot 10^1 t_s$. The confining pressure is $P_0= 6 \cdot 10^{-4} k_n$.}
\label{fig:N}
\end{figure}
As a consequence of the quasi-static change of the stresses, all the relevant time dependence occurs in the system through the number of cycles $N$. Figure $\ref{fig:N}$ shows the evolution of the resilient parameters from
the simulations for different deviatoric stresses. For low excitations, the
curves have already reached a {\it plateau} after a couple of cycles,
implying that the values of $\zeta$ and $M_R$ do not apparently change as
the number of cycles increases. In the initial post-compaction stage, the
system accumulates more deviatoric strain in the horizontal direction (perpendicular to the direction on which the cyclic load is applied), than it does in the final stage. This explains why Poisson ratio decreases slightly in the first cycles. The resilient modulus increases, however, implying a higher stiffness of the system after the post-compaction. Although the dependence of the final values on the imposed loading will be discussed in a latter section of this paper, it should now be remarked that the number of cycles needed for the system to reach a steady resilient response increases as the imposed deviatoric stress is increased. This is clearly observed in case $\Delta \sigma =0.35$ of the figure, where even after $N=1000$ cycles, neither $\zeta$ nor $M_R$ have reached a stationary value.
The peculiar behavior of the system in the ratcheting regime allows for the
characterization of the deformation state of the system through the strain rate and the resilient parameters. It is therefore crucial to know the influence of the confining pressure and the deviatoric stress on these parameters. For a complete review on the macroscopic factors affecting the resilient response of a granular material and some of the models proposed to account for it, we recommend references \cite{lekarpb00} and \cite{taciroglu02}.
To our knowledge, no systematic study has been carried out up to now elucidating the effect of the microscopic parameters of the system on the material reaction to cyclic loading, although they play an important role \cite{combe02, combe00}. Combe et al. have identified contact stiffness and friction as the relevant microscopic parameters in this limit. Inter-granular friction, in particular, appears then to be the dominating dissipative mechanism. The influence of contact stiffness and friction on the plastic behavior of a granular packing undergoing ratcheting will be also investigated in the following sections.
\section{Hysteretical behavior}
\label{hysteresis}
History dependence is one of the most essential features of granular soils. In our simple model, we have shown the existence of hysteresis both in the shakedown and in the ratcheting regime. This has forced us to identify two different components to the total strain, namely the permanent and the resilient strain. In any stress cycle, the sliding contacts behave differently in the loading and un-loading phase, leading to a different stiffness of the material in each of these phases. In this section, we are interested in the shape of the cycles and, more specifically,
in its relationship with the evolution of the area closed by the strain-stress loop. If we assumed that the deformation in both spatial directions is approximately the same, this area is the dissipated energy within the cycle. This energy relaxes during the {\it post compaction} from an initial high value to a constant value \cite{garcia-rojo04}, reflecting the similarity of the hysteresis loops in the ratcheting regime (see Figure ~\ref{fig:shear}). This final value is plotted in Figure ~\ref{fig:energy} for different deviatoric stress. A clear power law behavior is observed in a wide range of values above the shakedown regime.
For the purposes that will be seen next, let us introduce the following variables:
\begin{eqnarray}
\gamma^*=\gamma_0+\frac{\gamma_R}{2}-\gamma,\\
q^*=\frac{\Delta \sigma}{2}-\frac{\sigma_2-\sigma_1}{P_0}.
\end{eqnarray}
Being $\gamma_0$ the permanent strain accumulated up to the end of the previous cycle we are interested in.
We express in Figure ~\ref{fig:banana} the limit cycle on Figure ~\ref{fig:shear} on these new variables. The best-fit curve to the points in the loading and unloading are also included. These curves can be expressed, using the scaled variables:
\begin{equation}
\gamma^*_L = \frac{1}{M_R} q^* + B_L \left ( \left (\frac{\Delta \sigma}{2} \right )^2 - {q^*}^2 \right ),
\label{eq:fit2}
\end{equation}
in the loading. And
\begin{equation}
\gamma^*_U = \frac{1}{M_R} q^* - B_U \left ( \left (\frac{\Delta \sigma}{2} \right ) ^2 - {q^*}^2 \right ),
\label{eq:fit1}
\end{equation}
in the unloading phase. $B_L$ and $B_U$ are positive constants dependent on the confining pressure, but independent on the maximum deviatoric stress ($\Delta \sigma$). Note the use of the resilient parameter $M_R$ in the previous expressions. From these formulas, it is then trivial to find the area of the cycle ($A_H$):
\begin{eqnarray}
A_H= \oint \frac{\sigma_2-\sigma_1}{P_0} d\gamma = \oint \gamma^* dq^* ~~~~~~~~~~~~~~~~~~~ \\ = \int_{-\Delta \sigma / 2}^{\Delta \sigma /2} \left ( \gamma^*_L - \gamma^*_U \right) d q^* = ~~~~~~~~~~~~~~~~~~~~\nonumber \\
(B_L+B_U) \left [ \left ( \frac{\Delta \sigma}{2} \right ) ^2 - \frac{\Delta \sigma}{3} \right ]_{-\Delta \sigma /2}^{\Delta \sigma /2} = \frac{ 5 (B_L+B_U)}{24} \Delta \sigma^3. \nonumber
\end{eqnarray}
Due to our definition of $q^*$ and $\gamma^*$, the area $A_H$ is in fact the same as the area enclosed by the stress-strain cycle in Figure \ref{fig:shear}. Our simple calculation explains why, given the nature of the stress-strain cycles obtained in our model, the power law behavior on Figure ~\ref{fig:energy} should be expected. The explanation shown here somehow resembles the Rayleigh law for magnetization of ferromagnetic materials under low inductions
\cite{zapperi02}. Also in this case, the hysteresis energy loss
(the area of the induction versus magnetization loop) behaves like
the cube of the induction. This power law in ferromagnetic materials
results from the quadratic dependence of the magnetic field on the
magnetization. This is analogous to Eqs. (~\ref{eq:fit1}) and (~\ref{eq:fit2}) except for the fact that $B_L \ne B_U $, which reflects the asymmetry of the
loops in the granular ratcheting regime. It is interesting to observe
that the power law is identical to the one found for the dependence of
the strain-rate on the deviatoric strain, as shown in the previous
section. In fact, the closed-loop approximation given by
Eqs. (~\ref{eq:fit1}) and (~\ref{eq:fit2}) is not strictly valid in the limit $q^* \rightarrow 0$. The error of this quadratic approximation is of the order of $\mathcal{O} ( \sigma^3) $, and must be related to the cubic dependence of the strain accumulation on the load amplitude. A micro-mechanical explanation of this Rayleigh-like law in granular ratcheting is still an open issue.
\begin{figure} [ht]
\psfig{file=FIGURES/energy.eps,width=1.0\linewidth,angle=0}
\caption{Variation of the area enclosed by the stress-strain cycle $A_H$, for different values of $\Delta \sigma$. The area is scaled with the confining pressure. The dashed line shows the power law $y \propto x^{3}$. The data in the figure correspond to the simulation of a system with friction coefficient $\mu=0.1$, normal stiffness $k_n=1.6 \cdot10^6 N/m$, tangential stiffness $k_t=0.33 k_n$, and normal damping $1/\gamma_n=4 \cdot 10^3 t_s$. The confining pressure is $P_0=6 \cdot 10^{-3} k_n$ and the damping coefficient $\gamma_t=8 t_s$. }
\label{fig:energy}
\end{figure}
\begin{figure} [ht]
\psfig{file=FIGURES/figure52.eps,width=.7\linewidth,angle=-90}
\caption{Hysteresis stress-strain loop in the new variables $ \gamma^*$ and $q^*$. The solid points are the result of the simulation shown in Figure ~\ref{fig:shear} ($N=1000$). The solid lines are the best-fit to the expressions (~\ref{eq:fit1}) and (~\ref{eq:fit2}). The values of the constants for the theoretical lines are $B_L= 0.04543$, and $B_U=0.05554$. }
\label{fig:banana}
\end{figure}
In the ratcheting regime the factors follow $B_U > B_L$. It is still to be determined which precise effect has the behavior of the sliding contacts on this observation. A better understanding of the nature of these constants and their dependencies on the model parameters will help to gain insight into the overall plastic response of the material.
\section{Permanent strain accumulation}
\label{plastic}
The influence of macro-mechanical magnitudes and the microscopic parameters of the model on the accumulation of permanent strain will be shown in this section. This will be done by measuring the strain rate in simulations were the confining pressure, the deviatoric stress, the friction coefficient or the stiffness of the contacts are changed, while the rest of the parameters are kept fixed.
\subsection{Influence of the confining pressure and deviatoric stress}
Among all the possible parameters affecting the plastic behavior of a granular sample, the dependence on the confining pressure and on the deviatoric
stress are known to be the most relevant ones \cite{lekarp00}. Since $P_0$ is measured in units of the normal stiffness, $P_0= \hat{P_0} k_n$, in our simple model, there are two equivalent ways of studying the effect of the confining pressure: On the one hand, the normal stiffness of the contact can be changed while maintaining the ratio $k_t/k_n$ constant. On the other hand, the effective pressure $\hat{P_0}$ can be increased. In order to investigate the importance of the stress history of the sample, both methods have been used and the results are shown on Figure $\ref{fig:p0-s}$.(a). In each of the simulations, the system was first homogeneously compressed, and then subjected to cyclic loading. A power law relating the change of strain per cycle, $\Delta \gamma / \Delta N$, to $P_0/k_n$ in a wide range of values is found in our simulations. The best fit of the points leads to the linear behavior:
\begin{equation}
\frac{\Delta \gamma}{\Delta N} \propto \frac{P_0}{k_n}.
\label{eq:emplaw}
\end{equation}
Dispersion of the data with respect to the empirical law in Eq. (~\ref{eq:emplaw}), is a direct consequence of the dependence of the final strain rate on the preparation of the material. Different confining pressures imply a different post-compaction process \cite{garcia-rojo04} and therefore a different density of the sample before cyclic loading. The range of densities involved in Figure $\ref{fig:p0-s}$.(a) goes from solid fractions $\Phi = 0.82$ to $\Phi=0.9$. Our results show, in fact, that the strain-rate seems to be much more sensitive to changes in the density than the resilient parameters. This makes the investigation of the strain accumulation more difficult, limiting also the accuracy of our results on the relationship between the basic parameters of the system and the strain-rate.
\begin{figure} [ht]
\begin{tabular}{cc}
\psfig{file=FIGURES/figure43c.eps,width=1.0\linewidth} \\
\psfig{file=FIGURES/figure37c.eps,width=1.0\linewidth}
\end{tabular}
\caption{Strain-rate dependence on the confining pressure, $P_0$, and the
deviatoric stress $\Delta \sigma$. The solid line represents the best-fit
power law. The simulation details are those of Figure ~\ref{fig:energy}. Data on the top graph correspond to $\Delta
\sigma=0.2$ and tangential damping $1/\gamma_t=8 \cdot 10^2 t_s$. Solid
circles were obtained keeping $k_n$ constant and varying $\hat{P_0}$. The
open circles, on the contrary, are the result of a series of simulations
in which $k_n$ was changed. The solid line on this graph shows a linear behavior. Data for the plot on the bottom correspond to $P_0=6 \cdot
10^{-3} k_n$ and $\gamma_t=8 t_s$. The solid line represents the power
law $y \propto x^{3}$. This is close to the power law fitting in
polygonal packing, whose exponent lies between $2.7$ and $2.9$ \cite{alonso04}.}
\label{fig:p0-s}
\end{figure}
This history dependence of the material is not observed in part (b) of
Figure $\ref{fig:p0-s}$, where the strain-rate accumulation is plotted versus
the deviatoric stress for the same initial configuration of disks with solid
fraction $\Phi=0.85$. The measures indicate a clear potential dependence of
the strain-rate with $\Delta \sigma$. Also an exponential behavior (with exponent $m=2.8 \pm 0.1$) has been reported in a polygonal packing \cite{alonso04}.
\subsection{Influence of the micro-mechanical parameters}
The strain-rate behavior as friction changes is slightly more
complicated, if compared to the other parameters studied. For very low friction, no ratcheting is observed in the sample. Above a certain value of $\mu$,
however, a systematic ratcheting effect can be found. For the parameters used in the simulation shown in Figure ~\ref{fig:friction-s}, this limit value is $\mu=0.05$. The strain-rate is maximal at this friction, and (as observed in the figure) the strain-rate decreases from this point, as friction is increased. The explicit dependence on the friction coefficient follows the power law:
\begin{equation}
\frac{\Delta \gamma}{\Delta N} \propto ( \mu )^{-2. \pm 0.05}.
\end{equation}
\begin{figure}
\begin{center}
\psfig{file=FIGURES/figure48c.eps,width=1.0\linewidth,angle=0}
\caption{Dependence of the strain rate on the friction coefficient $\mu$. The data in the figure correspond to the simulation of a system normal stiffness $k_n=1.6 \cdot 10^6 N/m$, tangential stiffness $k_t=0.33 k_n$, normal damping $1/\gamma_n=4 \cdot 10^3 t_s$, and tangential damping $1/\gamma_t=8 t_s$. The stress conditions are $P_0= 10^{-3} \cdot k_n$ and $\Delta \sigma =0.1$. The solid fraction of the initial condition is $\Phi=0.93$. The solid line shows the law $y = x^{-2}$.}
\label{fig:friction-s}
\end{center}
\end{figure}
Figure $\ref{fig:em-s}$ shows the variation of the permanent strain
accumulation rate with the stiffness ratio for different samples prepared
with the same confining pressure $P_0$ and normal stiffness $k_n$. A power law
behavior with a negative exponent is found. The best fit of the points of the
figure gives:
\begin{equation}
\frac{\Delta \gamma}{\Delta N} \propto \left (\frac{k_t}{k_n} \right )^{-0.3},
\end{equation}
indicating that stronger tangential forces produce a higher rate of the deformation.
\begin{figure} [ht]
\begin{center}
\psfig{file=FIGURES/figure47c.eps,width=1.0\linewidth,angle=0}
\end{center}
\caption{Dependence of the strain-rate on the stiffness ratio
$k_t/k_n$. Data correspond to the simulation of a system with normal
damping $1/\gamma_n=4 \cdot 10^3 t_s$, and tangential damping
$1/\gamma_t=8 \cdot 10^2 t_s$, solid fraction $\Phi=0.845 \pm 0.005$, and
friction coefficient $\mu=0.1$. The stress conditions are kept constant,
$P_0=10^{-3} \cdot k_n $ and $\Delta \sigma =0.2$. The solid line represents the power law $y \propto x^{-0.3}$.} \label{fig:em-s}
\end{figure}
An interpretation of these power law relation could be done by exploring
the statistical distribution of the contact forces and its evolution during
the loading stage. An important parameter is the mobilized angle $\alpha = |f_t|/f_n $, which is bounded by the sliding condition $\alpha=\mu$. The statistical distribution of this variable is rather constant except for a peak at $\mu$ given by the sliding condition. The value of this peak depends on the friction coefficient. For small values of $\mu$ a large number of contacts can reach the sliding condition so that the ratcheting response is expected to be large. For big values of $\mu$ only a few number of contacts can reach the sliding conditions, which produces a small ratcheting response. A quantitative explanation for the power law dependence will require to calculate the evolution of the statistics of the sliding contacts and the contribution of the sliding to the global dissipation, but this is beyond the scope of this work.
\section{Resilient response}
\label{resilient}
Most theoretical models for the resilient response are based on curve fitting
procedures, using data from biaxial or triaxial tests. One of the most
popular and earlier models is the so-called $k-\theta$ model \cite{hicks71},
in which the resilient modulus is supposed to depend only on the mean stress
$\theta$:
\begin{equation}
M_r(\theta)=k \left ( \frac{\theta}{\eta} \right)^n,
\label{eq:kteta}
\end{equation}
where $k$ and $n$ are material constants, $\eta$ is a universal constant in
units of stress (included for normalization), and $\theta$ is the absolute
value of the first invariant of the stress tensor:
\begin{equation}
\theta \equiv | tr( \hat{\sigma})|.
\end{equation}
Many alternatives to and modifications of this model have been introduced, which are extensively used in practice \cite{hjelmstad00,nataatmadja01,lekarpb00}. One of the main restrictions of the $k-\theta$ model
is the assumption of a constant Poisson ratio. Several studies have shown
that the Poisson ratio is not a constant in the granular case, but varies with the applied stresses \cite{allen74}. Another drawback of the model is that the effect of the deviatoric stresses on the resilient modulus is neglected.
A straightforward modification of the $k-\theta$ model accounting for this latter restriction reads \cite{uzan85}:
\begin{equation}
M_r(\theta,\Delta \sigma)=k \left ( \frac{\theta}{\eta} \right)^n \left (
\frac{\Delta \sigma}{\eta} \right)^m.
\label{eq:kteta2}
\end{equation}
Note that, with respect to equation ($\ref{eq:kteta}$), a new material
constant $m$ has been introduced. In the simplest approximation both exponents
are assumed identical $n \equiv m$ \cite{tam88}.
The validity of the $k-\theta$ model will be checked in this section. Note
that, in the case of cyclic loading, given a fixed $\Delta \sigma$, the
dependence of the resilient modulus on $\theta$ is similar to its dependence
on $P_0$. Results will be shown on the influence of the confining stress and
deviatoric stress on the resilient modulus and Poisson ratio. In the latter case, it will be particularly interesting to investigate the limit of
validity of the common assumption of a constant
Poisson ratio for granular matter.
\subsection{Influence of the confining pressure}
\begin{figure} [ht]
\begin{tabular}{cc}
\psfig{file=FIGURES/figure43a.eps,width=1.0\linewidth,angle=0}\\
\psfig{file=FIGURES/figure43b.eps,width=1.0\linewidth,angle=0}
\end{tabular}
\caption{Variation of the resilient parameters with the confining
pressure $P_0$: resilient modulus $M_R$ (top) and Poisson ratio $\zeta$ (bottom). The conditions of the simulation are the same as in Fig. $\ref{fig:p0-s}$. The line in the left plot is the best fit to the $k-\theta$ model. The
solid line in the right figure is the value $\zeta=0.35$, estimation for the
Poisson ratio of granular materials. The different symbols refer to two
different methods explained in the text to study the influence of the
confining pressure on the system.}
\label{fig:p0}
\end{figure}
Figure $\ref{fig:p0}$ indicates that the $k-\theta$ model is in fact a very good approximation in the ratcheting regime for a wide range of pressures of
$P_0$. The best fit to the empirical law of Eq. (~\ref{eq:kteta}), gives
$n=0.34 \pm 0.02$. This value agrees well with the experimental values in
\cite{allen74}, where results on gravel show a power law with exponent
$n=0.31$.
The Poisson ratio behaves in a completely different way. For low pressures, it
decreases gradually as the pressure becomes higher. For $P_0 > 0.01 k_n$,
however, there is a change on the trend, and $\zeta$ grows fast with $P_0$. This reflects a higher anisotropy of the deviatoric strain in systems compressed
under a high pressure. Nevertheless, our results justify the use of a constant
value of $\zeta$ in a first approximation, for a wide range of $P_0$, $10^{-4}
k_n < P_0 < 10^{-2} k_n$. The most common estimate ($\zeta=0.35$), however, slightly overestimates the values obtained in most of our simulations.
\subsection{Influence of the deviatoric stress}
\begin{figure} [ht]
\begin{tabular}{cc}
\psfig{file=FIGURES/figure37a.eps,width=1.0\linewidth,angle=0}\\
\psfig{file=FIGURES/figure37b.eps,width=1.0\linewidth,angle=0}
\end{tabular}
\caption{Variation of the resilient parameters with the loading intensity
$\Delta \sigma$. The simulation details are similar to those in Figure
~\ref{fig:p0-s} but with $k_n=2 \cdot 10^6 N/m$, and $P_0=6 \cdot 10^{-4}k_n$. The
best fit curve to a second order polynomial is plotted for the values of
$M_R$ in the top graph. In the bottom (Poisson ratio),
the solid line corresponds to the value $\zeta=0.35$ and the dotted line
to the best fit to equation $y(x)=a+bx+cx^2$ (details are given in the
text).}
\label{fig:loading}
\end{figure}
Two stages are clearly distinguished in the behavior of the resilient
parameters as a function of $\Delta \sigma$. For low values of the deviatoric
stress, close to the shakedown regime, the resilient parameters remain
approximately constant. Poisson ratio, remains closer to the indicated
value $\zeta \approx 0.35$ which is the empirical fixed value usually assumed
for unbound granular matter \cite{allen74}. This value is shown in Figure
$\ref{fig:loading}$ with a solid line. For $\Delta \sigma > 0.1$, however,
$\zeta$ shows a strong dependence on the deviatoric stress $\Delta \sigma$.
A simple empirical polynomial law is proposed in reference \cite{allen74} for
the dependence of $\zeta$ on the ratio of the deviatoric and volumetric
stresses. Although the range of values studied in this experiment is larger
than the one presented here, our results confirm that the values of the Poisson
ratio follow a second order polynomial law on $\Delta \sigma$, being the
best-fit curve $\zeta = 0.336 (\pm 0.001)- 0.208 (\pm 0.001) \Delta \sigma +
3.061 (\pm 0.001) (\Delta \sigma)^2$. This curve is plotted in the lower part
of Figure $\ref{fig:loading}$.
As opposed to the behavior of Poisson ratio, the resilient modulus decreases
as $\Delta \sigma$ increases. the dependence is also polynomial. In
Figure ~\ref{fig:loading} (top), the curve $y(x)= 335.7 -316.8 x + 229.1 x^2$ is plotted. Note that this result disagrees with the simplification of the
generalized $k-\Theta$ model ($m \equiv n$) of equation
($\ref{eq:kteta2}$). The general law seems to be a better approximation in a
wide range of values of the deviatoric stress, where the system shows neither
collapse nor shakedown.
The dependence of the resilient parameters on the deviatoric
stress results from the anisotropy induced in the contact network
for large deviatoric loads. Near failure, a significant number
of contacts are open in the perpendicular direction of the load, resulting
in a decrease of the stiffness as shown in the top of Figure ~\ref{fig:loading}. The increase of the Poisson ratio in the bottom of this figure is
consequence of the formation of force chains, which enhance the anisotropy
and leads to an increase of the effective Poisson ratio. A detailed
description of the effect of these force chains in the resilient response
would require a detailed evaluation of the relation between the anisotropy of the contact network and the parameters of the anisotropic elasticity via fabric tensors \cite{luding04,alonso04c}.
\begin{figure} [ht]
\begin{tabular}{c}
\psfig{file=FIGURES/figure48a.eps,width=1.0\linewidth,angle=0}
\end{tabular}
\caption{Variation of the resilient modulus with the static friction
coefficient $\mu$. The conditions of the simulation are the same as in Fig. $\ref{fig:friction-s}$.}
\label{fig:friction}
\end{figure}
\subsection{Influence of the micro-mechanical parameters}
Figure $\ref{fig:friction}$ shows the change of the resilient modulus with friction. $M_R$ grows for small frictions. However, the curve seems to reach a saturation level for frictions $\mu \approx 0.4$.
\begin{figure} [ht]
\begin{tabular}{cc}
\psfig{file=FIGURES/figure47a.eps,width=1.0\linewidth,angle=0}\\
\psfig{file=FIGURES/figure47b.eps,width=1.0\linewidth,angle=0}
\end{tabular}
\caption{Influence of the ratio of contact stiffness $k_t/k_n$ on the resilient parameters. The details of the simulation are those of Fig. $\ref{fig:em-s}$. The solid line shows a power law with exponent $0.28$ in the top. The one at the bottom marks the value $\zeta = 0.35$.}
\label{fig:knkt}
\end{figure}
Changing the ratio of contact stiffness (Fig.~\ref{fig:knkt}), a power law dependence of $M_R$ is observed for $k_n/k_t < 0.1$, $M_R \propto \left ( \frac{k_n}{k_t} \right )^{0.28}$, being the exponent $0.28 \pm 0.03$. For stiffness ratios closer to unity $k_t/k_n \approx 1$, the resilient modulus remains approximately constant or even decreases. The Poisson ratio also appears to be constant for $k_t < 10^{-3} \cdot k_n$. Above $k_t/k_n= 0.001$, $\zeta$ decreases to values below the reference value $\zeta=0.35$. For $k_t \ge k_n$, $\zeta$ starts growing again.
\section{Discussion and final remarks}
\label{discussion}
A characterization of the material response in the
granular ratcheting has been presented in terms of the strain-rate, resilient modulus and the Poisson ratio. Studying the dependence of these parameters on the conditions of the biaxial test (stress configuration) and the main
microscopical constants of the sample (friction and contact stiffness) we
confirmed the persistence of the granular ratcheting in many
different conditions and systems.
Given a compressed sample subjected to a biaxial test in which a
cyclic loading is switched on, the system adapts to the new situation accumulating deformation and dissipating energy at a relatively high
rate. After this {\it post-compaction} stage, the dissipated energy, both
resilient moduli and the strain-rate reach stationary
values. The duration of the adaptation stage basically depends on the
deviatoric stress, and is usually shorter for the resilient moduli than
for the strain-rate \cite{garcia-rojo04}. If the deviatoric stress is small
enough, the perturbation introduced by the cyclic loading shakes down. The
material adapts to the new situation so that there is no
further accumulation of permanent strain. Above this limit the material accumulates a certain amount of strain in each cycle. If the stress is below the collapse limit, the permanent strain accumulated after each cycle is constant. This is the so-called granular ratcheting, which has been described both experimentally \cite{werkmeister01,werkmeister04} and in simulations \cite{alonso04,garcia-rojo04}.
Identical repetition of the strain-stress cycles is among the main
characteristics of the granular ratcheting. This periodicity reflects the
weak dependency of the resilient moduli on the stress history and, in the
particular case of cyclic loading, on the number of applied cycles
\cite{lekarp00}. In all the simulations, a steady and stable resilient
response is reached after some initial cycles. This kind of simple behavior is
expected as long as the applied deviatoric stress remains below the collapse
limit. Although many factors may influence the plastic response of the
system, there is a simple characterization of the deformation in the
ratcheting regime, in terms of the strain-rate and the resilient moduli.
This description takes advantage of the empirical fact that these magnitudes do not change in the ratcheting regime. We have investigated both micro-mechanical and macro-mechanical factors influencing the plastic response of the material, i.e. the dependency on the number of cycles, static friction, the confining pressure, the deviatoric stress and the stiffness.
It was shown that the use of a constant Poisson ratio is a good
approximation in most cases. It seems to be unsuitable, however, for very high confining pressures, very high deviatoric stresses, or for low values of the friction coefficient. The value for $\zeta$ estimated through our simulations would be slightly below the empirical value $0.35$, assumed in many models of the resilient response of granular materials. This might be a consequence of the simplicity of the visco-elastic model, which does not include all the mechanisms involved in a real biaxial experiment.
$M_R$ is a measure of the macroscopical stiffness of the material. Our results show that it is higher for strongly frictional materials. We also found that although preparing the sample with a higher confining pressure increases its stiffness, increasing the deviatoric stress reduces the stiffness of the packing.
Both the strain-rate and the resilient modulus $M_R$ show a power law
dependence with the confining pressure and the ratio of contact stiffness. The power law is similar for both magnitudes in the case of the confining pressure, but they have an opposed dependence on $k_t/k_n$. The dependence of $M_R$ on the deviatoric stress is a second order polynomial. The generalization of the $k-\theta$ model of equation ($\ref{eq:kteta2}$) is not sufficient for our system, although Eq.(~\ref{eq:kteta}) is a good approximation in many situations.
Re-analyzing our results on the strain-rate, we can summarize them in the formal expression:
\begin{equation}
\frac{\Delta \gamma}{\Delta N} \propto \frac{P_0}{\mu^2} \left ( \Delta \sigma \right ) ^3 \left ( \frac{k_n}{k_t} \right )^{0.3}.
\end{equation}
A direct relationship has been shown between this dependence, the power law behavior of the dissipated energy per cycles as a function of the deviatoric stress imposed, and the systematic accumulation of permanent strain. Although the resilient parameters are not much affected by the stress history of the material, the strain-rate is strongly dependent on it, complicating therefore the systematic investigation of the plastic response. In this context, it would be necessary to measure in more detail the influence of density and polydispersity on the possible shakedown of the material. The history dependence of the plastic response of the system is of vital importance to technical implications.
Future topics for investigation include the study of the shakedown-ratcheting transition as a function of the friction and the loading intensity. The influence of the system size and the dependence on the damping constants are subjects of current work.
{\bf Acknowledgments:} The authors would like to thank Proferssors Deepak Dhar and Ioannis Vardoulakis for very useful discussions. They also want to acknowledge the EU project Degradation and Instabilities in Geomaterials with Application to Hazard Mitigation (DIGA) in the framework of the Human Potential Program, Research Training Networks (HPRN-CT-2002-00220).
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 3,879 |
\section{Introduction}
Let $q$ be a power of a prime number and $\mathbb{F}_{q}$ the finite field with $q$ elements. Finite fields have a remarkable property that finite dimensional vector spaces over them are naturally endowed with a canonical and compatible field structure.
We refer to network coding as the best way to disseminate information over a network.
A network is usually represented by a directed multigraph with error free unit capacity edges. There are several source nodes and several destination nodes and data is transferred over a network using packets, where a packet is just an $m$-length vector over a finite field $F_{q}$.
The network nodes exchange messages being represented as a matrix.
It is convenient to describe a coding process in terms of operations in the extended field $\mathbb{F}_{q}^{m}$.
More generally, if $A$ is a commutative ring with identity, a linear code $C$ of length $n$ over $A$ is an $A$-submodule of $A^{n}$.
Let $V$ be an $n+1$ dimensional vector space over the field $\mathbb{F}_{q}$, we denote by
${\rm{\mathbb{P}}}(V)$ the $n$-dimensional projective space over it. The set of all subspaces of dimension $r$ is the Grassmannian $\mathcal{G}_{r,n}({\mathbb{F}_{q}})$ of $r$-dimensional subspaces in $(\mathbb{F}_{q})^{n}$. A subspace code is a constant dimension code (CDC), that is a subset of the Grassmannian
In general, for any integers $n, r$ with $n\geq r \geq 0$, we call $\phi(r;n,q):=|\PG^{r}(n,q)|$, the number of $r$ dimensional subspaces of an $n$ dimensional subspace over $\mathbb{F}_{q}$. It is the number of ways of choosing $r+1$ linearly independent points in $\PG(n,q)$ divided by the number of ways of choosing such a set of points in a particular $r$-space. It is given by the $q$-ary binomial coefficient,
$$\phi(q;n,r)=\left[
\begin{matrix}
n \\
r\\
\end{matrix}
\right]_{q}=\frac{(q^{n+1}-1)(q^{n+1}-q)\ldots (q^{n+1}-q^{r})}{(q^{r+1}-1)(q^{r+1}-q)\ldots (q^{r+1}-q^{r})}.$$
The general linear group $\GL(n,\mathbb{F}_{q})$ acts transitively on $\mathcal{G}_{k,n}(\mathbb{F}_{q})$:
\begin{eqnarray}\label{action}
\mathcal{G}_{k,n}(\mathbb{F}_{q}) \times \GL(n,\mathbb{F}_{q}) & \rightarrow & \mathcal{G}_{k,n}(\mathbb{F}_{q}) \\
(\mathcal{U},A) & \rightarrow & \mathcal{U}A.
\end{eqnarray}
Observe that the action is defined independent of the choice of the representation matrix $\mathcal{U}\in \mathbb{F}_{q}^{k\times n}$.
In order to classify the orbits of $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ by the action of the general linear group $\GL(n,\mathbb{F}_{q})$ we need to classify all the conjugacy classes of subgroups in $\GL(n,\mathbb{F}_{q})$.
A group divisible design (GDD) is an incidence structure $(X,\mathcal{G},\mathcal{B})$ where $X$ is a set of points, $\mathcal{G}$ is a partition of $X$ into groups, and $\mathcal{B}$ is a collection of subsets of $X$ called blocks such that any pair of distinct points from $X$ occurs either in some group or in exactly one block, but not both, see \cite{GW}.
Recently, $q$-ary designs (designs over finite fields) gained a lot of attention because of its applications for error-correcting in networks, and secret sharing scheme, a way for sharing a secret data among a group of participants so that only specific subsets (which are called qualified subsets) are able to recover the secret by combining their shares.
In this paper, we give an explicit method to construct large sets of $t$-designs over finite fields of given parameters $n,q, s$, by deriving ordered basis of $(\mathbb{F}_{q})^{n}$.
\subsection*{Notation}
For $d$ a positive integer, $\alpha=(\alpha_{1},\ldots, \alpha_{m})$ is a partition of $d$ into $m$ parts if the $\alpha_{i}$ are positive and decreasing. We will denote as $\mathcal{P}(d)$, the set of all partitions of $d$. We set $l(\alpha)=m$ for the length of $\alpha$, that is the number of cycles in $\alpha$, and $l_{i}$ for the length of $\alpha_{i}$. The notation $(a_{1},\ldots, a_{k})$ stands for a permutation in $S_{d}$ that sends $a_{i}$ to $a_{i+1}$.
We write $\PGL(2,k)=\GL(2,k)/k^{*}$, and elements of $PGL(2,k)$ will be represented by equivalence classes of matrices
$\left(\begin{array}{ll} a & b \\
c & d \end{array}\right)$, with $ad-bc\neq 0$.
In the sequel,
an $[n,k]_{q}$-code $C$ is a $k-$dimensional subspace of $(\mathbb{F}_{q})^{n}.$
\section{$t-(n,k,\lambda;q)$-designs}
An incidence structure with $v$ points, $b$ blocks and constant block size $k$ in which every point appears in exactly $r$ blocks is a GDD with parameters $(v,b,r,k,\lambda_{1},\lambda_{2},m,n)$ whenever the point set can be partitioned into $m$ classes of size $n$, such that two points from the same class appear together in exactly $\lambda_{1}$ blocks, and two points from different classes appear together in exactly $\lambda_{2}$ blocks, \cite{CMR}
\begin{example}\label{3-design} Consider the GDD given by the incidence structure $(\mathcal{P},\mathcal{B},I)$ on a 3-dimensional vector space $V$ over the finite field $\mathbb{F}_{p}$, where $\mathcal{P}$ is a set of $v$ smooth, reduced points in $V$, $\mathcal{B}$ is a set whose elements are triples of points $(p,q,r)\in \mathcal{P}\times \mathcal{P}\times \mathcal{P}$ defined by the condition $(p,q,r)\in \mathcal{B}$ if either $p+q+r$ is the full intersection cycle of the projective line with a $\mathbb{F}_{p}$-line $l\subset \mathbb{P}(V)(\mathbb{F}_{p})$ with the right multiplicities, or else if there exists a $\mathbb{F}_{p}-$line $l\subset V,$ such that $p,q,r \in l$, then the triple is called a plane section.
The number of points in the projective plane $PG(2,p)$ is $\frac{p^{3}-1}{p-1}=p^{2}+p+1$ and dually there are $p^{2}+p+1$ lines in $PG(2,p)$.
There are two types of GD designs on $V$:
\begin{enumerate}
\item For any $(p,q)\in \mathcal{P}^{2}(V^{*}),$ there exists an $r\in \mathcal{P}(S^{d}V^{*})$ such that $(p,q,r)\in l$, where $S^{d}V$ is the $d^{th}$ symmetric power of the dual of $V$. The triple $(p,q,r)$ is strictly collinear if $r$ is unique with this property, and $p,q, r$ are pairwise distinct. The subset of strictly collinear triples is a symmetric ternary relation.
\item Assume that $p\neq q$ and there are two distinct points $r_{1}, r_{2} \in \mathcal{P}$ with $(p,q,r_{1})\in \mathcal{B}$ and $(p,q,r_{2})\in \mathcal{B}$. Denote by $l=l(p,q)$ the set of all such points, then $l^{3}\in \mathcal{B}$, that is, any triple $(r_{1},r_{2},r_{3})$ of points in $l$ is collinear. Such sets are called lines in $\mathcal{B}$.
\end{enumerate}
\end{example}
If $X$ is the finite field $\mathbb{F}_{q}^{n}$, we consider the GDD where the set points correspond to vectors of $(\mathbb{F}_{q})^{n}$ as $n$-dimensional vector space over $\mathbb{F}_{q}$ and the block set $\mathcal{B}$ is a collection of $i-$subspaces $K\subseteq \mathbb{F}_{q}^{n}$ which geometrically correspond to points in the Grassmannian $\mathcal{G}_{n,i}(\mathbb{F}_{q})$. They live in a natural way as subspaces of the vector space $(\mathbb{F}_{q})^{n}$. More generally, assuming that $\dim K_{j}=j$ for $j=1,\ldots, n$, the sequence of nested subspaces
$$\{0\}\subset K_{1}\subset K_{2}\subset \ldots \subset K_{n}=\mathbb{F}_{q}^{n},$$ live in the whole lattice of subspaces of the vector space $(\mathbb{F}_{q})^{n}$.
If each $t$-subspace of $X$ is contained in exactly $\lambda$ blocks of $\mathcal{B}$ then it is called a $t$-$(n,k,\lambda;q)$ design.
A permutation matrix $\sigma \in \GL(n,q)$ acts on the Grassmannian by multiplication on the right of the corresponding representation matrix. In particular $\sigma$ is an automorphism of the design $\mathcal{D}=(X,\mathcal{B})$ if and only if $\sigma$ leaves the Grassmannian invariant, that is $\mathcal{B}^{\sigma}=\mathcal{B}$. In particular, we are interested in understanding the orbits by the action of any permutation matrix of $\GL(n,q)$ and moreover of any subgroup $G$ contained in $\GL(n,q)$. Further, it is possible to count the orbits of the action in several cases and these correspond to blocks of the design satisfying certain geometrical properties.
\begin{defi}
Let $\alpha\in \mathbb{F}_{q^{n}}$ be a generator of the underlying vector space over $\mathbb{F}_{q}$. Then an $r$-dimensional $W$ subspace is $\alpha$-splitting if $\alpha^{i}W=W$ is invariant under the action of any element $\alpha^{i}$ in the Galois group of the extension $\mathbb{F}_{q}\hookrightarrow \mathbb{F}_{q}(\alpha)$.
More precisely, given any $\mathbb{F}_{q}$-linear endomorphism $T:\,\mathbb{F}_{q^{n}}\rightarrow \mathbb{F}_{q^{n}}$, an $r$-dimensional subspace $W$ is $T$-splitting if $\mathbb{F}_{q^{n}}=W\oplus T(W)\oplus \cdots \oplus T^{n-1}(W),$ where $T^{j}$ denotes the $j$-fold composite of $T$ with itself.
\end{defi}
\begin{defi}
Let $T$ be the standard shift operator on $\mathbb{F}_{q}^{n}$, a linear code $C$ is said to be quasi-cyclic of index $l$ or $l-$quasi-cyclic if and only if is invariant under $T^{l}$. If $l=1$, it is just a cyclic code. The quantity $m:=n/l$ is called the co-index of $C$. Namely, if we view a codeword $(c_{0},c_{1},\ldots, c_{n-1})$ of $C$ as a polynomial $c_{0}+c_{1}x+\ldots+c_{n-1}x^{n-1}\in \mathbb{F}_{q}[x]$, then $T(c(x))=x\cdot c(x) \ {\rm{mod}}\, (x^{n}-1)$. In particular a cyclic code $C\subset (\mathbb{F}_{q})^{n}$ is identified with an ideal in the ring $\mathbb{F}_{q}[x]/(x^{n}-1)$ generated by a polynomial $g(x)$ which divides $(x^{n}-1)$.
\end{defi}
\begin{example}
For $n=6$, we consider the factorization into prime factors $r=2, s=3$, and let $\alpha$ be a primitive element of $\mathbb{F}_{q^{6}}$, then there are as many 2-subspaces of $(\mathbb{F}_{q})^{6}$ as $|\GL(2,\mathbb{F}_{q})|=(q^{3}-1)(q^{3}-q)(q^{3}-q^{2})$. There are as many 3-subspaces of $(\mathbb{F}_{q})^{6}$ as $|\GL(2,\mathbb{F}_{q})|=(q^{2}-1)(q^{2}-q)$.\
For $q=2$, we get a 2-(6,3,3) design.
\end{example}
One can study the orbits of $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ by the action of any subgroup in the general linear group $\GL(n,\mathbb{F}_{q})$. For example we can study the orbit of any triangle group: the Klein group $\mathbb{Z}_{2}\times \mathbb{Z}_{2}$, the dihedral group, the alternated groups $A_{4}$ and $A_{5}$ or the symmetric group $S_{n}$. We study the special case of the Grassmannian $\mathcal{G}_{2,4}(\mathbb{F}_{q})$ of lines in a 3-dimensional projective space.
\begin{lemma}\label{P1} The orbit of $\mathcal{G}_{2,4}(\mathbb{F}_{q})$ by the action of a rotation $\tau$ of angle $\alpha=\frac{2\pi}{n}$, corresponds to a cyclic code of order $n$. Furthermore, the orbit by the action of the element $\tau^{m}$ in $\GL(n,q)$ corresponding to the $m$-iterate composition of $\tau$ with itself is a quasi-cyclic code of index $\frac{m}{n}$.
\end{lemma}
{\it Proof.}
We study the action of a rotation element on the Grassmanian $\mathcal{G}_{2,4}(\mathbb{F}_{q})$ of lines in a 3-dimensional projective space $PG(3,q)$. We apply to any line $g$
a rotation $\tau$ of angle $\alpha=\frac{2\pi}{n}$, represented by the array of vec\-tors $<(1,0,0), (0,cos(\alpha), sin(\alpha)), (0,-cos(\alpha), sin(\alpha))>$. It is easy to see that the orbit code by the composed action $ \tau^{m}$ with $m$ a divisor of $n$ is a quasi-cyclic code of index $\frac{m}{n}$.
\hfill$\Box$
If we denote by $\mathcal{P}(n)$ the set of all linear subspaces inside the vector space $\mathbb{F}_{q}^{n}$, there is a natural metric on it defined by the function:
$$d_{S}(U,W):=\rm{dim}(U+W)-\rm{dim}(U\cap W).$$
The metric on $\mathcal{P}(n)$ induces a metric on the Grassmannian $\mathcal{G}_{n,k}(\mathbb{F}_{q})$.
For any subspace code $\mathcal{C}\subset \mathcal{P}(n)$, we define its distance through:
$$\rm{dist}\,(\mathcal{C}):=\rm{min}\,\{d_{S}(U,W)|\, U,W\in \mathcal{C},\, U\neq W\},$$ and its size as $M:=|\mathcal{C}|$.
A code is said to have minimum distance $d$ if $d_{S}(U,W)\geq d$ for all distinct words $U, W \in \mathcal{C}$. If the norm $|U|=w$ for every codeword in $\mathcal{C}$, then $\mathcal{C}$ is said to be of constant weight $w$. The number of codewords in $\mathcal{C}$ is called the size of the code.
We will say that a code $\mathcal{C}$ is of type $[n,k,d]$ if $\mathcal{C}$ has length $n$, minimum distance $d$, and its dimension is $k$.
\begin{defi} Given a linear $[n,k,d]$-code, a parity check matrix for $\mathcal{C}$ is an $(n-k)\times n$ matrix $H$ of rank $n-k$ such that $\mathcal{C}=\{x\in (\mathbb{F}_{q})^{n}:\, Hc^{T}=0\}$. Then the dual code $\mathcal{C}^{\bot}$ is the linear $[n,n-k,d]$ code generated by the parity check matrix of $\mathcal{C}$.
\end{defi}
\begin{defi} Given a linear $[n,k,d]$-code, a parity check matrix for $\mathcal{C}$ is an $(n-k)\times n$ matrix $H$ of rank $n-k$ such that $\mathcal{C}=\{x\in (\mathbb{F}_{q})^{n}:\, Hc^{T}=0\}$. Then the dual code $\mathcal{C}^{\bot}$ is the linear $[n,n-k,d]$ code generated by the parity check matrix of $\mathcal{C}$.
\end{defi}
Any element $\sigma$ of the general linear group $\GL(n, \mathbb{F}_{q})$ induces another code $$\mathcal{C}^{\sigma} =\{\left( f(\sigma(\alpha^{i}))_{i=0}^{n}\right):\, f\in I\}.$$
A singer cycle of $\GL(n,\mathbb{F}_{q})$ is an element of order $q^{n}-1$. Singer cycles can be constructed, for example, by identifying vectors in $\mathbb{F}^{n}_{q}$ with elements of the finite field $\mathbb{F}_{q^{n}}$. Since multiplication by a primitive element $\alpha \in \mathbb{F}_{q^{n}}$ is a linear operation, it corresponds to a singer cycle in $\GL(n,\mathbb{F}_{q})$.
For example, consider the codeword $a=(a_{1},\ldots, a_{n})\in \mathcal{C}$ and the permutation $\sigma \in \GL(n,\mathbb{F}_{q})$ which reverse the coordinates, so $\sigma(a)=(a_{n},a_{n-1},\ldots, a_{2},a_{1})$. If $\sigma(a)\in \mathcal{C}$, the code is called reversible.
The intersection code space $\mathcal{C}\bigcap \mathcal{C}^{\sigma}$ is given by the system of linear Diophantine equations:
$$f(\alpha^{i})=g(\sigma(\alpha^{i}))\, \forall\, i=0,\ldots, n.$$
In particular if $\sigma$ is a Singer cycle $\sigma(\alpha^{i})=(\sigma\alpha)^{i}$ permutes the elements $(\alpha^{i})$. Moreover if the permutation is in the automorphism group of the code, we get an equivalent code.
Given two permutation codes $\mathcal{C}$ and $\mathcal{C}^{\sigma}$ the distance between them in the subspace metric is given by the formula:
$$d(\mathcal{C},\mathcal{C}^{\sigma}):= {\rm{dim}}(\mathcal{C}+\mathcal{C}^{\sigma})-{\rm{dim}}(\mathcal{C}\cap \mathcal{C}^{\sigma}).$$
\begin{defi
Let $a$ be a word in $\mathcal{C}$, then the coset of $a$ is the set:
$$\{\pi(u)+ a: u\in \mathcal{C}, \pi\in S_{n}\}.$$
A coset leader is a word of minimum weight of any particular coset.
\end{defi}
Given a linear code $\mathcal{C}$, a non-trivial coset is a translation of $\mathcal{C}$ by a vector $v$ not in $\mathcal{C}$.
The main idea of coset coding is to map an information message not to a particular codeword but to a coset of this code.
We observe that two cosets are either equal or disjoint.
\begin{remark} The incidence vectors of the blocks of a t-$(v,k,\lambda; q)$ design with maximum block intersection number $s$ form a constant weight code of weight $w=k$, lenght $n=v$, and minimum distance $d=2\,(k-s)$.
\end{remark}
\begin{remark} A partition of the complete set of $k-$subspaces of $X$ into disjoint t-$(n,k,\lambda; q)$ designs is called a large set of $t$-designs over finite fields. Thus a partition of the Grassmannian $\mathcal{G}_{k,n}(\mathbb{F}_{q})$. Any point $\mathbb{F}_{q^{k},q^{n}}\subseteq \mathbb{F}_{q^{n}}$ in $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ is a code of parameters $[n,k,d]$ where $d$ is the minimum distance defined as ${\rm{min}}\{d\,(V,W)|\, V,W \in \mathcal{G}_{q}(k,n),\, V\neq W\}.$
\end{remark}
\subsection{Relation of $t-$designs with AG codes}
Algebraic geometric codes (AGC), use as an alphabet a set $\mathcal{P}=\{P_{1}, \ldots, P_{N}\}$ of $N$-$\mathbb{F}_{q}$-rational points lying on a smooth projective curve $\mathcal{C}$ defined over $\mathbb{F}_{q}$, that is, in projective coordinates $P_{i}=[a_{i}:1]$ with $a_{i}\in \mathbb{F}_{q}$. Namely, let $F/\mathbb{F}_{q}$ be the function field of the curve, $D$ a divisor of $F/\mathbb{F}_{q}$ supported on the set $\mathcal{P}$, and $G$ another divisor such that $\rm{Supp}\,G\cap \rm{Supp}\,D=\emptyset$. Then the geometric Goppa code $C(D,G)$ associated with the divisors $D$ and $G$ is defined by evaluation of a rational map $\varphi \in \mathcal{L}(G)$ in the linear series attached to the divisor $G$:
$$C(D,G)=\{(\varphi(P_{1}),\ldots, \varphi(P_{n})):\, \varphi \in \mathcal{L}(G)\}\subseteq \mathbb{F}_{q}^{n}.$$
It's an $\mathbb{F}_{q}-$subspace of $(\mathbb{F}_{q})^{n}$ and its dimension $k$ as an $\mathbb{F}_{q}-$vector space is the dimension of the associated Grassmannian code $G(n,k)$. Geometrically, it corresponds to a point in the Grassmannian $\mathcal{G}_{n,k}(\mathbb{F}_{q})$.
Observe that for the same subset of evaluation points and any $k'\leq k$, we have $G(n,k')\subseteq G(n,k)\subseteq \mathbb{F}^{n}_{q}$. In particular any $t-$design constructed from $G(n,k)$ is a $j-$design for $0\leq j \leq t-1$. It's well known that if ${\rm{deg}}(G)<n$, then $C(D,G)$ is a linear $[n,k,d]$ code over $\mathbb{F}_{q}$ with length $n$, $k=l(G)$ and minimum distance $d\geq n-{\rm{deg}}\,(G)$. We have $l(G)\geq deg\,(G)+1-g$ by the Riemann-Roch theorem, where $g$ is the genus of $F$.
More precisely, to each non constant rational function $\varphi$ over $C$ which is defined as the quotient of two polynomials $f(x), g(x) \in \mathbb{F}_{q}[x]$, one can associate a matrix $A$ with entries in the ring $\mathbb{F}_{q}[x]$. Then the generator matrix associated to the Goppa code $C(D,G)$ is defined to be the diagonal matrix with entries $q_{1}, q_{2},\ldots, q_{k}, k\leq n$, corresponding to the continued fraction expansion of the rational function $\varphi$. Namely, let us call $f_{0}:=f(x)$ and call $f_{1}$ the divisor polynomial $g(x)$, and $f_{2}$ the remainder polynomial, then by repeated use of the Euclid's algorithm, we construct a sequence of polynomials corresponding to the quotients $q_{1},\ldots, q_{k}$, $k\leq n$ of the continued fraction expansion $\frac{f}{g}=q_{1}+1/(q_{2}+1/q_{3}+1/(q_{4}+\ldots)))$. Observe that if ${\rm{deg}}\,\frac{f(x)}{g(x)}<1$, then $q_{1}$ belongs to the ground field.These matrices are in correspondence with endormorphisms $T:\,R\rightarrow R$, of $\mathbb{F}_{q}[x]$-modules, where $R=\mathbb{F}_{q}(\alpha)$, and $\alpha$ is a generator of $\mathbb{F}_{q^{n}}$ as an $\mathbb{F}_{q}$-vector space.
\begin{lemma}
The set of functions $\{q_{1},\ldots, q_{k}\}$ is in bijective correspondence with the set of codeword positions $f_{i}$ coming from the decomposition of the rational function $\varphi$ into partial fractions $f_{i}\in \mathbb{F}_{q}[x],\, 1\leq i \leq n$. Moreover, they are linearly equivalently as $\mathbb{F}_{q}[x]$-vector spaces.\end{lemma}
{\it Proof.} We write the denominator $g$ of the rational function $\varphi$ as a product of powers of distinct irreducible polynomials.
$$\frac{f}{g}=\frac{c_{1}}{x-\alpha_{1}}+\frac{c_{2}}{x-\alpha_{2}}+\ldots+\frac{c_{n}}{x-\alpha_{n}},$$ where the linear factors $(x-\alpha_{i})$ correspond to the roots of $g(x)$ counted with multiplicity. Since we are working over the finite field $\mathbb{F}_{q^{n}}$, the number of codeword positions $\{f_{i}\}_{i=1}^{n}$ is in correspondence with a base $\{1, \alpha, \ldots, \alpha^{n-1}\}$ of $\mathbb{F}_{q}^{n}$ as a vector space over $\mathbb{F}_{q}$, and they have the same cardinality as sets. \hfill$\Box$
\begin{defi} Let $C$ be the AG code associated with a rational function $\varphi$ defined over a smooth projective curve $C$. A typical codeword is an element of the form $\sum_{j=1}^{k}a_{ji}f_{i} \equiv 0 \, \, {\rm{mod}}\,\, f$, where $f_{i}$ are the functions obtained from the decompostion of $f$ into partial simple fractions, and $a_{i}\in \mathbb{F}_{q^{n}}$.
\end{defi}
Let $\mathbb{F}_{l}$ be the finite field of prime-power order $l$ and let $F$ be an algebraic function field with full constant field $\mathbb{F}_{l}$. Note that $F$ can also be considered as an algebraic function field over any subfield $\mathbb{F}_{q}$ of $\mathbb{F}_{l}$.
One of the main problems in coding theory concerns the size of the alphabet $\mathcal{P}$, thus one of the aims is to obtain non trivial lower bounds of the number $N(F_{i})$ of rational places of towers of function fields $\{F_{i}/\mathbb{F}_{q}\}_{i=1}^{\infty}$ such that $F_{i}\subset F_{i+1}$.
The first case of study will be when the rational function $\varphi$ admits a decomposition into linear simple fractions. These rational functions define what are known as Reed-Solomon codes. In the case where $\alpha$ is a generator of $\mathbb{F}_{q^{n}}$, as an $\mathbb{F}_{q}$-vector space, the set of codeword positions is identified with the set of linear fractions
$\{\frac{1}{x-1}, \frac{1}{x-\alpha}, \frac{1}{x-\alpha^{2}}\ldots, \frac{1}{x}\}$. Any linear combination of these elements produces a vector $a=(a_{1},\ldots, a_{n})$ in $(\mathbb{F}_{q})^{n}$ and thus a codeword of our AG code $\mathcal{C}$. Let $l$ be the maximum integer number such that the codeword position $a_{l}\neq 0$. The set of codewords $a$ satisfies the relation $$\sum_{i=1}^{n}a_{i}\frac{1}{x-\alpha_{i}}\cong 0\, {\rm{mod}}\, f,$$ where $L=\{\alpha_{i}\}_{i=1}^{n}$ is a subset of the Galois field $\mathbb{F}_{q^{n}}$. In several cases, it is possible to count the number of codewords of the AG code, by a simple count of the number of normalised polynomials of degree $l$ irreducible over $\mathbb{F}_{q^{n}}$. In the case of binary codes, where $q=2$, S. Bezzateev and N. Shekhunova (\cite{BS})
have obtained several closed formulas. The number of normalised polynomials $I_{2^{m}}(l)$ of degree $l$ over $\mathbb{F}_{2^{m}}$ satisfy the following equation:
\begin{equation}
I_{2^{m}}(l)=\frac{1}{l}\sum_{d / l}\mu(d)2^{m\, \frac{l}{d}},
\end{equation}
where $\mu(d)$ is the M\"oebius function. The number of unitary separable polynomials with coefficients from the field $\mathbb{F}_{2^{m}}$ whose degrees do not exceed $(l>1)$ is equal to:
\begin{equation}
N^{l}_{2^{m}}=\sum_{i=2}^{l}\, (2^{mi}-2^{m(i-1)})+2^{m}=2^{ml}.
\end{equation}
\begin{defi} The length of a codeword $(a_{1},\ldots, a_{n})$ in $(\mathbb{F}_{q})^{n}$ is $n=n_{1}+n_{2}+\ldots+n_{k}$, where $n_{i}$ is the number of positions of the vector $a$ with weight $v_{i}$ corresponding to the exponent of the corresponding fraction $f_{i}=\frac{1}{x-\alpha^{i}}$ in the partial fraction decomposition of the rational function $f$ associated to the AG code.
\end{defi}
We observe that in the case of cyclic codes the weight $v_{i}$ coincides with the exponent of the corresponding function $f_{i}$ whose denominator is a linear function and thus with the integer $n_{i}$.
\begin{lemma}\label{equivalencia}
The set of AG codes defined over the Normal Rational Curve is in bijective correspondence with the set of generalised Reed-Solomon codes
\end{lemma}
{\it Proof.} We observe that the $n$-Veronese embedding of the $n$-dimensional projective space $\PG(n,q)$ maps the line spanned by the vector $v\in \mathbb{F}^{n+1}_{q}$ to the line spanned by $v^{n}\in \mathbb{P}S^{n}\mathbb{F}^{n+1}_{q},$ where $\mathbb{P}S^{n}\mathbb{F}^{n+1}_{q}$ is the projectivization of the $n-$tensor power of the vector space $\mathbb{F}^{n+1}_{q},$ which is a projective space of dimension $n$. In particular, if the finite field $\mathbb{F}_{q}^{n+1}$ is generated as a vector space over $\mathbb{F}_{q}$ by a unique element $\alpha\in \mathbb{F}_{q}$, then the set $\{1,\alpha, \ldots, \alpha^{n}\}$ forms a basis of $\mathbb{F}_{q}^{n}$. Thus the Normal Rational Curve is defined as
$$\mathcal{C}^{n}:=\{\mathbb{F}_{q}(1,\alpha, \ldots,\alpha^{n}):\, \alpha\in \mathbb{F}_{q}\cup \{\infty\}\}.$$
In other words, its underlying vector space is the $\mathbb{F}_{q}$-vector space whose elements are the polynomials of degree less than $n$ with coefficients in $\mathbb{F}_{q}$ that we will denote as $\mathbb{F}_{q}[x]_{n}$. Let $\alpha_{1},\ldots, \alpha_{n}$ be a sequence of $n$ distinct elements in $\mathbb{F}_{q}$, if $k\leq n$, then the map
\begin{equation}
\epsilon: \mathbb{F}_{q}[x]\rightarrow \mathbb{F}_{q}^{n}, \ \ f\mapsto (f(\alpha_{1},\ldots, \alpha_{n}))
\end{equation}
is injective, since the existence of a non-zero polynomial of degree less than $k$ vanishing on all $\alpha_{i}$ implies $n<k$ by the fundamental theorem of algebra (a non-zero polynomial of degree $r$ with coefficients in a field can have at most $r$ roots). The image of $\epsilon$ is therefore an AG code of type $[n,k,d]$, where the minimum distance $d$ is always at least $n+2$. Just observe that since $\mathcal{C}^{n}$ is a Normal Rational Curve in $\mathbb{P}({\mathbb{F}_{q}^{n}})$, any $n+1$ of its points happen to be in general position.
Reciprocally, the AG codes of dimension $n$ defined over $\mathcal{C}^{n}$ are constructed by evaluating non-zero polynomials of degree less than $n$ over a location set $\{1,\alpha_{1}, \ldots, \alpha_{n}\}$ which coincide with the set of Reed-Solomon codes. Namely, consider a Reed-Solomon code of parameters $[n,k,d]$ over a finite field $\mathbb{F}_{q}$, with parity check polynomial $h(x)=\prod_{i=1}^{q}(x-\alpha^{i})$, where $\alpha$ is a primitive root of $\mathbb{F}_{q}$ such that $\alpha^{k+1}=\alpha+1$. Any codeword $(c_{0},c_{1},\ldots, c_{n-1})$ can be expanded into a $q$-ary $k$ vector with respect to the basis $\{1, \alpha,\ldots, \alpha^{k-1}\}$, that is, codewords from an $[n,k,d]$ code over a finite field are identified with the coefficients of a degree $k-1$ polynomial $f(x)\in \mathbb{F}_{q}[x]$.
\hfill$\Box$
\begin{example} Consider the AG code defined by the rational function $G(x)=\frac{5x^{2}+20x+6}{x^{3}+2x^{2}+x}$ which admits as decomposition into partial fractions
$G(x):=\frac{6}{x}-\frac{1}{x+1}+\frac{9}{(x+1)^{2}}$. The presence of a double factor $(x+1),,,,,^{2}$ corresponds to the existence of an eigenspace $E$ in the vector space $\mathbb{F}_{q}^{n}$ and thus an $\alpha-$splitting subspace where the operator $\alpha$ is just the linear operator $A-\lambda I$, with $\lambda$ the eigenvalue of multiplicity 2 associated to $E$ and $A$ is the generator matrix of the code.
\end{example}
\begin{prop}\label{fields}
The variety of $[n,k,d]_{q}$-codes over $\mathbb{F}_{q}$ is parametrized by a Grassmannian $\mathcal{G}_{n,k}(\mathbb{F}_{q})$ of $k$-di\-men\-sional subspaces in the $\mathbb{F}_{q}$-vector space $\mathbb{F}_{q}^{n}$, and the set of Reed-Solomon $(RS)$ codes arises as the set of $S_{n}$-invariants
\end{prop}
{\it Proof.}
Let $n=r\,s$ be a factorisation of an integer positive number $n$ into irreducible coprime factors and assume $s<r$, then there is a sequence of field extensions $\mathbb{F}_{q^{r}}\subset \mathbb{F}_{q^{s}}\subset \mathbb{F}_{q^{n}}$.
Namely, consider the map
$T_{n}:\, F^{n} \mapsto F^{n}$
$$t_{j}=(-1)^{j}\sigma_{j}(x_{1},\ldots, x_{n}),$$ where $\sigma_{j}$ is the $j^{th}$ elementary symmetric function in the variables $x_{i}$. Thus $\{t_{j}, j=1,\cdots n\}$, are the coefficients of the equation:
$$f(z,t_{1},\ldots, t_{n})=z^{n}+(-1)\,t_{1}z^{n-1}+\cdots +(-1)^{n}\,t_{n}=$$ $$(z-x_{1})\,(z-x_{2})\cdots (z-x_{n}).$$ Then by Hilbert's irreducibility theorem (see Theorem 1 of \cite{ Se}), it is well known that the splitting field of the polynomial $f(x)=x^{n}-t_{1}x^{n-1}+\ldots+(-1)^{n}t_{n},$ is the field of $S_{n}$ invariants of the polynomial $f(z,t_{1},\ldots, t_{n})$, where $S_{n}$ is the symmetric group in $n$ variables and
it contains an extension $\mathbb{F}_{q^{n}}$ of $\mathbb{F}_{q}$. Moreover, for any divisor $r$ of $n$, one can consider the field of $S_{r}$ invariants, and apply Hilbert theorem to the symbols $\alpha, \alpha^{q^{2s}},\ldots, \alpha^{q^{rs}}$, where $n=rs$. Then we get an extension $\mathbb{F}_{q^{s}}$ of $\mathbb{F}_{q^{r}}$ and all its $\mathbb{F}_{q}$-subspaces are stable under $Gal(\mathbb{F}_{q^{s}}/\mathbb{F}_{q^{r}})$. These are just the RS codes
\hfill$\Box$
\begin{coro} The set of RS codes is a closed set in the Zariski topology.
\end{coro}
{\it Proof.}This follows easily as a consequence of Proposition \ref{fields}, since the Grassmannian is a compact variety. It is well known that the corresponding points
$\mathbb{F}_{q^{k},q^{n}}\subset \mathbb{F}_{q^{n}}$ and $\mathbb{F}_{q^{n-k},q^{n}}\subset \mathbb{F}_{q^{n}}$ in the Grassmannians $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ of $k-$dimensional subspaces and the Grassmannian $\mathcal{G}_{n-k}(\mathbb{F}_{q})$ of $n-k$ dimensional subspaces are respectively dual subspaces in the underlying vector space $(\mathbb{F}_{q})^{n}$ for the Euclidean inner product. Note that the Hamming weight is preserved under invertible linear transformation
\hfill$\Box$
\begin{theorem}\label{goppa}
Let $S\leqslant \GL(n,\mathbb{F}_{q})$ be a subgroup containing a primitive element $\alpha$ in $\mathbb{F}_{q}$, where $q\geq 2$.
Then the family of AG codes $\{C^{\sigma}\}_{\sigma \in S}$ constitute a j-$(v,r,\lambda)$ design where $j$ is the number of generators of the subgroup $S$, $r$ is the number of orbits in the Grassmannian $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ by the action of the subgroup $S$, $v$ is the size of the code and $\lambda$ is the number of $\alpha-$splitting subspaces of $\mathbb{F}_{q^{n}}$.
\end{theorem}
{\it Proof.}
Consider the family of AG codes constructed out of the vector space of polynomials $I=\{f\in \mathbb{F}_{q}[x]: \partial\, f\leq k\}$, where $\partial\, f$ is the degree of the polynomial and fix a basis $\{1,\alpha, \alpha^{2},\ldots, \alpha^{n-1}\}$. To each polynomial $f$ we associate the AG code $C=
\{\left( f(\alpha^{i})_{i=0}^{n}\right):\, f\in I\}$.
We construct a $j$-design where the point set are the codewords of the AG codes and each AG code of constant dimension $r$ is a block, where $r$ is the number of orbits in the Grassmanian $\mathcal{G}_{k,n}(\mathbb{F}_{q})$ by the action of any representative of a conjugacy class in $S$.
Each polynomial $f(x)=a_{0}+a_{1}x+\ldots+a_{j}x^{j}$ defines a codeword $(a_{0},\ldots,a_{j})\in \mathbb{F}_{q}^{j}$ of the code.
Since the number of invariant polynomials in $I$ by conjugated elements $A$ and $B$ in $\GL(n,\mathbb{F}_{q})$ is the same, $r$ is the number of conjugacy classes in $S$. The intersection vector space is given by the evaluation set
$$\{\left(f(\alpha^{i})\right)_{i=0}^{n}:\, f\in \mathbb{F}_{q}[x]_{j},\, 1\leq j\leq r\},$$
of the polynomials of degree $j$ with coefficients in $\mathbb{F}_{q}$, $v$ is the size of the block codes which is constant and $\lambda$ is the number of $\alpha$-splitting subspaces of $\mathbb{F}_{q^{n}}$ as computed in \cite{BM2}.
\hfill$\Box$
Let $F$ be a field of characteristic $p$ and $\alpha \in \overline{F}$ be an $n^{th}$ primitive root of unity, where $\overline{F}$ denotes the algebraic closure of $F$.
The $n^{th}$ cyclotomic polynomial $\Phi_{n}(x)=\prod_{1<j<n, (j,n)=1}\,(x-\alpha^{j})\in \overline{F}[x]$ is the minimal polynomial of $\alpha$ over $F$. It is monic of degree the Euler's totient function $\varphi(n)$.
It has integer coefficients and it is irreducible over $\mathbb{Q}$. In $\mathbb{Q}[x]$, we have the factorization into irreducible polynomials:
$$x^{n}-1=\prod_{d|n}\Phi_{d}(x).$$
By M\"oebius inversion:
$$\Phi_{n}(x)=\prod_{d|n}(x^{d}-1)^{\mu(n/d)}$$
\begin{example} Consider the action of a permutation matrix $\beta$ in $\GL(n,q)$ given by the element $\beta\in \mathbb{F}_{q}^{n}:\,x\rightarrow a\,x$, which is given by multiplication by an element $a\in \mathbb{F}^{*}_{q}$ of multiplicative order $k>1$ with $n=km$. Then by Lemma \ref{equivalencia}, counting the codewords of the constant dimension code defined by the action of $\beta$ in the Grassmannian $\mathcal{G}_{k,n}(\mathbb{F}_{q})$, is equivalent to count the number $\mathcal{N}_{a,m}$ of irreducible monic polynomials of degree $n$ such that $f(x)=f(ax)$. This number is expressed in terms of the M\"oebius function:
$$\mathcal{N}_{a,m}=\frac{\Phi(k)}{km}\sum_{d|m, gcd(d,k)=1}=\mu(d)(q^{\frac{m}{d}} -1).$$
\end{example}
\begin{example}
We consider the roots of the polynomial $x^{8}-1\in \mathbb{F}_{5}[x]$ in the splitting field $\mathbb{F}_{5^{2}}$. The decomposition into irreducible polynomials over $ \mathbb{F}_{5}[x]$ is $(x-1)(x+1)(x-2)(x+2)(x^{2}+1)(x^{2}-2)(x^{2}+2)$. Now, we consider the field extensions $F_{1}:=\mathbb{F}_{5}[x]/(x^{2}-2)$ and $F_{2}:= \mathbb{F}_{5}[x]/(x^{2}+2)$ of $\mathbb{F}_{5}$ that are isomorphic to the field extension $\mathbb{F}_{25}$ of $\mathbb{F}_{5}$. Call $\alpha$ the root of $x^{2}-2$ in the field extension $F_{1}$, then $4\cdot \alpha$ is the other root of $x^{2}-2$, and $2\cdot \alpha$, $3\cdot \alpha$ the roots of $x^{2}+2$ in $F_{1}$. So $g(x)=(x-\alpha)(x-2\alpha)(x-3\alpha)(x-4\alpha)$ generates a Reed-Solomon code
over $\mathbb{F}_{5}[x]/(x^{8}-1)$.
We say that two roots are conjugated if they are roots of the same polynomial in the decomposition of $x^{8}-1$ in $\mathbb{F}_{5}[x]$, in particular this defines a non-crossing partition of the total set of roots and it is a 2-design of the splitting field $\mathbb{F}_{25}$ with parameters $n=2$, $k=4$ and $\lambda=2$.
From a geometric point of view,
the point $(\alpha, 0)\in \mathbb{P}(\mathbb{F}_{q}^{2})$ with $\alpha^{4}=4$ is an $\mathbb{F}_{25}-$rational point of the affine curve $y^{2}=(x^{4}+1)$. The other rational places are
$(2,0), (-2,0)$ and the place $(0,\alpha)$ at $\infty$.
\end{example}
It is well known how to factorize a polynomial over finite fields (see for example \cite{PFG}). In \cite{BM2} we give an updated proof expressing the number of polynomials decomposable into distinct linear factors in terms of Stirling numbers.
Given an integer $n$, it is possible to count the number of cyclic codes of parameters $[n,k]$ for each $0\leq k \leq n$ and set of roots $\alpha_{1},\ldots, \alpha_{k}$ in the splitting field of $x^{n}-1$, the corresponding polynomial $g(x)=\prod_{i=1}^{k}(x-\alpha_{i})$ generates a linear cyclic code in the ring $\mathbb{F}_{q}[x]/(x^{n}-1)$. Thus for each $0\leq k\leq n$ there are exactly $(q)_{k}/(q^{2}-q)$ cyclic codes.
These codes are of great importance in ADN-computing and as they are linear codes, they can be described as function fields.
\begin{remark}
A much greater variety of linear codes is obtained if one uses places of arbitrary degree rather than just places of degree 1 as in Goppa's construction. For example, the polynomial $x^{3}+4$ factorises as $(x-1)(x^{2}+x+1)$ over $\mathbb{F}_{5}[x]$, then the roots of the polynomial in the splitting field $\mathbb{F}_{5}[x]/x^{2}+x+1 \cong \mathbb{F}_{25}$ correspond to one place of degree 2 over the function field $\mathbb{F}_{5}(x)$ but of degree 1 over $\mathbb{F}_{25}$.
\end{remark}
\subsection{$t-$designs with an action of a $p-$group.}
During the last years, there has been an increasing interest in studying finite abelian groups due to its relationship with public key cryptography, quantum computing and error-correcting codes. Abelian groups as the groups $\mathbb{Z}_{n}^{*}$ of invertible elements of $\mathbb{Z}_{n}$, multiplicative groups of finite fields, the groups of elements of elliptic curves over finite fields, finite $p-$groups with unique cyclic subgroups of given order have been used for the designation of public key cryptosystems. In order to use cryptography to insure privacy, it is currently necessary for the communicating parties to share a key which is known to no one else.
As we showed in Theorem \ref{goppa}, we can construct $t$-designs from any $p-$group containing a cyclic subgroup.
\begin{prop}
For $q\geq 2$, the group $\GL(n,q)$ contains a least two different cyclic subgroups of orders $q-1$ and $q+1$ respectively. Each one corresponding to elements $\alpha, \gamma$ in $\GL(n,q)$ fixing an $\alpha-$splitting and $\gamma-$splitting subspaces respectively and the $t-$designs whose incidence vectors are the $\alpha-$splitting subspaces and $\gamma-$splitting subspaces respectively correspond to RS codes of length $n=q-1$ (respectively $n=q+1$) and dimension $r$ the maximum divisor of $n$.
\end{prop}
{\it Proof.}
For any divisor $d$ of $q-1$ (respectively of $q+1$), the $d$-$(q-1,\frac{q-1}{d},\lambda)$ design (respectively $d$-$(q+1,\frac{q+1}{d}),\lambda)$) corresponds to RS codes of length $n=q-1$ (respectively $n=q+1$) and dimension $d$. Moreover the matrix $A$ of row vectors the incidence vectors of the design, satisfies $\frac{q+1}{r}\leq rank(A) \leq \frac{q-1}{2}$, where $r$ is the maximum divisor of $q-1$ (respectively $q+1$). \hfill$\Box$
\begin{remark}
The generators of the cyclic groups of order $q-1$ ($q+1$, respectively) are the relative integers coprime with $(q-1)$ (respectively with $q+1$), that is $\varphi(q-1)$ (respectively $\varphi(q+1)$).
Let $m=\varphi(q-1)$ (respectively $m=\varphi(q+1)$), by Theorem \ref{goppa}, the family of RS codes of length $q-1$ (respectively $q+1$) constitute a $m$-$(q-1,r,\lambda)$ design (respectively a $m$-$(q+1,r,\lambda)$ design). These codes are indeed AG codes arising from genus 0 curves, and by Riemann-Roch theorem, their parameters satisfy the bound $d\geq n+1-k$, where $d$ is the minimum distance.
\end{remark}
The normalizer groups of the cyclic groups generated by $\alpha$ and $\gamma$ are dihedral groups, and it is possible to construct $t$-designs from them as we showed in Proposition 3.5 of \cite{BM2}
Next tables show $t$-designs constructed from abelian $p$-groups and their normalizers.
We assume that $q\leq 31$.
\newpage
\begin{center}
Table 1. $t-$designs constructed from a $p$-group.
\end{center}
\begin{center}
\begin{tabular}{|c|r|r|r|}
\hline
$q$ & group type & $t-(n,k,\lambda)$ \\
\hline
$q$ odd prime $q+1\equiv 0 (3)$ & cyclic of order $q+1$ & 3-$(q+1, \frac{q+1}{3},\lambda)$ \\
$q$ odd prime $q-1\equiv 0(3) $ & cyclic of order $q-1$ & 3-$(q-1, \frac{q-1}{3},\lambda)$ \\
$q$ odd & cyclic of order $q$ & 3-$(q,\frac{q}{3},\lambda)$ \\
$q=p^{e}$ & abelian $p$ group & $p$-$(q, p^{l},\lambda)$, $l<e$ \\
\hline
\end{tabular}
\end{center}
\vspace{0.5 cm}
\begin{center}
Table 2. $t-$designs constructed from their corresponding normalizers.
\end{center}
\begin{center}
\begin{tabular}{|c|r|r|}
\hline
$q$ & group type & $t-(n,k,\lambda)$ \\
\hline $q$ odd & dihedral of order $2\,(q-1)$ & 3-$(2\,(q-1), q-1,\lambda)$ \\
$q$ even & dihedral of order $2\,(q+1)$ & 2-$(2\,(q+1), q+1,\lambda)$ \\
$q=p^{e}$ & Borel & $p$-$(q\,(q-1),(q-1),\lambda)$ \\
\hline
\end{tabular}
\end{center}
\vspace{0.5cm}
Recall that the dihedral group of order $2\,(q-1)$ (respectively of order $2\,(q+1)$) is generated by a rotation $\tau_{q-1}$ of order $(q-1)$, (respectively of order $2\,(q+1)$ and a reflection. In particular the discrete logarithm problem (DLP) applied to this group reads:
Given an element $h\in D_{2\,(q-1)}$ find an integer $m$ satisfying $\tau^{m}=h$. The smallest integer $m$ satisfying the identity is called the index of $h$ with respect to $\tau$, and is denoted as $m=log_{\tau}(h)$ or $m=ind_{\tau}(h)$.
The DLP is used as underlying hard problem in many cryptographic constructions, including for example Diffie-Hellman key exchange, \cite{DH}.
Solving DLP takes time that is exponential in the order of the group $G$. For example, the group defined by the elliptic curve over a finite field $\mathbb{F}_{p}$ takes time $O(\sqrt(p)$. For this reason, it is used for cryptographic purposes.
\subsection{Diffie-Hellman key exchange for dihedral groups}
In Diffie-Hellman key exchange cryptosystem, the public key is an element of a group $G$ of public knowledge, in the case of study is a dihedral group of order $2\,(q-1)$ generated by a reflection $\sigma$ of order 2, and a rotation $\tau$ of order $(q-1)$. The generating algorithm produces an element $\tau$ which is the public key. Observe that since the group generated by $\tau$ is cyclic of order $q-1$, its elements $1,\tau, \tau^{2},\ldots, \tau^{q-2}$ are roots of unity, that is, $x-\tau^{i}$ divides the polynomial $x^{n}-1$, and the code is cyclic. Moreover it is the RS code of length $n=q-1$ and dimension $k$.
There are two participants involved in the encryption process, participant $P_{1}$ and participant $P_{2}$.
A third party eavesdropping on this exchange must find it computationally infeasible to compute the key from the information overheard.
First par\-ti\-ci\-pant $P_{1}$ randomly choose a secret $0<d<(q-1)$ and computes $D=\tau^{d}$. Second participant $P_{2}$ randomly choose a secret $0<e<(q-1)$ and computes $E=\tau^{e}$. Participant $P_{1}$ sends $D$ to participant $P_{2}$, and $P_{2}$ sends $E$ to $P_{1}$. Then $P_{1}$ computes $E^{d}=\tau^{e\,d}$ and $P_{2}$ computes $D^{e}=\tau^{d\,e}$ so that both participants $P_{1}$ and $P_{2}$ have the shared value $\tau^{d\,e}$ up to reflection $\sigma\in D_{q-1}$. Thus computing $\tau^{e\,d}$ from $\tau^{e}$ requires solving the DLP $log_{\tau^{e}}(\tau^{e\,d})=d$.
At each time $t$, the probability of select the element $\tau^{j}$ is distributed as a Bernoulli distribution with $Pr(x=\tau^{j})=\left(\frac{1}{q}\right)^{j}(1-\frac{1}{q})^{j}, \, j\in \{0,1,\ldots q-1\}.$
\section{Relation of $t$-designs with graph networks}
A standard way to do natural language processing (NLP) are networks.
A sample graph is a network constructed from data that has been collected from a random sample of nodes. Many problems are motivated by the need to infer global properties of the parent network (population) from the sampled version. Counting the number of features in a graph is an important statistical and computational problem. These features are typically basic local structures like motifs or graphlets (e.g., patterns of small subgraphs).
One of the most important classes of graphs considered in this framework is that of Cayley graphs.
Consider a network represented by a directed multigraph
$G=(V(G),E(G))$, with vertex set $V(G)$ and edge set, $E(G)$ with error free unit capacity edges, that is, a graph with loops (edges whose endpoints are equal) and multiple edges.
A subset of the vertex set is called independent set, if there is no edge between vertices in $X$. A matching is a set of disjoint edges of a graph.
A clique in an undirected graph is a subset of its vertices such that every two vertices in the subset are connected by an edge. Let $G$ be a simple graph and $H$ a subgraph of $G$. A $G$-design of $H$ is a pair where $X$ is the vertex set of $H$ and $\mathcal{B}$ is an edge-disjoint decomposition of $H$ also known as partition of the vertex set.
We say $G$ is a split graph if the vertex set $V(G)$ can be partitioned into a clique $C$ and an independent set $I$, where $(C,I)$ is called a plot partition of $G$.
The best known cryptographic problem is that of privacy: preventing the an authorised extraction of information from communications over an insecure channel. In order to use cryptography to insure privacy, however, it is currently necessary for the communicating parties to share a key which is known to no one else.
For applications in data privacy, we are interested to identify subgraphs in the complete graph that are identical, this gives a measure of the degree of anonymity of the graph.
An automorphism is a permutation of the vertices of the network which preserves adjacency. The set of automorphisms under composition forms a group $\rm{Aut}(G )$ of size $a_{G}$ which compactly describes network symmetry. The orbit of a vertex $v\in V(G)$ is the set:
$$\triangle(v)=\{\pi v\in V(G):\, \pi\in \rm{Aut}(G)\}.$$
Automorphism group orbits naturally partition network vertices into disjoint structural equivalence classes. Since two vertices in the same orbit may be permuted without altering network adjacency, they are structurally equivalent in the strongest possible way: they play exactly the same structural role in the network.
Let $G$ be a network with automorphism group $\rm{Aut}(G)$. Let $1\neq S$ be a set of generators of $\rm{Aut}(G)$. Suppose that we partition $S$ into $n$ support-disjoint subsets $S=S_{1}\cup \ldots \cup S_{n}$ such that each $S_{i}$ cannot itself be decomposed into smaller support-disjoint subsets. Call $H_{i}$ the subgroup generated by $S_{i}$. Since $S$ is a generating set and elements from different factors $H_{i}, H_{j}$ commute, this procedure gives a direct product decomposition: $$\rm{Aut}(G)=H_{1}\times H_{2}\times\ldots \times H_{n}.$$
The network automorphism group decomposition relates automorphism group structure to network topology. Moreover, automorphism groups of real-world networks such as scientific collaboration networks or technological networks such as the internet can typically be decomposed into direct and wreath products of symmetric groups, (see \cite{BRJ}).
Reciprocally, given a group presentation $S$ of $\GL(n,\mathbb{F}_{q})$, we can attach to it a Cayley graph which is defined as the directed graph having one vertex associated with each group element and directed edges $(e_{1}, e_{2})$ whenever $e_{1}e_{2}^{-1} \in S$. The Cayley graph may depend on the choice of a generating set, and it is connected if and only if $S$ generates $\GL(n,\mathbb{F}_{q})$.
A subset $S$ of an additive group is called sum-free if it contains no elements $x, y, z$ such that $x+y=z$. In particular, this means the corresponding vertices constitute an independent set in the Cayley graph, (see \cite{KTSZ}). Moreover, there are two distinguished sets of vertices, the set of independent vertices $L$ which satisfy the property that there is no edge between two vertices and the complement graph
We pass from network topology to vector network coding by thinking of the vertex set $V(G)=\{a_{1},\ldots,a_{n}\}$ as an alphabet of $n$ letters and defining a vector space $V$ on these $n$-generators over a ground field $k$. There is a natural representation $\rho: S_{n}\rightarrow \GL(V)$, where $S_{n}$ is the group of permutations of $n$ elements. As we showed in \cite{BM1}, vector network coding and moreover codes over a finite field $\mathbb{F}_{q}$ are very much related with the study of the representation theory of the symmetric group over finite fields and further with the representation theory of $\GL(n,\mathbb{F}_{q})$ over finite fields. From this representation, one can recognise more easily patterns and extract information from them.
In terms of designs over $\mathbb{F}_{q}$, we want to understand which subspaces are invariant by the action of elements of the general linear group $\GL(n, \mathbb{F}_{q})$ or finite subgroups of $\GL(n,\mathbb{F}_{q})$. In this way, one can construct designs with prescribed groups where the blocks are the orbits by the action, and thus to generalise to other Galois extensions not necessarily cyclic.
The adjacency matrix of the graph is interpreted as the incidence matrix of the design. Recall that the adjacency matrix $A$ of a multigraph is a $n\times n$ matrix (where $n=|V|$) with rows and columns indexed by the elements of the vertex set and the $(x,y)$- entry is the number of edges connecting $x$ and $y$. If the graph is directed, the matrix $A$ is symmetric and therefore all its eigenvalues are real. The degree of a vertex $deg(v)$ is the number of edges incident with $v$, where we count a loop with multiplicity 2. The largest eigenvalue $\lambda$ of the adjacency matrix describes the spectrum character of the graph topology.
Given a $t$-design you can associate to it a regular graph, where the points are the nodes of the graph, all the nodes have the same degree and two different nodes are connected if and only if they are in the same block of the design, that is, the neighbors of the vertices are the blocks. Reciprocally given a $k$-regular graph on $v$ vertices, if any two distinct vertices have exactly $\lambda$ common neighbors it is a 2-$(v,k,\lambda)$ design.
It is also possible to design a code which matches the network graph. Then ${\rm{Aut}}(G)$ coincides with the automorphism group ${\rm{Aut}}(D)$ of the design.
\subsection{Set systems}
A set system is a pair $(X,\mathcal{A})$ such that $X$ is a finite set of points and $\mathcal{A}$ is a set of subsets of $X$, called blocks. The number of points, $|X|$, is the order of the set system. Let $K$ be a set of positive integers. A set system $(X,\mathcal{A})$ is said to be $K$-uniform if $|A|\in K$ for all $A\in \mathcal{A}$. Let $\mathcal{G}=\{G_{1},\ldots, G_{s}\}$ be a partition of $X$ into subsets called groups. The triple $(X,\mathcal{G},\mathcal{A})$ is a group divisible design $(GDD)$ when every 2-subset of $X$ not contained in a group appear in exactly one block and $|A\bigcup\,G|\leq 1$ for all $A\in \mathcal{A}$ and $G\in \mathcal{G}$. A 3-GDD in which all the groups are of size 1 is known as a Steiner triple system
\begin{prop} There is bijective correspondence between ordered basis sets of $(\mathbb{F}_{q})^{n}$ and set systems of order $n$. \end{prop}
{\it Proof.}
This correspondence can be established by associating to any list of $t$ elements contained in $\GL(n,q)$ a partition of $t$ groups of size the order of the corresponding element in $\GL(n,q)$. Namely, to any list $\{\gamma_{1},\ldots, \gamma{t}\}$ of $t$ elements we associate the subgroup $G_{\lambda}$ generated by these $t$ elements. This is a group of type $\lambda$ the partition of orders $\lambda_{i}=ord(\gamma_{i})$ ordered in increasing order $\lambda_{1}\geq \lambda_{2}\geq\ldots \lambda_{t}> 0$
We assume that $n\geq q-1$ and $G$ is a group containing a Singer cycle $\alpha\in \GL(n,q)$. Let $\Gamma(G_{\lambda})$ be the Cayley graph attached to the subgroup $G_{\lambda}$, that is, the graph in which vertices 1 through $t$ corresponding to each generator are placed in a row with each vertex connected by an unlabelled edge of its immediate neighbors . There is an action of the symmetric group $S_{n}$ on the combinatorial class $\mathcal{G}_{n}$ of regular graphs with $n$ vertices. For any $\sigma\in S_{n}$ and $g\in \mathcal{G}_{n}$, the graph $\sigma\cdot g$ has the same vertex set and edge set as $g$, but each label $i$ in $g$ is replaced by $\sigma^{-1}(i)$ in $\sigma\cdot g$, they are isomorphic graphs.
We define the following linear map over $(\mathbb{F}_{q})^{n}$:
\begin{equation}\label{eq1}\Phi(\Gamma(G_{\lambda}))(x)=A^{G_{\lambda}}_{t,k}\,x. \end{equation}
Here $A^{G}_{t,k}$ is the adjacency matrix of graph $\Gamma(G)$, thus it is a $\{0,1\}$ matrix with rows and columns indexed by the $t$-subspaces and the $k$-subspaces of $\mathbb{F}^{n}_{q}$.
In particular, constructing $t-$designs over $\mathbb{F}_{q}$ is equivalent to solving the systems of linear Diophantine equations \ref{eq1}. There is a 1 in row $X$ and column $Y$ of M iff $t-$subspaces $X$ is contained in $k-$subspaces Y. With this definition, a $t-(n,k,\lambda)$ design over $\mathbb{F}_{q}$ is precisely a $\{0,1\}$ solution to $A^{G}_{t,k}x=(\lambda, \lambda, \ldots, \lambda)^{T}$, where $\lambda$ is the number of $k-$subspaces containing at least a $t$-subspace, in particular $rank\,(A^{G}_{t,k})\geq t$.
\hfill$\Box$
\subsection{r-designs constructed from the projective line}
Let $X$ be a $v$-set and $\mathcal{P}_{k}(X)$ denote the set of all $k$-subsets of $X$.
A $t-(v,k,\lambda)$-design is a set system $\mathcal{D}=(X,D)$ in which $D$ is a collection of $\mathcal{P}_{k}(X)$ (called blocks) such that every $t$-subset of $X$ appears in exactly $\lambda$-blocks
A 2-$(v,k,\lambda)$ design is a collection $\mathcal{B}$ of elements of $\mathcal{P}_{k}(X)$ (called blocks) such that every line of the incidence structure $(\mathcal{P}(X),\mathcal{B}(X), I)$ intersect $\mathcal{B}$ in exactly $\lambda$ points.
A 3-$(v,k,\lambda)$ design is a collection of $\mathcal{B}$ of elements of $\mathcal{P}_{k}(X)$ (called blocks) such that any triple $(r_{1},r_{2},r_{3})$ of points is collinear. Such sets are called lines in $\mathcal{B}$ and every line intersect $\mathcal{B}$ in exactly $\lambda$ points. In general $r$-designs admitting $\PG(2,q)$ as a group of automorphisms are known as $(k;r)$ arcs
Let $V$ be a 3-dimensional vector space over $\mathbb{F}_{q}$ and consider the projective plane $PG(2,q)$ defined by the incidence structure $(\mathcal{P}(V),\mathcal{B}(V), I)$.
\begin{defi} A $(k;r)$-arc $\mathcal{K}$ in $PG(2,q)$ is a set of $k$-points such that some $r$, but not $r+1$ of them are collinear. In other words, some line of the plane meets $\mathcal{K}$ in $r$ points and no more than $r$-points. A $(k;r)$-arc is complete if there is no $(k+1;r)$ arc containing it.
\end{defi}
\begin{defi} A $k$-arc is a $(k;n,n-1;n,p)$ set with $n\geq 3$ of $k$-points such that, every subset of $s$ points with $s\leq n$ points is linearly independent.
\end{defi}
Following the classification of conjugacy classes in $PG(2,q)$ in \cite{SG}, next Lemma classifies designs constructed from the projective line.
\begin{lemma} There are 3 types of $r$
designs constructed from $\PG(2,q)$: unipotent type, semisimple split or semisimple non-split according to the eigenvalues of the representation matrix of the generating elements in $\PG(2,q)$
\end{lemma}
{\it Proof.} If the characteristic polynomial $P(\lambda)$ of the representation matrix $A$ has only one root, call it $\alpha$, it is a primitive element of order $p$ a prime number, then the derived design is called unipotent. It is an arc containing $p+1$ points and for $n<p$ every set of $n+1$ points are linearly independent. If $P(\lambda)$ has two different roots $a, a^{-1}\in \mathbb{F}^{*}_{q}$, $tr(A)=a+a^{-1}$ is an element $\alpha$ of order dividing $\frac{q-1}{d}$. The corresponding design is called semisimple split, and finally if there are no roots, $tr(A)=a+a^{q}=\alpha$, where $a\in \mathbb{F}^{*}_{q^{2}}\backslash \mathbb{F}^{*}_{q}$ is an element $\alpha$ dividing $\frac{q+1}{d}$, the corresponding design is called semisimple non-split.
\hfill$\Box$
We associate to the 2-design generated by $\tau$ and $\sigma$ the graph which has as vertex set $V$ the points of the projective system $\mathbb{P}((\mathbb{F}_{2})^{m})$ and edge set $E\subseteq [V]^{2}$ the lines of the projective space which corresponds to the blocks of the design. There are $\left[
\begin{matrix}
m \\
2\\
\end{matrix}
\right]_{q}$ lines. For any two points there are as much blocks (lines) containing these points as eigenspaces $W_{j}$ by the action of the linear operators $\tau$ and $\sigma$. This special design with parameters $t=2$ and $k=3$ is a Steiner triple system.
The automorphism group of the projective line $\mathbb{P}(\mathbb{F}_{q})$ is the projective linear group $\PGL(2,q)$. Any finite subgroup $A\subset \PGL(2,q)$ defines a $k-$uniform Cayley (sum) hypergraph $\Gamma^{k}(A)$ whose vertices are the generating $k-$tuples of $A$ and the edges are $k-$element sets $\{x_{1},\ldots,x_{k}\}\in {G\choose k} $ represented by random variables $x_{1},\ldots, x_{k}$. In particular, if $f(z)$ is the ordinary generating function that enumerates $A$, that is, number of conjugacy classes in $A$, then $\frac{1}{1-f(z)}$ is the ordinary generating function enumerating sequences of $k$ elements in $A$. If $G$ is an abelian group, then $x_{1}+\cdots+x_{k}\in A$. In general, we will consider $k$-arcs in $\Gamma(A)$ which represent casual connections between the variables.
The group $\GL(n,q)$ acts transitively on subsets of size $n+1$ of the projective line whenever $q\equiv n+1 (mod\, n+2)$. We can construct secret sharing schemes from configurations of points of size $n+1$ on the projective line. Moreover we can construct secret sharing schemes from configuration of points on curves admitting a transitive linear action. Let $p$ be a prime number and $p\geq n+2$, then the Normal Rational Curve defined as:
$$\mathcal{V}^{n}_{1}:=\Big\{F (1,x,x^{2},\ldots,x^{n})| \ x\in \mathbb{F}_{p}\bigcup \{\infty\}\Big\}$$
is an example of a $(p+1)$-arc. It contains $p+1$ points, and every set of $n+1$ points are linearly independent.
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 2,020 |
using MongoDB.Bson;
using MongoDB.Driver;
using MongoDB.Driver.Linq;
using System;
using System.Linq;
using System.Text;
using Webdisk.Backend.Models;
namespace Webdisk.Backend.Helpers
{
/// <summary>
/// 用户辅助类
/// </summary>
public static class UserHelper
{
/// <summary>
/// 用户信息集合
/// </summary>
public static IMongoCollection<User> UserCollection => MongoInstance.BasicDatabase.GetCollection<User>("user");
/// <summary>
/// 用户信息 LINQ 对象
/// </summary>
public static IMongoQueryable<User> UserQueryable => UserCollection.AsQueryable();
/// <summary>
/// 从 HTTP Basic Authorization 字符串获取用户
/// </summary>
/// <param name="auth">HTTP Basic Authorization 字符串</param>
/// <returns>用户信息</returns>
public static User GetByAuth(string auth)
{
var strlist = Encoding.Default.GetString(Convert.FromBase64String(auth)).Split(':');
var name = strlist[0];
var pass = strlist[1];
return GetByNameAndPassword(name, pass);
}
/// <summary>
/// 从用户名密码获取信息
/// </summary>
/// <param name="username">用户名</param>
/// <param name="password">原始密码</param>
/// <returns>用户信息</returns>
public static User GetByNameAndPassword(string username, string password)
{
var query = from p in UserQueryable
where p.Username == username
where p.Password == CryptoHelper.GetMd5String(password)
select p;
var result = query.ToList();
return result.FirstOrDefault();
}
/// <summary>
/// 查找用户是否存在
/// </summary>
/// <param name="username">用户名</param>
/// <returns>是否存在</returns>
public static bool isExisted(string username)
{
var query = from p in UserQueryable
where p.Username == username
select p;
return query.ToList().Count != 0;
}
/// <summary>
/// 注册用户
/// </summary>
/// <param name="username">用户名</param>
/// <param name="password">原始密码</param>
/// <returns>用户信息</returns>
public static User Register(string username, string password)
{
if (isExisted(username)) throw new ApplicationException("User is existed.");
UserCollection.InsertOne(new User()
{
Username = username,
Password = CryptoHelper.GetMd5String(password),
Usage = 0,
Files = new FileInfo()
{
Id = new ObjectId(Guid.NewGuid().ToString("n")),
IsFolder = true,
Metadata = new FileMetadata()
{
Name = "root",
UploadTime = DateTime.Now
}
}
});
return GetByNameAndPassword(username, password);
}
}
} | {
"redpajama_set_name": "RedPajamaGithub"
} | 367 |
namespace arrow {
namespace r {
SEXP symbols::units = Rf_install("units");
SEXP symbols::xp = Rf_install(".:xp:.");
SEXP symbols::dot_Internal = Rf_install(".Internal");
SEXP symbols::inspect = Rf_install("inspect");
void inspect(SEXP obj) {
Rcpp::Shield<SEXP> call_inspect(Rf_lang2(symbols::inspect, obj));
Rcpp::Shield<SEXP> call_internal(Rf_lang2(symbols::dot_Internal, call_inspect));
Rf_eval(call_internal, R_GlobalEnv);
}
} // namespace r
} // namespace arrow
| {
"redpajama_set_name": "RedPajamaGithub"
} | 8,417 |
There is so much to see in Sicily; towering mountains, ancient Roman ruins, scenic gorges, not to mention the most active volcano in Europe. With the slow rail network, irregular bus service and crowded tourist coaches, the best way by far to explore the island is to rent a car.
Twelve car hire companies have desks in the arrivals hall of Palermo Airport and, with the wide variety of vehicles on offer, there will be something to suit you. You can wait until you get to the airport to organise your car hire but, to make sure the type of vehicle you want is available and to get the best deal, booking in advance online is the safest option.
Car hire comparison websites give you a wide choice of vehicles and at wildly varying prices. However, before you dive in and book that "bargain", check the small print. There can be hidden extras which make the price somewhat less attractive.
Some companies increase their profits by selling you a full tank of fuel at a premium price and tell you to return the car empty, which is very difficult, so you will be paying for fuel that you don't use. Look for a "full to full" fuel policy.
Insurance is another item to look at closely. Basic cover is included but you might have to leave a large deposit if you don't buy their expensive full cover. You can take out extra cover when you book at a lower price. A better alternative is to take out your own rental car excess policy which is very cost-effective and gives you peace of mind.
On arriving at the rental desk, if you booked in advance, the agent will ask for your booking reference, the credit card you secured the booking with, your passport and driving licence. Since the UK did away with the paper counterpart of the licence British drivers will need a code with which your driving record can be checked. Details are on the government website here.
It's worth taking some time to thoroughly check the car inside and out for any damage. Make a note on the rental form of anything and take photos so you have evidence that damage was pre-existing.
Give yourself time to get used to the controls and make yourself comfortable.
Top of the must-see list in Sicily is Mount Etna, at 3,295 metres one of the highest volcanoes in Europe and certainly the most active.
The historic city of Taormina sits on the east coast in the shadow of Mount Etna. Winding streets with medieval buildings take you back in time. The focal point is the Greco-Roman amphitheatre with vistas over the azure sea.
The most historical site in Sicily is Valle dei Templi (The Valley of the Temples) in Agrigento on the central south coast. The eight temples of the gods sit among the almond trees in the scenic valley.
You can get off the beaten track and visit Cava Grande del Cassibile, a ten-kilometre canyon in a nature park close to the town of Avola. The winding Cassibile river forms lakes where you can swim in the chilly waters. It is a tough climb down to the bottom of the canyon and an even harder climb back up, but the beauty of the area makes it worth the effort.
No visit to Sicily would be complete without going to the city of Syracuse. Steeped in history and renowned as the home of Archimedes, Syracuse has the power to enrapture your soul.
The island of Sicily has something to offer at every turn so forget the sat nav and just explore. | {
"redpajama_set_name": "RedPajamaC4"
} | 1,402 |
Q: Submit a POST request to controller on submit TYPO3? I have a problem submitting a post request to controller. I Created a new table in database Product. I created after the model, Repository and Controller. Then I registered in the plugin the method list which gets a list of product. It works very well but in the List.html I have put a form where I want to submit something to the same controller where list is but this time is a POST method. I get action is not allowed by this plugin/module.
[ext_localconf.php]
/***************
* Custom PLugins
*/
ExtensionUtility::configurePlugin(
'youtube_demo',
'InventoryList',
[
StoreInventoryController::class => 'list',
],
[StoreInventoryController::class => '',],
);
[StoreInventoryController]
<?php
namespace Contencance\YoutubeDemo\Controller;
use Contencance\YoutubeDemo\Domain\Repository\ProductRepository;
use TYPO3\CMS\Extbase\Mvc\Controller\ActionController;
/**
* Class StoreInventoryController
*
* @package MyVendor\StoreInventory\Controller
*/
class StoreInventoryController extends ActionController
{
/**
* @var ProductRepository
*/
private $productRepository;
/**
* Inject the product repository
*
* @param \MyVendor\StoreInventory\Domain\Repository\ProductRepository $productRepository
*/
public function injectProductRepository(ProductRepository $productRepository)
{
$this->productRepository = $productRepository;
}
/**
* list Action
*
* @return void
*/
public function listAction()
{
$products = $this->productRepository->findAll();
$this->view->assign('products', $products);
}
/**
* store Action
*
* @return void
*/
public function storeAction()
{
var_dump("Hellow World");
die();
}
}
I tried adding the "Store" method in ext_location.php but it got called imediatly I want it only when submitting.
[List.html]
<table border="1" cellspacing="1" cellpadding="5">
<tr>
<td>Product name</td>
<td>Product description</td>
<td>Quantity</td>
</tr>
<f:for each="{products}" as="product">
<tr>
<td align="top">{product.name}</td>
<td align="top"><f:format.crop maxCharacters="100">{product.description}</f:format.crop></td>
<td align="top">{product.quantity}</td>
</tr>
</f:for>
</table>
<f:form action="store" controller="StoreInventory" objectName="gamingData" method="post">
<label>Enter</label><br>
<f:form.textfield property="game-desc" /><br>
<f:form.button>Submit</f:form.button>
</f:form>
A: You need to add store to the list of methods in your ext_localconf.php, that's correct.
But you need to add it after list => list, store.
The first entry in the list is executed by default (if no action given).
Full code:
ExtensionUtility::configurePlugin(
'youtube_demo',
'InventoryList',
[
StoreInventoryController::class => 'list, store',
],
[StoreInventoryController::class => '',],
);
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 144 |
La Charme – francuska gmina w regionie Franche-Comté
Le Charme – francuska gmina w Regionie Centralnym
Charmé – francuska miejscowość i gmina w regionie Poitou-Charentes
La Charmée – francuska gmina w regionie Burgundia | {
"redpajama_set_name": "RedPajamaWikipedia"
} | 7,684 |
{"url":"https:\/\/everything.explained.today\/Singular_homology\/","text":"# Singular homology explained\n\nSingular homology should not be confused with singular homology of abstract algebraic varieties.\n\nIn algebraic topology, singular homology refers to the study of a certain set of algebraic invariants of a topological space X, the so-called homology groups\n\nHn(X).\n\nIntuitively, singular homology counts, for each dimension n, the n-dimensional holes of a space. Singular homology is a particular example of a homology theory, which has now grown to be a rather broad collection of theories. Of the various theories, it is perhaps one of the simpler ones to understand, being built on fairly concrete constructions (see also the related theory simplicial homology).\n\nIn brief, singular homology is constructed by taking maps of the standard n-simplex to a topological space, and composing them into formal sums, called singular chains. The boundary operation \u00a0- mapping each n-dimensional simplex to its (n-1)-dimensional boundary \u00a0- induces the singular chain complex. The singular homology is then the homology of the chain complex. The resulting homology groups are the same for all homotopy equivalent spaces, which is the reason for their study. These constructions can be applied to all topological spaces, and so singular homology is expressible as a functor from the category of topological spaces to the category of graded abelian groups.\n\n## Singular simplices\n\nA singular n-simplex in a topological space X is a continuous function (also called a map)\n\n\\sigma\n\nfrom the standard n-simplex\n\n\\Deltan\n\nto X, written\n\n\\sigma:\\Deltan\\toX.\n\nThis map need not be injective, and there can be non-equivalent singular simplices with the same image in X.\n\nThe boundary of\n\n\\sigma,\n\ndenoted as\n\n\\partialn\\sigma,\n\nis defined to be the formal sum of the singular (n\u00a0-\u00a01)-simplices represented by the restriction of\n\n\\sigma\n\nto the faces of the standard n-simplex, with an alternating sign to take orientation into account. (A formal sum is an element of the free abelian group on the simplices. The basis for the group is the infinite set of all possible singular simplices. The group operation is \"addition\" and the sum of simplex a with simplex b is usually simply designated a\u00a0+\u00a0b, but a\u00a0+\u00a0a\u00a0=\u00a02a and so on. Every simplex a has a negative -a.) Thus, if we designate\n\n\\sigma\n\nby its vertices\n\n[p0,p1,\\ldots,pn]=[\\sigma(e0),\\sigma(e1),\\ldots,\\sigma(en)]\n\ncorresponding to the vertices\n\nek\n\nof the standard n-simplex\n\n\\Deltan\n\n(which of course does not fully specify the singular simplex produced by\n\n\\sigma\n\n), then\n\n\\partialn\\sigma=\\partialn[p0,p1,\\ldots,pn]=\\sum\n\n n(-1) k=0\n\nk[p0,\\ldots,pk-1,pk+1,\\ldots,pn]=\n\n n \\sum k=0\n\n(-1)k\\sigma\\mid\n\n e0,\\ldots,ek-1,ek+1,\\ldots,en\n\nis a formal sum of the faces of the simplex image designated in a specific way.[1] (That is, a particular face has to be the restriction of\n\n\\sigma\n\nto a face of\n\n\\Deltan\n\nwhich depends on the order that its vertices are listed.) Thus, for example, the boundary of\n\n\\sigma=[p0,p1]\n\n(a curve going from\n\np0\n\nto\n\np1\n\n) is the formal sum (or \"formal difference\")\n\n[p1]-[p0]\n\n.\n\n## Singular chain complex\n\nThe usual construction of singular homology proceeds by defining formal sums of simplices, which may be understood to be elements of a free abelian group, and then showing that we can define a certain group, the homology group of the topological space, involving the boundary operator.\n\nConsider first the set of all possible singular n-simplices\n\n\\sigman(X)\n\non a topological space X. This set may be used as the basis of a free abelian group, so that each singular n-simplex is a generator of the group. This set of generators is of course usually infinite, frequently uncountable, as there are many ways of mapping a simplex into a typical topological space. The free abelian group generated by this basis is commonly denoted as\n\nCn(X)\n\n. Elements of\n\nCn(X)\n\nare called singular n-chains; they are formal sums of singular simplices with integer coefficients.\n\n\\partial\n\nis readily extended to act on singular n-chains. The extension, called the boundary operator, written as\n\n\\partialn:Cn\\toCn-1,\n\nis a homomorphism of groups. The boundary operator, together with the\n\nCn\n\n, form a chain complex of abelian groups, called the singular complex. It is often denoted as\n\n(C\\bullet(X),\\partial\\bullet)\n\nor more simply\n\nC\\bullet(X)\n\n.\n\nThe kernel of the boundary operator is\n\nZn(X)=\\ker(\\partialn)\n\n, and is called the group of singular n-cycles. The image of the boundary operator is\n\nBn(X)=\\operatorname{im}(\\partialn+1)\n\n, and is called the group of singular n-boundaries.\n\nIt can also be shown that\n\n\\partialn\\circ\\partialn+1=0\n\n, implying\n\nBn(X)\\subseteqZn(X)\n\n. The\n\nn\n\n-th homology group of\n\nX\n\nis then defined as the factor group\n\nHn(X)=Zn(X)\/Bn(X).\n\nThe elements of\n\nHn(X)\n\nare called homology classes.[2]\n\n## Homotopy invariance\n\nIf X and Y are two topological spaces with the same homotopy type (i.e. are homotopy equivalent), then\n\nHn(X)\\congHn(Y)\n\nfor all n \u2265 0. This means homology groups are homotopy invariants, and therefore topological invariants.\n\nIn particular, if X is a connected contractible space, then all its homology groups are 0, except\n\nH0(X)\\congZ\n\n.\n\nA proof for the homotopy invariance of singular homology groups can be sketched as follows. A continuous map f: XY induces a homomorphism\n\nf\\sharp:Cn(X)Cn(Y).\n\nIt can be verified immediately that\n\n\\partialf\\sharp=f\\sharp\\partial,\n\ni.e. f# is a chain map, which descends to homomorphisms on homology\n\nf*:Hn(X)Hn(Y).\n\nWe now show that if f and g are homotopically equivalent, then f* = g*. From this follows that if f is a homotopy equivalence, then f* is an isomorphism.\n\nLet F : X \u00d7 [0, 1] \u2192 Y be a homotopy that takes f to g. On the level of chains, define a homomorphism\n\nP:Cn(X)Cn+1(Y)\n\nthat, geometrically speaking, takes a basis element \u03c3: \u0394nX of Cn(X) to the \"prism\" P(\u03c3): \u0394n \u00d7 IY. The boundary of P(\u03c3) can be expressed as\n\n\\partialP(\\sigma)=f\\sharp(\\sigma)-g\\sharp(\\sigma)-P(\\partial\\sigma).\n\nSo if \u03b1 in Cn(X) is an n-cycle, then f#(\u03b1) and g#(\u03b1) differ by a boundary:\n\nf\\sharp(\\alpha)-g\\sharp(\\alpha)=\\partialP(\\alpha),\n\ni.e. they are homologous. This proves the claim.[3]\n\n## Homology groups of common spaces\n\nThe table below shows the k-th homology groups\n\nHk(X)\n\nof n-dimensional real projective spaces RPn, complex projective spaces, CPn, a point, spheres Sn(\n\nn\\ge1\n\n), and a 3-torus T3 with integer coefficients.\nSpaceHomotopy type\nRPn[4]\n\nZ\n\nk = 0 and k = n odd\n\nZ\/2Z\n\nk odd, 0 < k < n\n0otherwise\nCPn[5]\n\nZ\n\nk = 0,2,4,...,2n\n0otherwise\npoint[6]\n\nZ\n\nk = 0\n0otherwise\nSn\n\nZ\n\nk = 0,n\n0otherwise\nT3[7]\n\nZ\n\nk = 0,3\n\nZ\n\n3\nk = 1,2\n0otherwise\n\n## Functoriality\n\nThe construction above can be defined for any topological space, and is preserved by the action of continuous maps. This generality implies that singular homology theory can be recast in the language of category theory. In particular, the homology group can be understood to be a functor from the category of topological spaces Top to the category of abelian groups Ab.\n\nConsider first that\n\nX\\mapstoCn(X)\n\nis a map from topological spaces to free abelian groups. This suggests that\n\nCn(X)\n\nmight be taken to be a functor, provided one can understand its action on the morphisms of Top. Now, the morphisms of Top are continuous functions, so if\n\nf:X\\toY\n\nis a continuous map of topological spaces, it can be extended to a homomorphism of groups\n\nf*:Cn(X)\\toCn(Y)\n\nby defining\n\nf*\\left(\\sumiai\\sigmai\\right)=\\sumiai(f\\circ\\sigmai)\n\nwhere\n\n n\\to \\sigma i:\\Delta\n\nX\n\nis a singular simplex, and\n\n\\sumiai\\sigmai\n\nis a singular n-chain, that is, an element of\n\nCn(X)\n\n. This shows that\n\nCn\n\nis a functor\n\nCn:Top\\toAb\n\nfrom the category of topological spaces to the category of abelian groups.\n\nThe boundary operator commutes with continuous maps, so that\n\n\\partialnf*=f*\\partialn\n\n. This allows the entire chain complex to be treated as a functor. In particular, this shows that the map\n\nX\\mapstoHn(X)\n\nis a functor\n\nHn:Top\\toAb\n\nfrom the category of topological spaces to the category of abelian groups. By the homotopy axiom, one has that\n\nHn\n\nis also a functor, called the homology functor, acting on hTop, the quotient homotopy category:\n\nHn:hTop\\toAb.\n\nThis distinguishes singular homology from other homology theories, wherein\n\nHn\n\nis still a functor, but is not necessarily defined on all of Top. In some sense, singular homology is the \"largest\" homology theory, in that every homology theory on a subcategory of Top agrees with singular homology on that subcategory. On the other hand, the singular homology does not have the cleanest categorical properties; such a cleanup motivates the development of other homology theories such as cellular homology.\n\nMore generally, the homology functor is defined axiomatically, as a functor on an abelian category, or, alternately, as a functor on chain complexes, satisfying axioms that require a boundary morphism that turns short exact sequences into long exact sequences. In the case of singular homology, the homology functor may be factored into two pieces, a topological piece and an algebraic piece. The topological piece is given by\n\nC\\bullet:Top\\toComp\n\nwhich maps topological spaces as\n\nX\\mapsto(C\\bullet(X),\\partial\\bullet)\n\nand continuous functions as\n\nf\\mapstof*\n\n. Here, then,\n\nC\\bullet\n\nis understood to be the singular chain functor, which maps topological spaces to the category of chain complexes Comp (or Kom). The category of chain complexes has chain complexes as its objects, and chain maps as its morphisms.\n\nThe second, algebraic part is the homology functor\n\nHn:Comp\\toAb\n\nwhich maps\n\nC\\bullet\\mapstoHn(C\\bullet)=Zn(C\\bullet)\/Bn(C\\bullet)\n\nand takes chain maps to maps of abelian groups. It is this homology functor that may be defined axiomatically, so that it stands on its own as a functor on the category of chain complexes.\n\nHomotopy maps re-enter the picture by defining homotopically equivalent chain maps. Thus, one may define the quotient category hComp or K, the homotopy category of chain complexes.\n\n## Coefficients in R\n\nGiven any unital ring R, the set of singular n-simplices on a topological space can be taken to be the generators of a free R-module. That is, rather than performing the above constructions from the starting point of free abelian groups, one instead uses free R-modules in their place. All of the constructions go through with little or no change. The result of this is\n\nHn(X;R)\n\nwhich is now an R-module. Of course, it is usually not a free module. The usual homology group is regained by noting that\n\nHn(X;Z)=Hn(X)\n\nwhen one takes the ring to be the ring of integers. The notation Hn(X; R) should not be confused with the nearly identical notation Hn(X, A), which denotes the relative homology (below).\n\nThe universal coefficient theorem provides a mechanism to calculate the homology with R coefficients in terms of homology with usual integer coefficients using the short exact sequence\n\n0\\toHn(X;Z)R\\toHn(X;R)\\toTor(Hn-1(X;Z),R)\\to0.\n\nwhere Tor is the Tor functor.[8] Of note, if R is torsion-free, then Tor(G, R) = 0 for any G, so the above short exact sequence reduces to an isomorphism between\n\nHn(X;Z)R\n\nand\n\nHn(X;R).\n\n## Relative homology\n\nSee main article: Relative homology. For a subspace\n\nA\\subsetX\n\n, the relative homology Hn(X, A) is understood to be the homology of the quotient of the chain complexes, that is,\n\nHn(X,A)=Hn(C\\bullet(X)\/C\\bullet(A))\n\nwhere the quotient of chain complexes is given by the short exact sequence\n\n0\\toC\\bullet(A)\\toC\\bullet(X)\\toC\\bullet(X)\/C\\bullet(A)\\to0.\n\n[9]\n\n## Reduced homology\n\nSee main article: Reduced homology. The reduced homology of a space X, annotated as\n\n\\tilde{H}n(X)\n\nis a minor modification to the usual homology which simplifies expressions of some relationships and fulfils the intuiton that all homology groups of a point should be zero.\n\nFor the usual homology defined on a chain complex:\n\n...b\\overset{\\partialn+1\n\n}C_n\\oversetC_\\overset\\dotsb\\oversetC_1\\oversetC_0\\overset 0\n\nTo define the reduced homology, we augment the chain complex with an additional\n\nZ\n\nbetween\n\nC0\n\nand zero:\n\n...b\\overset{\\partialn+1\n\n}C_n\\oversetC_\\overset\\dotsb\\oversetC_1\\oversetC_0\\overset \\mathbb \\to 0\n\nwhere\n\n\\epsilon\\left(\\sumini\\sigmai\\right)=\\sumini\n\n. This can be justified by interpreting the empty set as \"(-1)-simplex\", which means that\n\nC-1\\simeq\\Z\n\n.\n\nThe reduced homology groups are now defined by\n\n\\tilde{H}n(X)=\\ker(\\partialn)\/im(\\partialn+1)\n\nfor positive n and\n\n\\tilde{H}0(X)=\\ker(\\epsilon)\/im(\\partial1)\n\n. [10]\n\nFor n > 0,\n\nHn(X)=\\tilde{H}n(X)\n\n, while for n = 0,\n\nH0(X)=\\tilde{H}0(X)Z.\n\n## Cohomology\n\nSee main article: Cohomology. By dualizing the homology chain complex (i.e. applying the functor Hom(-, R), R being any ring) we obtain a cochain complex with coboundary map\n\n\\delta\n\n. The cohomology groups of X are defined as the homology groups of this complex; in a quip, \"cohomology is the homology of the co [the dual complex]\".\n\nThe cohomology groups have a richer, or at least more familiar, algebraic structure than the homology groups. Firstly, they form a differential graded algebra as follows:\n\nThere are additional cohomology operations, and the cohomology algebra has addition structure mod p (as before, the mod p cohomology is the cohomology of the mod p cochain complex, not the mod p reduction of the cohomology), notably the Steenrod algebra structure.\n\n## Betti homology and cohomology\n\nSince the number of homology theories has become large (see), the terms Betti homology and Betti cohomology are sometimes applied (particularly by authors writing on algebraic geometry) to the singular theory, as giving rise to the Betti numbers of the most familiar spaces such as simplicial complexes and closed manifolds.\n\n## Extraordinary homology\n\nIf one defines a homology theory axiomatically (via the Eilenberg\u2013Steenrod axioms), and then relaxes one of the axioms (the dimension axiom), one obtains a generalized theory, called an extraordinary homology theory. These originally arose in the form of extraordinary cohomology theories, namely K-theory and cobordism theory. In this context, singular homology is referred to as ordinary homology.\n\n## References\n\n\u2022 Allen Hatcher, Algebraic topology. Cambridge University Press, and\n\u2022 J.P. May, A Concise Course in Algebraic Topology, Chicago University Press\n\u2022 Joseph J. Rotman, An Introduction to Algebraic Topology, Springer-Verlag,\n\n## Notes and References\n\n1. Hatcher, 105\n2. Hatcher, 108\n3. Theorem 2.10. Hatcher, 111\n4. Hatcher, 144\n5. Hatcher, 140\n6. Hatcher, 110\n7. Hatcher, 142-143\n8. Hatcher, 264\n9. Hatcher, 115\n10. 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# Interpersonal Relationships
# Professional Communication Skills for Nurses
**Sixth Edition**
Elizabeth C. Arnold, PhD, RN, PMHCNS-BC
Associate Professor, Retired, University of Maryland, Baltimore, Maryland
Family Nurse Psychotherapist, Montgomery Village, Maryland
Kathleen Underman Boggs, PhD, FNP-CS
Family Nurse Practitioner
Associate Professor Emeritus, College of Health and Human Services, University of North Carolina Charlotte, Charlotte, North Carolina
# Table of Contents
Cover image
Title page
Copyright
Dedication
Acknowledgments
Preface
Chapter 1: Theoretical Perspectives and Contemporary Dynamics
Basic concepts
Applications
Summary
Chapter 2: Professional Guides to Action in Interpersonal Relationships
Basic concepts
Applications
Using the nursing process in nurse-client relationships
Summary
Chapter 3: Clinical Judgment: Applying Critical Thinking and Ethical Decision Making
Basic concepts
Ethical reasoning
Critical thinking
Applications
Participation in clinical research
Solving ethical dilemmas in nursing
Professional values acquisition
Applying critical thinking to the clinical decision-making process
Summary
Chapter 4: Self-Concept in the Nurse-Client Relationship
Basic concepts
Definition
Applications
Self-efficacy
Summary
Chapter 5: The Nurse-Client Relationship
Basic concepts
Key concepts in therapeutic relationships
Applications
Chapter 6: Bridges and Barriers in the Therapeutic Relationship
Basic concepts
Applications
Steps in the caring process
Strategies for empowerment
Application of empathy to levels of nursing actions
Reduction of barriers in nurse-client relationships
Respect for personal space
Violations of confidentiality
Avoiding cross-cultural dissonance
Summary
Chapter 7: Role Relationship Patterns
Basic concepts
Applications
Chapter 8: Losses and Endings
Basic concepts
Death: the final loss
Theoretical framework: stages of dying
Palliative care
Concepts of grief and grieving
Patterns of grieving
Applications
Key issues and approaches in end-of-life care
Addressing cultural and spiritual needs in end-of-life care
Supportive strategies for children
Helping clients achieve a good death
Stress issues for nurses in palliative care settings
Summary
Chapter 9: Communication Styles
Basic concepts
Applications
Chapter 10: Developing Therapeutic Communication Skills
Basic concepts
Purpose of therapeutic communication
Client-centered communication
Applications
Active listening responses
Verbal responses
Other forms of communication
Specialized communication strategies
Cognitive behavioral strategies
Using technology in communication
Summary
Chapter 11: Intercultural Communication
Basic concepts
Intercultural communication
Cultural competence
Applications
Care of the culturally diverse client
Features of key cultural groups
Summary
Chapter 12: Communicating in Groups
Basic concepts
Applications
Summary
Chapter 13: Communicating with Families
Basic concepts
Theoretical frameworks
Applications
Applying the nursing process
Planning
Family-centered relationships in the community
Evaluation
Summary
Chapter 14: Resolving Conflict Between Nurse and Client
Basic concepts
Nature of conflict
Causes of conflict
Why work for conflict resolution?
Understanding own personal responses to conflict
Types of conflict: intrapersonal versus interpersonal
Functional uses of conflict
Nature of assertive behavior
Dysfunctional conflict
Principles of conflict resolution
Applications
Assessing the presence of conflict in the nurse-client relationship
Nursing strategies to enhance conflict resolution
Interpersonal conflict interventions
Summary
Chapter 15: Health Promotion and Client Learning Needs
Basic concepts
National health promotion and disease prevention agendas
Theory frameworks for health promotion
Applications
Health promotion strategies at the community level
Learner variables in education for health promotion
Summary
Chapter 16: Health Teaching in the Nurse-Client Relationship
Basic concepts
Domains of learning
Theoretical frameworks
Applications
Health teaching applications in different settings
Summary
Chapter 17: Communicating with Clients with Communication Disabilities
Basic concepts
Legal mandates
Types of deficits
Applications
Early recognition of communication deficits
Assessment of current communication abilities
Communication strategies
Client advocacy
Summary
Chapter 18: Communicating with Children
Basic concepts
Applications
Assessment
Communicating with children with psychological behavioral problems
Communicating with physically ill children in the hospital and ambulatory clinic
Preschoolers
Interacting with parents of ill children
Community, family, and nurse partnerships
Summary
Chapter 19: Communicating with Older Adults
Basic concepts
Applications
Supportive planning and intervention strategies in nurse-client relationships
Assessment and support interventions for cognitively impaired older adults
Summary
Chapter 20: Communicating with Clients in Stressful Situations
Basic concepts
Applications
Summary
Chapter 21: Communicating with Clients in Crisis
Basic concepts
Theoretical frameworks
Applications
Mental health emergencies
Crisis management
Helping children cope with trauma
Summary
Chapter 22: Communication for a Safe Environment
Basic concepts
Applications
New teaching strategies to help nurses learn to communicate for safer care
Team training: models of communication strategies for collaborative practice
Technology-oriented solutions create a climate of client safety to avoid errors
Other technology used to improve safe care
Improve care efficiency
Client outcomes of team training programs
Client-provider collaborations
Summary
Chapter 23: Communicating with Other Health Professionals
Basic concepts
Applications
Chapter 24: Communicating for Continuity of Care
Basic concepts
Current challenges in health care delivery
Continuity of care for chronic conditions
Applications
Creating relational continuity
Patient (client)-centered care
Relational continuity: professional perspectives
Informational continuity
Handoff care transitions
Case management
Advocacy at the community level
Summary
Chapter 25: Documentation in the Age of the Electronic Health Record
Basic concepts
Applications
Chapter 26: Communicating at the Point of Care: Application of eHealth Information Technology
Basic concepts
Applications
Summary
Glossary
Photograph Credits
Index
# Copyright
INTERPERSONAL RELATIONSHIPS: PROFESSIONAL COMMUNICATION SKILLS FOR NURSES, SIXTH EDITION
ISBN: 978-1-4377-0944-5
**Copyright © 2011, 2007, 2003, 1999, 1995, 1989 by Saunders, an imprint of Elsevier Inc.**
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
**Notices**
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
International Standard Book Number: 978-1-4377-0944-5
_Managing Editors:_ Jean Fornango and Michele D. Hayden
_Developmental Editors:_ Maria Broeker and Heather D. Bays
_Publishing Services Manager:_ Deborah Vogel
_Design Direction:_ Kim Denando
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
# Dedication
**To Jacob D. Goering, PhD**
His influence on my life as an educator and clinician was life changing and long lasting.
_Elizabeth C. Arnold_
**In Memoriam, Richard Daniel Underman, beloved brother.**
_Kathleen Underman Boggs_
# Acknowledgments
This sixth edition of _Interpersonal Relationships: Professional Communication Skills for Nurses_ continues to reflect the ideas and commitment of our students, valued colleagues, clients, and the editorial staff at Elsevier. As noted in earlier editions, the origin of the text began in conjunction with the development of an interpersonal relationship seminar at the University of Maryland School of Nursing. This seminar was designed by faculty to facilitate understanding of therapeutic communication across clinical settings through experiential simulations. Developing effective communication was important then, and it remains central to effective clinical practice in contemporary health care. The vitality of its contents reflects the commitment of faculty and students from many nursing programs and clinical nurses who have deepened the understanding of the materials presented in this text through their positive support, ideas, and constructive feedback. Their voices still find consistent expression in each chapter of this revision.
We acknowledge important past and present faculty and student contributors to the development of _Interpersonal Relationships: Professional Communication Skills for Nurses,_ in particular, Verna Benner Carson, PhD, RN, PCNS (Chapter 8); Judith W. Ryan, PhD, RN, CRNP (Chapter 19); Michelle Michael, PhD, APRN, PNP; Barbara Harrison, RN, PMH-NP; Ann O'Mara, PhD, RN, AOCN, FAAN; Barbara Dobish, MS, RN; Anne Marie Spellbring, PhD, RN, FAAN; Kristin Bussell, MS, RN, CS-P; Patricia Harris, MS, APRN, NP; and Jacqueline Conrad, BS, RN, from the University of Maryland, and Ann Mabe Newman, DSN, RN, CS (Chapter 4); and David R. Langford, RN, DSNc, from the University of North Carolina Charlotte.
This book is the result of the unique team effort of several talented developmental editors who worked hard to make the process of revision as seamless as possible. We are most grateful for their expertise and commitment to the completion of this book. Each went out of her way to make the revision a positive, quality experience. Tiffany Trautwein worked with us during the first part of the preparation for this edition. Maria Broeker stepped in during the next phase of the text, and Heather D. Bays worked with us to finish the book in the final phase of the project. Maria Broeker deserves special acknowledgment for her dedication to the preparation of this book. Her support and encouragement have been invaluable. We also express our appreciation to Jeff Somers from Graphic World Publishing Services, who coordinated the final production of this book for publication, and to Jeanne Robertson for the revised artwork in this edition.
Finally, we acknowledge the loving support of our families and Michael J. Boggs for their unflagging support and encouragement.
Elizabeth C. Arnold and Kathleen Underman Boggs
# Preface
Recognition of the importance of therapeutic communication and professional relationships with clients and families as a primary means of achieving treatment goals in health care continues to be the underlying theme in _Interpersonal Relationships: Professional Communication Skills for Nurses._ This sixth edition has been thoroughly revised, rewritten, and updated to meet the challenge of continuing to serve as a primary communication resource for nursing students and professional nurses. Although the content, exercises, and case examples continue to be written in terms of nurse-client relationships, they are applicable to clinical practice relationships conducted by other health care providers. This edition, like previous editions can be used as individual teaching modules, as a primary text, or as a communication resource integrated across the curriculum. Two new chapters related to communication strategies for client safety, and contemporary realities in continuity of care reflect the latest applications of communication in contemporary health care delivery.
The text is divided into five parts, using a similar format to that of previous editions. Part I, Conceptual Foundations of Nurse-Client Relationships, provides a theory-based approach to therapeutic relationships and communication in nursing practice, and identifies professional, legal, and ethical standards guiding professional actions. Chapters on the relevance of critical thinking and understanding of self-concept aid the students' comprehension of the many variables involved in communication. Part II, The Nurse-Client Relationship, discusses the fundamental structure and characteristics of effective nurse-client relationships and alliances, taking into account the context of short-term realities found in contemporary health care systems. Chapter 7, Role Relationship Patterns, establishes a framework for considering the issues surrounding new models of nursing education and explores role relationships as a nursing diagnosis. This section ends with a comprehensive discussion about palliative care and communication strategies in end-of-life care. Part III, Therapeutic Communication, explores basic concepts of therapeutic communication and applications of strategies nurses can use with different population groups: culturally diverse, family, and group communication. Applying therapeutic communication strategies in conflict situations and special attention to health promotion community strategies and health teaching complete this section. Part IV, Responding to Special Needs, focuses on the special communication needs of children, older adults, clients with communication deficits, and those experiencing stress or crisis. Part V, Professional Communication, describes communication issues with other health professionals and nursing applications in the use of electronic health records with accompanying taxonomies. Two new chapters address issues in contemporary health care related to the role of communication in promoting safety in the health care environment and principles related to supporting continuity of care within and across care settings. Major changes in managing health care data and transmitting vital health information including the place of the Internet for continual transmission of information in real time are addressed. The role of electronic communication as an increasingly important form of communication is highlighted at point of care and across clinical settings.
Each chapter is designed to illuminate the connection between theory and practice by presenting basic concepts, followed by clinical applications, using updated references and instructive case examples. _Developing an Evidence-Based Practice_ boxes offer a summary of a research article related to each chapter subject and are intended to stimulate awareness of the need to link research with practice. The _Ethical Dilemmas_ presented at the end of each chapter offer the student an opportunity to reflect on common ethical situations, which occur on a regular basis in health care relationships. The art program for the sixth edition has been enhanced with photos and drawings, which provide contemporary visual representations of chapter concepts.
Experiential exercises provide students with the opportunity to practice, observe, and critically evaluate their professional communication skills in a safe learning environment. The learning exercises are planned to encourage self-reflection about how one's personal practice fits with the larger picture of contemporary nursing, health practice models, and interdisciplinary communication. Through active experiential involvement with relationship-based communication principles, students can develop confidence and skill with using patient-centered communication in real-life clinical settings. The comments and reflections of other students provide a unique, enriching perspective on the wider implications of communication in clinical practice.
The text gives voice to the centrality of communication as the basis for helping clients, families, and communities make sense of relevant health issues and develop effective ways of coping with them. Our hope is that the sixth edition will continue to serve as a primary reference source for nurses seeking to improve their communication and relationship skills across traditional and nontraditional community-based health care settings. As the most consistent health care provider in many clients' lives, the nurse bears an awesome responsibility to provide communication that is professional, honest, empathetic, and knowledgeable in a person-to-person relationship that is without equal in health care. As nurses, we are answerable to our clients, our profession, and ourselves to communicate with clients in a therapeutic manner and to advocate for their health care and well-being in the larger sociopolitical community. We invite you as students, practicing nurses, and faculty to interact with the material in this text, learning from the content and experiential exercises but also seeking your own truth and understanding as professional health care providers.
_Instructor Resources_ are available on the textbook's Evolve Web site. Additional experiential exercises can be found in the _Instructor's Manual,_ together with strategies for teaching and learning, and brief chapter summaries with teaching tips. A revised Test Bank reflecting the updated content in the text is also included. Instructors are encouraged to contact their Elsevier sales representative to gain access to these valuable teaching tools.
Elizabeth C. Arnold and Kathleen Underman Boggs
CHAPTER 1
# Theoretical Perspectives and Contemporary Dynamics
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Describe the role of nursing theory in clinical practice, education, and research.
2 Discuss the historical development of nursing theory.
3 Describe the different types and levels of nursing theory.
4 Identify relevant nursing theory frameworks used in the nurse-client relationship.
5 Identify applications of psychodynamic, developmental, and behavior concepts in nurse-client relationships.
6 Describe the use of communication theory in nursing practice.
7 Discuss contemporary social perspectives and dynamics that influence nurse-client relationships in clinical practice.
Every nurse, regardless of specialty, uses the nurse-client relationship as a fundamental means for providing safe, effective, patient-centered nursing care. The nurse-client relationship is based on an integration of scientific evidence-based practice (EBP) guidelines and values-based application of nursing principles in health care.
This chapter introduces selected theory frameworks and contemporary perspectives related to communication and the nurse-client relationship. Included in this chapter are concepts related to nursing, developmental, psychological, and communication theories. A brief introduction to changes in the health care system and contemporary issues influencing nursing practice and the nurse-client relationship is included.
## Basic concepts
The discipline of nursing
Monti and Tingen (2006) define **discipline** as "a community of interest that is organized around the accumulated knowledge of an academic or professional group" (p. 28). Nurses globally represent the largest group of health care providers and are in a unique position to have a major impact on present and future nursing practice. They can be expected to take a key role in mapping a quality health care system in which nurses will increasingly support individuals and communities in self-managing their own health. As part of a collaborative team of health care professionals, nurses are able to seamlessly and appropriately link clients with health services and health professionals at the right time, across health care settings. Electronic records and communication technologies provide nurses with capabilities and clinical supports that were not possible even a decade ago, to assist clients at entry points to an increasingly complex health care system. According to Donaldson and Crowley (1978), the discipline of nursing is concerned with the following factors:
• "Principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well;
• Patterning of human behavior in interaction with the environment in critical life situations; and
• Processes by which positive changes in health status are affected." (p. 113)
Nurses see clients at their most vulnerable in health situations.
### Nursing theory
The fundamental knowledge base required of nurses includes human growth and development, pathophysiology, pharmacology, epidemiology, genetics, immunology, microbiology, health assessment and chronic disease management, psychology, and sociology. The theoretical foundations of nursing are drawn from philosophy, theory, research, and the practice wisdom of the profession (Smith & Liehr, 2008).
A **theory** represents a theorist's thoughtful examination of a phenomenon, defined as a concrete situation, event, circumstance, or condition of interest. Theory defines the relationships among its concepts, assumptions, and propositions in a formal, systematic manner, and provides a conceptual foundation for nursing research studies (Polit & Beck, 2007).
#### **Types** of theory
Four types of theory are used in nursing practice, education, and research:
• _Descriptive theory_ describes the properties and components of nursing as a professional discipline and explains what is important about the phenomenon.
• _Explanatory theory_ identifies the functions of nursing and describes how the properties and components relate to each other.
• _Predictive theory_ forecasts the relationships between the components of the model, how they occur, and what happens if an intervention is applied.
• _Prescriptive theory_ identifies the conditions under which relationships occur and focuses on nursing therapeutics (Polit & Beck, 2007).
#### Historical development
Theory development is essential to maintaining the truth of any discipline (Reed & Shearer, 2007). The first nursing theorist was Florence Nightingale. She wrote the first published work on nursing theory, in which she differentiated the practice of nursing from other disciplines. She linked health with the environmental factors and offered guidelines for influencing the client's environment to help clients heal. In her classic work _Notes on Nursing,_ Nightingale demonstrated through medical statistics that environmental cleanliness and hand washing were major factors in preventing infection in clinical situations. An early advocate for high-quality care, Nightingale's use of statistical data marks her as one of the first nurse researchers (Dossey et al., 2005; Kudzma, 2006).
Nursing theory development was relatively dormant until the middle of the 20th century, when nursing leaders in major universities began to describe a theoretical body of knowledge unique to professional nursing. Their graduate students provided ideas, struggled to understand the language and meaning of concepts, critiqued ideas, and developed important research studies to test the validity of nursing concepts (Fawcett, 2005).
Because nursing practice is embedded in a sociocultural context, nursing theory as a framework for practice has evolved as new information developed _._ Early nursing theorists, such as Virginia Henderson (1966) and Dorothy Johnson, supported the medical model, which focused primarily on identifying and modifying illness and disability. Modern nursing theorists, such as Rosemarie Parse and Betty Newman, incorporate a stronger emphasis on health promotion, client strengths, and preventive nursing strategies to facilitate health and well-being in line with today's conceptualization of health and well-being.
#### Nursing's metaparadigm
Nursing's metaparadigm, or worldview, distinguishes the nursing profession from other disciplines and emphasizes its unique functional characteristics. Four key concepts—person, environment, health, and nursing—form the foundation for all nursing theories. Although each theorist's theoretical interpretation differs, person, environment, health, and nursing are reflected as central constructs in all nursing theories (Marrs & Lowry, 2006). Despite major transformational changes in the health care system from a medical model to a public health model, the conceptual strength of person, environment, health, and nursing as the cornerstone of nursing theory persists.
Concept of Person: **Person,** defined as the recipient of nursing care, is considered from a holistic perspective as having unique biopsychosocial and spiritual dimensions. The term _person_ is applied to individuals, family units, the community, and target populations such as the elderly or mentally ill. Personal factors "comprise features of the individual that are not part of a health condition or health states" (World Health Organization [WHO], 2001, p. 17). For example, gender, lifestyle, coping styles, habits, among others, are a part of person, to be considered in conjunction with health and environment factors. The complexity of "person" as a key concept in nursing is evidenced in the increasingly robust explanations provided by current nursing theorists (Greene, 2009). Knowledge of the client as a person—his or her preferences, perceptions, beliefs, and values—is combined with the nurse's self-awareness as a basic understanding needed in all professional nursing relationships. This knowledge is an essential characteristic of "patient-centered care" currently identified as a central goal for the nation's health care system (Institute of Medicine [IOM], 2001; Shaller, 2007). Preserving and protecting a client's basic integrity and health rights as a unique individual is a unique ethical responsibility of nurse to client, whether the person is a contributing member of society, a critically ill newborn, a comatose client, or a seriously mentally ill individual. The concept of "person" supersedes health diagnosis, apart from and before a specific health care problem is considered (American Holistic Nurses Association, 2004).
Concept of Environment: **Environment** refers to the internal and external context of the client, as it shapes and is affected by a client's health care situation. The WHO (2001) states, "Contextual Factors include both personal and environmental factors" (p. 8). Person and environment are so intertwined that to consider person as an isolated variable in a health care situation is impracticable. The concept of environment includes the cultural, developmental, and biopsychosocial conditions that influence a client's perceptions or behavior. For example, poverty, education, religious or spiritual beliefs, type of community (rural or urban), family strengths and challenges, and access to resources are part of a client's environmental context. Even climate, space, pollution, and food choices are important dimensions of environment that nurses may need to consider in choosing the most appropriate nursing interventions. Hegyvary (2007) urges nurses to "take the lead in health ecology" (p. 103). The concept of environment and health ecology becomes increasingly important as health care becomes a global enterprise and nursing responsibility.
Concept of Health: Nursing actions emphasize health and well-being. The word _health_ derives from the word _whole._Weil (2004) defines **health** as "a dynamic and harmonious equilibrium of all elements and forces making up and surrounding a human being" (p. 51). The concept of health exists on a continuum, and encompasses the entire life span, beginning with birth, and including palliative care and a peaceful death. Health involves individuals, families, and communities as a multidimensional concept having physical, psychological, sociocultural, developmental, and spiritual elements. Health includes disease prevention and promoting healthy lifestyle behaviors, regardless of clinical diagnosis (Morgan & Marsh, 1998).
_Healthy People 2010_, the health agenda for the United States for the next decade, considers quality of life as a desired outcome of health and health promotion activities. **Quality of life** is defined as a personal experience of subjective well-being and general satisfaction with life that includes, but is not limited to, physical health. _Health is a social concern,_ particularly for people who do not have personal control over their health or the necessary resources to enhance their health status (Meleis, 1990). Exercise 1-1 provides an opportunity to explore the multidimensional meaning of health. Health is a cultural concern because people explain health, wellness, pathology, and treatment from the perspective of their cultural beliefs. For example, depression is explained as sadness in the Asian culture. Nurses play a major role in assessing health behaviors, and in recommending and working with individuals and families to achieve and maintain a healthy lifestyle.
EXERCISE 1-1 Understanding the Meaning of Health as a Nursing Concept
Purpose: To help students understand the dimensions of health as a nursing concept.
Procedure:
1. Write a one-page description about the characteristics of a healthy person that you know.
2. In small groups of three or four, read your stories to each other. As you listen to other students' stories, write down themes that you note.
3. Compare themes, paying attention to similarities and differences, and developing a group definition of health derived from the stories.
4. In a larger group, share your definitions of health and defining characteristics of a healthy person.
Discussion:
1. Were you surprised by any of your thoughts about being healthy?
2. Did your peers define health in similar ways?
3. Based on the themes that emerged, how is health determined?
4. Is illness the opposite of being healthy?
5. In what ways can a nurse support the health of a client?
Concept of Nursing: In 1956, Margaret Mead noted that nurses are invariably found wherever there is human pain and suffering. This statement has been expanded in modern times to include health promotion and disease prevention strategies designed to offset the occurrence of pain and suffering, and to minimize its effects once it has occurred. The International Council of Nursing (ICN) defines **nursing** as "encompassing autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings" (ICN, 2006).
The overarching goal of all nursing activities is to empower clients by providing them with the support they need to achieve optimal health and well-being. Nursing services are designed to build on and strengthen the natural capacities of individuals, families, and communities through a continuum of services ranging from health promotion and health education, to direct care, rehabilitation, and research evaluation.
Contemporary roles associated with nursing include advanced practice, community advocacy in shaping public health policies, and leadership in nursing management and education. Health behavior changes are strongly influenced by person-centered interventions promoted through normal nurse-client relationships. Exercise 1-2 looks at professional nursing.
EXERCISE 1-2 What Is Professional Nursing?
Purpose: To help students develop an understanding of professional nursing.
Procedure:
1. Interview a professional nurse. Ask for descriptions of what he or she considers professional nursing to be today, in what ways he or she thinks nurses make a difference, and how the nurse feels the role might evolve within the next 10 years.
2. In small groups of three to five students, discuss findings and develop a group definition of professional nursing.
Discussion:
1. What does nursing mean to you?
2. Is your understanding of nursing different from those of the nurse(s) you interviewed?
3. As a new nurse, how would you want to present yourself?
#### Levels of nursing theory
The levels of nursing theory are categorized according to their level of abstraction: grand theory, mid-range theory, and practice theory (Marrs & Lowry, 2006).
• **Grand theories** address the key concepts and principles of the discipline as a whole. Examples include Martha Rogers's theory of unitary beings, Margaret Neuman's theory of expanding consciousness, Parse's theory of human becoming, and Dorothea Orem's self-care deficit theory of nursing.
• **Mid-range theories** cover more discrete aspects of a phenomenon specific to professional nursing, exploring them in depth rather than exploring the full phenomena of nursing (Marrs & Lowry, 2006). To be classified as a mid-range theory, the concepts must be applicable to many nursing situations, easily recognized, operationalized in nursing practice, and capable of being tested (Whall, 2004). A mid-range theory can derive from a grand theory, or from inductive research methodologies such as concept analysis or grounded theory (Meleis, 2006). Examples include Peplau's theory of interpersonal relationships and Pender's theory of health promotion.
• **Practice theories** are the most limited form of nursing theory. Walker and Avant (2005) believe that practice theories should receive greater attention in guiding the direction of modern nursing. The value of practice theory lies in the development of situation-producing guidelines for EBP, based on the day-to-day experiences of professional nurses. Marrs and Lowry (2006) note that "practice theories may be as simple as a single concept that is operationalized, and may be linked to a special population or situation" (p. 47). Exercise 1-3 provides an opportunity to critique an article using nursing theory in clinical practice.
EXERCISE 1-3 Critiquing a Nursing Theory Article
Purpose: To provide students with an opportunity to understand the connection of nursing theory to research and clinical practice.
Procedure:
1. Select an article from a professional journal that describes the use of nursing theory or nursing concepts. Suggestions for journals include _Nursing Science Quarterly, Journal of Advanced Nursing, Journal of Professional Nursing,_ and _Advances in Nursing Science._
2. Read the article carefully and critique the article to include the following: (a) how the author applied the theory or concept; (b) relevance of the concept or theory for nursing practice; (c) how you could use the concept in your own clinical practice; and (d) what you learned from reading the article.
Discussion:
In your class group, share some of the insights you obtained from the article and engage in a general discussion about the relevance of nursing theory for professional nursing practice.
### Theory as a guide to practice
Donaldson and Crowley (1978) characterize a discipline as having "a unique perspective, a distinct way of viewing all phenomena, which ultimately defines and limits the nature of its inquiry" (p. 113). Nursing theory informs nursing practice by furnishing a distinct body of nursing knowledge that nurses universally recognize as being unique to their discipline. They offer a systematic, organized way to view and interpret nursing care. In addition, concepts, drawn from multiple interdisciplinary perspectives and sources, serve as a guide for curriculum development and clinical practice.
Nursing theories provide a basis for research and a framework for understanding study results. Theoretical frameworks guide nursing research by generating hypotheses that can be supported or refuted from a theoretical perspective. When the researcher completes a study, the discussion will contain an interpretation of the findings in relation to the identified theoretical framework.
#### The art of nursing
Theoretical understandings do not describe variations in a client's individual needs, perceptual or educational skills, or socioeconomic and cultural differences that require accommodations in therapeutic approach. This comes from the art of nursing, which includes caring and presence in combination with scientific applications to define nursing from a different, yet integrated perspective (Fingeld-Connett, 2008).
Integration occurs as a seamless interactive process in which nurses combine knowledge, skills, and scientific medical understandings with an individualized knowledge of the humanity of each client as a unique individual with physical, cognitive, emotional, and spiritual needs. Gramling (2004) describes the **art of nursing** as the "nurse's mode of being knowing, and responding" and suggests that it represents "an attunement rather than an activity" (p. 394). It is the element of care that nurses and clients tend to remember best.
Patterns of Knowing: In her classic work, Carper (1978) describes four patterns of knowing embedded in nursing practice: empirical, personal, aesthetic, and ethical. Although the patterns of knowing are described as individual prototypes, in practice, they inform care as an integrated focus of knowledge. Together they lay the epistemological and ontological foundation of nursing practice (Zander, 2007). Holtslander (2008) notes that "this integrated, inclusive, and eclectic approach is reflective of the goals of nursing, which are to provide effective, efficient, and compassionate care while considering individuality, context, and complexity" (p. 25). The four patterns of knowing include:
• **Empirical** ways of knowing, which are grounded in the science of nursing. Nurses incorporate empirical ways of knowing as the basis for scientific rationales when choosing appropriate nursing interventions.
• **Personal** ways of knowing, which help nurses connect with and acknowledge the humanness of another. Personal knowing occurs when a nurse is able to intuitively understand and treat individual clients as unique human beings because of the nurse's own personal experience and awareness of his or her own humanness.
• Carper equates esthetics with the art of nursing. **Aesthetic** ways of knowing are intangible, but they allow for creative applications in the relationship through meaningful connections with the larger environment and life experience. Esthetic ways of knowing link the art of nursing with its scientific application. An example of aesthetic ways of knowing is found in storytelling, in which the nurse seeks to understand the experience of the client's journey through illness (Leight, 2002). Nurses can use stories to clarify or enhance a variety of themes and supplement instructions.
• **Ethical** ways of knowing refer to the moral aspects of nursing. Ethical ways of knowing encompass knowledge of what is right and wrong, attention to standards and codes in making moral choices, responsibility for one's actions, and protection of the client's autonomy and rights (Altmann, 2007). Exercise 1-4 provides an application of patterns of knowing in clinical practice.
EXERCISE 1-4 Relevance of Patterns of Knowing for Clinical Practice
Purpose: To help students understand how patterns of knowing can be used effectively in clinical practice.
Procedure:
1. Break into smaller groups of three to four students. Identify a scribe for each student group.
2. Using the following case study, decide how you would use empirical, personal, ethical, and aesthetic patterns of knowing to see that Mrs. Jackson's holistic needs were addressed in the next 48 hours.
Case Study:
Mrs. Jackson, an 86-year-old widow, was admitted to the hospital with a hip fracture. She has very poor eyesight because of macular degeneration and takes eye drops for the condition. Her husband died 5 years ago, and she subsequently moved into an assisted housing development. She had to give up driving because of her eyesight and sold her car to another resident 5 months ago. Although her daughter lives in the area, Mrs. Jackson has little contact with her. This distresses her greatly, as she describes being very close with her until 8 years ago. She feels safe in her new environment but complains that she is very lonely and is not interested in joining activities. She has a male friend in the complex, but recently he has been showing less interest. Her surgery is scheduled for tomorrow, but she has not yet signed her consent form. She does not have advance directives.
Discussion:
1. In a large group, have each student share their findings.
2. For each pattern of knowing, write the suggestions on the board.
3. Compare and contrast the findings of the different groups.
4. Discuss how the patterns of knowing add to an understanding of the client in this case study.
Developing an Evidence-Based Practice
Awa M, Yamashita M: Persons' experience of HIV/AIDS in Japan: application of Margaret Newman's theory, _International Nursing Review_ 55:454–461, 2008.
This qualitative study was designed to describe the lived experience of clients diagnosed with HIV/AIDS using Margaret Newman's theory of health as expanding consciousness. The findings are based on the narratives of five men who had participated in a self-help group for men afflicted with HIV/AIDS. Each was interviewed twice, and study informants were asked to confirm, clarify, or revise the pattern inherent in his story. Expanding consciousness was noted as informants recognized the importance of significant personal relationships with family and significant others.
_Study Findings:_ Although their experiences were different, the five men experienced a unified sense of expanding consciousness described as an evolving five-stage pattern of the illness trajectory. The trajectory consisted of "a pattern of self consciousness of (their) own sexual orientation, chaos, stagnation, turning point and regaining a new identity" (p. 456). The process, enhanced by participation in a support group, allowed the men to accept their illness as a part of their identity and improved their ability to take responsibility for their actions. Acceptance of self and their chronic illness as part of the whole allowed for deeper, more enriching relationships with others. Peer support was acknowledged as an important facilitator of expanding consciousness.
_Application to Your Clinical Practice:_ As a profession, nurses need to develop theory-based research evidence to support effective practice. How do you see the role of self-help and support groups helping to improve the health and well-being of clients with chronic illness through expanded consciousness? What steps would you need to take as an individual nurse to encourage expanded consciousness as a part of your routine nursing care?
## Applications
Using nursing theory frameworks in clinical practice
Nursing theory and practice represent reciprocal interactive processes. Theory frameworks are used to guide critical thinking and actions in nursing practice; practice informs nursing theory. Different theories and nursing models provide a variety of lenses from which to approach the nursing process. This section addresses a short list of selected nursing theories with particular relevance for use with nurse-client relationships. Alligood (2010) notes a shift in the 21st century from theory development to a new era of theory applicability and utilization. Contemporary nurses will play an important role in this process.
#### Nursing theory and the therapeutic relationship
Hildegard Peplau's (1952; 1997) mid-range theory of interpersonal relationships is considered an essential nursing theory framework for the study of interpersonal relationships. The model describes how the nurse-client relationship can facilitate the identification and accomplishment of therapeutic goals to enhance client and family well-being (see Chapter 5). In today's health care environment, nurse-client relationships are of short duration, and nursing interventions have to be brief, concise, and effective. Despite the brevity of the relationship, Peplau's basic principles of building rapport, developing a working partnership, and terminating a relationship remain relevant. Originally conceptualized as a central phenomenon in psychiatric nursing, Peplau's framework for interpersonal relationships is applicable to all areas of nursing (McCarthy and Aquino-Russell (2009).
Holistic nursing theories focus on the meaning of a health experience and are used as guides in nurse-client relationships to help clients create a productive way of understanding and responding to difficult health situations. Exemplars include Rosemarie Parse's (1998) theory of human becoming and Margaret Newman's (1986) theory of expanding consciousness. Parse's theory, which focuses on valuing a person's health situation and quality of life from the client's perspective, is an important consideration in developing patient-centered approaches. Newman patterned her theory of health based on Martha Rogers's earlier theory of unitary human beings and interconnectedness with the environment. Her theory emphasizes mutual interaction between nurse and client unique to each client situation. Each therapeutic interaction is designed to move the human system toward making health choices that transcend physical limitations. Her theory is useful in helping clients with chronic illness find meaning in their situation through expanding consciousness about new possibilities for living with illness and maximizing patterns needed for health and well-being.
Caring: Caring is recognized as a hallmark of quality nursing practice and an essential concept in effective nurse-client relationships. Crowe (2000) suggests, "Caring does not involve specific tasks, instead it involves the creation of a sustained relationship with the other" (p. 966). Characteristics of professional caring, as identified by graduate nurses, include: (a) giving of self, (b) involved presence, (c) intuitive knowing and empathy, (d) supporting the patient's integrity, and (e) professional competence (Arnold, 1997). Caring is a relationship attitude and a commitment to the well-being of clients and families, demonstrated through actions for and on behalf of them.
Caring is a primary construct in nursing theories developed by Jean Watson (1988), and Madeleine Leininger (1985; 2002). Both theorists believe caring is central to the practice of nursing. Watson's theory promotes caring as a primary transpersonal value, and moral imperative concerned with protecting and preserving the dignity and humanity of the client. Her model describes the empathetic features of caring (Jasmine, 2009). Watson identified 10 carative factors, which are applicable to nurse client relationships (Box 1-1). These factors have, over time, evolved into a broader concept of "clinical caritas" and "caritas processes," terms that Watson considers to be a more fluid and mature framework for nursing in the 21st century. This expanded version is identified on Jean Watson's website: <http://www.nursing.ucdenver.edu/faculty/jw_evolution.htm>.
BOX 1-1 Watson's Carative Factors
1. The formation of a humanistic-altruistic system of values.
2. The instillation of faith-hope.
3. The cultivation of sensitivity to one's self and to others.
4. The development of a helping-trust relationship.
5. The promotion and acceptance of the expression of positive and negative feelings.
6. The systematic use of the scientific problem-solving method for decision making.
7. The promotion of interpersonal teaching-learning.
8. The provision for a supportive, protective, and (or) corrective mental, physical, sociocultural, and spiritual environment.
9. Assistance with the gratification of human needs.
10. The allowance for existential-phenomenological forces.
From Watson J: _Nursing: human science and human care: a theory of nursing_ (pp. 9–10), New York, 1988, National League for Nursing.
Leiniger's theory of cultural care expands on the concept of caring within a broader cultural context. Transcultural nursing theory incorporates cultural perspectives in applying relationship and nursing process concepts to culturally diverse clients. Leininger's sunrise diagram outlines the dimensions of cultural assessment).
### Theoretical perspectives from other disciplines
Professional nursing includes concepts and theoretical perspectives from other disciplines as a foundation for practice, related to the nurse-client relationship (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). Exemplar concepts from models are identified in this chapter and reintroduced in later chapters. They are not meant to be inclusive but were selected because of their relevance in implementing nurse-client relationships.
#### Psychodynamic models
Sigmund Freud (1937), acknowledged as the Father of Psychiatry, recognized the therapeutic value of talking about stressful life experiences as a way of reducing their impact, and problem-solving difficult life problems. Freud's ideas about **transference** , defined as projecting irrational attitudes and feelings from the past onto people in the present, are useful in understanding the origin of difficult behaviors in nurse-client relationships. For example, the client who says to the young nurse, "Get me a real nurse! You're young enough to be my daughter, and I don't want to talk with you about my personal life," may be having a transference reaction having little to do with the nurse's competence. Recognizing this statement as a transference reaction helps the nurse depersonalize the client's comment, allowing for a more appropriate response.
Transference feelings can also occur within the nurse. Unless these feelings are recognized and resolved, they can compromise the effectiveness of the therapeutic relationship. Referred to as **countertransference** , these feelings represent unconscious attitudes or exaggerated feelings a nurse may develop toward a client. Not all transference feelings are negative. Positive countertransferences of strong attraction, oversolicitousness, or special treatment can represent transference feelings that lead to boundary crossings or violations.
Freud was the first clinician to identify age-related sequential stages of personality development. His theory of linear psychosexual development focused on children from birth through adolescence. Failure to resolve stages of development result in immature behavioral response patterns such that the person remains "fixated" at an earlier stage of development. For example, a person experiencing little parental support in early childhood may find it difficult to trust that health providers will help.
Freud believed that people protect themselves against anxiety through the use of unconscious **ego defense mechanisms** (see Chapter 20). Defensive behaviors that compromise the development of a therapeutic relationship can reflect a person's use of ego defense mechanisms.
Carl Jung: Carl Jung's (1971) theoretical perspectives provide nurses with a basis for examining the complex dimensions of gender roles and our universal heritage as human beings. He referred to a person's universal heritage as the collective unconscious and suggested that forces from the past continue to influence behaviors in the present. Jung characterized the first half of life as a search for self, and the second half as a search for soul. Jung's personality theory for mid-life and beyond is relevant in helping nurses to understand and support the older adult's shifting needs to find new inner meaning and direction in the second half of life.
Interpersonal Relationship Approaches: Harry Stack Sullivan
Harry Stack Sullivan (1953) introduced the idea of the therapeutic relationship as a human connection that heals. Hildegard Peplau (1997) credits Sullivan's model of therapeutic relationship as a foundation for her mid range theory of interpersonal relationships in nursing practice. A corrective interpersonal experience with a helping professional can help individuals discover their strength and value through relationship.
Sullivan introduced the concept that people cannot always relate easily to a helping person and may need ongoing, compassionate, supportive encouragement to make use of the therapeutic relationship even when the helper is extremely empathetic. This is especially true for individuals experiencing shock, panic, serious mental illness, or brain damage. Further explanation of Sullivan's theory as it relates to therapeutic relationships is presented in Chapter 5.
#### Psychosocial development theories
Two developmental theories, adapted from psychology, guide the study of interpersonal relationships in health care. Nurses use Erik Erikson's (1950) theory of psychosocial development to assess developmental client needs, and to design _developmentally_ age-appropriate nursing interventions (see Chapter 4). Erikson modified Freud's age-related developmental stages to focus on progressive stages of psychosocial, rather than psychosexual, maturation. Erikson believed that people continue to mature throughout life. Exercise 1-5 offers an opportunity to review a person's perception of different developmental life stages.
EXERCISE 1-5 Completing the Life Cycle
Purpose: To help students understand the integration of psychosocial development through the life cycle.
Procedure:
1. Interview an adult who has reached at least the sixth decade of life.
2. Identify Erikson's psychosocial tasks, and ask the person to identify what factors in his or her life contributed to or interfered with mastery of the task for each stage.
3. Describe in short summary the factors that you believe contributed or interfered with each stage of the person's adult life.
Discussion:
1. In a larger group, share your examples.
2. For each stage, compile on the board a list of the factors identified.
3. Discuss the impact certain factors may have on the outcome of development through the life span.
Different life experiences and culture—for example, the death or divorce of a parent, frequent moves, family abuse, and ethnic norms—can affect the actual timetable and expression of psychosocial development of individuals. When life crises coincide with normal developmental crises, the developmental crisis can be more difficult to resolve, for example, a diagnosis of breast cancer occurring at menopause. Table 1-1 presents the key stage development theories. Exercise 1-6 provides an opportunity to look at the influence of life circumstances on psychosocial development.
EXERCISE 1-6 Time Line
Purpose: To give students experience with understanding psychosocial development through the life span.
Procedure:
1. Draw a time line of your life to date. Include all significant events and the age at which they occurred.
2. Insert Erikson's stages as markers in your time line.
Discussion:
1. In what ways did Erikson's stages provide information about expected tasks in your life?
2. In what ways did they deviate?
3. To what would you attribute the differences?
4. How could you use this exercise in your nursing care of clients?
TABLE 1-1
Distinguishing Freud's Psychosexual and Erikson's Psychosocial Stages of Personality Development
Data Source: Erikson E: Childhood and society, New York, 1950, WW Norton.Sigelma C, Rider E. Life-Span Human Development, 6th edition. Belvont CA: 2009, Wadsorth Cengage Learning.
Abraham Maslow: Nurses use Abraham Maslow's needs theory (1970) as a framework to _prioritize_ client needs and develop related nursing approaches. Maslow's hierarchy of needs theory proposes that people are motivated to meet their needs in an ascending order beginning with meeting basic survival needs, moving into psychological and social spheres as essential needs are satisfied, and ending with self-actualization. Figure 1-1 illustrates Maslow's model with associated nursing diagnoses.
Figure 1-1 Nursing diagnosis categories related to Maslow's hierarchy of needs.
Physiologic needs required for survival are the most fundamental. Maslow referred to basic needs as "deficiency" needs, meaning that if they cannot be met, the person is at risk for survival. Basic needs include satisfying hunger, thirst, and sexual appetites, and sensory stimulation. Maslow's second level, safety and security needs, includes physical safety and emotional security, for example, housing and freedom from abuse. Once a person meets safety and security needs, love and belonging needs, related to being a part of a family or community, become the focus. Basic need satisfaction allows for the attention to growth needs for self-esteem and self-actualization. A sense of dignity, respect, and approval by others for the self within is the hallmark of successfully meeting self-esteem needs.
Maslow's highest level of need satisfaction, self-actualization, represents humanity at its best. Self-actualized individuals are not superhuman; they are subject to the same feelings of insecurity that all individuals experience, but they recognize and accept their vulnerability as part of the human condition. Box 1-2 presents characteristics of self-actualization. Not everyone reaches Maslow's self-actualization stage.
BOX 1-2 Characteristics of Self-Actualization
• Quality of genuineness
• Passion for living
• Ability to get along well with others
• Strong sense of personal worth
• View of life situations as opportunities, not threats
• Ability to experience each moment fully
• Moments of intense emotional meaning, "peak experience"
• Full acceptance of self and others
• Identification with fellow human beings
• High sense of responsibility with a strong desire to serve humanity
• Integrity of purposes
Although nurses routinely use Maslow's theory to prioritize nursing interventions, how the client and/or family prioritize health care needs is an important assessment. This consideration will enhance client cooperation, and family support will affect compliance. Exercises 1-7 and 1-8 provide practice with using Maslow's model in clinical practice.
EXERCISE 1-7 Maslow's Hierarchy of Needs
Purpose: To help students understand the usefulness of Maslow's theory in clinical practice.
Procedure:
1. Divide the class into small groups, with each group assigned to a step of Maslow's hierarchy. Each group will then brainstorm examples of that need as it might present in clinical practice.
2. Identify potential responses from the nurse that might address each need.
3. Share examples with the larger group and discuss the concept of prioritization of needs using Maslow's hierarchy.
Discussion:
1. In what ways is Maslow's hierarchy helpful to the nurse in prioritizing client needs?
2. What limitations do you see with the theory?
EXERCISE 1-8 Case Application of Maslow's Theory
Purpose: To examine the use of Maslow's theory in a specific case.
Procedure:
In groups of three or four students, consider the following case study and apply Maslow's hierarchy of needs theory to Mr. Rodgers's case, from the time of admission to the coronary care unit until his discharge and follow-up care. Include any considerations for changing priorities because of fluctuations in his condition.
Case Study:
Mr. Rodgers was admitted to the cardiac intensive care unit with an acute myocardial infarction. He is an internationally known, middle-aged businessman, a corporate vice president of a major company, and very well liked by his employees. His blood pressure for the past two years has never fallen below a diastolic reading of 95, and he is being treated with a mild diuretic. Before this hospitalization, he had never been admitted to a hospital. Mr. Rodgers is anxious and perspiring profusely. He has many of the predisposing factors for heart problems present in his history, family, and lifestyle.
Discussion:
1. At what stage of Maslow's hierarchy is this client?
2. With what needs is the client likely to require nursing intervention during his hospitalization and after discharge?
3. In a large group, share your conclusions and recommendations for prioritizing Mr. Rodgers's care with a rationale.
#### Person-centered models
Carl Rogers: Carl Rogers's person-centered model forms a solid theoretical foundation for examining the current concepts of "client-centered care" as a key dimension of quality nurse-client relationships, as described in later chapters. Rogers emphasized an equal partnership between client and health care provider. He pointed to the primacy of client as the agent of healing. According to Rogers (1961), "If I can provide a certain type of relationship, the other person will discover within himself the capacity to use that relationship for growth and change, and personal development will occur" (p. 33).
Rogers identified three "helper" characteristics essential to the development of client-centered relationships: unconditional positive regard, empathetic understanding, and genuineness. He later added a fourth characteristic: a spiritual or transcendental presence as an intuitive way of being with a client (Anderson, 2001).
Rogers's concepts of a person-centered relationship also are applicable for nurse-client health teaching formats (see Chapter 16). They have found merit as a foundation for the patient-centered health care approaches advocated by the IOM.
Aaron Beck: Concepts from Aaron Beck's (1991) cognitive behavioral therapy (CBT) model uses a person-centered approach aimed at helping individuals troubled by faulty thinking reframe the meaning of difficult situations. Beck believed that there is a relationship between a person's thoughts, feelings, and behaviors. By helping people become aware of and modify negative or dysfunctional thoughts, beliefs, and perceptions (cognitive distortions), it is possible for individuals to change behavior patterns, resulting in a more constructive approach to a problem situation. The focus of treatment is not on the behavior itself, but rather on the internal perceptions and thoughts that create and perpetuate self-defeating behaviors. Table 1-2 identifies irrational beliefs and common triggers.
TABLE 1-2
Irrational Beliefs and Common Triggers
Orientation | Example | Common Triggers
---|---|---
Self | "I must do everything perfectly, and put 110% into everything I do. Otherwise, I will never be a good nurse." | Failing a test, being criticized by a client or instructor
Others | "Everyone must like and respect me. No one should be angry with me. I should always be able to get what I want, when I want it. Otherwise, I am not worth much." | Having someone cut in front of me, reject or challenge my opinions, waiting in line for services
World | "The world and everything in it should be predictable, and things should happen as I believe they should. Otherwise, there is no point to my doing anything." | Elections, allocation and availability of resources, taxes, lack of equal opportunities, prejudice
Faulty or negative thinking causes a person to interpret neutral situations in an unrealistic, exaggerated, or negative way. These automatic negative thoughts are classified as **cognitive distortions**. Examples include magnifying or minimizing the impact of a single behavior as being a commentary on the whole person, selective attention, mind reading, rigid rules about what a person "should" do, and so forth. Related to the concept of distortions is the concept of _schema or schemata._ This a term used to describe a person's learned rules and understandings of the stimulus world, and his/her relationship to it. A core schema becomes a template for understanding the meaning of incoming information and appraising its value to the self. It is more pervasive and harder to dislodge. Although distortions seem to be legitimate assessments, they are not valid. Cognitive distortions and schemata are related to behaviors of self, others, and the world (Hale-Evans, 2006).
Nurses can teach people to challenge distortions through Socratic questioning. By gathering and weighing evidence to support a position, people are able to distinguish between a distorted perception and a realistic appraisal of its validity. Ridding oneself of unrealistic expectations and negative self-thoughts allows cognitive space for thinking about possible options and broader choices. Once a problem is appropriately categorized, the solutions become more apparent.
### Communication theories
Communication theories are concerned with the transmission of information. Communication is an essential characteristic of human functioning. Through communication, we construct meaning and share it with others. Most of us take communication for granted until it is no longer a part of our lives. Communication can take place intrapersonally (within the self) or interpersonally (with others).
**Intrapersonal communication** takes place within the self in the form of inner thoughts and beliefs that are colored by feelings and influence behavior. **Interpersonal communication** is defined as a cyclic, reciprocal, interactive, and dynamic process, with value, cultural, and cognitive variables that influence its transmission and reception. Interpersonal communication has a content and a relationship dimension. The content dimension (verbal component) refers to the data. The relationship dimension (nonverbal metacommunication) helps the receiver interpret the message. People tend to pay more attention to nonverbal communication than to words when they are noncongruent with each other.
Human communication is unique. Only human beings have large vocabularies and are capable of learning new languages as a means of sharing their ideas and feelings. Communication includes language, gestures, and symbols to convey intended meaning, exchange ideas and feelings, and share significant life experiences. Basic assumptions serving as the foundation for the concept of communication are presented in Box 1-3.
BOX 1-3 Basic Assumptions of Communication Theory
• It is impossible not to communicate (Bateson, 1979).
• Every communication has a content and a relationship (metacommunication) aspect.
• We only know about ourselves and others through communication.
• Faulty communication results in flawed feeling and acting.
• Feedback is the only way we know that our perceptions about meanings are valid.
• Silence is a form of communication.
• All parts of a communication system are interrelated and affect one another.
• People communicate through words (digital communication) and through nonverbal behaviors and analog-verbal modalities, which are equally necessary to interpret a message appropriately.
• Interpersonal communication processes are either symmetric or complementary, and can reflect differences in the equality of the relationship (Waltzlawick, Beavin-Bevalas & Jackson, 1967).
#### Linear model
Linear models consist of three components:
• The **sender** is the source or initiator of the message. The sender encodes the message (i.e., puts the message into verbal or nonverbal symbols that the receiver can understand). Encoding a message appropriately requires a clear understanding of the receiver's mental frame of reference (e.g., feelings, personal agendas, past experiences) and knowledge of its purpose or intent.
• The **message** consists of the transmitted verbal or nonverbal expression of thoughts and feelings. Effective messages are relevant, authentic, and expressed in understandable language.
• The **receiver** is the recipient of the message. Once received, the receiver decodes it (i.e., translates the message into word symbols and internally interprets its meaning to make sense of the message). An open listening attitude and suspension of judgment strengthens the possibility of accurately decoding the sender's message. The **channels** of communication through which a person receives messages are the five senses: sight, hearing, taste, touch, and smell.
#### Circular transactional models
A circular model is a transactional model that expands linear models to include the context of the communication, feedback loops, and validation (Figure 1-2). With this model, the sender and receiver construct a mental picture of the other, which influences the message and includes perceptions of the other person's attitude and potential reaction to the message. In this sense, transactional models reflect system theory with feedback and context added to the linear model. Communication is conceptualized as a continuous, interactive activity in which sender and receiver continuously influence each other as they converse. The human system (client) receives information from the environment (input), internally processes the information and reacts to it based on its own internal functions (throughput), and produces new information or behavior (output) as a result of the process. Feedback (from the receiver or the environment) allows the system to correct or maintain its original information.
Figure 1-2 Circular transactional model of communication.
Circular models take into account the role relationships between communicators. People take either symmetric or complementary roles in communicating. Symmetric role relationships are equal, whereas complementary role relationships typically operate with one person holding a higher position than the other in the communication process. Nurses assume a complementary role of clinical expert when helping the client to achieve mutually determined health goals, and a symmetric role in working with the client as partner on developing mutually defined goals and the means to achieve them. Exercise 1-9 provides an opportunity to contrast linear versus circular models of communication.
EXERCISE 1-9 Differences Between Linear and Circular Models of Communication
Purpose: To help students see the difference between linear and circular models of communication.
Procedure:
1. Role-play a scenario in which one person provides a scene that might occur in the clinical area using a linear model: sender, message, and receiver.
2. Role-play the same scenario using a circular model, framing questions that recognize the context of the message and its potential impact on the receiver, and provide feedback.
Discussion:
1. Was there a difference in your level of comfort? If so, in what ways?
2. Was there any difference in the amount of information you had as a result of the communication? If so, in what ways?
3. What implications does this exercise have for your future nursing practice?
#### Therapeutic communication
Therapeutic communication is a term originally coined by Ruesch (1961) to describe a goal-directed form of communication used in health care to achieve goals that promote client health and well-being. Doheny et al. (2007) observed that "when certain skills are used to facilitate communication between nurse and client in a goal directed manner, the therapeutic communication process occurs" (p. 5). Nurses use therapeutic communication skills to provide new information, correct misinformation, promote understanding of client responses to health problems, explore options for care, assist in decision making, and facilitate client well-being.
### Contemporary social issues and dynamics
Theoretical frameworks sensitize nurses to perceive, think about, and act on relevant client information in a systematic way. In today's practice environment, theory is insufficient as a guide to practice. Recognition that nursing practice is deeply embedded in the political factors, and the cultural context in which nursing is practiced is critical. Engebretson (2003) notes that cultural constructions of health and illness determine the nature of helpful provider-client interactions and influence the ways in which people make decisions and use health care services. Many factors (e.g., economics, unprecedented changes in demographics, multidisciplinary approaches to health care delivery, and advances in technology) are changing nursing's professional landscape (Booth et al., 1997). Nurses must be knowledgeable about the contemporary societal issues and political dynamics that currently influence the conduct of the nurse-client relationship in fundamental ways. The clinical skill sets for nurses in the past need to be replaced with expanded competencies that reflect the changing health care delivery system.
#### Changes in health care delivery
A key change is a shift from health care delivery provided mainly in hospitals to care delivered in primary care settings in the community. Figure 1-3 displays fundamental characteristics of contemporary health care delivery systems. Science and technology are keeping people living longer with a better quality of life than could have been imagined even a few decades ago. Clients are discharged quicker and sicker than in previous decades, partly because of capitated management of health care. Most will require additional education and support to self-manage chronic health conditions. The emphasis in health care has changed from a focus solely on service delivery to an expanded population focus on health promotion for health and well-being. People are expected to take responsibility for their own health and well-being. These changes provide the impetus for exploring nursing practice from a broader perspective.
Figure 1-3 Characteristics of Contemporary Health Care Systems of Delivery.
As a result of these changes, the scope of practice and nature of work for contemporary nurses is multidimensional, multirelational, and highly complex. Managed care, the emergence of integrated interdisciplinary professional roles as the preferred model of provider service delivery, public reporting of clinical outcomes, and inclusion of client quality of life and satisfaction with care as expected clinical outcomes have revolutionized previous thinking about what needs to be included in nurse-client relationships. The length of the relationship is brief, with a focus on the client as the central person on the health care team.
Nurses practice across a wider range of clinical settings. They are expected to be multiskilled and able to function competently in a variety of health care environments. Health care relationships between clients and providers, and among interdisciplinary professional colleagues are collaborative and complementary.
Health care consumers expect more. They are better informed about their health conditions and are expected to take an active role in self-management of chronic diseases. The level of knowledge about health information on the Internet, medications, drug interactions, and health promotion/disease prevention strategies has increased exponentially.
New Professional and Consumer Roles: Nurses need to appreciate the larger number of stakeholders, including clients and families involved in health care relationships. Incorporating multiple perspectives in health care management across a continuum of care that extends into the community is the norm. Nurses are expected to have knowledge about and apply a variety of paradigms to real-life situations in clinical practice. Client roles have evolved from being passive recipients of health care into active autonomous partners, with providers involving shared authority over decision making in their treatment.
The context of the nurse-client relationship includes a broader connection with other clinicians, health care decision makers, and even occasionally policy makers. New interprofessional relationships are influencing the need for and provision of nursing services. Nurses have professional accountability, not only as a member of their profession but as members of a professional team. Instruction about interdisciplinary roles is evolving as a national curriculum thread in medical, nursing, social work, and pharmacy with combined student courses (see Chapter 7).
#### Demographic changes and health disparities
Health care in the United States is not equally accessible. There are glaring gaps in access to care, with many segments of a growing minority population receiving inadequate or no health care. Regulation and surveillance of quality in health care with reliance on performance measures to describe the nation's progress has made the quality of health care more transparent and has highlighted the plight of major segments of the nation's population (Institute of Medicine (IOM, 2003)).
Health disparities disproportionately impact the elderly, children, and minority populations. Demographic changes with a marked increase in the percentage of older adults and ethnically diverse consumers needing ongoing health care raise important ethical and medical issues.
_Healthy People 2010_ (U.S. Department of Health and Human Services, 2000) identifies "reducing health disparities" as a primary goal for health care. Appreciation for the rapidly increasing diversity of our society is compelling in health care, not only because of differences in health-related characteristics, but because of language, economic, and social barriers to seeking health care.
On March 23, 2010, President Obama signed an historic health care reform bill, passed by Congress. The Patient Protection and Affordable Care Act is designed to provide better health care insurance coverage for consumers of health care services. Included in the bill is health insurance for children with preexisting conditions, and access to affordable insurance for previously uninsured adults. Funding to increase the number of nurses, physicians, and other health professionals is included. Like all sweeping changes imposed by law, health care reform will take time to implement and will undergo modification as it is put into practice.
Health care reform is necessary to provide access to care and the level of health care services needed to reduce health disparities. Nurses can and should be in the forefront of helping the nation provide affordable, culturally congruent health care as an essential means of reducing health disparities.
#### Evidence-based practice
The IOM (2001) calls for an innovative health care system that is evidence based, patient centered, and systems oriented. Porter-O'Grady (2010) suggests that EBP represents an integration of client concerns and individual clinical applications with external evidence from clinical data and research, and best practices. The strength of the connection requires the blending of extensive clinical experience with sound clinical research and professional judgment in real-time situations with clients.
Quality nursing practice, implemented through the nurse-client relationship, is theory guided and evidence based. EBP is dynamically related to nursing theory through empirical ways of knowing. Nursing theory provides a reference framework for understanding the complex features of human responses in health care. This is a necessary, but insufficient condition for excellence. Since the late 1990s, EBP has emerged as a primary means to advance professional standards in nursing practice and to enhance the quality of care for clients (Van Achterberg, Holleman, & Van de Ven, 2006).
Sackett, Rosenberg, and Gray (1996) define EBP as "the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients" (p. 71). Systematic review of all randomized, controlled, clinical trials and EBP guidelines based on findings and opinions of expert committees provide the strongest evidence. EBP consists of four elements:
• Best practices, derived from consensus statements developed by expert clinicians and researchers
• Evidence from scientific findings in research-based studies found in published journals
• Clinical nursing expertise of professional nurses, including knowledge of pathophysiology, pharmacology, and psychology
• Preferences and values of clients and family members (Sigma Theta Tau International, 2003)
All health care disciplines are being called on to deliver quality health care according to standardized, evidence-based guidelines that in the future will be used "to define best practices rather than to support existing practices" (Youngblut & Brooten, 2001, p. 468).
#### Person-centered care
Scientific guidelines need to be balanced by values-based nursing knowledge. Person-centered care is mandated as an essential characteristic of contemporary health care. Ironically, it is a value that nursing has always championed. Gottlieb and Gottlieb (1998) identify nursing values important to health care in the 21st century as caring, holism, health promotion, continuity of care, family-based care, and working in partnership with individual and community agendas (see Chapters 15 and ).
Patterns of knowing help nurses individualize care tailored to the particular needs of each client (Mead, 2000; Fawcett, Watson, & Neuman, 2001). Issues related to making "the health care system patient centered and performance focused" include:
• "Continuous healing relationships,
• Customization as the source of control
• Shared knowledge and the free flow of information
• Safety as a system priority,
• Anticipation of patient needs rather than reacting to events" (Harris, 2001, p. 86)
In contemporary clinical practice, the client is recognized as a central person on the health care team. There is a clear assumption that clients and family will assume greater responsibility for maintaining health and well-being, as well as for primary self-management of chronic illness. Access to care, client safety, and continuity of care, health promotion, and maintenance of health represent an evolving emphasis in health care delivery. A person centered nursing framework developed by McCormack and McCance (2006) identifies environmental characteristics, pre-requisites and person centered outcomes associated with providing patient centered care.
Frist (2005) asserts that the focus of the 21st century health care system must be on the "patient, such that health care system will ensure that patients have access to the safest and highest-quality care, regardless of how much they earn, where they live, how sick they are, or the color of their skin" (p. 468). The concept of mutuality in treatment planning has been strengthened to include active involvement in shared decision making about treatment (Mead and Bower, 2000). New models of client-centered care can include shift reports in client rooms, reviewing care plans for the day early in the shift with clients, asking about their priorities, and working closely with other health team members to deliver quality care (Jasovsky, Morrow, Clementi, & Hindle, 2010).
#### System oriented continuity of care
Continuity of care delivered through a networked health care delivery system rather than an individualized clinical approach to health care is quickly becoming the norm in service delivery (see Chapter 24). The Pew Commission (Bellack & O'Neil, 2000) set forth 21 competencies that nurses will need to incorporate into their nursing care to be successful practitioners in the 21st century (Box 1-4). Communication skills and the development of team-based professional interpersonal relationships with clients, other professionals, and families will be key to achieving and integrating these competencies in health care delivery.
BOX 1-4 Pew Commission's Recommendations to Nursing Programs: 21 Nursing Competencies Needed for the 21st Century
1. Embrace a personal ethic of social responsibility and service.
2. Exhibit ethical behavior in all professional activities.
3. Provide evidence-based, clinically competent care.
4. Incorporate the multiple determinants of health in clinical care.
5. Apply knowledge of the new sciences.
6. Demonstrate critical thinking, reflection, and problem-solving skills.
7. Understand the role of primary care.
8. Rigorously practice preventive health care.
9. Integrate population-based care and services into practice.
10. Improve access to health care for those with unmet health needs.
11. Practice relationship-centered care with individuals and families.
12. Provide culturally sensitive care to a diverse society.
13. Partner with communities in health care decisions.
14. Use communication and information technology effectively and appropriately.
15. Work in interdisciplinary teams.
16. Ensure care that balances individual, professional, system, and societal needs.
17. Practice leadership.
18. Take responsibility for quality of care and health outcomes at all levels.
19. Contribute to continuous improvement of the health care system.
20. Advocate for public policy that promotes and protects the health of the public.
21. Continue to learn and help others learn.
From Bellack J, O'Neil E: Recreating nursing practice for a new century: recommendations and implications of the Pew Health Professions Commission's final report, _Nursing and Health Care Perspectives_ 21(1):20, 2000.
#### Advances in technology
Advances in technology have revolutionized health care delivery, documentation, and availability of medical information. With technology, communication is possible to any location at any time. Malloch (2010) notes, "What has not changed is the need for effective personal relationships in the evaluation and selection of new technologies; human to human sensitivity, acknowledgment, and respect for the patient care experience" (p. 1).
Nurses increasingly face the challenge of being present in relationships to clients and other health professionals in a digital age dominated by technology. Technologic advances such as the electronic house call, Internet support groups, and the virtual health examination are still in their infancy but may well take the place of office visits and become a major health care resource in the future, particularly in remote areas (Kinsella, 2003). Telehealth is fast becoming an integral part of the health care system, used both as a live interactive mechanism (particularly in remote areas, where there is a scarcity of health care providers) and as a way to track clinical data. Two important outcomes are reduction of health costs and access to care (Peck, 2005).
Telehealth technologies allow nurses a new level of interaction with clients and other health providers.
The Internet serves as a vital source of health information for consumers and health care providers, instantly linking them with current scientific and medical breakthroughs in diagnosis and treatment. Sophisticated technology allows health experts in geographically distant areas throughout the world to share information and to draw important conclusions about health care issues in real time. New technologies have the capacity to bring highly trained specialists into the home through the Internet and teleconferencing. Clark (2000) describes a "virtual" application of technology from the perspective of a Canadian nurse caring for a client in a remote area as it might occur in the year 2020.
Case Example
The computer gently hums to life as community health nurse Rachel Muhammat logs into Nursenet. She asks a research partner, a cyberware specialist in London, England, for the results from a trial on neurologic side effects of ocular biochips. Rachel, as part of a 61-member team in 23 countries, is studying 6 clients with the chips. Then it's down to local business. Rachel e-mails information on air contaminant syndrome to a client down the street whose son is susceptible to the condition and tells her about a support group in Philadelphia. She contacts a qigong specialist to see if he can teach the boy breathing exercises and schedules an appointment with an environmental nurse specialist. Moments before her 9:45 appointment, Rachel gets into her El-van and programs it to an address 2 kilometers away. Her patient, Mr. Chan, lost both legs in a subway accident and needs to be prepared for a bionic double-leg transplant. Together, they assess his needs and put together a team of health workers, including a surgeon, physiotherapist, acupuncturist, and home care helpers. She talks to him about the transplant, and they hook up to his virtual reality computer to see and talk to another client who underwent the same procedure. Before leaving, Mr. Chan grasps her hand and thanks her for helping him. Rachel hugs him and urges him to e-mail her if he has any more questions (Sibbald, 1995p. 3 [quoted in Clark, 2000]).
Positioning Nurses as Key Players: Nursing has had a long and honorable commitment to providing care for poor, marginalized, and vulnerable populations, consistent with the goal of reducing health disparities. Table 1-3 identifies seven conditions and their evolutionary correlates needed to secure a key player role for nurses in the new health care delivery system.
TABLE 1-3
Criteria for Survival of the Nursing Profession Based on Evolutionary Principles
Criteria or Condition | Evolutionary Principle
---|---
Nursing needs to be relevant. | In nature, an organism will survive only if it occupies a niche, that is, performs a specific role that is needed in its environment.
Nursing must be accountable. | In every environment there is a limited amount of resources. Organisms that are more efficient and use the available resources more effectively are much more likely to be selected by the environment.
Nursing needs to retain its uniqueness while functioning in a multidisciplinary setting. | In nature, an organism will survive only if it is unique. If it ceases to be so, it is in danger of losing its niche or role in the environment. In other words, it might lose out if the new species is slightly better adapted to the role, or if physically similar enough, it might even breed with that species and thus completely lose its identity. Successful organisms must also learn to coexist with many different species so that their role complements that of the other organisms.
Nursing needs to be visible. | In nature, organisms often are required to defend their niche and their territory usually by an outward display that allows other similar species to be aware of their presence. By being "visible," similar species can avoid direct conflict. In addition, visibility is also important for recognition by members of their own species, to allow for the formation of family and social units, based on cooperation and respect.
Nursing needs to have a global impact. | In nature, if a species is to survive, it must make its presence felt not just to its immediate neighbors but to all the members of its environment. Often, this results in a species adapting a unique presence, whether it is a color pattern, smell, or sound.
Nurses need to be innovators. | In evolution, the organisms that survive are, more often than not, innovators that have the flexibility to come up with new and different solutions to rapid changes in environmental conditions.
Nurses need to be both exceptionally competent and strive for excellence. | During evolution, when new niches open up, it is never possible for more than one species to occupy one niche. Only the best adapted and most competent among the competing organisms will survive; all others, even if only slightly less competent, will die.
From Bell (1997) as cited in Gottlieb L, Gottlieb B: Evolutionary principles can guide nursing's future development, _Journal of Advanced Nursing_ 28(5):1099, 1998.
## Summary
This chapter presents theoretical concepts important to the understanding of the nurse-client relationship. These models bring order to nursing practice, and provide a cognitive structure for developing a body of knowledge for professional nursing and a theoretical basis for nursing research. Four theoretical concepts found in all nursing theories are person, health, nursing, and environment. The art of nursing helps nurses integrate scientific understandings with a personalized approach to individual clients.
Hildegard Peplau's theory of interpersonal relationships form the theoretical basis for understanding the nurse's role in the nurse-client relationship. Concepts from other developmental and psychological theories broaden the nurse's perspective and understanding of client behaviors. Nurses use Erikson's model of psychosocial development to provide nursing care in line with developmental needs of their clients and Maslow's need theory to prioritize care activities. Carl Rogers offered basic concepts concerning the characteristics the nurse needs for developing effective interpersonal relationships with clients. Therapeutic communication is used in the nurse-client relationship as a primary means of achieving treatment goals.
Changes in the health care delivery system require nurses to embrace new skill sets consistent with contemporary health care changes. What nurses bring to the table, the essential values of professional nursing practice—caring relationships with clients, a holistic view of persons, a wide range of scientific and value-based knowledge combined with critical thinking and clinical reasoning skills—remain unchanged. Nurses have an unprecedented opportunity to make a difference and shape the future of nursing practice through communication at every level in health care delivery.
Ethical Dilemma
Note: Refer to Chapter 3, Clinical Judgment: Applying Critical Thinking and Ethical Decision Making, and values clarification as you consider the ethical dilemma.
Countertransference refers to strong feelings that nurses hold about clients that act as a major barrier in therapeutic relationships. These feelings interfere with fully understanding and appreciating the humanness of clients in professional relationships. In the following example, identify what you see as the countertransference issues involved in caring authentically and compassionately for this client. What would you do to resolve the countertransference issues?
Craig Montegue is a difficult client to care for. As his nurse, you find his constant arguments, poor hygiene, and the way he treats his family very upsetting. It is difficult for you to provide him with even the most basic care, and you just want to leave his room as quickly as possible. What are the ethical elements in this situation, and how would you address them in implementing care for Craig?
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CHAPTER 2
# Professional Guides to Action in Interpersonal Relationships
Elizabeth Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Describe the use of professional standards of care and professional performance standards in nurse-client relationships.
2 Identify regulatory bodies and state laws guiding the conduct of professional nursing practice.
3 Discuss legal standards used in nursing practice.
4 Discuss ethical standards and issues of professional nursing practice.
5 Apply the nursing process and SBAR format to structure professional nursing care.
6 Discuss client privacy, Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations, confidentiality, and informed consent as guides to action in nurse-client relationships.
This chapter introduces the student to the professional, legal, and ethical standards of practice that provide essential parameters for professional therapeutic activities occurring within the nurse-client relationship. Included in this chapter is an overview of the nursing process, which is used to sequence nursing actions in the nurse-client relationship and as a guide to chart client progress.
## Basic concepts
Standards as guides to action in clinical nursing practice
All legitimate professions have standards of conduct. Nursing's professional, legal, and ethical standards identify principles of professional nursing practice and govern its actions. Professional nurses, regardless of setting, are expected to follow these standards in their clinical practice, research, and education. The Code of Ethics for Nurses (ANA, 2001) establishes principled guidelines designed to protect the integrity of clients related to their care, health, safety, and rights. Nurses are held to federal and state regulatory laws for hospital and other health care facilities, and to the nursing standards, policies, and procedures of the health care facility in which they are employed (Guido, 2009). Professional nursing practice is legally regulated through state licensure, with additional education and national certification required for advanced practice. The American Nurses Credentialing Center (ANCC) certifies nurses for advanced practice in a nursing specialty once the applicant completes all requirements for national certification. Each state sets forth professional nursing standards and interpretive guidelines through its Nurse Practice Act. Professional, ethical, and legal standards are complementary but distinct guides to action in nurse-client relationships. They each reflect societal values.
#### Professional standards of care and nursing performance standards
The national professional organization for registered nurses (ANA), publishes standards of care and nursing performance that help ensure professional nursing competence and safe ethical clinical practice. Professional standards of practice serve the dual purpose of providing a standardized benchmark for evaluating the quality of their nursing care and offering the consumer a common means of understanding nursing as a professional service relationship. They inform the public what they can expect from professional nurses.
Specified competencies identified in nursing standards represent a uniform legal yardstick against which care can be measured. In legal situations, professional standards of practice would be used as a first-line defense, in conjunction with what a "reasonable and prudent nurse" would do in a similar nursing situation, to determine nursing accountability. Failure to adhere to established nursing practice and professional performance standards could result in a negative civil judgment against a professional nurse.
The Joint Commission (TJC, 2007) mandates that written nursing policies with specific standards of care be available on all nursing units. Professional standards of practice provide definitions of the minimum competencies needed for quality professional nursing practice Presented as principled statements, they designate the knowledge and clinical skills required of nurses to practice competently and safely.
**Professional performance standards** describe a competent level of professional role behaviors related to quality of care, practice evaluation, continuing education, collegiality, collaboration, ethics, research, resource utilization, and leadership. Nurses are expected to competently perform professional role behaviors consistent with published standards and appropriate to their education, position, and the practice setting. They are expected to refrain from performing any nursing activities for which they are not trained.
Professional nurses are accountable for adhering to professional standards regardless of their particular nursing role or the acuity of individual nursing circumstances. Additional specialty practice guidelines provide a customized set of standards for care of specific populations (e.g., children, the elderly, and psychiatric patients) and specialty areas of clinical practice (e.g., acute care or perioperative nursing).
Nursing's Social Policy Statement: **Nursing's Social Policy Statement** spells out the discipline's covenant with society and contractual obligations for care (LaSala, 2009). Nursing is conceptualized as a dynamic profession, operating within a social context, and being responsive to the ever-changing nature of societal health care needs. The American Nurses Association Social Policy Statement (American Nurses Association, 2003) describes the social values and assumptions inherent in professional nursing practice and identifies nursing's stewardship commitment to society. The ANA recently published a revised edition of Nursing's Social Policy Statement: The Essence of the Profession in 2010 (American Nurses Association, 2010).
Regulatory bodies: state boards of nursing: Each state has its own Board of Nursing. The National Council of State Boards of Nursing states, " ** _Boards of Nursing_** are state governmental agencies that are responsible for the regulation of nursing practice in each respective state. Boards of Nursing are authorized to enforce the Nurse Practice Act, develop administrative rules/regulations and other responsibilities per the Nurse Practice Act" (National Council of State Boards of Nursing, 2008).
In addition to issuing professional licenses to practice nursing, the state Board of Nursing is responsible for establishing and maintaining standards for safe nursing care in that state, and monitoring nurses' compliance with state laws governing their practice. Each state Board of Nursing has the authority to take disciplinary action against the licenses of those nurses who have exhibited unsafe nursing practice.
Nurse Practice Acts: Nurse Practice Acts are the most important statutory laws governing the provision of professional nursing care through the nurse-client relationship. **_Nurse Practice Acts_** are legal documents that communicate professional nursing's scope of practice, and outline nurses' rights, responsibilities, and licensing requirements in providing care to individual clients, families, and communities. Nurses appointed by the governor to serve on a state Board of Nursing develop the statutes' governing nursing practice in each state.
Each state's Board of Nursing develops and executes its own Nurse Practice Act. If a nurse practices in one state and then moves to another, the nurse has to follow the Nurse Practice Act guidelines in his or her new state of residence. Because all Nurse Practice Acts reflect standards of nursing care developed by the ANA, they do not usually differ significantly, but nurses are advised to have a working knowledge of the Nurse Practice Act in each state of planned employment.
Nurse Practice Acts authorize state boards of nursing to interpret the legal boundaries of safe nursing practice and give them the authority to punish violations, with suspension or loss of professional licensure.
Scope of Practice: **Scope of practice** is a broad term referring to the legal and ethical boundaries of practice for professional nurses The ANA (2010) recently published its latest revised edition of _Nursing: Scope and Standards of Nursing_. In addition to national standards, each state's Board of Nursing establishes the scope of nursing practice within its state. Scope of practice is defined in written state statutes. Scope of practice in most states reflects different levels of nursing practice, based on the nurse's education, special skill training, supervised experience, state and national professional credentials, and appropriate professional experience.
Scope of practice includes a broad range of nursing activities such as providing direct care, effectively managing emergency and crisis situations, administering medications, monitoring changes in client conditions, teaching and coaching clients and their families, prioritizing and coordinating care, delegating of nursing tasks, and supervision of unlicensed personnel.
Professional Licensure: The registered nurse's professional license ensures that each individual nurse has successfully completed an accredited nursing program and can demonstrate the knowledge, skills, and competencies to function as a health provider of safe, effective nursing care. All graduates must pass a national licensure examination (National Council Licensure Examination [NCLEX]) that tests core nursing knowledge before being granted a professional RN license to practice nursing. Practicing nursing without a license can result in legal prosecution.
Nursing licensure helps maintain standards for nursing. Although the NCLEX is a national examination, each nurse must apply for RN state licensure through the state Board of Nursing in his or her state of residence to practice as a registered nurse.
Compact State Recognition Model: In 2000, the National Council of State Boards of Nursing (NCSBN) developed a mutual recognition model of nurse licensure, permitting registered nurses licensed and residing in a compact state to practice in other compact states without obtaining a second license. The multistate license is issued by the compact state in which the nurse resides. The registered nurse is held to the state's nursing practice laws and regulations in which he or she is actually practicing at the time. The multistate license is valid only between compact states. Over the past few years, more than half the nation's state boards of nursing have enacted the RN and LPN/VN nurse licensure compact legislation. This legislation is particularly helpful for nurses working in states with large rural populations and few nurses.
#### Legal standards
Professional nurses are held legally accountable for all aspects of the nursing care they provide to clients and families, including documentation and referral. As the registered nurse's professional responsibilities have increased in depth and complexity, requiring greater levels of clinical judgment, so has the potential for legal liability (Aiken, 2004). Of special relevance to the nurse-client relationship are issues of professional liability, informed consent, and confidentiality.
Classifications of Laws in Health Care: Nurses need to take into consideration two types of law related to the care they provide for clients and families. **_Statutory laws_** are legislated laws, drafted and enacted at federal or state levels. Medicare and Medicaid amendments to the Social Security Act are examples of federal statutory laws. Nurse practice acts are examples of statutory laws enacted at the state level (Aiken, 2004).
**_Civil laws_** are developed through court decisions, which are created through precedents, rather than written statutes. Most infractions for malpractice and negligence are covered by civil law and are referred to as _torts._ A tort is defined as a private civil action that causes personal injuries to a private party. Deliberate intent is not present. Four elements are necessary to qualify for a claim of malpractice or negligence.
• The professional duty was owed to client (professional relationship)
• A breach of duty occurred in which the nurse failed to conform to an accepted standard of care
• Causality in which a failure to act by professional was a proximate cause of the resulting injury
• Actual damage or injuries resulted from breach of duty (Dimond, 2008).
Definitions of negligent actions and related examples are found in Table 2-1.
TABLE 2-1
Definition and Examples of Negligent Actions
Definition of Negligent Action | Example
---|---
Performing a nursing action that a prudent nurse would not perform | Carrying out a physician's order that would have been questioned by other reasonably prudent nurses in similar circumstances
Failing to perform a nursing action that a reasonably prudent nurse would perform | Failing to report suspected physical or sexual child abuse
Failure to provide routine or customary care | Failing to check vital signs before and after surgery; failing to perform postpartum checks on a client
Exhibiting conduct that a reasonably prudent nurse would recognize as posing an unreasonable risk to a client | Failing to give accurate information in a manner that the client can understand regarding choice of treatment and known adverse effects; sharing confidential information with a client's family or workplace without the client's permission
Failing to protect a client from unnecessary harm | Not putting up the guardrails on a bed with a newly diagnosed client suffering from a stroke; allowing unlicensed personnel to do a nursing procedure without appropriate experience or supervision
The nurse is bound legally by the principles of civil tort law to provide reasonable standard of care, defined as a level of care that a reasonably prudent nurse would provide in a similar situation (Catalano, 2008). If taken to court, this standard would be the benchmark against which the nurse's actions would be judged.
**_Criminal law_** is reserved for cases in which there was intentional misconduct, and/or the action taken by the health care provider represents a serious violation of professional standards of care (Scott, 2006). The most common violation of nurses related to criminal law is failure to renew a professional nursing license, which, in effect, means that a nurse is practicing nursing without a license (Calalano, 2008).
Legal Liability in Nurse-Client Relationships: In the nurse-client relationship, the nurse is responsible for maintaining the professional conduct of the relationship. Examples of unprofessional conduct in the nurse-client relationship include:
• Breaching client confidentiality
• Verbally or physically abusing a client
• Assuming nursing responsibility for actions without having sufficient preparation
• Delegating care to unlicensed personnel, which could result in client injury
• Following a doctor's order that would result in client harm
• Failing to assess, report, or document changes in client health status
• Falsifying records
• Failing to obtain informed consent
• Failure to question a physician's orders, if they are not clear
• Failure to provide required health teaching
• Failure to provide for client safety (e.g., not putting the side rails up on a client with a stroke)
Scott (2006) claims that effective and frequent communication with clients and other providers is one of the best ways to avoid and/or minimize the possibility of claims of malpractice or negligence. In-depth communication provided in simple layperson's language about what the nurse is doing, the status of the client's health care, the meaning of diagnostic tests for client care, and so forth allows clients to make more informed choices and leads to greater satisfaction.
#### Ethical standards and issues
Nurses have an ethical accountability to the clients they serve that extends beyond their legal responsibility in everyday nursing situations. Ethical issues of particular relevance to the nurse-client relationship relate to caring for clients in ambulatory managed care settings, the rights of clients participating in research, caring for mature minors, client education, right to die issues, transfer to long-term care of elderly clients, and telehealth nursing (Guido, 2009).
American Nurses Association Code of Ethics: The revised ANA Code of Ethics for Nurses (ANA, 2001) with interpretive statements provides ethical guidelines for nurses designed to protect client rights, provide a mechanism for professional accountability, and educate professionals about sound ethical conduct. The new provisions of the Code of Ethics for Nurses are identified in Box 2-1. Similar codes of ethics for nurses exist in other nations. For example, in Canada, nursing practice is guided by the Canadian Nurses Association Code of Ethics for Registered Nurses (1997).
BOX 2-1 American Nurses Association Code of Ethics for Nurses
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Reprinted from ANA (2001), by permission.
The ANA Code of Ethics for Nurses provides a broad conceptual framework outlining the principled behaviors and value beliefs expected of professional nurses in delivering health care to individuals, families, and communities. Ethical standards of behavior require a clear understanding of the multidimensional aspects of an ethical dilemma, including intangible human factors that make each situation unique (e.g., personal and cultural values or resources).
When an ethical dilemma cannot be resolved through interpersonal negotiation, an ethics committee composed of biomedical experts reviews the case and makes recommendations (Otto, 2000). Of particular importance to the nurse-client relationship are ethical directives related to the nurse's primary commitment to
• The client's welfare
• Respect for client autonomy
• Recognition of each individual as unique and worthy of respect, advocacy
• Truth telling
Exercise 2-1 provides an opportunity to consider the many elements in an ethical nursing dilemma.
EXERCISE 2-1 Applying the Code of Ethics for Nurses to Professional and Clinical Situations
Purpose: To help students identify applications of the Code of Ethics for Nurses.
Procedure:
Break into small groups of four or five students.
Consider the following clinical scenarios:*
1. Mrs. Jones has consented to participate in a phase I clinical trial for her cancer. She tells you that she feels very lucky to have met the criteria because now she has a good chance of "beating the cancer."
2. Barbara Kohn is a 75-year-old woman who lives with her son and daughter-in-law. She reveals to you that her daughter-in-law keeps her locked in her room when she has to go out because she does not want her to get in trouble. She asks you not to say anything as that will only get her into trouble.
3. The nursing supervisor asks you to "float" to another unit that will require some types of skills that you believe you do not have the knowledge or skills to perform. When you explain your problem, she tells you that she understands, but the unit is short staffed and she really needs you to do this.
4. Bill Jackson is an elderly client who suffered a stroke and is uncommunicative. He is not expected to live. The health care team is considering placement of a feeding tube based on his wife's wishes. His wife agrees that he probably won't survive, but wants the feeding tube just in case the doctors are wrong.
5. Dr. Holle criticizes a nurse in front of a client and the client's family.
Share each ethical dilemma with the group and collaboratively come up with a resolution that the group agrees on, using the nurse's code of ethics to work through the situation.
Discussion:
1. What types of difficulty did your group encounter in resolving different scenarios?
2. What type of situation offers the most challenge ethically?
3. Were there any problems in which the code of ethics was not helpful?
4. How can you use what you learned in this exercise in your nursing practice?
* * *
*An alternative would be to use an actual ethical dilemma you have experienced either as a student nurse, as a patient, or with a family member in a clinical situation.
Advance Directives: In 1991, the U.S. Congress passed the Patient Self-Determination Act. This legislation requires health care institutions to inform their clients, on admission, of their right to choose whether to have life-prolonging treatment should they become mentally or physically unable to make this decision (Westley & Briggs, 2004). An **_advance directive_** is a legal document, executed by a competent client or legal proxy, specifically identifying individual preferences for the level of care at end of life, related to treatment, medications, hydration, and nutrition (Basanta, 2002). Advance directives allow individuals to specify what actions should be taken on their behalf should they be unable to make health-related decisions. Types of advance directives are identified in Table 2-2. Because life-threatening medical emergencies can occur at any time, all adults—even the healthiest—can benefit from having advance directives in place concerning preferred end-of-life care. Advance directives can be revoked or revised at any time by its author. Exercise 2-2 provides an opportunity to understand the use of advance directives in clinical practice.
EXERCISE 2-2 Role Playing with Advance Directives
Purpose: To help students understand advance directives and their use in health care.
Procedure:
1. Obtain a copy of an advance directive from your hospital, or from the web.
2. Review the advance directive, and then in groups of 3 students, role play introducing the advance directive with one person taking the role of the client, another of the client's spouse or sibling, and the third taking the role of the nurse.
Case Study:
1. Greg Atkins has been diagnosed with stage IV colon cancer. He has metastasis to the liver and lung, and has been growing gradually weaker. This is his first admission to the hospital. He has been advised to get his affairs in order, as he is not expected to live too much longer. He is discouraged by his latest report as he is not ready to die.
Discussion:
1. How difficult was it to introduce the topic of the advance directive to the client and family?
2. What made it harder or easier to discuss the advance directive?
3. How could you use this experience in your clinical practice?
TABLE 2-2
Types of Advance Directives
Living will | Documents the client's preferences for medical treatment, artificial life support, nutrition, use of antibiotics, pain medication) should the client be unable or incompetent to state them (Legal status of living wills varies from state to state.)
---|---
Medical power of attorney for health care decisions | Legal document with designation of a proxy who is authorized to make health care decisions for a person should the individual be unable to express his or her wishes
Durable power of attorney | Legal document with designation of a proxy authorized to make financial decisions and to represent the client's interests should the client be unable to do so; durable power of attorney can be revoked in writing at any time, as long as the client is competent
Do-not-resuscitate (DNR) orders | Written directions about not resuscitating the client if the client's breathing or heartbeat stops
Durable mental health power of attorney | Legal document with designation of a proxy who is authorized to make mental health care decisions for a person should the individual be unable to do so because of mental symptoms
Psychiatric advance directives are legal, written documents used by people with mental illness to indicate their preference for treatment in the event that they are unable to make decisions about treatment because of mental symptoms (Vuckovich, 2003). A psychiatric advance directive specifies the person who the client wants to accept legal responsibility for making clinical decisions if the client is unable to do so. The document can identify the client's preferences for medication, treatment, and treatment setting. Having an advance directive in place helps decrease family anxiety and provides direction for health care, endorsed by the client.
Developing an Evidence-Based Practice
Shapiro S: Evaluating clinical decision rules, _Western Journal of Nursing Research_ 271(5):655–664, 2005.
This study examines the role of decision support tools needed to combine different clinical evidence into bedside tools for practice.
_Results:_ Clinical decision-making tools are similar to clinical pathways and treatment algorithms used to guide treatment and nursing care. To be effective, clinical decision rules (CDRs) must follow strict protocols and be research based, valid, and reflective of multiple sources of data. The impact of CDRs on client outcomes and costs of care is measured through implementation trials and cost-effectiveness analysis.
_Application to Your Clinical Practice:_ In today's health care arena, nurses find themselves increasingly dependent on methodologies developed to standardized practice protocols based on the best research evidence currently available. What do you see as the role of CDRs for clinical practice? What would be important to consider in protecting the integrity of the rules as an evidence-based rationale for improving client outcomes?
## Applications
The most common configuration for collecting, organizing, and analyzing data, and for sharing information with other professionals is the nursing process. The nursing process is an interpersonal, client-centered process. Assessment data, nursing diagnosis, and goals for treatment are systematically documented on treatment plans that can be easily shared with nurses and other health professionals.
## Using the nursing process in nurse-client relationships
The nursing process is the primary framework used to structure and organize nursing care. Nurses use the nursing process to apply problem-solving strategies to complex health problems and to develop individualized care plans. The Joint Commission has identified six interrelated elements required of the nursing care plan; these are presented in Box 2-2.
BOX 2-2 Joint Commission on Accreditation of Health Care Organizations Requirements for Nursing Care Plans
1. Initial assessment, modified as needed
2. Nursing diagnosis of patient care needs
3. Specified nursing interventions that address client health care needs
4. Provision of appropriate nursing interventions
5. Documentation of the client's response and achievement of treatment outcomes
6. Discharge plan providing direction to client and others involved in care to manage continuing health care needs after discharge
From TJC (1991).
The nursing process consists of five progressive phases: assessment, problem identification and diagnosis, outcome identification and planning, implementation, and evaluation. As a dynamic, systematic clinical management tool, it functions as a primary means of directing the sequence, planning, implementation, and evaluation of nursing care to achieve specific health goals. Communication plays an important role in all aspects of the nursing process by
• Helping clients to promote, maintain, or restore health, or to achieve a peaceful death
• Facilitating client management of difficult health care issues through communication
• Providing quality nursing care in a safe and efficient manner
The nursing process is closely aligned with meeting professional nursing standards in the total care of the client. Table 2-3 illustrates the relationship.
TABLE 2-3
Relationship of the Nursing Process to Professional Nursing Standards in the Nurse-Client Relationship
The nursing process begins with the nurse's first encounter with a client and family, and ends with discharge, referral, or both. There is an ordered sequence of nursing activities, with each activity linked to the trustworthiness of the activity that preceded it. Although the sequence of activities follows a distinctive order, each phase is flexible, flowing into and overlapping with other phases of the nursing process. For example, in providing a designated nursing intervention, the nurse might discover a more complex need than what was originally assessed. This could require a modification in the nursing diagnosis, identified outcome, intervention, or the need for a referral.
The nursing process is not complete until treatment outcomes and client responses are documented on the client's chart using correct spelling and terminology. Nurses are expected to report all relevant data to appropriate health care personnel at regular intervals and when there is a change in the client's condition.
### Assessment
A client-centered approach to assessment uses a systematic, dynamic process to gather data about the client seeking service. The assessment process begins when when you first meet the client and family. Introducing yourself and explaining the purpose of the assessment interview helps put the client at ease and sets the stage for the information that needs to be gathered. The next step is to ask the client to tell his or her story as it relates to the current request for nursing services. A simple statement, such as "Can you tell me what prompted you to seek treatment at this time?" usually is sufficient to start the conversation. Clients sometimes seek treatment for reasons that one would not ordinarily expect, so this type of open-ended question provides valuable information that otherwise might not emerge so quickly.
The intake assessment, usually completed on admission to the health care agency, serves as baseline data. Using open-ended and focused questions, you should collect data about
• The current problem for which the client seeks treatment
• The client's perception of his or her health patterns
• Presence of other health risk and protective factors
• Relevant social, occupational, and family history
• The client's medical and psychiatric history (e.g., previous hospitalizations, family history, medical and psychiatric treatment, and medications)
• The client's coping patterns
• Level and availability of the client's support system
Assessment of client needs should take the client's entire experience of an illness or injury into account, rather than simply focusing on clinical data related to the diagnosis. This is what is meant by "patient-centered" care. The behavior, attitude, and appearance of the client also are important sources of information. For example, does the client appear anxious, angry, apathetic, lethargic, cooperative, or uncooperative?
Assessment data should reflect behavioral observation and information from as many sources as is needed for complete accuracy. Sources of data include interview, history, physical assessment, review of records, family interviews, and in some instances, contact with previous health care providers, schools, or other referral sources. As new information becomes available, nurses are expected to refine and update the original assessment.
Two types of data are collected during an assessment interview. **Subjective data** refers to the client's perception of data and what the client or family says about the data (e.g., "I have a severe pain in my chest"). Client data about alternative forms of treatment, medications, and previously used care systems are relevant pieces of information. **Objective data** refers to data that are directly observable or verifiable through physical examination or tests (e.g., an abnormal electrocardiogram). Combined, these data will present a complete picture of the client's health problem.
Observations of the client's appearance and nonverbal behaviors can help nurses make inferences. An inference is an educated guess about the meaning of an observed behavior or statement. To be sure that the inference represents a correct interpretation of an observation or statement, you must validate the data with the client. For example, if a client is withdrawn and distractible, the nurse may infer that the client is struggling with an internal emotional issue. To validate this inference, you might comment, "You seem withdrawn, as though something is troubling you. Is that true for you right now?"
You also can use _data cues,_ defined as small pieces of data that would not reveal much when taken by themselves but, when considered within the total assessment picture, can lead the nurse to ask further questions (Avant, 1991). For example, hesitancy about a certain topic, complaints of hunger or thirst, dry skin, or agitation is a data cue that can help nurses to seek a fuller explanation.
The assessment should consider more than client problems. Appraisal of client strengths is an important dimension of the assessment process as it provides a built-in resource asset for resolving health problems. Identifying client strengths is particularly important in today's health care environment, when clients have to assume much more responsibility for their health care than previously. Analysis of the client's support systems including level of utilization, availability, and social role is relevant data, as is the client's spiritual or philosophical beliefs and values. Environmental, economic, and legal factors also should be included when related to the client's health and well-being.
Throughout the assessment phase, you will need to validate the information you receive from the client and significant others to make sure that the data are complete and accurate. Ask the client for confirmation that your perceptions and problem analysis are correct periodically throughout the assessment interview, and summarize your impressions at the end. An assessment summary should highlight important elements in ways that are easily understood and retrievable by everyone involved in the client's care. After the summary, you should thank the client or health informant for giving you the information, with a brief explanation of what will happen with this information. Respectful, regular communication represents an important intersection between the nurse-client relationship and the nursing process.
Once the assessment is complete, the next step is to analyze the information and identify gaps in the data collection or content. One way to do this is to compare individual client data with normal health standards, behavior patterns, and developmental norms. Gordon's 11 Functional Health Patterns (Box 2-3) provide a useful structure for clustering assessment data and help direct the choice of nursing diagnoses. The determination of whether a pattern is functional or dysfunctional is based on established norms for age and sociocultural standards (Gordon, 2007).
BOX 2-3 Gordon's Functional Health Patterns
1. Health perception-health management pattern
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-self-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern
In each clinical situation, you should take individual differences and preferences into consideration. For example, maintaining a sufficient intake of food needs to be assessed in terms of what is adequate intake for an individual on the basis of age, activity, height-to-weight ratio, and current health status. Nutritional needs for an active teenager are greater than those for an older, sedentary adult. The nurse would ask different specific questions of a client with diabetes, anorexia, or obesity regarding nutritional intake and food choices than of those for whom potential deviations would not appear to be an issue.
Environmental factors such as socioeconomic status and culture can influence the nature of a client's health care needs. For example, diet choices and lack of prenatal care can represent financial constraints, rather than preference. Lack of knowledge about health care options, access, and experience are additional issues that nurses need to consider.
Documentation of relevant problems, observations, and assessments form the basis for planning care. A direct relationship among assessment data, nursing diagnosis, treatment goals, and intervention strategies should exist. Health care concerns judged potentially responsive to nursing intervention form the basis for the selection of nursing diagnoses.
### Planning
Nursing Diagnosis
The planning phase begins with the development and prioritization of relevant nursing diagnoses related to identified nursing problems. Nursing diagnoses is the term used to describe the client's human responses to medical diagnoses (Carpenito-Moyet, 2008). They should complement, not compete, with the actual medical diagnosis of a health problem.
The nursing diagnosis consists of three parts: problem, cause, and evidence (North American Nursing Diagnosis Association [NANDA], 2005).
• _Problem:_ A statement identifying a health problem or alteration in a client's health status, requiring nursing intervention. Using a list of the most recent NANDA diagnoses, you would pick a NANDA diagnosis that best represents the identified problem or potential problem.
• _Cause:_ A statement specifying the probable causative or risk factors contributing to the existence or maintenance of the health care problem. The cause of a problem can be psychosocial, physiologic, situational, cultural, or environmental in nature. The phrase "related to" (R/T) serves to connect the problem and causative statements. Example: "Impaired communication related to a cerebrovascular accident."
• _Evidence:_ A statement identifying the clinical evidence (behaviors, signs, symptoms) that support the diagnosis. An example of a nursing diagnosis statement would be "Impaired verbal communication related to a cerebrovascular accident, as manifested by incomplete sentences and slurred words."
The nursing diagnosis should be written in such clear, precise language that any member of the interdisciplinary health care team can look at the statement and be able to identify relevant client issues.
Nurses use Maslow's Hierarchy of Needs (see Chapter 1) to prioritize goals and objectives. Examples of nursing problems associated with each level of Maslow's hierarchy are included in Table 2-4. Priority attention should be given to the most immediate, life-threatening problems. You also should consider what the client sees as his or her priorities, and incorporate this information in your prioritization. Otherwise, you and your client may be working at cross-purposes.
TABLE 2-4
Identifying Nursing Problems Associated with Maslow's Hierarchy of Needs
Physiologic survival needs | Circulation, food, intake/output, physical comfort, rest
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Safety/Security needs | Domestic abuse, fear, anxiety, environmental hazards, housing
Love and belonging | Lack of social support, loss of significant person or pet, grief
Self-esteem needs | Loss of a job, inability to perform normal activities, change in position or expectations
Self-actualization | Inability to achieve personal goals
Nurses may be able to address more than one nursing diagnosis at a time, because attention to several interconnected nursing diagnoses can often serve the same outcome. In addition to identifying and prioritizing nursing diagnoses, nurses are expected to monitor progress and look for potential complications accompanying nursing diagnoses. Examples of monitoring include vital signs, hydration, potential fluid imbalances, electrolytes, intravenous (IV) infusions associated with health issues requiring nursing diagnosis for resolution. Clearly written nursing diagnoses helps to ensure continuity and an ordered approach to meeting the individualized needs of the client (Carpenito-Moyet, 2008). Exercise 2-3 provides practice in considering cultural, age, and gender-related themes when using the nursing process with different types of clients.
EXERCISE 2-3 Using the Nursing Process as a Framework in Clinical Situations
Purpose: To help students develop skills in considering cultural, age, and gender role issues in assessing each client's situation and developing relevant nursing diagnoses.
Procedure:
1. In small groups of three to four students, discuss how you might assess and incorporate differences in client/family values, knowledge, beliefs, and cultural background in delivery of care for each of the following clients. Indicate what other types of information you would need to make a complete assessment.
2. Identify and prioritize nursing diagnoses for each client to ensure client-centered care.
a. Michael Sterns was in a skiing accident. He is suffering from multiple internal injuries, including head injury. His parents have been notified and are flying in to be with him.
b. Lo Sun Chen is a young Chinese woman admitted for abdominal surgery. She has been in this country for only 8 weeks and speaks very little English.
c. Maris LaFonte is a 17-year-old unmarried woman admitted for the delivery of her first child. She has had no prenatal care.
d. Stella Watkins is an 85-year-old woman admitted to a nursing home after suffering a broken hip.
Discussion:
1. In what ways might the needs of each client be different based on age, gender role, or cultural background? How would you account for the differences?
2. Were there any common themes in the types of information each group decided it needed to make a complete assessment?
3. How could you use what you learned from this exercise in your clinical practice?
#### Outcome Identification
Shaughnessy (1997) defines a health care outcome as "the change in health status between a baseline time point and a final time point" (p. 1225). The outcome refers to the result or end product of an identified nursing action. Some outcomes are unexpected. When this circumstance occurs, either the assessment failed to reveal a critical piece of data, the diagnosis or other issue was not validated with the client or family, the associated risks or plans for continuity of care were not factored into the treatment goals, or the treatment plan was not executed as collaboratively developed by the stakeholders in the process. Sometimes factors beyond the control of the client and health care provider interfere, for example, a change in the client's physical or mental status. At any point in the process, ongoing assessment data can be used to revise the diagnosis, the plan itself, or implementation to meet the emerging needs in the clinical situation.
Clients should be involved in a shared decision-making process with health care providers in choosing relevant goals and outcomes (Kerr, 2009). Evidence of shared decision making can be documented with a simple statement, such as "Client states that she is satisfied that she made the right decision to decline surgery at this time."
Outcome criteria need to take into account the client's culture and life situation, present mental status, strengths and limitations, and available resources. Important client values and preferences should be factored into the development of relevant outcome criteria. Time limits need to be realistic so that the client can be successful.
Outcomes should be client-centered (e.g., "The client will...") and described in specific, measurable terms. An appropriate treatment outcome for a client after surgery might be: "The client will show no signs of infection as evidenced by the incision being well-approximated and free of redness and swelling, normal temperature, and white blood cell count within normal limits by 9/21/09." Nursing outcomes should be
• Based on diagnoses
• Documented in measurable terms
• Developed collaboratively with the client and other health providers
• Realistic and achievable
Each treatment outcome specifies the action or behavior that the client will demonstrate once the health problem is resolved. Outcome criteria are stated as long- and short-term treatment goals. Using measurable action verbs to describe what the client will be doing to achieve a short-term goal is key to effective identification of treatment outcomes; for example, "The client will take his medicine, as prescribed" is measurable: He either takes his medicine or he does not. Other measurable verbs include "perform," "identify," "discuss," and "demonstrate." Broad-spectrum verbs such as "understand," "know," and "learn" are not easily measurable and should not be used. Note the conditions or circumstances for outcome achievement "as prescribed" is specifically identified. Documentation of clinical outcomes should include client response.
#### Planning
The care plan serves as the structural framework for providing safe quality care. Each care plan should be individualized to reflect client values, clinical needs, and preferences. The care plan provides for continuity of care and supplies a concrete basis for supportive documentation of client response. The care plan is dynamic, meaning that it needs to be continuously updated as the client's condition and health needs change.
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual.
#### Implementation
During the implementation phase, the client and nurse manage the care plan through specified nursing interventions and corresponding client actions. McCloskey and Bulechek (2000) define **_nursing intervention_** as "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes. Nursing interventions include both direct and indirect care, nurse-initiated, physician-initiated, and other provider-initiated treatments" (p. xix). Interventions appropriate to the purposes of the nurse-client relationship include giving direct physical, psychological, social, and spiritual support; health teaching; collaborating with other health professionals on behalf of the client; continuing to make ongoing assessments; documenting client responses; and updating or revising the care plan as needed.
Nursing interventions can be classified as independent, dependent, or collaborative (Snyder, Egan, & Nojima, 1996). Independent interventions are those that nurses can provide without a physician's order or direction from another health professional. Independent nursing interventions are permitted under Nurse Practice Acts and are protected through professional licensure and law. Many forms of direct care assistance, health education, health promotion strategies, and counseling fall into this category, and nurses are particularly well equipped to provide these functions. Dependent interventions require an oral or a written order from a physician to implement. For example, in most states, staff nurses cannot administer a medication without having a physician order it. The nurse is accountable for using appropriate knowledge, judgment, and competence in administering the medication at physician orders—and for questioning a physician about a problematic medical order. Thus, a nurse would not automatically carry out a physician's order without considering first the appropriateness of the medication or without knowing appropriate dosage, mode of action, side effects, and potential adverse reactions. Collaborative interventions are those performed by the nurse and other health care team members with the mutual goal of providing the most appropriate and effective care to clients (McCloskey & Bulechek, 2000). Box 2-4 identifies factors the nurse should consider in developing nursing interventions.
BOX 2-4 Factors for Consideration When Choosing a Nursing Intervention
• Desired client outcomes
• Characteristics of the nursing diagnosis
• Research base for the intervention
• Feasibility of doing the intervention
• Acceptability to the client
• Capability of the nurse
#### Evaluation
In the evaluation phase, the nurse and client mutually examine the client's progress or lack of progress toward achievement of treatment outcomes, mutually determined during the planning phase. When treatment goals are not achieved, or there is a lack of progress, the nurse needs to ask the following questions:
• Were the assessment data collected appropriate and complete?
• Was the nursing diagnosis appropriate?
• Were the treatment outcomes realistic and achievable in the time frame allotted?
• Were the nursing interventions chosen appropriate to the needs of the situation and the capabilities of the client?
• Was there any variable within the client, situation, or family that was overlooked and should have been addressed?
Issues and circumstances that can influence the achievement of treatment outcomes include the effectiveness, time efficiency, appropriateness, and adequacy of the nursing actions selected for implementation, economic barriers or assets, the motivation of the client, family obstruction or support, and obstacles in the setting, which could not have been anticipated. The nurse and client review progress, determine necessary modifications or need for referral, and terminate the relationship. Exercise 2-4 provides an opportunity to practice developing a care plan.
EXERCISE 2-4 Developing a Care Plan
Purpose: To provide students with experience developing care plans based on client-centered assessment data.
Procedure:
1. For a client you have been assigned to work with, develop an assessment summary from data obtained from the client, the client's chart, and other key informants.
2. Analyze and categorize specific assessment data.
a. Indicate relationships between nursing and medical diagnoses.
3. Develop relevant, individualized nursing diagnoses.
4. Specify client goals, outcomes, and nursing interventions for the top 2 nursing diagnoses.
Discussion:
In small groups of three to five students, discuss your findings and compare rationales for the plan you developed.
This exercise can also be done with a selected case study provided by your faculty.
#### Documentation
Nurses are responsible for careful, accurate, and timely documentation of nursing assessments, the care given, and the behavioral responses of the client. This documentation represents a permanent record of the client's health care experience. In the eyes of the law, failure to document in written form any of these elements means the actions were not taken.
Two common models for documenting nursing care are the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) systems, which complement the function of the other. The NOC model is linked to the problem (nursing diagnosis), whereas the NIC intervention classification is linked to the related or contributing factors (Marrs & Lowery, 2006). These classification systems help standardize the language used to describe the nursing process. Frisch (2001) observed, "Nurses documenting practice using these systems are accomplishing three important things: appropriate documentation of care, identification of work as within the scope of professional nursing, and building a body of knowledge for nurses on the use of specific interventions" (pp. 11–12).
Clients need to trust that their health care provider is accurately and appropriately representing their voice and experience in medical care records. The medical record of care and treatment is also used to direct and improve client-centered care. Although nursing documentation usually covers documentation of biophysical issues, important aspects of nursing care related to the client's perspective, spiritual state, and learning needs are not always adequately noted (Laitinen, Kaunonen & Astedt-Kurki, 2010). Statements related to accommodations made for cultural, religious, and spiritual practices and preferences should be included in the record of care.
#### Verbal Reporting: Using the SBAR as a Communication Tool
Nurses need to verbally communicate assessment data and changes in health status to physicians, nurse colleagues, and others involved in the client's care on a regular basis. The SBAR format is a standardized assessment reporting format that helps nurses communicate a clear, succinct overview of critical information in an organized, thoughtful way. This can be especially important when communicating with physicians by phone (Rodgers, 2007). When communicating by phone, it is useful to have the client's chart in front of you.
SBAR is an acronym used to describe the
**S** ituation (What is going on with the patient?)
**B** ackground (What is the key clinical background or context?)
**A** ssessment (What do I think the problem is?)
**R** ecommendation (What do I recommend or what do I want you to do?) (Guise & Lowe, 2006, p. 313)
Table 2-5 provides a sample of how nurses can use this structured format in communicating assessment data and changes in health status effectively.
TABLE 2-5
SBAR Example
Developed in consultation with Barbara Dobish, RN, MS, Assistant Professor, University of Maryland, March 10, 2010.
The Joint Commission, the Institute for Health Care Improvement, and the AACN all support the use of SBAR as a desirable structured communication format. Given these approvals, Pope et al. (2008) suggest that the SBAR should be considered a "best practice" communication tool. In addition to using SBAR when there is a change in a client's health status, this communication format is used between shifts between nurse colleagues, between nurses and physicians during rounds, transfer and handoffs from one care setting or unit to another, and presurgery handoffs (Dunsford, 2009).
A distinct advantage of using SBAR as a primary communication tool between physicians and nurses is that it cuts down on professional differences in communication styles (Haig, Sutton, & Whittington, 2006). In addition to communication with professional colleagues at regular intervals or when a client's condition changes, nurses are accountable for orally informing ancillary clinical staff about the meaning of changes in the client's condition. They are responsible for appropriately supervising their care of the client, and for questioning unclear or controversial orders made by a physician. (See Chapter 22 and for more information and related exercises).
### Protecting the client's privacy
Jones (1998) states: " ** _Privacy_** refers to a client's right to have control over personal information whereas confidentiality refers to the obligation not to divulge anything said in a nurse-client relationship" (p. 5). As data is increasingly stored and transmitted through electronic record keeping, issues related to maintaining client privacy are under greater scrutiny. Institutional policies and federal law provide specific guidelines that all health care providers are required to follow. Kerr (2009) refers to the nurse's obligation to protect a client's privacy as a "sacred trust" (p. 315). The client's right to have personal control over personal information is upheld through federal HIPAA regulations. The ANA Code of Ethics (2003) specifically addresses the nurse's responsibility to safeguard the client's right to privacy.
#### HIPAA Regulatory Compliance
In the United States, the first federal legislation dealing with privacy of medical records was part of P.L. 104-191, the Health Insurance Portability and Accountability Act of 1996 (U.S. Department of Health and Human Services [DHHS], 2003). HIPAA regulations protect the privacy of the client's medical record and the client's right to have control over his or her identifiable information in health care records. Health care providers must provide clients with a written notice of their privacy practices and procedures. Key elements of the HIPAA privacy regulations are presented in Box 2-5.
BOX 2-5 Overview of Federal HIPAA Guidelines Protecting Client Confidentiality
• All medical records and other individually identifiable health information used or disclosed in any form, whether electronically, on paper, or orally, are covered by HIPAA regulations.
• Providers and health plans are required to give clients a clear written explanation of how their health information may be used and disclosed.
• Clients are able to see and get copies of their records and request amendments.
• Health care providers are required to obtain client consent before sharing their information for treatment, payment, and health care operations.
• Clients have the right to request restrictions on the uses and disclosures of their information.
• People have the right to file a formal complaint with a covered provider or health plan, or with the U.S. Department of Health and Human Services (HHS), about violations of HIPAA regulations.
• Health information may not be used for purposes not related to health care (e.g., disclosures to employers to make personnel decisions) without explicit authorization.
• Disclosure of information is limited to the minimum necessary for the purpose of the disclosure.
• Written privacy procedures must be in place to cover anyone who has access to protected information related to how information will be used and disclosed.
• Training must be provided to employees about the use of HIPAA privacy procedures
• Health plans, providers, and clearinghouses that violate these standards will be subject to civil liability, and if knowingly violating client privacy for personal advantage, can be subject to criminal liability.
Adapted from HIPAA Guidelines: www.hhs.gov/ocr/hipaa.
HIPAA privacy rules govern the use and disbursement of individually identifiable health information, and give individuals the right to determine and restrict access to their health information. Clients have the right to access medical records, request copies, and/or request amendments to health information contained in the record. The Fair Health Information Practices Act of 1997 stipulates civil and criminal penalties for not allowing clients to review their medical records (Milton, 2009).
HIPAA regulations protect the confidentiality, accuracy, and availability of all electronic protected information, whether created, received, or transmitted. Strict maintenance of written records in a protected, private environment is required. Other potential issues of concern about privacy involve cell phones, picture taking, use of hand held devices, use of fax machines, internet user ID and passwords, and use of RFID technologies or electronic monitoring devices (Kerr, 2009).
Health care providers must get written authorization from clients before disclosing or sharing any personal medical information. Client authorization is not required in situations concerning the public's health, criminal and legal matters, quality assurance, and aggregate record reviews for accreditation. In addition, "information can and must be shared between healthcare providers who have a legitimate need to know in order to provide safe and appropriate care" (Brooke, 2009, p. 11). This provision typically refers to emergency situations such as in the case of a client who is unable because of a psychotic state to give accurate information, or to sign a release of information form in the emergency department. HIPAA provisions allow nurses to gather information about the client's medical condition or drug history in an emergency for the purpose of providing immediate treatment, without having the client's written permission. When this occurs, it is important to document in the client's chart the immediacy of the need to obtain the required information.
The Office of Civil Rights enforces HIPAA regulations. Agencies and providers face severe penalties for violations, with improper disclosure of medical information punishable by fines or imprisonment. Study your agency's policies to determine to whom and under what conditions personal health information can be released. More information can be obtained through their web site (www.hhs.gov/ocr).
#### Protecting Client Privacy in Clinical Situations
In addition to informational privacy, which is a legal mandate, informal protection of the client's right to control the access of others to one's person in clinical situations is an ethical responsibility. The client and family usually view protecting the client's privacy in the clinical setting as a measure of respect. Simple strategies that nurses can use to protect the client's right to privacy in clinical situations include:
• Providing privacy for the client and family when disturbing matters are to be discussed
• Explaining procedures to clients before implementing them
• Entering another person's personal space with warning (e.g., knocking or calling the client's name) and, preferably, waiting for permission to enter
• Providing an identified space for the client's personal belongings
• Encouraging the inclusion of personal and familiar objects on the client's nightstand
• Decreasing direct eye contact during hands-on care
• Minimizing body exposure to what is absolutely necessary for care
• Using only the necessary number of people during any procedure
• Using touch appropriately
#### Confidentiality
Protecting the privacy of client information and confidentiality are related, but separate concepts. **Confidentiality** is defined as providing _only_ the information needed to provide care for the client to other health professionals who are directly involved in the care of the client. Kerr (2009) notes that "a violation occurs when information deemed private, and divulged in confidence, is shared with others" (p. 315). The need to share information with other health professionals directly involved in care on a "need to know" basis should be made clear to the client as they enter the clinical setting. Other than these individuals, the nurse must have the client's written permission to share his or her private communication, unless the withholding of information would result in harm to the client or someone else, or in cases where abuse is suspected. Confidential information about the client cannot be shared with the family or other interested parties without the client or designated legal surrogate's written permission. Shared confidential information, unrelated to identified health care needs, should not be communicated or charted in the client's medical record.
Confidentiality within the nurse-client relationship involves the nurse's legal responsibility to guard against invasion of the client's privacy related to the following:
• Releasing information about the client to unauthorized parties
• Unwanted visitations in the hospital
• Discussing client problems in public places or with people not directly involved in the client's care
• Taking pictures of the client without consent or using the photographs without the client's permission
• Performing procedures such as testing for HIV without the client's permission
• Publishing data about a client in any way that makes the client identifiable without the client's permission (Cournoyer, 2001)
Professional Sharing of Confidential Information: Nursing reports and interdisciplinary team case conferences are acceptable forums for the discussion of health related communications shared by clients or families. Other venues include change-of-shift reports, one-on-one conversations with other health professionals about specific client care issues, and client-approved consultations with client families. Discussion of client care should take place in a private room with the door closed. Only relevant information specifically related to client assessment or treatment should be shared. Discussing private information casually with other health professionals without the client's permission is an abuse of confidentiality. The ethical responsibility to maintain client confidentiality continues even after the client is discharged from care.
Mandatory Reporting: Mandatory reporting of personal health information related to certain communicable or sexually transmitted diseases, child and elder abuse, and the potential for serious harm to another individual are considered exceptions to sharing of confidential information. Required mandatory disclosures may differ slightly from state to state. In general, nurses are required to report all notifiable infectious diseases and abuse to appropriate state and local reporting agencies. This duty to report supersedes the client's right to confidentiality or privileged communication with a health provider. Relevant client data should be released only to the appropriate local, state, or federal agency and as confidential information. The information provided must be the minimum amount needed to accomplish the purposes of disclosure, and the client needs to be informed about what information will be disclosed, to whom, and for what reason(s).
#### Informed Consent
Informed consent is more than a signature on a form indicating a client's willingness to undergo a treatment or procedure (Neary, Cahill, Kirwan, Kiely, & Redmond, 2008). **Informed consent** is defined as a focused communication process in which the professional nurse or physician discloses all relevant information related to a procedure or treatment, with full opportunity for dialogue, questions, and expressions of concern, before asking the client or health care agent for the client to sign a legal consent form. Unless there is a life-threatening emergency, all clients have the right to give informed consent. For legal consent to be valid, it must contain three elements (Northrop & Kelly, 1987):
• Consent must be voluntary.
• The client must have full disclosure about the risks, benefits, cost, potential side effects or adverse reactions of the proposed treatment or procedure, and should be provided with information about other treatment alternatives, if available.
• The client must have the capacity and competency to understand the information and to make an informed choice.
Before initiating an informed consent process, nurses need to assess the adequacy of a client's "hearing, sight, mental status, literacy level, and ability to understand the process or procedure" (Plawecki & Plawecki, 2009, p. 3). Essential disclosures needed to help ensure informed consent include:
• The nature and purpose of the proposed treatment or procedure
• The risks and benefits of not receiving or undergoing a treatment or procedure
• The client has the right to refuse treatment or discontinue it without penalty, unless it is an emergency situation
Clients should be given ample opportunity to ask questions and to express concerns. They should never feel coerced or pressured into consenting to treatment, as allowing a client to sign a consent form without fully understanding the meaning of what he or she is signing will invalidate the consent (Brooke, 2009). Ending the conversation leading to the actual signing of the consent form should always include the question, "Is there anything else that you think might be helpful in making your decision?" This type of dialogue gives the client permission to ask a question or address a concern that the nurse may not have given thought to in the informed consent discussion.
Guidelines Governing Legal Consent: Only legally competent adults can give legal consent; adults who are mentally retarded, developmentally disabled, or cognitively impaired cannot give legal consent (White, 2000). Evaluation of competency is made on an individual basis (e.g., in the case of emancipated adolescents no longer under their parent's control, brain-injured clients, or clients with early dementia) to determine the extent to which they understand what they are signing.
Legislation exists in all states, such that a legal guardian or personal health care agent can provide consent for the medical treatment of adults who lack the capacity to consent on their own behalf. In most cases, legal guardians or parents must give legal consent for minor children, defined as those younger than 18, unless the youth is legally considered an emancipated minor. Minors can also give consent in cases of immediate emergencies.
Emancipated minors are mentally competent adolescents younger than 18 who petition the courts for adult status. To be considered, adolescents must be financially responsible for themselves, and no longer living with their parents. Other criteria include being married, having a child, and/or being in military service.
## Summary
This chapter addresses the professional, legal, and ethical standards nurses use to guide their actions in the nurse-client relationship. Standards of professional practice provide a measurement benchmark, used to assess nursing competence in clinical situations regardless of specialty. Nurses are bound legally by the principles of tort law to provide a reasonable standard of care. This means that the nurse is obligated to provide a level of care that a reasonably prudent nurse with similar education and experience would provide in a similar situation. The ANA Code of Ethics for Nurses provides a conceptual framework for identifying the moral dimensions of nursing practice; it is an important guide to choice of actions in nurse-client relationships. Each state's Nurse Practice Acts defines the scope of nursing practice for nurses practicing in that state. Multistate licensure in a compact state allows registered nurses licensed and residing in a compact state to practice in other compact states without obtaining a second license.
The nursing process serves as a clinical management framework. It consists of sequential, overlapping phases: assessment, planning (including diagnosis and development of outcome criteria), implementation, and evaluation. The client is an active participant and decision maker in all phases. Nurses use the SBAR format to communicate essential information to other health professionals involved in the client's care.
Nurses are legally and ethically responsible for protecting the client's privacy. Privacy and confidentiality are related but separate concepts nurses use to protect a client's freedom of choice about sharing personal information with others. Privacy refers to a client's right to have control over personal information; confidentiality refers to the obligation not to divulge private information from a nurse-client relationship. HIPAA regulations, mandated by federal law govern the use and disbursement of personally identifiable health information, and give individuals the right to determine and restrict access to their health information.
Ethical Dilemma
What Would You Do?
As a student nurse, you observe a fellow nursing student making a medication error. She is a good friend of yours and is visibly upset by her error. She also is afraid that if she tells the instructor, she could get a poor grade for clinical, and she needs to have a good average to keep her scholarship. The client was not actually harmed by the medication error, and your friend seems sufficiently upset by the incident to convince you that she would not make a similar error again. What would you do?
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CHAPTER 3
# Clinical Judgment
## Applying Critical Thinking and Ethical Decision Making
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Define terms related to thinking, ethical reasoning, and critical thinking.
2 Identify and discuss the three principles of ethics underlying bioethical reasoning.
3 Describe the 10 steps of critical thinking.
4 Identify criteria necessary for acquisition of a value.
5 Discuss the application of ethics in nurse-client relationships.
6 Analyze the critical thinking process used in clinical judgments with clients.
7 Apply the critical thinking process to decision making in clinical nursing situations.
8 Demonstrate ability to analyze, synthesize, and evaluate a complex simulated case situation to make a clinical judgment.
9 Discuss application of findings from a research study to clinical practice.
This chapter examines the principles of ethical decision making and the process for critical thinking. Both are essential foundational knowledge for you to make effective nursing clinical judgments. These competencies, together with expert communication skills, are an integral part of nursing practice (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009). Ethical discussions in this book focus on the current literature in bioethics as held in Western society. In addition to basic content knowledge, throughout this book are included ethical dilemmas to help you begin applying your knowledge.
Critical thinking is a learned skill that teaches you how to "think about your thinking." In the past, expert nurses accumulated this skill with on-the-job experience, through trial and error. But this is an essential nursing skill that can be learned with practice while in school. The Applications section of this chapter specifically walks you through the reasoning process in applying the 10 steps of critical thinking.
## Basic concepts
Types of thinking
There are many ways of thinking (Figure 3-1). Students often attempt to use total recall by simply memorizing a bunch of facts (e.g., memorizing the cranial nerves by using a mnemonic such as "On Old Olympus' Towering Tops..."). At other times, we rely on developing habits by repetition, such as practicing cardiopulmonary resuscitation (CPR) techniques. More structured methods of thinking, such as inquiry, have been developed in disciplines related to nursing. For example, you are probably familiar with the scientific method. As used in research, this is a logical, linear method of systematically gaining new information, often by setting up an experiment to test an idea. The nursing process uses a method of systematic steps: assessment before planning, planning before intervention, and evaluation.
Figure 3-1 Mnemonics can be useful tools.
Knowing about your individual thinking style is vital not only for your own learning but also because your values affect the quality of relationships you are able to establish with clients. This chapter focuses on the most important concepts to help you develop your clinical judgment abilities. Completing the exercises will help you develop your skills.
## Ethical reasoning
In clinical situations, nurses often face ethical dilemmas. Most nurses report facing ethical dilemmas in their work on a weekly basis. Examples include issues involving client choice, quality of life, and end-of-life decisions. A nurse frequently has to act in value-laden situations. For example, you may have clients who request abortions or who want "do not resuscitate" (DNR; "no code") orders. Your decisions affect the client's rights and the client's quality of life. A willingness to comply with ethical and professional standards is a hallmark of a professional.
Yet, members of many professions have difficulty applying ethical principles to clinical care situations. When various professionals answered questions about ethical dilemmas presented to them, physician responses were correctly ethically based 49.2% of the time, nurse responses 46.3%, and adult citizens 40% (Johnson, 2005). Is being ethically correct less than half the time acceptable? Student practice in applying ethical principles is important. Although it is true that most agencies have ethics committees that often are the primary party involved with the client or family in resolving difficult ethical dilemmas, on many other occasions, you, the nurse, will be called on to make ethical decisions.
As nurses, we need to have a clear understanding of the ethics of the nursing profession. Nursing organizations have formally published ethical codes, such as those from American Nurses Association (ANA) or the Federation of European Countries (Sasso, 2008). Academic programs now include application to clinical practice in the curriculum.
Case Example
During an influenza pandemic, Michaela May, RN, is reassigned to work on an unfamiliar pulmonary intensive care unit. Clients there have a severe form of infectious flu with respiratory complications and are receiving mechanical ventilation. She worries that if she refuses to care for these assigned clients, she could lose her job or even her license. But she also fears carrying this infection home to her two preschool children.
This case highlights conflicting duties: employer/client versus self/family. According to the ANA, nurses are obligated to care for all clients but there are limits to the personal risk of harm a nurse can be expected to accept. It is her _moral duty_ if clients are at significant risk for harm that her care can prevent. This situation becomes a _moral option_ only if there are alternative sources of care (i.e., other nurses available). For a full discussion, read Stokowski (2009).
### Ethical theories and decision-making models
Ethical theories provide the bedrock from which we derive the principles that guide our decision making. There is no one "right" answer to an ethical dilemma: The decision may vary depending on which theory the involved people subscribe to. The following section briefly describes the most common models currently used in bioethics. They are, for the most part, representative of a Western European and Judeo-Christian viewpoint. As we become a more culturally diverse society, other equally viable viewpoints may become acculturated. This discussion focuses on three decision-making models: utilitarian/goal-based, duty-based, and rights-based models.
The **utilitarian/goal-based model** says that the "rightness" or "wrongness" of an action is always a function of its consequences. Rightness is the extent to which performing or omitting an action will contribute to the overall good of the client. Good is defined as maximum welfare or happiness. The rights of clients and the duties of a nurse are determined by what will achieve maximum welfare. When a conflict in outcome occurs, the correct action is the one that will result in the greatest good for the majority. An example of a decision made according to the goal-based model is forced mandatory institutionalization of a client with tuberculosis who refuses to take medicine to protect other members of the community. The client's hospitalization produces the greatest balance of good over harm for the majority. Thus, "goodness" of an action is determined solely by its outcome.
The **deontologic** or **duty-based model** is person centered. It incorporates Immanuel Kant's deontologic philosophy, which holds that the "rightness" of an action is determined by other factors in addition to its outcome. Respect for every person's inherent dignity is a consideration. For example, a straightforward implication would be that a physician (or nurse) may never lie to a client. Do you agree? Decisions based on this duty-based model have a religious-social foundation. Rightness is determined by moral worth, regardless of the circumstances or the individual involved. In making decisions or implementing actions, the nurse cannot violate the basic duties and rights of individuals. Decisions about what is in the best interests of the client require consensus among all parties involved. Examples are the medical code "do no harm" and the nursing duty to "help save lives."
The **human rights–based model** is based on the belief that each client has basic rights. Our duties as health care providers arise from these basic rights. For example, a client has the right to refuse care. Conflict occurs when the provider's duty is not in the best interests of the client. The client has the right to life and the nurse has the duty to save lives, but what if the quality of life is intolerable and there is no hope for a positive outcome? Such a case might occur when a neonatal nurse cares for an infant with anencephaly (born without brain tissue in the cerebrum) in whom even the least invasive treatment would be extremely painful and would never provide any quality of life.
Ethical dilemmas arise when an actual or potential conflict occurs regarding principles, duties, or rights. Of course, many ethical or moral concepts held by Western society have been codified into law. Laws may vary from state to state, but a moral principle should be universally applied. Moral principles are shared by most members of a group, such as physicians or nurses, and represent the professional values of the group. Conflict arises when a nurse's professional values differ from the law in her state of residence. Conflict may also arise when you have not come to terms with situations in which your personal values differ from the profession's values. One example is doctor-assisted suicide (euthanasia). _Legally,_ at the turn of the twenty-first century, such an act was legal in Oregon but illegal in Michigan. _Professionally,_ the ANA Code of Ethics guides you to do no harm. _Personally,_ your belief about whether euthanasia is right or wrong may be at variance with either of the above.
#### Bioethical Principles
To practice nursing in an ethical manner, you must be able to recognize the existence of a moral problem. Once you recognize a situation that puts your client in jeopardy, you must be able to take action. Three essential, guiding ethical principles have been developed from the theories cited earlier. The three principles that can assist us in decision making are autonomy, beneficence (nonmaleficence), and justice (Figure 3-2).
Figure 3-2 Guiding ethical principles that assist in decision making.
Autonomy versus Medical Paternalism: Autonomy is the client's right to self-determination. In the medical context, respect for a client's autonomy is a fundamental ethical principle. It is the basis for the concept of informed consent, which means your client makes a rational, informed decision without coercion (Ebbesen & Pedersen, 2008). The medical profession went from having a paternalistic relationship with clients to letting them decide. In the past, nurses and physicians often made decisions for clients based on what they thought was best for the client. This _paternalism_ sometimes discounted the wishes of clients and their families. The ethical concept of client autonomy has so strongly emerged as a client right in Western countries that aspects involved in an individual's right to participate in medical decisions about his own care have become law.
This moral principle of autonomy means that each client has the right to decide about his or her health care. Clients who are empowered to make such decisions are more likely to comply with your treatment plan. Internal factors such as pain may interfere with a client's ability to choose. External factors such as coercion by a care provider may also interfere. As a nurse, you and your employer must legally obtain the client's permission for all treatment procedures. In the United States, under the Patient Self-Determination Act of 1991, all clients of agencies receiving Medicaid funds must receive written information about their rights to make decisions about their medical care. Nurses, as well as physicians, must provide clients with all the relevant and accurate information they need to make an "informed" decision whether they agree to treatments. The ANA states that it is the nurse's responsibility to assist clients to make these decisions, as discussed in Chapter 2 (see Informed Consent section).
Many of the nursing theories incorporate concepts about autonomy and empowering the client to be responsible for self-care, so you may find this easy to accept as part of your nursing role. However, what happens if the client's right to autonomy puts others at risk? Whose rights take precedence?
Case Example
A child is admitted to the emergency department with life-threatening blood loss after an automobile accident. The father refuses transfusion on religious grounds. The hospital obtains a court order, and the physician gives the transfusion.
The concept of autonomy has also been applied to the way we practice nursing, but our professional autonomy has some limitations. For example, the American Medical Association's Principles of Medical Ethics says a physician can choose whom to serve, except in an emergency; however, the picture is a little different in nursing practice. According to the ANA Committee on Ethics, nurses are ethically obligated to treat clients seeking their care. For example, you could not refuse to care for a client with AIDS who is assigned to you.
A nurse has autonomy in caring for a client, but this is somewhat limited because legally she must also follow physician orders and be subject to physician authority. Before the nurse or physician can override a client's right to autonomy, he or she must be able to present a strong case for their point of view based on either or both of the following principles: beneficence and justice.
Case Example
Dorothy Kneut, 72, refuses physician-assisted suicide after being diagnosed with Alzheimer's disease. She also refuses entry into a long-term care facility, deciding instead to rely on her aged, disabled spouse to provide her total care as she deteriorates physically and mentally. As her home health nurse, you find he is unable to provide needed care, and ask her physician to transfer her to an extended care facility.
#### Beneficence and Nonmaleficence
Beneficence implies that a decision results in the greatest good or produces the least harm to the client. This is based on the Hippocratic Oath and its concept of "do no harm." Avoiding actions that bring harm to another person is known as _nonmaleficence._ An example is the Christian belief of "do not kill," which has been codified into law but has many exceptions (e.g., soldiers sent to war are expected to kill the enemy).
In health care, beneficence gives care providers the moral obligation to act at all times for the benefit of their clients. Again, nursing theorists have incorporated this into the nursing role, so you may find this easy to accept. Helping others may be why you chose to become a nurse. In nursing, you not only have the obligation to avoid harming your clients, but you also are expected to advocate for your clients' best interests.
Case Example
Mr. Harper, 62, is admitted with end-organ failure. You are expected to assess for pain that he has and treat it. Do you seek a palliative order even though his liver cannot process drugs? It is estimated that more than 50% of conscious clients spend their last week of life in moderate to severe pain. Who is advocating for them?
Beneficence is challenged in many clinical situations (e.g., requests for abortion or euthanasia). Currently, some of the most difficult ethical dilemmas involve situations where decisions may be made to withhold treatment. For example, decisions are made to justify such violations of beneficence in the guise of permitting merciful death. Is there a moral difference between actively causing death and withholding treatment, when the outcome for the client is the same death? There are clear legal differences. In most states, a health care worker who intentionally acts to cause a client's death is legally liable.
Other challenges to beneficence occur when the involved parties hold different viewpoints about what is best for the client. Consider a case in which the family of an elderly, poststroke, comatose, ventilator-dependent client wants all forms of treatment continued, but the health care team doesn't believe it will benefit the client. The initial step toward resolution may be holding a family conference and really listening to the viewpoints of family members, asking them whether the client ever expressed wishes verbally or in writing in the form of an advance directive. Maintaining a trusting, open, mutually respectful communication may help avoid an adversarial situation.
#### Justice
Justice is actually a legal term; however, in ethics, it refers to being fair or impartial. A related concept is equality (e.g., the just distribution of goods or resources, sometimes called _social justice_ or _distributive justice_ ). Within the health care arena, this distributive justice concept might be applied to scarce treatment resources. As new and more expensive technologies that can prolong life become available, who has a right to them? Who should pay for them? If resources are scarce, how do we decide who gets them? Should a limited resource be spread out equally to everyone? Or should it be allocated based on who has the greatest need?
Unnecessary Treatment: Decisions made based on the principle of justice may also involve the concept of unnecessary treatment. Are all operations that are performed truly necessary? Why do some clients receive antibiotics for viral infections, when we know they do not kill viruses? Are unnecessary diagnostic tests ever ordered solely to document that a client does not have Condition X, just in case there is a malpractice lawsuit?
Social Worth: Another justice concept to consider in making decisions is that of social worth. Are all people equal? Are some more deserving than others? If a client Dan is 7 years old instead of 77 years old, and the expensive medicine would cure his condition, should these factors affect the decision to give him the medicine? If there is only one liver available for transplant today, and there are two equally viable potential recipients—Larry, age 54, whose alcoholism destroyed his own liver; or Kay, age 32, whose liver was destroyed by hepatitis she got while on a life-saving mission abroad—who should get the liver?
Veracity: Truthfulness is the bedrock of trust. And trust is an essential component of the professional nurse-client relationship. Not only is there a moral injunction against lying, but it is also destructive to any professional relationship. Generally, nurses would agree that a nurse should never lie to a client. However, there is controversy about withholding information from a client. We need clarity about truth telling. There will be times when we need to exercise some judgment about to whom to disclose information. We have an obligation to protect potentially vulnerable clients from information that would cause emotional distress. Although it is never acceptable to lie, nurses have evaded answering questions by saying, "You need to ask your physician about that." Can you suggest another response?
### Steps in ethical decision making
The process of moral reasoning and making ethical decisions has been broken down into steps. These steps are only a part of the larger model for critical thinking. Table 3-1 summarizes a model useful for nurses that was adapted from Lincourt's model. This model covers the most essential parts of an ethical reasoning process. If you are the moral agent making this decision, you must be skillful enough to implement the actions in a morally correct way. Consider the following case.
TABLE 3-1
Moral Decision-Making Guide
Moral Component | Data | Evaluation
---|---|---
Claim | Clear statement of the claim or dilemma; issues and values are clearly identified | Are values of all parties represented? Who has a stake in the outcome? Are there any ethical conflicts between two or more values?
Evidence | Clarify the facts; list the grounds, statistics, and so on | Are they true? Relevant? Sufficient?
Warrant | Agency policy, professional standards of care, written protocols, legal precedents | Are they general? Are they appropriate?
Basis | Identify the moral basis for each individual's claim; list backing, such as ethical principle of autonomy, beneficence, or justice | Is the backing recognizable? Impressively strong?
Rebuttal | List the benefit and the burdens; weigh them for each alternative in terms of possible consequences for each of the parties involved* | How strong and compelling is the rebuttal argument? Is the decision in accord with or in conflict with the law?
*Benefits might include profit for one of the parties. Burden might include causing physical or emotional pain to one of the parties or imposing financial burden on them.
Case Example
You are assigned to four critical clients on your unit. Mrs. Rae, 83, is unconscious, dying, and needs suctioning every 10 minutes. Mr. Jones, 47, has been admitted for observation for severe bloody stools. Mr. Hernandez, 52, has newly diagnosed diabetes and is receiving intravenous (IV) drip insulin; he requires monitoring of vital signs every 15 minutes. Mr. Martin, 35, is suicidal and has been told today he has inoperable cancer.
In deciding how to spend your limited time with these clients, do you base your decision entirely on how much good you can do for each client? Under distributive justice, what should happen when the needs of these four conflict? You could base your decision on the principle of beneficence and do the greatest good for the most clients, but this is a very subjective judgment. Would one of these clients benefit more from nursing care than the others?
In using ethical decision-making processes, nurses must be able to tolerate ambiguity and uncertainty. One of the most difficult aspects for the novice nurse to accept is that there often is no one "right" answer; rather, usually several options may be selected, depending on the person or situation.
## Critical thinking
**Critical thinking** is an analytical process in which you purposefully use specific thinking skills to make complex clinical decisions. You are able to reflect on your own thinking process. We can paraphrase the American Philosophical Association definition, which considers critical thinking as a purposeful, self-regulating process of interpretation, analysis, evaluation, and inference for the purpose of making judgments (Worell & Profetto-McGrath, 2007).
Although no consensus has been reached on a critical thinking definition in the nursing arena, current definitions are similar (Ravert, 2008). Generally, we define critical thinking as the purposeful use of a cognitive framework to identify and analyze assumptions and evidence to recognize emergent client situations, make clear, objective clinical decisions, and intervene appropriately (Mangena & Chabeli, 2005; Wilgis & McConnell, 2008). It encompasses the steps of the nursing process, but possibly in a more circular loop than we usually envision the nursing process. Critical thinking allows the nurse to modify the care plan based on the client's responses to her nursing interventions (Fero et al., 2009).
Critical thinking is more than just a _cognitive process_ of following steps. It also has an _affective component_ —the willingness to engage in self-reflective inquiry. As you learn to be a critical thinker, you improve and clarify your thinking process skills, so that you are more accurately able to solve problems based on available evidence. Although the cognitive skills can be taught, the affective willingness to use critical thinking process is an ingrained trait that may be difficult to change. Changing from a lecture method of nurse education to a learner-centered approach would have faculty "model" the critical thinking process for students.
### Characteristics of a critical thinker
Critical thinkers are skilled at using inquiry methods. They approach problem solutions in a systematic, organized, and goal-directed way when making clinical decisions. They continually use past knowledge, communication skills, new information, and observations to make these clinical judgments. Table 3-2 summarizes the characteristics of a critical thinker.
TABLE 3-2
Characteristics of a Critical Thinker
Based on information from Facione PA: _Critical thinking: what is it and why it counts_ , Milbrae, CA, 2006, California Academic Press; Scheffer BK, Rubenfeld MG: A consensus statement on critical thinking in nursing, _J Nurs Educ_ 39(8):352–359, 2000; and Worrell JA, Profetto-McGrath J: Critical thinking as an outcome of context-based learning among post RN students: a literature review, _Nurse Educ Today_ 27:420–426, 2007.
Expert nurses recognize that priorities change continually, requiring constant assessment and alternative interventions. When the authors analyzed the decision-making process of expert nurses, they all used the critical thinking steps described in this chapter when they made their clinical judgments, even though they were not always able to verbally state the components of their thinking processes. Expert nurses organized each input of client information and quickly distinguished relevant from irrelevant information. They seemed to categorize each new fact into a problem format, obtaining supplementary data and arriving at a decision about diagnosis and intervention. Often, they commented about comparing this new information with prior knowledge, sometimes from academic sources but usually from information gained from preceptors. They constantly scan for new information, and constantly reassess their client's situation. This is not linear. New input is always being added. This contrasts with novice nurses who tend to think in a linear way, collect lots of facts but not logically organize them, and fail to make as many connections with past knowledge. Novice nurses' assessments are more generalized and less focused, and they tend to jump too quickly to a diagnosis without recognizing the need to obtain more facts.
Because nurses are responsible for a significant proportion of decisions that affect client care, and are key gatekeepers in preventing harm, employing agencies periodically retest staff nurses for competencies. This procedure was initially done just to retest or recertify technical skills, such as CPR. Now many agencies have added other competency testing, including evaluation of critical thinking/clinical judgment skills (Rush, 2008).
### Barriers to thinking critically and reasoning ethically
Attitudes and Habits
Barriers that decrease a nurse's ability to think critically, including attitudes such as "my way is better," interfere with our ability to empower clients to make their own decisions. Our thinking habits can also impede communication with clients or families making complex bioethical choices. Examples include becoming accustomed to acknowledging "only one right answer" or selecting only one option. Behaviors that act as barriers include automatically responding defensively when challenged, resisting changes, and desiring to conform to expectations. Cognitive barriers, such as thinking in stereotypes, also interfere with our ability to treat a client as an individual.
#### Cognitive Dissonance
_Cognitive dissonance_ refers to the mental discomfort you feel when there is a discrepancy between what you already believe and some new information that does not go along with your view. In this book, we use the term to refer to the holding of two or more conflicting values at the same time.
#### Personal Values versus Professional Values
We all have a _personal value system_ developed over a lifetime that has been extensively shaped by our family, our religious beliefs, and our years of life experiences. Our values change as we mature in our ability to think critically, logically, and morally. Strongly held values become a part of self-concept. Our education as nurses helps us acquire a _professional value system_. In nursing school, as you advance through your clinical experiences, you begin to take on some of the values of the nursing profession (Box 3-1). You are acquiring these values as you learn the nursing role. The process of this role socialization is discussed in Chapter 7. For example, maintaining client confidentiality is a professional value, with both a legal and a moral requirement. We must take care that we do not allow our personal values to obstruct care for a client who holds differing values.
BOX 3-1 Five Core Values of Professional Nursing
Five _core values of professional nursing_ have been identified by the American Association of Colleges of Nursing (AACN):
• Human dignity
• Integrity
• Autonomy
• Altruism
• Social justice
### Values clarification and the nursing process
The nursing process offers many opportunities to incorporate _values clarification_ into your care. During the assessment phase, you can obtain an assessment of the _client's values_ with regard to the health system. For example, you interview a client for the first time and learn that he has obstructive pulmonary disease and is having difficulty breathing, but he insists on smoking. Is it appropriate to intervene? In this example, you know that smoking is detrimental to a person's health and you, as a nurse, find the value of health in conflict with the client's value of smoking. It is important to understand your client's values. When your values differ, you attempt to care for this client within his reality. He has the right to make decisions that are not always congruent with those of his health care providers (Bromley & Braslow, 2008).
The values people hold often are observed in their interest in, involvement with, and commitment to people, places, and things.
When identifying specific nursing diagnoses, it is important that your diagnoses are not biased. Examples of value conflicts might be spiritual distress related to a conflict between spiritual beliefs and prescribed health treatments, or ineffective family coping related to restricted visiting hours for a family in which full family participation is a cultural value. In the planning phase, it is important to identify and understand the client's value system as the foundation for developing the most appropriate interventions. Plans of care that support rather than discount the client's health care beliefs are more likely to be received favorably. Your interventions include values clarification as a guideline for care. You help clients examine alternatives. During the evaluation phase, examine how well the nursing and client goals were met while keeping within the guidelines of the client's value system.
To summarize, in case of conflict (with own personal ethical convictions), nurses must put aside their own moral convictions to provide necessary assistance in a case of emergency when there is imminent risk to a patient's life (Sasso, 2008). Ethical reasoning and critical thinking skills are essential competencies for making clinical judgments, in an increasingly complex health care system (Carter & Ruckholm, 2008). To apply critical thinking to a clinical decision, we need to base our intervention on _the best evidence_ available. These skills can be learned by participating in simulated patient case situations. These skills will enable you to provide higher quality nursing care (Fero et al., 2009; Ravert, 2008).
Developing an Evidence-Based Practice
A nonrandom consecutive sample of 2,144 newly hired nurses completed a valid and reliable instrument, the Performance Based Development System Assessment (PBDS), which consists of 10 video vignettes depicting change in client status. Written answers for each nurse's response to each video were scored as meeting or not meeting expectations. The purpose of this research project was not explicitly stated, but seems to be determining which staff nurses were using critical thinking skills, and which specific skills could be identified.
_Results:_ Expectations for critical thinking process were met by 74.9% of nurse participants. Controlling for years of experience, new graduates were less likely to meet critical thinking expectations compared with nurses having 10 or more years' experience ( _P_ = 0.046). Among nurses not meeting expectations, areas needing improvement included: not identifying problem correctly (57.1%), not prioritizing urgency (67%), not reporting essential data (65.4%), unable to provide rationale to support decisions (62.6%), and not anticipating relevant medical orders (62.8%). Analysis of written responses for those not meeting expectations also showed that 97.2% did not initiate appropriate nursing interventions. ADN students (associate's degree) and BSN (bachelor's degree) students were more likely to meet expectations as years of experience accrued, a trend not seen in diploma nurses.
_Application to Your Clinical Practice:_ The PBDS tool was able to identify specific areas of learning needs in working nurses, as opposed to prior studies using student nurses. It is crucial for a client's safety that his or her nurse is able to recognize a significant change in his or her condition and make appropriate interventions. Identifying nurses unable to do so allows hospital inservice departments to initiate a learning program tailored to each individual's area of weakness to help them develop needed critical thinking abilities and to improve client care. As a student, would you be willing to use the PBDS to identify areas you need to work on?
Fero LJ, Witsberger CM, Wesmiller SW, Zullo TG, Hoffman LA: Critical thinking ability of new graduate and experienced nurses, _Journal of Advanced Nursing,_ 65(1):139–148, 2009.
## Applications
Accrediting agencies for nursing curriculums require inclusion of critical thinking curriculum. Accepted teaching-learning methods for assessing critical thinking include case studies, questioning, reflective journalism, client simulations, portfolios, concept maps, and problem-based learning (Sorensen & Yankech, 2008; Wilgis & McConnell, 2008). As a nurse, you are faced with processing copious amounts of information to be considered before making a decision about your client's situation. Often, you must consider more than one possibility but make your decision quickly. To provide safe care, you must be able to apply critical thinking skills to clinical situations (Fero et al., 2009; Rogal & Young, 2008).
## Participation in clinical research
You or your clients may be called on at some time to participate in clinical research trials. The focus of this book is to examine ethical dilemmas faced in nursing practice, and this does not encompass the ethical aspect of conducting or participating in research studies. To examine what makes clinical research ethical, consult a nursing research book.
## Solving ethical dilemmas in nursing
Nurses indicate a need for more information about dealing with the ethical dilemmas they encounter, yet most say they receive little education in doing so. Exercises 3-1 (autonomy), 3-2 (beneficence), and 3-3 (justice) give you this opportunity.
EXERCISE 3-1 Autonomy
Purpose: To stimulate class discussion about the moral principle of autonomy.
Procedure:
In small groups, read the three case examples on page 47 and discuss whether the client has the autonomous right to refuse treatment if it affects the life of another person.
Discussion:
Prepare your argument for an in-class discussion.
EXERCISE 3-2 Beneficence
Purpose: To stimulate discussion about the moral principle of beneficence.
Procedure:
Read the following case example and prepare for discussion:
Dawn, a staff nurse, answers the telephone and receives a verbal order from Dr. Smith. Ms. Patton was admitted this morning with ventricular arrhythmia. Dr. Smith orders Dawn to administer a potent diuretic, Lasix 80 mg, IV, STAT. This is such a large dose that she has to order it up from pharmacy.
As described in the text, you are legally obliged to carry out a doctor's orders unless they threaten the welfare of your client. How often do nurses question orders? What would happen to a nurse who questioned orders too often? In a research study using this case simulation, nearly 95% of the time the nurses participating in the study attempted to implement this potentially lethal medication order before being stopped by the researcher!
Discussion:
1. What principles are involved?
2. What would you do if you were this staff nurse?
EXERCISE 3-3 Justice
Purpose: To encourage discussion about the concept of justice.
Procedure:
Consider that in Oregon several years ago, attempts were made to legislate some restrictions on what Medicaid would pay for. A young boy needed a standard treatment of bone marrow transplant for his childhood leukemia. He died when the state refused to pay for his treatment.
Read the following case example and answer the discussion questions:
Mr. Diaz, age 74, has led an active life and continues to be the sole support for his wife and disabled daughter. He pays for health care with Medicare government insurance. The doctors think his cancer may respond to a very expensive new drug, which is not paid for under his coverage.
Discussion:
1. Does everyone have a basic right to health care, as well as to life and liberty?
2. Does an insurance company have a right to restrict access to care?
The ethical issues that nurses commonly face today can be placed in three general categories: moral uncertainty, moral or ethical dilemmas, and moral distress. _Moral uncertainty_ occurs when a nurse is uncertain as to which moral rules (i.e., values, beliefs, or ethical principles) apply to a given situation. For example, should a terminally ill client who is in and out of a coma and chooses not to eat or drink anything be required to have IV therapy for hydration purposes? Does giving IV therapy constitute giving the client extraordinary measures to prolong life? Is it more comfortable or less comfortable for the dying client to maintain a high hydration level? When there is no clear definition of the problem, moral uncertainty develops, because the nurse is unable to identify the situation as a moral problem or to define specific moral rules that apply. Strategies that might be useful in dealing with moral uncertainty include using the values clarification process, developing a specific philosophy of nursing, and acquiring knowledge about ethical principles.
Ethical or moral dilemmas arise when two or more moral issues are in conflict. An ethical dilemma is a problem in which there are two or more conflicting but equally right answers. Organ harvesting of a severely brain-damaged infant is an example of an ethical dilemma. Removal of organs from one infant may save the lives of several other infants. However, even though the brain-damaged child is definitely going to die, is it right to remove organs before the child's death? It is important for the nurse to understand that, in many ethical dilemmas, there is often no single "right" solution. Some decisions may be "more right" than others, but often what one nurse decides is best differs significantly from what another nurse would decide.
The third common kind of ethical problem seen in nursing today is _moral distress._ Moral distress results when the nurse knows what is "right" but is bound to do otherwise because of legal or institutional constraints. When such a situation arises (e.g., a terminally ill client who does not have a "do not resuscitate" medical order and for whom, therefore, resuscitation attempts must be made), the nurse may experience inner turmoil.
Nurses in the National Rural Bioethics Project reported that three of their most commonly encountered ethics problems had to do with resuscitation decisions for dying clients with unclear, confusing, or no code orders; patients and families who wanted more aggressive treatment; and colleagues who discussed clients inappropriately.
Because values underlie all ethical decision making, nurses must understand their own values thoroughly before making an ethical decision. Instead of responding in an emotional manner on the spur of the moment (as people often do when faced with an ethical dilemma), the nurse who uses the values clarification process can respond rationally. It is not an easy task to have sufficient knowledge of oneself, of the situation, and of legal and moral constraints to be able to implement ethical decision making quickly. Expert nurses still struggle. Taking time to examine situations can help you develop skill in dealing with ethical dilemmas in nursing, and the exercises in this book will give you a chance to practice. Each chapter in this book has also included at least one ethical dilemma, so you can discuss what you would do.
Finally, in thinking about your own ethical practice, reflect on how important it is for your client to be able to always count on you. Consider the following client journal entry (Milton, 2002):
I ask for information, share my needs, to no avail. You come and go...
"Could you find out for me?" "Sure I'll check on it."
[But] check on it never comes...
Who can I trust? I thought you'd be here for me...
You weren't. What can I do?
Betrayal permeates...
## Professional values acquisition
Professional values or ethics consist of the values held in common by the members of a profession. Professional values are formally stated in professional codes. One example is the ANA Code of Ethics for Nurses. Often, professional values are transmitted by tradition in nursing classes and clinical experiences. They are modeled by expert nurses and assimilated as part of the role socialization process during your years as a student and new graduate. Professional values acquisition should perhaps be the result of conscious choice by a nursing student. This is the first step in values acquisition. Can you apply it to your own life? It may also help you understand the value system of your clients. Refer to Box 3-2 for the seven criteria for aquisition of a value.
BOX 3-2 Seven Criteria for Acquisition of a Value
The value must be
1. Freely chosen.
2. Chosen from alternatives.
3. Chosen after careful consideration of each alternative.
There must be
4. Pride in and happiness with the choice.
5. Willingness to make the values known to others.
It must be acted on
6. In response to the choice.
7. In a pattern of behavior consistent with the choice (value is incorporated into the individual's lifestyle).
Values are a strong determinant in making selections between competing alternatives. Consider whether the nursing profession holds values regarding the following situation: What if you observed a nurse charting that a medicine was given to a client when you know it was not? What professional value should guide your response? Exercise 3-4 will give you an opportunity to practice explaining which of your choices are based on the profession's values.
EXERCISE 3-4 Professional Nurses' Values
Purpose: To begin to focus thinking on professional role values.
Procedure:
Read the following statements. Think about each situation carefully. How would you want to respond if you were the primary nurse in the situation?
1. An 8-year-old girl is admitted to the emergency department, immaculately dressed, with many bruises and welts on her arms and legs. Her mother states she was hurt on the playground.
2. You note that your student partner has alcohol on her breath when she picks up her assignments. This has happened on more than one occasion.
3. A client has been told his bone scan shows metastatic lesions. He tells you not to tell his wife because she will just worry.
4. You have an order to administer a narcotic to a client who clearly is not in pain.
Discussion:
Share the responses to this exercise in a class discussion.
1. How did your answers compare with those of your peers?
2. In what ways did your values enter into your choices?
## Applying critical thinking to the clinical decision-making process
This section discusses a procedure for developing critical thinking skills as applied to solving clinical problems. Different examples illustrate the reasoning process developed by several disciplines. Unfortunately, each discipline has its own vocabulary. Table 3-3 shows that we are talking about concepts with which you are already familiar. It also contrasts terms used in education, nursing, and philosophy to specify 10 steps to help you develop your critical thinking skills. For example, the nurse performs a "client assessment," which in education is referred to as "collecting information" or in philosophy may be called "identifying claims."
TABLE 3-3
Reasoning Process
The process of critical thinking is systematic, organized, and goal directed. As critical thinkers, nurses are able to explore all aspects of a complex clinical situation (Worrell & Profetto-McGrath, 2007). This is a learned process. Among many teaching-learning techniques helping you develop critical thinking skills, most are included in this book: reflective journaling, concept maps, role-playing, guided small group discussion, and case study discussion. An extensive case application follows. During your learning phase, the critical thinking skills are divided into 10 specific steps. Each step includes a discussion of application to the clinical case example provided.
To help you understand how to apply critical thinking steps, read the following case and then see how each of the steps can be used in making clinical decisions. Components of this case are applied to illustrate the steps and stimulate discussion in the critical thinking process; many more points may be raised. From the outset, understand that, although these are listed as steps, they do not occur in a rigid, linear way in real life. The model is best thought of as a circular model. New data are constantly being sought and added to the process.
Case Example
Day 1—Mrs. Vlios, a 72-year-old widowed teacher, has been admitted to your unit. Her daughter, Sara, lives 2 hours away from her mother, but she arrives soon after admission. According to Sara, her mother lived an active life before admission, taking care of herself in an apartment in a senior citizens' housing development. Sara noticed that for about 3 weeks now, telephone conversations with her mother did not make sense or she seemed to have a hard time concentrating, although her pronunciation was clear. The admitting diagnosis is dehydration and dementia, rule out Alzheimer's disease, organic brain syndrome, and depression. An IV of 1,000 ml dextrose/0.45 normal saline is ordered at 50 drops/hour. Mrs. Vlios's history is unremarkable except for a recent 10-pound weight loss. She has no allergies and is known to take acetaminophen regularly for minor pain.
Day 2—When Sara visits her mom's apartment to bring grooming items to the hospital, she finds the refrigerator and food pantry empty. A neighbor tells her that Mrs. Vlios was seen roaming the halls aimlessly 2 days ago and could not remember whether she had eaten. As Mrs. Vlios's nurse, you notice that she is oriented today (to time and person). A soft diet is ordered, and her urinary output is now normal.
Day 5—In morning report, the night nurse states that Mrs. Vlios was hallucinating and restraints were applied. A nasogastric tube was ordered to suction out stomach contents because of repeated vomiting. Dr. Green tells Sara and her brother, Todos, that their mother's prognosis is guarded; she has acquired a serious systemic infection, is semicomatose, is not taking nourishment, and needs antibiotics and hyperalimentation. Sara reminds the doctor that her mother signed a living will in which she stated she refuses all treatment except IVs to keep her alive. Todos is upset, yelling at Sara that he wants the doctor to do everything possible to keep their mother alive.
### Step 1: Clarify concepts
The first step in making a clinical judgment is to identify whether a problem actually exists. Poor decision makers often skip this step. To figure out whether there is a problem, you need to think about what to observe and what basic information to gather. If it is an ethical dilemma, you not only need to identify the existence of the moral problem, but you need to also identify all the interested parties who have a stake in the decision. Figuring out exactly what the problem or issue is may not be as easy as it sounds.
#### Look for Clues
Are there hidden meanings to the words being spoken? Are there nonverbal clues?
#### Identify Assumptions
What assumptions are being made?
#### Case Discussion
This case is designed to present both physiologic and ethical dilemmas. In clarifying the problem, address both domains.
• Physiological concerns: Based on the diagnosis, the initial treatment goal was to restore homeostasis. By Day 5, is it clear whether Mrs. Vlios's condition is reversible?
• Ethical concerns: When is a decision made to initiate treatment or to abide by the advance directive and respect the client's wishes regarding no treatment?
• What are the wishes of the family? What happens when there is no consensus?
• Assumptions: Is the diagnosis correct? Does the client have dementia? Or was her confusion a result of dehydration and a strange hospital environment?
### Step 2: Identify your own values
Values clarification helps you identify and prioritize your values. It also serves as a base for helping clients identify the values they hold as important. Unless you are able to identify your client's values and can appreciate the validity of those values, you run the risk for imposing your own values. It is not necessary for your values and your client's values to coincide; this is an unrealistic expectation. However, whenever possible, the client's values should be taken into consideration during every aspect of nursing care. Discussion of the case of Mrs. Vlios presented in this section may help you with the clarification process.
Having just completed the exercises given earlier should help your understanding of your own personal values and the professional values of nursing. Now apply this information to this case.
#### Case Discussion
Identify the values of each person involved:
• Family: Mrs. Vlios signed an advance directive. Sara wants it adhered to; Todos wants it ignored. Why? (Missing information: Are there religious beliefs? Is there unclear communication? Is there guilt about previous troubles in the relationship?)
• Personal values: What are yours?
• Professional values: The ANA says nurses are advocates for their clients; beneficence implies nonmaleficence ("do no harm"), but autonomy means the client has the right to refuse treatment. What is the agency's policy? What are the legal considerations? Practice refining your professional values acquisition by completing the values exercises in this chapter.
In summary, you need to identify which values are involved in a situation or which moral principles can be cited to support each of the positions advocated by the involved individuals.
### Step 3: Integrate data and identify missing data
Think about knowledge gained in prior courses and during clinical experiences. Try to make connections between different subject areas and clinical nursing practice.
• Identify what data are needed. Obtain all possible information and gather facts or evidence (evaluate whether data are true, relevant, and sufficient). Situations are often complicated. It is important to figure out what information is significant to this situation. Synthesize prior information you already have with similarities in the current situation. Conflicting data may indicate a need to search for more information.
• Compare existing information with past knowledge. Has this client complained of difficulty thinking before? Does she have a history of dementia?
• Look for gaps in the information. Actively work to recognize whether there is missing information. Was Mrs. Vlios previously taking medications to prevent depression? For a nurse, this is an important part of critical thinking.
• Collect information systematically. Use an organized framework to obtain information. Nurses often obtain a client's history by asking questions about each body system. They could just as systematically ask about basic needs.
• Organize your information. Clustering information into relevant categories is helpful. For example, gathering all the facts about a client's breathing may help focus your attention on whether the client is having a respiratory problem. In your assessment, you note rate and character of respirations, color of nails and lips, use of accessory muscles, and grunting noises. At the same time, you exclude information about bowel sounds or deep tendon reflexes as not being immediately relevant to his respiratory status. Categorizing information also helps you notice whether there are missing data. A second strategy that will help you organize information is to look for patterns. It has been indicated that experienced nurses intuitively note recurrent meaningful aspects of a clinical situation.
#### Case Discussion
Rely on prior didactic knowledge or clinical experience. Cluster the data. What was Mrs. Vlios's status immediately before hospitalization? What was her status at the time of hospitalization? What information is missing? What additional data do you need?
• Physiology: Consider pathophysiologic knowledge about the effects of hypovolemia and electrolyte imbalances on the systems such as the brain, kidneys, and vascular system. What is her temperature? What are her laboratory values? What is her 24-hour intake and output? Is she still dehydrated?
• Psychological/cognitive: How does hospitalization affect older adults? How do restraints affect them?
• Social/economic: Was weight loss a result of dehydration? Why was she without food? Could it be due to economic factors or mental problems?
• Legal: What constitutes a binding advance directive in the state in which Mrs. Vlios lives? Is a living will valid in her state, or does the law require a health power of attorney? Are these documents on file at the hospital?
### Step 4: Obtain new data
Critical thinking is not a linear process. Expert nurses often modify interventions based on the response to the event, or change in the client's physical condition (Fero et al., 2008). Constantly consider whether you need more information. Establish an attitude of inquiry and obtain more information as needed. Ask questions; search for evidence; and check reference books, journals, the ethics sources on the Internet, or written professional or agency protocols.
Evaluate conflicting information. There may be time constraints. If a client has suspected "respiratory problems," you may need to set priorities. Obtain data that are most useful or are easily available. It would be useful to know oxygenation levels, but you may not have time to order laboratory tests. But perhaps there is a device on the unit or in the room that can measure oxygen saturation.
Sometimes you may need to change your approach to improve your chances of obtaining information. For example, when the charge nurse caring for Mrs. Vlios used an authoritarian tone to try to get the sister and brother to provide more information about possible drug overdose, they did not respond. However, when the charge nurse changed his approach, exhibiting empathy, the daughter volunteered that on several occasions her mother had forgotten what pills she had taken.
#### Case Discussion
List sources from which you can obtain missing information. Physiologic data such as temperature or laboratory test results can be obtained quickly; some of the ethical information, however, may take longer to consider.
### Step 5: Identify the significant problem
• Analyze existing information: Examine all the information you have. Identify all the possible positions.
• Make inferences: What might be going on? What are the possible diagnoses? Develop a working diagnosis.
• Prioritize: Which client problem is most urgently in need of your intervention? What are the appropriate interventions?
#### Case Discussion
A significant physiologic concern is sepsis, regardless of whether it is an iatrogenic (hospital-acquired) infection or one resulting from immobility and debilitation. A significant ethical concern is the conflict among family members and client (as expressed through her living will). At what point do spiritual concerns take priority over a worsening physical concern?
### Step 6: Examine skeptically
Thinking about a situation may involve weighing positive and negative factors, and differentiating facts that are credible from opinions that are biased or not grounded in true facts.
• Keep an open mind.
• Challenge your own assumptions.
• Consider whether any of your assumptions are unwarranted. Does the available evidence really support your assumption?
• Discriminate between facts and inferences. Your inferences need to be logical and plausible, based on the available facts.
• Are there any problems that you have not considered?
In trying to evaluate a situation, consciously raising questions becomes an important part of thinking critically. At times there will be alternative explanations or different lines of reasoning that are equally valid. The challenge is to examine your own and others' perspectives for important ideas, complicating factors, other plausible interpretations, and new insights. Some nurses believe that examining information skeptically is part of each step in the critical thinking process rather than a step by itself.
#### Case Discussion
Challenge assumptions about the cause of Mrs. Vlios's condition. For example, did you eliminate the possibility that she had a head injury caused by a fall? Could she have liver failure as a result of acetaminophen overdosing? Have all the possibilities been explored? Challenge your assumptions about outcome: Are they influenced by expected probable versus possible outcomes for this client? If she, indeed, has irreversible dementia, what will the quality of her life be if she recovers from her physical problems?
### Step 7: Apply criteria
In evaluating a situation, think about appropriate responses.
• Laws: There may be a law that can be applied to guide your actions and decisions. For example, by law, certain diseases must be reported to the state. If you suspect physical abuse, there is a state statute that requires professionals to report abuse to the Department of Social Services.
• Legal precedents: There may have been similar cases or situations that were dealt with in a court of law. Legal decisions do guide health care practices. In end-of-life decisions, when there is no legally binding health care power of attorney, the most frequent hierarchy is the spouse, then the adult children, then the parents.
• Protocols: There may be standard protocols for managing certain situations. Your agency may have standing orders for caring for Mrs. Vlios if she develops respiratory distress, such as administering oxygen per face mask at 5 L/min.
#### Case Discussion
Many criteria could be used to examine this case, including the Nurse Practice Act in the area of jurisdiction, the professional organization code of ethics or general ethical principles of beneficence and autonomy, the hospital's written protocols and policies, state laws regarding living wills, and prior court decisions about living wills. Remember that advance directives are designed to take effect only when clients become unable to make their own wishes known.
### Step 8: Generate options and look at alternatives
• Evaluate the major alternative points of view.
• Involve experienced peers as soon as you can to assist you in making your decision.
• Use clues from others to help you "put the picture together."
• Can you identify all the arguments—pro and con—to explain this situation? Almost all situations will have strong counterarguments or competing hypotheses.
#### Case Discussion
The important concept is that neither the physician nor the nurse should handle this alone; rather, others should be involved (e.g., the hospital bioethics committee, the ombudsman client representative, the family's spiritual counselor, and other medical experts such as a gerontologist, psychologist, and nursing clinical specialist).
### Step 9: Consider whether factors change if the context changes
Consider whether your decision would be different if there were a change in circumstances. For example, a change in the age of the client, in the site of the situation, or in the client's culture may affect your decision. A competent nurse prioritizes which aspects of the situation are most relevant and can modify her actions based on the client's response (Fero et al., 2009).
#### Case Discussion
If you knew the outcome from the beginning, would your decisions be the same? What if you knew Mrs. Vlios had a terminal cancer? What if Mrs. Vlios had remained in her senior housing project and you were the home health nurse? What if Mrs. Vlios had remained alert during her hospitalization and refused IVs, hyperalimentation, nasogastric tubes, and so on? What if the family and Mrs. Vlios were in agreement about no treatment? Would you make more assertive interventions to save her life if she were 7 years old, or a 35-year-old mother of five young children?
### Step 10: Make the final decision
After analyzing available information in this systematic way, you need to make a judgment or decision. An important part of your decision is your ability to communicate it coherently to others and to reflect on the outcome of your decision for your client.
• Justify your conclusion.
• Evaluate outcomes.
• Test out your decision or conclusion by implementing appropriate actions.
The critical thinker needs to be able to accept that there may be multiple solutions that can be equally acceptable. In other situations, you may need to make a decision even when there is incomplete knowledge. Be able to cite your rationale or present your arguments to others for your decision choice and interventions.
After you implement your interventions, examine the client outcomes. Was your assessment correct? Did you obtain enough information? Did the benefits to the client and family outweigh the harm that may have occurred? In retrospect, do you know you made the correct decision? Did you anticipate possibilities and complications correctly? This kind of self-examination can foster self-correction. It is this process of reflecting on one's own thinking that is the hallmark of a critical thinker.
#### Case Discussion
The most important concept is to forget the idea that there is one right answer to the dilemmas raised by discussion of this case. Accept that there may be several equally correct solutions depending on each individual's point of view.
### Summarizing the critical thinking learning process
The most effective method of learning these steps in critical thinking results from repeatedly applying them to clinical situations. This can occur in your own clinical care. A new graduate nurse must, at a minimum, be able to identify essential clinical data, know when to initiate interventions, know why a particular intervention is relevant, and differentiate between problems that need immediate intervention versus problems that can wait for action. Repeated practice in applying critical thinking can help a new graduate fit into the expectations of employers.
Students have demonstrated that critical thinking can be learned in the classroom, as well as through clinical experience. Effective learning can occur when opportunities are structured that allow for repeated in-class applications to client case situations. This includes using real-life case interviews with experienced nurses, which allow you to analyze their decision-making process. The interview and analysis of an expert nurse's critical thinking described in Exercise 3-5 explains how this is done using a 10-minute recording.
EXERCISE 3-5 Your Analysis of an Expert's Critical Thinking: Interview of Expert Nurse's Case
Purpose: To develop awareness of critical thinking in the clinical judgment process.
Procedure:
Find an experienced nurse in your community and record him or her describing a real client case. You can use a computer or cell phone with recording capability, videotape, or audiotape to record an interview that takes less than 10 minutes. During the interview, have the expert describe an actual client case in which there was a significant change in the client's health status. Have the expert describe the interventions and thinking process that took place during this situation. Ask what nursing knowledge, laboratory data, or experience helped the nurse make his or her decision. You can work with a partner. Remember to protect confidentiality by omitting names and other identifiers.
Discussion:
Analyze the tape using an outline of the 10 steps in critical thinking. Discussion should first include citation examples of each step noted during their review of the taped interview, followed by application to the broad principles. Discussion of steps missed by the interviewed expert can be enlightening, as long as care is taken to avoid any criticism of the guest "expert."
You may also help increase your critical thinking and clinical problem-solving skills by discussing the following additional case example. Remember that most clinical situations requiring decision making will not involve the types of ethical dilemmas discussed earlier in this chapter.
Case Example
Mr. Gonzales has terminal cancer. His family defers to the attending physician who prescribes aggressive rescue treatment. The hospice nurse is an expert in the expressed and unexpressed needs of terminal clients. She advocates for a conservative and supportive plan of care. A logical case could be built for each position.
## Summary
Critical thinking is the ability to think about your thinking. It is not a linear process. Analysis of the thinking processes of expert nurses reveals that they continually scan new data and simultaneously apply these steps in clinical decision making. They monitor the effectiveness of their interventions in achieving desired outcomes for their client. A nurse's values and critical thinking abilities often have a profound effect on the quality of care given to a client, even affecting client mortality outcomes. Functioning as a competent nurse requires that you have knowledge of medical and nursing content, an accumulation of clinical experiences, and an ability to think critically. Almost daily, we confront ethical dilemmas and complicated clinical situations that require expertise as a decision maker. We can follow the 10 steps of the critical thinking process described in this chapter to help us respond to such situations. Developing skill as a critical thinker is a learned process, one requiring repeated opportunities for application to clinical situations. Reflecting on one's own thinking about case example situations provided in this chapter can assist such learning.
Ethical Dilemma
What Would You Do?
Rosa Smith, RN, is a newly graduated nurse employed on a medical unit in a county hospital system. She is a single mother and sole support for her toddler daughter. Nine clients are admitted with a new virulent pandemic flu that has killed citizens internationally in a manner similar to the SARS virus in the 1990s or the H1N1 virus of 2009. You know that both of these pandemics caused deaths in health care workers.
1. Identify Rosa's conflicting obligations.
2. Should Rosa continue to work, caring for such clients, putting herself and child at risk?
3. By virtue of her choosing to become a nurse, did she assume an ethical obligation/moral duty to treat clients during this disease outbreak?
4. What if Rosa's daughter were an adult?
5. What would you do if you worked on this unit?
6. When, if ever, is it okay to say "no"?
Developed based on information in Stokowski's (2009) article, "Ethical dilemmas for healthcare professionals: can we avoid influenza?"
## References
Bromley, E., Braslow, J.Y. Teaching critical thinking in psychiatric training: a role for the social sciences. _Am J Psychiatry_. 2008;165(11):1396–1401.
Carter, L.M., Rukholm, E. A study of critical thinking, teacher-student interaction, and discipline-specific writing in an online educational setting for registered nurses. _J Contin Educ Nurs_. 2008;39(3):133–138.
Ebbesen, M., Pedersen, B.D. The principle of respect for autonomy—concordant with the experience of oncology physicians and molecular biologists in their daily work? _BMC Med Ethics_. 2008;9:5.
Facione, P.A. Critical thinking: what is it and why it counts. Milbrae, CA: California Academic Press, 2006.
Fero, L.J., Witsberger, C.M., Wesmiller, S.W., et al. Critical thinking ability of new graduate and experienced nurses. _J Adv Nurs_. 2009;65(1):139–148.
Johnson, P. US journalists fare well on test of ethics, study finds. _USA Today_. 2005:5D. [February 2].
Mangena, A., Chabeli, M.M. Strategies to overcome obstacles in the facilitation of critical thinking in nursing education. _Nursing Education Today_. 2005;25:291–298.
Milton, C. Ethical implications for acting faithfully in nurse-person relationships. _Nurs Sci Q_. 2002;15:21–24.
Ravert, P. Patient simulator sessions and critical thinking. _J Nurs Educ_. 2008;47(12):557–562.
Rogal, S.M., Young, J. Exploring critical thinking in critical care nursing education: a pilot study. _J Contin Educ Nurs_. 2008;39(1):28–33.
Rush, K.L., Dyches, C.E., Waldrop, S., et al. Critical thinking among RN-to-BSN distance students participating in human patient simulation. _J Nurs Educ_. 2008;47(11):501–507.
Sasso, L. Federazione Europea delle Profeessioni Infermieristiche Action Plan 2007, 2008.
Sasso, L., Stievano, A., Jurado, M.G., et al. Code of ethics and conduct for European nursing. _Nurs Ethics_. 2008;15(6):821–836.
Sorensen, H.A., Yankech, L.R. Precepting in the fast lane: improving critical thinking in new graduate nurses. _J Contin Educ Nurs_. 2008;39(5):208–216.
Stokowski, L.A. Ethical dilemmas for healthcare professionals: can we avoid influenza? _Medscape Infectious Diseases_. 2009:1–7.
Wilgis, M., McConnell, J. Concept mapping: an educational strategy to improve graduate nurses' critical thinking skills during a hospital orientation program. _J Contin Educ Nurs_. 2008;39(3):119–126.
Worrell, J.A., Profetto-McGrath, J. Critical thinking as an outcome of context-based learning among post RN students: a literature review. _Nurse Educ Today_. 2007;27:420–426.
CHAPTER 4
# Self-Concept in the Nurse-Client Relationship
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define self-concept.
2 Describe the features of and functions of self-concept.
3 Identify theoretical models of the self and self-concept.
4 Discuss Erikson's theory of psychosocial ego development.
5 Identify functional health patterns and nursing diagnosis related to self-concept pattern disturbances.
6 Apply the nursing process to the nursing diagnosis of body image disturbance.
7 Apply the nursing process to the nursing diagnosis of personal identity disturbance.
8 Apply the nursing process to the nursing diagnosis of self-esteem disturbance.
9 Apply the nursing process to the nursing diagnosis of spiritual distress.
This chapter explores self-concept as a key informant of behavior in human interaction and nurse-client relationships. The chapter describes theoretical frameworks for how self-concept develops. The Applications section discusses body image, personal identity, spirituality, and self-esteem as important clinical components of self-concept and applies the nursing process to self-concept disturbances. The key role of self-concept in nurse-client relationships is explored.
## Basic concepts
Self-concept is an integral component of nurse-client relationships. It is a difficult idea to conceptualize due to its many facets and abstract nature. Figure 4-1 identifies aspects that are relevant to an appreciation of the self-concept's role in communication. The nursing diagnosis Association (NANDA International, 2009) recognizes self-concept pattern disturbances as approved nursing diagnoses. A healthy self-concept reflects attitudes, emotions and values that are realistically consistent with meaningful purposes in life and satisfying to the individual. A well-differentiated sense of personal identity permits the self-as-knower to experience a feeling of distinctness from others and a sense of sameness through time (Konig, 2009).
Figure 4-1 Characteristics of a healthy self-concept.
## Definition
**Self-concept** refers to an acquired set of thoughts, feelings, attitudes, and beliefs that individuals have about the nature and organization of their personality. Cunha and Goncalves (2009) refer to the self as an open system, which is fluid and dynamic. Like fingerprints, no two self-concepts are exactly alike. Self-concepts help people experience who they are and what they are capable of becoming physically, emotionally, intellectually, socially, and spiritually in relationship or community with others. McCormick & Hardy (2008) state, "identity, the definition of one's self, is the heart of one's life" (p. 405). Consciousness of one's personal identity allows a person to make authentic choices and maintain well-developed personal boundaries in relationships with others.
Self-concepts create and reflect our personal reality and worldview. The four aspects of self-concept—physical, cognitive, emotional, and spiritual—represent the holistic self, and are important determinants of behavior. Different aspects of self become more prominent, depending on the particular situation in which people find themselves (Prescott, 2006). From a patient-centered health care perspective, relevant self-concept patterns include body image (physical), personal identity (cognitive and perceptual awareness), self-esteem (emotional valuing), and spirituality (connectivity with a higher purpose or God).
### Features and functions of self-concept
Self-concept is an active, rather than static source of information about the self. Hunter (2008) suggests, "As one ages, the 'self' develops and becomes a more and more unique entity formed by personal experiences and personally developed values and beliefs" (p. 318). Self-concept is not necessarily a unified concept. It consists of multiple self-images, some of which may not match with each other or be supportive of the whole. For example, a star athlete can be a marginal student. Which is the true self-image, or are both valid? One can think of self-concept basically as the response to the question, "Who am I?" (Exercise 4-1).
EXERCISE 4-1 Who Am I?
Purpose: To help students understand some of the self-concepts they hold about themselves.
Procedure:
This exercise may be done as homework exercise and discussed in class. The class should sit face-to-face in a circle.
Fill in the blanks to complete the following sentences. There are no right or wrong answers.
The thing I like best about myself is ________________.
The thing I like least about myself is _______________.
My favorite activity is _____________________________.
When I am in a group, I ___________________________.
It would surprise most people if they knew _________.
The most important value to me is _________________.
I like ____________________________________________.
I most dislike ____________________________________.
I am happy when ________________________________.
I feel sad when __________________________________.
I feel most self-confident when I __________________.
I am ____________________________________________.
I feel committed to ______________________________.
Five years from now I see myself as _______________.
Discussion:
1. What were the hardest items to answer? The easiest?
2. Were you surprised by some of your answers? If so, in what ways?
3. Did anybody's answers surprise you? If so, in what ways?
4. Did anyone's answers particularly impress you? If so, in what ways?
5. What did you learn about yourself from doing this exercise?
6. How would you see yourself using this self-awareness in professional interpersonal relationships with clients?
Self-concepts provide important bridges to meaning. They help individuals make personal sense of their past, as it relates to the present and as it might be in the future (Lee & Oyserman, 2009). Personal decisions congruent with self-concept affirm the sense of self-identity, whereas those that are not consistent with important self-concepts create doubt and uncertainty.
#### Possible Selves
**Possible selves** is a term used to explain the future-oriented component of self-concept. Future expectations are important variables in goal setting and motivation (Lee & Oyserman, 2009). For example, a nursing student might think, "I can see myself becoming a nurse practitioner." Such thoughts help the novice nurse work harder to achieve professional goals. Blazer (2008) suggests self-perceptions of personal health and well-being may be as important as objective data for predicting health outcomes over time. Communication can provide important support for exploring positive possibilities for personal identity and for helping clients reframe or avoid the establishment of negative possible selves.
Negative concepts of possible selves can become a self-fulfilling prophecy (Markus & Nurius, 1986). For example, Martha receives a performance evaluation indicating a need for improved self-confidence. Viewing the criticism as a negative commentary on her "self," she performs awkwardly and freezes when asked questions in the clinical area.
#### Self-Concept/Environment Relationships
The social environment plays an important role in shaping a person's self-concept. Set factors such as poverty, dysfunctional parenting styles, loss of a parent, lack of educational opportunities, and level of parental literacy contribute to negative self-concepts. A stable home environment, sports, academic success, professional opportunities, praise for successful accomplishments, and supportive parents and mentors help to foster positive self-concepts. **Reflective appraisals** refer to the personalized messages received from others that help shape self-concepts and contribute to self-evaluations (Hybels & Weaver, 2008).
Understanding the interplay between person and environment in explaining self-concept has important implications for the nurse-client relationship. It is a reciprocal relationship in which the nurse's perceptions of self and other limit or enhance communication, and support or diminish a client's sense of self-esteem. Identity (self-concept) is carved out from personal experiences of life, and forms the basis for behavioral expression and interpersonal reactions to the environment. A well-defined, accurate self-concept allows nurses to effectively communicate in most situations.
Self-awareness for nurses is just as critical as it is for clients. Although cognitive awareness of the self-concept is never fully complete, the Johari Window (Luft & Ingham, 1955) provides a disclosure/feedback model to help people learn more about their self-concept. The model consists of four areas:
• Open self (arena): what is known to self and others
• Blind self: what is known by others, but not by self
• Hidden self (façade): what is known by self, but not by others
• Unknown self: what is unknown to self and also unknown to others
The larger the open self box is, the more one knows about oneself and the more flexibility there is to realistically interpret and constructively cope with challenging health situations. Increasing the open area through asking for and receiving feedback (decreasing blind self), and using self-disclosure (decreasing the hidden self) leads to more authentic self-awareness. Decreasing the level of unknown area through self-discovery, new observations by others, and mutual illumination of experiences increases the open area.
The basic goal of any constructive relationship is to help the participants enlarge self-knowledge and enhance their potential by integrating disowned, neglected, unrecognized, or unrealized parts of the self into the personality. Expected outcomes include enhanced self-esteem, greater productivity, and increased personal satisfaction.
### Theoretical models of self concept
William James (1890) was among the first theorists to address the self-concept as an important idea in psychology. He makes a distinction between "the I and the me: the I is equated with the self-as-knower and the me is equated with the self-as-known" (Konig, 2009, p. 102). James believed that a person has as many different social selves as there are distinct groups of persons about whose opinion he or she cares.
George Mead approaches the self from a sociologic perspective, emphasizing the influence of culture, moral norms, and language in framing self-concepts through interpersonal interactions (symbolic interactionism). The self affects and is influenced by how people experience themselves in relation to others (Elliott, 2008).
Any threat to the self-system creates anxiety. Freud's ego defense mechanisms help explain how a person unconsciously protect the self against full awareness of potential and actual threats (see Chapter 20).
The self is a central construct in humanistic and psychodynamic theories of personality. Carl Rogers (1951) defined the self as "an organized, fluid, but consistent conceptual pattern of perceptions of characteristics and relationships or the 'I' or the 'me' together with values attached to these concepts" (p. 498).
Harry Stack Sullivan (1953) believed that self-concepts begin in infancy. He referred to each person's self-images as a self-system that people develop to help them in the following ways: (1) develop a consistent image of self, (2) protect themselves against feeling anxiety, and (3) maintain their interpersonal security. Sullivan asserted that the self develops out of social interactions with others, most notably the mother. During early childhood, people develop self-personifications of a good me (resulting from reward and approval experiences), a bad me (resulting from punishment and disapproval experiences), and a not me (resulting from anxiety-producing experiences that are dissociated by the person as not being a part of their self-concept). Therapeutic interpersonal interactions can correct and build a different sense of self.
### Erikson's theory of psychosocial development
Erik Erikson (1968, 1982) believed that personality develops and becomes more complex as a person recognizes and responds to evolving developmental challenges (psychosocial crises) that occur with regularity throughout the life cycle. If individuals receive encouragement and support, they are more likely to master each psychosocial challenge and move successfully into the next stage of ego development with a strong sense of self.
The first four stages of Erikson's psychosocial model of development serve as building blocks for the central developmental task of establishing a healthy ego identity (identity vs. identity diffusion). Working through the remaining stages of ego development refines and expands the ego identity established in late adolescence.
Successful resolution of developmental tasks in adulthood includes finding a meaningful occupation, establishing committed relationships and starting a family, contributing to the welfare of family and others, and sharing one's wisdom with the larger community. A well-lived life results in a sense of integrity about oneself and one's life at life's closing chapter. Failure to master previous developmental stages can leave a person feeling despair and regret. Mastering psychosocial tasks successfully throughout the life cycle helps people feel a sense of integrity and enthusiasm about the life they have led, with few regrets, even when confronting death. Failure to successfully complete tasks associated with a developmental stage results in a reduced capacity to effectively negotiate later stages and a weakened sense of self. Erikson believed that stage development is never final. People have the potential to successfully rework developmental stages at a later time.
Erikson's stages of ego development are outlined in Table 4-1. Nurses use Erikson's model as an important part of client assessment. Analysis of behavior patterns using this framework can identify age-appropriateness or arrested ego identity development. Exercise 4-2 focuses on applying Erikson's concepts to client situations.
EXERCISE 4-2 Erikson's Stages of Psychosocial Development
Purpose: To help students apply Erikson's stages of psychosocial development to client situations.
Procedure:
This exercise may be done as a homework exercise with the results shared in class.
To set your knowledge of Erikson's stages of psychosocial development, identify the psychosocial crisis or crises each of the following clients might be experiencing:
1. A 16-year-old unwed mother having her first child
2. A 50-year-old executive "let go" from his job after 18 years of employment
3. A stroke victim paralyzed on the left side
4. A middle-aged woman caring for her mother, who has Alzheimer's disease
5. A 17-year-old high-school athlete suddenly paralyzed from the neck down.
Discussion:
1. What criteria did you use to determine the most relevant psychosocial stage for each client situation?
2. What conclusions can you draw from doing this exercise that would influence how you would respond to each of these clients?
TABLE 4-1
Erikson's Stages of Psychosocial Development, Clinical Behavior Guidelines, and Stressors
Developing an Evidence-Based Practice
Rowland JH, Desmond KA, Meyerowitz BE, et al.: Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors, _J Natl Canc Inst_ 92(17):1422–1429, 2000.
A self-report questionnaire was twice administered to 1957 breast cancer survivors to compare whether type of surgery influenced the psychosocial outcomes, including body image and feelings of attractiveness.
_Results:_ Of women who had a mastectomy with reconstructive surgery, 45.4% reported that the breast cancer had a negative impact on their sex lives. These negative outcomes were far greater than for women whose breast cancer was treated with a lumpectomy (29.8%), and more even than the women who had a mastectomy without reconstruction (41.3%). However, beyond the first year after diagnosis, the women's quality of life was more likely to be influenced by her age and exposure to adjuvant therapy than by her type of breast surgery.
_Application to Your Clinical Practice:_ More studies are needed on the effects of breast cancer surgical treatments on self-image, but based on results from this study, your counseling about treatment choices might need to consider age and surgical invasiveness as factors in the clients' decision-making process about treatment choices.
## Applications
Self-concept as a nursing diagnosis
The self-concept is an essential starting point for understanding the behavior of clients in nurse-client relationships. Serious injury or illness inevitably challenges self-concept. As a person's perception of inner self-coherence is disturbed, the future becomes uncertain and unpredictable (Ellis-Hill & Horn, 2000). The following case example illustrates the extent of challenge.
Case Example
My values in life have changed completely. It was incredibly difficult to realize that as a 45-year-old man I was "good for nothing." I was the rock that everybody relied on. Suddenly, it was I who had to ask others for help. I'm prone to this disease and I know that one day I will fall ill again (Raholm, 2008, p. 62).
Four aspects of self-concept are particularly relevant to consider in nurse-client relationships: body image, personal identity, self-esteem, and spirituality. These issues are addressed in Gordon's (2007) functional health patterns under self-perception, self-concept patterns, and value-belief patterns. North American Nursing Diagnosis Association (NANDA International, 2009). Relevant to self-concept are nursing diagnoses related to body image, human dignity, personal identity, powerlessness, self-concept, and self-esteem. Disturbances in self-concept directly and indirectly influence role relationships, as discussed in Chapter 7.
#### Body image
**Body image** is the physical dimension of self-concept. Our body image changes throughout life, influenced by the process of aging, the appraisals of others, cultural and social factors, and physical changes resulting from illness or injury.
Physical appearance and body image are not necessarily the same. Body image refers to how people perceive their physical characteristics. For example, individuals with an eating disorder may see themselves as a "fat" person despite being dangerously underweight.
The value individuals place on body image reflects sociocultural norms and media presentations. Different cultures characterize similar physical characteristics as positive and others as negative. In the United States, a trim figure for women and a lean, muscular body for men are admired (Vartanian, 2009). In other cultures, obesity may be viewed as a sign of prosperity, fertility, or the ability to survive (Boston Women's Health Book Collection, 1998).
Body image is closely intertwined with personal identity such that any change in body function or physical appearance can affect personal identity and challenge a person's self-esteem. Hair loss with chemotherapy, moon face with high doses of prednisone, stroke limitations, removal of a breast or limb, burns, and loss of energy can all affect body image.
Physical appearance influences how people respond to a person (Rhode, 2009). Physically attractive people, appropriately dressed, and well groomed typically command more positive attention than those who are not. Individuals who deviate significantly from the norm in height, weight, or physical characteristics, and those who look considerably older or younger than their chronologic age often suffer discrimination (Williams, 2009). They speak of receiving subtle inequities, of being treated differentially, and as having intellectual and character shortcomings attributed to them solely on the basis of appearance.
Case Example
Anne has been obese since she was a small child. In adulthood, she weighs 275 pounds, and is very self-conscious about her weight. Although she has tried many diets, she has been unsuccessful in losing significant amounts of weight. Whenever she visits her in-laws, her mother-in-law serves her small portions, reminds her that she is overweight, and makes subtle suggestions about how her marriage would be more successful if she were thinner. Anne feels even worse about herself and dreads visiting. She clearly knows she is obese and doesn't need a reminder that she is overweight articulated in a family social situation.
Disturbances in body image can be long lasting. In a study of overweight adolescents, a primary theme that emerged was "a forever knowing of self as overweight" (Smith & Perkins, 2008).
#### Hidden body image disturbances
Although most people think of body image as describing visible differences in physical characteristics, subtle differences related to loss of body function apply. Medical conditions such as traumatic brain injury, infertility, impotence, loss of bladder or bowel function, and reliance on mechanical devices such as dialysis and pacemakers can create unseen body image disturbances. Loss of energy from cancer treatments can change a person's self-image as a person with zest and vigor, to one who is frail and vulnerable.
Alteration in control and loss of sensation also represent body image disturbance. Clients in pain from fibromyalgia and those subject to seizures, alcoholism, cardiac arrhythmias, or diabetic fluctuations in blood sugar may exhibit few obvious physical changes, but they can experience similar feelings of insecurity and uncertainty about their body image.
Assessment Strategies: The _meaning_ of body image is an important dimension to assess as it differs from person to person. Some, like Ray Charles or Christopher Reeves frame a negative body image as a positive feature of who they are. Others let a physical deviation become their only defining feature.
Assessment data supportive of a nursing diagnosis related to a self-concept disturbance in body image might include one or more of the following behaviors:
• Verbal expression of negative feelings about the body
• No mention of changes in body structure and function, or preoccupation with changed body structure or function
• Reluctance to look at or touch a changed body structure
• Social isolation and loss of interest in friends after a change in body structure, appearance, or function
• Physical changes usually require significant psychosocial and role performance adjustment (Drench, Noonan, Sharby, & Ventura, 2006); a comprehensive assessment should include the client's strengths and limitations, expressed needs and goals, the nature and accessibility of the client's support oonansystem, and the impact of body image change on lifestyle
Supportive Nursing Strategies: Modeling acceptance starts with the nurse. Nurses see clients with serious body image changes on a regular basis; for the client, it is a unique and potentially horrifying experience. Showing the client that a physical change does not frighten the nurse reduces the fear that people will turn away. Anticipatory guidance with visitors to prepare them for dramatic changes in their family member's or friend's appearance helps promote acceptance.
Providing relevant information and creating opportunities for the client to ask questions make it acceptable for the client to explore changes in self-concept related to body image is an important nursing strategy. Validation checks, asking whether the client has any questions, and suggesting realistic responses can facilitate communication about alterations in body image.
Nurses can introduce adaptive functioning by helping clients anticipate and respond with dignity to the reactions of others. Clients often worry about how their physical or emotional changes will be accepted by others. Asking questions about what the client expects, providing coaching, and helping clients identify social supports is helpful. Talking with others, for example, having a Reach for Recovery volunteer visit with a mastectomy client, is a simple intervention that helps increase the client's adjustment and acceptance of body image disturbances.
#### Personal identity
Karademas et al. (2008) describe **personal identity** as an intrapersonal psychological process consisting of a person's perceptions or images of personal abilities, characteristics, and potential growth potential. Personal identity is based on cognitive understandings of the self derived from perceptual and cognitive processing of personally relevant data about the self.
Each person's self-concept is anchored in self-descriptions advanced by the culture. A clear cultural identity is positively related to self-concept clarity and self esteem (Usborne and Taylor, 2010). Understanding fundamental differences in cultural worldview orientation helps nurses frame interventions in ways that support ethno-cultural variations. For example, Western cultures tend to be individualistic, whereas Asian cultures see the individual as part of a collective group. Oyserman and Markus (1998) note:
From a North American perspective, a collective answer to the "who am I" question is that "I am a bounded, autonomous whole." The solution to this question from a Japanese perspective is "I am a member or a participant of a group." (p. 110)
Exercise 4-3 helps the nurse identify the contribution of life experiences that contribute to self-concept.
EXERCISE 4-3 Contribution of Life Experiences to Self-Concept
Purpose: To help students identify some of the many personal variations in lived experiences, contributing to self-concept. There are no right or wrong responses.
Procedure:
1. Pair off with another student, preferably one with whom you are not well acquainted.
2. Student A spends 5 minutes questioning Student B to collect a biography of facts, including such information as ethnic background, number of siblings, place of birth, job or volunteer experiences, unusual life experiences, types of responsibilities, and favorite leisure activities. The process is then reversed, and Student B interviews Student A.
3. Each student introduces the other to the class, using the information gained from the interview.
Discussion:
1. Were you surprised by any of the information you found out?
2. How did your perception of other students change in light of the information shared?
3. In what ways were your perceptions different from your initial impression of your partner after the interview portion of the exercise?
4. What did you learn about yourself from doing this exercise?
5. How do you think what you learned might apply to nursing practice?
The Challenge of Health Status Changes: Illness, genetic factors, pain, or injury affecting cognitive abilities can compromise or crush the sense of personal identity. For example, in a study of stroke victims, findings showed a more negative sense of self, reduced social activity, and lower self-esteem, even after rehabilitation (Ellis-Hill & Horn, 2000). Individuals with brain injury or dementia can suffer a complete loss of self. Although sensory images enter the psyche, the normal cognitive processes people use to interpret their meaning can't make sense of them. Without cognitive ability, people don't know who they are. People with dementia lose their ability to set realistic goals, implement coherent patterns of behavior, or control basic elements of their lives. As the disease progresses, they can no longer recognize significant others or retain a sense of their personal identity.
Perception and cognition play an important role in a person's recognition of personal identity and the ability to communicate who they are to other people. Any health change can challenge a person's stable sense of personal identity. People get used to other persons treating them in certain ways because of status, work, or personality characteristics. Heijmans et al. (2004) suggest that, in addition to accepting an illness with its accompanying personal needs, people may need to adapt to an altered social identity and find new ways to initiate and maintain social relationships. This requires an emotional appraisal and adjustment, because things are not the same for the client or for those with whom the person interacts. Renegotiating relationships can be awkward, and clients often need the nurse's help in how to respond.
Case Example
Linda is an RN working in a busy surgery center. Returning to work after a hospitalization for major depression, she was no longer allowed to be in charge of her unit. Other staff became highly protective of her. She was carefully watched to ensure that she was not going to relapse and given simpler tasks to avoid stressing her out. Linda couldn't understand why her coworkers didn't see her as the same person she was before. Her depression was in remission. But in the eyes of her coworkers, Linda had been reclassified as a mentally ill person. Their efforts were well-intentioned, but they had demoralizing effects on Linda's personal identity.
#### Perception
Perception is referred to as the gatekeeper of personal identity because it is the initial cognitive process through which a person transforms external sensory data into selected images of reality. Perception allows a person to cluster sensory images into a meaningful pattern. It is a cognitive process, not an emotional one. Consider the image in Figure 4-2. Depending on where your eyes focus, one can draw different conclusions about the image. The same is true about life: Reality lies in the eye of the beholder. Perceptions differ because people develop mindsets that automatically alter sensory data in personal ways. Messages perceived as being consistent with a person's self-concept are likely to be heard, whereas messages that are incompatible with self-images create emotional distress. Global perceptual distortions can occur as a result of delirium, psychosis, or psychoactive drug reactions.
Figure 4-2 The figure-ground phenomenon. Are the figures presented in white against a black background or in black against a white background? Does it make a difference in your perception of the figures? (From the Westinghouse Learning Corporation: _Self-instructional unit 12: perception, 1970._ Reprinted with permission.)
Mental disorders such as depression and schizophrenia generate a distorted perceptual filter affecting perception and cognitive interpretations. Clients can distort the meaning of objective data, leading the person to engage in dysfunctional behaviors as a result. Validation of perceptual data is needed because the nurse and the client may not be processing the same reality. For example, others may perceive a person as being witty and interesting, whereas the individual internally views himself as dull and boring. Simple perceptual distortions can be challenged with compassionate questioning and sometimes, targeted humor.
Case Example
Grace Ann Hummer is a 65-year-old widow with arthritis, a weight problem, and failing eyesight. She looks older than she is chronologically. Admitted for a minor surgical procedure, Ms. Hummer tells the nurse she does not know why she came. Nothing can be done for her because she is too old and decrepit.
_Nurse:_ As I understand it, you came in today for removal of your bunions. Can you tell me more about the problem as you see it? _(Asking for this information separates the current situation from an overall assessment of ill health.)_
_Client:_ Well, I've been having trouble walking, and I can't do some of the things I like to do that require extensive walking. I also have to buy "clunky" shoes that make me look like an old woman.
_Nurse:_ So you are not willing to be an old woman yet? _(Taking the client's statement and challenging the cognitive distortion presented in her initial comments with humor allows the client to view her statement differently.)_
_Client_ (laughing): Right, there are a lot of things I want to do before I'm ready for a nursing home.
#### Cognition
Cognition is a complex, creative, logical process that people use to make sense of perceptions. The cognitive aspects of self-concept are best characterized by the level, clarity, and logic of thinking. People with strong critical thinking skills tend to make good decisions. An example of a cognitive distortion is imagining the worst-case scenario when something minor goes wrong.
Assessment: Cognitive assessment is accomplished through client history, mental status examination, and assessment of functional capabilities. Clients or close significant others, or both, should be asked about the client's medical and psychiatric history, medications, and any significant changes in observed changes in memory, cognitive reasoning, or expressive language. Inquiring about functional abilities to perform activities of daily living is valuable. Client data are compared with the performance of others with similar demographic background and life experiences. Significant deviations, as well as defined changes in the quality and quantity of cognitive performance, are areas for concern. It is crucial for example, to differentiate between cognitive dysfunction as the result of medication adverse effects, delirium, or depression and a true dementia (Arnold, 2005).
Serious injury or illness creates major challenges to personal identity. Particularly devastating to one's self-concept is disease or injury affecting the brain because of their impact on processing information and communicating with others. They can erase memories, skills and the knowledge needed to conduct essential life tasks. Treating each client as a valued person, with relevant ideas, opinions, and feelings should underscore each specific treatment plan. With effort, it is usually possible to communicate even with cognitively compromised individuals in simple ways.
Planning and Intervention: Respect for the client perspective, active listening, and active involvement in collaborative planning strengthen a sense of personal identity through ownership and understanding of the treatment plan. Trying to understand the client as a valued person and the personalized meaning of the health disruption is an important common denominator in supporting the client's personal identity.
Case Example
Jenna was a professor at a major university when she was diagnosed with advanced metastatic breast cancer. All her life, Jenna had been a take-charge person, and relished her capacity to run her life effectively and efficiently. People responded to her with high regard and respect because of her position and her personality. Admitted to the hospital, Jenna brought her pre-illness self-image of being treated with deference and expected similar responsiveness from staff. Her health care providers, unfamiliar with her background and personal identity issues, expected compliance with no challenges to their authority. When she would become angry about her inability to have control about her medical situation, the staff considered her a difficult, obstinate client. Viewed from a "patient" context, her behavior seemed irrational; understood from the perspective of a having a sudden challenge to a lifelong self-concept of independence and deference, her seemingly "irrational" behavior made sense. Once the connection was made to Jenna's personal identity issues, a different dialogue emerged between staff and client, with a deeper respect for Jenna's set of expectations and interpersonal needs. Provision of needed support for information and collaborative interpersonal responses resulted in a positive change in Jenna's attitude, and full participation in her treatment.
Supportive Nursing Strategies: Interventions needed to strengthen personal identity in the face of major illness, injury, or death in clinical settings start with respecting individual preferences, values, and beliefs, and applying the simple axiom of treating each patient with the same respect as you would like to be treated in a similar situation. Box 4-1 presents guidelines to strengthen realistic perceptions and facilitate accurate cognitive processing of health care information.
BOX 4-1 Interventions to Enhance Personal Identity: Perceptions and Cognition
• Take time to orient newly admitted clients to the unit, patient rights, and the normal care routine.
• Pay close attention to the client's "story" of the present health care experience, including concerns about coping, impact on self and others, and hopes for the future.
• Remember that each client is unique. Respect and tailor responses to support individual differences in personality, personal responses, intellect, values, and understanding of medical processes.
• Encourage as much client input as is realistically possible into diagnostic and therapeutic regimens.
• Provide information as it emerges about changes in treatment, personnel, discharge, and after care. Include family members whenever possible, particularly when giving difficult news.
• Explain treatment procedures including rationale, and allow ample time for questions and discussion.
• Encourage family members to bring in familiar objects or pictures, particularly if the client is in the hospital or care facility for an extended period.
• Encourage as much independence and self-direction as possible.
• Avoid sensory overload, and repeat instructions if the client appears anxious.
• Use perceptual checks to ensure you and the client have the same understanding of important material.
Frequent perceptual checks and active listening are helpful interventions (see Chapter 10). When combined with well-thought-out inferences about the meaning of client behaviors, they enhance the quality of decision-making in the nurse-client relationship. Checking in with clients allows the nurse to use perceptual data in a conscious, deliberate way to facilitate the relationship process. Because the client feels heard and because communication focuses on matters of interest and concern to the client, mutuality occurs with greater frequency.
Successful outcomes related to a nursing diagnosis of personal identity disturbances include new adaptive coping skills, a richer appreciation of life and one's purpose, a reordering of priorities, and enriched relationships with family and friends. A positive reframing of personal identity in the face of serious illness can contribute to better treatment adherence and a stronger sense of well-being.
Responding to Cognitive Distortions: It is not so much what happens to us as it is how we interpret and respond to our circumstances that create problems. Box 4-2 identifies common cognitive distortions. Simple perceptual distortions can be challenged with compassionate questioning, new information, and simple targeted humor. Cognitive behavioral therapy (CBT), originally developed by Aaron Beck, is the treatment of choice for clients with significant perceptual/cognitive distortions. With CBT approaches, people are initially taught to recognize their cognitive distortions, when thoughts interact with inner emotions to control behavior. This awareness is followed with strategies designed to reframe negative thinking patterns. Providing additional information, using Socratic questioning, modeling cues to behavior, and coaching clients to challenge cognitive distortions through the use of positive self-talk, mindfulness, values exploration, and a present orientation are common techniques.
BOX 4-2 Examples of Cognitive Distortions
• "All or nothing" thinking—the situation is all good or all bad; a person is trustworthy or untrustworthy.
• Overgeneralizing—one incident is treated as if it happens all the time; picking out a single detail and dwelling on it.
• Mind reading and fortune-telling—deciding a person does not like you without checking it out; assuming a bad outcome with no evidence to support it.
• Personalizing—seeing yourself as flawed, instead of separating the situation as something you played a role in but did not cause.
• Acting on "should" and "ought to"—deciding in your mind what is someone else's responsibility without perceptual checks; trying to meet another's expectations without regard for whether it makes sense to do so.
• "Awfulizing"—assuming the worst; every situation has a catastrophic interpretation and anticipated outcome.
**Self-talk** is a cognitive strategy people can use to lessen cognitive distortions. When the thought carries a negative value, it can affect the individual as though the thought represented the whole truth about the person. The thought "I stuttered in the interview" becomes emotionally translated into "I know I probably won't get the job. I'm just no good." One feature of one interview suddenly becomes a major defining statement of self. The pervading thoughts create a decrease in self-esteem.
Supportive Nursing Strategies: Changing internal self-talk resets the thinking process. With positive self-talk as a therapeutic strategy, the person chooses the feeling he or she will have about a situation or person. Providing additional information, modeling cues to behavior, using Socratic questioning to challenge the validity of cognitive distortions, and coaching clients to use positive self-talk is helpful. Exercise 4-4 gives practice in recognizing and responding to cognitive distortions.
EXERCISE 4-4 Correcting Cognitive Distortions
Purpose: To provide students with practice in recognizing and responding to cognitive distortions.
Procedure:
This exercise may be done in small groups of four or five students. Using the definitions of cognitive distortions presented in the text, identify the type of cognitive distortion and the response you might make in each of the following situations:
1. I shouldn't feel anxious about making this presentation in class.
2. I am boring and people don't like to talk to me.
3. I shouldn't get upset when people don't approve of me.
4. If I hadn't been raised in a dysfunctional family, I would be a different person.
5. If I don't get high grades, my family will think less of me.
6. I can't experience true satisfaction unless I do things perfectly.
Discussion:
1. How do cognitive distortions affect behavior?
2. In what ways can you use this exercise to enhance your nursing practice and personal relationships?
Combining self-talk strategies with social support forms the basis for a prevention plan designed to correct cognitive distortions. A thinking schema that allows the client to step back and view the situation as an objective observer might before beginning to resolve it is helpful. Enlisting the help of others for support and advice leads to more effective problem solving.
Feedback and social support are powerful antidotes to cognitive distortions about responsibility. Although a plan to correct cognitive distortions is easier to articulate than to implement, these guidelines have proved useful in helping people to relinquish faulty thinking patterns and to take constructive action instead.
#### Self-esteem: emotional aspects of personal identity
Self-esteem refers to the affective or emotional aspects of self (Huitt, 2004). Representing an emotional appraisal of a person's worth or value, **self-esteem** is defined as the emotional value a person places on his or her personal self-worth in relation to others and the environment. Self-esteem affects a person's ability to weather stress without major changes in self-perception. With a positive attitude about self, an individual is more likely to view life as a glass that is half full rather than half empty. People who view themselves as worthwhile and as being valuable members of society have high self-esteem. People with low self-esteem do not value themselves and do not feel valued by others.
Self-esteem mirrors a person's inner sense of self and adds an additional filter to perceptual and cognitive awareness of self. It also reflects cultural norms, genetic temperament, and supportive relationships. A key characteristic is the respect people have for themselves and their opinion of their conduct of life. Self-esteem can be related to either a specific dimension of self, "I am a good writer," or it may have a more global meaning, "I am a good person who is worth knowing."
People with high self-esteem have a strong emotional and intellectual conviction that they are worthy of respect and recognition, and believe that they have something unique and useful to offer to society. They respect and like who they are, and are generally satisfied with their looks, personality, skills, and ability to successfully negotiate their lives. They accept responsibility for their success and failures, and take calculated risks to achieve important personal goals. They are more likely to be motivated to make changes. Life's inevitable problems are viewed as challenges that one can learn and grow from.
Self-esteem is not something that happens suddenly. People who learn to set realistic standards for themselves and strive to meet them are more likely to experience higher self-esteem. They are able to manage feelings and emotions in a positive way. They know and like themselves, based on an accurate perception of their strengths and limitations. In this way, the emotional components of self-concept are joined together with perceptual and cognitive components of personal identity.
By contrast, people with low self-esteem do not hold a high opinion of themselves and feel that they are worth less than others. They tend to be defensive in relationships and seek constant reassurance from others because of their own self-doubt. Instead of taking actions that could raise self-esteem, they worry and see challenges as problems rather than as opportunities.
Self-esteem tends to be relatively stable over time and across situations, but the experience of success or failure can cause fluctuations in self-esteem (Crocker, Brook, & Niiya, 2006). Sources of situational challenges to self-esteem include loss of a job; loss of an important relationship; negative change in appearance, role, or status; and verbal or physical abuse, neglect, chronic illness, codependency, and criticism by significant others. These situations leave people feeling unvalidated and undervalued as good persons. Illness, injury, and other health issues challenge a person's self-esteem. Findings from a sizable number of research studies demonstrate an association between lower self-esteem in clients and changes in health status, functional abilities, and emotional dysfunction (Vartanian, 2009; Vickery, Sepehri, & Evans, 2008).
Situational self-esteem can be influenced by cognitive strategies to correct affective distortions in communication and maladaptive thinking patterns interfering with a person's self-worth. Self-esteem can be enhanced through personal choices to engage fully with life, trying new things and learning new skills. Encouraging relationships with family, friends, teachers, and successful participation in social activities and clubs promote the process of achieving self-esteem. Exercise 4-5 introduces the role of social support in building self-esteem.
EXERCISE 4-5 Social Support
Purpose: To help students understand the role of social support in significant encounters.
Procedure:
1. Describe a "special" situation that had deep meaning for you.
2. Identify the person or people who helped make the situation meaningful for you.
3. Describe the actions taken by the people or person identified above that made the situation memorable.
Discussion:
1. What did you learn about yourself from doing this exercise?
2. What do you see as the role of social support in making memories?
3. How might you use this information in your practice?
Assessment Strategies: Self-esteem is closely linked to our emotions, particularly those that directly involve self-concepts such as pride or shame (Brown & Marshall, 2001). Verbal and nonverbal behaviors that indicate powerlessness, frustration, inadequacy, anxiety, anger, or apathy suggest low self-esteem. Factors that contribute to affective margins of distortion in communications with clients are presented in Figure 4-3. Exercise 4-6 provides practice with clarifying feelings.
EXERCISE 4-6 Clarifying Feelings
Purpose: To provide an opportunity to develop skill in recognizing underlying emotions and responding effectively to them.
Procedure:
This exercise should be done in small groups of three to five students.
A class has been assigned a group project for which all participants will receive a common group grade. Each group consists of six students. Develop a group understanding of the feelings experienced in each of the following situations, as well as a way to respond to each. Consider the possible consequences of your intervention in each case.
1. Don tells the group that he is working full time and will be unable to make any group meetings. There are so many class requirements that he also is not sure he can put much effort into the project, although he would like to help and the project interests him.
2. Martha is very outspoken in group. She expresses her opinion about choice of the group project and is willing to make the necessary contacts. No one challenges her or suggests another project. At the next meeting, she informs the group that the project is all set up and she had made all the arrangements.
3. Joan promises she will have her part of the project completed by a certain date. The date comes and Joan does not have her part completed.
Discussion:
1. What are some actions the participants can take to move the group forward?
2. How can you use this exercise as a way of understanding and clarifying feelings in clinical work situations?
Figure 4-3 Affective margin of distortion in communication.
Nurses can help clients sort out and clarify the facts and emotions that get in the way of a person's awareness of his or her intrinsic value. Note how the client describes achievements. Does the client devalue accomplishments, project blame for problems on others, minimize personal failures, or make self-deprecating remarks? Does the client express shame or guilt? Does the client seem hesitant to try new things or situations, or express concern about ability to cope with events? Observe defensive behaviors. Lack of culturally appropriate eye contact, poor hygiene, self-destructive behaviors, hypersensitivity to criticism, need for constant reassurance, and an inability to accept compliments are behaviors associated with low self-esteem. Table 4-2 identifies characteristic behaviors related to self-esteem.
TABLE 4-2
Behaviors Associated with High vs. Low Self-Esteem
People with High Self-Esteem | People with Low Self-Esteem
---|---
Expect people to value them | Expect people to be critical of them
Are active self-agents | Are passive or obstructive self-agents
Have positive perceptions of their skills, appearance | Have negative perceptions of their skills, appearance, sexuality, and behaviors
Perform equally well when being observed as when not being observed | Perform less well when being observed
Are nondefensive and assertive in response to criticism | Are defensive and passive in response to criticism
Can accept compliments easily | Have difficulty accepting compliments
Evaluate their performance realistically | Have unrealistic expectations about their performance
Are relatively comfortable relating to authority figures | Are uncomfortable relating to authority figures
Express general satisfaction with life | Are dissatisfied with their lot in life
Have a strong social support system | Have a weak social support system
Have a primary internal locus of control | Rely on an external locus of control
Therapeutic Strategies: Armed with an understanding of the underlying personalized feelings as a threat to self-esteem, (e.g., intense fear, anguish about an anticipated loss, and lack of power in an unfamiliar situation), nurses provide the opening for the client to tell his or her story. The nurse might identify a legitimate feeling by saying, "It must be frustrating to feel that your questions go unanswered," and then saying, "How can I help you?" From a nonreactive position, the nurse can demonstrate caring about the client as a person by helping the client obtain needed information and seeking validation of legitimate client concerns.
When people have low self-esteem, they feel they have little worth and that no one really cares enough to bother with them. The nurse helps clients increase self-esteem by being psychologically present as a sounding board. Just the process of engaging with another human being who offers a different perspective can have the effect of enhancing self-esteem. The implicit message the nurse conveys with personal presence and interest, information, and a guided exploration of the problem is twofold. The first is confirmation of the client: "You are important, and I will stay with you through this uncomfortable period." The second is the introduction of the possibility of hope: "There may be some alternatives you haven't thought of that can help you cope with this problem in a meaningful way." Once a person starts to take charge of his or her life, a higher level of well-being can result.
The nurse can use several strategies to help a client deepen self-esteem. Communication in the form of focused questions can assist clients in reflecting on their strengths and accomplishments. The nurse can give the client self-esteem–related feedback: "The thing that impresses me about you is..." or, "What I notice is that although your body is weaker, it seems as if your spirit is stronger. Is that your perception as well?" Such questions help the client focus on positive strengths. Exercise 4-7 strengthens the nurse's skill in this area.
EXERCISE 4-7 Positive Affirmations: Contributions to Self-Esteem
Purpose: To help students experience the effects of interpersonal comments on self-esteem.
Procedure:
This exercise may be done in a group or used as a homework assignment and later discussed in class.
1. List a positive affirming comment you received recently, something someone did or said that made you feel good about yourself.
2. List a disconfirming comment you received recently, something someone did or said that made you feel bad about yourself.
3. What have you done recently that you feel helped enhance someone else's self-esteem?
Discussion:
1. In general, what kinds of actions help enhance self-esteem?
2. What are some things people do or fail to do that diminish self-esteem?
3. What are some specific things you might be able to do in a clinical setting that might help a client develop a sense of self-worth?
4. What did you learn about yourself from doing this exercise?
Evaluation: Self-esteem behavior outcomes are evaluated by comparing the number of positive self-statements with those originally observed. Behaviors suggestive of enhanced self-esteem include the following:
• Taking an active role in planning and implementing self-care
• Verbalizing personal psychosocial strengths
• Expressing feelings of satisfaction with self and ways of handling life
## Self-efficacy
Self-efficacy is strongly associated with self-esteem, and the nursing diagnosis of powerlessness. People who believe that they can handle threatening situations value their competence and ability to succeed. They are less likely to harbor self-doubts or dwell on personal deficiencies when difficulties arise. **Self-efficacy** is a term originally developed by Albert Bandura (2007) in referring to a person's perceptual belief that he or she has the capability to perform general or specific life tasks successfully. Self-efficacy influences motivation and outcome expectancies. People need to believe that they can succeed in performing a task or coping with a difficult situation to actively try to master the tasks involved. People with a strong sense of self-efficacy can approach difficult tasks as challenging and master them. Self-efficacy helps them sustain their efforts in the face of temporary setbacks and decreases anxiety. Those with a weak sense of self-efficacy view difficult tasks as threatening and will not persist if obstacles or setbacks occur.
People develop self-efficacy through personal experience with mastering tasks, seeing others similar to themselves perform tasks successfully, and through verbal support. Breaking difficult tasks down into achievable steps and completing them constructs a resilient sense of self-efficacy.
Self-help and mutual support groups can be helpful adjuncts to treatment for clients having trouble with self-efficacy in managing their illness or injury. Discovering that others have similar issues and have found ways to cope with them successfully encourages clients and reinforces a sense of self-efficacy and hope that they too can achieve functional success. The understanding, social support, and reciprocal learning found in these groups provide opportunities for valuable information sharing and role modeling (Humphreys, 2004).
### Spiritual aspects of personal identity
Spiritual self-concepts, found in the innermost core of an individual, are concerned with a person's relationship with God or a higher power, and the vital life forces that support wholeness. When a person's body fails, or circumstances seem beyond one's control, it is often the spirit that sustains a person's sense of self-integrity and helps them maintain a more balanced equilibrium. Baldacchino and Draper (2001) note the presence of a spiritual force in a client's strong will to live, positive outlook, and sense of peace.
**Spirituality** is a unified concept, closely linked to a person's worldview, providing a foundation for a personal belief system about the nature of God or a Higher Power, moral-ethical conduct, and reality. Spirituality is a term often used synonymously with religion, but it is a much broader concept (Baldacchino & Draper, 2001). A key difference is that religion involves a formal acceptance of beliefs and values within an organized faith community, whereas spirituality describes self-chosen beliefs and values that give meaning to a person's life. It may or may not be associated with a particular faith (Tanyi, 2006).
Spirituality plays a significant in personal identity.
Spirituality is associated with meaning and purpose in life (Sessanna, Finnell, & Jezewski, 2007; Tanyi, 2006). A number of research studies link spirituality to health, quality of life, and well-being (Molzahn & Sheilds, 2008).
Spirituality helps us answer vital questions about what it is to be human, which human events have depth and value, and what are imaginative possibilities of being. Over the course of a lifetime, spiritual beliefs change, deepen, or are challenged by circumstances that are beyond a person's control. Spiritual strength allows nurses and other health care professionals to willingly stand with others in darkness, and yet remain whole—to deal with the everyday challenges and stresses of nursing in a spirit of peace and hope. Spiritual aspects of self-concept can be expressed through:
• Membership in a specific religious faith community with a set of formal, organized beliefs
• Nature, meditation, or other personalized lifeways and practices linked with a higher purpose in life
• Cultural and family beliefs about forgiveness, justice, human rights, right and wrong learned in early childhood
• Crisis, or existential situations that stimulate a search for purpose, meaning, and values lying outside the self
Health crises can be a time of spiritual renewal, when one discovers new inner resources, strengths, and capacities never before tested. Or it can be a time of spiritual desolation, leaving the individual feeling powerless to control or change important life circumstances (Krebs, 2001).
#### Assessment
The Joint Commission (2004) mandates that health care agencies, including long-term hospice and home care services, must assess spiritual needs, provide for the spiritual care of clients and their families, and supply appropriate documentation of that care. Carson and Stoll (2008) refer to three areas of spiritual concern as a framework for nursing assessment: spiritual distress, spiritual needs, and spiritual well-being. Spiritual distress wears many faces: a lack of purpose and meaning in life, inability to forgive, loss of hope, and spirit of alienation. NANDA (2009) nursing diagnoses present specific nursing interventions for providing spiritual support: Risk for Spiritual Distress, Spiritual Distress, Readiness for Enhanced Hope, and Readiness for Enhanced Spiritual Well-being.
Assessment of spiritual needs should be approached with respect and sensitivity for the client's beliefs and values. Assessment questions might include evaluation of the client's
• Willingness to talk about personal spirituality or beliefs
• Belief in a personal God or Higher Power
• Relevance of specific religious practices to the individual
• Changes in religious practices or beliefs
• Areas of specific spiritual concern activated by the illness; for example, is there an afterlife?
• Extent to which illness, injury, or disability has had an effect on spiritual beliefs
• Sources of hope and support
• Desire for visitation from clergy or pastoral chaplain
A client's spiritual needs may be quite obvious and firmly anchored in positive relationships with clergy and a personal God, or defined philosophical understanding of life and one's place in it. Spiritual needs also can reveal evidence of conflict or anger toward a Higher Power, who is held responsible for a negative health situation. For example, the noted author C. S. Lewis (1976) calls his God "the cosmic sadist" as he experienced his personal grief following the death of his wife. Spiritual pain can be as severe as physical pain and often is closely accompanied by emotional pain. Asking about the effect an illness or health problem has had on spiritual beliefs yields useful information. Being able to talk freely about spiritual distress helps put it into perspective (McSherry, 2000).
Identifying a client's current religious affiliations and practices is important, and inquiring about religious rituals important to the client is essential. Josephson and Peteet (2007) suggest that the client's words can be an entry into a discussion of spirituality; for instance, if the client uses a phrase such as "By the grace of God, I passed the final examination," you might ask something like, "It sounds like God plays a role in your life, is that true?" (p. 186).
Spiritual rituals and practices can be used to promote hope, support, and peace for a client experiencing spiritual pain. You can inquire about current spiritual practices and preferences by asking, "Are there any spiritual practices that are particularly important to you now?" When assessing the client's current spiritual preferences, you should also consider past religious affiliations. It is not unusual for the religion listed on the client's chart to be different from the religious practices the client currently follows. In addition, people who have never committed to a strong sense of religion previously will seek religious support in times of crisis (Baldacchino & Draper, 2001). Spiritual assessment information should be documented in the client's record.
Spiritual well-being can be demonstrated through hopefulness in the face of adversity, compassion for self and others, and a sense of inner peace. Miller (2007) suggests, "Hope is central to life and specifically is an essential dimension for successfully dealing with illness and for preparing for death" (p. 12). Hope is critical in maintaining the "spirit" of a person in health care settings. How else can one explain the will to live or the complete serenity of some individuals in the face of life's most adverse circumstances? Hope does not guarantee a positive outcome. It simply helps a person stay connected with life. Lack of hope is expressed in feelings of powerlessness, hopelessness, and frustration. Useful assessment questions might consist of: "What do you see as your primary sources of strength at the present time?" and, "In the past, what have been sources of strength for you in difficult times?" Miller (2007) identified several hope-inspiring strategies found in the literature, for example, helping clients and families to develop achievable aims, realize a sense of interpersonal connectedness, live in the present, and find meaning in their illness/situation. Sharing uplifting memories, affirmation of worth, and unconditional caring presence can stimulate a sense of hopefulness.
Case Example
At age 16, Robert became a double amputee as a result of a skiing accident. One morning, Mrs. Johnson walked into Robert's room and found him crying. Her first response was to leave the room as she thought, "I can't handle this today." But she managed to stop herself, and she went over to Robert and touched his shoulder. He continued to sob and said, "What am I going to do? I wish I were dead. My whole life is sports. I would have qualified for an athletic scholarship if this hadn't happened. I feel like my life is over at 16."
Mrs. Johnson recognized the feelings of despair that Robert was expressing, and said to him, "It doesn't seem like life has any meaning at all. You are feeling that this is such an unfair thing to have happened to you. I agree with you, it is. But let's talk about it" (Carson & Koenig, 2008, pp. 140–141).
Exercise 4-8 helps in understanding spiritual responses to distress. Spirituality can be a powerful resource for families and it is important to incorporate questions about the family's spirituality if they are involved with the client. Each family's expression of spirituality and use of spiritual resources is unique. Tanyi (2006) suggests nurses can incorporate spiritual assessment with the family, using questions such as
EXERCISE 4-8 Responding to Issues of Spiritual Distress
Purpose: To help students understand responses in times of spiritual distress.
Procedure:
Review the following case situations and develop an appropriate response to each.
1. Mary Trachter is unmarried and has just found out she is pregnant. She belongs to a fundamentalist church in which sex before marriage is not permitted. Mary feels guilty about her current status and sees it as "God punishing me for fooling around."
2. Linda Carter is married to an abusive, alcoholic husband. Linda reads the Bible daily and prays for her husband's redemption. She feels that God will turn the marriage around if she continues to pray for changes in her husband's attitude. "My trust is in the Lord," she says.
3. Bill Compton tells the nurse, "I feel that God has let me down. I was taught that if I was faithful to God, He would be there for me. Now the doctors tell me I'm going to die. That doesn't seem fair to me."
Discussion:
1. Share your answers with others in your group.
2. Give and get feedback on the usefulness of your responses.
3. In what ways can you use this new knowledge in your nursing care?
What gives the family meaning in their daily routines?
What gives the family strength to deal with stress or crisis?
How does the family describe their relationship with God/Higher Power or the universe?
What spiritual rituals, practices, or resources do the family use for support?
Are their any conflicts between family members related to spiritual views, and if so, what might be the impact on the current health situation?
### Strategies
The compassionate presence of the nurse in the nurse-client relationship is the most important tool the nurse has in helping the client explore spiritual and existential concerns (Carson & Koenig, 2008). Providing opportunities for clients to be self-reflective about their spirituality helps people sustain their beliefs, values, and spiritual sense of self in the face of tragedy. Gordon and Mitchell (2004) write, "Spiritual care is usually provided in a one-to-one relationship, is completely person centered and makes no assumptions about personal conviction or life orientation" (p. 646).
Providing privacy and quiet times for spiritual activities is important. The support of "nursing presence" and unstructured time for helping clients cope with spiritual issues, combined with referrals to chaplains, is an important component of nursing intervention. Nurses can help individuals and families contact spiritual advisors or clergy, or act as their advocate in ensuring appropriate spiritual rituals are followed related to dietary restrictions, Sabbath activities, meditating or praying, and at end of life. For example, in some forms of the Jewish religion, turning lights on or off or adjusting the position on an electric bed is not permitted on the Sabbath. There is no rule against these tasks being accomplished by the nurse.
Philosophical discussion may not be necessary. Spiritual connections can provide comfort for the dying and their families through prayer or hymns. Thomas (2009) describes the impact of familiar spiritual songs as he reflects on spiritual moments spent with his wife at the end of her life.
Case Example
Susan and I would share the passing alone. An elderly, angelic, soul-wizened, African American nursing assistant (Eleanor) had been assigned to assist us. She reminded me of a well-experienced midwife at the opposite end of life.
In the middle of the night, Eleanor quietly began to sing the old religious hymns that Susan and I knew so well. I watched tension drain from Susan's skin. [Susan knew the words by heart.] The words are so comforting, relaxing, reassuring. I was softly humming along as Susan was bathed in this blessing. This was an emotionally, spiritually perfect moment.
Just as I began to quietly tell Eleanor the story about the meaning of those songs to Susan, I observed Susan's hand come out from under the sheet, I was holding her foot at that point. Her index finger slowly, but firmly, wagged back and forth. DO NOT tell that story was the clear message. I continued to hum along softly. How did she know?
Here we are, deep into the night of September 14, 1999, and the same hymns are bathing, soothing, and reassuring us as they have generations of Believers. Susan knew, and I should have, that anything I said would cause this moment to evaporate. The precious, tender, delicate moment would be ruined (Thomas, 2009).
#### Prayer and Meditation
Praying with a client, even when the client is of a different faith, can be soothing for some patients. Nurses need to distinguish between their own spiritual orientation and needs, and that of their clients. It is not appropriate to impose a spiritual ritual on a client that would be at odds with his or her spiritual beliefs. There should be some evidence from the client's conversation that praying or reading the Bible with a client would be an acceptable support.
According to some researchers (Daaleman, Usher, Williams, Rawlings, & Hanson, 2008; Sulmasy, 2006), spiritual support can be effectively provided through indirect means such as recognizing the human value and dignity of clients, and respecting their autonomy in shared decision making, as by supporting them through prayer.
#### Evaluation
Client outcomes associated with successful resolution of spiritual distress, and/or spiritual well being include connecting, or reconnecting with God or a higher power, decreased guilt, forgiveness of others, expressions of hope, and evidence that the client finds meaning in his or her current situation. Thomas (2009) describes his spiritual process of journeying to a different place with grief as follows:
Twice walked into the Valley of the Shadow of Death with a dearly loved partner, lost that loved one to eternity, fell into the deeper Valley of Grief, and each time managed to climb out as a stronger, spiritually embraced person.
## Summary
Chapter 4 focuses on the self-concept as a key variable in the nurse-client relationship. Self-concept refers to an acquired constellation of thoughts, feelings, attitudes, and beliefs that individuals have about the nature and organization of their personality. Self-concepts are created through experiences with the environment and personal characteristics.
The four aspects of self-concept patterns most relevant to the practice of nursing and the nurse-client relationship are body image, personal identity, self-esteem, and spirituality. Disturbances in body image refer to issues related to changes in appearance and physical functions, both overt and hidden. Personal identity is constructed through cognitive processes of perception and cognition. Serious illnesses such as dementia and psychotic disorders threaten or crush a person's sense of personal identity. Self-esteem is associated with the emotional aspect of self-concept, and reflects the value a person puts on the personal self-concept and its place in the world. Assessment of spiritual needs and corresponding spiritual care is a Joint Commission requirement for quality care.
Understanding the dimensions of self-concept and the critical role it plays in directing behavior is key to working effectively with clients and families. It is always a core variable to consider in nurse-client relationships. Nurses play an important role in providing support and guidance for clients related to self-concept.
Ethical Dilemma
What Would You Do?
Sarah Best, a 16-year-old ice-skater, is brought into the emergency department after being in a car accident. The physician examines Sarah and determines that her right leg needs to be amputated below the knee. Sarah's parents are traveling in Europe and cannot immediately be located. Sarah refuses surgery. The physician asks Sarah's nurse, Ann, to get Sarah's consent. If you were in Ann's position, what would you do?
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CHAPTER 5
# The Nurse-Client Relationship
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define key concepts in the nurse-client relationship.
2 Describe the characteristics of therapeutic nurse-client relationships.
3 Discuss therapeutic use of self in nurse-client relationships.
4 Describe the four phases of a nurse-client relationship.
5 Discuss tasks in each of the four phases of the relationship.
6 Compare and contrast adaptations for short-term relationships.
This chapter focuses on the characteristics and structure of nurse-client relationships in clinical practice. Included in the chapter is a comprehensive discussion of the therapeutic relationship as the cornerstone of professional nursing practice (Carter, 2009). Characteristics of the helping relationship related to authenticity, presence, boundaries, and self-awareness are explored as essential components of effective therapeutic relationships. Developmental stages of relationship are identified, and strategies nurses can apply to long- and short-term relationships are addressed.
## Basic concepts
The Joint Commission (2001) affirms the role of the nurse in therapeutic relationships with clients and families: "Nearly every person's every health care experience involves the contribution of a registered nurse. Birth and death, and all the various forms of care in between, are attended by the knowledge, support and comforting of nurses" (p. 5). It is an awesome responsibility, and of particular importance as nursing moves into the community with shorter term, less structured therapeutic relationships between nurse and client/family.
## Key concepts in therapeutic relationships
Definitions
A **therapeutic relationship** is a professional, interpersonal alliance in which the nurse and client join together for a defined period to achieve health-related treatment goals. The time spent in the relationship may be short, spanning up to an 8-hour shift in a hospital, or it can be longer term, lasting weeks or months in a rehabilitation center. Because each nurse and client has a distinctive personality, the human interactions within each relationship are unique (Chauhan & Long, 2000). Regardless of the time spent, each relationship with a client can be meaningful and important to clients.
The term _client_ can refer to any individual, family, group, or community with an identified health care need requiring nursing intervention. Nurses enter therapeutic relationships with a specialized body of knowledge, a genuine desire to help others, and an openness to the client's experience. Guiding principles (e.g., presence, purpose, mutuality, authenticity, empathy, active listening, confidentiality, and respect for the dignity of the client) strengthen the healing influence of a therapeutic relationship (McGrath, 2005). Box 5-1 identifies strategies to facilitate empathy.
BOX 5-1 Suggestions for Facilitating Empathy
• Actively listen carefully to the client's concerns. (Use open-ended questions; avoid closed-ended questions).
• Tune in to physical and psychological behaviors that express the client's point of view.
• Do self-checks, often for stereotypes or premature understanding of the client's issues.
• Set aside judgments or personal biases.
• Be tentative in your listening responses and ask for validation frequently.
• Mentally picture the client's situation and ask appropriate questions to secure information about areas or issues you are not clear about.
• Give yourself time to think about what the client has said before responding or before asking the next question.
• Mirror the client's level of energy and language.
• Be authentic in your responses.
Modified from Egan G: _The skilled helper_ , ed 7, Pacific Grove, CA, 2002, Brooks Cole Publishing, by permission.
The nurse-client relationship is an interdependent relationship. Martin Buber's (1958) I and Thou relation in which each is aware of and respects the other in building a shared reality forms the foundation for therapeutic conversations. He described an I-thou relationship as an equal relationship marked by respect, mutuality, and reciprocity. Neither is an "object" of study. Instead, there is a process of mutual discovery and each person feels free to be authentic. The essence of the I-thou relationship allows each person to be who he or she is as a unique human being worthy of respect even when the person is being difficult.
Buber's work forms a theoretical foundation for using confirming responses in which the helping person identifies an observable strength of another person and comments on it. He described this way of responding as follows: "Man wishes to be confirmed in his being by man and wishes to have a presence in the being of the other. Secretly and bashfully, he watches for a yes which allows him to be" (Buber, 1957, p. 104).
With the current emphasis on team collaboration in health service care delivery, collaborative relationships with other professionals have become increasingly important. LaSala (2009) notes, "The core values of human dignity, respect, caring, and compassion are not only central to the care of patients but also to nurses' interactions with one another, members of the interdisciplinary team, and others" (p. 427).
### Characteristics of therapeutic relationships
Although therapeutic helping relationships share many characteristics of a social relationship, there are distinct structural and functional distinctions. Table 5-1 presents the differences between a therapeutic helping relationship and a social relationship. The goal of a therapeutic relationship is ultimately promotion of the client's health and well-being. This is true even when the client is dying or is uncooperative.
TABLE 5-1
Differences Between Helping Relationships and Social Relationships
Helping Relationships | Social Relationships
---|---
Helper takes responsibility for the conduct of the relationship and for maintaining appropriate boundaries. | Both parties have equal responsibility for the conduct of the relationship.
Relationship has a specific purpose and a health-related goal. | Relationship may or may not have a specific purpose or goals.
Relationship terminates when the identified goal is met. | Relationship can last a lifetime or terminate without goal achievement.
Focus of the relationship is on needs of the helpee. | The needs of both partners should receive equal attention.
Relationship is entered through necessity. | Relationship is entered into spontaneously, accompanied by feelings of liking.
Choice of who to be in relationship is not available to either helper or helpee. | Behavior for both participants is spontaneous; people choose companions.
Self-disclosure is limited for the helper, encouraged for the helpee. | Self-disclosure for both parties in the relationship is expected.
Understanding should always be put into words. | Understanding does not necessarily need to be put into words.
#### Client Centered
A therapeutic relationship is client or patient centered. Client-centered approaches, first described by Carl Rogers (1958), are based on the belief that each person has within him or herself the capacity to heal, given support from a helping person who treats the client with the utmost respect and unconditional regard in a caring, authentic relationship (Anderson, 2001). Client-centered care includes the client's individual preferences, values, beliefs, and needs as a fundamental consideration in all nursing interventions.
In therapeutic relationships, clients are the personal experts on their life experiences; the nurse is the consultive expert on health care matters. The nurse's expertise derives from integrated empirical, personal, aesthetic, and ethical ways of knowing. This knowledge helps guide the client to reflect on and clarify what is important in the dialogue, and offers professional insights that the client may not have considered previously.
The nurse-client relationship is an interdependent relationship.
In recent decades, patient- or client-centered care has been acknowledged as a core value in service delivery. Its relevance as an essential component of quality health care measures was strongly stated in the Institute of Medicine (2001) published report "Crossing the Quality Chasm: A New Health System for the 21st Century." This document charged health care systems to
• Respect patients' values, preferences and expressed needs
• Coordinate and integrate care across boundaries of the system
• Provide the information, communication, and education that people need and want
• Guarantee physical comfort, emotional support, and the involvement of family and friends (pp. 52–53)
From a functional perspective, client-centered relationships require nurses to step back and compassionately listen to each individual client or family concerns. Keeping in mind that each person's experience is different, despite similarities in diagnosis, relevant questions are: "What is this person's human experience of living with this illness or injury" and "How can I as a health care professional help you at this point in time?"
#### From Mutuality to Partnership
Health care consumers are increasingly expected to be active partners in their own health care (McGrath, 2005; McQueen, 2000). Nurse-client relationships are designed to empower clients and families to assume as much responsibility as possible in self-management of chronic illness. Both nurse and client have responsibilities, and work toward agreed-on goals. Shared knowledge, mutual decision-making power, and respect for the capacities of client to actively contribute to his or her health care to whatever extent is possible are active components of the partnership required of client centered care. Exercise 5-1 looks at shared decision making.
EXERCISE 5-1 Shared Decision Making
Purpose: To develop awareness of shared decision making in treatment planning.
Procedure:
1. Read the following clinical situation.
Mr. Singer, age 48 years, is a white, middle-class professional recovering from his second myocardial infarction. After his initial attack, Mr. Singer resumed his 10-hour workday, high-stress lifestyle, and usual high-calorie, high-cholesterol diet of favorite fast foods, alcohol, and coffee. He smokes two packs of cigarettes a day and exercises once a week by playing golf.
Mr. Singer is to be discharged in 2 days. He expresses impatience to return to work, but also indicates that he would like to "get his blood pressure down and maybe drop 10 pounds."
2. Role play this situation in dyads, with one student taking the role of the nurse, and another student taking the role of the client.
3. Develop treatment goals that seem realistic and achievable, taking into account Mr. Singer's preferences and values, and health condition.
4. After the role-play is completed, discuss some of the issues that would be relevant to Mr. Singer's situation and how they might be handled. For example, what are some of the ways in which you could engage Mr. Singer's interest in changing his behavior to facilitate a healthier life style?
A client-centered partnership honors the client's right to self-determination and gives the client and family maximum control over health care decisions. The client always has the right to choose personal goals and courses of action, even when they are at odds with the nurse's ideas. An effective collaborative partnership between nurse and client results in enhanced self-management, better health care utilization, and improved health outcomes (Hook, 2006).
#### Professional Boundaries
Emotional integrity in the nurse-client relationship is "reliant on maintaining relational boundaries" (LaSala, 2009, p. 424). **Professional boundaries** represent invisible structures imposed by legal, ethical, and professional standards of nursing that respect nurse and client rights, and protect the functional integrity of the alliance between nurse and client. Bruner and Yonge (2006) suggest that "rather than a line, boundaries represent a continuum with issues related to boundaries ranging from a lack of involvement to overinvolvement" (p. 39). Examples of relationship boundaries involve the setting, time, purpose, and length of contact, maintaining confidentiality, and use of appropriate professional behaviors.
Professional boundaries define how nurses should relate to clients as a helping person, that is, not as a friend, not as a judge, but as a skilled professional companion committed to helping the client achieve mutually defined health care goals (Briant & Freshwater, 1998). Maintaining appropriate professional behavior is a clear interpersonal boundary that makes the relationship safe for the client in much the same way as guardrails protect the public from falling into danger when observing a tourist attraction. Professional boundaries spell out the parameters of the health care relationship (Fronek, Kendall, Ungerer, Malt, Eugarde, & Geraghty, 2009). Nurses are ethically bound to observe the boundaries needed to make a relationship therapeutic (Sheets, 2001). When clients seek health care, they are in a vulnerable position and look to their health care providers as responsive guides to helping them achieve optimum health and well-being.
#### Boundary Violations and Crossings
The National Council of State Boards of Nursing (NCSBN, 2007) describes professional boundaries as the spaces between the nurse's position power and client vulnerability. The nurse, not the client, is responsible for maintaining professional boundaries. **Boundary violations** take advantage of the client's vulnerability and represent a conflict of interest that usually is harmful to the goals of the therapeutic relationship. Examples of boundary violations include sexual encounters with clients, excessive personal disclosures, personal or business relationships, and requests/acceptance of special favors or expensive gifts. Extensive following of a client after discharge is a common boundary violation. Boundary violations are ethically wrong.
**Boundary crossings** are less serious infractions. They give the appearance of impropriety but do not actually violate prevailing ethical standards. Hartley (2002) suggests, "With boundary crossings, context is everything. What is appropriate behavior in one context may not be in another" (p. 7). Examples of boundary crossings include meetings outside of the relationship or disclosing personal intimate details about aspects of the nurse's life that would not be common knowledge (Bruner & Yonge, 2006). Repeated boundary crossings such as continuing a biased, rather than an impartial, relationship with a client should be avoided.
Nurses need to carefully examine their behaviors, look for possible misinterpretations or unintended consequences, and seek supervision when boundary crossings occur. For example, suppose the client perceives your extra involvement as more than a responsive gesture. How will other clients or family members view the extra attention? Is reliance on the extra time or effort spent with a client likely to jeopardize that client's journey to independence (Hartley, 2002)?
### Level of Involvement
An important feature of a therapeutic relationship is the helping person's level of involvement. The term _involvement_ relates to the degree of the nurse's attachment and active participation in the client's care. The level of involvement may fluctuate, depending on the needs of the client, but it should never exceed the boundaries of professional behavior (see Figure 5-1). It becomes problematic when the nurse limits the level of involvement to perfunctory tasks or becomes emotionally overinvolved in the client's care. To be effective, nurses must maintain emotional objectivity, whilst remaining human and present to clients. Heinrich (1992) notes that nurses constantly walk a thin line between having compassion for a client and developing a relationship that is too close, resulting in a friendship with potential serious complications for the client, as well as the nurse.
Figure 5-1 Levels of Involvement: A Continuum of professional Behavior. From: National Council of State Boards of Nursing (NCSBN) Professional Boundaries. www.ncsbn.org/Professional_Boundaries_2007_Web.pdf, 2007.
Overinvolvement can be associated with countertransference (O'Kelly, 1998), resulting from the nurse's unresolved feelings about previous relationships. It often occurs when the client is particularly needy, or feeds the nurse's ego by considering him or her as special, or the only one who understands.
Overinvolvement results in the nurse's loss of an essential objectivity needed to support the client in meeting health goals (Kines, 1999). In addition to its impact on the nurse-client relationship, overinvolvement can compromise the nurse's obligation to the service agency, a professional commitment to the treatment regimen, collegial relationships with other health team members, and professional responsibilities to other clients (Morse, 1991).
Warning signs that the nurse is becoming overinvolved include the following:
• Giving extra time and attention to certain clients
• Visiting clients in off hours
• Doing things for clients that the clients could do for themselves
• Discounting the actions of other professionals
• Keeping secrets with the client
• Believing that the nurse is the only one who understands the client's needs
The opposite of overinvolvement is _disengagement,_ which occurs when nurses find themselves withdrawing from clients because of a client's behavior or the intensity of client suffering. Deaths and high stress levels on a unit can create compassion fatigue, which can lead to disengagement as a self-protective mechanism (Hofmann, 2009). Nurses tend to disengage from clients who are sexually provocative, complaining, hostile, or extremely anxious or depressed. Physical characteristics such as poor hygiene, marked physical disability, socially stigmatized illness, or an unusual or altered appearance can negatively affect the nurse's willingness to engage with a client.
Signs of disengagement include withdrawal, limited perfunctory contacts, minimizing the client's suffering, and defensive or judgmental communication. Regardless of the reason, the outcome of disengagement is that the client feels isolated and sometimes abandoned when care is mechanically delivered with limited human connection.
Maintaining a helpful level of involvement is always the responsibility of the professional nurse (see Figure 5-1). Carmack (1997) suggests that nurses can take the following actions to regain perspective:
• Assume full responsibility for the process of care while acknowledging that the outcome usually is not within your control.
• Focus on the things that you can change while acknowledging that there are things over which you have no control.
• Be aware and accepting of your professional limits and boundaries.
• Monitor your reactions, and seek assistance when you feel uncomfortable about any aspect of the relationship.
• Balance giving care to a client with taking care of yourself, without feeling guilty.
Debriefing after a highly emotional event helps nurses resolve and put strong feelings into perspective. Support groups for nurses working in high-acuity nursing situations and mentoring of new nurses are recommended.
### Therapeutic use of self
The therapeutic relationship is not simply about what the nurse does, but who the nurse _is_ in relation to clients and families. One of the most important tools nurses have at their disposal is the use of self. LaSala (2009) uses the words of Florence Nightingale, that a nurse achieves "the moral ideal" whenever he or she uses "the whole self" to form relationships with "the whole of the person receiving care" (p. 423) to explain the optimum involvement of self in the nurse-client relationship. The relationships that nurses establish with clients and their families and other practitioners in which "the whole self" is drawn into the process serves as the primary means for putting into action health treatments and healing interventions needed for client support and self-care.
#### Authenticity
Authenticity is a precondition for the therapeutic use of self in the nurse-client relationship. Authenticity requires recognizing personal vulnerabilities, strengths, and limitations, working within this knowledge in the service of the client, and seeking help when needed to further relationship goals. Self-awareness allows you to fully engage with a client, knowing that parts of the relationship may be painful, distasteful, or uncomfortable. Daniels (1998) suggests that when nurses recognize parts of themselves in their clients, they humanize the nurse-client relationship.
Nurses need to be clear about their personal values, beliefs, stereotypes, and personal perspectives because of their potential influence on client decisions (McCormack & McCance, 2006; Morse, Havens, & Wilson, 1997). There are some clients whom nurses simply don't like working with (Erlen & Jones, 1999). It is up to the nurse, not the client, to resolve interpersonal issues that get in the way of the relationship. Nurses need to acknowledge overinvolvement, avoidance, anger, frustration, or detachment from a client when it occurs. A useful strategy in such situations is to seek further understanding of the client as a person by acknowledging your knowledge deficit and seeking to correct it.
Case Example
Brian Haggerty is a homeless individual who tells the nurse, "I know you want to help me, but you can't understand my situation. You have money and a husband to support you. You don't know what it is like out on the streets." Instead of feeling defensive, the nurse might say, "You are right, I don't know what it is like to be homeless, but I would like to know more about your experiences. Can you tell me what it has been like for you?" With this listening response, the nurse invites the client to share his experience. The data might allow the nurse to appreciate and address the loneliness, fear, and helplessness the client is experiencing, which are universal feelings.
Authenticity requires admitting mistakes. For example, a nurse might promise a client to return immediately with a pain medication and then forget to do so because of other pressing demands. When the nurse brings the medication, the client might accuse the nurse of being uncaring and incompetent. It would be appropriate for the nurse to apologize for forgetting the medication, and for the extra discomfort suffered by the client.
#### Presence
Nursing presence involves being with the client in the moment, in a manner that both nurse and client can recognize. McDonough-Means, Kreitzer and Bell (2004) describe presence as having two dimensions: "being there" and "being with" (p. S25). The sense of connectivity is simultaneously experienced by those involved in the process: nurse, client, family. Nursing presence is evidenced through active listening, relevant caring communication, and sharing of skills, knowledge, and competencies related to client-specific problems (McCormack & McCance, 2006; Morse et al., 1997). Presence involves the nurse's capacity to know when to provide help and when to stand back, when to speak frankly, and when to withhold comments because the client is not ready to hear them. The gift of presence enriches the sense of self, and life of both patient and nurse, in ways that are unique to each person and situation (Covington, 2003; Easter, 2000).
#### Self-awareness
Peplau (1997) notes that nurses must observe their own behavior, as well as the client's, with "unflinching self-scrutiny and total honesty in assessment of their behavior in interactions with patients" (p. 162). Self-awareness requires a reflective process that seeks to understand one's personal values, feelings, attitudes, motivations, strengths, and limitations—and how these affect practice and client relationships. By critically and simultaneously examining the behaviors of the client and the nurse, and what is going on in the relationship, nurses can create a safe, trustworthy, and caring relational structure (Lowry, 2005). Questions developed by Carl Rogers (1958) that nurses can ask themselves to promote the professional self-awareness needed in nurse-client relationships are presented in Box 5-2.
BOX 5-2 Key Questions for Reflection in a Client-Centered Interaction
• Can I behave in some way that will be perceived by the other person as trustworthy and as dependable or consistent in some deep sense?
• Can I be expressive enough as a person that what I am will be communicated unambiguously?
• Can I let myself experience positive attitudes toward this other person—attitudes of warmth, caring, liking interest, and respect?
• Can I be strong enough as a person to be separate from the other?
• Can I let myself enter fully into the world of my client's feelings and personal meanings, and see these as he or she does?
• Can I act with sufficient sensitivity that my behavior will not be perceived as a threat in the relationship?
• Can I meet this other individual as a person who is in the process of becoming, or will I be bound by his or her past and by my past?
From Rogers C: The characteristics of a helping relationship. In Rogers C, editor: _On becoming a person_ , Boston, 1961, Houghton-Mifflin.
Developing an Evidence-Based Practice
Sahlsten M, Larsson I, Lindencrona C et al.: Patient participation in nursing care, _Journal of Clinical Nursing_ 14:35–42, 2005.
This qualitative study, using a grounded theory method, was designed to clarify the registered nurse's understanding of patient participation in nursing care by studying staff nurses' interpretations of patient participation and how it occurred. A purposive sample of 31 registered nurses providing inpatient nursing care in five different hospitals participated in focus groups.
_Results:_ Study results revealed four different approaches and procedures involved with patient participation: interpersonal procedure (mutual interaction between nurse and patient), therapeutic approach (understanding and being understood, contact, respect), focus on resources (exchange of information and knowledge), and opportunities for influence (information, choices, decisions).
_Application to Your Clinical Practice:_ As health consumers become active partners in their personal health care, their participation with nurses to achieve desired outcomes becomes an integral component of their nursing care. How would you see the factors identified in this study applied to your nursing care of clients?
## Applications
Phases of the relationship
Peplau (1952) described four sequential phases of a nurse-client relationship, each characterized by specific tasks and interpersonal skills: preinteraction, orientation, working (problem identification and exploitation), and termination. The phases are overlapping and serve to broaden as well as deepen the emotional connection with clients (Reynolds, 1997). Although her theoretical model of relationships is better applied to long-term relationships, the concepts hold true for short encounters. Peplau identified six professional roles the nurse can assume during the course of the nurse-client relationship (Box 5-3).
BOX 5-3 Peplau's Six Nursing Roles
1. _Stranger_ role: Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust
2. _Resource_ role: Answers questions, interprets clinical treatment data, gives information
3. _Teaching_ role: Gives instructions and provides training; involves analysis and synthesis of the learner experience
4. _Counseling_ role: Helps client understand and integrate the meaning of current life circumstances; provides guidance and encouragement to make changes
5. _Surrogate_ role: Helps client clarify domains of dependence, interdependence, and independence, and acts on client's behalf as advocate
6. _Leadership_ role: Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way
Peplau's developmental stages parallel the nursing process. The orientation phase correlates with the assessment phase of the nursing process. The identification component of the working phase corresponds to the planning phase, whereas the exploitation phase parallels the implementation phase. The final resolution phase of the relationship corresponds to the evaluation phase of the nursing process (see Chapter 2 for details on the nursing process). Table 5-2 identifies interviewing strategies associated with each phase of the nurse-client relationship.
TABLE 5-2
Interviewing and Relationship Skills
Data Sources: Ivey A, Ivey M: Ivey's five stage model of interviewing. In Ivey A, editor, _Intentional interviewing and counseling,_ Monterey, CA, 2002, Brooks/Cole; and Richmond V, McCroskey J, Payne S: _Nonverbal behavior in interpersonal relations,_ Englewood Cliffs, NJ, 1987, Prentice Hall; Peplau H: Peplau's theory of interpersonal relations, _Nursing Science Quarterly_ 10(4):162–167, 1997.
Concepts of the therapeutic relationship are present even in brief encounters.
#### Preinteraction phase
The preinteraction phase is the only one in which the client does not directly participate. Awareness of professional goals is important. Developing professional goals helps the nurse select concrete, specific nursing actions that are purposeful and aligned with individualized client needs.
Professional goals differ from client goals, having to do with the nurse's knowledge, competence, and control of role responsibilities in the nurse-client relationship. Although professional goals are not communicated directly to clients, they are present as professional behaviors in all aspects of nursing care.
Having an idea of potential client issues before meeting with the client is helpful. For example, a different approach is required for a client whose infant is in the neonatal intensive care unit, than for a client who is rooming in with a healthy infant.
If the relationship is to be ongoing, for example, in a subacute, rehabilitation, or psychiatric setting, it is important to share initial plans related to time, purpose, and other details with staff. This simple strategy helps avoid scheduling conflicts.
Creating the Physical Environment: Specific client needs dictate the most appropriate interpersonal setting. When the interview takes place at the client's bed in a hospital setting, the curtain should be drawn and the nurse can sit at an angle facing the client. One-on-one relationships with psychiatric clients commonly take place in a designated, noiseless room apart from the client's bedroom. In the client's home, the nurse is always the client's guest. A private space in which the nurse and client can talk without being uninterrupted is essential. Each time a nurse is sensitive to the environment in a nurse-client relationship, the nurse models thoughtfulness, respect, and empathy.
#### Orientation phase
The nurse enters the relationship in the "stranger" role and begins the process of developing trust by providing the client with basic information about the nurse (e.g., name and professional status) and essential information about the purpose, nature, and time available for the relationship (Peplau, 1997). It can be a simple introduction: "I am Susan Smith, a registered nurse, and I am going to be your nurse on this shift." Nonverbal supporting behaviors of a handshake, eye contact, and a smile reinforce spoken words. Introductions are important even with clients who are confused, aphasic, comatose, or unable to make a cogent response because of mental illness or dementia. Introductions may need to be repeated, particularly for cognitively disabled clients.
Next, the nurse can ask the client, "How would you prefer to be addressed?" Assure the client that personal information will be treated as confidential (Heery, 2000). Explain that data will be shared with other members of the health care team as needed for making relevant clinical decisions and informing the client about the general composition of the health care team. Exercise 5-2 is designed to give you practice in making introductory statements.
EXERCISE 5-2 Introductions in the Nurse-Client Relationship
Purpose: To provide experience with initial introductions.
Procedure:
The introductory statement forms the basis for the rest of the relationship. Effective contact with a client helps build an atmosphere of trust and connectedness with the nurse. The following statement is a good example of how one might engage the client in the first encounter:
"Hello, Mr. Smith. I am Sally Parks, a nursing student. I will be taking care of you on this shift. During the day, I may be asking you some questions about yourself that will help me to understand how I can best help you."
1. Role-play the introduction to a new client with one person taking the role of the client; another, the nurse; and a third person, an involved family member, with one or more of the following clients:
a. Mrs. Dobish is a 70-year-old client admitted to the hospital with a diagnosis of diabetes and a question about cognitive impairment.
b. Thomas Charles is a 19-year-old client admitted to the hospital after an auto accident in which he broke both legs and fractured his sternum.
c. Barry Fisheis is a 53-year-old man who has been admitted to the hospital for tests. The physician thinks he may have a renal tumor.
d. Marion Beatty is a 9-year-old girl admitted to the hospital for an appendectomy.
e. Barbara Tangiers is a 78-year-old woman living by herself. She has multiple health problems including chronic obstructive pulmonary disease and arthritis. This is your first visit.
Discussion:
1. In what ways did you have to modify your introductions to meet the needs of the client or circumstances, or both?
2. What were the easiest and hardest parts of doing this exercise?
3. How could you use this experience in your clinical practice?
Clarifying the Purpose of the Relationship: Clarity of purpose related to identifiable health needs is an essential dimension of the nurse-client relationship (LaSala, 2009). It is difficult to fully participate in any working partnership without understanding its purpose and expectations. Clients need basic information about the purpose and nature of the interview or relationship, including what information is needed and how the information will be used, how the client can participate in the treatment process, and what the client can expect from the encounter. To understand the importance of orientation information, consider the value of having a clear syllabus for your nursing courses.
The length of the relationship dictates the depth of the orientation. An orientation given to a client by a nurse assigned for a shift would be different from that given to a client when the nurse assumes the role of primary care nurse over an extended period. When the relationship is of longer duration, the nurse should discuss the parameters of the relationship (e.g., length of sessions, frequency of meetings, and role expectations of the nurse and client).
Initial meetings should have two outcomes: First, the client should emerge from the encounter with a better idea of the most relevant health issues; second, the client should feel that the nurse is interested in him or her as a person. At the end of the contact, the nurse should thank the client for his or her participation and indicate what will happen next.
Establishing Trust: Carter (2009) defines **_trust_** as "a relational process, one that is dynamic and fragile, yet involving the deepest needs and vulnerabilities of individuals" (p. 404). Starting with the first encounter, clients begin to assess the nurse's trustworthiness. Kindness, competence, and a willingness to become involved are communicated through the nurse's words, tone of voice, and actions. Does the nurse seem to know what he or she is doing? Is the nurse tactful and respectful of cultural differences? Data regarding the level of the nurse's interest and knowledge base are factored into the client's decision to engage actively in a therapeutic relationship. Confidentiality, sensitivity to client needs, and honesty strengthen the relationship.
The level of trust fluctuates with illness, age, and successful and unsuccessful encounters with others (Carter, 2009). Knowledge of the client's developmental level helps frame therapeutic conversations. For example, you would hold a different conversation with an adolescent client than you would with an elderly client. The acutely ill client will need short contacts that are to the point and related to providing comfort and care. The client's current health situation is a good starting place for choice of topic.
Trusting the nurse is particularly difficult for the seriously mentally ill, for whom the idea of having a professional person care about them can be incomprehensible. Having this awareness helps the nurse look beyond the bizarre behaviors that these clients present in response to their fears about helping relationships. Many mentally ill clients will respond better to shorter, frequent contacts until trust is established. Schizophrenic clients often enter and leave the space occupied by the nurse, almost circling around a space that is within visual distance of the nurse. With patience and tact, the nurse engages the client slowly with a welcoming look and brief verbal contact. Over time, brief meetings that involve an invitation and a statement as to when the nurse will return help reduce the client's anxiety, as indicated in the following dialogue.
Case Example
_Nurse_ (with eye contact and enough interpersonal space for comfort): Good morning, Mrs. O'Connell. My name is Karen Quakenbush. I will be your nurse today.
(Client looks briefly at the nurse and looks away, then gets up and moves away.)
_Nurse:_ This may not be a good time to talk with you. Would you mind if I checked back later with you? (The introduction coupled with an invitation for later communication respects the client's need for interpersonal space and allows the client to set the pace of the relationship.)
Later, the nurse notices that Mrs. O'Connell is circling around the area the nurse is occupying but does not approach the nurse. She smiles encouragingly and repeats nondemanding invitations to the client until the client is more willing to trust. (Creating an interpersonal environment that places little demand on either party initially allows the needed trust to develop in the relationship.)
Identifying Client Needs: Therapeutic relationships should directly revolve around the client's needs and preferences. Each person's experience and individualized expression of them will be different. How clients perceive their health status, reasons for seeking treatment at this time, and expectations for health care are critical data, which you can begin to elicit by simply asking the client why he or she is seeking treatment at this time. Using questions that follow a logical sequence and asking only one question at a time help clients feel more comfortable, and is likely to elicit more complete data.
Client and family expectations can facilitate or hinder the treatment process. When health professionals treat elderly, adolescent, or physically handicapped clients as though they are mentally incapacitated in assessment interviews, it devalues them as a person. On the other hand, family members are sometimes reluctant to challenge a client's perceptions in front of the client and may need a private interview. Nurses need to include _both_ perspectives for accurate assessment.
Similarities and differences between client and family perceptions of illness and treatment are important data. If there is reason to suspect the reliability of the client as a historian, interviewing significant others assumes greater importance. Family/client agreement or disagreement about diagnosis, treatment goals, or ways to provide care are critical data. For example, if a client has one perception about personal self-care abilities and family members have a completely different awareness, these differences can become a nursing concern.
Participant Observation: Peplau describes the role of the nurse in all phases of the relationship as being a participant observer. This means that the nurse simultaneously participates in and observes the progress of the relationship from the nurse and the client perspective. When validated with the client, observations about the client's behavior and words serve as guides for subsequent dialogue and actions in the relationship. According to Peplau, observation includes self-awareness and self-reflection on the part of the nurse. This is as critical to the success of the relationship as is the assessment of the client's situation (McCarthy and Aquino-Russell, 2009).
Case Example
_Terminally ill client_ (to the nurse): It's not the dying that bothers me as much as not knowing what is going to happen to me in the process.
_Nurse:_ It sounds as though you can accept the fact that you are going to die, but you are concerned about what you will have to experience. Tell me more about what worries you.
By linking the emotional context with the content of the client's message, the nurse enters into the client's world and shows a desire to understand the situation from the client's perspective. Nurses need to be aware of the different physical and nonverbal cues clients give with their verbal messages. Noting facial expressions and nonverbal cues with "You look exhausted" or "You look worried" acknowledges the presence of these factors and normalizes them. Exercise 5-3 is designed to help you to critically observe a person's nonverbal cues.
EXERCISE 5-3 Nonverbal Messages
Purpose: To provide practice in validation skills in a nonthreatening environment.
Procedure:
1. Each student, in turn, tries to communicate the following feelings to other members of the group without words. They may be written on a piece of paper, or the student may choose one directly from the following list.
2. The other students must guess what behaviors the student is trying to enact.
Discussion:
1. Which emotions were harder to guess from their nonverbal cues? Which ones were easier?
2. Was there more than one interpretation of the emotion?
3. How would you use the information you developed today in your future care of clients?
Defining the Problem: Nurses act as a sounding board, asking questions about parts of the communication that are not understood and helping clients to describe their problems in concrete terms. The nurse asks for specific details to bring the client's needs into sharper focus, for example, "Could you describe for me what happened next," or "Tell me something about your reaction to (your problem)," or "how do you feel about..."? Time should be allowed between questions for the client to respond fully. Commonly, such questions are asked but not enough time is allowed for the client to respond.
Clients usually find it easier to talk about factual data related to a problem rather than to express the feelings associated with the issue. For example, saying "It sounds as if you feel ____________ because of ____________" helps the client to articulate the relationships between situational data and its emotional impact.
Once the nurse and client develop a working definition of the problem, they can begin to brainstorm the best ways to meet treatment goals. The brainstorming process occurs more easily when nurses are relaxed and willing to understand views different from their own. Brainstorming involves generating multiple ideas and suspending judgment until after all possibilities are presented. The next step is to look realistically at ideas that could work given the resources the client has available right now. Resistance can be worked through with empathetic reality testing. Peplau (1997) suggests that a general rule of thumb in working with clients is to "struggle with the problem, not with the patient" (p. 164). The last part of the process relates to determining the kind of help needed and who can best provide it. Assessment of the most appropriate source of help is an important but often overlooked part of the evaluation needed in the orientation phase.
Defining Goals: Unless clients are physically or emotionally unable to participate in their care, they should be treated as active partners in developing personal goals. Goals should have meaning to the client. For example, modifying the exchange lists with a diabetic adolescent's input so that they include substitutions that follow normal adolescent eating habits can facilitate acceptance of unwelcome dietary restrictions. The nurse conveys confidence in the client's capacity to solve his or her own problems by expecting the client to provide data, to make constructive suggestions, and develop realistic goals.
#### Working (exploitation/active intervention) phase
With relevant treatment goals to guide nursing interventions and client actions, the conversation in the working phase turns to active problem solving related to assessed health care needs. Clients are able to discuss deeper, more difficult issues and to experiment with new roles and actions. Corresponding to the implementation phase of the nursing process, the working phase focuses on self-direction and self-management to whatever extent is possible in promoting the client's health and well-being.
Peplau (1997) has categorized the client role as dependent, interdependent, or independent, based on the amount of responsibility the client is willing or able to assume for his or her care. Nurses should provide enough structure and guidelines for clients to explore problem issues and develop realistic solutions, but no more than are needed (Ballou, 1998). Avoid taking more responsibility for actions than the client or situation requires. For example, it may seem more efficient to give a bath to a stroke victim than to watch the client struggle through the bathing process with the nurse providing coaching when the client falters. However, what happens when the client goes home if she has not learned to bathe herself?
Breaking a seemingly insoluble problem down into simpler chunks is a nursing strategy that makes doing difficult tasks more manageable. For example, a goal of eating three meals a day may seem overwhelming to a person suffering from nausea and loss of appetite associated with gastric cancer. A smaller goal of having applesauce or chicken soup and a glass of milk three times a day may sound more achievable, particularly if the client can choose the times.
In even the most difficult nursing situations, there are options, even if the choice is to die with dignity or to change one's attitude toward an illness or a family member. The client's right to make decisions, provided they do not violate self or others, needs to be accepted by the nurse, even when it runs contrary to the nurse's thinking. This protects the client's right to autonomy.
Case Example
LaSala (2009) presents a case example in which a client with lymphoma refused a blood transfusion after her first round of chemotherapy. Her physician was upset that she would not accept this logical treatment. The nurse in the situation said, "I explained to him what her beliefs were and why she refused blood. He continued to look confused, and I said, 'We may not understand it fully, but we have to respect her decision and not let our personal opinions impede our care.' He looked at me and said I was absolutely right" (p. 425).
Tuning in to Client Response Patterns: The art of nursing requires that nurses recognize differences in client response patterns. Elderly adults may need a slower pace, and people in crisis will need a simple structured level of support. Throughout the working phase, nurses need to be sensitive about whether the client is still responding at a useful level. Looking at difficult problems and developing strategies to resolve those problems is not an easy process, especially when resolution requires significant behavioral changes. If the nurse is perceived as inquisitive rather than facilitative, communication breaks down.
It is the responsibility of the nurse, not the client, to pace interactions in ways that offer support, as well as challenge. Deciding whether to proceed is a clinical judgment that should be based on the client's response and overall body language. Examples of warning signs that the pace may need adjustment include loss of eye contact, fidgeting, abrupt changes in subject, or asking to be left alone. At the same time, strong emotion should not necessarily be interpreted as reflecting a level of interaction stretching beyond the client's tolerance. Tears or an emotional outburst may reflect honestly felt emotion. A well-placed comment, such as, "I can see that this is difficult for you," acknowledges the feeling and may stimulate further discussion.
The working phase may produce uneven results, with two steps forward and one backward, even when the plan is appropriate. Mistakes are to be expected. They should be treated as temporary setbacks and new information requiring a modification in strategy. Developing alternative constructive coping mechanisms is as important to support as the actual plan. Coping with unexpected responses can strengthen the client's problem-solving abilities by compelling the person to consider alternative options (i.e., a Plan B) when the original plan does not bring about the desired results. Exercise 5-4 examines the role of brainstorming in generating alternative strategies.
EXERCISE 5-4 Selecting Alternative Strategies
Purpose: To help students develop a process for considering and prioritizing alternative options.
Procedure:
You have two exams within the next two weeks. Your car needs servicing badly. Because of all the work you have been doing, you have not had time to call your mother, and she is not happy. Your laundry is overflowing the hamper. Several of your friends are going to the beach for the weekend and have invited you to go along. How can you handle it all?
1. Give yourself 5 minutes to write down all the ideas that come to mind for handling these multiple responsibilities. Use single words or phrases to express your ideas. Do not eliminate any possibilities, even if they seem far-fetched.
2. In groups of three or four students, choose a scribe and then share the ideas you have written down.
3. Select the three most promising ideas.
4. Develop several small, concrete, achievable actions to implement these ideas.
5. Share the small-group findings with the class group.
Discussion:
1. In what ways were the solutions you chose similar or dissimilar to those of your peers?
2. Were any of your ideas or ways of achieving alternative solutions surprising to you or to others in your group?
3. What did you learn from doing this exercise that could help you and a client generate possible solutions to seemingly impossible situations?
As clients use the relationship to support coping with health-related situations, nurses can offer anticipatory guidance and role rehearsal for difficult aspects of this process. Sometimes, simply anticipating the worst-case scenario for a given action allows the client to see that even the worst possibility is manageable.
Defusing Challenging Behaviors: Challenging behaviors can sabotage the therapeutic relationship if they are not addressed early in the relationship process. There is no one way to approach a client, and no single interpersonal strategy that works equally well with every client. Some clients clearly are more emotionally accessible and attractive to work with than others. When a client seems unapproachable or uninterested in human contact, it can be quite disheartening for the nurse. It is not uncommon for the nurse to report the kind of initial contact with a client seen in the following case examples.
Case Example
"I tried, but he just wasn't interested in talking to me. I asked him some questions, but he didn't really answer me. So I tried to ask him about his hobbies and interests. It didn't matter what I asked him. He just turned away. Finally, I gave up because it was obvious that he just didn't want to talk to me."
Although, from the nurse's perspective, this client's behavior may represent a lack of desire for a relationship, in most cases, the rejection is not personal. It can reflect boredom, insecurity, or physical discomfort. Anxiety expressed as anger or unresponsiveness may be the only way a client can control fear in a difficult situation. Rarely does it have much to do with the personal approach used by the nurse unless the nurse is truly insensitive to the client's feelings or the needs of the situation. In this situation, the nurse might say, "It seems to me that you just want to be alone right now. But I would like to help you, so if you don't mind, I'll check back later with you. Would that be OK with you?" Most of the time, clients appreciate the nurse's willingness to stay involved.
For novice nurses, it is important to recognize that all nurses have experienced some form of client rejection at one time or another. The nurse needs to explore whether the timing was right, whether the client was in pain, and what other circumstances might have contributed to the client's attitude. Behaviors that initially seem maladaptive may appear quite adaptive when the full circumstances of the client's situation are understood.
Before confronting a client, the nurse should anticipate possible outcomes. The nurse needs to appreciate the impact of the confrontation on a client's self-esteem. Calling a client's attention to a contradiction in behavioral response is usually threatening. Constructive feedback involves drawing the client's attention to the existence of unacceptable behaviors or contradictory messages whereas respecting the fragility of the therapeutic alliance and the client's need to protect the integrity of the self-concept. To be effective, constructive confrontations should be attempted only when the following criteria have been met:
• The nurse has established a firm, trusting bond with the client.
• The timing and environmental circumstances are appropriate.
• The confrontation is delivered in a private setting, and in a nonjudgmental and empathetic manner.
• Only those behaviors capable of being changed by the client are addressed.
• The nurse supports the client's right to self-determination.
Case Example
Mary Kiernan is 5 feet 2 inches tall and weigh 260 pounds. She has attended weekly weight management sessions for the past 6 weeks. Although she lost 8 pounds the first week, 4 pounds in week 2, and another 4 pounds in week 2, her weight loss seems to have hit a plateau. Jane Tompkins, her primary nurse, notices that Mary seems to be able to stick to the diet until she gets to dessert; then she cannot resist temptation. Mary is very discouraged about her lack of further progress.
Consider the effect of each response on the client.
Response A:
_Nurse:_ You're supposed to be on a 1,200-calorie-a-day diet, but instead you're sneaking dessert. When you eat dessert when you are on a diet, you are kidding yourself that you will lose weight.
Response B:
_Nurse:_ I can understand your discouragement, but you have done quite well in losing 16 pounds. It seems as though you can stick to the diet until you get to dessert. Do you think we need to talk a little more about what hooks you when you get to dessert? Maybe we need to find alternatives that would help you get back on track.
The first statement is direct, valid, and concise, but it is likely to be disregarded or experienced as unfeeling by the client. In the second response, the nurse reframes a behavioral inconsistency as a temporary setback. By first introducing an observed strength of the progress achieved so far, the nurse reaffirms trust in the client's resourcefulness. Both responses would require similar amounts of time and energy on the part of the nurse; however, the client is more likely to accept the nurse's second comment as more supportive.
Self-disclosure: **Self-disclosure** by the nurse refers to the intentional revealing of personal experiences or feelings that are similar to or different from those of the client. The purpose of self-disclosure is to deepen trust, to role-model self-disclosure as a beneficial mode of communicating for people who have trouble disclosing information about themselves. Appropriate self-disclosure can facilitate the relationship, providing the client with information that is both immediate and personalized (Deering, 1999).
Quality, not quantity, is a key characteristic of effective sharing in the working phase. Sharing should be solely for the clinical benefit of the client and never to meet the personal agenda of the nurse. Nurses should not share intimate details of their lives with their clients. The nurse, not the client, is responsible for regulating the amount of disclosure needed to facilitate the relationship. If the client asks a nonoffensive, superficial question, the nurse may answer briefly with a minimum of information and return to a client focus. Simple questions such as, "Where did you go to nursing school?" and "Do you have any children?" may represent the client's effort to establish common ground for conversation (Morse, 1991). Answering the client briefly and returning the focus to the client is appropriate. If the client persists with questions, the nurse may need to redirect the client by saying, "I'd like to spend this time talking about you," or simply indicate that personal questions are not relevant to understanding the client's health care needs.
Deering (1999) suggests the following guidelines for keeping self-disclosure at a therapeutic level: (a) use self-disclosure to help clients open up to you, not to meet your own needs; (b) keep your disclosure brief; and (c) don't imply that your experience is exactly the same as the client's. Exercise 5-5 provides an opportunity to explore self-disclosure in the nurse-client relationship.
EXERCISE 5-5 Recognizing Role Limitations in Self-disclosure
Purpose: To help students differentiate between a therapeutic use of self-disclosure and spontaneous self-revelation.
Procedure:
1. Make a list of three phrases that describe your own personality or the way you relate to others, such as the following:
I am shy.
I get angry when criticized.
I'm nice.
I'm sexy.
I find it hard to handle conflicts.
I'm interested in helping people.
2. Mark each descriptive phase with one of the following:
A = Too embarrassing or intimate to discuss in a group.
B = Could discuss with a group of peers.
C = This behavior characteristic might affect my ability to function in a therapeutic manner if disclosed.
3. Share your responses with the group.
Discussion:
1. What criteria were used to determine the appropriateness of self-disclosure?
2. How much variation is there in what each student would share with others in a group or clinical setting?
3. Were there any behaviors commonly agreed on that would never be shared with a client?
4. What interpersonal factors about the client would facilitate or impede self-disclosure by the nurse in the clinical setting?
5. What did you learn from doing this exercise that could be used in future encounters with clients?
#### Termination Phase
It is important to be clear from the beginning about how long a therapeutic relationship will last. During the course of the relationship, termination can be mentioned, and clients should be told well in advance of an impending termination date. In the termination phase, the nurse and client evaluate the client's responses to treatment, and explore the meaning of the relationship and what goals have been achieved. Discussing client achievements, how the client and nurse feel about ending the relationship, and plans for the future are an important part of the termination phase.
Termination is a significant issue in long-term settings such as skilled nursing facilities, bone marrow transplant units, rehabilitation hospitals, and state psychiatric facilities. Significant long-term relationships can and do develop in these settings. If the relationship has been effective, real work has been accomplished. Nurses need to be sufficiently aware of their own feelings so that they may use them constructively without imposing them on the client. It is appropriate for nurses to share some of the meaning the relationship held for them, as long as such sharing fits the needs of the interpersonal situation and is not excessive or too emotionally intense.
Termination of a meaningful nurse-client relationship in long-term settings should be final. To provide the client with even a hint that the relationship will continue is unfair. It keeps the client emotionally involved in a relationship that no longer has a health-related goal. This is a difficult issue for nursing students, who either see no harm in telling the client they will continue to keep in contact or who feel they have used the client for their own learning needs and to completely close the door is unfair. However, this perception underestimates the positive things that the client received from the relationship and denies the fact that good-byes, painful as they may be, are a part of life and certainly not new for the client or for the nursing student.
Termination behaviors the nurse may encounter include avoidance, minimizing of the importance of the relationship, anger, demands, or additional reliance on the nurse. When the client is unable to express feelings about endings, the nurse may recognize them in the client's nonverbal behavior.
Case Example
A teenager who had spent many months on a bone marrow transplant unit had developed a real attachment to her primary nurse, who had stood by her during the frightening physical assaults to her body and appearance that were occasioned by the treatment. The client was unable to verbally acknowledge the meaning of the relationship with the nurse directly, despite having been given many opportunities to do so by the nurse. The client said she couldn't wait to leave this awful hospital and that she was glad she didn't have to see the nurses anymore. Yet, this same client was found sobbing in her room the day she left, and she asked the nurse whether she could write to her. The relationship obviously had meaning for the client, but she was unable to express it verbally.
Gift Giving: Clients sometimes wish to give nurses gifts at the end of a constructive relationship because they value the care nurses have given to them. Gift giving is a delicate matter that does not lend itself to absolute dictums, but instead invites reflection and professional judgment. Nurses should consider: What meaning does the gift have for the relationship, and in what ways might accepting it change the dynamics of the therapeutic alliance? Would giving or receiving a gift present issues for other clients or their families?
There is no one answer about whether gifts should or should not be exchanged. In fact, if the nurse handled every situation in the same fashion, the nurse would be denying the uniqueness of each nurse-client relationship. Each relationship has its own character and its own strengths and limitations, so what might be appropriate in one situation would be totally inappropriate in another. Token gifts such as chocolates or flowers may be acceptable. In general, nurses should not accept money or gifts of significant material value. Should this become an issue, you might suggest making the gift to the health care agency or a charity. It is always appropriate to simply thank the client for their generosity and thoughtfulness (Lambert, 2009). Exercise 5-6 is designed to help you think about the implications of gift giving in the nurse-client relationship.
EXERCISE 5-6 Gift-Giving Role-play
Purpose: To help students develop therapeutic responses to clients who wish to give them gifts.
Procedure:
Review the following situations and answer the discussion questions.
Situation:
Mrs. Terrell, a hospice nurse, has taken care of Mr. Aitken during the last 3 months of his life. She has been very supportive of the family. Because of her intervention, Mr. Aitken and his son were able to resolve a long-standing and very bitter conflict before he died. The whole family, particularly his wife, is grateful to Mrs. Terrell for her special attention to Mr. Aitken.
Role-play Directions for Mrs. Aitken
You are very grateful to Mrs. Terrell for all of her help over the past few months. Without her help, you do not know what you would have done. To show your appreciation, you would like her to have a $300 gift certificate at your favorite boutique. It is very important to you that Mrs. Terrell fully understand how meaningful her caring has been to you during this very difficult time.
Role-play Directions for Mrs. Terrell
You have given the Aitken family high-quality care and you feel very good about it, particularly the role you played in helping Mr. Aitken and his son reconcile before Mr. Aitken's death. Respond as you think you might in this clinical situation, given the previous data.
Discussion:
1. Discuss the responses made in the role-playing situation.
2. Discuss the other possible responses and evaluate the possible consequences.
3. Would you react differently if a client gave you a gift of $200 or a hand-crocheted scarf? If so, why?
4. Are there gifts clients give a nurse that are intangible? How should these gifts be acknowledged?
Evaluation: Objective evaluation of clinical outcomes achieved in the nurse-client relationship should focus on the following:
• Was the problem definition adequate and appropriate for the client?
• Were the interventions chosen adequate and appropriate to resolve the client's problem?
• Were the interventions implemented effectively and efficiently to both the client's and the nurse's satisfaction in the allotted time frame?
• Is the client progressing toward maximum health and well-being? Is the client satisfied with his or her progress and care received?
• If follow-up care is indicated, is the client satisfied and able to carry forward his or her treatment plan in the community.
#### Adaptations for short-term relationships
Hagerty and Patusky (2003) argue the need to reconceptualize the nurse-patient relationship to one of human relatedness, given the brevity of hospital stays in today's evolving health care arena. Driven by the economics of managed care, nurses must help clients determine what they need and how to develop solutions that fit their situation much more quickly than previously. Although nurses can and should follow the phases of the relationship, developing a therapeutic relationship in short-term care could be more accurately termed a working alliance with active support.
The same recommendations for self-awareness, empathy, therapeutic boundaries, active listening, competence, mutual respect, partnership, and level of involvement hold true as key elements of brief therapeutic relationships.
Orientation Phase: The therapeutic alliance begins with the same type of introduction and description of purpose identified for long-term relationships, with a focus on the nurse and client working as partners to develop a shared understanding of the client's health problems. Establishing a working alliance where time is an issue requires a "here and now" focus on problem identification and an emphasis on quickly understanding the context in which it arose.
Begin your client assessment by asking the client the reason for seeking care. Eliciting the client's concerns and allowing the client to tell his or her story conveys respect and interest. Listen for what is left out and pay attention to what the client's story elicits in you. Support and empathy help build trust quickly. Dealing with the client's feelings with a statement such as "Tell me more about..." (with a theme picked up from the client's choice of words, hesitancy, or nonverbal cues) keeps the conversation flowing.
As the nurse interacts with the client, there are opportunities to observe client strengths and to comment on them. Every client has healthy aspects of his or her personality, and personal strengths that can be drawn on to facilitate individual coping responses. Exercise 5-7 provides an opportunity to explore the value of acknowledging personal strengths.
EXERCISE 5-7 Identifying Client Strengths
Purpose: To identify personal strengths in clients with serious illness.
Procedure:
Think about a client you have had or a person you know who has a serious illness.
What personal strengths does this person possess that could have a healing impact? Strengths can be courage, patience, fighting spirit, family, and so on.
Write a one-page description of the client and the personal strengths observed (this can include how the client is coping with his or her medical or psychological condition).
Discussion:
1. If you hadn't had to write the description, would you have been as aware of the client's strengths?
2. How could you help the client maximize his or her strengths to achieve quality of life?
3. What did you learn from this exercise that you can use in your clinical practice?
An important component of brief therapeutic relationships is the rapid development of a central focus, which is developed during an initial client evaluation. Cappabianca, Julliard, Raso and Ruggiero (2009) suggest that a simple statement posed at the beginning of each shift, such as, "What is your most important need today?" or "What is the most important thing I can do for you today?" helps focus the relationship. This type of question demonstrates intent to understand and meet each client's unique needs in a shortened time frame. It helps client and nurse develop a shared understanding of what is uniquely important to the client in the present moment.
Because the time frame for a therapeutic relationship may be a few hours or days, nurses need to focus on what is absolutely essential, rather than what would be nice to know. Finding out how much the client already knows can save a lot of time. Developed from this discussion are treatment goals that can be realistically achieved, and are consistent with client goals, beliefs, and preferences.
Planning will be smoother if the nurse and client choose problems that are of interest to the client and that offer the best return on investment. Included in the planning should be the risks and cost/benefits for each targeted clinical outcome given the shortened time frame. Looking at the client's needs from a broader contextual perspective, one that takes into consideration which problems, if treated, would also help correct other health problems, has a double benefit in terms of client success and satisfaction. Engaging the client's family early in the treatment process is helpful.
As nurses increasingly move from a bedside role into a managerial coordination role, they become increasingly responsible for clarifying, integrating, and coordinating different aspects of the client's care, as part of an interdisciplinary team. An important component of this responsibility is ensuring that the client/family understands and is able to negotiate treatment initiatives with health care team providers.
Working Phase: Brief relationships need to be solution-focused right from the beginning. Giving clients your undivided attention and using concise active listening responses is absolutely essential to being able to frame issues in a solution focused way. A central focus, agreed on by nurse and client, allows for the small behavioral changes and related coping skills needed to meet client goals in short-term relationships. Finding ways to collaborate makes the most effective use of time, and confrontation should be avoided. Longer term issues are not examined in depth and support beyond what is needed to stabilize the client. Clients respond best to nurses who appear confident and empathetic. An excellent way of helping clients discover the solutions that fit them best is by engaging the client in determining and implementing activities to meet therapeutic goals at every realistic opportunity. Conveying a realistically hopeful attitude that the goals developed with the client are likely to be achieved is important. Action plans should be as simple and specific as possible. Changes in the client's condition or other circumstances may require treatment modifications that should be expected in short term relationships. Keeping clients and families informed and working with them on alternative solutions is essential to maintaining trust in short term relationships.
Termination Phase: The termination phase in short-term relationships can include discharge planning, agency referrals, and arranging for follow-up appointments in the community for the client and family. Anticipatory guidance in the form of simple instructions or review of important skills also may be appropriate, depending on the circumstances. Interpersonal relationships with other health care disciplines, families, and communities to support positive client health changes should be the norm, not the exception with short-term therapeutic relationships.
The importance of the relationship, no matter how brief, should not be underestimated. Although the client may be one of several persons the nurse has taken care of during that shift, the relationship may represent the only interpersonal or professional contact available to a lonely and frightened person. Even if contact has been minimal, the nurse should endeavor to stop by the client's room to say good-bye. The dialogue in such cases can be simple and short: "Mr. Jones, I will be going off duty in a few minutes. I enjoyed working with you. Miss Smith will be taking care of you this evening." If you will not be returning at a later date, this information should be shared with the client.
### Summary
The nurse-client relationship represents a purposeful use of self in all professional relations with clients and other people involved with the client. Respect for the dignity of the client and self, person-centered communication, and authenticity in conversation are process threads underlying all communication responses.
Therapeutic relationships have professional boundaries, purposes, and behaviors. Boundaries keep the relationship safe for the client. They spell out the parameters of the therapeutic relationship and nurses are ethically responsible for maintaining them throughout the relationship. Effective relationships enhance the well-being of the client and the professional growth of the nurse. The professional relationship goes through a developmental process characterized by four overlapping yet distinct stages: preinteraction, orientation, working phase, and termination phase. The preinteraction phase is the only phase of the relationship the client is not part of. During the preinteraction phase, the nurse develops the appropriate physical and interpersonal environment for an optimal relationship, in collaboration with other health professionals and significant others in the client's life.
The orientation phase of the relationship defines the purpose, roles, and rules of the process, and provides a framework for assessing client needs. The nurse builds a sense of trust through consistency of actions. Data collection forms the basis for developing relevant nursing diagnoses. The orientation phase ends with a therapeutic contract mutually defined by nurse and client.
The working phase is the problem-solving phase of the relationship, paralleling the planning and implementation phases of the nursing process. As the client begins to explore difficult problems and feelings, the nurse uses a variety of interpersonal strategies to help the client develop new insights and methods of coping.
The final phase of the nurse-client relationship occurs when the essential work of the active intervention phase is finished. The ending should be thoroughly and compassionately defined early enough in the relationship that the client can process it appropriately. Primary tasks associated with the termination phase of the relationship include summarization and evaluation of completed activities, and referrals when indicated. Short-term relationships incorporate the same skills and competencies as traditional nurse-client relationships, but with a sharper focus on the here and now. The action plan needs to be as simple and specific as possible.
Ethical Dilemma
What Would You Do?
Kelly, age 20 years, has been admitted with a tentative medical diagnosis: rule out AIDS. John is a 21-year-old student nurse assigned to care for Kelly. He expresses concern to his instructor about the client's sexual orientation. The instructor notes that John spends the majority of his time with his only other assigned client, who is in for treatment of a minor heart irregularity. What conclusions might be drawn regarding the reason John spends so little time caring for Kelly? If you were John, what would be important to you in understanding and resolving your feelings?
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CHAPTER 6
# Bridges and Barriers in the Therapeutic Relationship
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Identify concepts that enhance development of therapeutic relationships: caring, empowerment, trust, empathy, mutuality, and confidentiality.
2 Describe nursing actions designed to promote trust, empowerment, empathy, mutuality, and confidentiality.
3 Describe barriers to the development of therapeutic relationships: anxiety, stereotyping, and lack of personal space.
4 Identify nursing actions that can be used to reduce anxiety and respect personal space and confidentiality.
5 Identify research-supported relationships between communication outcomes, such as client empowerment and improvements in self-care.
6 Discuss how findings from research studies can be applied to clinical practice.
This chapter focuses on the components of the nurse-client relationship, showing how nursing communication affects client health outcomes and satisfaction. Health communication is a multidimensional process and includes aspects from both the sender and the receiver of the message. Your communication skills influence outcomes such as anxiety, adherence to treatments, and satisfaction with care. To establish a therapeutic relationship, you need to understand and apply the concepts of respect, caring, empowerment, trust, empathy, and mutuality, as well as confidentiality and veracity (Figure 6-1). Additional bridges fostering the relationship are your ability to put into practice the ethical aspects of respecting the client's autonomy and treating your client in a just and beneficent manner. Understanding communication barriers in the relationship (e.g., anxiety, stereotyping, or violations of personal space or confidentiality) affects the quality of the relationship. Implementing actions that convey feelings of respect, caring, warmth, acceptance, and understanding to the client is an interpersonal skill that requires practice. Caring for others in a meaningful way improves with experience. Novice students may encounter interpersonal situations that leave them feeling helpless and inadequate. Feelings of sadness, anger, or embarrassment, although overwhelming, are common. Through discussion of these feelings in peer groups and experiential learning practice activities, you gain skill. The self-awareness strategies identified in Chapter 4 and the use of educational groups described in Chapter 12 provide useful guidelines for working through your feelings.
Figure 6-1 Relationships can move in a positive or negative direction. Nursing actions can be bridges or barriers to a good nurse-client interaction.
## Basic concepts
Bridges to the relationship
Nursing communication is crucial to efficient provision of quality care for your clients (Finke, 2008). Your communication skills affect client outcomes such as satisfaction with care, improved coping, adherence to treatment, adaptation to institutional care, peaceful death, and level of anxiety. Communication also affects us as providers in terms of our job satisfaction and stress levels (Sheldon & Ellington, 2008). The following concepts will help you improve your communication. Barriers to use of each concept are described.
#### Respect
Conveying genuine respect for your client assists in building a professional relationship with him or her. As your mutual goal is to maximize the client's health status, you convey respect for his values and opinions. Asking clients what they prefer to be called and always addressing them as such is a correct initial step. Of course, you avoid the sort of casual addresses portrayed in bad television shows, such as "How are you feeling, honey?" "Mom, hold your baby," or "How are we feeling today?" We try to remember that hospitalized clients feel a loss of control in relation to interpersonal relationships with staff.
Barrier: Lack of Respect: In the Williams and Irurita study (2004), clients felt devalued when they perceived that staff were avoiding talking with them or were unfriendly; they felt comforted when a little "chitchat" was exchanged. Lack of respect among members of the team has also been often cited as a cause of adverse client outcomes. Lack of respect for the nurse by the physician has been cited as a factor leading to communication failures resulting in harm to the client (Sutcliffe, Leewton, & Rosenthal, 2004). Safety issues and communication is discussed in Chapter 22.
#### Caring
**Caring** is an intentional human action characterized by commitment and a sufficient level of knowledge and skill to allow you to support the basic integrity of your client. You offer caring to your client by means of the therapeutic relationship. Your ability to care develops from a natural response to help those in need, from the knowledge that caring is a part of nursing ethics, and from respect for self and others. As a caring nurse, you will involve clients in their struggle for health and well-being rather than simply doing things for your clients.
_Provision of a caring relationship that facilitates health and healing_ is identified as an essential feature of contemporary nursing practice in the Social Policy Statement of the American Nurses Association (ANA, 1995). In the professional literature, the focus of the caring relationship is clearly placed on meeting the client's needs. A formal model is even titled "patient-centered care." It involves understanding the client's perceived needs and expectations for health. This is a shift away from the old "I am the provider of treatment for this disease" kind of thinking. The behavior of "caring" is not an emotional feeling. Rather, it is a chosen response to your client's need. You willingly give of yourself to another through your compassion, concern, and interest. Caring is an ethical responsibility that guides a health care provider to advocate for the client.
_Clients want us to understand why they are suffering_. We tend to speak in a language in medicine that values facts and events. Clients, in contrast, value associations and causes. To bridge this potential gap, you need to convey a sense that you truly care about your client's perspective. Caring has a positive influence on health status and healing. Clients can focus on accomplishing the goals of health care instead of worrying about whether care is forthcoming. The nurse gains from the caring relationship by experiencing satisfaction in meeting the client needs.
Families also need to experience a sense of caring from the nurse. Many families do not believe we have a clear understanding of the problems they are encountering while caring for their ill family member. This is especially true if the illness is not easily observable. One French study of effects of proactive communication with families of dying clients found that "caring" interventions in the form of longer conferences where family members could express emotions and talk with ethics and palliative care experts in conjunction with written materials did decrease their anxiety and depression (Lautrette et al., 2007).
Barrier: Lack of Caring: Although nursing has had a long-standing commitment to client-focused care, sometimes you may observe a situation in which you feel a nurse is apathetic, trying to meet her own needs rather than the client's needs. Some nurses develop a detachment that interferes with expressions of caring behaviors. At other times, a nurse can be so rushed to meet multiple demands that she seems unable to focus on the client. Exercise 6-1 will help you focus on the concept of caring.
EXERCISE 6-1 Application of Caring
Purpose:
To help students apply caring concepts to nursing.
Procedure:
Identify some aspect of caring that might be applied to nursing practice. Write each on the chalkboard or a transparency on the overhead projector so the entire group can see.
Discussion:
In a large group, discuss examples of how this form of caring could be implemented in a nurse-client situation.
#### Empowerment
**Empowerment** is assisting the client to take charge of his own life. We use the interpersonal process to provide information, tools, and resources that help our clients build skills to reach their health goals. Empowerment is an important aim in every nurse-client relationship, and is addressed by nursing theories such as Orem's view of the client as an agent of self-care. Studies demonstrate that the more involved a client is in his own care, the better the health outcome.
At a personal level, empowered clients feel valued, adopt successful coping methods, and think positively. Empowerment has to do with people power: In helping our clients to take control of their lives, we identify and build on their existing strengths.
Barriers: Empowerment is purposeful. It encourages clients to assume responsibility for their own health. This is in direct contrast with the paternalistic attitude formerly found in medicine and characterized by the attitude of "I know what is best for you or I can do it better." An Australian study showed that lack of information about giving care, managing medicines, or recognizing approaching crises was the major impediment to empowering family members to care for sick relatives (Wilkes, White, & O'Riordan, 2000). Failure to allow our client to assume personal responsibility, or failure to provide him with appropriate resources and support, undermines empowerment.
#### Trust
Establishing **trust** is the foundation in all relationships. The development of a sense of interpersonal trust, a sense of feeling safe, is the keystone in the nurse-client relationship. Trust provides a nonthreatening interpersonal climate in which the client feels comfortable revealing his needs. The nurse is perceived as dependable. Establishment of this trust is crucial toward enabling you to make an accurate assessment of your client's needs.
Trust is also the key to establishing workable relationships. Lack of trust in the workplace has detrimental effects for the organization and coworkers, undermining performance and commitment (Laschinger & Finegan, 2005). According to Erikson (1963), trust is developed by experiencing consistency, sameness, and continuity during care by a familiar caregiver. Trust develops based on past experiences. In the nurse-client relationship, maintaining an open exchange of information contributes to trust. For the client, trust implies a willingness to place oneself in a position of vulnerability, relying on health providers to perform as expected. Honesty is a basic building block in establishing trust. Studies show that clients or their surrogates want "complete honesty" and most prefer complete disclosure (Evans et al., 2009). Box 6-1 lists interpersonal strategies that help promote a trusting relationship.
BOX 6-1 Techniques Designed to Promote Trust
• Convey respect.
• Consider the client's uniqueness.
• Show warmth and caring.
• Use the client's proper name.
• Use active listening.
• Give sufficient time to answer questions.
• Maintain confidentiality.
• Show congruence between verbal and nonverbal behaviors.
• Use a warm, friendly voice.
• Use appropriate eye contact.
• Smile.
• Be flexible.
• Provide for allowed preferences.
• Be honest and open.
• Give complete information.
• Provide consistency.
• Plan schedules.
• Follow through on commitments.
• Set limits.
• Control distractions.
• Use an attending posture: arms, legs, and body relaxed; leaning slightly forward.
Barrier: Mistrust: Mistrust has an impact not only on communication but on healing process outcomes. Trust can be replaced with mistrust between nurse and client. Just as some agency managers treat employees as though they are not trustworthy, some nurses treat some clients as though they are misbehaving children. Such would be the case if a client fails to follow the treatment regimen and is labeled with the nursing diagnosis of "noncompliant." In other examples, the community health nurse who is inconsistent about keeping client appointments or the pediatric nurse who indicates falsely that an injection will not hurt are both jeopardizing client trust. It is hard to maintain trust when one person cannot depend on another. Energy that should be directed toward coping with health problems is rechanneled into assessing the nurse's commitment and trustworthiness. Having confidence in the nurse's skills, commitment, and caring allows the client to place full attention on the situation requiring resolution. Clients can also jeopardize the trust a nurse has in them. Sometimes clients "test" a nurse's trustworthiness by sending the nurse on unnecessary errands or talking endlessly on superficial topics. As long as nurses recognize testing behaviors and set clear limits on their roles and the client's role, it is possible to develop trust. Exercise 6-2 is designed to help students become more familiar with the concept of trust.
EXERCISE 6-2 Techniques That Promote Trust
Purpose:
To identify techniques that promote the establishment of trust and to provide practice in using these skills.
Procedure:
1. Read the list of interpersonal techniques designed to promote trust (Box 6-1).
2. Describe the relationship with your most recent client. Was there a trusting relationship? How do you know? Which techniques did you use? Which ones could you have used?
or
In triads, have one learner interview a second to obtain a health history, whereas the third observes and records trusting behaviors. Rotate so that everyone is an interviewer. Interviews should last 5 minutes each. At the end of 15 minutes, each observer shares findings with the corresponding interviewer.
Discussion:
Compare techniques.
#### Empathy
**Empathy** is the ability to be sensitive to and communicate understanding of the client's feelings. It is a crucial characteristic of a helping relationship. Empathy is an important element of effective communication and is associated with improved client satisfaction and adherence to treatments (Morse et al., 2008). The American Academy of Pediatrics has a policy statement emphasizing the need to communicate empathy to clients and family (Levetown, 2008). An empathetic nurse perceives and _understands_ the client's emotions _accurately_. Empathy is the ability to put oneself into the client's position. Some nurses might term this as _compassion,_ which has been identified by staff nurses as being crucial to the nurse-client relationship. Communication skills are used to convey respect and empathy. Although expert nurses recognize the emotions a client feels, they hold on to their objectivity, maintaining their own separate identities. As a nurse, you should try not to overidentify with or internalize the feelings of the client. If internalization occurs, objectivity is lost, together with the ability to help the client move through his or her feelings. It is important to recognize that the client's feelings belong to the client, not to you.
Communicate your understanding of the meaning of a client's feelings by using both verbal and nonverbal communication behaviors. Maintain direct eye contact, use attending open body language, and keep a calm tone of voice. Acknowledge your client's message about his feelings by restating what you understand him to be conveying. Then, have him validate that this is accurate. If you need more information about his feelings, ask him to expand on his message, perhaps asking, "Are there other things about this that are bothering you?" Now that you have full information, you can directly make interventions to address his needs. Armed with accurate data, you can communicate your client's feelings to other providers if necessary.
Barrier: Lack of Empathy: Failure to understand the needs of clients may lead you to fail to provide essential client education or to provide needed emotional support. The literature indicates that major barriers to empathy exist in the clinical environment, including lack of time, lack of trust, lack of privacy, or lack of support. Several studies suggest that lack of empathy will affect the quality of care, result in less favorable health outcomes, and lower client satisfaction (Levetown, 2008). However, providers can be taught to express empathy.
#### Mutuality
**Mutuality** basically means that the nurse and the client agree on the client's health problems and the means for resolving them, and that both parties are committed to enhancing the client's well-being. This is characterized by mutual respect for the autonomy and value system of the other. In developing mutuality, you maximize your client's involvement in all phases of the nursing process. Mutuality is collaboration in problem solving and "drives" the communication at the initial encounter (Feldman-Stewart & Brundage, 2008). Evidence of mutuality is seen in the development of individualized client goals and nursing actions that meet a client's unique health needs. Exercise 6-3 gives practice in evaluating mutuality.
EXERCISE 6-3 Evaluating Mutuality
Purpose:
To identify behaviors and feelings on the part of the nurse and the client that indicate mutuality.
Procedure:
Complete the following questions by answering yes or no after terminating with a client; then bring it to class. Discuss the answers. How were you able to attain mutuality, or why were you unable to attain it?
1. Was I satisfied with the relationship?
2. Did the client express satisfaction with the relationship?
3. Did the client share feelings with me?
4. Did I make decisions for the client?
5. Did the client feel allowed to make his or her own decisions?
6. Did the client accomplish his or her goals?
7. Did I accomplish my goals?
Discussion:
In a large group, discuss mutuality.
Nurses need to respect interpersonal differences. We involve clients in the decision-making process. We accept their decisions even if we do not agree with them. Effective use of values clarification as described in Chapter 3 assists clients in decision making. Clients who clearly identify their own personal values are better able to solve problems effectively. Decisions then have meaning to the client. There is a greater probability he will work to achieve success. When a mutual relationship is terminated, both parties experience a sense of shared accomplishment and satisfaction.
#### Veracity
As described in Chapters 2 and , legal and ethical standards mandate specific nursing behaviors, such as confidentiality, beneficence, and respect for client autonomy. These behaviors are based on professional nursing values that stem from the ethical principles. By adhering to these "rules," nurses build their therapeutic relationships with individual clients. _Veracity_ contributes to the establishment of a therapeutic relationship. When the client knows he can expect the truth, the development of trust is promoted and helps build the relationship.
#### Other barriers to the relationship
A few additional barriers that affect the development of the nurse-client relationship include anxiety, stereotyping, and lack of personal space. Barriers inherent in the health care system are also commonly discussed in the professional literature. Under managed care, barriers often reflect cost-containment measures. Such barriers include lack of consistent assignment of nurse to client and increased use of temporary staff such as agency nurses or "floats." Lack of time can result from low staff/client ratios or early discharge. The primary care literature describes agency demand for minimal appointment time with clients. Primary care providers such as nurse practitioners are often constrained to focus just on the chief complaint to maximize the number of clients seen, leading to "the 15-minute office visit." Other system barriers include communication conflicts with other health professionals, conflicting values, poor physical arrangements, and lack of value placed on caring by for-profit agencies. These system barriers limit the nurse's ability to develop substantial rapport with clients. Adequate time is essential to develop therapeutic communication to achieve effective care responsive to client needs. Try Exercise 6-4.
EXERCISE 6-4 Building Communication Bridges Simulation
Purpose:
To evaluate current communication skills.
Directions:
In small groups, one student role-plays a client telling the nurse her story of some past unpleasant medical experience; one student is the nurse conversing with the client; the rest of the group is listeners.
Discussion:
1. What aspects of the interaction demonstrated empathy, respect, caring, etc.?
2. Listeners should give the following feedback:
a. Comment on positive aspects observed.
b. Offer constructive criticism only after making a positive comment.
c. Identify any behaviors that served as barriers.
d. Suggest alternative strategies the nurse could use.
e. Think about times when you used bridges or barriers.
Anxiety: **Anxiety** is a vague, persistent feeling of impending doom. It is a universal feeling; no one fully escapes it. The impact on the self is always uncomfortable. It occurs when a threat (real or imagined) to one's self-concept is perceived. Lower satisfaction with communication is associated with increased client anxiety. Anxiety is usually observed through the physical and behavioral manifestations of the attempt to relieve the anxious feelings. Although individuals experiencing anxiety may not know they are anxious, specific behaviors provide clues that anxiety is present Exercise 6-5 identifies behaviors associated with anxiety. Table 6-1 shows how an individual's sensory perceptions, cognitive abilities, coping skills, and behaviors relate to the intensity and level of anxiety experienced.
EXERCISE 6-5 Identifying Verbal and Nonverbal Behaviors Associated with Anxiety
Purpose:
To broaden the learner's awareness of behavioral responses that indicate anxiety.
Procedure:
List as many anxious behaviors as you can think of. Each column has a few examples to start. Discuss the lists in a group and then add new behaviors to your list.
Verbal | Nonverbal
---|---
Quavering voice | Nail biting
Rapid speech | Foot tapping
Mumbling | Sweating
Defensive words | Pacing
TABLE 6-1
Levels of Anxiety with Degree of Sensory Perceptions, Cognitive and Coping Abilities, and Manifest Behaviors
*Functioning refers to the ability to perform activities of daily living for survival purposes.
A mild level of anxiety heightens one's awareness of the surrounding environment, and fosters learning and decision making. Therefore, it may be desirable to allow a mild degree of anxiety when health teaching is needed or when problem solving is necessary. It is not prudent, however, to prolong even a mild state of anxiety.
Greater levels of anxiety decrease perceptual ability. The anxious state is accompanied by verbal and nonverbal behaviors that inhibit effective individual functioning. For example, anxiety causes you to hold your breath, which can lead to even greater levels of anxiety (Puetz, 2005). Moderate-to-severe anxiety on the part of either nurse or client hinders the development of the therapeutic relationship. To accomplish goals and attain mutuality, greater levels of anxiety must be reduced. Once the presence of anxiety has been identified, the nurse needs to take appropriate action. Strategies to reduce anxiety are listed in Box 6-2.
BOX 6-2 Nursing Strategies to Reduce Client Anxiety
• Active listening to show acceptance
• Honesty; answering all questions at the client's level of understanding
• Clearly explaining procedures, surgery, and policies, and giving appropriate reassurance based on data
• Acting in a calm, unhurried manner
• Speaking clearly, firmly (but not loudly)
• Giving information regarding laboratory tests, medications, treatments, and rationale for restrictions on activity
• Setting reasonable limits and providing structure
• Encouraging clients to explore reasons for the anxiety
• Encouraging self-affirmation through positive statements such as "I will" and "I can"
• Using play therapy with dolls, puppets, and games
• Drawing for young clients
• Using therapeutic touch, giving warm baths, back rubs
• Initiating recreational activities such as physical exercise, music, card games, board games, crafts, and reading
• Teaching breathing and relaxation exercises
• Using guided imagery
• Practicing covert rehearsal
From Gerrard B, Boniface W, Love B: _Interpersonal skills for health professionals,_ Reston, VA, 1980, Reston Publishing.
Severe anxiety requires medical and psychiatric intervention to alleviate the stress. A prolonged panic state is incompatible with life. It is such an extreme level of anxiety that, without immediate medical and psychiatric assistance, suicide or homicide may ensue. Some of these interpersonal strategies used to reduce moderate anxiety also are used during severe anxiety and panic attacks as part of a team approach to client care.
Choosing from various strategies to reduce client anxiety can be difficult. Not all methods are appropriate or work equally well with all clients. If a nurse attempting to build trust pushes a client too fast into revealing what he is not yet ready to discuss, this can increase anxiety. You need to accurately identify your client's level of anxiety. You should also identify and reduce your own anxiety. Anxiety can cloud your perceptions and interfere with relationships.
Stereotyping and Bias: **Stereotyping** is the process of attributing characteristics to a group of people as though all persons in the identified group possessed them. People may be stereotyped according to ethnic origin, culture, religion, social class, occupation, age, and other factors. Even health issues can be the stimulus for stereotyping individuals. For example, alcoholism, mental illness, and sexually transmitted diseases are fertile grounds for the development of stereotypes. Stereotypes have been shown to be consistent across cultures and somewhat across generations, although the value placed on a stereotype changes.
Stereotypes are learned during childhood and reinforced by life experiences. They may carry positive or negative connotations. For example, Harding, North, and Perkins (2008) suggest that our culture has stereotyped an image of men as less feeling than women. We all have personal biases, usually based on unconscious past learning. As nurses, we may act on these unknowingly. Stereotypes negate empathy and erode the nurse-client relationship. As nurses, we must work to develop insight into our own expectations and prejudgments about people. Telenurses in Hoglund and Holmstrom's (2008) study revealed distrust in fathers' competence to provide care for ill children, an example of stereotyping by nurses. Stewart and Payne's (2008) study showed that mentally making an intentional resolution to avoid a stereotype enables one to change.
Stereotypes are never completely accurate. No attribute applies to every member of a group. All of us like to think that our way is the correct way, and that everyone else thinks about life experiences just as we do. The reality is that there are many roads in life, and one road is not necessarily any better than another.
Emotions play a role in the value we place on negative stereotypes. Stereotypes based on strong emotions are called prejudices. Highly emotionally charged stereotypes are less amenable to change. In the extreme, this can result in discrimination. Discrimination as a legal statute refers to actions in which a person is denied a legitimate opportunity offered to others because of prejudice. In the United States, federal laws prohibit workplace discrimination based on age, creed, gender, sexual preference, disability, race, religion, or genetics.
Everyone has biases. If nurses bring their biases with them to the clinical situation, they will distort their perception, prevent client change, and disrupt the provider-client relationship. Nurses need to make it a goal to reduce bias. We do this by recognizing a client as a unique individual, both different from and similar to self. Acceptance of the other person needs to be total. This unconditional acceptance, as described by Carl Rogers (1961), is an essential element in the helping relationship. It does not imply agreement or approval; acceptance occurs without judgment. Mr. Fred Rogers, the children's television show host, ended his programs by telling his audience, "I like you just the way you are." How wonderful if we, as nurses, could convey this type of acceptance to our clients through our words and actions. Exercise 6-6 examines ways of reducing clinical bias.
EXERCISE 6-6 Reducing Clinical Bias by Identifying Stereotypes
Purpose:
To identify examples of nursing biases that need to be reduced. Practice in identifying professional stereotypes and in how to reduce them is one component of maintaining high-quality nursing care.
Procedure:
Each of the following scenarios indicates a stereotype. Identify the stereotype and how it might affect nursing care. As a nurse, what would you do to reduce the bias in the situation? Are there any individuals or groups of people for whom you would not want to provide care (e.g., homeless women with foul body odor and dirty nails)?
Situation A
Mrs. Daniels, an obstetric nurse who believes in birth control, comments about her client, "Mrs. Gonzales is pregnant again. You know, the one with six kids already! It makes me sick to see these people on welfare taking away from our tax dollars. I don't know how she can continue to do this."
Situation B
Mrs. Brown, a registered nurse on a medical unit, is upset with her 52-year-old female client. "If she rings that buzzer one more time, I'm going to disconnect it. Can't she understand that I have other clients who need my attention more than she does? She just lies in bed all day long. And she's so fat; she's never going to lose any weight that way."
Situation C
Mrs. Waters, a staff nurse in a nursing home, listens to the daughter of a 93-year-old resident, who says, "My mother, who is confused most of the time, receives very little attention from you nurses, while other clients who are lucid and clear-minded have more interaction with you. It's not fair! No wonder my mother is so far out in space. Nobody talks to her. Nobody ever comes in to say hello."
Overinvolvement as a Barrier: Objectivity is important if you are to provide competent, professional care. This may be more likely to occur in a long-term relationship. Sharing too much information about yourself, your job problems, or about your other clients can become a barrier if your client becomes unclear about his role in your relationship. Many of us enjoy warm relationships with our clients, but if we are to remain effective, we need to be alert to the disadvantages of overinvolvement.
Violation of Personal Space: **Personal space** is an invisible boundary around an individual. The emotional personal space boundary provides a sense of comfort and protection. It is defined by past experiences, current circumstances, and our culture.
**Proxemics** is the study of an individual's use of space. Optimal territorial space needed by most individuals living in Western culture: 86 to 108 square feet of personal space. Other research has found that 60 square feet is the minimum needed for each client in multiple-occupancy rooms, and 80 square feet is the minimum for private rooms in hospitals and institutions. Critical care units offer even less square footage.
Among the many factors that affect the individual's need for personal distance are cultural dictates. In some cultures, people approach each other closely, whereas in others, more personal space is required. In most cultures, men need more space than women do. People generally need less space in the morning. The elderly need more control over their space, whereas small children generally like to touch and be touched by others. Although the elderly appreciate human touch, they generally do not like it to be applied indiscriminately. Situational anxiety causes a need for more space. Persons with low self-esteem prefer more space, as well as some control over who enters their space and in what manner. Usually people will tolerate a person standing close to them at their side more readily than directly in front of them. Direct eye contact causes a need for more space. Placing oneself at the same level (e.g., sitting while the client is sitting, or standing at eye level when the client is standing) allows the nurse more access to the client's personal space because such a stance is perceived as less threatening.
Hospitals are not home. Many nursing care procedures are a direct intrusion into your client's personal space. Commonly, procedures that require tubes (e.g., nasal gastric intubation, administration of oxygen, catheterization, and intravenous initiation) restrict the mobility of the client and the client's sense of control over personal territory. When more than one health professional is involved, the impact of the intrusion on the client may be even stronger. In many instances, personal space requirements are an integral part of a person's self-image. When clients lose control over personal space, they may experience a loss of identity and self-esteem. It's recommended you maintain a social physical body distance of 4 feet when not actually giving care. Consider the issue of respect for personal space in the clinical examples presented in Box 6-3.
BOX 6-3 Clinical Examples of Personal Space Issues for Clients
• The nurse places the client on the bedpan without drawing the curtain on a postpartum unit. When the client protests, the nurse states, "Well, we're all girls here."
• The chief resident comes in with an entourage of residents and medical students. They draw the curtain and the chief resident, standing close to the client, informs the client that his cancer is terminal. The entourage moves on to the next client.
• Miss Jones has just been brought to the emergency department as a rape victim. Because of the circumstances, she is unable to change her clothes until she has been examined. It is an unusually busy night in the emergency department, and the policy is to practice triage and treat the most serious cases first. Because Miss Jones is not considered an emergency case, it will be some time before she is examined.
• Dr. Michaels has had an auto accident for which he is receiving emergency treatment by a multidisciplinary team. He is conscious, but no one calls him by name or seems to notice his wife standing outside the door.
• Barbara Burk has just been admitted to a psychiatric unit. The policy on the unit is to keep all valuables, razors, hand mirrors, and money locked up in the nurses' station. All clients must strip and shower under supervision soon after they arrive on the unit. It was not Barbara's choice to seek inpatient treatment, and she is very scared.
• Mr. Novack is admitted to the coronary care unit. He is hooked up to a cardioscope so his cardiac condition can be monitored continuously, and nasal oxygen is applied. The defibrillator is located close to his bed. His family is allowed to come in one at a time for 5 minutes once every hour as long as the visits do not interfere with nursing care or necessary treatment procedures.
When institutionalized clients are able to incorporate parts of their rooms into their personal space, it increases their self-esteem and helps them to maintain a sense of identity. This feeling of security is evidenced when a client asks, "Close my door, please." Freedom from worry about personal space allows the client to trust the nurse and fosters a therapeutic relationship. When invasions of personal space are necessary while performing a procedure, you can minimize impact by explaining why a procedure is needed. Conversation with clients at such times reinforces their feelings that they are human beings worthy of respect and not just objects being worked on. Advocating for the client's personal space needs is an aspect of the nursing role. This is done by communicating your clients preferences to the members of the health team and including them in their care plan.
Home is not quite home when the home health nurse, infusion nurse, or other aides invade the client's personal space. Some modification of "take-charge" behavior is required when giving care in a client's home.
Cultural Barriers: Cross-cultural communication is discussed extensively in Chapter 11. Every interaction encounters a basic challenge of communicating between the culture of a client and the medical culture of the health professional (Teal & Street, 2009). Cultural background and level of health literacy may have a powerful influence on communication practices. For example, Gordon and associates (2006) found lower levels of participation in cancer communication by ethnic minority clients. It is important to identify any cultural issues that will influence how your client or their family responds to your type of health communication. In some cultures, the sick role is no longer valid after symptoms disappear, so when your client's diabetes is under control, he and his family may no longer see the need for special diet or medication (Chang & Kelly, 2007). As we move into a more multicultural society, all health care providers need to work to become culturally competent communicators.
Cultural competence requires us to become aware of the arbitrary nature of our own cultural beliefs. _Culturally competent communication_ is characterized by a willingness to try to understand and respond to your client's beliefs. Knowledge of the client's cultural preferences helps you avoid stereotyping and allows you to adapt your communication (Ngo-Metzger, August, Srinivasan, Liao, & Meyskens, 2008; Teal & Street, 2008).
Gender Differences: Gender is defined as the culture's attributions of masculine or feminine. Recently, more attention has been given to gender role, communication barriers, and health inequalities. In Hoglund and Holmstrom's (2008) study, phone calls by male clients to female telenurses revealed expressions of disrespect related to the nurse's gender, as well as her professional advice. Earlier studies seemed to show little communication or outcome difference relevant to the gender of the care provider. But Harding and coauthors' (2008) more recent study indicated that male nurses' touching of clients is problematic. This is because although our culture equates female touch with caring, being touched by a male individual is perceived as sexual. Women traditionally were considered to be better communicators, but some studies found no differences. Although results are mixed, it appears that gender need not be a factor in developing therapeutic communication with clients.
Developing an Evidence-Based Practice
Rask MT, Jensen ML, Andersen J, Zachariae R: Effects of an intervention aimed at improving nurse-patient communication in an oncology outpatient clinic, _Cancer Nursing_ , 32(1):E1–E11, 2009.
This Danish study evaluated the effects of a 2-day training program for nurses working in a cancer treatment clinic. The hypothesis was that the training would improve nurse empathy and attentiveness, and client perception of their own mood and self-efficacy. Nurses (N = 24) and clients (N = 413) were randomly assigned to treatment and control groups. Outcomes were measured at baseline entry into this study, then at 1 week, and again at 3 months after the workshop.
_Results:_ The hypothesis was not supported. The researchers gave many explanations including study design weaknesses, brevity of the skills training, the baseline already high levels of nurse competencies (all nurses were very experienced with more than 5 years' working time), and high client satisfaction; thus, there was not much room for improvement. At baseline, 21.7% of the nurses reported feeling "burned out," and although this improved at the 1-week measurement, the improvement did not persist (i.e., a "treatment effect"). Interestingly, the only measure of difference between control group and treatment group nurses was that control nurses reported greater frequency of stress related to conflicts with other nurses. Total stress scores for both groups were stable over time. Clients rated nurses they knew as having higher empathy than those having their first contact with the nurse. Clients were satisfied (99.8%) with nurse interpersonal and professional skills.
_Application to your practice:_ Nurses dealing with clients who are being treated for cancer have a relatively high level of job-related stress. You and your coworkers need to be aware of indications of stress and develop some stress reduction strategies. You need to monitor peer interactions for conflict and actively use conflict reduction strategies. Assignments should allow for the client to be cared for by a familiar nurse as often as possible.
The researchers support the need for communications training for nurses and suggest that it takes a longer time than was available in this workshop to master nurse-client communication skills such as clarification, use of open-ended questions, empathy, listening, self-disclosure, and confrontation. They state that nurses need to tailor their communication to meet the needs and preferences of their clients, and suggest that there is a need to determine what type of communication is expected by clients in cancer outpatient settings.
## Applications
Many nursing actions recommended here are mandated by the American Nurses Association Code of Ethics for Nurses discussed in Chapter 2. The actions specified include confidentiality, autonomy, beneficence, veracity, and justice. Mutuality is addressed in the ANA position statement on human rights. Providers with good communication skills have greater professional satisfaction and experience less job-related stress (Maguire & Pitceathly, 2002; Rask et al., 2009). Studies of client perceptions generally show a correlation between good nurse communicators and good quality of care (Jha, Orav, & Zheng, 2008), although not all do so (Rask et al., 2009). Practice exercises provide you with opportunities to improve your skills. Part of any simulation exercise to strengthen nursing communication is the offering of feedback (Kim, Heerey, & Kols, 2008).
## Steps in the caring process
Several articles identify four steps to help you communicate C.A.R.E. to your client:
C = First _connect_ with your client. _Offer your attention._ Here you introduce your purpose in developing a relationship with your client (i.e., meeting his health needs). Use his formal name, and avoid terms of endearment such as "sweetie." Show an intent to care. Attentiveness is a part of communication skill training that is probably decreased by work-related stress, time constraints, and so forth.
A = The second step is to _appreciate_ the client's situation. Although the health care environment is familiar to you, it is a strange and perhaps frightening situation for your client. Acknowledge his point of view and express concern.
R = The third step is to _respond_ to what your client needs. What are his priorities? Expectations for health care?
E = The fourth step is to _empower_ the client to problem-solve with you. Here he gains strength and confidence from interactions with providers enabling him to move toward achievement of goals.
Infants lack verbal communication skills. The nurse's comforting touch and pleasant vocal tone help overcome this barrier. (Courtesy Adam Boggs.)
The ability to become a caring professional is influenced by your previous experiences. A person who has received caring is more likely to be able to offer it to others. Caring should not be confused with caretaking. Although caretaking is a part of caring, it may lack the necessary intentional giving of self. Self-awareness about feelings, attitudes, values, and skills is essential for developing an effective, caring relationship.
## Strategies for empowerment
Your goal is to assist the client to assume more responsibility for their health conditions by teaching them new roles and skills to manage their illnesses (Sullivan, 2008). We may never fully understand the decisions some clients make, but we support their right to do so. Your method for empowering should include the following key strategies:
• _Accept_ your clients as they are by refraining from any negative judgments.
• Assess their level of understanding, _exploring their perceptions and feelings_ about their conditions and discussing issues that may interfere with self-care.
• Establish mutual goals for client care by forming an alliance, _mutually deciding_ about their care.
• Find out how much information your clients want to know.
• Reinforce the client _autonomy,_ for example, by allowing them to choose the content in your teaching plan.
• _Offer information_ in an environment that enables them to use it.
• Make sure your clients _actively participate_ in their care plan.
• Encourage clients to network with a support group.
• Clarify with your clients that they hold the major _responsibility_ for both the health care decisions they make and their consequences.
## Application of empathy to levels of nursing actions
Nursing actions that facilitate empathy can be classified into three major skills: (a) recognition and classification of requests, (b) attending behaviors, and (c) empathetic responses.
Processing requests: Two types of requests are for information and action. These requests do not involve interpersonal concerns and are easier to manage. Another form of request is for understanding involvement, which entails the client's need for empathetic understanding. This type of request requires greater interpersonal skills. It can be misinterpreted as a request for action or information. The nurse may have to clarify whether the client needs only what he or she specifically asks for, or whether further exploration of the meaning of the need is necessary.
Use attending behaviors: _Attending behaviors_ facilitate empathy and include an attentive, open posture; responding to verbal and nonverbal cues through appropriate gestures and facial expressions; using eye contact; and allowing client self-expression. Verbally acknowledging nonverbal cues shows you are attending. As does offering time and attention, showing interest in the client's issues, offering helpful information, and clarifying problem areas. These responses encourage clients to participate in their own healing.
Make empathetic responses: You communicate _empathy_ when you show your client that you understand how he is feeling. This helps him identify emotions that are not readily observable and connect them with the current situation. For example, observing nonverbal client cues such as worried facial expression and verbalizing this reaction with an empathetic comment, such as "I understand that this is very difficult for you," validates what your client is feeling and tells him you understand him. Using the actions listed in Table 6-2, the nurse applies attending behaviors and nursing actions to express empathy. Verbal prompts such as "Hmm," "Uh-huh," "I see," "Tell me more," and "Go on" facilitate expression of feelings. The nurse uses open-ended questions to validate perceptions. Using informing behaviors listed in Table 6-2 enlarges the database by providing new information and gives feedback to your client. If your client's condition prevents use of familiar communication strategies to demonstrate empathy, the nurse can use alternative techniques such as touch (refer to Chapter 17).
TABLE 6-2
Levels of Nursing Actions
## Reduction of barriers in nurse-client relationships
Recognition of barriers is the first step in eliminating them, and thus enhancing the therapeutic process. Practice with exercises in this chapter should increase your recognition of possible barriers. Findings from many studies (Evans et al., 2009) emphasize the crucial importance of honesty, cultural sensitivity, and caring, especially in listening actively to suggestions and complaints from client and family. Refer to Box 6-4 for a summary of strategies to reduce barriers to the nurse-client relationship.
BOX 6-4 Tips to Reduce Relationship Barriers
• Establish trust.
• Demonstrate caring and empathy.
• Empower the client.
• Recognize and reduce client anxiety.
• Maintain appropriate personal distance.
• Practice cultural sensitivity and work to be bilingual.
• Use therapeutic relationship-building activities such as active listening.
• Avoid medical jargon.
## Respect for personal space
Before providing care, you need to assess your client's personal space needs. A comprehensive assessment includes cultural and developmental factors that affect perceptions of space and reactions to intrusions. (Discuss Exercise 6-7.) To increase your client's sense of personal space, you can decrease close, direct eye contact. Instead, sit beside the client or position the chairs at angles for counseling or health teaching. Clients in intensive care units, where there are many intrusive procedures, benefit from decreased eye contact during certain times, such as when being bathed or during suction, wound care, and changing of dressings. At the same time, it is important for you to talk gently with your client during such procedures and to elicit feedback, if appropriate.
EXERCISE 6-7 Personal Space Differences
Purpose:
To identify individual needs for personal space among different client populations.
Procedure:
Following is a list of factors that affect personal space. Each has a clinical example. Write another example (clinical or personal) for each factor.
1. Culture
Mrs. Hopi, a Native American who is in the intensive care unit for a heart attack, is surrounded by her family and tribe members throughout her stay in the hospital. Would your family insist on being with you?
2. Sex
Mr. Smith, a retired steel worker, greets his community health nurse with a smile and a gesture to enter his apartment. His ailing wife greets the nurse with outstretched arms and a kiss. If Mr. Smith greeted you this way, would your response be different?
3. Degree of acquaintance
The nurse meets Mrs. Parker at the prenatal clinic for the first time. They maintain a distance of 5 feet during the initial interview. How far away would you sit?
4. Situational anxiety
Mrs. Cook just returned from a brain scan, and she is quite anxious about the results. As the nurse attempts to comfort Mrs. Cook by placing her hand on Mrs. Cook's arm, Mrs. Cook snatches her arm away and retorts, "Just leave me alone."
Discussion:
1. What is your own preferred space distance? To what do you attribute this preference?
2. Under what circumstances do your needs for personal space change?
To minimize the loss of a sense of personal space, we should demonstrate regard for our client's dignity and privacy. Closed doors for private rest and periods of uninterrupted relaxation are respected. Personal belongings are arranged and treated with care, particularly with very old and very young clients, for whom personal items may be highly significant as a link with a more familiar environment. Elderly clients can become profoundly disoriented in unfamiliar environments because their internal sensory skill in processing new information is often reduced. Encouraging persons in long-term facilities to bring pictures, clothing, and favorite mementos is an important nursing intervention with such clients.
### Respect for personal space in hospital situations
Obviously, there is a discrepancy between the minimum amount of space an individual needs and the amount of space hospitals are able to provide in multiple-occupancy rooms. Actions to ensure private space and show respect include:
• Providing privacy when disturbing matters are to be discussed
• Explaining procedures before implementing them
• Entering another person's personal space with warning (e.g., knocking or calling the client's name) and, preferably, waiting for permission to enter
• Providing an identified space for personal belongings
• Encouraging the inclusion of personal and familiar objects on the client's nightstand
• Decreasing direct eye contact during hands-on care
• Minimizing bodily exposure during care
• Using only the necessary number of people during any procedure
• Using touch appropriately
## Violations of confidentiality
Discussing private information casually with others is an abuse of confidentiality. Nursing reports and interdisciplinary team case conferences are examples of acceptable forums for the discussion of privileged communication. This information is not discussed outside what is needed for nursing or medical care; to do so would undermine the basis for your therapeutic relationship with your client. Federal confidentiality regulations are discussed in Chapter 2.
## Avoiding cross-cultural dissonance
The ANA's statement on cultural diversity in nursing practice highlights the importance of recognizing intracultural variation and assessing each client as an individual (ANA, 1991). Becoming culturally sensitive includes avoiding barriers to communication that occur when generalizing about our client's beliefs based on his membership, rather than taking the time to learn personal preferences. Identify your client's health values, beliefs, health practices, or family factors that may affect his communication with you (Neuhauser & Kreps, 2008).
## Summary
This chapter focuses on essential concepts needed to establish and maintain a therapeutic relationship in nursing practice: caring, empowerment, trust, empathy, mutuality, and confidentiality. Respect for the client as a unique person is a basic component of each concept.
Caring is described as a commitment by the nurse that involves profound respect and concern for the unique humanity of every client and a willingness to confirm the client's personhood.
Empowerment is assisting the client to take charge of his or her own health.
Trust represents an individual's emotional reliance on the consistency and continuity of experience. The client perceives the nurse as trustworthy, a safe person with whom to share difficult feelings about health-related needs.
Empathy is the ability to perceive accurately another person's feelings and to convey their meaning to the client. Nursing behaviors that facilitate the development of empathy are accepting, listening, clarifying and informing, and analyzing. Each of these behaviors implicitly recognizes the client as a unique individual worthy of being listened to and respected.
Mutuality includes as much shared communication and collaboration in problem solving as the client is capable of providing. To foster mutuality within the relationship, nurses need to remain aware of their own feelings, attitudes, and beliefs.
Barriers that affect the development of the nurse-client relationship, such as anxiety, stereotyping, overfamiliarity, or intrusion into personal space, are described. High levels of anxiety decrease perceptual ability. The nurse needs to use anxiety- and stress-reduction strategies when clients demonstrate moderate anxiety levels. Stereotypes are generalizations representing an unsubstantiated belief that all individuals of a particular social group, race, or religion share the same characteristics. No allowance is made for individual differences. Developing a nonjudgmental, neutral attitude toward a client helps the nurse reduce clinical bias in nursing practice. Personal space, defined as an invisible boundary around an individual, is another conceptual variable worthy of attention in the nurse-client relationship. The emotional boundary needed for interpersonal comfort changes with different conditions. It is defined by past experiences and culture. Proxemics is the term given to the study of humans' use of space. To minimize a decreased sense of personal space, you demonstrate a regard for your client's dignity and privacy.
Ethical Dilemma
What Would You Do?
There are limits to your professional responsibility to maintain confidentiality. Any information that, if withheld, might endanger the life or physical and emotional safety of the client or others needs to be communicated to the health team or appropriate people immediately.
Consider the teen who confides his plan to shoot classmates. Can you breach confidentiality in this case? How about the 5-year-old child in whom you notice genital warts (human papillomavirus) on his anus, but who shows no other signs of sexual abuse?
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CHAPTER 7
# Role Relationship Patterns
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define role as a framework for role performance and role relationships.
2 Discuss the professional roles of the nurse.
3 Describe the components of professional role socialization in professional nursing education.
4 Describe interprofessional education.
5 Discuss professional role development as a registered nurse.
6 Identify factors needed to create supportive work environments for nurses.
7 Discuss professional role relationship behaviors with colleagues.
8 Describe professional role behaviors supporting nurse-client relationships.
9 Discuss the advocacy role in nurse-client relationships.
10 Discuss role performance as a nursing diagnosis.
This chapter explores the concept of role and role relationships in nursing practice from two perspectives: (a) professional nursing role; and (b) role as a functional health pattern, and nursing diagnosis. Key concepts of professional socialization, professional communication, and professional development are addressed.
## Basic concepts
Role
Role is defined as the traditional pattern of behavior and self-expression performed by or expected of an individual within a given society. People develop social and professional roles throughout life. Some are conferred at birth (ascribed roles) and some are attained (acquired roles) during a lifetime. People can have several social roles at the same time (Chaudhary & Sriram, 2001). For example, Marge is a professional nurse, a mother, a wife, a daughter, a lay minister in her church, and president of the parent-teacher association at her children's school. Each role carries different expectations. When the expectations of one role interfere with the discharge of other important life roles, conflict, burnout, or both can occur.
#### Role relationships
Roles have performance and relationship dimensions that affect how people relate to one another. Social customs and expected professional standards of practice reinforce the performance aspect of role relationships. For example, consider the different professional role expectations of a lawyer, a physician, and a dentist. Each profession has a different set of skills and professional role competencies based on their education and training.
Behavioral expectations in role relationships are reciprocal as role perceptions and expectations influence communication content and delivery. Consider your own "role" as a nursing student and how it has influenced your relationships and communication with clinical instructors, your clients, professional peers, your friends, and other significant people in your life. What do others expect of you, simply because you are now a nursing student?
Roles provide guides for behavior that are in part socially regulated and in part individually determined. Standards for individual role performance reflect personal, social, cultural, gender, institutional, and family expectations. Role relationships are recognizable through membership in a community or through differences in work responsibilities, cooperative activities, education, and social affiliations. Stronger role expectations may be held for people in public roles, for example, elected politicians, ministers, and teachers because of the trust people have in them as a function of their role. Changes in social circumstances such as marriage, widowhood, retirement, job promotions, or birth of a child can alter personal and societal interpretations of individual and professional roles. Exercise 7-1 is designed to help you focus on the complexity of different life roles.
EXERCISE 7-1 Understanding Life Roles
Purpose: To expand students' awareness of the responsibilities, stressors, and rewards of different life roles.
Procedure:
1. Think of all the roles you assume in life.
2. Write a description of the specific responsibilities, stressors, and rewards related to each role.
3. Share some of your roles and their descriptions. (Share only what you feel comfortable revealing.)
Discussion:
As a group, discuss how these different aspects of life roles affect a person's overall functioning.
1. How can this help you to understand your clients better?
2. Discuss what would happen with these roles if you were incapacitated?
3. How might such a situation affect your coping ability?
4. How might it affect others?
5. What roles do you hold in common with other participants in this exercise?
6. What does this exercise suggest about possible role overload or conflict?
#### Professional nursing roles
Nursing roles are developed from and linked to the discipline of nursing. The criteria (Box 7-1) for describing a professional discipline, originally developed by Flexner (1915), still hold true today. In their seminal work on nursing as a discipline, Donaldson and Crowley (1978) identify three key themes that distinguish and delimit the discipline of professional nursing:
BOX 7-1 Flexner's Criteria of a Professional Role
• Members share a common identity, values, attitudes, and behaviors.
• A distinctive specialized substantial body of knowledge exists.
• Education is extensive, with both theory and practice components.
• Unique service contributions are made to society.
• There is acceptance of personal responsibility in discharging services to the public.
• There is governance and autonomy over policies that govern activities of profession members.
• There is a code of ethics that members acknowledge and incorporate in their actions.
1. Concern with principles and laws that govern the life processes, well-being, and optimum functioning of human beings
2. Concern with the patterning of human behavior in interaction with the environment in critical life situations
3. Concern with the processes by which positive changes in health status are affected (p. 113)
Willis, Grace, and Roy (2008) identify a similar unifying focus for the discipline related to facilitating meaning, choice, quality of life, humanization, and healing through nursing interventions.The robustness of nursing as a professional discipline is evidenced in the fact that its core descriptors as a discipline are as salient today as they were elegantly described in 1978. Clearly, the nursing role is much more complex than it was in 1978. Evidence for expanded roles is found in the transition of nursing education from the hospital training to increasing levels of educational preparation and practice certifications required of professional nurses. Nursing content and skill sets necessarily change in relation to new and different health care situations; the fundamental essence of nursing as a discipline remains constant.
#### Role behaviors in professional nursing
Anthony and Landeen (2009) note, "Nursing education has a history of tension and inter-reliance with historical events that encompasses nursing practice, human and social needs, geo- and socio-political processes" (p. 2). At no time in recent history has there been such a complex accumulation of historical events directly and indirectly impacting health care delivery and nursing education. Professional nursing roles have evolved and expanded to reflect the increasing complexities of health care, globalization, changing client demographic characteristics and diversity, and the exponential growth of health information technology (Hegarty, Condon, Walsh, & Sweeney, 2009). With the rapid changes in health care, there is no single role descriptor to explain how professional nursing roles fit in to the health care hierarchy, or will do so in the future. Figure 7-1 identifies the evolving role competencies required of contemporary nurses, identified by the Institute of Medicine (2003).
Figure 7-1 Professional nursing role: core competencies for health professionals. Adapted from Institute of Medicine (IOM): _Health professions education: a bridge to quality_ (pp. 45–46). Washington, DC, 2003, National Academies Press, 2003.
Types of Professional Roles: The significance of the professional nurse's role is emphasized in the Joint Commission's first white paper, entitled _Health Care at the Crossroads_ (2002), which states, "... in the end, nurses are the primary source of care and support for patients at the most vulnerable points in their lives" (p. 4). Clinical skills related to health promotion, risk reduction, and collaboration with clients and health care providers in primary care are recognized as modern hallmarks of clinical role competence. As providers of care, nurses delegate and supervise related care activities for allied professional staff. Nurses provide leadership and coordination in health care improvement through advocacy and education, and participate in research. Proficiency in biotechnology and health information technology has become an expected competency required of professional nurses (American Association of Colleges of Nursing [AACN], 2008; Gugerty, 2007). Regardless of setting, nurse-client relationships and professional communication provide a primary means through which nurses implement professional roles in providing quality health care and contribute to shaping the health care delivery system.
Table 7-1 identifies the many different types of roles associated with professional nursing practice. Nursing roles are adapted for practice in prisons, schools, home care, shopping malls, and faith-based settings. Nurses provide care individually and as part of multidisciplinary health care teams with the military, during disasters, in the juvenile justice system, with the homeless, in the fields with migrant workers, and in clinics for the uninsured. Increasingly, nurses are assuming active advocacy roles to inform policy makers, educators, other health care providers and consumers to increase and protect the funding, accessibility, and availability of quality health services. Exercise 7-2 is designed to help you look at the different role responsibilities of practicing nurses.
EXERCISE 7-2 Professional Nursing Roles
Purpose: To help students explore different nursing roles.
Procedure:
Conduct an occupational interview with a practicing nurse about the different responsibilities involved in his or her job, the training and credentials required for the position, the client population encountered, the difficult and rewarding aspects of the job, and why the nurse chose a particular area or role in nursing. Write your findings in a short, descriptive summary. Questions you might ask are listed below, but you are also encouraged to create your own explorative questions.
• What made you decide to pursue nursing?
• What kinds of clients do you work with?
• What do you like best about your job?
• What would you do in an average workday?
• What is the most difficult aspect of your job?
• What kinds of preparation or credentials does your position require?
• What is of greatest value to you in your role as a professional nurse?
Discussion:
1. Were you surprised by any of your interviewee's answers? If so, in what ways?
2. What similarities and differences do you see in the results of your interview compared with those of your classmates?
3. In what ways can you use what you learned from doing this exercise in your future professional life?
TABLE 7-1
Professional Nursing Roles with Associated Responsibilities
Advanced Practice Roles: Advanced practice nurses are registered nurses with a baccalaureate degree in nursing and an advanced degree in a selected clinical nursing specialty with relevant clinical experience. Certification and state licensing requirements vary according to state for practice in advanced practice roles. Box 7-2 identifies the four categories of advanced practice nursing in contemporary health care.
BOX 7-2 Advanced Practice Roles
**Nurse practitioners (NPs)** provide first-line health care services across the health-illness continuum in a variety of primary and acute care settings. They may practice either as an independent practitioner or in collaboration with a physician, depending on state laws. NPs can diagnose and treat common medical conditions and injuries, conduct physical examinations and provide preventive care, and medically manage common chronic health problems in the community such as diabetes and high blood pressure. Acute care and specialty NPs (such as neonatal, pediatric, psychiatric, and geriatric NPs) use advanced clinical skills, diagnostic reasoning, and direct skilled management of specialized health care needs. Nurse practitioners can have prescriptive authority in most states, in conjunction with a statutorily mandated written agreement with a designated collaborating physician, approved by the state Board of Nursing.
**Certified nurse-midwives** provide a wide variety of first-line and clinical management of prenatal and gynecologic care to normal, healthy women. They perform uncomplicated delivery of babies in hospitals, private homes, and birthing centers, and continue with follow-up postpartum care. Certified nurse-midwives also have prescriptive authority under a mandated agreement with a designated collaborating physician, approved by the state Board of Nursing.
**Clinical nurse specialists** provide care and consultation in a specialty area, such as cardiac, oncology, neonatal, pediatric, obstetric/gynecologic, medical-surgical, or psychiatric nursing. In some states, clinical specialists in psychiatric nursing have limited prescriptive authority. Clinical nurse specialists also perform indirect clinical nursing roles such as staff development, nursing education, administration, and informatics.
**Certified registered nurse anesthetists** administer anesthesia and conscious sedation in more than one third of the hospitals in the United States.
Expanded advanced practice roles can include "entrepreneur, recruiter, editor, publisher, ethicist, labor relations expert, nurse anesthetist, lobbyist, [and] culture broker" (Roberson, 1992, p. 4). Many advanced practice nurses (nurse practitioners and some clinical specialists) have prescriptive authority. In addition to clinical roles, advanced practice nurses function in research, educational, and administrative roles. Each expanded role requires specialized competency training to manage care independently in an advanced specialty role. Exercise 7-3 helps you to explore the different specialty areas available for professional nurses in advanced practice.
EXERCISE 7-3 Exploring Advanced Practice Roles in Nursing Practice
Purpose: To explore different specialty areas in nursing.
Procedure:
1. Select a specialty area about which you have an interest in learning more and obtain the American Nurses Association standards of practice for that specialty.
2. Interview a nurse in that specialty area.
3. Write a summary of your impressions of the practice of nursing in that specialty area, describing aspects that are especially important to you.
Discussion:
Students or student groups can present their summaries and discuss aspects of the specialty area that impress them the most. Do you see common threads across clinical specialties?
#### Nursing education and professional role performance
The nursing profession has evolved from a primarily apprenticeship model to one with sophisticated educational models and multiple training options. All registered nurses currently are educationally prepared in colleges and universities, at associate's degree, baccalaureate, master's, and doctoral levels (Erickson & Ditomassi, 2005). Educational career ladders are available for nurses to advance from bedside nurses to advanced practice levels involved with research, clinical expertise, consultation, education, and administration. Hegyvary (2007) asserts that there is no form of self-investment more significant than education for realizing one's full potential as a nurse.
#### New models in nursing education
In 2003, the American Association of Colleges of Nursing (AACN) introduced two new models of professional education. They were developed in response to expanded clinical roles in nursing practice, the Institute of Medicine's Report on Medical Errors, and to offset nursing faculty shortages. The clinical nurse leader (CNL) role prepares students with a baccalaureate degree in another field to become an advanced nurse generalist. An accelerated generalist nursing curriculum combines baccalaureate and master's level courses, which emphasize clinical leadership skills, and training in health care systems management at the clinical unit level. The CNL "designs, implements, and evaluates client care by coordinating, delegating and supervising the care provided by the health care team, including licensed nurses, technicians, and other health professionals" (AACN, 2003, paragraph 2). Students who satisfactorily complete program requirements are awarded a generic master's degree. Graduates can sit for the NCLEX professional nursing licensing examination and are eligible for certification as a CNL. To practice as an advanced practice nurse in a clinical specialty, the CNL must complete master's-level preparation in an advanced practice specialty.
A second professional role, Doctor of Nursing Practice (DNP), represents a terminal degree in advanced clinical nursing practice. It is designed for nurses who want a clinical rather than research-focused doctorate. The curriculum combines advanced nursing practice competencies with a solid foundation in clinical science, evidence-based practice methods, system leadership, information technology, health policy, and interdisciplinary collaboration (American Association of Colleges of Nursing, AACN, 2004). According to Mundinger (2005), the DNP degree will expand and complement current master's specialty education and roles.
Interprofessional education: The Institute of Medicine (2003), in its landmark report, _Health Professions Education: A Bridge to Quality_ , calls for health professionals to develop competencies in working together in interdisciplinary teams. The report identifies "working in interdisciplinary teams" as one of five core competencies needed in today's health care delivery. Promoting interdisciplinary education and providing shared learning opportunities is an important way to develop the respect and integration students need to function in interdisciplinary health care teams.
**Interprofessional education** is defined as "occasions when two or more professions learn from and about each other to improve collaboration and the quality of care" (Oandasan & Reeves, 2005, p. 24). This does not mean that nursing and other health care professional roles are interchangeable. Nursing, medicine, dentistry, pharmacy and social work are distinct health disciplines that prepare clinicians to assume different practice roles using discipline specific practice standards. Helping students understand the natural interdependence between professions required for today's interdisciplinary care, whereas at the same time recognizing the unique knowledge and skill set of each discipline, is a critical foundation for interprofessional training. Students gain firsthand understanding of the professional values held by other disciplines and collectively identify with important health care issues. In the process of sharing knowledge and experience, students learn the tools of collaborative problem solving (Fronek et al., 2009).
The goal of interprofessional education is to provide students with the knowledge, skills, and attitudes needed to effectively collaborate and improve the quality of health care through interdisciplinary problem solving. Skills to enhance teamwork and to clarify roles in providing client-centered care are important in both discipline-specific and interprofessional learning (Pecukonis, Doyle, & Bliss, 2008).
The impetus for interprofessional education comes from many sources. The Pew Health Professions Commission (1993) recommends revision of health professions curricula to include shared interprofessional learning in academic settings, and the AACN (2008) recently identified "interprofessional communication and collaboration for improving patient health outcomes" (p. 3) as one of nine essential outcomes expected of nursing graduates. The Joint Commission suggests that safe, effective clinical care requires an interdisciplinary collaborative team approach (Walsh, Gordon, Marshall, Wilson, & Hunt, 2005).
Introducing interprofessional courses as part of the basic nursing curriculum helps students articulate their own professional roles, and understand how collaboration and teamwork can more effectively resolve complex issues to enhance clinical outcomes (Margalit, Thompson, Visovsky, et al., 2009). Students can learn trust and respect for each discipline's competencies, and the team building collaborative skills through direct experience with each other's clinical practices. Collaborative interactions modeled by interdisciplinary faculty add to the learning experience.
Learning about Interdisciplinary Collaboration: Rodts and Lamb (2008) state that "any new role requires an understanding of what it is and what it is not" (p. 131). An interdisciplinary, collaborative role is no different. Nursing students must have a solid understanding of their own discipline's specific roles and responsibilities so that they can articulate them clearly to professionals in other disciplines. To maintain nursing's integrity as a profession, the profession must retain control of its knowledge base, skills, and accountability for practice. At the same time, nurses must be willing to work collaboratively with other professionals as part of an interdisciplinary team. Figure 7-1 identifies core competencies needed in today's health care delivery system.
Although interdisciplinary collaboration is still in its infancy as an integral part of professional curriculums, shared elective classes involving interdisciplinary education for two or more disciplines are increasing at the baccalaureate and graduate level (Herbert, 2005). Frequent topics covered in interprofessional electives include ethics, death and dying, emergency preparedness, gerontology, and legal issues. In preparing courses, Aveyard, Edwards, and West (2005) suggest topics need to be "both enhanced by an interdisciplinary approach and not hindered by a lack of detailed attention to field-specific content" (p. 64). As student nurses, you have a unique opportunity to help make the nursing discipline visible as a key player and carve out nursing's role in the evolution of interdisciplinary collaboration as a primary care strategy.
#### Nursing values and role socialization
Although the core values and fundamental features of professional nursing remain constant, the scope of practice and implementation of associated professional nursing roles continues to evolve as we enter the 21st century.
#### Professional role socialization
Essential Values and Professional Behaviors: The AACN (1986) first published examples of the essential values, attitudes, personal qualities, and professional behaviors associated with the profession of nursing and later refined them in 2008 (see Table 7-2). Key elements of the professional nursing role include the acquisition, development, and integration of health-related psychomotor, social, and cognitive skills, and the achievement of a sense of self as a professional nurse within an ethical, competency-based framework.
TABLE 7-2
Values and Qualities of Professionalism in Nursing
Adapted from American Association of College and University Education for Professional Nursing: _Final report,_ Washington, DC, 1986, American Association of Colleges of Nursing; and American Association of Colleges of Nursing: _Essentials of baccalaureate nursing education for professional nursing practice_ (pp. 27–28), Washington, DC, 2008, Author.
_Role socialization_ refers to the process through which a student nurse learns the professional norms, values, and skills associated with the professional nursing role, and acquires identity features of the profession. It is an interactive developmental process that starts when students enter a nursing program and begin to learn the "pure" form of nursing knowledge. Initially, nursing students are absorbed in learning the basic knowledge required of the professional role. They are dependent on textbooks and their instructor to help them find the one "right answer" to health care problems. As students become comfortable with foundational nursing knowledge, they begin to consider multiple options as they integrate professional judgment into clinical care planning. Students are able to apply scientific knowledge to practice in a realistic manner and "to relate new material to their previous knowledge base" (Cohen, 1981, p. 18).
The next phase involves internalizing the culture, that is, the values, standards, and role behaviors associated with professional nursing. Pecukonis, Doyle, and Bliss (2008) note that "each discipline possesses its own professional culture that shapes the educational experience; determines curriculum content, core values, dress, salience of symbols" (p. 417). Student nurses are accountable for presenting themselves as professionals to other health providers and the public. For example, professional appearance is important. Although a common dress code for professional nurses is "scrubs," attire should be neat, clean, and properly fitted. The professional "image" of the nurse is an unspoken factor in how others perceive the profession.
Nursing faculty and clinical preceptors serve as important socializing agents, helping students learn the values, traditions, norms, and competencies of the nursing profession (Neil et al., 1998). A clinical preceptor is an experienced nurse, chosen for clinical competence and charged with supporting, guiding, and participating in the evaluation of student clinical competence (Paton, Thompson-Isherwood, & Thirsk, 2009). Clients/families, mentors, and peers serve as informal socializing agents in ways that can contribute to a student's understanding of the professional nursing role. As preceptors, other nurses and clinical faculty model desirable nursing role behaviors; students begin to identify with them and learn the normative expectations associated with the professional nursing role.
Nurses learn behavioral standards from instructors, nursing staff, and other students.
The last phase of the socialization process focuses on an internalization of professional norms and values as an integral part of self. With increasing clinical experience, nursing students become self-directed and committed to the role of professional nurse.
#### Professional role development as a registered nurse
Professional role development does not end with graduation and licensure as a registered nurse. After graduation, standard means of continued professional development include continuing education, staff development, conference attendance, academic education, specialized training, and research activities. Professional learning occurs through informal means such as consultation, professional reading, experiential learning, giving presentations, and self-directed activities. At advanced practice levels, nurses are required to complete a certain level of continuing education activities within designated time frames to maintain their specialty certification.
From Novice to Expert: Process of Skill Acquisition: Patricia Benner (1984, 2000; Norman, 2008) describes five developmental stages of increasing proficiency associated with the professional nursing role: novice, advanced beginner, competence, proficiency, and expert. The first developmental stage is referred to as the _novice stage._ With limited nursing experience, novice nurses need structure and tend to compare clinical findings with the textbook picture because they lack the practice experience to do otherwise. Theoretical knowledge and confidence in the expertise of more practiced nurses serve as guides to practice. Veteran nurses can re-experience the novice stage any time that nurse makes a career change and enters a new clinical area or specialty, never having had experience with a particular client population (Thomas, 2003).
In stage 2, the advanced beginner stage, nurses understand the basic elements of practice and can organize and prioritize clinical tasks. Although clinical analysis of health care situations occurs at a higher level than strict association with the textbook picture, the advanced beginner is only able to partially grasp the unique complexity of each client's situation.
Stage 3, the competence stage, occurs 1 to 2 years into nursing practice. The competent nurse is able to easily "manage the many contingencies of clinical nursing" (Benner, 1984, p. 27). Nurses in this stage begin to practice the "art" of nursing. The nurse views the clinical picture from a broader perspective and is more confident about his or her role in health care.
Stage 4, the proficiency stage, occurs 3 to 5 years into practice. Nurses in this stage are self-confident about their clinical skills and perform them with competence, speed, and flexibility. The proficient nurse sees the clinical situation as a whole, has well-developed psychosocial skills, and knows from experience what needs to be modified in response to a given situation (Benner, 1984). Stage 5, expert, is marked by a high level of clinical skill and the capacity to respond authentically and creatively to client needs and concerns. Expert nurses can recognize the unexpected and work with it creatively. They demonstrate mastery of technology, sensitivity in interpersonal relationships, and specialized nursing skills in all aspects of their caregiving. Being an expert nurse is not an end point; nurses have the professional and ethical responsibility to continuously upgrade and refine their clinical skills through professional development and clinical skill training. Table 7-3 identifies behaviors associated with different levels of Benner's model (Norman, 2008).
TABLE 7-3
Benner's Stages of Clinical Competence
From Norman V: Uncovering and recognizing nurse caring from clinical narratives, _Holistic Nursing Practice_ 22(6):324, 2008, by permission.
Mentoring: Expert or seasoned nurses often serve as mentors for their less-experienced colleagues. Mentoring is defined as a special type of professional relationship in which an experienced nurse or clinician (mentor) assumes a role responsibility for guiding the professional growth and advancement of a less-experienced person (protégé). Yonge, Billay, Myrick, and Luhanga (2007) make several distinctions between mentorship and preceptorship. A mentoring relationship can last over several months or years, whereas the assigned relationship between a preceptor and less experienced nurse is a short-term relationship with a defined end date focused on clinical teaching and role modeling. The mentor relationship is broader and more personal. Nurses choose a mentor rather than having one assigned.
Each mentoring experience is unique because of the people and situations involved. Excellent mentors demonstrate role expertise and model the highest levels of personal professionalism. They share values and tips for success, and provide support, structure, and challenges to the mentee or protégé. In many instances, they help facilitate contacts with significant people. Benefits to the mentor include satisfaction in seeing the achievements of the mentee and expansion of clinical excellence through interacting others. Hoffman, Harris, and Rosenfield (2008) suggest that mentoring of students in interprofessional education should contain the following elements:
• Engagement in students' own values
• Guidance reflecting principles of self-directed learning
• Creation of awareness for opportunities that facilitate self-discovery and maturation (p. 103)
Networking: Networking is an essential component of personal role development, and ultimately of advancing the status of professional nursing roles in health care delivery systems. Professional networking is defined as "establishing and using contacts for information, support, and other assistance in order to achieve career goals" (Puetz, 2007, p. 577). Nurses can use networking when they are in the market for a new job, need a referral, want to receive or share information about an area of interest, or need assistance with making a career choice. For example, if you want to write an article, you might want to discuss your ideas and get guidance from someone who is published.
Networking contacts can be with peers from as close as the nursing unit on the floor below, or people you meet at an international professional conference. Participating in activities of nursing organizations or continuing education events provides fertile opportunities for networking. Having business cards with you and following up with a thank-you e-mail or note is helpful.
Networking can offer professional opportunities for developing new ideas and receiving feedback that might not otherwise be available. Through networking contacts, nurses can communicate their expertise and share their ideas while gathering information from their contacts. This give and take of information is often the bridge to developing or strengthening collaborative relationships with others in the field. For example, extensive networking among oncology nurses was the impetus for the formation of the Oncology Nursing Society. Networking is closely associated with coordination and collaboration activities, and is destined to become increasingly important in determining the future impact of advanced practice nursing.
Developing an Evidence-Based Practice
Foley BJ, Minick P, Kee C: Nursing advocacy during a military operation, Western Journal of _Nursing Research_ 22(4):492–507, 2000.
This qualitative phenomenologic study was designed to explore the advocacy role experiences of military nurses and to provide a rich description of the common meanings of their advocacy practices. A purposive sample of 24 military nurses was interviewed and data analysis completed using a constant comparison methodology.
_Results:_ Themes revealed one constitutive pattern associated with the concept of advocacy, namely, safeguarding, with four related themes described as being the patient's voice, protecting, attending the whole person, and preserving the patient's personhood. A recommendation from this study is the need to coach nurses in how to relate to other members of the health team as the patient's advocate.
_Application to Your Clinical Practice:_ As a profession, nurses need to develop research evidence and implement relevant study findings to advocate for the health and well-being of their clients. What themes do you associate with client advocacy in your clinical setting? Would these themes be the same or different in a community setting?
## Applications
Professional role behaviors with colleagues
Developing productive role relationships with other professionals does not just happen. Professional role behaviors and strong relationships with nursing and other professional colleagues include full acceptance of one's fair share of the workload. Masters (2005) asserts that if nurses are to engage in interprofessional work relationships, they must be able to clearly articulate professional nursing values. Development of supportive, dependable relationships with coworkers—with those you dislike as well as with those you can work with easily—is essential. Maintaining zero tolerance for gossip and criticism helps establish you as a professional with ethical integrity and worthy of trust.
Respecting the views of other disciplines and communicating in an organized, thoughtful manner has an impact on how practitioners from other disciplines perceive the nurse's role and value as competent health care professionals. Using critical thinking, focused communication skills, and professional behaviors in interactions with professional colleagues is just as important as it is with clients and their families.
How nurses present their ideas in writing and speaking is critical. If you use e-mails to communicate, remember that your e-mail is a reflection of you as a professional person. Use complete, well-thought-out sentences, and check punctuation, grammar, and spelling. Likewise, voice-mail messages should be professional in content and delivery.
#### Verbal communication with professional colleagues
When communicating with professional colleagues, it is important to remain sensitive to the tasks at hand, and to develop an understanding of how the work of different disciplines affects the nurse's work and contributes to overall treatment goals. Collaboration in joint decision making and coordination of care with colleagues requires knowing when to hold and when to let go of ideas and opinions. Most of the time, decisions are not either/or processes, but it is easy to lose sight of alternative options. Placing issues in order of priority is a useful organizing strategy for assessing, defining, and clarifying problems. Persistence and a good sense of humor are essential characteristics of honest interpersonal relationships with professional peers.
E-mail or memos can provide quick routine information that does not require discussion. Face-to-face interaction or telephone conversations are preferred for communicating in the professional environment about difficult or emotional issues that could be misinterpreted. Serving as an informed resource to other providers helps build rapport and encourages others to work with you to achieve relevant treatment and organizational goals.
#### Self-awareness
Self-awareness is an essential aspect of effective professional relationships with colleagues and a necessary antecedent to the full development of the professional role in nursing. Malloch and Porter-O'Grady (2005) assert that "knowing from the internal self what needs to be done and living those beliefs and values in the real world marks the leader's journey" (p. 101).
Professional self-awareness promotes recognition of the need for continuing education, the acceptance of accountability for one's own actions, the capacity to be assertive with professional colleagues, and the capability of serving as a client advocate when the situation warrants it, even if it is uncomfortable to do so. Exercises 7-4 and 7-5 are designed to help you explore the use of personal strengths in professional role development.
EXERCISE 7-4 Incorporating Personal Strengths in Role Development
Purpose: To help highlight the use of personal strengths as skills or assets in role development.
Procedure:
1. Pair up with another student.
2. Share a personal strength that you have observed about your assigned partner related to implementation of the professional nursing role and describe the behavior that supports your assessment. (Examples might be persistence, sense of humor, balanced approach, energetic, thoughtful, caring, inquisitive, take charge, laid-back, etc.)
Discussion:
1. Discuss how personal strengths can be used to enhance the professional role.
2. Compare and contrast what different students envisioned as personal strengths.
3. Did doing this exercise help you to learn something about the value of personal strengths?
4. Did anything surprise you about doing this exercise?
5. How can you use this information in your own role development?
EXERCISE 7-5 Looking at My Development as a Professional Nurse
Purpose: To help students focus on their self-development as professional nurses.
Procedure:
Write the story of how you chose to become a nurse in a one- or two-page essay (may be done as a homework assignment). There are no right or wrong answers; this is simply your story. You may use the following questions as guides in developing your story.
1. What are your reasons for choosing nursing as a profession?
2. What factors influenced your decision (e.g., people, circumstances, or situations)?
3. What does being a nurse mean to you?
4. What fears do you have about your ability to function as a professional nurse?
5. How do you think being a nurse will affect your personal life?
6. What type of nursing do you want to pursue?
Discussion:
1. In what ways is your story similar to or different from those of your classmates?
2. As you wrote your story, were you surprised by any of the data or feelings?
3. Students can discuss some of the realistic difficulties encountered as nursing students, both professionally and personally, and ways to handle them. Through discussion, explore the following:
a. The practices nursing students will need to follow to achieve their vision
b. The types of supports nurses need to foster their ongoing professional development
#### Professional rights
All health professionals, including nurses, have rights as well as significant responsibilities in interprofessional relationships with colleagues. Box 7-3 lists the American Nurses Association (2002) Bill of Rights for Registered Nurses. Rights carry with them corresponding responsibilities. Think about your professional collegial relationships and your dual professional commitment to self and others. Think about the professional values identified in this textbook, and reexamine the components of professionalism. Each of those components is basically a professional responsibility. Add your ideas for rights next to those responsibilities. Exchange ideas about professional rights and responsibilities with others.
BOX 7-3 The American Nurses Association's Bill of Rights for Registered Nurses
• Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care.
• Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice.
• Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses and its interpretive statements.
• Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
• Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities.
• Nurses have the right to a work environment that is safe for themselves and their patients.
• Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.
Reprinted from American Nurses Association: Know your rights: ANA's Bill of Rights arms nurses with critical information. _American Nurse_ 34(6), 16, 2002, by permission.
### Creating supportive work environments
A responsive work environment that values nurses and is committed to quality client-centered care attracts nurses and improves clinical outcomes for clients. Likewise, nurses who are enthusiastic, competent, dependable, adaptable, and responsible are key variables in creating a satisfying, quality work environment. In a study of what types of environmental support create satisfaction for professional nurses, Kramer and Schmalenberg (2002) uncovered the following factors chosen by the majority of the nurses surveyed:
• Working with other nurses who are clinically competent
• Good nurse-physician relationships and communication
• Nurse autonomy and accountability
• Supportive nurse manager-supervisor
• Control over nursing practice and practice environment
• Support for education (in-service, continuing education, etc.)
• Adequate nurse staffing
• Paramount concern for the patient
In an effort to develop and support work environments favorable to nurses, the American Nurses Association, through its American Nurses Credentialing Center (ANCC), developed the Magnet Recognition Program in 1993. Over the years, magnet recognition has become "the global standard for excellence in nursing practice" (Morgan, 2009, p. 105).
#### Magnet recognition
The **magnet recognition program** recognizes nursing excellence in health care institutions and agencies, and identifies them as work environments that act as a "magnet" for professional nurses desiring to work there because of the institutions' excellence (American Nurses Credentialing Center [ANCC] 2004). In 2008, the magnet model was redesigned to include five interactive elements known to support excellence in nursing practice work environments (see Figure 7-2). Characteristics of a magnet culture include:
Figure 7-2 Magnet model components. (Developed from Morgan S: The magnet (TM) model as a framework for excellence, _Journal of Nursing Care Quality_ 24(2):105–108, 2009 (p. 106).
• Active support of education
• Clinically competent nurses
• Positive interdisciplinary professional relationships
• Control over and autonomy in nursing practice
• Client-centered care for clients and families
• Adequate staffing and nurse-manager support (ANCC, 2006).
A magnet health care facility is characterized as one in which nurses have a high level of job satisfaction and lower staff nurse turnover, exemplary professional practice, and demonstrate commitment at every nursing level to effective, efficient, quality care (American Nurses Credentialing Center). Nurses in a magnet work environment are valued and have a strong voice in decision making about care delivery. They are encouraged and rewarded for involvement in shaping research-based nursing practice. Staffing ratios are viewed as appropriate, and the hospital demonstrates excellent treatment outcomes and client satisfaction. Communication among health professionals is open, and there is an appropriate mix of health care personnel to ensure quality care. Exercise 7-6 can help you think about how you would see yourself in the professional nursing role in the future.
EXERCISE 7-6 Envisioning the Future
Purpose: To help students think about the nursing role they would like to aspire to in the future. Envisioning the future helps nurses to develop focused career goals.
Procedure:
1. Envision your career 5 years after graduation.
2. Write a detailed narrative of what you would be doing and what your career would be like as you might describe it to a classmate at your 5-year reunion.
3. Have one student take the role of the storyteller and the other the role of the classmate at the reunion. The person taking the role of the classmate should ask questions to clarify any aspects of the speaker's career vision that are not clear.
4. Reverse positions and repeat.
Discussion:
1. How difficult was it for you to think about what you want to do in the future?
2. What steps will you have to take to achieve your goal?
3. How will you go about finding out more about the career path you see yourself taking?
### Becoming key players in a global health care arena
Malloch and Porter-O'Grady (2005) suggest that we are living in an information-based societal infrastructure that is primarily relational and that functions horizontally in a global world without boundaries. Professional nursing requires an expanded set of skill competencies in the 21st century, as presented in Table 7-4.
TABLE 7-4
Old versus New Skill Sets for Professional Nurses in the 21st Century
Employee | Knowledge Worker
---|---
Functional analysis | Conceptual synthesis
Manual dexterity | Competent integrated care
Fixed skill set | Mobile skill set
Process, value-based practice | Outcome-based practice
Individual practice | Interdisciplinary team performance
Modified from Mallach K, Porter-O'Grady T: A new vessel for leadership: new rules for a new age. In _The quantum leader: applications for the new world of work,_ Sudbury, MA, 2005, Jones and Bartlett.
Making the role of the professional nurse visible in the 21st century is a task that nurses must undertake to strengthen the public's recognition of the nursing profession in an interdisciplinary health care delivery system. Although nurses are the largest professional group in the health care workforce (Hassmiller & Cozine, 2006), their role is not as visible as it should be. Neither physicians nor nurses seem to fully appreciate the depth of the nurse's contribution to health care delivery (Coombs, 2004). In some ways, the work of the nurse is invisible until a crisis such as the nursing shortage brings the work of nurses to the forefront of people's attention. Individual nurses and nursing organizations need to work together to strengthen the professional nursing role.
In addition to defining our professional roles in ways that are understandable, nurses need to project a positive activist image of the professional nursing role within their communities by
• Developing partnerships with clients, health care professionals, policy makers, and community agencies in the care of vulnerable populations
• Reflecting on and documenting what nurses do and the broad scope of services they provide for the public
• Participating as members of interdisciplinary teams and multidisciplinary groups with defined expertise as nurses to address significant health care issues from a nursing perspective
• Maintaining competence and acting in a professional manner
• Advocating for systems of care that provide adequate accessible health care for all people
• Developing and participating in continuing education programs to ensure continued competence as a professional nurse
• Promoting the public and professional understanding of the professional nursing role
• Contributing to ethical discussions that support principled practices in clinical settings
#### Professional role behaviors in nurse-client relationships
A nurse's first professional role responsibility is to the client. Acting in a professional manner at all times is essential to maintaining the integrity of nursing as a profession. Expected professional role behaviors in nurse-client relationships emphasize the following qualities:
• An ability to view clients as individual, holistic beings
• Respect for the basic human dignity of all clients, regardless of differences from oneself
• An attitude of cultural openness and tolerance for divergent ways of thinking
• Sensitivity to individual clients' ability to access health care and adhere to prescribed regimens
• An understanding of the impact that illness and/or disability may have on clients
• Adherence to nursing standards of care
• Use of research evidence to improve nursing practice (Masters, 2005, pp. 156–157)
Role relationships with a client can affect the quality of nursing care in the nurse-client relationship when the worth of the client as a person, for example, is judged on the basis of socioeconomic status, level of education, ethnicity, health state, or level of consciousness. Perceptions of role relationships can affect effective treatment decision making. For example, roles become important when questioning a health care provider's professional judgment is not considered an appropriate behavior in the client's culture, or when the family, rather than the client, is culturally expected to make important health care decisions.
Professional performance behaviors in the nurse-client relationship include much more than simple caring; they require a sound knowledge base, as well as specific technical and interpersonal competencies. On a daily basis, nurses must collect and process multiple, often indistinct pieces of behavioral data. Nurses work creatively with clients and families to come up with workable solutions that are realistic and in tune with the client's beliefs, values, and preferences. Through words and behaviors in relationship with other health care providers and agencies, nurses consistently serve as advocates for their clients and family members.
Today's nurse functions in a high-tech, managed health care environment in which the human caring aspects of nursing are easier to overlook. Unique challenges to the nurse-client relationship include shorter client contacts, decreased continuity, technology, and lower levels of trust in relation to these factors. Yet, the nurse-client relationship will become increasingly important in helping clients feel cared for in a health care environment that sometimes neglects the psychosocial needs of clients in favor of cost-effectiveness and efficient use of time.
Case Example
Marilyn describes her experience with her husband's nurse:
"It was truly amazing. Whenever she came into the room, she always washed her hands, while asking me how the day had gone, and how I was doing. She made direct eye contact, and seemed genuinely interested in hearing from me directly about the day's events, rather than simply reading the chart. It was such a simple thing, but it made all the difference." (O'Connell, 2009)
In today's health care environment, clients are expected to take an active role in self-management of their condition to whatever extent is possible. The expectation is for an equal partnership, with clients having shared power and authority as joint decision makers in their health care. With a client-centered model of health care delivery, the client's thoughts, concerns, and questions are welcomed and encouraged. Every decision related to the client's diagnosis and treatment should be a shared determination made with the medical team based on combined input and joint responsibility for implementing the recommendations. This use of the client's self-knowledge and inner resources allows nurses to more effectively respond to client needs.
Client Rights and Responsibilities: The American Hospital Association (AHA, 2003) has developed a brochure outlining the rights and responsibilities of patient care partnership in lieu of its former Patient's Bill of Rights. It is accessible in multiple languages on the AHA Web site. Hospitals today have copies of comprehensive patient rights posted on their Web site. Written copies are given to clients on admission. A sample listing of common patient rights and responsibilities is provided in Box 7-4.
BOX 7-4 Patient Rights and Responsibilities
All clients have the following rights:
• Impartial access to the most appropriate treatment regardless of race, age, sexual preference, national origin, religion, handicap, or source of payment for care
• To be treated with respect, dignity, and personal privacy in a safe, secure environment
• Confidential treatment of all communication and other records related to care or payment, except as required by law or signed insurance contractual arrangements (all clients should receive Notice of Privacy Practices)
• Active participation in all aspects of decision making regarding personal health care
• To know the identity and professional status of each health care provider
• To have treatments and procedures explained to them in ways they can understand
• To receive competent interpreter services, if required to understand care or treatment
• To refuse treatment, including life-saving treatment, after being told of the potential risks associated with such refusal
• To receive appropriate pain management
• To express grievances regarding any violation of patient rights internally and/or to the appropriate agency
All clients have the following responsibilities:
• To treat their care providers with respect and courtesy, including timely notification for appointment cancellations
• To provide accurate, complete information about all personal health matters
• To follow recommended treatment plans
• To assume responsibility for personal actions, if choosing to refuse treatment
• To follow hospital regulations regarding safety and conduct
Sources: The patient care partnership: rights and responsibilities. Available at: <http://www.aha.org/aha/issues/Communicating-With-Patients/pt-care-partnership.html>. and President's Advisory Commission on Consumer Protection and quality in the health care industry (1997). Available at: <http://www.hcqualitycommission.gov/final/append_a.html>.
#### Advocacy roles in the nurse-client relationship
_Merriam-Webster's Dictionary_ (2009) defines advocate as "one that pleads the cause of another; one that supports or promotes the interests of another." Nurses are advocates for clients every time they protect, defend, and support a client's rights, and/or intervene on behalf of clients who cannot do so for themselves. The ANA (2001) affirms advocacy as an essential role in its Code of Ethics for Nurses, stating, "The nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient."
Clients who benefit from advocacy fall into two categories: those who need advocacy because of vulnerability caused by their illness, and those who have trouble successfully navigating the health care system. Nursing actions that constitute client advocacy include facilitating access to essential health care services for clients, ensuring quality care, protecting client rights, and acting as a liaison between clients and the health care system to procure quality care.
A key means of employing client advocacy is the nurse-client relationship (Negarandeh, Oskouie, Fhmadi, Nikravesh, & Hallberg, 2006). Within the relationship, nurses listen carefully to clients, help them foresee potential difficulties, answer questions honestly, and apply the clinical knowledge and skills identified in Box 7-5 for the benefit of the client.
BOX 7-5 Knowledge Base Needed for Client Advocacy
• Knowledge of the client's values, beliefs, and preferences, and alignment with treatment goals
• Knowledge of informed consent procedures, current third-party payment policies, institutional policies
• Awareness of one's own personal, professional, and cultural biases, and the ways they might impact client advocacy
• Awareness of potential power or recognition needs that could compromise the integrity of the client advocacy process
• Knowledge of print materials and online resources relevant to the client's needs
• Knowledge of organizational system variables related to service delivery
• Knowledge of current laws, policies, and regulations that affect service delivery
• Knowledge of community resources including referral processes, eligibility and access requirements
• Effective communication strategies for consultation and collaboration needed for advocacy of the client's issues
• Knowledge of required documentation, management, and interpretation of client records needed for effective advocacy
The goal of advocacy support is to empower clients and to help them attain the services they need for self-management of health issues. Examples of individuals needing advocacy include survivors of domestic violence, chronically mentally ill clients, pregnant teenagers, the homeless, frail elders—in fact, virtually anyone unable to act cogently on their own behalf. As health care services in the public sector become scarcer because of economic considerations, advocacy becomes an even greater emphasis. Several authors (Welchman and Griener, 2005; Mahlin, 2010) argue that nursing's professional organizations need to take up the gauntlet to collectively advocate for resolution of systemic client care issues in health care settings. For more information on nurse involvement in advocacy at the community level, see Chapter 24.
An important component of the nurse's role is advocacy for clients.
Advocacy should support client autonomy. Zomorodi and Foley (2009) note the importance of differentiating advocacy strategies from paternalism in which the nurse decides what is best for the client. Clients need to be in control of their own destiny, even when the decision reached is not what you as the nurse would recommend for the client's health and well-being. You need to recognize when to speak for the client and when to encourage the client to speak up. In general, encouraging clients to take responsibility to speak on their own behalf is more effective.
To be effective, the nurse's advocacy efforts should be systematically implemented and related to client identified needs, beliefs and values, and preferences. Questions you might ask include: (a) What does the client believe is the most pressing problem? (b) What supports (e.g., family, minister, rabbi, social services) are in place? (c) What health or social services is the client familiar with or resistant to considering? A client's sense of powerlessness can decrease when the answers to these questions become the starting points for developing realistic solutions to difficult problems. When advocacy efforts include referrals to community resources, factors to be considered include compatibility with the client's expressed need, financial resources, accessibility (time as well as place), and ease of contact.
Client advocacy sometimes provides a connective link between ethics and the law. Nurses must be willing and able to take a stand in situations involving poor medical management of a client. This is not easy, when risk to employment or possibility of censure is associated with this form of client advocacy. On the other hand, being too cautious or having misplaced loyalties to colleagues that interfere with appropriate protective advocacy can become a legal as well as an ethical issue. Sometimes, the only person willing to defend or promote the cause of the client is the nurse.
In the following case example, a client admitted to postanesthesia care unit (PACU) suddenly had a significant change in his vital signs. The nurse called the operating room (OR), but the surgeon was scrubbing for the next operation and said he would call her later.
Case Example
The PACU nurse said to tell the surgeon that he needed to break scrub and come to PACU immediately to check his patient. So he quickly came. When he checked the patient, he asked for OR to bring a tray so that he could open the incision to take a quick look and let it drain. "No," the PACU nurse responded. "You need to take her back to the OR, where anesthesia can keep watch on her airway." As the patient returned to the PACU, the surgeon approached the PACU nurse and thanked her for her assertiveness on behalf of the patient (Odom, 2002, p. 76).
Exercise 7-7 provides a clinical situation in which the nurse's advocacy role is in conflict with traditional nursing and medical advice. Sometimes the nurse serves as dual advocate for the client and a family member. For example, in a child abuse situation, nurses act as an advocate of the child by taking the steps necessary to provide a protective and safe environment for the child, including reporting abuse situations. The same nurse can be an advocate for the parents by referring them to appropriate community resources and helping them develop more productive methods for coping with situational stressors.
EXERCISE 7-7 Client Advocate Role-play
Purpose: To understand the nurse advocacy role in difficult and conflict-filled clinical situations.
Procedure:
1. Read the following clinical situation and answer the questions in writing.
2. Have one student play the role of the client and another play the role of the nurse.
3. After the role-play, examine your written answers. See whether there are any changes you would like to make.
4. Finally, make up a situation and give it to your colleague with the same questions. Role-play the situation with your colleague, this time taking the role of the client.
Situation:
A 65-year-old man has been a client on the medical unit for 10 days, and you are assigned to care for him for the next 4 days. Diagnostic workup and tests reveal that he has cancer of the larynx. Surgery is indicated and has been scheduled. The doctor discusses his diagnosis and prognosis with him in your presence.
During the next 2 days, the client becomes increasingly withdrawn and introspective. Subsequently, he requests to speak with you and the physician. He states that he does not wish to have any surgery performed and no medication given, that he "has lived a good life" and would like you and the health team to accept his decision to die. He asks that no tube feedings or intravenous fluids be given. He asks that you cooperate and support his wishes.
Discussion:
1. What would your reaction be in this situation?
2. What does the statement "death with dignity" mean to you?
3. Do you think the client has the right to refuse treatment that may be life-sustaining?
4. What nursing care should you provide for this man as he continues to refuse food and fluids (keeping in mind that the client is an equal partner in his care)?
5. What conflicts does this situation pose for you? How would you see yourself dealing with them?
6. How can you, as a nurse, respect the integrity of a client's decision when it conflicts with promoting maximum client health functions?
7. Does the client's age influence your acceptance of his decision?
8. How will you support the client when faced with other health care professionals who disapprove of the client's decision?
9. What risks will you be taking in supporting the client?
Adapted from Uusral D: Values clarification in nursing: application to practice, _American Journal of Nursing_ 78:2058–2063, 1978.
#### Role performance as a nursing diagnosis
Role performance disturbance has been designated by NANDA (2009) as a nursing diagnosis. _Healthy People 2010_ identifies quality of life as a priority goal. Quality of life and role performance are interconnected. How effectively a person is able to function within expected roles influences his or her reputation within society and affects his or her sense of self-esteem. That role relationships and performance matter to people as essential elements of their well-being is evidenced in the emergence of symptoms of depression, feelings of emptiness, and even suicidal thoughts when a significant personal or professional role ceases to exist. Examples of lost role relationships include job loss, divorce, retirement, death of a significant person, and a chronic or debilitating illness.
For clients, significant changes in their behavioral ability to function in expected roles as a result of illness, disability, or other life changes can be devastating. Alterations in normal roles, compromised role performance, and changes in role relationships are common sources of frustration and emotional pain to clients and families. The effects of alteration in role performance and role relationships within the family and work environment are such an important dimension of self-concept that they warrant a nursing diagnosis: ineffective role performance.
Nurses need to be sensitive to the changes in role relationships that even a minor illness or injury produces. An altered health status can change an individual's social role from one of independent self-sufficiency to one of vulnerability and dependence on others. For example, when lack of physical stamina after a heart attack prevents a woman from fulfilling her customary caregiving roles in the home, she can experience a loss of self-confidence and personal value that can affect her rehabilitation (Arnold, 1997).
Most people do not assume the sick role voluntarily. At the hospital door, the client forsakes, either temporarily or permanently, recognized social roles in the family, work situation, and community. Regardless of how competent the person may be in other life roles, questions about role performance inevitably arise when illness strikes. Often, clients must learn new role behaviors that are unfamiliar and unsettling to previously held self-concepts. Illness or disability, whether actual or perceived, also strain family equilibrium and coping abilities. Sometimes alterations in role performance are intimately associated with the illness and will never be regained.
Case Example
Dan was diagnosed with dementia in his mid-50s. He was a man of many talents who headed a large accounting firm before his illness. His wife had never worked outside of the home. Dan handled all of the finances, and his wife generally deferred to him for decisions. His son is in his first year of college on a 4-year scholarship, and there is one younger child in the home. The progression of the disease has been swift and incapacitating. Dan had not yet invested in long-term care insurance. He is too young for Social Security and is functional enough to not qualify for disability retirement. His illness creates significant changes for his wife, who now must take over running the household finances. His son is not sure whether he should come home or continue his studies. The younger child is robbed of a normal childhood role because of his father's illness. Dan himself feels depressed and unsure of what roles he can still fulfill. If you were Dan's nurse, what suggestions might you have for Dan and his family related to role relationships?
Clients and their families need the compassionate support of the nurse to incorporate the meaning of role changes occasioned by their illness or disability into an otherwise basically healthy self-concept. Asking open-ended, focused questions about the client's family relationships, work, and social roles helps the nurse to accurately assess potential alterations in role relationships in personal, social, and work relationships (Box 7-6). The questions should be asked in a conversational manner at a pace the client can tolerate.
BOX 7-6 Sample Assessment Questions Related to Role Relationships
Family
• "What changes do you anticipate as a result of your illness (condition) in the way you function in your family?"
• "Who do you see in your family as being most affected by your illness (condition)?"
• "Who do you see in your family as being supportive of you?"
Work
• "What are some of the concerns you have about your job at this time?"
• "Who do you see in your work situation as being supportive of you?"
Social
• "How has your illness affected the way people who are important to you treat you?"
• "To whom do you turn for support?"
• "If ________________ is not available to you, who else might provide social support for you?"
With shortened hospital stays, potential role changes should be addressed as part of discharge planning or follow-up in the community, or both. Nurses working in long-term rehabilitation settings can help their clients look at transferable skills and personal strength they may possess that could be used in a different way, for example, good communication skills, persistence, patience, and so on. Many times clients are not aware of transferable skills that can be put to good use when previous capabilities are no longer available to them. Exercise 7-8 can help you understand the nature of transferable skills.
EXERCISE 7-8 Transferable Skills
Purpose: To help students understand the nature of transferrable skills that can be used in other situations.
Procedure:
1. Think of the one achievement of which you are most proud.
2. List the strengths or personal actions that went into this accomplishment. For example, "I was a good swim instructor" can be recast into personal strengths, such as "I was a good swim instructor because I was dependable, organized, patient, and persistent; I am able to relate easily to children; and I was compassionate with slow learners and able to inspire others."
3. Identify the physical, psychological, and psychosocial characteristics that contributed to the accomplishment (e.g., athletic ability, being raised in a large family, ethnic origin).
4. Share your achievement with your classmates.
Discussion:
1. How many different aspects of yourself were you able to identify as being a part of your accomplishment?
2. What physical, psychological, and psychosocial characteristics contributed to your achievement?
3. As you listened to the other students' reports, did you think of any other factors present in your situation?
4. Do you see any of these talents or strengths as "transferable skills" you might use in other situations?
5. What did you learn about yourself from this exercise?
6. How might you apply what you learned in this exercise to working therapeutically with clients?
Health is a value-laden concept for many people. Preconceived notions of role disruption for an ill or disabled person occur more commonly when the illness is protracted, recurrent, or seriously role disruptive. Even when the person is fully capable of resuming previous role responsibilities after a documented extended illness, it is not uncommon for them to find that they are being "laid off" when they return to work.
Nurses need to help clients learn how to respond to subtle and not-so-subtle discriminatory actions associated with people's lack of understanding of the client's health situation.
### Summary
How nurses perceive their professional role and how they function as a nurse in that role has a sizable effect on the success of interpersonal communication in the nurse-client relationship. The professional nursing role should be evidenced in every aspect of nursing care, but nowhere more fully than in the nurse-client relationship. A professional nurse's first role responsibility is to the client. Because hospitals no longer are the primary settings for nursing practice, nurse practice roles take place in nontraditional and traditional community based health care settings. Advanced practice roles include the nurse practitioner, clinical nurse specialist, certified nurse-midwife, and nurse anesthetist. Two new roles, the CNL and the DNP, were introduced in 2003. A new concept in nursing education is interdisciplinary course
Nurses learn professional role behaviors through the process of professional role socialization. Professional development as a nurse is a lifelong commitment. Benner's five developmental stages of increasing proficiency describe the nurse's progression from novice to expert. Mentorship and continuing education assist nurses in maintaining their competency and professional role development. Interdisciplinary collaboration and health care teams have stimulated the development of shared elective classes involving two or more disciplines, for example, nursing and medicine or pharmacy.
Role performance disturbance has been designated by NANDA (2009) as a nursing diagnosis. Quality of life and role performance are interconnected. Examples of lost role relationships include job loss, divorce, retirement, death of a significant person, and a chronic or debilitating illness. Clients and their families need the compassionate support of the nurse to incorporate the meaning of role changes occasioned by their illness or disability into an otherwise basically healthy self-concept. Nurses can help clients and families identify and use transferable skills learned in previous roles in different ways.
Ethical Dilemma
What Would You Do?
Bishop and Scudder (1996) said that nurses have a professional obligation not only to provide efficient, effective, and attentive care, but to do so in the context of a caring relationship. What do you think they meant by this statement? What does this statement have to do with the nurse's role? Why is this an ethical issue?
## References
American Association of Colleges of Nursing. Values, qualities, and behaviors associated with professionalism in nursing practice. Washington, DC: Author, 1986.
American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author, 2008.
American Association of Colleges of Nursing Working paper on the role of the clinical nurse leader, 2003. Available online:, <http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader.htm>. [Accessed August 28, 2009].
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CHAPTER 8
# Losses and Endings
## Communication Skills at End of Life
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Describe the concept of loss.
2 Describe the stages of death and dying.
3 Discuss the concept of palliative care.
4 Discuss theory-based concepts of grief and grieving
5 Define grief and describe common patterns of grieving.
6 Describe the nurse's role in palliative care.
7 Discuss key issues and approaches in end-of-life (EOL) care.
8 Identify cultural and spiritual needs in EOL care.
9 Describe supportive strategies for children.
10 Discuss strategies to help clients achieve a good death.
11 Identify stress issues for nurses in EOL care.
This chapter examines the nurse-client relationship in the context of palliative and EOL care. The chapter identifies theory frameworks related to the stages of dying and the process of grief and grieving. The Application section discusses the process of identifying and responding to client and family needs in EOL care. This chapter spotlights the communication issues in the care nurses provide to dying clients and as they meet the needs of grieving families. Helping clinicians recognize and cope with the high stress of providing quality EOL care is also addressed.
## Basic concepts
The concept of loss
Corless (2001) defines **loss** as "a generic term that signifies absence of an object, position, ability or attribute" (p. 352). Important losses occur as part of everyone's personal experience. Anything or anyone in whom we invest time, energy, or a part of ourselves can be experienced as a loss. When people _suffer the loss of_ someone or something important to them, there is a loss of their sense of "wholeness" and a break in the person's expected life story (Attig, 2004). The loss remains in that person's mind, even with the passage of time (Levine, 2005). When a fresh loss occurs, previous losses are remembered. Consider the theme of loss in each of the following normal life experiences:
• A wife loses a 35-year-old marriage through divorce
• A cherished family pet dies
• A couple loses their dream home through foreclosure
• A woman suffers a miscarriage
• A parent dies
The feelings associated with loss differ only in the intensity with which one experiences them. Mark Twain noted: "Nothing that grieves us can be called little; by the eternal laws of proportion a child's loss of a doll and a king's loss of a crown are events of the same size" (Mark Twain Quotations, 2002). Some losses are unfinished; others occur simultaneously or sequentially.
Multiple losses occurring over a short period intensify the experience. Older adults will experience the deaths of friends and family members with greater frequency. One loss can precipitate multiple losses. For example, the client with Alzheimer's disease doesn't simply lose memory. Accompanying cognitive loss are profound losses of role, communication, independence, and loss of identity. Lifestyle changes are required to accommodate for the cognitive loss.
Multiple losses complicate the grieving process and usually take longer to resolve. Helping people focus on one relationship at a time instead of trying to address the losses together is helpful. Acknowledgment of the differences between single and multiple loss helps put the enormity of multiple losses into perspective (Mercer & Evans, 2006). Exercise 8-1 is designed to help you understand the dimensions of personal loss.
EXERCISE 8-1 The Meaning of Loss
Purpose:
To consider personal meaning of losses.
Procedure:
Consider your answers to the following questions:
• What losses have I experienced in my life?
• How did I feel when I lost something or someone important to me?
• How was my behavior affected by my loss?
• What helped me the most in resolving my feelings of loss?
• How has my experience with loss prepared me to deal with further losses?
• How has my experience with loss prepared me to help others deal with loss?
Discussion:
1. In the larger group, discuss what gives a loss its meaning.
2. What common themes emerged from the group discussion about successful strategies in coping with loss?
3. How does the impact of necessary losses differ from that of unexpected, unnecessary losses?
4. How can you use in your clinical work what you have learned from doing this exercise?
## Death: the final loss
Death is associated with loss; it signals the end of all that life holds on this earth: successes, failures, relationships, careers, laughter, and pain. More than a biological event, dying has spiritual, social, and cultural features that help people make sense of its meaning. Dobratz (2002) describes a human life pattern in dying patients that is "shaped by self-integration, inner cognition, creation of personal meanings, and connection to others and a higher being" (p. 139).
Silveira and Schneider (2004) suggest that "planning for the end of life is planning for the unknown" (p. 349). Although death is a necessary part of the circle of life, dying is often feared, even if people believe in an afterlife. As Chenitz (1992), a nurse dying of AIDS noted, "Like many people with AIDS, I am not afraid of death. I am afraid of dying. The dying process and how that will be handled is of great concern to me" (p. 454).
When asked, most clients identify fear of pain and of experiencing their last phase of life unaccompanied as their two principal fears (Pashby, 2010). Clients and families need to know that help is always available from someone knowledgeable, who cares about them, and is willing to anticipate and respond to their personal care needs as they appear.
Nurses are not immune from these fears. It is often difficult for nurses to maintain a balance between their own sensitivity to death and well-being, and providing the empathy and support needed by clients and families. This is why self-awareness about death and dying issues is so important in providing palliative care.
## Theoretical framework: stages of dying
Elisabeth Kübler-Ross (1969) provides a five-stage framework for understanding the process of dying. Not every person experiences each stage.
### Denial
Kübler-Ross (1969) characterizes denial stage as the "No, not me" stage. Nurses should be sensitive to the client's need for denial. Some people remain in the denial stage throughout their illness; their right to do so should be respected.
### Anger
Kübler-Ross (1969) refers to anger as the "Why me?" stage, associated with feelings about the unfairness of life, or anger with God. Feelings get projected on those closest to the client. The client lashes out at family, friends, and staff members. Those closest to the client may need support in recognizing that the anger is not a personal attack.
### Bargaining
Kübler-Ross (1969) refers to the bargaining stage as the "Yes, me, but... I need just a little more time." The bargaining stage involves pleading for time extension or special consideration. Bargaining is not a futile exercise. Sometimes the extra energy a person gets by trying to postpone death can provide a meaningful moment for client and family; consider the father, wanting to stay alive for his daughter's wedding. By supporting hope and avoiding challenges to the client's reality, the nurse facilitates the process of living while dying.
### Depression
Kübler-Ross (1969) characterizes the depression stage as the "Yes, me" stage, accompanied by depressive feelings. Mood swings and depressive feelings are hard for families to tolerate, but very common. Nursing strategies in this stage include helping clients to accept depression as being a normal response, and being present to clients and families as an empathetic, listening witness to their experience.
### Acceptance
Pashby (2010) notes that the theoretical stages seem to mirror the physiologic decline experienced at the EOL. Clients who are weak and bedridden with declining consciousness as death approaches come more readily to the final stage of acceptance. The acceptance stage is characterized by an acknowledgment of the inevitable EOL. As the client approaches death, there is a gradual detachment from the world, and the person is almost "void of feeling" (Kübler-Ross, 1969, p. 124). Because of this, there can be a sense of peace.
## Palliative care
**Palliative care** is defined as "a clinical approach designed to improve the quality of life for clients and families coping with a life threatening illness" (Davies & Higginson, 2004, p. 14). It is recognized as a philosophy of care and as an emerging practice discipline. The dimensions of palliative care identified by the World Health Organization (WHO) are presented in Box 8-1.
BOX 8-1 Dimensions of Palliative Care
• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten nor postpone death
• Integrates the psychological and spiritual aspects of patient care
• Offers a support system to help patients live as actively as possible until death
• Offers a support system to help the family cope during the patients illness and in their own bereavement
• Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated
• Will enhance quality of life, and may also positively influence the course of illness
• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
From World Health Organization: _WHO Definition of Palliative Care,_ 2008; available online: <http://www.who.int/cancer/palliative/definition/en/>. Accessed February 28, 2009.
Clients are admitted to palliative care services when the client has a life-limiting disease with care needs that will go beyond traditional modes of medical intervention (Galanos, 2004; Morrison & Meier, 2004). Palliative care is unique in that it includes involved family members and the client with the life-limiting disease as one integrated unit of care. Clients initially admitted to palliative care services may still be receiving active treatment for their disease process to control symptoms and improve quality of life (McIlfatrick, 2007). Palliative care can augment treatment with attention directed to providing the secondary psychosocial, practical, and spiritual support services and assistance people need regarding EOL decisions and care. As the disease or disability progresses, palliative care still supports living while dying, but the focus becomes symptom management and movement toward achieving a good death, rather than active treatment. Table 8-1 identifies proposed quality measures for palliative care in the critically ill.
TABLE 8-1
Quality Measures for Palliative and End-of-Life Care by Domain
From Mularski R, Curtis J, Billings J et al: Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation care group, _Critical Care Medicine_ 34(11 suppl):S406, 2006.
Palliative care strategies are designed to help clients and families understand the dying process as a part of life and to assist terminally ill clients to achieve the best quality of life in the time left to them. The basic axiom for palliative EOL care is to follow what clients actually want for themselves (Silveira & Schneider, 2004). Palliative care is dedicated to supporting families as resources and as units of care themselves. After the client's death, palliative care offers grief support for family members.
Palliative care and hospice are related concepts. A fundamental difference between the two approaches is that the palliative care team can admit and serve patients still receiving curative treatment, with no time restrictions regarding prognosis. Hospice clients must have a prognosis of 6 months or less, and cannot be receiving active medical treatment. Hospice is considered part of the continuum of palliative care; it offers a quality care environment in the last segment of life.
### Nursing initiatives
Nurses have taken a leadership role in developing guidelines for quality EOL care through national initiatives. Nationally recognized nursing experts, funded by the American Association of Colleges of Nursing (AACN) and the City of Hope, have developed the End-of-Life Nursing Education Consortium (ELNEC), a national education initiative to improve EOL care in the United States. The ELNEC project targets undergraduate and graduate nursing faculty, continuing education providers, staff development educators, and pediatric and oncology specialty nurses in EOL care (AACN, 2006). Specific EOL training allows nurses to teach others and to enter into the lives of many more people facing EOL as skilled, compassionate professionals with specialized care tools (Malloy, Paice, Virani, Ferrell, & Bednash, 2008).
## Concepts of grief and grieving
The concept of **grief** describes the personal emotions and adaptive process a person goes through in recovering from loss. Common feelings include sadness and an acute awareness of the void accompanied by recurring, wavelike feelings of sadness and loss. Certain situations, time alone, holidays, and anniversaries allow grief feelings to resurface.
Case Example
"I would think I was doing okay, that I had a handle on my grief. Then without warning, a scent, a scene on television, an innocuous conversation would flip a switch in my mind, and I would be flooded with memories of my mother. My eyes would fill up with tears as my fragile composure dissolved. My grief lay right under the surface of my awareness and ambushed me at times and in places not of my choosing" (Anonymous).
### Theory-based frameworks of grieving
Lindemann's Work on Grief
Eric Lindemann (1944/1994) pioneered the concept of grief work based on interviews with bereaved persons suffering a sudden tragic loss. He described patterns of grief, and the physical and emotional changes that accompany significant losses. Lindemann observed that grief can occur immediately after a loss, or it can be delayed. He summarized three components of support: (a) open, empathetic communication; (b) honesty; and (c) tolerance of emotional expression as being important in grieving. When the symptoms of grief are exaggerated or absent, it is considered pathologic or complicated grief. People experiencing complicated grief may require psychological treatment to resolve their grief and move into life again.
#### Engel's Contributions
George Engel's (1964) concepts built on Lindemann's work. He described three sequential phases of grief work: (a) shock and disbelief, (b) developing awareness, and (c) restitution.
In the shock and disbelief phase, a newly bereaved person may feel alienated or detached from normal—"literally numb with shock; no tears, no feelings, just absolute numbness" (Lendrum & Syme, 1992, pp. 24–25). Seeing or hearing the lost person, or sensing his or her presence is a normal, temporary altered sensory experience related to the loss, which should not be confused with psychotic hallucinations.
In the immediate aftermath of death, families and friends surround a person with support and opportunities to talk. This support diminishes over time. The developing awareness phase occurs slowly as the void created by the loss fully enters consciousness. There is a loss of energy, not the kind that requires sleep, but rather a desire to accomplish things without having either the organizational capacity or energy to follow through with related tasks.
Case Example
"Throughout the year following my mother's death, I was aware of a persistent feeling of heaviness—not physical heaviness, but emotional and spiritual. It was as if a dark cloud hung over my heart and soul. I tired easily, with little energy to do anything but the most essential activities, and even those frequently received perfunctory attention. My usual pattern of 'sleeping like a log' was disrupted, and in its place I experienced uneasy rest that left me feeling as if I had never closed my eyes" (Anonymous).
Listening, identifying feelings, and having an empathetic willingness to repeatedly hear the client's story without needing to give advice or interpretation are helpful nursing interventions (Jeffries, 2005).
The _restitution phase_ is characterized by adaptation to a new life without the deceased. There is a resurgence of hope and a renewed energy to fashion a new life. With successful grieving, the loss is not forgotten, but the pain diminishes, and is replaced with memories that enrich and give energy to life. John Thomas (2010) describes his sense of new beginnings:
I want to be known as one who
• Has one foot planted firmly in this life and the other seeking a firm footing in the spiritual realm
• Is identified with life and love rather than loss and grief
• Walks with the stride of renewal rather than the shuffle of grief; a vigorous man with an appreciation for beauty and quality
• Is confident about the future without needing a tangible GPS
• Can still embrace life knowing that the pain of loss is intense
• Can be alone without being lonely
• Faced grief head-on and reached a deeper core of self and spirituality
• Has much to give in many arenas living a life that honors my past and sharing the blessing derived from it
### Contemporary models of grieving
Florczak (2008) states, "The newer worldview considers loss to be a unique, intersubjective process in which the individual maintains connections with the absent and the meaning of the experience continually changes" (p. 8). The past is not forgotten, and there is a continuous spiritual connection with the deceased, which illuminates different features of self and possibilities for fuller engagement with life. Features of past experiences with the loved one are rewoven into the fabric of a person's life in a new form. Contemporary authors Neimeyer (2001) and Attig (2001) emphasize meaning construction as a central issue in grief work.
## Patterns of grieving
Acute grief
**Acute grief** occurs as "somatic distress that occurs in waves with feelings of tightness in the throat, shortness of breath, an empty feeling in the abdomen, a sense of heaviness and lack of muscular power, and intense mental pain" (Lindemann, 1994, p. 155). Sudden traumatic deaths are more likely to stimulate acute grief reactions.
When the death is untimely (as with an accident or fatal heart attack), out of normal sequence (as in the case of a child's death), or complicated by stigma (as with death from addiction or suicide), the challenge for the family is greater. Survivors feel more guilt, anger, and helplessness.
Suicide survivors are at a disadvantage. Survivors typically overestimate their ability to influence the suicidal behavior or outcome. They are reluctant to discuss death details because of shame or perceived stigma. Survivors usually need more support. Often they get less because people don't know how to talk to them about suicides (Harvard Women's Health Watch, 2009). Suicide survivor support groups can offer the specialized help that many survivors need after a suicide (Felgelman, 2008).
#### Anticipatory Grief
**Anticipatory grief** is an emotional response that occurs before the actual death around a family member with a degenerative or terminal disorder. It also is experienced by a person anticipating his or her own death. Symptoms can be similar to those experienced after death and can be colored by ambivalent feelings.
Case Example
Marge's husband, Albert, was diagnosed with Alzheimer's disease 5 years ago. Albert is in a nursing home, unable to care for himself. Marge grieves the impending loss of Albert as her mate. At the same time, she would like a life of her own. Her "other feelings" of wishing it could all be over cause her to feel guilty. Exercise 8-2 helps you explore personal thoughts about grief.
EXERCISE 8-2 A Personal Grief Inventory
Purpose:
To provide a close examination of one's history with grief.
Procedure:
Complete each sentence and reflect on your answers:
The first significant experience with grief that I can remember in my life was ___________.
The circumstances were ___________.
My age was ___________.
The feelings I had at the time were___________.
The thing I remember most about that experience was ___________.
I coped with the loss by ___________.
The primary sources of support during this period were ____________.
What helped most was _________________________.
The most difficult death for me to face would be ___________.
I know my grief over a loss is resolved when ___________.
Adapted from Carson VB, Arnold EN: _Mental health nursing: the nurse-patient journey_ (p. 666), Philadelphia, 1996, WB Saunders.
#### Chronic Sorrow
**Chronic sorrow** is an ill-defined form of grief, occurring while a person is still alive, in relation to a limiting disease, or as an ongoing loss of potential in a loved one (Bowes, Lowes, Warner, & Gregory, 2009). It has been identified in parents of disabled or mentally ill children, spouses of dementia victims, and adults with a permanent disability or severe chronic illness.
Chronic sorrow is an intermittent grief process. In between, there are periods of emotional neutrality and positive emotions. It presents as a recurring sadness, particularly during exacerbations of symptoms, or comparisons with healthy people. Key distinctions between chronic sorrow and other forms of grieving include an inability to achieve closure and its discontinuous nature. Clients and family members may not be aware that they are grieving because they don't recognize having an ongoing incomplete loss as a legitimate loss to be grieved (Lafond, 2002). Providing timely support for families when there is a resurgence of symptoms can reduce stress.
#### Complicated Grieving
**Complicated grieving** represents a form of grief, distinguished by being unusually intense, significantly longer in duration, or incapacitating. A history of depression, substance abuse, death of a parent or sibling during childhood, prolonged conflict or dependence on the deceased person, or a succession of deaths within a short period predispose a person to complicated grief. Statements such as "I never recovered from my son's death," or "I feel like my life ended when my husband died" may indicate the presence of complicated grief.
Symptoms can appear as an absence of grief in situations where it would be expected, for example, a marine who displays no emotion over the deaths of war comrades. When deaths and important losses are not mourned, the feelings don't just disappear; they reappear in unexpected ways sometimes years later. Subsequent losses trigger an extreme reaction to a current loss. Complicated grief can result in clinical symptoms such as depression or anxiety disorders that require professional help. Exercise 8-3 provides a personal opportunity to reflect on the grieving process.
EXERCISE 8-3 Reflections on the Grieving Process
Purpose:
To provide students with an opportunity to see how putting into words the meaning a person had for you could facilitate the grieving process.
Procedure:
1. Write a letter to someone who has died or is no longer in your life. Before writing the letter, reflect on the meaning this person had for you and the person you have become.
2. In the letter, tell the person what they meant to you and why it is that you miss them.
3. Tell the person what you remember most about your relationship.
4. Tell the person anything you wished you had said but didn't when the person was in your life.
With a partner, each student should share his or her story without interruption. When the student finishes his or her story, the listener can ask questions for further understanding.
Discussion:
1. What was it like to write a letter to someone who had meaning in your life and is no longer available to you?
2. Were there any common themes?
3. In what ways was each story unique?
4. How could you use this exercise in your care of clients who are grieving?
Developing an Evidence-Based Practice
Beckstrand R, Callister L, Kirchhoff K: Providing a "good death": critical care nurses' suggestions for improving end-of-life care, _American Journal of Critical Care_ 15(1):38–45, 2006.
This survey study was part of a larger national study designed to elicit critical care nurses' views (N = 861) of EOL care in intensive care units. The goal of this report, consistent with the Institute of Medicine's recommendation to strengthen the knowledge base on EOL care, was to elicit suggestions on ways to improve EOL care.
_Results:_ Study results indicated a common commitment of study subjects to helping clients achieve a good death, one marked with dignity and peace. Ways to achieve this goal were described as managing pain and discomfort, eliciting and following the clients' wishes for EOL care, facilitating family presence at time of death, and communicating effectively with other members of the health care team. Barriers were identified as time constraints, staffing patterns, and treatment decisions that did not reflect the clients' needs or wishes.
_Application to Your Clinical Practice:_ As people live longer and the trajectory between time of diagnosis and time of death lengthens, palliative care becomes increasingly important. How could you, as a nurse, effectively help clients to die with dignity in a hospital setting? In a home setting?
## Applications
Nursing roles in palliative care
#### Implementing palliative care concepts
Palliative care operates as a 24-hour resource, providing comprehensive, holistic services to clients and families in hospitals, people's homes, nursing homes, and outpatient settings. Ideally, palliative services are integrated at all levels of care, and are adapted to a client's specific cultural, social, and economic circumstances. Palliative care can be used concurrently with disease-modifying care, with the level of comfort care increasing according to client need (Savory & Marco, 2009).
The palliative care team is interdisciplinary, consisting of physicians, nurses, social workers, psychologists, and clergy specially trained in palliative care. In addition to supportive care for clients and families, team members provide education and consultation about EOL care for hospital staff. The treatment focus of palliative care is on pain control, physical symptom management, and easing the secondary psychosocial and spiritual distress experienced by clients with a terminal illness. If the client has had a special relationship with a physician, before admission to palliative care, the client or nurse can contact them. In some cases, the physician will stay involved; this can be a major source of comfort for clients and families.
Nurses play a pivotal role as professional coordinators, direct providers of care, and advocates for client autonomy and control in EOL care. They are in a key position to help families maintain family integrity, and to support their efforts in managing the process of living until death and in preparing for the death of their loved one. Quality indicators for EOL care are displayed in Figure 8-1.
Figure 8-1 Model of curative and palliative care for progressive illness.
Nurses must be aware of their own EOL experiences, including attitudes, expectations, and feelings about death and the process of dying. Miller (2001) notes, "As you become more clear about who you are and why you do what you do, you will become more receptive to whomever you are with" (p. 23). Exercise 8-4 is designed to promote self-awareness.
EXERCISE 8-4 Self Awareness about Death: A Questionnaire
Purpose:
To explore students' feelings about death.
Procedure:
Answer the following questions.
1. Who died in your first personal involvement with death?
a. Grandparent or great-grandparent
b. Parent
c. Brother or sister
d. Other family member
e. Friend or acquaintance
f. Stranger
g. Public figure
h. Animal
2. To the best of your memory, at what age were you first aware of death?
a. Younger than 3 years
b. 3–5 years
c. 5–10 years
d. 10 years or older
3. When you were a child, how was death talked about in your family?
a. Openly
b. With some sense of discomfort
c. Only when necessary, and then with an attempt to exclude the children
d. As though it were a taboo subject
e. Do not recall any discussion
4. Which of the following most influenced your present attitudes toward death?
a. Death of someone else
b. Specific reading
c. Religious upbringing
d. Introspection and meditation
e. Ritual (e.g., funerals)
f. Television, radio, or motion pictures
g. Longevity of my family
h. My health or physical condition
i. Other
5. How often do you think about your own death?
a. Very frequently (at least once a day)
b. Frequently
c. Occasionally
d. Rarely (no more than once a year)
e. Very rarely or never
6. What does death mean to you?
a. The end; the final process of life
b. The beginning of a life after death; a transition; a new beginning
c. A joining of the spirit with a universal cosmic consciousness
d. A kind of endless sleep; rest and peace
e. Termination of this life, but with survival of the spirit
f. Do not know
7. If you had a choice, what kind of death would you prefer?
a. Tragic, violent death
b. Sudden, but not violent death
c. Quiet, dignified death
d. Death in the line of duty
e. Death after a great achievement
f. Suicide
g. Homicide victim
h. There is no "appropriate" kind of death
8. If it were possible, would you want to know the exact date on which you are going to die?
a. Yes
b. No
9. If your physician knew that you had a terminal disease and a limited time to live, would you want him or her to tell you?
a. Yes
b. No
c. It would depend on the circumstances
10. What efforts do you believe ought to be made to keep a seriously ill person alive?
a. All possible efforts should be made (e.g., transplantation, kidney dialysis)
b. Efforts should be made that are reasonable for that person's age, physical condition, mental condition, and pain
c. After reasonable care, a natural death should be permitted
d. A person with dementia should not be kept alive by artificial methods
11. If or when you are married, would you prefer to outlive your spouse?
a. Yes, I would prefer to die second and outlive my spouse
b. No, I would rather die first and have my spouse outlive me
c. Undecided or do not know
12. What effect has this questionnaire had on you?
a. It has made me somewhat anxious or upset
b. It has made me think about my own death
c. It has reminded me how fragile and precious life is
d. Other effects
## Key issues and approaches in end-of-life care
Transparent decision making
Clients and families face difficult, irreversible decisions in the last phase of life. Decisions related to discontinuation of fluids, antibiotics, blood transfusions, and ventilator support require a clear understanding of a complex care situation. Thelan (2005) defines **end-of-life decision making** as "the process that healthcare providers, patients and patients' families go through when considering what treatments will or will not be used to treat a life threatening illness" (p. 29).
EOL decisions should be transparent, meaning that all parties involved in the decision should fully understand the implications of their decision. For example, to make an informed decision about use of life supports for terminal clients, clients and families need to know whether further treatments will enhance or diminish quality of life, their potential impact on life expectancy, whether the treatment is known to be effective or is an investigative treatment, and what types of adverse effects the client is likely to experience.
When the client is fully competent, he or she should make all treatment decisions. Ideally, EOL care choices should be made before a life-threatening illness occurs, or as early as possible after diagnosis (Kirchhoff, 2002). The nurse's role is to provide the client with full information, and to serve as his or her advocate in support of the person's right to make decisions about treatment and care (ANA, 1991; Erlen, 2005). Box 8-2 provides guidelines for talking with families about care options at EOL when an advance directive or durable power of attorney is not in effect.
BOX 8-2 Talking with Families about Care Options at End of Life
If neither durable power of attorney nor written directive is in effect:
• Determine who should be approached to make the decisions about care options.
• Determine whether any key members are absent. (Try to keep those who know the client best in the center of decision making.)
• Find a quiet place to meet where each family member can be seated comfortably.
• Sit down and establish rapport with each person present. Ask about the relationship each person has with the client and how each person feels about the client's current condition.
• Try to achieve a consensus about the patient's clinical situation, especially prognosis.
• Provide a professional observation about the client's status and expected quality of life—survival vs. quality of life. Ask what each person thinks the client would want.
• Should the family choose comfort measures only, assure the family of the attention to patient comfort and dignity that will occur.
• Seek verbal confirmation of understanding and agreement.
• Attention to the family's emotional responses is appropriate and appreciated.
Adapted from Lang F, Quill T: Making decisions with families at the end of life, _American Family Physician_ 70(4):720, 2004.
### Using advance directives
Miscommunication is a common underlying theme in creating confusion and delaying appropriate decisions about EOL care (Lang & Quill, 2004). Preferences are best expressed in advance directives (see Chapter 2), with discussions taking place in a compassionate, gentle manner, paced at the client/family's pace and level of understanding. Studies of family use of advance directives demonstrate significantly lower stress in families using them (Davis et al., 2005). In the hospital, advance directives should be kept in the front of the client's chart.
### Pain control and management
Pain control and management is an essential component of quality EOL care. Standards for pain management established by the Joint Commission (2010) require that every inpatient be routinely assessed for pain, with documentation of appropriate monitoring, and pain management. The American Pain Society (APS), Joint Commission, and Veteran's Administration have identified pain as the fifth vital sign with a nursing expectation of pain evaluation together with the standard vital signs (temperature, pulse, respiration, and blood pressure).
Pain is a subjective assessment, assessed verbally with the client and/or observed in client behavior. Routine assessments can identify previously unreported incidences of pain symptoms (Morrison & Meier, 2004).
Assessment questions include:
• Onset and duration of pain
• Location of the pain
• Character of the pain (sharp, dull, burning, persistent, changes with movement, direct or referred pain)
• Intensity—using a 0 to 10 numerical rating scale, with 0 being no pain and 10 being unbearable pain; assess children and clients having limited English with the Wong–Baker FACES Pain Rating Scale (Figure 8-2).
Figure 8-2 Wong–Baker FACES Pain Rating Scale.
• History of substance dependence (crossover tolerance)
Behavioral indicators include abrupt changes in activity, crying, inability to be consoled, listlessness or unwillingness to move, rubbing a body part, wincing, or facial grimacing (Atkinson, Chesters, & Heinz, 2009).
Having appropriate pain control for moderate-to-severe pain usually requires the use of opioids. Misperceptions about pain-relieving opioids are a major, unnecessary barrier to adequate pain control. Families will attribute signs and symptoms of approaching death such as increased lethargy, confusion, and declining appetite to side effects of opioids. With or without pain medication, actively dying clients become less responsive as death approaches. Although clients may experience drowsiness with initial dosing, this side effect quickly disappears.
Nurses should educate the family and client about the differences between disease progression and adverse effects related to opioids (Pashby, 2010). Essential information includes action, dosing intervals, side effects, and role pain control in client comfort and quality of life.
A second unfortunate barrier is fear of addiction (Clary & Lawson, 2009). All clients, including addicts, are entitled to appropriate and adequate pain management of severe pain. People do not become addicted from taking legally prescribed opioid medications for pain associated with terminal illness. There is a fundamental difference between taking essential medication for pain control on a prescribed scheduled basis and addictive uses. Addicted clients may require larger doses of pain medication because of cross-tolerance. Once the family understands the mechanisms and goals of pain control, and is assured that the client will not die or become addicted from its _appropriate_ use, most will support its use in EOL care.
Clients approaching death can experience "breakthrough" pain, which occurs episodically as severe pain spikes. When breakthrough pain occurs, rescue medications, which are faster acting, can be used. Touch and light massage are helpful adjuncts for pain relief.
### Communication in end-of-life care
Curtis (2004) suggests that communication skill is equal to or supersedes clinical skill in EOL care. Everyone experiences a death differently; it is the uniqueness of each person's experience that the nurse attempts to tap into and facilitate through conversation. Conversations with clients and families provide nurses with insights about personal values and preferences regarding EOL care, and provide a forum to answer difficult questions in a supportive environment.
The quality of the relationship between nurse, patient, and family members is a key factor in how the last phase of life is experienced and negotiated (Mok & Chiu, 2004; Olthuis et al., 2006). EOL interactions help people find meaning, achieve emotional closure, and provide the best means for helping clients and families make complex life decisions. Listening and responding to clients as they cope with difficult issues around dying is easier said than done (Larson & Tobin, 2000). The challenge for nurses is to remain in a relationship with clients and families even when one feels inadequate to the task.
Schim and Raspa (2007) believe that the process of dying is a narrative: "Life-altering happenings are expressed through stories" (p. 202). Personal reflections are critical sources of assessment data. Once rapport is established, Pashby (2010) suggests nurses can ask clients how they learned of their diagnosis. She notes that a terminal diagnosis is usually a "Technicolor Moment" that the person remembers vividly and appreciates talking about. Other questions such as "What has changed for you since the diagnosis?" or "What is it like for you now?" provide additional data. Giving voice to the experience helps clients to consider its personal meaning and provides the nurse with a more complete picture of each person's distinctive concerns and goals.
Although most dying clients know that they are dying, it is not unusual for a client to ask in the course of conversation, "Am I going to die?" Before answering, find out more about the origin of the question. A useful listening response is, "What is your sense of it?" Box 8-3 provides guidelines for communicating with terminally ill clients.
BOX 8-3 Guidelines for Communicating with Dying Clients
• Avoid automatic responses and trite reassurances.
• Each death is a unique, deeply personal experience for the client and should be treated as such.
• Avoid destroying hope. Reframe hope to what can happen in the here and now.
• Let the client lead the discussion about the future. Be comfortable with focusing on the here and now. (This discussion is not a one-time event; openings for discussion should be encouraged as the client's condition worsens.)
• Relate on a human level. Show humor, as well as sorrow.
• Use your mind, eyes, and ears to hear what is said, as well as what is not said.
• Respect the individual's pattern of communication and ways of dealing with stress. Support the client's desire for control of his or her life to whatever extent is possible.
• Maintain a sense of calm. Use eye contact, touch, and comfort measures to communicate.
• Do not force the client to talk. Respect the client's need for privacy and be sensitive to the client's readiness to talk, and let him or her know that you will be available to listen.
• Humility and honesty are essential. Be willing to admit when you do not know the answer.
• Be willing to allow the client to see some of your fears and vulnerabilities. It is much easier to open up to someone who is "human and vulnerable" than to someone who appears to have all the answers.
• Provide short, frequent times for family members to be with the dying client (without overtiring the client). Let them provide simple comfort measures if they desire to do so.
Morgan (2001) suggests using a basic social process between nurse and client in palliative care, which she labeled protective coping and adjustment. The process involves nursing interactions that protect, maintain, and safeguard the integrity of clients, whereas at the same time helping them to determine and act on actions that are in their own best interests.
#### Communicating with Families
Family members have different levels of readiness to engage in discussions about the dying process. It is "normal" for an impending death to have a different impact on each family member, because each has had a unique relationship with the dying person. Conversations with families need not be long in duration, but regularity is important. Box 8-4 identifies family communication needs at EOL.
BOX 8-4 Family Communication Needs at End of Life
• Honest and complete answers to questions; repetition and further explanation if needed
• Updates about the client's condition and changes as they occur
• Clear, understandable explanations, delivered with empathy and respect
• Frequent opportunities to express concerns and feelings in a supportive, unhurried environment
• Information about what to expect—physical, emotional, spiritual—as death approaches
• Discussion of whom to call, legal issues, memorial or funeral planning
• Appreciation of the conflicts that families experience when the illness dictates that few options exist; for example, a frequent dilemma at EOL is whether life support measures are extending life or prolonging the dying phase.
• Short private times to be present and/or minister to the client
• Permission to leave the dying client for short periods with the knowledge that the nurse will contact the family member if there is a change in status
Common concerns include discontinuing life support; conflicts among family members about care; tensions between the client, family, and/or physician and family about treatment; where death should occur (home, hospital, hospice); if/when hospice should be engaged; and other concerns. Active listening can produce a creative outcome.
Case Example
The baby kind of started to dwindle real early in the morning. Mom was there by herself and all of a sudden wanted everything done... she was changing her mind. Once you started to talk to them further, and talk to the grandma, what her real problem was is that she didn't want that baby to die while she was there by herself. She wanted her mom to be there... so that changed the whole story quite a bit. We were like, "Yeah, we can keep this baby going for an hour until your mom gets here" (Lee & Dupree, 2008, p. 988).
#### Creating Family Memories
Clients and families need to talk about things other than the disease process and treatments. Nurses can help make this happen. There are spiritual stories, cultural stories, funny stories, developmental stories, narratives of advocacy, and family stories. Each reinforces the bonds and affirms the depth of meaning a family holds with a dying person. The moments of laughter, foibles, and shared experiences are connections that need to be remembered.
Case Example
Evelyn was an 83-year-old woman diagnosed with terminal lung cancer. During a guided imagery exercise, the nurse asked her to recall a time when she felt relaxed and happy. Evelyn described in vivid detail being with her family at a picnic near a lake many years ago. When her family came to visit that night, Evelyn related the story again, and the entire family talked about their parts in the remembered event. How they all laughed, what fun they had! It was one of their last conversations; one that reinforced family bonds in the initial telling and later as her family remembered Evelyn after her death. Her adult daughter made a special point of letting the nurse know how important sharing this story was to the client and family.
#### Providing Information
Nurses are key informants about client status and changes in the client's condition. There are fundamental differences in the level of information an individual or family will desire. The response of the client should determine the content and pace of sharing information. Talking with families about care details and potential outcomes should happen often, but even more frequently when the client's health status begins to decline or show a change.
Ideally, one nurse serves as the primary contact for the client and family, and acts as a liaison between providers and clients. This nurse keeps other health team members informed of new issues, and shares their input into planning and evaluation of care with the family. Using precise language, giving full and truthful information about the client's condition, and admitting to uncertainty, when it exists, are important dimensions of EOL information giving.
#### Family Conferences
Family conferences are effective tools to alleviate family anxiety about the dying process, reduce unnecessary conflict between family members, and assist family members with important decision-making processes. Principles related to EOL care, as presented in Box 8-5, offer guidelines for discussions. Gavrin (2007) notes, "the analog of informed consent is informed refusal" (p. S86). This concept becomes important to clients and families as a component of decision making related to withdrawing or withholding life support in EOL care. Although a physician commonly leads the discussion, nurses often present data and answer questions. Data sharing should be compassionate, accurate, and presented in language understandable to the family. Contradictory recommendations and incomplete information add to a family's confusion and cause unnecessary distress (Wright, Wurr, Tomlinson, & Miller, 2009). A coordinated approach prevents fragmentary and inconsistent care.
BOX 8-5 Principles Guiding End-of-Life Care
• Discussions of medical futility with patients and family will be more effective if they include concrete information about treatment, its likelihood of success, and the implications of the intervention and nonintervention decisions.
• Effective decision making at the end of life can be improved with the use of advance directives and surrogate decision makers.
• Ethnic and cultural traditions and practices influence the use of advance directives and health care decision-making surrogates.
• Taking the time to explore the client's perceptions about quality of life at the end of life is a core component of clinical assessment and is essential to ensuring optimal outcomes.
• The cost of failing to offer clients and families a full range of end-of-life care options, services, and settings is an incalculable toll in terms of quality of life and utilization of appropriate health care resources at the end of life.
Modified from Bookbinder M, Rutledge DN, Donaldson NE et al.: End-of-life care series: part I: principles, _Online Journal of Clinical Innovations_ 4(4):1–30, 2001, by permission. © 2001, Cinahl Information Systems.
Curtis (2004) recommends that there be a higher ratio of family member–to–health care provider speaking time, and that there be follow-up communication using a consistent physician-nurse team approach. Helping clients and families understand the importance of advance directives and do not resuscitate (DNR) orders can prevent later conflicts when tensions arise near the time of death (Boyle, Miller, & Forbes-Thompson, 2005). Nurses are invaluable resources in clarifying meanings with clients or individual family members after the conference.
## Addressing cultural and spiritual needs in end-of-life care
Cultural Differences
Different cultures have distinctive communication and care standards for clients with life-threatening conditions, some of which are identified in Box 8-6 (Searight & Gafford, 2005). Other distinctions include: (a) type of care that provides comfort to the dying person; (b) understanding of the causes of illness and death; (c) appropriate care of the body and burial rites; and (d) expression of grief responses (Doolen & York, 2007; LaVera et al., 2002).
BOX 8-6 Cross-Cultural Variations in End-of-Life Care
• Emphasis on autonomy vs. collectivism
• Attitudes toward advance directives
• Decisions making about life support, code status guidelines
• Preference for direct vs. indirect disclosure of information
• Individual vs. family-based decision making about treatment
• Disclosure of life-threatening diagnoses
• Provider's choice of words in verbal exchanges
• Reliance on physician as the ultimate authority
• Specific rituals or practices performed at time of death
• Role of religion and spirituality in coping and afterlife
• Views about suffering
Adapted from Searight H, Gafford J: Cultural diversity at the end of life: issues and guidelines for family physicians, _American Family Physician_ 71(3):515–522, 2005.
Asking clients/families directly about their cultural values and issues as a starting point helps ensure cultural safety for clients and families. A simple question such as "Can you tell me about how your family/culture/spiritual beliefs views serious illness or treatment?" provides a framework for discussion. When cultural differences are considered, it is important to avoid stereotyping, as each person's interpretation of their culture is unique. Once cultural needs are identified, every effort should be taken to honor their meaning to clients and families by incorporating them in care.
### Spiritual needs
Glass, Cluxton, and Rancour (2001) note, "The transition from life to death is as sacred as the transition experienced at birth" (p. 49). The dying process, grief, and death itself herald a spiritual crisis—a crisis of faith, hope, and meaning for many people. Spiritual pain occurs when a person's sense of purpose is challenged or one's existence is threatened (Millspaugh, 2005).
Case Example
As I was assessing her, she burst into tears and told me that she thinks "God is punishing her for something and that this is why she has cancer." This was not the first time I heard this from a patient (LaPorte Matzo & Witt-Sherman, 2006, p. 1).
Spirituality becomes a priority for many people at EOL (Williams, 2006). It is not unusual for clients who have previously declined spiritual interventions to desire them as they move into the final phase of life. Spiritual beliefs and religious rituals provide a tangible vehicle for individuals and families to express and experience meaning and purpose. Religious practices and rituals relevant to EOL can be important to clients even if the person no longer formally practices the religion. Facilitating these practices touches the client's inner core and helps the person move toward a peaceful death (Bryson, 2004).
Most people welcome an inquiry about their spiritual well-being (Morrison & Meier, 2004). People having a strong relationship with God and/or religious beliefs will usually indicate this connection. To elicit more information about its nature, an appropriate question is: "Is there anything I should know about your spiritual or religious views?" The answer can tell you what is important related to their current circumstances. Steinhauser et al. (2006) suggest that using the probe "Are you at peace?" is a useful way to ask the client about spiritual concerns without being intrusive. Nurses can ask the client and/or family if they would like a visit from an appropriate clergy or hospital chaplain, facilitate the initial contact if the answer is yes and provide essential information about the client's condition and/or family concerns (Barclay & Lie, 2007).
Not all people attach their concept of spirituality to a particular belief system. Instead, they define their spirituality from an existential perspective. Attig (2001) describes this sense of spirituality as follows:
That within us that reaches beyond present circumstances, soars in extraordinary experiences, strives for excellence and a better life, struggles to overcome adversity, and searches for meaning and transcendent understanding. (p. 37)
When individuals frame their spirituality from an existential perspective, it is appropriate to explore spirituality sources in terms of meaningful relationships. Asking a question such as "Can you tell me about the relationship you had with someone whom you loved who has died?" helps start the conversation. A follow-up question relates to how the client feels about the person now. The value of this intervention is that it emphasizes that the person's life held meaning for this other person. This line of questioning indirectly tells the person that they too will be remembered after death (Pashby, 2010).
People benefit from telling stories about how they view their life and validate its meaning. A life review helps people consider the deeper values and purpose of their lives, the experience of joy and sorrow. As one person stated, "I lived my life as best I could. I have no regrets." A follow-up listening response to help the person put into words what he or she reflect on the meaning of a life well lived might be: "Tell me more about this."
Whatever form spiritual distress takes, it is essential for the nurse to address it. Spiritual issues that trouble clients relate to forgiveness, unresolved guilt issues, expressions of love, saying good-bye to important people, and existential questions about the meaning of life, the hereafter, and concern for their family.
Clary and Lawson (2009) suggest that the EOL offers a final opportunity for people to experience spiritual growth. The most important intervention nurses can provide is to actively and respectfully listen to each client's search for clarity about their spirituality with compassion and a desire to understand. Helping clients think through spiritual preferences and assisting them to identify resources that can give them strength, courage, purpose, and encouragement to cope with their situation is highly valued. Providing explicit attention to inclusion of appropriate spiritual advisors, prayer, and scripture reading can be helpful to faith-based clients and families coping with a terminal condition.
Nurses need to take an honest look at their own spirituality. Self-awareness allows nurses to enter their client's spiritual world from an authentic position, without imposing personal values and beliefs. Exercise 8-5 is designed to help nurses understand the value of reflecting on a purposeful life.
EXERCISE 8-5 Blueprint for My Life Story
Purpose:
To view life as a whole, integrated process.
Procedure:
This is a two-part exercise. First, make a single life line across a blank sheet of paper, beginning with your birth. Identify the significant events in your life and then insert on your worksheet the age that you were when the event or moment occurred. When you are finished, answer the following questions:
Childhood
1. What was your happiest time as a child?
2. What were your saddest times?
3. What did you hope to become when you grew up?
4. Who were your companions as a child?
5. How did you view your mother? Your father? Your grandparents?
6. How did you feel about your home? Your neighborhood?
7. As a child, who was your most important relationship with?
8. Were boys and girls treated alike in school? In the family?
9. Where was your favorite space?
10. Where did you live as a child?
Adolescence
1. What subjects did you like best in school?
2. How and when did you get your first job?
3. Who were your companions as an adolescent, and what did you do with them?
4. Who was your first girlfriend or boyfriend?
5. Who had the most significant influence on you as an adolescent? In what ways?
6. What was most important to you as an adolescent?
Adulthood
1. What was the best job you ever had? The worst?
2. If you could choose your career again, what would you choose?
3. If you could relive any part of your life, what would it be?
4. What parts of your life are you particularly proud of?
5. Look back over your life. When were you happiest? Saddest?
6. What have you learned about life from the process of living?
7. What was the most exciting part of your life?
8. Who has influenced your life most as an adult?
9. If you could make three wishes, what would they be?
Record your answers in whatever way seems most appropriate to you. Spend some time thinking about the events you have identified on your lifeline and the answers you have provided in the narrative. Reflect on your life as a whole, with you as the primary actor, producer, and director. Think about ways in which you could write the remaining chapters of your life so they have special meaning for you.
Discussion:
In the larger group, discuss your lifeline.
1. In what ways were you surprised or comforted by the events that emerged from your lifeline?
2. As you contrast your lifeline with those of your classmates, do common themes emerge?
3. How could you use common themes as the basis for discussion with clients?
## Supportive strategies for children
When a child is diagnosed with a terminal illness or condition, the effect on parents is devastating and can last a lifetime. It can influence role functioning, friendships, and treatment of siblings (Hinds, Schum, Baker, & Wolfe, 2005). Children are such an integral part of their parent's identity that issues of parental protectiveness, guilt, caregiving, balancing family demands, and helplessness must be addressed in the course of providing direct care for the child. When caring for children, there are always two clients to consider: the parent(s) and the child.
Parents are the major anchoring force for most children, so supporting them as primary caregivers for their child is important. They need to be recognized as the expert and primary advocate for their child. Some may not feel they are up to the task, but with appropriate support surprise themselves. Critical to parent satisfaction is knowledge that everything possible was done for their child; that they received accurate, timely information and support; and that preventable suffering was not permitted.
Parents often maintain hope for the child's survival even with a terminal diagnosis. This is because of a belief that it is not the natural order of things for a child to die, and because terminal symptom profiles for children are less predictable. Nurses can help identify situations in which there is a mismatch between a child's condition and a parent's understanding of that condition (Field & Behrman, 2002). They can help decrease parental anxiety by explaining changes in the child's appearance, and observing signs of distress in parents and siblings related to the child's progressive deterioration. If the child or family requires additional counseling to reduce stress, nurses can make appropriate referrals. Table 8-2 identifies common goals and provides examples of supportive care for children.
TABLE 8-2
Common Goals and Examples of Supportive Care for Children
From Field M, Behrman R: _When children die: improving palliative and end of life care for children and their families_ (p. 128). Washington DC, 2002, National Academies Press.
### Talking with children about death
_Developmental level_ is a key factor in the child's attitude toward death. A child younger than 5 years has no clear concept of what death means. As a child matures, the finality of death becomes more real. Death is difficult for children because they don't have the cognitive development and life experiences to process them completely. Until children reach the formal operations stage of cognitive development, they can have fantasies about the circumstances surrounding the death, and their part in it.
Children don't express their grief in the same way as adults. Acting out, anger, fear, and crying are common responses, which appear spontaneously. One minute the child may be playing, the next he or she is angry or withdrawn. Preschoolers may repeatedly ask when someone close to them will be coming home even if parents tell them the person has died. Developmentally, they don't understand the permanence of death. Elementary school children accept the permanence of death, but view it in a concrete manner. Adolescents are aware of death as a final act.
Case Example
A short time after 5-year-old Aidan's grandfather died, he asked his grandmother where his grandfather had gone. His grandmother told him that grandpa had died, and was in heaven, to which Aidan said, "Oh no, grandma, he's in that brown box in the ground."
Regardless of age, parents can help their children understand the impending death or loss of a relative by explaining in a concrete, direct way what has happened, using clear, concrete language suitable to the child's developmental level. Children should be encouraged to talk about changes in the health of a parent or the impending death of a central person in their lives. Questions should be answered directly and honestly at the child's developmental level of comprehension. Check in with the child to find out how the child is coping at regular intervals.
The National Cancer Institute (2010) identifies three key concerns of children:
1. Did I cause the death to happen?
2. Is it going to happen to me?
3. Who is going to take care of me?
Parents can anticipate that these will be issues for children, and create opportunities for children to ask these questions. For example, if a child around the same age or a sibling dies, a child may be fearful that something similar will happen to him or her. Maintaining daily routines in the child's life after the death of a parent or primary caregiver is critical. Children need to know that they are safe and will be taken care of by the remaining adults in their life. If changes are needed, children should have ample time to make the adjustment rather than have a sudden move thrust on them without discussion. Children need physical contact, reassurance, and relevant discussions about the person who has died. If parents are unable to provide the level of communication a child needs, nurses can help them with appropriate referrals.
Sometimes a family will want to exclude young children from contact with or knowledge about a person who is likely to die soon. Usually children are aware of what is happening (Loomis, 2009). Encouraging family members to talk with children about changes in their relative's condition using clear, simple terms and allowing them to express their feelings freely is important. Drawing a picture or sending a note can be a useful way for the child to connect with a critically ill relative, if direct contact is not advised. With preparation, adolescents can benefit from being allowed to visit with the client.
Case Example
Brendan and his grandfather had a close relationship. Earlier in life, they would stroke each other's thumbs as part of a "special handshake." Now, at 15, his grandfather was close to death and unresponsive. As Brendan sat next to him, stroking his thumb in the remembered way, he felt sure that his grandfather had squeezed his hand more than once. This was a meaningful connection for Brendan.
## Helping clients achieve a good death
The Institute of Medicine (1997) defines a **good death** as "one that is free from unavoidable distress and suffering for patients, families and caregivers; in general accord with patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards" (p. 82). Death is a deeply personal experience. In a study of what constitutes a good death from the perspective of families, clients, and professionals, Steinhauser et al. (2000) identified six elements:
• Pain and symptom relief
• Transparent decision making
• Preparation for what to expect
• Achieving a sense of completion
• Contributing to others
• Receiving affirmation as a whole person
Maintaining a sense of control over what happens during the dying process and who is present at the end, having access to spiritual, emotional, and knowledgeable supports and being afforded hope, dignity, and privacy are also client/family values associated with a good death (Côté & Peplar, 2005; Kirchhoff, 2002; Smith, 2000). Exercise 8-6 provides you with the opportunity to personally think about what constitutes a good death.
EXERCISE 8-6 What Makes for a Good Death
Purpose:
To help students focus on defining the characteristics of a good death.
Procedure:
1. In pairs or small groups, think about, write down, and then share briefly examples of a "good" and a "not-so-good" death that you have witnessed in your personal life or clinical setting.
2. What were the elements that you thought contributed to its being a "good" or "not-so-good" death?
Discussion:
Were there any common themes found in the stories as to what constitutes a "good" death? How could you use the findings of this exercise in helping clients achieve a "good" death?
### Signs of approaching death
As death approaches, there are subtle but significant changes in a person's behavior. With some people, changes are progressive and swift. With others, there is gradual downward spiral. Common symptoms include long periods of sleeping or coma, decreased urinary output, changes in vital signs, disorientation, restlessness and agitation, severe dyspnea (breathlessness), skin temperature, and color. Dying clients experience profound weakness such that they cannot independently complete even basic hygiene.
The process of watching someone die is frightening to families. Family members feel increasingly helpless in being able to properly meet client needs. They need anticipatory guidance about what to expect and concrete suggestions about ways to connect with their loved one. The American Cancer Society Web site offers an excellent description of typical changes in the client when death is near and a clear outline of what caregivers can do to provide comfort to the client. The Internet is an invaluable resource for general information and for family-to-family support. Recommended sites should be carefully screened for accuracy and appropriateness.
Direct comfort care is essential. Practical suggestions for care and availability are critical components of care as clients approach death. Nurses can recommend simple care measures such as positioning, mouth and hygiene care, and so forth, to support family member efforts. They can provide immediate assessment data and explain its meaning. Nurses can encourage out-of-town family to visit, refer caregivers to support groups, and offer resource referrals for respite care. Most important, they can listen.
A common concern is the client's loss of appetite and interest in food. Most stop eating. Explaining that this is a natural process that occurs as the body begins to shut down in preparation for death helps with family understanding (Reid, McKenna, Fitsimons, & McCance, 2009). As death approaches, clients become increasingly unresponsive to voice and stimulus. Because hearing is the last sense to go, talking with the dying person in a soft voice, playing calming music, and using gentle touch can soothe the client in a meaningful way.
Creating a care environment in which the dying person feels valued, comforted, and treated as a unique individual (Volker & Limerick, 2007) is vital, even when the client is no longer cognizant of what is happening. Flexibility in allowing family and/or significant others open access to the client, while taking care that the visits are not taxing for the client, reduces family anxiety and can be comforting for all concerned. As clients weaken, they typically want to engage with fewer family and friends. Nurses can act as gatekeepers in helping clients balance their own needs for relationship with the needs of others, and helping everyone concerned to engage with each other in a meaningful way.
### Communication strategies
Presence is an important form of communication with dying clients and families. Casarett, Kutner, and Abrahm (2001) assert that simply by being with a family and bearing witness to the family's expression of grief, health care providers provide important emotional and practical support.
Case Example
"I remember standing next to my mom's bed. We had gone to her room to pay our last respects. A young nurse stood near to me and reached out gently and touched my shoulder. Softly she said, 'I'll just stay here with you in case you need something.' When I looked at her I saw eyes brimming with tears and a profound sadness on her face. Her presence meant so much; I was grateful for her open expression of sorrow. It confirmed the pain we were all experiencing" (Anonymous).
Most families find it difficult to leave a dying client, even for a short period. Assuring family members that the nurse will check on the client frequently, and will call the family immediately if change occurs, gives families permission to take a brief respite from the client.
### Caring of the client after death
Respect for the dignity of the client continues after death. If the family is present at time of death, allowing uninterrupted private time with the client, before initiating postmortem care is important. If the family is not present, all excess equipment and trash should be removed from the room. You can offer presence and emotional support as you escort the family into the room. Some families will want privacy; others will appreciate having the presence of the nurse or chaplain. Family preference should be honored.
If the family is not immediately present, the client's belongings should be placed in a bag and given to the family after the visitation. Provide soft lighting, chairs for the family, and tissues. The client's head should be elevated at a 30-degree angle, in a natural position. Hair should be combed, exposed body parts cleaned, and dentures replaced, if possible. The tone of the room and the positioning of the client should "give a sense of peace for the family" (Marthaler, 2005, p. 217). It is important for the nurse to allow the family as much time as they need with the client. The nurse can obtain signatures to release the client to the funeral home after the family has spent some time with the client.
Nurses can offer healing presence for the family after death.
Case Example
"A nurse washes the body of a stillborn child, then wraps and brings the baby to the mother and father. She models for them the naturalness of holding their child as they say their goodbyes. She stays close for a while, then she recedes, allowing their privacy. Later she is quietly available as parents make plans for what they will do next. That is healing presence" (Miller, 2001, p. 11).
## Stress issues for nurses in palliative care settings
Nurses deeply invest themselves in the care and comfort of clients and families facing death, and can experience grief when the client dies. **Disenfranchised grieving** is a term applied to the grief nurses can experience after the death of a client with whom they have had an important relationship (Brosche, 2007; Rushton et al., 2006). Unacknowledged grieving in professional nurses can be cumulative. Unlike their clients, who live through one loss at a time, nurses can experience several losses a week while caring for terminally ill clients and their families (Brunelli, 2005).
Nurses can experience **compassion fatigue** , a syndrome associated with serious spiritual, physical, and emotional depletion related to caring for clients that can affect the nurse's ability to care for other clients (Worley, 2005). Unrelieved compassion fatigue can result in burnout and a nurse's decision to leave nursing.
Case Example
Barbara was a new graduate, selected as a nursing intern on a research oncology unit, providing care for seriously ill pediatric oncology clients. She had a degree in another field and an excellent job, but always wanted to pursue nursing. Her original preceptor left the hospital and was replaced by an efficient nurse without much empathy. The stress of weekly deaths, severe symptomatology, and lack of empathetic support led Barbara to leave nursing entirely after less than a year. She returned to her former position.
Another source of stress is the moral distress associated with helping clients and families resolve conflicts about EOL care (Rushton et al., 2006). For example, the use of technology and life support, and use of phase I or II clinical trial drugs with terminally ill clients can create significant ethical dilemmas for nurses caring for these clients. Support groups in which nurses can successfully address and resolve the secondary stress of continuously caring for terminally ill clients and some of the ethical issues involved with that care are helpful to nurses.
## Summary
This chapter describes the stages of death and dying, and theory frameworks of Eric Lindeman and George Engel for understanding grief and grieving. Palliative care is discussed as a philosophy of care and an emerging discipline focused on making EOL care a quality life experience. A good death is defined as a peaceful death experienced with dignity and respect; one that wholly honors the client's values and wishes at the EOL. Nurses can offer compassionate communication, presence, and anticipatory guidance to ease the grief of loss. Seven domains of quality indicators for palliative and EOL care are identified as pain and symptom control, transparent decision making, communication, emotional and practical support, spiritual support, and continuity of care.
Nursing strategies are designed to help clients cope with the secondary psychological and spiritual aspects of having a terminal illness such that they achieve the best quality of life in the time left to them. Talking with clients about advance directives is a professional responsibility of the nurse, and it reduces unnecessary conflict among family members at this critical time in a person's life.
Talking with children about terminal illness and death in a relative, or in coping with a terminal diagnosis themselves should take into consideration the child's developmental level. Questions should be answered honestly and empathetically. Nurses can help families understand the behavioral changes signaling the body's natural shutdown of systems as death approaches. Providing support for clinicians is considered a quality indicator in EOL care. When not addressed, the disenfranchised grief that nurses experience with providing EOL care to multiple clients can lead to compassion fatigue, burnout, and moral distress.
Ethical Dilemma
What Would You Do?
Francis Dillon has been on a ventilator for the past 3 weeks. Although there is virtually no chance of recovery, his family is reluctant to take him off the ventilator. What do you see as the ethical issues, and how would you, as the nurse, address this problem from an ethical perspective?
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CHAPTER 9
# Communication Styles
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Describe the component systems of communication.
2 Discuss influence of gender and culture on professional communication.
3 Identify five communication style factors that influence the nurse-client relationship.
4 Discuss how metacommunication messages may affect client responses.
5 Cite examples of body cues that convey nonverbal messages.
6 Discuss application of research studies for evidence-based clinical practice.
This chapter explores styles of communication that serve as a basis for communications in the nurse-client relationship. Effective communication has been shown to produce better health outcomes, greater client satisfaction, and increased client understanding. Style is defined as the manner in which one communicates. Verbal style includes pitch, tone, and frequency. Nonverbal style includes facial expression, gestures, body posture and movement, eye contact, distance from the other person, and so on. These nonverbal behaviors are clues clients provide to us to help us understand their words. Sharpening our observational skills helps us gather data needed for nursing assessments and interventions. Both the client and the nurse enter their relationship with their own specific style of communication. Some individuals depend on a mostly verbal style to convey their meaning, whereas others rely on nonverbal strategies to send the message. Some communicators emphasize giving information; others have as a priority the conveying of interpersonal sensitivity. Longer nurse-client relationships allow each person to better understand the other person's communication style.
## Basic concepts
Metacommunication
**Communication** is a combination of verbal and nonverbal behaviors integrated for the purpose of sharing information. Within the nurse-client relationship, any exchange of information between two individuals also carries messages about how to interpret the communication.
**Metacommunication** is a broad term used to describe all of the factors that influence how the message is perceived (Figure 9-1). It is a message about how to interpret what is going on. Metacommunicated messages may be hidden within verbalizations or be conveyed as **nonverbal** gestures and expressions. The following case example should clarify this concept.
Figure 9-1 Factors in communication styles.
Case Example
Some studies find greater compliance to requests when they are accompanied by a metacommunication message that demanded a response about the appropriateness of this request:
_Student_ (smiling): We nursing students are trying to encourage community awareness in promoting environmental health and are looking for people to hand out fliers. Would you be willing?
_(Metacommunication):_ I realize that this is a strange request, seeing that you do not know who I am, but I would really appreciate your help. I am a nice person.
In this metacommunicated message about how to interpret meaning, the student nurse used both verbal and nonverbal cues. She conveyed a verbal message of caring to her white, middle-class client by making appropriate, encouraging responses, and a nonverbal message by maintaining direct eye contact, presenting a smooth face without frowning, and using a relaxed, fluid body posture without fidgeting.
In a professional relationship, verbal and nonverbal components of communication are intimately related. A student studying American Sign Language for the deaf was surprised that it was not sufficient merely to make the sign for "smile," but rather she had to actually show a smile at the same time. This congruence helped convey her message. You can nonverbally communicate your acceptance, interest, and respect for your client.
### Verbal communication
Words are symbols used by people to think about ideas and communicate with others. Choice of words is influenced by many factors (e.g., your age, race, socioeconomic group, educational background, and sex) and by the situation in which the communication is taking place.
The interpretation of the meaning of words may vary according to the individual's background and experiences. It is dangerous to assume that words have the same meaning for all persons who hear them. Language is useful only to the extent that it accurately reflects the experience it is designed to portray. Consider, for example, the difficulty an American has communicating with a person who speaks only Vietnamese, or the dilemma of the young child with a limited vocabulary who is trying to tell you where it hurts. Our voice can be a therapeutic part of treatment.
Case Example
For weeks while giving care to Mrs. Garcia, a 42-year-old unconscious woman, her nurse used soothing touch and conversation. She also encouraged the client's husband to do the same. When the woman later regained consciousness, she told the nurse that she recognized her voice.
#### Meaning
There are two levels of meaning in language: denotation and connotation. Both are affected by one's culture. **Denotation** refers to the generalized meaning assigned to a word; **connotation** points to a more personalized meaning of the word or phrase. For example, most people would agree that a dog is a four-legged creature, domesticated, with a characteristic vocalization referred to as a bark. This would be the denotative, or explicit, meaning of the word. When the word is used in a more personalized way, it reveals the connotative level of meaning. "What a dog" and "His bark is worse than his bite" are phrases some people use to describe personal characteristics of human beings, rather than a four-legged creature. We need to be aware that many communications convey only a part of the intended meaning. Don't assume that the meaning of a message is the same for the sender and the receiver until mutual understanding is verified. To be sure you are getting your message across, ask for feedback.
#### Culture
Some people speaking English as a second language say the most difficult aspect is trying to translate the many slang terms and phrases that have double meanings. Extra time is needed when clients are experiencing stress or with clients who speak English as a second language. Use planned spaces of silence, which allows time to understand your meaning and to prepare a response. Verify to make sure that nuances of communication do not get lost.
Culture affects the pitch and tone clients use. For example, the tone of voice used to express anger varies according to culture and family. It may be difficult for you to tell when someone from another culture is angry because their vocalization of strong emotion may be more controlled. By contrast, you might interpret loud conversation with rapid vocalization as conveying anger when it is just a culturally acceptable way to convey emotional intensity. Chapter 11 discusses cultural communication in detail.
### Verbal style factors that influence nurse-to-client professional communication
The following six styles of communication are summarized in Table 9-1:
TABLE 9-1
Styles That Influence Professional Communications in Nurse-Client Relationships
Verbal | Nonverbal
---|---
Moderates pitch and tone | Allows therapeutic silences
Varies vocalizations | Uses congruent nonverbal behaviors
Encourages client involvement | Uses facilitative body language
Validates client's worth | Uses touch appropriately
Advocate for client as necessary | Proxemics
Appropriately provides needed information | Attends to client's nonverbal cues
1. _Moderate pitch and tone in vocalization._ The oral delivery of a verbal message, expressed through tone of voice, inflection, sighing, and so on, is referred to as **paralanguage.** It is important to understand this component of communication because it affects how the verbal message is likely to be interpreted. For example, you might say, "I would like to hear more about what you are feeling" in a voice that sounds rushed, high-pitched, or harsh. Or you might make this same statement in a soft, unhurried voice that expresses genuine interest. In the first instance, the message is likely to be misinterpreted by the client, despite your good intentions. Your caring intent is more apparent to the client in the second instance. Voice inflection (pitch and tone), loudness, and fast rate either supports or contradicts the content of the verbal message. Ideas may be conveyed merely by emphasizing different portions of your statement (LeFebvre, 2008). When the tone of voice does not fit the words, the message is less easily understood and is less likely to be believed. A message conveyed in a firm, steady tone is more reassuring than one conveyed in a loud, abrasive, or uncertain manner. In contrast, if you speak in a flat, monotone voice when you are upset, as though the matter is of no consequence, you confuse the client, making it difficult for him to respond appropriately.
2. _Vary vocalizations._ In some cultures, sounds are punctuated, whereas in other cultures, sounds have a lyrical or singsong quality. We need to orient ourselves to the characteristic voice tones associated with other cultures.
3. _Encourage client involvement._ Professional styles of communication have changed over time. We now partner with our clients in promoting their optimal health. We expect and encourage our clients to assume responsibility for their own health. Consequently, provider-client communication has changed. Paternalistic, "I'll tell you what to do" styles are no longer acceptable.
4. _Validate client's worth._ Styles that convey "caring" send a message of individual worth that sustains the relationship with the client. For example, clients prefer providers who use a "warm" communication style to show caring, give information, and to allow them time to talk about their own feelings.
Confirming responses validate the intrinsic worth of the person. These are responses that affirm the right of the individual to be treated with respect. They also affirm the client's autonomy (i.e., his or her right, ultimately, to make his or her own decisions). Disconfirming responses, in contrast, disregard the validity of feelings by either ignoring them or by imposing a value judgment. Such responses take the form of changing the topic, offering reassurance without supporting evidence, or presuming to know what a client means without verifying the message with the client. More-experienced nurses use more confirming communication. These communication skills are learned.
5. _Advocate for client when necessary._ Our personalities affect our style of social communication; some of us are naturally shy. But in our professional relationships, it often becomes necessary that we take on an assertive style of communicating with other health providers or agencies to obtain the best care or services for our client.
6. _Provide needed information appropriately._ Providing accurate information to our client in a timely manner in understandable amounts is discussed throughout this book. In our social conversations there often is a rhythm: "you talk—I listen," then "I get to talk, you listen." However, in professional communications, the content is more goal focused. Self-disclosure from the nurse needs to be limited. Telling a client your problems is not appropriate.
### Nonverbal communication
The majority of person-to-person communication is nonverbal. Think of the most interesting lecturer you ever had. Did this person lecture by making eye contact? Using hand gestures? Moving among the students? Learners generally are most interested in lecturers whose nonverbal actions convey enthusiasm. The function of nonverbal communication is to give us cues about what is being communicated. Skilled use of nonverbal communication through (therapeutic) silences, use of congruent nonverbal behaviors, body language, touch, proxemics, and attention to client nonverbal cues such as his facial expression can improve your relationship and build rapport with a client (Kacperek, 1997).
Emotional meanings are communicated through body language, particularly facial expression.
#### Nonverbal style factors that influence nurse-to-client professional communication
We need to be aware of the position of our nonverbal messages as we talk to our client. Awareness of the position of our hands, the look on our face, and our body movements gives cues to our client (LeFebvre, 2008; Levy-Storms, 2008). It is important to use attending behaviors to convey to the client that his conversation is worth listening to. Think of the last time an interviewer kept fidgeting in his seat, glancing frequently at his wall clock or shuffling papers. How did this make you feel? What nonverbal message was being conveyed? Table 9-1 summarizes the following six nonverbal behaviors of a competent nurse:
1. _Allow silences._ In our social communications, we often become uncomfortable if conversation lags. There is a tendency to rush in to fill the void. But in our professional nurse-client communication, we use silence therapeutically, as described in Chapter 10, giving our clients needed time to think about things.
2. _Use congruent nonverbal behaviors._ Nonverbal behavior should be congruent with the message and reinforce it. If you knock on your instructor's office door to seek help, do you believe her when she says she'd love to talk if you see her grimace and roll her eyes at her secretary? In another example, if you smile while telling your nurse-manager that your assignment is too much to handle, the seriousness of the message is negated.
Try to give nonverbal cues that are congruent with the message you are verbally communicating (Stovis, 2008). When nonverbal cues are incongruent with the verbal information, messages are likely to be misinterpreted. When your verbal message is inconsistent with the nonverbal expression of the message, the nonverbal expressions assume prominence and are generally perceived as more trustworthy than the verbal content.
You need to comment on any incongruences to help your client. For example, when you enter a room to ask Mr. Sala if he is having any postoperative pain, he may say "No," but he grimaces and clutches his incision. After you comment on the incongruent message, he may admit he is having some discomfort. Can you think of a clinical situation in which you changed the meaning of a verbal message by giving nonverbal "don't believe what I say" cues?
3. _Use facilitative body language. Kinesics_ is an important component of nonverbal communication. Commonly referred to as **body language** , it is defined as involving the conscious or unconscious body positioning or actions of the communicator. Words direct the content of a message, whereas emotions accentuate and clarify the meaning of the words. Some nonverbal behaviors such as tilting your head or facing your client promote communication.
• **Posture.** Leaning forward slightly communicates interest and encourages your client to keep the conversation going. Keep your knees unlocked and body loose, not tight and tense.
• **Facial expression.** Six common facial expressions (surprise, sadness, anger, happiness/joy, disgust/contempt, and fear) represent global, generalized interpretations of emotions common to all cultures. Facial expression either reinforces or modifies the message the listener hears. The power of the facial expression far outweighs the power of the actual words. So try to maintain an open, friendly expression without being boisterously cheerful. Avoid furrowed forehead or a distracted or bored expression.
• **Eye contact.** Making direct eye contact with your client generally conveys a positive message. Most clients interpret direct eye contact as an indication of your interest in what they have to say, although there are cultural differences.
• **Gestures.** Some gestures such affirmative head nodding help facilitate conversation by showing interest and attention. Use of open-handed gestures can also facilitate your nurse-client communication. Avoid folding arms across chest or fidgeting.
4. **_Touch_.** Touching a client is one of the most powerful ways you have to communicate nonverbally. Within a professional relationship, affective touch can convey caring and reassurance. In studies, nurses' touching clients has been reported to be perceived both positively as an expression of caring and negatively as threat (Harding, North, & Perkins, 2008; Inoue, Chapman, & Wynaden, 2006). Care must be taken to abide by the client's cultural proscriptions about the use of touch. This varies across cultures. An example would be the proscription some Muslim men and Orthodox Jewish men follow against touching women outside of family members. They might be uncomfortable shaking the hand of a female health care provider. In another example, some Native Americans use touch in healing, so that casual touching may be taboo.
All nurses caring directly for clients use touch to assess and to assist. We touch to help our client walk, roll over in bed, and so on. However, just as you are careful about invading the client's personal space, you are careful about when and where on his body you touch your clients. Gender of the nurse nuances the client's perception of the meaning of being touched. Harding et al.'s (2008) findings suggest that in our culture, whereas a woman's touch is seen as a normal expression of caring, we have sexualized male touching. This is a potential problem for male nurses. Therapeutic touch is discussed in Chapter 10.
5. _Proxemics._ We can use physical space to improve our interactions with clients (Buetow, 2009). Proxemics refers to a client's perception of what is a proper distance to be maintained between him and others. Use of space communicates messages. You've heard the phrase "Get out of my face" used when someone stands too close, often interpreted as an attempt to intimidate.
• Each culture proscribes expectations for appropriate distance depending on the context of the communication. For example, the Nonverbal Expectancy Violations Model defines "proper" social distance for an interpersonal relationship as 1.5 to 4 feet in Western cultures. Americans feel crowded if someone stands closer than 3 feet (Stuart, 2009). The interaction's purpose determines appropriate space, so that appropriate distance in space for intimate interaction would be zero distance, with increased space needed for personal distance, social distance, and public distance. In almost all cultures, zero distance is shunned except for loving or caring interaction. In giving physical care, nurses enter this "intimate" space. Care needs to be taken when you are at this closer distance, lest the client misinterpret your actions. Violating the client's sense of space can be interpreted as threatening.
6. _Attend to Client's Nonverbal Body Cues_.
• _Posture._ Often, the emotional component of a message can be indirectly interpreted by observing the client's body language. Rhythm of movement and body stance may convey a message about the speaker. For example, when a client speaks while directly facing you, this conveys more confidence than if he turns his body away from you at an angle. A slumped, head-down posture and slow movements might give you an impression of lassitude or low self-esteem, whereas his erect posture and decisive movements suggest confidence and self-control. Rapid, diffuse, agitated body movements may indicate anxiety. Forceful body movements may symbolize anger. Bowing his head or seeing him slump his body after receiving bad news conveys his sadness. Can you think of other cues your client's body posture might give you?
• _Facial expression._ Facial characteristics such as frowning or smiling add to the verbal message conveyed. Almost instinctively, we use facial expression as a barometer of another person's feelings, motivations, approachability, and mood. From infancy, we respond to the expressive qualities of another's face, often without even being aware of it. Therefore, assessing our client's facial expression together with his other nonverbal cues may reveal vital information that will affect the nurse-client relationship. Observing your client's facial expressions can signal his feelings. For example, a worried facial expression and lip biting may suggest an anxious client. Absence of a smile in greeting or grimacing may convey a message about how ill the client feels.
• _Eye contact._ Research suggests that individuals who make direct eye contact while talking or listening create a sense of confidence and credibility, whereas downward glances or averted eyes signal submission, weakness, or shame. In addition to conveying confidence, maintaining direct eye contact communicates honesty (Puetz, 2005). Failure to maintain eye contact, known as _gaze aversion,_ is perceived by adults and children as a nonverbal cue meaning that the person is lying to you. If your client's eyes wander around during a conversation, you may wonder if he is being honest. Even 6- and 9-year-olds in Einav and Hood's (2008) study were more likely to attribute lying to those who avert their gaze.
• _Gestures._ Movements of his extremities may give cues about your client. Making a fist could convey how angry he is, just as use of stabbing, abrupt hand gestures may suggest distress or hugging arms (self-embracing gestures) might suggest fear.
Assessing the extent to which the client uses these nonverbal cues to communicate emotions helps you communicate better. Studies repeatedly show us that failure to acknowledge nonverbal cues is often associated with inefficient communication by the health provider (Mauksch, Dugdale, Dodson, & Epstein, 2008; Uitterhoeve et al., 2008).
It is best if we verify our assessment of the meaning of our client's nonverbal behaviors. Body cues, although suggestive, are imprecise. When communication is limited by the client's health state, pay even closer attention to nonverbal cues. Pain, for example, can be assessed through facial expression even when the client is only partially conscious.
Case Example
A client smiles but narrows his eyes and glares at the nurse. An appropriate comment for the nurse to make might be, "I notice you are smiling when you say you would like to kill me for mentioning your fever to the doctor. It seems that you might be angry with me."
### Effects of sociocultural factors on communication
Communication is also affected by such factors as gender, cultural background, ethnicity, age, social class, and location.
#### Gender
Communication patterns are integrated into gender roles defined by an individual's culture. Gender differences in communication studies have been shown to be greatest in terms of use and interpretation of nonverbal cues. This may reflect gender differences in intellectual style, as well as culturally reinforced standards of acceptable role-related behaviors. Of course, there are wide variations within the same gender.
We are now questioning whether traditional ideas about male and female differences in communication are as prevalent as previously thought. Is there really a major difference in communication according to gender? Not according to many reports. Some studies suggest different styles may be more greatly associated with social status differences in the two communicators rather than being a function of their gender (Helweg-Larsen et al., 2004).
What is factual and what is stereotype? More health care communication studies need to be done before we will really know. Because traditional thinking about gender-related differences in communication content and process in both nonverbal and verbal communication are being revised, consider critically what you read.
Traditionally, female individuals in most cultures were said to tend to avoid conflict and to want to smooth over differences. They were said to demonstrate more effective use of nonverbal communication and to be better decoders of nonverbal meaning. Feminine communication was thought to be more person centered, warmer, and more sincere. Studies show that women tend to use more facial expressiveness, smile more often, maintain eye contact, touch more often, and nod more often. Women have a greater range of vocal pitch and also tend to use different informal patterns of vocalization than men. They use more tones signifying surprise, cheerfulness, and unexpectedness. Women tend to view conversation as a connection to others.
Traditionally, male individuals in Western cultures were thought to communicate in a more task-oriented, direct fashion, demonstrate greater aggressiveness, and boast about accomplishments. They also have been viewed as more likely to express disagreement. Studies show that men prefer a greater interpersonal distance between themselves and others, and that they use gestures more often. Men are more likely to maintain eye contact in a negative encounter, though overall they maintain less direct eye contact; they use less verbal communication than women in interpersonal relationships. Men are more likely to initiate an interaction, talk more, interrupt more freely, talk louder, disagree more, use hostile verbs, and talk more about issues.
Gender Differences in Communication in Health Care Settings: It has been suggested that more effective communication occurs when the provider of the care and the client are of the same gender, although this was not found to be true in some studies. In professional health care settings, women have been noted to use more active listening, using encouraging responses such as "Uh-huh," "Yeah," and "I see," and to use more supportive words.
#### Culture
Although there is clear evidence that effective communication is related to better client health outcomes, greater client satisfaction, and better compliance, there is less evidence showing how cultural competency directly affects health outcomes. However, there is anecdotal information indicating our communication is perceived through the filter of our client's cultural beliefs. For this reason, our health information is not always relevant to the client. Do you feel skillful in communicating with culturally diverse clients? To communicate as a culturally competent professional, you need to develop an awareness of the values of a specific client's culture and adapt your style and skills to be compatible with that culture's norms. Chapter 11 deals in depth with intercultural communication concepts.
#### Location
A few studies, such as the one by Wallace et al. (2008), indicate that clients in urban areas report poorer communication by their health care providers. One factor that might affect these results is that rural clients tend to be cared for by the same "usual" providers. In a clinic or other busy location, lack of privacy certainly affects the style, as well as the content of your communication.
Developing an Evidence-Based Practice
Ness SM: Pain expression in the perioperative period: insights from a focus group of Somali women, _Pain Manage Nurs_ 10(2):65–75, 2009.
The verbal and nonverbal expression of pain varies across cultural groups. Expression of pain has not previously been studied in groups of Somali clients treated in the United States. This qualitative research study design used a focus group of four English-speaking postsurgical Somali immigrants to answer the research question: "How do Somali women express and communicate pain?"
_Results:_ These adult women agreed that it was culturally acceptable to verbalize about their pain to anyone, describing it with words like "bad" or "huge," after staff nurses inquired if they were all right with expressing feeling pain (though they stated that only Allah really understands and, therefore, needs to be asked for help). Nonverbally, they believed they needed to be very quiet and make minimal body movements to avoid pain. They reported using sad facial expressions and eye-rolling movements. One very interesting common theme was their feeling of fear, because "in Somalia surgery is only performed for very severe problems... and then you usually die."
_Application to your clinical practice:_ Because of the small size and methodology of this study, it is difficult to make generalizations to all Somalis. The author believes it is important to communicate before surgery what to expect in the postoperative experience. She recommends that family members be part of this education, both because of the common fear of death and the fact that these women felt bad that they could not carry out their usual duties during their recovery period. Results support findings from many other studies that indicate that pain needs to be understood within your client's cultural perspective, reflecting its subjective meaning to this person—its psychological, social, and spiritual significance.
## Applications
Knowing your own communication style
The style of communication you use can influence your client's behavior and his compliance with treatment. According to Milton (2008), evidence suggests clients are dissatisfied with poor communication more than other aspects of their care. Exercises in prior chapters should give you basic skills used in the nurse-client relationship, but you bring your own communication style with you, as does your client. Because we differ widely in our personal communication styles, it is important for you to identify your style and to understand how to modify it for certain clients. Experienced nurses adapt their innate social style so their professional communication fits the client and the situation. Personality characteristics influence your style. For example, would you be described as more shy or assertive? One nurse might be characterized as "bubbly," whereas another is thought of as having a "quiet" manner. Similarly, clients have various styles. You need to make modifications so your style is compatible with client needs. Think about the potential for incompatibility in the following case.
Case Example
_Nurse_ (in a firm tone): Mr. Michaels, it is time to take your medicine.
_Mr. Michaels_ (complaining tone): You are so bossy.
Recognize how others perceive you. Consider all the nonverbal factors that affect a client's perception of you. Your gender, manner of dress, appearance, skin tone, hairstyle, age, role as a student, gestures, or confident mannerisms may make a difference. Exercise 9-1 may increase your awareness of gender bias.
EXERCISE 9-1 Gender Bias
Purpose: To create discussion about gender bias.
Procedure:
In small groups, read and discuss the following comments that are made about care delivery on a geriatric psychiatric unit by staff and students: "Male staff tend to be slightly more confident and to make quicker decisions. Women staff are better at the feeling things, like conveying warmth."
Discussion:
1. Were these comments made by male or female staff?
2. How accurate are they?
3. Can you truly generalize any attribute to all male and female individuals?
The initial step in identifying your own style may be to compare your style with that of others. Ask yourself, "What makes a client perceive a nurse either as authoritarian or as accepting and caring?" The Exercise 9-2 video may help you to compare your style with that of others. The next step is to develop an awareness of alternative styles that you can comfortably assume if the occasion warrants. Next, it is important to figure out whether some other factors influence whether your style is appropriate for a particular client. How might their age, race, socioeconomic status, or gender affect their response to you?
EXERCISE 9-2 Self-Analysis of Video Recording
Purpose: To increase awareness of students' own style.
Procedure:
With a partner, role-play an interaction between nurse and client. Video record or use the video capacity of your cell phone to record a 1- to 2-minute interview with the camera focused on you. The topic of the interview could be "identifying health promotion behaviors" or something similar.
Discussion:
What posture did you use? What nonverbal messages did you communicate? How did you communicate them? Were your verbal and nonverbal messages congruent?
### Interpersonal competence
As early as 1984, Kasch proposed that nurse-client communication processes are based on the nurse's interpersonal competence. **Interpersonal competence** develops as the nurse comes to understand the complex cognitive, behavioral, and cultural factors that influence communication. This understanding, together with the use of a broad range of communication skills, helps you interact with your client as he or she attempts to cope with the many demands placed on him or her by the environment. Good communication skills are associated with competency. Competent communication skills are identified as one of the attributes of expert nurses who were perceived as having clinical credibility (Smith, 2005). In dealing with the client in the sociocultural context of the health care system, two kinds of abilities are required: social cognitive competency and message competency.
**Social cognitive competency** is the ability to interpret message content within interactions from the point of view of each of the participants. By embracing the client's perspective, you begin to understand how the client organizes information and formulates goals. This is especially important when your client's ability to communicate is impaired by mechanical barriers such as a ventilator. Clients who recovered from critical illnesses requiring ventilator support reported fear and distress during this experience.
**Message competency** refers to the ability to use language and nonverbal behaviors strategically in the intervention phase of the nursing process to achieve the goals of the interaction. Communication skills are used as a tool to influence the client to maximize his adaptation. When your instructor responds to your answer with a smile and affirmative head nod, saying, "Great answer," doesn't this make you feel successful?
### Style factors that influence relationships
The establishment of trust and respect in an interpersonal relationship with client and family is dependent on open, ongoing communication style. Having knowledge of communication styles is not sufficient to guarantee successful application. You need to understand how the materials discussed in this chapter interrelate. For example, providers who sit at client's eye level, at optimal distance (proxemics), without furniture between them (special configuration) will likely have more eye contact and use more therapeutic touching (Gorawara-Bhat, Cook, & Sachs, 2007). Box 9-1 contains suggestions to improve your own professional style of communicating.
BOX 9-1 Suggestions to Improve Your Communication Style
• Adapt yourself to your client's cultural values.
• Use nonverbal communication strategies, such as:
• Maintain eye contact.
• Display pleasant, animated facial expressions.
• Smile often.
• Nod your head to encourage the client to continue talking.
• Maintain attentive, upright posture and sit at his or her level, leaning forward toward the client slightly.
• Attend to proper proximity and increase space if client shows signs of discomfort, such as gaze aversion, leg swinging, or rocking.
• Use touch with client if appropriate to the situation.
• Use active listening and respond to client's cues.
• Use verbal strategies to engage your client.
• Use humor, but avoid gender jokes.
• Attend to proper tone and pitch, avoiding being overly loud.
• Avoid using jargon.
• Use nonjudging language and open-ended questions.
• Listen and avoid jumping in too soon with problem solving.
• Verbalize respect for client.
• Ask permission before addressing client by his first name.
• Convey caring comments.
• Use confirming, positive comments.
#### Slang and jargon
Different age groups even in the same culture may attribute different meanings to the same word. For example, an adult who says, "That's cool," might be referring to the temperature, whereas a teenager might convey his satisfaction by using the same phrase. In health care, the "food pyramid" is understood by nurses to represent the basic nutritional food groups needed for health; however, the term may have limited meaning for individuals not in the health professions.
#### Medical Jargon
Beginning nursing students often report confusion while learning all the medical terminology required for their new role. Remembering our own experiences, we can empathize with clients who are attempting to understand their own health care. Careful explanations help clients overcome this communication barrier. For successful communication, words used should have a similar meaning to both individuals in the interaction. An important part of the communication process is the search for a common vocabulary so that the message sent is the same as the one received. Consider the oncology nurse who develops a computer databank of cancer treatment terms. When admitting Mr. Michaels as a new client, the nurse uses an existing template model on her computer to create an individualized terminology sheet with just the words that would be encountered by him during his course of chemotherapy treatment.
#### Responsiveness of participants
How responsive the participants are affects the depth and breadth of communication. Reciprocity affects not only the relationship process, but also client outcomes (Sheldon & Ellington, 2008). Some clients are naturally more verbal than others. It is easier to have a therapeutic conversation with extroverted clients who want to communicate. You will want to increase the responsiveness of less verbal clients and enhance their communication responsiveness. Verbal and nonverbal approval encourages clients to express themselves. Elsewhere, we discuss skills that promote responsiveness such as active listening, demonstration of empathy, and acknowledgment of the content and feelings of messages. Sometimes acknowledging the difficulty your client is having expressing certain feelings, praising efforts, and encouraging use of more than one route of communication helps. Such strategies demonstrate interpersonal sensitivity. Studies show that listening to the care experience of a client, responding to verbal or nonverbal cues, and not "talking down" empowered open speaking (Sadler, 2008; Uitterhoeve et al., 2008). A responsive care provider has been shown to improve compliance with the treatment regimen in multiple studies. Exercise 9-3 will help you practice using confirming responses.
EXERCISE 9-3 Confirming Responses
Purpose: To increase students' skills in using confirming communication.
Procedure:
Change these disconfirming, negative messages into positive, confirming, caring comments.
1. "Three of your 14 blood sugars this week were too high. What did you do wrong?"
2. "Your blood pressure is dangerously high. Are you eating salty foods again?"
3. "You gained five pounds this week. Can't you stick to a simple diet?"
Discussion:
Was it relatively easy to send a positive, confirming message?
#### Roles of participants
Paying attention to the role relationship of the communicators may be just as important as deciphering the content and meaning of the message. The relationships between the roles of the sender and of the receiver influence how the communication is likely to be received and interpreted. The same constructive criticism made by a good friend and by one's immediate supervisor is likely to be interpreted differently, even though the content and style are quite similar. Communication between subordinates and supervisors is far more likely to be influenced by power and style than by gender. When roles are unequal in terms of power, the more powerful individual tends to speak in a more dominant style. This is discussed in Chapter 23.
#### Context of the message
Communication is always influenced by the environment in which it takes place. It does not occur in a vacuum but is shaped by the situation in which the interaction occurs. Taking time to evaluate the physical setting and the time and space in which the contact takes place, as well as the psychological, social, and cultural characteristics of each individual involved, gives you flexibility in choosing the most appropriate context.
#### Involvement in the relationship
Relationships generally need to develop over time because communication changes with different phases of the relationship. Uitterhoeve and colleagues (2008) validated prior research showing that nurses respond to less than half of client concerns, and tend to focus on physical care whereas ignoring client's social emotional care. In these days of managed care, nurses working with hospitalized clients have less time to develop a relationship, whereas community-based nurses may have greater opportunities. To begin to explore ethical problems in your nursing relationships, consider the ethical dilemma provided.
### Advocate for continuity of care
DeVoe et al.'s (2008) study showed that client's perception of positive health care communication is higher when the same individuals provide their care. These providers were more likely to listen to them, to explain things clearly, to spend enough time with them, and to show them respect. Because physicians and nurses communicate differently with clients, it is crucial that these professionals pool their information.
### Summary
Communication between nurse and client or nurse and another professional involves more than the verbalized information exchanged. Suggestions for improving your communication style are provided. Professional communication, like personal communication, is subtly altered by changes in pitch of voice and use of accompanying facial expressions or gestures. This chapter explores factors related to effective styles of verbal and nonverbal communication. Cultural and gender differences associated with each of these three areas of communication are discussed. For professionals, maintaining congruence is important. Style factors that affect the communication process include the responsiveness and role relationships of the participants, the types of responses and context of the relationships, and the level of involvement in the relationship. Confirming responses acknowledge the value of a person's communication, whereas disconfirming responses discount the validity of a person's feelings. More nonverbal strategies to facilitate nurse-client communication are discussed in later chapters.
Ethical Dilemma
What Would You Do?
Katy Collins, RN, is a new grad who learns that a serious error has occurred on her unit that harmed a client. She realizes that if staff continue to follow the existing protocol, there is a risk this error will occur again. In a team meeting lead by an administrator, Katy raises this issue in a tentative manner. The leader speaks in a loud, decisive voice and states he wants input from the staff nurses. However, he glances at the clock, gazes over her head, and maintains a bored expression. Katy gets the message that the administration wants to smooth over the error, bury it, and go on as usual, rather than using resources and time to correct the underlying problem.
1. What ethical principle is being violated in this situation?
2. What message does the administrator's behavior convey?
3. Is his verbal and nonverbal message congruent?
4. What would you do if you were in Katy's place?
## References
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CHAPTER 10
# Developing Therapeutic Communication Skills
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Discuss the concept of therapeutic communication.
2 Describe the characteristics of client-centered communication.
3 Apply communication strategies and skills in client-centered relationships.
4 Discuss active listening responses used in therapeutic communication.
5 Discuss the use of verbal responses as a communication strategy.
6 Describe other forms of communication used in nurse-client relationships.
Communication is an important cornerstone of all clinical encounters. This chapter focuses on therapeutic communication skills and strategies that nurses need to support, educate, and empower people to effectively cope with their health-related issues. The chapter reviews the purpose and components of therapeutic communication, using a client-centered focus. Applications describe active listening responses, verbal communication strategies, and other communication techniques applicable in nurse-client relationships.
## Basic concepts
Therapeutic communication
**Therapeutic communication,** a term first coined by Jurgen Ruesch in 1961, refers to an interactive dynamic process entered into by nurse and client for the purpose of achieving identified health-related goals. It takes place within the context of a healing conversation, and encompasses both verbal and nonverbal components. Therapeutic communication skills serve as fundamental building blocks for the development of effective therapeutic relationships.
It differs from "social chit chat" in that it promotes the client's personal development (Peplau, 1960, p. 964). Therapeutic communication is the primary means through which nurse and client exchange information about health matters, plan treatment approaches, reach consensus about treatment decisions, conduct treatment activities, and evaluate clinical outcomes. It is the basis for developing the working partnerships between client and health providers needed to support improved treatment outcomes.
Each therapeutic conversation is unique because the people holding them are different (Caughan & Long, 2000). Communication techniques are similar to those used spontaneously in social situations, with notable modifications. Therapeutic conversations have a specific health related purpose. They take place within a defined health care format and are time limited. These conversations are subject to federal guidelines and professional standards regarding confidentiality and protected information. Characteristics of therapeutic communication are displayed in Figure 10-1. Therapeutic communication is client centered and uses a deliberate, health-focused dialogue. Direct interaction comes to an end when health goals are achieved, clients are discharged, or clients are referred to a different care setting.
Figure 10-1 Characteristics of therapeutic communication.
## Purpose of therapeutic communication
Therapeutic conversations offer a safe, empathetic way for clients to explore the meaning of their illness experience and to learn the best ways of coping with it. Therapeutic conversations tell the story of a personal illness, with nurse and client both contributing to the telling of it.
Quality clinical communication is essential to achieving positive health outcomes and client satisfaction. Interpersonal communication skills influence the completeness of diagnostic information, compliance with treatment, and client satisfaction with care. "Good" clinical experiences typically involve human communication encounters in which human needs are respected and the humanity of the clinician is transparent. With "negative" clinical encounters, clients experience disconnects with the knowledge and interpersonal care the client or family expects from the provider. Poor communication is implicated as a key factor in clinical safety errors and malpractice allegations.
### Essential components
Fundamental components of communication—sender, receiver, message, channels, and context—are also applied to therapeutic communication. Therapeutic communication is a reciprocal process that begins with active listening (Bush, 2001). Active listening combines verbal and nonverbal components of a message into an integrated, meaningful whole.
**Active listening** is a dynamic process in which a nurse hears a client's message, decodes its meaning, asks questions for clarification, and provides feedback to the client. Active listening allows people to offer presence and to bear witness to one another (Kagan, 2008). Attentive listening for the client's perspective without making judgments and also using listening responses increase understanding.
The goal of active listening is to fully understand what the client is trying to communicate through his or her story. As you ask clarifying questions and share your own thinking process about what you are hearing, you are developing a more in-depth understanding of the health care situation from the client's perspective.
Included in each participant's communicated message are important nonverbal instructions ( **metacommunication** ) about the interpretation of the message. If a nurse sits down in a relaxed position with good eye contact and actively listens, the verbal and nonverbal message of interest is congruent. The same verbal message, delivered while looking at the clock or a watch, provides a nonverbal message that the nurse doesn't have time to listen. When verbal and the nonverbal messages are congruent, the message is credible. If the two are incongruent, it creates doubt in the mind of the listener, and the message is suspect. If you notice nonverbal behaviors that seem to contradict words, or the client seems sad or distracted, you might want to call the client's attention to the discrepancy with a simple statement, such as, "You seemed quite animated yesterday; I notice that you seem a little subdued today. Is something going on that we should talk about?"
**Verbal responses** refer to the spoken words people use to communicate with each other. Unlike the written word, they cannot be erased, although they can be explained, or modified. Words are the primary means through which nurse and client will organize data about problems, explore different options, make meaning of experiences, and dialogue with each other. The meaning of words resides in the person who uses them, not in the words themselves. When languages or word connotations differ, meaning changes. Nurses should pay close attention to the client's verbal expression and forms of language (Kettunen, Poskiparta, & Liimatainen, 2001) and mirror them, when possible. Verbal responses should be clear, complete, and easily understandable. Choice of words is important. Words should neither overstate nor understate the situation. Words are not the sole source of meaning. Nadzam (2009) notes, "Communication is not just about what a person says, but how he or she says it" (p. 184). Nurses also need to be sensitive to what is left out of the message, as well as to what is included. How words are used should not cast doubt on the implications of the message. Straightforward messages are trustworthy. Vague messages are not.
Both words and nonverbal behaviors are subject to misinterpretation. Nurses need to check in with clients to ensure the accuracy of their perceptions. You can simply say, "I'd just like to check in with you to make sure that I understand. Are you saying that... ?"
### Factors that affect communication
Personal Factors
Readiness to engage in therapeutic relationships is influenced by personal and environmental factors that the nurse should take into consideration when relating to clients and families. Eye contact, genuine respect for the client, and clear, concise messages are fundamental tools. Words that respect a person's culture, spiritual beliefs, and educational level capture the client's attention. Conversely, words that disregard or dismiss the fundamental personhood of the client or family as being less important than that of the health care provider cause unnecessary damage.
Whether you are sitting or standing, your posture should be relaxed, with the upper part of your body inclined slightly toward the client.
People communicate nonverbally through body language, eye contact, and level of attention. The nurse consciously uses body language, gestures, and minimal verbal cues to encourage further communication. Physical cues are used to accentuate words or connect with people nonverbally, as well as verbally (Box 10-1).
BOX 10-1 Physical Behavioral Cues
Emblems: Gestures or body motions having a generalized verbal interpretation (e.g., handshaking, baby waving bye-bye, sign language).
Illustrators: Actions that accompany and exemplify the meaning of the verbal message. Illustrators are used to emphasize certain parts of the communication (e.g., smiling, a stern facial expression, pounding the fist on a table). Illustrators usually are not premeditated.
Affect displays: Facial presentation of emotional affect. Similar to the illustrators just discussed, the sender has more control over their display (e.g., a reproving look, an alert expression, a smile or a grin, a sneer). Affect displays seem to be more pervasive nonverbal expressions of the client's emotional state. They have a larger range of meaning and act to support or contradict the meaning of the verbal message. Sometimes the generalized affect is not related to a specific verbal message (e.g., a depressed client may have a retarded emotional affect throughout the relationship that has little to do with the communicated message).
Regulators: Nonverbal activities that adjust the course of the communication as the receiver gives important information to the sender about the impact of the message on the sender. Regulators include nodding, facial expressions, some hand movements, and looking at a watch.
Adaptors: Characteristic, repetitive, nonverbal actions that are client specific and of long duration. They give the nurse information about the client's usual response to difficult emotional issues. Sample behaviors include a psychogenic tic, nervous foot tapping, blushing, and twirling the hair.
Physical characteristics: Nonverbal information about the client that can be gleaned from the outward appearance of the person (e.g., skin tone, descriptions of height and weight and relation to body shape, body odor, physical appearance [dirty hair, unshaven, teeth missing or decayed]).
Adapted from Blondis M, Jackson B: _Nonverbal communication with patients: back to the human touch_ (pp. 9–10), ed 2, New York, 1982, Wiley.
Communication breaks down when the nurse or client do not share the same understanding of messages. Barriers to effective communication occur in clients when they are:
• Preoccupied with pain, physical discomfort, worry, or contradictory personal beliefs
• Unable to understand the nurse's use of language or terminology
• Struggling with an emotionally laden topic
• Feeling defensive, insecure, or judged
• Confused by the complexity of the message—too many issues, tangential comments
• Deprived of privacy, especially if the topic is a sensitive one
• Have hearing or cognitive deficits that compromise receiving accurate messages
Barriers within the nurse occur when the nurse is not fully engaged with the client for the following reasons:
• Preoccupation with personal agendas
• Being in a hurry to complete physical care
• Making assumptions about client motivations
• Cultural stereotypes
• Defensiveness or personal insecurity about being able to help the client
• Thinking ahead to the next question
• Client emotionality or aggressiveness
Exercise 10-1 is designed to help students identify difficult communication issues in nursing practice.
EXERCISE 10-1 Identifying Difficult Communication Issues
Purpose: To help students identify common complicated communication issues with clients.
Procedure:
In groups of three to five students:
1. In round robin fashion, each student should share an elevator version of a nursing experience that illustrates a challenging communication encounter you have had or witnessed in a nurse-client encounter.
2. Identify what qualities made it difficult.
3. Describe what you did or would do next time to make it a positive experience for the client, nurse, or both.
Discussion:
1. Were there any common themes that your group found in the identified communication challenges?
2. Explore the insights you gained from doing this exercise.
3. How could you use what you learned from doing this exercise in your future nursing practice?
### Professional self-awareness
Client-centered communication requires greater self-awareness. Nurses must become aware of their behaviors and responses, and recognize the sometimes unintentional effects these may have on the communication process.
Knowing your own biases and values is critical. Communication can be limited by a nurse's standards concerning, for example, different sexual preferences, alcoholism, and teenage pregnancy. Nurses may feel intimidated by clients who have higher social status, education, or influence, and respond in subtle ways to these differences. Caring for clients who refuse to comply with treatment or who have given up can be a communication challenge for the nurse.
Self-awareness of personal prejudices and stereotypes allows nurses to separate the person from the behavior or problem, and to maintain the patience, neutrality, and understanding needed for therapeutic communication. Nurses have an ethical and professional responsibility to resolve personal issues so that countertransference feelings do not affect communication.
### Environmental factors
Privacy, space, and timing are important factors that nurses need to consider. Clients need privacy, free from interruption and elimination of noise for meaningful conversations. "Noise" refers to any distraction, which interferes with being able to pay full attention to the discussion (Weiten, Lloyd, Dunn & Hammer, 2009). For example, TV or music can be distracting.
People require different amounts of personal space for conversation (Hall, 1959). Therapeutic conversations typically take place within a social distance (3–4 feet is optimal). Culture, personal preference, nature of the relationship, and the topic will influence personal space needs. Clients experiencing high anxiety may need more physical space, whereas clients experiencing a sudden physical injury or undergoing a painful procedure appreciate having the nurse in closer proximity. Sitting at eye level with bedridden clients is helpful.
Most conversations take place within a social distance.
Timing is critical. Planning communication for periods when the client is able to participate physically and emotionally is both time-efficient and respectful of the client's needs. Clients must be given enough time to absorb material, to share their impressions, and to ask questions.
Client behavior can cue the nurse about emotional readiness and available energy. The presence of pain or variations in energy levels, anger, or anxiety will require extra time to inquire about the change in the client's behavior and its meaning, before proceeding with the health care dialogue.
## Client-centered communication
Characteristics
Client-centered care and collaborative partnerships in current health care deliverables require a broader span of communication skills. In the past, healing relationships were important sources of clinician information and expertise, which was shared with clients. Today, clients are viewed as equally important informational resources and collaborators in health care. Clients expect emotional support and guidance to assume greater personal responsibility for their health care. They not only require their clinicians to be technically competent; they expect them to be sensitive and accommodating of their concerns and treatment preferences. Clients want to be listened to, involved in their own care, and able to choose between treatment options. Epstein and Street (2007) identify six core, overlapping functions of patient-centered communication needed to achieve beneficial health outcomes.
• Fostering healing relationships
• Exchanging information
• Responding to emotions
• Managing uncertainty
• Making decisions
• Enabling patient self-management (p. 17)
Client-centered communication is an interactive reciprocal exchange of ideas in which nurses try to understand what it is like to be _this_ person in _this_ situation with _this_ illness. Each client and family has its unique set of values, patterns of behavior, and preferences that must be taken into account. How clients communicate with the nurse varies, based on culture and social background factors. Client readiness to learn, personal ways of relating to others, physical and emotional conditions, life experiences, and place in the life cycle are related factors in planning and implementing contemporary care through therapeutic communication.
Client-centered conversations are structured to be person focused rather than problem focused. They include discussions needed for collaborative decision making and teaching clients self-management skills. Talking about complex health problems with a trained health professional allows clients and families to hear themselves, as they put health concerns into words. The feedback provided by the health professional ideally helps clients realistically sort out priorities and determine the actions they want to take in effectively coping with their health circumstances.
### Active listening in client-centered conversations
Active listening is an intentional form of listening, which contributes to fewer incidents of misunderstanding, more accurate information, and stronger health relationships (Straka, 1997). Listening responses in a client-centered health environment ask about _all_ relevant client health concerns, and take into account the client's values, preferences, and expectations related to treatment goals, priorities, and attitudes about treatment suggestions. Queries might include open-ended questions such as "What is important to you now?" or "What are you hoping will happen with this treatment?" Sufficient information to support client decision-making and self-management of health problems is expected. Validation of client preferences might consist of asking the client, "How does the idea of __________ sound to you?" or "How easy will it be for you to learn to use your crutches?" Adding these questions may seem time consuming. If the answers lead to greater compliance and client satisfaction, then it may be more time efficient.
Developing an Evidence-Based Practice
McCabe C: Nurse-patient communication: an exploration of patients' experiences, _J Clin Nurs_ 13:41–49, 2004.
This qualitative study was designed to elicit patient experiences of how nurses communicate. The study used a hermeneutic phenomenologic methodology to analyze data from unstructured interviews. A purposive sample of eight patients in a general hospital was interviewed. The researcher used a reflective process of describing and interpreting themes and subthemes, and yielded four themes related to the patient's experience of how nurses communicated with them.
_Results:_ Identified were lack of communication, attending, empathy, and friendly nurses. The lack of communication perceived by patients related to nurses making assumptions about their concerns and needs.
_Application to Your Clinical Practice:_ As a profession, nurses need to develop patient-centered communication, which involves letting patients know the nurse recognizes their feelings. What steps could you take to ensure that your patients feel heard?
## Applications
Applying concepts of client-centered communication
#### Building rapport
A client-centered communication process starts with the first encounter. Your initial presentation of yourself will influence the communication that follows. Your client should have your full attention. Entering the client's space with an open, welcoming facial expression, respectful tone, and direct eye contact declares your interest and intent to know this person.
Communication involves the whole self. Your posture immediately gives a message to the client, either inviting trust or conveying disinterest. Whether you are sitting or standing, your posture should be relaxed, facing the client and leaning slightly forward.
Introduce yourself and identify the client by name before beginning conversation. Introductions are important, especially if many health professionals are involved in the client's care (Van Servellen, 2009). When more than the client is involved in a discussion, expand the introductions if you are meeting other people for first time. It is important to center your attention on the client, but not ignore other family members. Speak directly to the client, but include family members with eye contact, physical cues, and so forth. Eye contact is an important inclusive gesture.
Keep in mind that clients will vary in their ability to effectively communicate their feelings, preferences, and concerns (Epstein & Street, 2007). Even their willingness to treat their clinicians as partner rather than absolute authority can reflect personality features, communication style, socioeconomic status, previous life experiences, and education level. Considering these factors allows you to phrase questions and interpret answers in meaningful ways.
Being fully present, providing relevant information, and listening to client concerns help build rapport through personalized communication. Clients who feel safe, accepted, and validated by their nurses find it easier to collaborate with them. Although rapport building begins with the initial encounter, it continues as a thread throughout the nurse-client relationship. Remember that clients are looking to you for not only competence, but for sincerity and genuine interest in them as individuals.
A client-centered communication process seeks to understand critical links between the client's life experiences and values, and their current health problems. Nurses should strive to understand the _whole_ person, including information from and about family members affected by the client's illness.
The goal of client-centered communication is to find common ground related to identification of client problems, priorities, and treatment goals. Nurses need to understand what aspects of care are most important to a client and family, and what helps or hinders their capability to self-manage their health problems. Clients need to understand the full range of therapeutic choices available to them in treating and self-managing their illness.
The idea of health care as a shared partnership in which the client is an _equal_ stakeholder and communicator in ensuring quality health care is relatively new. Building rapport requires:
• Empathetic objectivity, which allows you to experience clients as they are, not the way you would like them to be
• A "here and now" focus on the current issues and client concerns
• Demonstration of respect, and asking questions about cultural and social differences that can influence treatment
• Authentic interest in the client and a confident manner that communicates competence
• The capability to consider competing goals and alternative ways to meet them
Exercise 10-2 is designed to increase the student's understanding of communication strategies using a client-centered focus.
EXERCISE 10-2 Using Client-Centered Communication Role-Play
Purpose: To use client-centered communication strategies.
Procedure:
1. Develop a one-paragraph scenario of a client situation that you are familiar with before class.
2. Pair off as client and nurse.
3. Conduct an initial _client-centered_ 15-minute assessment interview using one of the scenarios, with the author of the paragraph taking the role of the nurse and the other student taking the client role.
4. Reverse roles and repeat with the second student's scenario.
Discussion:
1. In what ways were client-centered communication strategies used in this role-play?
2. How awkward was it for you in the nursing role to incorporate queries about the client's preferences, values, and so on?
3. What parts of the interview experience were of greatest value to you when you assumed the client role?
4. If you were conducting an assessment interview with a client in the future, what modifications might you make?
5. How could you use what you learned from doing this exercise in future nurse-client interviews?
### Observation
There are different "channels" of nonverbal communication (e.g., facial expressions, vocal tones, gestures and body positions, body movements, touch, and personal space). Take note of whether cues such as the client's facial expression, body movements, posture, and breathing rate support or negate the meaning of the spoken message.
Burgoon, Guerrero, & Floyd (2009) note up to 65% of interpersonal communication is nonverbal. Clients cannot always put their concerns into words. Some are not aware of them. Others experience powerful emotions that make verbalizing personal concerns difficult. Watch for nonverbal cues from the client. Changes in body language and nonverbal cues noted when the nurse or clinician is speaking can indicate discomfort with the message. The client who declares that he is ready for surgery and seems calm may be sending a different message through the tense muscles the nurse accidentally touches. This body language cue suggests that the client may be worried about the surgery. Environmental cues such as a half-eaten lunch or noncompliance with treatment can provide nonverbal evidence that a client is in distress. Calling attention to conflicting verbal and nonverbal responses is useful if done in a spirit of tentative inquiry. You might note that the client seems nervous or is not paying attention to what you are saying. Inquire about your perception: "I'm wondering what you are feeling right now, about what I am saying," or "I noticed when I mentioned __________, your expression changed." (Weiten, Lloyd, Dunn, & Hammer, 2009). Nonverbal behaviors and signals are culture bound so they may mean different things in different cultures (Samovar, Porter, & McDaniel, 2009). Exercise 10-3 provides practice with observing and interpreting the meaning of nonverbal behaviors.
EXERCISE 10-3 Observing for Nonverbal Cues
Purpose: To develop skill in interpreting nonverbal cues.
Procedure:
1. Watch a dramatic movie (that you haven't seen before) with the sound off for 15 minutes.
2. As you watch the movie, write down the emotions you see expressed, the associated nonverbal behavior, and your interpretations of the meaning and the other person's response.
Discussion:
In a large group, share your observations and interpretations of the scenes watched. Discussion should focus on the variations in the interpretations of the nonverbal language. Discuss ways in which the nurse can use observations of nonverbal language with a client in a therapeutic manner to gain a better understanding of the client. Time permitting, the movie segment could be shown again, this time with the sound. Discuss any variations in the interpretations without sound versus with verbal dialogue. Discuss the importance of validation of nonverbal cues.
### Asking questions
A client-centered interview begins with encouraging clients to tell their story in an authentic way (Platt & Gaspar, 2001). Applicable questions are a primary means of helping clients tell their story, obtaining relevant information, and reducing misunderstandings. There are different ways of asking questions. Questions fall into three categories: open ended, closed ended, and circular.
#### Open-Ended Questions
**Open-ended questions** encourage the client to take the initiative. An open-ended question is similar to an essay question on a test. It is open to interpretation and cannot be answered by "yes," "no," or a one-word response. Questions are designed to permit the client to express the problem or health need in his or her own words. They usually begin with words such as "what," "why, "how," "can you describe for me..." etc. Telling the story of an illness rather than listing discrete facts helps the client and nurse link the context of a health disruption with symptoms and provides more complete information. Open-ended questions ask the client to think and reflect on their situation. They help connect relevant elements of the client's experience (e.g., relationships, impact of the illness on self or others, environmental barriers, potential resources). Open-ended questions are used to elicit the client's thoughts and perspectives without influencing the direction of an acceptable response. For example,
"Can you tell me what brought you to the clinic (hospital) today?"
"What has it been like for you since the accident?"
"Where would you like to begin today?"
"What can I do to help you?"
These questions are general, rather than specific, and open to a variety of answers. An open-ended question is usually just the introduction, requiring further dialogue about relevant topics. Ending the dialogue with a general open-ended question, such as "Is there anything else that is concerning you right now?" can provide relevant information that might otherwise be overlooked. Look for tone of voice, body movements, and so on as clues to the level of anxiety. Exercise 10-4 provides an opportunity to practice the use of open-ended questions.
EXERCISE 10-4 Asking Open-Ended Questions
Purpose: To develop skill in the use of open-ended questions to facilitate information sharing.
Procedure:
1. Break up into pairs. Role-play a situation in which one student takes the role of the facilitator and the other the sharer. (If you are in the clinical area, you may want to choose a clinical situation.)
2. As a pair, select a topic. The facilitator begins asking open-ended questions.
3. Dialogue for 5 to 10 minutes on the topic.
4. In pairs, discuss perceptions of the dialogue and determine what questions were comfortable and open ended. The student facilitator should reflect on the comfort level experienced with asking each question. The sharing student should reflect on the efficacy of the listening responses in helping to move the conversation toward his or her perspective.
Discussion:
As a class, each pair should contribute examples of open-ended questions that facilitated the sharing of information. Compile these examples on the board. Formulate a collaborative summation of what an open-ended question is and how it is used. Discuss how open-ended questions can be used sensitively with uncomfortable topics.
#### Focused Questions
Focused questions require more than a yes or no answer, but place limitations on the topic to be addressed. Emergencies or other circumstances requiring immediate answers involve the use of focused or closed-ended questions. Focused questions can clarify the timing and sequence of symptoms, and concentrate on details about a client's health concerns, for example, when symptoms began, what other symptoms the client is having, or what the client has done to date to resolve the problem. Clients with limited verbal skills sometimes respond better to focused questions because they require less interpretation. Examples include:
"Tell me more about the pain in your arm."
"Can you give me a specific example of what you mean by... ?"
Focused questions can be used to help clients prioritize immediate concerns; for example, "Of all the concerns we have talked about today, which is the most difficult for you?"
Circular questions are a form of focused questions that give attention to the interpersonal context in which an illness occurs. They identify differences in the impact of an illness on individual family members or changes in relationship brought about by the health circumstances (see Chapter 13).
#### Closed-Ended Questions
**Closed-ended questions** narrow the focus of the question to a single answer, for example, yes, no, or simple phrase answer. They are useful in emergency situations, when the goal is to obtain information quickly, and the context or client's emotional reactions are of secondary importance in the immediate situation. Examples of closed-ended questions include:
"Does the pain radiate down your left shoulder and arm?"
"When was your last meal?"
### What the nurse listens for
Themes
Box 10-2 identifies what the nurse listens for in client-centered conversations. Therapeutic communication involves both intrapersonal and interpersonal processes. As Myers (2000) suggests, "Any actual dialogue has an inner, subjectively experienced component" (p. 151). Intrapersonal communication refers to the internal processing that goes on within a person about the underlying feeling or core idea associated with the verbal message. It is not usually intentionally expressed.
BOX 10-2 Guidelines to Effective Verbal Expressions in the Nurse-Client Relationship
• Define unfamiliar terms and concepts.
• Match content and delivery with each client's developmental and educational level, experiential frame of reference, and learning readiness.
• Keep messages clear, concrete, honest, and simple to understand.
• Put ideas in a logical sequence of related material.
• Relate new ideas to familiar ones when presenting new information.
• Repeat key ideas.
• Reinforce key ideas with vocal emphasis and pauses.
• Keep language as simple as possible; use vocabulary familiar to the client.
• Focus only on essential elements; present one idea at a time.
• Use as many sensory communication channels as possible for key ideas.
• Make sure that nonverbal behaviors support verbal messages.
• Seek feedback to validate accurate reception of information.
Listening for themes requires observing and understanding what the client is not saying, as well as what the person actually reveals. Identifying the underlying themes presented in a therapeutic conversation can relieve anxiety and provide direction for individualized nursing interventions. For example, the client may say to the nurse, "I'm worried about my surgery tomorrow." This is one way of framing the problem. If the same client presents his concern as "I'm not sure I will make it through the surgery tomorrow," the underlying theme of the communication changes from a generalized worry to a more personal theme of survival. Alternatively, a client might say, "I don't know whether my husband should stay tomorrow when I have my surgery. It is going to be a long procedure, and he gets so worried." The theme (focus) expresses her concern about her relationship with her husband. In each communication, the client expresses a distinct theme of concern related to a statement, but the emphasis in each requires a different response.
Emotional objectivity in making sense of client themes is essential. "Objectivity here refers to seeing what an experience is for another person, not how it fits or relates to other experiences, not what causes it, why it exists, or what purposes it serves. It is an attempt to see attitudes and concepts, beliefs and values of an individual as they are to him at the moment he expresses them—not what they were or will become" (Moustakas, 1974, p. 78). Exercise 10-5 provides practice in listening for themes.
EXERCISE 10-5 Listening for Themes
Purpose: To help students identify underlying themes in messages.
Procedure:
1. Divide into groups of three to five students.
2. Take turns telling a short story about yourselves—about growing up, important people or events in your life, or significant accomplishments (e.g., getting your first job).
3. As each student presents a story, take mental notes of the important themes. Write them down so you will not be tempted to change them as you hear the other students. Notice nonverbal behaviors accompanying the verbal message. Are they consistent with the verbal message of the sharer?
4. When the story is completed, each of the other people in the group shares his or her observations with the sharer.
5. After all students have shared their observations, validate their accuracy with the sharer.
Discussion:
1. Were the underlying themes recorded by the group consistent with the sharer's understanding of his or her communication?
2. As others related their interpretations of significant words or phrases, did you change your mind about the nature of the underlying theme?
3. Were the interpretations of pertinent information relatively similar or significantly different?
4. If they were different, what implications do you think such differences have for nurse-client relationships in nursing practice?
5. What did you learn from doing this exercise?
### Communication patterns
Communication patterns provide a different type of information. Some clients exaggerate information; others characteristically leave out highly relevant details. Some talk a lot, using dramatic language and multiple examples; others say very little and have to be encouraged to provide details. Evaluation of the client's present overall pattern of interaction with others includes strengths and limitations, family communication dynamics, and developmental and educational levels. Culture, role, ways of handling conflict, and ways of dealing with emotions reflect and influence communication patterns. Being respectful of the client's communication pattern involves accepting the client's communication style as a part of who the person is, and not expecting the person to be different. For example, AJ is a client with chronic mental illness. She frequently interrupts and presents with a loud, ebullient opinion on most things. This is AJ's communication pattern. To engage successfully with her, you would need to listen, while accepting her way of communicating as a part of who she is, without getting lost in detail.
### Using intuitive feelings
Intuitive feelings can emerge as a personal listening response from within the nurse during the course of a conversation with a client or family. Personal ways of knowing represent a body-centered way of listening to feelings about underlying issues and concerns (Klagsbrun, 2001). For example, if a nurse has no particular personal reason for reacting to the client with anger, fear, or sadness, this inner response may reflect a client's unexpressed feeling. Behavioral reactions that the nurse feels are out of proportion to the situation (e.g., complete calm before surgery, excessive anger, noncompliance or passive compliance with no questions asked, guarded verbalizations, incongruent facial expressions or body language, or social withdrawal) can be danger signals that need further exploration.
## Active listening responses
Active listening responses show the client that the nurse is fully present as a professional partner in helping the client understand a change in health status and the best ways to cope with it (Keller & Baker, 2000). Minimal verbal cues, clarification, restatement, paraphrasing, reflection, summarization, silence, and touch are examples of skilled listening responses nurses can use to guide therapeutic interventions (Table 10-1).
TABLE 10-1
Listening Responses
### Minimal cues and leads
Simple, encouraging leads communicate interest. **Minimal cues** transmitted through body actions (e.g., smiling, nodding, and leaning forward) encourage clients to continue with their story. By not detracting from the client's message and by giving permission to tell the story as the client sees it, minimal cues promote client comfort in sharing intimate information. Short phrases such as "Go on" or "And then?" or "Can you say more about... ?" are useful prompts. Exercise 10-6 provides an opportunity to see the influence of minimal cues and leads on communication.
EXERCISE 10-6 Minimal Cues and Leads
Purpose: To practice and evaluate the efficacy of minimal cues and leads.
Procedure:
1. Initiate a conversation with someone outside of class and attempt to tell the person about something with which you are familiar for 5 to 10 minutes.
2. Make note of all the cues that the person puts forth that either promote or inhibit conversation.
3. Now try this with another person and write down the different cues and leads you observe as you are speaking and your emotional response to them (e.g., what most encouraged you to continue speaking).
Discussion:
As a class, share your experience and observations. Different cues and responses will be compiled on the board. Discuss the impact of different cues and leads on your comfort and willingness to share about yourself. What cues and leads promoted communication? What cues and leads inhibited sharing?
Variation:
This exercise can be practiced with a clinical problem simulation in which one student takes the role of the professional helper and the other takes the role of client. Perform the same scenario with and without the use of minimum encouragers. What were the differences when encouragers were not used? Was the communication as lively? How did it feel to you when telling your story when this strategy was used by the helping person?
### Clarification
Clarification seeks to understand the message of the client by asking for more information or for elaboration on a point. The strategy is most useful when parts of a client's communication are ambiguous or not easily understood. Failure to ask for clarification when part of the communication is poorly understood means that the nurse will act on incomplete or inaccurate information.
Clarification listening responses are expressed as a question or statement followed by a restatement or paraphrasing of part of the communicated message; for example, "You stated earlier that you were concerned about your blood pressure. Tell me more about what concerns you." The tone of voice used with a clarification response should be neutral, not accusatory or demanding. Practice this response in Exercise 10-7.
EXERCISE 10-7 Using Clarification
Purpose: To develop skill in the use of clarification.
Procedure:
1. Write a paragraph related to an experience you have had.
2. Place all the student paragraphs together and then pick one (not your own).
3. Develop clarification questions you might ask about the selected paragraph.
Discussion:
Share with the class your chosen paragraph and the clarification questions you developed. Discuss how effective the questions are in clarifying information. Other students can suggest additional clarification questions.
### Restatement
Restatement is an active listening strategy used to broaden a client's perspective or when the nurse needs to provide a sharper focus on a specific part of the communication. Restatement is particularly effective when the client overgeneralizes or seems stuck in a repetitive line of thinking. To challenge the validity of the client's statement directly could be counterproductive, whereas repeating parts of the message in the form of a query serves a similar purpose without raising defenses; for example, "Let me see if I have this right..." (Coulehan et al., 2001). Restating a self-critical or irrational part of the message in a questioning manner focuses the client's attention on the possibility of an inaccurate or global assertion.
### Paraphrasing
**Paraphrasing** is a response strategy used to check whether the nurse's translation of the client's words is an accurate interpretation of the message. The strategy involves the nurse taking the client's original message and transforming it into his or her own words, without losing the meaning. The paraphrase is shorter and more specific than the client's initial statement so that the focus is on the core elements of the original statement.
Case Example
_Client:_ "I don't know about taking this medicine the doctor is putting me on. I've never had to take medication before, and now I have to take it twice a day.
_Nurse:_ It sounds like you don't know what to expect from taking the medication.
### Reflection
**Reflection** as a listening response focuses on the emotional implications of a message. This listening response helps the client clarify important feelings and experience them with their appropriate intensity in relation to a particular situation or event. There are several ways to use reflection, for example:
• _Reflection on vocal tone:_ "I can sense anger and frustration in your voice as you describe your accident."
• _Linking feelings with content:_ "It sounds like you feel ___________ because _____________."
• _Linking current feelings with past experiences:_ "It seems as if this experience reminds you of feelings you had with other health care providers where you didn't feel understood."
Reflection as a listening response gives clients permission to have feelings and helps them to identify feelings they may not be aware of in new and unfamiliar circumstances. Sometimes nursing students feel they are putting words into the client's mouth when they "choose" an emotion from their perception of the client's message. This would be true if you were choosing an emotion out of thin air, but not when the nurse empathetically considers the client's situation and presents the underlying feelings present in the client's narrative, without interpreting its meaning. Exercise 10-8 provides practice in using paraphrasing and reflection as listening responses.
EXERCISE 10-8 Role-Play Practice with Paraphrasing and Reflection
Purpose: To practice use of paraphrasing and reflection as listening responses.
Procedure:
1. The class forms into groups of three students each. One student takes the role of client, one the role of nurse, and one the role of observer.
2. The client shares with the nurse a recent health problem he or she encountered, and describes the details of the situation and the emotions experienced. The nurse responds, using paraphrasing and reflection in a dialogue that lasts at least 5 minutes. The observer records the statements made by the helper. At the end of the dialogue, the client writes his or her perception of how the helper's statements affected the conversation, including what comments were most helpful. The helper writes a short summary of the listening responses he or she used, with comments on how successful they were.
Discussion:
1. Share your summary and discuss the differences in using the techniques from the helper, client, and observer perspectives.
2. Discuss how these differences related to influencing the flow of dialogue, helping the client feel heard, and the impact on the helper's understanding of the client from both the client and the helper positions.
3. Identify places in the dialogue where one form of questioning might be preferable to another.
4. How could you use this exercise to understand your client's concerns?
5. Were you surprised by any of the summaries?
### Summarization
Summarization is an active listening skill used to review content and process. Summarization pulls several ideas and feelings together, either from one interaction or a series of interactions, into a few succinct sentences. This would be followed by a comment seeking validation, such as "Tell me if my understanding of this agrees with yours." A summary statement is useful as a bridge to changing the topic or focus of the conversation. The summarization should be completed before the end of the conversation. A summary statement should not be delivered as the nurse leaves the room. Exercise 10-9 is designed to provide insight into the use of summarization as a listening response.
EXERCISE 10-9 Practicing Summarization
Purpose: To provide practice in summarizing interactions.
Procedure:
1. Choose a partner for a pairs discussion.
2. For 10 minutes, discuss a medical ethics topic such as euthanasia, heroic life support for the terminally ill, or "Baby Doe" decisions to allow malformed babies to die if the parents desire.
3. After 10 minutes, both partners must stop talking until Participant A has summarized what Participant B has just said to Participant B's satisfaction, and vice versa.
Discussion:
After both partners have completed their summarizations, discuss the process of summarization, answering the following questions:
1. Did knowing you had to summarize the other person's point of view encourage you to listen more closely?
2. Did the act of summarizing help clarify any discussion points? Were any points of agreement found? What points of disagreement were found?
3. Did the exercise help you to understand the other person's point of view?
4. What should an effective summary contain? Is it hard to summarize a long conversation?
5. How did you determine which points to focus on in your summarization?
### Silence
Silence, used deliberately and judiciously, is a powerful listening response. Intentional pauses can allow the client to think. A short pause also lets the nurse step back momentarily and process what he or she has heard before responding. Too often a quick response addresses only a small part of the message or gives the client an insufficient opportunity to formulate an idea fully.
Silence can be used to emphasize important points that you want the client to reflect on. By pausing briefly after presenting a key idea and before proceeding to the next topic, you can encourage a client to notice vital elements. When a client falls silent, it can mean many things: something has touched the client, the client is angry or does not know how to respond, or the client is thinking. A verbal comment to validate meaning is helpful. Exercise 10-10 provides practice with the use of silences.
EXERCISE 10-10 Therapeutic Use of Silence
Purpose: To experience the effect of the use of silence as a listening response.
Procedure:
1. Two people act as Participants A and B.
2. Participant A plays the role of the nurse. Participant B is a healthy, ambulatory, 80-year-old female client in an extended-care facility who was placed there against her will by her family, who are moving to another state.
3. Participant B's role is to describe feelings (shock) at being institutionalized and to discuss the slow adjustment to new surroundings and new companions, describing both the positive and the negative aspects.
4. Participant A's objective is to make at least three deliberate efforts to use silence during the conversation (as a therapeutic device to encourage Participant B's consideration of life and problems).
Discussion:
After 10 minutes of role-playing, have a general discussion to share feelings about the effective use of silence.
Not all listening responses are helpful. Nurses need to recognize when their responses are interfering with objectivity or inviting premature closure. Table 10-2 provides definitions of negative listening responses that block communication. Exercise 10-11 provides practice with using active listening responses.
EXERCISE 10-11 Active Listening
Purpose: To develop skill in active listening and an awareness of the elements involved.
Procedure:
1. Students break up into pairs. Each will take a turn reflecting on and describing an important experience they have had in their lives. The person who shares should describe the details, emotions, and outcomes of his or her experience. During the interaction, the listening partner should use listening responses such as clarification, paraphrasing, reflection, and focusing, as well as attending cues, eye contact, and alert body posture to carry the conversation forward.
2. After the sharing partner finishes his or her story, the listening partner indicates understanding by: (a) stating in his or her own words what the sharing partner said; and (b) summarizing perceptions of the sharing partner's feelings associated with the story and asking for validation. If the sharing partner agrees, then the listening partner can be sure he or she correctly utilized active listening skills.
Discussion:
In the large group, have pairs of students share their discoveries about active listening. As a class, discuss aspects of nursing behavior that will foster active listening in client interactions.
TABLE 10-2
Negative Listening Responses
Category of Response | Explanation of Category | Examples
---|---|---
False reassurance | Using pseudocomforting phrases in an attempt to offer reassurance | "It will be okay." "Everything will work out."
Giving advice | Making a decision for a client; offering personal opinions; telling a client what to do (using phrases such as "ought to," "should") | "If I were you, I would..." "I feel you should..."
False inferences | Making an unsubstantiated assumption about what a client means; interpreting the client's behavior without asking for validation; jumping to conclusions | "What you really mean is you don't like your physician." "Subconsciously, you are blaming your husband for the accident."
Moralizing | Expressing your own values about what is right and wrong, especially on a topic that concerns the client | "Abortion is wrong." "It is wrong to refuse to have the operation."
Value judgments | Conveying your approval or disapproval about the client's behavior or about what the client has said using words such as "good," "bad," or "nice" | "I'm glad you decided to..." "That really wasn't a nice way to behave." "She's a good patient."
Social responses | Polite, superficial comments that do not focus on what the client is feeling or trying to say; use of clichés | "Isn't that nice?" "Hospital rules, you know?" "Just do what the doctor says." "It's a beautiful day."
## Verbal responses
Active listening and verbal responses are inseparable from each other. Each informs and reinforces the other. Table 10-3 presents a summary of the therapeutic interviewing skills presented in this chapter as they apply to the phases of the nurse-client relationship. With shorter time frames for client contact, nurses need to verbally connect with clients, beginning with the first encounter.
TABLE 10-3
Interviewing and Relationship Skills
As the relationship develops, the quality of verbal and listening responses ensure that care remains client centered. Most clients are not looking for brilliant answers from the nurse, but rather seek feedback and support that suggests a compassionate understanding of their particular dilemma. No matter what level of communication exists in the relationship, the same needs—"hear me," "touch me," "respond to me," "feel my pain and experience my joys with me"—are fundamental themes. These are the themes addressed by client-centered communication.
Nurses use verbal responses to teach, encourage, support, provide and gather information, in guiding a client toward goal achievement. Words help clients assess the healthy elements of their personality (their strengths) and enables them to use these elements in coping with their current health problems. Accurate, appropriate language is critical for informed consent.
Verbal response strategies include mirroring, focusing, metaphors, humor, reframing, feedback, and validation, all of which are designed to strengthen the coping abilities of the client, alone or in relationship with others. Nurses use observation, validation, and patterns of knowing to gauge the effectiveness of verbal interventions. On the basis of the client's reaction, the nurse may decide to use simpler language or to try a different strategy in collaboratively working with a client.
When making verbal responses or providing information, do not overload the client with too many ideas or details. If you find you are doing most of the talking, you need to back up and use listening responses to elicit the client's perspective. People can absorb only so much information at one time, particularly if they are tired, fearful, or discouraged. Introducing new ideas one at a time allows the client to process data more efficiently. Repeating key ideas and reinforcing information with concrete examples facilitates understanding and provides an additional opportunity for the client to ask questions. Paying attention to nonverbal response cues from the client that support understanding or that reflect a need for further attention is an important dimension of successful communication.
### Matching responses
Regardless of content, the nurse's verbal responses should match the client's message in level of depth, meaning, and language (Johnson, 1980). The client needs to lead the way to any exploration of deeper feeling. If the client makes a serious statement, the nurse should not respond with a flip remark. Likewise, a superficial statement does not warrant an intense response. Responses that encourage a client to explore feelings about limitations or strengths at a slightly deeper but related level of conversation are likely to meet with more success.
Verbal response should neither expand nor diminish the meaning of the client's remarks. Notice the differences in the nature of the following responses to a client.
Case Example
_Client:_ I feel so discouraged. No matter how hard I try, I still can't walk without pain on the two parallel bars.
_Nurse:_ You want to give up because you don't think you will be able to walk again.
At this point, it is unclear that the client wants to give up, so the nurse's comment expands on the client's meaning without having sufficient data to support it. Although it is possible that this is what the client means, it is not the only possibility. The more important dilemma for the client may be whether his or her efforts have any purpose. The next response focuses only on the negative aspects of the client's communication and ignores the client's comment about his or her efforts.
_Nurse:_ So you think you won't be able to walk independently again.
In the final response example below, the nurse addresses both parts of the client's message and makes the appropriate connection. The nurse's statement invites the client to validate the nurse's perception.
_Nurse:_ It sounds to me as if you don't feel your efforts are helping you regain control over your walking.
### Using understandable language
Using simple, clear-cut words, keeping the client's developmental and educational level in mind, and speaking with a general spirit of inquiry and concern for the client stimulates trust. Verbal messages should address core issues in a comprehensible, concise manner, taking into account the guidelines for effective verbal expressions, listed in Box 10-3.
BOX 10-3 What the Nurse Listens For
• Content themes
• Communication patterns
• Discrepancies in content, body language, and vocalization
• Feelings, revealed in a person's voice, body movements, and facial expressions
• What is not being said, as well as what is being said
• The client's preferred representational system (auditory, visual, tactile)
• The nurse's own inner responses
• The effect communication produces in others involved with the client
Avoid using jargon or clinical language that clients may have trouble understanding. Unless clients can associate new ideas with familiar words and ideas that have meaning to him or her, the nurse might as well be talking in a different language. Clients may not tell the nurse that they do not understand for fear of offending the nurse or revealing personal deficits. Giving information that fails to take into account a client's previous experiences, or assumes that clients have knowledge they do not possess, tends to fall on deaf ears. Frequent validation with the client related to content helps reduce this problem.
### Focusing
In the past, nurses had more time to talk with clients. In today's health care delivery system, nurses must make every second count. It is important for nurses and clients to select the most pressing health care topics for discussion. For example, the nurse can redirect the conversation to immediate nursing needs.
Case Example
"Mr. Solan, you have given me a lot to think about here, but I would like to hear more about how you are handling the surgery tomorrow. You mentioned that you were feeling afraid, and this is normal. I wonder if we could talk more about this."
Sensitivity to client need and preferences, and client readiness are factors to take into consideration. You should not force a client to focus on an issue that he or she is not yet willing to discuss unless it is an emergency situation. You can always go back to a topic when the client is more receptive. For example, you might say, "I can understand that this is a difficult topic for you, but I am here for you if you would like to discuss [identified topic] later."
### Presenting reality
Presenting reality to a client who is misinterpreting it can be helpful as long as the client does not perceive that the nurse is criticizing the client's perception of reality. A simple statement such as "I know that you feel very strongly about ___________, but I don't see it that way" is an effective way for the nurse to express a different interpretation of the situation. Another strategy is to put into words the underlying feeling implied but not directly stated.
Case Example
_Client:_ I can't talk to anyone around here. All you people seem to care about is the money, not the patient.
_Nurse:_ It sounds like you are really feeling all alone right now.
### Giving feedback
**Feedback** is a message given by the nurse to the client in response to a message or observed behavior. Feedback can focus on the content, the relationship between people and events, the feelings generated by the message, or parts of the communication that are not clear. Feedback should be specific and directed to the behavior. It should not be an analysis of the client's motivations.
Feedback responses reassure the client that the nurse is directing full attention to what the client is communicating through words or nonverbal behavior. Verbal feedback provides the receiver's understanding of the sender's message and personal reaction to it. Effective feedback offers a neutral mirror, which allows a client to view a problem or behavior from a different perspective. Feedback is most relevant when it only addresses the topics under discussion and does not go beyond the data presented by the client.
Effective feedback is specific rather than general. Telling a client he or she is shy or easily intimidated is less helpful than saying, "I noticed when the anesthesiologist was in here that you didn't ask her any of the questions you had about your anesthesia tomorrow. Let's look at what you might want to know and how you can get the information you need." With this response, the nurse provides precise information about an observed behavior and offers a solution. The client is more likely to respond with validation or correction, and the nurse can provide specific guidance.
Feedback can be about the nurse's observations of nonverbal behaviors; for example, "You seem (angry, upset, confused, pleased, sad, etc.)." It can be framed as a question, requiring the client to elaborate; for example, "I want to be sure that we have the same understanding of what we have talked about. Can you summarize for me what we have discussed?"
Not all feedback is equally relevant, nor is it always uniformly accepted. The benchmark for deciding whether feedback is appropriate is to ask, "Does the feedback advance the goals of the relationship?" and "Does it consider the individualized needs of the client?" If the answer to either question is "no," then the feedback may be accurate but inappropriate for the moment.
Timing of feedback is important. Feedback given as soon as possible after a behavior is observed is most effective. Other factors (e.g., a client's readiness to hear feedback, privacy, and the availability of support from others) contribute to effectiveness. Providing feedback about behaviors over which the client has little control only increases the client's feelings of low self-esteem and leads to frustration. Feedback should be to the point and empathetic.
Case Example
An obese mother in the hospital was feeding her newborn infant 4 ounces of formula every 4 hours. She was concerned that her child vomited a considerable amount of the undigested formula after each feeding. Initially, the nursing student gave the mother instructions about feeding the infant no more than 2 ounces at each feeding in the first few days of life, but the mother's behavior persisted, and so did that of her infant. The nursing student began to ask questions and discovered that the client's mother had fed her 4 ounces right from birth with no problem, and she considered this the norm. This additional information helped the nurse work with the client in seeing the uniqueness of her child and understanding what the infant was telling her through his behavior. The client began to feel comfortable and confident in feeding her infant a smaller amount of formula consistent with his needs.
Effective feedback is clear, honest, and reflective. Feedback supported with realistic examples is believable, whereas feedback without documentation to support it can lack credibility. To illustrate from your nursing school experience, if you were told that you would have no trouble passing any of the exams in nursing school, you would wonder whether the statement was true. However, if your instructor said, "On the basis of past performance and the fact that your score on the entrance exams was high, I think you should have little problem with our tests as long as you study," you would have more confidence in the statement.
Nonverbal feedback registers the other's reaction to the sender's message through facial expressions such as surprise, boredom, or hostility. When you receive nonverbal messages suggesting uncertainty, concern, or inattention, use a listening response to fully inquire about what the client is having trouble understanding. Feedback can have a surprise twist leading to an unexpected conclusion, as shown in the following example.
Case Example
It was Jovan's third birthday. There was a party of adults (his mother and father; his grandparents; his great-uncle and great-aunt; and me, his aunt), because Jovan was the only child in the family. While we were sitting and chatting, Jovan was running around and playing. At a moment of complete silence, Jovan's great-uncle asked him solemnly: "Jovan, who do you love the best?" Jovan replied, "Nobody!" Then Jovan ran to me and whispered in my ear: "You are Nobody!" (Majanovic-Shane, 1996, p. 11).
### Asking for validation
Meanings are in people, not in the words themselves. Validation is a special form of feedback, used to ensure that both participants have the same basic understanding of messages. Simply asking clients whether they understand what was said is not an adequate method of validating message content. Instead, you might ask, "How do you feel about what I just said?" or "I'm curious what your thoughts are about what I just told you." If the client does not have any response, you can suggest that the client can respond later, "Many people do find they have reactions or questions about [the issue] after they have had a chance to think about it. I would be glad to discuss this further." Validation can provide new information that helps the nurse frame comments that match the client's need.
Case Example
_Mr. Brown_ (to nurse taking his blood pressure): I can't stand that medicine. It doesn't sit well. (He grimaces and holds his stomach.)
_Nurse:_ Are you saying that your medication for lowering your blood pressure upsets your stomach?
_Mr. Brown:_ No, I just don't like the taste of it.
Sometimes validation is observational rather than expressed through words.
Case Example
Jane Smith has been coming to the clinic to lose weight. At first she was quite successful, losing 2 pounds per week. This week she has gained 3 pounds. The nurse validates the weight change with the client and asks for input.
_Nurse:_ Jane, over the past 6 weeks you have lost 2 pounds per week, but this week you gained 3 pounds. There seems to be a problem here. Let's discuss what might have happened and how you can get back on track with your goal of losing weight.
## Other forms of communication
Touch
Touch, the first of our senses to develop, and the last to leave, is a nurturing form of communication and validation. Intentional comforting touch benefits the nurse, as well as the client (Connor & Howett, 2009). Touch is a powerful listening response used when words would break a mood or when verbalization would fail to convey the empathy or depth of feeling between nurse and client (Straneva, 2000). A hand placed on a frightened mother's shoulder or a squeeze of the hand can speak far more eloquently than words in times of deep emotion. Touch stimulates comfort, security, and a sense of feeling valued (Sundin & Jansson, 2003). Clients in pain, those who feel repulsive to others because of altered appearance, lonely and dying clients, and those experiencing sensory deprivation or feeling confused respond positively to the nurse who is unafraid to enter their world and touch them. Children and the elderly are comforted by touch.
Case Example
"I found out that if I held Sam's hand he would lie perfectly still and even drift off to sleep. When I sat with him, holding his hand, his blood pressure and heart rate would go down to normal and his intracranial pressure would stay below 10. When I tried to calm him with words, there was no response—he [had] a blood pressure of 160/90!" (Chesla, 1996, p. 202).
How you touch a client in providing everyday nursing care is a form of communication. For example, gentle massage of a painful area helps clients relax. Holding the hand of a client with dementia can reduce agitation. Gently rubbing a client's forehead or stroking the head is comforting to very ill clients.
Touch can be an important form of communication.
People vary in their comfort with touch. Touch is used as a common form of communication in some cultures, whereas in others, it is reserved for religious purposes, or seldom used as a form of communication (Samovar, Porter, & McDaniel, 2009). Before touching a client, assess the client's receptiveness to touch. Observation of the client will provide some indication, but you may need to ask for validation. If the client is paranoid, out of touch with reality, verbally inappropriate, or mistrustful, touch is contraindicated as a listening response.
## Specialized communication strategies
Metaphors
Familiar images promote understanding. Metaphors can help clients and families process difficult new information by connecting it with familiar images from ordinary life experience. For example, Arroliga et al. (2002) describe chronic lung disease as "emphysema is like having lungs similar to 'swiss cheese,'" and the airways in asthma are "different sized drainpipes that can get clogged up and need to be unclogged" (p. 377). These are familiar images that the client can appreciate and connect with a disease that is harder to comprehend.
In health care situations, metaphors need to be used carefully. Periyakoil (2008) suggests that using war or sports metaphors with clients experiencing advanced metastatic cancer can result in an unintended impact when the client can no longer fight the valiant battle or win the game by playing according to prescribed moves.
### Humor
Humor is a powerful therapeutic communication technique when used with deliberate intent for a specific therapeutic purpose. Humor recognizes the incongruities in a situation, or an absurdity present in human nature or conduct (Random House Dictionary, 2009). Humor allows taboo topics to be raised without creating hostility or discomfort.
Humor and laughter have healing purposes. Laughter generates energy and activates β-endorphins, a neurotransmitter that creates natural highs and reduces stress hormones (Hassed, 2001). Humorous remarks are best delivered as simple statements that contain positive kernels of truth and are conveyed with calmness. The surprise element in humor can cut through an overly intense situation and put it into perspective.
Case Example
Karen, the mother of 4-year-old Megan, had just returned from a long shopping trip in which she had purchased several packages of paper towels. While she was in another room, Megan took everything out of four kitchen drawers, put them on the floor, and put the paper towels in the drawers. Her mother expressed her anger to Megan in no uncertain terms. As she was leaving the kitchen, she heard Megan say to herself, "Well, I guess she didn't like that idea." Karen's anger was permanently interrupted by her daughter's innocent humorous remark.
Humor is most effective when rapport is well established and a level of trust exists between the nurse and client (McGhee, 1998). When humor is used, it should focus on the idea, event, or situation, or something other than the client's personal characteristics. Humor that ridicules is not funny. Some clients respond well to humor; others are insulted or perplexed by it. Humor is less effective when the client is tired or emotionally vulnerable. Instead, that client may need structure and calming support.
Humor should fit the situation, not dominate it. The following factors contribute to its successful use:
• Knowledge of the client's response pattern
• An overly intense situation
• Timing
• Situation that requires an imaginative or paradoxical solution
• Gearing the humor to the client's developmental level
• Focus on a situation or circumstance, rather than client characteristics
### Reframing
Bandler and Grindler (1997) define **reframing** as "changing the frame in which a person perceives events in order to change the meaning" (p. 1). Reframing offers a different positive interpretation designed to broaden the client's perspective.
Reframing strategies should accentuate client strengths. The new frame must fit the current situation _and_ be understandable to the client; otherwise, it will not work.
Reframing a situation is helpful when blame is a component of a family's response to the client's illness, for example, with alcoholism. Helping a family view the alcoholism as a disease rather than as a reaction to family members permits necessary detachment.
## Cognitive behavioral strategies
Reality often is not the problem; rather it lies with negative thinking that creates emotional responses and influences behavior. Cognitive behavioral communication strategies are helpful in helping clients challenge self-defeating thoughts that threaten productive engagement in recovery. Once the nurse helps clients identify negative thoughts, clients are taught to challenge the validity of those thoughts and/or to replace them with a positive thought. By interrupting negative thinking patterns and replacing them with positive thoughts, people can modify behavior.
Case Example
Jack Norris is receiving an antidepressant medication for depression symptoms associated with his cancer diagnosis. He tells the nurse he wants to stop the medication because it feels like a "crutch" to him, and he doesn't want to depend on medication "to make him feel better." When the nurse queries him about his other medications, he says, "That's different, those are medications I need. My antidepressant is just to make me feel better."
Applying the cognitive behavioral therapy model (Box 10-4), the activating event (A) is Jack's prescription for depressive symptoms associated with cancer. His belief (B) that using psychotropic medication is a sign of weakness and that he should be able to get along as well without it gets in the way of his being able to resolve his depressive symptoms. This belief affects his efforts to cope with his cancer. The consequence (C) of going off the medication is a return of his depressive symptoms. In this case example, how would you help the client receive the help he needs for his emotional well-being?
BOX 10-4 ABCs of a Cognitive Behavioral Approach
**A** refers to the Activating event, which creates an image in the person's mind.
**B** refers to the Beliefs surrounding the activating event. Beliefs can also include personal rules or demands a person makes on himself and fixed attitudes.
**C** refers to the Consequences, which include a person's decision and behaviors representing the person's beliefs.
## Using technology in communication
Increasingly, nurses are using technology to communicate with clients and families. Although technology can never replace face-to-face time with clients, voice mail, e-mail, and telehealth virtual home visits help connect clients with care providers and provide critical information. Currently, technology is used as a form of communication to augment onsite communication. For example, routine laboratory results, appointment scheduling, and links to information on the Web can be transmitted through technology. Present-day technology allows people to use the Internet as a communication means to share common experiences with others who have a disease condition, to consult with experts about symptoms and treatment, and to learn up-to-date information about their condition.
The electronic nurse-client relationship begins when the nurse comes online or begins speaking to the client on the phone (Sharpe, 2001). From that point forward, the nurse needs to follow defined standards of nursing care, using communication principles identified in this chapter. At the end of each telehealth encounter, nurses need to provide their clients with clear directions and contact information should additional assistance be required. Confidentiality and protection of identifiable client information is an essential component of telehealth conversations.
Telephone communication is an essential communication link. Periodic informational telephone calls enhance family involvement in the long-term care of clients. Over time, some families lose interest or find it too painful to continue active commitment. Interest and support from the nurse reminds families that they are not simply nonessential, interchangeable parts in their loved one's life; their input is important.
## Summary
This chapter discusses basic therapeutic communication strategies nurses can use with clients across clinical settings. Nurses use active listening responses such as paraphrasing, reflection, **clarification** , silence, summarization, and touch to elicit complete information. Observation is a primary source of information, but all nonverbal behaviors need to be validated with clients for accuracy.
Open-ended questions give the nurse the most information because they allow clients to express ideas and feelings as they are experiencing them. Focused or closed-ended questions are appropriate in emergency clinical situations, when precise information is needed quickly.
Nurses use verbal communication strategies that fit the client's communication patterns in terms of level, meaning, and language to help clients meet treatment goals. Other strategies include use of metaphors, reframing, humor, confirming responses, feedback, and validation. Feedback provides a client with needed information.
Ethical Dilemma
What Would You Do?
You have had a wonderful relationship with a client and the client's family. They have revealed issues they had never talked about before and raised questions that extended beyond the health care situation that they did not have the time to finish. You are about to end your rotation. What do you see as your ethical responsibility to this client and family?
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CHAPTER 11
# Intercultural Communication
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define culture and related terms.
2 Discuss the concept of intercultural communication.
3 Describe the concept of cultural competence.
4 Apply the nursing process to the care of culturally diverse clients.
5 Discuss characteristics of selected cultures as they relate to the nurse-client relationship.
This chapter is designed to equip nurses with the knowledge and skills needed to interact with clients from varied cultural backgrounds. The chapter describes communication principles and applications from a multicultural perspective. Included are social and cultural factors associated with the United States' four major cultural groups.
## Basic concepts
Culture
**Culture** is a complex social concept that encompasses the entirety of socially transmitted communication styles, family customs, political systems, and ethnic identity held by a particular group of people. "Culture is primarily learned and transmitted through family and other social institutions" (p. 213), for example schools and church. (Giger, Davidhizar, Purnell, Harden, Phillips, & Strickland, 2007(a)). Exercise 11-1 offers an opportunity to reflect on how culture is learned within the family.
EXERCISE 11-1 Family Culture Experiences
Purpose:
To help students appreciate how people learn about their culture within their family in the course of everyday living.
Procedure:
1. Identify and describe one family custom or tradition. It can relate to special family foods, a holiday custom, a child-rearing practice, or any other special tradition.
2. Describe the custom or tradition in detail.
3. Talk with a family member about how this family tradition originated in your family.
4. Discuss how this custom or tradition has changed over time.
5. Describe how this family tradition has affected your family functioning.
Discussion:
1. Share your family tradition with your classmates.
2. As a class, discuss how differences in family culture can influence health.
3. Discuss how knowledge of family customs can influence communication and health care promotion.
Culture develops from the customs, beliefs, and social institutions associated with different ethnic, racial, religious, and social groups. Cultural patterns shape health-related beliefs, attitudes, values, and behaviors (Kleinman & Benson, 2006). Culture differences relate to some or all of the life issues identified in Box 11-1. Culture is a strong determinant of social behavior. The meaning of the word culture extends beyond country of origin and ethnic background to include professional, organizational, and religious cultures (Betancourt, 2004).
BOX 11-1 Points of Cultural Diversity in Health Care
• People's feelings, attitudes, and behavioral standards
• Ways of living, language, and habits
• How people relate to others, including attitudes about health professionals
• Nutrition and diet
• Personal views of what is right and wrong
• Perspectives on health, illness, and death, including appropriate rituals
• Hearing about and discussing negative health information
• Decisional authority, role relationships, and truth-telling practices
• Child-rearing practices
• Use of advance directives, informed consent, and client autonomy (Calloway, 2009; Carrese & Rhodes, 2000; Karim, 2003; Searight & Gafford, 2005)
**Multiculturalism** describes a heterogeneous society in which diverse cultural worldviews can coexist with some general (-etic) characteristics shared by all cultural groups and some (-emic) perspectives that are unique to a particular population.
Ethnic and cultural differences need not be barriers to relationships
**Worldview** is defined as "the way people tend to look out upon their world or their universe to form a picture or value stance about life or the world around them" (Leininger & McFarland, 2006, p. 15). It is closely linked to cultural and spiritual beliefs, but it is not the same. Culture describes the social characteristics of a society. Worldview describes an individual's perceptions of his or her reality within that society. A teenager and an older adult can have similar beliefs about their culture, but their worldviews would be dissimilar because of the age difference.
The existence of cultural patterns as part of personal identity and client preferences is fundamental to understanding nurse and client behavior in therapeutic relationships. Delivering safe, effective, client-centered care requires sensitivity to cultural differences, with specialized skill development in multicultural interpersonal communication skills.
#### Related concepts
Subculture: **Subculture** refers to a smaller group of people living within the dominant culture who have adopted a cultural lifestyle distinct from that of the mainstream population. The Amish are an important subculture. Dress, loyalty to a leader or cause, language, social patterns, philosophies, and behavior distinguish members of a subculture. The differences between subculture orientations and mainstream cultural expectations can create conflict (Drench, Noonan, Sharby, & Ventura, 2009).
Ethnicity: **Ethnicity** is used to describe "groups in which members share a cultural heritage from one generation to another" (Day-Vines et al., 2007, p. 403). Personal awareness of a common racial, geographic, religious, or historical history binds people together, with a strong commitment to ethnic values and practices. Research indicates that ethnicity is an important aspect of a person's social identity (Malhi, Boon, & Rogers, 2009).
Ethnicity describes a sociopolitical construct, different from race and physical characteristics (Ford & Kelly, 2005). People with similar skin color and features can have a vastly different ethnic heritage: Jamaican versus African American. Ethnicity can reflect spiritually based membership, for example, Amish (Donnermeyer & Friedrich, 2006).
Ethnocentrism: **Ethnocentrism** refers to a belief that one's own culture should be the norm because it is considered better or more enlightened than others. Other cultures are judged as inferior (Lewis, 2000). Taking pride in one's culture is appropriate, but when a person fails to respect the value of other cultures, it is easy to develop stereotypes and prejudice. Ethnocentrism fosters the belief that one culture has the right to impose its standards of "correct" behavior and values on another. Prejudice can be felt or expressed, and directed to either a group as a whole or toward an individual associated with the group (Allport, 1979). The deadly consequences of prejudice were evidenced in the persecution of innocent people during Hitler's regime, and continue today with terrorist attacks and violence embedded in ethnocentric views and sectarian differences.
A variation of ethnocentrism labels people who are different from the mainstream as being inferior (Canales & Howers, 2001). Examples include physical or mental disability, sexual orientation, ageism, morbid obesity, and unusual physical or personal characteristics.
Case Example
"I knew a man who had lost the use of both eyes. He was called a 'blind man.' He could also be called an expert typist, a conscientious worker, a good student, a careful listener, and a man who wanted a job. But he couldn't get a job in the department store order room where employees sat and typed orders, which came over the phone. The personnel man was impatient to get the interview over. 'But you are a blind man,' he kept saying, and one could almost feel his silent assumption that somehow the incapability in one aspect made the man incapable in every other. So blinded by the label was the interviewer that he could not be persuaded to look beyond it" (Allport, 1979, p. 178). Exercise 11-2 explores the prevalence of cultural stereotypes.
EXERCISE 11-2 Exploring Cultural Stereotypes
Purpose:
To help students examine stereotypes and their impact on communication and relationships.
Procedure:
The first part of this exercise should be written outside of class, anonymously, to encourage honest answers. The following list represents some of the groups in our society that carry familiar value-laden stereotypes:
African Americans | Alcoholics | Hispanics
---|---|---
AIDS victims | Immigrants | People on welfare
Asian Americans | Mentally ill persons | Homeless people
Native American | Elderly adults | Homosexuals
Teenage mothers | Hearing deficit | Migrant workers
1. Write down the first three words or phrases that come into your mind regarding each of these groups.
2. Make a grid with headings representative of positive, negative, and neutral connotations.
3. As a class group, take the collected words and phrases and place each word or phrase under the appropriate column for each group. Use an X to indicate repetitive words or phrases.
Discussion:
For each cultural group, consider the following:
1. Why do you think people believe that this cultural group possesses these characteristics? Are the characteristics good, bad, or evil as an abstract concept?
2. What were the common themes of these groups? Did certain groups have more negative than positive responses? If so, how would you account for this?
3. In what ways did this exercise help you to think about your own cultural socialization process?
4. Did this exercise cause you to question any of your own assumptions about culturally different values?
5. From your view, what implications do these stereotypes hold for providing appropriate nursing care?
6. How can you use this exercise in your future care of culturally different populations?
Modified from Eliason M, Macy N: A classroom activity to introduce cultural diversity, _Nurse Educ_ 17(3):32–35, 1992.
Cultural Relativism: **Cultural relativism** holds that each culture is unique and should be judged only on the basis of its own values and standards. Behaviors viewed as unusual from outside a culture make perfect sense when they are evaluated within a cultural context (Aroian & Faville, 2005).
Case Example
Benjamin Franklin's Comments on Native Americans
"Savages we call them, because their Manners differ from ours, which we think the Perfection of Civility; they think the same of theirs. Perhaps if we could examine the Manners of Different Nations with Impartiality, we should find no people so rude, as to be without any Rules of Politeness; nor any so polite, as not to have some Remains of Rudeness" (Benjamin Franklin, quoted in Jandt, 2003, p. 76).
Exercise 11-3 examines how culture shapes values and perceptions.
EXERCISE 11-3 Values and Perceptions Associated with Different Cultures
Purpose:
To help students appreciate values and generalized perceptions associated with different cultures.
Procedure:
1. Select a specific ethnic culture
2. Interview someone from that culture and ask them to tell you about their culture related to family values, religion, what is important in social interaction health care beliefs, and end-of-life rituals.
3. Write a short report on your findings.
4. Share your written report with your classmates.
Discussion:
1. What important values did you uncover?
2. In what ways did the person's answers agree or disagree with the generalized cultural characteristics of the culture?
3. What did you learn from doing this exercise that you could use in your clinical practice with culturally diverse clients?
Cultural Diversity: **Cultural diversity** refers to variations among cultural groups. People notice differences related to language, mannerisms, and behaviors in people of different cultures, in ways that do not happen with people from their own culture (Spence, 2001). Lack of exposure to and understanding of people from other cultures reinforces stereotypes and creates prejudice.
Diversity exists _within_ a culture too. The Institute of Medicine (2002) identifies economic status and social class as components of diversity related to health risk and treatment outcomes. More differences can exist among individuals within a culture than between cultural groups related to educational and socioeconomic background, age, gender, and life experiences. This is true of providers and clients even when they share the same spoken language. Exercise 11-4 examines cultural diversity in the nursing profession.
EXERCISE 11-4 Diversity in the Nursing Profession
Purpose:
To help students learn about the experience of nurses from a different ethnic group.
Procedure:
1. Each student will interview a registered nurse from an ethnic minority group different from their own ethnic origin.
2. The following questions should be asked:
a. In what ways was your educational experience more difficult or easier as a minority student?
b. What do you see as the barriers for minority nurses in our profession?
c. What do you see as the opportunities for minority nurses in our profession?
d. What do you view as the value of increasing diversity in the nursing profession for health care?
e. What do you think we can do as a profession and personally to increase diversity in nursing?
3. Write a one- to two-page narrative report about your findings to be presented in a follow-up class.
Discussion:
1. What were the common themes that seemed to be present across narratives?
2. How do professional nurses view diversity, and how did doing this exercise influence your thinking about diversity?
3. Did you find any of the answers to the interview questions disturbing or surprising?
4. How could you use this exercise in becoming culturally competent?
Acculturation: **Acculturation** describes how a person from a different culture initially learns the behavior norms and values of the dominant culture, and begins to adopt its behaviors and language patterns. Physical acculturation takes place before emotional acculturation. Higher socioeconomic status, social support, and education facilitate the process of acculturation. The client's level of acculturation is a factor in client assessment and nursing care.
Assimilation: **Assimilation** refers to a person's full adoption of the behaviors, customs, values, and language of the mainstream culture. By the third generation, people may have little knowledge of their traditional culture and language, or allegiance to their original heritage. Even so, people carry unconscious vestiges of cultural traditions with them throughout life (Bacallao & Smokowski, 2005).
## Intercultural communication
**Intercultural communication** refers to conversations between people from different cultures. The concept embraces differences in perceptions, language, and nonverbal behaviors, and recognition of dissimilar contexts for interpretations (Samovar, Porter, & McDaniel, 2008). It is a primary means of sharing meaning and developing relationships between people of different cultures. Successful outcomes emphasize a common understanding and inclusion of issues and values that facilitate treatment (Purnell, Purnell, Paulanka, et al. 2008).
The goal of intercultural communication is to find a common ground through which people from different cultures can connect on many different levels with each other.
With intercultural communication, the perception of relationship between care provider and client is just as important as the words used to communicate. Interactions take place within "transcultural caring relationships" (Pergert, Ekblad, Enskar, & Bjork, 2007, p. 18). Relationships are carefully designed to provide a respectful, encouraging environment in which the client's cultural values and beliefs can be freely expressed and responded to with empathy (Pergert et al., 2007).
Case Example
A Chinese first-time mother, tense and afraid as she entered the transition phase of labor, spoke no English. Her husband spoke very little, and saw birthing as women's work. Callister (2001) relates, "The nurse could feel palpable tension that filled the room. The nurse could not speak Chinese either, but she tried to convey a sense of caring, touching the woman, speaking softly, modeling supportive behavior for her husband and helping her to relax as much as possible. The atmosphere in the room changed considerably with the calm competence and quiet demeanor of the nurse. Following the birth... the father conveyed to her how grateful he was that she spoke Chinese. She tactfully said, 'Thank you, but I don't speak Chinese.' He looked at her in amazement and said with conviction, 'You spoke Chinese.' The language of the heart transcends verbal communication" (p. 212).
### Limited language proficiency
Limited language proficiency is a fundamental barrier to effective health care delivery. Different languages create and express different cultural and personal realities. Understanding vocabulary and grammar is not enough. Language competence requires "knowing what to say, and how, when, where, and why to say it" (Hofstede, Pedersen, & Hofsted, 2002, p. 18).
Linguistic rules, language structures, and meanings vary among cultures. Different dialects even within the same culture create language difficulties. Within the same language, words can have more than one meaning. For example, the words _hot, warm,_ and _cold_ can refer to temperature, or to impressions of strong personal characteristics, or responses to new ideas (Sokol & Strout, 2006). Idioms are particularly problematic because they represent a nonliteral expression of an idea.
Case Example
A nursing student from the Philippines said she was thoroughly confused by her instructor's slang expression, "I want to touch base with you." The student did not know how to respond because her literal translation of the instructor's sentence did not express its meaning to her. Had the instructor said, "I would like to talk with you," the student would have known how to respond.
Nonverbal behaviors, designed to clarify messages and demonstrate relations, are not the same in different cultures. Most people are reasonably comfortable about the meanings of common nonverbal symbols in their own culture—and even then, they have to clarify that the nonverbal has the same meaning for both parties. But consider going to a different culture, where the same gesture or nonverbal symbol has the opposite meaning or is meaningless (Anderson & Wang, 2008). Understanding cultural differences in nonverbal behavior is a dimension of intercultural communication. Exercise 11-5 provides an opportunity to consider the implications of language barriers.
EXERCISE 11-5 Understanding Language Barriers Role-Play
Purpose:
To help students understand the role of language barriers.
Procedure:
Situation 1
Lee Singh is a 24-year-old Korean patient who speaks no English. She was admitted to the maternity unit and has just delivered her first child, a 9-pound infant. It was a difficult labor because the infant was so big. The initial objectives of the health care providers are to help the client understand what is happening to her and to help her become comfortable with her baby.
Situation 2
Jose Perot is a 30-year-old Hispanic man who was admitted to the emergency department with multiple injuries after a car accident. His family has been notified, but the nurse is not sure they understand what has happened. They have just arrived in the emergency department.
1. Break up into groups of four or five students. Each group acts as a unit. The groups role-play Situation 1 and reverse roles for Situation 2.
2. The client group should completely substitute made-up words that only they understand for the words they would normally use to communicate in this situation. The made-up words should have the same meaning to all members of the client group.
3. The health provider group must figure out creative ways to understand and communicate with the client group.
Discussion:
1. In what ways was it different being the client and being the health provider group?
2. What was the hardest part of this exercise?
3. In what ways did this exercise help you understand the frustrations of being unable to communicate?
## Cultural competence
**Cultural competence** is defined as "a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations" (Sutton, 2000, p. 58). The Institute of Medicine (2003) and the American Association of Colleges of Nursing (AACN, 2008) identify cultural competence as an essential skill set required for health care providers.
Self-awareness of unintentional bias in health care is essential. Value judgments are hard to eliminate, particularly those outside of awareness. Developing competence begins with self-awareness of your own cultural values, attitudes, and perspectives, followed by developing knowledge and acceptance of cultural differences in others (Gravely, 2001; Leonard & Plotnikoff, 2000). This allows you to own your own biases and not project them onto clients. Exercise 11-6 provides an opportunity for you to reflect on personal cultural beliefs, values, and behaviors.
EXERCISE 11-6 Self-awareness Cultural Assessment
Purpose:
To help students develop awareness of their own culture.
Procedure:
Think about your own culture and answer the following questions. Be as honest as you can; this will help you to be open and honest toward clients from culturally diverse backgrounds. There are no right or wrong answers.
1. Where did my family originate?
2. What do I attach importance to that could be considered a cultural value?
3. What do I believe about the gender roles of men and women? Are my beliefs different or consistent with those of my parents?
4. How much physical distance do I need in social interactions?
5. Who are the decision makers in my family, and whom do I look to for guidance in important matters?
6. What are my definitions of health and well-being?
7. If I needed health care, how would I respond to this need and what would be my expectations?
8. In a health care situation, what would be the role of my family?
9. In a health care situation, how important would religion be, and what would I need for spiritual comfort?
Discussion:
1. Share your observations with your classmates.
2. How difficult was it for you to really identify some of the behaviors and expectations that are part of your cultural self?
3. Were you surprised with any of your answers? If so, in what ways?
4. What did you learn about culture from hearing stories of other students? In what ways were their stories the same or different from your cultural story?
5. How can you use this exercise in communicating with clients from culturally diverse backgrounds?
Cultural competence is expressed through cultural sensitivity. The Office of Minority Health (U.S. Department of Health and Human Services [DHHS], 2001) describes **cultural sensitivity** in health care as "the ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage" (p. 131). Used with clients, cultural sensitivity is expressed through the use of neutral words, categorizations, and behaviors that respect the culture of the client, and avoidance of those that could be interpreted as offensive (AACN, 2008). Practiced by health care providers, cultural sensitivity refers to an understanding of one's own cultural beliefs, and how these beliefs and values affect their practice with minority clients. The goal of culturally sensitive communication is to find common ground.
Case Example
"There weren't many Filipino nurses [in that hospital] and a lot of them were Caucasian and I remember this Black nurse... who was very, very nice. I think it was because she is not a Caucasian and she is able to feel with me. She probably sympathized with me who like her is from a different culture and had to move to Canada" (Pasco, Morse, & Olson, 2004, p. 243).
A valuable way to learn about another person's culture is to spend time with them and to ask questions about what is important to them about their culture (Jandt, 2003).
### Health disparities
**Health disparities** is defined as "a chain of events signified by a difference in the environment, access to, utilization of, and quality of care, health status, or a particular health outcome that deserves scrutiny" (Villarruel, 2004, p. 8). In 2002, the Institute of Medicine reported that people of color and ethnic minorities receive a lower quality of care even when insurance and income are considered. This phenomena has been confirmed in a number of research studies (Giger, Davidhizar, Purnell, Harden, Phillips, Strickland, 2007(b)). _Healthy People 2010_ identifies "eliminating health disparities" and "improving the quality of life" for U.S. citizens as overarching goals. The _National Healthcare Disparities Report_ (2007) confirms that minority status accounts for significant differences and inequality in the quality of health care related to access, screenings, and level of care.
The National Center for Health Statistics (2007) indicates that ethnic and racial minorities, which make up 30% of the adult population, and almost 40% of the U.S. population younger than 18 have greater mortality and morbidity rates (Edwards, 2009; National Center for Health Statistics, 2007). These demographics, coupled with a sharp increase in the number of immigrants entering the United States and Canada, require a special focus on the role of culture in nurse-client relationships. By 2050, ethnic minorities are expected to become a numerical majority (Sue & Sue, 2003).
Developing an Evidence-Based Practice
McElmurry B, Park C, Buseh A: The nurse-community health advocate team for urban immigrant primary health care, _J Nurs Sch_ 35(3):275–280, 2003.
This descriptive study was designed to describe an urban outreach health program for Latino immigrants, using a professional nurse and community advocate teamed together in providing health care delivery. Convenience samples of participants, staff, and other sources were used to describe the program and its effects in the Latino community.
_Results:_ Findings indicated that pairing nurses with community health advocates greatly enhanced the project team's ability to provide preventive care in the Latino community. The combined resources provided culturally sensitive care to Latino immigrants, and enabled them to seek and obtain appropriate health care.
_Application to Your Clinical Practice:_ As professionals working in an increasingly multicultural society, nurses need to develop innovative ways to reach out to immigrants with limited knowledge and limited ways to access the health care system. What steps would you need to take as an individual nurse to encourage a stronger connection between culturally sensitive nursing care and the needs of immigrant populations?
## Applications
Minorities are less likely to participate in screening or to seek early treatment for recognizable symptoms. They have misgivings about the health care system and feel uncomfortable about using it (Johnstone & Kanitsaki, 2009). Fundamental cultural differences in health beliefs, unfamiliarity with the health care system, language or literacy, and fear of discrimination contribute to gaps in assessment and treatment. Healthy People 2010 (DHHS, 2000) identifies eliminating health disparities among different population groups as one of its overarching goals.
Accessing health care for minority clients can be frustrating. Minority populations, especially new immigrants, often are marginalized economically, occupationally, and socially in ways that adversely affect their access to mainstream health care. Seeking treatment and compliance with treatment is complicated by an inability to effectively describe health problems in terms health providers understand. Undocumented immigrants have an added burden of fearing deportation if their legal status is revealed (Chung, Bernak, Otiz, & Sandoval-Perez, 2008).
## Care of the culturally diverse client
This section describes the integration of cultural sensitivity into the assessment, diagnosis and treatment planning, implementation, and evaluation of client-centered professional nursing care. When health recommendations conflict with a client's worldview, it is unlikely they will be followed. Having knowledge and constructive attitudes about health traditions associated with different cultures increases client comfort and engagement with caregivers. Hulme (2010) distinguishes between the folk domain and alternative health care remedies. She emphasizes the need to understand the client's health care traditions which are "specific to—and fundamentally a part of—an individual's culture" (p. 276).
### Building rapport
Minority clients often have limited firsthand experience with the complexity of the U.S. health care system that could help them negotiate it successfully. They respond better to providers who orient them to the setting and set the stage for a comfortable encounter. Ideally, when meeting a client for the first time, you should perform the following tasks:
• Pronounce the client's name correctly. Calling the client by title and last name shows respect. If the name presents a challenge, ask the client how to pronounce it correctly.
• Speak clearly and spend time with the client before asking assessment questions to make the client or family comfortable.
• Avoid assumptions or interpretations about what you are hearing without validating the information.
• Allot more time to conduct a health assessment, to accommodate language needs and cultural interpretations.
• Have as your goal the client's feelings of satisfaction and success in communicating health concerns and expectations.
• Take the position of interested co-learner when inquiring about cultural values and standards of behavior.
• Inquire about individual perceptions, as well as cultural explanatory models associated with the illness, and preferences for treatment.
• Explain treatment procedures at every opportunity and alert clients ahead of time of potential discomfort.
• Ask permission for and explain the necessity for any physical examination and use of assessment tools.
### Guides to cultural assessment
Cultural competence is described as "the adaptation of care in a manner that is congruent with the client's culture" (Giger, Davidhizar, Purnell, Harden, Phillips, & Strickland, 2007(b), p. 98). Madeleine Leininger's Theory of Culture Care (2006) is recognized as a major contribution to nursing's understanding of culture in health care. Leininger believes that nurses must have knowledge about diverse cultures to provide care that fits the client. Her sunrise model is composed of "enablers," which help explain each person's cultural environmental context, language, and ethnohistory. Enabling factors reflect the person's worldview and a person's social and culture structures. Each influences verbal and nonverbal expressions, patterns, and understandings of health and health practices.
Larry Purnell's model (see Table 11-1) examines cultural competence from both its macro aspects (global society, community, family, and the person), and its micro aspects consisting of 12 interconnected domains at the person level. Using Purnell's domains as a framework for understanding individual differences dictated by national cultural standards and practices allows for a comprehensive cultural assessment and a culturally congruent, individualized, patient-centered approach to client care.
TABLE 11-1
Purnell's Domains of Cultural Assessment
Domains of Cultural Assessment | Sample Areas for Inquiry
---|---
Personal Heritage | Country of origin, reasons for migration, politics, class distinctions, education, social and economic status
Communication | Dominant language and dialects, personal space, body language and touch, time relationships, greetings, eye contact
Family Roles and Organization | Gender roles; roles of extended family, elders, head of household; family goals, priorities, and expectations; lifestyle differences
Workforce Issues | Acculturation and assimilation, gender roles, temporality, current and previous jobs, variance in salary and status associated with job changes
Bioecology | Genetics, hereditary factors, ethnic physical characteristics, drug metabolism
High Risk Health Behaviors | Drugs, nicotine and alcohol use, sexual behaviors
Nutrition | Meaning of food, availability and food preferences, taboos associated with food, use of food in illness
Pregnancy and Childbearing | Rituals and constraints during pregnancy, labor and delivery practices, newborn and postpartum care
Death Rituals | How death is viewed, death rituals, preparation of the body, care after death, use of advance directives, bereavement practices
Spirituality | Religious practices, spiritual meanings, use of prayer
Health Care Practices | Traditional practices, magiocoreligious health care beliefs, individual versus collective responsibility for health, how pain is expressed, transplantation, mental health barriers
Health Care Practitioners | Use of traditional and/or folk practitioners, gender role preferences in health care
Adapted from Purnell, J.D., and Paulanka, B.J. (2008). _Transcultural health care: A culturally competent approach_ (3rd Ed.), FA Davis; and Purnell, J.D. (2009). _Guide to culturally competent health care_ (2nd Ed.), F.A. Davis.
### Assessment through a cultural lens
Assessment should start with the client's reality. Although actual symptoms may be similar, clients will express symptoms consistent with their ethnic beliefs (DHHS, 2001). How clients answer questions about symptoms can reveal which aspects of their complaints are culturally acceptable, and how the client's culture permits their expression. Asking questions like "Can you tell me about your illness and how it developed?" provides information about cultural explanatory models of illness. The information you need would include the client's
• Identified cultural affiliation
• Health beliefs, and values
• Customary health practices
• Spiritual beliefs and practices
• Culturally specific social structures related to health care
Although clients from a different culture may not spontaneously volunteer information about their cultural practices, they often are willing to share this information when asked by an empathetic, interested health care provider. Table 11-2 provides sample questions to assess client preferences when the client is from a different culture.
TABLE 11-2
Assessing Client Preferences When the Client Is from a Different Culture
Areas to Assess | Sample Assessment Approaches
---|---
Explanatory models of illness | "What do you think caused your health problem? Can you tell me a little about how your illness developed?"
Traditional healing processes | "Can you tell me something about how this problem is handled in your country? Are there any special cultural beliefs about your illness that might help me give you better care? Are you currently using any medications or herbs to treat your illness?"
Lifestyle | "What are some of the foods you like? How they are prepared? What do people do in your culture to stay healthy?"
Type of family support | "Can you tell me who in your family should be involved with your care? Who is the decision maker for health care decisions?"
Spiritual healing practices and rituals | "I am not really familiar with your spiritual practices, but I wonder if you could tell me what would be important to you so we can try to incorporate it into your care plan."
Cultural norms about cleanliness | "A number of our patients have special needs related to cleanliness and modesty of which we are not always aware. I am wondering if this is true for you and if you could help me understand what you need to be comfortable."
Truth-telling and level of disclosure | Ask the family about cultural ways of talking about serious illness. In some cultures, the family knows the diagnosis/prognosis, which is not told to the ill person (e.g., Hispanic, Asian).
Ritual and religious ceremonies at time of death | Ask the family about special rituals and religious ceremonies at time of death.
### Diagnosis
Cultural beliefs and values play a role in the interpretation and response to a clinical diagnosis, especially if the culture relates the development of illness to personal weakness or the will of God. For example, it is not uncommon for Asian and Arab Israeli women to believe that breast cancer is God's will or fate (Kim & Flaskerud, 2008; Baron-Epel, Friedman & Lernau, 2009). Such cultural beliefs can affect use of early detection mammograms. Nurses need to be aware that the clinical diagnosis of a disease is embedded in cultural understandings about its etiology and its meaning. This is particularly true for the diagnosis and treatment of mental disorders. Cross and Bloomer (2010) caution that culturally specific expressions of mental illness vary and can lead to misdiagnosis.
Client-centered care in the United States advocates for a shared understanding of illness, diagnosis, and prognosis. Some cultures have strong beliefs about providing full disclosure of diagnosis and prognosis to clients. Cultural preference may dictate that the family be notified first. The family then decides when and if the disclosure should be made to the client. Before discussing important health matters, ask the client who should be involved. Careful, unhurried discussion and inclusion of family members in decision-making processes can be helpful. Asian and Hispanic cultures traditionally prefer family centered decision-making about care for a family member with a terminal diagnosis (Kwak & Haley, 2005). Although informed consent forms require full disclosure, the cultural acceptability of autonomous informed consent can be an ethical issue when interacting with clients who hold different cultural values (Calloway, 2009). When the family is authorized by the client to discuss diagnosis and make treatment decisions, the client's preference should be honored. Exploration of each client's preferences about disclosure should take place early in the clinical relationship.
Case Example
Wilma Martinez is a 67-year-old immigrant from El Salvador who moved to the United States to live with her daughter. Mrs. Martinez speaks only Spanish. Through her daughter's translations, the patient appears to comprehend details of her illness and treatment. When asked if she understands what the doctor is saying, she invariably nods affirmatively. During a clinic visit, when Mrs. Martinez's daughter is not present, the physician arranges for a trained medical interpreter to be present. Later, the interpreter explains that Mrs. Martinez could not understand why the staff was insistent that she, rather than her daughter, make decisions. Mrs. Martinez stated, "In my country, the family decides." Assuming that her daughter would make the decisions for her, she saw no reason to sign the forms. She worried that signing forms would cause legal problems because of her immigration status (Crawley, Marshall, Lo, & Koenig, 2002, p. 675).
### Communication issues in planning and intervention
Clients from different cultures often identify language barriers as the most frustrating aspect of communicating in health care situations. Following are communication principles to keep in mind when planning and implementing care.
• Limitations in English proficiency should not be construed as a limitation of intellectual functioning.
• People can be highly literate in their language of origin, but functionally illiterate in English.
• Internal interpretation of a message is often accompanied by visual imagery reflecting the person's cultural beliefs and experiences. (This can change the meaning of the original message, with neither party having awareness of the differences in interpretation.)
People tend to think and process information in their native language, translating back and forth from English. This results in delayed responses that need to be taken into account, particularly in health teaching. Sometimes the nurse is aware only that the client seems to be taking more time than usual. With clients demonstrating limited English proficiency, speak slowly and clearly; use simple words; and avoid slang, technical jargon, and complex sentences. All written information should be provided in the person's native language whenever possible, to avoid misinterpretation. It is important that the translator of information be as well versed in medical interpretations as in relevant terms used in both languages.
### Role relations
Understanding that role interactions between health providers and clients are embedded in cultural influences helps nurses structure meaningful interactions. In many minority cultures, there is an unspoken tendency to view health professionals as authority figures, treating them with deference and respect. This value can be so strong that a client will not question the nurse or in any way indicate mistrust of professional recommendations. They just do not follow the professional advice.
Asian clients typically respond better to a formal relationship and an indirect communication style characterized by polite phrases and marked deference. They work better with well-defined boundaries and clear expectations (Galanti, 2008). The client waits for the information to be offered by the nurse as the authority figure. Sometimes this gets interpreted as timidity. A better interpretation is that the client is deferring to the health professional's expertise.
### Level of family involvement
Level of family involvement can be an issue for people from collectivistic cultures. Distinctions between male and female roles are well defined in these cultures, and this can affect decision making in health care. In Hispanic and Asian cultures, male family members are likely to be the identified decision makers. Age and position in the family are relevant. Decisions may be deferred to elders, and there may be distinct role expectations of the eldest man, of women, and of children within the family. Identifying and including from the outset all those who will be taking an active part in the care of the client recognizes the communal nature of family involvement in health care. For the Native American client, this may include members of an immediate tribe or its spokesperson.
### Time orientation
Galanti (2008) distinguishes between present and future time. American culture is a future-oriented culture in which people are accustomed to meeting exact time frames for appointments and taking medications. Present time cultures do not consider the commitment to a future appointment as important as attending to what is happening in the moment. They deal with things as they come up, and not before. Giger and Davidhizar (1991) note, "A common belief shared by some African Americans and Mexican Americans is that time is flexible and events will begin when they arrive" (p. 105). Usually it is necessary to explain not once but many times why a precise schedule is required, and to extend some flexibility when possible.
Clock time versus activity time also reflects culture (Galanti, 2008). Contrast the difference in time orientation of a clock-conscious German person with that of his Italian counterpart.
Case Example
Germans and Swiss love clock-regulated time, for it appears to them as a remarkably efficient, impartial, and very precise way of organizing life—especially in business. For Italians, on the other hand, time considerations will usually be subjected to human feelings. "Why are you so angry because I came at 9:30?" an Italian asks his German colleague. "Because it says 9 a.m. in my diary," says the German. "Then why don't you write 9:30 and then we'll both be happy?" is a logical Italian response. The business we have to do and our close relations are so important that it is irrelevant at what time we meet. The meeting is what counts (Lewis, 2000, p. 55).
### Communication principles
Clients from minority backgrounds respond better to health care providers who ask about and take into account their social circumstances, values, and cultural experiences. Framing interventions within a culturally sensitive format that the client recognizes as familiar and valid, and openly discussing differences in backgrounds, norms, and health practices increases client understanding and compliance.
Interventions for culturally diverse clients use the same communication strategies discussed in other chapters, with special accommodation for cultural differences. Client-centered principles include:
• Respect for the client's belief in folk and natural traditional remedies
• Combining cultural folk treatments with standard medical practices to whatever extent is possible
• Familiarity with formal and informal sources of health care in the cultural community, including churches, Shamans, medicine men/women, curanderos, and other faith healers
• Respect for family position and gender distinctions when relating to family members about health care concerns
• Continuous use of active listening strategies, with frequent validation to ensure the cultural appropriateness of provider assumptions
• Remembering that the client is a person first and a cultural person second
#### Informed Consent and Client Autonomy
Issues such as client autonomy and informed consent need to be reframed within a cultural context (Calloway, 2009). Without full disclosure, consent forms are not valid.
Philosophical differences about end-of-life care exist between Western values and those of the four major minority groups. Many minority clients believe in prolonging life and are reluctant to use advance directives (Thomas, 2001). Exercise 11-7 provides an opportunity to explore the role of cultural sensitivity in care planning.
EXERCISE 11-7 Applying Cultural Sensitivity to Care Planning
Purpose:
To practice cultural sensitivity in care planning.
Procedure:
This can be done in small, even-numbered groups rather than as an individual exercise.
1. Out of class, create a written clinical scenario based on a client from a cultural group. Be creative and write a situation in which ethnicity or cultural factors are present in the client's nursing needs.
2. Trade scenarios with another student.
3. Write what should be included in a culturally sensitive care plan.
4. Discuss each of the care plans and make any revisions.
Discussion:
1. What were the areas of agreement and disagreement about the care plan?
2. What questions would you need to ask to clarify needs?
3. In developing the plan, did you find any additional needs?
4. How could you use this exercise to improve your clinical practice?
### Health teaching principles
Health teaching strategies for culturally diverse populations is a challenge. Specific approaches include the following:
• Be patient when teaching; extra time is always needed.
• Look for facial expressions indicating bewilderment, frustration, or being overwhelmed. If the client seems confused, stop and ask the client to explain how it works in his or her culture.
• Use an English-as-a-second-language style of phrasing; that is, speak words slowly, with distinct separation of words and accentuation of important terms.
• Explain information in greater depth. Repeat explanations of important information in another way if the client does not seem to understand the original explanation.
• Use gestures, pantomime, body language, and visual cues to enhance words.
• Acknowledge effort and express belief in the client's ability to grasp the material (Tong, Huang, & McIntyre, 2006).
Cultural differences affect a nurse's coaching functions. A useful teaching sequence for clients from culturally diverse backgrounds is to use the mnemonic LEARN: Listen, Explain, Acknowledge, Recommend, and Negotiate (Campinha-Bacote, 1992). With this process, you _listen_ carefully to the client's perspective on his or her health problem, including cause, expectations for treatment, and information about family and others who traditionally are involved in the client's care.
Once you have a clear understanding of the client's perception of the problem, you can _explain_ your understanding, using simple, concrete terminology, and then ask for validation that your perspective is accurate. Acknowledge the differences and similarities between perceptions. Specific _recommendations_ to the client flow from shared understanding of the issues.
The final step is _negotiating_ a mutually acceptable treatment approach. This may take longer because of language and cultural expectations. The client's right to hold different cultural views and to make decisions reflective of those views must be respected. If family members traditionally are involved in decision making (with the client's consent), they should be actively involved in decision making. Box 11-2 provides general guidelines for teaching clients from culturally diverse backgrounds.
BOX 11-2 Communication Guidelines for Teaching Clients
• Use the same sequence and repeat phrases, expanding on the same basic questions.
• Speak slowly and clearly, and use concrete language the client can understand. Make the sentence structure as simple as possible.
• Encourage the client by smiling and by listening. Provide cues such as pictures and gestures.
• Avoid the use of technical language, and choose words that incorporate cultural terms whenever possible.
• Allow enough time, and do not assume that simply because the client nods or smiles that the communication is understood.
• Identify barriers to compliance, such as social values, environment, and language.
• Help the client develop realistic, culturally relevant goals.
• Incorporate culturally specific teaching formats (e.g., use an oral or storytelling format with clients who have oral teaching traditions).
• Close with cultural sensitivity: "I've really learned a lot today about [restate highlights]. Thanks for sharing with me."
### Use of interpreters
Federal law (Title VI of the Civil Rights Act) mandates the use of a trained interpreter for any client experiencing communication difficulties in health care settings because of language. Interpreters should have a thorough knowledge of the culture, as well as the language. They should be carefully chosen, keeping in mind variations in dialects, as well as differences in the sex and social status of the interpreter and the client if these are likely to be an issue. In general, family members, particularly children, should not be used as interpreters. Box 11-3 provides guidelines for the use of interpreters in health care interviews.
BOX 11-3 Guidelines for Using Interpreters in Health Care
• Whenever possible, the translator should not be a family member.
• Orient the translator to the goals of the clinical interview and expected confidentiality.
• Look directly at the client when either you or the client is speaking.
• Ask the translator to clarify anything that is not understood by either the nurse or the client.
• After each completed statement, pause for translation.
#### Cultural Brokering
Cultural brokering refers to advocacy actions of mediating between persons or groups from different cultural backgrounds for the purpose of increasing understanding, reducing conflict, or generating change. The cultural broker acts as a go-between and/or advocate for a specified person or group.
## Features of key cultural groups
Having basic knowledge of the common cultural features of the four major cultures in the United States enhances service delivery and the nurse's capacity to respond with sensitivity to client needs and preferences (Eiser & Ellis, 2007). It provides a social context for understanding cultural differences.
As you review characteristics of each culture group, it is important to avoid overgeneralizing or viewing them as applicable to all members of a culture or **ethnic group**. Each client is a unique individual. Galanti (2008) distinguishes between generalizations, which can be helpful, and stereotypes. The generalization serves as a cue to ask further questions about social factors impacting health care. Stereotypes make an invalid assumption about an individual, based on general data.
Case Example
An example is the assumption that Mexicans have large families. If I meet Rosa, a Mexican woman, and I say to myself, "Rosa is Mexican; she must have a large family," I am stereotyping her. But if I think Mexicans often have large families and wonder whether Rosa does, I am making a generalization (Galanti, 2008, p. 7).
Education, income, individual characteristics, and level of acculturation are modifiers to be considered in cultural assessment and treatment planning (Kline & Huff, 2008).
Each minority culture discussed in the following sections is a collectivistic society, compared with the United States, which is an individualistic society. Collectivism views people as being fundamentally connected with each other as an integral part of a larger society. Duty to others is considered before duty to self. Individualism views people as being independent parts of the universe and society. Western health care approaches need to respect this difference in communication.
### Hispanic/latino culture
Hispanic Americans account for 15% of the population (Office of Minority Health & Health Disparities [OMHD], 2010), making them the largest minority group in the United States. Identifying themselves as Hispanics, or Latinos, they are more racially diverse, and represent a wider range of cultures than other minority groups. Mexican Americans may refer to themselves as Chicanos.
Current growth in the Hispanic population of the United States consists mainly of first-generation and younger immigrants with lower socioeconomic status and undocumented legal status. Many do not speak English or do not speak it well enough to negotiate the U.S. health care system. Implementation of bilingual education in schools acknowledges the significance of the growth in the Hispanic population and social repositioning of diversity as a fact of life in the United States (Cavazos-Rehg & DeLucia-Waack, 2009).
#### Family
**_Familismo_** is a strong value in the Hispanic community (Juarez, Ferrell, & Boreman, 1998). The family is the center of Hispanic life and serves as a primary source of emotional support. Hispanic clients are "family members first, and individuals second" (Pagani-Tousignant, 1992, p. 10). Family units tend to live in close proximity with each other and close friends are considered a part of the family unit. Latino families have strong cultural values and beliefs about the sanctity of life. Families show their love and concern in health care situations by pampering the client.
Gender roles are rigid, with the father viewed as head of the household. Latino women are socialized to serve their husbands and children without question ( _la sufrida,_ or the long-suffering woman; Pagani-Tousignant, 1992). The nurse needs to be sensitive to gender-specific cultural values in treatment situations. Family inclusion in health care planning serves as a focus of care and as a resource to the client.
#### Religion
Hispanic clients take religion seriously. The predominant religion is Catholicism. Receiving the sacraments is important to Hispanics, and call for family celebration. The final sacrament in the Catholic Church, anointing of the sick, offers comfort for clients and families.
Hispanic clients view health as a gift from God, related to physical, emotional, and social balance (Kemp, 2004). Many believe that illness is the result of a great fright _(susto),_ or falling out of favor with God.
Faith in God is closely linked with the Hispanic population's understanding of health care problems (Zapata & Shippee-Rice, 1999). Their relationship with God is an intimate one, which may include personal visions of God or saints. This should not be interpreted as a hallucination.
#### Health Beliefs and Practices
They identify a "hot-cold balance," referring to a cultural classification of illness resulting from an imbalance of body humors, as essential for health. When a person loses balance, illness follows (Juckett, 2005). "Cold" health conditions are treated with hot remedies, and vice versa. Mental illness is not addressed as such. Instead, a Hispanic client will talk of being sad _(triste)._
Modesty is important to Hispanic women. They may be reluctant to discuss matters of sexuality. Women may be reluctant to express their private concerns in front of their children, even adult children.
Hispanics use the formal health care system only as a short-term problem-solving strategy for health problems. The value of _familisimo_ discourages revealing problems outside the family. Hispanic men may view asking for help as a weakness, incompatible with being machismo (Ramos-Sánchez & Atkinson, 2009). Many are illegal immigrants and/or have low incomes, limited education, and no health insurance. A source of health care outside the family is the use of _curanderos_ (local folk healers and herb doctors) for initial care. The _curandera_ uses a combination of prayers, healing practices, medicines, and herbs to cure illness (Amerson, 2008).
It is not uncommon for clients to share medications with other family members. Aponte (2009) suggests that nurses should ask Hispanic clients about the use of folk medicine and explain, if needed, the reason and importance of sharing this information with the nurse. A proactive prevention approach tailored to the health care needs of this minority population is essential.
#### Social Interaction Patterns
Spanish is the primary language spoken in all Latin American countries except Brazil (Portuguese) and Haiti (French). Hispanics are an extroverted people who value interpersonal relationships. They appreciate recognition that their speech comes from the heart. Hispanic clients trust feelings more than facts. Strict rules govern social relationships _(respeto),_ with higher status being given to older individuals and to male over female individuals. Nurses are viewed as authority figures, to be treated with respect. Clients hesitate to ask questions, so it is important to ask enough questions to ensure that they understand their diagnosis and treatment plan (Aponte, 2009).
Hispanic clients look for warmth, respect, and friendliness _(personalismo)_ from their health care providers. It is important to ask about their well-being and to take extra time with finding out what they need. They value smooth social relations, and avoid confrontation and criticism _(simpatia)._ Hispanic people are sensitive and easily hurt.
Hispanic clients need to develop trust _(confianza)_ in the health care provider. They do this by making small talk before getting down to the business of discussing their health problems. Knowing the importance of _confianza_ to the Hispanic client allows nurses to spend initial time engaging in general topics before moving into assessment or care (Knoerl, 2007).
### African american culture
African Americans account for 13.5% of the population of the United States (OMHD, 2010), making them the second largest minority group in the nation A smaller group (referred to as African American or Black) emigrated voluntarily from countries such as Haiti and Jamaica.
Purnell and Paulanka (2008) note, "Black or African American refers to people having origins in any of the black racial groups of Africa, and includes Nigerians and Haitians or any person who self-designates this category regardless of origin" (p. 2). Although African Americans are represented in every socioeconomic group, approximately one-third of them live in poverty (Spector, 2004). For many, their cultural heritage traces back to slavery and deprivation. This unfortunate legacy colors the expectations of African Americans with health care issues, and explains the distrust many African Americans have about the American health care system (Eiser & Ellis, 2007). African Americans need to experience feeling respected by their caregivers to counteract the sense of powerlessness and lack of confidence they sometimes feel in health care settings.
The African American worldview consists of four fundamental characteristics:
• _Interdependence:_ feeling interconnected and as concerned about the welfare of others as of themselves
• _Emotional vitality:_ expressed with intensity and animation in lifestyle dance, language, and music
• _Harmonious blending:_ "going with the flow" or natural rhythm of life
• _Collective survival:_ sharing and cooperation is essential to everyone surviving and succeeding (Parham, White, & Ajamu, 2000)
#### Family
The family is considered the "primary and most important tradition in the African American community" (Hecht et al., 2003, p. 2). Women are often considered the head of the family, consistent with vestiges of a matriarchal tradition in many African villages. Many low-income African American children grow up in extended families. Grandparents assume caregiving responsibilities for working parents. Including grandparents, particularly grandmothers, is useful when caring for African American clients in the community (Purnell & Paulanka, 2005).
African Americans depend on kinship networks for support. Loyalty to the extended family is a dominant value, and family members rely on each other for emotional and financial support (Sterritt & Pokorny, 1998). The combination of strong kinship bonds and the value of "caring for one's own" are important aspects of the African American culture. Caring for less fortunate family members is viewed as a resource strength of African American families (Littlejohn-Blake & Darling, 1993). When planning interventions, taking advantage of kinship bonds and incorporating family as supportive networks can greatly enhance the quality of care.
#### Religion and Spiritual Practices
The church serves the dual purpose of providing a structure for meeting spiritual needs and functioning as a primary social, economic, and community life center. Chambers (1997) explains, "Since its inception, the black church has been more than a place of worship for African-Americans. It is where the community has gathered to lobby for freedom and equal rights" (p. 42). African American political leaders (e.g., Jesse Jackson and Dr. Martin Luther King, Jr.) are revered as influential church leaders.
Major religions include Christianity (predominantly Protestant), Islam, and to a lesser extent, Pentecostal. Although fairly rare, beliefs associated with ancient religious practices (voodoo) provide explanatory models for illness and emotional disturbance.
Case Example
Ms. Jones is a 56-year-old African American who was brought by her family to the psychiatric emergency service of a large city hospital. She claimed that her husband's lover had poisoned her. After a psychiatric examination, Ms. Jones was given the diagnosis of delusional disorder, jealous type. She was admitted to the inpatient psychiatric unit and started on a neuroleptic medication. However, the diagnostician failed to conduct a cultural assessment, which would have revealed that Ms. Jones felt she was experiencing voodoo illness. A more culturally relevant treatment would have included consultation with a folk healer (Campinha-Bacote, 1992).
Christianity is often associated with evangelical expression. Prayer and the "laying on of hands" may be very important to the African-American client (Purnell & Paulanka, 2005). Because of the central meaning of the church in African-American life, incorporating appropriate clergy as a resource in treatment is a useful strategy. Readings from the Bible and gospel hymns are sources of support during hospitalization.
African Americans account for approximately 30% of the U.S. Muslim population. Islam influences all aspects of life. Muslim clients are expected to follow the Hallal (lawful) diet, which calls for dietary restrictions on eating pork or pork products, and drinking alcohol (Rashidi & Rajaram, 2001).
#### Health Beliefs and Practices
Lower income African-American clients statistically are less likely to use regular preventive health services. They frequently delay seeking treatment for serious diseases, which results in a poorer prognosis and fewer, more expensive treatment options. Because of cost, many African Americans use emergency departments as a major health care resource (Lynch & Hanson, 2004).
African Americans tend to rely on informal helping networks in the community, particularly those associated with their churches, until a problem becomes a crisis. Purnell and Paulanka (2005) advise engagement of the extended family system, particularly grandmothers, in providing support and health teaching when working with African American clients in the community.
#### Social Interaction
Establishing trust is essential for successful communication with African American clients. They are more willing to participate in treatment when they feel respected and are treated as treatment partners in their health care. Allowing clients to have as much control over their health care as possible reinforces self-efficacy and promotes self-esteem.
Recognizing and respecting African American values of interdependence, emotional vitality, and collective survival helps facilitate confidence in health care. Awareness of community resources in the African American community and incorporation of informal care networks such as the church, neighbors, and extended family can help provide culturally congruent continuity of care.
African Americans suffer more health disparities than any other minority population. They have a greater rate of HIV infection and are less likely to be on appropriate treatment. African Americans have greater rates of hypertension, adolescent pregnancy, diabetes, heart disease, and stroke, and male African Americans have a significantly greater chance of developing cancer and of dying of it (Spector, 2004).
### Asian american
The third most common minority group in the United States is Asian Americans. Currently, they make up 5% of the population (OHMD, 2010) and represent the fastest growing of all major ethnic groups. Pagani-Tousignant (1992) notes that the cultural community of Asians and Pacific Islanders comprises more than 32 ethnic groups, with the best known being Chinese, Japanese, Indian, Korean, and Vietnamese.
Even within the same geographic grouping, significant cultural differences exist. For example, in India, there are more than 350 "major languages," with 18 being acknowledged as "official languages," and a complex caste system defines distinctive behavioral expectations for gender roles within the broader culture (Chaudhary, 2004).
Asian culture values hard work, education, and going with the flow of events. In most Asian countries, there is an emphasis on politeness and correct behavior. The correct cultural behavior is to put others first and not to create problems. This can lead to vagueness in communication that is not always understandable to cultures that use a more direct communication style. Traditionally, the Asian client exercises significant emotional restraint in communication. Interpersonal conflicts are not directly addressed, and challenging an expert is not allowed (Chen, 2001). Jokes and humor are usually not appreciated because "the Confucian and Buddhist preoccupation with truth, sincerity, kindliness and politeness automatically eliminates humour techniques such as sarcasm, satire, exaggeration and parody" (Lewis, 2000, pp. 20–21).
#### Family
Asian families traditionally live in multigenerational households, with extended family providing important social support. Individual privacy is uncommon. The Asian culture places family before individual welfare. The centrality of the family unit means that individuals will sacrifice their individuality if needed for the good of the family. The need to avoid "loss of face" by acting in a manner that brings shame to the individual is paramount, because loss of face brings shame to the whole family, including ancestors.
The family may consist of father, mother, and children; nuclear family, grandparents, and other relatives living together; or a broken family in which some family members are in the United States and other nuclear family members are still living in their country of origin (Gelles, 1995). There is family pressure on younger members to do well academically, and the behavior of individual members is always considered within the context of its impact on the family as a whole. Family members are obligated to assume a great deal of responsibility for each other, including ongoing financial assistance. Older children are responsible for the well-being of younger children.
Family communication takes place through prescribed roles and obligations, taking into account family roles, age, and position in the family. The husband (father) is the primary authority and decision maker. He acts as the family spokesperson in crisis situations. Elders in the Asian community are highly respected and well taken care of by younger members of the family (Pagani-Tousignant, 1992). The wisdom of the elders helps guide younger family members on many life issues, including major health decisions (Davis, 2000).
The family is a powerful force in maintaining the religious and social values in Asian cultures. "Good health" is described as having harmonious family relationships and a balanced life (Harrison et al., 2005). Tradition strongly regulates individual behavior. Traditional Chinese culture does not allow clients to discuss the full severity of an illness; this creates challenges for mutual decision making based on full disclosure that is characteristic of Western health care. Family members take an active role in deciding whether a diagnosis should be disclosed to a client. They frequently are the recipients of this information before the client is told of the diagnosis, prognosis, and treatment options.
#### Religion and Spiritual Practices
Religion plays an important role in Asian society, with religious beliefs tightly interwoven into virtually every aspect of daily life. Referred to as "Eastern religions," major groups include Hindus, Buddhists, and Muslims.
Hinduism is not a homogeneous religion, but rather a living faith and philosophical way of life with diverse doctrines, religious symbols, and moral and social norms (Michaels, 2003). Being a Hindu provides membership in a communal society. Hinduism represents a pragmatic philosophy of life that articulates harmony with the natural rhythms of life, and "right" or "correct" principles of social interaction and behavior. The _veda_ refers to knowledge passed through many generations from ancient sages, which combined with Sanskrit literature provides the "codes of ritual, social and ethical behavior, called dharma, which that literature reveals" (Flood, 1996, p. 11).
Hindus are vegetarians: It is against their religion to kill living creatures. Sikhism is a reformed variation of Hinduism in which women have more rights in domestic and community life.
Buddhism represents a philosophical approach to life that identifies fate, Inn and Ko, as the primary factors impacting health and illness. Buddhists believe that In (cause) and Ko (effect) are variables that interact with fate and can influence people to be righteous and experience less stress and guilt, thereby promoting better health (Chen, 2001). Referred to as the four noble truths, Buddhists believe:
• All life is suffering.
• Suffering is caused by desire or attachment to the world.
• Suffering can be extinguished by eliminating desire
• The way to eliminate desire is to live a virtuous life (Lynch & Hanson, 2004).
Buddhists follow the path to enlightenment by leading a moral life, being mindful of personal thoughts and actions, and by developing wisdom and understanding. Buddhists pray and meditate frequently. They eat a vegetarian diet, and alcohol, cigarettes, and drugs are not permitted.
The Muslim religion (Islam) is a way of life. Muslims adhere to the Quran/Koran, the holy teaching of Muhammad. Faith, prayer, giving alms, and making a yearly pilgrimage to Mecca are requirements of the religion.
Identified as an Eastern monotheistic religion, Islam is practiced throughout the world. Followers are called Muslims. Allah is identified as a higher power or God. Muhammad is his prophet. Muslims submit to Allah and follow Allah's basic rules about everything from personal relationships to business matters, including personal matters such as dress and hygiene. Islam has strong tenets that affect health care, an important one being that God is the ultimate healer.
Dietary restrictions center on consuming Halaal (lawful) food. Excluded from the diet are pork and pork products, and alcohol. In the hospital, Muslims can order Kosher food because it meets the requirements for Halaal (Davidson, Boyer, Casey, Matzel, & Walden, 2008). The Muslim client values physical modesty, and the family may request that only female staff care for female family members. Physical contact, eye contact, touch, and hugs between members of the opposite sex who are not family are avoided (McKennis, 1999).
Muslims believe death is a part of Allah's plan, so to fight the dying process with treatment is wrong. They believe that the dying person should not die alone. A close relative should be present, praying for God's blessing or reading the Quran/Koran. Once the person actually dies, it is important to perform the following: turn the body toward Mecca; close the person's mouth and eyes, and cover the face; straighten the legs and arms; announce the death to relatives and friends; bathe the body (with men bathing men and women bathing women); and cover the body with white cotton (Servodido & Morse, 2001).
#### Health Care Beliefs and Practices
Ayurveda represents an ancient system of medicine endogenous to Asian culture, particularly India. The term describes a "way of living with awareness and promoting longevity" (Lic & Ayur, 2006, p. xix). Mind, body, and spirit are considered an integrated whole, and Ayurveda differentiates between substances, qualities, and actions that are life enhancing and those that are not. It is considered a form of complementary alternative treatment consisting of herbs, yoga, and massage, and is designed to reestablish harmony between the mind, body, and spirit.
Health, based on the ayurvedic principle, requires harmony and balance between yin and yang, the two energy forces required for health (Louie, 2001). A blockage of qi, defined as the energy circulating in a person's body, creates an imbalance between yin (negative energy force) and yang (positive energy force), resulting in illness (Chen, 2001). Yin represents the female force, containing all the elements that represent darkness, cold, and weakness. Yang symbolizes the male elements of strength, brightness, and warmth. Ayurveda emphasizes health promotion and disease prevention.
The influence of Eastern health practices and alternative medicine is increasingly incorporated into the health care of all Americans. Many complementary and alternative medical practices in the United States (acupuncture, botanicals, and massage and therapeutic touch) trace their roots to Eastern holistic health practices. Acupressure and herbal medicines are among the traditional medical practices used by Asian clients to reestablish the balance between yin and yang. In some Asian countries, healers use a process of "coining," in which a coin is heated and vigorously rubbed on the body to draw illness out of the body. The resulting welts can mistakenly be attributed to child abuse if this practice is not understood. Traditional healers, such as Buddhist monks, acupuncturists, and herbalists, also may be consulted when someone is ill.
#### Social Interaction Patterns
Health care providers are considered health experts, so they are expected to provide specific advice and recommendations (Lynch & Hanson, 2004). Asian clients prefer a polite, friendly, but formal approach in communication. They appreciate clinicians willing to provide advice in a matter-of-fact, concise manner.
Asian clients favor harmonious relationships. Confrontation is avoided; clients will nod and smile in agreement, even when they strongly disagree (Xu, Davidhizar, & Giger, 2004; Cross & Bloomer, 2010). Nurses need to ask open-ended questions and clarify issues throughout an interaction. If you use questions that require a yes or no answer, the answer may reflect the client's polite deference rather than an honest response. Explain treatment as problem solving, ask the client how things are done in his or her culture, and work with the Asian client to develop culturally congruent solutions (McLaughlin & Braun, 1998).
Asian clients are stoic. They may not request pain medication until their pain is quite severe (Im, 2008). Asking the client about pain and offering medication as normal management is helpful. Sometimes it is difficult to tell what Asian clients are experiencing. Facial expressions are not as flexible, and words are not as revealing as those of people in the dominant culture.
Health care concerns specifically relevant to this population include a higher-than-normal incidence of tuberculosis, hepatitis B, and liver cancer (OMHD, 2010). People with mental health issues do not seek early treatment because of shame and the lack of culturally appropriate mental health services (Louie, 2001).
Asian men may have a difficult time disclosing personal information to a female nurse unless the nurse explains why the data are necessary for care, because in serious matters, women are not considered as knowledgeable as men. Asian clients may be reluctant to be examined by a person of the opposite sex, particularly if the examination or treatment involves the genital area.
### Native american clients
Native Americans account for 1.6% of the U.S. population (OMHD, 2010). They represent the smallest of the major ethnic groups in the United States. There are more than 500 federally recognized tribes, and another 100 tribes or bands that are state-recognized but are not recognized by the federal government. Native Americans include First or Original Americans, American Indians, Alaskan Natives, Aleuts, Eskimos, Metis (mixed blood), or Amerindians. Most will identify themselves as members of a specific tribe (Garrett & Herring, 2001). Tribal identity is maintained through regular powwows and other ceremonial events. Like other minority groups with an oppressed heritage, the majority of Native Americans are poor and undereducated, with attendant higher rates of social and health problems (Hodge & Fredericks, 1999).
#### Family
The family is highly valued by the Native American. Multigenerational families live together in close proximity. When two individuals marry, the marriage contract implicitly includes attachment and obligation to a larger kinship system (Red Horse, 1997). Both men and women feel a responsibility to promote tribal values and traditions through their crafts and traditional ceremonies. However, women are identified as their culture's standard bearers. A Cheyenne proverb graphically states, "A nation is not conquered until the hearts of its women are on the ground. Then it is done, no matter how brave its warriors nor how strong their weapons" (Crow Dog & Erdoes, 1990, p. 3), and Cheshire (2001) notes, "It is the women—the mothers, grandmothers and aunties—that keep Indian nations alive" (p. 1534).
Gender roles are egalitarian, and women are valued. Being a mother and auntie gives a social standing as a life giver related to the survival of the tribe (Barrios & Egan, 2002). Because the family matriarch is a primary decision maker, her approval and support may be required for compliance with a treatment plan (Cesario, 2001).
#### Spiritual and Religious Practices
The religious beliefs of Native Americans are strongly linked with nature and the earth. There is a sense of sacredness in everyday living between "grandmother earth" and "grandfather sky" that tends to render the outside world extraneous (Kavanagh et al., 1999, p. 25).
#### Health Beliefs and Practices
Illness is viewed as a punishment from God for some real or imagined imbalance with nature. Native Americans believe illness to be divine intervention to help the individual correct evil ways, and spiritual beliefs play a significant role in the maintenance and restoration of health (Cesario, 2001; Meisenhelder, Bell, & Chandler, 2000). Spiritual ceremonies and prayers form an important part of traditional healing activities, and healing practices are strongly embedded in religious beliefs. Recovery occurs after the person is cleansed of "evil spirits."
Medical help is sought from tribal elders and Shamans (highly respected spiritual medicine men and women) who use spiritual healing practices and herbs to cure the ill member of the tribe (Pagani-Tousignant, 1992). For example, spiritual and herbal tokens or medicine bags placed at the bedside or in an infant's crib are essential to the healing process and should not be disturbed (Cesario, 2001). Native Americans view death as a natural process, but they fear the power of dead spirits and use numerous tribal rituals to ward them off.
#### Social Interaction Patterns
Building a trusting relationship with the health care provider is important to the Native American client. Native American clients respond best to health professionals who stick to the point and don't engage in small talk. On the other hand, they love story telling and appreciate humor.
Nurses need to understand the value of nonverbal communication and taking time in conversations with Native American clients. Direct eye contact is considered disrespectful. Listening is considered a sign of respect and essential to learning about the other (Kalbfleisch, 2009). The client is likely to speak in a low tone. Native Americans are private people who respect the privacy of others and prefer to talk about the facts rather than emotions about them.
Native Americans live in "present" time. They have little appreciation of scheduled time commitments, which in their mind do not necessarily relate to what needs to be achieved. For Native Americans, being on time or taking medication with meals (when three meals are taken on one day and two meals are eaten on another day) has little relevance (Kavanagh et al., 1999). Understanding time from a Native American perspective decreases frustration. Calling the client before making a home visit or to remind the client of an appointment is a useful strategy.
Native Americans are experiential learners.
Case Example
When the nurse is performing a newborn bath demonstration, the Native American mother is likely to watch from a distance, avoid eye contact with the demonstrator, ask few or no questions, and decline a return demonstration. This learning style should not be seen as indifference or lack of understanding. Being an experiential learner, the Native American woman is likely to assimilate the information provided and simply give the newborn a bath when it is needed (Cesario, 2001, p. 17).
Their learning style is observational and oral, so the use of charts, written instructions, and pamphlets is usually not well received. Verbal instructions delivered in a story-telling format is more familiar to Native Americans (Hodge et al., 2002).
Native Americans suffer from greater rates of mortality from chronic diseases such as tuberculosis, alcoholism, diabetes, and pneumonia. Domestic violence, often associated with alcoholism, is a significant health concern. Pain assessment is important, because the Native American client tends to display a stoic response to pain (Cesario, 2001). Homicide and suicide rates are significantly greater for Native Americans (Meisenhelder et al., 2000). Health concerns of particular relevance to the Native American population are unintentional injuries (of which 75% are alcohol related), cirrhosis, alcoholism, and obesity.
### Culture of poverty
The worldview of those who fall below the poverty line is significant enough to warrant special consideration of their needs in the nurse-client relationship. Raphael (2009) notes, "Poverty is not only the primary determinant of children's intellectual, emotional, and social development but also an excellent predictor of virtually every adult disease known to medicine" (p. 10).
Health disparities are as clearly tied to economy and social disparities in education as they are to other cultural factors. The uncertainty of today's economy is further likely to decrease the distribution of resources that influence health in ways we have not seen before.
People without money or insurance, or both, do not have the same access to the health care system that others have. The type of health insurance a person has determines the level of care that a person will receive and what treatments are allowable. Poor people have to think carefully about seeking medical attention for anything other than an emergency situation. Medications are expensive and may not be taken. The emergency department becomes a primary health care resource, and health-seeking behaviors tend to be crisis oriented. Things that most of us take for granted, such as food, housing, clothing, the chance for a decent job, and the opportunity for education, are not available, or are insufficient to meet needs. People at the poverty level have to worry on a daily basis about how to provide for basic human needs.
Poverty is a difficult but important sociocultural concept because it has an adverse effect on a large segment of the population, limiting their options in health care. Lack of essential resources is associated with political and personal powerlessness (Reutter et al., 2009). The idea that the poor can exercise choice or make a difference in their lives is not part of their worldview. People living in poverty may overlook opportunities simply because life experience tells them that they cannot trust their own efforts to produce change. Poor people often look to but do not expect others to work with them in making things better. This mindset prompts the poor to avoid and distrust the health care system for anything other than emergencies. Care strategies require a proactive, persistent, client-oriented approach to helping clients and families self-manage health problems (Minick et al., 1998). Communication strategies that acknowledge, support, and empower the poor to take small steps to independence are most effective.
Respect for the human dignity of the poor client is a major component of care. This means that the nurse pays strict attention to personal biases and stereotypes so as not to distort assessment or implementation of nursing interventions. It means treating each client as "culturally unique," with a set of assumptions and values regarding the disease process and its treatment, and acting in a nonjudgmental manner that respects the client's cultural integrity (Haddad, 2001). Ethics become particularly important in client situations requiring informed consent, health care decision making, involvement of family and significant others, treatment choices, and birth and death.
## Summary
This chapter explores the intercultural communication that takes place when the nurse and client are from different cultures. Culture is defined as a common collectivity of beliefs, values, shared understandings, and patterns of behavior of a designated group of people. Culture needs to be viewed as a human structure with many variations in meaning.
Related terms include cultural diversity, cultural relativism, subculture, ethnicity, ethnocentrism, and ethnography. Each of these concepts broadens the definition of culture. Intercultural communication is defined as a communication in which the sender of a message is a member of one culture and the receiver of the message is from a different culture. Different languages create and express different personal realities.
A cultural assessment is defined as a systematic appraisal of beliefs, values, and practices conducted to determine the context of client needs and to tailor nursing interventions. It is composed of three progressive, interconnecting elements: a general assessment, a problem-specific assessment, and the cultural details needed for successful implementation.
Knowledge and acceptance of the client's right to seek and support alternative health care practices dictated by culture can make a major difference in compliance and successful outcome. Health care professionals sometimes mistakenly assume that illness is a single concept, but illness is a personal experience, strongly colored by cultural norms, values, social roles, and religious beliefs. Interventions that take into consideration the specialized needs of the client from a culturally diverse background follow the mnemonic LEARN: Listen, Explain, Acknowledge, Recommend, and Negotiate.
Some basic thoughts about the traditional characteristics of the largest minority groups (African American, Hispanic, Asian, Native American) living in the United States relating to communication preferences, perceptions about illness, family, health, and religious values are included in the chapter. The culture of poverty is discussed.
Ethical Dilemma
What Would You Do?
Antonia Martinez is admitted to the hospital and needs immediate surgery. She speaks limited English, and her family is not with her. She is frightened by the prospect of surgery and wants to wait until her family can be with her to help her make the decision about surgery. As a nurse, you feel there is no decision to be made: She must have the surgery, and you need to get her consent form signed now. What would you do?
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CHAPTER 12
# Communicating in Groups
Elizabeth C. Arnold
Objectives
**At the end of the chapter, the reader will be able to:**
1 Define group communication.
2 Identify the stages of group development.
3 Discuss theory-based concepts of group dynamics.
4 Apply group concepts in therapeutic groups.
5 Compare and contrast different types of therapeutic groups.
6 Apply concepts of group dynamics to work groups.
This chapter describes concepts related to group dynamics in therapeutic and organizational settings. Theoretical frameworks related to the stages of group development and role functioning provide a background. Different types of group formats and the stages of group relationships are identified. Applications of group concepts in therapeutic and in work groups complete chapter content.
## Basic concepts
Definitions of group
A **_group_** is more than a random number of individuals occupying the same space. Forsyth (2009) defines group as "two or more individuals who are connected by and within social relationships" (p. 3). Relationships among members are interdependent; each member's behavior affects the behavior of other group members. Group cultures develop through shared images, values, and meanings that over time become the stories, myths, and metaphors about the group and how it functions.
#### Primary and secondary groups
Groups are categorized as primary or secondary groups. _Primary_ groups are characterized by an informal structure and social process. Group membership is automatic (e.g., in a family) or is voluntarily chosen because of a common interest (e.g., in scouting, religious, or civic groups). Primary groups are an important part of a person's self-concept, revealed in self-descriptions such as "I am Jamie's mother."
_Secondary_ groups differ from primary groups in structure and purpose; they have a planned, time-limited association; a prescribed structure; a designated leader; and a specific, identified purpose. When groups achieve their goals, the group disbands. Examples include focus groups, therapy and health-related groups, discipline-specific work groups, interdisciplinary health care teams, and educational groups. People join secondary groups for one of three reasons: to meet personally established goals, to develop more effective coping skills, or because it is required by the larger community system to which the individual belongs. Exercise 12-1 identifies the role that group communication plays in a person's life.
EXERCISE 12-1 Groups in Everyday Life
Purpose:
To help students gain an appreciation of the role group communication plays in their lives.
Procedure:
1. Write down all the groups in which you have been a participant (e.g., family; scouts; sports teams; community, religious, work, and social groups).
2. Describe the influence membership in each of these groups had on the development of your self-concept.
3. Identify the ways in which membership in different groups was of value in your life.
4. Identify the primary reason you joined each group. If you have discontinued membership, specify the reason.
Discussion:
1. How similar or dissimilar were your answers from those of your classmates?
2. What factors account for differences in the quantity and quality of your group memberships?
3. How similar were the ways in which membership enhanced your self-esteem?
4. If your answers were dissimilar, what makes membership in groups such a complex experience?
5. Could different people get different things out of very similar group experiences?
6. What implications does this exercise have for your nursing practice?
Groups offer a special forum for learning and emotional support.
#### Therapeutic groups
The value of group communication as a therapeutic tool was first introduced by Joseph Pratt, who found that he was able to expand positive outcomes with people treated for tuberculosis (TB), through group classes. Group therapy for psychological issues became apparent during World War II when it was used as a primary treatment modality to treat soldiers for war-related stress (Corey & Corey, 2008). The outcomes were so successful that mental health professionals continued to use group therapy to treat people with psychological problems. Jacob Moreno later developed psychodrama as an experiential form of group therapy, and introduced sociometry as a way to diagram group participation. In the 1930s, Samuel Slavson introduced the idea of using therapeutic activity groups for disturbed children (Rutan, Stone, & Shay, 2007). Many others contributed to the development of group communication as a treatment modality for psychological problems and general medical issues. Some health related groups are one session; most meet on a regular basis to share common concerns and experiences, and to learn new skills. With the exception of self-help groups, and some support groups, a trained group facilitator guides groups in health care.
Irvin Yalom's classic work (2005) on interactional group process is recognized as the gold standard for describing group communication processes and dynamics in therapeutic settings. Curative changes occur in therapy groups as a result of 11 therapeutic process factors. Yalom and Leszcz (2005) identify these as follows:
1. Instillation of hope
2. Universality
3. Imparting information
4. Altruism
5. The corrective recapitulation of the primary family group
6. Development of socializing techniques
7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
10. Catharsis
11. Existential factors (pp. 1–2).
#### Group dynamics
**Group dynamics** is a term used to describe the communication processes and behaviors occurring during the life of the group. They represent a complex blend of individual and group characteristics that interact with each other to achieve a group purpose. Factors that influence dynamics are illustrated in Figure 12-1.
Figure 12-1 Factors that affect group dynamics.
Functional Similarity: Careful selection of group members, based on the person's capacity to derive benefit from the group and to contribute to group goals, is a critical variable in successful groups. One variable is **functional similarity** , defined as choosing group members who have enough in common intellectually, emotionally, and experientially to interact with each other in a meaningful way. Exercise 12-2 shows the value of finding things in common. An older, highly educated adult placed in a group of young adults with limited verbal and educational skills can be a group casualty or scapegoat simply because there is not enough in common to be viewed as a peer. Placed in a different group, with clients of a similar intellectual, emotional, and experiential level, the outcome might be quite different.
EXERCISE 12-2 Group Self-Disclosure: The Impact of Universality
Purpose:
To provide students with the experience of universality and insight.
Procedure:
1. Break into groups of four to six people.
2. One person should act as a scribe.
3. Identify three things all members of your group have in common other than that you are in the same class and you are human (e.g., have siblings, have parents in the military, like sports or art).
4. Identify two things that are unique to each person in your group (e.g., only child, never moved from the area, born in another country, collects stamps).
5. Each person should elaborate on both the common and different experiences.
Discussion:
1. What was the effect of finding common ground with other group members?
2. In what ways did finding out about the uniqueness of each person's experience add to the discussion?
3. Did anything in either the discussion of commonalities or differences in experience stimulate further group discussion?
4. How could you use what you have learned in this exercise in your clinical practice?
Whereas it is important that group members have enough in common to understand each other, differences in interpersonal styles help clients learn a broader range of behavioral responses.
Group Purpose: Group purpose supplies the rationale for each group's existence (Powles, 2007). It provides direction for decisions, encourages the development of relevant group norms, and determines the type of communication and activities required to meet group goals. For example, if a group's purpose relates to medication compliance, the interventions would be educational. The purpose of a therapy group would be to improve interpersonal functioning and insight into behavior. Purposes of different group types are presented in Table 12-1.
TABLE 12-1
Group Type and Purpose
Group | Purpose
---|---
Therapy | Reality testing, encouraging personal growth, inspiring hope, strengthening personal resources, developing interpersonal skills
Support | Giving and receiving practical information and advice, supporting coping skills, promoting self-esteem, enhancing problem-solving skills, encouraging client autonomy, strengthening hope and resiliency
Activity | Getting people in touch with their bodies, releasing energy, enhancing self-esteem, encouraging cooperation, stimulating spontaneous interaction, supporting creativity
Education | Learning new knowledge, promoting skill development, providing support and feedback, supporting development of competency, promoting discussion of important health-related issues
Norms: **Group norms** refer to the behavioral rules of conduct expected of group members. Norms provide needed predictability for effective group functioning and make the group safe for its members. There are two types of group norms: universal and group specific. _Universal norms_ are stated behavioral standards that must be present in all groups for effective outcomes. Examples include confidentiality, regular attendance, and not socializing with members outside of group (Burlingame et al., 2006). Unless group members can trust that personal information will not be shared outside the group setting (confidentiality), trust will not develop. Regular attendance at group meetings is critical to group stability and goal achievement. Personal relationships between group members outside of the group threaten the integrity of the group as the therapeutic arena for the group's work.
_Group-specific norms_ evolve from the group itself in the storming phase. They represent the shared beliefs, values, and unspoken operational rules governing group function. Examples include tolerance for latecomers, use of humor or confrontation, and talking directly to other group members rather than about them. Exercise 12-3 will help you develop a deeper understanding of group norms.
EXERCISE 12-3 Identifying Norms
Purpose:
To help identify norms operating in groups.
Procedure:
1. Divide a piece of paper into three columns.
2. In the first column, write the norms you think exist in your class or work group. In the second column, write the norms you think exist in your family. Examples of norms might be as follows: no one gets angry, decisions are made by consensus, assertive behaviors are valued, and missed sessions and lateness are not tolerated.
3. Share your norms with the group, first related to the school or work group and then to the family. Place this information in the third column.
Discussion:
1. Were there many similarities between the norms you think exist in your school or work group and those that others in the same group had on their list?
2. Were there any "universal" norms on either of your lists?
3. Were you surprised either by some of the norms you wrote down when you thought about it or by those of your classmates?
4. Did you or other members in the group feel a need to refine or discuss the meaning of the norms on your list?
5. How difficult was it to determine implicit norms operating in the group?
Group Role Positions: People in groups assume and/or are ascribed roles that influence their communication and the responses of others. A person's role position in the group corresponds with the status, power, and internal image that other members in the group have of the member. Group members usually have trouble breaking away from roles they have been cast in despite their best efforts. For example, people will look to the "helper" group member for advice, even when that person lacks expertise or personally needs the group's help. Other times, group members "project" a role position onto a particular group member that represents a hidden agenda or unresolved issue for the group as a whole (Gans & Alonso, 1998). If the group as a whole seems to scapegoat, ignore, defer to, or consistently idealize one of its members, this group phenomenon can signify a group projection (Moreno, 2007). Exercise 12-4 considers group role position expectations.
EXERCISE 12-4 Headbands: Group Role Expectations
Purpose:
To experience the pressures of role expectations on group performance.
Procedure:
1. Break the group up into a smaller unit of six to eight members. In a large group, a small group performs while the remaining members observe.
2. Make up mailing labels or headbands that can be attached to or tied around the heads of the participants. Each headband is lettered with directions on how the other members should respond to the role. Examples include:
• Comedian: laugh at me
• Expert: ask my advice
• Important person: defer to me
• Stupid: sneer at me
• Insignificant: ignore me
• Loser: pity me
• Boss: obey me
• Helpless: support me
3. Place a headband on each member in such a way that the member cannot read his or her own label, but the other members can see it easily.
4. Provide a topic for discussion (e.g., why the members chose nursing, the women's movement) and instruct each member to interact with the others in a way that is natural for him or her. Do not role-play, but be yourself. React to each member who speaks by following the instructions on the speaker's headband. You are not to tell each other what the headbands say, but simply to react to them.
5. After about 20 minutes, the facilitator halts the activity and directs each member to guess what his or her headband says and then to take it off and read it.
Discussion:
Initiate a discussion, including any members who observed the activity. Possible questions include:
1. What were some of the problems of trying to "be yourself" under conditions of group role pressure?
2. How did it feel to be consistently misinterpreted by the group—to have them laugh when you were trying to be serious or ignore you when you were trying to make a point?
3. Did you find yourself changing your behavior in reaction to the group treatment of you—withdrawing when they ignored you, acting confident when they treated you with respect, giving orders when they deferred to you?
Modified from Pfeiffer J, Jones J: _A handbook of structured experiences for human relations training, Vol. VI,_ La Jolla, CA, 1977, University Associate Publishers.
### Group dynamics
Phases of the group life cycle
**Group process** refers to the structural development of the group, and describes the phases of its life cycle. Tuckman's (1965, 1977) model of small-group development provides a framework for examining group process at different stages in the life of the group. He describes five stages: forming, storming, norming, performing, and adjourning (see Figure 12-2). Stages of group development are applicable to work groups, as well as therapeutic groups. Each sequential phase has its own set of tasks that build and expand on the work of previous phases. The concept of stage development is operationalized in the application section of the chapter.
Figure 12-2 The life cycle of groups.
Forming Phase: The forming phase begins when members come together to form a group. Members enter group relationships as strangers to each other. There is high dependence on the leader for direction, and orientation of members to purpose and expectations for behavior is a fundamental leadership responsibility. Getting to know each other, finding common threads in personal experience, and learning about group goals and tasks are emphasized. Members have a basic need for acceptance. Minimal work on the task is accomplished, but this phase cannot be shortchanged without having a serious impact on the evolving effectiveness of the group (Yalom & Leszcz, 2005).
Storming Phase: When a group moves into the storming phase, the gloves come off. This phase is characterized by conflict around interpersonal issues. Members focus on power and control issues. They use testing behaviors around boundaries, communication styles, and personal reactions with other members and the leader. Characteristic behaviors include disagreement with the group format, topics for discussion, the best ways to achieve group goals, and comparisons of member contributions. Although the storming phase is uncomfortable, successful resolution leads to the development of group-specific norms.
Norming Phase: In the norming phase, cohesiveness develops as standards evolved by members are accepted as operational norms. Individual goals become aligned with group goals. The group holds members accountable and challenges individual members who fail to adhere to expected behaviors. Group norms make the group safe, and members begin to experience the cohesiveness of the group as "their group."
Performing Stage: The group's "work" is accomplished in the performing phase, which is characterized by interdependence and cohesion. People feel loyal to the group and to individual members. Members are comfortable taking risks, and are invested enough in each other and the group process to offer constructive comments.
Adjourning Phase: Tuckman introduced the adjourning phase as a final phase of group development at a later date (Tuckman & Jensen, 1977). This phase is characterized by reviewing what has been accomplished, reflecting on the meaning of the group's work together, and making plans to move on in different directions.
#### Functional group roles
Functional roles differ from positional roles group members assume in that they are related to the type of member contributions needed to achieve group goals. Benne and Sheats (1948) described constructive role functions as the behaviors members use to move toward goal achievement ( **task functions** ) and behaviors designed to ensure personal satisfaction ( **maintenance functions** ).
Balance between task and maintenance functions increases group productivity. When task functions predominate, member satisfaction decreases and a collaborative atmosphere is diminished. When maintenance functions override task functions, members have trouble reaching goals. Members do not confront controversial issues, so the creative tension needed for successful group growth does not occur. Task and maintenance role functions found in successful small groups are listed in Box 12-1. Exercise 12-5 provides practice in identifying task and maintenance functions.
BOX 12-1 Task and Maintenance Functions in Group Dynamics
Task Functions: Behaviors Relevant to the Attainment of Group Goals
• _Initiating_ : identifies tasks or goals; defines group problem; suggests relevant strategies for problem solving
• _Seeking information or opinion:_ requests facts from other members; asks other members for opinions; seeks suggestions or ideas for task accomplishment
• _Giving information or opinion:_ offers facts to other members; provides useful information about group concerns
• _Clarifying, elaborating:_ interprets ideas or suggestions placed before group; paraphrases key ideas; defines terms; adds information
• _Summarizing:_ pulls related ideas together; restates key ideas; offers a group solution or suggestion for other members to accept or reject
• _Consensus taking:_ checks to see whether group has reached a conclusion; asks group to test a possible decision
Maintenance Functions: Behaviors That Help the Group Maintain Harmonious Working Relationships
• Harmonizing: attempts to reconcile disagreements; helps members reduce conflict and explore differences in a constructive manner
• Gatekeeping: helps keep communication channels open; points out commonalties in remarks; suggests approaches that permit greater sharing
• Encouraging: indicates by words and body language unconditional acceptance of others; agrees with contributions of other group members; is warm, friendly, and responsive to other group members
• Compromising: admits mistakes; offers a concession when appropriate; modifies position in the interest of group cohesion
• Setting standards: calls for the group to reassess or confirm implicit and explicit group norms when appropriate
Note: Every group needs both types of functions and needs to work out a satisfactory balance of task and maintenance activity.
Modified from Rogers C: The process of the basic encounter group. In Diedrich R, Dye HA, editors: _Group procedures: purposes, processes and outcomes,_ Boston, 1972, Houghton Mifflin.
EXERCISE 12-5 Task Functions versus Maintenance Functions
Purpose:
To help students identify task functions versus maintenance functions.
Procedure:
1. Break up into groups of eight students each.
2. Choose a topic to discuss (e.g., how you would restructure the nursing program; nursing and the women's movement; the value of a group experience; nursing as a profession).
3. Two students should volunteer to be the observers.
4. The students discuss the topics for 30 minutes; observers use the initial of each student and the grid below to mark with a tick (/) the number of times each student uses a task or maintenance function.
5. After completion of the group interaction, each observer shares his or her observations with the other group members.
Task Functions
Initiating ______________________________________.
Information seeking ____________________________.
Clarifying _____________________________________.
Consensus taking ______________________________.
Testing _______________________________________.
Summarizing __________________________________.
Maintenance Functions
Encouraging __________________________________.
Expressing ___________________________________.
Group feeling _________________________________.
Harmonizing __________________________________.
Compromising ________________________________.
Gatekeeping __________________________________.
Setting standards ______________________________.
Discussion:
1. Was there an adequate balance between task and maintenance activity?
2. What roles did different members assume?
3. Were the two observers in agreement as to members' assumptions of task versus maintenance functions? If there were discrepancies, what do you think contributed to their occurrence?
4. What did you learn from this exercise?
Benne and Sheats (1948) also identified nonfunctional role functions. _Self-roles_ are roles a person uses to meet self-needs at the expense of other members' needs, group values, and goal achievement. Self-roles, identified in Table 12-2, detract from the group's work and compromise goal achievement by taking time away from group issues and creating discomfort among group members.
TABLE 12-2
Nonfunctional Self-Roles
Role | Characteristics
---|---
Aggressor | Criticizes or blames others, personally attacks other members, uses sarcasm and hostility in interactions
Blocker | Instantly rejects ideas or argues an idea to death, cites tangential ideas and opinions, obstructs decision making
Joker | Disrupts work of the group by constantly joking and refusing to take group task seriously
Avoider | Whispers to others, daydreams, doodles, acts indifferent and passive
Self-confessor | Uses the group to express personal views and feelings unrelated to group task
Recognition | Seeks attention by excessive talking, seeker trying to gain leader's favor, expressing extreme ideas, or demonstrating peculiar behavior
Modified from Benne KD, Sheats P: Functional roles of group members, _J Soc Issues_ 4(2):41–49, 1948.
#### Group leadership
Two basic assumptions support the function of group leadership: (1) Group leaders have a significant influence on group process; and (2) most problems in groups can be avoided or reworked productively if the leader is aware of and responsive to the needs of individual group members, including the needs of the leader (Corey & Corey, 2008).
Effective leadership behaviors require adequate preparation, professional leadership attitudes and behavior, responsible selection of members, and use of a responsible scientific rationale for determining a specific group approach. Personal characteristics demonstrated by effective group leaders include commitment to the group purpose, self-awareness of personal biases and interpersonal limitations, careful preparation for the group and with the group, and an open attitude toward group members. Knowledge of group dynamics, training, and supervision are additional requirements for leaders of psychotherapy groups. Educational group leaders need to have expertise on the topic for discussion.
Throughout the group's life, the leader models attitudes of caring, objectivity, and integrity. Effective leaders are good listeners, and are able to adapt their leadership style to fit the changing needs of the group. They respectfully support the integrity of group members as equal partners in meeting group goals. Successful leaders trust the group process enough to know that group members can work through conflict and difficult situations. They know that even mistakes can be used to promote group member growth (Rubel & Kline, 2008).
Some individuals, because of the force of their personalities, knowledge, or experience, will emerge as informal leaders within the group. Power is given to members who best clarify the needs of the other group members, or who move the group toward goal achievement. They are not always the group members making the most statements.
Case Example
Al is a powerful informal leader in a job search support group. Although he makes few comments, he has an excellent understanding of and sensitivity to the needs of individual members. When these are violated, Al speaks up and the group listens. Al's observations reflect that the group themes are trustworthy.
_Emergent informal leaders_ such as Al are recognized by other group members as being powerful, and their comments are equated with those of the designated leader. Ideally, group leadership is a shared function of all group members, with many opportunities to divide up responsibility for achieving group goals. Exercise 12-6 is designed to help you develop an appreciation of leadership role preferences.
EXERCISE 12-6 Clarifying Leadership Role Preferences
Purpose:
To help students focus on how they personally experience the leadership role.
Procedure:
Answer the following questions briefly:
1. What do you enjoy most about the leadership role?
2. What do you like least about the leadership role?
3. What skills do you bring to the leadership role?
4. What are the differences in your functioning as a group member and as a group leader?
Discussion:
1. What types of transferable skills did you find you bring to the leadership role? For example, are you an oldest child? Did you organize a play group? Did you teach swimming to mentally handicapped children in high school? Are you a member of a large family?
2. Were some of the uncomfortable feelings "universal" for a majority of the group?
3. What skills would you need to develop to feel comfortable as a group leader?
4. What did you learn about yourself from doing this exercise?
Co-Leadership: Yalom and Leszcz (2005) suggest that co-leadership has advantages and disadvantages. The advantages are that co-leaders can complement and support each other. Co-leaders provide a wider variety of responses, dual points of view that can be helpful to group members, and feedback to each other. When one leader is under fire, it can increase the other's confidence, knowing that in-group support and an opportunity to process the session afterward is available.
Problems arise when co-leaders have different theoretical orientations or are competitive. Needing to pursue solo interpretations rather than explore or support the meaning of co-leader's interventions is distracting to the group. Yalom and Leszcz (2005) state, "You are far better off leading a solo group with good supervision than being locked into an incompatible co-therapy relationship" (p. 447).
If you decide to co-lead a group, you need to spend sufficient prep time together before meeting with a therapy group to ensure personal compatibility, and that you have the same understanding of the group purpose. Depending on time availability, it is sometimes advantageous for both group co-leaders to hold pregroup interviews with clients. You will also need to process the group dynamics together, preferably after each meeting.
It is important for co-leaders to work together harmoniously. This requires developing respect for each other's skills, maintaining authenticity for yourself, and sensitivity to your co-leaders style of communicating (Corey & Corey, 2008).
Developing an Evidence-Based Practice
Erwin P, Purves D, Johannes K: Involvement and outcomes in short-term interpersonal cognitive problem solving groups, _Couns Psychol Q_ 18(1):41–46, 2005.
This quantitative study was designed to explore the extent to which involvement in a short-term, interpersonal, cognitive problem-solving group could predict improvement in interpersonal cognitive problem-solving skills. A convenience sample of 31 children were assigned to either an experimental (N = 16) or control (N = 15) group. All study participants were given a pretest and post-test for interpersonal cognitive problem-solving skills.
_Results:_ Findings indicated significantly greater improvement in these skills with study participants in the experimental group compared with the control group (N= 761) regarding barriers and facilitators to their utilizing research in clinical practice. Reported barriers included time constraints, lack of awareness about availability of research literature, insufficient authority and/or lack of support to make changes based on research findings, and lack of knowledge needed for critique of research studies. Facilitators included availability of time, access and support for review and implementation of research findings, and support of colleagues.
_Application to Your Clinical Practice:_ Study findings suggest a significant relationship between group learning and positive outcomes for problem-solving skills. What kinds of problems do you see in your clinical experience that might lend themselves to short-term group intervention?
## Applications
Applying group concepts to therapeutic groups
#### Differences between individual and group communication
Group communication encompasses characteristics of individual communication. Acceptance, respect, understanding, and listening responses found in individual relationships are essential components of effective group communication. Similar therapeutic strategies of using open-ended questions, listening responses, and minimal cues are important in group communication.
There also are key differences. Group communication is more complex than individual communication because each member brings to the group a different set of perspectives, perception of reality, communication style, and personal agenda. Counselman (2008) suggests, "Group demonstrates that there truly are multiple realities" (p. 270). Group themes, rather than individual feelings with situations, form the basis for conversation.
Case Example
_Martha:_ I was upset with last week's meeting because I didn't feel we made any progress. Everyone complained, but no one had a solution.
_Leader:_ I wonder if other people feel as Martha does?
In therapeutic groups, clients are sources of help, as well as recipients. Groups offer a simulated forum for learning. Members not only talk about interpersonal issues; they can practice interpersonal skills with other group members. Disclosures from other group members help individuals recognize the universality of their problems at a personal level (Forsyth, 2009; Yalom & Leszcz, 2005). The leader relates to the group as a whole, instead of with only one person.
Case Example
_Carrie:_ I feel like giving up. I've tried to do everything right, and I still can't seem to get good grades in my classes.
_Leader:_ I wonder if the discouragement you are feeling is similar to Mary's disenchantment with her job, and Bill's desire to throw in the towel on his marriage.
#### Group structure and format
Group purpose and goals dictate group structure, membership, and format. For example, a medication group would have an educational purpose. A group for parents with critically ill children would have a supportive design, whereas a therapy group would have restorative functions. Exploration of personal feelings would be limited and related to the topic under discussion in an education group. In a therapy group, such probing would be encouraged.
#### Group size
The size of the group depends on its purpose. In general, therapy and personal growth groups consist of six to eight members. Generally, therapy groups should not have fewer than five members. With less than this number, interaction tends to be limited, and if one or more members are absent, the group interaction can become intense and uncomfortable for the remaining members. Powles (2007) argues, "The threesome rarely leads to solid group formation or a productive group work" (p. 107). Support, education, and skills training groups can have from 10 to 30 members.
Group Membership Issues: Groups are categorized as closed or open groups, and as having homogeneous or heterogeneous membership (Corey, 2007). _Closed_ groups have a predefined selected membership with an expectation of regular attendance for an extended time period, usually at least 12 sessions. Group members may be added, but their inclusion depends on a match with group-defined criteria. Most psychotherapy groups fall into this category. _Open_ groups do not have a defined membership. Individuals come and go depending on their needs. One week the group might consist of 2 or 3 members and the next week 15 members. Most community support groups are open groups. Some groups, such as Alcoholics Anonymous, have "open" meetings, which anyone can attend, and "closed" meetings, which only alcoholic members can attend.
Therapeutic groups are composed of a homogeneous or heterogeneous membership. **Homogeneous** groups share common characteristics, for example, diagnosis (e.g., breast cancer support group) or a personal attribute (e.g., gender or age). Twelve-step programs for alcohol or drug addiction, eating disorder groups, and gender-specific consciousness-raising groups are familiar examples of homogeneous groups.
**Heterogeneous** groups represent a wider diversity of human experience and problems. Members vary in age, gender, and psychodynamics. Most psychotherapy and insight-oriented personal growth groups have a heterogeneous membership. Educational groups held on inpatient units (e.g., medication groups) may have a homogeneous membership related to diagnosis or specific learning needs.
Group Goals: Group goals define the therapeutic outcome that a group hopes to achieve. Group goals need to be achievable, measurable, and within the capabilities of group membership. Identifying a group goal helps the leader determine the time frame and type of membership needed to achieve the goal. Evidence of goal achievement justifies the existence of the group and increases client satisfaction.
Matching group goals with client needs and characteristics is essential. The leader needs to ask, "How will being in this group enhance a client's health and well-being?" When there is a good match and the mix of clients has the capacity to contribute to the group (functional similarity), members develop commitment and perceive the group as having value.
#### Creating a safe group environment
Privacy and freedom from interruptions are key considerations in selecting an appropriate location. A sign on the door indicating the group is in session promotes privacy. Seating should be comfortable and arranged in a circle so that each member has face-to-face contact with all other group members. Being able to see facial expressions and to respond to several individuals at one time is essential to effective group communication.
The number of sessions, times, and frequency of meetings depend on the type of group and group goals. Therapy groups usually meet weekly. Support groups meet at regular intervals, ranging from weekly to monthly. Educational groups meet for a predetermined number of sessions and then disband. Once established, agreed-on times and days should be maintained, except for emergency situations. Meetings should start and end on time.
Most groups, other than educational groups, meet for 60 to 90 minutes on a regular basis with established, agreed-on meeting times. A regular time that does not conflict with a member's other obligations should be established. Groups that begin and end on time foster trust and predictability. Characteristics of effective and ineffective groups are presented in Table 12-3.
TABLE 12-3
Characteristics of Effective and Ineffective Groups
Effective Groups | Ineffective Groups
---|---
Goals are clearly identified and collaboratively developed. | Goals are vague or imposed on the group without discussion.
Open, goal-directed communication of feelings and ideas is encouraged. | Communication is guarded; feelings are not always given attention.
Power is equally shared and rotates among members, depending on ability and group needs. | Power resides in the leader or is delegated with little regard to member needs. It is not shared.
Decision making is flexible and adapted to group needs. | Decision making occurs with little or no consultation. Consensus is expected rather than negotiated based on data.
Controversy is viewed as healthy because it builds member involvement and creates stronger solutions. | Controversy and open conflict are not tolerated.
There is a healthy balance between task and maintenance role functioning. | There is a one-sided focus on task or maintenance role functions to the exclusion of the complementary function.
Individual contributions are acknowledged and respected. Diversity is encouraged. | Individual resources are not used. Conformity, the "company man," is rewarded. Diversity is not respected.
Interpersonal effectiveness, innovation, and problem-solving adequacy are evident. | Problem-solving abilities, morale, and interpersonal effectiveness are low and undervalued.
### Leader tasks applied to group stage development
Pregroup interview
Pregroup interview has several purposes. This individual interview is used to explain group goals and commitment, and affirm the client's suitability for the group.
Adequate preparation of group members in pregroup interviews and the early stages of the group life cycle enhances the effectiveness of therapeutic groups (Corey, 2007; Yalom & Leszcz, 2005). Leaders should keep the description of the group and its members short and simple. Ask clients about previous group experiences and concerns. Allow ample time for questions and comments.
#### Forming stage
The forming stage is an orientation phase. Communication is tentative and structured to allow members to learn about each other and develop trust. The leader takes an active role in helping group members feel accepted during the forming stage. Members are asked to introduce themselves and share a little of their background or their reason for coming to the group. Corey and Corey (2008) state that how well leaders prepare themselves and group members has a direct impact on building the trust needed within the group.
In the first session, the leader identifies the purpose and goals of the group and allows ample time for questions. Although members may know the purpose ahead of time, taking the time to verbalize the purpose allows group members to hear it in the same way. The leader clarifies how the group will be conducted and what the group can expect from the leader and other members in achieving group goals. It is helpful to ask clients in round robin fashion about their personal expectations.
Clients need to be educated about the nature of the group process and the behaviors required to achieve group goals. Successful short-term groups focus on "here and now" interactions, giving practical feedback, sharing personal thoughts and feelings, and listening to each other (Corey & Corey, 2008). Orienting statements may need to be restated in subsequent early sessions if there is a lot of anxiety in the group.
The leader introduces universal behavioral norms such as confidentiality, attendance, and mutual respect (Corey & Corey, 2008). Confidentiality is harder to implement in group formats because members are not held to professional legal standards. However, for the integrity of the group, all members need to commit to confidentiality as a group norm (Lasky & Riva, 2006). Limits to confidentiality related to treatment disclosures to other providers for therapeutic purposes need to be clearly stated and agreed to by all members early in the group.
#### Storming phase
The storming phase helps group members move to a deeper level. In the storming phase, the gloves come off and communication can become controversial. The leader plays an important facilitative role in the storming phase by accepting differences in member perceptions as being normal and growth producing. By affirming genuine strengths in individual members, leaders model handling conflict with productive outcomes. Linking constructive themes while stating the nature of the disagreement is an effective modeling strategy.
Members who test boundaries through sexually provocative, flattering, or insulting remarks should have limits set promptly. Refer to the work of the group as being of the highest priority, and tactfully ask the person to align remarks with the group purpose. Resolution of the storming stage is evidenced in the willingness of members to take stands on their personal preferences without being defensive, and to compromise.
#### Norming phase
Once initial conflict is resolved in the storming phase, the group moves into the norming phase. Group-specific norms have developed from discussions in the previous phase. The leader encourages member contributions and emphasizes cooperation in recognizing each person's talents related to group goals.
During the norming phase, cohesion begins to develop and is carried forward into the remaining stages of group development as a critical variable related to success. Similar to the concept of therapeutic alliance in individual relationships, cohesion is considered the most central therapeutic factor, influencing all others (Bernard et al., 2008). The group itself now becomes the agent of change.
Group Cohesion: **Cohesion** refers to the value a group holds for its members and their investment in being a part of the group. It describes the emotional bonds among members for each other and underscores their commitment to the group (Yalom & Leszcz, 2005). Evidence of group cohesion occurs when the group demonstrates a sense of common purpose, caring, collaboration in problem solving, a sense of feeling personally valued, and a team spirit (Powles, 2007). Research suggests that cohesive groups experience more personal satisfaction with goal achievement, and that members of such groups are more likely to join other group relationships. See Box 12-2 for communication principles that facilitate cohesiveness. Exercise 12-7 provides experience with understanding the relationship between individual involvement and group cohesion.
BOX 12-2 Communication Principles to Facilitate Cohesiveness
• Group tasks are within the membership's range of ability and expertise.
• Comments and responses are nonevaluative; they are focused on behaviors rather than on personal characteristics.
• The leader points out group accomplishments and acknowledges member contributions.
• The leader is empathetic and teaches members how to give feedback.
• The leader sanctions creative tension as necessary for goal achievement.
EXERCISE 12-7 Cohesion and Member Commitment
Purpose:
To help students understand the concept of cohesion.
Procedure:
1. In small groups of three to five students, think of a group to which you belonged that you would characterize as being successful.
2. What did you do in this group that contributed to its success?
3. What made this group easier to commit to than other groups to which you belonged? Be as specific as you can be about the factors that enhanced your commitment.
4. Have one student act as scribe and write down the factors that increased commitment to share with the rest of the class.
Discussion:
1. What are the common individual themes that emerged from the discussion?
2. Discuss the relationship of commitment to success.
3. Did commitment emerge as a major factor related to goal achievement?
4. Did commitment emerge as a major factor related to personal satisfaction?
5. What factors emerged as important variables in personal commitment?
6. How could you use what you learned in this exercise in client groups?
#### Facilitating the performing phase
In the performing stage of group development, members focus on problem solving. Working together and participating in another person's personal growth allows members to experience one another's personal strengths and the collective caring of the group. Of all the possibilities that can happen in a group, feeling affirmed and respected is most highly valued by group members (Table 12-4).
TABLE 12-4
Leader Strategies in the Performing (Working) Stage
Dissent is expected, but because members function interdependently and respect each other, they are able to work through issues in ways that are acceptable to the individual and the group. Effective group leaders trust group members to develop their own solutions, but call attention to important group dynamics when needed. This can be done with a simple statement such as "I wonder what is going on with her right now" (Rubel & Kline, 2008).
Monopolizing: Despite clear operational roles, the performance stage can get bogged down when one person monopolizes conversation. _Monopolizing_ is a negative form of power communication used to advance a personal agenda without considering the needs of others. When one person monopolizes the conversation, the leader should address the behavior, not an individual's motivation. For example, the leader might affirm the monopolizer's contribution and ask for group input: "Has anyone else had a similar experience?" Looking in the direction of positive group members as the statements are made also encourages member response. If a member continues to monopolize, the leader can respectfully acknowledge the person's comment and refocus the issue within the group directly: "I appreciate your thoughts, but I think it would be important to hear from other people as well. What do you think about this, Jane?"
#### Completing the adjourning phase
The final phase of group development, termination or adjournment, ideally occurs when the group members have achieved desired outcomes. This phase is about task completion and disengagement. The leader encourages the group members to express their feelings about one another with the stipulation that any concerns the group may have about an individual member or suggestions for future growth should be stated in a constructive way. The leader closes the group with a summary of goal achievement. By being the last person to share closing comments, the leader has an opportunity to soften or clarify previous comments, and to connect cognitive with feeling elements that need to be addressed. The leader needs to remind members that the norm of confidentiality continues after the completion of the group (Mangione, Forti, & Iacuzzi, 2007). Referrals are handled on an individual basis. Exercise 12-8 considers group closure issues.
EXERCISE 12-8 Group Closure Activities
Purpose:
To experience summarizing feelings about group members.
Procedure:
1. Focus your attention on the group member next to you and think about what you like about the person, how you see him or her in the group, and what you might wish for that person as a member of the group.
2. After 5 minutes, your instructor will ask you to tell the person next to you to use the three themes in making a statement about the person. For example, "The thing I most like about you in the group is..."; "To me you represent the __________ in the group"; and so on.
3. When all of the group members have had a turn, discussion may start.
Discussion:
1. How difficult was it to capture the person's meaning in one statement?
2. How did you experience telling someone about your response to him or her in the group?
3. How did you feel being the group member receiving the message?
4. What did you learn about yourself from doing this exercise?
5. What implications does this exercise have for future interactions in group relationships?
### Types of therapeutic groups
Individuals tend to act in groups as they do in real life. The group provides a mirror with which clients can learn how others perceive them so that they can learn more adaptive responses.
The term _therapeutic,_ as it applies to group relationships, refers to more than treatment of emotional and behavioral disorders. In today's health care arena, short-term groups are being designed for a wide range of different client populations as a first-line intervention to either remediate problems or prevent them (Corey & Corey, 2008). Therapeutic groups offer a structured format that encourages a person to experience his or her natural healing potential (instillation of hope), and other group members reinforce individual group member's resolve.
Therapeutic groups provide reality testing. People under stress lose perspective. Other group members can gently challenge cognitive distortions. They rarely accept unsubstantiated comments at face value and can say things to the client that friends and relatives are afraid to say. It is difficult to turn aside the energy and caring of five or six people when member comments are delivered in a caring, but reality-based way.
#### Therapy groups
Therapy groups are designed to remediate or correct behavioral disorders and issues that limit a person's potential in personal and work relationships.
Group psychotherapy is a primary form of treatment for inpatient stabilization of mental disorders. In a number of studies, clients ranked group psychotherapy as one of the most valuable components of their treatment (Hoge & McLoughlin, 1991). Psychotherapy groups focus on "here and now group interaction" as the primary vehicle of treatment (Beiling, McCabe, & Antony, 2009). Treatment goals relate to modification of maladaptive interpersonal behaviors and development of constructive coping strategies. Clients are expected to share personal feelings, develop insights about personal behaviors, and practice new and more productive interpersonal responses. When situations cannot be changed, psychotherapy groups help clients accept that reality and move on with their lives by empowering and supporting their efforts to make constructive behavioral changes. A hidden benefit of group therapy is the opportunity to experience giving, as well as receiving help from others. Helping others enhances self-esteem (altruism), especially for people who feel they have little to offer others.
Therapy groups in inpatient settings are designed to stabilize the client's behavior enough for them to functionally transition back into the community. Therapeutic groups in the community are particularly effective for adolescents as a preventive strategy because peer group interaction is such an intrinsic part of the adolescent's life (Aronson, 2004).
Leading Groups for Psychotic Clients: Staff nurses are sometimes called on to lead or co-lead unit-based group psychotherapy on inpatient units for chronically ill clients (Clarke, Adamoski, & Joyce, 1998). Other times, staff nurses participate in community group meetings composed mostly of psychotic clients. Although acutely psychotic clients usually cannot participate until they are stabilized, community groups and small, structured therapy groups can be useful.
A directive, but flexible leadership approach is needed. Because the demands of leadership are so intense with psychotic clients, co-leadership is recommended. Co-therapists can share the group process interventions, model healthy behaviors, offset negative transference from group members, and provide useful feedback to each other. Every group session should be processed immediately after its completion.
If a group topic is not forthcoming from members, the leader can introduce a relevant, concrete, problem-centered topic of potential interest to the group. For example, the group might discuss how to handle a simple behavior in a more productive way. Other members can provide feedback, and the group can choose the best solution.
A primary goal in working with psychotic clients is to understand each person as a unique human being. Although their needs are disguised as symptoms, you can help clients "decode" a psychotic message by uncovering the underlying theme and translating it into understandable language. Sometimes other members will translate the message if called on by the nurse leader. The leader might say to the group, "I wonder if anyone in the group can help us understand better what John is trying to say." Keep in mind how difficult it is for the psychotic client to tolerate close interaction, and how necessary it is interact with others, if the client is to succeed in the outside environment.
#### Therapeutic groups in long-term settings
Therapeutic groups in long-term settings offer opportunities for socially isolated individuals to engage with others. Common types of groups include reminiscence, reality orientation, resocialization, remotivation, and activity groups.
Reminiscence Groups: Reminiscence groups focus on life review and/or pleasurable memories (Stinson, 2009). They are not designed as insight groups, but rather to provide a supportive, ego-enhancing experience. Each group member is expected to share a few memories about a specific weekly group focus (holiday, first day of school, family photos, songs, favorite foods, pets, etc.). The leader encourages discussion. Depending on the cognitive abilities of members, the leader will need to be more or less directive. Sessions are held on a weekly basis and meet for an hour.
Reality Orientation Groups: Used with confused clients, reality orientation groups help clients maintain contact with the environment and reduce confusion about time, place, and person. Reality orientation groups are usually held each day for 30 minutes. Nurses can use everyday props such as a calendar, a clock, and pictures of the seasons to stimulate interest. The group should not be seen as an isolated activity; what occurs in the group should be reinforced throughout the 24-hour period. For example, on one unit, nurses placed pictures of the residents in earlier times on the doors to their bedrooms.
Resocialization Groups: Resocialization groups are used with confused clients who are too limited to benefit from a remotivation group but still need companionship and involvement with others. Resocialization groups focus on providing a simple social setting for clients to experience basic social skills again, for example, eating a small meal together. Although the senses and cognitive abilities may diminish in the elderly, basic needs for companionship, interpersonal relationships, and a place where one is accepted and understood remain the same throughout the life span. Improvement of social skills contributes to an improved sense of self-esteem.
Remotivation Groups: Remotivation groups are designed to stimulate self-esteem and socialization in a small group environment of acceptance and appreciation. Originally developed by Dorothy Hoskins Smith for use with patients with chronic mental illness, remotivation groups represent an effort to reach the unwounded healthy areas of the patient's personality. It differs from other forms of therapy because of its exclusive focus on client strengths and abilities rather than on his or her disabilities (Dyer & Stotts, 2005).
Remotivation groups are composed of 10 to 15 members who sit in a circle. They focus on everyday topics, such as the way plants or trees grow, or they might consist of poetry reading or art appreciation. Visual props engage the participant and stimulate more responses. Steps for conducting remotivation groups are presented in Box 12-3.
BOX 12-3 Steps for Conducting Remotivation Groups
1. Provide an accepting environment and greet each member by name.
2. Offer a bridge to reality by discussing topics of interest, such as news items and historical items.
3. Develop topic with group members through the use of questions, props, or visual aids.
4. Encourage members to discuss the topic in relation to themselves.
5. Express verbal appreciation to members for their contributions and plan the following session.
#### Therapeutic activity groups
Activity groups offer clients a variety of self-expressive opportunities through creative activity rather than through words. The nurse may function as group leader or as a support to other disciplines in encouraging client participation. Activity groups include the following:
• _Occupational therapy groups_ allow clients to work on individual projects or to participate with others in learning life skills. Examples are cooking, making ceramics, or activities of daily living groups. Tasks are selected for their therapeutic value, as well as for client interest. Life skills groups use a problem-solving approach to interpersonal situations.
• _Recreational therapy groups_ offer opportunities to engage in leisure activities that release energy and provide a social format for learning interpersonal skills. Some people never learned how to build needed leisure activities into their lives.
• _Exercise groups_ allow clients to engage in structured exercise. The nurse models the exercise behaviors, either with or without accompanying music, and encourages clients to participate. This type of group works well with chronically mentally ill clients.
• _Art therapy groups_ encourage clients to reveal feelings through drawing or painting. It is used in different ways. The art can be the focus of discussion. Children and adolescents may engage in a combined group effort to make a mural. Clients are able to reveal feelings through expression of color and abstract forms that they have trouble putting into words.
• _Poetry and bibliotherapy groups_ select readings of interest and invite clients to respond to literary works. Sluder (1990) describes an expressive therapy group for the elderly in which the nurse leader first read free verse poems and then invited the clients to compose group poems around feelings such as love or hate. Clients then wrote free verse poems and read them in the group. In the process of developing their poetry, clients got in touch with their personal creativity.
#### Self-help and support groups
Self-help and support groups provide emotional and practical support to clients and/or families experiencing chronic illness, crises, or the ill health of a family member. Held in the community, most support groups are led informally by group members rather than professionals, although often a health professional acts as an adviser. A suggested format for leading a support group is presented in Table 12-5.
TABLE 12-5
Sample Introductory Format for Support Group Leaders
Steps | Examples
---|---
Introduce self. | "I am Christy Atkins, a staff nurse on the unit, and I am going to be your group facilitator tonight."
Explain purpose of the group. | "Our goal in having the group is to provide a place for family members to get support from each other and to provide practical information to families caring for victims of Alzheimer's disease."
Identify norms. | "We have three basic rules in this group: (1) We respect one another's feelings; (2) we don't preach or tell you how to do something; and (3) the meetings are confidential, meaning that everything of a personal nature stays in this room."
Ask members to identify themselves and have each one tell something about his or her situation. | "I'd like to go around the room and ask each of you to tell us your name and something about your situation."
Link common themes. | "It seems as if feeling powerless and out of control is a common theme tonight. What strategies have you found help you to feel more in control?"
Allow time for informal networking (optional). | Providing a 10-minute break with or without refreshments allows members to talk informally with each other.
Provide closure. | "Now I'd like to go around the group and ask each of you to identify one thing you will do in the next week for yourself to help you feel more in control."
Self-help groups are voluntary groups, led by consumers and designed to provide peer support for individuals and their families struggling with mental health issues (Solomon, 2004). Examples include 12-step groups, On our own for chronic mentally ill clients, bipolar support alliance, and National Alliance on Mental Illness. Self-help groups are often associated with hospitals, clinics, and national health organizations.
Support groups, for example, for Alzheimer's and related dementias, compassionate friends, and cancer support groups foster creative problem solving and provide community-based opportunities for people with serious health care problems to interact with others experiencing the same kinds of problems. Support groups have an informational function in addition to social support (Percy, Gibbs, Potter, & Boardman, 2009).
Nurses are encouraged to learn about support group networks in their community. Exercise 12-9 offers an opportunity to learn about them.
EXERCISE 12-9 Learning about Support Groups
Purpose:
To provide direct information about support groups in the community.
Procedure:
1. Contact a support group in your community. (Ideally, students will choose different support groups so that a variety of groups are shared.)
2. Identify yourself as a nursing student and ask for information about the support group (e.g., the time and frequency of meetings, purpose and focus of the group, how a client joins the group, types of services provided, who sponsors the group, issues the group might discuss, and fee schedules).
3. Write a two-paragraph report including the information you have gathered, and describe your experience in asking for the support group information.
Discussion:
1. How easy was it for you to obtain information?
2. Were you surprised by any of the informants' answers?
3. If you were a client, would the support group you chose to investigate meet your needs?
4. What did you learn from doing this exercise that might be useful in your nursing practice?
#### Educational groups
Community health agencies provide education groups to impart important knowledge about lifestyle changes needed to promote health and well-being and to prevent illness. Family education groups provide families of clients with the knowledge and skills they need to care for their loved ones.
Educational groups are reality-based and related to client needs. They are time-limited group applications (e.g., the group might be held as four 1-hour sessions over a 2-week period or as an 8-week, 2-hour seminar). Examples of primary prevention groups are childbirth education, parenting, stress reduction, and professional support groups for nurses working in critical care settings. Suitable adolescent groups include those that deal with values clarification, health education, and sex education, as well as groups to increase coping skills (e.g., avoiding peer pressure to use drugs).
Medication groups are an excellent example of educational group formats used in hospitals and community clinics. Clients are taught effective ways to carry out a therapeutic medication regimen while learning about their disorder. A typical sequence would be to provide clients with the following information:
• Details about their disorder and how the medication works to reduce symptoms
• Medications, including purpose, dosage, timing, and side effects; what to do when they do not take the medication as prescribed; what to avoid while on the medication (e.g., some medications cause sun sensitivity); and tests needed to monitor the medication
Giving homework, written instructions, and materials to be read between sessions can be helpful if the medication group is to last more than one session. You should allow sufficient time for questions and, by encouraging an open, informal discussion of the topic, engage individual members in the group activity.
#### Focus groups
Clark et al. (2003) describe a focus group as "a group of people who have personal experience of a topic of interest and who meet to discus their perceptions and perspectives on that topic" (p. 457). Focus groups are used to elicit feedback about important social and health issues as a basis for health policy recommendations. Focus groups allow qualitative researchers to "see the world from the participants' perspectives" (Heary & Hennessy, 2002, p. 47). It is a very powerful and respected tool. In the process of participating in a focus group, clients learn more about health care issues affecting them, and have the opportunity to reflect on their own perceptions (Laube & Wieland, 1998).
#### Discussion groups
Functional elements appropriate to discussion groups are found in Table 12-6. Careful preparation, formulation of relevant questions, and use of feedback ensure that personal learning needs are met. Group participation on an equal basis should be a group expectation. Although the level of participation is never quite equal, discussion groups in which only a few members actively participate are disheartening to group members and limited in learning potential. Because the primary purpose of a discussion group is to promote the learning of all group members, other members are charged with the responsibility of encouraging the participation of more silent members. Sometimes, when more verbal participants keep quiet, the more reticent group member begins to speak. Cooperation, not competition, needs to be developed as a conscious group norm in all discussion groups. Discussion group topics often include prepared data and group-generated material, which then is discussed in the group. Before the end of each meeting, the leader or a group member should summarize the major themes developed from the content material.
TABLE 12-6
Elements of Successful Discussion Groups
Element | Rationale
---|---
Careful preparation | Thoughtful agenda and assignments establish a direction for the discussion and the expected contribution of each member.
Informed participants | Each member should come prepared so that all members are communicating with relatively the same level of information and each is able to contribute equally.
Shared leadership | Each member is responsible for contributing to the discussion.
Good listening skills | Members concentrate on the material and listen to content; challenge, anticipate, and weigh the evidence; they listen between the lines to emotions about the topic.
Relevant questions | Focused questions keep the discussion moving toward the group objectives.
Useful feedback | Thoughtful feedback maintains the momentum of the discussion by reflecting different perspectives of topics raised and confirming or questioning others' views.
### Group principles applied to professional work groups
Professional work groups
Multiple group membership is a fact of life in most organizations. Groups found in organizational settings (e.g., standing committees, ad hoc task forces, and quality circles) accomplish a wide range of tasks related to organizational goals.
In work groups, there are two main elements: content and process. Task group content is predetermined by an assignment or charge given to the group. Group process relates to the ways in which group members interact with each other to achieve goals.
### Applying group concepts to work groups
Leadership styles
Flexibility of leadership style is an essential characteristic of successful work groups. Effective leadership develops from leader characteristics, situational features, and member needs in combination with each other. Different groups require different leadership behaviors. Leadership is contingent on a proper match between a group situation and the leadership style.
Three types of **leadership** styles found in groups are authoritarian, democratic, and laissez-faire. Leaders demonstrating an **authoritarian leadership** style take full responsibility for group direction and control group interaction. Authoritarian leadership styles work best when the group needs structure and there is limited time to reach a decision. **Democratic leadership** involves members in active discussion and decision making. Democratic leaders are goal-directed but flexible. They offer members a functional structure, whereas preserving individual member autonomy, and members feel ownership of solutions. Members of a group with a **laissez-faire** leader function without significant leader input or structure. They are likely to be less productive or satisfying to group members.
Another way to look at leadership styles in professional group life is by using a situational leadership framework, originally developed by Hershey and Blanchard (Hershey, Fowler, Hawkins, et al., 2005). This format requires group leaders to match their leadership style to the situation and the maturity of the group members. The situational leader varies the amount of direction and support a group needs based on the complexity of the task and the follower's experience and confidence with achieving task or group goals.
Group maturity involves two forms of maturity: _job maturity_ and _psychological maturity_ related to the work. Job maturity refers to the level of work abilities, skills, and knowledge. Psychological job maturity refers to the followers' accurate knowledge of personal assets and limitations, feelings of confidence, willingness, and motivation. The capacity and readiness of situational maturity plays a role in the type of preferred leadership style to accomplish goals. A basic assumption is that leadership should be flexible and adapted to group needs. The situational leadership framework describe four leadership styles, matched to employee's maturity level in a particular work situation and dependent on their need for structure and direction.
• Telling: high structure, low consideration
• Selling: high structure, high consideration
• Participating: high consideration, low structure
• Delegating: low consideration, low structure
The leader must consistently monitor group member readiness level and must be willing to adapt to changes in the group's maturity in working together. As the group matures, leaders turn more of the responsibility for the group to its members. Decision making is collaborative. The leader seeks member input, acts as discussion facilitator, and seeks consensus.
Leader and Member Responsibilities: Box 12-4 summarizes guidelines for groups charged with making organizational changes. The group leader takes the following responsibilities:
BOX 12-4 Guidelines for Organizational Planning Groups
1. Clarify plans.
• Make one person responsible for implementation plans.
• Formulate clear, simple, time-bound goals.
• Make specific plans with milestones and outcomes.
• Make plans public.
• Give and solicit frequent face-to-face feedback.
2. Integrate new practices.
• Limit the amount of change introduced at any one time.
• Slow the change process.
• Introduce the change to receptive users first.
• Ensure that the rationale and procedure for change are well-known.
3. Provide education.
• Involve the end users and incorporate their experience.
• Provide "hands-on" training whenever possible.
• Design training from the end-user's perspective.
• Train motivated or key end-users first.
• Evaluate the effects of training or work practices and end-users' attitudes.
4. Foster ownership.
• Ensure that the change improves end-users' ability to accomplish work.
• Provide incentives for end-users applying the change.
• Specify milestones for obtaining end-user feedback.
• Incorporate end-user suggestions in the implementation plans.
• Publicize end-user suggestions.
5. Give feedback.
• Document and communicate the expected outcomes of the change.
• Ensure frequent face-to-face feedback.
• Identify clear milestones.
• Make sure feedback includes the large organization.
• Acknowledge key successes.
From Schoonover S, Dalziel M: Developing leadership for change. In Cathcart R, Samovar L, editors: _Small group communication: a reader,_ ed 5, Dubuque, IA, 1988, WC Brown.
• Forms the committee structure and establishes the agenda
• Clarifies the group's tasks and goals (providing background data and material if needed)
• Notifies each member of meeting dates, times, and place
• Keeps group members focused on tasks
• Adheres to time limits
• Concludes each meeting with a summarization of progress
Group members take responsibility for coming prepared to meetings, demonstrating respect for other members' ideas, and taking an active participatory role in the development of viable solutions. Each member should take responsibility for the overall functioning of the group and the achievement of group goals.
### Stage development leader tasks applied to work groups
Pregroup tasks
Before the group starts, participants should have a clear idea of what the group task commitment will entail in terms of time, effort, and knowledge. Group members should have enough in common to engage in meaningful communication, relevant knowledge of the issues and/or expertise needed for resolution, a willingness to make a contribution to the group solution, and the ability to complete the task.
#### Forming
Even if members are known to each other, it is useful to have each person give a brief introduction that includes his or her reason for being part of the work group. The leader should explain the group's purpose and structural components (e.g., time, place, and commitment). Member responsibilities should be outlined clearly with time for questions. A task group with vague or poorly understood goals or structure can breed boredom or frustration, and lead to power struggles and inadequate task resolution.
#### Norming
To be successful, group norms should support accomplishment of stated goals. In general, all data developed within the group context should be kept confidential until officially ready for publication. Otherwise, the "grapevine" can distort information and sabotage group efforts. Members should be accountable for regular attendance. If administrative staff is part of the group membership, they should attend all or designated meetings. Few circumstances are more threatening to a work-related group than having a supervisor enter and exit the task group at will.
#### Performing
In the performing phase, leader interventions should be consistent and well defined as the group works to fulfill its charge. Most of the group's work is accomplished, including development of recommendations and preparation of final reports. Suggestions for leader feedback in work groups are presented in Box 12-5. Brainstorming is a commonly used strategy to generate solutions. Exercise 12-10 provides practice in the use of brainstorming. Guidelines for brainstorming include:
BOX 12-5 Suggestions for Leader Feedback in Work Groups
• Be specific and direct.
• Support comments with evidence.
• Separate the issue from the person.
• "Sandwich" negative messages between positive ones.
• Pose the situation as a mutual problem.
• Mitigate or soften negative messages to avoid overload.
• Deliver feedback close to occurrence.
• Manner of delivery:
• Assertive, dynamic
• Trustworthy, fair, and credible
• Relaxed and responsive
• Preserve public image of recipient
From Haslett B, Ogilvie J: Feedback processes in task groups (p. 397). In Cathcart R, Samovar L, editors: _Small group communication: a reader,_ ed 5, Dubuque, IA, 1988, William C. Brown. Copyright © 1988, Wm. C. Brown Communications, Inc., Dubuque, IA. All rights reserved. Reprinted by permission.
EXERCISE 12-10 Brainstorming: A Family Dilemma
Purpose:
To increase self-awareness and provide practical experience with the use of brainstorming as a group activity.
Procedure:
1. Using the format on brainstorming identified in this chapter, consider the following clinical problem:
Mrs. Joan Smith is an 80-year-old woman living in Florida. Her husband recently suffered a stroke, which has affected his speech. All he is able to say to his wife is that he loves her, although he seems to understand her words to him. He is paralyzed on one side. When he tried to get out of bed, he fell and broke his hip, so he is confined to a wheelchair. No longer able to care for him, Mrs. Smith moved to Virginia to be close to her daughter, and Mr. Smith is being cared for in a nearby nursing home. Mrs. Smith is living temporarily in her daughter's home, sleeping on the couch because her daughter has a 15-year-old boy and a 3-year-old girl occupying the bedrooms.
Mrs. Smith visits her husband every day and entertains the idea that he will get well enough that they will be able to return to Florida. She tries to be there at mealtime because she thinks no one will feed him if she doesn't, and he can't eat by himself. Now that the evenings are getting darker, her daughter fears her driving after dark. She hesitates to bring up the idea of selling the house in Florida for fear it will distress her mother. Mrs. Smith is not sleeping at night and seems driven to be with her husband. Her daughter worries that her mother will collapse if she keeps up her current pace. Meanwhile, the house in Florida remains empty, her mother has taken no steps to secure legal advice, and the current living situation is becoming more permanent by default.
2. Divide the class into groups of three to six students, depending on class size.
3. Each group should identify a spokesperson to the larger group. Use a flip chart or board to record ideas.
4. Brainstorm to generate ideas for a practical solution to the Smith family's problem. Allow 15 minutes for the first part of the exercise and 20 minutes for the brainstorming section.
5. Describe your group's solution, and give the rationale for your selection.
Discussion:
In the larger group, each spokesperson presents the smaller group's solution to the Smith family's problem.
1. How did your group's answers compare with those of other groups?
2. What did you learn about the brainstorming process as a problem-solving format?
3. What was the most difficult part of the process for your group?
4. As you listen to how other groups implemented the process, what ideas came to mind?
5. How might you use this format in your nursing practice?
• Entertaining all ideas without censure
• Testing the more promising ideas for relevance
• Exploring consequences of each potential solution
• Identifying human and instrumental resources, including availability
• Achieving agreement about best possible solutions
Group formats are particularly useful for facilitating changes in organizational life.
Group Think: Although cohesiveness is an essential characteristic of effective work groups, carried to an extreme, it results in **group think** , defined by Janis (1971, 1982) as a phenomenon that occurs when loyalty and approval by other group members become so important that members are afraid to express conflicting ideas and opinions for fear of being excluded from the group. The group exerts pressure on members to act as one voice in decision making, so that realistic appraisal of issues gets lost. The warning signs of group think are listed in Box 12-6. Group think can create irrational decisions and dissatisfaction with goal achievement. Figure 12-3 displays the characteristics.
BOX 12-6 Warning Signs of Group Think
1. Illusion of invulnerability
2. Collective rationalization that disregards warnings
3. Belief in inherent morality of the decision
4. Stereotyped or negative views of people outside of group
5. Direct pressure on dissenters to not express their concerns
6. Self-censorship: individual members with doubts do not express them
7. Illusion of unanimity in which majority view is held to be unanimous
8. Self-appointed "mindguards" within the group who withhold problematic or contradictory data
Adapted from Janis I: _Groupthink: psychological studies of policy decisions and fiascoes,_ ed 2, New York, 1982, Houghton Mifflin.
Figure 12-3 Characteristics of Group Think.
Ways to reduce the potential for group think in work groups include developing norms that make it acceptable to disagree with other group members, and to seek fresh information and outside opinions. Individual members who act as "devil's advocate" about important issues should be respected and their ideas explored.
#### Adjourning phase
Termination in work groups takes place when the group task is accomplished. The leader should summarize the work of the group, allow time for processing level of goal achievement, and identify any follow-up. Work groups need to disband once the initial charge is satisfied. They should not simply move on into a never-ending commitment without negotiation and the agreement of participants to continue with another assignment.
## Summary
This chapter outlines key concepts associated with group communication and explores how it is used to help clients cope with their health or personal issues more effectively. Differences between individual and group communication are described. Group dynamics include individual member commitment, functional similarity, and leadership style. Group concepts related to group dynamics consist of purpose, norms, cohesiveness, roles, and role functions.
Group processes refer to the structural phases of group development as described by Tuckman (1965, 1977): forming, storming, norming, performing, and adjourning. In the forming phase of group relationships, the basic need is for acceptance. The storming phase focuses on issues of power and control in groups. Behavioral standards are formed in the norming phase that will guide the group toward goal accomplishment, and the group becomes a safe environment in which to work and express feelings. Once this occurs, most of the group's task is accomplished during the performing phase. Feelings of warmth, caring, and intimacy follow; members feel affirmed and valued. Finally, when the group task is completed to the satisfaction of the individual members, or of the group as a whole, the group enters an adjourning (termination) phase. Different types of groups found in health care include therapeutic, support, educational, and discussion focus groups. Group communication principles can be applied to task groups in work settings and strategies for conducting successful work groups are addressed.
Ethical Dilemma
What Would You Do?
Mrs. Murphy is 39 years old and has had multiple admissions to the psychiatric unit for bipolar disorder. She wants to participate in group therapy but is disruptive when she is in the group. The group gets angry with her monopolization of their time, but she says it is her right as a patient to attend if she chooses. Mrs. Murphy's symptoms could be controlled with medication, but she refuses to take it when she is "high" because it makes her feel less energized. How do you balance Mrs. Murphy's rights with those of the group? Should she be required to take her medication? How would you handle this situation from an ethical perspective?
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CHAPTER 13
# Communicating with Families
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define family and identify its components.
2 Compare and contrast theoretical frameworks used to study family relationships.
3 Apply family-centered concepts to the care of the family in clinical settings, using standardized family assessment tools.
4 Apply the nursing process to the care of families in clinical settings.
5 Identify nursing interventions for families in the intensive care unit (ICU).
6 Identify nursing interventions for families in the community.
The purpose of this chapter is to describe family-centered relationships and communication strategies that nurses can use to support family integrity in health care settings. The chapter identifies family theory frameworks, which provide a common language for describing family relationships. Practical assessment and intervention strategies address family issues that affect a client's recovery, and support self-management of chronic health conditions, or peaceful death in clinical practice.
## Basic concepts
Definition of family
Wright and Leahey (2009) state, "A **family** is who they say they are" (p. 70). Identified family members may or may not be blood related. Strong emotional ties and durability of membership characterize family relationships regardless of how uniquely they are defined. Even when family members are alienated, or distanced geographically, they "can never truly relinquish family membership" (Goldenberg & Goldenberg, 2008, p. 3).
Some people identify their family as those with whom they have close relationships and who care for them (Kristjanson & Aoun, 2004). Each family member relates to the other and to crisis affecting the family in unique ways. Communication, even when reactive, is designed to maintain the integrity of the family. Understanding the family as a system is relevant in today's health care environment, as the family is an essential part of the health care team.
The family represents the primary sociocultural system, in which children learn values and behavior patterns (Novilla, Barnes, De La Cruz, & Williams, 2006). Family health beliefs, past family experience with illness or injury, family loyalties and conflicts are important pieces of information that help explain client and family responses to health disruptions.
Families have a profound influence on sick clients as advisors, caretakers, supporters, and sometimes irritants. Clients who are very young, very old, and those requiring assistance with self-management of chronic illness are particularly dependent on their families.
Young children learn family rules for communication from their parents.
Learning about the family's dynamics provides:
• Awareness of family relationships that can be rallied for support, or that may need special attention because of a negative impact on the client's situation
• Awareness of who else in the family has had a similar illness or medical problem and family coping strategies
• Awareness of cultural and family factors that influence a client's attitudes, beliefs, and willingness to take action related to health care (Cole-Kelly & Seaburn, 1999).
### Family composition
There is significant diversity in the composition of families, family beliefs and values, how they communicate with each other, ethnic heritage, life experiences, commitment to individual family members, and connections with the community (Schor, 2003). Box 13-1 identifies different types of family composition.
BOX 13-1 Types of Family Composition
• **Nuclear family** : a father and mother, with one or more children, living together as a single family unit
• **Extended family** : nuclear family unit's combination of second- and third-generation members related by blood or marriage but not living together
• **Three-generational family** : any combination of first-, second-, and third-generation members living within a household
• **Dyad family** : husband and wife or other couple living alone without children
• **Single-parent family** : divorced, never married, separated, or widowed male or female and at least one child; most single-parent families are headed by women
• **Stepfamily** : family in which one or both spouses are divorced or widowed with one or more children from a previous marriage who may not live with the newly reconstituted family
• **Blended or reconstituted family** : a combination of two families with children from one or both families and sometimes children of the newly married couple
• **Common law family** : an unmarried couple living together with or without children
• **No kin** : a group of at least two people sharing a nonsexual relationship and exchanging support who have no legal, blood, or strong emotional tie to each other
• **Polygamous family** : one man (or woman) with several spouses
• **Same-sex family** : a homosexual or lesbian couple living together with or without children
• **Commune** : more than one couple living together and sharing resources
• **Group marriage** : all individuals are "married" to one another and are considered parents of all the children
Families today are much more complex than in past generations. Modern definitions of family include "declared commitment" family households without marriage (Levine, 2004). Single-parent families must accomplish the same developmental tasks as two-parent families, but in many cases, they do it without the support of the other partner or sufficient financial resources.
Blended families have a different life experience than those in an intact family because their family structure is more complex. Children may be members of more than one family unit, linked biologically, physically, and emotionally to people who may or may not be part of their daily lives. Their "family" may include two or more sets of grandparents, step- or half-brothers and sisters, and multiple aunts and uncles (Byng-Hall, 2000). The child may spend extended periods in separate households, each with a full set of family expectations that may or may not be similar. Blended families can offer a rich experience for everyone concerned, but they are more complex because of multiple connections. Table 13-1 displays some of the differences between biological and blended families. Issues for blended families include discipline, money, use of time, birth of an infant, death of a stepparent, inclusion at graduation, and marriage and health care decisions.
TABLE 13-1
Comparing Differences Between Biological and Blended Families
Biological Families | Blended Families
---|---
Family is created without loss. | Family is born of loss.
There are shared family traditions. | There are two sets of family traditions.
One set of family rules evolves. | Family rules are varied and complicated.
Children arrive one at a time. | Instant parenthood of children at different ages occurs.
Biological parents live together. | Biological parents live apart.
## Theoretical frameworks
General systems theory
Kurt von Bertalanffy's (1968) general systems theory provides a conceptual foundation for family system models (Barker, 1998). A systems perspective examines the interdependence among all parts of the system and how they support the system as a functional whole. Systems' thinking maintains that the whole is greater than the sum of its parts with each part reciprocally influencing its function. If one part of the system changes or fails, it affects the functioning of the whole. A clock is a useful metaphor. It displays time correctly, but only if all parts work together. If any part of the clock breaks down, the clock no longer tells accurate time.
A system interacts with other systems in the environment. An interactional process occurs when " _inputs_ " are introduced into the system in the form of information, energy, and resources. Within each system, the information is processed internally as the system actively processes and interprets its meaning. The transformation process of raw data into desired outputs is referred to as _throughput_. The _output_ refers to the result or product that leaves the system. Each system is separated from its environment by boundaries that control the exchange of information, energy, and resources into and out of the system. Evaluation of the output and feedback loops from the environment inform the system of changes needed to achieve effective outputs. Figure 13-1 identifies the relational components of a human system's interaction with the environment, using von Bertalanffy's model.
Figure 13-1 Systems model: Interaction with the Environment.
Applied to the human system, individuals take in food, liquids, and oxygen to nourish the body (inputs). Within the body, a transformational process occurs through enzymes and other metabolic processes (throughputs). so that the body can use them. This interactional process results in the human organism's growth, health, and capacity to interact with the external environment (outputs). Nonusable outputs excreted from the body include urine, feces, sweat, and carbon dioxide. A person's skin represents an important boundary between the environment and the human system.
Family systems have boundaries that regulate information coming into and leaving the family system. Family systems theory helps explain how families strive for harmony and balance _(homeostasis),_ how the family is able to maintain its continuity despite challenges, _(morphostasis),_ and how the family is able to change and grow over time in response to challenges _(morphogenesis). Feedback loops_ describe the patterns of interaction that facilitate movement toward morphogenesis, or morphostasis. They impact goal setting in behavior systems _._ The systems principle of _equifinality_ describes how the same outcome or end state can be reached through different pathways. This principle helps explain why some individuals at high risk for poor outcomes do not develop maladaptive behaviors (Cicchetti & Blender, 2006). Hierarchy is the term used to describe the complex layers of smaller systems that exist within a system. _Subsystems_ refer to the smaller parts within the system, and _suprasystems_ help describe the larger economic, social, and political systems in which the family system exists.
### Bowen's systems theory
Murray Bowen (1978) family systems theory conceptualizes the family as an interactive emotional unit. He believed that family members assume reciprocal family roles, develop automatic communication patterns, and react to each other in predictable connected ways, particularly when family anxiety is high. Once anxiety heightens within the system, an emotional process gets activated (Nichols & Schwartz, 2009) and dysfunctional communication patterns can emerge. For example, if one person is overly responsible, another family member is less likely to assume normal responsibility. Until one family member is willing to challenge the dysfunction of an emotional system by refusing to play his or her reactive part, the negative emotional energy fueling a family's dysfunctional communication pattern persists.
Bowen developed eight interlocking concepts to explain his theoretical construct of the family system (Bowen Center, 2004; Gilbert, 2006). He viewed self-differentiation as the fundamental means of reducing chronic anxiety within the family system and enhancing effective problem solving. Self-differentiation emphasizes thinking rather than feeling in communication.
• **Self-differentiation** refers to a person's capacity to define himself/herself within the family system as an individual having legitimate needs and wants. It requires making "I" statements based on rational thinking rather than emotional reactivity. Self-differentiation takes into consideration the views of others but is not dominated by them. Poorly differentiated people are so dependent on the approval of others that they discount their own needs.
• **Multigenerational transmission** refers to the emotional transmission of behavioral patterns, roles, and communication response styles from generation to generation. It explains why family patterns tend to repeat behaviors in marriages, child rearing, choice of occupation, and emotional responses across generations without understanding why it happens.
• **Nuclear family emotional system** refers to the way family members relate to one another within their immediate family when stressed. Family anxiety shows up in one of four patterns: (1) dysfunction in one spouse, (2) marital conflict, (3) dysfunctional symptoms in one or more of the children, or (4) emotional distancing _._
• **Triangles** refer to a defensive way of reducing, neutralizing, or defusing heightened anxiety between two family members by drawing a third person or object into the relationship (Glasscock & Hales, 1998). If the original triangle fails to contain or stabilize the anxiety, it can expand into a series of "interlocking" triangles, for example, into school issues or an affair.
• **Family projection process** refers to an unconscious casting of unresolved anxiety in the family on a particular family member, usually a child. The projection can be positive or negative, and it can become a self-fulfilling prophecy as the child incorporates the anxiety of the parent as part of his or her self-identity.
• **Sibling position** , a concept originally developed by Walter Toman (1992), refers to a belief that sibling positions shape relationships and influence a person's expression of behavioral characteristics. Each sibling position has its own strengths and weaknesses. This concept helps explain why siblings in the same family can exhibit very different characteristics. For example:
• Oldest or only children are more serious, assume leadership roles, and like to be in control. They may experience more trouble with staying connected with others, or depending on them.
• Youngest siblings are characterized as being followers, spontaneous and fun loving, with a stronger sense of humor. They are more likely to be interested in quality of life and relationships.
• Middle child positions embrace characteristics of oldest and youngest; they are likely to be adventuresome and independent, but not leaders. The child in the middle position may feel neglected or take on the role of peacemaker.
• An age differential of 6 years or more, illness, life circumstances, gender, and personality can modify typical sibling position characteristics. Children in well-differentiated families are less likely to be affected by sibling position characteristics than those in fused family systems. Complementary matches, for example, oldest/youngest work best in marriage and work situations. When two people occupy the same sibling position, issues can arise. For example, competitiveness in two oldest or only child marital partners, or difficulty making decisions with two youngest pairings is not uncommon.
• Although sibling position is a factor in explaining different relational behaviors, it is not useful as a descriptor of life functioning as a person occupying any sibling position can be successful or unsuccessful (Gilbert, 2006).
• **Emotional cutoff** refers to a person's withdrawal from other family members as a means of avoiding family issues that create anxiety. Emotional cutoffs range from total avoidance to remaining in physical contact, but in a superficial manner. Emotional cutoffs contain a negative anxiety that drains personal energy. The problems creating the emotional cutoff persist.
• **Societal emotional process** refers to parallels that Bowen found between the family system and the emotional system operating at the institutional level in society. As anxiety grows within a society, many of the same polarizations, lack of self-differentiation, and emotion-based thinking dominate behavior and system outcomes.
Family legacies have a powerful influence on family relationships and in shaping parenting practices. Knowledge of family relationships helps explain behaviors that would not be clear without having a family context. Helping families gain clarity about how their family heritage can be used as an asset in health care and/or what areas need work strengthens the potential for effective family-centered care.
### Minuchin's structural model
Family structure models, pioneered by Salvador Minuchin (1974), emphasize the structure (subsystems, hierarchies, and boundaries) of the family unit as the basis for understanding family function. Family structure refers to how the family is constructed legally and emotionally. The concept of _hierarchy_ describes how families organize themselves into various smaller units, referred to as the subsystems that comprise the larger family system.
**Subsystems** are organized by position, gender, generation, interest, or function to accomplish the goals of the family through related tasks. Common subsystems include spousal, parental, and sibling units. Family members typically belong to several subsystems simultaneously (Goldenberg & Goldenberg, 2008). Their behaviors in each subsystem reflect the nature of the relationship, for example, an adult feeling like a child when visiting parents. Being in multiple subsystems can generate conflict when the expectations of one subsystem interfere with those of another, for example, being a parent while having caregiving responsibility as a daughter for a frail elder and finding time for the spousal subsystem.
**Boundaries** , defined as invisible limits surrounding the family unit, protect the integrity of the family system. Boundaries draw a line in the sand by identifying what belongs within the family system and what is external to it. They define the level of participation between family members (Nichols & Schwartz, 2009). Clear generational boundaries provide security for family members, for example, setting legitimate limits with children and balancing individual needs with caring for the needs of chronically ill family members.
Boundaries regulate the flow of information into and out of the family. Permeable boundaries welcome interactions with others and allow information to flow freely. Families with clear, permeable boundaries are better able to balance the demands of the illness with other family needs and can communicate more effectively with care providers (Dalton & Kitzmann, 2008). Diffuse boundaries lead to family overinvolvement, whereas rigid boundaries are operative in families with little interaction between members and family secrets. Rigid boundaries restrict flow of information. Interaction with outsiders is discouraged or heavily regulated. Diffuse boundaries are found in enmeshed families.
Exercise 13-1 provides an opportunity to look at the communication process of family from a structural functional perspective. Structural and functional aspects of families determine the nature of interactions between family members. Family interactions offer protective and health-promoting support for members in crisis when they function well, and are an area of concern when they function ineffectively.
EXERCISE 13-1 Family Structures and Processes
Purpose: To develop an awareness of the different structures and processes within families.
Procedure:
Each student will attempt to spend time with a family other than his or her own family of origin. (Family can be any two or more persons of relation.) Students should observe the communication patterns, roles, and norms of the family and write a descriptive summary of their experience. How do you think this family would cope with one of the members becoming ill? Think about how this family differs from your own regarding structure and process.
Discussion:
Each student will share experiences with the group. Identify how families are different and similar. What are some of the coping strategies that you predicted based on observations? Discuss how the nurse can interface with families and assist them with coping.
The family performs its functions through subsystem alliances and coalitions to maintain the system as a whole (homeostasis). Wright and Leahey (2009) describe two ways of examining family functioning: instrumental and expressive. Both are important descriptors of family functioning.
• _Instrumental_ functioning refers to task activities of daily living (e.g., eating, sleeping, or caring for a sick member).
• _Expressive_ functioning looks at the communication, problem-solving skills, roles, beliefs, spheres of influence, and power that govern how individual members interact with one another.
Assessment of a family's structure and function for strengths and weaknesses, and comparing current functionality with previous functioning helps focus nursing interventions and supports.
### Duvall's developmental framework
Evelyn Duvall (1958) proposed a family life stage framework for understanding issues that normal families experience based on expected family development through the life span, each with its own set of tasks. Her model describes the life cycle of a family, using the age of the oldest child in the family as the benchmark for determining the family's developmental stage. Developmental tasks represent the challenges and growth responsibilities each family experiences at different life stages (Table 13-2).
TABLE 13-2
Duvall's Family Life Cycle and Related Developmental Tasks
State Family Life Cycle Stage | Family Development Tasks
---|---
I. Beginning families (married couples without children) | Establishing a mutually satisfying marriage; adjusting to pregnancy and the promise of parenthood; fitting into the kin network
II. Child-bearing families (oldest child birth through 30 months) | Having, adjusting to, and encouraging the development of infants; establishing a satisfying home for both parents and infants
III. Families with preschool-age children (oldest child 2.5–6 years of age) | Adapting to the critical needs and interests of preschool-age children in stimulating, growth-promoting ways; coping with energy depletion and lack of privacy as parents
IV. Families with school-age children (oldest child 6–13 years of age) | Fitting into the community of school-age families in constructive ways; encouraging children's educational achievement
V. Families with teenagers (oldest child 13–20 years of age) | Balancing freedom with responsibility as teenagers mature and emancipate themselves; establishing postparental interests and careers as growing parents
VI. Families launching young adults (first child leaving home through last child leaving home) | Releasing young adults into work, college, marriage with appropriate rituals and assistance; maintaining supportive home base
VII. Middle-age parents (empty nest to retirement) | Rebuilding the marriage relationship; maintaining kin ties with older and younger generations
VIII. Family during retirement and aging (retirement) | Adjusting to retirement; closing the family home or adapting it to aging; coping with bereavement and living alone
From Duvall EM, Miller BC: _Marriage and family development_ , ed 6, Boston, 1985, Allyn and Bacon. Copyright © 1985 by Pearson Education. Adapted by permission of the publisher. by Pearson Education. Adapted by permission of the publisher.
Duvall's stages of family development are helpful in guiding nurses about possible concerns families may have at different stages of family development. It helps nurses appreciate a family's current developmental needs that may coincide with their family member's illness or injury. Nurses can provide information about natural family development as a basis for discussion of the limitations imposed by the health deviation.
Duvall (1958) identified nine family characteristics indicative of successful family development:
1. An independent home
2. Satisfactory ways of earning and spending money
3. Mutually acceptable patterns in the division of labor
4. Continuity of mutually satisfying sexual relationships
5. An open system of communication
6. Workable relationships with relatives
7. Ways of interacting with the larger social community
8. Competency in childbearing and child-rearing
9. A workable philosophy of life
Developmental family theory helps nurses appreciate the family's current developmental needs that may coincide with their family member's illness or injury. This knowledge helps nurses craft a developmentally appropriate level of involvement for each family system (Leon, 2008). Families benefit from information about normal developmental patterns and typical limitations imposed by a health deviation. For example, hair loss for the adolescent having chemotherapy can be devastating because of the heightened attention to appearance during this developmental stage. Anticipatory guidance about natural developmental milestones and associated behaviors is helpful.
### Mccubbin's resiliency model of family coping
McCubbin's Resiliency Model of Family Stress, Adjustment, and Adaptation is considered the most extensively studied model of family coping with traumatic and chronic illness (McCubbin, McCubbin, Thompson, et al, 1993; Clark, 1999). In this model, A (an event) interacts with B (resources) and with C (family's perception of the event) to produce X (the crisis). An expansion of this model adds the concepts of _"pileup of demands, family system resources_ , and _postcrisis behavior"_ (McCubbin, McCubbin, & Thompson et al., 1998, p. 49). With any serious illness, most people experience a roller coaster emotional response that parallels the course of the illness—optimism and hope when things are going well, disappointment and anger when they are not.
Protective factors related to stress adaptation include good problem-solving skills and flexibility to try different constructive actions. Successful coping built on family capabilities, strengths, and resources leads to positive adaptation. Unsuccessful coping strategies result in maladaptive behaviors (Greeff & Human, 2004). Exercise 13-2 provides an opportunity to look at the differences between positive and negative family interactions.
EXERCISE 13-2 Positive and Negative Family Interactions
Purpose: To examine the effects of functional versus dysfunctional communication.
Procedure:
Answer the following questions in a brief essay:
1. Recall a situation in dealing with a client's family that you felt was a positive experience? What characteristics of that interaction made you feel this way?
2. Recall a situation in dealing with a client's family that you felt was a negative experience? What characteristics of that interaction made you feel this way?
Discussion:
Compare experiences, both positive and negative. What did you see as the most striking differences? In what ways were your responses similar or dissimilar from those of your peers? What do you see as the implications of this exercise for enhancing family communication in your nursing practice?
Pile-up demands (McCubbin et al., 1998) from the environment such as job loss, unexpected expenses, overcrowded housing conditions, and limited caregiving skills can place children and vulnerable adults at risk for significant stress. Family violence, substance abuse, neglect, and dysfunction are on the rise as families become more and more stressed while trying to cope with the demands of chronically ill clients. Nurses must be able to recognize families who are providing unsafe environments for individual family members or who have reached dangerous stress levels themselves.
#### Recognizing Families at Risk
Medalie and Cole-Kelly (2002) describe the course of chronic illness as being a series of health crises with relatively stable times in between. Knowledge of risk factors for family coping is an important dimension of providing family-centered care for the person with chronic illness and the family caring for the family member. Equally essential is knowledge and an assessment of family assets. Assets can include support from other family members, shared family activities, connections with supportive people in the community, and parental involvement in child care and school activities.
An atmosphere of openness to family concerns helps families feel comfortable in sharing painful feelings of anger or guilt. Psychosocial screening for risk factors should include asking relevant questions about family relationships, domestic violence, maternal depression, substance abuse, and suicidal ideation. There are brief written screening tools for depression and stress that nurses can also use. Individuals found to be at risk through screening can be referred to appropriate resources.
Just talking about the impact of a significant illness on family roles and function is helpful for families. Relevant questions should focus on how each family member is coping with the situation, what types of changes are needed in family functioning to cope with the illness over time, and the degree to which the family is able to meet the requirements of the crisis situation. Exercise 13-3 examines coping strategies that families use in crisis situations.
EXERCISE 13-3 Family Coping Strategies
Purpose: To broaden awareness of coping strategies among families.
Procedure:
Each student is to recall a time when his or her family experienced a significant health crisis and how they coped. (Alternative strategy: Pick a health crisis you observed with a family in clinical practice.) Respond to the following questions:
1. Did the crisis cause a readjustment in roles?
2. Did it create tension and conflict, or did it catalyze members, turning to one another for support? Look at individual members' behavior.
3. What would have helped your family in this crisis? Write a descriptive summary about this experience.
Discussion:
Each student shares his or her experience. Coping strategies and helpful interventions will be compiled on the board. Discuss the differences in how families respond to crisis. Discuss the nurse's role in support to the family.
The McCubbin model is helpful in assessing and responding to a family's psychosocial needs around the serious illness of a family member, particularly a child. Families of seriously ill children face many competing demands—care for the ill child, attention to other children, balancing work responsibilities, and having any kind of a normal life for themselves. Using this model, the nurse might inquire about how the family is able to work together in dealing with the challenges of the current illness.
Providing timely information and promoting connections with community supports and parent-to-parent networks is helpful. When significant problems exist, referring families to professionals able to deal with these complex problems and notifying protective service authorities become essential roles. Nurses are considered reporting agents in most states and, therefore, are required by law to report suspicion of child physical or sexual abuse to child protection agencies.
#### Family Resilience
Resilience refers to the ability to cope positively with adversity. It is recognized as a protective factor in times of family stress. Family resilience is associated with a healthy family atmosphere of positive support, warmth, and affection. Walsh (1996) identifies four characteristics found in resilient families:
• Capacity to derive meaning from adversity
• A positive outlook
• The capacity to affirm strengths and consider alternative possibilities
• Transcendent and spiritual beliefs that allow families to connect with a larger purpose and commitment to help others
Serious illness or injury creates many challenges to family integrity, all occurring within a short period. In addition to fear and anxiety about the illness itself, the internal image of what the family is and the meaning it holds for each person within it is challenged. In some cases, the experience strengthens the family unit. In others, it leads to disruption of family functioning. Normal life routines are suspended. Families automatically become involved in the client's care as participant, critic, support, or advocate with health care providers.
Nurses can support family resilience by providing emotional support for individual family members and vital updated information about the client's condition. Psychosocial support makes a difference. Families need attention, repeated information, and assurances (Van Horn & Kautz, 2007). Other strategies include encouraging collaboration among family members, reinforcing a sense of teamwork. Referrals to support groups for peer support of shared experiences and verbalizing observations of personal and family strengths are helpful.
Developing an Evidence-Based Practice
Wigert H, Berg M, Hellstrom AL: Parental presence when their child is in neonatal intensive care, _Scand J Caring Sci_ 23:139–146, 2010.
This article describes a study of parents with children hospitalized in a neonatal intensive care unit (NICU) in a university-based hospital and a rural hospital in a smaller city. The goal of the study was to identify parent-identified factors that facilitated or obstructed family presence with their child in the NICU. These data can help inform nurses about the types of optimal conditions needed to encourage parental presence with their children in the NICU. The study used a quantitative descriptive design to assess the amount of time parents spent with their hospitalized child, combined with an interview guide. The interview guide asked parents to answer questions about the reasons for their presence at the NICU, and factors that facilitated or obstructed their presence. The use of the interview allowed parents to expand their answers and ask for clarification. Data were collected over a 2-week period on each unit with the parents of 43 infants hospitalized at one of the NICUs (N = 67; 36 mothers, 31 fathers). Descriptive data analysis was conducted with a one-way analysis of variance designed to describe variance with the type of accommodation and time of presence within and between groups. Choice of accommodation was limited to availability at the time and the condition of the infant (maternity ward, parent rooms at the ICU, a family hotel, and the family home).
_Results:_ Study findings indicated that parents having the availability of a parent room at the NICU resulted in parents spending more time with their children ( _P_ < 0.001) in the NICU. Reasons given by parents for wanting to be present with their child centered around wanting to have more control over what was happening with their infant and wanting to assume as much parental responsibility as possible. The most important factors facilitating parental presence were good treatment by the staff and a family-friendly environment. Availability of staff and being given attention and support were other important factors. Parents appreciated being invited to participate, being given permission to choose visiting times, and getting regular information. Obstacles to being present, as identified by parents, included a non–family-friendly environment and poor treatment by staff. Responsibilities for children and care of the home were other obstacles. Lack of information and not knowing whom to turn to with questions was viewed as an obstruction. Other reasons for limited presence, as identified by parents, consisted of distance and economic situations that precluded spending significant amounts of time with the child in the NICU. Findings from this study point out that parental presence can be facilitated with a family-friendly environment, and a supportive nursing staff dedicated to providing tangible supports and optimal conditions for parents to be with their child in an NICU.
_Application to Your Clinical Practice:_ Family presence is an important dimension of family-centered care for infants in the NICU. Presence promotes bonding between parent and child, helps parents develop the skills they need to care for their infant, and reduces the parent's psychological stress. Understanding the factors that encourage parental presence and involvement with critically ill infants in the NICU can help nurses develop carefully targeted interventions.
## Applications
Family-centered care
Family-centered care allows health care providers to have a more uniform understanding of the client and family's knowledge, preferences, and values in health care as the basis for shared decision making. This information allows them to provide consistent information to all those involved in the client's care, and to identify any barriers that might arise with the care plan.
The health events of one family member affect the whole family. Trotter and Martin (2007) note, "Families share genetic susceptibilities, environments, and behaviors, all of which interact to cause different levels of health and disease" (p. 561). Families bear a bulk of the care and/or support of client self-management of chronic health conditions. They are instrumental in helping clients appreciate the need for diagnosis and treatment, and in encouraging the patient to seek treatment. Family members are involved in a client's health care decisions ranging from treatment options to critical decisions about end of life care. Families play a pivotal advocacy role in treatment by monitoring and insisting on quality care actions for an individual family member.
The challenges for the nurse in family-centered care are:
• To understand the impact of the medical crisis on family functioning and dynamics
• To appreciate and respond empathetically to the emotional intensity of the experience for the family
• To determine the appropriate level of family involvement in holistic care of the client, based on an understanding of fundamental family system concepts (Leon & Knapp, 2008)
### Assessment
For immediate health care purposes, family is defined as the significant people in the client's environment who are capable and willing to provide family-type support. This definition of family includes members who may not be related by blood, marriage, or adoption (Medalie & Cole-Kelly, 2002). Regardless of how it occurs, any health disruption becomes a family event. Even when the family is not directly involved in the client's care, they will have feelings about it—individually or collectively—that support or sabotage the effectiveness of treatment and the client's quality of life (Bell, 2000). Box 13-2 lists sample indicators that could warrant family assessment and nursing intervention.
BOX 13-2 Indicators for Family Assessment
• Initial diagnosis of a serious physical or psychiatric illness/injury in a family member
• Family involvement and understanding needed to support recovery of client
• Deterioration in a family member's condition
• Illness in a child, adolescent, or cognitively impaired adult
• A child, adolescent, or adult child having an adverse response to a parent's illness
• Discharge from a health care facility to the home or an extended care facility
• Death of a family member
• Health problem defined by family as a family issue
• Indication of threat to relationship (abuse), neglect, or anticipated loss of family member
### Assessment tools
Wright and Leahey's (2009) 15-minute interview, consisting of the genogram, ecomap, therapeutic questions, and commendations provide a comprehensive look at family relationships. Assessment tools such as the genogram, ecomap, and family time lines are used to track family patterns. The structured format of these tools focuses on getting relational data quickly and can sensitize clinicians to systemic family issues that affect patterns of health and illness (Gerson, McGoldrick, & Petry, 2008).
#### Genograms
Most family members enjoy constructing a genogram and learn about themselves in the process (Cole-Kelly & Seaburn, 1999). A **genogram** uses a standardized set of connections to graphically record basic information about family members and their relationships over three generations. Genograms are updated and/or revised as new information emerges.
There are three parts to genogram construction: mapping the family structure, recording family information, and describing the nature of family relationships. Figure 13-2 identifies the symbols used to map family structure, with different symbols representing pregnancies, miscarriages, marriages, deaths, and other nodal family events. Male family members are drawn on the left of the horizontal line as a square and female members on the right as a circle. The oldest sibling is placed on the left, with younger siblings following from left to right, in order of birth. In the case of multiple marriages, the earliest is placed on the left and the most recent on the right. Lines drawn between significant family members identify the strength of relational patterns that are overly close, close, distant, cut off, or conflicted. An example of a family genogram is presented in Figure 13-3. Exercise 13-4 provides practice with developing a family genogram.
EXERCISE 13-4 Family Genograms
Purpose: To learn to create a family genogram.
Procedure:
Students will break into pairs and interview one another to gain information to develop a family genogram. The genogram should include demographic information, occurrence of illness or death, and relationship patterns for three generations. Use the symbols for diagramming in Figure 13-2 to create a visual picture of the family information. Ask the author for validation of accuracy as you develop the genogram.
Discussion:
Each person will display their genogram and discuss the process of obtaining information. Discuss strategies for obtaining information expediently yet sensitively and tactfully. Discuss how genograms can be used in a helpful way with families.
Figure 13-2 Symbols for a genogram.
Figure 13-3 Basic family genogram.
The genogram explores the basic dynamics of a multigenerational family. Its multigenerational format, which traces family structure and relationships through three generations is based on the assumption that family relationship patterns are systemic, repetitive, and adaptive. Data about ages, birth and death dates, miscarriages, relevant illnesses, immigration, geographical location of current members, occupations and employment status, educational levels, patterns of family members entering or leaving the family unit, religious affiliation or change, and military service are written near the symbols for each person. The recorded information about family members allows families and health professionals to simultaneously analyze complex family interaction patterns in a supportive environment. The impact of multiple generations on family relationships is more readily visible.
The genogram offers much more than a simple diagram of family relationship. Formal and informal learning about appropriate social behaviors and roles takes place within the family of origin. People learn role behaviors and responsibilities expected in different life stages experientially, by way of role modeling, and through direct instruction.
As you help a client construct a family genogram, you can ask questions regarding family thoughts about the role of gender, spiritual beliefs, or cultural values in shaping personal identity, managing conflict, and handling life issues (McCormick & Hardy, 2008). For example, girls are exposed to different role behaviors and social expectations than their male siblings. Although they are less rigid than in previous generations, the differences persist. Both men and women carry these understandings into "contemporary" family relationships when they marry. Fundamental differences in family rules and role expectations especially about parenting, handling of finances, and the nature of male and female complementary roles can lead to conflict and misunderstandings if not identified, shared, and dealt with. Exercise 13-5 provides an opportunity to trace gender role development and socialization within a family and how it affects adult communication and behaviors.
EXERCISE 13-5 Using a Gendergram to Understand Gender Role Development in Families and Its Influence on Current Role Enactments
Purpose: To assist students in developing an understanding of family contributions to gender role development.
Procedure:
Each student should ask older family members of the same sex (e.g., mother, aunt, grandmother or father, uncle, grandfather) to talk about their experience growing up as a girl or a boy. Dialogue about what they see as different about gender roles today and how their gender has influenced who they are today. Compare their impressions with your own gender role development in a short essay.
Discussion:
Each student will share his or her findings with the larger group. Discussion can focus on how gender role expectations are different and similar to those held in the past. Discuss differences and similarities in the gender role development of men and women. Discuss implications of this exercise for health care delivery.
#### Ecomaps
An **ecomap** is essentially a sociogram, illustrating the shared relationships between family members and the external environment (Rempel, Neufeld, & Kushner, 2007). Beginning with an individual family unit or client, the diagram extends to include significant social and community-based systems with whom they have a relationship. These data identify at a glance the family's interaction with environmental supports, and their use of resources available through friends and community systems. Adding the ecomap is an important dimension of family assessment, providing awareness of community supports that could be or are not being used to assist families. Ecomaps can point out resource deficiencies and conflicts in support services that can be corrected.
An ecomap starts with an inner circle representing the family unit, labeled with relevant family names. Smaller circles outside the family circle represent significant people, agencies, and social institutions with whom the family interacts on a regular basis. Examples include school, work, church, neighborhood friends, recreation activities, health care facilities or home care, and extended family.
Lines are drawn from the inner family circle to outer circles indicating the strength of the contact and relationship. Straight lines indicate relation, with additional lines used to indicate the strength of the relationship. Dotted lines suggest tenuous relationships. Stressful relationships are represented with slashes placed through the relationship line. Directional arrows indicate the flow of the relational energy. Figure 13-4 shows an example of an ecomap. Exercise 13-6 provides an opportunity to construct an ecomap.
EXERCISE 13-6 Family Ecomaps
Purpose: To learn to create a family ecomap.
Procedure:
Using the interview process, students will break into pairs and interview one another to gain information to develop a family ecomap. The ecomap should include information about resources and stressors in the larger community system, such as school, church, health agencies, and interaction with extended family and friends for each student's family.
Discussion:
Each person will display his or her ecomap and discuss the process of obtaining information. Discuss strategies for obtaining information expediently yet sensitively and tactfully. Discuss how ecomaps broaden the structural information about a family and can be used in a helpful way with families.
Figure 13-4 Example of an Ecomap. (From: Rempel GR, Neufeld A, Kushner KE: Interactive use of genograms and ecomaps in family caregiving research, J Fam Nurs 13(4):403-419, 2007.)
#### Family Time Lines
A family systems framework acknowledges that each family is unique with its own set of expertise, knowledge, and skills. Vertical and horizontal stressors affect the family systems level of functioning in both positive and negative ways. Medical crises tend to exacerbate unresolved issues, which can create additional challenges for nurses (Leon & Knapp, 2008).
Time lines offer a visual diagram that captures significant family stressors, life events, health, and developmental patterns through the life cycle. Family history and patterns developed through multigenerational transmission are represented as vertical lines. Horizontal lines indicate timing of life events occurring over the current life span. These include such milestones as marriages, graduations, and unexpected life events such as disasters, war, illness, death of person or pet, moves, births, and so forth (Figure 13-5). Time lines are useful in looking at how the family history, developmental stage, and concurrent life events might interact with the current health concern.
Figure 13-5 Time line assessment example identifying vertical and horizontal stressors.
## Applying the nursing process
Orienting the family
The nurse-family relationship in client care depends on a reciprocal relationship between the nurses and family in which both are equal partners and sources of information. Nurses should begin offering information to the family as soon as the client is admitted to the hospital or service agency. Orientation to the unit, location of the cafeteria and restrooms, parking options, nearby lodging, and access to the hospitalist or physician are important data points.
The initial encounter sets the tone for the relationship. How nurses interact with each family member may be as important as what they choose to say. Begin with formal introductions and explain the purpose of gathering assessment data. Even this early in the relationship, you should listen carefully for family expectations and general anxiety that may be revealed more through behavior than through words.
### Gathering assessment data
Inquiring about the relationship the family member has with the identified client is an initial step nurses can take in establishing a relationship with the family. For example, you can initially say, "I would like to understand more about the effect of your husband's heart attack on the family." This simple statement frames the information needed. It also serves as a reminder that each family member plays a role in the health care scenario and has associated support needs that the nurse needs to consider (Vandall-Walker, Jensen, & Oberle, 2007). Box 13-3 illustrates a framework for a family assessment with a client entering cardiac rehabilitation.
BOX 13-3 Family Assessment for Client Entering Cardiac Rehabilitation
Coping/Stress
• Who lives with you? _____________________________
• How do you handle stress? _____________________________
• Have you had any recent changes in your life (e.g., job change, move, change in marital status, loss)? _____________________________
• On whom do you rely for emotional support? _____________________________
• Who relies on you for emotional support? _____________________________
• How does your illness affect your family members/significant other? _____________________________
• Are there any health concerns of other family members? _____________________________
• If so, how does this affect you? _____________________________
Communication/Decision Making
• How would you describe the communication pattern in your family? _____________________________
• How does your family address issues/concerns? _____________________________
• Can you identify strengths/weaknesses within the family? _____________________________
• Are family members supportive of each other? _____________________________
• How are decisions that affect the entire family made? _____________________________
• How are decisions implemented? _____________________________
Role
• What is your role in the family? _____________________________
• Can you describe the roles of other family members? _____________________________
Value Beliefs
• What is your ethnic/cultural background? _____________________________
• What is your religious background? _____________________________
• Are there any particular cultural/religious healing practices in which you participate? _____________________________
Leisure Activities
• Do you participate in any organized social activities? _____________________________
• In what leisure activities do you participate? _____________________________
• Do you anticipate any difficulty with continuing these activities? _____________________________
• If so, how will you make the appropriate adjustments? _____________________________
• Do you have a regular exercise regimen? _____________________________
Environmental Characteristics
• Do you live in a rural, suburban, or urban area? _____________________________
• What type of dwelling do you live in? _____________________________
• Are there stairs in your home? _____________________________
• Where is the bathroom? _____________________________
• Are the facilities adequate to meet your needs? _____________________________
• If not, what adjustments will be needed? _____________________________
• How do you plan to make those adjustments? _____________________________
• Are there any community services provided to you at home? (explain) _____________________________
• Are there community resources available in your area? _____________________________
• Do you have any other concerns at this time? _____________________________
• Is there anything that we have omitted? _____________________________
• Signature _____________________________ (must be completed by RN) Date/Time
Developed by Conrad J, University of Maryland School of Nursing, 1993.
Family participation in the data assessment process enhances the therapeutic relationship and completeness of the data. It is important to inquire about the family's cultural identity, rituals, values, level of family involvement, decision making, and traditional behaviors as it relates to the health care of the client (Leon & Knapp, 2008).
Knowledge of a family's past medical experiences, particularly whether they were positive or negative, the family's medical beliefs, major family events a family is struggling with concurrently, plus family expectations for treatment and care are essential pieces of family assessment data. Suggested questions include:
• How does the family view the current health crisis?
• What is each family member's most immediate concern?
• Has anyone else in the family experienced a similar problem?
• What do family members believe would be most helpful to the client at this time?
• How does the family explain the reasons for the illness or injury?
• Are there any other recent changes or sources of stress in the family that make the current situation worse (pile up of demands?)
• How has the family handled the problem to date?
• What would the family like to achieve with the nurse's help in resolving issues related to the client's health and well-being (McBride, 2004)?
• As you close the session, ask, "Is there anything else I should know about your family and this experience?"
## Planning
Interventive questioning
Wright and Leahey (2009) identify therapeutic questioning as a nursing intervention that nurses can use with their client families to identify family strengths; help family members sort out their personal fears, concerns, and challenges in health care situations; and provide a vehicle for exploring alternative options. Interventive questioning can be either linear or circular.
**Circular questions** focus on family interrelationships and the impact a serious health alteration has on individual family members and the equilibrium of the family system. Examples of therapeutic questions are found in Box 13-4. The nurse uses information the family provides as the basis for additional questions.
BOX 13-4 Examples of Therapeutic Questions
• What is the greatest challenge facing your family now?
• On whom in the family do you think the illness has the most impact?
• Who is suffering the most?
• What has been most and least helpful to you in similar situations?
• If there were one question you could have answered now, what would it be?
• How can we best help you and your family?
• What are your needs/wishes for assistance now?
From Leahey M, Svaavarsdottir E: Implementing family nursing: how do we translate knowledge into clinical practice. _J Fam Nurs_ 15(4):445–460, 2009.
The following case example demonstrates its use when the nurse asks a family, "What has been your biggest challenge in caring for your mother at home?"
Case Example
_Daughter:_ My biggest challenge has been finding a balance between caring for my mother and also caring for my children and husband. I have also had to learn a lot about the professional and support resources that are available in the community.
_Son-in-law:_ For me, the biggest challenge has been convincing my wife that I can take over for a while, in order for her to get some rest. I worry that she will become exhausted.
_Mother:_ I have appreciated all the help that they give me. My biggest challenge is to continue to do as much as possible for myself so that I do not become too much of a burden on them. Sometimes I wonder about moving to a palliative care setting or a hospice (Leahey & Harper-Jaques, 1996, p. 135).
In this example, each family member's concern is related but different. The therapeutic circular question opens a discussion about each person's anxiety. As family members hear the concerns of other family members, and as they hear themselves respond, their perspective broadens. The resulting conversation forms the basis for developing strategies that are mutually acceptable to all family members.
Selekman (1997) identifies four elements to consider when designing therapeutic interventions within a family context:
• The family's definition of the problem
• Key family characteristics (e.g., language, beliefs, and strengths)
• Unique cooperative response patterns of family members
• Family treatment goals
Meaningful involvement in the client's care not only differs from family to family, it differs among individual family members (Sydnor-Greenberg, Dokken, & Ahmann, 2000). Individual family members have different perspectives. Hearing each family member's perspective helps the family and nurse develop a unified understanding of significant treatment goals and implications for family involvement.
Although treatment plans should be tailored around personal client goals, acknowledging family needs, values, and priorities enhances compliance, especially if they are different. Shared decision making and development of realistic achievable goals makes it easier for everyone concerned to accomplish them with a sense of ownership and self-efficacy about the process. Taking little achievable steps is preferred to attempting giant steps that misjudge what the family can realistically do.
Exercise 13-7 provides practice with developing a family nursing care plan.
EXERCISE 13-7 Developing a Family Nursing Care Plan
Purpose: To practice skills needed with difficult family patterns.
Procedure:
Read the case study and think of how you could interact appropriately with this family.
Mr. Monroe, age 43 years, was chairing a board meeting of his large, successful manufacturing corporation when he developed shortness of breath, dizziness, and a crushing, viselike pain in his chest. An ambulance was called, and he was taken to the medical center. Subsequently, he was admitted to the coronary unit with a diagnosis of an impending myocardial infarction (MI).
Mr. Monroe is married, with three children: Steve, age 14; Sean, age 12; and Lisa, age 10. He is the president and majority stockholder of his company. He has no history of cardiovascular problems, although his father died at the age of 38 of a massive coronary occlusion. His oldest brother died at the age of 42 from the same condition, and his other brother, still living, became a semi-invalid after suffering two heart attacks, one at the age of 44 and the other at 47.
Mr. Monroe is tall, slim, suntanned, and very athletic. He swims daily; jogs every morning for 30 minutes; plays golf regularly; and is an avid sailor, having participated in every yacht regatta and usually winning. He is very health-conscious and has had annual physical checkups. He watches his diet and quit smoking to avoid possible damage to his heart. He has been determined to avoid dying young or becoming an invalid like his brother.
When he was admitted to the coronary care unit, he was conscious. Although in a great deal of pain, he seemed determined to control his own fate. While in the unit, he was an exceedingly difficult patient, a trial to the nursing staff and his physician. He constantly watched and listened to everything going on around him and demanded complete explanations about any procedure, equipment, or medication he received. He would sleep in brief naps and only when he was totally exhausted. Despite his obvious tension and anxiety, his condition stabilized. The damage to his heart was considered minimal, and his prognosis was good. As the pain diminished, he began asking when he could go home and when he could go back to work. He was impatient to be moved to a private room so that he could conduct some of his business by telephone.
When Mrs. Monroe visited, she approached the nursing staff with questions regarding Mr. Monroe's condition, usually asking the same question several times in different ways. She also asked why she was not being "told everything."
Interactions between Mr. Monroe and Mrs. Monroe were noted by the staff as Mr. Monroe telling Mrs. Monroe all of the things she needed to do. Little intimate contact was noted.
Mr. Monroe denied having any anxiety or concerns about his condition, although his behavior contradicted his denial. Mrs. Monroe would agree with her husband's assessment when questioned in his company.
Discussion:
1. What questions would you ask the client and family to obtain data regarding their adaptation to crisis?
2. What family nursing diagnosis would apply with this case study?
3. What nursing interventions are appropriate to interact with this client and his family?
4. How would you plan to transmit the information to the family?
5. What outcomes and measures would you use to determine success or failure of the nursing care plan?
Developed by Conrad J: University of Maryland School of Nursing, Baltimore, MD, 1993.
### Implementation
Nurses can only _offer_ interventions; it is up to the family to accept them (Wright & Leahey, 2009). Suggested nursing actions to promote positive change in family functioning include
• Encouraging the telling of illness narratives
• Commending family and individual strengths
• Offering information and opinions
• Validating or normalizing emotional responses
• Encouraging family support
• Supporting family members as caregivers
• Encouraging respite
#### Encouraging Family Narratives
Families need to tell their story about the experience of their loved one's illness or injury; it may be quite different from how the client is experiencing it. The differences can lead to a more complete understanding.
Case Example
Frances is a client with a diagnosis of breast cancer. When she sees her oncologist, Frances reports that she is feeling fine, eating and able to function in much the same way as before receiving chemotherapy. Her husband's perception differs. He reports that her appetite has declined such that she only eats a few spoonfuls of food and she spends much of the day in bed. What Frances is reporting is true. When she is up, she enjoys doing what she did previously, although at a slower pace, and she does eat at every meal. Frances is communicating her need to feel normal, which is important to support. What her husband adds is also true. Her husband's input allows Frances to receive the treatment she needs to stimulate her appetite and give her more energy.
Nurses play an important role in helping families understand, negotiate, and reconcile differences in perceptions without losing face.
#### Incorporating Family Strengths
Otto (1963) introduced the concept of family strengths as potential and actual resources families can use to make their life more satisfying and fulfilling to its members. When health care changes are required, and they usually are with clients suffering from serious illness or injury, working through family strengths rather than focusing on deficits is useful. Viewing the family as having strengths to cope with a problem rather than _being_ a problem is a healing strategy, giving the family hope that a problem is not the end point but rather only a circumstance in need of a solution.
Feeley and Gottlieb (2000) identify four different types of strengths nurses can help the family use to achieve important health outcomes:
• Traits that reside within an individual or a family (e.g., optimism, resilience)
• Assets that reside within or are associated with an individual or a family (e.g., finances, social, spiritual, or work relationships)
• Capabilities, skills, or competencies that an individual or a family has developed (e.g., problem-solving skills)
• A quality that is more transient in nature than a trait or asset (e.g., motivation)
Questions nurses can use specifically to elicit family strengths include:
• What has the family been doing so far that has been helpful?
• What is going well for this family?
• How have they (family) been able to do as well as they have done?
• What beliefs or previous experiences or relationships are sustaining them and preventing the problem from being worse?
• What advice would they give to other people in the same situation? (Tapp & Moules, 1997)
#### Giving Commendations
Limacher and Wright (2003) define **commendations** as "the practice of noticing, drawing forth, and highlighting previously unobserved, forgotten, or unspoken family strengths, competencies or resources" (p. 132). Commendations are particularly effective when the family seems dispirited or confused about a tragic illness or accident. More than a simple compliment, commendations should reflect _patterns_ of behavior existing in the family unit over time. Wright and Leahey (2009) differentiate between a commendation ("Your family is showing much courage in living with your wife's cancer for 5 years.") and a compliment ("Your son is so gentle despite feeling so ill.") (p. 270). They suggest giving at least one commendation per interview.
Ryan and Steinmiller (2004) recommend naming family strengths in front of the family. For example, nurses can verbally reflect on the strength of the family in coping with multiple problems, the capacity to stay involved when client anger threatens the relationship, or the ability of the family to thoroughly research a health problem. Exercise 13-8 provides practice with giving commendations.
EXERCISE 13-8 Offering Commendations
Purpose: To provide practice with using commendation skills with families.
Procedure:
Students will work in groups of three students. Each student will develop a commendation about the two other students in the group. The commendation should reflect a personal strength that the reflecting student has observed over a period time. Examples might include kindness, integrity, commitment, persistence, goal-directedness, tolerance, or patience. Write a simple paragraph about the trait or behavior you observe in this person. If you can, give some examples of why you have associated this particular characteristic with the person. Each student, in turn, should read his or her reflections about the other two participants, starting the conversation with good eye contact, the name of the receiving student, and a simple orienting statement (e.g., "Kelly, this is what I have observed in knowing you...").
Discussion:
Class discussion should focus on the thought process of the students in developing particular commendations, the values they focused on, and any consideration they gave to the impact of the commendation on the other students. The students can also discuss the effect of hearing the commendations about themselves and what it stimulated in them. Other areas of focus might be how commendations can be used with families and how they can be used to counteract family resistance to working together.
#### Informational Support
Helping a family become aware of information from the environment and how to access it empowers families. By showing interest in the coping strategies that have and have not worked, the nurse can help the family see progress in their ability to cope with a difficult situation.
You can offer family members informational support related to talking with extended family, children, and others about the client's illness. You can help family members prepare questions for meeting with physicians. Finally, you can engage with families in discussions about the cultural, ethical, and physical implications of using or discontinuing life support systems. This is nursing's special niche, as these conversations are rarely one-time events, and nurses can provide informal opportunities for discussing them during care provision.
#### Meeting the Needs of Families with Critically Ill Clients
Having a family member in an ICU represents a serious crisis for most families. Eggenberger and Nelms (2007) suggest, "Patients enter a critical care unit in physiological crisis, while their families enter the hospital in psychological crisis" (p. 1619). Box 13-5 identifies care needs of families of critically ill clients. Family-centered relationships are key dimensions of quality care in the ICU.
BOX 13-5 Caring for Family Needs in the Intensive Care Unit
Families of critically ill clients need to:
• Feel there is hope
• Feel that hospital personnel care about the patient
• Have a waiting room near the patient
• Be called at home about changes in the patient's condition
• Know the prognosis
• Have questions answered honestly
• Know specific facts about the patient's prognosis
• Receive information about the patient at least once a day
• Have explanations given in understandable terms
• Be allowed to see the patient frequently
Perrin K: _Understanding the essentials of critical care nursing_ (pp. 40–41), Upper Saddle River, NJ, 2009, Pearson Prentice Hall.
### Proximity to the client
The need to remain near the client is a priority for many family members of clients in the ICU (Perrin, 2009; Verhaeghe et al., 2005). Although the family may appear to hover too closely, it is usually an attempt to rally around the client in critical trouble (Leon, 2008). Viewed in this way, nurses can be more empathetic. As the family develops more confidence in the genuine interest and competence of staff, the hovering tends to lessen. Liberal visitation policies can result in "increased family involvement with patient care, increased family communication with nurses, and greatly decreased number of complaints from families" (Van Horn & Kautz, 2007, p. 102).
Families can be a primary support to clients, but they usually need encouragement and concrete suggestions for maximum effect and satisfaction. Family members feel helpless to reverse the course of the client's condition and appreciate opportunities to help their loved one. Suggesting actions that family members can take at the bedside include doing range-of-motion exercises, holding the client's hand, positioning pillows, providing mouth care or ice chips. Talking with the client, even if the person is unresponsive, can be meaningful.
Helping families balance the need to be present with the client's needs to conserve energy and have some alone time to rest or regroup is important. Family members also need time apart from their loved one for the same reasons. Tactfully explaining the need of critically ill clients to have family presence without feeling pressure to interact can be supportive. Encouraging families to take respites is equally important.
At the same time, nurses need to be sensitive to and respect a family member's apprehension or emotional state about their critically ill family member. Individual family members may need the nurse's support in talking about difficult feelings.
Nurses can role model communication with clients, using simple caring words and touch. Families are quick to discern the difference between nurses who are able to connect with a critically ill client in this way, as evidenced in a family member's comment that "some seem to have a way with him and they talk to him like he is awake" (Eggenberger & Nelms, 2007, p. 1623).
#### Caring for Families in the Pediatric Intensive Care Unit
Parents of children in the pediatric intensive care unit (PICU) want to be with their children as often as possible, but particularly when the child is having a procedure or is uncomfortable (Aldridge, 2005). Parents of children in the PICU need frequent reassurance from the nurse about why things are being done for their child and about treatment-related tubes and equipment. They want to actively participate in their child's care and have their questions honestly answered (Aldrich).
Families often act as the child's advocate during hospitalization, either informally by insisting on high-quality care or formally as the legal surrogate decision maker designated to make health care decisions on behalf of the client. The nurse is a primary health care provider agent in working with families facing these issues. A critical intervention for the family as a whole and its individual members is to help them recognize their limitations and hidden strengths, and to maintain a balance of health for all members.
### Providing information
Families with clients in the ICU have a fundamental need for information, particularly if the patient is unresponsive—"Not knowing is the worst part." This cannot be stressed enough. Providing updated information as a clinical situation changes is critical. Even if there is no change in the client's condition, most families will need to have information repeated because of anxiety that may limit processing of complex or emotionally difficult information (Van Horn & Kautz, 2007). They need to know exactly what is being done for their loved one in simple understandable terms, and to have their questions answered honestly (Miracle, 2006). This information is particularly critical when family members must act as decision makers for clients who cannot make them on their own (Perrin, 2009).
How health care providers deliver information is important. Even if the patient's condition or prognosis leaves little room for optimism, the family needs to feel some hope and that the staff genuinely cares about what is happening with the client and family (Perrin, 2009; Verhaeghe, Defloor, Van Zuuren, et al., 2005).
Daily contact with the nurse assigned to the client in the ICU is a critical nursing action (Miracle, 2006) that the family needs. Identifying one family member to act as the primary contact helps ensure continuity between staff and family. A short daily phone call when family members cannot be present keeps the family connection and reduces family stress (Leon, 2008). Families need ongoing information on the client's progress, modifications in care requirements, and any changes in expected outcomes, with opportunities to ask questions and clarify information. Nurses in the ICU often serve as mediators between client, family, and other health providers to ensure that data streams remain open, coordinated, and relevant.
## Family-centered relationships in the community
The Centers for Disease Control and Prevention (CDC) estimates that approximately 70% of deaths in the United States are the result of chronic disease. Although many of these individuals are able to self-manage their disease, an increasing number will require family support with coping, self-management, and palliative care. Increasingly, nurses are called on to help families effectively manage the care of people with chronic illness who can no longer take care of themselves or who require additional support to maintain their independence (McKenry & Price, 2005).
The concept of the family caregiver as a key member of the health care team has become increasingly important as more people live with chronic illness on a daily basis in the community or subacute care facility. Medalie and Cole-Kelly (2002) define the functional family as the group coping with the everyday affairs of the client. Caregiving responsibilities can include providing personal care, performing medical procedures, managing a client's affairs, and facilitating or coordinating medical care and social services for the client (Levine, 2004).
Healthy family members have concurrent demands on their time from their own nuclear families, work, church, and community responsibilities. This is particularly true when spouses have to become caregivers in younger families (Gordon & Perrone, 2004). A significant change in health status can cause previous unresolved relationship issues, which may need advanced intervention in addition to the specific health care issues. When individual family members are experiencing a transition, for example, ending or entering a relationship, or job change, they may not be as available as support and can experience unnecessary guilt about it. Nurses need to consider the broader family responsibilities people have as an important part of the context of health care in providing holistic care to a particular family.
### Meeting family informational needs
Sharing information is a mutual process. Nurses need to welcome and respect family input and engage the family in mutual decision making (Levine, 2004). Helping client families anticipate what will happen as a chronic disease progresses and how the day-to-day needs will change helps eliminate the stress of the unknown. Nurses can offer suggestions about how to respond to these changes, and offer support to the family caregiver as they emerge. Helping family members access services, support groups, and natural support networks at each stage of their loved one's illness empowers family members because they feel they are helping in a tangible way.
### Supporting the caregiver
Providing emotional support is crucial to helping families cope. Remaining aware of one's own values and staying calm and thoughtful can be very helpful to a family in crisis. Remember that your words can either strengthen or weaken a family's confidence in their ability to care for an ill family member.
Focus initially on issues that are manageable within the context of home caregiving. This provides a sense of mastery and satisfaction. The nurse can encourage the family to develop new ways of coping or can list alternatives and allow the family to choose coping styles that might be useful to them. Focus on what goes well, and ask the family to share with you their ideas about how to best care for the client.
Many families will need information about additional home care services, community resources and options needed to meet the practical, and financial and emotional demands of caring for a chronically ill family member.
Encouraging families to use natural helping systems increases the network of emotional and economic support available to the family in time of crisis. Examples include contact with other relatives, neighbors, friends, and churches. Spiritual beliefs and support from extended family and friends enhance family resilience in times of trauma and loss (Greeff & Human, 2004).
### Validating and normalizing emotions
Families can experience many conflicting emotions when placed in the position of providing protracted care for a loved one. Compassion, protectiveness, and caring can be intermingled with feelings of helplessness and being trapped. Major role reversals can stimulate anger and resentment for both client and family caregiver.
Sibling or family position or geographic proximity may put pressure on certain family members to provide a greater share of the care. Criticism or advice from less involved family members can be disconcerting and conflicts about care decisions can create rifts in family relationships. Some caregivers find themselves mourning for their loved one, even though the person is still alive, wishing it could all end and feeling guilty about having such thoughts.
These emotions are normal responses to abnormal circumstances. Listening to the family caregiver's feelings and struggles without judgment can be the most healing intervention you can provide. Nurses can normalize negative feelings by offering insights about common feelings associated with chronic illness. Family members may need guidance and permission to get respite and recharge their commitment by attending to their own needs. Support groups can provide families with emotional and practical support, and a critical expressive outlet.
Psychosocial issues for parents with chronically ill children can cover many relationship issues, for example, how to respond and discipline children with chronic illness. Siblings sometimes get shortchanged emotionally, if not physically, when the focus necessarily is on the child with a serious illness or disability (Drench, Noonan, Sharby, & Ventura, 2007). Well siblings may experience feelings of resentment, worry that they might contract a similar illness, or have unrealistic expectations of their part in the treatment process. Siblings need clear information about the sick child's diagnosis and care plan. They need to be treated as children with needs of their own and should not be expected to assume adult caretaker responsibility for younger siblings while parents focus on the ill child (Fleitas, 2000). Exercise 13-9 provides practice with using intervention skills with families.
EXERCISE 13-9 Using Intervention Skills with Families
Purpose: To provide practice with using intervention skills with families.
Procedure:
Each student will work with a family related to a specific problem. This can be a current or previous situation for the family. Talk with the family about the problem and learn how they have dealt with the problem, their perception of the problem, and its impact on their family. Use some of the approaches identified in the text to help them explore the problem in more depth and begin to develop viable options.
Write a descriptive summary of your experiences, including a self-evaluation. Evaluate the experience with the family as well, specifically for feedback regarding your approach. Did they feel you were too intrusive or not assertive enough? Did you validate all members' perceptions and perspectives? Did you clarify information and feelings? Did you remain nonjudgmental and objective? Did you respect the family's values and beliefs without imposing your own? Did you assist the family in clarifying and understanding the problem in a way that could lead to resolution?
Discussion:
Students share their experience and the feedback they received from the family. Discuss the obstacles encountered when communicating with families. Discuss strategies to facilitate goal-directed communication and resolution of problems. How can nurses best provide support to families? How could families learn to use honest communication most of the time? How does one influence this in one's own family?
## Evaluation
Referrals, continuing the contact with another health professional, or family education about when to contact the health system may be needed (Wright & Leahey, 2004). The referral should include a summary of the information gained to date and should be communicated by the health team member most knowledgeable about the client's condition. Discuss with the client what will be shared with the referral resource.
## Summary
This chapter provides an overview of family communication and the complex dynamics inherent in family relationships. Families have a structure, defined as the way in which members are organized. Family function refers to the roles people take in their families, and family process describes the communication that takes place within the family. Theoretical frameworks, developed by Bowen, Minuchin, Duvall, and McCubbin, are particularly relevant for nurses in understanding family dynamics in health care settings.
Family-centered care is developed through a combination of strategies designed to gather information in a systematic, efficient manner starting with the genogram and ecomap. Therapeutic questions and giving family commendations are interventions nurses can use with families.
Families with critical illness need continuous updated information, and the freedom to be with their family member as often as possible. Involving the family in the care of the client is important. Parents want to participate in the care of their acutely ill client.
Nursing interventions are aimed at strengthening family functioning and supporting family coping during hospitalization and in the community.
Ethical Dilemma
What Would You Do?
Terry Connors is a 90-year-old woman living alone in a two-story house. Her daughter Maggie lives in another state. So far, Terry has been able to live by herself, but within the past 2 weeks, she fell down a few stairs in her house and she has trouble hearing the telephone. Terry walks with a cane and relies on her neighbors for assistance when she cannot do things for herself. Maggie worries about her and would like to see her in a nursing home close to Maggie's home. Terry will not consider this option. As the nurse working with this family, how would you address your ethical responsibilities to Terry and Maggie?
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CHAPTER 14
# Resolving Conflict Between Nurse and Client
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Define conflict and contrast the functional with the dysfunctional role of conflict in a therapeutic relationship.
2 Recognize and describe personal style of response to conflict situations.
3 Discriminate among passive, assertive, and aggressive responses to conflict situations.
4 Specify the characteristics of assertive communication.
5 Identify four components of an assertive response and formulate sample assertive responses.
6 Identify appropriate assertive responses and specific nursing strategies to promote conflict resolution in relationships.
7 Discuss how findings from research studies can be applied to clinical practice.
Conflict is a natural part of human relationships. We all have times when we experience negative feelings about a situation or person. When this occurs in a nurse-client relationship, clear, direct communication is needed. This chapter emphasizes the dynamics of conflict and the skills needed for successful resolution.
Effective nurse-client communication is critical to efficient care provision and to receiving quality care (Finke, Light, & Kitko, 2008). Knowing how to respond in emotional situations allows you to use feelings as a positive force. Nurses often find themselves in dramatic situations in which a calm response is required. Some clients approach their initial encounter with a nurse with hostility or embarrassment, such as the intoxicated client admitted to an emergency department (Baillie, 2005). To listen and to respond creatively to intense emotion when your first impulse is to withdraw or to retaliate demands a high level of skill. It requires self-control and empathy for what your client may be experiencing. It is difficult to remain cool under attack, and yet your willingness to stay with the angry client may mean more than any other response.
Assertive skills, described in this chapter, can help you deal constructively with conflict. As nurses, our goal is to prevent or reduce levels of conflict (Bowers et al., 2008). We know that resolving some long-standing conflicts is a gradual process in which we may have to revisit the issue several times to fully resolve the conflict. Workplace conflict between nurse and colleagues will be discussed in Chapter 23. The focus of this chapter is conflict between nurse and client.
## Basic concepts
**Conflict** has been defined as tension arising from incompatible goals or needs, in which the actions of one frustrate the ability of the other to achieve their goal, resulting in stress or tension (Wikipedia). Conflicts in any relationship are inevitable: They serve as warning that something in the relationship needs closer attention. Conflict can lead to improved relationships.
## Nature of conflict
All conflicts have certain things in common: (a) a concrete _content problem issue_ ; and (b) relationship or _process issues,_ which involve our emotional response to the situation. It is immaterial whether the issue makes realistic sense to you. They feel real to your client and need to be dealt with. Unresolved, they will interfere with success in meeting goals. Most people experience conflict as discomfort. Previous experiences with conflict situations, the importance of the issue, and possible consequences all play a role in the intensity of our reaction. For example, a client may have great difficulty asking appropriate questions of the physician regarding treatment or prognosis, but experience no problem asking similar questions of the nurse or family. The reasons for the discrepancy in comfort level may relate to previous experiences. Alternatively, it may have little to do with the actual persons involved. Rather, the client may be responding to anticipated fears about the type of information the physician might give.
## Causes of conflict
Lack of communication is a main cause of misunderstanding and conflict (Jasmine, 2009). Other psychological causes of conflict include poor communication, differences in values, personality clashes, and stress. Clashes occur between nurse and client or even between two clients. If your nursing care does not fit in with your client's cultural belief system, conflict can result (Chang & Kelle, 2007).
Case Example
Two women who gave birth this morning are moved to a semiprivate room on the postpartum floor. Ms. Patton is 19 years old, likes loud music, and is feeling fine. Her roommate, Mrs. DiSauro, is 36 years old, has four children at home, and wants to rest ( _latent_ ). The music and visitors to Ms. Patton repeatedly wake up Mrs. DiSauro ( _perceived_ ), who yells at them ( _overt_ ). The nurse arranges to transfer Mrs. DiSauro to an unoccupied room ( _resolution_ ).
## Why work for conflict resolution?
Unresolved conflicts impede quality of client care. Conflicts, even those between two clients, poison the working environment. Nurse-client conflict undermines your therapeutic relationship with your client. Energy is transferred to conflict issues instead of being used to build the relationship. Once you identify a conflict, take action immediately and work to resolve it.
## Understanding own personal responses to conflict
Conflicts between nurse and client are not uncommon. The first step is to gain a clear understanding of your own personal response. No one is equally effective in all situations. Completing Exercise 14-1 may help you identify your personal responses.
EXERCISE 14-1 Personal Responses to Conflict
Purpose:
To increase awareness of how students respond in conflict situations and the elements in situations (e.g., people, status, age, previous experience, lack of experience, or place) that contribute to their sense of discomfort.
Procedure:
Break up into small groups of two. You may do this as homework or create an Internet discussion room. Think of a conflict situation that could be handled in different ways.
The following feelings are common correlates of interpersonal conflict situations that many people say they experienced in conflict situations that they have not handled well:
Anger | Competitiveness | Humiliation
---|---|---
Annoyance | Defensiveness | Inferiority
Antagonism | Devaluation | Intimidation
Anxiousness | Embarrassment | Manipulation
Bitterness | Frustration | Resentment
Although these feelings generally are not ones we are especially proud of, they are a part of the human experience. By acknowledging their existence within ourselves, we usually have more choice about how we will handle them.
Using words from the list, describe the following as concretely as possible:
1. The details of the situation: How did it develop? What were the content issues? Was the conflict expressed verbally or nonverbally? Who were the persons involved, and where did the interaction take place?
2. What feelings were experienced before, during, and after the conflict?
3. Why was the situation particularly uncomfortable?
Discussion:
Suggest different ways to respond. Might these lead to differences in outcome?
The second step is to understand the context of the situation. Most interpersonal conflicts involve some threat to one's sense of control or self-esteem. Nurses have been shown to respond to the stress of not having enough time to complete their work by imposing more controls on the client, who then often reacts by becoming more difficult (Macdonald, 2007). Other situations that may lead to conflict between you and your client include:
• Having your statements discounted
• Being asked to give more information than you feel comfortable sharing
• Encountering sexual harassment
• Being the target of a personal attack
• Having the client's family make demands
• Wanting to do things the old way instead of trying something new
Clients who feel listened to and respected are generally receptive. Be careful what you say and how you say it. Avoid acting in ways which create anger or conflict with your client; examples are listed in Box 14-1.
BOX 14-1 Behaviors That Create Anger in Others
• Providing unsolicited advice
• Conveying ideas that try to create guilt
• Offering reassurances that are not realistic
• Communicating using "gloss it over" positive comments
• Speaking in a way that shows you do not understand your client's point of view
• Exerting too much pressure to make a person change their unhealthy behavior
• Placing blame, speaking in an accusing tone
• Portraying self as an infallible expert
• Using excessively histrionic language or sarcastic retorts
• Using an authoritarian tone
• Using "hot button" words that have heavy emotional connotations
### Four styles of personal conflict management
There are distinct styles of response to conflict. Although not specifically addressing nurse-client conflict, the literature shows that, in the past, corporate managers felt that any conflict was destructive and needed to be suppressed. Current thinking holds that conflict can be healthy and can lead to growth. These concepts can be applied to nursing.
A common response to conflict by nurses is to distance themselves from their client or to provide them less support (Macdonald, 2007); this is known as **avoidance**. Sometimes an experience makes you so uncomfortable that you want to avoid the situation or person at all costs, so you withdraw. This style is appropriate when the cost of addressing the conflict is higher than the benefit of resolution. Sometimes you just have to "pick your battles," focusing your energy on the most important issues. However, use of avoidance postpones the conflict, leads to future problems, and damages your relationship with your client, making it a _lose-lose_ situation.
**Accommodation** is another common response. We surrender our own needs in a desire to smooth over the conflict. This response is cooperative but nonassertive. Sometimes this involves a quick compromise or giving false reassurance. By giving into others, we maintain peace but do not actually deal with the issue, so it will likely resurface in the future. It is appropriate when the issue is more important to the other person. This is a _lose-win situation_. Harmony results and credits may be accumulated that can be used at some future time (McElhaney, 1996).
**Competition** is a response style characterized by domination. In this contradictory style, one party exercises power to gain his own goals at the expense of the other person. It is characterized by aggression and lack of compromise. Authority may be used to suppress the conflict in a dictatorial manner. This leads to increased stress. It is an effective style when there is a need for a quick decision, but it leads to problems in the long term, making it a _lose-lose situation_.
**Collaboration** is a solution-oriented response in which we work together cooperatively to problem solve. To manage the conflict, we commit to finding a mutually satisfying solution. This involves directly confronting the issue, acknowledging feelings, and using open communication to solve the problem. Steps for productive confrontation include identifying concerns of each party; clarifying assumptions; communicating honestly to identify the real issue; and working collaboratively to find a solution that satisfies everyone. This is considered to be the most effective style for genuine resolution. This is a _win-win situation_.
### Factors that influence responses to conflict
Gender
Expression of emotion may differ according to gender. A traditional female socialized response was to "smooth over" conflicts. Women still tend to use more accommodative conflict management styles such as compromise and avoidance, whereas men tend to use collaboration more often and prefer competitive or aggressive methods. However, the literature is inconclusive regarding the effects of gender and style on the outcome of conflict resolution.
#### Culture
Many of a nurse's responses are determined by cultural socialization, which prescribes proper modes for behaviors. Personal style and past experiences influence the typical responses to conflict situations. Individuals from societies that emphasize group cooperation tend to use more avoidance and less confrontation in their conflict resolution styles. People from cultures that value individualism more tend to more often use competing/dominating styles. Nurses are individuals with different attitudes toward the existence of conflict and different ways of responding. The underlying feelings generated by conflict situations may be quite similar. Common emotional responses to conflict include anger, embarrassment, and anxiety. Awareness of how we cope with conflict is the first step in learning assertiveness strategies. Fortunately, assertiveness and other skills essential to conflict resolution are learned behaviors that any nurse can master.
## Types of conflict: intrapersonal versus interpersonal
A conflict can be internal (intrapersonal); that is, it can represent opposing feelings within an individual. Intrapersonal conflict arises when nurses are faced with two different choices, each supported by a different ethical principle. For example, nurses traditionally were socialized to follow orders. Studies have shown that up to 75% of the ethical dilemmas reported in nurse surveys involve their perceptions about inadequate client care (Redman & Fry, 1996). Conflict more often occurs between two or more people (interpersonal).
## Functional uses of conflict
Traditionally, conflict was viewed as a destructive force to be eliminated. Actually, conflicts that are successfully resolved lead to stronger relationships. The critical factor is the willingness to explore and resolve it mutually. Appropriately handled, conflict can provide an important opportunity for growth. Box 14-2 gives helpful guidelines regarding your responsibilities when involved in a conflict.
BOX 14-2 Personal Rights and Responsibilities in Conflict Situations
## Nature of assertive behavior
**Assertive behavior** is defined as setting goals, acting on those goals in a clear, consistent manner, and taking responsibility for the consequences of those actions. The assertive nurse is able to stand up for the rights of others, as well as for her own rights. Box 14-3 lists characteristics of assertive behaviors.
BOX 14-3 Characteristics Associated with the Development of Assertive Behavior
• Express your own position, using "I" statements.
• Make clear statements.
• Speak in a firm tone, using moderate pitch.
• Assume responsibility for personal feelings and wants.
• Make sure verbal and nonverbal messages are congruent.
• Address only issues related to the present conflict.
• Structure responses so as to be tactful and show awareness of the client's frame of reference.
• Understand that undesired behaviors, not feelings, attitudes, and motivations, are the focus for change.
Components of assertion include the following four abilities: (1) to say no; (2) to ask for what you want; (3) to appropriately express both positive and negative thoughts and feelings; and (4) to initiate, continue, and terminate the interaction. This honest expression of yourself does not violate the needs of others but does demonstrate self-respect rather than deference to the demands of others.
The goal of assertiveness is to communicate directly, standing up for your personal rights while respecting the rights of others (Stuart, 2009). Conflict creates anxiety that may prevent us from behaving assertively. Assertive behaviors range from making a direct, honest statement about your beliefs to taking a very strong, confrontational stand about what will and will not be tolerated in the relationship. Assertive responses contain "I" statements that take responsibility. This behavior is in contrast with **aggressive behavior** , which has a goal of dominating while suppressing the other person's rights. Aggressive responses often consist of "you" statements that fix blame on the other person.
Assertiveness is a learned behavior. Some nurses were socialized to act passively. Passive behavior is defined as a response that denies our own rights to avoid conflict. An example is remaining silent and not responding to a client's demands for narcotics every 4 hours when he displays no signs of pain out of fear that he might report you to your superior.
Assertiveness needs to be practiced to be learned (Exercises 14-2 and 14-3). Effective nursing encompasses mastery of assertive behavior (see Box 14-3). Nonassertive behavior in a professional nurse is related to lower levels of autonomy. Continued patterns of nonassertive responses have a negative influence on you and on the standard of care you provide. Evaluate your own assertiveness with Exercise 14-4.
EXERCISE 14-2 Pitching the Assertive Message
Purpose:
To increase awareness of how the meaning of a verbal message can be significantly altered by changing one's tone of voice.
Procedure:
Place individual slips of paper in a hat so that every student in class can draw one. On each slip of paper should be written one of the five vocal pitches commonly used in conversation: whisper, soft tone with hesitant delivery, moderate tone and firm delivery, loud tone with agitated delivery, and screaming. Divide into groups, and have each student take a turn drawing and demonstrating the tone while the others in the group try to identify correctly which person is giving the assertive message.
Discussion:
How does tone affect perceptions of a message's content?
EXERCISE 14-3 Assertive Responses
Purpose:
To increase awareness of assertiveness.
Procedure:
Have three students volunteer to read each answer to the following scenario:
You are working full time, raising a family, and taking 12 credits of nursing classes. The teacher asks you to be a student representative on a faculty committee. You say the following:
1. "I don't think I'm the best one. Why don't you ask Karen? If she can't, I guess I can."
2. "Gee, I'd like to, but I don't know. I probably could if it doesn't take too much time."
3. "I do want students to have some input to this committee, but I am not sure I have enough time. Let me think about it and let you know in class tomorrow."
Discussion:
Ask students to choose the most assertive answer and comment about how other options could be altered.
EXERCISE 14-4 Assertiveness Self-Assessment Quiz
Purpose:
To help students gain insight into their own responses.
Procedure:
Read and answer "yes" (2 points), "sometimes" (1 point), or "no" (0 points). A score of more than 10 points suggests the need to practice assertiveness.
Do you:
1. Feel self-conscious if someone watches you work with a client?
2. Not feel confident in your nursing judgment?
3. Hesitate to express your feelings?
4. Avoid questioning people in authority?
5. Feel uncomfortable speaking up in class?
6. Ever say, "I hate to bother you..."?
7. Feel people take advantage of you at work?
8. Ever feel reluctant to turn down a classmate who asks you to do his or her work?
9. Avoid protesting an unfair grade or evaluation?
10. Have trouble starting a conversation?
## Dysfunctional conflict
Several elements may occur in **dysfunctional conflict**. The dysfunction occurs when emotions distort the content issue (e.g., when some information is withheld so that you must guess at what is truly going on in the mind of the other person). Sometimes the conflict is obscured by hidden messages, denied feelings, or feelings projected onto others. Nonproductive conflicts are characterized by feelings that are misperceived or stated too intensely. In other dysfunctional conflicts, the feelings are stated accurately, but they are expressed so strongly that the listener feels attacked. The listener then tends to respond in a defensive manner.
## Principles of conflict resolution
Figure 14-1 describes the principles of conflict resolution. Recognize your own "trigger" or "hot buttons." What words or client actions trigger an immediate emotional response from you? These could include having someone yelling at you or speaking to you in an angry tone of voice. Once you recognize the triggers, you can better control your own response. It is imperative that you focus on the current issue. Put aside past history. Listing prior problems will raise emotions and prevent both of you from reaching a solution. Identify _available options._ Rather than immediately trying to solve the problem, look at the range of possible options. Create a list of these options and work with the other party to evaluate the feasibility of each option. By working together, the expectation shifts from adversarial conflict to an expectation of a win-win outcome. After discussing possible solutions, select the best one to resolve the conflict. Evaluate the outcome based on fair, objective criteria.
Figure 14-1 Principles of conflict resolution.
• Identify conflict issue
• Know own response
• Stay focused on issue
• Identify options
• User standards/criteria
• Seperate issue from people involved
Developing an Evidence-Based Practice
Kelly J, Ahern K: Preparing nurses for practice: a phenomenological study of the new graduate in Australia, _J Clin Nurs_ 18:910–918, 2008.
This exploratory descriptive study examined the views of 13 graduating baccalaureate student nurses before employment, after 1 month, and again after 6 months of employment. Semistructured interviews were conducted using a phenomenologic "lived experience" approach. Findings were analyzed for themes.
_Results:_ The major theme that emerged was workplace bullying/"eating your young," All these new graduate professional nurses struggled with socialization in their employment roles, experiencing "reality shock." They were unprepared for the culture of "cliques" that existed on their units and the lack of support they received. More experienced nurses gave them limited assistance with unfamiliar tasks; were perceived to act in a "bitchy" manner; used silence to communicate lack of acceptance; and seemed to subscribe to a philosophy that new nurses should learn by being "thrown into the deep end."
_Application to Your Clinical Practice:_ As new graduates, you are a valuable resource. Seek positions with agencies that want to promote retention and thus provide extensive orientation programs with experienced staff nurse mentors.
## Applications
Preventing conflict
In addition to managing your own responses to client provocations by adopting a professional, "calm" demeanor and low tone of voice, other conflict prevention strategies may be useful. Signal your readiness to listen with attending behaviors such as good body position, eye contact, and receptive facial expression (Jasmine, 2009). Give your undivided extra attention to a client or a visitor whom you identify as potentially becoming aggressive. Finke et al.'s (2008) review of 12 nurse-client communication studies showed that nurses' anti-communication attitudes were cited in half the studies as a barrier to communication. Increasing your positive appreciation of your client does facilitate communication. As nurses, we hold the belief that all clients have worth as human beings. Remind yourself of this basic belief whenever you are in a conflict situation with your client. Remember we "choose" to enter into each relationship in a therapeutic manner (Milton, 2008). These strategies may be effective in preventing conflict or in preventing escalation of the conflict. Remember your primary goal is to prevent conflict or defuse escalating aggressive behavior (Phillips, 2007).
## Assessing the presence of conflict in the nurse-client relationship
To get resolution, you need to acknowledge the presence of conflict. Often the awareness of our own feelings of discomfort is an initial clue. Evidence of the presence of conflict may be _overt,_ that is, observable in the client's behavior and expressed verbally. For example, the client may criticize you. No one likes to be criticized, and a natural response might be anger, rationalization, or blaming others. But as a professional nurse, you recognize your response, recognize the conflict, and work toward resolution so that constructive changes may take place.
More often, conflict is _covert_ and not so clear-cut. The conflict issues are hidden. Your client talks about one issue, but talking does not seem to help and the issue does not get resolved. He continues to be angry or anxious. Subtle behavioral manifestations of covert conflict might include a reduced effort by your client to engage in self-care; frequent misinterpretation of your words; behaviors that are out of character for him such as excessive anger. For example, when your client seems unusually demanding, has a seemingly insatiable need for your attention, or is unable to tolerate reasonable delays in having needs met, the problem may be anxiety stemming from conflictive feelings. Client behaviors are often negatively affected by feelings of pain, loss, frustration, or fear. As nurses, we affect the behavior of our clients through our actions. This can lead to positive or negative outcomes. See Exercise 14-5 for practice in defining conflict issues.
EXERCISE 14-5 Defining Conflict Issues
Purpose:
To help students begin to organize information and define the problem in interpersonal conflict situations.
Procedure:
In every conflict situation, it is important to look for specific behaviors (including words, tone, posture, and facial expression); feeling impressions (including words, tone, intensity, and facial expression); and need (expressed verbally or through actions).
Identify the behaviors, your impressions of the behaviors, and needs that the client is expressing in the following situations. Then suggest an appropriate nursing action. Situation 1 is completed as a guide.
Situation 1
Mrs. Patel, an Indian client, does not speak much English. Her baby was just delivered by cesarean section, and it is expected that Mrs. Patel will remain in the hospital for at least 4 days. Her husband tells the nurse that Mrs. Patel wants to breast-feed, but she has decided to wait until she goes home to begin because she will be more comfortable there and she wants privacy. The nurse knows that breast-feeding will be more successful if it is initiated soon after birth.
_Behaviors:_ The client's husband states that his wife wants to breast-feed but does not wish to start before going home. Mrs. Patel is not initiating breast-feeding in the hospital.
_Your impression of behaviors:_ Indirectly, the client is expressing physical discomfort, possible insecurity, and awkwardness about breast-feeding. She may also be acting in accordance with cultural norms of her country or family.
_Underlying needs:_ Safety and security. Mrs. Patel probably will not be motivated to attempt breast-feeding until she feels safe and secure in her home environment.
_Suggested nursing action:_ Provide family support and guarantee total privacy for feeding.
Situation 2
Mrs. Moore is returned to the unit from surgery after a radical mastectomy. The doctor's orders call for her to ambulate, cough, and deep breathe, and to use her arm as much as possible in self-care activities. Mrs. Moore asks the nurse in a very annoyed tone, "Why do I have to do this? You can see that it is difficult for me. Why can't you help me?"
Sometimes the feelings themselves become the major issue, so that valid parts of the original conflict issue are hidden; consequently, conflict escalates. Consider the following situation.
Case Example
Ms. Denton is scheduled for surgery at 8 a.m. tomorrow. As the student nurse assigned to care for her, you have been told that she was admitted to the hospital 3 hours ago, and that she has been examined by the house resident. The anesthesia department has been notified of the client's arrival. Her blood work and urine have been sent to the laboratory. As you enter her room and introduce yourself, you notice that Ms. Denton is sitting on the edge of the bed and appears tense and angry.
_Client:_ I wish people would just leave me alone. Nobody has come in and told me about my surgery tomorrow. I don't know what I'm supposed to do—just lay around here and rot, I guess.
At this point, you probably can sense the presence of conflictive feelings, but it is unclear whether the emotions being expressed relate to anxiety over the surgery or to anger over some real or imagined invasion of privacy because of the necessary laboratory tests and physical examination. Your client might also be annoyed by you or by a lack of information from her surgeon. She may feel the need to know that hospital personnel see her as a person and care about her feelings. Before you can respond empathetically to the client's feelings, they will have to be decoded.
_Nurse_ (in a concerned tone of voice): You seem really upset. It's rough being in the hospital, isn't it?
Notice that the reply is nonevaluative and tentative, and does not suggest specific feelings beyond those the client has shared. There is an implicit request for her to validate your perception of her feelings and to link the feelings with a concrete issue. You process verbal as well as nonverbal cues. Concern is expressed through your tone of voice and words. The content focus relates to the client's predominant feeling tone, because this is the part of the conflict that she has chosen to share with you. It is important to maintain a nonanxious presence.
## Nursing strategies to enhance conflict resolution
One goal is to _de-escalate_ the conflict (Pryor, 2006). Use the strategies for conflict resolution described in this section. Mastery takes practice. Although this
Reaching a common understanding of the problem in a direct, tactful manner is the first step in conflict resolution.
seems like a lot of information, Susanne Gaddis, the "Communications Doctor," calls these a "4-second rule" to improve communications.
### Prepare for the encounter
Careful preparation often makes the difference between being successful or failing to assert yourself when necessary. Clearly identify the issue in conflict. In discussing assertive communication, For communication to be effective, it must be carefully thought out in terms of certain basic questions:
• _Purpose_. What is the purpose or objective of this information? What is the central idea, the one most important statement to be made?
• _Organization._ What are the major points to be shared, and in what order?
• _Content._ Is the information to be shared complete? Does it convey who, what, where, when, why, and how?
• _Word choice._ Has careful consideration been given to the choice of words?
If you wish to be successful, you must consider not only what is important to you in the discussion but what is important to the other person. Bear in mind the other person's frame of reference when acting assertively. The following clinical example illustrates this idea.
Case Example
Mr. Pyle is an 80-year-old bachelor who lives alone. He has always been considered a proud and stately gentleman. He has a sister, 84 years old, who lives in Florida. His only other living relatives, a nephew and his wife, also live in another state. He recently changed his will so that it excludes his relatives, and he refuses to eat. When his neighbor brings in food, he eats it, but he won't fix anything for himself. He tells his neighbor that he wants to die and that he read in the paper about a man who was able to die in 60 days by not eating. As the visiting nurse assigned to his area, you have been asked to make a home visit and assess the situation.
The issue in this case example is not one of food intake alone. Any attempt to talk about why it is important for him to eat or expressing your point of view in this conflict immediately on arriving is not likely to be successful. Mr. Pyle's behavior suggests that he feels there is little to be gained by living any longer. His actions suggest further that he feels lonely and may be angry with his relatives. Once you correctly ascertain his needs and identify the specific issues, you may be able to help Mr. Pyle resolve his intrapersonal conflict. His wish to die may not be absolute or final, because he eats when food is prepared by his neighbor and he has not yet taken a deliberate, aggressive move to end his life. Each of these factors needs to be assessed and validated with him before an accurate nursing diagnosis can be made.
### Organize information
Organizing your information and validating the appropriateness of your intervention with another knowledgeable person who is not directly involved in the process is useful. Sometimes it is wise to rehearse out loud what you are going to say. Remember to adhere to the principle of focusing on the conflict issue. Avoid bringing up the past.
### Manage your own anxiety or anger
Recognizing and controlling your own natural emotional response to your client's upsetting behavior may be one key factor in managing conflict. Conflict produces anxiety, but anxiety increases your perception of conflict, creating feelings of helplessness (Stuart, 2009). This discomfort should signal you that you need to deal with the situation. Confronting the client's behavior now should keep you from losing control later as the problem escalates. Most people experience some variation of a physical response when taking interpersonal risks. A useful strategy for managing your own anger is to vent to a friend using "I" statements, as long as this does not become a complaining, whining session. Another strategy to manage your own anger is to "take a break." A cooling-off period, doing something else for a few minutes or hours until your anger subsides, is acceptable. Take care that you reengage, however, so that this does not become just an avoidance response style. Communicate with the correct person; do not take out your frustration on someone else. Focus on the one issue with the client involved. Try saying, "I would like to talk something over with you before the end of shift/before I go." Before you actually enter the client's room, do the following:
• Cool off. Wait until you can speak in a calm, friendly tone.
• Take a few deep breaths. Inhale deeply and count "1-2-3" to yourself. Hold your breath for a count of 2 and exhale, counting again to 3 slowly.
• Fortify yourself with positive statements (e.g., "I have a right to respect."). Anticipation is usually far worse than the reality.
• Defuse your own anger before confronting the patient.
• Focus on one issue.
### Time the encounter
Timing is a determinant of success. Know specifically the behavior you wish to have the client change. Make sure that the client is capable physically and emotionally of changing the behavior. Select a time when you both can discuss the matter privately and use neutral ground, if possible. Select a time when the client is most likely to be receptive.
Timing is also important if an individual is very angry. The key to assertive behavior is choice. Sometimes it is better to allow your client to let off some "emotional steam" before engaging in conversation. In this case, the assertive thing to do is to choose silence accompanied by a calm, relaxed body posture. These nonverbal actions convey acceptance of feeling and a desire to understand. Validating the anger and reframing are useful. Comments such as "I'm sorry you are feeling so upset" recognize the significance of the emotion being expressed without getting into the cause.
### Put situation into perspective
Don't play the blame game. Put the issue into perspective. Will the issue be significant in a year? In 10 years? Will there be a significant situational change with resolution? This is another way of saying to pick your battles. Not every situation is worth using up your time and energy. Remind yourself that anger may be caused by a problem communicating; the client who is frustrated may become angry when he cannot make staff understand.
### Use therapeutic communication skills
Refer to the discussion on therapeutic communication in Chapter 10. Particularly useful is _active listening._ Really trying to understand what the client is upset about requires more skill than just listening to his or her words. Listening closely to what the client is saying may help you understand his or her point of view. This understanding may decrease the stress. Repeat to assure the client you have heard what was said.
### Use clear, congruent communication
Riley (2008) adapted a CARE acronym to help nurses confront conflict situations. Refer to Box 14-4. The C is _clarify_. Choose direct, declarative sentences. Use objective words, and directly state the behavior that is the problem. Then proceed to A and _articulate_ why their behavior is a problem by stating facts.
BOX 14-4 Potential Approaches for Dealing with Difficult Clients
1. **C** larify the behavior that is a problem:
• Use active listening skills to identify issues of concern to the client.
• Use a calm tone and avoid conveying irritation.
• Use medical and nonmedical interventions to decrease anxiety (e.g., medicine, touch, relaxation, and guided imagery).
• Factually state the problem.
2. **A** rticulate why the behavior is a problem:
• Explain the institution policies.
• Explain the limits of your role.
• Set limits.
• Give family permission (e.g., to rest or to leave).
3. **R** equest a change in the problem behavior:
• Work with staff so all use the same uniform approach to the client's demands.
• Develop a nursing care plan: involve patient in care and set goals; review and reevaluate whether nurse and client have same goals.
4. **E** ncourage change:
• Evaluate progress.
• Provide education; explain all options, with outcomes.
• Use incentives and withdrawal of privileges to modify unacceptable behavior.
• Promote trust by providing immediate feedback.
Make sure verbal and nonverbal communication is congruent. Maintain an open stance and omit any gestures that might be interpreted as criticism, such as rolling your eyes or sighing heavily. Avoid mixed messages. One example of inappropriate communication might be found in the case of Larry, a staff nurse who works the 11-7 shift. Larry needs to get home to make sure his children get on the bus to school. A geriatric client routinely asks for a breathing treatment while Larry is reporting off. Instead of setting limits, Larry uses a soft voice and smiles as he tells her he can be late to begin the report. Another example is Mr. Carl, the 29-year-old client in Room 122 who constantly makes sexual comments to a young student nurse. She laughs as she tells him to cut it out.
### Take one issue at a time
You may need to first focus on acknowledging the feelings associated with the conflict, because it is these that generally escalate conflict. It is always best to start with one issue at a time.
• Choose words that may lead to a positive outcome.
• Focus only on the present issue. The past cannot be changed.
Limiting your discussion to one topic issue at a time enhances the chance of success. Usually it is impossible to resolve a conflict that is multidimensional in nature with one solution. By breaking the problem down into simple steps, enough time is allowed for a clear understanding. In the case example just given, you might paraphrase the client's words, reflecting the meaning back to the client to validate accuracy. Once the issues have been delineated clearly, the steps needed for resolution may appear quite simple.
### Mutually generate some options for resolution
Focus on ways to resolve the problem by listing possible options. You are familiar with the "fight-or-flight" response to stress: Many people can respond to conflict only by either fighting or avoiding the problem. But brainstorming possible options and discussing pros and cons can turn the "fight" response into a more mutual "seeking a solution" mode of operations.
### Make a request for a behavior change
Avoid blaming. This would only make your client feel defensive or angry. As in Box 14-4, the R in the CARE acronym is your _request for a change_ in his behavior. Clearly ask him or her for the needed behavior change. Take into consideration his developmental stage, values, and life experiences. His willingness to change needs to be considered. In addition, for an ill client, level of self-care, as well as outside support systems, are factors. To approach the task without this information is risky.
Rather than just stating your position, try to use some objective criteria to examine the situation. Saying, "I understand your need to_______, but the hospital has a policy intended to protect all our clients" might help you talk about the situation without escalating into anger. Psychiatric units have known rules against verbal abuse, violence such as throwing objects, violence against others, and so on. You can restate these "rules," together with their known violation outcomes (medication, seclusion, manual restraint), in a calm but firm voice.
There obviously will be situations in which such a thorough assessment is not possible, but each of these variables affects the success of the confrontation. For example, a client with dementia who makes a pass at a nurse may simply be expressing a need for affection in much the same way that a small child does; this behavior needs a caring response rather than a reprimand. A 30-year-old client with all his cognitive faculties who makes a similar pass needs a more confrontational response.
Client readiness is vital. The behavior may need to be confronted, but the manner in which the confrontation is approached and the amount of preparation or groundwork that has been done beforehand may affect the outcome.
### Understand cultural implications
Often what appears to be an inappropriate response in Western culture is a highly acceptable way of interacting in a different culture. For example, some clients experience conflict related to taking pain medication. In the cultures of these clients, pain is supposed to be endured with stoicism. It is often necessary to help such clients express their discomfort when it occurs and to give them guidelines, as well as explicit permission to develop a different behavior. It is easier for these clients to take such medication when they can assure their families that the nurse said it was necessary to take it. By focusing on the behavior required to meet the client's physical needs, the nurse bypasses placing a value on the rightness or wrongness of the behavior. Refer to chapter 11 for a more detailed discussion of cultural differences that can create conflict.
### Evaluate the conflict resolution
The E is the CARE acronym stands for encouraging the client to change by stating the outcomes, the positive consequences of changing or the negative implications for failing to change (Riley, 2008). The E could also stand for _evaluation of conflict resolution_. Evaluate the degree to which the interpersonal conflict has been resolved. This depends somewhat on the nature of the conflict. Sometimes a conflict cannot be resolved in a short time, but the willingness to persevere is a good indicator of a potentially successful outcome. Accepting small goals is useful when large goal attainment is not possible. Your goal is open communication with frequent feedback leading to successful problem solving.
For a client, perhaps the strongest indicator of conflict resolution is the degree to which he is actively engaged in activities aimed at accomplishing tasks associated with treatment goals. As the nurse, there are two questions you might want to address if modifications are necessary:
• What is the best way to establish an environment that is conducive to conflict resolution? What else needs to be considered?
• What self-care behaviors can be expected of the client if these changes are made? These need to be stated in ways that are measurable.
### Identify client intrapersonal conflict situations
The initial interpersonal strategy used to help clients reduce strong emotion to a workable level is to provide a neutral, accepting, interpersonal environment. Within this context, you can acknowledge your client's emotion as a necessary component of adaptation to life. You convey acceptance of the individual's legitimate right to have feelings. Telling a client, "I'm not surprised that you are angry about..." or simply stating, "I'm sorry you are hurting so much," acknowledges the presence of an uncomfortable emotion in the client, conveys an attitude of acceptance, and encourages the client to express himself or herself. Once a feeling can be put into words, it becomes manageable because it has concrete boundaries.
### Talk about IT
The second step in defusing the strength of an emotion is to talk the emotion through with someone. For the client, this someone is often the nurse. For the nurse, this might be a nursing supervisor or a trusted colleague. Unlike complaining, the purpose of talking the emotion through is to help the person connect with all of his or her personal feelings surrounding the incident. If one client seems to produce certain negative emotional reactions on a nursing unit, the emotional responses may need the direct attention of all staff on the unit.
### Use tension-reducing actions
The third phase is to take action. The specific needs expressed by the emotion suggest actions that might help the client come to terms with the consequences of the emotion. This responsibility might take the form of obtaining more information or of taking some concrete risks to change behaviors that sabotage the goals of the relationship. Convey mutual respect and avoid any "put-down" type of comment about yourself or the client.
Sometimes the most effective action is simply to listen. Active listening in a conflict situation involves concentrating on what the other person is upset about. Listening can be so powerful that it alone may reduce the client's feelings of anxiety and frustration.
Physical activity can reduce tension. For example, taking a walk can help your client control his anxiety behaviors and can defuse an emotionally tense situation. If your client is so upset that he constitutes a danger to himself or others, talk softly in a calm tone; face him but allow maximum space and an exit for yourself should it become necessary. Many hospitals and psychiatric units have a "code word " that is used to summon trained help.
Humor is frequently used by nurses to engage a client or to initiate an interaction. Humor can also be used as a means of reducing tension. To paraphrase a famous advice columnist, two of the most important words in a relationship are "I apologize." And she recommended making amends immediately when you've made a mistake, because it is easier to eat crow while it is still warm. Is this advice easier to take (we won't say swallow) since it comes with a chuckle? Humor serves as an immediate tension reliever.
### Defuse intrapersonal conflict
Intrapersonal conflicts develop when you hold opposing feelings within yourself. The client with a myocardial infarction who insists on conducting business from the bedside probably feels conflicted about the restraints placed on his or her activities, as does the diabetic client who sneaks off to the food vending machine for a candy bar.
There are times when the conflictive feelings begin intrapersonally within the nurse (e.g., in working with parents of an abused child or treating a foul-mouthed alcoholic client in the emergency department). Such situations often stir up strong feelings of anger or resentment in us. In this case, we may need to defuse destructive emotions before proceeding further. The following are interventions you can use to defuse intrapersonal conflicts:
• Identify the presence of an emotionally tense situation.
• Talk the situation through with someone.
• Provide a neutral, accepting environment.
• Take appropriate action to reduce tension.
• Evaluate the effectiveness of the strategies.
• Generalize behavioral approaches to other situations.
For the nurse, the first step in coping with difficult emotional responses is to recognize their presence and to assess the appropriateness of expressing emotion in the situation. If expressing the emotion does not fit the circumstances, one must deliberately remain unruffled when every natural instinct argues against it. Ambivalence, described as two opposing ideas or feelings related to any life situation or relationship coexisting within the same individual, is relatively common. It is not the responsibility of the nurse to help a client resolve all intrapersonal conflict. Long-standing conflicts require more expertise to resolve. In such cases, refer your client to the appropriate resource.
### Evaluate
The final step in the process is to evaluate the effectiveness of responses to emotions and to generalize the experience of confronting difficult emotions to other situations. Each step in the process may need to be taken more than once and refined or revised as circumstances dictate.
## Interpersonal conflict interventions
Developing assertive skills
#### Demonstrate Respect
Responsible, assertive statements are made in ways that do not violate the rights of others or diminish their standing. They are conveyed by a relaxed, attentive posture and a calm, friendly tone of voice. Statements should be accompanied by the use of appropriate eye contact.
#### Use "I" Statements
Statements that begin with "You" sound accusatory and always represent an assumption because it is impossible to know exactly, without validation, why someone acts in a certain way. Because such statements usually point a finger and imply a judgment, most people respond defensively to them.
"We" statements should be used only when you actually mean to look at an issue collaboratively. Thus, the statement "Perhaps we both need to look at this issue a little closer" may be appropriate in certain situations. However, the statement "Perhaps we shouldn't get so angry when things don't work out the way we think they should" is a condescending statement thinly disguised as a collaborative statement. What is actually being expressed is the expectation that both parties should handle the conflict in one way—the nurse's way.
Use of "I" statements are one of the most effective conflict management strategies you can use. Assertive statements that begin with "I" suggest that the person making the statement accepts full personal responsibility for his or her own feelings and position in relation to the presence of conflict. It is not necessary to justify your position unless the added message clarifies or adds essential information. "I" statements seem a little clumsy at first and take some practice. The traditional format is this:
"I feel _____ (use a name to claim the emotion you feel) when ______ (describe the behavior nonjudgmentally) because _____ (describe the tangible effects of the behavior)."
_Example:_
"I feel uncomfortable when a client's personal problems are discussed in the cafeteria because someone might overhear confidential information."
#### Make Clear Statements
Statements, rather than questions, set the stage for assertive responses to conflict. When questions are used, "how" questions are best because they are neutral in nature, they seek more information, and they imply a collaborative effort. "Why" questions ask for an explanation or an evaluation of behavior and often put the other person on the defensive. It is always important to state the situation clearly; describe events or expectations objectively; and use a strong, firm, yet tactful manner. The following example shows how a nurse can use the three levels of assertive behaviors to meet the client's needs in a hospital situation without compromising the nurse's own needs for respect and dignity.
Case Example
Mr. Gow is a 35-year-old executive who has been hospitalized with a myocardial infarction. He has been acting seductively toward some of the young nurses, but he seems to be giving Miss O'Hara an especially hard time.
_Client:_ Come on in, honey, I've been waiting for you.
_Nurse_ (using appropriate facial expression and eye contact, and replying in a firm, clear voice): Mr. Gow, I would rather you called me Miss O'Hara.
_Client:_ Aw, come on now, honey. I don't get to have much fun around here. What's the difference what I call you?
_Nurse:_ I feel that it does make a difference, and I would like you to call me Miss O'Hara.
_Client:_ Oh, you're no fun at all. Why do you have to be so serious?
_Nurse:_ Mr. Gow, you're right. I am serious about some things, and being called by my name and title is one of them. I would prefer that you call me Miss O'Hara. I would like to work with you, however, and it might be important to explore the ways in which this hospitalization is hampering your natural desire to have fun.
In this interaction, the nurse's position is defined several times using successively stronger statements before the shift can be made to refocus on underlying client needs. Notice that even in the final encounter, however, the nurse labels the behavior, not the client, as unacceptable. Persistence is an essential feature when first attempts at assertiveness appear too limited. After careful analysis, if you find that a client's behavior is infringing on your rights, it is essential that the issues be addressed directly in a tactful manner. If they are not, it is quite likely that the undesirable behavior will continue until you are no longer willing to tolerate it.
#### Use Proper Pitch and Tone
The amount of force used in delivery of an assertive statement depends on the nature of the conflict situation, as well as on the amount of confrontation needed to resolve the conflict successfully. Starting with the least amount of assertiveness required to meet the demands of the situation conserves energy and does not place the nurse into the bind of overkill. It is not necessary to use all of one's resources at one time or to express ideas strongly when this type of response is not needed. You can sometimes lose your effectiveness by becoming long-winded in your explanation when only a simple statement of rights or intent is needed. Long explanations detract from the true impact of the spoken message. Getting to the main point quickly and saying what is necessary in the simplest, most concrete way cuts down on the possibility of misinterpretation. This approach increases the probability that the communication will be constructively received.
Pitch and tone of voice contribute to another person's interpretation of the meaning of your assertive message. A soft, hesitant, passive presentation can undermine an assertive message as much as vocalizing the message in a harsh, hostile, and aggressive tone. A firm but moderate presentation often is as effective as content in conveying the message (see Exercise 14-3).
#### Analyze Personal Feelings
As mentioned earlier, part of an initial assessment of an interpersonal conflict situation includes recognition of the nurse's intrapersonal contribution to the conflict, as well as that of the client. It is not wrong to have ambivalent feelings about taking care of clients with different lifestyles and values; however, this needs to be acknowledged to yourself.
#### Focus on the Present
The focus of assertive responses should always be on the present. Because it is impossible to do anything about the past except learn from it, and because the future is never completely predictable, the present is the only reality in which we have much decision-making power as to how we act. To be assertive in the face of an emotionally charged situation demands thought, energy, and commitment. Assertiveness also requires the use of common sense, self-awareness, knowledge, tact, humor, respect, and a sense of perspective. Although there is no guarantee that the use of assertive behaviors will produce desired interpersonal goals, the chances of a successful outcome are increased because the information flow is optimally honest, direct, and firm. Often the use of assertiveness brings about changes in ways that could not have been anticipated. Changes occur because the nurse offers a new resource in the form of objective feedback with no strings attached.
#### Structure Your Response
In mastering assertive responses, it may be helpful initially to use these steps in an assertive response.
1. Express empathy: "I understand that ______"; "I hear you saying ______."
_Example:_
"I understand that things are difficult at home."
2. Describe your feelings or the situation: "I feel that ______"; "This situation seems to me to ______.
_Example:_
"But your 8-year-old daughter has expressed a lot of anxiety, saying, 'I can't learn to give my own insulin shots.'"
3. State expectations: "I want _________"; "What is required by the situation is _______."
_Example:_
"It is necessary for you to be here tomorrow when the diabetic teaching nurse comes so you can learn how to give injections and your daughter can, too, with your support."
4. List consequences: "If you do this, then __________ will happen" (state positive outcome); "If you don't do this, then __________ will happen" (state negative outcome).
_Example:_
"If you get here on time, we can be finished and get her discharged in time for her birthday on Friday."
### Clinical encounters with demanding, difficult clients
Every nurse encounters clients who seem overly demanding of your limited time and resources. Although this may reflect a personality characteristic, most often it is sign of their anxiety. Box 14-1 describes behaviors that increase anger in others. Nurses often respond to difficult clients, especially those who display inappropriate sexual aggression, by ignoring their verbal comments, physically avoiding the client, or by adopting a very "no-nonsense" professional behavior (Higgins, 2009). Try some of the more therapeutic approaches in Box 14-4. Usually we have labeled people as "difficult to deal with" when our normal way of dealing with them has failed. So remember, we cannot change other's personalities, but we can change the way we react to them (Salazar, 2004).
### Clinical encounters with angry clients
You can expect to encounter clients who express anger. This may take the form of refusal to comply with the treatment plan, exhibition of hostile behaviors toward staff, verbal or even physical actions, or perhaps withdrawal from any positive interaction with you. When dealing with a difficult client, ask yourself what the client is gaining from such behavior. Some people have not learned successful communication, so they revert to behavior that has gained them something in the past. For example, as children they may have only gotten needed attention when they acted out in a negative way or when they pouted or sulked. Ask yourself if the client behaving in a difficult way is getting rewarded by focusing a lot of staff attention on himself, for example. Does the client just need to learn a more effective way of communicating? Remind yourself that usually the client's feeling center on their disease or treatment and are not a reflection of their feeling about you. Nurses cited by Servodidio (2008) comment, "One of the hardest things to learn as a nurse is not to take a patient's frustration or anger personally" (p. 17).
Nonverbal clues to anger include grimacing, clenching jaws or fists, turning away, and refusing to maintain eye contact. Verbal cues by a client may, of course, include use of an angry tone of voice, but they may also be disguised as witty sarcasm or as condescending or insulting remarks. To become comfortable in dealing with client anger, the nurse must first become aware of his or her own reactions to anger so that the nurse does not threaten or reject the individual expressing anger, or respond in anger. Interventions include those listed in Box 14-5.
BOX 14-5 Strategies for Dealing with an Angry Client
• Call the client by name while making occasional eye contact.
• Use active listening while allowing client to ventilate some of his or her anger and discuss his problem.
• Use body language that is confident but nonthreatening: neutral position, hands down by your side, one foot in front of the other in a relaxed posture; do not "crowd" the client, maintain space (a safe distance).
• Take a deep breath and respond in a low, calm, gentle tone of voice (avoid being defensive).
• Restate the issue briefly, be friendly.
• For some clients with brain damage or mental illness, it is appropriate to remove them from the source of their irritation to a calm environment, sort of a time-out.
• Help client identify his or her own anger, for example: "I notice you are clenching your fists and talking more loudly than usual. These are things people do when angry. Are you feeling angry right now?"
• Give permission to feel angry, but set limits on acting out/violent behavior: "It's okay to feel angry about...but not okay to act on it," or "It's natural to feel angry about...but throwing isn't okay..."
• Avoid arguing, saying no, hurrying, or touching.
• Offer to work with client to help him deal with the issue.
• Get help _immediately_ or _leave_ if you feel in danger of physical harm; always maintain a space for safety and plan an exit.
Help the client own the angry feelings by getting the client to verbalize things that make him or her angry. Acknowledging a client's anger may prevent an expression of abusive ranting. It is essential that you use empathetic statements or active listening to acknowledge the client's anger and maintain a nonthreatening demeanor _before_ moving on to try to discuss the issue. Remember your goal is to maintain _safety_ while helping your client.
#### Defuse Hostility
Avoid responding to a client's anger by getting angry yourself. Verbal attacks follow certain rules, in that the abusive person expects you to react in specific ways. Usually people will respond by becoming aggressive and attacking back or by becoming defensive and intimidated. Keep your cool using strategies discussed earlier. Take a deep breath! Remember, if you lose control, you lose! If you become defensive, you lose! Abusive people want to provoke confrontations as a means of controlling you.
• Use empathy in your communication. An angry client needs to have you acknowledge both the issue and their feelings about that issue. Only then can the client begin to interact in a meaningful way. Your empathy may help defuse the situation (Nau, Dassen, Halfewns, & Needham, 2007).
• Deliberately begin to lower your voice and speak more slowly. When we get upset, we tend to speak quickly and use a higher tone of voice. If you do the opposite, the client may begin to mimic you and thus calm down.
• Realistically analyze the current situation that is disturbing the client.
• Be assertive in setting limits. If the client persists, you need to assert limits, saying, for example, "Jim, I want to help you sort this out, but if you continue to raise your voice, I'm going to have to leave. Which do you want?" or, "Yelling at me isn't going to get this worked out. I will not argue with you. Come back when you can talk calmly and I will try to help you."
• Assist the client in developing a plan to deal with the situation (e.g., use techniques such as role-playing to help the client express anger appropriately, using "I" statements such as "I feel angry" rather than "You make me angry"). Bringing behavior up to a verbal level should help alleviate the need for other acting out of destructive behaviors.
#### Prevent Escalation of Conflict
Depending on the type of feedback received, an intrapersonal conflict can take on interpersonal dimensions. In the following example, the mother initially experiences an intrapersonal conflict. The wished-for perfect infant has not appeared, and her personal ambivalence related to coping with her infant's defect is expressed indirectly through her partial noncompliant behavior. If the nurse interprets the client's behavior incorrectly as poor mothering and acts in a manner that reflects this attitude, the basically intrapersonal conflict can become interpersonal.
Case Example
A mother with her first infant is informed soon after delivery that her child has a cleft palate (missing roof of mouth). The physician explains the infant's condition in detail and answers the mother's questions. The mother requests rooming in and seems genuinely interested in the infant. Each time the nurse enters the client's room, the mother complains that her child does not seem hungry and states how difficult it is to feed the baby. Although the nurse spends a great deal of time teaching the mother the special techniques necessary for feeding, and the mother seems interested at the time, she seems unable or unwilling to follow any of the nurse's suggestions when she is by herself. Later, the nurse finds out that the mother has been asking for guidance and appears to be resisting what is offered. Although she may simply need further instruction in technique, the presence of an underlying intrapersonal conflict is worth investigating. Before proceeding with teaching, the nurse needs to find out about the mother's perceptions. Does she feel competent in the mothering role? What does having a less than perfect child mean to her? What are her fears about caring for an infant with this particular type of defect? Until the underlying feelings are identified, client teaching is likely to have limited success.
This client appears to reframe the experience from her own perspective. In this situation, a client strength would be the mother's ability and willingness to express her uncomfortable feelings so that they can be addressed. Even though the mother may be unclear about the nature of her feelings, reframing the issues in this way builds on strengths instead of on personal deficits.
Prevent any escalation in interpersonal conflict. Hurt feelings or misunderstandings can quickly escalate a conflict. In talking to an angry client, as his voice rises, lower yours. If eye contact seems confrontational, then break eye contact. If the client is acting out by throwing or hitting, set limits: "No hitting (spitting, or other physical behavior) is allowed here." If you set limits, be sure to follow through. Ask the client to verbalize his or her anger (e.g., "Talk about how you feel, instead of throwing things"). Studies show that talking will dramatically reduce aggressive behavior. Use other strategies described in this book for defusing conflict situations. Active listening (i.e., really listening to your client's viewpoint), using attentive body language, and summarizing the client's viewpoint can defuse some of the tension of the conflict.
### Clinical encounters with aggressive/violent clients
Some clients have mental problems, are truly confused, intoxicated, or have cognitive deterioration. The U.S. Preventive Services Task Force (USPSTF, 2008) recommends clinicians assess the client's level of cognitive functioning when this is suspected, using the Mini-Mental Status Examination (MMSE). It helps you to respond more positively if you perceive that their behavior is not "evil" but a result of their illness. Be aware that escalating conflict can be a threat not only to your client, but to your own safety. In no case is violence acceptable. Limits must be set. Failing this, you need to remove yourself from a potentially harmful situation. Starcher (1999) describes the behavior of an emotionally disturbed client admitted to a geriatric unit. Sam's behavior ranged from bullying or pushing other clients to noncompliance with his treatment. Staff tried setting clear limits and identifying specific negative outcomes, including restraints and medication, without success. Eventual successful interventions included consistent response by all staff members and using written patient contracts for each of his unacceptable behaviors. Outcomes were specifically stated for both negative behaviors (restrictions) and positive acceptable behaviors (rewards with his favorite activities).
Box 14-5 lists some useful strategies for coping with angry clients. Deliberate use of "calming interventions" have been validated in Pyror's (2006) analysis of expert nurses' behaviors. An additional strategy for helping nurse-client problem interactions is the staff-focused consultation. Consider the following situation.
Case Example
Mr. Plotsky, age 29, has been employed for 6 years as a construction worker. About 4 weeks ago, while operating a forklift, he was struck by a train, leaving him paraplegic. After 2 weeks in intensive care, he was transferred to a neurologic unit. When staff members attempt to provide physical care, such as changing his position or getting him up in a chair, Mr. Plotsky throws things, curses angrily, and sometimes spits at the nurses. Staff members become very upset; several nurses have requested assignment changes. Some staff members try bribing him with food to encourage good behavior; others threaten to apply restraints. The manager schedules a behavioral consultation meeting with a psychiatric nurse or clinical specialist. The immediate goal of this staff conference is to bring staff feelings out into the open and to facilitate increased awareness of the staff's behavioral responses when confronted with this client's behavior. The outcome goal is to use a problem-solving approach to develop a behavioral care plan, so that all staff members respond to Mr. Plotsky in a consistent manner.
Students are particularly prone to feeling rebuffed when they first encounter negative feedback from a client. Support from staff, instructors, and peers, coupled with efforts to understand the underlying reasons for the client's feelings, help you resist the trap of avoiding the relationship. To develop these ideas further, practice Exercise 14-5.
### Defusing potential conflicts when providing home health care
Recognizing potential situations lending themselves to conflict is, of course, an important initial step. Caregivers have been shown to experience conflict through incompatible pressures suffered between caregiver demands and demands from their other roles, such as parenting their children or maintaining employment (Stephens et al., 2001). In addition to this inter-role conflict, caregivers suffer pressures when a nurse comes into their home to participate in the care of an ill relative. A Canadian study of home health nurses and family caregivers of elderly relatives identified four evolving stages in the nurse-caregiver relationship. The initial stage is "worker-helper," with the nurse providing care to the ill client and the family helping. Next comes "worker-worker," when the nurse begins teaching the needed care skills to family members. Third is "nurse as manager; family as worker," as the family members learn needed care skills. The final stage, "nurse as nurse for family caregiver," occurs as the family member becomes exhausted (Butt, 2000). A source of conflict for nurses was the dual expectation of the family that the nurse would provide care not only for the identified client but also provide relief for the exhausted primary caregiver. When the nurse operated as manager and treated the caregiver as worker, the discrepancy in expectations and values resulted in increased tension in the relationship. Discussion of role expectations is essential. Because of the high cost of providing direct care to chronically ill clients, home health nurses may be expected to quickly shift to teaching the necessary skills to the family members. You can clarify that this shift in responsibility results in a reduction of expensive professional time but not in your commitment to the family.
## Summary
Conflict represents a struggle between two opposing thoughts, feelings, or needs. It can be intrapersonal in nature, deriving from within a particular individual; or interpersonal, when it represents a clash between two or more people.
All conflicts have certain things in common: a concrete content problem issue and relationship issues arising from the process of expressing the conflict. Generally, intrapersonal conflicts stimulate feelings of emotional discomfort. Strategies to defuse strong emotion include talking the emotion through with someone and temporarily reducing stress through the use of distraction or additional information. Most interpersonal conflicts involve some threat, either to one's sense of power to control an interpersonal situation or to ways of thinking about the self. Giving up ineffective behavior patterns in conflict situations is difficult; such patterns are generally perceived to be safer because they are familiar.
Behavioral responses to conflict situations fall into four categories. Nurses most commonly choose avoidance. However, this chapter describes other strategies (e.g., assertion) that have been more successfully used by nurses to manage client-nurse conflicts. Assertive behaviors range from making a simple statement, directly and honestly, about one's beliefs, to taking a very strong, confrontational stand about what will and will not be tolerated.
The principles of conflict management are described. To apply conflict management principles, you need to identify your own conflictive feelings or reactions. For internal conflict, feelings usually have to be put into words and related to the issue at hand before the meaning of the conflict becomes understandable. In conflict between nurse and client, you need to think through the possible causes of the conflict, as well as your own feelings, before making a response. To resolve these kinds of conflict, you need to use "I" statements and respond assertively.
Ethical Dilemma
What Would You Do?
You are caring for Kim, born at the gestational age of 24 weeks in a rural hospital and transferred this morning to your neonatal intensive care unit. Today her father arrives on the unit. Seeing you taking a blood sample from one of the many intravenous lines attached to her body, he yells at you to "Stop poking at her! What are you trying to prove by keeping her alive? Turn off those machines." This is both a communication and an ethics problem. How do you respond to his anger?
## References
Baillie, L. An exploration of nurse-patient relationships in accident and emergency. _Accid Emerg Nurs_. 2005;13(9):9–14.
Bowers, L., Flood, C., Brennan, G., et al. A replication study of the city nurse intervention: reducing conflict and containment on three acute psychiatric wards. _J Psychiatr Ment Health Nurs_. 2008;15(9):739–742.
Butt, G. Nurses and family caregivers of elderly relatives engaged in 4 evolving types of relationships. _Evid Based Nurs_. 2000;3:134.
Chang, M., Kelle, A.E. Patient education: addressing cultural diversity and health literacy issues. _Urol Nurs_. 2007;27(5):411–417.
Finke, E.H., Light, J., Kitko, L., et al. A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of argumentative and alternative communication. _J Clin Nurs_. 2008;17(16):2102–2115.
Higgins, A., Barker, P., Begley, C.M., et al. Clients with mental health problems who sexualize the nurse-client encounter: the nursing discourse. _J Adv Nurs_. 2009;65(3):616–624.
Jasmine, T.J.X. The use of effective therapeutic communication skills in nursing practice. _Singapore Nurs J_. 2009;36(1):35–40.
Macdonald, M. Origins of difficulty in the nurse-patient encounter. _Nurs Ethics_. 2007;14(4):510–521.
McElhaney, R. Conflict management in nursing administration. _Nurs Manag_. 1996;27(3):49–50.
Milton, C. Boundaries: ethical implications for what it means to be therapeutic in the nurse-person relationship. _Nurs Sci Q_. 2008;21(1):18–21.
Nau, J., Dassen, T., Halfewns, R., et al. Nursing students' experiences in managing patient aggression. _Nurs Educ Today_. 2007;27(8):933–946.
Phillips, S. Countering workplace aggression: an urban tertiary care institution exemplar. _Nurs Adm Q_. 2007;31(3):209–218.
Pryor, J. What do nurses do in response to their predictors of aggression? _J Neurosci Nurs_. 2006;28(3):177–182.
Redman, B.K., Fry, S.T. Ethical conflicts reported by RN/certified diabetes educators. _Diabetes Educ_. 1996;22(3):219–224.
Riley, J.B. Communication in nursing, ed 6. St. Louis, MO: Mosby/Elsevier Inc, 2008.
Salazar, J. Dealing with difficult people, Michigan Nurses Association. Available online: <http://www.minurses.org>. [Accessed May 5, 2009].
Servodidio, C.A. Nurses discuss working with challenging patients. _ONS Connect_. 2008;23(3):17.
Starcher, S. Sam was an emotional terrorist. _Nursing_. 1999;99(2):40–41.
Stephens, M.A., Townsend, A.L., Martire, L.M., et al. Balancing parent care with other roles: interrole conflict. _J Gerontol B Psychol Sci Soc Sci_. 2001;56(1):24–34.
Stuart, G.W. Principles and practice of psychiatric nursing. St. Louis: Mosby/Elsevier, 2009.
USPSTF, U.S. Preventive Services Task Force The Guide to Clinical Preventive Services, 2008. Available online:, www.preventiveservices.ahrq.gov, http://en.wikipedia.org/wiki/Conflict.
15
# Health Promotion and Client Learning Needs
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define health promotion and disease prevention and related concepts.
2 Identify national agendas for health promotion and disease prevention.
3 Describe relevant theory frameworks for health promotion strategies.
4 Apply health promotion and disease prevention strategies for individuals.
5 Apply health promotion strategies at the community level.
6 Discuss the role of learner variables in client education.
This chapter focuses on health promotion and disease prevention concepts used in health care. Included in the chapter are theory-based frameworks for health promotion as the starting point for improving the health of our nation and reducing health disparities. The chapter describes communication strategies designed to support clients, families, and targeted populations in achieving a better health quality of life, through education and lifestyle changes. The chapter addresses health literacy, readiness, and ability to learn as important components of health promotion/disease prevention efforts. A framework for developing and implementing community-based health promotion programs completes the chapter.
## Basic concepts
Definitions
#### Health and health promotion
The concept of health and its importance as an essential underpinning in nursing practice are explored from the perspective of the social determinants influencing health and well-being in this chapter. Quality of life is viewed as a constituent of health.
Contemporary thinking recognizes that many determinants of health and well-being are embedded in the economics, culture, and social community in which people live and work. Health communication is conceptualized as being more than simple information transfer. Clients are held accountable for their health care decisions and expected to actively participate in shared decision making with their health care providers. Client education is viewed as part of a larger context of health promotion and disease prevention strategies (Hoving, Visser, Mullen & Borne, 2010).
**Health** in 2010 is described as "being free from disease, being able to function normally, experiencing well-being, and having a healthy lifestyle" (Fagerlind et al., 2010, p. 104). Health is identified as a fundamental human right intimately tied to a nation's social and economic development (Jakarta Declaration; World Health Organization [WHO], 1997). Engaging in activities to promote a healthy lifestyle is viewed as a personal responsibility. Clients are expected to actively change lifestyle behaviors and make treatment choices to enhance personal health and well-being. Contemporary thinking is that the dialogue between providers and clients about health should be an equal exchange of information. The emotional impact of the health disruption, environmental factors, and client preferences are parts of clinical assessment. A focus on teaching self-management skills, with clients taking primary responsibility for implementation, directs content in client-centered care (Hoving et al., 2010).
**Health promotion** is an interactive education and support process. It enables and empowers people to reach their highest health potential by taking control of and improving the circumstances pertaining to their health and well-being (Green, 2008). Health promotion and disease prevention activities are essential elements of U.S. health, as "treatment alone is unlikely to have marked effects on health inequities or health status" (Frankish et al., 2006, p. 271).
Health promotion is more than disease prevention. The concept of health promotion embraces resources and actions to improve quality of life and well-being. For health promotion activities to fully succeed, they need to address environmental circumstances that can be detrimental to a healthy living style, and include advocacy for change through health policy initiatives and social action. Reliable access to resources and leadership training are part of an essential infrastructure needed to support health promotion approaches in the community.
Organized health promotion strategies can target individuals, families, high-risk groups, or communities. Health promotion interventions focus on helping people develop the self-management skills they need to achieve maximum functional health and personal well-being. Examples range from coaching new mothers (individual) to parenting groups (group or community). Health promotion activities related to exercise, nutrition, job stress, and a balanced lifestyle are increasingly incorporated as essential components into occupational settings.
Health Promotion as a Population Concept: Health promotion as a population concept recognizes the community as its principal voice in assuming control of and improving health and well-being. Strategies involve organized actions and educational programs to support and inform individuals, families, and communities about better ways to improve and maintain a healthy lifestyle.
In 1986, the WHO's _Ottawa Charter for Health Promotion_ documented essential prerequisites and resources needed for health promotion as "peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity" (WHO, 1986). Desired outcomes of health promotion activities are optimum health and well-being. The Jakarta Declaration on Health Promotion (1997) reaffirmed its relevance and called for the following actions:
• Building _healthy public_ policy
• Creating _supportive environments_ for health
• Strengthening _community action_ for health
• Developing _personal skills_
• Reorienting _health services_
#### Disease prevention
Health promotion and disease prevention are related concepts. **Disease prevention** is concerned with identifying modifiable risk and protective factors associated with diseases and disorders. Zubialde, Mold, and Eubank (2009) assert, "The goal of prevention is managing risk of future disease, disability, or premature death" (p. 194). Interventions are designed to help individuals at risk for chronic disease avoid the occurrence of a disease, disorder, or injury, to slow the progression of detectable disease and/or reduce its consequences (WHO, 1998).
The emphasis is always on averting health problems _before_ they occur or decreasing their impact once the health problem occurs. Disease prevention activities involve proactive decision making at all levels of prevention (Edelman & Mandel, 1998). The three tiers of prevention—primary, secondary, and tertiary prevention—represent a continuum of health care delivery focus.
• _Primary prevention_ strategies emphasize reduction of risk factors, including genetic susceptibility as a methodology for preventing the initial appearance of a disease or disorder. Strategies emphasize establishing and maintaining lifestyles favorable to health and well-being. Examples include prenatal clinics, parenting classes, and stress management programs. Nutrition, exercise, and environmental safety are other examples, easily incorporated into ordinary health teaching conversations.
• _Secondary prevention_ involves interventions designed to promote early diagnosis of symptoms through health screening, or timely treatment after the onset of the disease, thus minimizing their effects on a person's life. Examples include mammograms, diabetes, respiratory, and blood pressure screenings. Screening for mental health problems during the course of primary care visits can detect undiagnosed depression, anxiety, and substance abuse. Early diagnosis has a direct impact on the course and treatment of acute and chronic illness (WHO, 2008).
• _Tertiary prevention_ describes rehabilitation strategies designed to minimize the handicapping effects of a disease or injury once it occurs. Examples include teaching a cancer victim to manage chemotherapy symptoms, helping a stroke victim with bladder retraining to avoid infection, and teaching a client to cope effectively with the necessary adjustments a serious physical, social, or emotional illness imposes.
Well-being: Health promotion activities incorporate the WHO concept of an inseparable construct of health and well-being (Figure 15-1). Wellness or **well-being** is defined as a person's subjective experience of satisfaction about his or her life related to six personal dimensions: intellectual, physical, emotional, social, occupational, and spiritual (Edlin & Golanty, 2009). People experience well-being as being at peace with themselves and others. People can experience well-being even with a serious health problem or terminal diagnosis (Saylor, 2004).
Figure 15-1 Critical elements for maintaining health and well-being.
Lifestyle: Milio (1976) defines **lifestyle** as "patterns of choices made from the alternatives that are available to people according to their socioeconomic circumstances and the ease with which they are able to choose certain ones over others" (quoted in Cody, 2006, p. 186). The significance of this statement is that not everyone has the same options for having a healthy lifestyle.
Lifestyle factors are implicated as root factors in up to half of deaths in the United States (Edlin & Golanty, 2009). Deaths and chronic disease that compromise quality of life because of lifestyle factors can be prevented with changes in health habits. Chronic diseases and degenerative health conditions can be prevented or put off with changes in lifestyle. At the same time, it is important that lifestyle reflects socioeconomic and environmental circumstances such as diet, social isolation, lack of access, language barriers, and poverty. Action plans to help people take charge of their health and make a commitment to positive lifestyle changes must take into account the close relationship between individual factors and environmental supports in health promotion.
Ideally, building healthy lifestyles begins in childhood. As Frederick Douglass (Brainy Quotes, 2010) noted years ago, "It is easier to build strong children than to repair broken men." Pender, Murdaugh, and Parsons (2006) identified six principles for achieving a healthy lifestyle: eating well, staying active, getting adequate sleep, managing stress, building supportive relationships, and nurturing one's spirit. Comprehensive health promotion activities focused on individuals and their families, set within community, and larger ecosystem initiatives produce the best benefit, particularly when paired with social and resource support.
Resilience: **Resilience** is defined as "strength in the midst of change and stressful life events; the power of springing back or recovering readily from adversity" (Chapman, Lesch, & Aitken, 2005, p. 4). Resilience is a concept that helps explain why some people seem to weather adversity more easily than others and are able to grow from the experience. People can do this more easily when their stress is balanced with mechanisms to help them process it, and they acquire the skills they need to move forward with their lives (Schieveld, 2009). Psychosocial resilience is associated with self-efficacy, developing an organized way of coping with stressors, and the cultivation of a meaningful support system. A strong faith and sense of purpose also are factors (Freedman, 2008).
## National health promotion and disease prevention agendas
The Committee on Assuring the Health of the Public in the 21st Century (2003) has cited three major trends influencing health care in the United States:
1. Demographic changes with the "population growing larger, older, and more racially and ethnically diverse, with a higher incidence of chronic disease"
2. Technical and scientific advances, which "create new channels for information and communication, as well as novel ways of preventing and treating disease"
3. "Globalization and health, to include the geopolitical and economic challenge of globalization, including international terrorism" (pp. 34–41)
### Healthy people: national health promotion and disease prevention agendas
Each decade, the U.S. Department of Health and Human Services (HHS) publishes an updated health promotion and disease prevention agenda for the nation with specific national goals and objectives. _Healthy People_ 2010 (HHS, 2000) presents the health promotion and disease prevention agenda for the nation. The third document of its kind, _Healthy People 2010_ puts forth 28 focus areas with corresponding national health objectives designed to identify and reduce the most preventable threats to health. Federal agencies intimately involved with health care developed the document with input from more than 350 national membership organizations and 250 state health, mental health, substance abuse, and environmental agencies.
The overarching goals for Healthy People 2010 are to "achieve increased quality and years of healthy life and the elimination of health disparities" (U.S. Department of Health and Human Services, HHS, 2002). _Healthy People 2010_ provides strong support for the nation's move from a predominantly medical model of health care to a public health model. It incorporates the most relevant scientific expertise on health care as the basis for evaluating leading health indicators against outcome benchmarks for preventive health care. Each leading health indicator listed in Box 15-1 has associated objectives.
BOX 15-1 _Healthy People 2010:_ Leading Health Indicators
• Physical activity
• Overweight and obesity
• Tobacco use
• Substance abuse
• Responsible sexual behavior
• Mental health
• Injury and violence
• Environmental quality
• Immunization
• Access to health care
From U.S. Department of Health and Human Services: What are the leading health indicators? _Healthy People 2010;_ available online: <http://www.healthypeople.gov/LHI/lhiwhat.htm>. Accessed September 19, 2009.
_Healthy People 2020_ is conceptualized as continuing earlier Healthy People initiatives related to addressing environmental factors contributing to the health status of individuals and populations, with a stronger focus on action plans and strategies. The vision for _Healthy People 2020_ is to have "a society in which all people live long, healthy lives" (U.S. Department of Health and Human Services, HHS, 2010). Proposed overarching goals to achieve this vision include the following:
• Eliminate preventable disease, disability, injury, and premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote healthy development and healthy behaviors across every stage of life.
Action models, proposed to achieve these goals, will provide clear priorities for what needs to be done, with focused strategies for addressing each goal. Objectives are projected to be organized in three categories—interventions, determinants, and outcomes—rather than in specific focus areas. More information about recommendations for the framework and format for _Healthy People 2020_ is available online (www.healthypeople.gov/HP2020).
### Centers for disease control and prevention
Surveillance of health events is an important component of population-focused health promotion and disease prevention because it alerts health care providers to potential and actual health problems, and provides morbidity and mortality rates for evaluation purposes. The Centers for Disease Control and Prevention (CDC) is "the nation's premiere health promotion, prevention and preparedness agency and a global leader in public health" (CDC, 2006). It is the operational part of the HHS, which is directly responsible for protecting the health and safety of the nation's citizens and is committed to achieving improvement in people's health. As such, it is an important resource for health promotion activities.
The CDC collects data about the incidence and prevalence of diseases and chronic illnesses, and ranks illnesses that kill Americans. It tracks the development of new health problems and illnesses appearing in the United States and is recognized globally for its dedication to promoting people's health and well-being. This agency provides funding to states to implement health programs for Americans, and funding to developing countries related to prevention and treatment of AIDS. The CDC applies research findings to improve people's daily lives. State and municipal health departments receive support from the CDC to detect and reduce health threats from bioterrorism. The CDC has four health promotion impact goals:
• _Healthy people in every stage of life:_ All people, and especially those at greater risk for health disparities, will achieve their optimal life span with the best quality of life in every stage of life.
• _Healthy people in healthy places:_ The places where people live, work, learn, and play will protect and promote their health and safety, especially those at greater risk for health disparities.
• _People prepared for emerging health threats:_ People in all communities will be protected from infectious, occupational, environmental, and terrorist threats.
• _Healthy people in a healthy world:_ People around the world will live safer, healthier, and longer lives through health promotion, health security, and health diplomacy (CDC, n.d.).
In 2001, the Institute of Medicine (IOM) published a landmark report, _Crossing the Quality Chasm: A New Health System for the 21st Century,_ which identified six areas of focus for improvement of health care. The areas identified for health care improvement (Table 15-1) have relevance for preventive interventions. A second report in 2006 outlined recommendations to improve the quality of health care for mental and substance-use conditions (IOM, 2006).
TABLE 15-1
Institute of Medicine's Six Aims for Improvement of Health Care
Aim | Descriptor
---|---
Safe | Avoiding injuries to patients from the care that is intended to help them
Effective | Providing services based on scientific knowledge to all who could benefit and refraining from providing services for those not likely to benefit
Patient centered | Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions
Timely | Reducing waits and sometimes harmful delays for both those who receive and those who give care
Efficient | Avoiding waste, including waste of equipment, supplies, ideas, and energy
Equitable | Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
Source: Institute of Medicine: _Crossing the quality chasm: a new health system for the 21st century_ (p. 3), Washington, DC, 2001, Author.
## Theory frameworks for health promotion
Theory frameworks for health promotion focus on how people make choices and decisions about their health. Redman (2004) suggests that the health belief model, the transtheoretical model, and social learning theory are particularly relevant in health education for self-management of chronic diseases. This section presents three theoretical frameworks, each of which takes into consideration a person's beliefs about his or her ability to determine and influence health status and well-being.
### Pender's health promotion model
Pender's (2006) revised health promotion model expands on an earlier health belief model developed by Rosenstock and his associates in the 1950s. The health belief model proposed that a person's willingness to engage in health promotion behaviors is best understood through examining a person's beliefs about the seriousness of a health condition and his or her capacity to influence its outcome.
Nola Pender's revised health promotion model continues to include perceived benefits, barriers, and ability to take action related to health and well-being as important components of people's health decision making. Added to these prior considerations is an emphasis on personal factors, including interpersonal influences and situational pressures, that can sway a person's commitment to plan of action and health-promoting behaviors (Figure 15-2). Taken together, these dynamics act as internal or external "cues to action" influencing a person's decision to seek health care or to engage in health-promoting activities. Examples include required school immunizations; interpersonal reminders, such as a family member's experience with the health care system; the mass media; and ethnic approval. Using the health promotion model allows nurses to understand each person's combination of personal and behavioral variables as a consideration in choosing the best approach to engage a client in advancing health and well-being.
Figure 15-2 Health promotion model. (From Pender N: _Health promotion in nursing practice_ (p. 50), Upper Saddle River, NJ, 2006, Prentice Hall.)
Case Example
Mary Nolan knows that walking will help diminish her risk for developing osteoporosis, but the threat of having this problem in her 60s is not sufficient to motivate her to take action in her 40s. Mary does not feel any signs or symptoms of the disorder, and it is easier to maintain a sedentary lifestyle. The nurse will have to understand the client's internal value system and other factors that influence readiness to learn to create the most appropriate learning conditions and types of teaching strategies Mary will need to effect positive change in health habits. The nurse might show Mary a video of the changes osteoporosis creates in spinal structure or ask an older adult with this disease to share her experience.
Exercise 15-1 provides practice with applying Pender's health promotion model to common health problems.
EXERCISE 15-1 Pender's Health Promotion Model
Purpose:
To help students understand the value of the health promotion model in assessing and promoting healthy lifestyles.
Procedure:
1. Using the health promotion model as a guide, interview a person in the community about his or her perception of a common health problem (e.g., heart disease, high cholesterol, osteoporosis, breast or prostate cancer, obesity, or diabetes).
2. Record the person's answers in written diagram form following Pender's model of health promotion. Identify the behavior-specific cognitions and affect action that would best fit the person's situation.
3. Share your findings with your classmates, either in a small group of four to six students with a scribe to share common themes with the larger class or in the general class.
Discussion:
1. Were you surprised by anything the client said, his or her perception of the problem, or interpretation of its meaning?
2. As you compare your findings with other classmates, do common themes emerge?
3. How could you use the information you obtained from this exercise in future health care situations?
### Transtheoretical model of change
Prochaska's model provides a simple way to help identify the motivational readiness of people to engage in specific health-promoting behaviors (Daley, Fish, Frid, & Mitchell, 2009; Prochaska, DiClemente, & Norcross, 1992). The transtheoretical model of change recognizes the difficulty most people have with changing longstanding unhealthy lifestyle habits. Their model describes motivation to change as a state of readiness, which fluctuates and can be influenced by external encouragement (DiClemente, Schlundt, & Gemmell 2004). The model identifies five stages through which people make a decision to make an intentional behavioral change and carry through with implementation.
The transtheoretical model proposes that the client's intrinsic motivation is key to behavioral change and establishing preventive health behavior practices. Even people who are highly resistant to change can be motivated to change unhealthy behaviors. Assessment of the client's motivation, or lack thereof, is coupled with targeted interventions to match an individual's level of motivation or "readiness" to change the behavior. When motivational strategies match an individual's readiness, the likelihood that the client will follow a recommended course of action toward behavior change increases. The strategies challenge, support, and accept the client's readiness to change as the starting point for intervention.
The transtheoretical model is not a linear model. Clients can cycle through one or more of the stages several times before a permanent change takes place. Longstanding habits are hard to break. Setbacks and relapse with return to old behaviors can be expected, with an assumption that people will learn from the experience. Table 15-2 presents Prochaska's Model of Change with suggested approaches for each stage and corresponding sample statements.
TABLE 15-2
Prochaska's Stages of Change with Suggested Approaches and Sample Statements Applied to Alcoholism
Case Example
_Client:_ "I'm ready to go home now. I know once I get home, that I'll be able to get along without help. I've lived there all my life and I know my way around."
_Nurse:_ "I know that you think you can manage yourself at home. But most people need some rehabilitation after a stroke to help them regain their strength. If you go home now without the rehabilitation, you may be shortchanging yourself by not taking the time to develop the skills you need to be independent at home. Is that something important to you?" _(precontemplation approach to raise awareness of the problem)_
Exercise 15-2 provides an opportunity to work with the transtheoretical model in understanding learning readiness.
EXERCISE 15-2 Assessing Readiness Using Prochaska's Model
Purpose:
To identify elements in teaching that can promote readiness using Prochaska's Model.
Procedure:
Identify as many specific answers as possible to the following questions:
1. Patrick drinks four to six beers every evening. Last year he lost his job. He has a troubled marriage and few friends. Patrick does not consider himself an alcoholic and blames his chaotic marriage for his need to drink. There is a strong family history of alcoholism.
What kinds of information might help Patrick want to learn more about his condition?
2. Lily has just learned she has breast cancer. Although there is a good chance that surgery and chemotherapy will help her, she is scared to commit to the process and has even talked about taking her life.
What kinds of health teaching strategies and information might help Lily become ready to learn about her condition?
3. Shawn has just been diagnosed as having epilepsy. He is ashamed to tell his friends and teachers about his condition. Shawn is considering breaking up with his girlfriend because of his newly diagnosed illness.
How would you use health teaching to help Shawn cope more effectively with his illness?
### Motivational interviewing
Motivational interviewing (MI) is "theoretically congruent" with the transtheoretical model of behavior change (Goodwin, Bar, Reed & Ashford, 2009, p. 204). Originally conceptualized for use in the treatment of alcoholism, the MI framework is used with a growing range of chronic health conditions that are caused by or exacerbated by unhealthy lifestyle behaviors, for example, diabetes and obesity (Carels et al., 2007; Kirk, Mutrie, Macintyre, & Fisher, 2004).
MI is an evidenced-based treatment approach to helping clients address resistance or ambivalence about health-related lifestyle changes. Motivational learning represents an interactive process in which the clinician strives to learn about the client's goals, values, and concerns as they relate to consideration of targeted health behavior changes. Developed by Miller and Rollnick (2002), MI is part of a cooperative partnership between client and clinician characterized by "an active collaborative conversation and joint decision making process" (Rollnick, Miller, & Butler, 2008, p. 6). Strategies include listening carefully to the client's description of the problem and the client's ideas about how the problem might be resolved. This step is followed by mutually exploring the pros and cons of each proposed solution. It is important for the nurse to express empathy for the challenges faced by the client and to affirm the client's opinions and progress (Levensky, Forcehimes, O'Donohue, & Bietz, 2007).
A motivational framework to change unhealthy behaviors is based on a person's values, beliefs, and preferences and fits well with the current emphasis on client-centered health care (Miller, 2004; Sandelowski, DeVellis, & Campbell, 2008). The client and clinician form a collaborative relationship in which they are equal partners, each contributing a knowledge and expertise to the situation. The clinician provides guidance, knowledge, and support. The final decision is always the client's responsibility. A critical component of MI is an acceptance of the client's right to make the final decision and the need for the clinician to honor each client's right to do so.
### Social learning theory
Bandura's (1997) contribution to the study of health promotion is his concept of self-efficacy. He believed that _self-efficacy,_ described as a personal belief in one's ability to execute the actions required to achieve a goal, is a powerful mediator of behavior and behavioral change. Having self-confidence in one's ability to determine and implement actions has a direct influence on motivation and readiness to learn.
Self-efficacy and **motivation** are reciprocal processes; increased self-efficacy strengthens motivation, which, in turn, strengthens the client's capacity to complete the learning task. A person's perception of his her capability is a strong motivator even if it is not completely validated by the reality of the person's abilities. This is a critical concept because both clients and family caregivers may have reservations about their competence to carry out treatments in the home or make changes in lifestyle. Providing support at critical junctions can improve motivation and beliefs in one's ability to master essential tasks. Mastery is considered to be the strongest foundation of self-efficacy (Srof & Velsor-Friedrich, 2006).
Bandura considers learning to be a social process. He identified three sets of motivating factors that promote the learning necessary to achieve a predetermined goal: physical motivators, social incentives, and cognitive motivators. Physical motivators can be internal, such as memory of previous discomfort or a symptom that the client cannot ignore. Social incentives such as praise and encouragement increase self-esteem and give the client reason to continue learning.
Bandura refers to a third set of motivators as cognitive motivators, describing them as internal thought processes associated with change.
Case Example
Francis Edison agrees wholeheartedly with his nurse that smoking is bad and is likely to cause an earlier death from emphysema. However, in his mind, it is impossible for him even to contemplate giving up smoking. His mind-set precludes learning until he can see the connection between giving up cigarettes and avoiding painful symptoms. A severe bronchitis creating air hunger and a hacking cough finally convinces Francis to give up cigarettes.
Below, the nurse combines the concept of a physical motivator with a social incentive related to something the client values (his grandson). The intervention is designed to help Francis recognize how changes in his health behavior can not only improve his health and well-being but give him a social outlet that could be important to him.
_Nurse:_ I'm worried that you are continuing to smoke, because it does affect your breathing. There is nothing you can do about the damage to your lungs that is already there, but if you stop smoking it can help preserve the healthy tissue you still have _(physical motivator)_ and you won't have as much trouble breathing. I bet your grandson would appreciate it if you could breathe better and be able to play with him _(social incentive)._ As Francis notices that he is coughing less when he gives up smoking, this new perceptual knowledge can act as an internal _cognitive motivator_ to remain abstinent.
Developing an Evidence-Based Practice
Markle-Reid M, Weir R, Browne G, et al: Health promotion for frail older home care clients, _J Adv Nurs_ 54(3):381–395, 2006.
This experimental study was designed to evaluate the comparative effects and costs of a proactive health promotion intervention provided to frail, elderly, home care clients. The sample, with an 84% completion rate, was randomly assigned to a control group (N = 120) or the experimental group (N = 120), who received health promotion nursing care in addition to their normal home care. This health promotion strategy consisted of a health assessment combined with their regular home visits or telephone contacts, education about the management of their illness, coordination of community services, and the use of empowerment strategies to enhance their independence.
_Results:_ The frail elderly home care clients receiving the health promotion strategy in addition to their usual health care demonstrated significantly better mental health functioning, a reduction in depression, and enhanced perceptions of social support. Offering home-based health promotion activities can enhance the quality of life without increasing overall cost of services to homebound clients.
_Application to Your Clinical Practice:_ As a profession, nurses are providing more and more community services reflective of a public health model. The frail elderly are a population that is growing exponentially. Finding creative, cost-effective ways to promote health and independence for this population needs to be a goal of professional nursing. What are some ways you can think of to promote health and quality of life for homebound clients with chronic illnesses?
## Applications
Applying health promotion and disease prevention strategies
The American Association of Colleges of Nursing (2008) identifies health promotion and disease prevention at individual and population levels as an essential component of professional nursing practice. It can be integrated informally into everyday nursing care, and formally in client education and screening programs. Nurses can play an important role in health promotion and disease prevention regardless of whether they work in primary or hospital care settings.
Nurses have unique opportunities to include primary and secondary prevention strategies with clients during routine health maintenance examinations and routine treatment. In the 21st century, health promotion strategies should be a part of everyday nursing care (Beckford-Ball, 2006). All nurses can participate in health screenings and client education. Examples of individualized health promotion strategies include encouraging regular medical checkups, providing client education, and offering health screenings to promote health and prevent disease (Maltby & Robinson, 1998).
Health promotion instruction can focus on condition-specific topics, or they can emphasize general education about healthy lifestyles. Condition-specific activities might include anticipatory guidance, and coaching for new mothers and caregivers of clients with chronic illness. Secondary prevention strategies focus on lifestyle/rehabilitative planning and interventions for clients with chronic conditions such as cardiac disorders or diabetes.
General education strategies related to positive lifestyle habits would emphasize diet, physical activity, regular sleep patterns, and stress reduction. Exercise 15-3 provides an opportunity to develop your own personal health portfolio.
EXERCISE 15-3 Developing a Health Profile
Purpose:
To help students understand the relationship between lifestyle health assessment factors and related health goals from a personal perspective.
Procedure:
Out of class assignment:
1. Assess your own personal risk factors related to each of the following:
a. Family risk factors (diabetes, cardiac, cancer, osteoporosis)
b. Diet and nutrition
c. Exercise habits
d. Weight
e. Alcohol and drug use
f. Safe sex practices
g. Perceived level of stress
h. Health screening tests: cholesterol, blood pressure, blood sugar
2. Identify unhealthy behaviors or risk factors
3. Develop a personalized action plan, to identify strategies to address areas that need strengthening.
4. Identify any barriers that might prevent you from achieving your personal goals.
Discussion:
1. In small groups, discuss findings that you feel comfortable sharing with others.
2. Get input from others about ways to achieve health-related goals.
3. In the larger group, discuss how doing this exercise can inform your practice related to lifestyle changes and health promotion.
A wide variety of topics lend themselves to health promotion focus. A sampling includes the following:
• Alcohol, nicotine, and other drug abuse prevention
• Anger management
• Prevention and early detection of common chronic diseases such as diabetes, cancer, heart disease, osteoporosis, co-occurring disorders
• Behaviors needed for a healthy lifestyle
• Family issues related to communication and parenting
• Job stress and burnout prevention for informal caregivers and at work sites
• Coping with grief and crisis
#### Promoting health for individuals
MI emphasizes a person's capacity to take charge of their health and to master the lifestyle factors that interfere with optimal health and well-being. The communication process starts with establishing a collaborative relationship with a client and family before beginning to assess their readiness for change. You can use the stages of change identified in Table 15-2 to determine where you should start. Focusing on the family's beliefs and values about health behaviors allows nurses to ease into a dialogue in which clients explore the pros and cons of different behaviors. Open-ended questions that place health issues within the context of everyday life provide broader information about issues that otherwise might not be identified. For example, asking a client about exercise may yield a one-sentence answer. Asking the same client to describe his activity and exercise during a typical day, and what makes it easier or harder for him to exercise provides better data. Potential concerns about strategies that may not be consistent with values, preferences, or goals are more readily identified. Client-centered and family perspectives on disease and treatment are not necessarily the same as those of their health care providers.
Assessment of social and environmental supports is important. Because _perception_ of self-efficacy and competence influences a person's willingness to participate in health-promoting behaviors, the assistance and support that others can provide to enable client success is critical. With this information, nurses are able to tailor their interventions to the client's capacity to change. Although initially an MI approach may take a little longer, it is likely to be more effective because the client chooses actions with personal meaning and will be more committed to it.
Nurturing the development of self-efficacy helps people to feel more confident. Opportunities for shared decision making and learning self-management skills empower clients to take an active role in treatment and health promotion activities (Hoving et al., 2010). Nurses empower clients and families through provision of accurate, timely information, coaching supports, and targeted links to health screening and community services. Educational and referral supports enable clients and families to learn the skills they need to effectively manage chronic conditions and to live a healthy lifestyle. Helping people use technology to find information and resources is another form of encouraging clients to take charge of their health and well-being.
Gance-Cleveland (2007) suggests setting an agenda with clients as a way of determining what is most important to clients and what they are willing to change. Effective health promotion activities perceived as being relevant are more likely to produce positive results. Tailoring instruction and coaching to the needs, abilities, and characteristics of the client and/or target population is important.
Timing is important for full effectiveness. For example, providing pregnant mothers with a tour of the obstetrics (OB) unit and providing information before admission is more effective than providing it after admission.
Working with Disparities: Although disparities refer to differences in health across ethnic groups, gender, education, or income, the term usually is associated with inequalities in access, service use, and health outcomes. Although major advances in health care have occurred since the beginning of the 21st century these developments have not benefited target health populations equally (Kline & Huff, 2008, p. 180),
People with the greatest health burdens often have the least access to information, communication technologies, health care, and supporting social services. For example, people living in extreme poverty may not have access to preventive care, adequate nutrition, or the opportunity to live in a healthy environment, because of finances. They may not even think about it because they are at the survival level. Noting environmental deficits in the client's environment that are beyond individual control can help you tailor meaningful health promotion supports.
Case Example
Michelle is a nurse practitioner in an inner city pediatric clinic. After examining a child with strep throat, she prescribed an antibiotic for her. She instructed the mother to give the child the medication four times a day, and to store it in the refrigerator between doses. She asked the mother if she had any questions or concerns, and the mother indicated she did not have any. But as the mother and child were leaving the exam room, the mother turned to the nurse practitioner and said, "You know, we don't have a refrigerator. Will anything happen if I don't refrigerate the antibiotic?" If you were the nurse in this situation, how would you respond to this client? What supports would you suggest?
Health promotion and disease prevention strategies help people to recognize health problems and support them in choosing the most effective ways to self-manage their symptoms in the community. In many instances, clients presenting with physical complaints in primary care have an underlying mental disorder or substance abuse problem. Making it a practice to assess for mental problems and co-occurring disorders during intake with a few well-placed questions can help detect mental health issues or negative substance use.
Nurses use one-to-one counseling and community-based group education formats to meet educational health care objectives related to health promotion and maintenance of health, prevention of illness, restoration of health, coping with impaired functioning, and rehabilitation.
## Health promotion strategies at the community level
At the community level, nurses help locate populations at risk for health problems. They can use casefinding strategies to recognize individuals and families with identified risk factors and to connect them with needed supports, resources, and services. Uncovering unhealthy physical and social environments or living circumstances can start within the formal health system during intake, or informally through liaisons with the justice system and schools.
Nurses can help design and provide health education, social marketing, and screening services to targeted populations with unrecognized health risk factors. They can instruct targeted populations about the nature of an illness, disability, or unhealthy environment, and the use of their medications. Nurses can identify what community supports are available, and/or how services can be obtained and how to access them. Examples include drug prevention and teenage pregnancy prevention programs, plus one-on-one coaching with step-by-step instructions on how to access critical supports.
### Community-based health promotion strategies
Although health promotion strategies at the individual level are associated with improved health and well-being, health promotion is also a community concept. It is difficult to change attitudes and lifestyles to promote health when a client's social environment does not support these changes. Reducing generic environmental risks to maintaining health and well-being requires a community approach to health promotion.
_Community_ is defined as "any group of citizens that have either a geographic, population-based, or self-defined relationship and whose health may be improved by a health promotion approach" (Frankish et al., 2006, p. 174). Equity and empowerment related to health care are the expected outcome of health promotion activities at the community level. Equity corresponds to the WHO directive that all people should have an equal opportunity to enjoy good health and well-being.
Empowerment at the community level recognizes the need for citizen participation in improving and promoting health. Community empowerment "seeks to enhance a community's ability to identify, mobilize, and address the issues that it faces to improve the overall health of the community (Yoo, Weed, & Lempa, 2004, p. 256).
Unless the community as a whole can collectively challenge and eradicate inequities in health care access and treatment provision, health promotion activities will fall short of their targeted goals (Messias, De Jong, & McLoughlin, 2005). Health promotion activities use a proactive approach to capture the attention of people who otherwise might not be predisposed to taking charge of their health and/or may not know that they are at risk.
Grass roots health promotion activities provided for "at-risk" populations are a community resource designed to influence personal lifestyle choices, coping skills, and health behaviors. They are designed to engage those people who are most involved with a common environmental concern related to health as active participants. Key health issues in economically disadvantaged communities often are those with social roots such as violence or abuse, substance abuse, teen pregnancies, and AIDS (Blumenthal, 2009). Socioenvironmental factors that affect health include income, education, health insurance, cultural health practices, social support, and accessibility of health services.
Successful health promotion programs require individuals, groups, and organizations to act as active agents in shaping health practices and policies that have meaning to the target population. Community-based health promotion activities must be grounded in a community analysis of health issues of concern, as identified by the community itself. They must begin with an engagement and buy-in of the community in which the activity is to take place. WHO notes that health promotion activities should be "carried out by and with people, not on, or to people" (Jakarta Declaration; WHO 1997). Active participation of individuals, communities, and systems means a stronger and more authentic commitment to the establishment of realistic regulatory, organizational, and sociopolitical supports needed to achieve targeted health outcomes (Kline & Huff, 2008).
### Using the precede-proceed model in community education
Community education is an important component of health promotion and disease prevention. The precede-proceed community-based health education model that Green and Kreuter (2005) developed is based on two fundamental assumptions: (1) health and health risks are multidetermined, and (2) health teaching must be multidimensional and participatory to be effective.
The PRECEDE component of the health education model refers to the assessment and planning components of program planning. The acronym PRECEDE stands for Predisposing, Reinforcing, Enabling Causes in Educational Diagnosis and Evaluation factors associated with the targeted problem area. Examples of these diagnostic behavioral factors are presented in Table 15-3. Careful assessment of these factors provides direction for the type of program and content most likely to engage the interest of diverse learners in community-based settings. The PRECEDE assessment takes place as a part of the planning process before the educational program is offered. Nurses also determine population needs and establish evaluation methods before implementation. Evaluation is a continuous process that begins when the program is implemented, and is exercised throughout the educational experience.
TABLE 15-3
PRECEDE-PROCEED Model: Examples of PRECEDE Diagnostic Behavioral Factors
Factors | Examples
---|---
Predisposing factors | Previous experience, knowledge, beliefs, and values that can affect the teaching process (e.g., culture and prior learning)
Enabling factors | Environmental factors that facilitate or present obstacles to change (e.g., transportation, scheduling, and availability of follow-up)
Reinforcing factors | Perceived positive or negative effects of adopting the new learned behaviors, including social support (e.g., family support, risk for recurrence, and avoidance of a health risk)
The PROCEED component (Policy, Regulatory, Organizational Constructs in Educational and Environmental Development) was added to the model by Green in the late 1980s. He realized that any viable educational model needed political, managerial, and administrative supports for full implementation of a community-based approach to health promotion and disease prevention. The utility of including the PROCEED component is that it explicitly considers critical environmental and cost variables such as budget, personnel, and critical organizational relationships as part of the planning process. Having the resources in place and assessing their sustainability is important in health promotion planning, though it is not always thought through in the planning phase. Bernard (2006) also observes that, because health promotion and disease prevention activities do not generate the same level of revenue, they may not be as sustainable when resources become tight. Nurses can play an important role in advocating for public policies supporting sustainable access to appropriate health resources. The full PRECEDE-PROCEED model is presented in Table 15-4. Exercise 15-4 provides an opportunity to think about community health problems that could be addressed with the PRECEDE-PROCEED model in planning appropriate health promotion interventions.
EXERCISE 15-4 Analyzing Community Health Problems for Health Promotion Interventions
Purpose:
To develop an appreciation for the multidimensional elements of a community health problem.
Procedure:
In small groups of four to six students, brainstorm about health problems you believe exist in your community and develop a consensus about one public health problem that the group would prioritize as being most important.
Use the following questions to direct your thinking about developing health promotion activities for a health-related problem in your community.
What are the most pressing health problems in your community?
What are the underlying causes or contributing factors to this problem?
In what ways does the selected problem impact the health and well-being of the larger community?
What is the population of interest you would need to target for intervention?
What types of additional information would you need to have to propose a solution?
Who are the stakeholders, and how should they be involved?
What step would you recommend as an initial response to this health problem?
What is one step the nurse could take to increase awareness of this problem as a health promotion issue?
Discussion:
How hard was it for your group to arrive at a consensus about the most pressing problem? Were you surprised with any of the discussion that took place about this health problem? How could you use what you learned in doing this exercise in your nursing practice?
TABLE 15-4
PRECEDE-PROCEED Model Definitions
Adapted from Green L, Kreuter M: _Health program planning: an educational and ecological approach,_ ed 4, New York, 2005, McGraw Hill.
## Learner variables in education for health promotion
Pender's health promotion model serves as a guide for planning successful education with individuals and targeted high-risk groups. A person's capacity to absorb and use health promotion information depends to a large degree on what the person believes about his or her health, and the extent to which personal actions will influence their health. Nurses can use the health belief model to focus on behaviors that have the greatest potential to meet specific health needs. Examples of health promotion education topics can relate to sexual health; developing a healthy lifestyle through eating well, physical activity, and stress reduction; organizational wellness; parenting skills; and anger management.
Guidelines proposed by the U.S. Preventive Services Task Force for health-promoting education and counseling are presented in Box 15-2. As with all types of education and counseling, learners need to be actively engaged in goal setting and developing action plans that have meaning to them. Choosing the right strategies requires special attention to the learner's readiness, capabilities, and skills (see Chapter 16).
BOX 15-2 Strategies in Health Education and Counseling: Recommendations of the U.S. Preventive Services Task Force
• Frame the teaching to match the client's perceptions.
• Fully inform clients of the purposes and expected outcomes of interventions, and when to expect these new effects.
• Suggest small changes and baby steps rather than large ones.
• Be specific.
• Add new behaviors rather than eliminating established behaviors whenever possible.
• Link new behaviors to old behaviors.
• Obtain explicit commitments from the client and client family support regarding actions.
• Refer clients to appropriate community resources.
• Use a combination of strategies to achieve outcomes.
• Monitor progress through follow-up contact.
Adapted from: U.S. Preventive Services Task Force: Guide to Clinical Preventive Services, 2nd ed. Baltimore: 1996, Williams and Wilkins, p. lxxvii-lxxx.
Ochieng (2006) contends that socioeconomic factors, level of education, age, and social networks are important contributors to understanding client preferences and working with clients to enable them to make the changes needed for a healthy lifestyle.
Clients requiring the same education program may demonstrate a wide range of learning, cognitive, experiential, and communication diversity, which may require adaption to maximize learning. Clients also will differ in their intellectual curiosity, learning preferences, motivation for learning, learning styles, and rate of learning.
Teaching and counseling initiatives related to health promotion need to be safe, timely, effective, client centered, equitable, and efficient. Health promotion programs should be designed to empower clients through an emphasis on the active role of the client as a stakeholder and inclusion in all aspects of the health promotion process.
Education and counseling for health promotion can include information on risk factors or behaviors impacting on health and ways to address negative social, economic, and environmental determinants of health. A health promotion format considers a person's personal values and beliefs about his or her ability to achieve health behavior changes (self-efficacy) as part of client assessment.
Evaluation of health promotion activities is essential. In addition to evaluating immediate program effects, longitudinal evaluation of the impact of health promotion activities on morbidity, mortality, and quality of life is desirable. Keep in mind that what constitutes quality of life is a subjective reality for each client and may differ from person to person (Fagerlind et al., 2010).
### Empowerment strategies
There seems to be little question of a "direct relationship between an individual's level of health and the amount of perceived control the individual has in life situations" (Sheinfeld-Gorin & Arnold, 2006, p. 135). Empowering people to take the initiative with their own health and well-being is the cornerstone of health promotion and disease prevention strategies.
Information to empower clients in learning about healthy lifestyles, treatment, and potential side effects is readily available through the Internet (Coward, 2006). For many illnesses and health problems, clients and families can find specific information, regardless of the stage of their illness. Online support groups, chat rooms, and sharing of patient and family stories provide additional social support and practical learning tips for people who live in areas that are not geographically convenient to person-to-person contact. In the community, support groups are available for a wide variety of diagnoses. If the client or family does not use the Internet, flyers, fact sheets, and direct dialogue with opportunity for questions and follow-up can be helpful.
Active involvement of the learner enhances learning. Most people learn best when they engage more than one sense in the learning process and have an opportunity to practice essential skills. A highly participatory learning format, one that encourages different ways of thinking and opportunities to try out new behaviors, is far more effective than giving simple instructions to a client or family, or demonstration without teach back feedback (Willison, Mitmaker, & Andrews, 2005).
Case Example
Soon Mrs. Hixon began learning how to dress herself. At first she took an hour to complete this task. But with guidance and practice, she eventually dressed herself in 25 minutes. Even so, I practically had to sit on my hands as I watched her struggle. I could have done it so much faster for her, but she had to learn, and I had to let her (Collier, 1992, p. 63).
Strategies should demonstrate a sensitive appraisal and choice of targeted strategies, matched to the relevant needs of the individual, family, or group. When time is short, you will need to focus on the health teaching that addresses the most pressing of health needs. Many of the teaching learning strategies presented in Chapter 16 can be used or modified for health promotion health teaching. Exercise 15-5 provides an opportunity to use Maslow's theory in structuring health promotion activities.
EXERCISE 15-5 Applying Maslow's Theory to Learning Readiness
Purpose:
To develop skill in facilitating learning readiness.
Procedure:
Students will break into four groups and receive a case scenario that depicts a client learning need. Using Maslow's hierarchy of needs, prioritize the client's needs and plan your teaching approach based on the client's current level. Include in your plan the supportive measures that would be necessary to foster readiness to learn.
Discussion:
Each group will present their case and plan. Discuss how the use of Maslow's hierarchy can be effective in addressing learning needs and determining nursing approach. Discuss factors that contribute to resistance to learning and noncompliance. Discuss the supportive measures that nurses must include as part of the learning process with clients.
#### Community Empowerment
Social and political action to enhance health services can augment educational efforts using a PRECEDE-PROCEED framework at the community level. Community empowerment strategies are used to help identify and address environmental and social issues needed to improve the overall health of the community.
Empowerment at the community level is sometimes referred to as "capacity building." Community-focused empowerment strategies build on the personal strengths, community resources, and problem-solving capabilities already existing in individuals and communities that can be used to address potential and actual health problems (Leddy, 2005). Capacity building requires the inclusion of informal and formal community leaders as valued stakeholders. Networking, partnering, and creating joint ventures with indigenous and local religious infrastructures is a powerful consensus building strategy needed for effective health promotional education planning and implementation. Box 15-3 outlines a process for engaging the community in health promotion activities.
BOX 15-3 Guiding Principles for Community Engagement
Before starting a community engagement effort:
• Be clear about the purposes or goals of the engagement effort and the populations and/or communities you want to engage.
• Become knowledgeable about the community in terms of its economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts. Learn about the community's perceptions of those initiating the engagement activities.
For engagement to occur, it is necessary to:
• Go into the community, establish relationships, build trust, work with the formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community.
• Remember and accept that community self-determination is the responsibility and right of all people who make up a community. No external entity should assume it can bestow to a community the power to act in its own self-interest.
For engagement to succeed:
• Partnering with the community is necessary to create change and improve health.
• All aspects of community engagement must recognize and respect community diversity. Awareness of the various cultures of a community and other factors of diversity must be paramount in designing and implementing community engagement approaches.
• Community engagement can be sustained only by identifying and mobilizing community assets, and by developing capacities and resources for community health decisions and action.
• An engaging organization or individual change agent must be prepared to release control of actions or interventions to the community, and be flexible enough to meet the changing needs of the community.
• Community collaboration requires long-term commitment by the engaging organization and its partners.
From CDC/ATSDR Committee on Community Engagement: _Principles of community engagement,_ Atlanta, 1997, Centers for Disease Control and Prevention Program Office; available online: <http://www.cdc.gov/phppo/pce/part3.htm>. Accessed, July 28, 2010.
#### Health Literacy
Parker, Ratzan, and Lurie (2003) define **health literacy** as "the degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (p. 194). Approximately 21% of U.S. adults would be classified as functionally illiterate, which means they read at or below a ninth grade level and would have trouble comprehending written instructions on medication bottles, negotiating the health care system, and fully understanding consent forms (Davis et al., 1998). Health literacy can be further compromised with visual or auditory impairment, or diminished mental alertness, acute illness, limited education, and cultural differences. Health literacy is more than the capacity to read. It also includes medical knowledge, system navigational skills and initiative (Dewalt & Pignone, 2005).
Low health literacy is associated with medication nonadherence, increased incidence of side effects, and inadequate understanding of the impact of a medication on health outcomes (Ownby, 2006). People with inadequate health literacy tend to have worse health status, and functional physical and mental health. They also are less likely to seek preventive health care (Baker et al., 2002; Cutilli, 2007).
Low health literacy is not the same as having below average intelligence. People with inadequate health literacy may be highly intelligent, but functionally unable to fully grasp medical terminology. People with English as a second language can exhibit a much lower level of functional health literacy that is directly attributable to language limitations. Others demonstrate a lower level of functional literacy related to limited education or learning disabilities.
A persistent stigma about low literacy and learning disabilities exists even though it is unfounded. For this reason, many people try to hide the fact that they cannot read or do not know the meaning of complex words. They feel ashamed, so they fake their inability to understand by appearing to agree with the nurse educator, by saying they will read the instructions later, or by not asking questions. Functional illiteracy influences the type of questions a client might ask of a health professional and the adequacy of their descriptions about their illness or disability. Some of the problems clients with low literacy skills have in accessing health information include the following:
• Taking instructions literally
• Having a limited ability to generalize information to new situations
• Decoding one word at a time rather than reading a passage as a whole
• Skipping over uncommon or hard words
• Thinking in individual rather than categorical terms (Doak, Doak, & Root, 1996)
Educationally disadvantaged or functionally illiterate people are interested in learning, but nurses should adapt teaching situations to accommodate literacy learning differences. Marks (2009) suggests having written materials modified to six- to eighth-grade reading levels, and providing lists of key instructions for use after visits.
Using symbols and images with which the client is familiar helps overcome the barriers of low literacy. Taking the time to understand the client's use of words and phrases provides the nurse with concrete words and ideas that can be used as building blocks in helping the client understand difficult health-related concepts. Otherwise, the client may misunderstand what the nurse is saying.
Case Example
The discharge nurse said to a new mother, "Now you know to watch the baby's stools to be sure they're normal. You do know what normal stools look like, don't you?" The mother replied, "Oh, yeah, sure...I've got four of them in my kitchen" (Doak, Doak, & Root, 1985).
Safeer and Keenan (2005) suggest that clients can understand medical information better when a small amount of information is presented slowly, in easily understood everyday words. . Box 15-4 identifies guidelines for teaching low-literacy clients. Nurses should keep instructions as simple as possible, presenting ideas in an uncomplicated, step-by-step format. Advance organizers help low-literacy clients remember important concepts (see Chapter 16). Familiar words supplemented by common related pictures provide an extrasensory input for the client and improve retention. Drawings, diagrams, and photographs provide additional cues, allowing the client to understand meanings he or she would be unable to grasp through words alone.
BOX 15-4 Guidelines for Teaching Low-Literacy Clients
• Teach the smallest amount necessary to do the job for each session.
• Sequence key behavior information first.
• Use common concrete words and short sentences
• Make your point as vividly as you can (e.g., use visual aids and examples for emphasis).
• Incorporate as many senses as possible in the learning process.
• Break complex tasks into smaller sub-tasks that the client will find easy to achieve.
• Include interaction; have the client restate and demonstrate the information.
• Review repeatedly.
Adapted from Doak CC, Doak LG, Root JH, editors: _Teaching patients with low literacy skills,_ ed 2, Philadelphia, 1996, JB Lippincott.
Use common concrete words rather than abstract or medical terminology and examples, for example, "Call the doctor on Monday if you still have pain or swelling in your knee." In addition to using simple words and literal interpretations, the nurse should use the same words to describe the same thing. For example, if you use "insulin" in one instance and "medicine" or "drug" later to describe the same medication, the client may become confused. The same instructions, written exactly as they were spoken, act as a reminder once the person leaves the actual teaching situation.
Sequence the content logically beginning with a core concept. Remember that the client with low health literacy may not be able to read or interpret the label instructions on the bottle. You can use the following question sequence to teach a client about taking a new medication.
• What do I take?
• How much do I take?
• When do I take it?
• What will it do for me?
• What do I do if I get a side effect?
Apply simple concrete common words such as "You should take your medicine with your meals," or "Call your doctor if you have stomach pain." Teach a little at a time. Select small, related pieces of data and structure them into informational chunks so that the client can remember the information through association, even if one fact is forgotten.
Whenever possible, link new information and tasks with what the client already knows. This strategy builds on previous knowledge and reinforces self-efficacy in mastering new concepts. Keeping sentences short and precise, and using active verbs helps clients understand what is being taught. When technical words are necessary for clients to communicate about their condition with other health professionals, clients may need direct instruction or coaching about appropriate words to use. Table 15-5 presents core constructs of health literacy.
TABLE 15-5
Core Constructs of Health Literacy
I. Basic Literacy or Comprehension | Reading information, appointment cards
---|---
| Interpreting medical tests, dosages, and instructions, side effects, contraindications
| Understanding brochures, medication labels, informed consent, insurance documents
II. Interactive and Participatory Literacy (able to engage in two way Interactions) | Provision of appropriate and usable information Comprehension and ability to carry out information Mutual decision making Remembering and carrying out information
III. Critical literacy | Ability to weigh critical scientific facts Capacity to assess competing treatment options
Adapted from Marks R: Ethics and patient education: Health literacy and cultural dilemmas, _Health Promot Pract_ 10(3):328–332, 2009.
#### Developmental Level
Developmental level affects both teaching strategies and subject content. You will find that clients are at all levels of the learning spectrum with regard to their social, emotional, and cognitive development. Developmental learning capacity is not always age related. It is easily influenced by culture and stress. Social and emotional development does not always parallel cognitive maturity. Mirroring the client's communication style and framing messages that reflect developmental characteristics helps improve comprehension and understanding. Parents can provide useful information about their child's immediate life experiences and commonly used words to incorporate in health teaching.
#### Culture
Culture adds to the complexity of health promotion strategies in health care. Values, norms, and beliefs are an integral part of a person and heavily influence collective community lifestyles (See Chapter 11). Culture helps explain assumptions about health and illness, the causes of and treatments for different types of illnesses, and traditionally accepted health actions or practices to prevent or treat illness. Incorporating health-related cultural beliefs in health teaching promotes better acceptance.
In many cultures, the family assumes a primary role in the care of the client even when the client is physically and emotionally capable of self-care. All parties needing information, especially those expected to support the learning process of the client, should be included from the outset in all aspects of health teaching for health promotion. "Empowering ethnocultural communities through informal care may be the most culturally appropriate approach for improving the health status of ethnocultural populations" (Chiu, Balneaves, & Barroetavena 2006, p. 3)
Client motivation and participation increase with the use of indigenous teachers and cultural recognition of learning needs. If health literacy is related to language, qualified interpreters should be used for translation and preparation of written materials.
The culturally sensitive nurse develops knowledge of the preferred communication style of different cultural groups and uses this knowledge in choosing teaching strategies. For example, Native Americans like stories. Their tradition of telling stories orally is a primary means of teaching that the nurse can use as a teaching methodology for health promotion purposes.
#### Self-Awareness
Nurses have an ethical and legal responsibility in health teaching to maintain the appropriate expertise and interpersonal sensitivity to client needs required for effective learning. It is easy enough to remain engaged and to provide interesting teaching formats for the self-directed, highly motivated learner. It takes much more energy and imagination to impart hope to clients and to stimulate their emotions and interest when they see little reason to participate in learning about lifestyle changes and self-care management. Although the nurse is responsible for the quality of health teaching, only the client can assure the outcome. At all times, the nurse respects the client's autonomy. Some clients want symptom relief, whereas others want more in-depth teaching. Nurses have an ethical responsibility to provide appropriate health teaching and the right to hope that if the information is not used now, perhaps later it will be.
## Summary
This chapter focuses on health promotion as the basis for health education that can be applied at all practice levels. The WHO describes health promotion as a process of enabling people to increase control over and improve their health. Optimal health and well-being are considered the desired outcomes of health promotion activities. A health promotion/disease prevention focus views the client as an informed consumer and a valued partner in health care. Theory models relevant to health promotion include Pender's health promotion model, Prochaska's transtheoretical model, Miller's MI, and Bandura's social learning theory.
Learner variables important to the success of health promotion activities can be categorized as readiness to learn and ability to learn. Physical factors, level of anxiety, level of social support, active involvement of the learner, and inclusion of family members are identified as elements of readiness to learn. Lack of appropriate supports, physical barriers, health literacy, culture, and developmental status are factors that may influence the client's ability to learn.
Nurses participate routinely in community health promotion and disease prevention activities. They have an ethical and legal responsibility in health teaching to maintain the appropriate expertise and interpersonal sensitivity to client needs required for effective learning.
Ethical Dilemma
What Would You Do?
Jack Marks is a 16-year-old boy who comes to the clinic complaining of symptoms of a sexually transmitted disease (STD). He receives antibiotics, and you give him information about safe sex and preventing STDs. Two months later, he returns to the clinic with similar symptoms. It is clear that he has not followed instructions and has no intention of doing so. He tells you he's a regular jock and just can't get used to the idea of condoms. He really can't tell you the names of his partners—there are just too many of them. What are your ethical responsibilities as his nurse in caring for Jack?
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CHAPTER 16
# Health Teaching in the Nurse-Client Relationship
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define health teaching and client education.
2 Identify the domains of learning.
3 Discuss theoretical frameworks used in client-centered health teaching.
4 Apply the nursing process in health teaching.
5 Discuss health teaching applications in different settings.
6 Describe applications in different care settings.
This chapter focuses on specialized communication strategies for health teaching and client education. The chapter explores theories of teaching and learning as the basis for effective health teaching and client education. It describes instructional principles and strategies that nurses can use with clients and families to help them make sound judgments about their health, learn technical skills needed to self-manage chronic illness, and work effectively with community resources to maximize health and well-being.
## Basic concepts
Definitions
Taylor, Lillis, and Lemone (2005) define teaching as "a planned method or series of methods used to help someone learn" (p. 477). **Health teaching** is a specialized form of teaching, defined as a focused, creative, interpersonal nursing intervention in which the nurse provides information, emotional support, and health-related skills training. Although health teaching has many definitions, most do not address the complexity of the teaching process in health care (Wellard, Turner, & Bethune, 1998). For example, the "learner" in a health care setting can be a client, the client's family, a caregiver, or a community. Whereas other teaching situations instruct learners having a similar level of education and knowledge, health-teaching formats must be designed to meet the diverse learning needs of individuals from different socioeconomic, educational, and experiential backgrounds. A highly educated client, a noncompliant client, and a low-literacy client with the same medical condition have similar content requirements for health teaching but may demonstrate very different learning needs.
Masters (2008) describes **client (patient) education** as a set of planned educational activities, resulting in changes in health-related behaviors and attitudes, as well as knowledge. Health teaching is a highly participatory process involving multilevel interventions, linked by a common goal of maximizing client health and well-being. Specific teaching strategies, the type of involvement of others, and the level of content will necessarily reflect each client's unique learning needs.
### Contemporary contexts of health teaching
The context of health teaching shapes how knowledge is constructed and delivered. Although health teaching has always been an integral part of the nurse-client relationship, it is even more prominent in a managed-care health care delivery system with mandated limitations on time and resources (Greiner & Valiga, 1998). Nurses carry larger caseloads and generally have less time to spend with their clients. They must help clients achieve favorable health outcomes with fewer visits. This requires a stronger emphasis on helping clients to develop critical thinking skills, and encouragement of greater client responsibility for the self-care management of complex health problems. The realities of a managed health care environment requires a practical approach to health teaching with additional opportunities for critical questions specifically related to the situation.
An evolving paradigm shift in health care delivery from a medical hospital-based model of health care to a community-based, public health emphasis creates new learning conditions and challenges. Today's health care requirements mandate a broader content base for health teaching that includes primary prevention and quality-of-life issues (Ragland, 1997). Structured learning situations have yielded to a dynamic context-based format for health teaching, with a greater emphasis on the coaching components of health care teaching. Short, clear instructions, coupled with reflective prompts to elicit client feedback, create critical thinking opportunities.
Opportunities for health teaching occur can anywhere, for example, in the community, schools, parish nursing, the home, the hospital, and in clinics. Health teaching can be formal or informal. Ideally, it is a continuous process beginning in the community and extending across health care settings and systems. Even emergency departments provide opportunities for "teachable moments" for clients (Szpiro, Harrison, Van Den Kerkhof, & Lougheed, 2008).
Health teaching can take place under less-than-ideal circumstances. For many clients, the hospital or medical office is an anxiety-producing environment in which only part of what is said gets heard. Time constraints can limit the amount of material that can be covered in an individual session. Follow-up instructions or contacts, and written backup materials are useful adjuncts to onsite teaching. Physical and/or mental symptoms, difficulty with concentration or memory, and hearing and vision loss can further compromise the ability of a client to receive or process information. Health teaching can occur during home visits as the nurse observes clients having specific difficulties with aspects of health care. Referred to as guided care, this type of on the spot health teaching is targeted to specific health issues as they appear (Doherty, 2009).
Health teaching formats range from informal one-to-one relationships, formal structured group sessions, and family conferences. The media provides health teaching guidelines related to primary prevention (e.g., safe sex and drug abuse prevention commercials) to targeted community groups.
Technology is rewriting virtually every form of education. Advances have expanded the depth and breadth of health information available to the health consumer and are an important resource for nurses. Telehealth formats work by telecasting health information through video or interactive computers. This type of health teaching is becoming increasingly important in rural areas, where distance precludes onsite nursing health teaching and support.
The Internet provides instant health information, with a wide range of learning resources to accommodate different levels of knowledge and learning styles. People can also learn from the experience of others with similar health conditions through chat rooms and blogs.
Information on the Internet is searchable, up to date, inexpensive to obtain, and accessible at any time of day. For example, the American Diabetes Association and the American Cancer Society have online tools to help clients understand their disease and related treatment options. Although the Internet is a powerful learning tool, it has limitations as an accurate information resource. Not all information is relevant or credible. Helping clients to interpret content as it applies to their health situation and to differentiate appropriate information from misinformation is a vital component of health teaching using this instructional modality.
### Professional, legal, and ethical mandates
Health teaching is not an option. It is a legal and ethical responsibility. The Joint Commission has established educational standards _requiring_ health care agencies to provide systematic health education and training for clients that is:
• Specific to the client's needs
• Sufficient for clients to make informed decisions and to take responsibility for self-management activities related to their needs
• Provided to clients in an understandable manner, and designed to accommodate various learning styles
• Reflected in documented evidence of the client's understanding and response to the medical information
Professional nursing standards, developed by the American Nurses Association (ANA), reinforce the importance of health teaching as an essential nursing intervention (ANA, 2004). State Nurse Practice Acts mandate health teaching as an independent professional nursing function. Medicare requirements portray health teaching as a skilled nursing intervention for reimbursement purposes. The ANA Credentialing Center's Magnet Recognition Program (2005) devotes an entire section to the role of the nurse related to client education. Educating clients about their health conditions and treatment options is a legal and ethical responsibility of the nurse related to informed consent.
## Domains of learning
Health teaching is a dynamic process that involves making relevant connections to meaning within three domains initially described by Benjamin Bloom as _cognitive_ (understanding content), _affective_ (changing attitudes and promoting acceptance), and _psychomotor_ (hands-on skill development). The domains are interrelated. When people learn about and practice a skill, they also develop "cognitive knowledge" about the factors that contribute to its success. As they become more proficient in performing a skill, people accept and value the skill and knowledge. Bloom's taxonomy describes a hierarchy of learning objectives ranging from the least to the most complex that are applicable to learning in each domain.
The **cognitive domain** is the focus when the client has a knowledge deficit. For example, objectives in the cognitive domain for a client with a recent diagnosis of diabetes would include understanding the disease; the role of diet, exercise, and insulin in diabetic control; and trouble signs that would require immediate attention. Learning outcomes would consist of having a basic understanding of the disease process and treatment protocols, and being able to apply new information to meet personal health needs. A certain level of cognitive knowledge is an essential pre-requisite for learning in the affective and psychomotor domains.
The information clients and families need related to informed consent falls into the cognitive domain. **Cognitive learning** formats allow for clarification of information and correction of misinformation that may have been received from other providers, family, friends, or the Internet.
Appealing to the cognitive domain, the nurse would provide concrete explicit information verbally, in writing, and/or with related pictures to explain the desired outcome and steps needed to achieve it. . Avoid the use of general abstract terms. "You must lose 7 pounds" is better that "you must lose weight" (Redman, 2007, p. 14).
Bloom's levels of knowledge acquisition (in ascending order) were revised in the 21st century to represent verbs rather than nouns. The hierarchy of synthesis and evaluation was reversed. The revised Bloom's taxonomy for the cognitive domain now consists of:
• Knowledge Remembering: recognizing, recalling information and facts
• Comprehension Understanding: interpreting, explaining, or constructing meaning
• Application Applying: carrying out or executing a procedure; using information in a new way
• Analysis Analyzing: considering constituent parts and how they relate to each other, and the whole
• Evaluation Evaluating: making judgments, critiquing, prioritizing, selecting, verifying
• Synthesis Creating: putting material together in a coherent whole, reorganizing material into a new pattern, creating something new (Anderson & Krathwohl, 2001)
The **affective domain** is concerned with emotional attitudes related to acceptance, compliance, valuing, and taking personal responsibility. Affective learning is essential when the client has issues that interfere with compliance or has reservations about treatment or self-efficacy. Health teaching targeted at the affective domain is more complex because of its association with values and beliefs. It usually takes longer than learning in the cognitive domain (Leahy & Kizilay, 1998).
Case Example
Jack cognitively understands that adhering to his diabetic diet is essential to control of his diabetes. He can tell you everything there is to know about the relationship of diet to diabetic control. Although he follows his diet at home, he eats snack foods at work and insists on extra helpings at dinner. His problem with compliance lies in the affective domain, because he resents having a lifelong condition that limits his food selections. Desired outcomes for Jack's learning in the affective domain include his accepting responsibility for treatment compliance despite his reservations. The nurse will need to allow him time to vent his frustration and help him figure out ways to cope with a chronic illness in less self-destructive ways. If you were Jack's nurse, what health teaching strategies could you use to help him become more comfortable with the changes he needs to make to promote his health and well-being?
The **psychomotor domain** refers to learning a skill through _hands-on practice_. Performance learning promotes greater understanding than reading or hearing about a skill and is more likely to be remembered. Many skills required for effective self-care management require hands-on training, and supervised practice of a skill is one of the best ways for the nurse to evaluate the client's mastery of essential skills required for self-care management. Usually psychomotor learning involves demonstration of the skill by the nurse, followed by the client's return demonstration. Desired outcomes relate to proficiency in performing the motor skill, developing personal confidence, and the ability to adjust the performance of the skill when challenged with new situations.
Another factor to consider is how people learn best. Box 16-1 presents characteristics of different learning styles.
BOX 16-1 Characteristics of Different Learning Styles
Visual
• Learns best by seeing
• Likes to watch demonstrations
• Organizes thoughts by writing them down
• Needs detail
• Looks around; examines situation
Auditory
• Learns best with verbal instructions
• Likes to talk things through
• Detail is not as important
• Talks about situation and pros and cons
Kinetic
• Learns best by doing
• Hands-on involvement
• Needs action and likes to touch, feel
• Loses interest with detailed instructions
• Tries things out
## Theoretical frameworks
Client-centered health teaching
Carl Rogers' (1983) ideas provide a theoretical foundation for the use of teaching methodologies in client-centered health teaching. Rogers emphasizes the primacy of the teacher-learner relationship as the means through which learning occurs. He describes learner-centered teaching as an interactive process. Applied to health care, a learner-centered approach involves engaging clients as active partners in the learning process and helping them take responsibility for their own learning, to whatever extent is possible. Rogers insists that the teacher must start where the learner is, structuring the learning process to support the learner's natural desire to learn, and being mindful of learner characteristics that enable or impede the process.
The same conditions of unconditional positive regard related to empathy, authenticity, and respect that are required for a successful therapeutic relationship apply to health teaching. Through a teaching relationship, clients begin to challenge old, unworkable ideas and habits; transform unproductive understandings and actions; and act on new perspectives (Hansen & Fisher, 1998).
Client-centered strategies place the learner in charge of his or her learning and build on personal strengths to achieve learning objectives. A highly participative learning environment, in which the nurse provides the teaching while the learner assumes primary responsibility for the learning process, encourages empowerment (Post-White, 1998). Empowerment strategies include providing sufficient information, specific instructions, and emotional support—but no more than is required—to allow each client to take charge of his or her health care to whatever extent is possible. The following case example illustrates the impact of a client-centered teaching encounter on a client.
Case Example
There was Nadine, who was an excellent preoperative teacher. She was the first person who clearly explained what a bladder augmentation entailed. She described different tubes I'd have and the purpose of each. When I returned from surgery, she helped me cope with my body image by teaching me how to use my bladder and by being a compassionate listener (Manning, 1992, p. 47).
Providing health information in unambiguous, concrete, objective terms using the client's terminology allows the client to integrate the health teaching in his or her unique way.
### Andragogy and pedagogy
**Andragogy** refers to the "art and science of helping adults learn" (Knowles, Holton & Swanson, 1998). According to Knowles, who applied the term andragogy to adult learning, adult learners are self-directed and goal oriented. The adult's orientation to learning is practical and action oriented. Adult learners want to see the practicality of what they are learning. They favor a problem-focused approach to learning, and learn best when directly engaged in learning the skills and knowledge to help them master immediate life problems. The adult client learner expects the nurse to inquire about previous life experience and to incorporate this knowledge into the teaching plan. Figure 16-1 identifies Knowles' model of adult learning.
Figure 16-1 Andragogy model: a core set of adult learning principles. (From Knowles M, Holton E, Swanson R: _The adult learner: the definitive classic on adult education and training_ (p. 182), Terre Haute, IL, 1998, Butterworth-Heinemann.)
**Pedagogy** refers to the processes used to help children learn. A key difference between pedagogy and andragogy is the need to provide the child learner with additional direct guidance and structure in learning content. Children come to the learning experience with far less life experience that can be tapped as resources for learning. Recommended teaching strategies for learners at different developmental levels are presented in Table 16-1.
TABLE 16-1
Recommended Teaching Strategies at Different Development Levels
### Behavioral models
Behavioral approaches are based on the theoretical framework of B. F. Skinner (1971). He believed that behavior is learned, and that it is possible to change behavior by altering the predictable consequence or response to the behavior. Behavioral approaches use a structured learning format in which learning occurs by linking a desired behavior with reinforcement for performing the behavior. Behavior modification is used to teach people skills, to get children to assume a responsibility, and to curb or break an undesired behavior or habit.
**Reinforcement** , which refers to the consequences of performing targeted behaviors, is a central concept. Behaviorists believe that reinforcement strengthens learner responses. Behaviors that are rewarded (positive reinforcement) tend to be repeated. Ignored behaviors tend to diminish or disappear (extinction). When undesired behaviors are penalized, by having a reward removed or by a negative consequence, they tend to decrease. Different types of reinforcement with examples are found in Table 16-2. Research demonstrates that positive reinforcement produces the best results. As a person begins to routinely do desired behaviors, material or tangible rewards are gradually replaced with social reinforcement such as praise.
TABLE 16-2
Types of Reinforcement
Concept | Purpose | Example
---|---|---
Positive reinforcer | Increases probability of behavior through reward | Stars on a board, smiling, verbal praise, candy, tokens to "purchase" items
Negative reinforcer | Increases probability of behavior by removing aversive consequence | Restoring privileges when client performs desired behavior
Punishment | Decreases behavior by presenting a negative consequence or removing a positive one | Time-outs, denial of privileges
Ignoring | Decreases behavior by not reinforcing it | Not paying attention to whining, tantrums, or provocative behaviors
Reinforcement schedules refer to the timing of rewards. Schedules are identified as being continuous with rewards given for each success or interval schedules in which the reward is not given for each performance; instead, the reinforcement is given after a certain number of successful attempts (fixed interval) or after a random number of responses (variable ratio).
Selecting rewards (reinforcers) that have meaning to the learner is critical because what is reinforcing to one person may not be so for another. Referred to as the **Premack principle** , the choice of reinforcer should always be something of value to the individual learner. Initially, reinforcement is given immediately after each successful performance. Once a behavioral outcome is achieved, new content is introduced and rewards are distributed less frequently. Variable ratio reinforcement schedules are the most effective for maintaining behaviors.
#### Behavioral Strategies
**Modeling** is a behavioral strategy that describes learning by observing another person performing a behavior. Nurses model behaviors both unconsciously and consciously in their normal conduct of nursing activities and teaching situations. Bathing an infant, feeding an older person, and talking to a scared child in front of significant caregivers provide opportunities for informal teaching through modeling behaviors.
**Shaping** refers to the reinforcement of successive approximations of the target behavior. The long-term goal is broken down into smaller steps. The person is reinforced for any behavior that gets him or her closer to accomplishing the desired behavior. Rewarding specific behaviors that move the person in the direction of the desired behavior (successive approximations) motivates the person to engage in the desired behavior. Steps build one upon the other, moving learners from the familiar to the unfamiliar as they progress toward meeting treatment goals.
**Chaining** refers to linking single behaviors together in a series of steps leading to the targeted desired behavior, for example, having a client with diabetes draw up insulin in the syringe. Once this task is mastered, the client can be instructed to inject an orange, followed by learning body sites for injection, and finally to inject the medication into identified sites. Prompts are faded as the single action tasks are mastered.
#### Implementing a Behavioral Approach
A behavioral approach starts with a careful description and quantification of a concrete behavior requiring change. Describe each action as a single behavioral unit (e.g., failing to take a medication, cheating on a diet, or not participating in unit activities). It is important to start small so the client will experience success. Counting the number of times the client engages in a behavior as a baseline before implementing the behavioral approach allows the nurse and the client to monitor progress.
The next step in the process is to define the problem in behavioral terms and to validate the problem statement with the client (e.g., "The client does not take his medication as prescribed," or "The client does not attend any unit activities."). A behavioral approach requires the cooperation of the client and a mutual understanding of the problem on the part of the nurse and the client. Active listening skills can alert the nurse to any concerns or barriers to implementation.
Next, the nurse and client reframe the problem as a solution statement (e.g., "The client will attend all scheduled unit activities."). If the problem and solution are complex, you can break them down into simpler definitions, beginning with the simplest and most likely behavior to stimulate client interest. Identify the tasks in sequential order; define specific consequences, positive and negative, for behavioral responses; and solicit the client's cooperation.
Once these data are complete, the next step is to establish a learning contract with the client that serves as a formal commitment to the learning process. Contracts spell out the responsibilities of each party and the consequences if positive behaviors are completed or, in the case of undesired behaviors, negative consequences if behaviors persist. The contract should include:
• Behavioral changes that are to occur
• Conditions under which they are to occur
• Reinforcement schedule
• Time frame
Initially, each instance of expected behavior should be rewarded. If the client is noncompliant or needs to pay more attention to a particular aspect of behavior, the nurse can say, "This _(name the behavior or skill)_ needs a little more work." One advantage of a behavioral approach is that it never considers the client as bad or unworthy.
Case Example
Peggy Braddock, a student nurse, was working with a seriously mentally ill client with diabetes. All types of strategies were used to help the client take responsibility for collecting and testing her urine. Regardless of whether she was punished or pushed into performing these activities, the client remained resistant. To avoid taking insulin injections, this client would take urine from the toilets or would simply refuse to produce a urine sample. Peggy decided to use a behavioral approach with her. She observed that the client liked sweets. Consequently, the reward she chose was artificially sweetened Jell-O cubes. To earn a Jell-O cube, the client had to bring her urine to Peggy. After some initial testing of Peggy's resolve to give the cubes only for appropriate behavior, the client began bringing her urine on a regular basis. Once this behavior was firmly established, Peggy began to teach the client how to give her own insulin. The reward remained the same, except that now the client received praise for what she had accomplished to date, and she had to achieve more complex tasks to receive the reward. Peggy used the time she spent with the client to build trust and acceptance. She became the client's coach and supporter. She wrote her plan in the Kardex, so other nurses could use the same approach with the client. Over time, this client took full responsibility for testing her urine and administering her own insulin. The intervention also increased the client's sense of independence and self-esteem.
Exercise 16-1 provides practice with a behavioral learning approach.
EXERCISE 16-1 Using a Behavioral Approach
Purpose: To help students gain an appreciation of the behavioral approach in the learning process.
Procedure:
Think about a relationship you have with one or more people that you would like to improve. The person you choose may be a friend, teacher, supervisor, peer worker, parent, or sibling.
1. Set a goal for improving that relationship.
2. Develop a problem statement as the basis for establishing your goal.
3. Identify the behaviors that will indicate you have achieved your goal.
4. Identify the specific behaviors you will have to perform to accomplish your goal.
5. Identify the personal strengths you will use to accomplish your goal.
6. Identify potential barriers to achieving your goal.
7. In groups of four or five students, present your goal-setting agenda and solicit feedback.
Discussion:
1. Do any of your peers have ideas or information that might help you reach your goals?
2. Are there any common themes, strengths, or behaviors related to goal setting that are found across student groups?
3. What did you learn about yourself that might be useful in helping clients develop goals using a behavioral approach?
Developing an Evidence-Based Practice
Ruffolo M, Kuhn M, Evans M: Support, empowerment and education: a study of multiple family group psychoeducation, _J Emot Behav Disord_ 13(4):200–212, 2005.
This quasi-experimental study was designed to evaluate a multiple family group psychoeducation intervention (MFGPI) for parents and primary caregivers of children with serious emotional disturbance who were enrolled in a community-based case management program. Parents and primary caregivers (N = 94) were randomly assigned to one of two treatment conditions (intensive case management plus adjunctive MFGPI or the usual treatment of intensive case management). Parent problem-solving skills, parental coping skills, perceived social support resources, and child behavior were measured initially, at 9 months, and at 18 months.
_Results:_ At the 9-month measurement point, parents and primary caregivers in the treatment group reported significantly more people in their lives to turn to for help and significantly more coping resources. There were no significant differences between the two groups at the 18-month marker. The children in both groups demonstrated behavioral improvements, leading the authors to draw the conclusion that the parental involvement in both the case management and teaching sessions and the social support received was the most important element in behavioral change.
_Application to Your Clinical Practice:_ As a profession, nurses need to develop effective strategies for involving parents and caregivers in the care of their children. How could you incorporate support and education as a way of empowering the clients that you see in your clinical practice?
## Applications
Applying the nursing process in health teaching
_Patient education_ consists of clinical teaching, which is provided in all clinical settings and health education, which focuses on wellness, health promotion and disease prevention (Dreeben, 2010). As people assume greater responsibility for managing their own health, client and health education become increasingly important as a vital nursing function, Nurses assume different roles in health teaching. Depending on the situation and specific client needs, the nurse can act as a guide, an information provider, or as a resource and emotional support. As a _guide,_ you can coach clients on actions they can take to improve their health and offer suggestions on the modifications needed as their condition changes. As _information provider,_ you can help clients become more aware of why, what, and how they can learn to take better care of themselves. As _resource support,_ you can help the client connect with appropriate community and health supports. By providing emotional support and appropriate descriptive, evaluative feedback, you can encourage positive learning efforts and help clients minimize the impact of negative events or temporary setbacks. Helping clients to anticipate actual and potential effects of a medication or treatment reduces anxiety and the incidence of errors. Health teaching responsibilities can be categorized into three broad categories: information gathering, information giving, and relationship building, as presented in Figure 16-2. Before beginning the education process, you should learn about all aspects of care for the client's condition (Bonaldi-Moore, 2009).
Figure 16-2 Health teaching categories.
### Assessment
Health teaching formats follow the nursing process, beginning with an assessment of client learning needs, strengths, and limitations. Bastable (2008) notes, "Learners are usually the most important source of needs assessment data about themselves" (p. 98).
Clients enter a learning situation with a story model of their illness or disability that helps them make sense of what is happening to them. Understanding the story forms the basis for intervention. Physical symptoms have an emotional, relational, and social context that have important diagnostic value for health teaching focus. They can have an effect on relationships, work, and engagement in activities, which can be of considerable concern to the client and/or others involved with the client.
Broad, open-ended questions help nurses understand the learning needs of individual clients and families in a practical way, for example, "Tell me what this illness has been like for you so far," or "Tell me what your doctor has told you about your treatment." Asking questions demonstrates a genuine interest in what is important to clients and families, and helps tailor teaching responses to each client's unique needs. Box 16-2 provides other questions nurses can use to assess client learning needs.
BOX 16-2 Questions to Assess Learning Needs
• What does the client already know about his or her condition and treatment?
• In what ways is the client affected by it?
• In what ways are those persons intimately involved with the client affected by the client's condition or treatment?
• What does the client idtentify as his or her most important learning need?
• To what extent is the client willing to take personal responsibility for seeking solutions?
• What goals would the client like to achieve?
• What will the client need to do to achieve those goals?
• What resources are available to the client and family that might affect the learning process?
• What barriers to learning exist?
Probing the learner's beliefs about his or her illness and proposed treatment is important because beliefs and values influence learning. For example, the client who believes that _any_ drugs taken into the body are harmful will have a hard time learning about the insulin injection he needs to take every day. The same would be true of a client with depression, who views taking antidepressant medication as a "crutch," and not as a necessary treatment of a mental disorder. Finding out what the client feels is his or her primary health concern is important. This may differ from the reason that the client is seeking treatment.
Assessment of client learning needs should include the client's knowledge level, motivation, and ability to learn (see Chapter 15). A sometimes overlooked component in a learning assessment involves potential environmental barriers, such as limited health insurance, transportation difficulties, lack of follow-up facilities, and cultural dietary considerations and poverty. People may not have the money for medication, or a visit to the pediatrician for an ear infection may have a co-pay that the mother cannot afford. Health illiteracy can be a product of poverty, as well as culture (Lowenstein, Foord-May, & Romano, 2009). Failure to consider these factors can impact the effectiveness of health teaching and produce dangerous outcomes.
Case Example
"Everything was happening so fast and everybody was so busy," and that is why Mitch Winston, 66 years old and suffering from atrial fibrillation, did not ask his doctor to clarify the complex and potentially dangerous medication regimen that had been prescribed for him on leaving the hospital emergency department.
When he returned to the emergency department via ambulance, bleeding internally from an overdose of Coumadin, his doctor was surprised to learn that Mitch had not understood the verbal instructions he had received, and that he had ignored the written instructions and orders for follow-up visits that the doctor had provided. In fact, these had never been retrieved from Mitch's wallet. Despite their importance, they were useless pieces of paper. Mitch cannot read (Joint Commission, 2007, p. 5)
When processing assessment data as the basis for planning teaching interventions, it is appropriate to ask yourself the following questions:
• What specific _information_ does the client need to enhance self-management and/or compliance with treatment?
• What _attitudes_ does the client hold that potentially could enable or hinder the learning process?
• What specific _skills_ does this client need for self-management?
Learner variables important in the teaching/learning process generally fall into two categories: readiness to learn and ability to learn. Incorporation of cultural values and the nurse's self-awareness of bias are other important features of effective client education at individual, family, community, and society levels.
### Learning readiness
Teaching cannot begin until the client is ready. The teachable moment takes place when the learner feels that there is a need to know the information and has the capacity to learn it. Two of the most important variables affecting learning new behaviors involve readiness and ability to learn. **Learning readiness** refers to a person's mind-set and openness to engaging in a learning or counseling process for the purpose of adopting new behaviors.
### Factors that affect readiness to learn
Readiness to learn is not the same as the cognitive ability to learn. Nurses need to remember that learning is never smooth or linear in its development. Rather than challenge the client's learning pattern, the nurse needs to understand it and incorporate it into new opportunities for learning (Blackie, Gregg, & Freeth, 1998). This is the art of health teaching. For example, a statement "I notice that we don't seem to be making much headway with the dietary changes required by your high cholesterol. I wonder if there are some issues that we have not addressed that may be getting in the way" is empathetic, and directly focused on what needs to happen next.." Psychosocial and physical factors that can affect the learner's ability to learn include previous knowledge and experience about the illness, as well as its personal and cultural meaning.
#### Level of Anxiety
High anxiety can compromise the teaching/learning process by interfering with the client's ability to focus attention and comprehend the material. Accurately assessing and managing a client's level of anxiety before health teaching is essential, as is choosing a time when the client is most likely to be receptive (Stephenson, 2006). Developing a relationship with the client helps establish credibility and trust, and decreases anxiety. Active listening and eliciting the expectations of clients help the nurse get a more complete picture of a situation and can illuminate less obvious apprehension.
### Factors that affect ability to learn
Many factors affect a client's capacity to learn new information and ways of behaving. Some clients are ready to learn but are unable to do so with traditional learning formats (Hemmings, 1998). Assessing the client's ability to learn and adapting the learning format to the learner's unique characteristics makes a difference. If the client cannot understand what is being taught, learning does not take place.
#### Physical Barriers
A client's physical condition or emotional state can temporarily preclude teaching. A client in pain can focus on little else. A client emerging from the shock of a difficult diagnosis may require teaching in small segments or postponement of serious teaching sessions until time to absorb the diagnosis has elapsed. Certain physical and mental conditions limit attention or compromise cognitive processing abilities. The client with significant thought disorders may need very concrete instructions and frequent prompts to perform adequately. Nausea, weakness, or speech or motor impairments may make it difficult for the client to maintain motivation. Medications or the period of disorientation after a diagnostic test or surgical procedure can influence the level of the client's ability to participate in learning. Careful assessment will usually reveal when the client's physical or emotional condition is a barrier to learning.
Comorbid health problems that could interfere with the goals or process of teaching are important pieces of data that influence what can and should be taught. For example, an exercise program might be useful for an overweight person, but if the client also has a cardiac condition or other problem that would limit activity, this information has a direct impact on the goals and strategies of the intervention.
Other physical or emotional issues favor learning. Mezirow (1990) notes that crisis and life transitions provide a format for the most significant adult learning because the anxiety associated with the crisis situation (if it is not extreme) can create the need to learn, and attention is likely to be more intense. Crisis learning is particularly effective with homeless and immigrant clients, who may not voluntarily seek health care or want to engage in health teaching at any other time. Health teaching for these clients should be immediate, practical, designed to resolve the crisis situation, and carefully organized to maximize client attention.
Assessment is an interactive process in which clients should be encouraged to ask questions. By introducing the idea that most people have questions, clients feel freer to question data or to ask for more explanation. At the end of an assessment interview, you can summarize important points and ask for validation. This helps to ensure a common understanding of the issues and identify any misinformation. It also reinforces the idea of a reciprocal relationship as the basis for health teaching.
#### Family Support and Teaching Needs
Health teaching can involve family members in either a supportive role or as a primary recipient. Comprehensive health teaching is required for those actively involved as a primary caregiver, for example, with children, or clients with significant mobility, sensory deficits, or cognitive deficits. Content presentations to these family members would be the same as those given to the client.
When family members take supportive roles, for example, with teenagers, clients in crisis, and frail elder or critically ill clients with intact cognitive abilities, health teaching should focus on what they need to know to support the client. Family caregivers need to be in a position to support the client's efforts to implement new behaviors. Information and anticipatory guidance about what to expect when the client goes home and early warning signs of complications or potential problems should be given to family support members, as well as to clients. Knowing when to seek professional assistance and resource support is critical information.
Family support is an important dimension of health maintenance for frail elders, and individuals who depend on others for direction and oversight of treatment for a chronic condition. Any change in the level of support from primary caregivers can affect a client's willingness or ability to learn. When these supports are no longer available through death or incapacity, the client may lack not only motivation but the skills to cope with complex health problems.
Case Example
Edward Flanigan, an 82-year-old man who was recently widowed, has moderately severe diabetes. There is no evidence of memory problems, but there are some significant emotional components to his current health care needs. All his life, his wife pampered him and did everything for him, from meal preparation to monitoring his diabetes. Now that his wife is dead, Edward takes no interest in controlling his diabetes. The home care nurse who visits him on a regular basis is discouraged because, despite careful instruction and seeming comprehension, Edward appears unwilling to follow the prescribed diabetic diet and is not consistent in taking his medication. Predictably, he goes into diabetic crisis. His family worries about him, but he is unwilling to consider leaving his home of 42 years.
Emotional issues of loss and change complicate the learning needs of this client. Edward could function and maintain his health when he could rely on his wife for support. To enhance Edward's learning readiness, the nurse might initially have to assess for depression and then help him find alternative ways to meet his dependency needs, for example, by expanding his social support system.
### Planning
Health teaching is not a static process or one-time event. Stephenson (2006) notes that nurses need to consider the following questions:
What does the client understand so far?
What is the most important to learn about now?
What is the amount of information desired, prioritization preferred, and method of learning? (p. 243)
Planning requires more than knowledge of current client status. Each learning situation has a past and a present reality. Past experience and beliefs about illness, medications, certain treatments, cultural values, and the reactions of others produce assumptions that influence motivation and the acceptance of health teaching. Sample nursing diagnoses amenable to health teaching are presented in Box 16-3.
BOX 16-3 Sample Nursing Diagnoses Amenable to Health Teaching
• Risk for injury or violence
• Ineffective coping
• Alternations in parenting or family process
• Self-care deficits
• Anxiety
• Noncompliance
• Impaired home maintenance
• Deficient knowledge
Nurses need to know what previous information the client has received and to whom the client looks for health information. Focusing on accurate information without destroying the credibility of well-meaning and influential informal health informants in the client's life is part of the art of health teaching. Nothing is gained by injuring the reputation of the person who gave the client the information. Instead, you could say, "There have been some new findings that I think you might be interested in. Current thinking suggests that _(give example)_ works well in situations like this." With this statement, the nurse can introduce a different way of thinking without challenging the person identified in the client's mind as expert.
Although too much information puts the learner into informational overload so that critical content is not learned, not enough direction can also prove harmful.
Case Example
A nurse on the evening shift instructed an 85-year-old man to keep his arm in an upright position after a treatment procedure. The nurse neglected to tell him that he could release his arm once the needle was securely in place. The man called his wife at 5 a.m. the next day to tell her he did not think he could hold his arm in that position any longer. The man had been awake all night, his arm felt numb, and he was at his wits' end because of incomplete health teaching. Had the nurse told him to keep his arm elevated for a specific period of time (e.g., 30 minutes), the outcome and level of client satisfaction could have been different.
Organized planning is pivotal to the purpose and methodology of health teaching. Timely comprehensive health information presented in an orderly fashion is a critical component of successful coping and treatment compliance. For example, a person with a recent myocardial infarction will need to learn about:
• The disease process
• The medications, diet, and exercise regimens needed to improve cardiac function
• Lifestyle changes to reduce stress and improve cardiac function
• Warning signs and symptoms requiring medical follow-up
In addition to giving complete information, the nurse can ask, "Do you have any questions for me?" and suggest that if things come up that the client has questions about later, the client should ask for further clarification.
Often hours or days after the teaching takes place clients will have questions or concerns about the information they received. Planning should include additional opportunities for discussion after the client has had time to absorb the initial information. You can encourage the client to jot down questions that may develop as they occur.
#### Developing Learning Goals
Setting mutual goals with clients with periodic reviews helps to motivate clients and serves as a benchmark for evaluating change. It is important to establish goals _with_ your client rather than _for_ your client. Clear learning goals that the client is interested in meeting, and has the necessary ability and resources to achieve increase the chances that the information will be understood and applied (London, 2001). Prioritizing goals and objectives that are important to client health and well-being helps nurses and clients focus on the most relevant specifics.
Identify outcome goals with a general statement about what the client needs to achieve as a result of the teaching. (e.g., "After health teaching, the client will maintain dietary control of her diabetes."). An interim goal might be, "After health teaching, the client will develop an appropriate diet plan for 1 week."). Setting realistic goals prevents disappointment. Box 16-4 summarizes guidelines to use in the development of effective health teaching goals and objectives. Exercise 16-2 provides experience with developing relevant behavioral outcome goals.
BOX 16-4 Guidelines for Developing Effective Goals and Objectives
• Link goals to the nursing diagnosis.
• Make goals action-oriented.
• Make goals specific and measurable.
• Define objectives as behavioral outcomes.
• Design objectives with a specific time frame for achievement.
• Show a logical progression with established priorities.
• Review periodically and modify goals as needed.
EXERCISE 16-2 Developing Behavioral Goals
Purpose: To provide practical experience with developing teaching goals.
Procedure:
Establish a nursing diagnosis related to health teaching and a teaching goal that supports the diagnosis in each of the following situations:
1. Jimmy is a 15-year-old adolescent who has been admitted to a mental health unit with disorders associated with impulse control and conduct. He wants to lie on his bed and read Stephen King novels. He refuses to attend unit therapy activities.
2. Maria, a 19-year-old single woman, is in the clinic for the first time because of cramping. She is seven months pregnant and has had no prenatal care.
3. Jennifer is overweight and desperately wants to lose weight. However, she cannot walk past the refrigerator without stopping, and she finds it difficult to resist the snack machines at work. She wants a plan to help her lose weight and resist her impulses to eat.
Discussion:
1. What factors did you have to consider in developing the most appropriate diagnosis and teaching goals for each client?
2. In considering the diagnosis and teaching goals for each situation, what common themes did you find?
3. What differences in each situation contributed to variations in diagnosis and teaching goals? What contributed to these differences?
4. In what ways can you use the information in this exercise in your future nursing practice?
#### Developing Measurable Objectives
Objectives are powerful guides to organizing content and suggesting appropriate planning activities. Each objective should describe an immediate action step that the client should take to accomplish relevant treatment outcomes. Teaching objectives should be modest and achievable in the time frame allotted. They should be logically organized and build on one another for maximum effectiveness. To determine whether an objective is achievable, consider the client's level of experience, educational level, resources, and motivation. Then define each learning objective needed to achieve the health goal in specific measurable behavioral terms.
Objectives should support the overall health outcome and directly relate to the nursing diagnosis. For example, the nursing diagnosis for a client with newly diagnosed diabetes might read, "knowledge deficit related to diabetic diet." Examples of appropriate progressive learning objectives required for mastering diabetic control might occur as follows:
• First teaching session: The client will identify the purpose of a diabetic diet and appropriate foods.
• Second teaching session: The client will identify appropriate foods and serving sizes allowed on a diabetic diet.
• Third teaching session: The client will demonstrate actions for urine/blood testing for glucose at home.
• Fourth teaching session: The client will identify foods to avoid on the diabetic diet and the rationale for compliance.
• Fifth teaching session: The client will describe symptoms and actions to take for hyperglycemia and hypoglycemia.
#### Timing
Health teaching is not an add-on; it is an essential nursing intervention. Factors involved in timing are presented in Box 16-5. Teaching interventions should never be eliminated because the nurse lacks time, but they can be streamlined. Even in the most limited situation, schedule a block of time for health teaching. You will need to consider how much time is required to learn a particular skill or body of knowledge, and build this into the learning situation. Complicated and/or essential skill development needs blocks of time and repeated practice with feedback.
BOX 16-5 Factors Involved in Timing
• Client readiness
• Time needed to learn skill or body of knowledge
• Possible need for attitude change by client
• Time constraints of nurse
• Client priorities about information or skill
• Client's energy level
• Atmosphere of trust
Pick times for teaching when energy levels are high, the client is not distracted by other things, it is not visiting time, and the client is not in pain. Careful observation of the client will help determine the most appropriate times for learning.
People have saturation points as to how much they can learn in one time period. Because even under the best of circumstances, people can absorb only so many details and fine points, limit information to two or three points at a time. Keep the teaching session short, interesting, and to the point. Ideally, teaching sessions should last no longer than about 20 minutes, including time for questions. Otherwise, the client may tire or lose interest. Scheduling shorter sessions with time in between to process information helps prevent sensory overload and reinforces teaching points.
In addition to scheduled teaching sessions, nurses have many opportunities for informal teaching that occur during the course of providing care. Simple, spontaneous health teaching takes minutes, yet it can be highly effective. The following case example, taken from _Heartsounds_ (Lear, 1980), illustrates this point.
Case Example
A nurse came in while he was eating dinner. "Dr. Lear," she said, "after angiography the patients always seem to have the same complaints, and I thought you might want to know about them. It might help." (This was a good nurse. I didn't know it then, because I didn't know how scared he was. But later I understood that this was a darned good nurse.)
"Thanks, it would help," he said.
"It's mostly two things. The first is, they say that during the test, they feel a tremendous flush. It's very sudden and it can be scary."
He responds to the nurse, "Okay, the flush. And what's the other thing?"
"It's...well, they say that at a certain point, they feel as though they are about to die. But that feeling passes quickly." He thanked her again. He was very grateful.
(Later, during the actual procedure, Dr. Lear remembered the nurse's words and found comfort.) "Easy. Easy. You're supposed to feel this way. This is precisely what the nurse described. The moment you feel you are dying." (Lear, 1980, pp. 120–121)
This teaching intervention probably took less than 5 minutes, yet its effect was long-lasting and healing. There are countless opportunities for informal health teaching in clinical practice if the nurse consciously looks for them.
### Implementation
Each teaching session should demonstrate a thorough knowledge of the topic, a keen understanding of the client's learning needs, and a genuine interest in the client. The client must be actively involved in the process. Effective teaching involves not only a healthy exchange of information, but plenty of opportunities to ask questions and to receive feedback.
A key element in successful health teaching is an enthusiastic presentation.
#### Health Teaching Format
No one teaching strategy can meet the needs of all clients (Rycroft-Malone et al., 2000), but people learn best when there is a logical flow and building of information from simple to complex. Begin by presenting a simple overview of what will be taught and why the information is important to learn. Include only essential information in your overview; for example, give a brief explanation of the health care problem, risk factors, treatment, and self-care skills the client will need to manage at home (Lee et al., 1998). Incorporate or ask about previous related experience. Introductory content that builds on the person's experiences, abilities, interests, motivation, and skills is more likely to engage the learner's attention.
Deliver key points and allow regular opportunities for client feedback and questions. If the material is complex, it can be broken down into smaller learning segments. For example, diabetic teaching could include the following segments:
• Introduction, including what the client does know
• Basic pathophysiology of diabetes (keep description simple and short)
• Diet and exercise
• Demonstration of insulin injection with return demonstration
• Recognizing signs and symptoms of hyperglycemia and hypoglycemia
• Care of skin and feet
• How to talk to the doctor
A strong closing statement summarizing major points reinforces the learning process. Exercise 16-3 provides practice with developing a mini teaching plan.
EXERCISE 16-3 Developing Teaching Plans
Purpose: To provide practice with developing teaching plans.
Procedure:
1. Develop a mini teaching plan for one of the following client situations:
a. Jim Dolan feels stressed and is requesting health teaching on stress management and relaxation techniques.
b. Adrienne Parker is a newly diagnosed diabetic. Her grandfather had diabetes.
c. Vera Carter is scheduled to have an appendectomy in the morning.
d. Marion Hill just gave birth to her first child. She wants to breast-feed her infant, but she does not think she has enough milk.
e. Barbara Scott weighs 210 pounds and wants to lose weight.
2. Use guidelines presented in Chapter 15 and this chapter in the development of your teaching plan. Include the following data: a brief statement of client learning needs and a list ofrelated nursing diagnoses in order of priority.
3. For one nursing diagnosis, develop an educative/supportive teaching plan outline that includes specific client-focused objectives, topical content outline, planned teaching strategies, time frame for planned activities, and evaluation criteria.
#### Using Clear Language
Use clear precise language. Choice of words should be familiar to the client. Whenever possible, avoid the use of nonessential adjectives. Place words with more than one meaning in context as many words have more than one connotation. Consider the word _cold._ It can refer to temperature, an illness, an emotional tone, or a missed opportunity. Using too general or vague language leaves the learner wondering what the nurse actually meant. For example, "Call the doctor if you have any problems" has more than one meaning. "Problems" can refer to side effects of the medication, a return of symptoms, problems with family acceptance, changed relationships, and even alterations in self-concept. In this case, clear descriptors should cover the following:
• Identification of specific behaviors warranting attention
• What needs to happen if problems arise and under what specific circumstances
• Who needs to be contacted (with contact information) if something goes wrong
A clear statement that the nurse might use is, "If you should develop a headache or feel dizzy in the next 24 hours, call the emergency room doctor right away."
Note that comprehension involves more than simply hearing or decoding written words. It includes understanding language nuances and being able to put underlying themes together in ways that make sense of the message as a unified whole. Verbally checking in with clients to confirm a common understanding of words and concepts is critical to knowledge transfer in health teaching. Doak, Doak, Gordon, and Lorig (2001) suggest asking the client, "What does this material tell you about____________ [subject]? What does it tell you to do?" (p. 188).
#### Visual Aids
Visual aids can be used to reinforce a message by providing concrete images. Simple images and few words work better than complex visual aids (Huntsman & Binger, 1981). For example, the nurse might show a new mother pictures of common infant rashes. A chart or model showing the heart might help another client understand the anatomy and physiology of a heart disorder. Perdue, Degazon, and Lunny (1999) suggest that DVD tapes are useful in teaching clients with limited reading skills. They have the advantage of allowing clients to watch them again at their convenience. Related discussions help to correct misinterpretations and emphasize pertinent points.
Visual aids provide concrete images that help clients remember essential information.
#### Preparing Written Handouts
Written backup materials to which clients can refer when needed reinforce learning. Attention to the client's reading level and health care literacy helps ensure that the pamphlets can be read. Most reading materials should be geared to a sixth-grade reading level. Even people with adequate health literacy comprehend information better when the language is simple and clear. Incorporating relevant line drawings or pictures can be useful with clients who have language issues. Large-print pamphlets and audiotapes are helpful learning aids for those with sight problems.
Guidelines for preparing effective written materials include the following:
• Present the most important information first.
• Illustrations and diagrams should be designed to enhance clarity and appeal.
• Make sure that the content is current, accurate, objective, and consistent with information provided by other health providers.
• Use appropriate language at a literacy level that the reader can understand.
• Use a 12-point font and avoid using all capital letters for reading ease.
• Define technical terms in lay language and avoid medical jargon.
• Check for spelling errors and stay away from complicated sentences.
• Include resources with contact information that the client can refer to for further information or for help with problems.
#### Using Advance Organizers
Advance organizers, sometimes called a mnemonic, consist of cue words, phrases, or letters related to more complex data. They are designed to help people remember and recall difficult concepts. For example, the letters in the word _diabetes_ can help a client remember key concepts about diabetes:
D = diet
I = infections
A = administering medications
B = basic pathophysiology
E = eating schedules
T = treatment for hyperglycemia or hypoglycemia
E = exercise
S = symptom recognition
Each letter stands for a concept or action needed to control diabetes. Taken together, the client has a useful tool for remembering _all_ related concepts.
Nursing students can use mnemonics to help them remember key points. Word associations promote remembering in much the same way that linking new information to previously learned information does. For example, the four F's (fat, forty, female, family history) can help students remember risk factors for gallbladder disorder. Developing mnemonics can be fun and creative.
#### Accommodating Special Learning Needs
The level of information and amount of time for health teaching should reflect differences and changes in client circumstances. Clients experiencing a recent diagnosis will need more detailed basic information than clients having an unanswered question or requiring follow-up information. If a client's condition worsens, becomes stable, or improves, you will need to modify teaching goals, content, and strategies to reflect relevant changes.
Accommodating for Cultural Diversity: Clients with English as a second language or a strong ethnic background usually require learning accommodations. Health teaching and educational programs that take into consideration the cultural health practices of individuals and families are likely to be more successful. Whenever possible, include cultural values or beliefs about health in teaching content and delivery. Use culturally relevant terminology.
Use fewer, rather than more words to explain a concept and allow extra time to practice psychomotor skills with feedback. When teaching a client with English as a second language, keep in mind that words from one language do not necessarily translate with the same meaning into another. Words for certain concepts either do not exist or the phrases used for expressing and describing them can differ. Sometimes there is a tendency for people to speak louder when instructing someone from a different culture. This is not necessary. People with health literacy issues because of language are neither deaf nor unable to grasp information, if their special needs are taken into account. Speak slowly in a normal conversational tone. Lorig (2001) suggests that in preparing teaching materials for translation, the following are important:
• Use nouns rather than pronouns, and simple unambiguous language
• Use short simple sentences of less than 16 words each
• Avoid the use of metaphors and informal slang
• Avoid verb forms that have more than one meaning, or include would or could (p. 181).
If the client still is unable to understand important concepts with accommodations, enlisting the services of a trained medical interpreter becomes an essential intervention.
Learners handicapped by memory deficits, lack of insight, poor judgment, and limited problem-solving abilities also require special accommodations. Special needs learners respond best when the content is presented in a consistent, concrete, and patient manner, with clear and frequent cues to action. Clients with limited literacy skills may benefit from using audiotapes in addition to or instead of written materials.
#### Giving Feedback
Feedback is an essential component of successful health teaching programs. To appreciate its significance, consider the effect on your performance if you never received feedback from your instructor. Feedback about how the client is accomplishing teaching goals should be descriptive, and include areas of accomplishment and need for growth. Effective feedback is honest and based on concrete data. When providing feedback, keep it simple and focus only on behaviors that can be changed. Behavioral statements on a continuum (e.g., "You seem skilled with drawing up the medication, but you may need a little more practice with selecting sites.") are more effective than absolute statements (e.g., "You still are not doing this correctly.").
Feedback given as soon as possible after an observation is more likely to be accepted by the client. Indirect feedback—provided through nodding, smiling, and sharing information about the process and experiences of others—reinforces learning. Exercise 16-4 provides practice with giving feedback in health teaching.
EXERCISE 16-4 Giving Teaching Feedback
Purpose: To give students perspective and experience in giving usable feedback.
Procedure:
1. Divide the class into working groups of three or four students.
2. Present a 3-minute sketch of some aspect of your current learning situation that you find difficult (e.g., writing a paper, speaking in class, coordinating study schedules, or studying certain material).
3. Each person, in turn, offers one piece of usable informative feedback to the presenter. In making suggestions, use the guidelines on feedback given in this chapter.
4. Place feedback suggestions on a flip chart or chalkboard.
Discussion:
1. What were your thoughts and feelings about the feedback you heard in relation to resolving the problem you presented to the group?
2. What were your thoughts and feelings in giving feedback to each presenter?
3. Was it harder to give feedback in some cases than in others? In what ways?
4. What common themes emerged in your group?
5. In what ways can you use the self-exploration about feedback in this exercise in teaching conversations with clients?
Giving immediate feedback is important with learning psychomotor tasks.
### Teaching self-management and caregiving skills
The subject of health teaching would be incomplete without a discussion of strategies focused on the development of self-management and caregiving skills needed by an increasing number of people coping with chronic illness and disability in the community. Although a lot of self-management strategies are disease or disability specific, common to most chronic conditions are issues of fatigue, pain, sleep management, lifestyle adjustments, limitations in social/role activities, self-efficacy, and identity issues.
#### Using a Problem-Solving Teaching Approach
Teaching about medications is a critical example of self-management education related to client safety where you can use a problem-solving approach. Begin by providing the client with both generic and commercial names of medications. Many medications look alike, so correctly labeling them and having clients/family caregivers visually identify the medication is helpful. Medication reconciliation is extremely important for elderly clients who usually are taking multiple medications, with the potential for getting them mixed up. Make sure that the client has the finances to obtain medication on a regular basis. If equipment is used, for example, syringes for insulin, make sure the client can read the calibrations and is injecting in appropriate areas.
You will need to clearly identify the purpose of the medication, expected therapeutic response, and side effects of the medications the client is receiving. Discuss what happens if the client misses a dose or decides to stop the medication. For example, doubling up on the next dose or stopping a medication abruptly may create significant issues for clients. Missing birth control pills even for a short period may result in an unwanted pregnancy. If blood tests are required to determine the efficacy or toxicity of the prescribed drug, the rationale and timing should be explained. Talk about symptoms that could require immediate medical attention and what to do in case of emergency. As with other forms of health teaching, summarize key points at the conclusion of the teaching session. Family members need to be given enough information to support client adherence to the treatment protocol. Box 16-6 provides medication teaching tips developed by the Institute for Safe Medication Practices.
BOX 16-6 Medication Teaching Tips
• Provide clients with written drug information, particularly for metered-dose inhalants and high-alert medications such as insulin.
• Include family or caregivers in the teaching sessions for clients who need extra support or reminders.
• Do not wait until discharge to begin education about complex drug regimens.
• Clearly explain directions for using each medication.
• Always require repeat demonstrations or explanations about medications to be taken at home, particularly for those requiring special drug administration techniques.
• Use the time you already spend with clients during assessments and daily care to evaluate their level of understanding about their medications.
• Keep medication administration schedule as simple and easy to follow as possible.
Adapted from Institute for Safe Medication Practices: Patient medication teaching tips, Huntingdon Valley, PA, 2006, Author.
The Center for the Advancement of Health (2002) has identified problem solving, decision making, utilization of resources, development of client/provider partnerships, and taking action as essential self-management skills. Key caregiving skills identified in the literature are those involving "monitoring, interpreting, making decisions, taking actions, making adjustments, accessing resources, providing hands-on care, working together with the ill person, and navigating the health care system" (Schumacher & Marren, 2004, p. 460).
Not all of these skills can be taught simultaneously. Development of self-management and caregiving skills requires a contextual, problem-based teaching approach. In addition to medical management of chronic conditions, people need coaching and support to integrate health-related changes into life roles, and management of the emotions created by having a chronic condition (Lorig & Holman, 2003). _Repetition is important_ , as is careful inquiry with open-ended questions about any issues that might compromise compliance.
Clients and families should be advised of what to expect from treatment and medications, as well as risks, benefits, prognosis, and options for treatment. This information allows them to make better health care decisions. They should understand why an action is important, what they can expect from following a treatment protocol, and how aspects of treatment can help them.
Clients and families need to know the danger signals to watch for that would require a prompt call for assistance. They should be coached on the types of circumstances requiring a call to their health care provider.
Health teaching can take place in the home, as well as in the hospital.
#### Teach-Back Method
Allowing extra time for the client to talk about and do return demonstrations of tasks reinforces learning (Bohny, 1997). Teach back or show back is a teaching strategy used to evaluate and verify a client's understanding of health teaching and/or ability to execute self-management skills. It involves asking the learner to repeat back relevant information and treatment instructions in his or her own words (Lorenzen, Melby, & Earles, 2008). Asking the learner to describe actions that would need to be taken if a protocol or procedure cannot be followed exactly or if the actions a client takes fails to produce the desired effect can be included. The method provides the nurse with valuable data about areas of skill learning that may need additional attention. Using it as you go along reinforces each piece of information and eliminates the problem of delivering a comprehensive teaching plan only to discover that the client lost your train of thought after the first few sentences.
#### Coaching Clients
Coaching is an effective teaching strategy used to teach self-management and problem-solving skills to clients and families experiencing unfamiliar tasks and procedures (Lewis & Zahlis, 1997). For example, coaching can help clients distinguish between which symptoms require immediate medical attention and which ones can be handled with self-management strategies.
Coaching clients as they negotiate a complex health care system can prove invaluable. For example, the nurse might assist the client or family in opening a communication with a health agency and choosing the appropriate questions to ask. Or, it may be as simple as coaching people to seek information from several sources rather than calling only one and waiting for a response (Lorig & Holman, 2003).
Coaching emphasizes the client's autonomy in developing appropriate solutions, as the client is always in charge of the pace and direction of the learning. Through a coaching dialogue, you can encourage a client to critically think about the elements of a situation, consider multiple options, and evaluate the appropriateness of choosing one option over another. Assessment for coaching purposes starts with an exploration of how the client is experiencing the fundamental patterns of a situation. This assessment assists clients to challenge obstructive perceptions, connect past experience with current knowledge about the context of a situation, look for cues in a situation, and consider the consequences of taking different actions.
In the coaching role, nurses can present different perspectives that the client may not have considered. Coaching can include role-playing and value clarification. The process can inform the client about timing of actions, potential outcomes, areas that need special attention, and contextual issues that might not otherwise emerge in a teaching situation. In addition to giving appropriate information, coaching involves taking the client step by step through a procedure or activities in which the client takes the lead in choice of actions. The secret of successful coaching is to provide enough information to help the client take the next step without taking over. Coaching involves a number of skills presented Figure 16-3. Exercise 16-5 provides practice with coaching as a teaching strategy.
EXERCISE 16-5 Coaching
Purpose: To help students understand the process of coaching.
Procedure:
Identify the steps you would use to coach clients in each of the following situations. Use Figure 16-1 as a guide to develop your plan.
1. A client returning from surgery, with pain medication ordered "as needed"
2. A client newly admitted to a cardiac care unit
3. A client with a newly inserted intravenous catheter for antibiotic medications
4. A child and his parents coming for a preoperative visit to the hospital before surgery
Share your suggestions with your classmates.
Discussion:
1. What were some of the different coaching strategies you used with each of these clients?
2. In what ways were your coaching strategies similar to or unlike those of your classmates?
3. How could you use the information you gained from this exercise to improve the quality of your helping?
Figure 16-3 The nurse's role in coaching clients.
#### Providing Transitional Cues
Directions for self-management of illness or disability may seem simple and obvious to you, but clients or families may have difficulty with material simply because they do not know how the information fits together in their particular circumstances. Instead of using generic explanations of skills and medication management, use language and concepts specific to the client's situation. For example, connecting the purpose of taking a medication with the actual actions you want the client to take helps fix the process in a person's mind and makes it easier to remember related instructions. Ask clients how they will implement an essential medical management strategy such as using an inhaler or adhering to a therapeutic diet. This discussion requires clients to seriously consider how an application directly affects them and any changes in lifestyle behaviors needed to accommodate for it.
## Health teaching applications in different settings
Group presentations
Group presentations offer the advantage of being able to teach a number of people at one time. The format allows people to learn from each other, as well as from the teacher. Health teaching topics that lend themselves to a group format include care of the newborn, diabetes, oncology, and prenatal and postnatal care (Redman, 2007).
Formal group teaching should be structured in a space large enough to accommodate all participants. The learner should be able to hear and see the instructor and visual aids without strain. Technical equipment should be available and in working order. Should the equipment not work, it is better to eliminate the planned teaching aid completely than to spend a portion of the teaching session trying to fix it.
Preparation and practice can ensure that your presentation is clear, concise, and well spoken. In a group presentation, you will need to establish rapport with your audience. Make eye contact immediately and continue to do so throughout the presentation. Extension of eye contact to all participants communicates acceptance and inclusion. A quote at the beginning capturing the meaning of the presentation or a humorous opening grabs the audience's attention. Strengthen content statements with careful use of specific examples. Citing a specific problem and the ways another person dealt with it gives general statements credibility. Repeating key points and summarizing them again at the conclusion of the session helps reinforce learning.
If you plan to use PowerPoint, use a font that is large enough to see from a distance (32 point is recommended) and include no more than four or five items per slide. Use the slides wisely to identify key points, not as the primary content for the presentation. Face the audience, not the slides. Practice your presentation to ensure that you keep within the time frame and allot time for short discussion points. The key points can help you stay on track and move through the agenda. It is up to you as the presenter to set the pace. No matter how interesting the presentation and dialogue that it stimulates, running out of time can be frustrating for the audience and presenter.
Anticipate questions and be on the alert for blank looks. No matter how good a teacher you are, you will from time to time experience the blank look. When this occurs, it is appropriate to ask, "Does anyone have any questions about what I just said?" Give reinforcement for participation verbally, "I'm so glad you brought that up," or "That's a really interesting question (or comment)." Smiling and nodding your head are nonverbal reinforcers. If a participant has a question that you cannot answer, do not bluff it. Instead, say, "That is a good question. I don't have an answer at this moment, but I will get back to you with it." Sometimes another person will have the required information and will share it.
Handouts and other materials provide additional reinforcement. Make sure that the information is accurate, complete, easy to understand, logical, and very important, that you have enough for all participants. Exercise 16-6 provides an opportunity to practice health teaching in a group setting.
EXERCISE 16-6 Group Health Teaching
Purpose: To provide practice with presenting a health topic in a group setting.
Procedure:
1. Plan a 15- to 20-minute health presentation on a health topic of interest to you, including teaching aids and methods for evaluation.
Suggested topics:
Nutrition | Weight control
---|---
Drinking and driving | Mammograms
High blood pressure | Safe sex
Dental care |
2. Present your topic to your class group.
#### Health Teaching in the Home
Preparing for discharge has specialized teaching/learning needs that nurses need to consider in caring for clients and families (see also Chapter 24). Relevant areas of learning needs to assess are identified in Box 16-7.
BOX 16-7 Assessing Teaching/Learning Needs at Discharge
• What potential problems are likely to prevent a safe discharge?
• What potential problems are likely to cause complications or readmission?
• What prior knowledge or experience does the patient and family have with this problem?
• What skills and equipment are needed to manage the problem at home?
• Who (what agency) will assume responsibility for continuing care?
In home care, the nurse is a guest in the client's home. Part of the teaching assessment includes appraisal of the home environment, family supports, and resources, as well as client needs. Although teaching aids and structured teaching strategies available in the hospital setting may not be available, in many ways the home offers a teaching laboratory unparalleled in the hospital. The nurse can actually "see" improvisations in equipment and technique that are possible in the home environment. Family members may have ideas that the nurse would not have thought of, and the nurse can see the obstacles the family face.
Always call before going to the client's home. This is common courtesy; it also protects the nurse's time if the client is going to be out. Teaching in home care settings is rewarding. Often, the nurse is the client's only visitor. Family members often display a curiosity and willingness to be a part of the learning group, particularly if the nurse actively uses knowledge of the home environment to make suggestions about needed modifications.
When in the home, it is important to model appropriate behaviors (e.g., washing hands in the bathroom sink before touching the client). Simple strategies, like not washing one's hands in the kitchen sink where food is prepared, encourage the client to do likewise.
Teaching in home care settings has to be short-term and comprehensive, because most insurance companies will provide third-party reimbursement only for intermittent, episodic care. Nurses need to plan teaching sessions realistically so that they can be delivered in the shortest time possible. Content must reflect specific information the client and family need to provide immediate effective care for the client, _nothing more and nothing less_. Sometimes it is tempting to include more than what is essential to know. Because there are so many regulations regarding the length and scope of skilled nursing interventions imposed by third-party reimbursement guidelines, the nurse needs to pay careful attention to health teaching content and formats. At the same time, reviewing medications with clients and families at every visit is useful.
Helping clients access supportive services can be extremely helpful to families who would not otherwise do so even with the appropriate written information. Having knowledge of community resources is essential. This knowledge allows you to help clients and families select from a number of existing resources and create new ones through novel uses of family and community support systems. Expert nurses know that clients often can be a source of information about resources they may not know about. An understanding of Medicare, Medicaid, and other insurance matters (e.g., regulations, required documentation, and reimbursement schedules) is factored into the management of health care teaching in home health care.
### Evaluation
Regardless of the setting in which health teaching takes place, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) _requires_ written documentation of client health teaching. Notes about the initial assessment should be detailed, comprehensive, and objective. Teaching content and delivery should be related to assessment data, including client preferences, previous knowledge, and values. Included in the documentation are the teaching actions, the client response, and any clinical issues or barriers to compliance. If family members are involved, this information should be acknowledged. Accurate documentation serves a critical purpose in health teaching, helps ensure continuity, and prevents duplication of teaching efforts. The client's record informs other health care providers of what has been taught and what areas need to be addressed in future teaching sessions. See the following example for documentation of home health teaching:
4/8/Blood glucose check normal. Vital signs stable. Client on insulin for 10 years; has difficulty prefilling syringes. Lives with son who works. Nursing diagnosis: knowledge deficit related to prefilling syringes and ineffective coping in self-medication related to poor eyesight. Nurse prefilled syringes, wrote out med schedule, and discussed in detail with client. Client receptive to medication instruction, but may have difficulty with insulin prefill secondary to poor vision. Instructed client on medications, signs and symptoms to report to MD, diet and safety measures. Client able to repeat instructions. Spoke with son regarding medication supervision.
M. Haggerty, RN
## Summary
This chapter describes the nurse's role in health teaching. Theoretical frameworks, client-centered teaching, critical thinking, and behavioral approaches guide the nurse in implementing health teaching. Teaching is designed to access one or more of the three domains of learning: cognitive, affective, and psychomotor. Assessment for purposes of constructing a teaching plan centers on three areas: What does the client already know? What is important for the client to know? What is the client ready to know?
Essential content in all teaching plans includes information about the health care problem, risk factors, and self-care skills needed to manage at home. No one teaching strategy can meet the needs of all individual clients. The learning needs of the client will help define relevant teaching strategies. Several teaching strategies, such as coaching, use of mnemonics, and visual aids, are described. Repetition of key concepts and frequent feedback make the difference between simple instruction and teaching that informs. Documentation of the learning process is essential. The client's record becomes a vehicle of communication, informing other health care workers what has been taught and what areas need to be addressed in future teaching sessions.
Ethical Dilemma
What Would You Do?
Jack is a 3-year-old boy recently admitted to your unit with a high fever, headache, and stiff neck. The physician wants to do a spinal tap on him to rule out meningitis. The family is opposed to this procedure, fearing it will further traumatize their child. What are the ethical considerations related to health teaching regarding this procedure?
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CHAPTER 17
# Communicating with Clients with Communication Disabilities
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Identify common communication deficits.
2 Describe nursing strategies for communicating with clients experiencing communication deficits secondary to visual, auditory, cognitive, or stimuli-related disabilities.
3 Discuss application of research findings to your clinical practice.
This chapter presents an overview of communication difficulties commonly encountered when caring for clients with sensory or cognitive deficits. Strategies for enhancing communication are described. The World Health Organization's (WHO's; 2001) International Classification of Functioning, Disability and Health shifted away from a medical diagnosis model to a functional model (i.e., how the person with a sensory impairment functions in his or her everyday life). Under this model, a communication disability definition includes any client who has any impairment in body structure or function that interferes with communication. Specifically, the client has a communication difficulty because of impaired functioning of one or more of his five senses, or he has impaired cognitive functioning. Examples include hearing loss, blindness, aphasia, or mental disorders. Communication deficits can also arise from the kind of sensory deprivation that occurs in some intensive care hospital units. The degree of difficulty in communicating is an interaction between the client's type of functional impairment, his personal adaptability, and the healthcare environment (i.e., body factors, personal factors, and environmental factors as stated in WHO's model).
Any impairment of a client's ability to send and/or receive information from health care providers may compromise his or her health, health care, and rights to make decisions. When working with these clients, you may need to modify communication strategies presented earlier in this textbook. Assess your client's communication. Two individuals can have the same sensory impairment but not be equally communication disabled. Each person compensates for their impairment in different ways. Our primary nursing goal is to maximize our client's ability to successfully interact with the health care system. This chapter focuses on suggested strategies for communication.
## Basic concepts
Clients with communication deficits are known to encounter barriers in obtaining adequate health care (Levy-Storms, 2008; O'Halloran, 2008). Studies show that when their nurses are unable to understand them, clients with communication disabilities become frustrated, angry, depressed, or uncertain. Some clients become so frustrated that they omit needed care. Even when care is accessed, communication deficits interfere with the therapeutic relationship and delivery of optimum care (McDonald, 2008). The client's deficit is one barrier. But other barriers may be staff's negative attitude or failure to adapt communication.
## Legal mandates
In the legal system, the standard of "effective communication" is based on several statutes. The Americans with Disabilities Act (ADA) prohibits discrimination on the basis of a disability. Thus, physician offices are required to provide reasonable accommodations to ensure effective communication. The Rehabilitation Act bars discrimination by those providers receiving federal monies, including Medicare. Title VI of the 1964 Civil Rights Act prohibits discrimination on the basis of national origin. Health care agencies are required to develop a plan for accommodating non–English-speaking clients.
## Types of deficits
Hearing loss
Nearly 28 million Americans have some problem hearing. Loss can be conductive, sensorineural, or functional. Nurses have both a legal and ethical obligation to provide appropriate care. Yet, deaf people are less likely to seek health-related information from care providers. Title III of the ADA delineates rights of the deaf and applies to communication between deaf clients and medical services (Lieu, Sadler, & Stohlmann, 2007).
People's sense of hearing alerts them to changes in the environment so they can respond effectively. The listener hears sounds and words, and also a speaker's vocal pitch, loudness, and intricate inflections accompanying the verbalization. Subtle variations can completely change the sense of the communication. Combined with the sound and intensity, the organization of the verbal symbols allows the client to perceive and interpret the meaning of the sender's message. The extent of your client's loss is not always appreciated because they often look and act in a normal fashion. Deprived of a primary means of receiving signals from the environment, clients with hearing loss may try to hide deficits, may withdraw from relationships, become depressed, or be less likely to seek information from health care providers.
#### Children
Nearly 3 of every 1,000 newborns are deaf or have hearing loss. Fortunately, many of these deficits are diagnosed at birth. Newborn hearing is tested in the nursery via auditory brainstem response tests (National Institute on Deafness and Other Communication Disorders, www.nidc.nih.gov/. **Hearing screening** is recommended for all newborn children by U.S. Preventive Services Task Force (USPSTF, online) and American Academy of Pediatrics.
#### Older Adults
As we age, we have an increased likelihood for experiencing sensory deficits related to the aging process. _Presbycusis,_ or degeneration of ear structures, is a sensorineural dysfunction that normally occurs as we age. British studies found that older adults, as a group, have significant decreases in hearing, poorer consonant discrimination, and changes in their conversational styles, especially in those older than 75 years.
### Vision loss
Humans rely more heavily on vision than do most species. More than 21 million adult Americans are blind or have low vision (Pleis & Lethbridge-Cejku, 2007). Clients who lack vision loose a primary method to decode the meaning of messages. All of the nonverbal cues that accompany speech communication (e.g., facial expression, nodding, and leaning toward the client) are lost to blind clients.
#### Children
Children with visual impairments lack access to visual cues, such as the facial expressions that encourage them to develop communication skills (Parker, Grimmett, & Summers, 2008). The USPSTF (2008) recommends testing children younger than 5 years for amblyopia, strabismus, and acuity. But traditional vision screening requires a verbal child and cannot be done reliably until age 3 (Rosenberg & Sperazza, 2008).
#### Older Adults
As your clients age, they are more likely to have vision problems that may interfere with the communication process. As we age, the lens of the eye becomes less flexible, making it difficult to accommodate shifts from far to near vision; this is a condition known as _presbyopia._ A British study found substantial decreases in visual acuity in older adults. These decreases ranged from 3% at age 65 to more than 35% in those older than 85 (van der Pols et al., 2000). Macular degeneration has become a major cause of vision loss in older adults.
### Impaired verbal communication secondary to speech and language deficits
Clients who have speech and language deficits resulting from neurologic trauma present a different type of communication problem. Normal communication allows people to perceive and interact with the world in an organized and systematic manner. People use language to express self-needs and to control environmental events. Language is the system people rely on to represent what they know about the world. Early identification of children with at-risk prelinguistic skills may allow intervention to improve communication competencies (Crais, Watson, & Baranek, 2009). Clients unable to speak, even temporarily because of intubation or ventilator dependency, incur feelings of frustration, anxiety, fear, or even panic (Braun-Janzen, Sarchuk, & Murray, 2009).
When the ability to process and express language is disrupted, many areas of functioning are assaulted simultaneously. _**Aphasia**_ is a neurologic linguistic deficit, such as occurs after a stroke. Aphasia can present as primarily an expressive or receptive disorder. The client with _expressive aphasia_ can understand what is being said but cannot express thoughts or feelings in words.
Touch, eye movements, and sounds can be used to communicate with clients experiencing aphasia.
_Receptive aphasia_ creates difficulties in receiving and processing written and oral messages. With _global aphasia,_ the client has difficulty with both expressive language and reception of messages. Your client may have feelings of loss and social isolation imposed by the communication impairment. Although there may be no cognitive impairment, the client may need more "think time" for cognitive processing during a conversation.
### Impaired cognition
Impaired cognition can interfere with the communication process. The responsibility for assessing ability to understand, to give consent, and to overcome communication difficulties rests with both social services and health care workers. At times staff fail to determine the extent to which the client can understand or fail to effectively use alternative communication aids (O'Halloran et al., 2008).
#### Children
Atypical communication is often the first behavioral clue to cognitive impairment in young children, associated with conditions such as mental retardation, autism, and affective disorders. As these children grow, subtle distortions in communication may exist. For example, children with Down syndrome, have been shown to judge nonverbal facial expressions more positively than other children, which could lead to a misinterpretation of the nurses' messages.
#### Older Adults
Older cognitively impaired clients also have altered communication pathways (Magee & Bowen, 2008). While older adults retain their mental acuity, a study by Naylor and colleagues (2005) found cognitive deficits in 35% of 145 adults older than 70 years who were hospitalized for routine medical or surgical events. Memory loss, for example, interfered with client ability to correctly take prescribed medications.
### Communication deficits associated with some mental disorders
Clients with serious mental disorders have a different type of communication deficit resulting from a malfunctioning of the neurotransmitters that normally transmit and make sense out of messages in the brain. Social isolation and impaired coping may accompany the client's inability to receive or express language signals.
Other communication problems occur with different mental disorders. As an example, some clients with mental disorders can have intact sensory channels, but they cannot process and respond appropriately to what they hear, see, smell, or touch. In some forms of _schizophrenia_ there are alterations in the biochemical neurotransmitters in the brain, which normally conduct messages between nerve cells and help orchestrate the person's response to the external environment. Messages have distorted meanings. It is beyond the scope of this text to discuss the psychotic client's management. Basic communications strategies are described.
Some clients with mental disorders present with a poverty of speech and limited content. Speech appears blocked, reflecting disturbed patterns of perception, thought, emotions, and motivation. You may notice a lack of vocal inflection and an unchanging facial expression. A "flat affect" makes it difficult to truly understand your client. Illogical thinking processes may manifest in the form of illusions, hallucinations, and delusions. Common words assume new meanings known only to the person experiencing them.
### Environmental deprivation as related to illness
Communication is particularly important in nursing situations characterized by sensory deprivation, physical immobility, limited environmental stimuli, or excessive, constant stimuli (Figure 17-1). Nurses need to show concern for the client in bewildering situations, such as emergency departments or intensive care units (ICUs). Clients may be frightened, in pain, and may by unable to communicate easily with others, because of intubation or other complications. Research indicates that the absence of interpersonal stimulation and the subsequent gradual decline of cognitive abilities are related. Clients with normal intellectual capacity can appear dull, uninterested, and lacking in problem-solving abilities if they do not have frequent interpersonal stimulation.
Developing an Evidence-Based Practice
Lindenmayer JP, Liu-Seifert H, Kulkarni PM et al.: Medication nonadherence and treatment outcome in patients with schizophrenia of schizoaffective disorder with suboptimal prior response, _J Clin Psychiatry_ 70(7):990–997, 2009.
Figure 17-1 Situational Factors that Affect Client Responses to Critical Care Hospital Situations.
• Anxiety/fear
• Pain
• Altered stimuli - too much/too little [includes unusual noises, isolation]
• Sleep deprivation
• Unmet physiological needs such as thirst
• Losing track of time
• Multiple life changes
• Multiple care providers
• Immobility
• Frequent diagnostic procedures
• Lack of easily understood information
In an extensive review of research dealing with health care issues and clients with communication disabilities, O'Halloran et al. (2008) reported an astonishing lack of available studies. Schizophrenic clients with better symptom control are better able to communicate.
This large, randomized, 8-week study of antipsychotic medication compliance in 599 schizophrenic clients was conducted in 55 centers. In the post hoc analysis, (partial) nonadherence was determined by daily pill count and, in some, by plasma levels of medication. Baseline behaviors and treatment outcomes were assessed using multiple measurement tools.
_Results:_ Thirty-four percent of subjects were nonadherent at least once during the study. Nonadherence was significantly related to reduced likelihood of treatment response (control of schizophrenic symptoms). No baseline characteristics were predictive of nonadherence to medication treatment except depression level. Higher depressive symptom scores (more sadness, concentration difficulties, and pessimistic thoughts as measured on the Montgomery–Asberg Depression Rating Scale MADRS]) were significantly related to greater nonadherence. A lower response rate was notable by Week 2.
_Application to Your Clinical Practice:_ Clients who receive antipsychotic prescriptions should be assessed for (and treated for) depression. Clients who show poor control of their schizophrenic symptoms by the second week of treatment should be specifically, carefully assessed for medication full compliance. Targeting clients at greater risk for nonadherence and devising appropriate early interventions may improve medication adherence, and thus improve symptom control/treatment outcome.
## Applications
Communication deficits may be developmental or acquired. Some nurse authors are redefining our nursing role from caregiver to care partner. This embodies the idea that clients living with communication disabilities need to be active participants in their care (Boyles, Bailey, & Mossey, 2008). All staff needs to be aware of the client's communication disability, using a sign or symbol on the door, and so on. In a number of studies, nurses lacked abilities to communicate effectively with these clients (Braun-Janzen et al., 2009; Gordon, Ellis-Hill, & Ashburn, 2009).
Nursing _goals_ are to enable our clients to communicate effectively with a variety of health professionals. The following section should give you some basic strategies for fostering communication with these clients. Aspects of your nurse role include assessment, development of strategies to facilitate communication, education, provision of psychological support, and advocacy.
## Early recognition of communication deficits
Identification of communication deficit is one aspect of your role. For example, if your 4-year-old client fails to speak at all or uses a noticeably limited vocabulary for his or her age, cannot name objects or follow your directions, would you recognize the need for further assessment? Given this history, you could make a referral for speech and language evaluation.
## Assessment of current communication abilities
You need to assess each client's communication problems. Your plan of care can then be tailored to help meet identified communication needs. Provision of alternative communication methods is required by law.
## Communication strategies
Evidence-based practice suggests you create a quiet environment, allocate more of your time to facilitate communication, take time to listen, ask yes/no questions, observe nonverbal cues, repeat back comments, effectively use communication equipment, assign same staff for care continuity, and encourage family members to be present to assist in communications (Finke, Light, & Kitko, 2008; O'Halloran et al., 2008).
### Clients with hearing loss
Assessment of functional hearing ability is recommended for all your clients. Assessment of auditory sensory losses can provide an opportunity for referral. Your assessment should include the age of onset and the severity of the deficit. Hearing loss that occurs after the development of speech means that the client has access to word symbols and language skills. Deafness in children can cause developmental delays, which may need to be taken into account in planning the most appropriate communication strategies. Clues to hearing loss occur when clients appear unresponsive to sound or respond only when the speaker is directly facing them. Ask clients whether they use a hearing aid and whether it is working properly.
Strategies for communicating with clients who have a hearing loss depend on the severity of the deafness. Covering your face with a mask or speaking with an accent may make it impossible for a lip reader to understand you. Communication-assisting equipment should be available. We need to know how to operate auditory amplifiers such as assisted listening devices, hearing aids, and telephone attachments. Often, clients have hearing aids but fail to use them because they do not fit well or are hard to insert. Some complain that the hearing aid amplifies all sounds indiscriminately, not just the voices of people in conversation. O'Halloran et al. (2008) cautions about the attitude displayed by providers. The client may have had a prior experience in which the provider viewed his deafness as sign of lack of intelligence or treated him with a lack of respect. Exercises 17-1 and 17-2 will help you understand what it is like to have a sensory deficit.
EXERCISE 17-1 Loss of Sensory Function in Geriatric Clients
Purpose: To assist students in getting in touch with the feelings often experienced by older adults as they lose sensory function. If the younger individual is able to "walk in the older person's shoes," he or she will be more sensitive to the losses and needs created by those losses in the older person.
Procedure:
1. Students separate into three groups.
2. Group A: Place cotton balls in your ears. Group B: Cover your eyes with a plastic bag. Group C: Place cotton balls in your ears and cover your eyes with a plastic bag.
3. A student from Group B should be approached by a student from Group A. The student from Group B is to talk to the student from Group A using a whispered voice. The Group A student is to verify the message heard with the student who spoke. The student from Group B is then to identify the student from Group A.
4. The students in Group C are expected to identify at least one person in the group and describe to that person what he or she is wearing. Each student who does not do the description is to make a statement to the other person and have that individual reveal what he or she was told.
5. Having identified and conversed with each other, hold hands or remain next to each other and remove the plastic bags and cotton balls (to facilitate verification of what was heard and described).
Discussion:
1. How did the loss you experienced make you feel?
2. Were you comfortable performing the function expected of you with your limitation?
3. What do you think could have been done to make you feel less handicapped?
4. How did you feel when your "normal" level of functioning was restored?
5. How would you feel if you knew the loss you just simulated was to be permanent?
6. What impact do you think this experience might have on your future interactions with older individuals with such sensory losses?
Courtesy B. J. Glenn, former member of the North Carolina State Health Coordinating Council Acute Care Committee, 1998.
EXERCISE 17-2 Sensory Loss: Hearing or Vision
Purpose: To help raise consciousness regarding loss of a sensory function.
Procedure:
• Pair up with another student. One student should be blindfolded. The other student should guide the "blind" student on a walk around the campus.
• During a 5- to 10-minute walk, the student guide should converse with the "blind" student about the route they are taking.
or
• Watch the first 2 minutes of a television show with the sound turned off. All students should watch the same show (e.g., the news report or a rerun of a situation comedy).
• In class, students share observations and answer the following questions.
Discussion:
1. Were perceptual differences noted? What implications do you think these differences have in working with blind or deaf clients?
2. How frustrating was it for you to be sensory deprived? How did it make you feel?
3. What did you learn about yourself from this exercise that you can apply to your nursing clinical practice?
Refer to Box 17-1 to adapt your communication techniques. American Sign Language has been a standard communication tool for many years; however, few care providers were able to use it. Basic strategies include use of paper and pencil, use of hand signals or gestures, and use of technologic communication assistance devices such as:
BOX 17-1 Suggestions for Helping the Client with Sensory Loss
• Always maximize use of sensory aids, such as hearing aid, pictures, sign language, regular or laser cane (which vibrates a warning if an obstacle is within 5 feet).
• Pick the means of available communication best suited to your client.
• Help elderly clients adjust hearing aids. Lacking fine motor dexterity, the elderly client may not be able to insert aids to amplify hearing.
For Hearing-Impaired Clients
• Stand or sit so that you face the client and the client can see your facial expression and mouthing of words. Communicate in a well-lighted room.
• Use facial expressions and gestures that reinforce verbal content.
• Speak distinctly without exaggerating words. Partially deaf clients respond best to well-articulated words spoken in a moderate, even tone.
• Write important ideas and allow the client the same option to increase the chances of communication. Always have a writing pad available.
• Always face the client when communicating so the client can see your lips move.
• Tap on the floor or table to get client's attention via the vibration.
• Arrange for TTY (amplified telephone handset) for client with partial hearing loss.
• If unable to hear, rely primarily on visual materials.
• Arrange for closed-captioned television.
• Use text messaging on client's cell phone or e-mail at his or her computer.
• Encourage the client with hearing loss to verbalize speech, even if the person uses only a few words or the words are difficult to understand at first.
• Use an intermediary, such as a family member who knows sign language, to facilitate communication with deaf clients who sign.
For Vision-Impaired Clients
• Let the person know when you approach by a simple touch, and always indicate when you are leaving.
• Adapt teaching for low vision by using large print, audiotaped information, or Braille.
• Do not lead or hold the client's arm when walking; instead, allow the person to take your arm.
• Use touch and close physical proximity while you are with the client; give the person something substantial to touch in your absence.
• Develop and use signals to indicate changes in pace or direction while walking.
• _Speech amplifiers_ such as the pocket talker
• Spelling boards or communication boards
• **Wireless text communication** (text messaging) on cell phones: deaf clients use handheld electronics to exchange e-mail and receive instant alphanumeric messaging, paging, and so on.
• The **Optacon** : a reading device that converts printed letters into a vibration that can be felt by the client who is both deaf and blind
• Pictographs: laminated **cards** that show drawings of common foods and activities; products such as the "AT&T Picture Guide" are commercially available and help you get your point across; these may be useful also with clients whose language you do not speak, as well as those clients with aphasia or altered hearing
• **Pagers** : vibrate to alert the deaf person to an incoming message, convert voice mail into e-mail that can be read
• **Real-time captioning devices** : allow spoken words to be typed simultaneously onto a screen
• **Interactive videodiscs** : have signing avatars, which are on-screen figures that sign words preprogrammed into bar codes that you select or that you speak into a microphone
• **Speech-generating devices** are also available, including laptop computers, fax machines, and PDAs (electronic personal digital assistant computers small enough to be held in one hand)
• Devices such as hearing-amplified stethoscopes also allow hearing-impaired nurses to care for clients
Case Example
Two student nurses were assigned to care for 9-year-old Timmy, who is deaf and mute. When they went into his room for assessment, he was alone and appeared anxious. No information was available as to his ability to read lips, the nurses were not sure what reading skills he had, and they did not know sign language. So, instead of using a pad and paper for communication, they decided to role-play taking vital signs by using some funny facial expressions and demonstrating on a doll.
### Clients with vision loss
Vision assessment for impairment is recommended for all clients routinely. Nurses caring for any client with vision limitations should perform some evaluation and ensure that glasses and other equipment are available to hospitalized clients. Use of prompting and reinforcement are recommended (Parker et al., 2008).
Case Example
You can use words to supply additional information to counterbalance the missing visual cues. Ms. Sue Shu is a blind, elderly client who commented to Ruth, her student nurse, that she felt Ruth was uncomfortable talking with her and perhaps did not like her. Not being able to see Ruth, Ms. Shu interpreted the hesitant uneasiness in Ruth's voice as evidence that Ruth did not wish to be with her. Ruth agreed with Ms. Shu that she was quite uncomfortable but did not explain further. Had Ms. Shu been able to see Ruth's apprehensive body posture, she would have realized that Ruth was quite shy and ill at ease with _any_ interpersonal relationship. To avoid this serious error in communication, Ruth might have clarified the reasons for her discomfort, and the relationship could have moved forward.
Refer to Box 17-1 for strategies of use in caring for vision-impaired clients. Use of vocal cues (e.g., speaking as you approach) helps prevent startling the blind client. Because clients cannot see our faces or observe our nonverbal signals, we need to use words to express what the client cannot see in the message. It also is helpful to mention your name as you enter the client's presence. Even people who are partially blind appreciate hearing the name of the person to whom they are speaking. Vision enhancing equipment includes:
• Electronic magnifier machines
• Auditory teaching materials, such as on an audio-cassette
• Computer screen readers with voice synthesizers
• Braille keypads
• The Braille Alphabet Card (letters in both print and Braille, so both nurse and client can understand)
• The **Tellatouch** , a portable machine into which the nurse types a message that emerges in Braille on a punched-out paper in Braille format
• Large print materials
• **Voice synthesizers** (available in a wide variety of household appliances such as talking scales)
• **Telemicroscopes** : handheld telescopes
• **Video magnifying machines**
• Enhanced lighting, light filters that reduce glare and enhance contrast
When caring for clients with macular degeneration, remember to stand to their side, an exception to the "face them directly" rule applied with clients with hearing loss. Macular degeneration clients often still have some peripheral vision.
#### Use of Touch
The social isolation experienced by blind clients can be profound, and the need for human contact is important. Touching the client lightly as you speak alerts the client to your presence. Voice tones and pauses that reinforce the verbal content are helpful. The client needs to be informed when the nurse is leaving the room. Compensatory interventions for the blind include a plentiful assortment of auditory stimuli, such as books on tape and music, as well as tactile stimuli.
### Orientation to environmental hazards
When a blind client is being introduced to a new environmental setting, you should orient the client by describing the size of the room and the position of the furniture and equipment. When placing their food tray, describe the position of items, perhaps using a clock face analogy (i.e., "Carrots are at 2 o'clock, potatoes at 11 o'clock, etc.). If other people are present, you could name each person. A good communication strategy is to ask the other people in the room to introduce themselves to the client. In this way, the client gains an appreciation for their voice configurations. You should avoid any tendency to speak with a blind client in a louder voice than usual or to enunciate words in an exaggerated manner. This may be perceived by some clients as condescending or insensitive to the nature of the handicap. Voice tones should be kept natural.
The blind client needs guidance in moving around in unfamiliar surroundings. For example, surveyed blind clients said they needed assistance getting to and from their bathroom. One way of preserving the client's autonomy is to offer your arm to the client instead of taking the client's arm. Mention steps and changes in movement as they are about to occur to help the client navigate new places and differences in terrain.
### Impaired verbal communication secondary to speech and language deficits
Assessment of speech and language is part of the initial evaluation. For adults with aphasia, an assessment of the type your client is experiencing will aid in selecting the most appropriate intervention. Expressive language problems are evidenced in an inability to find words or to associate ideas with accurate word symbols. Some clients with expressive aphasia can find the correct word if given enough time and support. Other clients have difficulty organizing their words into meaningful sentences or describing a sequence of events. Clients with receptive communication deficits have trouble following directions, reading information, writing, or relating data to previous knowledge. Even when your client appears not to understand, you should explain in very simple terms what is happening. Using touch, gestures, eye movements, and squeezing of the hand should be attempted. Clients appreciate nurses who take the time to respond to communication attempts.
Refer to Box 17-2 for strategies to use with clients having speech deficits. Clients who lose both expressive and receptive communication abilities have _global aphasia._ These clients can become frustrated when they are not understood. Struggling to speak causes fatigue. Short, positive sessions are used to communicate. Otherwise, the client may become nonverbal as a way of regaining energy and composure. Changes in self-image occasioned by physical changes, the uncertain recovery course and outcome of strokes, shifts in family roles, and the disruption of free-flowing verbal interaction among family members all make the loss of functional communication particularly agonizing for clients. Any language skills that are preserved should be exploited. Other means of communication (e.g., pointing, gesturing, using pictures, and repeating phrases) can be used.
BOX 17-2 Strategies to Assist the Client with Speech and Language Difficulties
• Avoid prolonged, continuous conversations; instead, use frequent, short talks. Present small amounts of information at a time.
• When clients falter in written or oral expression, supply needed compensatory support.
• Praise efforts to communicate.
• Provide regular mental stimulation in a nontaxing way.
• Help clients focus on the faculties still available to them for communication.
• Allow extra time for delays in cognitive processing of information.
• For print materials, use short, bulleted lists.
Case Example
Your client Mr. Lopez is totally paralyzed immediately after a rupture of a blood vessel in his brain, except he can still blink his eyes. You tell him, "Blink once for yes and twice for no." You point out familiar objects in his immediate environment.
### Clients with impaired cognition or learning delay
As a nurse providing care to learning delay (LD) clients, you need to adapt your messages to an understandable level. This is crucial when you are seeking to gain informed consent for treatment. The rules outlining who can give informed consent were discussed in Chapter 2. To what extent should you involve your cognitively impaired client? Sowney and Barr (2007) note that emergency department nurses tend to overlook involving LD patients when explaining treatments and making care decisions, not just when obtaining informed consent. They recommend that nurses make the effort to involve cognitively impaired clients.
A good strategy is to enhance social interaction by emphasizing any activity that can be shared between nurse and client and between caregiver and client. Communication adaptations include simple explanations, touch, and use of familiar objects. Alternative methods of communication include music, _communication boards,_ picture _card,_ and use of _picture pain rating scales._
### Communication deficits associated with some mental disorders
When working with some clients with mental disorders, you will face a formidable challenge in trying to establish a relationship. Clients with altered reality discrimination have both verbal and nonverbal communication deficits. Rarely will this client approach you directly. The client generally responds to questions, but the answers are likely to be brief, and the client does not elaborate without further probes. Although the client appears to rebuff any social interaction, it is important to keep trying to connect. People with mental disorders such as schizophrenia are easily overwhelmed by the external environment. Tremeau and colleagues (2005) demonstrate that schizophrenic clients have the same expressive deficits as do depressed clients. Keeping in mind that the client's unresponsiveness to words, failure to make eye contact, unchanging facial expression, and monotonic voice are parts of the disorder and not a commentary on your communication skills helps you to continue to engage with the client.
If your client is hallucinating or using delusions as a primary form of communication, you should neither challenge their validity directly nor enter into a prolonged discussion of illogical thinking. Often you can identify the underlying theme the client is trying to convey with the delusional statement. For example, when your client says, "Voices are telling me to do...," you might reply, "It sounds as though you feel powerless and afraid at this moment." Listening to your client carefully, using alert posture, nodding to demonstrate active listening, and trying to make sense out of his underlying feelings models effective communication and helps you decode nonsensical messages. Exercise 17-3 may help you gain some understanding of communication problems experienced by the client with schizophrenia.
EXERCISE 17-3 Schizophrenia Communication Simulation
Purpose: To gain insight into communication deficits encountered by clients with schizophrenia.
Procedure:
1. Break class into groups of three (triads) by counting off 1, 2, 3.
2. Person 1 (the nurse) reads a paragraph of rules to the client and then quizzes him or her afterward about the content.
3. Person 2 (the client with schizophrenia) listens to everything and tries to answer the nurse's questions correctly to get 100% on the test.
4. Person 3 (representing the mental illness) speaks loudly and continuously in the client's ear while the nurse is communicating, saying things like "You are so stupid," "You have done bad things," and "It is coming to get you" over and over.
Discussion:
Did any client have 100% recall? Ask the client to share how difficult is it to communicate to the nurse when you are "hearing voices."
Courtesy Ann Newman, PhD, University of North Carolina, Charlotte.
### Clients experiencing treatment-related communication disabilities
Communication disabilities can stem from sedative medications, mechanical ventilation, isolation in an ICU, or isolation such as occurs when older adults are in long-term care facilities. A number of recent studies of client communication in intensive care show that they are very dependent on their nurse to institute communication. Specific recommended skills include asking many questions, asking questions your client can answer with yes or no, reading lips, using a communication board, offering pen and paper, and assessing whether your communication was successful. When a client is not fully alert, it is not uncommon for nurses to speak in his presence in ways they would not if they thought the client could fully understand what is being said, forgetting that hearing can remain acute. Good practice suggests you never say anything you would not want the client to hear.
In addition to conveying a caring, compassionate attitude, you may use several of the strategies for communicating listed in Box 17-3. Giving orienting cues is recommended, such as labeling of meals as breakfast, lunch, or dinner, and linking events to routines (e.g., saying, "The x-ray technician will take your chest x-ray right after lunch") helps secure the client in time and space. When clients are unable or unwilling to engage in a dialogue, you should continue to initiate communication in a one-way mode.
BOX 17-3 Strategies for Communicating with Clients in the Intensive Care Unit
• Encourage the client to display pictures or a simple object from home.
• Orient the client to the environment.
• Frequently provide information about the client's condition and progress.
• Reassure the client that cognitive and psychological disturbances are common.
• Give explanations before procedures by providing information about the sounds, sights, and feelings the client is experiencing.
• Provide the client with frequent orienting cues to time and place.
Case Example
_Nurse:_ I am going to give you your bath now. The water will feel a little warm to you. After your bath, your wife will be in to see you. She stayed in the waiting room last night because she wanted to be with you. (No answer is necessary if the client is unable to talk, but the sound of a human voice and attention to the client's unspoken concerns can be very healing.)
Your client should be called by name. We need to identify our name and explain procedures in simple language even if our client does not appear particularly alert. Clients who are awake or even semi-alert should not be allowed to stare at a blank ceiling for extended periods. Changing the client's position frequently benefits the person physiologically and offers us something to talk about. Our efforts to create a more stimulating environment, to offer reassurance and support have later been reported to have been meaningful to the client. If clients in ICUs become temporarily delusional or experiences hallucinations, you can use strategies similar to those used with the psychotic client. The client is reassured if you are able to confirm to him that experiencing strange sensations, thoughts, and feelings is a common occurrence in the ICU.
## Client advocacy
Our nurse role also includes acting as an advocate for our clients who have communication disabilities. Too often these clients are discounted. Medical treatment decisions may be made without seeking input from them. Appropriate communication aids may be withheld while the client is hospitalized. In the larger community, we need to advocate for community services designed to foster communication, including referrals to speech and language therapists.
## Summary
This chapter discusses the specialized communication needs of clients with communication deficits. Adapting our communication skills and projecting a caring, positive attitude are important in overcoming barriers. Basic issues and applications for communicating with clients experiencing sensory loss of hearing and sight are outlined. Sensory stimulation and compensatory channels of communication are needed for clients with sensory deprivation. All workers who come in contact with the client need to be aware of their communication impairments. We need to learn how to operate and fit equipment such as hearing aids, because hospitalized
Ethical Dilemma
What Would You Do?
Working in a health department clinic, the nurse—through a Spanish-speaking translator—interviews a 46-year-old married woman about the missing results of her recent breast biopsy for suspected cancer. Because the translator is of the same culture as the client and holds the same cultural belief that suicide is shameful, he chooses to withhold from the nurse information he obtained about a recent suicide attempt. If this information remains hidden from the nurse and doctor, could this adversely affect the client? What ethical principle is being violated?
clients often need help with devices. The mentally ill client has intact senses, but information processing and language are affected by the disorder. It is important for you to develop a proactive communication approach with clients who are learning impaired or who suffer from mental disorders. For clients such as those with aphasia, you can develop alternative methods of communicating. Other clients can experience communication isolation and temporary distortion of reality. Such clients need frequent cues that orient them to time and place, as well as providing sensory stimulation. Evidence shows that we need to be careful not to associate communication disability with intellectual dysfunction. Our skill in adapting communication is important to the client.
## References
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Crais, E.R., Watson, L.R., Baranek, G.T. Use of gesture development in profiling children's prelinguistic communication skills. _Am J Speech Lang Pathol_. 2009;18:95–108.
Finke, E.H., Light, J., Kitko, L. A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication. _J Clin Nurs_. 2008;17:2102–2115.
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Lieu, C.C., Sadler, G.R., Stohlmann, P.D. Communication strategies for nurses interacting with patients who are deaf. _Dermatol Nurs_. 2007;19(6):541–544. [549–551].
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McDonald, H.L. Inpatients with cerebral palsy and complex communication needs identified barriers to communicating. _Evid Based Nurs_. 2008;11(1):30.
Naylor, M.D., Stephens, C., Bowles, K.H., et al. Cognitively impaired older adults: from hospital to home. _Am J Nurs_. 2005;105(2):52–61.
O'Halloran, R., Hickson, L., Worrall, L. Environmental factors that influence communication between people with communication disability and their healthcare providers in hospital: a review of the literature within the International Classification of Functioning, Disability, and Health (ICF) framework. _Int J Lang Commun Disord_. 2008;43(6):601–632.
Parker, A.T., Grimmett, E.S., Summers, S. Evidence-based communication practices for children with visual impairments and additional disabilities: an examination of single-subject design studies. _J Vis Impair Blind_. 2008;102(9):540–552.
Pleis, J.R., Lethbridge-Cejku, M. Summary health statistics for US adults: National Health Interview Survey, 2006. National Center for Health Statistics. _Vital Health Stat_. 2007;10:235.
Rosenberg, E.A., Sperazza, L.C. The visually impaired patient. _Am Fam Physician_. 2008;77(100):1431–1436.
Sowney, M., Barr, O. The challenges for nurses communicating with cognitively impaired. _J Clin Nurs_. 2007;16(9):1678–1686.
Tremeau, F., Malaspina, D., Duval, F., et al. Facial expressiveness in patients with schizophrenia compared to depressed patients and nonpatient comparison subjects. _Am J Psychiatry_. 2005;162(1):92–101.
van der Pols, J.C., Bates, C.J., McGraw, P.V., et al. Visual acuity measurements in a national sample of British elderly people. _Br J Ophthalmol_. 2000;84(2):165–170.
World Health Organization. International classification of functioning, disability, and health. Geneva, Switzerland: Author, 2001.
USPSTF [United States Preventive Health Services Task Force], Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services: Recommendations of the US Preventive Services Task Force. author, 2008, <http://epss.ahrq.gov/ePSS/>. [accessed 5/20/09].
CHAPTER 18
# Communicating with Children
Kathleen Underman Boggs
Objectives
**At the end of the chapter, the reader will be able to:**
1 Identify how developmental levels impact the child's ability to participate in interpersonal relationships with caregivers.
2 Briefly discuss one research-based application in communicating with a child.
3 Describe modifications in communication strategies to meet the specialized needs of children.
4 Describe interpersonal techniques needed to interact with concerned parents of ill children.
5 Discuss application on one research study results to clinical practice.
This chapter is designed to help you recognize and apply communication concepts related to the nurse-client relationship in pediatric clinical situations. Each nursing situation represents a unique application of communication strategies. Tools needed by caregivers to provide effective and ethical care are attitudinal, cognitive, developmentally appropriate, and interpersonal. For each of these domains, the child's and family's socioeconomic status and cultural background must be considered.
Communicating with children at different age levels requires modifications of the skills learned in previous chapters. By understanding the child's cognitive and functional level, you are able to select the most appropriate communication strategies. Children undergo significant age-related changes in the ability to process cognitive information and in the capacity to interact effectively with the environment. To have an effective therapeutic relationship with a child, you need to understand the feelings and thought processes from the child's perspective and convey honesty, respect, and acceptance of feelings.
Communicating with parents of seriously ill children requires a deliberate effort. Hong, Murphy, and Connolly's (2008) study found that less than half of parents surveyed rated communication with nurses as excellent. Parents need explanations they can understand, need to have established trust with the nurse, and need to feel they have some control over what is happening to their child. This chapter identifies strategies to enhance communication with parents.
## Basic concepts
Location
More than 70% of pediatric care occurs in ambulatory settings. Quality of care studies indicate that in all settings children receive only half to two thirds of "best evidence" interventions (Mangione-Smith et al., 2007). These deficits may compromise child safety.
### Attitude
Major changes in society are mirrored in changing health care for children. Involving children in their own health care decision making is seen as desirable. Yet few care providers give real choices (Coad & Shaw, 2008). Serious consideration needs to be given to educating care providers about the need to involve children in their care, to devolve adult control and give the child some choices. Making the child a (limited) partner might lead to better health outcomes than the current attitude of treating him as a target for our delivery of care.
### Cognition
Childhood is very different from adulthood. A child has fewer life experiences from which to draw and is still in the process of developing skills needed for reasoning and communicating. Every child's concept of health and illness must be considered within a developmental framework. Erikson's (1963) concepts of ego development and Piaget's (1972) description of the progressive development of the child's cognitive thought processes together form the theoretical basis for the child-centered nursing interventions described in this chapter. Both theorists say that the child's thought processes, ways of perceiving the world, judgments, and emotional responses to life situations are different from those of the adult. Cognitive and psychosocial development unfold according to an ordered hierarchical scheme, increasing in depth and complexity as the child matures.
#### Developmentally appropriate
Piaget's descriptions of stages of cognitive development provide a valuable contribution toward understanding the dimensions of a child's perceptions. Cognitive development and early language development are integrally related. Although current developmental theorists expand on Piaget's theoretical model by recognizing the effects of the parent-child relationship and a stimulating environment on developing communication abilities, his work forms the foundation for the understanding of childhood cognitive development. Piaget observed cognitive development occurring in sequential stages (Table 18-1). The ages are only approximated, because Piaget himself was not specific.
TABLE 18-1
Stages of Cognitive Development
Adapted from Piaget J: _The child's conception of the world,_ Savage, MD, 1972, Littlefield, Adams.
Wide individual differences exist in the intellectual functioning of same-age children. Variations also occur across situations, so that the child under stress or in a different environment may process information at a lower level than he would under normal conditions. Because two children of the same chronologic age may have quite different skills as information processors, we need to assess level of functioning. Language alternatives familiar to one child because of certain life experiences may not be useful in providing health care and teaching with another. Integrating cognitive and psychosocial developmental approaches into communication with children at different ages enhances effectiveness.
### Interpersonal
Gender differences in communication
Some studies show school-age children are more satisfied if their health care provider is the same sex. Woman providers tend to engage in more social conversation, spend more time giving encouragement and reassurance, and more often speak directly to children when gathering information. Use of good age-appropriate communication strategies probably outweighs gender as a factor in successful communication with a child, but gender cannot be excluded as a factor affecting this communication.
#### Understanding the Ill Child's Needs
Difficulties arise in adult-child communication, in part, because of the child's limited experience in interpreting subtle nuances of facial expression, inflection, and word meanings. When illness and physical or developmental disabilities occur during formative years, situational stressors are added that affect the way children perceive themselves and the environment. Illness may lead to significant alterations in role relationships with family and peers. You need to assess not only the physical care needs of the child but the impact of the illness on the child's self-esteem and on his or her relationships with family and friends. Responses to hospitalization vary with the individual according to his or her age. Negative responses may include separation anxiety, night terrors, feeding disturbances, or regression to earlier developmental stage behavior. Things that affect a child's response may include the chronicity of illness, its impact on lifestyle, the child's cognitive understanding of the disease process, and the family's ability to cope with care demands.
Children with Special Health Care Needs: Some children have chronic physical, developmental, behavioral, or emotional conditions that require health services. In the United States, 1 in every 5 households has a child with a chronic condition, totaling more than 10 million children (Looman, O'Connor-Von, & Lindeke, 2008). Many of these children previously would have died but were saved by current technology. Some are left with chronic problems (see discussion in Chapter 17).
#### Family-centered care
The trend toward family-centered health care of children will continue with attention to family diversity and family processes in "successful" families. A growing body of research is documenting relationships between such processes and child health outcomes. If the child needs to be hospitalized, this is a _situational crisis_ for the child and the entire family. Hospitalization is always stressful. Hospitalized children have to contend not only with physical changes but with possible separation from family and friends, as well as living in a strange, frightening, and probably hurtful environment. Nurses need to assist parents to meet their hospitalized child's needs. The family needs to learn new interactional patterns and coping strategies that take into consideration the meaning of an illness and disability in family life. _Prehospitalization preparation_ needs to be done to decrease the child's anxiety. Before elective procedures, many hospitals now offer orientation education tours to youngsters. There are many good books designed to prepare children for their hospitalization available in most public libraries. In the case of hospitalization for critical illness, good communication between staff and family is viewed as most important. A key component of this communication is sharing decision making with the child.
Developing an Evidence-Based Practice
Hong SS, Murphy SO, Connolly PM: Parental satisfaction with nurses' communication and pain management in a pediatric unit, Pediatr Nurs 34(4):289–293, 2008.
To test the hypothesis that parental satisfaction with communication with nurses caring for their child would increase after an intervention, 50 parents randomly selected from a total of 400 whose child was treated on one pediatric unit were surveyed in a pretest and post-test study. The intervention consisted of a 30-minute educational inservice for 20 nurses and distribution of a written brochure to parents explaining pain management.
_Results_ : Mean satisfaction scores for nurses' communication increased from 81.6 to 85.3; satisfaction with explanations of treatment increased from 78 to 82, and satisfaction with pain management increased from 80.8 to 82.4. These increases show a positive trend, but none was statistically significant.
_Application to Your Clinical Practice_ : Lack of significant findings limits application. Both presurvey and postsurvey scores show that there are still parents with needs for improved communication. Specifically, they need better explanations about treatments, tests, and pain management. All parents need clear communication from nursing staff. Written materials can successfully be used to reinforce this communication.
## Applications
Although children historically have not been the subjects of study, research has contributed to our knowledge of child learning and development. Children are more vulnerable, and thus are entitled to extra protection as research subjects, though Pieper (2008) argues that some would want to participate and are entitled to. Findings are limited because of over-reliance on what parents have told us. Agencies see children as similar, without consideration of differences because of age, gender, race, or culture. To give one example, many of the medicines we use to treat children have been tested only on adults by pharmaceutical companies.
Major sources of stress for parents of critically ill children include uncertainty about current condition or prognosis, lack of control, and lack of knowledge about how to best help their hospitalized child or how to deal with their child's response. Although more nursing research is being conducted on effective communication with both parents and their ill children, many of the applications we discuss are based more on experience than on research.
## Assessment
Assessing a child's reaction to illness requires knowing the child's normal patterns of communication. Interactions are observed between parent and child. The child's behavioral responses to the entire interpersonal environment (including nurse and peers) are assessed. Are the child's interactions age-appropriate? Are behaviors organized, or is the child unable to complete activities? Does the child act out an entire play sequence, or is such play fragmented and disorganized? Do the child's interactions with others suggest imagination and a broad repertoire of relating behaviors, or is communication devoid of possibilities? Because children cannot communicate fully with us, we have a special responsibility to assess for problems. For example, nearly a million American children are victims of neglect, physical abuse, psychological abuse, or even sexual abuse (Taylor, Guteman, Lee, & Rathouz, 2009). Once baseline data have been collected, you can plan specific communication strategies to meet the specialized needs of the child client (Figure 18-1). An overview of nursing adaptations needed to communicate effectively with children is summarized in Box 18-1.
BOX 18-1 Nurse-Child Communication Strategies: Adapting Communication to Meet the Needs of the Ill Child
• Develop an understanding of age-related norms of development
• Let the child know you are interested in him or her; convey respect and authenticity.
• Let the child know how to summon you (call bell, etc.).
• Develop trust through honesty and consistency in meeting the child's needs.
• Use "transitional objects" such as familiar pictures or toys from home.
• Assess:
• Level of understandings
• The child's needs in relation to the immediate situation
• The child's capacity to cope successfully with change
• Observe for nonverbal cues.
• Use _nonverbal_ communication:
• Tactile (soothing strokes)
• Kinesthetic (rocking)
• get down to the child's height; don't tower over him or her
• Make eye contact and use reassuring facial expressions
• Interpret the child's nonverbal cues verbally back to him
• Instead of conversation, use some indirect age-appropriate communication techniques (e.g., storytelling, picture drawing, music, creative writing)
• Use _verbal_ communication:
• Use familiar vocabulary
• Listen without interrupting
• Humor and active listening to foster the relationship
• Use open-ended questions
• Use "I" statements
• Help child to clarify his ideas and feelings ("Tell me more...," "You got scared when...")
• Respect the child's privacy.
• Accept child's emotions.
• Help child with the difference between thoughts and actions.
• Increase coping skills by providing play opportunities; use creative, unstructured play, medical role-play, and pantomime.
• Use alternative, supplementary communication devices for children with specialized needs (e.g., sign language and computer-enhanced communication programs).
Revisions include limited material from University of California Library Systems: "Communicating with Your Child," 2007; see online references, www.mdconsult.com/das/patient/body/115729442-4/788918080/10068/18752.html.
Figure 18-1 Nursing strategies must be geared toward the developmental level of the child.
### Regression as a form of childhood communication
A severe illness can cause a child to show behaviors that are reminiscent of an earlier stage of development. A certain amount of regression is normal. Common behaviors include whining, demanding undue attention, withdrawal, or having toileting "accidents." These behaviors might stem from the powerlessness the child feels in attempting to cope with an overwhelming, frightening environment. Reassuring the parent that this is a common response to the stress of illness can be helpful.
Because children have limited life experience to draw from, they exhibit a narrower range of behaviors in coping with threat. The quiet, overly compliant child who does not complain may be more frightened than the child who screams or cries. This should alert you to the child's emotional distress. You need to obtain detailed information regarding the usual behavioral responses of the family and child. Some behaviors that look regressive may be a typical behavioral response for the child (e.g., the 2-year-old who wants a bedtime bottle). A complete baseline history offers a good counterpoint for assessing the meaning of current behaviors.
### Age-appropriate communication
An assessment of vocabulary and understanding is essential in fostering communications. Whenever possible, you should communicate using words familiar to the child. Parents are valuable resources in helping interpret behavioral data. You might assist a child who is having difficulty finding the right words by reframing what he said and repeating it in a slightly different way.
The ill child's peers often have difficulty accepting individual differences created by health deviations. They lack the knowledge and sensitivity to deal with physical changes that they do not understand, as evidenced by "bald" jokes about the child receiving chemotherapy. Children with hidden disorders such as diabetes, some forms of epilepsy, or minimal brain dysfunction are particularly susceptible to interpersonal distress. For example, it may be difficult for diabetics to regulate their intake of fast foods when all of their friends are able to eat what they want. When peer pressure is at its peak in adolescence, a teenager with a newly diagnosed convulsive seizure disorder may find it difficult to tell peers he no longer can ride his bicycle or drive a car. Unless the family and nurse provide appropriate interpersonal support, such children have to cope with an indistinct assault to their self-concept alone. A summary of age-appropriate strategies is provided in Box 18-2.
BOX 18-2 Key Points in Communicating with Children According to Age Group
Infants
• Nonverbal communication is a primary mode.
• Infants are biologically "wired" to pay close attention to words. In first year, infants are able to distinguish all conversational sounds.
• Infants are bonded to primary caregivers only. Those older than 8 months may display separation anxiety when separated from parent or when approached by strangers.
Use Kinesthetic Communication
• Use stroking, soft touching, and holding.
• Use motion (e.g., rocking) to reassure. Allow freedom of movement, and avoid restraining when possible.
• Learn specifically how the primary caregiver provides care in terms of sleeping, bathing, and feeding, and attempt to mimic these approaches.
Hold Close to Adapt to Limited Vision (20/200–20/300 at Birth)
• Encourage the infant's caregivers (parents) to use a lot of intimate space interaction (e.g., 8–18 inches). Mimic the same when trust is established.
Talk with Infants
• Talk with infants in normal conversational tones; soothe them with crooning voice tone.
Establish Trust
• Use parents to give care. Arrange for one or both parents to remain within the child's sight.
Shorten Your Stature
• Sit down on chair, stool, or carpet to decrease posture superiority, so as to look less imposing.
Handle Separation Anxiety When Primary Caregiver Is Absent
• Establish rapport with the caregiver (parent) and encourage them to be with child and reassure child that staff will be there if they are away. At first keep at least 2 feet between nurse and infant. Talk to and touch the infant and initially smile often. Provide for kinesthetic approaches; offer self while infant is protesting (e.g., stay with the child; pick the child up and rock or walk; talk to the child about Mommy and Daddy and how much the child cares for them).
1- to 3-year-olds
• Child begins to talk around 1 year of age; learns nine new words a day after 18 months.
• By age 2, child begins to use phrases; should be able to respond to "what" and "where" type questions.
• By age 3, child uses and understands sentences.
Adapt to Limited Vocabulary and Verbal Skills
• Make explanations brief and clear. Use the child's own vocabulary words for basic care activities (e.g., use the child's words for defecate [poop, goodies] and urinate [pee-pee, tinkle]). Learn and use self-name of the child.
• Rephrase the child's message in a simple, complete sentence; avoid baby talk. Child should be able to follow two simple directions.
Continue to Use Kinesthetic Communication
• Allow ambulating where possible (e.g., using toddler chairs or walkers). Pull the child in a wagon often if child cannot achieve mobility.
Facilitate Child's Struggle with Issues of Autonomy and Control
• Allow the child some control (e.g., "Do you want a half a glass or a whole glass of milk?").
• Reassure the child if he or she displays some regressive behavior (e.g., if child wets pants, say, "We will get a dry pair of pants and let you find something fun to do.").
• Allow the child to express anger and to protest about his or her care (e.g., "It's okay to cry when you are angry or hurt.").
• Allow the child to sit up or walk as often as possible and as soon as possible after intrusive or hurtful procedures (e.g., "It's all over and we can do something more fun.").
• Use nondirective modes, such as reflecting an aspect of appearance or temperament (e.g., "You smile so often."), or playing with a toy and slowly coming closer to and including the child in play.
Recognize Fear of Bodily Injury
• Show hands (free of hurtful items) and say, "There is nothing to hurt you. I came to play/talk."
Accept Egocentrism and Possible Regression
• Allow child to be self-oriented. Use distraction if another child wants the same item or toy rather than expect the child to share. Some children cope with stress of hospitalization by regressing to an earlier mode of behavior, such as wanting to suck on a bottle, and so forth.
Redirect Behavior to a Verbal Level
• Use a nondirective approach. Sit down and join the parallel play of the child. Reflect messages sent by toddler (nonverbally) in a verbal and nonverbal manner (e.g., "Yes, that toy does lots of interesting and fun things.").
Deal with Separation Anxiety
• Accept protesting when parent(s) leave. Hug, rock the child, and say, "You miss Mommy and Daddy! They miss you too." Play peek-a-boo games with the child. Make a big deal about saying, "Now I am here."
• Show an interest in one of the child's favorite toys. Say, "I wonder what it does" or the like. If the child responds with actions, reflect them back.
3- to 5-year-olds
• Most children this age can make themselves understood to strangers.
• They speak in sentences but are unable to comprehend abstract ideas.
• Unable to recognize their own anxiety, at this age some will somaticize (i.e., complain only of stomachache, etc.).
• They begin to understand cause-and-effect relationships; should be able to understand "If you do..., then we can..."
• Can follow a series of up to four directions, unless anxious about being hurt, and so on.
Use Age-Appropriate, Simple Vocabulary
• Use simple vocabulary; avoid lengthy explanations. Focus on the present, not the distant future; use concrete, meaningful references. For example, say, "Mommy will be back after you eat your lunch" (instead of "at 1 o'clock").
Behave in a Culturally Sensitive Manner
• In some cultures, child is unable to tolerate direct eye-to-eye contact, so use some eye contact and attending posture. Sit or stoop, and use a slow, soft tone of voice.
Attempt to Decrease Anxiety about Being Hurt
• Use brief, concrete, simple explanations. Delays and long explanations before a painful procedure increase anxiety.
• Be quick to complete the procedure; give explanations about its purpose afterward. For example, say, "Jimmy, I'm going to give you a shot," then quickly administer the injection. Then say, "There. All done. It's okay to cry when you hurt. I'd complain too. This medicine will make your tummy feel better." Some experts suggest you create a "safe zone" in the child's bed by doing all painful procedures elsewhere, perhaps in a treatment room.
Use Play Therapy
• Explanations and education can be done using imagination (puppetry, drama with dress-ups), music, or drawings.
• Allow the child to play with safe equipment used in treatment. Talk about the needed procedure happening to a doll or teddy bear, and state simply how it will occur and be experienced. Use sensory data (e.g., "The teddy bear will hear a buzzing sound.").
Use Distraction and a Sense of Humor
• Tell corny jokes and laugh with the child.
Allow for Child's Continuing Need to Have Control
• Provide for many choices (e.g., "Do you want to get dressed now or after breakfast?").
5- to 10-year-olds
• They are developing their ability to comprehend. Can understand sequencing of events if clearly explained: "First this happens..., then..."
• They can use written materials to learn.
Facilitate Child to Assume Increased Responsibility for Own Health Care Practices
• Include the child in concrete explanations about condition, treatment, and protocols.
• Use draw-a-person to identify basic knowledge the child has and build on it.
• Use some of the same words the child uses in giving explanations.
• Use sensory information in giving explanations (e.g., "You will smell alcohol in the cast room.").
• Reinforce basic health self-care activities in teaching.
Respect Increased Need for Privacy
• Knock on the door before entering; tell the client when and for what reasons you will need to return to his or her room.
11-year-olds and older
• Have an increased comprehension about possible negative threats to life or body integrity, yet some difficulty in adhering to long-term goals.
• Continue to use mainly concrete rather than abstract thinking.
• They are struggling to establish identity and be independent.
Verbalize Issues in Age-Appropriate Ways
• Talk about treatment protocols that require giving up immediate gratifications for long-term gain. Explore alternative options (e.g., tell a diabetic adolescent who must give up after-school fries with friends that he or she could save two breads and four fats exchanges to have a milkshake). If you use abstract thinking, look for nonverbal cues (e.g., puzzled face) that may indicate lack of understanding; then clarify in more concrete terms. Use humor or street slang, if appropriate.
Remember That Confidentiality May Be an Issue
• Reassure the adolescent about the confidentiality of your discussion, but clearly state the limits of this confidentiality. If, for example, the child should talk of killing himself, this information needs to be shared with parents and staff.
Allow Sense of Independence
• Allow participation in decision making, wearing own clothes. Avoid an authoritarian approach when possible. Avoid a judgmental approach. Use a clarifying and qualifying approach. Actively listen. Accept regression.
Assess Sexual Awareness and Maturation
• Offer self and a willingness to listen. Provide value-free, accurate information.
Updated 2010, from material originally supplied by Joyce Ruth, MSN, University of North Carolina Charlotte, College of Health Sciences.
## Communicating with children with psychological behavioral problems
One out of 10 adolescents and children in our society suffer from a mental illness These illnesses lead to some level of interactional problems, which may be encountered by nurses in schools, hospitals, or clinics treating common physical illnesses. Discussion of mental illness and appropriate interventions is beyond the scope of this textbook. Please refer to a multitude of hot links available through U.S. Health and Human Services Web site in the Maternal Child Health Library (Online Resources: MCH, www.hhs.gov/mch).
## Communicating with physically ill children in the hospital and ambulatory clinic
Overestimating a child's understanding of information about illness results in confusion, increased anxiety, anger, or sadness. Beyond physiologic care, ill children of all ages need support from every member of the health team—support that they normally would receive from parents. The nurse must provide stimulation to talk, listen, and play. Play is their language, especially because children have major difficulties verbalizing their true feelings about the treatment experience. As nurses, we adapt our communication to meet the ill child's needs. Many agencies also have play therapists who serve as excellent resources for staff.
### Infants
Cues to assessment of the preverbal infant include tone of the cry, facial appearance, and body movements. Because the infant uses the senses to receive information, nonverbal communication (e.g., touch) is an important tool for the pediatric nurse. Tone of voice, rocking motion, use of distraction, and a soothing touch can be used in addition to or in conjunction with verbal explanations. Face-to-face position, bending or moving to the child's eye level, maintaining eye contact, and making a reassuring facial expression further help in interactions with infants.
Anticipate developmental behaviors such as "stranger anxiety" in infants between 9 and 18 months of age. Rather than reaching to pick a child up immediately, the nurse might smile and extend a hand toward the child or stroke the child's arm before attempting to hold the child. In this way, the nurse acknowledges the infant's inability to generalize to unfamiliar caregivers. If the child is able to talk, asking the child his or her name and pointing out a notable pleasant physical characteristic conveys the impression that you see the child client as a unique person. To a tiny child, this treatment can be synonymous with caring.
### Toddlers
Almost all small children receiving invasive treatment feel some threat to their safety and security, one of Maslow's hierarchies of human needs. This need is exaggerated in toddlers and young children, who cannot articulate their needs or understand why they are ill. To help the child's comprehension, use phrases rather than long sentences and repeat words for emphasis. Because the toddler has a limited vocabulary, you may need to put into words the feelings that the ill child is conveying nonverbally.
#### Evaluate the Agency Environment
Is it safe? Does it allow for some independence and autonomy? Care in the ambulatory setting is facilitated if a parent or caregiver is present. Agency policies should promote parent-child contact (e.g., unlimited visiting hours, rooming in, or use of audiocassettes of a parent's voice). Familiar objects make the environment feel safer. Use transitional objects such as a teddy bear, blanket, or favorite toy to remind the alone or frightened child that the security of the parent is still available even when he is not physically present. Some hospitals offer a prehospitalization orientation.
Distraction is a successful strategy with toddlers in ambulatory settings. Use of stuffed animals, wind-up toys, or "magic" exam lights that blow out "like a birthday candle" can turn fright into delight. The author wears a small toy bear on her stethoscope and asks the child to help listen for a heart sound from the bear, so the child focuses on the toy, making it easier to listen to the child's heart.
## Preschoolers
Throughout the preoperational period, young children tend to interpret language in a literal way. For example, the child who is told that he will be "put to sleep" during the operation tomorrow may think it means the same as the action recently taken for a pet dog who was too ill to live. Children do not ask for clarification, so messages can be misunderstood quite easily.
Preschool children have limited auditory recall and are unable to process auditory information quickly. They have a short attention span. Verbal communication with the preschool child should be clear, succinct, and easy to understand.
Before the age of 7 years, most children cannot make a clear distinction between fantasy and reality. Everything is "real," and anything strange is perceived as potentially harmful. In the hospital, preschool children need frequent concrete reminders to reinforce reality. Assigning the same caregiver reduces insecurity. Visiting the preschooler at the same time each day and posting family pictures are simple strategies to reduce the child's fears of abandonment. You can link information to activities of daily living. For example, saying, "Your mother will come after you take your nap," rather than "at 2 o'clock" is much more understandable to the preschool client.
Children need to be assessed for misconceptions and troubling problems, preferably using free play and fantasy storytelling exercises. Egocentrism can be a normal developmental process that may prevent children from understanding why they cannot have a drink when they are fasting before a scheduled test. Explanations given a long time beforehand may not be remembered. If something is going to hurt, you should be forthright about it, while at the same time reassuring the child that he will have the appropriate support. Simple explanations reduce the child's anxiety. No child should ever be left to figure out what is happening without some type of simple explanation. Reinforce the child's communication by praising the willingness to tell you how he feels. Avoid judging or censuring the child who yells such things as "I hate you," or "You are mean for hurting me." Not being able to recognize or communicate anxiety, the child may just complain of a physical symptom, like a headache or stomachache (Emslie, 2008). Box 18-2 can help you focus on specific communication strategies with the hospitalized preschooler.
#### Play as a Communication Strategy
The preschooler lacks a suitable vocabulary to express complex thoughts and feelings. Small children cannot picture what they have never experienced. Play is an effective means by which a puzzling and sometimes painful real world can be approached. Play allows the child to create a concrete experience of something unknown and potentially frightening. By constructing a situation in play, the child is able to put together the components of the situation in ways that promote recognition and make it a concrete reality. When the child can deal with things that are small or inanimate, the child masters situations that might otherwise be overwhelming. Cartoons, pictures, or puppets can be used to demonstrate actions and terminology. Dolls with removable cloth organs help children understand scheduled operations.
Preschoolers tend to think of their illness, their separation from parents, and any painful treatments as punishment. Play can be used to help children express their feelings about an illness and to role-play coping strategies. Allowing the young child to manipulate syringes and give "shots" to a doll, or put a bandage or restraint on a teddy bear's arm allows the child to act out his feelings. The child becomes "the aggressor." Play can be a major channel for communication in the nurse-client relationship involving a young child. Preschool children develop communication themes through their play and work through conflict situations in their own good time; the process cannot be rushed.
Play materials vary with the age and developmental status of the child. Simple, large toys are used with young children; more intricate playthings are used with older preschoolers. Clay, crayons, and paper become modes of expression for important feelings and thoughts about problems.
Play can be your primary tool for assessing preschool children's perceptions about their hospital experience, their anxieties, and their fears. Play can increase their coping ability. Preschoolers love jokes, puns, and riddles; the cornier, the better. Using jokes during the physical assessment, such as "Let me hear your lunch," or, "Golly, could that be a potato in your ear?" helps form the bonds needed for a successful relationship with the preschool client.
#### Storytelling as a Communication Strategy
A communication strategy often used with young children is the use of story plots. As early as 1986, Gardner described a mutual storytelling technique. You ask the child whether he would like to help make up a story. If the child is a little reluctant, you may begin, as described in Exercise 18-1. At the end of the story, the child is asked to indicate what lesson might be learned from the story. If the child seems a little reluctant to give a moral to the story, you might suggest that all stories have something that can be learned from them. Analyze the themes presented by the child, which usually reveal important feelings. Is the story fearful? Are the characters scary or pleasing? The child should be praised for telling the story. The next step in the process is to ask yourself what would be a healthier resolution than the one used by the child. Then suggest an alternative ending. In your version of the story, the characters and other details remain the same initially, but the story contains a more positive solution or suggests alternative answers to problems. The object of mutual storytelling is to offer the child an opportunity to explore different alternatives in a neutral communication process with a helping person. Exercise 18-1 provides an opportunity to experiment with a mutual storytelling strategy.
EXERCISE 18-1 Using a Mutual Storytelling Technique
Purpose: To give practical experience with the mutual storytelling technique.
Procedure:
1. Use the mutual storytelling process described in the text with a 5- to 8-year-old child in your neighborhood.
2. Write down the story the child told and suggest alternate endings.
3. Share your stories in turn during the next class period.
Discussion:
1. How difficult was it for you to engage the child? If you had trouble, what alternate actions would you incorporate in using the technique again?
2. Were you surprised at the story the child produced? If so, in what ways?
3. What did you learn about the child when using this technique?
4. What conclusions might you draw from hearing the other students relate their experiences about the use of this technique? In what situations was it most effective? Least effective?
5. What did you learn about yourself as a helping person in using this technique?
Sample Answer:
_Nurse_ : Once upon a time in a land far away, there lived a...
_Child_ : Dragon.
_Nurse_ : A dragon who ate...
_Child_ : Carrots.
_Nurse_ : The dragon ate carrots and slept...
_Child_ : In a cave.
_Nurse_ : One day he left the cave to go out and find many sweet carrots to eat, but as he walked along he ran into a...
_Child_ : Bike.
_Nurse_ : He was afraid of the bike and so he...
_Child_ : Kicked it and ran away.
_Nurse_ : After he ran away, is there any more to the story?
_Child_ (upset): He got hit with a stick.
_Nurse_ : What is the message to this story? What does it tell us?
_Child_ : About running away not to be punished.
### School-age children
As children move into concrete operational thinking, they begin to internalize the reasons for illness: illness is caused by germs, or you have cavities because you ate too much candy or did not brush your teeth. In later childhood, most children become better able to work with you verbally. It still is important to prepare responses carefully and to anticipate problems, but the child is capable of expressing feelings and venting frustration more directly through words. Use Exercise 18-2 to reformulate medical technology into age-appropriate expressions.
EXERCISE 18-2 Age-Appropriate Medical Terminology
Purpose: To help students think of terminology appropriate to use with young clients.
Procedure:
This can be fun if the instructor quickly asks students, going around the room.
Reformulate the following expressions using words a child can understand:
Anesthesia | Inflammation | NPO
---|---|---
Cardiac catheterization | Injection | Operating room
Disease | Intake and output | Sedation
Dressings | Isolation | Urine specimen
Enema | IV needle | Vital signs
Infection | Nausea |
Discussion:
Think of any experiences you might have had as a child client or may have observed. What were some of the troublesome words you remember from these experiences?
Assessment of the child's cognitive level of understanding continues to be essential. Search for concrete examples to which the child can relate rather than giving abstract examples. If children are to learn from a model, they must see the model performing the skill to be learned. School-age children thrive on explanations of how their bodies work and enjoy understanding the scientific rationales for their treatment. Ask questions directly to the child, consulting the parent for validation.
#### Using Audiovisual Aids as a Communication Strategy
Audiovisual aids and reading material geared to the child's level of understanding may supplement verbal explanations and diagrams. Details about what the child will hear, see, smell, and feel are important. For the younger school-age child, expressive art can be a useful method to convey feelings and to open up communication. The older school-age child or adolescent might best convey feelings by writing a poem, a short story, or a letter. This written material can assist you in understanding hidden thoughts or emotions.
#### Mutuality in Decision Making
Children of this age need to be involved in discussions of their illness and in planning for their care. Explanations giving the rationale for care are useful. Involving the child in decision making may decrease fears about the illness, the treatment, or the effect on family life. Videos and written materials may be useful in involving the child in the management phase of care.
### Adolescents
An understanding of adolescent developmental principles is essential in working with teens. Adolescence is the time when we clinicians encourage a shift in responsibility for health-related decisions from parent to the teen. Even teens enjoying good health are forced to deal with new health issues such as acne, menstrual problems, or sexual activity. The adolescent vacillates between childhood and adulthood, and is emotionally vulnerable. The ambivalence of the adolescent period may be normally expressed through withdrawal, rebellion, lost motivation, and rapid mood changes. A teen may look adult-like, but in illness especially may be unable to communicate easily with care providers. Identity issues become more difficult to resolve when the normal opportunities for physical independence, privacy, and social contacts are compromised by illness or handicap. All adolescents have questions about their developing body and sexuality. Ill teens have the same longings, but problems may be greater because the natural outlets for their expression with peers are curtailed by the disorder or by hospitalization. Use of peer groups, adolescent lounges (separate from the small children's playroom), and telephones, as well as provisions for wearing one's own clothes, fixing one's hair, or attending hospital school, may help teenagers adjust to hospitalization. When the developmental identity crisis becomes too uncomfortable, adolescents may project their fury and frustration onto family or staff. Identifying rage as a normal response to a difficult situation can be reassuring.
Assessment of the adolescent should occur in a private setting. Attention to his comfort and space will have a tremendous impact on the quality of the interaction. To the teenager, the nurse represents an authority figure. The need for compassion, concern, and respect is perhaps greater during adolescence than at any other time in the life span. Often lacking the verbal skills of adults, yet wishing to appear in control, adolescents do well with direct questions. Innocuous questions are used first to allow the teenager enough space to check the validity of his reactions to the nurse. In caring for a teen in an ambulatory office or clinic, conduct part of the history interview without the parent present. If the parent will not leave the exam room, this can be done while walking the teen down to the laboratory. Questions about substance use, sexual activity, and so on demand confidentiality.
To assess a teen's cognitive level, find out about his ability to make long-term plans. An easy way to do this is the "three wishes question." Ask the teen to name three things he would expect to have in 5 years. Answers can be analyzed for factors such as concreteness, realism, and goal-directness.
Some teens lack sufficient experience to recognize that life has ups and downs, and that things will eventually be better. Suicide is the second leading cause of death in teenagers, and many experts think that the actual rate is greater because many deaths from the number one cause, motor vehicle accidents, may actually be attributed to this cause. Be aware of danger signs such as apathy, persistent depression, or self-destructive behavior. When faced with a tragedy, teens tend to mourn in doses, with wide mood swings. Grieving teens may need periods of privacy, but also need the opportunity for relief through distracting activities, music, and games. In communicating with an ill adolescent, remember to listen. When a teen asks a direct question, he or she is ready to hear the answer. Answer directly and honestly. In an analysis of pediatric nursing interventions, one category identified as a recurrent activity was helping the child find meaning, a form of spiritual nurturance (Zengerle-Levy, 2006).
#### Using Hobbies as a Communication Strategy
Adolescents still rely primarily on feedback from adults and from friends to judge their own competency. A teen may not yet have developed proficiency and comfort in carrying on verbal conversations with adults. The teen may respond best if the nurse uses several modalities to communicate. Using empathy, conveying acceptance, and using open-ended questions are three useful strategies. Sometimes more innovative communication strategies are needed. In the following case example, the teen has a difficult time talking, so the use of another modality is appropriate.
Case Example
Ashley, a first-year student nurse, becomes frustrated during the course of her conversation with her assigned client, 17-year-old Cary, admitted 5 days ago to the psychiatric unit. Despite a genuine desire to engage him in a therapeutic alliance, the client would not talk. Attempts to get to know him on a verbal level seemed to increase rather than decrease his anxiety. The nurse correctly inferred that, despite his age, this adolescent needed a more tangible approach. Knowing that the client likes cars, Ashley brought in an automotive magazine. Together, they looked at the magazine; the publication soon became their special vehicle for communication, bridging the gap between the client's inner reality and his ability to express himself verbally in a meaningful way. Feelings about cars gradually generalized to verbal expressions about other situations, and Cary quickly began describing his life dreams, disappointments, and attitudes about himself. When Ashley left the unit, he asked to keep the magazine and frequently spoke of her with fondness. This simple recognition of his awkwardness in verbal communication and use of another tool to facilitate the relationship had a positive effect.
### Dealing with care problems
Pain
The literature has identified a lack of understanding about pain in children, as well as nurses' personal beliefs that children over-report their pain, as a barrier to giving optimal nursing care (Van Hulle Vincent, 2005). For years, children's ability to feel pain has been underrated by adult caregivers. For example, male newborns were routinely circumcised in the last century without pain relief. Since 1999, the American Academy of Pediatrics no longer recommends circumcision, but it takes years for evidenced-based information to become accepted common practice. When circumcision is performed now, pain interventions are recommended. Lack of adequate pain relief may, in part, be due to fears of oversedating a child, but more likely are due to the child's limited capacity to communicate the nature of his or her discomfort. Infants indicate pain with physiologic changes (e.g., diaphoresis, pallor, increased heart rate, increased respirations, and decreased oxygen saturation). Migdal and associates (2005) found lidocaine, a local anesthetic, effective in reducing the pain associated with venipuncture. Effective nonpharmacologic interventions for pain include pacifiers, rocking, physical contact, and sometimes even swaddling. We now use age-specific pain assessment instruments, such as smiley faces or poker chips with toddlers and preschoolers, to evaluate levels of pain with our pediatric clients. Exercise 18-3 will stimulate discussion about care for children in pain.
EXERCISE 18-3 Pediatric Nursing Procedures
Purpose: To give practice in preparing young clients for painful procedures.
Procedure:
Timmy, age 4, is going to have a bone marrow aspiration. (The insertion of a large needle into the hip is a painful procedure.) Answer the following questions:
1. What essential information does Timmy need?
2. If this is a frequently repeated procedure, how can you make him feel safe before and after the procedure?
3. How soon in advance should you prepare him?
#### Anxiety
Illness is often an unanticipated event. Uncertainty and even anxiety should be expected when both treatment and outcome are unknown. Young children react to unexpected stimuli, to painful procedures, and even to the presence of strangers with fear. Older children fear separation from parents, but also may fear injury, loss of body function, or even just being perceived by friends as different because of their illness. Exercise 18-4 helps develop age-appropriate explanations that may reduce anxiety.
EXERCISE 18-4 Preparing Children for Treatment Procedures
Purpose: To help students apply developmental concepts to age-appropriate nursing interventions.
Procedure:
Students divide into four small groups and design an age-appropriate intervention for the following situation. As a large group, each small-group spokesperson writes the intervention on the board under the label for the age group.
Situation:
Jamie is scheduled to go to the surgical suite later today to have a central infusion catheter inserted for hyperalimentation. This is Jamie's first procedure on the first day of this first hospitalization experience.
Discussion:
Group focuses on comparing interventions across the age spans.
1. How does each intervention differ according to the age of the child? (Describe age-appropriate interventions for preschooler, school-age child, and adolescent.)
2. What concept themes are common across the age spans? (education components; assessing initial level of knowledge; assessing ability to comprehend information, readiness to receive information; adapting information to cognitive level of child)
3. What formats might be best used for each age group? (Role-play with tools such as dolls, pictures, comic books, educational pamphlets, and peer group sessions.)
#### Acting-Out Behaviors
Behavior problems present a special challenge to the nurse. Clear communication of expectations, treatment protocols, and hospital rules is of value. As much as possible, adolescents should be allowed to act on their own behalf in making choices and judgments about their functioning. At the same time, limits need to be set on acting-out behavior. Limits define the boundaries of acceptable behaviors in a relationship. Initially determined by the parents or the nurse, limits can be developed mutually as an important part of the relationship as the child matures. Determining consequences has a positive value in that it provides the child with a model for handling frustrating situations in a more adult manner.
Once the conflict is resolved and the child has accepted the consequences of his behavior, the child should be given an opportunity to discuss attitudes and feelings that led up to the need for limits, as well as his reaction to the limits set. Serious symptoms such as substance abuse require specialist interventions. Estimates are that 75% of abusers have serious mental adjustment problems, especially depression (Griswold, Aronoff, Kernan, & Kahn, 2008).
Although communication about limits is necessary for the survival of the relationship, it needs to be balanced with time for interaction that is pleasant and positive. Sometimes with children who need limits set on a regular basis, discussion of the restrictions is the only conversation that takes place between nurse and client. When this is noted, nurses might ask themselves what feelings the child might be expressing through his or her actions. Putting into words the feelings that are being acted out helps children trust the nurse's competence and concern. Usually it is necessary for the entire staff to share this responsibility. Box 18-3 presents ideas for setting limits within the context of the nurse-client relationship.
BOX 18-3 Guidelines for Developing Workable Limit-Setting Plan
1. Have the child describe his or her behavior.
_Key:_ Evaluate realistically.
2. Encourage the child to assess behavior. Is it helpful for others and himself or herself?
_Key:_ Evaluate realistically.
3. Encourage the child to develop an alternative plan for governing behavior.
_Key:_ Set reasonable goals.
4. Have the child sign a statement about his or her plan.
_Key:_ Commit to goals.
5. Consequences for unacceptable behavior are logical and fit the situation.
_Key:_ Consequences are known.
6. At the end of the appropriate time period, have the child assess his or her performance.
_Key:_ Evaluate realistically.
7. Consequences are applied in a matter-of-fact manner, without lengthy discussion.
_Key:_ Consequences immediately follow the transgression.
8. Provide positive reinforcement for those aspects of performance that were successful.*
_Key:_ Evaluate realistically.
9. Encourage the child to make a positive statement about his or her performance.
_Key:_ Teach self-praise.
* * *
*If the child's performance does not meet the criteria set in the plan, return to Step 3 and assist the child in modifying the plan so that success is more possible. If, on the other hand, the child's performance is successful, help him or her to develop a more ambitious plan (e.g., for a longer period or for a larger set of behaviors).
### More helpful strategies for communicating with children
Adapting the general communications strategies studied earlier in this book to interactions with children requires some imagination and creativity.
#### Active Listening
Knowing what a child truly needs and values is the heart of successful interpersonal relationships in health care settings. The process of active listening takes form initially from watching the behaviors of children as they play and interact with their environments. As a child's vocabulary increases and the capacity to engage with others develops, listening begins to approximate the communication process that occurs between adults, with one important difference: Because the perceptual world of the child is concrete, the nurse's feedback and informational messages should coincide with the child's developmental level.
Working with children is rewarding, hard work that sometimes must be evaluated indirectly. For instance, George was the primary care nurse who had worked very hard with a 13-year-old girl over a 6-month period while the girl was on a bone marrow transplant unit. He felt bad when, at discharge, the girl stated, "I never want to see any of you people again." However, just before leaving, the nurse found her sobbing on her bed. No words were spoken, but the child threw her arms around George and clung to him for comfort. For this nurse, the child's expression of grief was an acknowledgment of the meaning of the relationship. Children, even those who can use words, often communicate through behavior rather than verbally when under stress.
#### Authenticity and Veracity
Crises are an inevitable part of life. Many parents and health professionals ignore children's feelings or else deceive them about procedures, illness, or hospitalization in the mistaken belief that they will be overwhelmed by the truth. Just the opposite is true. Children, like adults, can cope with most stressors as long as they are presented in a manner they can understand and given enough time and support from the environment to cope. In fact, very ill children often are a source of inspiration to the adults working with them because of their courage in facing the truth about themselves and dealing with it constructively. Teens rate honesty, attention to pain, and respect as the three most important factors in their quality of care. Completing Exercise 18-5 may stimulate some discussion.
EXERCISE 18-5 Working with the Newly Diagnosed HIV-Positive Teenager
Purpose: To stimulate class discussion about how to deal with the adolescent with whom it is difficult to communicate.
Procedure:
Read the case situation and answer the questions that follow. Questions can be done out of class, with class time used only for discussion.
Situation:
Bill, age 17, seeks treatment for gonorrhea. He is hospitalized for further testing after his initial workup reveals he is seropositive for human immunodeficiency virus (HIV) type 1. For 2 days on the unit he has cried, cursed, and been uncooperative. Staff tends to avoid him when possible. A team of residents begins a bone marrow aspiration procedure in the treatment room after obtaining his absent mother's permission. (She has expressed condemnation and has not yet been to visit.) A technician walks in and out of the room to obtain supplies while the doctors concentrate on completing the procedure. A student nurse is asked to come in to help restrain Bill, who is alternately screaming, crying, and being very quiet.
1. What communication strategies could this student use while squeezing into this small room? (Clue: Verbal and nonverbal directed to the client and to the doctors)
2. What assessment might the nurse want to make? (Clue: What are Bill's feelings about his diagnosis?)
3. What can be inferred about Bill's current behavior?
4. What interventions would you suggest for initiating interaction with his single mom?
5. What additional data are needed before attempting any teaching about acquired immunodeficiency syndrome (AIDS)?
Discussion:
May be discussed in small groups.
You should never allow any individual, even a parent, to threaten a child. For example, a few parents have been heard to say, "You be good or I'll have the nurse give you a shot." It is appropriate to interrupt this parent. Children respect honest expression of emotions in adults. Being truthful and trustworthy with children is a crucial factor in the development of a therapeutic relationship.
Case Example
In a community setting, an older student nurse, with a family of her own, was monitoring a family in which the mother had terminal cancer. There were three children in the family, and the identified client of the student was a 13-year-old boy. He was abnormally quiet, and it was difficult to draw him out. Halfway through the semester, the boy's father died unexpectedly of a heart attack. When the boy and student nurse next met, the nurse asked the boy whether there was anything special that had happened between father and son that the boy would remember about his father. The boy replied that the day before his father's death he had received a letter of acceptance to the same school his father had attended, and he had shared this with his father. He said his father was very proud that he had been accepted. The student nurse could feel her eyes fill as the boy revealed himself to her in this special way. Her sharing of honest emotion was a significant turning point in what became a very important relationship for both participants. It was a moment of shared meaning for both of them and, from that time on, the needed common ground for communication existed.
Being authentic does not mean being overly familiar. Trying to interact with older children and adolescents as though the nurse is a buddy is confusing to the client. What the child wants is an emotionally available, calm, caring, competent resource who can protect, care about, and above all, listen to him or her.
#### Conveying Respect
It is easy for adults to impose their own wishes on a child. Respecting a child's right to feel and to express his or her feelings appropriately is important. Providing truthful answers is a hallmark of respect. When interacting with the older child, using the concept of mutuality will promote respect and should foster more positive and lasting health care outcomes. Confidentiality needs to be maintained unless the nurse judges that revealing information is necessary to prevent harm to the child or adolescent. In such cases, the child needs to be advised of the disclosure.
#### Providing Anticipatory Guidance to the Child
The nursing profession advocates client education. A physician would call similar preventive education anticipatory guidance. As more clinics become located within schools, more emphasis is being placed on anticipatory guidance. The American Academy of Pediatrics has published guidelines for health care providers working with well children in the community. These suggestions focus on health promotion information to be given to caretakers at appropriate ages. Managed care has brought an increased focus on the role a child can assume in being responsible for his or her own health care. It is never too early to begin. For example, McCarthy and Hobbie (1997) provide very clear written handouts for incorporating violence prevention into well-child visits made to nurse practitioners. This shift in placing responsibility for good health practices onto the individual is in line with recommendations in _Healthy People 2010_ (Online Resources, <http://hp2010.nhlbihin.net/>).
## Interacting with parents of ill children
Having an ill child is stressful for parents. Many research studies have shown that loss of the ability to act as the child's parent, to alleviate the child's pain, and to comfort the child is more stressful than factors connected with the illness, including coping with uncertainty over the outcome. Other stressors include financial and marital strains. Studies pointed to a lack of needed information and support from professionals as being a top stressor, exacerbating already existing family problems and resulting in feelings of fear and helplessness. Parents want to participate in their child's care during acute hospitalizations but need information, advice, and clarification as to their role—that is, what is okay to do. They need to feel valued but not pressured into doing tasks they are uncomfortable with or do not want to do.
Parents often have questions about discussing their child's illness or disability with others. Telling siblings and friends the truth is important. For one thing, it provides a role model for the siblings to follow in answering the curious questions of their friends. Issues such as overprotectiveness, discipline, time out for parents to replenish commitment and energy, and the quality and quantity of interactions with the hospitalized child have a powerful impact on the child's growth and development. However, older children have a need for confidentiality and respond better if the nurse interviews and treats them away from parents' presence. Consider the ethical dilemma provided.
More frustrating to nurses are parents who are critical of the nurse's interventions, displacing the anger they feel about their own powerlessness onto the nurse (Box 18-4). The nurse may be tempted to become defensive or sarcastic, or simply to dismiss the comments of the parent as irrational. However, a more helpful response would be to place oneself in the parents' shoes and to consider the possible issues. Asking the parents what information they have or might need, simply listening in a nondefensive way, and allowing the parents to vent some of their frustrations facilitate the possibility of dialogue about the underlying feelings. The listening strategies given in Chapter 10 are helpful. Sometimes a listening response that acknowledges the legitimacy of the parent's feeling is helpful: "I'm sorry that you feel so bad," or "It must be difficult for you to see your child in such pain." These simple comments acknowledge the very real anguish parents experience in health care situations having few palatable options. If possible, parental venting of feeling should occur in a private setting out of hearing range from the child. It is very upsetting to children to experience splitting in the parent-nurse relationship.
BOX 18-4 Representative Nursing Problem: Dealing with a Frightened Parent
During report, the night nurse relates an incident that occurred between Mrs. Smith, the mother of an 8-year-old admitted for possible acute lymphocytic leukemia, and the night supervisor. Mrs. Smith told the supervisor that her son was receiving poor care from the nurses, and that they frequently ignored her and refused to answer her questions. While you are making rounds after the report, Mrs. Smith corners you outside her son's room and begins to tell you about all the things that went wrong during the night. She goes on to say, "If you people think I'm going to stand around and allow my son to be treated this way, you are sadly mistaken."
Problem
Frustration and anger caused by a sense of powerlessness and fear related to the son's possible diagnosis
Nursing Diagnosis
Ineffective coping related to hospitalization of son and possible diagnosis of leukemia
Nursing Goals
Increase the mother's sense of control and problem-solving capabilities; help the mother develop adaptive coping behaviors.
Method of Assistance
Guiding; supporting; providing developmental environment
Interventions
1. Actively listen to the client's concerns with as much objectivity as possible; maintain eye contact with the client; use minimal verbal activity, allowing the client the opportunity to express her concerns and fears freely.
2. Use reflective questioning to determine the client's level of understanding and the extent of information obtained from health team members.
3. Listen for repetitive words or phrases that may serve to identify problem areas or provide insight into fears and concerns.
4. Reassure the mother when appropriate that her child's hospitalization is indeed frightening and it is all right to be scared; remember to demonstrate interest in the client as a person; use listening responses (e.g., "It must be hard not knowing the results of all these tests.") to create an atmosphere of concern.
5. Avoid communication blocks, such as giving false reassurance, telling the client what to do, or ignoring the concerns; such behavior effectively cuts off therapeutic communication.
6. Keep the client continually informed regarding her child's progress.
7. Involve the client in her son's care; do not overwhelm her or make her feel she has to do this; watch for cues that tell you she is ready "to do more."
8. Acknowledge the impact this illness may have on the family; involve the health team in identifying ways to reduce the client's fears and provide for continuity in the type of information presented to her and to other family members.
9. Assign a primary nurse to care for the client's son and serve as a resource to the client. Identify support systems in the community that might provide help and support to the client.
From M. Michaels, University of Maryland School of Nursing, Baltimore.
You can reduce parents' stress by educating them about their child's condition. When the child has a chronic illness, the family is called on to continually adjust the family system to adapt to changing demands in the child's health. Because nursing care is largely moving to care in the home, nurses will have an increasing need to help families cope with seriously chronically ill children. At times, the nurse will be called on to act as the child's advocate in giving parents helpful information, anticipatory guidance, and complex technical assistance in caring for the health and developmental needs of their child. Guidelines for communicating with parents are presented in Box 18-5.
BOX 18-5 Guidelines for Communicating with Parents
• Present complex information in informational chunks.
• Repeat information and allow plenty of time for questions.
• Keep parents continually informed of progress and changes in condition.
• Involve parents in determining goals; anticipate possible reactions and difficulties.
• Discuss problems with parents directly and honestly.
• Explore all alternative options with parents.
• Share knowledge of community supports; help parents role-play responses to others.
• Acknowledge the impact of the illness on finances; on emotions; and especially on the family, including siblings.
• Use other staff for support in personally coping with the emotional drain created by working with very ill children and their parents.
### Communicating with parents of special health care needs children
Approximately 29% of American children have a chronic health condition requiring additional services. Caring for these children requires parental time and alters family communication patterns. Studies show these families have less time for communication (Bransletter et al., 2008). Nurses need to provide care and information about the child's condition, time for discussions about balancing family needs with care for this child, suggest strategies for moving the child toward future independence, and refer parents to community resources. We need to recognize that as the child reaches developmental milestones, this can be a time of increased family stress, requiring additional support from us.
### Anticipatory guidance in the community
Every parent is entitled to a full explanation of his child's condition and treatment. Because the parents usually assume responsibility for the child's care after they leave the hospital, it is essential to encourage active involvement from the very beginning of treatment. Many parents look to the nurse for guidance and support in this process. All parents need facts about normal development and milestones to expect, as well as information about prevention of illness.
## Community, family, and nurse partnerships
Forming a nurse-parent partnership
Partnering with the family can be the best method you have to address the complex health care needs of children. Parents' participation in the care of their child, and active involvement in decision making regarding the youngster's treatment, ensure a more stable environment for the child. Providing family support is important for those caring for chronically ill children.
The focus of care is shifting to parents, who are the central figures in care planning. They need information about which community agencies, networks, and professionals will be mobilized to provide care to their child. Successful collaboration requires active commitment to meet client needs by all parties involved. School nurses are often crucial to the ability of the child with a chronic illness to maintain school attendance. In addition, school nurses often act as case managers by communicating about the child's needs among parent, care providers, teachers, and other resource personnel. By law in the United States, children with special needs in the educational system are required to have an Individualized Education Plan. A part of this may be the health plan for children who need medical intervention/treatment during school.
### Support groups
Community groups have organized to assist families. Often information about the group's meeting times can be obtained from health care providers, from the national or local organization, or even from the phone book. For parents who cannot travel to meetings, a new form of support may be available via the Internet, as described in Chapter 26.
### Nurse as advocate for children in the community
Because children cannot communicate their needs, we need to broaden our advocacy to fight for better child health at local and national levels. For example, _Healthy People 2010_ (online, <http://hp2010.nhlbihin.net/>) has designated obesity and physical activity as 2 of 10 priorities for action. Nurse researchers such as Kubic (2008) have signaled concern about an epidemic of childhood obesity and have piloted school intervention programs. Child obesity is causing a huge increase in related health problems such as diabetes (Lawlor & Chaturvedi, 2006; "Hospitalizations for Obese Kids Double," 2009). Poor and low-income children more often lack parks, safe neighborhoods for exercising, and tend to have an abundance of fast-food restaurants selling high-calorie foods (Blacksher, 2008). Examples of nursing advocacy interventions include organizing campaigns to eliminate sale of junk food in schools, reinstituting recess and physical education opportunities, joining community activist groups advocating restructuring of community neighborhoods to allow for increased exercise with sidewalks to school and safe bike paths.
## Summary
Working with children requires patience, imagination, and creative applications of therapeutic communication strategies. Children's ability to understand and communicate with nurses is largely influenced by their cognitive developmental level and their limited life experiences. Nurses need to develop an understanding of feelings and thought processes from the child's perspective, and communication strategies with children should reflect these understandings. Various strategies for communicating with children of different ages are suggested, as are strategies for communicating with their parents. A marvelous characteristic of children is how well they respond to caregivers who make an effort to understand their needs and take the time to relate to them.
Ethical Dilemma
What Would You Do?
You are caring for Mika Soon, a 15-year-old adolescent. She has confided to you that she is being treated for chlamydia. Her mother approaches you privately and demands to know if Mika has told you if she is sexually active with her boyfriend. Since Mika is a minor and Mrs. Soon is paying for this clinic visit, are you obligated to tell her the truth?
## References
Blacksher, E. Children's health inequalities: ethical and political challenges to seeking social justice. The Hastings Center available online: http://www.the hastingscenter.org/Publications/HCR/Detail.aspx?id=1750. [Accessed November 18, 2008].
Bransletter, J.E., Domain, E.W., Williams, P.D., et al. Communication themes in families of children with chronic conditions. _Issues Compr Pediatr Nurs_. 2008;31(4):171–184.
Coad, J.E., Shaw, K.L. Is children's choice in health care rhetoric of reality: a scoping review. _J Adv Nurs_. 2008;64(4):318–327.
Emslie, G.J. Pediatric anxiety-under recognized and under treated. _N Engl J Med_. 2008;359(26):2835–2836.
Erickson, E.H. Childhood and society. New York: Norton, 1963.
Gardner, R. Therapeutic communication with children, ed 2. New York: Science Books, 1986.
Griswold, K.S., Aronoff, H., Kernan, J.B., Kahn, L.S. Adolescent substance use and abuse: recognition and management. _Am Fam Physician_. 2008;77(3):331–336.
Hong, S.S., Murphy, S.O., Connolly, P.M. Parental satisfaction with nurses' communication and pain management in a pediatric unit. _Pediatr Nurs_. 2008;34(4):289–293.
Hospitalizations for obese kids double. _USA Today_. 2009:6D. [July 9].
Kubic, M. Personal interview. University of Minnesota, 2008. [May 23].
Lawlor, D.A., Chaturvedi, N. Treatment and prevention of obesity-are there critical periods for intervention? _Int J Epidemiol_. 2006;35:3–9.
Looman, W.S., O'Connor-Von, S., Lindeke, L.L. Caring for children with special healthcare needs and their families: what advanced practice nurses need to know. _J Nurse Pract_. 2008;4:512–517.
Mangione-Smith, R., DeCristofaro, A.H., Setodji, C.M., et al. The quality of ambulatory care delivered to children in the United States. _N Engl J Med_. 2007;35715:1515–1523.
McCarthy, V., Hobbie, C. Incorporating violence prevention into anticipatory guidance for well child visits. _J Pediatric Health Care_. 1997;11(5):222–226.
Migdal, M., Chudzynska-Pomianowska, E., Vause, E., et al, Rapid, needle-free delivery of lidocaine for reducing the pain of venipuncture among pediatric subjects. _Pediatrics_ , 2005;115(4):e393–e398. available online:, <http://pediatrics.aappublications.org/cgi/content/full/115/4/e393>.
Piaget, J. The child's conception of the world. Savage, MD: Littlefield, Adams, 1972.
Pieper, P. Ethical perspectives of children's assent for research participation: deontology and utilitarianism. _Pediatr Nurs_. 2008;34(4):319–323.
Taylor, C.A., Guteman, N.B., Lee, S.J., Rathouz, P.J., Intimate partner violence, maternal stress, nativity, and risk for maternal maltreatment of young children. _Am J Public Health_ 2009:1–25. available online, www.medscape.com/viewarticle/702408_print. [Accessed May 20, 2009].
Van Hulle Vincent, C. Nurses' knowledge, attitudes and practices regarding children's pain. _MCN Am J Matern Child Nurs_. 2005;30(3):177–183.
Zengerle-Levy, K. Nursing the child who is alone in the hospital. _Pediatr Nurs_. 2006;32(3):226–231.
CHAPTER 19
# Communicating with Older Adults
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Discuss concepts of normal aging.
2 Identify the use of theoretical frameworks used in the care of older adult clients.
3 Describe assessment strategies with older adults.
4 Describe supportive nursing care strategies with older adults.
5 Discuss assessment and support interventions for cognitively impaired older adults.
This chapter focuses on assessment and communication strategies related to client-centered relationships with older adults. The chapter presents basic concepts about aging as part of the life process and explores age-related changes that can affect communication. Developmental frameworks and the nursing process form a structural foundation for providing care to older adults. Communication strategies to support successful aging and to use with clients demonstrating cognitive impairment are included. Effective communication is critical to the health and well-being of older adults.
## Basic concepts
Concepts of normal aging
Effective communication with older adult adults requires a thorough understanding of the normal health-related changes associated with aging. **Aging** is a term used to describe "advancing through the life cycle, beginning at birth and ending at death" (Pankow & Solotoroff, 2007, p. 19). Although aging is a lifelong process, the most common interpretation refers to physiologic decline, and associated mental and social changes occurring in late adulthood.
Aging is a normal physiologic process, accompanied to a greater or lesser degree by changes in appearance and energy levels, degenerative changes in organs and tissues, a weaker immune system, sensory losses, and decreased functional capacity related to mobility. Aging affects physical strength, stamina, and flexibility, and ultimately, an individual's ability to negotiate the physical environment. Cotter and Gonzalez (2009) define " _successful aging_ as the ability to adapt flexibly to age-related changes without relinquishing the central components of self-definition" (p. 335).
Older adults are often treated as if they represent a single cohort, when, in fact, there are huge differences in their life experiences, opportunities, capabilities, interests, and relationships. As people live longer, the term _older adult_ or _senior_ is broken down into three age cohorts: young old (65–74 years), old-old (75–84 years), and oldest-old (85 years and older) (Moody, 2010). A lot of older adults are frail and can have reduced function because of age-related disease, but many will retain a high level of physical and intellectual function until close to their death.
Each person's experience of the aging process is unique, reflecting his or her genetic makeup, personality, life experiences, as well as environmental and cultural factors. Aging is a life process influenced by many factors, some of which are preventable or reversible. Although genetic and physiologic factors are not totally within an older person's control, learning adaptive self-management strategies can make a major difference in an older adult's overall health and quality of life.
Aging need not be a negative experience. Healthy older adults generally have more time and less responsibilities. There is time to travel, engage in activities one didn't have time for previously, develop new interests, take a course, take an active role in community activities, share their talents with others, and enjoy family and grandchildren. Our attitude toward aging can become a self-fulfilling prophecy. Bortz (1990) states:
If we dread growing old, thinking of it as a time of forgetfulness and physical deterioration, then it is likely to be just that. On the other hand, if we expect it to be full of energy and anticipate that our lives will be rich with new adventures and insight; then that is the likely reality. We prescribe who we are. We prescribe what we are to become. (p. 55)
Biggs (2001) notes that positive stories of aging need to be told and incorporated into contemporary social policy. Older adults often lack the developmental supports provided earlier in life. People take pride in teaching and supporting children and young adults to achieve the life building skills they need as their developmental needs change. Articles detail the signs and symptoms of degenerative changes, with less attention paid to what older adults need to enhance quality of health and well-being.
Aging has direct and indirect effects on communication and interpersonal relationships. Nurses working with older clients need to have a thorough understanding of the aging process and positive respect for their struggles. Exercise 19-1 provides you with an opportunity to explore your personal ideas about aging.
EXERCISE 19-1 What Is It Like to Be Old?
Purpose: To stimulate personal awareness and feelings about the aging process.
Procedure:
Think about and write down the answers to the following questions about your own aging process:
1. What do you think will be important to you when you are 65?
2. Prepare a list of the traits, qualities, and attributes you hope you will have when you are this age.
3. What do you think will be different for you in terms of physical, emotional, spiritual, and social perceptions and activities?
4. How would you like people to treat you when you are an older adult?
Discussion:
In groups of three to four students, share your thoughts. Have one person act as a scribe and write down common themes. Students should ask questions about anything they don't understand.
1. In what ways did doing this exercise give you some insight into what the issues of aging might be for your age group?
2. In what ways might the issues be different for people in your age group and for people currently classified as older adults?
3. How could you use this exercise to better understand the needs of older adults in the hospital, long-term setting, or home?
#### Aging and health
Sowers and Rowe (2007) note, "By 2050, the number of persons aged 60 and over is projected to increase from 600 million to almost 2 billion (p. 11). Four- and five-generation families are becoming common as life span increases. Family-based assistance as the primary source of long-term care for the frail elderly will continue to increase (Gavan, 2003).
Older adults are not a homogenous population with similar health needs. Individual differences in the aging process allow many to experience relatively few health problems even into their eighties. But it is true that after the age of 60, people are more vulnerable to a variety of age-related diseases, such as cancer, cardiac and circulatory problems, stroke, and degenerative bone loss. Older people may gradually lose control over some of their bodily functions and movements, which interferes with their sense of dignity and self-image (Franklin, Ternestedt, & Nordenfelt, 2006). Older adults disproportionately experience a larger number of chronic conditions and diseases. As a cohort, they are the largest users of health services (Scholder, Kagan, & Schumann, 2004).
Older adults can experience subtle discrimination in accessing health care, level of screening and choice of treatment options. Physicians are less likely to use extensive diagnostic testing or aggressive treatment with older adults and they are underrepresented in clinical trials in part because of co-existing medical conditions. Medicare does not pay for experimental drugs. Other obstacles include navigating the complexity of the medical system, and limitations and gaps in services for chronic health care conditions. The decreasing number of physicians and other health care providers accepting elderly clients and/or suboptimal Medicare reimbursement for chronic care conditions is another factor.
#### Contemporary older adults
Our view of the elderly is changing as people live longer and experience less disability for shorter periods before death. Our perception of quality of life for older adults is changing and is likely to continue to evolve.
Contemporary "older adults" are not the same as they were even a few decades ago. They have been exposed to different opportunities than their parents had, related to economics, health, information technology, gender roles, and so on (Curtis & Dixon, 2005). As baby boomers "come of age," they represent a highly educated cohort who is more health conscious and better informed about health matters than in previous generations. By 2030, the baby boomers will have all reached the age of 65, double the number of older adults at the beginning of the 21st century (Mellor & Rehr, 2005). To date, this cohort represents the future for health care needs of older adults. Very shortly, it will become the present. Exercise 19-2 offers an opportunity to think about the implications of planning health care for contemporary older adults (baby boomers).
EXERCISE 19-2 Quality Health Care for Baby Boomers
Purpose: To provide an understanding of changes needed to provide quality health care for baby boomers.
Procedure:
Break into groups of four to six students. Allow yourself to go beyond the facts and think about your personal response.
Answer the following questions:
1. How do you think the influx of baby boomers will affect health care?
2. What should be the focus of health care for the baby boomer generation?
3. What types of challenges do you see the health care system facing with the anticipated dramatic increase in numbers of older adults?
4. What are your ideas as a health professional to resolve the health care issues of the future related to care of older adults.
Older adults are generally healthier in terms of less severe functional problems and chronic disability. They are living longer with a more robust quality of life (Maples & Abney, 2006). With current recessionary trends and Social Security changes, people are retiring later, and many remain actively engaged in the community. With many more people living into their 90's, living adult children in their fifties and sixties are likely to become primary caregivers for very old relatives. Health care reform, long-term care, the future of Medicare, and new images of health and well-being in older adults are important issues that health care professionals will need to consider.
The literature, anchored by Rowe and Kahn (1998), identifies three fundamental characteristics associated with successful aging:
• Low risk for disease and disease-related disability
• High mental and physical function
• Active engagement with life (p. 38)
### Theoretical frameworks used in the care of older adult clients
Erik erikson's ego development model
Erikson's (1982) model of psychosocial development is one of the only developmental models that specifically addresses later adulthood (>60 years) as a stage of ego development. Erikson portrays the maturational crisis of old age as that of ego integrity versus ego despair. Awareness of one's personal mortality leads to the psychosocial crisis identified with this last stage of ego development.
**Ego integrity** relates to the capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. Integrity involves acceptance of "one's one and only life cycle as something that had to be and that by necessity permitted of no substitution" (Erikson, 1950, p. 268). Acceptance develops through self-reflection and dialogue with others about the meaning of one's life. Nursing strategies encourage life review, and reminiscence groups facilitate the process. **Ego despair** describes the failure of a person to accept one's life as appropriate and meaningful. Left unresolved, despair leads to feelings of emotional desolation and bitterness.
**Wisdom** , the virtue associated with Erikson's eighth and final stage of ego development, represents an integrated system of "knowing" about the meaning and conduct of life. It involves a general knowledge about human nature and specific knowledge about its variations. (Kunzmann & Baltes, 2003). Sharing one's wisdom with others enhances the experience of ego integrity. Wisdom includes deep understanding of self and others, good judgment, and the insights that people have about living a life filled with courage, purpose, and meaning.
Le (2008) discusses two forms of wisdom: practical wisdom and transcendent wisdom. Practical wisdom emphasizes good judgment and the capacity to resolve complex human problems in the real world. Transcendent wisdom focuses on existential concerns and development of the self-knowledge that allows a person to transcend subjectivity, bias, and self-centeredness. Wisdom encourages older adults to share their understanding of life with those who will follow. Erikson (Erikson, Erikson, & Kivnick, 1986) believed that wisdom develops from confronting and successfully resolving life's psychosocial crises. Sharing wisdom in the form of personal stories creates a strong legacy for those in the next generation. Exercise 19-3 explores the relationship of life experiences with wisdom.
EXERCISE 19-3 The Wisdom of Aging
Purpose: To promote an understanding of the sources of wisdom in the older adult.
Procedure:
1. Interview an older adult (75 years or older) who, in your opinion, has had a fulfilling life. Ask the person to describe his or her most satisfying life events, and what he or she did to accomplish them. Ask the person to identify his or her most meaningful life experience or accomplishment. Immediately after the interview, write down your impressions, with direct quotes if possible to support your impressions.
2. Reflect on the person's comments and your ideas of what strengths this person had that allowed him or her to achieve a sense of well-being, and to value his or her accomplishments.
Discussion:
1. Were you surprised at any of older adults' responses to the question about most satisfying experiences? Most meaningful experiences?
2. On a blackboard or flip chart, identify the accomplishments that people have identified. Classify them as work-related or people-related.
3. What common themes emerged in the overall class responses that speak to the strengths in the life experience of older adults?
4. How can you apply what you learned from doing this exercise in your future nursing practice?
#### Abraham maslow's basic needs model
Maslow's (1954) hierarchy of needs (see Chapter 1) helps nurses prioritize nursing actions, beginning with basic survival needs. Physiologic integrity, followed by safety and security, emerge as the most basic critical issues for aging adults and need to be addressed first. Love and belonging needs are challenged by increased losses associated with death of important people. Esteem needs, especially those associated with meaningful purpose, and independence remain important issues in later life. Abraham Maslow believed that self-actualization occurs more often in middle-aged and older adults (Moody, 2010).
Developing an Evidence-Based Practice
Weman K, Fagerberg I: Registered nurses working together with family members of older people, _J Clin Nurs_ 15(3):281–289, 2006.
Murray LM, Boyd S: Protecting personhood and achieving quality of life for older adults with dementia in the U.S. health care system, _J Aging Health_ 21:350–373, 2009.
This aim of this study was to explore the perceptions of nurses working in elder care about the difficulties and problems encountered in working with families of elder clients. Positive and negative aspects of working with family members to ensure quality care of their elderly family member were examined using a latent content analysis methodology of responses to open-ended questions related to the topic.
_Results:_ Findings stressed the need for family members and nurses to work together cooperatively as a team in their care of the elderly.
_Application to Your Clinical Practice:_ Family members are and can be an important resource for older adults. Keeping family members informed and having a good relationship with them is essential in building the type of cooperative working relationship needed for quality care, especially when time and/or resources are needed. As a professional nurse, what factors do you see as being most important in building an effective working relationship with family members of older adults? How would you involve the client's family in clinical decision making?
## Applications
Assessment strategies with older adult clients
New situations can cause transitory confusion for older adults, apart from cognitive impairment. Many clients are aware of the stereotypes associated with aging and are reluctant to expose themselves as inadequate in any way. Knowing what to expect helps decrease anxiety and build trust. Continuity of care with one primary caregiver, when possible, helps foster the development of a comfortable nurse-client relationship.
Older adults are likely to be more responsive when time is taken to establish a supportive environment before conducting a formal assessment. Otherwise, it can be difficult for clients to discuss emotional issues associated with the aging process or their physical ailments. Sensitive issues such as loneliness, abuse and neglect, caregiver burden, fears about death or frailty, memory loss, incontinence, alcohol abuse, and sexual dysfunction will only be discussed within a trustworthy relationship (Adelman, Greene, & Ory, 2000).
Older adults appreciate having the nurse provide structure to the history-taking interview by explaining the reasons for it and what it will involve (Cochran, 2005). Asking clients to share something about themselves and their life history, apart from the reasons for the health visit or admission, helps to establish rapport and increases the client's comfort level.
By relating their life stories and exploring options relevant to their current health situation, older adults are able to step back and look at their situation in the present from a broader perspective. Nurses get to know the client as a person, rather than categorically as an "older adult." Box 19-1 identifies communication guidelines for assessment interviews.
BOX 19-1 Communication Guidelines for Assessment Interviews
• Establish rapport.
• Use open-ended questions first, followed by focused questions.
• Ask one question at a time.
• Elicit client perspectives first.
• Elicit family perspectives, if indicated.
• Invite ideas and feelings about diagnosis and treatment.
• Acknowledge feelings and emotions.
• Communicate a willingness to help.
• Provide information in small segments.
• Summarize the problem or condition discussed in the interview.
• Validate with the client and/or family for accuracy.
• Provide contact information for further questions or concerns.
Moody (2010) maintains that old age "is shaped by a life time of experience" (p. 2). Assessment of older adult clients begins with their story. As they relate their story, look for value-laden psychosocial issues (e.g., independence, fears about being a burden, role changes, and vulnerability) and client preferences. These are significant issues for older adults clients that may not be directly expressed.
Case Example
_Nurse:_ You seem concerned that your stroke will have a major impact on your life.
_Client:_ Yes, I am. I'm an old woman now, and I don't want to be a burden to my family.
_Nurse:_ In what ways do you think you might be a burden?
_Client:_ Well, I obviously can't move around as I did. I can't go back to doing what I used to do, but that doesn't mean I'm ready for a nursing home.
_Nurse:_ What were some of the things you used to do?
_Client:_ Well, I raised three children, and they're all married now with good jobs. That's hard to do in this day and age. I did a lot for the church. I held a job as a secretary for 32 years, and I got several awards for my work.
_Nurse:_ It sounds as though you were very productive and were able to cope with a lot of things. Those coping skills are still a part of you, and can be used in a different way now."
Helping clients identify sources of social support, personal resources, and coping strategies helps soften the impact of physical and emotional stressors associated with age-related transitions (Gilmer & Aldwin, 2003). Exercise 19-4 provides a glimpse into the life stories of older adults.
EXERCISE 19-4 The Story of Aging
Purpose: To promote an understanding of older adults.
Procedure:
1. Interview an older adult in your family (minimum age, 65 years). If there are no older adults in your family, interview a family friend whose lifestyle is similar to your family's.
2. Ask this person to describe what growing up was like, what is different today from the way it was when he or she was your age, what are the important values held, and if there have been any changes in them over the years. Ask this person what advice he or she would give you about how to achieve satisfaction in life. If this person could change one thing about our society today, what would it be?
Discussion:
1. Were you surprised at any of the answers older adults gave you?
2. What are some common themes you and your classmates found that related to values and the type of advice older adults gave each of you?
3. What implications do the findings from this exercise have for your future nursing practice?
#### Assessing age-related sensory changes
Sensory changes occur with normal aging. In particular, hearing and vision changes can have a direct and significant impact on communication and cognitive processing (Gonsalves & Pichora-Fuller, 2008). Vision and hearing enhancements are essential to ensuring client safety and staying connected with people in their environment. Anderson (2005) notes that addressing common causes of sensory impairment and providing sensory cues can help reduce confusion.
Hearing: According to the National Institute on Deafness and Other Communication Disorders (NIDCD, 2010), one in three people older than 60 and half of those older than 85 will experience hearing loss. Hearing loss associated with normal aging begins after age 50 years and is due to loss of hair cells (which are not replaced) in the organ of Corti in the inner ear. This change leads initially to a loss in the ability to hear high-frequency sounds (e.g., f, s, th, sh, ch) and is called presbycusis (Gallo, 2000). Lower frequency sounds of vowels are preserved longer. Older adults have special difficulty in distinguishing sounds against background noises and in understanding fast-paced speech. Hearing problems can diminish an older person's ability to interact with others, attend concerts and other social functions, and understand medical directions.
Adaptive Strategies for Hearing Loss: With a little planning in modifying communication with the hearing-impaired older adult, the relationship should not be any different from one with a client who does not have this disability. Ideally, you should position yourself at the same level as the client. It is important to speak with a normal or slightly louder than normal voice tone. You do not need to shout. Other strategies include the following:
• Address the person by name before beginning to speak. It focuses attention.
• If the person has a "better" ear, sit or stand on the side with the more functional ear.
• Speak slowly and distinctly.
• If your voice is high-pitched, lower it.
• If older adults doesn't understand certain words, rephrase rather than repeat the words.
• Face older adults so they can see your facial expression and/or read your lips to enhance comprehension. Keep the client's view of your mouth unobstructed.
• Help older adults adjust hearing aids. Lacking fine-motor dexterity, older adults may not be able to insert aids correctly to amplify hearing. Make sure hearing aids are turned on. If difficulties persist, check the batteries.
• Keep background noise to a minimum (e.g., radio or television).
• Solicit feedback to monitor how much and what the person has heard.
Vision: Vision normally declines as a person ages (Whiteside, Wallhagen, & Pettengill, 2006). Colors become dimmer, and images are less distinct. Even with corrective lenses, blurring occurs, and words are harder to read in soft lighting. Brighter lighting and larger print help immensely. More serious age-related vision problems such as cataracts, glaucoma, and age-related macular degeneration can cause blindness.
Vision has implications for effective communication and functional ability. Older adults with progressive vision loss may not see you shaking your head or nodding. They may see changes in emotional facial expressions. Loss of vision can affect a person's ability to perform everyday activities (e.g., dressing, preparing meals, taking medication, driving, handling the checkbook, and seeing phone numbers). Vision affects functional ability to engage in hobbies or leisure activities (e.g., reading, doing handwork, and watching television). Poor vision is a major safety issue related to falls.
Adaptive Strategies for Vision Loss: Nurses can play a vital role in supporting the independence of the visually impaired client with a few simple strategies.
• If eyeglasses are worn, make sure they are clean, and in place.
• Stand in front of the client.
• Verbally explain all written information, allowing time for the client to ask questions.
• Provide bright lighting with no glare.
• When using written materials, consider font and letter size for readability. Use upper and lowercase letters rather than all capitals. Use solid paper, with sharp contrasting writing, and a lot of white space.
#### Assessment of cognitive changes
Age-related changes in cognition for healthy adults are minimal and should not require major modifications in communication, although mental processing and reaction times may be slower (Moody, 2010). Without the ravages of disease, older adults show little loss of intelligence but may require more time in completing verbal tasks or in retrieving information from long-term memory (Wilson, Bennet, & Swartzendruber, 1997). Older adults are less likely to make guesses when they are presented with ambiguous testing items in mental status examinations. They may hesitate or not respond as well if they are under time pressure to perform. Otherwise, there should be no difference in functioning.
Approximately 6% to 8% of the population older than 65 years and more than 30% of those who reach the age of 85 will experience profound progressive cognitive changes associated with dementia (Yuhas et al., 2006). Dementia is characterized by memory loss, personality changes, and a deterioration in intellectual functioning that affects every aspect of the person's life. A small percentage of abnormal cognitive changes are caused by other organic problems (e.g., drug toxicity, metabolic disorders, and depression) and may be reversed with treatment.
Appraisal of serious cognitive changes is critical to assessment of older adults, because it has the most impact on a person's ability to perform activities of daily living (Moody, 2010). When the nurse has concern about a client's cognitive capability, it is prudent to perform a mental status assessment early in the interview to avoid obtaining questionable data. The Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) measures several dimensions of cognition (e.g., orientation, memory, abstraction, and language). Guidelines for mental status testing with older adults are presented in Box 19-2.
BOX 19-2 Guide for Mental Status Testing with Older adults
1. Select a standardized test such as the Mini-Mental State Examination (MMSE), which can be completed in 5 minutes.
2. Administer the test in a quiet, nondistracting environment at a time when the client is not anxious, agitated, or tired.
3. Make sure the client has eyeglasses or hearing aids, if needed, before testing.
4. Ask easier questions first and provide frequent reassurance that the client is doing well with the testing.
5. Determine the client's level of formal education. If the client never learned to spell, it will be impossible to spell "world" backward. Saying the days of the week backward is a good alternative.
6. Document your findings clearly in the client's record, including the client's response to the testing process, so that future comparisons can be made.
Another useful assessment tool is the clock drawing test (CDT). The client is asked to draw a clock with numbers and a selected time; for example, 20 minutes after 8. A normal score is given if the numbers are presented in the correct sequence and position, and the clock displays the requested time. An abnormal score suggests dementia, and further evaluation is recommended.
#### Assessment of functional status
More than any other factor, impaired functional status is associated with an older adult's inability to live independently. **Functional status** refers to a broad range of purposeful abilities related to physical health maintenance, role performance, cognitive or intellectual abilities, social activities, and level of emotional functioning. Stress, acute and chronic illness, and age-related physiologic changes influence a person's ability to function (Zisberg, Zysberg, Young, & Schepp, 2009).
Functional status rather than chronologic age should be the stronger indicator of disability-related needs in older adults. Chronologic age is somewhat of a misnomer, in that functional impairment is not associated solely with age. Burke and Laramie (2004) note that a chronically ill 50-year-old with no support system may have more disabling symptoms of aging than a healthy, active 75-year-old with a strong social support system in place.
Although age typically robs some of life's vigor from older adults, most healthy cognitively intact older adults are able to perform activities of daily living (ADLs) independently, or with a little assistance. Instrumental activities of daily living (IADLs) are more complex than basic ADLs. IADLs refer to tasks older adults have to cope with on a daily basis, include cooking, cleaning, shopping, managing medications, getting to places beyond walking, using a telephone, and paying bills (Kleinpell, 2007).
From a basic health perspective, function relates to a person's ability to perform essential ADLs. Essential ADLs refer to six areas of essential function: "toileting, feeding, dressing, grooming, bathing, and ambulation" (Miller, 2009, p. 96).
Evaluation of functional abilities helps determine the type and level of care an older adult requires. Functional abilities in older adults can range from vigorous, active, and independent, to frail and highly dependent, with serious physical, cognitive, psychological, and sensory deficits (Bonder & Bello-Haas, 2009).
#### Assessment of pain
Persistent pain is a common concern of older adults, related to chronic conditions such as osteoarthritis, diabetic peripheral neuropathy, constipation, among others (Jansen, 2008). Both client and health care professionals can assume that moderate or episodic pain associated with chronic disorders of aging is a natural part of growing old. Pain limits an older adult's functional ability and compromises well-being; it should not be considered a normal consequence of aging. There is no more reason for an older adult client to suffer with chronic pain than there is for the younger client.
Chronic coexisting disorders such as depression or dementia can limit an older adult's ability to report or to correctly interpret underlying causes of pain. For example, undiagnosed depression may present as neck or shoulder pain, severe enough to interfere with sleep or activity. Liberal dispensing of analgesics to older adults for pain relief without full assessment of the nature of the pain and considering compliance issues can lead to undesired outcomes. Rowan and Faul (2007) label prescription drug abuse as one of the fastest growing public health problems among older adults in the United States.
Older adults, even those who are cognitively intact, can have trouble interpreting the level of their pain with the commonly used Faces Pain Scale. Although they can report whether their pain interferes with daily functioning, identifying pain levels on a linear scale is more of a challenge (Gloth, 2004).
A comprehensive pain assessment for older adults should ask the client to
• Describe the quality and nature of the pain, for example, aching, burning, pressure, acute, or stabbing. (Some older adults will use the word _discomfort_ instead of _pain_.)
• Identify when the pain occurs and under what circumstances.
• Identify specific pain patterns and/or changes in pain intensity.
• Describe how the pain affects the client's physical, psychological, and social functioning (Feldt, 2008).
• Define the area of the body where the pain occurs, whether it is deep or superficial, localized or radiating.
Assessment of pain in cognitively impaired clients and in those who cannot communicate verbally, for example, a stroke victim with receptive aphasia, is accomplished through behavioral observation. Behaviors suggestive of pain include grimacing, tightened muscles, groaning, crying, agitation, lethargy, and unwillingness to move.
#### Psychosocial assessment
Windsor and Anstey (2008) cite several studies indicating that older adults experience higher psychosocial well-being compared with younger counterparts. Older adults are more likely to seek emotionally meaningful activities in the moment and are less concerned with future achievements.
Loss is a reoccurring issue for older adults. Most will suffer more meaningful losses of people, activities, and functions that were important to them than earlier in life.
Although most people weather the necessary losses of life, late-life depression is an often untreated problem in older adults. Unlike symptoms of depression in younger people, somatization with vague physical complaints may be its first presenting sign (Arnold, 2005). Whenever the nurse senses a loss of emotional energy in life and feelings of desolation about their situation, it is important to seek additional data from the client. Statements warranting further exploration include:
"I am just useless."
"Life doesn't hold much for me anymore."
"I'd never do anything to myself, but sometimes I wish I wasn't here."
Age is a strong risk factor for suicide, among older white men (Groh & Whall, 2001). Statements reflecting helplessness and hopelessness should never be taken lightly.
## Supportive planning and intervention strategies in nurse-client relationships
Personal strengths form the basis for planning and interventions. Although older adults face many negative situational stressors, they also possess a lifetime of strengths that can be temporarily forgotten. Many older adults can live independently with social, spiritual, and environmental supports, with a good quality of life.
General nursing care for cognitively intact older adult clients, with the exception of acute care, centers around providing supports related to self-management of chronic illness and promoting healthy lifestyles. The level of support people need depends on personal, financial, and social resources that the older adult has at his or her disposal, and is willing and able to use. Asking questions such as "Can you tell me who visits you, or whom you have visited in the last month?" "If you needed immediate help, whom are you able to call?" and "Do you have enough sources of income to meet your basic needs?" gives nurses important data needed for planning and intervention.
### Psychosocial communication supports
Older adults who are institutionalized in nursing homes appreciate short, frequent conversations. Like everyone else, the need to be acknowledged is paramount to older adults' sense of self-esteem. Heliker (2009) describes a story sharing intervention identified as "a reciprocal give-and-take process of respectful telling and listening that focuses on what matters to the individual and minimizes the power of one over another" (p. 44). Conducted in long-term care facilities, this strategy emphasizes simple one-on-one human conversations with older adults about topics of interest to them.
Everyone has a story to tell. The use of short stories to frame conversation as a shared experience reminds clients that they have a valued social identity that goes beyond descriptions of their health. Each time an older adult tells their story, they remember when they saw themselves as a valued, productive member of society and that someone cares to listen. Nurses can teach and model this communication strategy with nursing assistants.
The conversational world for older adults can narrow for many reasons, for example, mobility, death of friends, and transportation. Spontaneous current events to draw from as a means of starting a conversation are not as available. A limited conversation repertoire happens with cognitively intact older adults, and they may repeat stories.
Repetitive stories can be frustrating for nurses. Rather than thinking, "Oh my, here he goes again with that old 'Model T' car story," it is better to respond to the story and enter the conversation as fully as possible. Each conversation is an opportunity to gain insight into the person who he or she was, what aspirations and dreams were fulfilled or unfulfilled, what contributions are valued, and what goals are yet to be attained.
#### Life Review
Life review is a useful intervention with older adult clients. Gentle prompts and relevant questions for clarification are required. Sharing recollections from youth or early adulthood days with a compassionate listener helps older adults review their life, establish its meaning, and confront their conflicts, as well as pleasures. Sometimes it provides opportunities for older adults to reconcile long-standing conflicts (Bohlmeijer et al., 2009).
#### Reminiscence Groups
The interpersonal contact in groups can be therapeutic for lonely, isolated older adults (Henderson & Gladding, 2004). Guidelines for group communication with older adult clients in long-term care settings are presented in Box 19-3.
BOX 19-3 Working with Older Adult Groups
• Affirm the dignity, intelligence, and pride of elderly group members.
• Ask group members to introduce themselves and ask how they would like to be called.
• Make use of humor, but never at the expense of an individual group member.
• Keep the communication simple, but at an adult level.
• Ask relevant questions at important points in a client's story.
• Call attention to the range of life experiences and personal strengths when they occur.
• Allow group members to voice their complaints, even when nothing can be done about them, and then refocus on the group task.
• Avoid probing for the release of strong emotions that neither you nor they can handle effectively in the group sessions.
• Thank each person for contributing to the group and summarize the group activity for that session.
Adapted from Corey M, Corey G: _Groups for the elderly_ (p. 406), ed 7, Belmont, CA, 2006, Thompson/Brooks Cole.
A specialized therapeutic form of group for older adults in long-term settings is the reminiscence group. Minardi and Hayes (2003) differentiate between life review, which explores life events in depth, and reminiscence groups, which focus on sharing life experiences from a socializing and a therapeutic perspective. They are powerful sources of self-esteem for older adult clients.
Reminiscence groups follow a structured format, with themes decided beforehand. Examples include special times in childhood or adolescence, child-rearing or work experience, and handling of a crisis. The leader guides the group in telling their stories, asking questions, and points out common themes to stimulate further reflections. Members create for themselves a shared reality by revealing to one another what life has meant and can be for them. In the process of remembering critical incidents, people can reconnect with sometimes forgotten parts of their life that held meaning for them. Jonsdottir, Jonsdottir, Steingrimsdottir and Tryggvadottir, 2001) note, "Recalling the past helps people to adjust to life's changes and thus provides a sense of continuity, integrity and purpose within the person's current life context" (p. 80).
### Social and spiritual supports
Social isolation compromises the health and well-being of older adults (Strine, Chapman, Balluz, & Mokdad, 2008). Staying engaged with life to whatever extent is possible and stimulating the mind are two critical strategies healthy older adults can use on a daily basis to promote health and well-being as they grow older.
Quality friendship is an incomparable resource for older adults. Social support for older adults may need to be more proactive and wide-ranging than for younger people, because the older adults' physical or intellectual vulnerability. They may require instrumental support with self-management of IADLs from family and friends. Helping family members and friends balance necessary assistance with the client's need for autonomy is a delicate art.
Bishop (2008) notes, "Social and spiritual ties share an interdependent link to positive psychological well-being in late adulthood (p. 2). For people who have lost a "people" support system, connection with a personal God or faith can be a very important source of support. Older adults express their spirituality through prayer, reading their bible, and engaging in religious or spiritual practices.
Awareness of a shortened life span promotes thinking about existential issues, death, and for some, the need to work through unresolved life issues. Spiritual interventions relevant to the care of older adults include instilling hope, prayer, and talking about the client's spiritual concerns. Helping clients cope with unfinished business and find forgiveness for self and others is identified as an important nursing intervention (Delgado, 2007). Clients with advanced dementia will often respond positively to spiritual hymns remembered from the past and to Bible readings.
Case Example
Lois visited an elderly patient with dementia in a nursing home on a weekly basis. The woman was mostly mute except for occasional words. One day Lois read her the 23rd Psalm. The woman spontaneously repeated the psalm from a different version, following Lois's reading in its entirety. She could not respond in the present; she could in the past when something was meaningful to her.
### Environmental supports
Maintaining independence for as long as possible with a good quality of life should be a goal for older adults. Independence is something most people take for granted as a younger adult, but it becomes a significant issue for older adults and their caregivers. Corey and Corey (2006) note, "As we age, we have to adjust to an increasingly external locus of control when confronted with losses over which we have little control" (p. 403).
The nurse plays a critical role in helping older adults maintain their autonomy. For older clients, being independent means that they are still in charge of their lives. As nurses assist clients to clarify values, make choices, and take action, a stronger understanding of their unique needs and strengths emerges. Older adults need to take as much responsibility for their choices and goal setting in health care as is possible.
Case Example
_Nurse:_ Mr. Matturo, it sounds as if being in charge of your life is very important to you.
_Client:_ Yes, it is. I grew up on a farm and was always taught that I should pull my own weight. You have to on a farm. I've lived my entire life that way. I've never asked anyone for anything.
_Nurse:_ I can hear how important that is to you. What else has been important?
_Client:_ Well, I was a Marine sergeant in World War II, and I led many a platoon into battle. My men depended on me, and I never let them down. My wife says I've been a good provider, and I've always taught my children to value honor and the simple way of life.
_Nurse:_ It sounds as though you have led a very interesting and productive life. Tell me more about what you mean by honor and the simple way of life.
Dialogues linking successful past coping experiences with present situations make it easier for the client to imagine possible individualized coping skills in the present. At the end of the dialogue, the nurse might summarize what the client has expressed and follow up with, "I enjoyed talking with you. You've had a fascinating life. What do you think is next for you?"
Nurses need to be sensitive to the unexpressed fears of older adults around surrendering their independence. Formal support services in the community, home health aides, and informal family supports can be critical factors in enabling frail older adults to remain independent.
You may need to directly observe environmental supports, bearing in mind a potential association in the older adults' mind between accepting help and relinquishing independent living. For example, an older adult in cardiac rehabilitation told his nurse that he had a bedside commode and no stairs in his home. When the nurse visited the home, there was no commode, and the client's home had a significant number of stairs. He told the nurse that he was afraid she would take steps to make him move if these facts were known.
### Safety supports
Although there will always be a delicate balance between the client's needs and restrictions or supports needed for safety, usually at least some areas can be negotiated. Simple interventions to promote independence include the following:
• Allowing elders personal choices about their bedtime, within reason
• Respecting choices in food selection
• Providing chair risers that help elders raise themselves from sitting to standing position
• Safety modifications in the home (e.g., bathtub rails, scatter rug removal, night lights)
• Including elder clients in decision making about health care and giving them the information they need to make responsible choices
Modern technology presents new possibilities to support the independence of older adults. Telehealth assistive services encompass virtual health visits, reminder systems, home security, social and health alarm monitors, and compensatory supports for failing functional abilities (Magnusson, Hanson, & Borg, 2004). Although telehealth is currently unavailable in many areas, innovative technology is likely to become an increasingly important component of support care for independent older adults.
#### Medication Supports
Polypharmacy is a fact of life for older adults. As people age, many need multiple medications to maintain a healthy lifestyle. Polypharmacy places older adults at risk for side effects and drug interactions because of age-related changes in metabolism (Cochran, 2005). Medications in general have a stronger effect on the older population and take longer to eliminate from the body.
Health teaching for older adults is critical if they are to achieve and maintain their health.
Keeping track of medications can be challenging for older adults. Usually there is more than one provider. Prescriptions from different providers can create adverse reactions. When a provider lacks access to the complete client profile of medications, or does not have knowledge that the client is taking over-the-counter medications, the client suffers. Encouraging clients or a family to keep a written list of all medications to be shared with each provider helps prevent adverse drug interactions.
_Healthy People 2010_ objectives (Department of Health and Human Services [USDHHS], 2000) identify polypharmacy among older adults with chronic illness as a key safety issue. Medication mismanagement is associated not only with adverse drug reactions, but with hospital and nursing home admission. It is a major contributor to falls and hip fractures. Factors associated with poor self-management of medications include complexity of taking multiple medications, using incorrect techniques, improper medication storage, level of health literacy, cost of medications factors, and poor eyesight. Nurses should use every opportunity, informal as well as formal, to help clients establish and maintain appropriate self-management of medications (Curry, Walker, Hogstel, & Burns, 2005). The adage "start low, and go slow" (Miller, 2009, p. 129), which is a basic principle of geriatric drug prescription and regular communication with prescribers, is essential. Simplifying the older adult's medication regimen and regular checking of expiration dates enhance medication management and lessen the possibility of adverse reactions.
During an assessment interview, and on each subsequent home or primary care visit, you should ask specifically about medication and treatment implementation. Ownby (2006) recommends using an open-ended question, such as "Tell me how you take your medications," rather than asking, "Are you taking your medication as prescribed?" (p. 33). Box 19-4 covers key areas for medication assessment. Visually checking medications with the client and talking about how the medication is working with the client and/or primary caretaker is useful in home care.
BOX 19-4 Teaching Medication Self-Management
Areas of Assessment:
• List of current and previously taken medications, herbal and over-the-counter medications
• Medications taken episodically for insomnia, pain, intestinal upsets, colds, and coughs
• Allergies (include exact symptoms)
• Does the client know what each medication is for, storage, what to do for missed doses, drug interactions, side effects
• Ability to read medication labels or printed instructions
• Motor difficulties with appropriate medication administration
• Expiration dates, brown bag syndrome (having older adult bring all medications in a brown bag for clinic visit observation)
• Determination of family responsibility, and availability if medication administration support is needed
Careful instruction as to the purpose, dosage, anticipated outcomes, and side effects can increase medication compliance. Establish a system with the client or family for medication administration, for example, prefilled medication dispensers or a medication calendar. Use a teach-back strategy to ensure that instructions are understood, and the client or family feels comfortable with their knowledge and capacity to implement administration.
#### Elder Abuse
Elder abuse represents a major threat to the safety and well-being of older adults. The term refers to the mistreatment of vulnerable older adults, usually at the hands of caregivers, including professional personnel. The most common form of elder abuse is neglect, both passive and active. Active neglect is deliberate. Passive neglect occurs when clients, most notably those with dementia, do not receive properly supervised care.
Elder abuse is a difficult problem to identify and treat. Diminished mental capacity compromises an older adult's ability to even understand what is happening, let alone take constructive actions to stop the abuse, or to use any community services available to them (Nerenberg, 2008). Alternative options for older adults are not readily available, and older adults are reluctant to consider a nursing home as an option. Pride, embarrassment, and a desire to protect family members prevent vulnerable older adults from wanting to prosecute a family member for abuse or neglect. If the nurse identifies abuse or neglect, it must be reported to appropriate social and legal protective services.
### Advocacy support
Fundamental rights of older adults in health care settings are identified in Box 19-5. Nurses play an important service in explaining treatment to clients and families, and helping them frame questions for physicians and hospitalists. Nurses assume advocate roles with older adults around the following issues:
BOX 19-5 Fundamental Older Adult Rights
Older adults need to be able to:
• Live in safe and appropriate living environments.
• Establish and maintain meaningful relationships and social networks.
• Have equal access to health care, legal, and social services consistent with their needs.
• Have the right to make decisions about their care and quality of life.
• Have their rights, autonomy, and assets protected.
• Have appropriate information to make reasoned decisions.
• Have their personal, cultural, and spiritual values, beliefs, and preferences respected.
• Participate in all aspects of their care plan, including care decisions to the fullest extent possible.
• Expect confidentiality of all communication and clinical records related to their care.
• Be involved in advocacy and the formulation of policies that directly impact their health and well-being.
• Referrals and home care
• Right to refuse medication or treatment
• Informed consent
• End-of-life decisions about care and life support issues
• Liaison between an older adult client and other health professionals
• Mediator with family and client concern around treatment, level of care, and placement issues
• Third-party reimbursement
• Suspected cases of elder abuse
• Balancing an older adult's need for freedom with necessary protections
Role modeling is an indirect form of advocacy, affecting the interpersonal relationships older adults have with their caregivers. Nursing assistants or professional caregivers provide the majority of care for older adult clients. Role-modeling excellent care and respect for the dignity of the older client, regardless of medical condition, is important. It is noted by family and nonprofessional staff, and has a ripple effect on the care that they provide.
Nurses can refer client family members to local Alzheimer's disease and related dementia support groups. Support groups provide a place to talk about the challenges of caring for their family member. The _36-Hour Day_ (Mace & Rabins, 2006), developed from the insights of family members coping with dementia in a loved one, is an excellent resource.
#### Advocating for Legal Protections
Frail older adults and particularly clients with dementia usually need legal protection to safeguard their personal and financial affairs, and to allow others by proxy to make health care decisions when they are unable to do so. Nurses can be invaluable resources and advocates for clients and families in discussing health-related personal legal matters. Advance directives and a durable power of attorney for health care (proxy) provide direction for the client's health care wishes should the person become incapacitated. For financial and property manners, the client needs to have a durable power of attorney, a living trust, and/or a will. Power of attorney documents are subject to state laws and are only in effect when people are unable to manage their own affairs. Under broad federal guidelines, state laws determine qualifications for Medicaid and property distribution if a person dies with no will or trust. Guidelines vary from state to state. Medicaid qualifications may be important for families requiring long-term care for a family member.
The time to execute legal documents to client rights is _before_ clients become unable to cognitively assign decision-making authority to someone they trust. Clients in the early stages of dementia usually have sufficient mental competence to participate in legal decisions regarding their health care and finances. Later, they may not be able to execute the documents. Consultation with a lawyer regarding wills, durable and health powers of attorney, and living wills should be initiated at this time (Arnold, 2005).
Once cognitive capacity is lost, a court procedure is necessary to establish a conservatorship or guardianship. This action is more costly and emotionally painful for most families, as it requires legally certifying the person as incompetent. Mental incompetence is a medicolegal determination that identifies a person's inability to manage his or her personal affairs because of injury, disease, or disability.
Clinical incompetence refers to a person's inability to make appropriate health care decisions or to carry them out, as determined by a physician or qualified health care practitioner. Nurses can help clients make their wishes known and feel more comfortable about allowing trusted people in their lives to act on their behalf.
### Health promotion for older adults
The CDC maintains that health-damaging behaviors such as poor nutrition, inactivity, and alcohol and tobacco abuse contribute heavily to the onset of disability in the elderly. They recommend an integrated health promotion approach to address common risk factors and comorbidities in older adults (Lang et al., 2005).
Older adults are much more health conscious today. They benefit from health promotion activities tailored to their stage of life. It is never too late to practice good nutrition; engage in healthful exercise such as strength training, walking, and yoga; connect with social relationships on a regular basis; and improve safety factors.
At the same time, healthy older adults are not young people. Their nutrition, exercise, and other health needs are different. Health promotion strategies need to be modified to meet the unique requirements of this population (Nakasato & Carnes, 2006). Box 19-6 identifies areas of relevant health promotion activities for older adults.
BOX 19-6 Areas of Relevant Health Promotion Activities
• Health protection: public health approaches promoting flu vaccines
• Health prevention: environmental or home assessments to prevent falls
• Health education: information about healthy eating and exercise
• Health preservation: promoting optimal levels of functioning by increasing the control older adults have over their lives and health
Adapted from Sanders K: Developing practice for healthy aging, _Nurs Older People_ 18(3):18–21, 2006; Bernard M: _Promoting health in old age,_ Buckingham, England, 2000, Open University Press.
Through regularly scheduled health promotion activities, nurses can assist clients in learning about a healthier lifestyle. Nurses can engage older adults in health promotion activities by appealing to their interests and by incorporating cultural values in the presentation. Examples of relevant activities can include:
• Preparing examples of healthy ethnic food (e.g., "soul cooking the healthy way")
• Assigning blocks of time for preventive screening, specifically for older adults
• Combining multiple prevention services into one clinical visit
• Providing free flu and pneumonia immunizations at convenient times in traditional and nontraditional settings (Lang et al., 2005; Penprase, 2006)
#### Health Teaching
Moody (2010) notes that health teaching for the elderly is critical if they are to master the tasks of old age and maintain their health. Healthy older adult clients are similar to other adult learners, except that they may need more time to think about how they want to handle a situation. The sensitive nurse observes the client before implementing teaching and gears teaching strategies to meet the individual learning needs of each client.
Assuming that older adult clients lack the capacity to understand instructions is a common error. Health care providers often direct instruction to the older adult client's younger companion, even when the client has no cognitive impairment. This action invalidates the client and diminishes self-worth. Mauk (2006) identifies simple modifications to reduce age-related barriers to learning when teaching older adults. Suggestions include:
• Explain why the information is important to the client.
• Use familiar words and examples in providing information.
• Draw on the client's experiences and interests in planning your teaching.
• Make teaching sessions short enough to avoid tiring the client and frequent enough for continuous learning support.
• Speak slowly, naturally, and clearly.
## Assessment and support interventions for cognitively impaired older adults
Assessment of cognitive function should occur early in the client relationship. Dementia is a neurologic syndrome characterized by a progressive decline in intellectual and behavioral functioning that ends in death. Alzheimer's disease is the most common form, followed by vascular dementia and rare forms of dementia.
Symptoms of cognitive impairment and communication difficulties in older adults can be similar in clients suffering from depression, delirium, and dementia. Diagnosis has important implications for treatment. Communicating with a client suffering from dementia requires a different set of strategies than for the client with depression. Clients with depression can still communicate normally. Table 19-1 identifies important differences between these three common disorders in late adulthood. Secondary clinical depression and/or delirium can be superimposed on dementia, making a difficult situation even more challenging. Exercise 19-5 provides an opportunity to distinguish between dementia, delirium, and depression, using a case study.
EXERCISE 19-5 Distinguishing Between Dementia, Delirium, and Depression in the Older Adult
Purpose: To differentiate between the 3 D's.
Mrs. S. is a recently widowed 78-year-old woman living alone in a senior apartment complex in a suburban community. Her son and his wife live nearby and visit weekly. Over the last month, the family has noticed that Mrs. S. "has not been herself." Once a meticulous dresser, she shows no current interest in dressing and grooming. She has had difficulty keeping doctor appointments and getting medications refilled. When approached by the family regarding her change in behavior, Mrs. S. says that she "doesn't know—if I could just get a good night's sleep, I would feel better."
Discussion:
What distinguishing alterations in cognition does Mrs. S exhibit to suggest a depression or a dementia?
What additional questions would you like to ask to support your observations?
What screening tools are appropriate?
What approaches would you suggest for communicating with Mrs. S?
Identify ways to improve ability to function safely and independently for Mrs. S.
What sources of support can you identify to help Mrs. S and her family cope?
Developed by A. M. Spellbring, PhD, RN, FAAN, February 9, 2010.
TABLE 19-1
Sorting Out the Three D's: Delirium, Dementia, Depression
Adapted from Arnold E: Sorting out the three D's: delirium, depression, dementia, _Holist Nurs Pract_ 19(3):99–104, 2005.
### Supporting adaptation to daily life
Box 19-7 outlines early cognitive changes seen with dementia. Memory loss is a consistent finding. Structure and consistency in the environment are important themes to consider. In the early stages, nurses can help clients develop reminder strategies such as making notes to themselves and using colored labels, alarms, or calendars. Focusing on what the client can do, rather than on deficits, does not change the course of the dementia. This strategy taps into the functions still available to the client and decreases feelings of hopelessness (Cotter, 2009).
BOX 19-7 Signs of Early Cognitive Changes with Dementia
• Difficulty remembering appointments
• Difficulty recalling the names of friends, neighbors, and family members
• Using the wrong word when talking
• Jumbling words: mixing up or missing letters in words when talking
• Not following the conversation of friends or coworkers
• Not understanding an explanation or story
• Difficulty recalling whether a task was just completed the day or week before
• Difficulty keeping up with all the steps to a task
• Difficulty planning and doing an activity such as a board meeting or family reunion
• New difficulty filling out complicated forms such as income tax forms
• Different behavior: restless, quick to get angry, constant hunger (especially for sweets), quiet or withdrawn, etc.
• Buying items and forgetting there is plenty at home
• Struggling with work or home tasks that used to be routine and easy
• Loss of interest in meeting with friends or doing activities
**_Apraxia_** , defined as the loss of the ability to take purposeful action even when the muscles, senses, and vocabulary seem intact is a common feature of dementia. The person appears to register on a command but acts in ways that suggest he or she has little understanding of what transpired verbally. In the following case example, the caregiver observes the client's difficulty. Notice how her response supports his ability to function. The client in the example had been the president of his company before being diagnosed with dementia.
Case Example
The care staff member noticed IA's restlessness as he struggled to figure out which shoes to put on. IA began looking around with darting eyes, quickly shifting his gaze from here to there. The care staff member said, "I am sorry. I have put two pairs of shoes here and it is confusing. Please put these on." IA looked relieved, put on the shoes, and moved to a table where the care staff member placed a box that had many small articles brought from IA's company. The care staff member said, "Would you help us, president?" IA smiled and said, "Okay...I can see you need help here," as he began to organize the articles into piles. He did not wander on that day (Ito, Takahashi, & Liehr, 2007, p. 14).
### Supporting communication
Difficulty with communication is a hallmark of dementia. The dementia client's loss of communication is a gradual process initially and most clients can maintain superficial conversation, with empathetic support. Miller (2008) notes that dementia affects basic receptive (decoding and understanding) and expressive (conveying information) forms of communication. These deficits impact the person's capacity to think abstractly and solve problems. Clients may have more difficulty with communication when stressed or tired. Identify yourself and address the client by name before beginning each conversation. Clients benefit from frequent orientations, word sharing, and redundancy. Box 19-8 summarizes communication guidelines.
BOX 19-8 Communication Do's and Don'ts with Dementia Clients
Communication Do's
1. Simplify environmental stimuli before beginning to converse.
2. Look directly at the client when talking.
3. Refer to the client by surname (Mrs. Jones rather than Mary).
4. Try to identify the emotions behind the client's words or behavior.
5. Identify and minimize anything in the environment that creates anxiety for the client
6. Watch your body language; convey interest and acceptance.
7. Repeat simple messages slowly, calmly, and patiently.
8. Give clear, simple directions one at a time in a step-by-step manner.
9. Direct conversation toward concrete, familiar objects.
10. Communicate with touch, smiles, calmness, and gentle redirection.
11. Structure the environment and routines, to allow freedom within limits
12. Use soft music or hymns when the client seems agitated.
Communication Don'ts
1. Don't argue or reason with the client; instead, use distraction.
2. Avoid confrontation.
3. Don't use slang, jargon, or abstract terms.
4. If attention lapses, don't persist. Let the client rest a few minutes before trying to regain his or her attention.
5. Don't focus on difficult behavior; look for the underlying anxiety and redirect.
6. Avoid hand restraints if at all possible.
7. Avoid small objects that could be a choking hazard.
The use of cues in communication is helpful to the older adult with short-term memory impairment. Word retrieval to express ideas diminishes _(aphasia)_ over time. The dementia client, unable to continue, stops in mid-sentence or continues with phrases that have little to do with the intended meaning (Mace & Rabins, 2006). Allow extra time for clients to decode the material.
Anything to help reduce the client's anxiety about groping for thoughts that do not come easily is useful. Helping clients put words or thoughts together allow the conversation to continue. Nurses can support clients by filling in missing words, or supplying a logical meaning, and then asking the client if this is what he or she meant. Another strategy is to almost finish a sentence and have the client supply the last word. If there are terms the client typically substitutes for common words or phrases, for example, the word "clock" for asking about time, use the client's term. You also can ask the client to point to an object or describe something similar if you don't understand what the client is referencing (Miller, 2008). As dementia progresses, clients become increasingly unable to understand and express complete thoughts. Eventually the client with dementia cannot carry on even simple conversations. Use questions that can be answered with a yes or no for clients with less verbal skill. Note whether the client's behavior is consistent with the yes or no answer, and follow up if the behavior is incongruent with the words.
Restate ideas using the same words and sequence, and validate the meaning of a client's response. Instead of using abstract prompts (like a specific time), use words directly applicable to the client's daily routine, such as "before lunch" to anchor the client's recognition of time frames. If a client rambles, you can refocus attention by selecting a single relevant thought from the stream of loosely connected ideas.
Cognitively impaired clients often are unable to follow instructions that consist of multiple steps. Breaking instructions down into single smaller steps helps mildly impaired clients master tasks that otherwise are beyond their comprehension.
Case Example
A young woman in a dementia support group for family members spoke of a meaningful experience with her grandmother. As she went to make a tuna fish sandwich for her grandmother, she decided to involve her in the process. She gave her grandmother step-by-step verbal instructions (e.g., "Get the tuna fish out of the cabinet," "Get the knife from the drawer," etc.), all of which her grandmother was able to do with her verbal guidance. As the granddaughter was spreading the mayonnaise, her grandmother said, "Now don't forget the onions." It was a priceless moment of connection for the granddaughter.
Asking mild to early moderate cognitively impaired older adults about their past life experiences serves as a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago. Nurses should appreciate that when cognitively impaired adults share memories they are giving a gift to the nurse by sharing part of themselves when they may have very little else to give.
Remote memory (recall of past events) is retained longer than memory for recent events. Family members can be encouraged to reminisce with dementia clients. This can be a meaningful experience for the family member even when the client cannot actively engage in the discussion, as it is a means of connecting. It is not uncommon for a dementia client to show through facial expression or garbled words that he or she too experiences the connection, even if only for a fleeting moment. Or it may come later.
Case Example
Mary was visiting her sister with dementia in the nursing home. She had traveled from Ohio to to Maryland to visit her. Her sister was unresponsive to her and Mary was upset that she didn't seem to realize that she was her sister. A few days after Mary returned home, her sister told the nurse, "You know, my sister Mary was here last week." Things register with dementia clients that are not always visible.
#### Touch
Touch is something clients with dementia can no longer ask for, create for themselves, or tell another of its meaning. Touch is a form of communication, used to reinforce simple verbal instructions with cognitively impaired adults, and as a primary form of communication. It is experienced "not only physically as sensation, but also affectively as emotion and behavior" (Kim & Buschmann, 2004, p. 35). As dementia progresses, gentle touch can anchor an anxious or disoriented person in present time, space, and humanity. When used to gain a client's attention, or to guide a person toward an activity, touch can acknowledge a client's stress, calm an agitated client, or provide a sense of security. In general, clients with dementia appreciate the use of touch. But to some, it can be frightening if the client perceives the caregiver as threatening. You can usually tell when a client thinks you are entering his or her personal space by looking at facial expression. Before using touch, make sure that the client is open to it.
Putting lotion on dry skin, giving back rubs, and warming cold hands or feet can be meaningful to the dementia client, as is something as simple as holding the client's hand. When a person is no longer able to recognize familiar caregivers by name, nurturing touch provides a touchstone with the physical reality of someone who cares about the client. It may be his or her only remaining opportunity for human interaction.
### Reality orientation groups
Reality orientation groups are used with older adults experiencing moderate-to-severe cognitive impairment. Focusing on their personal environment, these groups keep people in touch with time, place, and person. Topics can include landmarks in the dining room, routes to the dining room or bathroom, the date, time and weather, what people would like to wear, and so on. Reality orientation groups may be conducted daily or weekly with three to four clients (Minardi & Hayes, 2003).
### Validation therapy
Validation describes a therapeutic communication process used in later stages of dementia. Developed by Naomi Feil, validation recognizes that a client is responding to a different reality related to time, place, or person (Minardi & Hayes, 2003). Rather than confronting dementia clients with "facts"—that people they knew or places they have lived are no longer available to them—the nurse focuses on the personal meaning events and people hold for the client. For example, you might say, "Tell me about Mary," or "What was it like living on M street?"
### Defusing catastrophic reactions
Older adults with memory loss lack the cognitive ability to develop alternatives. They emotionally overreact to situations, and can have what look like temper tantrums in response to real or perceived frustration. Older adult tantrums are called **catastrophic reactions** , and they represent a completely disorganized set of responses. Usually there is something in the immediate environment that precipitates the reaction. Fatigue, multiple demands, overstimulation, misinterpretations, or an inability to meet expectations are contributing factors (Mace & Rabins, 2006).
The emotion may be appropriate, even if its behavioral manifestation is not. Warning signs of an impending catastrophic reaction include restlessness, body stiffening, verbal or nonverbal refusals, and general uncooperativeness.
Instead of focusing on the behavior, try to identify and eliminate the cause(s) (Hilgers, 2003). Use distraction to move older adults away from the offending stimuli in the environment; use postponement. For example, you could say, "We will do that later; right now, let's go out on the porch," while gently leading the person away. Direct confrontation and an appeal for more civilized behavior usually serve to escalate rather than diminish the episode.
**Sundowning** is the term used to describe episodic agitated behavior occurring in the late afternoon or early evening with clients in the middle stages of dementia. Common childlike behaviors of whining, agitation, and temper tantrums characterize the syndrome. Small doses of medication are used to alleviate symptoms. Caution is needed to avoid over-sedating the client.
### Caring for clients with advanced dementia
As the dementia progresses, people lose control over most of their body functions and will experience one or more psychopsychiatric symptoms. They will require total care, which, in many cases, will include formal and informal caregiving strategies. Table 19-2 identifies common neuropsychiatric symptoms associated with advanced dementia, with suggested behavioral communication interventions.
TABLE 19-2
Neuropsychiatric Symptoms with Suggested Behavioral Communication Interventions
Neuropsychiatric Symptom Pattern | Suggested Intervention
---|---
Agitation | Identify and remove cause
Assess for physical problems
Reduce stimuli, suggest a walk
Use simple repetitive activities: folding towels, rolling socks
Use soothing music, Bible verses
Look for patterns that trigger agitation
Aggression: grabbing, hitting | Recognize that the client is frightened
Decrease stimuli, move client to a quiet place
Don't take the client's behavior personally
Respect and enlarge the client's personal space
Identify and minimize cause
Make eye contact; speak in a calm voice
Acknowledge frustration; don't reprimand
Check medications
Withdrawal: decreased socialization, apathy, social isolation | Use simple activities
Find simple socialization opportunities, and support client involvement
Refusal/resistance to suggestions | Drop the topic/activity and reintroduce later
Disturbed motor activity: wandering, pacing, raiding waste cans, shadowing caregiver | Keep the environment safe
Remove trash
Use medical alert bracelets
Label drawers, room (photos help)
Use locks on doors at home
Sleep disturbances: Day/night sleep reversal, calling out/moaning in sleep | Keep active during the day
Toilet client as needed during night without conversation
Control wandering at night; lead back to bed; avoid use of restraints
Hallucinations, delusions, illusions | Respond to the emotion, not content
Reduce stimuli
Use good nonglare lighting
Use distraction, e.g., walk, simple activity
Use touch, reassurance, postponement
Disinhibition: inappropriate speech, touching, improper body exposure, entering other people's space | Don't reprimand
Respond to the emotion
Redirect client
Incontinence: urine, feces, eliminating in wrong places | Check for bladder infection, fecal impaction
Note elimination pattern; establish corresponding toileting timetable
Schedule toileting at frequent intervals
Toilet before bedtime
Take client to bathroom, verbally cue
Use washable clothing, Velcro closings
Swallowing difficulty: choking, stuffing mouth, not swallowing | Cut food into small pieces, offer small quantities of liquid at one time
Check medications for size, modify as needed
Sit with client while eating
Verbally cue to chew and swallow
Agnosia: difficulty recognizing faces, including one's own | Remove or cover mirrors if client is frightened by self-image
Verbally identify familiar people and their relationship to the client
Treatment goals for clients with advanced dementia should emphasize dignity, quality of life, and supportive comfort strategies, rather than focusing on prolonging life (Rabins, Lyketsos, & Steele, 2006).
## Summary
This chapter discusses concepts of aging and presents supportive communication strategies nurses can use in client-centered relationships with older adults. Aging is associated with a decline in sensory and motor functions for most people, but contemporary older adults can expect to live longer and enjoy a better quality of life than in previous generations.
Erikson's theory of psychosocial development identifies wisdom as the virtue associated with his last stage of ego development, integrity versus despair. Supportive strategies to assist clients maximize their health and well-being during this important stage of life focus on communication, social and spiritual structure, the environment, safety, and medication management.
Assessment of depression, delirium, and dementia is important, as some symptoms are hard to differentiate. Guidelines for communicating with clients with dementia emphasize touch, as well as verbal supports. Strategies such as reminiscing, promoting client autonomy, using a proactive approach, acting as a client advocate, and treating older adults with dignity are proposed. Health promotion activities that take into account the unique needs and cultural values of older adults are more likely to be successful. As a primary provider in long-term care and in the community, the nurse is in a unique role to support and meet the communication needs of older adult clients.
Ethical Dilemma
What Would You Do?
Mrs. Porter's mother, Eileen O'Connor, is a feisty, independent, 86-year-old. She lives alone and treasures her independence. Mrs. O'Connor is in your urgent care clinic for suturing of a lesion on her leg, which was injured in a fall. Mrs. Porter accompanies her mother and you listen to them argue; it is clear to you that Mrs. Porter wants to commit her mother to a long-term care facility. While you are alone with Mrs. O'Connor in the examination room, taking her history, she swears you to silence and confides in you that she is having increasingly frequent lapses in memory, sometimes forgetting to eat. You are aware of the need to maintain client confidentiality, but you also recognize that to ignore the ethical concept of beneficence and keep silent may well endanger Mrs. O'Connor's life. What would you do?
Courtesy Elaine Cloud, MD, 2002.
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CHAPTER 20
# Communicating with Clients in Stressful Situations
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define stress and associate concepts.
2 Describe biological and psychosocial models of stress.
3 Identify concepts related to coping with stress.
4 Discuss stress assessment strategies.
5 Describe stress reduction strategies nurses can use in stressful situations.
6 Identify stress management therapies.
7 Address occupational stress in nurses.
This chapter provides a framework for understanding basic concepts of stress, and supporting client and family coping with stress through the nurse-client relationship. Included in the chapter are physiologic and psychological models of stress reactions, and descriptions of behaviors associated with stress reactions. The chapter addresses nursing interventions and communication strategies nurses can use to help people cope more effectively with stress.
## Basic concepts
Definitions
**Stress** represents a natural physiologic, psychological, and spiritual response to the presence of a stressor. Stress feelings set into motion an immediate emergency physiologic response to real or perceived threats. Normally, the stress response turns off when the immediate danger has passed.
A **stressor** is defined as a demand, situation, internal stimulus, or circumstance that threatens a person's personal security or self-integrity. Stressors can be catastrophic (war, hurricane, earthquake), related to a major life change (marriage, divorce, death, moving to a new area), or experienced as a minor hassle (traffic jam, child misbehavior, computer crashes).
Stressors can be potential, actual or imagined, and negative or positive. Illness, significant loss (e.g., job or relationship, home), a move to a different city, and loss of income can create negative stress. A job promotion, impending wedding and birth of a child are positive events that can be stressors. Box 20-1 lists personal sources of stress.
BOX 20-1 Personal Sources of Stress
Physical Stressors
• Aging process
• Chronic illness
• Trauma or injury
• Pain
• Sleep deprivation
• Mental disorder
Psychological Stressors
• Loss of a job or job security
• Loss of a significant person or pet
• Significant change in residence, relationship, work
• Personal finances
• Work relationships
• High-stress work environment
• Caretaking (frail elderly, children)
• Loss of role
Spiritual Stressors
• Loss of purpose
• Loss of hope
• Questioning of values or meaning
• Disenchantment with religious affiliation
Stressors likely to stimulate an intense stress response are those in which a person has limited control over the situation, the situation is ambiguous, or the current situation resembles unresolved stressful events in the past. Concurrent and cumulative stressors increase the stress response level. The intensity and duration of stress varies according to the circumstances, level of social support, and the emotional state of the person. People have different tolerance levels for stress. Some people are highly sensitive to any stressor, others are more laid-back and have selective responses to stressful circumstances. Stress reduces the efficiency of cognitive functions and reduces access to previous knowledge. Caplan (1981) emphasizes the importance of community education, and socio-cultural support as a way to compensate for perceptual deficits and minimize the impact of negative stress.
### Characteristics of stress
Hans Selye used the term **eustress** to describe a short-term, mild level of stress. It acts as a positive stress response with protective and adaptive functions, and is perceived as being within the person's ability to manage. **Distress** is defined as a negative stress that causes a higher level of anxiety, and is perceived as exceeding the person's coping abilities. It is experienced as being unpleasant and diminishes performance.
Current research suggests that men and women respond to stress differently. Men respond with patterns of "fight or flight," whereas women use a "tend and befriend" approach. Women use nurturing activities to reduce stress and promote safety for self and others. They seek social support from others, particularly from other women (Taylor, Klein, Lewis, Gruenewald et al. 2000). Children express stress through behavior, according to their stage of development, and family patterns. Acting out behaviors can mask a child's distress.
### Levels of stress
Mild stress can be beneficial. It helps people stay focused and alert. Mild stress serves as a motivator to develop skills to meet challenges and accomplish goals. Awareness of personal strengths and mastery of coping strategies learned in mastering a stressful situation helps people cope better in other life circumstances (Aldwin & Levenson, 2004).
Moderate stress occurs when people experience frustration or conflict over an inability to change a desired outcome through their own efforts. When people are stressed, they are more susceptible to illness (Dolbier, Smith & Steinhardt (2007). Chronic stress is implicated in the development and exacerbation of cardiac conditions, migraine, and digestive disorders. Stress create comorbidities between physical disease and mental disorder (Askew & Keyes, 2005).
High stress levels interfere with a person's ability to function because anxiety reduces a person's objectivity. People have trouble envisioning possibilities, weighing options, making choices, and taking action. They can exhibit anger, anxiety, and depressive symptoms. Severe or chronic stress weakens the immune system, thereby contributing to the development of stress-related illnesses (Martin, Lae, & Reece, 2007). Untreated, severe mental stress reactions associated with traumatic events can develop into post-traumatic syndrome, a clinical disorder. Stress and coping is said to account for up to 50% of the variation in psychological symptoms (Sinha & Watson, 2007).
### Biological and psychosocial models of stress
Physiologic response models
Walter Cannon (1932) was the first to describe a scientific physiologic basis for an acute stress response. Cannon believed that when people feel physically well, emotionally centered, and personally secure, they are in a state of dynamic equilibrium or **homeostasis**. Stress disturbs homeostasis. Physiologically, the sympathetic-adrenal medulla system in the brain sets into motion an immediate hormonal cascade designed to mobilize the body's energy resources to cope with acute stress.
Cannon proposed that people attempt to adapt to stress with either a "fight or flight" response. The fight response refers to a person's inclination to take action against a threat if the threat appears to be resolvable, and the flight component, to flee, if it is unlikely that the threat can be overcome.
#### General adaptation syndrome
Stress hormone levels generally revert to normal once the cause of the stress is resolved. Hans Selye (1950) expanded on Cannon's work in describing responses to longer term stress exposure. He described a three-stage progressive pattern of nonspecific physiologic responses, which he branded as alarm, resistance, and exhaustion. The alarm stage is similar to Cannon's acute stress response, characterized by increased activity in the hypothalamic-pituitary-adrenal (HPA) axis. Corticosteroids are released, which mobilizes the body's energy resources. If the stressor is not resolved in the initial alarm stage, a second adaptive phase referred to as "resistance" occurs as the body tries to accommodate for the stressor. In the resistance stage, the alarm symptoms subside as the immune system helps the body to adapt as best it can. Although the acute stress symptoms seem to disappear, the body functions less efficiently, and the resistance stage drains productive energy. If the body fails to adapt, or is still unable to resist the continued stress, it leads to "exhaustion." In the exhaustion stage, people are at high risk for stress-related illness or mental disorder.
The same physiologic response occurs regardless of whether a stressor is psychological or physical. Activation of the HPA axis occurs with the stress of critical illness, surgery, trauma, and emotional disorders (Johnson & Renn, 2006). The longer the physiologic responses remain elevated, the greater its negative effect on the organism.
#### Allostasis
A recent theory of stress response challenges the idea that physiologic systems respond to stressors as an attempt to achieve a fixed level of homeostasis (Sterling & Eyer, 1988). Allostasis describes how the organism achieves homeostasis through adaptation, referred to as "stability through change" (McEwen, 2000, p. 1219). The interaction between stressors and physical responses is ongoing such that individuals become more or less susceptible to the negative consequences of stress over time.
The brain serves as a "primary mediator" between the "current stressor exposure, internal regulation of bodily processes, and health outcomes" (Ganzel, Morris, & Wethington, 2010, p. 134). The brain determines what experiences are threatening or nonthreatening, and the physiologic response requirements of each situation. It tries to find a new homeostasis that better fits the requirements of the environmental stressor, using a range of adaptive functioning (allostatic accommodation). The inclusion of genetic risk factors, early life events, and lifestyle behaviors in the model offers a way to understand the interaction between stressful events and physiologic adaptation processes (McEwen & Wingfield, 2003). Figure 20-1 identifies relationships in the allostasis model.
Figure 20-1 Allostasis model of stress.
Stress hormones protect the body against short-term acute stress (allostasis). Stress mediators, such as social support, are capable of producing protective effects. When small or moderate levels of stressor exposure are encountered, and social support is available, the outcome is increased health and functioning. If a stressor continues, presents repeated challenges, or stress responses are ineffective, there is "wear and tear" on the body, which can have a damaging effect. McEwen (2007) terms this phenomena _allostatic load._ The allostatic load can be negligible or severe and protracted enough to result in significant illness or death.
#### Stimulus stress model
In 1967, Thomas Holmes and Richard Rahe developed a stress model that considered stressful life events such as marriage, divorce, death, losing a job, and so on as stimuli that threaten or disrupt homeostasis. The Holmes and Rahe scale gave each individual life event a weighted numerical score reflecting its stress impact on a person. Stressors requiring a significant change in the lifestyle of the individual have greater impact, as do cumulative stresses occurring within a short time. The quantity and severity of stressors influence a person's potential for developing later physical illness.
#### Transactional model of stress
Lazarus and Folkman's (1984) transactional model of stress is one of the most widely used to explain stress responses. It is based on the premise of a stressful experience is the result of a transaction between a situation or circumstance in the environment (stressor) and the individual experiencing the stressor. The transaction is the dynamic that accounts for a stressor's impact on a person. A person's perception of stressful events and interpretation of its meaning, and not the objective stress value of a stressor, determines the stress response.
Stress responses to cumulative daily stressors are a primary focus of the transactional model (Neale, Arentz, & Jones-Ellis, 2007). The model asserts that stress is as likely to occur with daily "hassles" as it is with major life events. The transactional model considers appraisal of stressors and coping strategies as a primary emphasis.
Primary and Secondary Appraisal: A person's interpretation of a stressful event is the result of two levels of cognitive appraisal. A primary appraisal initially evaluates the magnitude of the stressor, followed by a secondary appraisal evaluating an individual's perceived ability to cope with it (Figure 20-2). Both are required to determine whether a stressor will be appraised as harm, threat, or challenge (Folkman, 2008).
Figure 20-2 Primary and secondary appraisal in stress reactions.
**Primary appraisal** focuses on the stressor or stressful event itself—its content and strength as a personal threat. A person determines whether an event is stressful and draws one of three conclusions: It is not stressful, it is a relatively benign stressor, or it poses a significant threat to self-integrity. Stressors perceived as a major threat to self elicit a stronger stress response, for example, losing an important relationship or being diagnosed with a serious illness. Primary stress appraisals can include threat of harm or losses that are anticipated but have not yet occurred.
When a primary cognitive appraisal determines a stressor to be a significant threat, the person automatically switches to a secondary appraisal related to coping skills. **Secondary appraisal** involves a person's perception of personal coping skills and the availability of resources in the environment to aid in reducing stressor impact.
### Coping with stress
Knowledge of coping is essential to understanding how stress affects people (Skinner, Edge, Altman, & Sherwood, 2003). Coping strategies can reduce or increase the effects of stressors and the development of distress. In their classic work, Pearlin and Schooler (1978) define **coping** as "any response to external life strains that serves to prevent, avoid, or control emotional distress" (p. 2). They identify three purposes of coping strategies:
• To change the stressful situation
• To change the meaning of the stressor
• To help the person relax enough to take the stress in stride
People learn coping strategies from parents, peers, and the circumstances life presents to them. Those with a variety of life opportunities and supportive people in their lives have an advantage over people who lack either opportunity or support system. People who have been overprotected or have been exposed to danger without support or mentoring generally lack experience with coping skills. Exercise 20-1 helps identify adaptive and maladaptive coping strategies in your life.
EXERCISE 20-1 Identifying Adaptive and Maladaptive Coping Strategies
Purpose: To help students identify the wide range of adaptive and maladaptive coping strategies.
Procedure:
1. Identify all of the ways in which you handle stressful situations.
2. List three personal strategies that you have used successfully in coping with stress.
3. List one personal coping strategy that did not work, and identify your perceptions of the reasons it was inadequate or insufficient to reduce your stress level.
4. List on a chalkboard or flip chart the different coping strategies identified by students.
Discussion:
1. What common themes did you find in the ways people handle stress?
2. Were you surprised at the number and variety of ways in which people handle stress?
3. What new coping strategy might you use to reduce your stress level?
4. Are there any circumstances that increase or decrease your automatic reactions to stress?
#### Types of coping strategies
Lazarus and Folkman (1984) identify two types of coping. **Problem-focused coping** strategies use approach behaviors, for example, confronting a problem directly, seeking social support, and constructive problem solving. Negotiation, directly confronting challenging issues, and taking action are deliberately used to change a stressful situation. Recognition of personal and outside resources can foster options, and people who have options generally are better able to cope with stress. Balancing coping resources include health, energy, problem-solving skills, the amount and availability of social supports and other material resources to cope effectively with the stressor. Individuals who are generally capable, have financial resources, and are by nature optimistic typically handle stress more easily.
**Emotion-focused coping** refers to avoidance behaviors that serve to distance the person from stress. They can be helpful alone or in combination with problem-solving strategies when people are faced with overwhelming irreversible situations.
Research suggests that constructive emotion-focused coping, featuring change in attitude, acceptance, and emotional respite from overthinking about a stressful situation, is associated with positive outcomes (Mohr, Goodkin, Gatto, & Van der Wende, 1997). Emotion-focused coping can be a positive realistic choice when a situation cannot be changed, and the person deliberately chooses to "let go" of negative feelings associated with it. Most people use both types of coping strategies, with the choice of strategy being somewhat dependent on the nature of the stressor.
Helping clients and families develop a different perspective can be just as important as the more traditional problem-solving strategies used to cope with stress (Michalenko, 1998).
Defensive Coping Strategies: People need time to absorb the meaning of a serious stressor. As a short-term coping strategy, defense mechanisms can be temporarily adaptive in minimizing the threat of a potentially overwhelming stressor (Richards & Steele, 2007). As a primary stress reducer, and over time, defense mechanisms are ineffective because they serve as a disincentive to action. **Ego defense mechanisms** represent a largely unconscious pattern of coping that people use to protect the self from full awareness of challenging conflict situations. They are designed to protect the ego from anxiety and loss of self-esteem by denying, avoiding, or attributing responsibility for a challenging conflict to an external source. Persistent use of ego defense mechanisms as a primary coping strategy generally is considered pathologic, although a few have positive value. Recent authors (Reich, Zautra and Hall, 2010; Vaillant and Mukamal, 2001) contend that healthy defense mechanisms; humor, anticipation, affiliation (asking for help) and sublimation can be adaptive and are associated with resilience. For example, sublimation is used to channel extreme anger impulses into acceptable behaviors, for example, by becoming a butcher or boxer. Table 20-1 provides definitions and examples of common defense mechanisms.
TABLE 20-1
Ego Defense Mechanisms
Ego Defense Mechanism | Clinical Example
---|---
Regression: returning to an earlier, more primitive form of behavior in the face of a threat to self-esteem | Julie was completely toilet trained by 2 years. When her younger brother was born, she began wetting her pants and wanting a pacifier at night.
Repression: unconscious forgetting of parts or all of an experience | Elizabeth has just lost her job. Her friends would not know from her behavior that she has any anxiety about it. She continues to spend money as if she were still getting a paycheck.
Denial: unconscious refusal to allow painful facts, feelings, or perceptions into awareness | Bill Marshall has had a massive heart attack. His physician advises him to exercise with caution. Bill continues to jog 6 miles a day.
Rationalization: offering a plausible explanation for unacceptable behavior | Annmarie tells her friends she is not an alcoholic even though she has blackouts, because she drinks only on weekends and when she is not working.
Projection: attributing unacceptable feelings, facts, behaviors, or attitudes to others; usually expressed as blame | Ruby just received a critical performance evaluation from her supervisor. She tells her friends that her supervisor does not like her and feels competitive with her.
Displacement: redirecting feelings onto an object or person considered less of a threat than the original object or person | Mrs. Jones took Mary to the doctor for bronchitis. She is not satisfied with the doctor's explanation and feels he was condescending, but says nothing. When she gets to the nurse's desk to make the appointment, she yells at her for not having the prescription ready and taking too much time to set the next appointment.
Intellectualization: unconscious focusing on only the intellectual and not the emotional aspects of a situation or circumstance | Johnnie has been badly hurt in a car accident. There is reason to believe he will not survive surgery. His father, waiting for his son to return to the intensive care unit, asks the nurse many questions about the equipment, and philosophizes about the meaning of life and death.
Reaction formation: unconscious assuming of traits opposite of undesirable behaviors | John has a strong family history of alcoholism on both sides. He abstains from liquor and is known in the community as an advocate of prohibition.
Sublimation: redirecting socially unacceptable unconscious thoughts and feelings into socially approved outlets | Bob has a lot of aggressive tendencies. He decided to become a butcher and thoroughly enjoys his work.
Undoing: verbal expression or actions representing one feeling, followed by expression of the direct opposite | Barbara criticizes her subordinate, Carol, before a large group of people. Later, she sees Carol on the street and tells her how important she is to the organization.
It is important to remember most ego defense mechanisms are unconscious. Because a defensive reframing of a conflict in a person's mind is usually not under the conscious control of the client, it is difficult to help them consider alternative coping strategies without support. Challenging defense mechanisms directly usually is not successful. The Prochaska model and motivational interviewing (see Chapter 15) offer guidelines for gently casting doubt, providing new information and introducing problem-solving strategies to assist clients in positively reframing secondary appraisals.
Case Example
Lynn was diagnosed as having a high cholesterol count and was advised to go on a low-fat diet. Basically, she knows she needs to do this, but Lynn says she sees no purpose in going on a low-fat diet because "it's all in the genes." Both her parents had high cholesterol and died of heart problems. Lynn claims there is nothing she can do about it, even though the physician has advised her differently. Her defensive interpretation prevents her from taking action needed to reduce her risk for cardiovascular disease and can result in a heart attack or death. Here the nurse might inquire about the client's health goals and provide the client with information about the link among diet, exercise, and heart disease. Linking the information to Lynn's stated life goals provides her with a different frame of reference.
#### Social support
Social support is a key factor in alleviating stress and promoting the self-efficacy people need for successful coping and mastery of stress (Caplan, 1981). **Social support** is defined as the emotional comfort, advice, and instrumental assistance that a person receives from other people in their social network (Taylor, Welch, Kim, & Sherman, 2007). Social support has three distinct functions: validation, emotional support, and correction of distorted thinking. Social support can refer to both the "perceived availability of help, or support actually received (Schwarzer & Knoll, 2007, p. 244). A person's social networks are drawn from family, friends, church, work, social groups, or school. Being able to contact family and friends when you need an emergency babysitter or an extra hand in a stressful situation immediately lessens stress.
Social support allows for honest sharing of feelings and concerns in an emotionally supportive relationship. Not only does sharing with others reduce stress by "externalizing" negative emotions, but family and friends can provide a sounding board, practical assistance, and tangible encouragement. Seeking help can empower both seeker and provider of emotional support. Sharing a laugh, eating a meal with others, and being in good company helps people feel more relaxed, which, in turn, reduces stress levels.
Social support does not have the same meaning for all cultures in terms of self-disclosure. Taylor et al. (2007) report that Asian American clients may be more comfortable with an implicit form of social support that does not require extensive sharing of thoughts. Examples of implicit social support include showing kindness, caring, acceptance, and positive regard for a client.
Developing an Evidence-Based Practice
Drageset S, Lindstrom T, Christine MA: Coping with a possible breast cancer diagnosis: demographic factors and social support, _J Adv Nurs_ 51(3):217–226, 2005.
The authors completed an exploratory study examining the relationships between demographic characteristics, social support, anxiety, coping, and defense among women with a possible breast cancer diagnosis. A survey design was used to elicit data from a nonprobabilistic convenience sample of 117 women who had recently undergone breast biopsy. Study instruments included the Social Provisions Scale, State-Trait Anxiety Scale, Utecht coping list, and Defense Mechanisms Inventory. Demographic data were also collected. Data were analyzed using stepwise linear regression and statistical analysis methods.
_Results:_ Study results indicated high internal reliability for the instruments used in the study. The social provisions scale was positively related to instrumental-oriented and emotion-focused coping, and unrelated to cognitive defense and defensive hostility. Social support was most strongly correlated to coping style. There were positive correlations between education, attachment, and instrumental coping, with education emerging as the most important determinant. Family was also found to be an important source of social support. A defensive hostile style of relating was negatively related to social support.
_Application to Your Clinical Practice:_ This study demonstrates the need to educate clients experiencing the stress of a new diagnosis about the benefits of social support. Defensive hostility is a behavior that often masks anxiety. How could you use this information to help clients experiencing the stress of a new diagnosis cope more effectively?
## Applications
Stress assessment
Stress can worsen almost any illness. Factors that influence the impact of stress are identified in Box 20-2. Addressing relevant issues and teaching clients related coping strategies as early as possible enhances recovery potential. Clients and family members usually welcome an opportunity to tell their story and talk about concerns beyond the concrete needs of a stressful situation.
BOX 20-2 Factors That Influence the Impact of Stress
• Magnitude and demands of the stressor on self and others
• Multiple stressors occurring at the same time
• Suddenness or unpredictability of a stressful situation
• Accumulation of stressors and duration of the stress demand
• Level of social support available to the client and family
• Previous trauma, which can activate unresolved fears
• Presence of a co-occurring mental disorder
• Developmental level of the client
• Attitude and outlook
• Knowledge, expectations, and realistic picture
Understanding how a stressful event relates to other life issues, including stressors from the past, and current financial or family concerns puts the current stressor in context. Ask open-ended questions about changes in daily routines, new roles and responsibilities, and the client/family's understanding of diagnosis and treatment options.
Pay attention to cultural values. What is a small stressor in one culture can be huge in another, and normal coping strategies can be quite different. When clients present with stress-related symptoms, an initial assessment should include:
• Identification of stress factors the person is experiencing, including which one(s) is causing the most stress
• Perception of stressor as being harmful, threatening, or challenging
• Value or meaning attached to the stressor
• Identification of usual coping strategies and methods used to cope with current stressors
• Assessment of linked or underlying issues such as developmental stage, culture, family understandings, and level of support
#### Identifying sources of stress in health care
Disruptions in health status create stress, anxiety, and vulnerability. Health-related stressors for clients and families include fear of death, uncertainty about clinical outcome, changes in roles, disruption of family life, and financial concerns created by the hospitalization (Leske, 1998).
Hospitalization intensifies stress. Hospital-related stress can negatively impact client outcomes, level of satisfaction with care, and compliance with treatment. Examples include physical discomfort, strange noises and lights, unfamiliar people asking personal questions, and strange equipment. Clients and their families experience anxiety with transfer to the intensive care unit, and again when they are preparing to a step-down or regular unit, and still again when they are transitioning to home (Chaboyer, James, & Kendall, 2005). Providing immediate practical and emotional support during each of these transitions can reduce unnecessary stress. Box 20-3 provides an assessment/intervention tool that you can use to organize assessment data and plan interventions.
BOX 20-3 Assessment/Intervention Tool
Assessment
A Perception of stressors
1. Major stress area or health concern
2. Present circumstances related to usual pattern
3. Experienced similar problem? How was it handled?
4. Anticipation of future consequences
5. Expectations of self
6. Expectations of caregivers
B Intrapersonal factors
1. Physical (mobility, body function)
2. Psychosociocultural (attitudes, values, coping patterns)
3. Developmental (age, factors related to present situation)
4. Spiritual belief system (hope and sustaining factors)
C Interpersonal factors
1. Resources and relationship of family or significant other(s) as they relate to or influence interpersonal factors
D Environmental factors
1. Resources and relationships of community as they relate to or influence interpersonal factors
Prevention as Intervention
A Primary
1. Classify stressor
2. Provide information to maintain or strengthen strengths
3. Support positive coping mechanisms
4. Educate client and family
B Secondary
1. Mobilize resources
2. Motivate, educate, involve client in health care goals
3. Facilitate appropriate interventions; refer to external resources as needed
4. Provide information on primary prevention or intervention as needed
C Tertiary
1. Attain/maintain wellness
2. Educate or reeducate as needed
3. Coordinate resources
4. Provide information about primary and secondary interventions
Developed by J. Conrad, University of Maryland School of Nursing, Baltimore, MD, 1993.
A client-centered approach involves differentiating the type of stress a client is experiencing. For example, stress perceived as a threat provokes anxiety, whereas stress associated with loss presents as depression and grief. The strategies that nurses would use to help clients reduce their stress would differ based on the source of the stress. When stress presents as anxiety, the nurse might suggest problem-solving techniques. However, if the stress is related to a significant loss, the nurse would want to focus on the loss and work with the client from a grief perspective.
Behavioral Observations: Distress often presents through behavior rather than being communicated with words. Emotional distress in collectivistic cultures, for example, Hispanic and Asian, are commonly expressed through somatic symptoms (Lehrer, Woolfolk, & Sime, 2007). Physical and mental symptoms of stress include:
• Significant changes in eating or sleeping habits
• Headaches, gastric problems, muscular tension, aches and pains, tightness in the throat
• Restlessness and irritability
• Inability to cope with normal everyday concerns and obligations
• Inability to concentrate
Anger, hostility, shame, embarrassment, dread, and social withdrawal are behaviors associated with anxiety. Stress anxiety can present as emotional numbness, feelings of going crazy, a déjà vu experience, or night terrors. Other symptoms can include inability to recall information, blocked speech, and fear of losing control (Arnold, 1997).
Putting your observations into words helps clients link emotional states to specific stress reactions using words rather than behavior. For example, you might say, "This (name stressor) must be very upsetting," or "It seems like you are pretty anxious about..." If individual clients feel uncomfortable about talking about stress initially, let them know that you will be there when they do feel like talking. When people can put their needs and behaviors in words, they experience less anxiety. They need additional information and frequent support delivered in a calm, competent manner.
Anger and Hostility: Anger and hostility are the most common stress emotions associated with feeling helpless or psychologically threatened. Blame is a frequent form of hostility. Family members angrily blame each other for an injury, blame the physician for operating (or not operating) on a loved one, and criticize the nurse for not responding quickly enough.
Anger projected on the nurse can temporarily threaten a nurse's involvement. Recognizing hostility as a cry for help in coping with escalating stress makes it easier to respond empathetically. Most outbursts have little to do with you, personally, other than that you are available, you are the one most involved with the care of the loved one, and you are least likely to retaliate.
Reflecting on how hostility relates to underlying anxiety helps nurses remain empathetic. Often, people become hostile when they don't understand what is happening or have little control over a treatment outcome. What a hostile anxious client or family needs most at that moment, despite their behavior, is understanding, comfort, and human caring. Listen, ask, and respond empathetically to contributory themes and feelings.
Case Example
_Client:_ I'm paying a lot of money here and no one is willing to help me. The nursing care is terrible, and I just have to lie here in pain with no one to help me.
_Nurse:_ I'm sorry you are feeling so bad. Can you tell me a little more what's going on with you so we can try to do something a little differently to help you.
Allow verbal venting within reason. Set limits if necessary, but do so with a calm attitude and manner. Carefully listening to a client's concerns goes a long way toward neutralizing anger and hostility. The client feels heard, even if the issues cannot be fully resolved to the client's satisfaction. In the course of the conversation, both nurse and client can sort out how the client perceptually experiences a stressor as a basis for focusing on productive solutions. Exploring anger and anxiety as a normal response to stress allows a conversational space to contradict false information. If client and/or family expectations are unrealistic, or can't be met in the current situation, alternative explanations and suggestions can be introduced. Exercise 20-2 is designed to address the relationship between anger and anxiety.
EXERCISE 20-2 Relationship Between Anger and Anxiety
Purpose: To help students appreciate the links between anger and anxiety, and understand how anger is triggered.
Procedure:
1. Think of a time when you were really angry. It need not be a significant event or one that would necessarily make anyone else angry.
2. Identify your thoughts, feelings, and behavior in separate columns of a table you construct. For example, what were the thoughts that went through your head when you were feeling this anger? What were your physical and emotional responses to this experience? Write down words or phrases to express what you were feeling at the time. How did you respond when you were angry?
3. Identify what was going on with you before experiencing the anger. Sometimes it is not the event itself, but your feelings before the incident that make the event the straw that breaks the camel's back.
4. Identify underlying threats to your self-concept in the situation (e.g., you were not treated with respect, your opinion was discounted, you lost status, you were rejected, you feared the unknown).
Discussion:
1. In what ways were your answers similar to and different from those of your classmates?
2. What role did anxiety and threat to the self-concept play in the development of the anger response? What percentage of your anger related to the actual event and to self-concept?
3. In what ways did you see anger as a multidetermined behavioral response to threats toself-concept?
4. Did this exercise change any of your ideas about how you might handle your feelings and behavior in a similar situation?
5. What are the common threads in the events that made people in group angry?
6. In what ways could experiential knowledge of the close association between anger and anxiety be helpful in your nursing practice?
#### Assessment of coping skills
Assessment of a client's coping behaviors and social support network is critical to understanding stress from a holistic perspective. Ask about coping strategies a client has used in the past and what the person is currently using to resolve stress. Relevant issues include those about the cultural meanings of stressors and typical family coping strategies. Sample questions might include:
• What kinds of things increase your stress?
• What leisure activities do you engage in?
• What do you do to relieve your stress?
• What are your usual methods of coping when you do not feel stress?
Nurses should ask these questions using an informal conversational format. Clients will feel more comfortable if their nurse presents an open, nonthreatening stance and a calm attitude. Appearing patient, being willing to listen, and being attentive without being intrusive is reassuring to anxious clients. The client's reactions will serve as a guide as to how much and how quickly the information can be gathered.
#### Assessment of immediate social support
Asking questions about how the client and family is coping with the current situation provides useful contextual data. Stress-related family assessments can include the following questions:
• Does the family perceive the stressors in the same way as the client?
• Have important issues been discussed fully?
• To what extent are family values challenged by the current situation?
• How might the family and client work together to improve their stress management skills?
• Are family members and the client communicating with each other?
Because family members can be a major support for clients experiencing stress, nurses can inquire about their willingness to be involved with a different set of questions.
• What are the family's and client's expectations of care?
• In what ways, if any, are the expectations different?
• What does the family or client need from you as the nurse? From each other?
• Is there a family spokesperson?
• What are the client's cultural, religious, and family values concerning the meaning of the stressor?
#### Identifying sources of strength and hope
In times of stress, people, particularly women, will reach out to others for solace, support, and direction (Taylor et al., 2000; Taylor, 2006). Some people turn to their God or Higher Power, others to family and friends. People without a social network should be linked with community resources, the point being that interpersonal connection is an essential buffer against stress. Community resources include support groups, social services, and other public health agencies that provide practical support, as well as social contacts. The more knowledgeable the nurse is about community resources, the better the client and family are served. Exercise 20-3 is designed to help you become better acquainted with resources in your community.
EXERCISE 20-3 Community Resources for Stress Management
Purpose: To help students become aware of the community resources available in the community for stress management.
Procedure:
1. Contact a community agency, social services group, or support group in your community that you believe can help clients cope with a particularly stressful situation. Look in the newspaper for ideas.
2. Find out how a person might access the resource, what kinds of cases are treated, what types of treatment are offered, the costs involved, and what you as a nurse can do to help people take advantage of the resource.
Discussion:
1. How did you decide which community agency to choose?
2. How difficult or easy was it to access the information about the agency?
3. What information about the community resource did you find out that surprised or perplexed you?
4. In what ways could you use this exercise in planning care for your clients?
Stress challenges and/or strengthens people's spirituality. Health disruptions bring mortality and morbidity into sharper relief as personal issues. This is because before having a significant illness or a life-changing health-related crisis, people don't think about their personal death or the fact that a life can be changed completely. They haven't seen firsthand the effects of death or potentially lethal complications of disorders.
Belief in a personal God provides interested clients with an incomparable personal resource that helps them cope with shattered dreams and incomprehensible life crises. Some people rely on faith to facilitate their acceptance of a reality that cannot be changed. Stress can challenge a person's spiritual connections and it is not uncommon for people to experience a spiritual void in stressful times. Assessing and providing spiritual comfort to clients is an important consideration in caring for clients experiencing stress.
#### Assessing impact on family relationships
Nurses play an important role in helping client families reduce their own stress levels in health care situations. They can help families process complex information and address specific concerns. Topics can include what will happen next, how to explain the illness, or what the client or family could have done differently to change the situation. For example, the nurse might say to the wife of a recent paraplegic, "Seeing your husband like this must be a terrible shock. I suspect you might be wondering how you are going to cope with his care at home." This type of statement normalizes feelings and introduces subjects that are difficult but necessary to talk about. Table 20-2 identifies interventions to decrease family stress.
TABLE 20-2
Nursing Interventions to Decrease Family Anxiety
Recommendation | Specific Actions
---|---
Identify a family spokesperson and support persons involved in decision making | Choose a person the family/client trusts; Establish mechanisms for contact
Identify a primary nursing contact for the family | If possible, choose the nurse most in contact with the client,
Meet with the family within 24 hrs of admission to explain roles of each healthcare team member,
Provide contact number to family spokesperson.
Discuss family access to the client | Arrange for visitation based on unit protocols, client condition/needs, family preferences,
Educate the family about visiting hours, how to reach the hospitalist, when rounds occur,
Involve family in client care whenever possible and desired.
Call the family about any changes in client condition or treatment | Inform family of changes as they occur,
Provide frequent status reports,
Allow time for questions.
Provide complete data in easily understandable terms | Ask questions about what the client/family understands about the client's condition, how they are coping, what they fear,
Check for misunderstandings, incomplete information,
Provide information based on family needs,
Respect cultural and personal desire for level of information disclosure.
Actively involve the client/family in all clinical decisions; | Hold formal care conferences for important care decisions,
Take into account and respect client preferences, spiritual and cultural attitudes,
Allow time for questions,
Strive for consensus in decisions
Connect family with support services | Provide information about support groups, hospital based social, spiritual, medicare, hospice, home care, and other care services as needed.
Ensure collaborative rapport and support among health care team members. | Maintain clear communication among health care team members.
Avoid conflicting messages to the family.
Provide opportunities for staff to decompress and discuss difficult situations and feelings.
Data from: Davidson J, Powers K, Hedayat K, Tieszen M, Kon A. et. Al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2005-2005. _Critical Care Medicine_. 35(2): 605-622, 2007; Leske J: Interventions to decrease family anxiety, _Crit Care Nurs_ 22(6):61–65, 2002.
#### Considering stress issues for children
Health disruptions create special problems for children because they lack the words and life experience to sort out the meaning of illness, either their own or that of a significant family member (Compas et al., 2001). Children express their stress through behavior. Signs of distress such as academic decline, gastric distress, and headaches can alert the nurse to unvoiced stress. In the hospital, children withdraw, demonstrate clinging behaviors, or have frequent meltdowns. Uncertainty creates stress for both parents and children (Stewart & Mishel, 2000).
Parents may need help with communicating information about serious illness to children, with thinking through their children's reactions, and with advice on ways to break bad news or set realistic limits with an ill child. Nurses should base their responses on detailed knowledge of the child's cognitive and psychosocial development, as well as concrete data. Children need to have their questions answered simply and honestly. Hearing information from someone they trust is important in modifying the uncertainty of a serious illness. Small children can be encouraged to express their stress feelings through drawings and manipulating puppets.
#### Considering stress issues for older adults
Stress issues for older adults occur during a phase of life when health and loss of important personal supports are no longer the assets they were during other phases of adulthood. Changes in lifestyle and financial status after retirement are sources of stress, particularly for people who have not thought about necessary changes in the life cycle associated with retirement or loss of a spouse. Worries about finances, fears of not being able to live independently, or of being moved to an assisted living or nursing home are common. Older adults living alone can feel vulnerable about their safety or ability to reach help should they experience a sudden physical change. The loss of significant people, isolation and loneliness can complicate treatment issues.
In addition to the normal stress reducers and coping strategies discussed in this and other chapters, nurses can help older clients develop tangible ways to promote physical and emotional safety, and to maximize their health situation. Sometimes all it takes is simple suggestions and well-timed questions about recreational activities or hobbies that the older adult has not considered.
Stress management strategies for the older adult from a health promotion perspective include maintaining an active social life and a healthy lifestyle that keeps mind and body active. Sharing concerns and developing leisure or volunteer interests help older adults develop a harmonious lifestyle that acts to release and reduce stress. Most communities have low-impact exercise activities, continuing education, and social outlets for older adults. Elderly caregivers of clients with dementia can benefit from some of the suggestions in Chapter 19 to reduce stress and balance their health and well-being with that of a family member with dementia.
### Stress reduction strategies
Providing information
Information is an essential need for both clients and families, and an important stress reducer. Each family member's health and well-being is affected by the communication and actions of the health care team during a hospitalization (Davidson, 2009). Relevant information can range from providing basic data about visiting hours, the timing of tests and procedures, plans for discharge, to complex facts about the client's condition or treatment. Information sharing should begin with orienting clients and families to the health care situation or unit, and providing enough information to familiarize but not overwhelm them as to what they might expect from health care. Take time to briefly explain the following:
• What will happen during tests or surgery
• Who is likely to interview the client, and why
• How the client can best cooperate or assist in his or her treatment process
In stressful situations, the perceptual field narrows so most people hear only a fraction of what has been said. Information and directions given in the first 48 hours of an admission should be repeated, usually more than once, because this is the time of highest stress. A calm approach and repetition of instructions can help clients in stressful situations relax enough to hear important instructions. Providing written instructions that can be discussed at the time and then left with the client or family enhances understanding. Allow time to answer questions and provide the client's family with the health provider's contact numbers to call if other issues arise.
#### Processing strong feelings
Clients experiencing stress should be given the opportunity to express their feelings, thoughts, and worries. Crying, anger, and magical thinking are normal reactions to situations that one cannot control. Although aggression toward self or others cannot be tolerated, the client should be allowed to express anger and should be given the lead in how he or she wants to address stressors, if there is no immediate jeopardy to treatment.
Listen carefully and ask gentle, probing questions. Helpful statements can include, "This must be very difficult for you to absorb. Can you tell me what you are experiencing right now?" This listening response allows the client to put concerns into words. If the client tells the nurse, "I think I'm losing my mind," the nurse might respond, "Many people feel that way. It feels that way, but what is happening is that you are feeling disoriented because this situation is sudden and overwhelming. It's a normal response. Can you identify what worries you the most?" Notice in both probes, the nurse normalizes the client's "strange" feelings. Acknowledging the legitimacy of feelings as a normal response to an abnormal situation reinforces the client's self-integrity and helps the client put boundaries on his or her anxiety.
Allowing clients to be in charge of areas and issues that are not at odds with a treatment protocol, and helping clients discover the real causes of their frustration can reduce stress through direct action. Encourage clients to take one day at a time in their expectations and recovery activities. Concrete assistance with negotiating appropriate referral resources is helpful.
A calm approach and repetition of instructions can help clients in stressful situations relax enough to hear important instructions.
#### Anticipatory guidance
**Anticipatory guidance** is a term used to describe the process of sharing information about a circumstance, concern, or situation before it occurs. Fear of the unknown intensifies the impact of a stressor. Knowing what lies ahead can often prevent the development of a crisis (Hoff & Hallisey, 2009).Your response to client/family anxiety should be tentative and reflect your level of knowledge about the unique concerns of the client, as well as the condition and situation. In framing a response, you might reflect on the following:
• What type of information would be most helpful to this particular client at this particular time, given what the client has told me?
• How would I feel if I was in this person's position, and what would I want to know that might bring me comfort in this situation?
It is difficult to directly answer stress-related questions about uncertainties, such as "If I take the chemotherapy, will I be cured, or am I going to die anyway?" The reality is that there may be no single answer. It helps to ask the client what prompted the question, and to have a good idea of the client's level of knowledge before answering. Honest communication is essential, but sensitivity to the client's experience is critical.
Providing anticipatory guidance can put needless worry to rest. For example, you could use a simple statement such as "You've never had this procedure before. Let me explain how it works" (Keller & Baker, 2000).
When providing anticipatory guidance, do not offer more than what the situation dictates. Encourage the client to expand on suggestions rather than presenting a full plan. The growth in client ability to set priorities, to develop a plan that has meaning to them, and to establish milestones in the evaluation process stimulates self-confidence and decreases stress. Exercise 20-4 provides practice in helping clients handle stressful situations.
EXERCISE 20-4 Role-Play: Handling Stressful Situations
Purpose: To give students experience in responding to stressful situations.
Procedure:
Use the following case study as the basis for this exercise.
Dave is a 66-year-old man with colon cancer. In the past, he had a colostomy. Recently, he was readmitted to your unit and had an exploratory laparotomy for small-bowel obstruction. Very little can be done for him because the cancer has spread. He is in pain, and he has to have a feeding tube. His family has many questions for the nurse: "Why is he vomiting?" "How come the pain medication isn't working?" "Why isn't he feeling any better than he did before the surgery?" You have just entered the client's room; his family is sitting near him, and they want answers now.
1. Have different members of your group role-play the client, the nurse, the son, the daughter-in-law, and the wife. One person should act as observer.
2. Identify the factors that will need to be clarified in this situation to help the nurse provide the most appropriate intervention.
3. Using the strategies suggested in this chapter, intervene to help the client and the family reduce their anxiety.
4. Role-play the situation for 10 to 15 minutes.
Discussion:
1. Have each player identify the interventions that were most helpful.
2. From the nurse's perspective, which parts of the client and family stress were hardest to handle?
3. How could you use what you learned from doing this exercise in your clinical practice?
Anticipatory guidance can be helpful in preparing family members for their first visit with a client with a visible disfigurement, a marked physical or psychological deterioration, or the presence of life support machines. If you sense family awkwardness in how to approach a vulnerable or comatose client, you could say to a family member: "You might want to identify yourself and tell your father you are here with him."
Priority Setting: Clients need support and encouragement when coping with stress, but they don't always know where to start. Priority setting helps reduce hesitation and offers a stepwise framework for stress resolution. In addition to helping clients determine which task elements are critical and which can be addressed later, nurses can help clients break down tasks into smaller manageable segments. The most important tasks should be scheduled during times when the client or family has the most energy and freedom from interruption.
Nurses need to help clients identify the concrete tasks needed to achieve treatment goals, including the people involved, the necessary contacts, the amount of time each task will take, and specific hours or days for each task. Some tasks are more important than others in stressful situations, and not everything can be handled at once. A helpful suggestion might be, "Let's see what you need to do right now and what can wait until tomorrow." Tasks that someone else can do and those that are not essential to the achievement of goals should be delegated or ignored for the moment.
#### Supporting client efforts
Without command over the controllable parts of life, people feel helpless and stressed. Coping mechanisms such as negotiation, specific actions, seeking advice, and rearranging priorities can significantly diminish stress through direct action. Once stressors are named, nurses can use health teaching formats and coaching that help clients to:
• Develop a realistic plan to offset stress
• Deal directly with obstacles as they emerge
• Evaluate action steps
• Make needed modifications in the plan and often lifestyle
Case Example
Sam Hamilton received a diagnosis of prostate cancer on a routine physical examination. His way of coping included obtaining as much information on the disease as possible. He researched the most up-to-date material on treatment options and sought advice from physician friends as to which surgeons had the most experience with this type of surgery. As he shared his diagnosis with friends and colleagues, he found several men who had successfully survived without a cancer recurrence. Sam used the time between diagnosis and surgery to finish projects and delegate work responsibilities. He attended a support group with his wife and was able to obtain valuable advice on handling his emotional responses to what would happen. When the time came for his surgery, Sam was still apprehensive, but he felt as though he had done everything humanly possible to prepare for it. The actions he took before surgery reduced his stress.
#### Promoting a healthy lifestyle
Encouraging a healthy lifestyle is an essential but sometimes overlooked component of stress reduction strategies. Good health habits improve stress resistance. Eating a healthy diet, and avoiding emotional eating and the wrong foods give people a sense of control and well-being. Too much caffeine and alcohol can exacerbate stress. Laughter dissolves it.
Adequate quality sleep is restorative. Healthy nighttime habits, such as establishing a scheduled bedtime and having a small snack before bedtime, encourages sleep. Regular exercise helps the body release tension, as well as contributes to fitness. Exercise can be accomplished in a social setting, for example, hiking or biking. Certain exercise programs such as yoga or tai chi incorporate meditation, deep breathing, and muscle stretching, all of which are known to reduce stress.
Organizing time and doing activities that energize rather than stress, balancing work with leisure activities, restructuring priorities, and eliminating unnecessary obligations reduce stress.
#### Helping families handle stress
Families can suffer potentially overwhelming stress when their family member is critically ill or injured. Contemporary health care environments with advanced technology, shorter stays, and multiple caregivers are complex and anxiety producing. Sources of stress for families can include "fear of death, uncertain outcome, emotional turmoil, financial concerns, role changes, disruption of routines, and unfamiliar hospital environments" (Leske, 2002, p. 61). Families look to nurses for support and direction. Consistent regular communication is key to family satisfaction and effective shared decisions. Direct family contact offers firsthand insight into client preferences, health care needs and resources especially when the client is unable to provide this information (Davidson, 2009).
It is helpful to put yourself in the family's position and to put into words how you might feel in a similar situation. Statements such as "Most people would feel anxious in this situation," or "It would be hard for anyone to have all the answers in a situation like this" help put stressors and stress responses into perspective.
Families have a strong need to remain physically close to the client in critical care situations and there is a strong correlation between proximity to the client and satisfaction with care (Davidson, 2009). When this need translates into constant attendance, family members can become physically and emotionally exhausted (Leske, 2000). A preventive strategy is to suggest that the family members take short breaks. Family members may need "permission" to go to a movie or eat in a restaurant outside the hospital. Usually, they will do so only with an assurance that they will be called should there be any change in the client's condition.
Being able to "do something" for the client helps family members defuse their anxiety. Family members want to provide support and comfort. Letting family members participate in the client's care to whatever extent is possible for the client and comfortable for the family can be a meaningful experience for both. On the other hand, it is important to ask family members about how they would like to participate, rather than making assumptions.
### Stress management therapies
Mind/body therapies
Mind/body therapies are coping strategies designed to lessen the intensity of the stressor on a person once the stress response has occurred. Examples include meditation, relaxation techniques, yoga, and cognitive restructuring. Altering physiologic reactions such as blood pressure, heart rate, muscle tension, and respiratory rate helps people experience greater calm and peace of mind (Luskin et al., 1998). Regular practice of these techniques can improve physical and emotional well-being.
Meditation: Meditation is a stress-reduction strategy dating back to early Christian times. People use meditation to develop a sense of inner peace and tranquility, and to center themselves. Meditation allows people to decrease stress by focusing their attention on something other than the stress, and clears the mind of disturbing thoughts. This action helps to reduce the concentration of stress hormones attached to stressful thinking. A guide to meditation is provided in Box 20-4.
BOX 20-4 Meditation Techniques
1. Choose a quiet, calm environment with as few distractions as possible.
2. Get in a comfortable position, preferably a sitting position.
3. To shift the mind from logical, externally oriented thought, use a constant stimulus: a sound, word, phrase, or object. The eyes are closed if a repetitive sound or word is used.
4. Pay attention to the rhythm of your breathing.
5. When distracting thoughts occur, they are discarded and attention is redirected to the repetition of the word or gazing at the object. Distracting thoughts will occur and do not mean you are performing the techniques incorrectly. Do not worry about how you are doing. Redirect your focus to the constant stimulus and assume a passive attitude.
Adapted from Benson H: _The relaxation response,_ New York, 1975, Morrow.
Mindfulness is a stress management tool that can be used at any point. It can be as simple as focusing on deep breathing. Focusing completely on your breathing, music, or what is happening in the current moment forces you to at least momentarily let go of stressful thoughts. It is an easy way of quieting the mind and decreasing the intensity of stressful feelings.
Biofeedback: Biofeedback plays an important role in management of clients with chronic stress responses affecting individual body systems (e.g., essential hypertension, migraine headaches, Raynaud's disease, and ulcerative colitis). People are trained to voluntarily take control over a variety of physiologic activities such as their brain activity, blood pressure, heart rate, pain, migraine or tension headaches, and other bodily functions as a means to improve their health. Biofeedback provides awareness of minute-by-minute changes in biologic activity. The goal is to lower physiologic arousal and promote relaxation (Grazzi & Andrasik, 2010). Equipment used with biofeedback includes the electroencephalogram, skin temperature devices; blood pressure measures; galvanic skin resistance measurements; and the electromyogram, which measures muscle tension.
Progressive Relaxation: Progressive relaxation is a technique that focuses the client's attention on conscious control of voluntary skeletal muscles. Originally developed by Edmund Jacobson (1938), a physiologist physician, the technique consists of alternately tensing and relaxing muscle groups. Each muscle group is worked with individually with the client sitting in a relaxed position in a chair with arm supports or lying down. Davis, Eshelman and McKay (2008) provide an excellent step-by-step description of the basic procedure for progressive relaxation.
A variant of progressive relaxation is deep breathing. This can be accomplished anywhere and at any time a person experiences stress.
• Deeply inhale to the count of 10, and hold your breath.
• Exhale slowly, again to the count of 10.
• Concentrate as you do this exercise only on your breathing.
• Feel the tension leave your body.
The person breathes 10 times in a row with each inhalation/exhalation counted as 1 breath. Focusing the mind on the continuous rhythm of inhaling and exhaling turns the mind away from thinking about specific stressors. To experience the progressive relaxation technique, see Exercise 20-5.
EXERCISE 20-5 Progressive Relaxation
Purpose: To help students experience the beneficial effects of progressive relaxation in reducing tension.
Procedure:
This exercise consists of alternately tensing and relaxing skeletal muscles.
1. Sit in a comfortable chair with arm supports. Place the arms on the arm supports, and sit in a comfortable upright position with legs uncrossed and feet flat on the floor.
2. Close your eyes and take 10 deep breaths, concentrating on inhaling and exhaling.
3. Your instructor or a member of group should give the following instructions, and you should follow them exactly:
• I want you to focus on your feet and to tense the muscles in your feet. Feel the tension in your feet. Hold it, and now let go. Feel the tension leaving your feet.
• I would like you to tense the muscles in your calves. Feel the tension in your calves and hold it. Now let go and feel the tension leaving your calves. Experience how that feels.
• Tense the muscles in your thighs. Most people do this by pressing their thighs against the chair. Feel the tension in your muscles and experience how that feels. Now release the tension and experience how that feels.
• I would like you to feel the tension in your abdomen. Tense the muscles in your abdomen and hold it. Hold it for a few more seconds. Now release those muscles and experience how that feels.
• Tense the muscles in your chest. The only way you can really do this is to take a very deep breath and hold it. (The guide counts to 10.) Concentrate on feeling how that feels. Now let it go and experience how that feels.
• I would like you to tense your muscles in your hands. Clench your fist and hold it as hard as you can. Harder, harder. Now release it and concentrate on how that feels.
• Tense the muscles in your arms. You can do this by pressing down as hard as you can on the arm supports. Feel the tension in your arms and continue pressing. Now let go and experience how that feels.
• I would like to you to feel the tension in your shoulders. Tense your shoulders as hard as you can and hold it. Concentrate on how that feels. Now release your shoulder muscles and experience the feeling.
• Feel the tension in your jaw. Clench your jaw and teeth as hard as you can. Feel the tension in your jaw and hold it. Now let it go and feel the tension leave your jaw.
• Now that you are in this relaxed state, keep your eyes closed and think of a time when you were really happy. Let the images and sounds surround you. Imagine yourself back in that situation. What were you thinking? What are you feeling?
• Open your eyes. Students who feel comfortable may share the images that emerged in the relaxed state.
Discussion:
1. What are your impressions in doing this exercise?
2. Do you feel more relaxed after doing this exercise?
3. If applicable, after doing the exercise, in what ways do you feel differently?
4. Were you surprised at the images that emerged in your relaxed state?
5. In what ways do you think you could use this exercise in your nursing practice?
Yoga and Tai Chi: Yoga is a mind/body exercise practice rooted in ancient India. The practice of yoga emphasizes correct alignment, controlled postures or poses, and regulated breathing to help people relax and reduce stress. Controlling breathing helps to quiet the mind. Some forms of yoga place an emphasis on meditation and developing self-awareness.
Tai chi is a system initially developed in China. It consists of posture or movements practiced in a slow, graceful manner. It involves stretching, rhythmic movements coordinated with controlled breathing. The concentration required for both yoga and tai chi require a person to forget distressing thoughts at least for the moment.
Guided Imagery: Guided imagery is a technique often used in combination with relaxation strategies for cancer pain and stress (Kwekkeboom, 2008). Imagery techniques use the client's imagination to stimulate healing mental images designed to promote stress relief. The process involves asking the client to imagine a scene, previously experienced as safe, peaceful, or beautiful. Supportive prompts to engage all of senses deepen the imagery experience. The healing scene can be used each time that the client begins to experience stress.
### Addressing occupational stress in nurses
Burnout
Nurses face a greater risk for burnout than people in other lines of work. They work in high-stress service environments, helping people cope with serious life and death situations every day. Freudenberger (1980) defines **burnout** as "a state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that failed to produce an expected reward" (p. 13). It develops in individuals involved with "people work," and is characterized by emotional exhaustion, depersonalization, and a sense of diminished professional accomplishment (Maslach, 2001). Although burnout shares some characteristics with depression and anxiety, it is a different syndrome, clearly linked to a work environment, and personal expectations of self and others within that setting.
The development of burnout begins insidiously, particularly in nurses who strive for perfection. Unchecked, it is a progressive syndrome associated with emotional exhaustion and loss of meaning. Freudenberger (1980) refers to burnout as the "overachievement syndrome." People who are high achievers, committed, and passionate about their work are more at risk to develop burnout symptoms.
The need to be perfect does not allow for error, or the reserve needed to correct for unexpected events (Porter-O'Grady, 1998). A story about Babe Ruth offers an appropriate metaphor. Coaching a young, aspiring ball player, he asked the boy how he planned to pitch the ball. The boy answered, "I'm going to throw it with all my might and get it right where it needs to go. I'm going to give it 110 percent." Ruth had different advice: "Throw the ball with 80 percent of your might. You will need the reserve to correct for any mistakes." Nurses need the same reserve to correct for the inevitable curve balls inherent in clinical practice—and life in general. Contemporary thinking about burnout considers it as originating from combined factors in the work environment and within the person. Six areas of organizational contributors to burnout include workload, control, reward, community, fairness, and values (Freeney & Tiernan, 2009; Maslach & Leiter, 1997). Sources of work-related burnout for nurses include working too many hours or at an accelerated pace with no respite, feeling unappreciated, giving too much to needy clients, trying to meet multiple demands of administrators, lack of community with coworkers, and feeling resentment, in place of the meaning that work once held.
Symptoms of Burnout: A person experiencing burnout is always tired and preoccupied with work (Vernarec, 2001). People who are burned out feel disillusioned and lack zest for their work. Other signs include loss of motivation and ideals, boredom or dissatisfaction at work, irritability and cynicism, resentment of expectations, and avoidance of meaningful encounters with clients and families. Headaches, gastric disturbances, skipping meals or eating compulsively on the run, feeling irritated by the intrusion of others, and a lack of balance between a nurse's work and personal life can signal the onset of burnout. In a study of co-workers' perceptions of colleagues suffering from burnout, signs observed included a struggle to achieve unobtainable goals, wanting to manage alone, and becoming isolated from others (Ericson-Lidman & Strandberg, 2007). Figure 20-3 identifies common symptoms of burnout.
Figure 20-3 Symptoms of burnout.
Burnout Prevention Strategies: The ABCs of burnout prevention (Arnold, 2008) are presented in Table 20-3. Reflecting on the sources of stress in your life puts boundaries on it. Think about your goals, and what is important to you. Rather than simply complaining, seek role models or trusted coworkers who can offer you the support and sensitivity you need to become aware of what is going on in your life. A useful exercise is to imagine yourself a year from now and ask yourself how important the issue would be a year from now.
TABLE 20-3
ABCs of Burnout Prevention
| Suggested Strategy
---|---
Awareness | Use self-reflection and conversations with others to sort out priorities and identify parts of life out of balance. Recognize and allow feelings.
Balance | Maintain a healthy lifestyle. Balance care of others with self-care/self-renewal needs.
Choice | Differentiate between things you can change and those you cannot. Deliberately make choices that are purpose driven and meaningful.
Detachment | Detach from excessive ego involvement and personal ambition. Share responsibility and credit for care. Use meditation to center self.
Altruistic Egoism | Take scheduled time for self, learn to say no, practice meditation, and develop outside interests that enrich the spirit.
Faith | Burnout is a malaise of the spirit. Trust in a higher power or purpose to center yourself when you do not know what will happen next.
Goals | Identify and develop realistic goals in line with personal strengths. Seek feedback and support.
Hope | Hope is nurtured through conversations with others that lighten the burden, and a belief in one's possibilities and personal worth in the greater scheme of things.
Integrity | Recognize that each of us is the only person who can determine the design and application of meaning in our lives.
Data from: Arnold E: Spirituality in educational and work environments (pp. 386–399). In Carson V, Harold Koenig, editors: _Spiritual dimensions of nursing practice,_ revised edition, Conshohocken, PA, 2008, Templeton Foundation Press.
Identifying realistic goals that are achievable and in line with your personal values is an excellent burnout prevention strategy. Goals should be aligned with purpose and values. Focusing on one thing at a time and finishing one project before starting another has several benefits. Achieving small related goals promotes self-efficacy and offers hope that more complex goals are achievable.
Maintaining a healthy balance among work, family, leisure, and lifelong learning activities enhances personal judgments, satisfaction, and productivity in all three spheres. Actively schedule a time for each of these activities and stick to it.
Remember that you always have choices. People experiencing burnout lose sight of this fact. Life is a series of choices and negotiations. The choices we make create the fabric of our lives. Refusing to delegate work because someone else cannot do it as well, or not going out to dinner with friends because you have too much work to do are choices—bad options that lead to burnout.
Detachment from ego and/or taking responsibility for outcomes is a critical component of burnout prevention. It means that you don't allow emotional involvement in a task or relationship to undermine your quality of life, values, or needs. Someone once asked Mother Teresa how she was able to remain so energetic and hopeful in the midst of suffering she encountered in Calcutta. She replied that it was because she did the best she could and didn't worry about the outcome because she couldn't control it.
It is important to pay as much attention to your own personal needs as you do to the needs of others. Although this seems obvious, nurses sometimes consider attention to their own needs as being selfish. However, one cannot give from an empty cupboard. Replenishing the self actually improves what one can give to others.
Faith is defined as an intangible connection with a larger purpose or higher power to guide and support a person during both good and bad times. Faith helps people develop an optimistic worldview and experience less distress.
Nurses experiencing burnout often feel helpless and hopeless about changing their situation, other than to leave it. Hope is a powerful antidote for burnout. Exercise 20-6 provides an opportunity to think about your personal burnout potential and ways to achieve better balance in your life.
EXERCISE 20-6 Burnout Assessment
Purpose: To help students understand the symptoms of burnout.
Procedure:
Consider your life over the past year. Complete the questionnaire by answering with a 5 if the situation is a constant occurrence, 4 if it occurs most of the time, 3 if it occurs occasionally, 2 if it has occurred once or twice during the last 6 months, and 1 if it is not a problem at all. Scores ranging from 60 to 75 indicate burnout. Scores ranging from 45 to 60 indicate you are stressed and in danger of developing burnout. Scores ranging from 20 to 44 indicate a normal stress level, and scores of less than 20 suggest you are not a candidate for burnout.
1. Do you find yourself taking on, or being overwhelmed by other people's problems?
2. Do you feel resentful about the amount or nature of claims on your time?
3. Do you find you have less time for social activities?
4. Have you lost your sense of humor?
5. Are you having trouble sleeping?
6. Do you find you are more impatient and less tolerant of others?
7. Is it difficult for you to say no?
8. Are the things that used to be important to you slipping away from you because you don't have time?
9. Do you feel a sense of urgency and not enough time to complete tasks?
10. Are you forgetting appointments, friends' birthdays?
11. Do you feel overwhelmed and unable to pace yourself?
12. Have you lost interest in intimacy?
13. Are you overeating, or have you begun to skip meals?
14. Is it difficult to feel enthusiastic about your work?
15. Do you feel it is difficult to connect on a meaningful level with others?
Tally up your scores and compare your scores with your classmates. Nursing school is a strong breeding ground for the development of burnout (demands exceed resources). To offset the possibility of developing burnout symptoms, do the following:
1. Think about the last time you took time for yourself. If you cannot think of a time, you really need to do this exercise.
2. Identify a leisure activity that you can do during the next week to break the cycle of burnout.
3. Describe the steps you will need to take to implement the activity.
4. Identify the time required for this activity and what other activities will need rearrangement to make it possible.
5. Describe any obstacles to implementing your activity and how you might resolve them.
Discussion:
1. Was it difficult for you to come up with an activity? If so, why?
2. Were you able to develop a logical way to implement your activity?
3. Were the activities chosen by others surprising or helpful to you in any way?
4. How might you be able to use this exercise in your future practice?
Burnout challenges personal integrity in the sense that important values are ignored or devalued. When you begin to forget who you are and try to become what everyone else expects of you, you are in trouble. Reclaim yourself. Taking responsibility for yourself and doing what is important to you helps to reverse burnout. Take the risk to be all that you are, as well as all that you can be, without worrying about what others think. Seek professional supports such as training, staff retreats, staff support networks, and job rotation to stimulate new ideas and insights. Professional support groups are effective as a means of providing encouragement to nurses in acute settings (Parish, Bradley, & Franks, 1997).
## Summary
This chapter focuses on the stress response in health care, and supporting client and family coping with stress through nurse-client relationships. Stress can negatively impact client outcomes, level of satisfaction with care, and compliance with treatment. A fundamental goal in the nurse-client relationship is to empower clients and families with the knowledge, support, and resources they need to cope effectively with stress.
Stress is a part of everyone's life. Mild stress can be beneficial, but greater stress levels can be unhealthy. Concurrent and cumulative stresses increase the response level. Theoretical models address stress as a physiologic response, as a stimulus, and as a transaction between person and environment. Factors that influence the development of a stress reaction include the nature of the stressor, personal interpretation of its meaning, number of previous and concurrent stressors, previous experiences with similar stressors, and availability of support systems and personal coping abilities.
People use problem- and emotion-focused coping strategies to minimize stress. Social support is key to effectively coping with stress. Assessment should focus on stress factors the person is experiencing, the context in which they occur, and identification of coping strategies. Supportive interventions include giving information, opportunities to express their feelings, thoughts, and worries, and anticipatory guidance.
Nurses are at the forefront of health care delivery to clients and families experiencing complex health and life issues. They too can experience stress and need support to do their job effectively. Burnout prevention requires recognition and resolution of organizational and personal factors contributing to job-related stress in professional nurses.
Ethical Dilemma
What Would You Do?
The mother of a client with AIDS does not know her son's diagnosis because her son does not want to worry her and fears her disapproval if she knows he is gay. The mother asks the nurse if the family should have an oncology consult because she does not understand why, if her son has leukemia, as he says he does, that an oncologist is not seeing him. What should the nurse do?
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CHAPTER 21
# Communicating with Clients in Crisis
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Define crisis and related concepts.
2 Discuss theoretical frameworks related to crisis and crisis intervention.
3 Identify and apply structured crisis intervention strategies in the care of clients experiencing a crisis state.
4 Apply crisis intervention strategies to mental health emergencies.
5 Discuss crisis management strategies in disaster and mass trauma situations.
This chapter describes nurse-client relationships in crisis situations and discusses related communication strategies. The chapter focuses on the nature of crisis and presents crisis intervention guidelines nurses can use with clients and families in clinical and community settings. Included are theoretical frameworks that guide the process of crisis intervention. The application section provides practical guidelines nurses can use with clients in crisis, mental health emergencies, and disaster management.
## Basic concepts
Definitions
#### Crisis
Flannery and Everly (2000) state, "A **_crisis_** occurs when a stressful life event overwhelms an individual's ability to cope effectively in the face of a perceived challenge or threat" (p. 119). People in crisis experience an actual or perceived overwhelming threat to self-concept, or a loss that conventional coping measures cannot handle. Unabated, the resulting tension continues to increase, creating major personality disorganization and a crisis state.
The word _crisis_ comes from the Greek root word _krisis,_ meaning "turning point." The Chinese ideograph used to represent crisis consists of one character for danger and another for opportunity (Roberts, 2005). Personal responses to crisis can be adaptive or maladaptive. Successfully working through a crisis strengthens people's coping responses and sense of self-efficacy. People can learn new coping skills, expand their support system, and raise their level of functioning. Maladaptive responses can result in the development of acute or chronic psychiatric symptoms requiring professional treatment.
#### Crisis State
Everly (2000) defines a **_crisis state_** as an acute _normal_ human response to severely abnormal circumstances; it is _not_ a mental illness. Because a crisis state represents a personal response, two people experiencing the same crisis event will respond differently to it. Understanding the _person_ who is experiencing the crisis rather than an objective crisis stressor is critical to successful crisis intervention.
A crisis state creates a temporary disconnect from attachment to others, loss of meaning, and a disruption of previous mastery skills (Flannery & Everly, 2000). Individuals feel vulnerable. People in crisis are open to but also need a goal-directed approach to resolve a crisis state. Crisis intervention strategies are designed to help support people experiencing crisis achieve psychological homeostasis. A favorable outcome depends on the person's interpretation of the crisis, perception of coping ability, resources, and level of social support.
### Types of crisis
Developmental Crises
A crisis is commonly classified as developmental or situational. Erik Erikson's (1982) stage model of psychosocial development forms the basis for understanding developmental crisis. Each stage is associated with a psychosocial crisis to be resolved. Successful resolution of each maturational stage leaves a person better able to meet the interpersonal challenges and stressors of the next. Examples of critical incidents associated with developmental crises include marriage, pregnancy and birth of a child, midlife crisis, retirement, meaning in aging, and so on.
Erikson's (1982) descriptions of normative psychosocial crisis are used as benchmarks for assessing signs and symptoms of developmental crisis. When a situational crisis is superimposed on a normative developmental crisis, the crisis experience can be more intense. For example, a woman losing a spouse at the same time she is going through menopause experiences the double impact of a situational crisis and a normal maturational crisis associated with midlife.
#### Situational Crises
A situational crisis refers to an unusually stressful life event that exceeds a person's resources and coping skills. Examples include unexpected illness or injury, rape, car accident, loss of home, spouse, job, and so forth. In health care settings, most crises are situational.
A situational crisis is _not_ defined by the life event itself (Hoff, 2009). Rather, it is the person's experience of the event—its origin and meaning to an individual, plus combined individual and social factors that influence a person's perception of the event as a crisis. Common factors influencing how successfully a person responds to a crisis include:
• Previous experience with crises, coping, and problem solving
• Perception of the crisis event
• Level of help or obstruction from significant others
• Developmental level and ego maturity
• Concurrent stressors
#### Adventitious Crisis
An adventitious crisis is _not_ a part of everyday experience. It is unplanned, unusual, horrific, and beyond anyone's control. Examples of adventitious crisis include:
• Natural disasters such as floods, earthquakes, fires, mudslides
• National disasters such as terrorism, riots, wars
• Crimes of violence such as rape, child abuse, assault, or murder (Boyd, 2008)
Disasters are catastrophic for large groups of people or whole communities simultaneously (Michalopoulos & Michalopoulos, 2009).
#### Other Classifications
Roberts and Yeager (2009) differentiate between a private and public crisis. A _private_ crisis affects individuals and families, but not the community at large. Examples include suicide, terminal diagnosis, a car crash, rape, or the death of a family member. A _public_ crisis event, more commonly referred to as a disaster, affects a whole community or large groups of people simultaneously. People are acutely aware of the precipitating events, for example, with Hurricane Katrina and terrorist attacks.
James (2008) describes two additional types of crisis. An _existential_ crisis occurs when a person questions the meaning of his or her life, and whether it has any value. Midlife crisis falls into this category. _Environmental_ crises are associated with major changes in the ecosystem, such as global warming, volcanic eruptions, disease epidemics, wars, and severe economic depression. Table 21-1 presents the Burgess and Roberts continuum of the different levels of crisis (Roberts & Yeager, 2009).
TABLE 21-1
Burgess and Roberts' Stress-Crisis-Trauma Continuum
Levels | Type | Actions/Approach
---|---|---
Levels 1 and 2 | Somatic distress crisis and transitional stress crisis | Brief crisis intervention and primary outpatient mental health care/treatment
Level 3 | Traumatic stress crisis | Traumatic and group crisis–oriented therapy
Level 4 | Family crises | Individual, couple, or family therapy, case management, and crisis intervention focus with forensic intervention
Level 5 | Mentally ill persons in crisis | Crisis intervention, psychopharmacology, case and medication monitoring, day treatment, and community support
Level 6 | Psychiatric emergencies | Crisis stabilization, outpatient treatment, inpatient hospitalization, and/or legal intervention
Level 7 | Catastrophic traumatic stress crises | Application of multiple levels of crisis/trauma intervention inclusive of all previously listed intervention strategies
From Roberts A, Yeager K: _Pocket guide to crisis intervention_ (p. 15), New York, 2009, Oxford University Press.
### Crisis intervention
**Crisis intervention** represents a systematic application of theory-based problem-solving strategies designed to help individuals and families resolve a crisis situation quickly and successfully, with an anticipated outcome of achieving precrisis level functional capacity (Roberts & Yeager 2009). Each person's experience of a crisis is unique to that person and situation. Crisis intervention strategies should be adapted to fit each client's preferences, beliefs, values, and individual circumstances.
Crisis intervention is a _time-limited_ treatment modality. Four to six weeks is considered the standard time frame for crisis resolution, although full recovery can take a much longer period of time, particularly from a disaster crisis (Callahan, 1998).
Strategies are focused on immediate problem solving and strengthening the personal resources of clients and their families. Nurses function as advocate, resource, partner, and guide in the crisis intervention process. There should be a strong focus on helping clients mobilize personal resources and use support resources effectively (Hoff, 2009). The goal of crisis intervention is to return the client to his or her previous level of functioning. Specific goals include:
• Stabilization of distress symptoms
• Reduction of distress symptoms
• Restoration of functional capabilities
• Referrals for follow-up support care, if indicated (Everly, 2000, pp. 1–2)
## Theoretical frameworks
Erich Lindemann (1944) and Gerald Caplan (1964, 1989) are considered primary contributors to the development of crisis theory. Lindemann's study of bereavement in survivors coping with the crisis of death of a loved one or experiencing a disaster provided an initial frame of reference for understanding the stages involved in resolving emotional crisis and bereavement. His findings suggest, "Proper psychiatric management of grief reactions may prevent prolonged and serious alterations in the patient's social adjustment, as well as potential medical disease" (p. 147).
Caplan broadened Lindemann's model to include developmental crisis and personal crisis (Roberts, 2005). Although the direct focus of crisis intervention is on secondary prevention because the crisis state is already in motion, Caplan applied concepts of primary, secondary, and tertiary prevention to crisis intervention. His model of preventive psychiatry incorporates reducing the incidence of mental disorders in the community, limiting the duration of mental upset, and reducing impairment from clinical symptoms. Consistent with Caplan's ideas was the development of practical crisis intervention strategies related to crisis telephone lines, training for community workers, and crisis response strategies. Caplan viewed nurses as key service providers in crisis intervention.
Caplan (1964) described the initial response to a crisis situation as _shock,_ with variations in emotions ranging from anger, laughing, hysterics, crying, and acute anxiety to social withdrawal. Then follows an extended period of adjustment, a period of _recoil_. This period can last from 2 to 3 weeks. Client behaviors can appear normal to outsiders, but the person often describes nightmares, phobic reactions, and flashbacks of the crisis event.
Caplan uses the term _restoration_ or reconstruction to describe the final phase of crisis intervention. This phase involves taking constructive actions to face and resolve the reality issues present in a crisis situation. If successfully negotiated, the person achieves precrisis functioning or better. When people use self-destructive coping strategies such as drug or alcohol use, violence, or avoidance, restoration is delayed and/or the person is at risk for development of physical or mental symptoms.
Donna Aguilera (1998) developed a nursing model identifying how a crisis develops and corresponding factors needed for resolution. The model proposes that a crisis state occurs in response to a potentially life-changing event because of a distorted perception of a situation or because the client lacks the resources to cope successfully with it. Balancing factors include a realistic perception of the event, the client's internal resources (beliefs or attitudes), and the client's external (environmental) supports. These factors can reduce the impact of the stressor, leading to the resolution of the crisis, and can help minimize overreactions.
The absence of adequate situational support and coping skills and/or a distorted perception of the crisis event can result in a crisis state, leaving individuals and families feeling overwhelmed and unable to cope. Interventions are designed to increase the balancing factors needed to restore the person to precrisis functioning. Exercise 21-1 provides insight into the nature of crisis.
EXERCISE 21-1 Understanding the Nature of Crisis
Purpose: To help students understand crisis in preparation for assessing and planning communication strategies in crisis situations.
Procedure:
1. Describe a crisis you experienced in your life. There are no right or wrong definitions of a crisis, and it does not matter whether the crisis would be considered a crisis in someone else's life.
2. Identify how the crisis changed your roles, routines, relationships, and assumptions about yourself.
3. Apply a crisis model to the situation you are describing.
4. Identify the strategies you used to cope with the crisis.
5. Describe the ways in which your personal crisis strengthened or weakened your self-concept and increased your options and your understanding of life.
Discussion:
What did you learn from doing this exercise that you can use in your clinical practice?
Developing an Evidence-Based Practice
Dirkzwager A, Kerssens J, Yzermans C: Health problems in children and adolescents before and after a man-made disaster, _J Am Acad Child Adolesc Psychiatry_ 45(1):94–103, 2006.
The authors completed an exploratory study designed to examine the health problems of children ages 4 to 12 and adolescents ages 13 to 18 before and after exposure to a manmade fireworks disaster, and to compare these with a control group of children and adolescents who had not experienced this disaster. Longitudinal data were collected from electronic medical records of family practitioners related to health problems from 1 year before disaster until 2 years after disaster (N = 1,628 for victims; N = 2,856 for the control group). Prevalence rates of health problems were calculated for the two age groups related to psychological and social problems; medically unexplained physical symptoms; and gastrointestinal, musculoskeletal, respiratory, and skin problems.
_Results:_ Study results indicated that postdisaster increases in health problems were significantly greater for the postdisaster group related to psychological and musculoskeletal problems and stress reactions. Children in the 4 to 12 age group experienced significantly greater rates of sleep problems than the control group, whereas adolescents 13 to 18 years old showed larger increases in anxiety problems than the control subjects. Significant predictors for postdisaster psychological problems included being relocated, low socioeconomic status, and having psychological problems before the disaster.
_Application to Your Clinical Practice:_ This study strongly suggests that young victims of disaster experience significant and long-lasting sequelae following a disaster. Particularly at risk are those who must be relocated. What implications do you see in your nursing practice for promoting the health and well-being of children and adolescents exposed to a disaster?
## Applications
Structuring crisis intervention strategies
Roberts (2005) provides a seven-stage sequential blueprint for clinical intervention, which can be used to structure the crisis intervention process in nurse-client relationships. This model is compatible with the nursing process sequencing of assessment, planning, implementation, and evaluation.
### Step 1 (assessment): Assessing lethality and mental status
Safety should be the foremost assessment in any crisis situation. Assessment should focus on determining the severity of the crisis state, and the client's current danger potential—both to self and to others. If a person's crisis state is induced or complicated by physiologic factors, the person should be treated as a medical emergency first and then as a psychiatric emergency. Assessment for suicide and homicide should be part of every crisis care assessment.
Nurses need to evaluate the client's mental status if there is any reason to suspect unsafe or unusual thoughts and behaviors. Clients who are psychotic, under the influence of drugs, severely agitated, or temporarily out of control for medical reasons will require immediate triage to stabilize their physical condition. Close one-to-one observation is critical until the situation is brought under control. Table 21-2 provides guidelines for communicating with a client who is unable to cooperate with assessment or treatment. Family and significant others can provide additional assessment data related to the current crisis state (e.g., documenting changes in behavior, ingestion of drugs, or medical history) if the client is unable to do so.
TABLE 21-2
Guidelines for Working with Uncooperative Clients in the Emergency Department
Stage | Client Behavior | Nurse Actions
---|---|---
1. Environmental trigger | Stress response | Encourage venting: avoid challenge; speak calmly, clearly; offer alternative
2. Escalation period | Movement toward loss of control | Take control: maintain safe distance, acknowledge behavior, medicate if appropriate, remove to quiet area, "show force" if necessary
3. Crisis period | Emotional/physical discharge | Apply external control: implement emergency protocol, initiate confinement, give focused intensive care
4. Recovery | Cool down | Reassure: support; no retaliation; encourage to discuss behavior and alternative; release when in control; assess reaction to environment; conduct sessions for staff to process all areas of incident
5. Postcrisis and letdown | Reconciliatory | Demonstrate acceptance while continuing clarification of unit standards and expectations
From Steele RL: Staff attitudes toward seclusion and restraint: anything new? _Perspect Psychiatr Care_ 29(3):28, 1993. Reprinted by permission of Nursecom, Inc.
### Step 2: Establishing rapport and engaging the client
• A simple introductory statement can quickly orient the client to the purpose of the crisis questions and how the information will be used. Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulations require confidentiality. If clients expect family members to give or receive information to health providers when the client is not present, they will need to sign a consent form. Clients in crisis look to health professionals to structure interactions.
• Providing professional support to help the client and family feel more comfortable helps reduce anxiety in crisis situations. Clients and families experiencing a crisis state require a compassionate, flexible, but clearly directive calm approach from nurses. The client should be placed in a quiet, lighted room with no shadows, away from the mainstream of activity.
• Only a minimum number of people should be involved with the client, until he or she is stabilized. If the client is unable to cooperate, for safety reasons, more than one professional may be needed. Ideally, one nurse should be the primary contact for information. Depending on the nature of the crisis and client's personal responses, family members may be included or asked to return when the client is stabilized. The condition, as well as the preferences of the client, should be determining factors.
• In the early stages of crisis, people need to be listened to, rather than being given elaborate information (Artean & Williams, 1998). It is important to find out the client's perception of the crisis—how it developed, how it impacts on a person's life, is this a first encounter with a serious crisis, or one of many that the client has experienced? Questions to assess the client's perception of the client's emotional coping strength are important. James (2008) suggests asking question such as "How were you feeling about this before the crisis got so bad?" "Where do you see yourself headed with this problem?" (p. 51).
Let clients tell you what they are experiencing. Listen for facts and associated feelings. Use a reflective listening response to identify applicable feelings (e.g., "It sounds as if you are feeling very sad [angry, lonely] right now."). You can help clients focus on relevant points by repeating a phrase found in the dialogue, asking for validation of its importance, or asking for clarification to focus further thought. Exercise 21-2 offers an opportunity to understand reflection as a listening response in crisis situations.
EXERCISE 21-2 Interacting in Crisis Situations
Purpose: To give students experience in using the three-stage model of crisis intervention.
Procedure:
1. Break up into groups of three. One student should take the role of the client and one the role of the nurse; the third functions as observer.
2. Using one of the following role-plays, or one from your current clinical setting, engage the client and use the crisis intervention strategies presented in this chapter to frame your interventions.
3. The observer should provide feedback.
(This exercise can also be handled as discussion points rather than a role-play, with small-group or class feedback as to how students would have handled the situations.)
Role-Play:
Julie is a 23-year-old graduate student who has been dating Dan for the past 3 years. They plan to marry within the next 6 months. Last summer she had a brief affair with another graduate student while Dan was away but never told him. She is seeing you in the clinic having just found out that she has herpes from that encounter.
Sally is a 59-year-old postmenopausal woman admitted for diagnostic testing and possible surgery. She has just found out that her tests reveal a malignancy in her colon with possible metastasis to her liver. You are the nurse responsible for caring for her.
Bill's mother was admitted last night to the ICU with sepsis. She is on life support and intravenous antibiotics. Bill had a close relationship with his mother earlier in his life, but he has not seen her in the past year. You are the nurse for the shift but do not yet know her well.
Discussion:
1. What would you want to do differently as a result of this exercise when communicating with the client in crisis?
2. What was the effect of using the three-stage model of crisis intervention as a way of organizing your approach to the crisis situation?
### Step 3 (assessment): Identifying major problems
The following are guidelines for identifying major problems:
• Ask for a general outline of how the client has experienced the crisis, and note the sequential order of the crisis.
• Keep the focus on the here and now. Questions should be short and relevant to the crisis.
• Request more specific details (e.g., ask who was involved, what happened, and when it happened) if this information is not easily forthcoming from the client.
• Ask about the feelings associated with the immediate crisis.
• Responses to clients should be brief, empathetic, and clearly related to the client's story.
• Note changes in expression, body posture, and vocal inflections as clients tell their story and at what points they occur.
• Identify central emotional themes in the client's story (e.g., powerlessness, shame, hopelessness) to provide a focus for intervention.
• Periodically summarize content so that you and your client simultaneously arrive at the same place with a comprehensive understanding of major issues.
#### Dealing with Feelings
People do not necessarily link a crisis event to their feelings about it. Nurses can call the client's attention to the linkage by specifically connecting crisis data with observations about client response (e.g., "I wonder if because you think your son is using drugs _[precipitating event],_ you feel helpless and confused _[client emotional response],_ and it seems you don't know what to do next _[client behavioral reaction]._ "). Checking in with clients helps ensure that your interpretations represent the client's truth.
Clients in crisis often feel that their emotional reactions to a situation are abnormal because they are intense or uncomfortable. It is helpful to point out that most people will experience a variety of powerful feelings in crisis situations.
#### Recognizing Personal Strengths
In a crisis, people have a tendency to focus on what is wrong, which stimulates negative thinking patterns. Empowering clients to identify existing personal strengths through compassionate witnessing is an important strategy. Compassionate witnessing is defined as "noticing and feeling empathy for others" (Powley, 2009, p. 1303). When combined with social supports and community resources, compassionate witnessing of personal strengths can significantly enhance coping skills. For example, having a job, financial resources, and knowledge about accessing health care services are critical assets people can use in crisis situations. In the heat of the moment, clients may not recognize their value. Reinforce strengths as you observe them or as the client identifies them. Exercise 21-3 provides an opportunity to experience the value of personal support systems in crisis situations.
EXERCISE 21-3 Personal Support Systems
Purpose: To help students appreciate the breadth and importance of personal support systems in stressful situations.
Procedure:
All of us have support systems we can use in times of stress (e.g., church, friends, family, coworkers, clubs, recreational groups).
1. Identify a support person or system you could or do use in times of stress.
2. What does this personal support system or person do for you (e.g., listen without judgment; provide honest, objective feedback; challenge you to think; broaden your perspective; give unconditional support; share your perceptions)? List everything you can think of.
3. What factors go into choosing your personal support system (e.g., availability, expertise, perception of support)? Which is the most important factor?
4. How did you develop your personal support system?
Discussion:
1. What types of support systems were most commonly used by class or group members?
2. What were the most common reasons for selecting a support person or system?
3. After doing this exercise, what strategies would you advise for enlarging a personal support system?
4. What applications do you see in this exercise for your nursing practice?
#### Providing Truth in Information
Being truthful about what is known and unknown, and updating information as you learn about it is a critical strategy for building trust with clients in crisis. Explain what is going to happen, step by step. Letting clients know as much as possible about progress, treatment, and consequences of choosing different alternatives allows clients to make informed decisions and reduces the heightened anxiety associated with a crisis situation.
### Step 5 (planning): Exploring alternative options and partial solutions
People in crisis often develop tunnel vision (Dass-Brailsford, 2010) and feel they have no resolution of their problem. Finding viable solutions to seemingly impossible problems challenges this assumption, and helping clients to develop targeted alternative strategies increases self-efficacy. Problems not related to the crisis can be handled later.
Clients in crisis generally feel powerless. Nurses can introduce alternative methods that the client may not have considered. Helping a client examine the consequences of proposed solutions and breaking tasks down into small, achievable parts empowers clients. Proposed solutions should accommodate both the problem and client resources. Its helpful to assist clients in discussing the consequences, costs, and benefits of choosing of one action versus another (e.g., "What would happen if you choose this course of action as compared with...?" or "What is the worst that could happen if you decided to...?").
The locus of control for decision making should always remain with the client to whatever extent is possible. Making autonomous choices encourages clients to become invested in the solution-finding process and hopeful about finding a resolution to a crisis situation.
#### Involving Social Support Systems
Positive social supports and available community resources act as a buffer to the intensity of a crisis state. Evaluating the availability and ability of a client's support system to be involved is a critical assessment. Support networks provide practical advice and a sense of security. Equally important, they are a source of encouragement that can reaffirm a client's worth and help defuse anxiety associated with the uncertainty present in most crisis situations.
Not everyone in a client's support system holds equal or positive resource value for the client or family. It is important to ask not only about the number and variety of people in the client's support network, but "who does the client and/or family trust," and "who would they be most comfortable telling about their situation." In crisis situations, many clients and families temporarily withdraw from natural support systems and may need encouragement to reconnect.
### Step 6 (planning): Developing a realistic action plan
Crisis intervention "is action-oriented and situation focused" (Dass-Brailsford, 2010, p. 56). Formulating a realistic action plan starts with prioritizing identified problems. An effective crisis plan should have a practical, here-and-now, therapeutic, short-term focus and should reflect the client's choices about best options. Keep in mind the overarching goal of crisis intervention: to restore the functional capabilities of the individuals to their precrisis state.
Introduce consideration of immediate small steps to encourage stabilization. Provide instructions as clearly and simply as possible, explain what is going to happen step by step, and have clients repeat instructions back to you to ensure mutual understanding.
#### Focusing on the Present
Help your clients to think in terms of short time intervals and immediate next steps (e.g., "What can you do with the rest of today just to get through it better"?) Examples include getting more information, gathering essential data, taking a walk, calling a family member, taking time for self. When people begin to take even the smallest step, they gain a sense of control, and this stimulates hope for future mastery of the crisis situation. Thinking about crisis resolution as a whole is counterproductive.
#### Incorporate Previously Successful Coping Strategies
People with a record of resiliency and creativity in other aspects of their lives are more likely to weather a crisis satisfactorily. Looking at past coping strategies can reveal skills that can be used in a current crisis situation and offer hope that the current crisis also is resolvable. Ask, "What do you usually do when you have a problem?" or "To whom do you turn when you are in trouble?"
Explore the nature of tension-reducing strategies the client has used in the past (e.g., aerobics, Bible study, calling a friend). If the client seems immobilized and unable to give an answer about usual coping strategies, the nurse can offer prompts such as "Some people talk to their friends, bang walls, pray, go to church..." Usually, with verbal encouragement, clients begin to identify successful coping mechanisms, which can be built on, for use in resolving the current crisis.
### Step 6 (implementation): Developing an action plan
Developing Reasonable Goals
Developing realistic goals is a critical component of crisis intervention. This process includes becoming aware of choices, letting go of ideas that are toxic or self-defeating, and making the best choice among the viable options. Goal-directed activities should reflect the client's strengths, values, capabilities, beliefs, and preferences.
Achievable goals give clients and families hope that they can get to a different place with their emotional and physical pain. Goals that have meaning to the client are more likely to be accomplished. Crisis offers clients an opportunity to discover and develop new self-awareness about things that are important to them and skills.
#### Designing Achievable Tasks
Help clients choose tasks that are within their capabilities, circumstances, and energy level. Achievable tasks can be as simple as getting more information or making time for self. You can suggest, "What do you think needs to happen first?" or "Let's look at what you might be able to do quickly." Engaging clients in simple problem solving can help with crisis-related feelings of helplessness and hopelessness. Problem-solving tasks that strengthen the client's realistic perception of the crisis event, incorporate a client's beliefs and values, and integrate social and environmental supports offer the best chance for success. Greene, Lee, Trask and Rheinscheld (2005) suggest that helping clients tap into and use their personal resources to achieve goals facilitates crisis resolution and provides individuals with tools for further personal development.
#### Providing Structure and Encouragement
Clients need structure and encouragement as they perform the tasks that will move them forward. Making a commitment to achieve a small task related to crisis resolution helps clients see crisis resolution as a process they can master and stimulates hope. Setting time limits and monitoring task achievement is important.
Resolving a crisis state is not experienced as only steady movement forward. There will be setbacks. Clients need ongoing affirmation of their efforts. Supportive reinforcement includes validation of the struggles clients are coping with, anticipatory guidance regarding what to expect, the normalcy of ambivalent feelings, uncertainty, and discussion of fears surrounding the process. Comparing current functioning with baseline admission presentations helps nurses and their clients mutually evaluate progress, foresee areas of necessary focus, and measure achievement of treatment goals.
#### Providing Support for Families
Part of crisis intervention strategies includes providing support for family members. Crisis for the family can be experienced collectively as a direct strike in a disaster, or as a secondary individual response to the illness or injury of a family member. Family members supporting individuals in crisis are coping not only with the acute emotional fallout brought about by the client's crisis, but with the management of an unstable home environment created by the client's absence or inability to function in previous roles. There may be legal or safety issues that family members have to address.
Bluhm (1987) suggests an image of a family in crisis as "a group of people standing together, with arms interlocked. What happens if one family member becomes seriously ill and can no longer stand? The other family members will attempt to carry their loved one, each person shifting his weight to accommodate the additional burden" (p. 44).
Individual family members will experience the crisis in diverse ways, so different levels of information and support will be required. Giving families an opportunity to talk about the meaning of the crisis for each family member, and offering practical guidance about resources they can use to support the client and take care of themselves are important strategies nurses can use with families. Communication strategies the nurse can use to help families in crisis are presented in Box 21-1.
BOX 21-1 Interventions for Initial Family Responses to Crisis
Anxiety, Shock, Fear
• Give information that is brief, concise, explicit, and concrete.
• Repeat information and frequently reinforce; encourage families to record important facts in writing.
• Determine comprehension by asking family to repeat back to you what information they have been given.
• Provide for and encourage or allow expression of feelings, even if they are extreme.
• Maintain constant, nonanxious presence in the face of a highly anxious family.
• Inform family as to the potential range of behaviors and feelings that are within the "norm" for crisis.
• Maximize control within hospital environment, as possible.
Denial
• Identify what purpose denial is serving for family (e.g., Is it buying them "psychological time" for future coping and mobilization of resources?).
• Evaluate appropriateness of use of denial in terms of time; denial becomes inappropriate when it inhibits the family from taking necessary actions or when it is impinging on the course of treatment.
• Do not actively support denial, but don't dash hopes for the future (You might say, "It must be very difficult for you to believe your son is nonresponsive, and in a trauma unit.").
• If denial is prolonged and dysfunctional, more direct and specific factual representation may be essential.
Anger, Hostility, Distrust
• Allow for venting of angry feelings, clarifying what thoughts, fears, and beliefs are behind the anger; let the family know it is okay to be angry.
• Do not personalize family's expressions of these strong emotions.
• Institute family control within the hospital environment when possible (e.g., arrange for set times and set person to give them information in reference to the patient and answer their questions).
• Remain available to families during their venting of these emotions.
• Ask families how they can take the energy in their anger and put it to positive use for themselves, for the patient, and for the situation.
Remorse and Guilt
• Do not try to "rationalize away" guilt for families.
• Listen and support their expression of feeling and verbalizations (e.g., "I can understand how or why you might feel that way; however...").
• Follow the "however's" with careful, reality-oriented statements or questions (e.g., "None of us can truly control another's behavior"; "Kids make their own choices despite what parents think and want"; "How successful were you when you tried to control __________'s behavior with that before?"; "So many things happen for which there are no absolute answers").
Grief and Depression
• Acknowledge family's grief and depression.
• Encourage them to be precise about what it is they are grieving and depressed about; give grief and depression a context.
• Allow the family appropriate time for grief.
• Recognize that this is an essential step for future adaptation; do not try to rush the grief process.
• Remain sensitive to your own unfinished business, and hence comfort or discomfort with family's grieving and depression.
Hope
• Clarify with families their hopes, individually and with one another.
• Clarify with families their worst fears in reference to the situation. Are the hopes/fears congruent? Realistic? Unrealistic?
• Support realistic hope.
• Offer gentle factual information to reframe unrealistic hope (e.g., "With the information you have or the observations you have made, do you think that is still possible?").
• Assist families in reframing unrealistic hope in some other fashion (e.g., "What do you think others will have learned from ____________ if he doesn't make it?" "How do you think ____________ would like for you to remember him/her?").
Adapted from Kleeman K: Families in crisis due to multiple trauma, _Crit Care Nurs Clin North Am_ 1(1):25, 1989.
### Step 7 (evaluation): Developing a termination and follow-up protocol
Kavan, Guck, and Barone (2006) note, "Follow up provides patients with a lifeline and improves the likelihood that they still follow through with the action plan (p. 1164). All clients should receive verbal instructions, and _written_ discharge or follow-up directives, with phone numbers to call for added help or clarification. Although acute symptoms may subside with standard crisis intervention strategies, some clients will need follow-up for residual clinical issues. Many agencies include a follow-up call to the client or family to check on how things are going after crisis discharge.
Mobilizing resources in the community often is necessary in helping clients maintain continued mastery of health care situations. Community agency resources can provide clients with essential supports. An important piece of assessment data is whether the client is willing to use outside resources, and if so, which ones. Some clients are reluctant to use social services, medications, or mental health services, even short term, because of the stigma they feel about their use. Nurses can help clients and families sort out their concerns, assess their practicality, and develop viable contacts.
If indicated, nurses can facilitate the referral process by sharing information with community agencies and by giving clients enough information to follow through on getting additional assistance. Having written referral information available regarding eligibility requirements, location, cost, and accessibility can make a difference in compliance. Exercise 21-4 provides an opportunity to practice crisis intervention skills.
EXERCISE 21-4 Using Reflective Responses in a Crisis Situation
Purpose: To provide students with a means of appreciating the multipurpose uses of reflection as a listening response in crisis situations.
Procedure:
Have one student role-play a client in an emergency department situation involving a common crisis situation (e.g., fire, heart attack, auto accident). After this person talks about the crisis situation for 3 to 4 minutes, have each student write down a reflective listening response that they would use with the client in crisis. Have each student read their reflective response to the class. (This can also be done in small groups of students if the class is large.)
Discussion:
1. Were you surprised at the variety of reflective themes found in the students' responses?
2. In what ways could differences in the wording or emphasis of a reflective response influence the flow of information?
3. In what ways do reflective responses validate the client's experience?
4. How could you use what you learned from doing this exercise in your clinical practice?
## Mental health emergencies
Mental health emergencies present significant challenges for nurses. Whether encountered in the community or admitted to an emergency department, these clients often present as a danger to themselves or others. These clients present with chaotic distress behaviors, which are not under the client's control. Many communities have trained first responders in methods of dealing with individuals experiencing psychiatric crisis and have crisis response teams.
The client who presents as a mental health emergency is generally unable to participate in his or her care. Although mental health emergencies share some similarities with other types of crisis, they usually require a higher, more immediate level of assessment and intervention to protect the client from harming himself or others. Examples of a mental health emergency include suicidal, homicidal, or threatening behavior, self-injury, severe drug or alcohol impairment, and highly erratic or unusual behavior associated with serious mental disorders. Nurses can find it difficult to tolerate the intensity of the relationship associated with mental health emergencies.
Myer (2006) describes a triage assessment system (TAS) for mental health crises that can help nurses understand a client's responses across 3 domains: affective, behavioral, and cognitive. He suggests that clinicians identify the primary affective reaction, for example, anger, fear, or sadness. Next the client's behavioral reaction is assessed related to mobility, avoidance, or approach. The client's immediate perception of a transgression, threat, or loss in relation to the crisis event constitutes the cognitive domain. Treatment should focus on the most severe reaction.
This is where you should begin. Think about what the client sees. Remember that although defensive behaviors seem threatening, usually these clients feel vulnerable. Clients may feel they are in acute danger. They are not in control of their behavior or capable of logical reasoning. Keep communication short, compassionate and well defined. Do not be intimidated, but avoid intimidation. Find out where the fear is coming from. Go slow and avoid sudden movements. Box 21-2 provides de-escalation tips developed by Scott Davis of the Montgomery Police Department (2010) for use with clients presenting in the community with mental health emergencies.
BOX 21-2 De-escalation Tips for Mental Health Emergencies
• Use a nonthreatening stance—open, but not vulnerable. Have them "take a seat"
• Eye contact—not constant, brief to show concern
• Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed
• Movement—not sudden, announce actions when possible, keep hands where they can be seen
• Attitude—calm, interested, firm, patient, reassuring, respectful, truthful
• Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client "I understand you are seeing or feeling this, but I am not"
• Remove distractions, upsetting influences
• Keep the client talking/focused on the here and now
• Ignore rather than argue with provocative statements
• Allow verbal venting within reason
• Be sensitive to personal space/comfort zone
• Remove client to a quiet space; remove others from immediate area (avoid the "group spectators").
• Give some choices or options, if possible
• Set limits if necessary
• Limit interaction to just one professional and let that person do the talking.
• Avoid rushing—slow things down
• Give yourself an out; don't put the client between yourself and the door.
Adapted from Officer Scott A Davis, Crisis Intervention Team (CIT) Coordinator: De-escalation tips, Rockville, MD, February 10, 2010, Montgomery County Police Department.
Clinicians need to be respectful and avoid traumatizing individuals who are already experiencing a chaotic, distressed state. Patient-centered care requires assessment and treatment approaches that are compassionate, and as acceptable to the client as is possible. Whenever possible, offer simple choices with structured coaching.
Psychiatric emergency clients usually require medication for stabilization of symptoms and close supervision. Whereas crisis intervention represents a short-term response, a mental health emergency requires an _immediate_ coordinated response designed to alleviate the potential for harm and restore basic stability.
### Types of mental health emergencies
Callahan (1998) identifies three types of mental health emergencies in health care: violence, suicide, and psychosis.
#### Violence
**Violence** is a mental health emergency that can create a critical challenge to the safety, well-being, and health of the clients and others in their environment. Officer Scott Davis, crisis intervention team coordinator with the Montgomery County Police Department shares a field expedient tool, using the acronym "DANGEROUS PERSON" (Box 21-3), to assess dangerousness to self or others in clients presenting as mental health emergency.
BOX 21-3 Field Expedient Tool to Assess Dangerousness to Self or Others
**D** epression/suicidal
**A** nger/agitation, aggressive
**N** oncompliance with requests/taking medication
**G** eneral appearance/inappropriate dress/poor hygiene
**E** vidence of self-inflicted injury
**R** esponding/reacting to delusions or hallucinations
**O** wns/displays weapon(s)
**U** norganized thoughts/appearance/behavior
**S** peech pattern/substance/rate (too fast, too slow, jumps all over)
**P** aranoid
**E** rratic or fearful behavior
**R** ecent loss of job/loved one/home
**S** ubstance abuse
**O** rientation to date/time/location/situation/insight into illness
**N** umber and type of previous contacts with police, social or crisis workers
From Officer Scott A Davis, Crisis Intervention Team (CIT) Coordinator: _Field expedient tool to assess dangerousness to self or others,_ Rockville, MD, February 2010, Montgomery County Police Department.
Nurses should assume an organic component (drugs, alcohol, psychosis, or delirium) underlying the aggression in clients presenting with disorganized impulsive or violent behaviors, until proven otherwise. Violent clients must be stabilized immediately for the protection of themselves and others. Perry and Jagger (2003) advise that at least two health care providers should be present at the bedside for all procedures if the client is suicidal, delirious, or under the influence of drugs or alcohol.
The client's body language often offers the nurse clues to escalating anxiety, which can end in violent behavior if left unchecked. Table 21-3 presents characteristic indicators of increasing tension leading to violence. A history of violence, childhood abuse, substance abuse, mental retardation, problems with impulse control, and psychosis, particularly when accompanied by command hallucinations, are common contributing factors.
TABLE 21-3
Behavioral Indicators of Potential Violence
Data from: Keely B: Recognition and prevention of hospital violence. _Dimens Crit Care Nurs_ , 21(6): 236-241, 2002; Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. _Journal of Advanced Nursing_. 59(1): 11-19, 2007.
Treatment of violent clients consists of providing a safe, nonstimulating environment for the client. Often clients calm down if taken to an area with less sensory input. The client should be checked thoroughly for potential weapons and physically disarmed, if necessary. Short-term medication is usually indicated to help defuse potentially harmful behaviors.
Communication strategies to defuse violent behaviors are useful adjuncts to treatment, and can prevent escalation of violent behavior. The nurse can use simple strategies such as calling the client by name; using a low, calm tone of voice; or presenting a show of force if necessary to help the client defuse tension. Encouraging the client to physically walk and to vent emotions verbally can be helpful.
Organically impaired clients may perceive necessary medical procedures as being intrusive and threatening. Perry and Jagger (2003) advise that, before you start any procedure, you should tell the client exactly what you are going to do and why the procedure is necessary, with a request to cooperate. If the client refuses, don't insist, but explain the reason for doing the procedure in a calm, quiet voice. If you help your client regain a sense of control, he or she will be more likely to cooperate with you. Your movements should be calm, firm, and respectful.
#### Suicide
Suicide is the ultimate personal crisis. People turn to suicide as an option in times of acute distress, when under the influence of drugs, or when they believe there are no other alternatives. A major goal in evaluating suicidal risk is to assess whether the client is in imminent danger of doing harm to self (Stellrecht, Gordon,Van Orden et al., 2006).
It is a myth that people who talk about harming themselves are at less risk. Every suicidal statement, however indirect, should be taken seriously. Even with clients who have indicated that they are "just kidding," the fact that they have verbalized the threat places them at greater risk. Verbal indicators of potential suicide include statements such as "I don't think I can go on without..." "I sometimes wish I wasn't here," or "People would be better off without me." Less direct indicators include statements like "I don't see anything good in my life." Any of these statements requires further clarification (e.g., "You say you can't go on any longer. Can you tell me more about what you mean?").
Nurses should ask directly:
• Are you thinking of hurting yourself? (include frequency and intensity of thoughts)
• Do you have a plan? (If the person indicates a plan, additional inquiry about the methods and availability of the method is needed.) Inquiring if the client has a plan is essential. Individuals with a detailed plan and the means to carry it out are at greatest risk for suicide, particularly if they do not have a reliable support system. In assessing the lethality of the plan, inquire about the method, and the client's knowledge and skills about its use (Roberts, Monferrari, & Yeager, 2008).
• What do you hope to accomplish with the suicide attempt? (look for hopelessness, including severity and duration)
• Have you thought about when you might do this? (immediate vs. chronic thinking)
• Who are you able to turn to when you are in trouble? (social support)
Behavioral indicators of escalating suicidal ideation include giving away possessions, apologizing for previous bad behaviors, writing letters to significant people, intense sharing of personal data from people who do not normally share with others, and frequent accidents.
Irrational behaviors, drug and alcohol abuse, previous suicide attempts, and verbal threats are matters of concern, as is a sudden mood change, especially if the client demonstrates much more energy. Clients with certain mental illnesses such as bipolar disorder or schizophrenia with command hallucinations are more at risk. Antisocial and borderline personality disorders are associated with increased suicide attempts. Suicide rates are greater for older adults, especially for white men, and among adolescents, particularly male African Americans. Men are more likely to complete suicide, whereas more women attempt suicide (American Psychiatric Association, 2003). Clients who verbalize or behaviorally demonstrate "a weight being lifted off the shoulders" should be watched carefully.
Other high-risk factors include:
• Previous attempts, or family history of suicide
• Major physical illness
• Social isolation
• Recent major loss
• History of trauma or abuse
Most clients are ambivalent about ending their life and experience relief that the decision has been taken out of their hands. Introduce the idea of psychiatric evaluation after disclosure of suicidal ideation in a calm, compassionate manner with a simple statement: "I'm worried that you might harm yourself because of how you say you are feeling right now. You have several of the factors that place you at high risk for suicide. I would like you to see Dr. Jones for an evaluation."
Stabilization and safety of the client is the most immediate concern with clients experiencing suicidal crisis. Clients exhibiting high-risk behaviors require one-to-one constant staff observation, and a potentially suicidal client should never be left alone. Possible weapons (e.g., mirrors, belts, knitting needles, scissors, razors, medications, clothes hangers) should be confiscated. When taking these items, explain in a calm, compassionate manner the general reason why the items should not be in the client's possession, and where they will be kept. The client needs to be compassionately informed of the reason unsafe items are being removed. They need to be assured that the items will be returned when the danger of self-harm resolves.
Documentation of the suicidal risk assessment, interventions, and client responses is essential. Included in the documentation should be any quotes made by the client, details of observed behavior, review of identified risk factors, and client responses to initial crisis intervention strategies. The names and times of anyone you notified and contacts with family should be incorporated in the narrative note. These data provide direction for future clinicians involved in the client's care. The Joint Commission requires that any death that is not consistent with a client's disease process or any permanent loss of function occurring as a consequence of an attempted suicide in a hospital be reported as a sentinel event (Captain, 2006).
Most inpatient settings have written suicide precaution protocols that must be followed with clients presenting with suicidal ideation. Observational monitoring of acutely suicidal clients ranges from constant 1:1 observation, to 15- or 30-minute observational checks. Less restrictive checks can include supervised bathroom, unit restriction or restriction to public areas, and supervised sharps (Jacobs, 2007). The frequency and type of observation is dependent on the suicidal assessment of the client.
After the initial focus of suicide intervention on stabilizing acute distress, helping the client identify triggers, and understand the reasons that led to suicidal ideation and/or suicide attempt becomes important. Helping people reestablish a reason for living and getting others involved as a support system are critical interventions.
Acceptance of the client is a critical element of rapport. Nurses need to explore their own feelings about suicide behaviors as the basis for understanding the client in danger of self-injury. Consistent with a high risk for suicidal behavior is a sense of hopelessness, lack of meaningful connection with others, and the feeling of being a burden to others (Stellrecht et al., 2006).
Speak slowly, gently, and clearly. Once the client's suicidal behaviors and feelings are brought under control, the crisis interventions presented earlier in the chapter can be instituted. Suicidal ideation waxes and wanes, so careful observation is critical even after the acute crisis has subsided. Captain (2006) suggests reassessing a client's suicidal intent every shift, using a 10-point scale and asking the client to "rate your level of suicidal intent on a 0-to-10 scale, with 0 meaning no thoughts of suicide and 10 meaning constant thoughts of suicide" (p. 47). Assessments should be repeated any time changes in behavior are noted and again before discharge.
#### Crisis Intervention with Psychotic Clients
A psychotic break in which a client is threatening harm to self or to others, is out of touch with reality, or is responding to hallucinations represents a serious mental health crisis. Acutely psychotic and delirious clients have disorganized thinking, reduced insight, and limited personal judgment. The individual is experiencing severe distress and is unable to manage himself or herself. Medication is usually indicated to manage psychotic symptoms.
The florid behavior symptoms associated with psychosis can be frightening for both nurse and client. Nurses should recognize the existence of the client's feelings and perceptions, even if the logic for their existence is not well understood. Psychotic clients do better in a quiet, softly lighted room, with no shadows, and out of the mainstream. One-to-one supervision usually is required for clients experiencing a psychotic break. Allow the client sufficient space to feel safe, and never try to subdue a client by yourself. Remain calm and positive. An open expression, eye contact, a calm voice, and simple concrete words invite trust. Do not use touch, as it can be misinterpreted.
## Crisis management
Disaster and mass trauma situations
A **disaster** is defined as "a calamitous event of slow or rapid onset that results in large-scale physical destruction of property, social infrastructure, and human life" (Deeny & McFetridge, 2005, p. 432). Recent years have borne witness to more unprecedented natural disasters, terrorism, and barbaric war than the world has seen in many decades. The September 11th terrorist attack on the World Trade Center in 2001, the Oklahoma City bombing, and the devastation of Hurricane Katrina, which demolished a thriving city in a matter of days, stimulated a fresh awareness of the need for community and national planned responses to mass trauma events that can happen anywhere, and at any time, to innocent masses of people. Webb (2004) identifies the components of mass trauma events in Table 21-4.
TABLE 21-4 Assessing Elements of Mass Trauma Events Rights were not granted to include this table in electronic media. Please refer to the printed book. From Webb N: The impact of traumatic stress and loss on children and families (p. 6.). In Webb N, editor: _Mass trauma and violence: helping families and children cope,_ New York, 2004, The Guilford Press. Reprinted by permission. Webb N
Myer and Moore (2006) note, "Crises do not happen in a vacuum, but are shaped by the cultural and social contexts in which they occur" (p. 139). From the perspective of its victims, terrorism is a random event, which reinforces insecurity, creates lingering anxiety, and increases avoidant behaviors around potential risks. The idea of a reciprocal relation between social forces and disaster crisis is supported by the Institute of Medicine (2003).
### Planning for disaster management
In the United States, The Federal Emergency Management Agency (FEMA) is responsible for setting forth recommendations related to creating an effective disaster plan (Hendriks & Bassi, (2009). FEMA recommendations provide guidelines for the creation of local disaster planning teams. Community-based governments and businesses, first responders, hospitals, and health providers are expected to be actively involved in community disaster planning. Around the globe, tsunamis in Indonesia, earthquakes occurring in rapid succession in China, Iceland, and South America, the threat of nations developing nuclear weapons, pandemic flu, and severe acute respiratory syndrome (SARS) remind us of a global approach to emergency preparedness.
Strategies for creating and sustaining community-wide emergency preparedness are published by the Joint Commission (2003), which states, "It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday" (p. 5). Disaster planning can act as a deterrent to terrorist activity, as well as immediate resource in a disaster situation.
### Disaster intervention protocols
Disaster intervention protocols focus on treating injury and acute illness, rather than chronic health conditions (Spurlock, Brown, & Rami, 2009). Crisis intervention responses to mass violence and disaster are quite distinct from treating individual traumas and crisis. Interventions must be embedded in community systems, and must be consistent with societal norms and available resources.
Disaster management requires providing immediate physical and emotional first aid. Instead of initially eliciting details of the experience, Everly and Flynn (2006) stress promotion of adaptive functioning and stabilization as a first response. They use the acronym BICEPS, which stands for brevity, immediacy, contact, expectancy, proximity, and simplicity to describe the type of psychological first aid needed in mass disaster situations.
Noji (2000) identifies four goals to guide disaster management:
• Assess the needs of disaster-affected populations.
• Match available resources to those needs.
• Prevent further adverse health effects; implement disease-control strategies for well-defined problems.
• Evaluate the effectiveness of disaster relief programs and improve contingency plans for various types of future disasters.
Any declared disaster situation affects individuals differently.
### Critical incident debriefing
Disasters, deliberate violence, and terrorist attacks are random events producing permanent changes in people's lives and shaking their perception of being in charge of their lives. Everly and Mitchell (2000) use the term **critical incident** to describe "an event, which is outside the usual range of experience and challenges one's ability to cope" (p. 212).
**Critical incident debriefing** is a type of crisis intervention used to help a group of people who have witnessed or experienced a mass trauma event process its meaning and talk about feelings that otherwise might not surface. The debriefing is designed to help the people directly involved in witnessing or caring for victims and survivors process first the facts and then the feelings associated with a traumatic or critical incident.
The process should allow for free expression of feelings, including guilt, anxiety, and anger. Guided mutual sharing of the crisis experience increases empathy and understanding of its meaning. The debriefing team teaches about the nature of distress reactions and offers helpful hints to mitigate their effects (Dietz, 2009).
The debriefing is conducted as a highly structured group intervention, which is held as soon as possible after the critical incident. The goal of critical incident debriefing is to lessen the symptoms of traumatic stress associated with a sudden crisis or trauma. The debriefing allows the people involved in a traumatic situation to achieve a sense of psychological closure. Although the critical incident will not be forgotten, people are better able to let go of its horror, which increases their potential for a return to normal life for individuals, communities, and organizations. Contact information for the group leader and possible referrals for further intervention should be provided.
#### Critical Incident Stress Debriefing Process
A specially trained professional generally leads the debriefing. Only those actively involved in the critical incident can attend the debriefing session.
The leader introduces the purpose of the group and assures the participants that everything said in the session will be kept confidential. People are asked to identify who they are and what happened from their perspective, including the role they played in the incident. After preliminary factual data are addressed, the next step is to explore feelings. The leader asks participants to recall the first thing they remember thinking or feeling about the incident. Participants are asked to discuss any stress symptoms they may have related to the incident. The final discussion focuses on the emotional reactions associated with the critical incident. This part of the session is followed by psycho-educational strategies to reduce stress. Any lingering questions are answered, and the leader summarizes the high points of the critical incident debriefing for the group (Rubin, 1990).
Critical incident debriefing is a useful strategy with families witnessing a tragedy involving one of their family members, for children and adolescents dealing with the death of a classmate, mass murders, or environmental disasters. A critical incident stress debriefing offers people an opportunity to externalize a traumatic experience through being able to vent feelings, discuss their role in the situation, develop a realistic sense of the big picture, and receive peer support in putting a crisis event in perspective (Curtis, 1995).
#### Critical Incident Debriefing for First Responders and Health Care Providers
Critical incidents in health care affect the personnel who respond to them. If there is no opportunity to process the meaning of a critical situation, an involved health care provider can become a psychological casualty. Research indicates that individuals, including health care providers who assist or witness critical incidents, are vulnerable to experiencing "secondary traumatization" similar to that experienced by direct survivors of the incident. Principles of critical incident debriefing can also be applied to strengthen the emotional coping skills of staff working in clinical settings on units with frequent or unexpected loss (Dietz, 2009).
Because of their magnitude, disasters present a more complicated coping process for family survivors and the community at large (Flannery, 1999). Survivors of disaster experience personal crisis response patterns similar to those described earlier in the chapter. In addition, they can experience what Lahad (2000) terms "breaks in continuity." He suggests that victims, their families, and those secondarily exposed to a disaster are subject to a sudden, serious break in their belief in the continuity of their personal lives that is difficult to ease. The break in continuity occurs in four spheres:
• I don't understand what is happening _(cognitive continuity)._
• I don't know myself _(historical continuity)._
• I don't know what to do, how to act here, what it is to be a bereaved person/an injured or wounded person _(role continuity)._
• Where is everyone? I am so alone. Where are my loved ones? _(social continuity)._
The experience of trauma from a disaster or terrorist event varies in intensity and impact for survivors. Each survivor brings to the experience a unique personal history, interpersonal strengths, and deficits. Each will interpret the meaning of the crisis differently. Individual, family, and community beliefs about a disaster's cause and meaning influence each person's response. Past experience with trauma makes a person more vulnerable to future impairment with traumatic situations (Maguen, Papa, & Litz, 2008). Having limited resources, lack of social support, or mental illness creates additional stress. The level of direct involvement, degree of uncertainty about outcome, nature of the loss, and personal resiliency of the individual and family also affects the impact of the trauma or disaster event, both short and long term. Client needs and individual service delivery requirements will also vary across the entire recovery period.
Another variable in crisis management is culture. Culture plays a role in how a crisis situation is interpreted, and the best means by which people and communities can be helped. Understanding and accepting cultural differences is an important dimension of helping to restore people to their precrisis level of functioning (Dykeman, 2005).
### Community response patterns
The Joint Commission (2003) explicitly portrays disaster management and emergency preparedness as a community responsibility. When disaster strikes, the existence and function of the community are significantly impaired, and even in danger of extinction. Initially people are confused and stunned. Emotions vary as the extent of the impact is realized. The closer the person is to the crisis event, the more intense is the impact (Myer & Moore, 2006). The immediate concern is protection of self and those closest to them. The community response to disaster characteristically consists of four phases:
• Heroic phase
• Honeymoon phase
• Disillusionment phase
• Reconstruction phase
The shock of the disaster pulls people together. Emergency medical teams, neighbors, and friends rally around the survivors, offering emotional support and tangible supplies needed for recovery. The _honeymoon phase_ occurs when the "community pulls together and outside resources are brought in" after an initial search and recovery phase (Bowenkamp, 2000, p. 159). This phase typically lasts up to 6 months after disaster. The focus of intervention is to ensure the public health safety of the victims. Establishing an infrastructure to support the immediate needs of the population related to water, sanitation, food supplies, and insect and rodent control are essential services (Campos-Outcalt, 2006). Sharing the experience of the trauma with others and having tangible evidence of continuing support are crucial components of effective response.
The _disillusionment phase_ usually appears as the initial emergency response starts to subside. The "shared community" feeling starts to leave as people begin to realize the extent of their losses and the limitations of external support. Survivors can experience anger, resentment, and bitterness at the loss of support, particularly if it is sudden and complete. Kaplan, Iancu, and Bodner (2000) suggest that opportunities for psychological debriefing sessions should continue for a period well beyond the initial disaster experience for victims of extreme stress.
The final _reconstruction phase_ occurs when the survivors begin to take the primary responsibility for rebuilding their lives. This period can last for several years after a disaster. Ongoing support is required as survivors learn to cope with new roles and responsibilities, and to develop new alternatives to living a full life after trauma. Although the disaster experience recedes in memory, it is never lost, and the person may never again fully trust in the continuity of life and being in control of one's destiny. Kaminsky, McCabe, Langlieb, and Everly (2007) describe recovery from the clinical distress, impairment, and dysfunction associated with terrorism and mass disaster as evidenced in the ability to adaptively function psychologically and behaviorally.
### Disaster management in health care settings
In 2006, the Joint Commission added new standards for credentialing volunteer health care professionals in declared emergency situations. All hospitals are required to form disaster committees composed of key departments within the hospital, including nursing. That committee is charged with developing disaster plans and implementing practice with them at least twice a year. A rapid credentialing process must be in place. Nurses interested in emergency volunteer activities should become aware of credentialing requirements to ensure their participation as part of a national emergency volunteer system for health professionals.
The Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) provides consistent standards designed to facilitate organized response efforts among volunteer health practitioners in declared emergencies, disaster relief, and public health crisis situations (National Conference of Commissioners on Uniform State Laws, 2006).
Hospital and community disaster planning must be coordinated so that all phases of the disaster cycle are covered. Designated hospital personnel must receive training to carry out triage at the emergency department entrance. Protocols should contain the capability to relocate staff and clients to another facility if necessary, and a plan must be in place detailing mechanisms for equipment resupply. Policies regarding notification, maintenance of accurate records, and establishment of a facility control center are required.
#### Citizen Responders
Unsolicited responders will play a large role in sudden onset, large scale disasters. Auf der Heide (2006) suggests that emergency plans should anticipate the presence of unsolicited responders and have an infrastructure for coordinating their efforts. Public education related to the citizen role in disaster management is essential.
Citizen Corps Programs, developed by FEMA, is a grassroots crisis intervention strategy that can provide community volunteers with a program to develop emergency preparedness and first-aid skills. The Web site (<http://www.citizencorps.gov>) provides training and tool kits to help improve the on-site care of disaster victims. It also provides links to information for families interested in developing emergency preparedness around the following issues:
• Providing children and family members with family work and cell phone numbers; name and number of neighbor, friend, or relative; emergency 911, fire, poison control, and police number (these should be posted in a conspicuous place).
• Choosing an out of town contact and instructions on how to make contact.
• Choosing a place to meet with other family members in case of emergency.
• Planning for pets, as they are not allowed in emergency shelters.
Family emergency preparedness plans should be updated annually.
## Helping children cope with trauma
Children do not have the same resources when coping with traumatic events as adults do. Preexisting exposure to traumatic events and lack of social support increases vulnerability. It is not unusual for children to demonstrate regressive behaviors as a reaction to crisis. Knapp (2010) suggests that using rituals and memorials for children experiencing loss of peers at school is helpful in mitigating trauma impact. Having a place where children can bring flowers and other mementos commemorating their peer's death is important.
Children will look for cues from key adults in their lives and tend to mirror their adult caregivers, so it is essential to communicate calm and confidence. More than anything else, children need reassurance that they and the people who are important to them are safe. Encourage the family to maintain regular routines. Parents need to provide children with opportunities both to talk about crisis and to ask questions. Repetitive questions are to be expected. Often they reflect the child's need for reassurance. Offering factual information helps dispel misperceptions.
### Helping older adults cope with trauma
Functional limitations associated with compromised physical mobility, diminished sensory awareness, and preexisting health conditions can create special issues for older clients impacted by a disaster. Older adults have more injury and greater disaster-related deaths than adults in other age groups (Fernandez, Byard, Lin, Benson, & Barbera, 2002). Especially vulnerable are house bound and socially isolated individuals. Other population groups needing extra attention are those who require medical or nursing care, and those receiving services, care, or food from health, social, or volunteer agencies.
Disaster management for older adults needs to be proactive. The following core actions can make a difference in helping older adults weather a disaster event successfully. Proactive planning includes:
• Identify a support network that can be used in an emergency situation. Facilitate connections with social support systems and community support structures. Have this information readily available for use in an emergency situation.
• Older adults with a disability should wear tags or a bracelet to identify their disability. Keeping extra eyeglasses and hearing aid batteries on hand, and identifying any assistive devices is essential.
• Identify the closest special needs evacuation center.
• Develop a written list of all medications, with any special directions, for example, crushing pills, hours of administration, and dietary restrictions.
• Identify physicians and social support contacts, including someone apart from people in the local area who can be contacted.
Other actions, such as ensuring the safety, meeting mobility needs, and medication administration, will need careful attention during the course of actual disaster management. Even the most capable older adult can appear confused and vulnerable in a disaster situation. Reducing anxiety is especially important for the older adult disaster victim. Actions nurses can take include the following:
• Initiate contact and take the older adult to as safe a place as possible.
• Speak calmly and provide concrete information about what is happening, and what you need the older adult to do in simple terms.
• Assess for mobility and provide assistance where needed.
• Older adults may need warmer clothing because of compromised temperature regulation.
## Summary
Crisis is defined as an unexpected, sudden turn of events or set of circumstances requiring an immediate human response. People experience a crisis as overwhelming, traumatic, and personally intrusive. It is an unexpected life event challenging a person's sense of self and his or her place in the world. The most common types of crisis are situational and developmental crises. Most health crises are situational. Crisis can be private involving one person, or public involving large numbers of people. James (2008) describes two additional types of crisis: existential and ecosystem crisis.
Theoretical frameworks guiding crisis intervention include Lindemann's (1944) model of grieving, derived from his clinical work with survivors of a nightclub fire. Caplan's (1964) model is based on preventive psychiatry concepts. Aguilera's nursing model explores the role of balancing factors in defusing the impact of a crisis state. Erikson's (1982) model of psychosocial development forms the basis for developmental crisis.
Crisis intervention is a time-limited treatment that focuses only on the immediate problem and its resolution. Roberts' (2005) seven-stage model is used to guide nursing interventions: assessing lethality, establishing rapport, dealing with feelings, defining the problem, exploring alternative options, formulating a plan, and follow-up measures. The goal of crisis intervention is to return the client to his or her precrisis level of functioning.
Mental health emergencies require immediate assessment interventions and close supervision. The most common types are violence, suicide, and a psychotic break. Guidelines for communication with clients experiencing mental health emergencies (e.g., violence and suicide) focus on safety and rapid stabilization of the client's behavior.
As the world becomes more dynamically unstable, nurses will need to understand the dimensions of disaster management and develop the skills to respond effectively in disaster situations. Disaster management is a special kind of crisis intervention applied to large groups of people. The Joint Commission (2003) requires hospitals to develop and exercise disaster management plans at regular intervals. Critical incident debriefing is a crisis intervention strategy designed to help those closely involved with disasters process critical incidents in health care, thereby reducing the possibility of symptoms occurring.
Ethical Dilemma
What Would You Do?
Sara Murdano was only 20 when she came to the mobile intensive care unit (MICU), but this is not her first hospital admission. She has been treated for depression previously. She states she is determined to kill herself because she has nothing to live for, and that is her right to do so because she is no longer a minor. As she describes her life to date, you can't help but think that she really doesn't have a lot to live for. How would you respond to this client from an ethical perspective?
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CHAPTER 22
# Communication for a Safe Environment
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Identify client communication safety goals.
2 Identify how communication skills enhance client safety, as well as quality of care.
3 Describe why client safety is a complex system issue, as well as an individual function.
4 Describe how open communication and organizational error reporting contribute to a culture of safety.
5 Discuss how to advocate for safe, high-quality care as a team member.
6 Use simulations to demonstrate communication skills that affect client care; specifically apply standardized formats such as SBAR in a simulated conversation with a physician.
This chapter focuses on communication concepts designed to assist nurses and their health team colleagues in creating a safe environment for their clients. Although "safety" is recently getting increased attention, client safety is (and has always been) a priority in nursing care (Gore, Hunt, & Raines, 2008). Quality of care is dependent, in part, on communication (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2008). Miscommunication is a dominant factor cited in error reports. The quality of communication and the quality of the client-provider relationship have long been used as indicators of quality of care (Agency for Healthcare Research and Quality [AHRQ,c]).
## Basic concepts
Safety definition
In healthcare organizations, safety is generally defined as freedom from accidental injury. Since the days of Hippocrates, the concept of "do no harm" has been incorporated into healthcare ethical practice. The nursing profession has always had safe practice as a major goal _._ It is the basic tenet of the American Nurses Association's Code of Ethics for Nurses. The National Patient Safety Foundation (NPSF; online, www.npsf.org/pdf/r/researchagenda.pdf) has a more specific definition: "avoidance, prevention, amelioration of adverse outcomes or injuries stemming from the process of healthcare itself." In a more comprehensive definition, the American Association of Colleges of Nursing (AACN, 2006a) defines safety as the minimalization of risk for harm to patients and to providers through both system effectiveness and individual performance. _Health care organizations_ and _professional organizations_ generally try to ensure safe care by establishing safety rules and procedures. This chapter restricts discussion to innovations in communication procedures designed to improve client safety.
### Recent overall safety issues
In the early part of this century, the quality and safety of health care in the United States was mediocre or worse (Bates, 2009). In a British study comparing mortality data from the United States with 14 other Western countries between 1997 and 2003, the United States had only a 4% decrease in deaths from amenable causes, whereas the average decrease for other countries was 17% (Nolte & McKee, 2008). Much has changed in our practice since the landmark 1999 Institute of Medicine (IOM) study that found that preventable health care errors were responsible for almost 98,000 deaths each year in the United States. This IOM report, "To Err Is Human: Building a Safer Health System," made client safety a national American priority (Kohn, 1999).
Expense, resistance to change, and the lack of centralized data reporting slowed adoption of new practices. Worldwide, unsafe practice has compromised care for clients in many countries. Errors have a high financial cost in addition to the human cost, exceeding $29 billion dollars per year just in the United States (AHRQb). It is estimated that 70% of reported errors are preventable. "Preventable" means the error occurs through a medical intervention, not because of the client's illness. Fatigue is repeatedly cited as a factor contributing to errors. Risk doubled when nurses worked more than 12 consecutive hours (Scott, Rodgers, Hwang, & Zhang, 2006). Medical and Nursing organizations, as well as health care delivery organizations, have taken initiatives designed to foster " **best practice** " safer client care by designing protocols for care that are evidence based. At the same time, new technology tools are making care safer (refer to Chapters 25 and ). This chapter limits discussion to only those practices relevant to communication.
Nurses are often the "last line of defense" against error. It is an ethical imperative (Lachman, 2008). Nurses are in a position to prevent, intercept, or correct errors. Individual nurses have many opportunities to prevent error, particularly by communicating clearly to others even when the hierarchy seems to discourage questioning authorities (Donaldson, 2008). The quality of your communication affects safety factors such as medication errors, client injuries from falls, clinical outcomes related to client adherence to his treatment plan, and rehospitalization rates. The Applications section of this chapter focuses on nursing communication practices to promote safer care.
#### Poor communication compromises client safety
Multiple studies have pinpointed miscommunication as a major causative agent in sentinel events, that is, errors resulting in unnecessary death and serious injury (Leonard & Bonacum, 2008). Poor communication has been identified as the root cause of serious medical errors as much as 70% of the time in reported errors (Joint Commission, b,c). However, errors do not usually have one cause but result from a series of flaws in the care system. The problem is complex; therefore, solutions also will be complex.
#### Medication errors
According to the American Medical Association (AMA, eVoice, 2008), approximately 80% of medication errors are due to communication breakdown. Although some medication errors stem from lack of knowledge about the drug (its side effects, etc.), many other drug errors occur when a nurse fails to follow the rules for verification: right med, right client, right dose, and right time.
#### Miscommunication during "handoff" transfers of client
Miscommunication errors most often occur during a handoff procedure, when one staff member transfers responsibility for care to another staff member. More than half of incidences of reported serious miscommunications occurred during _client handoff,_ when those assuming responsibility for the client (coming on duty) are given a verbal, face-to-face synopsis of the client's current condition by those who had been caring for him and are now going off duty (Evans, Pereira, & Parker, 2008; Henkind & Sinnett, 2008).
#### Client outcomes
The literature suggests some progress in preventing sentinel events, but errors are still common, resulting in unnecessary harm to clients. In addition to errors, outcomes include increased costs, increased rates of hospitalization, longer recovery rates, and more medical complications. Beside risks to client safety, poor communication is also related to client dissatisfaction and risk for malpractice lawsuits. A survey of clients found that 34% experienced errors and 68% cited poor communication between nurses and physicians and others as a cause of errors (Kaiser Family Foundation, 2004). Annual current statistics about sentinel events are available on the Joint Commission Web site (TJC, c).
### New initiatives for safer care
We are redeveloping our health care system to make client care safer. There is consensus that this requires improving communication. Best nurse-physician collaborative communication has empirically been associated with lower risk for negative client outcomes and greater satisfaction. Research studies support this concept (DeVoe, Wallace, Pandhi, Solotaroff, & Fryer, 2008; Elder, Brungs, Nagy, Kudel, & Render, 2008). The current renewed focus on improving patient safety will cause standardization of many health care practices. "Standardization is among the best methods to improve quality and reduce costs of care...even if the standard is something as simple as a checklist" (Mathews & Pronovost, 2008, p. 2914). Changes in communication to reduce errors and increase safety need to be institutionalized at the system level and implemented consistently at the staff level. Safe communication about client care matters needs to be clear, unambiguous, timely, accurate, complete, open, and understood by the recipient to reduce errors (Amato-Vealey, Barba, & Vealey, 2008).
### Communication goals and standards to improve client safety
Overall, medical goals are complex and have shifting priorities. Safe client care is always a priority, however. Measuring safety is problematic because not everyone uses the same definitions of "unsafe," nor do they use the same outcome measures. The number of surgeries done on the wrong site is a very specific outcome, even though most hospitals do not report to a national overseer in the United States, so data may not be readily accessible. When we focus on communication problems leading to adverse client outcomes, the data are much less specific. With the current increased focus on improving communication to promote a climate of client safety, we need communication that is open and client centered. Safety goals to improve communication about clients among his or her various providers are aimed at reducing client mortality, decreasing medical errors, and promoting effective health care teamwork. These goals need to be mutually established by the health team in a climate of respect to assure maximum clarity among providers.
_Communication health care safety goals from governing organizations_ include:
1. _IOM's 8 Goals._ A worldwide wake up occurred when IOM published their report, citing hospital errors as causing almost 100,000 deaths per year. Yet, 5 years later, Nolte and McKee's (2008) analysis showed more than 101,000 preventable deaths per year in clients younger than 75 years. The IOM specifically included improving accurate, complete communication as one of their eight goals. IOM has suggested that hospitals need to create structured handoff protocols, that is, a standardized format for reporting client status when care provider A goes off duty, turning care responsibility over to care provider B. This standardized communication format is needed to facilitate better communication for patient safety.
2. _AHRQ_ in the Department of Health and Human Services, with a Congressional mandate, has taken a leading role in the United States to improve client safety. AHRQ's role is to prevent medical errors and promote client safety. They fund research and compile data to develop and publish "best practices" evidenced-based care protocols. Several other sites publish "best practice info" (online resources such as <http://healthlinks.washington.edu/ebp>).
3. The _World Health Organization_ (WHO), a part of the United Nations, has actively sought to improve worldwide client safety. In 2005, WHO designated Joint Commission International as the WHO Collaborating Center for patient safety solutions. In 2007, WHO (Joint Commission International) published nine solutions; number 2 is "correctly identifying the patient," and number 3 is "better communication during patient hand-over" (from one caregiver to another).
_Communication goals for healthcare safety from professional organizations_ include:
1. _Joint Commission Guidelines._ This organization regulates hospitals. They attribute more than 60% of sentinel events in hospitals to miscommunication. Many of their current National Patient Safety Goals are aimed at structuring and improving communication. Goal 2 is to improve the effectiveness of communication among caregivers. Section 2E addresses communication guidelines needed to manage handoff communication. When a client is transferred or "handed off" to another care provider, unit, or agency, hospitals are encouraged to develop a standard communication protocol to improve the effectiveness of communication. This should result in increased client safety (AHRQ,c).
2. _AACN._ Recommendations for nursing curriculums related to safety and communication include application of research-based/evidence-based knowledge as the basis for practice; recognition that safety is a complex issue that involves all providers; establishing and maintaining...open communication and cooperation within the interdisciplinary team; and using standardized "hand off" communications (AACN, 2006a).
### Changes toward bettering communications leading to safer care
General communication problems identified by the AMA are listed in Box 22-1. Foremost recommendations include:
BOX 22-1 Patient Communication Universal Precautions [Communication Problems]
1. Difficulty obtaining, processing, and understanding information
2. Health care system complexity
3. Practice pressures
4. Cultural and language issues
5. Lack of clinician training on effective communication strategies
6. Low health literacy
From AMA, Safe Communications Universal Precautions, Patient safety tip card. AMA Bookstore, 2008. Modified from AMA: American Medical Association eVoice, Best Practice Information, October 2, 2008. Only available on-line by subscription. Downloaded 5/2/09.
_Use "best practices" by increasing use of evidenced-based "best practice" versus "usual practice."_ Agencies such as AHRQ (c) have begun to fund research to identify the most effective methods of promoting clear communication among health team members and agencies, as well as the most effective treatments. This information is used to develop and distribute protocols for best practice, including formats of standard communication techniques. We need more studies of interventions to promote best communication between nurse and physician with documented outcomes for clients.
_Create a team culture of safety communication._ Creating effective health teams means getting all team members to value teamwork more than individual autonomy. Team culture includes shared norms, values, beliefs, and staff expectations. In Canada, Sutter et al.'s 2009 study, as well as findings from the Canadian Health Services Research Foundation, identified effective team communication as a core competency. Team _collaborative communication strategies_ involve shared responsibility for problem solving and decision making, as well as coordination of care. Teamwork failures including poor communication and failures in physician supervision have been implicated in two-thirds of harmful errors to clients (Singh, Thomas, Peterson, & Studdert, 2007). Creating a safe environment requires us to communicate openly, to be vigilant and accountable. Systems should create expectations of a work environment in which staff can speak up and express concerns, and alert team members to unsafe situations.
### Problems or barriers for individual health care workers
Strategies for effective communication to promote client safety are listed in Box 22-2. They are discussed in the following subsections.
BOX 22-2 Strategies for Effective Communication to Promote Client Safety
1. Use standardized interdisciplinary communication tools/formats that promote collaboration, so everybody is "on the same page."
2. Use communication tools that promote clear, comprehensive communication when clients are moved between units or agencies, such as checklists.
3. Establish a psychological safe climate: identify opportunities for improving safety.
4. Participate in ongoing dialogue (via team meetings, periodic conference calls, etc.) to share successes.
5. Maintain awareness of potential situational safety concerns and planning standardized contingency responses (e.g., critical event training using simulation).
6. Restructure into teams that maintain a climate of open communication.
#### Usual practice versus empirically derived best practices
There is a major lack of research utilization for best practice. Though you are exposed to the use of research findings in your practice, many staff nurses lack the time and skills to actively seek new study results that would improve their daily practice. Physicians are still likely to use their own experience rather than documented recommended best practice methods. Research-based evidence is often absent or lacks high-quality consensus. Widespread adoption of best practices had not yet been accomplished in the decade after IOM's 1999 report. Best practice recommended therapies were found to have been received by only 55% of adult clients and 47% of child clients (Mangione-Smith et al., 2007).
#### Communication differences among professions
Each profession has its unique vocabulary and method of communicating. Physician's expectations may be "just the facts" briefly, whereas nurses have been educated to describe the broad picture. Medical communication is a goal-oriented, problem-solving behavior, which requires not only skill practicing but reflection on the process and outcome. Developing communication skills has now become a curriculum thread in nursing educational programs.
Hierarchical power differences exist between physicians and nurses. This difference in power intimidates some nurses communicating with physicians. Historic autonomy for physicians is being replaced by empowerment of teams for decision making. The concept of equity is integral to a functioning team. Historically, physicians and nurses are accustomed to working in a hierarchy where physicians make treatment decisions independently rather than though consultations with a team. This is sometimes termed medicine's "culture of individualism." Implementing measures specified by best practice evidence and sharing decision making about the client's care require that physicians correspondingly relinquish some autonomy (Mathews & Pronovost, 2008). Effective teamwork, including open communication, openness to new concepts, and honest error reporting, are basic components in establishing a new safety culture. This requires some readjustment in the way both physicians and nurses think about their roles.
#### Reluctance to report errors
According to IOM, only a tiny fraction of unsafe care incidents are submitted to reporting databases or agencies (Kohn, 1999). Some estimate that more than 90% of errors go unreported (Elder et al., 2008). A redesign is needed if we really want to create a culture of safety. The health care industry is looking at models created by other industries such as aviation or nuclear power, which have excellent safety records. Aviation's successful Crew Resource Management practice model has been used as a template for some in the health care industry. One needed step is to require the reporting of "near misses" so new safer protocols can be created. A centralized agency, such as the United Kingdom's Patient Safety Agency, with a database on instances of errors and near misses would provide a database for analyses that would be of great use in designing safer delivery systems. In the United States, error reporting is hidden, underreported, and local, rather than being nationally available. Accurate incident reporting and greater transparency are crucial if future errors are to be prevented.
Another step in creating a culture of safety is to overcome current fear of punitive outcomes involved in error reporting. Providers are concerned about negative consequences of disclosing errors, such as malpractice litigation, reputation damage, job security, personal feelings such as loss of self-esteem, among others. Elder et al.'s (2008) study reported that nurses remain strongly conflicted about disclosing their errors to peers and physicians. In their survey, less than half of the intensive care unit nurses witnessing a near-miss error were likely to report it. Creating a new safety climate would require retraining nurses in error disclosure to help prevent future errors. Meanwhile providers struggle with the current systems for reporting errors.
#### Low level of client health literacy versus client education
Multiple studies show that health-care–related communication occurs at a level far exceeding the understanding abilities of the majority of average persons (Denham, 2008). According to the AMA, 50% of adults are at increased risk for serious adverse health consequences because of their low level of understanding of medical terminology and their tendency to hide this problem from their doctors and nurses. Inadequate heath literacy leads clients to misunderstand information about their treatment, causing errors.
### Barriers in the current health care system
Problems with structural barriers in health care organizations that impede communications
The greatest barrier to safer care is fragmentation of care systems. Evidenced-based practices have to be reinforced and implemented at a system-wide level. Although most hospitals and agencies have some form of error reporting, they lack a system-wide department for processing safety information. One model to be emulated is that of Kaiser Permanente, which implemented a national patient safety plan in 2000.
Developing an Evidenced-Based Practice
Messmer PR: Enhancing nurse-physician collaboration using pediatric simulation, _J Contin Educ Nurs_ 39(7):319–327, 2008.
The purpose of this study was to describe levels of nurse-physician collaboration during simulation training. Videos of collaborative behaviors of 55 pediatric residents and 50 nurses during 3 mock codes using a pediatric human patient simulator depicting life-threatening scenarios were analyzed using standardized measures and observations.
_Results:_ In the initial scenario, there was little collaborative discussion between nurses and residents, but overtime by the third scenario collaborative communication predominated. Scores showed high levels of group cohesion and collaboration, and participants expressed satisfaction with patient care decisions. Male respondents regardless of discipline had significantly greater cohesion scores than did female respondents. Competency scores increased over time.
_Application to Your Practice:_ Interdisciplinary clinical simulation exercises can increase your ability to communicate and collaborate successfully with physicians, as well as increasing your care skill competency.
## Applications
Discussion in this section is limited to safety strategies that promote effective communication such as the mantra "Simplify, Clarify, Verify" (Fleischmann, 2008). A few general strategies are mentioned. (For a complete discussion, refer to OM [2001, 2004].) Consider how you will apply evidence-based practice information such as that in the sample.
## New teaching strategies to help nurses learn to communicate for safer care
Quality and Safety Education competencies for all Nurses (QSEN) have been developed by national leaders in nursing education (for full discussion, refer to Cronenwett et al. [2007]). Among these competencies are communication skills. Some new teaching strategies help students.
### Develop a safety priority attitude
The IOM has urged organizations to create an environment in which safety is a top priority. For example, equipment can be standardized and simplified, and display a readout about the reason an alarm is ringing. One of our primary roles as nurses is to advocate for client safety. Beyea (2008a) recommends that nurses, as individuals, take active efforts to improve our safety understanding, beginning by assessing our own safety learning needs in our particular area of practice (online, NPSF: EdNeedsAsessment, www.npsf.org/pdf/r/researchagenda.pdf). Errors occur when you assume someone else has addressed a situation (Beyea, 2008b). A prime goal is to improve communication about client condition among all the people providing care to that client.
### Use practice simulations
Virtual client-nurse scenarios, whether using technologically enhanced dummies or active learning situations such as case studies provided in this textbook, allow practice without risk for potentially devastating outcomes with an actual client care situation. Nursing education programs are beginning to use "live models" to simulate clients. Actors are trained to portray clients with specific illnesses. Student nurses practice communicating with them to elicit histories, as well as practicing skills such as physical examinations. (For more ideas, read Gore et al. [2008] and Henneman [2009].)
### Develop an evidence-based practice
Close the gap between best evidence and the way communication occurs in your current practice (Figure 22-1). Apply information from evidence-based best practice databanks for safe practice. The process for development of practice guidelines, protocols, situation checklists, and so on is not transparent or easy. Solutions include gathering more evidence on which to base our practice. When is the "evidence" sufficiently strong to warrant adoption of a standardized form of communication about care? At the nurse-client level, Beauregard, nurse-administrator at Beaumont Hospital in Royal Oak, Michigan, has commented that "the nurse-patient relationship is a pivotal component of any patient safety program...(and) the number one driver of patient safety is communication" (Runy, 2008). We are beginning to compile best practice protocols for acute and preventative care; many are available on AHRQ's Web site (online, www.ahrq.gov) or in their _Patient Safety and Quality: An Evidence-Based Handbook for Nurses_ (Hughes, 2008). Even though these are free and available to all, studies show that best care is delivered only half of the time (Mangione-Smith et al., 2007). In regard specifically to communication, so far there is relatively scant research to designate specific communication formats that will lead to safer care. Some of the clinical strategies that show promise are described in the following subsections.
Figure 22-1 Communication competencies for creating safer care. (Adapted from Carey M, Buchan H, Sanson-Fisher R: The cycle of change: implementing best-evidence clinical practice, _Int J Qual Healthc_ 21(1):37–43, 2009; Cronenwett L, Sherwood G, Barnsteiner J, et al.: Quality and safety education for nurses, _Nurs Outlook_ 55(3):122–131, 2007.)
#### Use Data from Analyses of Error Data Reporting to Improve Nursing Practices
A metaanalysis of results from error reporting demonstration grants found that as error reporting improves, error detection rates increase and severity decreases (AHRQ, b,d).
#### Use Standardized Communication Tools
Safety communication improvement solutions include using standardized communications tools, participating in team training communicating seminars, adopting technology-oriented tools, and empowering clients to be partners in safer care. Communication that promotes client safety needs to include both communication of concise critical information and active listening. Physicians, nurses, medical technologists, pharmacists, and other givers of care work in what Shortell and Singer (2008) call "functional silos"; that is, they are educated separately and for the most part work separately, which has caused them to have differing methods of communication. Educational programs impart very different communication expectations for nurses than those taught to medical students. Nurses are taught to communicate in detailed narrative form, to describe the broad picture when discussing a client with his physician. Physicians are taught to speak concisely, to diagnose and summarize. Or as Leonard and Bonacum (2008) say, "Physicians want bullet points," or just the headlines. Each group holds slightly different expectations about communication content and may have separate vocabularies. Nurses want their observations or assessments taken seriously. Solutions include team training and use of a standardized communication tool. Although currently there is no one universally accepted process, use of a shared format across disciplines can promote effective communication and client safety. The following are a sample of newer, more commonly used forms of team strategies designed to decrease or avoid errors of communication that lead to mistakes in health care.
#### Use of Checklists
Checklists serve as cognitive guides to accurate task completion. Checklists have been effectively used to improve client safety, especially in areas managing rapidly change, such as preoperative areas, emergency departments, and anesthesiology. Checklists have built-in redundancy. The floor nurse uses the preoperative checklist to verify that everything has been completed before sending the client to the surgical suite, but then this list is again checked when the client arrives but before the actual surgery. Such system redundancies are used to prevent errors. But they have limited and specific uses, and do not address underlying communication problems. No standardized protocol exists for checklist development, but use of expert panels with multiple pilot testing is recommended. One example found in most agency preoperative areas is a checklist where standard items are marked as having been done and available in the client's record/chart. For example, laboratory results are documented regarding blood type, clotting time, and so forth. In one cardiac area study, one common cause of adverse events was missing equipment; therefore, a checklist might be used before surgery to verify the presence of specific needed equipment (Wong et al., 2007). Adoption of assertion checklists empowers any team member to speak up when they become aware of missing information.
#### Use of SBAR
In 2002, at Kaiser Permanente's northern California regional risk management department's perinatal patient safety project, physicians and nurses training together expressed disappointment with their communication. In response, Bonacum, Leonard, and other Kaiser administrators developed and encouraged staff to begin implementing a standardized briefing format (known by its acronym **SBAR** ) for use by all staff communicating with each other—nurses, physicians, and all other team members. Adapted by Bonacum (2009) from principles used in communication on nuclear submarines, the SBAR tool provides structured language and fosters active listening. SBAR is designed to convey only the most critical information by eliminating excessive language. SBAR eliminates the authority gradient, flattening the traditional physician-to-nurse hierarchy. This makes it possible for staff to say what they think is going on. This improves communication and creates collaboration. This concise format is gaining wide adoption in the United States and Great Britain (Bonacum, 2009; Fleishmann, 2008; Leonard, 2009; Leonard & Bonacum, 2008). Refer to Box 22-3.
BOX 22-3 SBAR Example
Clinical Example of Use of SBAR Format for Communicating with Client's Physician
S | Situation | "Dr. Preston, this is Wendy Obi, evening nurse on 4G at St. Simeon Hospital, calling about Mr. Lakewood, who's having trouble breathing."
---|---|---
B | Background | "Kyle Lakewood, DOB 7/1/60, a 53-year-old man with chronic lung disease, admitted 12/25, who has been sliding downhill × 2 hours. Now he's acutely worse: VS heart rate 92, reparatory rate 40 with gasping, B/P 138/94, oxygenation down to 72%."
A | Assessment | "I don't hear any breath sounds in his right chest. I think he has a pneumothorax."
R | Recommendation | "I need you to see him right now. I think he needs a chest tube."
Adapted from Leonard M, Graham S, Bonacum D: The human factor: the critical importance of effective teamwork and communication in providing safe care, _Qual Saf Health Care_ 13(Suppl 1):i85–i90, 2004.
SBAR is used as a situational briefing, so the team is "on the same page" (Bonacum, 2009). SBAR simplifies verbal communication between nurses and physicians because content is presented in an expected format. In addition to communications between two individuals, it is used in small groups, such as the obstetrical delivery team and the surgical team. Success soon spread this format to use in surgery, for telephone contacts and in other acute care settings. Velji et al. (2008) have shown SBAR use to also be effective in improving safe communication in other types of agencies, such as rehabilitation facilities. Some, including Kaiser Staff, have even informally adopted it for their e-mail communications (Bonacum, 2009). Some hospitals use laminated SBAR guidelines at the telephones for nurses to use when calling physicians about changes in client status and requests for new orders (Leonard, 2009). Documenting the new order is the only part of SBAR that gets recorded. Refer to Table 22-1 for an example. Then practice your use of SBAR format in Exercise 22-1.
EXERCISE 22-1 Using Standardized Communication Formats
Purpose: To practice the SBAR technique.
Case Study:
Mrs. Robin, date of birth 1/5/50, is a preoperative client of Dr. Hu's. She is scheduled for an abdominal hysterectomy at 9 a.m. She has been NPO [fasting] since last midnight. She is allergic to penicillin. The night nurse reported she got little sleep and expressed a great deal of anxiety about this surgery, immediately after her surgeon and anesthesiologist examined her at the time of admission. Preoperative medication consisting of atropine and were administered at 8:40 instead of 8:30 as per order. Abdominal skin was scrubbed with Betadine per order, and an IV of 1 L 0.45 saline was started at 7 a.m. in her left forearm. She has a history of chronic obstructive pulmonary disease, controlled with an albuterol inhaler, but has not used this since admission yesterday.
Directions:
In triads, organize this information into the SBAR format. Student #1 is giving report. Student #2 role-plays the nurse receiving report. Student #3 acts as observer and evaluates the accuracy of the report.
Adapted from Amato-Vealey EJ, Barba MP, Vealey RJ: Hand-off communication: a requisite for perioperative patient safety, _AORN J_ 88(5):763–770, 2008.
TABLE 22-1
SBAR Structured Communication Format
S | Situation | Identify yourself; identify the client and the problem. In 10 seconds state what is going on. This may include client's date of birth, hospital ID number, verification that consent forms are present, etc.
---|---|---
B | Background | State relevant context and brief history. Review the chart if possible before speaking or telephoning to the physician. Relate the client's background, including client's diagnosis, problem list, allergies, as well as relevant vital signs, medications that have been administered, laboratory results, etc.
A | Assessment | State your conclusion, what you think is wrong. List your opinion about the client's current status. Examples would be client's level of pain, medical complications, level of consciousness, problem with intake and output, or your estimate of blood loss, etc.
R | Recommendation or request | State your informed suggestion for the continued care of this client. Propose an action. What do you need? In what time frame does it need to be completed? Always should include an opportunity for questions. Some sources recommend that any new verbal orders now be repeated for feedback clarity. If no decision is forthcoming, reassert your request.
Adapted from information during interviews with Leonard (2009), Bonacum (2009), and Fleishmann (2008).
"Evidence-based reports show that [client] adverse events have decreased through use of SBAR" (Denham, 2008, p. 39). Practicing use of standardized communication formats by student nurses has been found to improve their ability to effectively communicate with physicians about emergent changes in client condition (Krautscheid, 2008). Use of a common communication tool with non-nurse members of the health team should also reduce risk (see Figure 22-1). This format sets expectation about what will be communicated to another member of the health care team. Practice using this format in Exercises 22-2 and 22-3.
EXERCISE 22-2 Telephone Simulation: Conversation Between Nurse and Physician about a Critically Ill Client
Purpose: To increase your telephone communication technique using structured formats.
Procedure:
Read case and then simulate making a phone call to the physician on call. It is midnight.
Case:
Ms. Babs Pointer, date of birth 1/13/42, is 6 hours postop for knee reconstruction, complaining of pain and thirst. Her leg swelling has increased 4 cm in circumference, lower leg has notable ecchymosis spreading rapidly. Temp 99, R 20; pedal pulse absent.
Discussion/written paper:
Record your conversation for later analysis. In your analysis, write up an evaluation of this communication for accurate use of SBAR format, effectiveness, and clarity.
EXERCISE 22-3 SBAR for Change of Shift Simulation
Purpose: To practice use of SBAR.
Procedure:
In postconference have Student A be the day-shift nurse reporting to Student B, who is acting as the evening nurse. Practice reporting on their assigned client conditions or simulate four or five postoperative clients' status. Use the SBAR format.
Discussion:
Have the entire postconference group of students critique the advantages and disadvantages of using this type of communication.
## Team training: models of communication strategies for collaborative practice
Health provider collaborations
There is a close relationship between effective teamwork and client safety. Kramer and Schmalenberg developed a scale of five levels of collaboration based on their nursing research: collegial (equal in power but different); collaborative (mutual but not equal power); student-teacher (physicians have the power but are friendly and willing to inform nurses); neutral; and negative (physicians have total power and are disruptive to nurses, who then feel frustrated or hostile). The first three have good physician-nurse communication.
The majority of reported errors have been found to stem from poor teamwork and poor communication. An effective team has clear, accurate communication understood by all. All team members work together to promote a climate of client safety. To improve interdisciplinary health team collaboration, Boone and associates (2008) recommend that physicians and nurses jointly share communication training and team building sessions to develop an "us" rather than "them" work philosophy. When clashes occur, differences need to be settled. Specific conflict resolution techniques are discussed in Chapter 23.
### Various models of team training
Team training is a tool to increase collaboration between physicians and nurses. Use of teams is a concept that has been around for years within medical and nursing professions. For example, medicine has used medical rounds to share information among physicians. Nursing has end-of-shift reports, when responsibility is handed over to the next group of nurses. Team training programs are available such as " **TeamSTEPPS** ," or Team Strategies and Tools to Enhance Performance and Patient Safety. This program emphasizes improving client outcomes by improving communication using evidence-based techniques.
Communication skills include briefing and debriefing, conveying respect, clarifying team leadership, cross-monitoring, situational monitoring feedback, assertion in a climate valuing everyone's input, and use of standard communication formats such as SBAR and CUS. Creating a team culture means each member is committed to:
• Open communication with frequent timely feedback
• Protecting others from work overload
• Asking for and offering assistance
### Nursing teamwork
The traditional client report from one nurse handing over care to another nurse needs to be accurate, specific, and clear, and allow time for questions to foster a culture of client safety. Using SBAR or any other standardized communication format for report would result in a safer environment for your clients (Amato-Vealey et al., 2008), as well as having staff work staggered shifts (Woods et al., 2008).
Regarding handoffs, AHRQ's TeamSTEPPS program (2008) recommends that all team members use the "I PASS the BATON" acronym during any transition by staff in client care. Table 22-2 explains this communication strategy.
TABLE 22-2
I PASS the BATON
I | Introduction | Introduce yourself and your role
---|---|---
P | Patient | State patient's name, identifiers, age, sex, location
A | Assessment | Present chief complaint, vital signs, symptoms, diagnosis
S | Situation | Current status, level of certainty, recent changes, response to treatment
S | Safety concerns | Critical laboratory reports, allergies, alerts (e.g., falls)
the | |
B | Background | Comorbidities, previous episodes, current medications, family history
A | Actions | State what actions were taken and why
T | Timing | Level of urgency, explicit timing and priorities
O | Ownership | State who is responsible
N | Next | State the plan: what will happen next, any anticipated changes
Developed by the US Department of Defense. Department of Defense Patient Safety Program: Healthcare Communications Toolkit to Improve Transitions in Care. Falls Church, VA: TRICARE Management Activity; 2005.
### Interdisciplinary rounds
Contemporary health care teams use "interdisciplinary **rounds** " to increase communication among the whole team—physicians, pharmacists, therapists, nurses, and dieticians (Woods et al., 2008). This strategy may increase communication and positively affect client outcome. For example, daily discharge multidisciplinary rounds have been correlated with decreased length of hospital stay.
_Interdisciplinary "team" meetings_ can be used daily or weekly to explore common goals/concerns/options, smooth problems before they escalate into conflicts, or provide support. Lower on the scale are _clinical teaching rounds,_ where a physician once weekly teaches nurses, which has the goal of encouraging physician communication with the nursing staff.
### Establish open communication about errors
Most state Boards of Nursing require nurses to report unsafe practice by coworkers, but many nurses have mixed feelings about reporting a colleague, especially to a state agency (Elder et al., 2008). Physicians also have reservations about reporting problems (Zbar, Taylor, & Canady, 2009). One focus of team training can be creating an in-house agency system climate in which team members feel comfortable speaking out about their safety concerns. In this new nonpunitive reporting environment, staff are encouraged to report errors, mistakes, and near misses. In safety literature, compiling a database that includes near-miss situations that could have resulted in injury is important information in preventing future errors. They work in a climate in which they feel comfortable making such reports. A complete error reporting process should include feedback to the person reporting. Administrators should assume errors will occur and put in place a plan for "recovery" that has well-rehearsed procedures for responding to adverse events.
### Briefings and debriefings
In team situations, such as in the operating room, the team may use another sort of standardized format. The leader (the surgeon, in this case) presents to the team a brief overview of what procedure is about to happen, asking anyone who sees a potential problem to speak up. In this manner, the leader "gives permission" for every team member to speak up. This can include the client also, as many clients will not speak unless specifically invited to do so. A debriefing is usually led by someone other than the leader. It occurs toward the end of a procedure and is a "recap" or summary as to what went well or what might be changed (Bonacum, 2009). This is similar to the feedback nurses ask clients to do after they have presented some educational health teaching, which verifies that the client understood the material.
## Technology-oriented solutions create a climate of client safety to avoid errors
Prevention of misidentification of client is an obvious error prevention strategy. Before administering medication, the nurse needs to verify client allergies, use another nurse to verify accuracy for certain stock medications, and re-verify client's identity. **Joint Commission's** best practice recommendation is to check the client's name band and then ask him to verbally confirm his name and give a second identifier such as his date of birth. Use of technology such as _bar-coded name bands_ may offer protection against misidentification (AHRQ, d). Some name bands include the client's picture, as well as name, date of birth, and _bar code_ for verification of client identity.
Many agencies including the Veterans Administration (VA) Hospital System have used bar codes for years. When a new medication is ordered by a physician, it is transmitted to the pharmacy, where it is labeled with the same bar code as is on the client's name band. The nurse administering that medication must first verify both codes by scanning with the battery-operated bar code reader, just as a
grocery store employee scans merchandise. In the VA, this resulted in a 24% decrease in medication administration errors (Wright & Katz, 2005). In a similar fashion, bar-coded labels on laboratory specimens prevent mixups.
## Other technology used to improve safe care
Health information technologies are said to be a key tool for increasing safety, as well as decreasing health care costs, and increasing quality of care (Bates, 2009). These are discussed in Chapters 25 and and include electronic health records, clinical decision supports, and computerized registries or national databanks that monitor treatment. _Electronic transmission of prescriptions_ to pharmacies in the community could help decrease errors caused by misinterpretation of handwritten scripts, yet by 2008 only 6% of American physicians had adopted electronic prescribing. _Radiofrequency identification_ is an emerging technology allowing you to locate a certain nurse, identify a patient, or even locate an individual medication. Radiofrequency identification may be able to be incorporated into the nurse's handheld computer.
## Improve care efficiency
Measures to improve efficiency may also increase the time you have for communication with clients. Some changes such as equipment at bedside may increase client safety by decreasing possible infections.
### TCAB (Transforming Care At the Bedside)
Begun in 2003, Transforming Care At the Bedside **TCAB** ; pronounced tee-cab] is an Institute for Healthcare Improvement Initiative funded by the Robert Wood Johnson Foundation to improve client safety and the quality of hospital bedside care by empowering nurses at the bedside to make system changes (online, TCAB;[www.rwj.org/pr/product.jsp?id=31512; Runy, 2008; Stefancyk, 2008a, 2008b, 2009).
This program has four core concepts to improve care:
1. Create a climate of safe, reliable patient care. Uses practices such as brainstorming and retreats for staff nurses, to develop better practice and better communication ideas. One example is nurses initiate presentation of the client's status to physicians at morning rounds, using a standard format. Another strategy is to empower staff nurses to make decisions.
2. Establish unit-based vital teams. Interdisciplinary, supportive care teams foster a sense of increased professionalism for bedside nurses. This together with better nurse-physician communication should positively affect client outcomes.
3. Develop client-centered care. This ensures continuity of care and respects family and client choices.
4. Provide value-added care. This eliminates inefficiencies, for example, by placing high-use supplies in drawers in each client's room
Evaluation in more 60 project hospitals showed that units using this method cut their mortality rate by 25% and reduced nosocomial infections significantly. Nurse-physician collaboration and communication was improved, with both physicians and nurses voicing increased satisfaction. Nurses said that overall they felt empowered (Stefancyk, 2008b).
## Client outcomes of team training programs
Multiple studies tend to demonstrate increased satisfaction, primarily from nurses, when team communication strategies are implemented. To date, little evidence exists about effects on client outcomes, although some literature indicates anesthesia team training has reduced errors. More research into the effects of communication interventions is needed. But what is really needed is an overhaul in the conception of what an interdisciplinary "team" is.
### Advantages
Ideally, the health care team would provide the client with more resources, allow for greater flexibility, promote a "learning from each other" climate, and promote collective creativity to problem solving. Use of standardized communication tools would foster collaborative practice by creating shared communication expectations.
Obstacles to effective teamwork include lack of time, culture of autonomy, heavy workloads, and different terminologies and communication styles held by each discipline. Building in redundancy cuts errors but takes extra time, which can be irritating.
## Client-provider collaborations
Communicating with clients about the need for them to participate in their care planning is a goal set in 2009 by Joint Commission (online, www.jcipatientsafety.org/). Goal 13 states, "Encourage patients' active involvement in their own care as a patient safety strategy," which includes having clients and families report their safety concerns. Clients and their families should be specifically invited to be an integral part of the care process. Another strategy is to provide more opportunities for communication.
Emphasize to each client that he is a valued member of the health team who is expected to actively participate in his care. Safe care is a top goal shared by client and care provider. Empowering your client to be a collaborator in his or her own care should enhance error prevention. Emphasizing this provider-client partnership is the second step in a communication model described by Fleischmann and Rabatin (2008). In building the relationship, to establish rapport, participants follow the acronym PEARLS: P = partnership; E = empathy; A = apology, such as "sorry you had to wait"; R = respect; L = legitimize or validate your client's feelings and concerns with comments such as "many people have similar concerns"; S = support. One outcome measured before and then 6 months after staff participated in a communications continuing education program was an increase in client satisfaction with care, up 16% in the emergency departments, up 17% in inpatient units, and up 28% in outpatient settings (Fleischmann, 2008). AHRQ advises clients to speak up if they have a question or concern, to ask about test results rather than to assume that "no news is good news."
### Daily client briefings
Physicians have long used hospital rounds to briefly speak with each of their patients. Some supervising nurses have begun this practice.
### Use of written materials
In one hospital system, written pamphlets are given to each client on admission instructing them to become a partner in their care. A nurse comes into the client's room at a certain time each day, sits, and makes eye contact. Together, nurse and client make a list of today's goals, which are written on a whiteboard in the client's room (Runy, 2008). As part of safety and communication, awareness of language barriers can be signaled to everyone entering the room by posting a logo on the chart, and room or bed. Use of interpreters and information materials written in the client's primary language may also reduce risk (AHRQ, 2004).
### Assessment of client's level of health literacy
The IOM has stressed that it is important to make verbal and written information as simple as possible (Denham, 2008). As a nurse, you need to assess the health literacy level of each client. Provide privacy to avoid embarrassment. Obtain feedback to determine client's understanding of teaching: Simplify, Clarify, Verify! In evaluating for literacy levels, some clues to low literacy or limited understanding are excuses such as "forgot my glasses," humor, or use of a family member to read written materials.
## Summary
There is a renewed effort to maximize client safety by minimizing errors made by all health care workers. Because miscommunication has been documented to be a most significant factor in occurrence of errors, this chapter focused on communication solutions. It described some individual and system solutions.
Ethical Dilemma
What Would You Do?
You are a new nurse working for Hospice, providing in-home care for Ms. Wendy, a 34-year-old with recurrent spinal cancer. At a multidisciplinary care planning conference 2 months ago, Dr. Chi, oncologist, and Dr. Spenski, family physician, Hospice staff, and Ms. Wendy agreed to admit her when her condition deteriorated to the point that she would require ventilator assistance. Today, however, when you arrive at her home, she states a desire to forego further hospitalization. Her family physician is a personal friend and agrees to increase her morphine to handle her increased pain, even though you feel that such a large dose will further compromise her respiratory status.
1. What are the possibilities for miscommunication?
2. What steps would you take to get the health care team "on the same page"?
## References
Agency for Healthcare Research and Quality AHRQ, a]. National healthcare quality report. [www.ahrq.gov/qual/nhqr05.htm. [Author].
Agency for Healthcare Research and Quality AHRQ, b]. Medical errors: the scope of the problem: an epidemic of errors. [www.ahrq.gov/qual/errback.htm. [Author].
Agency for Healthcare Research and QualityAHRQ, c], Patient safety initiative: building foundations, reducing risk. Patient Safety Goals, 2009. Available online:, [www.ahrq.gov/qual/pscongrpt/psinisum.htm. [Accessed February 28, 2009].
Agency for Healthcare Research and Quality[AHRQ, d]. Mistaken identity. <http://cme.medscap.com/viewarticle/586256_2>. [Author].
Agency for Healthcare Research and Quality [AHRQ, e] Literacy and health outcomes: summary, evidence report/technology assessment number 87, 2004. Available online:, <http://www.ahrq.gov/clinic/epcsums/litsum.htm>. [Accessed March 1, 2009].
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CHAPTER 23
# Communicating with Other Health Professionals
Kathleen Underman Boggs
Objectives
**At the end of the chapter, the reader will be able to:**
1 Identify standards for the healthcare work environment.
2 Identify communication barriers in professional relationships, including disruptive behaviors.
3 Describe methods to handle conflict through interpersonal negotiation when it occurs.
4 Discuss methods for communicating effectively in organizational settings.
5 Apply group communication principles to work groups.
6 Discuss application of research studies to clinical practice.
To be effective as a nursing professional, it is not enough to be deeply committed to the client. Ultimately, the workplace's corporate climate and work atmosphere will have an effect on the relationship that takes place between you and your client. **Disruptive behavior (workplace bullying)** creates conflicts on the job. The negative consequences of working in a dysfunctional atmosphere are adverse effects on client care and on the staff's physical and psychological health. This chapter focuses on principles of communication and strategies you can use to help deal with other professionals, promote more collaborative relationships, and function more effectively as an interdisciplinary team member and leader. Specific bridges to communication with other health professionals are described, together with strategies to remove communication barriers.
## Basic concepts
Standards for a healthy work environment
A culture of collegiality is essential for a work environment that is to provide high-quality client care. Yet, when the Joint Commission surveyed nurses, more than 90% reported witnessing disruptive behavior; more than half reported they themselves had been subjected to verbal abuse (Joint Commission, 2008). As described in Chapter 22, failures in collaboration and communication among health care providers are among the most common factors contributing to increased errors and adverse client outcomes. Other outcomes include nurse dissatisfaction, job turnover, lost productivity, absenteeism, task avoidance, poor morale, impact on nurse's physical and mental health, and even legal action (Gerardi & Connell, 2007; Kerfoot, 2008; Olender-Russo, 2009; Rosenstein & O'Daniel, 2005; Spence-Laschinger, Leiter, Day, & Gilin, 2009).
The American Association of Critical Care Nurses (ACCN) in 2004 issued six standards characteristic of a healthy workplace (online, www.aacn.org):
• Nurses must be as efficient in communication skills as they are in clinical skills.
• Nurses must be relentless in pursuing and fostering true collaboration.
• Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
• Staffing must ensure the effective match between patient needs and nurse competencies.
• Nurses must be recognized and recognize others for the value each brings to the work of the organization.
• Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.
Professional Nursing organizations have identified eight elements of a healthy workplace environment:
• Collaborative culture with respectful communication and behavior
• Communication-rich culture that emphasizes trust and respect
• Clearly defined role expectations with accountability
• Adequate workforce
• Competent leadership
• Shared decision making
• Employee development
• Recognition of workers' contributions
#### Code of Behavior
The goal of collaboration is to communicate effectively with team members to provide best care. As part of creating a culture of teamwork where staff is valued, a standard across organizations should be zero tolerance for disruptive or bullying behaviors. To accomplish this, each organization needs one well-defined code of behavior applied consistently to all staff. The Joint Commission adopted standards originally scheduled to begin in 2009 that state each health care organization must create a code of conduct defining acceptable and unacceptable behaviors, as well as establishing an agency process for handling disruptive behaviors (Joint Commission line, www.jointcommission.org/SentinelEventAlert/Issue40, July 9, 2008).
#### Incidence
Incivility is common in large organizations, especially hospitals. Although less than 3% of physicians and less than 3% of nurses exhibit disruptive behaviors, this is enough to effect client outcomes (Rosenstein & O'Daniel, 2005). Seventeen percent of professionals surveyed knew of a disruptive behavior that resulted in a specific adverse client outcome; 86% of nurses reported witnessing disrespect or harassment from physicians; and 72% reported receiving disrespectful behavior from other nurses (O'Daniel & Rosenstein, 2008). A number of authors have found that nurse-to-nurse destructive, disruptive behaviors occur more frequently than such physician-nurse interactions (Woelfle, 2007).
#### Definitions
Conflict was defined in Chapter 14 as a hostile encounter. The nursing literature uses a variety of terms to refer to persistent uncivil behaviors such as workplace bullying; verbal abuse; horizontal/lateral violence; "eating your young"; in-fighting; mobbing, harassment, or scapegoating. In this situation, the nurse victim is less powerful and is thus unable to bring an end to this behavior. For discussion in this textbook, we use the term _disruptive behavior_ and use the original definition from Leymann in Sweden: at least two negative acts per week, occurring over more than 6 months in duration (Johnson, 2009).
Disruptive behaviors are prolonged and may include overt behaviors: rudeness, verbal abuse, intimidation, putdowns; angry outbursts, yelling, blaming, or criticizing team members in front of others; sexual harassment; or even threatening physical confrontations. Other disruptive behaviors are more covert and passive: withholding information, withholding help, giving unreasonable assignment loads, refusal to perform an assigned task, impatience or reluctance to answer questions, not returning telephone calls or pages, and speaking in a condescending tone (O'Reilly for Joint Commission, 2008, online). These behaviors threaten the well-being of nurses and the safety of clients (Wachs, 2009).
### Creating a culture of regard
Organizations have sometimes tolerated disruptive workplace behaviors (Olender-Russo, 2009). Australian nurses associated this with organizational restructuring or downsizing, or both (Hutchinson, Vickers, Jackson, & Wilkes, 2005). There are organizational pressures on nurses to increase their productivity and be more cost-effective. In Johnson's survey, 95% of emergency department nurses reported that disruptive bullying was done to two or more staff nurses by a supervisor in their department, leading us to speculate that agencies accept this as a useful management strategy (Johnson & Rea, 2009).
We need to become aware of how to discourage disruptive behaviors as we work to develop a healthy, collaborative workplace atmosphere. A climate that promotes collaboration and positive communication among caregivers contributes to satisfaction with one's work and better job retention. Most importantly, commitment to collaboration with other professionals helps sustain a high quality of client care (Joint Commission Resources, 2006). Building an organizational infrastructure that creates a climate that stresses our common mission and core values, and empowers nurses, starts with explicitly stated expectations of mutual respect. Administrators and nurse managers need to model behaviors that convey regard for staff and enforce policies of zero tolerance for disrespect.
#### Respect
Feeling respected or not respected is an integral part of how nurses rate the quality of their work environment (Bournes & Milton, 2009). Three key factors are a positive climate of professional practice, a supportive manager, and positive, respectful relationships with other staff.
#### Etiology
Nurses say they feel respected and appreciated if their opinions are listened to attentively and they receive feedback from authority figures as to the value of their work competence. When their opinions are discounted or ridiculed, they feel disrespected, angry, and frustrated (Parse, 2006). Feelings of powerlessness decrease self-esteem and increase anger. In an unhealthy atmosphere in which a staff member feels intimidated by authority and unable to change disruptive behaviors, they may direct their anger toward peers (Gerardi & Connell, 2007). Respect is a natural extension of the practice of nursing, as identified in the American Nurses Association's Code of Ethics (2001). Typically, nurses describe behaviors indicating lack of respect to include demeaning verbal comments, nonverbal actions such as eye rolling, not paying attention to their opinions, interrupting, not responding to telephone or e-mail, and physical or sexual harassment.
Developing an Evidence-Based Practice
Bourses DA, Milton CL: Nurses' experience of feeling respected-not respected, _Nurs Sci Q_ 22(1):47–56, 2009.
The purpose of this study was to gain understanding of nurses' experience in feeling respected or not respected. Participants were 37 staff or administrative nurses in a Canadian hospital. The Parse research method used involved analysis of content from small discussion groups.
_Results:_ Concepts common to all the groups include respected nurses have their opinions listened to attentively, and they are given feedback as to the value of their work contributions (recognition). This made them feel good, empowered, and appreciated. Lack of respect was described as getting little appreciation, having your opinion discounted, and being patronized or belittled. This made them feel intimidated, demoralized, angry, or insecure.
_Application to Your Clinical Practice:_ Each of us as nurses could make an effort to convey these positive behaviors to make our colleagues feel respected.
## Applications
Conflict resolution
Conflicts will inevitably arise in the work setting. Nurses have a responsibility to learn to work cooperatively. Refer to Box 23-1. Aside from the nurse-client conflicts described in Chapter 14, most workplace conflicts occur between the nurse and authority figures. In addition, conflict may arise from agency employee policies. Internal employee-management disputes detract from the agency's health care mission and from its financial bottom line.
BOX 23-1 Interpersonal Sources of Conflict in the Workplace: Barriers to Collaboration and Communication
1. Different expectations
• Being asked to do something you know would be irresponsible or unsafe
• Having your feelings or opinions ridiculed or discounted
• Getting pressure to give more time or attention than you are able to give
• Being asked to give more information than you feel comfortable sharing
• Differences in language
2. Threats to self
• Maintaining a sense of self in the face of hostility or sexual harassment
• Being asked to do something to a client that is in conflict with your personal or professional moral values
3. Differences in role hierarchy
• Differences in education or experience
• Differences in responsibility and rewards (payment)
4. Clinical situation constraints
• Emphasis on rapid decision making
• Complexity of care interventions
Many of the same strategies for conflict resolution discussed for conflicts between client and nurse can be applied to conflicts between the nurse and other health care workers. Review the principles of conflict management in Figure 14-1 in Chapter 14. As mentioned, conflict is not necessarily detrimental to productivity and job satisfaction. Successful resolution often has a positive effect on both outcomes.
#### Identify sources of conflict
Conflict often stems from miscommunication.You need to think through the possible causes of the conflict. Conflict also stems from overly defensive responses to a situation. So you need to identify your own feelings about it and respond appropriately, even if the response is a deliberate choice not to respond verbally. Interpersonal conflicts that are not dealt with leave residual feelings that reappear in future interactions.
#### Set goals
Your primary goal in dealing with workplace conflict is to find a high-quality, mutually acceptable solution: a win-win strategy. In many instances, a better collaborative relationship can be developed through the use of conflict management communication techniques (Bacal, n.d.; Boone, King, Gresham, Wahl, & Suh, 2008). To reframe a clinical situation as a cooperative process in which the health goals and not the status of the providers becomes the focus:
• _Identify your goal._ A clear idea of the outcome you wish to achieve is a necessary first step in the process. Remember the issue is the conflict, not your coworker.
• _Obtain factual data._ It is important to do your homework by obtaining all relevant information about the specific issues involved—and about the client's behavioral responses to a health care issue—before engaging in negotiation.
• _Intervene early._ Be assertive. The best time to resolve problems is before they escalate to a conflict. Create a forum for two-way communication, preferably meeting periodically. Structured formats have been developed for you to use in conflict resolution, especially in team meetings. Nielsen and Mann (2008) mention the format of **_DESC:_**
• D = describe the behavior (the problem)
• E = express your concern
• S = specify a course of action
• C = obtain consensus
• _Avoid negative comments that can affect the self-esteem of the receiver._ Even when the critical statements are valid (e.g., "You do..." or "You make me feel..."), they should be replaced with "I" statements that define the sender's position. Otherwise, needless hostility is created and the meaning of the communication is lost.
• _Consider the other's viewpoint._ Having some idea of what issues might be relevant from the other person's perspective provides important information about the best interpersonal approach to use. In addition to dealing with your own feeling, you need an ability to deal with the feelings of the others. Be cooperative, acknowledging the team's interdependence and mutual goals.
#### Avoiding barriers to resolution
Refer to Box 23-2 for tips on how to turn conflict into collaboration. Much of the individual behavior was discussed in Chapter 14, such as avoiding the use of negative or inflammatory, anger-provoking words. Also avoid phrases that imply coercion or that are patronizing. Examples include: "We must insist that..." or "You claim that..." Most individuals react to anger directed at them with a fight-or-flight response. Anyone can have a moment of rudeness, but monitor your own communications to avoid any pattern of abusive behaviors, including blaming or criticizing staff to others. Katrinli et al.'s study (2008) showed that when nurse supervisors become aware of how their behavior affects their nurses, they can increase the nurses' performance, increase their job involvement, and increase organizational identification.
BOX 23-2 Strategies to Turn Conflict into Collaboration
1. Recognize and confront disruptive behaviors.
• Use conflict-resolution strategies.
• Take the initiative to discuss problems.
• Use active listening skills (refrain from simultaneous activities that interrupt communication).
• Present documented data relevant to the issue.
• Propose resolutions.
• Use a brief summary to provide feedback.
• Record all decisions in writing.
2. Create a climate in which participants view negotiation as a collaborative effort.
• Develop agency behavior policies with stated zero tolerance for disruptive or bullying behaviors.
• Model communicating with staff in a respectful, courteous manner.
• Participate in organizational interdisciplinary groups.
• Solicit and give feedback on a regular, periodic basis.
• Clarify role expectations.
#### Physician-nurse conflict resolution
The history of nurse-physician communication is described by Seago (2008) as a "game" in which nurses made treatment recommendations without appearing to do so, and physicians asked for recommendations without appearing to do so, with both parties striving to avoid open disagreements. She notes that the literature indicates that communication between doctor and nurse is still often contentious. Remarkable increases in safety in airline and space programs were achieved by creating a climate in which junior team members were free to question decisions of more senior, powerful team members. It is recommended that health care adopt a similar philosophy. The American Medical Association (AMA, 2008) has specifically stated that codes of conduct define appropriate behavior as including a right to appropriately express a concern you have about client care and safety. While this is being set forth as a medical code of conduct for physicians, should it also apply to nurses?
Nurses influence physician-client communication. Nurses assess what physicians tell clients, encourage clients to seek clarification, encourage second opinions, and spend time defending the physician's competence. Better collaboration and better communication are associated with safer care and better client care outcomes. In a meta-analysis of existing research, Seago (2008) found these factors to be associated with reduced drug errors, reduced client mortality, improved client satisfaction, and somewhat with shorter hospital stays. Methods to improve safe communication are discussed in Chapter 22.
There will be occasions when you have collaboration difficulties. One major factor related to job satisfaction and job retention is _"disruptive" communication_ between other professionals, especially physician-nurse interactions. Case law defines disruptive physician behavior as conduct that disrupts the operation of the hospital, affects the ability of others to get their jobs done, and creates a hostile work environment.
Gender and Historic Communication: The relationship between the doctor and the nurse remains an evolving process. Changes in the physician-nurse communication process are occurring as nurses become more empowered, more assertive, and better educated. Most nurses occasionally encounter problems in the physician-nurse relationship. The differences in power, perspective, education, pay, status, class, and sometimes gender are contributing factors. Contemporary society is redefining traditional gender role behavior, negating some of the traditional "nurse as subservient female" stereotypical behaviors. Reflect on content presented on gender differences in communication to determine whether your current situation might be related to gender differences in communication styles rather than a more serious problem. Some doctors are reluctant to be challenged; some nurses are quick to feel slighted. Some physician-nurse relationships are marked with conflict, mistrust, and disrespect. Although these feelings are changing, it is slow, and some physicians still regard themselves as the only legitimate authority in health care, seeing the professional nurse as an accessory. An attitude that excludes the nurse as a professional partner in health care promotion benefits no one and is increasingly challenged as being costly to professionals and clients alike.
It is important to remain flexible yet not to yield on important, essential dimensions of the issue. Sometimes it is difficult to listen carefully to the other person's position without automatically formulating your next point or response, but it is important to keep an open mind and to examine the issue from a number of perspectives before selecting alternative options. The communication process should not be prematurely concluded. You can apply the same principles of conflict resolution discussed in Chapter 14 when dealing with a physician-nurse conflict. Make a commitment to open dialogue. Listening should constitute at least half of a communication interaction. Foster a feeling of collegiality. Use strategies from that chapter to defuse anger. During your negotiation, discussion should begin with a statement of either the commonalities of purpose or the points of agreement about the issue (e.g., "I thoroughly agree Mr. Smith will do much better at home. However, we need to contact social services and make a home care referral before we actually discharge him; otherwise, he will be right back in the hospital again"). Points of disagreement should always follow rather than precede points of agreement. Empathy and a genuine desire to understand the issues from the other's perspective enhance communication and the likelihood of a successful resolution.
Nurses have a responsibility to foster good physician-client communication. This is especially true when it becomes obvious to you from content, tone, or body language that antagonism is developing. Do you think it is ever appropriate for a nurse to criticize a physician's actions to a client? A common underlying factor in at least 25% of all malpractice suits is an inadvertent or deliberate critical comment by another health care professional concerning a colleague's actions. So think before you speak!
Solutions that take into consideration the needs and human dignity of all parties are more likely to be considered as viable alternatives. Backing another health professional into a psychological corner by using intimidation, coercion, or blame is simply counterproductive. More often than not, solutions developed through such tactics never get implemented. Usually there are a number of reasons for this, but the basic issues have to do with how the problem was originally defined and the control issues that were never actually dealt with in the problem-solving discussion. The final solution derived through fair negotiation is often better than the one arrived at alone.
#### Nurse-to-nurse conflict resolution
Although it is inevitable that you will encounter some communication problems with nurse colleagues, remember that, if managed appropriately, these conflicts can lead to innovative solutions and improved relationships.
Negotiating with Nursing Authority Figures: Negotiating can be even more threatening with a nursing supervisor or an instructor who has direct authority, because these people have some control over your future as a staff nurse or student. Supervision implies a shared responsibility in the overall professional goal of providing high-quality nursing care to clients. The wise supervisor is able to promote a nonthreatening environment in which all of the aspects of professionalism are allowed to emerge and prosper. In a supervisor-nurse relationship, conflict may arise when expectations for performance are unclear or when the nurse is unable to perform at the desired level. Communication of expectations often occurs after the fact, within the context of an employee performance evaluation. To effectively manage requires that performance expectations are known from the beginning. The supervisor needs to advise you about the need for improvement as part of an ongoing, constructive, interpersonal relationship. When the supervisor gives constructive criticism, it is in a nonthreatening and genuinely caring manner. In studying approaches to authority figures, you are encouraged to analyze your overall personal responses to authority, as in Exercise 23-1.
EXERCISE 23-1 Feelings about Authority
Purpose: To have students recognize their feelings about authority.
Procedure:
1. Lean back in your chair, close your eyes, and think of the word _authority._
2. Who is the first person that comes to mind when thinking of that word?
3. Describe how this person signifies authority to you. Next, think of an incident in which this person exerted authority and how you reacted to it.
4. After you have visualized the memory, answer the following questions:
a. What were your feelings about the incident after it was over?
b. What changes of feelings occurred from the start of the incident until it was over?
c. Was there anything about the authority figure that reminded you of yourself?
d. Was there anything about the authority figure that reminded you of someone else with whom you once had a strong relationship (if the memory viewed is not mother or father)?
e. How could you have handled the incident more assertively?
f. Can you see any patterns in yourself that might help you handle interactions with authority figures?
g. What about those patterns are not assertive?
h. How could those patterns be improved to be more assertive?
Adapted from Levy R: _Self-revelation through relationships_ , Englewood Cliffs, NJ, 1972, Prentice Hall.
Managing Nursing Staff Problems: Improving how nurses deal with conflict is an investment in coworkers, our organization, and ultimately in improved client outcomes. Nonaction has been identified as the most common repressive management strategy (Bacal, n.d.). Nurse managers have learned that ignoring conflict among staff does not solve problems. Avoidance perpetuates the status quo or leads to an escalation. When managed appropriately, you reduce time wasted by staff in griping, defending, and so on, as illustrated in the following case.
Case Example
Two nursing teams work the day shift on a busy surgical unit. As nurse manager, Ms. Libby notices that both teams are arguing over use of the computer, have become unwilling to help cover the other team's client, and are taking longer to complete assigned work, and so on. To achieve a more harmonious work environment, she arranges a staff meeting to get the teams communicating. Rather than just issues about sharing the computer, these multiple problems suggest inadequate time management and overload. Ms. Libby listens actively, responds with empathy, and provides positive regard and feedback for solutions proposed by the group. She asks the group to decide on two prioritized solutions. Recognizing that her staff feel unappreciated and knowing that compromise is a strategy that produces behavior change, she resolves to offer more frequent performance feedback. She herself assumes responsibility for requesting an immediate second computer purchase under her unit budget's emergency funding allocation. A team member who is on the employee relations committee assumes responsibility for requesting that the Human Services Department schedule an inservice training on time management and stress reduction within the next month. The group agrees to meet in 6 weeks to evaluate.
#### Collaborating with peers
The nurse-client relationship occurs within the larger context of the professional relationship with other health disciplines. How the nurse relates to other members of the health team will affect the level and nature of the interactions that transpire between nurse and client. Interpersonal conflict between health team members periodically is concealed from awareness and projected onto client behaviors.
Case Example
On a psychiatric nursing unit, the nursing staff found Mr. Tomkins's behavior highly disruptive. At an interdisciplinary conference attended by representatives from all shifts, there was general agreement that Mr. Tomkins should spend 1 hour in the seclusion room each time his agitated behavior occurred. The order was written into his care plan. The plan was implemented for a week with a noticeable reduction in client symptoms. During the second week, however, Mr. Tomkins was be placed in the seclusion room for the reasons just mentioned, but the evening staff would release him after 5 or 10 minutes if he was quiet and well-behaved.
The client's agitated behavior began to escalate again, and another interdisciplinary conference was called. Although the stated focus of the dialogue was on constructive ways to help Mr. Tomkins cope with disruptive anxiety, the underlying issues related to the strong feelings of the day nursing staff that their interventions were being undermined. Equally strong was the conviction of the evening staff that they were acting in the client's best interest by letting him out of the seclusion room as soon as his behavior normalized. Until the underlying behaviors could be resolved satisfactorily at the staff level, the client continued to act out the staff's anxiety, as well as his own.
Similar types of issues arise now and again when there is no input from different work shifts in developing a comprehensive nursing care plan. The shift staff may not agree with specific interventions, but instead of talking the discrepancy through in regularly scheduled staff conferences, they may act it out, unconsciously undoing the work of the other shifts.
Occasionally you may have to work with a peer with whom you develop a "personality conflict." Stop and consider what led up to the current situation. Generally it is due to an accumulation of small annoyances that occurred over time. The best method to avoid such situations is to verbalize occurrences rather than ignoring them until they become a major problem. Avoid the "blame game" and discuss in a private, calm moment what you _both_ can do to make things better.
Case Example
"Jane, we seem to disagree about the best way to teach Mr. Santos about his...He seems to be getting confused about our two different approaches. Let's talk about how we might be able to work more effectively together. What is the most important point you want to teach him?"
Use active listening skills to really pay attention to what Jane says. Do a self-inventory to eliminate any nonverbal behavior that is triggering Jane's reaction and eliminate it. Ask yourself, "Do I want to win, or do I want to fix this problem?" Then state your expectations in a calm tone.
Whenever there is covert conflict among nursing staff or between members of different health disciplines, it is the client who ultimately suffers the repercussions. The level of trust the client may have established in the professional relationship is compromised until the staff conflict can be resolved.
### Delegation or supervision of unlicensed personnel
**Delegation** is defined as the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome. Whether delegating to a peer or unlicensed assistive personnel (UAP), the nurse is only transferring the responsibility for the performance of the activity, not the professional accountability for the overall care (American Nurses Association, 1994). In earlier times, delegating and trusting went hand in hand, because the nurse was transferring responsibility to a peer and had some assurance of the skills and knowledge of that peer. The present health care environment poses a much different reality in which some UAPs possess minimal experience, skills, or knowledge.
The challenges of maintaining professional integrity and concurrently surviving in today's health care arena are felt by nurses in all settings. Effective and appropriate use of delegation can facilitate your ability to meet these challenges. But more often than not, novice nurses are inadequately prepared for the demands of delegating much of their nursing tasks to UAPs while retaining responsibility for interpreting patient outcomes.
Inherent in effective delegation is an adequate understanding of the skills and knowledge of UAPs, as well as of the Nurse Practice Act of the state in which you are practicing. Within each state's Nurse Practice Act are specific guidelines describing what nursing actions can and cannot be delegated, and to what type of personnel these actions can be delegated. In addition to knowing nurse practice guidelines and the skills and knowledge level of UAPs, the nurse must educate and reinforce the UAPs' knowledge base, assess the UAPs' readiness for delegation, delegate appropriately, oversee the task, and evaluate and record the outcomes. The appropriate implementation of these principles (e.g., educating, assessing, overseeing, and evaluating) is a costly process both in time and energy. Practice Exercise 23-2 to facilitate your understanding of the principles. The following case example highlights one particular principle.
EXERCISE 23-2 Applying Principles of Delegation
Purpose: To help students differentiate between delegating nursing tasks and evaluating client outcomes.
Procedure:
Divide the class into two groups: A and B. The following case study is a typical day for a charge nurse in an extended-care facility. After reading the case study, Group A is to describe the nursing tasks they would delegate and instructions they would give the nursing assistants and certified medicine aides (CMAs). Group B is to describe the professional nursing responsibilities related to the delegated tasks. The two groups then share their reports.
Situation:
Anne Marie Roache is the day-shift charge nurse on one of the units at Shadyside Nursing and Rehabilitation Facility. On this particular day, her census is 24, and her staff includes four nursing assistants and two CMAs who are allowed to administer all oral and topical medications. Her nursing assistants are qualified to perform morning care: assist with feedings; obtain and record vital signs, fluid intake and output, and blood glucose finger sticks; turn and position residents; assist with ambulation; and perform decubitus dressing changes. Of the residents, 12 are bedridden, requiring complete bed baths and some degree of assistance with feeding. The remaining 12 require varying degrees of assistance with their morning baths and assistance to the dining rooms for their meals. Nine of the residents are diabetics requiring premeal blood glucose finger sticks; seven are recovering from cerebrovascular accidents and display varying degrees of right- or left-sided weakness; three require care of their sacral decubiti; and all of the residents are at risk for falling because of varying degrees of confusion, disorientation, or general weakness. The night shift reported that all the residents' conditions were stable and they had slept well. Ms. Roache is ready to assign her staff.
Discussion:
Entire class can identify client goals.
Case Example
After receiving the report on her client assignments, Monica Lewis, RN, assigns a newly hired UAP to provide routine care (e.g., morning care, assistance with meals, vital signs, finger sticks for glucose, and reporting of any changes) to Mrs. Jones, who was recently admitted for exacerbation of her type 2 diabetes. While on routine rounds during lunch, Monica finds Mrs. Jones unresponsive, with cold, clammy skin, a heart rate of 110, and a finger stick reading of 60 mg/dL, which the UAP had obtained. Thinking Mrs. Jones was experiencing hypoglycemia, Monica requested the UAP to obtain another blood glucose reading. While administering high-glucose intravenous solutions to raise Mrs. Jones's blood sugar, Monica observed the UAP violate a number of basic principles in obtaining an accurate blood glucose level. On further questioning, the UAP admitted never having been taught the proper procedure and thought reading the directions was sufficient. Monica had wrongly assumed all UAPs underwent training on the principles of obtaining blood glucose finger sticks.
### Advocacy
Nursing organizations have identified trends toward increased use of unlicensed workers in agencies wishing to reduce costs. Such organizations speak out about the burden this places on registered nurses. Becoming active in your state nurses' association or professional specialty organization allows you to add your voice to this debate. Obtain a copy of your state's Nurse Practice Act. Usually these can be downloaded from your state Board of Nursing's Web site. This document will spell out what you, as a registered nurse, can delegate and to whom.
Even as a beginning staff nurse you will be expected to delegate some client care duties to others. You are responsible for the completeness, quality, and accuracy of this care. To avoid conflicts in delegating client care, clearly state your expectations. It is your responsibility to ensure that care was given correctly.
### Strategies to remove barriers to communication with other professionals
Convey respect
Just as you treat clients with respect, you have an ethical responsibility to treat coworkers with respect. Nurses need to be appreciated, recognized, and respected as professionals for the work they do. Unsupportive and uncivil coworkers and workplace conflicts negatively influence retention of nursing staff. Communication can become distorted rather than open when you are concerned about offending a more powerful individual. Strategies for dealing with disrespectful or disruptive behaviors include establishing common communication expectations and skills (described in Chapter 22), teaching conflict resolution skills, and creating a culture of mutual respect within the health care system. Ideally, the system has ongoing education, leadership and team collaboration support, and policies to evaluate behavior violations.
#### Clarify communications
You can use skills taught in this textbook to improve both the clarity of message content and the emotional tone of interactions. Communication problems lead to a large percentage of disruptive behaviors, especially telephone communication. Message clarity is enhanced when standardized formats such as SBAR, discussed in Chapter 22, are used: The nurse identifies self by name, position, the client by name, diagnosis, the problem (include current problem, vital signs, new symptoms, etc.), and clearly states his or her request.
#### Use conflict resolution strategies and respond to putdowns and destructive criticisms
The strategies for handling angry clients, as described in Chapter 14, can be applied to your relations with anger from colleagues. This chapter details a number of conflict resolution steps (see Box 23-3). In addition, you need to develop a strategy to respond to unwarranted putdowns and destructive criticisms. Generally, they have but one intent: to decrease your status and enhance the status of the person delivering the putdown. The putdown or criticism may be handed out because the speaker is feeling inadequate or threatened. Often it has little to do with the actual behavior of the nurse to whom it is delivered. Other times the criticism may be valid, but the time and place of delivery are grossly inappropriate (e.g., in the middle of the nurses' station or in the client's presence). In either case, the automatic response of many nurses is to become defensive and embarrassed, and in some way actually begin to feel inadequate, thus allowing the speaker to project unwarranted feelings onto the nurse.
BOX 23-3 Steps to Promote Conflict Resolution among Health Care Workers
1. Set the stage for collaborative communication.
• Privacy: meet, bringing together all involved groups
• Acknowledge the conflict problem
2. Maintain a respectful, nonpunative atmosphere.
• Solicit the perspectives of each.
• Define the problem issue clearly.
• Respect the values and dignity of all parties.
• Group members can be assertive but not manipulative.
• Remember to criticize ideas, not people.
3. Discussion:
• Identify the conflict's key points.
• Have an objective or a goal clearly in mind.
• Discuss solutions.
• Identify the merits/drawbacks of each solution.
• Be open to alternative solutions in which all parties can meet essential needs.
• Depersonalize conflict situations.
• Avoid emotion.
4. Decide to implement the best solution.
• Specify persons responsible for implementation (role clarity).
• Establish timeline.
• Decide on the evaluation method.
• Emphasize common goal is our shared value of quality client care.
• Emphasize shared responsibility for team success.
Recognizing a putdown or unwarranted criticism is the first step toward dealing effectively with it. If a comment from a coworker or authority figure generates defensiveness or embarrassment, it is likely that the comment represents more than just factual information about performance. If the comment made by the speaker contains legitimate information to help improve one's skill and is delivered in a private and constructive manner, it represents a learning response and cannot be considered a putdown. Learning to differentiate between the two types of communication helps the nurse to "separate the wheat from the chaff."
Case Example
You examine a crying child's inner ears and note that the tympanic membranes (eardrums) are red. You report to your supervisor that the child may have an ear infection.
A. _Response:_ When a child is crying, the drums often swell and redden. How about checking again when the child is calm? _(Learning response)_
_Or_
B. _Response:_ Of course they are red when the child is crying. Didn't you learn that in nursing school? I haven't got time to answer such basic questions! _(Putdown response)_
Which response would you prefer to receive? Why?
Whereas the first response allows the nurse to learn useful information to incorporate into practice, the second response serves to antagonize, and it is doubtful much learning takes place. What will happen is that the nurse will be more hesitant about approaching the supervisor again for clinical information. Again, it is the client who ultimately suffers.
Once a putdown is recognized as such, you need to respond verbally in an assertive manner as soon as possible after the incident has taken place. Waiting an appreciable length of time is likely to cause resentment and loss of self-respect. It may be more difficult later for the other person to remember the details of the incident. At the same time, if the nurse's own anger, not the problem behavior, is likely to dominate the response, it is better to wait for the anger to cool a little and then to present the message in a more reasoned manner.
#### Process for responding to putdowns
In responding to putdowns, the nature of the relationship should be considered. Attitudes are important. Respect for the value of each individual as a person should be evidenced throughout the interaction. Try to determine how to respond to this person in a productive way so that you are on speaking terms but still get your point across. Even if you do not fully succeed in your initial tries, you probably will have learned something valuable in the process.
_Address the objectionable or disrespectful behaviors first._ Briefly state the behavior and its impact on you. It is important to deliver a succinct verbal message without getting lost in detail and without sounding apologetic or defensive. Do not try to give a prolonged explanation of your behavior at this point in the interaction and do not suggest possible motivations.
_Emphasize the specifics of the putdown behavior._ Once the putdown has been dealt with, you can discuss any criticism of your behavior on its own merits. Refer only to the behaviors identified and do not encourage the other person to amplify the putdown.
_Prepare a few standard responses_. Because putdowns often catch one by surprise, it is useful to have a standard set of opening replies ready. Examples of openers might include the following:
"I think it was out of line for you to criticize me in front of the client."
"I found your comments very disturbing and insulting."
"I feel what you said as an attack. That wasn't called for by my actions."
"I thought that was an intolerable remark."
A reply that is specific to the putdown delivered is essential. The tone of voice needs to be even and firm. In the clinical example given previously, the nurse might have said to the head nurse: "My school is not an issue, and your criticism is unnecessary," or "It seems to me that the assessment of the child's ears, not my school, is the issue, and your superior tone is uncalled for."
An important aspect of putdowns is that they get in the way of the nurse's professional goal of providing high-quality nursing care to clients. The effect of the head nurse's second response is for both nurses to assume the reddened eardrums are from crying and not to reevaluate the child's eardrums. Feeling resentful and less sure of her clinical skills, the staff nurse is less likely to risk stirring up such feelings again. If fewer questions are asked, important information goes unshared. In the clinical example just cited, a possible ear infection might not be detected.
#### Criticize constructively
Giving constructive criticism and receiving criticism is difficult for most people (Box 23-4). When a supervisor gives constructive criticism, some type of response from the person receiving it is indicated. Initially, it is crucial that the conflict problem be clearly defined and acknowledged. To help handle constructive criticism, nurses can do the following:
BOX 23-4 Constructive Criticism
Steps in Giving
1. Express sympathy.
_Sample statement_ : "I understand that things are difficult at home."
2. Describe the behavior.
_Sample statement_ : "But I see that you have been late coming to work three times during this pay period."
3. State expectations.
_Sample statement_ : "It is necessary for you to be here on time from now on."
4. List consequences.
_Sample statement_ : "If you get here on time, we'll all start off the shift better. If you are late again, I will have to report you to the personnel department."
Steps in Receiving
1. Listen and paraphrase. If unclear ask for specific examples.
_Sample reply:_ "You are saying being late is not acceptable."
2. Acknowledge you are taking suggestions seriously.
_Sample comment_ : "I hear what you are saying."
3. Give your side by stating supportive facts, without being defensive.
_Sample comment_ : "My car would not start."
4. Develop a plan for the future.
_Sample plan_ : "With this paycheck I will repair my car. Until then I'll ask Mary for a ride."
• Schedule a time when you are calm.
• Request that supervisory meetings be in a place that allows privacy.
• Defuse personal anxiety.
• Listen carefully to the criticism and then paraphrase it.
• Acknowledge that you take suggestions for improvement seriously.
• Discuss the facts of the situation but avoid becoming defensive.
• Develop a plan for dealing with similar situations; become proactive rather than reactive.
#### Use peer negotiation
As students, you will encounter situations in which the behavior of a colleague causes a variety of unexpressed differences or disagreement because the colleague's interpretation of a situation or meaning of behavior is so different from yours. The conflict behaviors can occur as a result of age differences, differences in values, philosophical approaches to life, ways of handling problems, lifestyles, definitions of a problem, goals, or strategies to resolve a problem. These differences cause friction and turn relationships from collaborative to competitive.
Generally, conflict increases anxiety. When interaction with a certain peer or peer group stimulates anxious or angry feelings, the presence of conflict should be considered. Once it is determined that conflict is present, look for the basis of the conflict and label it as personal or professional. If it is personal in nature, it may not be appropriate to seek peer negotiation. It might be better to go back through the self-awareness exercises presented in previous chapters and locate the nature of the conflict through self-examination.
Sharing feelings about a conflict with others helps to reduce its intensity. It is confusing, for example, when nursing students first enter a nursing program or clinical rotation, but this confusion does not get discussed, and students commonly believe they should not feel confused or uncertain. As a nursing student, you face complex interpersonal situations. These situations may lead you to experience loneliness or self-doubt about your nursing skills compared with those of your peers. These feelings are universal at the beginning of any new experience. By sharing them with one or two peers, you usually find that others have had parallel experiences. In reviewing Exercise 23-3, think of a conflict or problem that has implications for your practice of nursing, one you would be willing to share with your peers.
EXERCISE 23-3 Applying Principles of Confrontation
Purpose: To help students understand the importance of using specific principles of confrontation to resolve a conflict.
Procedure:
1. Divide the class into two groups: Group A is the day shift (7 a.m. to 7 p.m.) and Group B is the night shift (7 p.m. to 7 a.m.).
2. The following case study is an example of some problems between the night and day shifts resulting in mistrust and general tension between the two groups. After reading the case study, each group is to use three principles as identified in the text (i.e., identify concerns, clarify assumptions, and identify real issue). The two groups then share their concerns, assumptions, and what they believe to be the real issue. Finally, both groups are to apply the fourth principle, collaboratively identifying a solution or solutions that satisfy both groups.
Situation:
The night shift's (Group B) responsibilities include completing as many bed baths as possible and the taping report as close to the shift change (7 a.m.) as possible. The day shift (Group A) finds that few, if any, of the bed baths are completed and that the taped report is usually done at about 5 a.m., reflecting few of the client changes that occurred between 5 a.m. and 7 a.m. The day shift is angry with the night shift, feeling they are not assuming their fair share of the workload. The night shift feels the day shift does not understand their responsibilities; they believe they are contributing more than their fair share of work.
Discussion:
Instructor might role-play the part of the nurse manager who acts to facilitate resolution of this conflict.
Self-awareness is beneficial in assessing the meaning of a professional conflict. Now that you have had an opportunity to study different types of conflict, work on Exercise 23-4.
EXERCISE 23-4 Barriers to Interprofessional Communication
Purpose: To help students understand the basic concepts of client advocacy, communication barriers, and peer negotiation in simulated nursing situations.
Procedure:
1. Here is an example of situations in which interprofessional communication barriers exist. Refamiliarize yourself with the concepts of professionalism, client advocacy, communication barriers, and peer negotiation.
2. Formulate a response.
3. Compare your responses with those of your classmates, and discuss the implications of common and disparate answers. Sometimes dissimilar answers provide another important dimension of a problem situation.
Dr. Tanlow interrupts Ms. Serf, RN, as she is preparing pain medication for 68-year-old Mrs. Gould. It is already 15 minutes late. Dr. Tanlow says he needs Ms. Serf immediately in Room 20C to assist with a drainage and dressing change. Knowing that Mrs. Gould, a diabetic, will respond to prolonged pain with vomiting, Ms. Serf replies that she will be available to help Dr. Tanlow in 10 minutes (during which time she will have administered Mrs. Gould's pain medication). Dr. Tanlow, already on his way to Room 20C, whirls around, stating loudly, "When I say I need assistance, I mean now. I am a busy man, in case you hadn't noticed."
If you were Ms. Serf, what would be an appropriate response?
Discussion:
This situation could be discussed in class, assigned as a paper, or used as an essay exam.
### Develop a support system
Collegial relationships are an important determinant of success as professional men and women entering nursing practice. Studies show the importance of mutual support (Woelfle & McCaffrey, 2007).
Although there is no substitute for outcomes that demonstrate professional competence, interpersonal strategies can facilitate the process. Integrity, respect for others, dependability, a good sense of humor, and an openness to sharing with others are communication qualities people look for in developing a support system.
Forming a reliable support system at work to share information, ideas, and strategies with colleagues adds a collective strength to personal efforts and minimizes the possibility of misunderstanding. With problem or conflict situations, getting ideas from trusted colleagues beforehand enhances the probability of accomplishing outcomes more effectively. An Australian study of 157 registered nurses working in a private hospital found that support lowered job-related stress and increased job satisfaction. Support was given to nurses by supervisors and other nurses (Bartram, Joiner, & Stanton, 2004).
Professional organizations do not usually have the primary purpose of providing emotional support; however, small subgroups within professional organizations may be used for personal support. A professional support group composed of individuals with similar work experience can be comforting. Often, family and friends have a limited understanding of the emotional impact of your experiences.
### Use group process
Creating opportunities for interdisciplinary groups to get together is a highly effective strategy for enhancing collaboration and communication. Ideas include collaborative rounds, team briefings, and committees to discuss problems. Some studies associate daily team rounds and joint decision making with shorter hospital stay and lower hospital charges.
#### Team briefing meetings
In addition to clarifying client information exchange and opening communication, some meetings could focus on opening up communication in a nonantagonistic fashion focusing on improving "people skills" such as conveying mutual respect and improving staff relations. Conflict situations among colleagues or among departments become negative when not dealt with. Recognition provides a potential opportunity for improvement. When effectively addressed, there is a tendency for the team to become stronger and to function more effectively.
#### Organizational work groups
Successful participation in work groups requires flexibility and good communication. This is especially true when the task is to implement some agency change. The Joint Commission also recommends violence audits and violence prevention inservice programs for all employees to address techniques for violence de-escalation (www.jointcommission.org/SentinelEventAlert/Issue45, June 3, 2010).
### Work toward an organizational climate of mutual respect
As mentioned earlier, the Joint Commission is requiring all health care organizations to have written codes of behavior and to establish internal processes to handle disruptive behaviors. Organizational strategies are discussed in Chapter 22; other strategies within the organization could include understanding the organizational system.
#### Understand the organizational system
Whenever you work in an organization, you automatically become a part of a system that has norms for acceptable behavior. Each organizational system defines its own chain of command and rules about social processes in professional communication. Even though your idea may be excellent, failure to understand the chain of command or an unwillingness to form the positive alliances needed to accomplish your objective dilutes the impact. For example, if your instructor has been defined as your first line of contact, then it is not in your best interest to seek out staff personnel or other students without also checking with the instructor.
Although sidestepping the identified chain of command and going to a higher or more tangential resource in the hierarchy may appear less threatening initially, the benefits of such action may not resolve the difficulty. Furthermore, the trust needed for serious discussion becomes limited. Some of the reasons for avoiding positive interactions stem from an internal circular process of faulty thinking. Because communication is viewed as part of a process, the sender and receiver act on the information received, which may or may not represent the reality of the situation. Examples of the circular processes that block the development of cooperative and receptive influencing skills in organizational settings are presented in Table 23-1.
TABLE 23-1
Examples of Unclear Communication Processes That Block the Development of Cooperative and Receptive Influencing Skills
### Document and use the complaint procedure to report incidences
In handling disruptive behavior occurrences, documentation is a key step. Some suggest beginning with a staff survey. Some agencies may hold "communication training sessions" after the offenses have been documented. Prevention strategies might include participation in assertiveness training inservices or the TeamSTEPPS program as cited in Chapter 22. Educational interventions that increase staff awareness are extremely effective, as are rehearsals similar to the exercises in this book (Bigony et al., 2009).
### Summary
In this chapter, the same principles of communication used in the nurse-client relationship are broadened to examine the nature of communication among health professionals. Most nurses will experience conflicts with coworkers at some time during their careers. The same elements of thoughtful purpose, authenticity, empathy, active listening, and respect for the dignity of others that underscore successful nurse-client relationships are needed in relations with other health professionals. Building bridges to professional communication with colleagues involves concepts of collaboration, coordination, and networking. Modification of barriers to professional communication includes negotiation and conflict resolution. Learning is a lifelong process, not only for nursing care skills but for communication skills. These will develop as you continue to gain experience working as part of an interdisciplinary group.
Ethical Dilemma
What Would You Do?
You are working a 12-hour shift on a labor and delivery unit. Today, Mrs. Kalim is one of your assigned clients. She is fully dilated and effaced, but contractions are still 2 minutes apart after 10 hours of labor. Mrs. Kalim, her obstetrician Dr. Mary, and you have agreed on her plan to have a fully natural delivery without medication. However, her obstetrician's partner is handling day shift today, and Dr. Mary goes home. This new obstetrician orders you to administer several medications to Mrs. Kalim to strengthen contractions and speed up delivery, because he has another patient across town to deliver. Your unit adheres to an empowering model of practice that believes in client advocacy. How will you handle this potential physician conflict? Is this a true moral dilemma?
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CHAPTER 24
# Communicating for Continuity of Care
Elizabeth C. Arnold
Objectives
At the end of the chapter, the reader will be able to:
1 Describe current challenges in health care delivery creating the need for continuity of care (COC).
2 Define COC and describe its relational, informational, and management dimensions.
3 Discuss the application of relational continuity concepts: client-centered care, professional collaboration, and team communications.
4 Discuss the application of informational continuity concepts related to discharge planning and handoffs.
5 Discuss the application of management COC concepts related to case management and community advocacy.
Modern clinical practice requires new approaches to health care service delivery, with an emphasis on developing cost-saving coordination of health care delivery for individuals with chronic medical and mental disorders. This chapter provides a framework for exploring communication concepts and relationship strategies within and across health care systems. The chapter describes the concept of continuity of care (COC) and identifies its key components: relational, informational, and management continuity (Haggerty et al., 2003). Applications related to each dimension are discussed.
## Basic concepts
Continuity of Care COC provides a new model for describing the coordination and connections required across time, multiple clinical settings, and provider/agencies to effectively manage the health care of individuals with chronic conditions in the community (Sparbel & Anderson, 2000). Developing community-based collaborative models of care related to need assessments, referral, and early intervention will be key to providing quality health care, particularly for youths and seniors as budgets tighten (Tractenberg, 2010).
The World Health Organization (WHO) calls for an emphasis on continuous care by skilled and primary care health teams, rather than on episodic hospital care of seriously ill clients to ensure quality care (Thomas, 2009). The Institute of Medicine (IOM, 2001a) identifies continuity of care (COC) as an essential component of quality primary care. At the core of COC is the therapeutic nurse-client relationship. This relationship serves as a critical communication bridge between clients and their health providers in developing and implementing comprehensive care plans.
## Current challenges in health care delivery
The nation's health care delivery system currently faces major challenges for complex interconnected reasons. The need for health care delivery systems organized around an acute, episodic medical model of care no longer suffices as a primary service model. Needed is a redesign of the health care system to include a prominent emphasis on chronic disease self-management (Thorne, 2008).
Clients today are discharged earlier, have complex medication and treatment regimens, and are seen by different health care providers in multiple care settings. Self-management, family involvement, and shared decision making have become an indispensable means of bridging the gap between diminishing financial support for chronic care and multifaceted health care demands that can last for years. To achieve quality health outcomes with chronic conditions, clients and families must have dependable relationships, accurate information, and ongoing collaborative support from coordinated health services.
Managed care is now the dominant form of health care financing in the United States. The goal of this new system of care reimbursement is to administratively lower costs, while providing quality health care delivery (Lein, Collins, Lyles, Hillman, & Smith, 2003). The bulk of health care is increasingly provided in primary care settings, with acute episodic care reserved for short-term hospital stays. People are better informed, more assertive, and more insistent on prompt access and value for their health care dollar (von Bultzingslowen, Eliasson, Sarvimaki, Mattson, & Hjortdah, 2006).
Other factors such as _Healthy People 2010_ objectives, growing globalization, a sharp increase in migration of people without health insurance to the United States and Canada, and turbulent economic changes call sharp attention to widespread escalating public health issues and health care disparities. Provider shortages in the health care system, notably physicians and nurses, mandate a search for different and more effective, efficient ways of meeting client health care needs across multiple clinical settings.
## Continuity of care for chronic conditions
COC is recognized as an essential component of comprehensive care for individuals with chronic health conditions. WHO (2002) defines chronic health conditions as "health problems that require ongoing management over a period of years or decades" (p. 11). Examples include fibromyalgia, cancer, multiple sclerosis, and serious persistent mental disorders. What chronic conditions share in common is a requirement for ongoing health care management.
Kleinman (1988) describes chronic illness from the client perspective:
The undercurrent of chronic illness is like the volcano: it does not go away, It menaces. It erupts. It is out of control...confronting crises is only one part of the total picture. The rest is coming to grips with the mundaneness of worries...Chronic illness also means the loss of confidence in one's health and normal bodily processes. (pp. 44–45)
### Continuity of care
Sparbel and Anderson (2000) define **COC** as "a series of connected patient-care events both within a health care institution and among multiple settings" (p. 17). Nurses have an important role in implementing COC as a multidimensional concept, which according to Haggerty et al. (2003) is concerned with the following factors:
• Ensuring accessibility to coordinated health care services
• Personalization of care to meet a client's changing needs across delivery systems
• Informational data sharing of various elements of personal and medical data electronically over time and place, which contribute to appropriate care delivery
• Health services provided in an organized, logical, and timely manner, using a shared management plan
COC is described as a thread binding together episodes of care, and providing linkages across time, service providers and health care settings (Fletcher et al., 1984).
#### Dimensions of Continuity of Care
COC is an interdependent systems concept, consisting of three interlocking components: relational, informational, and management continuity. Each is dependent on the others (Schultz, 2009). Relational (interpersonal) continuity occurs through relationships with trusted care providers such that discrete health care events are experienced as being coherent and connected. Informational continuity is achieved through accurate record sharing and frequent team communication. Management continuity is accomplished through case management that can be flexibly adjusted to meet changing client needs in the community (Haggerty et al., 2003).
Relational Continuity: Haggerty et al. (2008) define relational continuity as "a therapeutic relationship with a practitioner that spans more than one episode of care and leads, in the practitioner, to a sense of clinical responsibility and an accumulated knowledge of the patient's personal and medical circumstances" (p. 118). A sustained relationship between health care providers and clients gives clients confidence that their providers know their circumstances well and are able to coordinate care between different providers and specialists.
Respect for client and family values, beliefs, knowledge, cultural background, and preferences are fundamental aspects of the relational continuity required for planning, delivery, and evaluation of comprehensive reliable care, particularly for chronic health conditions. Client participation offers health care providers unique insights into the context of an illness experience.
Providing health care for individuals with complex health care needs can exceed the energy and expertise of any one provider, even when highly talented. Current health care delivery systems emphasize team functioning in which professionals from different disciplines assume treatment responsibility for a common client population, develop common client-centered treatment goals, and function as a unified entity in providing client-centered care.
Professional team collaboration describes a communication process among health professionals required for promoting coordination of services and resolving complex treatment issues. Increasing the level of collaboration among health care professionals has been identified as one of the best strategies to improve the level of continuity in the health care system (San Martin-Rodriguez, D'Amour, & Leduc, 2008).
Informational Continuity: Communication of complete unbiased information is critical to ensuring safe, reliable care continuity (Kohn et al., 2000). Informational continuity refers to data exchanges among providers and provider systems, and between providers and clients related to care. Informational continuity is what "links provider to provider, and health care event to health care event" (Pontin & Lewis, 2008, p. 1199). As the client's condition changes, alterations are communicated quickly and accurately.
Sources of informational continuity include multidisciplinary team meetings, progress notes, handoff reporting, discharge plans, referral contacts, and client summaries. The SBAR is a new situational briefing format, which provides critical information about changes in a client's condition and is used in handoff or discharge/transfer of clients (Leonard, Graham, & Bonacum, 2004).
Management Continuity: Nazareth et al. (2008) define management continuity as "the delivery of health care by several providers in a complementary and timely manner through shared management plans that are consistent and flexible" (p. 570). The expectation is that health and complementary delivery services responsive to client needs will be provided to clients and families in a timely coordinated manner over an extended period. Management continuity represents a longitudinal pattern of health care utilization (Saultz & Albedaiwi, 2004), usually coordinated through case management.
#### Functionality of Continuity of Care
COC describes the communication bridge between discrete illness episodes and coordination of interventions by different providers to address changes in illness status (Mainous & Gill, 1998). When services are effectively coordinated, there is less potential for duplication of services, conflicting assessments, gaps in service, and decreased use of preventable acute care services. COC reduces medication and treatment errors, provides timely follow-up, and eases transitions between care settings for everyone concerned. Clients and families experience greater satisfaction.
Sharing of clinical activities makes for more holistic interventions (San Martin-Rodriguez, D'Amour, & Leduc, 2008). For chronically ill and elderly clients, COC means that they are more likely to have health care providers familiar with their overall history, who can notice subtle changes in the client's health status (von Bultzingslowen et al., 2006).
Developing an Evidence-Based Practice
Balaban M, Weissman J, Samuel P, Woolhandler S: Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study, _J Gen Intern Med_ 23(8):1228–1233, 2008.
This randomized, controlled study was designed to evaluate a low-cost intervention for culturally and linguistically clients being discharged from a small community hospital. The intervention, designed to improve COC, involved a "user-friendly" patient discharge form, with electronic transmission to a primary care site, telephone contact from a nurse at the primary care site, and primary care review/modification of the discharge-transfer plan. The study sample of 122 patients was randomized to intervention and control groups (historical and concurrent). The outcome variable related to preventable negative clinical outcomes. Comparative differences between the control groups and the intervention group were statistically analyzed using chi-squared tests. _t_ Tests were used to analyze continuous variables.
_Results:_ Study results showed that among participants in the study sample, the intervention significantly increased outpatient follow-up and completion of outpatient workups recommended by the hospitalist. The intervention was especially effective with short hospital stays (1–2 days) and with study participants 60 years and older.
_Application to Your Clinical Practice:_ The systematic transfer of client care from the hospital to a primary care "medical home" is needed to provide seamless medical care during the transition. This study proposes a new paradigm to formalize communication such that all parties involved in the client's care are well informed about postdischarge care. In what ways do you think studies of discharge-transfer interventions are important components of COC? How can you as a nurse facilitate compliance with follow-up treatment in a hospital setting? In a community or home setting?
## Applications
COC approaches are designed to provide a seamless continuum of care for clients through coordinated, acute, and community-based health services and relationships based on client needs and preferences. Multiple research studies have demonstrated improved clinical outcomes, satisfaction with care, and enhanced quality of life related to COC (van Servellen, Fongwa, & Mockus D'Errico, 2006).
## Creating relational continuity
Relational stability is the interpersonal aspect of COC. It is a fundamental communication channel used to guarantee well-coordinated health care service delivery, free from errors and tailored to meet the individual client's health needs. Interdisciplinary collaboration within a health organization and professional communication across health care systems are essential characteristics of professional relationships.
In today's health care system, a person's health care is looked on as the joint responsibility of clients, their families, and professional care providers. Although the emphasis with each health care episode may differ depending on the type and setting of care, the client is always the central focus.
## Patient (client)-centered care
The IOM (2001a) defines **patient (client)-centered care** as "providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" (p. 40). Client-centered care is designed to recognize subtle differences among clients having the same diagnosis and cultural experiences, and to incorporate this knowledge into the care of the whole individual (Engebretson, Mahoney, & Carlson, 2008; Hasnain-Wynia, 2006).
Client-centered care requires individualizing nursing interventions based on a person's values, preferences, and beliefs as the basis for customized clinical decisions (Engebretson et al., 2008; Hasnain-Wynia, 2006). Being attuned to cultural cues about beliefs and values, including attitudes about illness, provider relationships, and the nature of healing helps nurses make better sense of the clinical reality of a client's illness from the client and family perspective.
Client-centered care supports client autonomy and helps people take control of their health care, to whatever extent is possible. Individual need for full disclosure can vary as the client's condition changes and is affected by cultural norms. Client-centered care respects the amount of information desired by clients and their families, and to whom it should be provided. Attending to the physical and emotional comfort of the client, providing sufficient information with plenty of time for questions, feedback, and time spent on reducing client or family anxiety about new information are significant aspects of patient-centered care. Box 24-1 identifies IOM guiding principles for providing client-centered care.
BOX 24-1 Institute of Medicine Guiding Principles for Client-Centered Care
• Care is based on continuous healing relationships and not just face-to-face visits, implying that the health care system must be responsive at all times and care should be provided by the most expedient means.
• Care should be designed to meet the most common types of needs but should have the capability to respond to individual patient choices, need, values, and preferences.
• The patient is the source of control by being given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them.
• Patients should have unfettered access to their own medical information and to clinical knowledge; clinicians and patients should communicate effectively and share information.
• Decision-making is research based, with care being consistent across clinicians and jurisdictions.
• Transparency is necessary, making available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments including information describing patient safety, research-based practice, outcomes, and patient satisfaction.
From Coleman EA, Fox PD: One patient, many places: managing health care transitions, Part 1: introduction, accountability, information for patients in transition, Annals of Long-Term Care, 12(9): 25-32, 2004.
### Building collaborative partnerships with clients
Well-planned, competently executed, client-centered care results in improved practice efficiency and better client outcomes (Epstein, Fiscella, Lesser & Stange, 2010). . Client-centered care emphasizes partnerships between clients and providers, consisting of following factors:
• Mutual respect for the skills and knowledge of client consumers and the health care team
• Accessibility and respectful empathetic responsiveness to client and family needs
• Shared planning and development of mutually agreed-on goals that reflect the client's needs, beliefs, values, and preferences
• Frequent evaluation, based on a mutual exchange of information, constructive feedback, and negotiation of care strategies that are empowering and practical.
Family-centered care comes into play when the health needs of children are involved. Family-centered care is more complex. Parents may need help with parenting skills both in handling the needs of a chronically ill child and in providing support and direct care. Box 24-2 offers principles of family-centered care.
BOX 24-2 Selected Principles of Family-Centered Care in Working with Parents
• Families represent a central constant construct in children's lives.
• Each family is unique, with diverse clinical needs and strengths.
• Parents are ultimately responsible for the health and welfare of their children.
• Family-centered care should be based on family strengths and competencies.
• An important source of support for families is networking and family-to-family support.
• All family members should be encouraged to participate in the child's care.
• Family members should have the right to determine how much they will participate in decision making for their child.
Adapted from O'Neil M, Ideishi R, Nixon-Cave K, Kohrt A: Care coordination between medical and early intervention services: family and provider perspectives, _Fam Syst Health_ 26(2):119–134, 2008.
### Shared decision making
A client-centered care views the client and family as equal partners with providers in negotiating treatment decisions and evaluating treatment outcomes (Engebretson et al., 2008; IOM, 2001b). To ensure that care decisions respect client values, needs, and preferences, health care providers need to: (1) observe and listen carefully; and (2) provide clients and families with the education and support they need to make reasoned decisions, and actively participate in their health care. Full disclosure of information is a prerequisite for effective shared decision making. Relevant information includes:
• Detailed information on diagnosis
• Options for treatment
• Anticipated clinical outcomes
• Treatment and care processes required to achieve desired clinical outcomes
Shared decision making requires client and family involvement in all health care decisions.
## Relational continuity: professional perspectives
Sheehan, Robertson, and Ormond (2007) differentiate between multidisciplinary and interdisciplinary teams. Professionals on multidisciplinary teams "each work within their particular scope of practice and interact formally. Interdisciplinary teams are characterized by greater overlapping of professional roles, formal and informal communication and shared problem solving for the good of the patient" (p. 18).
Although multidisciplinary teams share information with each other, and work in tandem with other disciplines, they function independently, with each being responsible for different care needs. By contrast, an interdisciplinary team develops a collective vision and common language to support a collaborative unified working approach to clinical problems. An interdisciplinary team actually integrates services, using teamwork principles, whereas on a multidisciplinary team, each profession maintains its own silo of expertise without much interaction (Margalit, Thompson, & Visovsky, 2009).
The interdisciplinary team consists of a core group of health professionals (commonly physician, nurse, social worker, pharmacist, and caseworker). Although each discipline has its central role, integrated client-centered care represents the team's core value. Decision making is nonhierarchal, with every professional being willing and ready to assume responsibility for achieving positive treatment outcomes (Jansen, 2008).
Interdisciplinary team function takes into account the diverse standards and behaviors associated with each clinical discipline, and emphasizes the common mission of working together to resolve complex clinical problems (Clark, Cott, & Drinka, 2007; D'Amour & Oandasan, 2005). Figure 24-1 presents the dimensions of patient centered care.
Figure 24-1 Dimensions of client-centered care.
Each member of the team functions as both an individual and a health care professional representing a distinct discipline. Fundamental to effective participation on an interdisciplinary team is a clear understanding of one's own discipline, plus a knowledge and mutual respect for each other's discipline's roles, professional responsibilities, and expertise (Lidskog, Lofmark, & Ahlstrom, 2007).
Even when core personal and professional values, attitudes, and practices are not at odds with each other, professional training and interpretations of standards can shape how professional values are prioritized (D'Amour & Oandasan, 2005; Hall, 2005). Sparbel and Anderson (2000) identify team role confusion, fueled by professional rivalries, territoriality, and lack of clarification about job responsibilities, as a potential barrier to effective team communication. Exercise 24-1 explores the impact of discovering commonalities in people.
EXERCISE 24-1 Characteristics in Common
Purpose: To help students develop a sense of rapport with others as a basis for team understanding and communication.
Procedure:
1. Break up into teams of three students and appoint a scribe. Each group has 10 minutes.
2. In each group, answer this question: What is the most unexpected thing each group member holds in common with the other two group members?
3. Return to the larger group and share the answers with the larger class group.
Discussion:
1. How easy was it to share with others information about yourself that they didn't know previously?
2. What things made it easier or harder to share?
3. In what ways were you surprised to learn about something unexpected that you had in common with your teammates.
4. How could you use what you learned in this exercise to create better communication with other health care professionals?
### Professional collaboration
The goal of interprofessional collaboration is to produce "a synthesis of the information such that the outcomes are more than additive" (Muir, 2008, p. 5). Interdisciplinary team collaboration enables practitioners to learn new skills and approaches, and encourages synergistic creativity among professionals. Collaboration decreases fragmentation and duplication of effort and promotes safe quality care (Figure 24-2) presents desired characteristics of professional collaboration.
Figure 24-2 Characteristics of collaboration.
Team collaboration includes the client as an essential collaborative partner. Within nurse-client relationships, nurses help clients interpret clinical findings, frame important questions about their diagnosis, treatment, or prognosis, and follow through with treatment recommendations.
TeamSTEPPS (Department of Defense, 2009) represents an accepted, evidence-based framework developed jointly by the Agency for Health Care Research and Quality and Department of Defense to guide development and implementation of interdisciplinary team collaboration in health care centers. Competency elements are identified in Box 24-3. Professional collaboration takes place through formally scheduled team meetings, informal huddles, and client comfort rounds.
BOX 24-3 Competency Elements of TeamSTEPPS
• Team leadership—the ability to direct and coordinate activities of team members, assess team performance, assign tasks, develop team knowledge and skills, motivate team members, plan and organize, and establish a positive team atmosphere
• Situation monitoring (or mutual performance monitoring)—the capacity to develop common understandings of the team environment and apply appropriate strategies to monitor teammate performance accurately
• Mutual support (or backup behavior)—the ability to anticipate other team members' needs and to shift workload among members to achieve balance
• Communication—including the efficient exchange of information and consultation with other team members
#### Team Meetings
Interdisciplinary team collaboration differs from group communication in that team membership, focus of communication, and anticipated outcomes are consistently and solely focused on present moment client needs and solution planning. Team meetings serve the distinct purpose of concentrated discussion about targeted client and family needs, and meeting related treatment goals.
A smoothly run team meeting is one in which the team understands the mission of providing holistic care through defined membership, and where any problem related to client and family care can be worked through to the joint satisfaction of the team and client/family. Wise team leadership and careful attention to member relationships are essential.
The shared goals of client and health care team focus the discussion. Unrelated discussion or focus on routine details or on competing goals are discouraged because they distort or compromise the concentration of the team on key client/family needs and solutions. Time is a precious commodity for busy health care providers, so team meetings begin and end on time. Exercise 24-2 provides an opportunity for students to understand collaboration skills in team decision making.
EXERCISE 24-2 Team Decision Making
Purpose: To help students work together to discover how they work together to develop a consensus about an uncertain situation.
Procedure:
Break up the students into groups of four to six students. Each group should consider the scenario below and decide on which four people should be allowed to enter the life raft in a 15- to 20-minute time frame.
The group should provide a rationale for selection.
Scenario:
A small aircraft crashes on a small island in the Pacific Ocean. There are six survivors, but the life raft can only hold four people.
1. Bill is the pilot. He is a veteran pilot, with a good flying record. Recently, there has been a concern that he is depressed and showing signs of a drinking problem.
2. Jack is a successful physician about to turn 60, and a bachelor. He is planning to retire next year and is looking forward to a life of leisure and travel, which he feels he deserves and has looked forward to all his life.
3. Mary is a gifted musician in her early 30s. She is married, has three children, and recently received her first contract with a major orchestra.
4. Maria is a 45-year-old diabetic. She has had a difficult life but is planning to marry the man of her dreams when she returns from this trip.
5. Jeff is a broker with a major investment company. He recently resigned in the midst of a scandal involving insider trading, although he personally was never legally charged. He is married and has two teenage boys.
6. John is a health director of an HIV treatment center. He was instrumental in acquiring properties and acceptance of HIV patients, which would not have been possible without his expertise. His treatment center is used as a model for treating HIV patients. Recently, John was diagnosed with HIV.
Discussion:
How did each group reach their decision?
What was it like to know you had to make a team decision about an issue for which there is no perfect answer?
What factors made the discussion easier or harder?
What did you learn about how people function as a team in making a difficult decision within a short time frame?
#### Huddles
Sometimes an urgent problem arises that cannot wait until the team meets again. Huddles, defined as limited spontaneous or scheduled briefings, allow interdisciplinary team members to meet briefly with each other or with bedside caregivers for the purpose of staying informed, making on-the-spot decisions, and being able to move ahead quickly in rapidly changing health circumstances. Huddles are held more frequently than team meetings, sometimes daily. They typically last no more than 7 to 10 minutes and are convened spontaneously in a convenient location with team members standing rather than sitting close to the site of action (Institute for Healthcare Improvement, 2007).
#### Sharing Critical information
Leonard et al. (2004) advocate the use of the SBAR format as a succinct way to share critical information with physicians and other team members about sudden changes in a client situation. The statements should contain a concise, convincing statement about the severity of the client's condition.
Case Example
• **Situation:** "Dr. Preston, I'm calling about Mr. Lakewood, who's having trouble breathing."
• **Background:** "He's a 54-year-old man with chronic lung disease who has been sliding downhill, and now he's acutely worse."
• **Assessment:** "I don't hear any breath sounds in his right chest. I think he has a pneumothorax."
• **Recommendation:** "I need you to see him right now. I think he needs a chest tube" (Leonard et al., 2004, p. i86).
#### Nursing Comfort Rounds
Studies have identified nursing rounds as a way to enhance client-centered care, improve client satisfaction, and enhance client safety (Bourgault et al., 2008; Meade, Bursell, & Ketelsen, 2006). Regular comfort rounds with professional nurses and/or clinical support staff provide opportunities to continuously meet client nonmedical needs and to share information with clients (Castledine, 2002). Common components include assessment of the environment to ensure that equipment is within easy reach of the client, adequate pain management, and attention to personal needs such as repositioning and toileting (Meade et al., 2006).
### Role of the hospitalist
A new professional role designed to improve COC in acute care settings is that of the "hospitalist" (Amin & Owen, 2006; Wachter & Goldman, 1996). The hospitalists may be a physician or nurse practitioner employed by the hospital to clinically manage inpatient medical care, with specialty physicians acting as consultants. The hospitalist assumes responsibility for coordinating care, integrating diagnostic test results, making decisions, presenting options to the client and family, and communicating with other professionals who may be or will become involved in the client's care after discharge. The specific dimensions of the hospitalist role are determined by the care site rather than clinical specialty (Schneller & Epstein, 2006).
Although hospitalists are often the client's main point of contact throughout the acute hospitalization phase, they may have limited knowledge of the client's health care patterns before hospitalization. The primary physician may have limited contact with the client during the hospitalization but will be expected to re-engage with the client on discharge.
Nurses have an important communication role with hospitalists. Clients cannot always easily interpret the events related to rapidly changing prognostic changes or treatment options. They are more likely to discuss their concerns regarding particular treatment issues with the nurse during the course of care provision than they are in formal meetings with the health care team. Nurses can and should be proactive in talking informally with physicians about their clients and in contributing data in huddles and team meetings.
Periodically, and or when the client's condition changes, the hospitalist or entire treatment team may meet with the family to discuss changes, treatment options, and family concerns. Even in the best of circumstances, client/family meetings with the health care team to discuss sensitive health issues such as discontinuing life support or transfer of clients to subacute or community settings with anxious clients and concerned family members can be highly intimidating. Nurses can help clients and families by continuing conversations after the health care team leaves, answering questions and providing support.
## Informational continuity
Informational COC allows for an uninterrupted flow of data and clinical impressions between health care providers and agencies, with clients and their families, over time and space. Gaps in informational continuity can occur as a result of misplaced clinical records, inadequate discharge planning or referral data, deficient or delayed authorization for treatment, and lack of understanding by the client of their illness or treatment, or self-management guidelines. Lack of information at time of transfer can result in treatment delays, and can increase the client and/or family's anxiety unnecessarily. When clients get full information and a consistent message from their health care providers, regardless of where they are in the health care system, they become more relaxed and open to treatment recommendations.
Informational continuity requires sharing health and treatment information and changes with clients and families that are consistent, complete, accurate, value neutral, and delivered in an easily understandable and supportive manner. Notifying the family of changes in the client's condition or treatment recommendations is an essential part of ensuring informational continuity, particularly if the family is not in close contact with the client.
## Handoff care transitions
Communication at transition points in health care takes place in the form of handoffs. **Handoffs** refer to transfer processes taking place when clients are reassigned to another level of care, for example, from the intensive care unit to a step-down unit, or to a less intensive care facility for continued rehabilitation services. Carr (2008) advises, "Handoffs or care transitions shouldn't be an abrupt end of care previously provided, but rather considered to be a coordinated changeover for the patient to a new team of involved caregivers" (p. 26). The Joint Commission (2009) mandates timely and accurate transfer of handoff information related to transfer of clients from one unit to another and from one clinical setting to another.
Transitions from one clinical unit to another, and discharge to a different clinical setting provide opportunities for unintentional information gaps (Coleman & Berenson, 2004; Greenwald, Denham, & Jack, 2007). Core functions for transitional sending and receiving teams designed to limit information gaps are presented in Box 24-4.
BOX 24-4 SBAR Handoff Content Format in Inpatient Settings
Situation
Nurse name and unit
Reporting on (patient name and room number)
Background
Admission diagnosis and date of admission
Pertinent medical history
Brief synopsis of treatment to date
Patient code status (if applicable)
Family/significant other involvement
Isolation and type
Precautions (fall, suicide, seizure, restraints)
Medication reconciliation status
Assessment
Vital signs
Abnormal laboratory results within 24 hours
Postoperative day (wounds/dressing/intravenous sites with date)
Mobility (number of staff and lifting device needed)
Mental status
Pain assessment/reassessment (last time pain medication was given)
Physician orders (received, carried out, pending)
Oxygen (yes or no)
Changes from prior assessments (vital signs, neurologic changes, skin, pain)
Recommendation
Items that require follow-up
State of patient teaching needs
Discharge needs.
From Mikos K: Monitoring handoffs for standardization: 2008 guide to patient safety technology regulatory compliance, _Nurs Manag_ 38(12):16, 18, 20, 2007.
### Documenting transfer information
SBAR is the most commonly used format for communicating pertinent information during handoff transfers and increasingly for shift reports. The format presents a clear, organized picture of a client's care during a shift or care episode to the different set of health professionals who will be assuming primary responsibility for client care. Mikos (2007) specifies the content information that nurses should include in Box 24-5. Exercise 24-3 provides practice with using the SBAR format.
BOX 24-5 Nursing Components of a Comprehensive Discharge Process
• Assessing the client's understanding of the discharge plan by asking them to explain it in their own words.
• Advising clients/family of any tests completed at the hospital with pending results at time of discharge, and notifying appropriate clinician of this contingency.
• Scheduling follow-up appointments or tests after discharge, if needed.
• Organizing home or health care services that needed to be initiated after discharge.
• Confirming the medication plan and ensuring that the client/family understands any changes (e.g., medication in the hospital not available or accessible in the community).
• Reviewing with the client/family what to do if a problem develops.
• Expediting transmission of the discharge summary to health care providers and case managers accepting responsibility.
EXERCISE 24-3 Using the SBAR Report Format
Purpose: To provide an opportunity for students to use the SBAR format (found in Box 24-5) in a care transition report.
Procedure:
Using the following case study*, prepare a care transition report to accompany the client to his new unit.
Jeff O'Connor is a 66-year-old man originally admitted to the emergency department with severe chest pain, shortness of breath, dizziness, and intermittent palpitations. He was diagnosed with a myocardial infarction and admitted to the coronary care unit. He was placed on oxygen and remained there for several days because his serum markers continued to rise. He received morphine for pain and sedatives to keep him comfortable. He is currently stabilized with digoxin, demonstrates a normal sinus rhythm, and is being transferred to the step-down unit this afternoon. His wife and daughter have visited him several times each day. His wife states she is exhausted but is glad he is being transferred. Jeff has long-standing coronary artery disease, and a family history of cardiac events. This is his first heart attack.
Discussion:
If this is the only information you have on Jeff, what other data might you need to develop a full transitional report using the SBAR format?
* * *
*This exercise can be completed using a current client transfer.
### Discharge planning and referrals
Han, Barnard, and Chapman (2009) use the American Hospital Association (AHA, 1983) definition of **discharge planning** "as a process of concentration, coordination and technology integration, through the cooperation of healthcare professionals, patients and their families, to ensure that all patients receive continuing care after being discharged" (p. 5).
Discharge planning begins with the client's admission to the hospital (Birmingham, 2004; Cotera-Perez, 2005). Nurses should educate clients and families about diagnosis and treatment throughout hospitalization, so that by the time the client is discharged, the client and family have a full understanding of the client's condition as a basis for follow-up care.
#### Assessment of Postdischarge Needs
Much of the care previously provided in acute care settings for clients has shifted to the home care environment (Cooke, Gemmill, & Grant, 2008). In the community, professional team care will involve interactions separated by both time and space.
Many clients/caregivers will require specific instruction in treatment-related tasks to successfully self-manage health problems at home. Arrangements and/or referrals for essential training needs should be implemented before discharge, if possible. Table 24-2 presents some of the key elements needed to plan for a successful transition from the hospital to the client's home.
TABLE 24-2
Key Elements in Planning for Successful Transitions
Data from: Boling P: Care transitions and home health care, _Clin Geriatri Med_ 25:135–148, 2009.
Not all clients are discharged back to their home. Clients with complex disability or care needs may need to be discharged to a subacute or transitional skilled nursing facility for extended care. As soon as this is known, the client and the family need to be informed of the need for transfer and what parameters for discharge will be used for each client (Joint Commission, 2009). Recommendations for transfer should be thoroughly discussed with the family and included in the client's treatment plan. The goal of discharge planning is to provide clients and their families with the level and kind of information they will need to secure their recovery and/or maintain health status during the immediate posthospital period.
Clients may have multiple care transitions as part of their experience after discharge from a hospital setting (Boling, 2009). Frequent communication and careful coordination are keys to ensuring safe, effective care across settings. Successful transitioning involves consideration of the combined needs of the client and family, and the resources of the agency or health care provider to meet those needs. Table 24-1 provides guidelines for helping clients and families.
TABLE 24-1
Collaborative Communication Protocol for Interdisciplinary Team Development
_Name:_ Introduce yourself to other member(s) by name and discipline.
_Role:_ Declare your professional role on the team, and describe it with respect to the target client under discussion.
_Issue:_ Share with other team members your discipline-specific professional ideas regarding the treatment of the target client under discussion.
_Feedback:_ As client issues are discussed, elicit interaction-specific feedback from other team participants in the interaction using prompts such as "Do you have any concerns?" or "Is there something else I should consider?"
Adapted from Zwarenstein M, Reeves S, Russell A, et al: Structuring communication relationships for interpersonal teamwork (SCRIPT): a cluster randomized controlled trial, _Trials_ 8:23–36, 2007.
Clients admitted to emergency departments usually have limited information to prepare them for self-care after discharge. Nurses are responsible for communicating and coordinating postdischarge instructions with clients and families, quickly educating them about the client's condition and treatment-related tasks, and coordinating care with other health professionals as needed (Han et al., 2009).
#### Discharge Summary
The discharge summary is the most commonly used format for communicating diagnostic findings, hospital management, and plans for follow-up at the end of a client's hospitalization (Kripalani et al., 2007). Content mandated for each client's written discharge summary includes:
• Reason for hospitalization
• Significant findings
• Procedures and treatment provided
• The patient's condition at discharge
• Patient and family instructions (as appropriate)
• Attending physician's signature
Clients should be encouraged to bring their discharge summary to initial follow-up appointments. The Joint Commission (2009) mandates that discharge summaries be completed within 30 days of hospital discharge.
Nurses are accountable for verbally reviewing discharge summaries with the client and/or caregiver as appropriate, providing written instructions, and completing discharge documentation in the chart. Although the physician is responsible for initiating and signing discharge summaries and orders, nurses play a critical role in the discharge of clients, as identified in Box 24-6.
BOX 24-6 Core Functions for Transitional Sending and Receiving Teams Rights were not granted to include this textbox in electronic media. Please refer to the printed book. From HMO Work Group on Care Management: _One patient, many places: managing health care transitions_ (p. 7), Washington, DC, 2004, AAHP-HIAA Foundation. HMO Work Group on Care Management
Discharge instructions are not the same as discharge orders. Specific written discharge instructions should include a basic follow-up plan identifying diet, activity level, weight monitoring, what to do if symptoms develop or worsen, and the contact numbers of relevant hospital and primary care providers. Written instructions should be simple and concrete—for example, "Call the doctor if you gain more than 2 pounds in 1 week." A written list of all medications prescribed at discharge, including prescription, over-the-counter medications, and herbals, should be given to the client/caregiver.
Discharge documentation in the client's chart should include the client's condition or functional status at time of discharge, followed by a summarization of the treatment and nursing care provided, discharge instructions given to the client/family and the client's responses. The place to which the client is charged (home, nursing home, rehabilitation center) should be identified. Subheadings help organize and highlight pertinent information for follow-up care (Kripalani et al., 2007). Nurses need to document that the client and/or caregiver was actually given a copy of the discharge instructions.
### Management continuity
Management continuity represents a longitudinal approach to the clinical management of chronic disorders in the community. Care is delivered through coordinated referrals, case management, and community supports over a significant period.
### The medical home
A new concept in primary care service delivery designed to promote COC is the client/family-centered medical home. The **medical home** is defined as a community-based delivery process involving a primary care team, led by an identified personal physician for the client. The client's medical home accepts responsibility for coordinating health care across care settings, and providing accessible, comprehensive primary care services across time for designated clients and families.
The medical home serves as a central point of contact in primary care through which the majority of client health needs are met (Grumbach & Bodenheimer, 2002). Having a primary care home that coordinates care for all aspects of health care including acute and chronic care, preventive care, and palliative care is reassuring to clients and families. Over time, clients learn to depend on the medical home as a first-line treatment resource for all aspects of care. Physicians and other health care providers can provide better quality care because they have knowledge of the client's lifestyle and can better detect subtle changes in the client's situation or condition.
Using the medical home care delivery model provides an opportunity to effectively blend relational, informational, and management continuity into a holistic system of care for the client. A qualified provider consistent with the client's choice takes a clinical leadership role in coordinating care, with other care providers within and external to the medical home, providing skilled services when indicated. Medical homes provide quick access to health care and can facilitate connections to other providers or medical and mental health services when needed.
## Case management
Whether one works in the hospital or primary care setting, all nurses should have knowledge of how case management works and how it fits into COC. Carter (2009) states, "Case management is a core component of what is needed to improve health care quality overall, while reducing costs" (p. 166). Knowledge of community resources needed to facilitate health care delivery in primary care settings allows nurse case managers to consistently deliver the right care at the right time to the right client/family.
The Case Management Society of America (2009) defines **case management** as "a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes." Standards of practice for case management related to quality of care, collaboration, and resource utilization are consistent with National Patient Safety goals developed by the Joint Commission (Amin & Owen, 2006).
With the help of a case manager, clients with serious chronic conditions are able to stay in their homes and function in the community (Ploeg, Hayward, Woodward, & Johnston, 2008). Case managers help individuals and families identify providers and facilities in the community capable of providing an essential continuum of services. For example, the case manager might help the client and/or family locate rehabilitation facilities, make recommendations for placement, serve as a liaison with reimbursement sources, and/or help the family evaluate the care provided at the facility.
The goal of case management strategies is to help clients at their highest possible level in the least restrictive environment. Case management strategies are designed with the following purposes:
• To enhance the client's quality of life
• To decrease fragmentation and duplication of health delivery processes
• To contain unnecessary health care costs (Gallagher, Truglio-Londrigan, & Levin, 2009)
### Populations served by case management
Essentially, clients need a case manager when they are unable to establish or maintain self-management of a chronic health condition in a consistent manner without external support. Included in the population group served by case managers are frail elders and housebound adults or children, clients with minimal brain dysfunction, chronic mental illness, gait or balance problems, individuals with delirium or dementia and/or chronic physical disabilities affecting activities of daily living. Sometimes, the person requiring ongoing case management services is neither elderly nor mentally incapacitated. He or she can be overlooked as a potential recipient of case management services despite significant impairments that interfere with quality of life.
Case Example
Ray Bolton is a 48-year-old man with severe chronic Crohn's disease, which has gotten progressively worse since age 24. He has a permanent ileostomy and suffers from periodic exacerbations in his condition usually resulting in hospitalization. Because of the severity of his illness, he is on Social Security disability. Ray lives by himself with his cat. He has neurologic issues that affect his balance and gait, and cause him significant pain. In the past, he has had Meals-on-Wheels, but prefers to make his own food because he suffers less digestive disturbance. He can't sleep because of pain. Ray is socially isolated. Apart from his 80-year-old father and a brother, both of whom live some distance from him, Ray has no support system other than his physicians. He identifies them as his only friends. Ray's lack of a social support system, the seriousness of his medical condition, and his lack of knowledge about essential services warrant consideration of case management services.
In addition to symptom management, Ray's quality of life will require attention to the life skill domains needed to support Ray's independence. Exercise 24-4 provides an opportunity to assess and plan for client care using a case management approach.
EXERCISE 24-4 Planning Care for Ray Bolton: Case Management Approaches
Purpose: To provide practice with assessing and planning care for Ray Bolton using a case management approach.
Procedure:
(Initial consideration of Ray's issues can be completed as an out-of-class assignment.) In groups of four to five students, consider the case example of Ray Bolton on page 481.
Each group should identify:
• Relevant assessment data
• The best ways to address Ray's complex health needs and why
• What kinds of resources Ray will need to effectively self manage his multiple chronic health problems
After 15 to 20 minutes, have each student group share with the rest of the students what their plan would be, the resources they will need to accomplish the task, and why.
Discussion:
1. What was your experience of doing this exercise?
2. What were the commonalities and differences developed by different student teams?
3. Were you surprised by anything in doing this exercise?
4. What are the implications for your future practice?
### Case management principles and strategies
Case management strategies are designed to coordinate and manage client care across a wide continuum of health care services and community supports. With the help of a case manager, clients with serious chronic conditions are able to stay in their homes and function in the community (Ploeg et al., 2008). Case management frameworks follow the nursing process as a structural framework in service provision. Strategies incorporate COC concepts related to communication, team building, and data sharing with all members of the multidisciplinary care team, including the client and family caregivers.
#### Case Finding
Case management is a proactive form of care delivery. Case-finding activities, especially in areas of high prevalence, can identify individuals at high risk for potential health problems and provide opportunities for early intervention (Thomas, 2009). Networking and communication with other health professionals involved with the client helps prevent or minimize emergence of full-blown health problems.
#### Assessment
Comprehensive assessment forms the basis for case management care coordination. In addition to basic health and demographic information, assessment for case management purposes should include the names, addresses, and phone numbers of the client's health care providers, social service representatives, school or work contacts, if applicable, and health insurance information. Availability of social supports and religious affiliations, previous hospitalizations, and history of treatment, current medications and allergies, advance directives and DNR (do not resuscitate) status, cognitive and mental status, mobility status, and functional assessment of activities of daily living is important case management assessment data. Identifying potential barriers to treatment adherence, including the impact that the client's diagnosis has on family members and coworkers can be helpful information. Baseline assessment data can be modified as the client's condition changes.
#### Treatment Planning
Case management treatment plans are designed to promote treatment compliance and continuity. Case management strategies are customized for each client, based on their needs, values, and preferences. The client/family has final power over decision making and control of a personal recovery process.
Because case management represents a longitudinal treatment management process, the plan will necessarily change over time to reflect changes in the client's situation and personnel/agency changes.
#### Implementation
Case managers meet with clients at regularly scheduled intervals. They assess client needs for changes in level of care, monitor client compliance with the plan of care, help clients procure needed supplies and medical equipment, and help clients obtain essential support services. Examples of non-nursing professional assistance clients may need to be linked with include legal aid, Social Security benefits, safe affordable housing, social services, and/or mental health and addiction services.
Effective case managers have a strong understanding of community resources' strengths and weaknesses, including accessibility, availability, and affordability. They have an understanding of how health care systems work and can navigate the system.
Case managers need to be aware of the client's needs, values, and preferences, and they need to be able to express these data to the treatment team and agencies involved in the client's care in a clear, nonjudgmental, manner.
It is not enough to simply provide a referral. Additional follow-up may be necessary to assist clients with scheduling appointments, filling out required forms, getting transportation, or getting finances for participation in referral opportunities. Case managers may need to negotiate on the client's behalf with insurance companies and equipment suppliers. When single agency resources are insufficient to meet a client's complex health needs, case managers help clients and families identify and coordinate services with other agencies.
In the process of identifying and coordinating community-based resources, Hawranik and Strain (2007) note, "Nurses, as client advocates and agents of health promotion, can play an important role in modifying the focus of the system and of agency policies to include greater input by caregivers and clients" (p. 168).
Case managers are in a unique position to educate people in the community who work with disabled or chronically ill clients about the social aspects of disability to facilitate understanding and acceptance of the client's problems. They can be helpful in linking clients and families with faith or social support groups, in initiating contacts for housing or job training, and in coaching clients about seeking social acceptance.
#### Evaluation
Case management outcomes are described in terms of client satisfaction, clinical outcomes, and cost. Quality improvement variances related to achievement of actual clinical outcomes are analyzed with recommendations for treatment planning, related to observed changes in the client's situation, health condition, or in health care resources.
#### Documentation
The case manager is responsible for ensuring that all members of the multidisciplinary team accurately complete written documentation. Documentation from external providers and agencies needs to be included in the client's case management record, as do variances from the treatment plan, reasons for the variance, and plans for modification in care plans.
### Supporting informal family caregivers
COC involves supporting informal family caregivers. As health care delivery moves into the community, living with chronic illness increasingly becomes a home care responsibility, with family members as informal caregivers providing most of the care. Cott, Falter, Gignac, and Badley (2008) describe the home as "a unique clinical setting, different from acute care or institutional environments" (p. 19).
Family caregiving is neither a career choice nor a role for which one can prepare...and the caregiver has no "care map to lead the way," states Wright, Doherty, and Dumas (2009, p. 209). Exercise 24-5 offers insights into the role of family caregivers from the caregiver perspective. Although many variables cannot be controlled, research findings indicate that caregiver training and support reduces caregiver strain and results in better clinical outcomes for clients (Weinberg, Lusenhop, Gittell, & Kautz, 2007).
EXERCISE 24-5 Interview a Family Caregiver
Purpose: To help students understand the caregiver role from the perspective of family caregivers.
Procedure:
1. Interview the family caregiver of a client with a long-standing chronic illness or mental disability, and write a summary of the caregiver's responses.
2. Use the following questions to obtain your data.
a. Can you tell me why and how you assumed responsibility for caregiving?
b. In what ways has your life changed since you became a caregiver for your parent, spouse, disabled child/adult, or mentally ill family member?
c. What do you find most challenging about the caregiving role?
d. What do you find rewarding about the caregiving role?
e. How do you balance caring for your ill or disabled family member with caring for yourself?
f. What advice would you give someone who is about to assume the caregiving role for a chronically ill or disabled family member?
Discussion:
What was it like to enter the life of the caregiver? Were you surprised by any of the responses? How can you incorporate what you learned doing this exercise in your clinical practice?
Caring for clients with significant disability at home has positive and negative aspects. Being cared for at home offers stronger COC management as home is associated with personal identity, security and relationships with people who genuinely care about the client. Variation exists in a family member's capacity to be supportive, especially if the caregiver's health is not optimal, the care is labor intensive and time consuming, or the relationship with the client is conflictual (Weinberg et al., 2007). The need for information and assistance by family caregivers is often unspoken, as demonstrated in this case example.
Case Example
A participant whose husband had urinary incontinence had been doing laundry every day, unaware that pads for incontinency were available free of charge through a publicly funded home-care program. A granddaughter expressed interest in attending a support group but did not know that there were support groups for family caregivers. These caregivers apparently assumed that no assistance was available and received no information about home care from acquaintances or family members (Hawranik & Strain, 2007, p. 166).
Case managers and home care nurses can fill in essential information gaps for family caregivers through careful questioning, observation, validation about feelings and observations, and consultation about emerging health issues.
### Case management for chronically mentally ill clients
Continuity of care is essential for effectively managing chronically mentally ill clients in the community (Wierdsma, Mulder, deVries, & Sytema, 2009). For clients with chronic mental illness, fulfilling even basic needs for shelter, food, clothing, and transportation can be issues, with the result that many of these clients are homeless and in poor physical health. Individuals with serious emotional and behavioral problems often function at a marginal level because of their symptoms. Many need consistent support to maintain themselves independently in the community. In addition to individualized treatment, COC for mentally ill and dually diagnosed clients includes formal wrap-around support services for mentally ill children and their families and case management for adults and children. Wrap-around services use a strengths based format and involve the family, community, school and service providers of the child's environment working together as a team with the family to prompt adaptive functioning (Walker & Schutte, 2004). Many of these clients will not avail themselves of the opportunity, even when available.
Case managers provide individual mentoring and coaching, and job training services. They help clients avert crisis relapses that precipitate rehospitalization. Case managers offer strength-based community interventions such as linking clients with counseling and alternative treatment services, social services, and community networks, based on recovery principles of care. Consumer advocacy groups such as the National Alliance for the Mentally Ill (NAMI) provide support and practical advice for clients and families.
## Advocacy at the community level
Chinn (2009) challenges nurses as one of the largest professional groups in the health care system to become the leaders, movers, and shakers in bringing about essential and fundamental changes in health care delivery. Sustaining quality health programs and services costs money. Advocacy to influence policy change that promotes availability and adequacy of health services in the public sector becomes urgent as escalating financial constraints narrow availability of community services. The positive policy environment promoted by WHO (2002) and linking community and health organizational efforts to achieve better outcomes for chronic conditions is a useful framework (Figure 24-3) for achieving COC objectives.
Figure 24-3 Building a positive policy environment for innovative continuity of care. From: World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva, Switzerland, 2002, p. 65.
Mason, Leavitt, and Chaffee (2007) define health policy as "the choices that a society, segment of society, or organization makes regarding its goals and priorities and the ways it allocates its resources to attain those goals" (p. 3). Advocacy at the system or community level tends to focus on adequate public health service provision, funding for essential health programs, and protecting the rights of vulnerable people to treatment.
Nursing practice in recent years has increasingly recognized political advocacy and involvement at the systems and policy level as a leadership responsibility of the professional nursing role (Francis-Baldesari & Williamson, 2008). Although nurses are on the front lines of the health care system as advocates of individual clients, they sometimes overlook their potential for helping to improve service delivery through advocacy at the community and national level. Clarke and Gottlieb (2008) declare that "keeping silent is no longer an option" (p. 7). Nurses must be willing to join together with other health professionals, their professional organizations, and community commissions and boards to argue for successful resolution of key quality-cost-access issues related to the financing and safe, effective delivery of health care (Spenceley, Reutter, & Allen, 2006).
Nurses can contribute to the development of effective health policy by writing e-mails to policy makers, becoming informed about public issues, sharing impressions with colleagues, testifying at public hearings, conducting and publishing research with health policy implications, and joining professional organizations with advocacy missions (Taft & Nanna, 2008). Concrete suggestions for improving community advocacy are highlighted in Box 24-7.
BOX 24-7 Suggestions for Nurses Interested in Advocacy
1. Volunteer to serve on community advisory boards and commissions.
2. Join professional organizations and community groups with common interests in promoting advocacy (e.g., NAMI).
3. Encourage clients to provide personal testimonials related to program impact at public hearings.
4. Send e-mails (these are more effective than phone calls), with follow-up hard copy to public officials to support advocacy efforts.
5. Be an active participant. Show up at public hearings. Numbers and visibility count with advocacy efforts.
6. Make your voice heard in letters to the editor on important health issues.
7. Be persistent, cooperative, and solution focused; pay attention to timing.
To be effective, nurses must thoroughly understand the issues on current and proposed legislation, and the formal/informal processes involved in shaping policy and passing legislation. Social networking and interpersonal interaction between providers and policy makers is key to getting research and practice initiatives into policy (Taft & Nanna, 2008). If you testify at a public hearing, you will need to:
• Dress professionally.
• Keep your message simple and easy to understand; that is, What is your key message? Why is it important? What is the solution?
• Provide hard statistical data and support materials for your position. Produce one-page fact sheets.
• If there is time, add one powerful anecdote. Be descriptive, but concise.
• Know your audience; tailor your message and language accordingly.
• Keep within time limits. Memorize key points and practice your testimony. End with restating what you are advocating for.
• Acknowledge controversies and concerns, but do not dwell on them. Exercise 24-6 provides practice with effective advocacy efforts.
EXERCISE 24-6 Nurse Advocacy
Purpose: To help students think through on a relevant health issue.
Procedure:
1. As an out-of-class assignment, each student should develop a one-page advocacy letter on a relevant health care issue in his or her community, using the chapter suggestions. Check your local government Web sites, newspapers, or state legislative Web sites for ideas.
2. Bring your advocacy letter to class. Break the group into three to five students, depending on the size of the group. Each group should pick one advocacy topic and develop a 5-minute public testimony script highlighting important elements (allow 20 minutes to develop the testimony).
3. One student will present the testimony, followed by a 5-minute period for questions or public comment from the group.
Discussion:
1. How difficult was it to condense the material into a 5-minute segment?
2. Were you surprised at any of the comments or questions?
3. How could you use what you learned in this exercise in your practice?
## Summary
COC is a dynamic, client-centered service delivery process characterized as much by attitude as by actions. It is a multidimensional concept, consisting of relational, informational, and management continuity, and focused on assisting individuals and families with the resources they need to manage chronic illness within and across clinical settings. Conceptualized as the joint responsibility of patient, family, and multidisciplinary health care provider teams, the goal of COC is to ensure a seamless continuum of care for clients, provided through coordinated, community-based health services.
COC in clinical practice means building integrated delivery systems that focus on what really matters to a patient and family, and have the capacity to provide services to meet the patient's needs.
Relational continuity embraces collaborative relationships and shared decision making between health care providers and clients to whatever extent is possible. Successful outcomes also depend on interdisciplinary collaboration and interprofessional team communication caring for the client, who can be defined as an individual, family, or community in need of care.
Informational COC allows for an uninterrupted flow of data and clinical impressions between health care providers and agencies, with clients and their families, in a care experience that is connected and coherent over time.
Discharge planning and handoff reporting represent important linkages between changes in clinical settings and between nurses at change of shift. The SBAR format for communicating important information offers a standardized comprehensive methodology for transmitting information.
Management continuity is achieved through case management strategies preparation and support of family caregivers in the home, and advocacy to ensure access and adequate funding for high-quality community-based care across health care systems.
Ethical Dilemma
What Would You Do?
Paul is ready to be discharged from the hospital, but it is clear that he can no longer live independently by himself. He has had several heart attacks in the past with significant heart damage and currently suffers from chronic obstructive pulmonary disease (COPD). His recent hospitalization was for uncontrolled diabetes. Paul has difficulty complying with diet restrictions and his need to take daily insulin. He is not an easy person to live with, but Paul is sure that his daughter will welcome him into her home because he is family.
Although his daughter agrees to assume care for her father, she does so reluctantly as she has her own life and has never had a positive relationship with her father. Without her support, however, Paul cannot live independently in the community. What would you do as the nurse in this situation to promote quality of life for both individuals involved in the discharge process?
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CHAPTER 25
# Documentation in the Age of the Electronic Health Record
Kathleen Underman Boggs
Objectives
**At the end of the chapter, the reader will be able to:**
1 Identify five purposes for documentation.
2 Discuss electronic health records (EHRs) as part of a larger electronic Health Information Technology (HIT) system.
3 Discuss the need for coding and nursing taxonomy in the use of EHRs.
4 Identify how use of clinical pathways and electronic HIT systems improves client outcomes.
5 Identify legal aspects of documenting in client records.
6 Discuss how evidence-based clinical practice may change the way nursing is practiced and documented.
7 Discuss why "use of technologies to assist in effective communication in a variety of healthcare settings" is listed as an expected nurse competency by nursing organizations
The process of obtaining, organizing, and conveying client health information to others in print or electronic format is referred to as **documentation**. As illustrated in Figure 25-1, documentation serves five purposes: communicates to others care received or not received; conveys pertinent information about the client's condition and response to treatment interventions; substantiates the quality of care by showing adherence to care standards; provides evidence for reimbursement; and serves as source of data, which can be aggregated and analyzed for client care research to establish "best practice" interventions. Documentation should show evidence of effective care and client outcomes during accreditation reviews.
Figure 25-1 Why do I document?
This chapter focuses on electronic health records (EHRs) and documenting client care. In recent years, computerization of records in hospitals has gone from a leading-edge experiment to mainstream management. Regulatory and ethical implications of documentation, use of coding and of nursing taxonomies, as well as use of clinical pathways are also discussed in this chapter. The newest technology devices for medical communication at the point of care, including clinical decision support, remote monitoring, secure messaging, and telehealth, are discussed in Chapter 26.
## Basic concepts
Documenting client information
Documentation of client care must be complete and accurate. Standards of documentation must meet the requirements of government, health care agency, professional standards of practice, accreditation standards, third-party payers, and the legal system. Every health care agency has its own version of clinical documentation, but in the United States, Medicare has published guidelines for primary providers affecting advanced nurse practitioners. This documentation includes a client history (a database that often includes a summary list of health problems and needs); physical examination findings; a description of the presenting problem; and rationales for decision making, counseling, and coordination of care in a client-centered care plan. These guidelines specify what is to be examined in each body system. Nursing documentation also includes a Nursing Care Plan, daily records of client progress, and evaluation of outcomes. These daily records may include flow sheets, nursing notes, intake and output forms, and medication records.
### Computerized health information technology systems
A major communication revolution in health care is under way internationally, made possible by the increased use of computers. The U.S. Health Information Technology for Economic and Clinical Health Act of 2009 provides major resources to care providers to assist them in computerization of client care information. Computers make information more accessible to all who are involved, including your client. The U.S. Federal Government, the American Nurses Association, and the Institute of Medicine, among others, believe computerization offers opportunities to improve the quality of health care and to reduce its cost. This use of **Health Information Technology (HIT)** involves creation of a whole new electronic interactive system. It is far more than just putting existing documentation, as in paper charting, on a computer. HIT is designed to support the multiple information needs required by today's complex client care by providing you with assistance such as clinical decision support. Refer to Table 25-1 for a list of EHR components. Despite the federal government mandate that every American's health records be electronic by 2014, hospitals in the United States have been amazingly slow to adopt fully integrated computerized health systems. By 2008, less than 11% of hospitals and 20% of physician offices had even basic EHR systems, in contrast with 98% in the Netherlands and 89% in Great Britain (Carter, 2008; Silva, 2009).
TABLE 25-1
Components of a Health Information Technology System
• An integrated, accessible electronic repository of client data with easy access by a variety of health care providers and agencies
• Client health record history, physical examination findings, medications, laboratory tests, imaging files with real-time access at the point of care
• Electronic clinical documentation of care available to nurses, physicians, other providers
• Computerized provider (or physician) order entry (CPOE)
• Clinical decision support alerts and reminders, standard "best practice" protocols that monitor your care and send you prompts if care is not recorded
• Ease of access to allow aggregation of data from many clients
#### Advantages of computerized client electronic health records
EHRs, as one part of the overall computerized HIT system, are now the accepted process for documenting care. The authors use the term _EHR_ in this book, although electronic records are also known as electronic clinical records, electronic patient records, person-centered health records, or electronic medical records (Figure 25-2).
Figure 25-2 Example of an electronic health record. (Courtesy MediNotes Corporation.)
Interagency Accessibility: Electronic records are more durable than paper charting and easily transferable. For example, during Hurricane Katrina in 2005, the New Orleans Veterans Administration (VA) was able to send their 50,000 client health records to a secure site, while untold thousands of paper records at other New Orleans hospitals were destroyed by flood waters. The VA record system is fully integrated with the Department of Defense. Therefore, if a soldier is wounded abroad, diagnosed and treated, shipped home, and eventually discharged, his record including computed axial tomography (CAT) scans are seamlessly available to his VA doctor. Another example might be a client who travels across the country on vacation. His records are potentially available if he is admitted to an emergency department in another state.
Cost Savings: Initial transition from paper records is expensive, but cost reduction is expected to occur in the long run. Administrators estimate that the cost of using paper records in an agency is 25% of total health care costs. In addition to the actual paper and printing costs, there are costs involved in record transcription, filing, storage, and retrieval of information. Under Medicare and Medicaid reimbursement, hospitals maximized reimbursement through use of the computer-driven MS-DRG system.
Increased Access to Client Information: A client's EHR may be stored so that it is accessible to all of a client's care providers. Electronic records support telehealth, for example, in the case of a fully computerized medical record that includes graphic files (e.g., sonograms, x-ray scans, and other diagnostic imaging) that can be sent and analyzed by specialists hundreds of miles away. Information is instantly available to a variety of users. Results of your client's laboratory tests, posted in the laboratory, can be accessed by you from the client's inpatient unit, by the community health nurse, and by the primary physician's office as soon as the laboratory technician enters them into the hospital computer system. Your clients also can have access to some areas of their EHR. For example, Kaiser Permanente's nearly 9 million members can access their immunization records at any time from anywhere. When seeking care outside their own health system, clients can carry their entire health record on a flash drive until we achieve universal interoperatibility.
Efficiency and Ease of Use: The potential impact of EHRs on nursing efficiency is measured by a reduction in the amount of time you spend doing activities other than direct care of your client (Thompson, Johnston, & Spurr, 2009). Computer-assisted charting can reduce the time you spend charting. This allows you to spend more time with your client, possibly increasing client satisfaction. In a meta-analysis by Poissant et al. (2005), nurses reduced their time documenting by 24%, an average of almost an hour of their time in an 8-hour workday. Though there are some study results showing that computer charting takes a nurse more time, the Agency for Healthcare Research and Quality reports that there is up to a 50% decrease in time spent charting.
EHR also improves the quality of charting (Moody et al., 2004). Duplication is eliminated, increasing efficiency. This includes eliminating duplication in questioning your client about his history, as his answers about his medical history are available to you from admission. A greater impact on nursing efficiency is the elimination of duplication when charting.
Efficiency is increased because providers across all agencies have immediate access to client information. Some Canadian provinces and states such as Minnesota are examples of regions with integrated electronic health infrastructures, attained by legislating and financing a region-wide system. Thompson and colleagues (2009) list HIT benefits that improve nursing efficiency in other "downstream" ways beyond what is apparent in documentation activities, such as medication record resolution, automatic medication calculations, automatic downloading of bedside monitoring records, automated nursing discharge summaries, and so forth.
Computers should be easy to use. Your terminal may be located at the nurses' station, in your client's room, or it may be portable wherever you go, including to a client's home or a community clinic. When charting, you type in your password/identification number, scan your identity card, or scan your fingerprint. Then you enter data into the client's computer file. Some systems use a mouse or light pen to select from a menu of standard groupings or categories in documenting client care information. Many systems have template outlines to prompt you, for example, when you are doing your intake interview. Capability to document your care from your client's bedside or home is known as "point of care" and is described in Chapter 26.
Enhanced Quality of Care and Communication: A comprehensive computer information system changes the way information flows through the health care delivery system. Communication is more rapid. For example, after the client's admission to an acute care hospital, a physician's orders entered into the computer are transmitted simultaneously to the pharmacy, the laboratory, and the nursing unit. HIT can be used to communicate quickly among doctors, nurses, client, families, and across agency departments.
Quality of care can be maximized with clinical decision-making electronic "prompts" that remind you to do complete care or to chart comprehensively. This prompt function also enhances the quality of care by reminding you about the specific standards of care that may apply to your client. Most electronic client monitors, such as those recording blood pressure, pulse, and oxygenation, record this information directly into the client's EHR. This saves charting time and eliminates transcription errors. The computer sends you an "alert" to notify you about increases in your client blood pressure or other abnormalities. Records over time can be examined to determine the percentage of time you delivered care that was "best practice." In another example, your diabetic client's insurance company may be able to monitor whether his physician is appropriately checking his HbA1c levels routinely. Your client may also have limited access to his own health record, for example, to check results of his laboratory tests, his immunization records, and so on. Participation in Centralized Disease Registries can give real-time feedback to providers of care. For example, participants in the National Cancer Data System can receive electronic "alerts" if "best practice" care is not started within a certain time frame. So if the standard of care for your postoperative lumpectomy client for diagnosed early-stage breast cancer is to begin radiation within a week, the registry notifies the hospital and the physician if this fails to happen.
Communication among health professionals coordinating client care can also be improved with HIT use. For example, Nemeth's study (2007) showed that point-of-care access to current laboratory tests allowed providers to discuss changes in care at the time of the visit. An example might be instant access to laboratory results on blood clotting time, allowing you to contact the physician for a change in medication levels while you are still at your client's home.
Safety: As discussed in Chapter 22, one of the most important reasons for computerizing is to reduce errors. HITs force standardization of nursing terminology, eliminate use of inappropriate abbreviations, and avoid problems of illegibility. Errors are prevented because assistance is given with drug calculations, and in assisting with decision support such as checking drug incompatibility, allergies, and so on.
Aggregated Data: Computerized systems offer ease of access to aggregate (combine together) information from many clients for reports, disease surveillance, and to research best practice nursing care. An audit trail promotes greater accountability. Aggregated information from a number of records can be analyzed to determine outcomes, for example, the number of postoperative infections that have occurred on your unit. Access time to records is also enhanced. For example, when using paper files, it took a lengthy time to do audits for agency quality assurance or by insurance companies verifying reimbursement.
In addition to documentation, nurses use HIT systems to identify contributions nurses make to attain better client outcomes. By combining data, nurses identify better treatment methods and transfer this new knowledge to colleagues (Gruber, Cummings, Leblanc, & Smith, 2009). It is crucial to nursing that nursing terminologies become embedded into EHRs, both to improve communication between nurses, such as at change of shift, and to allow data to be extracted to describe nursing care. In the past, EHRs did not contain nursing terminologies (Westra, Delaney, Konicek, & Keenan, 2008). Thus, no data could be aggregated to identify best practice nursing care.
Keepnews, Capitman, and Rosati (2004) demonstrated that one computer charting system could be used to obtain reports about predictors of client outcomes in home health care. For example, you can easily get information identifying the most effective specific nursing interventions to establish best practice and identify other interventions that need to be changed. Combining data from many clients quickly can speed identification of adverse outcomes. For example, public health agencies analyze information about illness to generate epidemiologic information such as the spread of influenza across the world. In another example, Kaiser Permanente was able to analyze information from 1.3 million clients receiving Vioxx to identify potential harm from this medication, which led to its removal from the market.
#### Disadvantages of computerized patient electronic health records
In 2009, the American Health Information Management Association published a citizen's Health Information Bill of Rights, which states that all clients have the right to secure and accurate electronic records which they can access free of charge. Other professional organizations and governments advocate protection and privacy of client information, including electronic records.
Initial Cost: Barriers to adoption of the EHR include high start-up costs. In the United States, several government statutes provide financial incentives for adopting EHR, but beginning in 2014, there are penalties for not e-prescribing. Future changes in technologies associated with your client care will necessitate expensive software periodic revisions. These may be offset by the increased efficiency and the improved ability to capture billing levels.
Lack of Legal Guidelines: Your client's record is a legal document. Few nations have adequate laws governing information misuse of EHRs. In the United States, government Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations provide some privacy guidelines for your client's records, limiting with whom you can share this information, and these will be expanded to include associated businesses. More rigorous penalties will be imposed. When computers are located at the bedside, the screen displays information to anyone who stops by the bedside. You need to be alert to this potential violation of your client's privacy.
Lack of Uniform Standards and Universal Client Identifier Numbers: Although many countries use the same universal number to identify the client in all their agencies, in the United States, our clients often have multiple identity numbers across agencies. Proposals for using one's Social Security number have received criticism, with some favoring a separate national identification number. During the transitional phase-in stage, some information is still in paper charts whereas other data are in a computer.
Problems with System Function: Vendors created systems that were incompatible with competing software. The Office of the National Coordinator for HIT created a certification process to harmonize EHR products for better interoperatibility. Not only must EHRs be integrated in multiple departments such as pharmacy, radiology, physical therapy, and nursing, they must be accessible across agencies. A number of companies are now marketing software applications to maximize interoperatibility.
User Frustration: Incompatibility of software would make it difficult to follow care from acute treatment to rehabilitation to home care. The lack of standardized data terminology and classification in the past was a key barrier to EHR information sharing. As with the medical profession, the nursing profession has been intensely engaged in developing standardized languages for their practice.
Insurance companies, banks, and others have been doing business electronically for years. But initially, health care providers complained that software was difficult to use. Staff do have a challenge, particularly those who work in multiple agencies having different computer systems, such as nurses who float to several hospitals. New users complain HIT is time consuming, but once use is mastered, their efficiency increases. Periodic system upgrades also require readjustment.
A staff nurse on a busy unit might not have a computer terminal immediately available. Client files are routinely backed up usually once a day. If there is a dysfunction or glitch and your computer crashes, you get frustrated. Computer systems require "downtime" for storing records on backup software or while technicians service system hardware. Any time the computer is unavailable for entering your documentation, you need alternative documentation forms.
Misuse of Technology: Several articles have addressed the potential possibility of abusing the unique capabilities of computer entry, such as a temptation to "cut and paste" an old client care entry when documenting today's care (Siegler & Adelman, 2009).
Confidentiality Issues: Confidentiality and legal issues are by far the biggest areas of concern. Whenever there are multiple users, there are risks that others not involved in a client's care may access confidential information. This is particularly true for computerized data, but it is also a concern with any data transmitted electronically (e.g., information sent by fax or through telehealth networks). Ensuring privacy and developing security safeguards have become a requirement for electronic records. Procedures requiring passwords, preset log-on time limitations, and internal computer system safeguards to prevent tampering with or unauthorized access to client data are now routine expectations of nursing documentation.
### Classification of care: use of standardized terminologies
The nursing profession has been very active in developing **coding systems** for the classification of nursing care. If nursing cannot categorically classify the care provided and the outcomes of that care, there is little hope that the profession will be able to effectively communicate, document nursing care electronically, or get reimbursed for its essential role in the health care of the individual, family, and community.
#### Goal for the classification of nursing care
Problem statements, interventions, and outcomes recorded using a standard language communicate a commonly understood message across a variety of health care settings. These terms, consistent with the scope of nursing practice, are necessary to electronically document our care. When standardized language is used to document practice, we can compare and evaluate effectiveness of our care, regardless of which nurse in which setting is delivering this care. In the past, nursing has been unable to describe the units of care, its effect on client outcome, or to establish a cost for its contributions to client care. Nowhere on a client's hospital bill does the cost of our nursing care appear. It traditionally has been part of the "room charge." The goals of developing standardized terminology and classification codes are to improve communication, to make nursing practice visible within (computerized) health information systems, and to assist in establishing evidenced-based nursing practices.
#### Developing classifications for coding
Use of a standardized nursing classification language can save time by clearly describing clients' needs, interventions used, and the outcomes of care; by improving communication among staff members, in writing nursing care plans and nursing notes; and in conferring with health team members across the continuum of primary care, acute care, and home care practices. Use of standard language is instrumental in describing nursing practice. The time spent teaching, providing support, and assisting in grieving are the types of nursing activities that nurses spend considerable time doing, yet they rarely show up in the medical record. In home health records, nurses most often document nursing problems or diagnoses related to the medical diagnosis, but some report they spend most of their care in client teaching.
Taxonomies: Standardized Language Terminology in Nursing: The challenge for nursing is to communicate clearly. For decades, efforts have been made to improve communication among nurses caring for the same clients, as well as those working across different health care settings and different cultures. Our profession is building a scientific knowledge base so we can identify, teach, and give "best care" that creates the best possible outcome for our clients. With the shift to electronic records, terms must also be codable. Utilization of standardized nursing terms to describe nursing practices and their outcomes accomplishes this (Rutherford, 2008). The American Nurses Association recognizes a number of different taxonomies for describing nursing care, based on specific criteria. In 1998, McCormick and Jones predicted that because no one system could meet the needs of nurses in all areas of practice, technologic applications would be developed that would communicate across classification systems.
**Taxonomy** is defined as a hierarchical method of classifying a vocabulary of terms according to certain rules. Various taxonomies have been developed to be used in communication and comparisons across health care settings and providers, insurers/payers, and policy makers who set priorities and allocate resources. So far, the international nursing community has not agreed on one common terminology. Research by Muller-Staub and colleagues (2007) found North American Nursing Diagnosis Association International (NANDA-I) to be the best researched and most widely implemented nursing classification internationally.
Four of the most commonly used nursing taxonomies are briefly discussed: NANDA-I, the Nursing Interventions Classification system (NIC), the Nursing Outcomes Classification system (NOC), and the Omaha system.
The first three terminologies (NANDA-I, NIC, and NOC), are used together to plan and document nursing care, sometimes referred to as **NNN**. NNN use creates a systematic schema for implementing the nursing process. Table 25-2 presents an example of the linkages for the nursing diagnosis of chronic pain, linking nursing diagnosis, intervention, and outcome aids in developing electronic records so that for each diagnosis there are specific interventions and outcomes that can be selected and saved into a client database.
TABLE 25-2
Example of Linkages of North American Nursing Diagnosis Association, Nursing Interventions Classification, and Nursing Outcomes Classification
Modified from Bulechek GM, Butcher HK, Dochterman J [McCloskey]: _Nursing classification (NIC),_ ed 5, St. Louis, 2008, Mosby/Elsevier; Johnson M, Bulechek G, Dochterman JM et al: _Nursing diagnosis, outcomes, and interventions: NANDA, NOC, and NIC linkages,_ St. Louis, 2001, Mosby; and Moorhead M, Johnson M, Maas M, Swanson E: _Nursing outcomes classification (NOC)_ , ed 4, St. Louis, 2008, Mosby/Elsevier.
North American Nursing Diagnosis Association International: NANDA uses domains based on Gordon's Functional Health Patterns with diagnoses of actual problems, at-risk for diagnoses, potential problems or syndromes in illness, as well as wellness diagnoses. A nursing diagnosis is a clinical judgment and is the basis for your selection of nursing interventions. Diagnosis domains are health promotion, nutrition, elimination, rest/activity, perception/cognition, self-perception, role relationships, sexuality, coping-stress tolerance, life principles, safety/protection, comfort, and growth and development. NANDA has approved for clinical testing and refinement more than 150 standardized terms to describe nursing diagnoses. Initially designed to classify the problems of hospitalized ill clients, nursing diagnoses have been expanded to include community nursing, especially in areas used by home health nurses
A nursing diagnosis is not another name for a medical diagnosis; rather, it delineates areas for independent nursing actions. When a physician orders a primary intervention, the nursing actions are collaborative, secondary interventions that include monitoring and managing physician-prescribed interventions. A sample list of NANDA-I diagnoses is provided in Box 25-1, with the intent of generating enough material for application in the accompanying learning exercises. Refer to books on nursing diagnoses for complete information. Writing nursing diagnoses takes practice.
BOX 25-1 Sample North American Nursing Diagnosis Association Nursing Diagnoses
Nursing Diagnosis Problem Statement Relevant to Interpersonal Relationships
**Directions:** When writing a diagnostic statement for an actual nursing diagnosis (which describes a human response the nurse can treat), the nurse should use the PES formula, stating the _P_ roblem, the _E_ tiology, and the _S_ ymptoms or signs of risk factors that validate the diagnosis. Take any of the case studies in this textbook and practice writing a diagnosis.
**Example:** _Impaired verbal communication_ related to inability to speak English as evidenced by inability to follow instructions in English and verbalizing requests in Spanish
Sample Diagnosis (updated 1/2/2010):
1. Regarding ROLE (interpersonal) relationships:
Impaired parenting (associated with...)
Risk for impaired parenting...
Sexual dysfunction
Social isolation (related to...)
Interrupted family processes (related to...)
Readiness for enhanced family processes...
Ineffective role performance (related to...)
2. Regarding PERCEIVING:
Disturbed sensory perception: visual (associated with...)
Chronic low self-esteem
See North American Nursing Diagnosis Association (NANDA): _Nursing diagnoses: definitions and classifications 2009-2011_ , Philadelphia, 2009, Wiley-Blackwell.
Nursing Interventions Classification: This classification of nursing interventions was developed as a standardized language that names and defines an intervention you will use to give direct and indirect care. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. The NIC is used to communicate a common meaning across settings. Its focus is on describing nursing behaviors in the logical order you use to improve client outcomes. There are 542 recognized nursing interventions that are classified in 7 domains. The domains are physiologic basic, physiologic complex, behavioral, safety, family, health systems, and community. Under each domain are classes, and under the classes are the specific interventions. For example, in the domain of physiologic basic there is a class called "immobility management." Specific intervention activities include bedrest care, cast care maintenance, physical restraint, positioning, splinting, traction, and transport. You can use or modify these interventions to meet your client's need. Each nursing intervention has a unique code number, and thus can be computerized and potentially could be used to reimburse the nurse. In one example relevant to mobility, the code for "Body mechanics promotion" is 0140, under Class A "Activity and exercise management" (Park, Lu, Konicek, & Delaney, 2007). More than half of the most common nursing interventions are in the physiologic domain. The following case example demonstrates how NIC is used.
Case Example
Barbara, a 64-year-old woman, is 1 day after surgery for heart valve replacement. Using NIC with a diagnosis in the Physiologic Domain, Class: 1 (Respiratory management: ventilation adequate to maintain arterial blood gases within normal limits), our NIC Intervention is Labeled: Airway management with a code [#3140] and Definition: Facilitation of patency of air passages. Thus, our standardized activities include maintaining our client in a position that maximizes ventilation potential; monitoring rate, rhythm, depth, and effort of respirations q4h; removing secretions by teaching client how to cough effectively and assess ability; and auscultating breath sounds, noting changes in Sao2 and arterial blood gases.
(Case example is based on content in Bulechek, Butcher, & Dochterman [2008].)
NIC experts identify core nursing interventions. A partial list is presented in Box 25-2 (refer to the Elsevier Evolve Web site for complete information). Identification of core interventions provides nurse educators and clinicians with a focus for developing entry-level competencies for nursing practice.
BOX 25-2 Nursing Intervention Classification Core Nursing Interventions
Example Core NIC Interventions, codes, and definitions, with two samples of the many nursing intervention activities listed for each intervention:
• Active Listening (4920): attending closely to and attaching significance to a client's verbal and nonverbal messages, using activities such as using nonverbal behaviors to facilitate communication; verifying understanding of messages by use of questions or feedback
• Anxiety Reduction (5820): minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger using activities such as using a calm, reassuring approach; explaining all procedures
• Coping Enhancement (5230): assisting a client to adapt to perceived stressors...using activities such as appraising client's understanding of his disease process; encouraging verbalization of concerns
• Documentation (7920): recording all pertinent client data in a clinical record using activities such as recording complete assessment findings in initial record; charting baseline assessments and care activities using agency-specific forms/flow sheets
• Emotional Support (5270): provision of reassurance, acceptance, and encouragement during times of stress using activities such as making supportive or empathetic statements; encouraging client to express feelings of anxiety, anger, or sadness
For a complete listing of interventions, definitions, and specific nursing activities, see Bulechek GM, Butcher HK, Dochterman JM: _Nursing interventions classification (NIC),_ St. Louis, 2008, Mosby/Elsevier.
Nursing Outcomes Classification: NOC provides a standard language to name and define client outcomes attained through nursing actions to communicate among nurses and across settings. NOC complements NANDA-I and NIC, and provides a language and coding numbers for evaluating the nursing process. NOC experts identified 385 nursing-sensitive outcomes. An outcome assesses the client's actual status on specific behaviors (indicators) using a five-point scale, ranging from 1 (severely compromised function) to 5 (function not compromised). The following case example demonstrates how NOC is used.
Case Example
Mr. Lee, 46 years old, is admitted with right-sided paralysis. In the physiologic Health Domain, neurocognitive class, we use the nursing diagnosis of impaired verbal communication related to a left hemisphere bleed as evidenced by expressive aphasia. Using NOC, we get a code number (0903), Communication: Expressive, and rate him as 1 (severely compromised) on seven indicators listed. A student is assigned to his care. Her interventions to increase his expressive communication ability as listed in NOC include naming things aloud as she gives care, encouraging speech, encouraging nonverbal gestures, introducing a board displaying the pictures and words for several common needs for him to point at. After 2 days of care, Mr. Lee is assessed on the seven indicators. His use of spoken language is still rated as 1 (severely compromised). But the nurse assesses two of the other listed indicators (his use of nonverbal language and ability to point to the picture board to communicate) as having progressed to 4, mildly compromised. This shows a specific change in Mr. Lee's status after specific nursing interventions. It is numerical and thus can be coded.
(Updated based on Moorhead, Johnson, Maas, & Swanson [2008].)
The Omaha System: In the 1970s, Omaha System research was initiated to address the needs of community health nurses, managers, and administrators. The **Omaha System** is a comprehensive practice, documentation, and information management tool used by nurses and other health providers (Martin, 2005). Studies show it can also be used in acute care situations. Categories cover common transitional care problems as clients move from hospitalized care to long-term or home care. Transitional care problems include categories such as nutrition, communication, pain, physical activity, and medication administration.
The Omaha System includes an assessment, or Problem Classification Scheme. This consists of four levels: (a) the major domains (environmental, psychosocial, physiologic, and health-related behaviors), (b) specific problems, (c) modifiers, and (d) signs and symptoms. The Intervention Scheme is similarly organized into categories: (a) teaching guidance and counseling, (b) treatments and procedures, (c) case management, and (d) surveillance. Each domain has targets of the intervention. Lastly, it has an outcome component, the Problem Rating Scale for Outcomes. This consists of a five-point ordinal scale assessing the client's knowledge, behavior, and condition (the status or symptoms of the identified problem). The outcomes rating scale can be applied as a baseline and then reevaluated after the intervention to measure change in knowledge, related behaviors, and symptoms of the originally identified problem (Martin, 2005).
#### Advantages of nursing classification systems
Nursing classification systems provide a standard and common language for nursing care so that nursing contributions to client care become visible and define professional practice. The ANA has issued a position statement stating that standards for terminology are an essential requirement for a computer-based patient record (ANA, 1995b). A standardized language of nursing can help develop realistic standards of care. Groups of client records can be analyzed to describe the client population (e.g., to discover the most common interventions used for a specific nursing diagnosis). Analyzing client records in this way can lead to developing benchmarks that set the desired outcomes for a condition or diagnosis and then measure the client's actual level of achievement. Agencies could use a nursing classification system to bill for specific nursing care and build further accountability into the care and its documentation. Figure 25-3 shows how coding allows a client's data to be easily aggregated with other cases to produce a larger picture describing health care delivered by the agency.
Figure 25-3 Coding in nursing practice.
#### Disadvantages of nursing classification systems
Standardized nursing languages need to convince the business and medical interests managing health care agencies of the need to incorporate nursing classification codes as part of their information technology systems. The greatest problem has been that nursing classifications have not yet been thoroughly incorporated into many agency clinical records. Other difficulties include awkward syntax, lack of completeness, and problems with portability to other cultures. As is true of medical classification systems, nursing classification systems continue to evolve and develop as they are used in practice.
### Other coding systems in health care
The National Library of Medicine maintains a meta-thesaurus for a unified medical language. Because of the complexity of health care and the variety of providers involved, multiple medical classification systems have emerged. Often providers use several in combination. A major drawback for nursing is that use of computerized documentation systems based on medical code numbers often forces nurses to use classification systems designed to describe medical practice instead of describing nursing assessment and care of clients. In doing so, the richness of the nursing care provided often goes undocumented. Four common medical classification and coding systems are described here.
#### International classification of diseases
One of the most common medical coding systems is the ICD codes. Classifications in use include ICD-9-CM, ICD-10-CM (codes for inpatient and outpatient diagnoses), and ICD-10-PCS (codes for procedures). The World Health Organization (WHO) published a revised 10th edition in 1994, but the United States did not mandate use until 2013.
Generally, diseases are classified according to body system. ICD-10 uses three to seven digits in an alphanumeric code that begins with a letter to record diagnosis and care interventions, and has 3,000 more categories than ICD-9, which used a 4-digit numeric code. The first digit is always alpha. For example, fractures are coded beginning with S, so a displaced fracture of the neck of the right radius in an initial treatment for closed fracture is S52.131a. In another example, respiratory diseases are all classified beginning with the letter J. Pneumonia is listed in this grouping. Death from pneumonia and influenza is classified under ICD-9 as 480, but under ICD-10 code, it is J10, while to the right of this decimal, the coder can enter codes that identify very specific information, such as the type of pneumonia, which lung was affected, and so on. It is crucial when documenting care to provide enough specificity so that information management workers can correctly and accurately code. Data management and reimbursement depend on the accuracy of this coding.
#### ICD-10-PCS (Codes for procedures)
These new codes replace CPT codes, which were originally developed by the American Medical Society to provide coding for diagnostic procedures. The client's record must provide sufficient information about a diagnosis so that the insurance company computer accepts the diagnostic test as relevant and necessary for reaching a correct diagnosis. For example, the ordering of a digoxin level by a provider would be appropriate related to a diagnosis with a code for hypertension with congestive failure, but would not be appropriate or reimbursable for a diagnosis code for epilepsy.
#### Diagnosis-related groups
Diagnosis-related groups [DRGs] were originally developed for use in prospective payment for the Medicare program. Diagnosis-related group coding provided a small number of codes for classifying client hospitalizations based on diagnosis and severity of illness.
#### Diagnostic and statistical manual of mental disorders, fourth edition, text revision
The _Diagnostic and Statistical Manual of Mental Disorders,_ Fourth Edition, Text Revision (DSM-IV-TR) is the standardized diagnostic classification for mental illness. The _DSM-IV-TR_ is organized using five axes describing psychiatric diagnosis and functional status. It provides a comprehensive assessment and labeling of psychiatric and mental health–related conditions. The five axes are clinical disorders, personality disorders, general medical conditions, psychosocial and environmental problems, and global assessment of functioning (American Psychiatric Association, 2000).
#### Joint commission computerized documentation guidelines
Electronic Clinical Information Systems promote entry, storage, and linkage of _all_ information about a client's health care. Ideally, any Clinical Information System allows ease of access to one client's information as inputted by any of the client's health care providers, including the hospital and community. The Joint Commission on Accreditation of Healthcare Organizations has developed standards for uniform data for agencies it accredits. In the past, the Joint Commission required that nurses repeat information recorded by the physician. Now, nursing documentation may consist merely of updating.
#### Outcome and assessment information set
Beginning in 1998, home care agencies phased in a new requirement to complete a functional health assessment on all Medicare clients before they begin care. The results of the assessment feed into a standardized database. The Health Care Financing Administration (HCFA) developed the Outcome and Assessment Information Set (OASIS) assessment for the purpose of describing home care clients, developing outcome benchmarks, and providing feedback regarding quality of care to home health agencies.
The OASIS assessment is required for home health agencies to receive reimbursement for the care provided to Medicare recipients. Home health care agencies are sent reports comparing their client populations and functions with benchmarks established through analysis of multiple home health agency clients. OASIS can be used to establish standards of quality. The report can also be used by individual home health agencies to monitor and improve outcomes of care. The components of OASIS are essential items for documenting a comprehensive assessment of functional health status of adult home care clients. The assessment documentation is used by HCFA to analyze the health status and needs of Medicare recipients.
OASIS data items include the sociodemographic, environmental, support system, health status, and functional status attributes of nonmaternity adult clients, as well as the attributes of health service utilization. OASIS was not developed as a comprehensive health assessment tool, and home care agencies need to supplement the assessment items. The items of OASIS have evolved over time.
Home health agencies are required to submit OASIS data to a designated state site. The state agency then has the responsibility of collecting OASIS data that can be retrieved from a central repository. These data provide a national picture of health status, outcome, and cost of Medicare enrollees who require home health care. To learn more, visit HCFA's Medicare Web site (www.HCFA.gov).
### Reference terminology systems that exchange data between classification systems
The American Nurses Association recognizes two reference terminologies that can translate the terms between the various classification systems. These allow us to retrieve data even when agencies use several different classification systems.
#### Systematized nomenclature of medical-clinical terms
Systematized nomenclature of medical-clinical terms (SNOMED-CT) is the most comprehensive reference of medical terminology from many health care languages. Originally developed by American pathologists and the U.K. Department of Health (National Health Service), its goal is to accurately record health care encounters to avoid the injuries or deaths arising from poor communication between health care practitioners. It is endorsed by the American Nurses Association and is used in several other countries including Australia (www.ihtsdo.org/snomed-ct/).
#### Logical observation identifiers names and codes
Logical Observation Identifiers Names and Codes (LOINC) was developed originally to provide electronic exchange of laboratory data but evolved to include data from lots of classification systems. For example, it includes terms from the Omaha System and the Nursing Management Minimum Data Set (Westra et al., 2008).
### Charting formats for documenting nursing care
Use of structured documentation has been found to be associated with more complete nursing records, better continuity of care, more meaningful nursing data, and perhaps with better client outcomes. Use of EHRs has made written charting formats, such as the narrative **Problem-Oriented Record** (POR), the SOAP format, and so on, obsolete. Still, the focus of the POR on the client's identified list of health problems can be adapted for electronic charting. A problem list typically consists of medical diagnoses. In POR, nurses refer to the problem list and chart their observations by referring to the listed problem. Information about the client's progress in each problem area is documented when some measurable change occurs.
In charting electronically, the nurse can call up a preformulated template to record today's data. There is some evidence that use of EHRs that provide reminders or "prompts" results in more complete documentation (Gunningberg, Fogelberg-Dahm, & Ehrenberg, 2009).
Electronic charting can use **flow sheets** with predefined client progress parameters based on written standards with preprinted categories of information. They contain daily assessments of normal findings. For example, in assessing lung sounds, the nurse needs to merely check "clear" if that information is normal. Deviations from norm must be completely documented. By marking a flow sheet, you are saying all care was performed according to existing agency protocols. The best example of this format is known as critical pathways or clinical pathways.
**Clinical pathways** are a documentation system based on standardized plans of care. They are derived by aggregating computerized assessment and outcome data from client records. Locally developed by consensus, they incorporate national evidence-based best practice recommendations. A "pathway" is created, with benchmark milestones clients are expected to achieve within an identified time frame. Each specific disease or procedure has a standard path developed by an interdisciplinary team. The path describes expected care for each day and also permits the nurse to record care given. This improves communication and reduces unnecessary variations in care.
The trend toward more streamlined yet comprehensive and meaningful charting is exemplified in clinical pathways. The goals are to provide a structured tool for planning the highest quality of care; encourage interdisciplinary communication; decrease the time spent charting, because you are **charting by exception** ; focus care on expected client outcomes; and facilitate quality assurance evaluations. Most agencies give the client a copy of the pathway at the time of admission, so that he understands what is expected each day (Figure 25-4). Thus, the pathway becomes a teaching tool for client education and a tool to measure quality.
Figure 25-4 Clinical pathway for endoscopy.
_DRG_ , Diagnosis-related group; _ECG_ , electrocardiogram; _H &P_, history and physical; _IV_ , intravenous; _LOS_ , length of stay; _NPO_ , nothing by mouth; _O 2_, oxygen; _PACU_ , postanesthesia care unit; _prn_ , as needed. (From Monahan FD: _Phipps' Medical-Surgical Nursing: Health and Illness Perspectives_ , ed 8, 2007, Mosby.)
The clinical pathway is truly an _interdisciplinary tool_. It allows the entire health team to monitor the client's progress compared with a standard time frame for progress. A variance or exception occurs when a client does not progress as anticipated or an expected outcome does not occur. A variance is a red flag, alerting staff of a need for further action to assist the client.
#### Advantages
Use of clinical pathways provides a concise method for documenting routine care. Nurses direct attention to abnormal or significant findings, rather than spending time detailing normal findings. This documentation method is efficient and cost-effective. Multiple studies show it takes less nursing time. Use of pathways is associated with fewer complications and reduced length of hospital stays (Barbieri et al., 2009). Loeb et al.'s 2006 study in nursing home clients showed use of pathways was associated with fewer admissions to hospital, again showing pathways to be cost-effective.
#### Disadvantages
Charting by exception does not allow for qualitative information. If you fail to perform even one step of the protocol, you are guilty of falsifying the client's record. Legal decisions in the early 1990s found that certain nurses charting by exception were negligent by virtue of items not charted. Clinical pathways are labor-intensive to develop, and they require "buy-in" by both physicians and nursing staff.
#### Ethical, regulatory, and professional standards
The use of electronic medical records and storage of personal health information in computer databases has refocused attention on issues of ethics, security, privacy, and confidentiality. For example, a nurse in one unit of a hospital who accesses the electronic medical record of a client who is in another unit and for whom the nurse has no responsibilities for care is violating confidentiality. Ethical professional practice requires that you do not allow others to use your access log-on. Other ethical issues with electronically generated care plans and standard orders center on how to determine who is responsible for the computer-generated care decisions.
#### Confidentiality and privacy
The Institute of Medicine defines **confidentiality** as the act of limiting disclosure of private matters appropriately, maintaining the trust that an individual has placed in an agent entrusted with private matters. In the United States, most states have laws that grant the client ownership rights to the information contained in the client's health record. Electronic storage and transmission of medical records have sparked intense scrutiny over privacy protection. More than two thirds of consumers express concerns that their personal health records stored in an EHR with Internet connections will not remain private. Violations of confidentiality because of unauthorized access or distribution of sensitive health information can have severe consequences for clients. It may lead to discrimination at the workplace, loss of job opportunities, or disqualification for health insurance. Issues of privacy will dominate how nurses and other health care providers address clinical documentation in the years ahead. Currently, a **personal medical identification number** is used on client records. Hardware safeguards such as workstation security, keyed lock hard drives, and automatic log-offs are used in addition to user identification and passwords to prevent unauthorized access. Some advocate that clients be able to choose how much of their information is shared and be notified when their information is accessed. In the United States, federal law now requires clients be notified in the event of a breach of their EHR. Authorization is not needed in situations concerning the public's health, criminal, or legal matters. Refer to Chapter 2 for Federal Medical Record Privacy Regulations (HIPAA).
#### Other legal aspects of charting
Management literature emphasizes the need for quicker documentation that still reflects the nursing process. At the same time, documentation must be legally sound. The legal assumption is that the care was not given unless it is documented in the client's record. Malpractice settlements have approached the multimillion-dollar mark for individuals whose charts failed to document safe, effective care.
"If it was not charted, it was not done." This statement stems from a legal case _(Kolesar v. Jeffries)_ heard before Canada's Supreme Court, in which a nurse failed to document the care of a client on a Stryker frame before he died. Because the purpose of the medical record is to list care given and client outcomes, any information that is clinically significant must be included. Legally, all care must be documented. Aside from issues of legal liability, third-party reimbursement depends on accurate recording of care given. Major insurance companies audit client records and contest any charges that are not documented. Every nurse should anticipate having their clients' records subpoenaed at some time during their nursing career (refer to Box 25-3 for recommendations).
BOX 25-3 Documentation Suggestions
Content
• Chart promptly, but never ahead of time. Do not wait until end of shift.
• Document complete care reflecting the nursing process.
• Document all noncooperative or bizarre behavior.
• Document all refusals of ordered treatments.
• Document teaching (information you gave the client and/or family).
• When care or medicine is omitted, document action and rationale (who was notified and what was said).
• Document all significant changes in the client's condition and who was notified, as well as your nursing interventions.
Mistakes to Avoid
• Failing to record complete, pertinent health information
• Making "untimely" entries (e.g., charting after the fact, passed the day)
• Failing to record drug administration, route, outcome
• Not recording all nursing actions
• Recording on the wrong chart
• Failing to document a discontinued medication
• Failing to record outcome of an intervention such as a medicine
• Writing about mistakes or incident reports in the client record; incident reports are stored separately.
Any method of documentation that provides comprehensive, factual information is legally acceptable. This includes graphs and checklists. By signing a protocol, check sheet, pathway, and so forth, you are documenting that every step was performed. If a protocol exists in a health care agency, you are legally responsible for carrying it out.
### Communicating medical orders
Written orders
Nurses are required to question orders that they do not understand or those that seem to them to be unsafe. Failure to do so puts the nurse at _legal risk_. "Just following orders" is not an acceptable excuse. On the other hand, nurses can be held liable if they arbitrarily decide not to follow a legitimate order, such as choosing to withhold ordered pain medication. Reasons for such a decision would have to be explicitly documented. With computerization, it is possible to have standing orders, such as for administering vaccines. The computer is programmed to recognize the absence of a vaccination and then to automatically write an order for a nurse to administer. What might the legal implications be?
Persons licensed or certified by appropriate government agencies to conduct medical treatment acts include physicians, advance practice nurses, and physician assistants. These providers have their own state prescribing numbers and must abide by government rules and restrictions. To prescribe controlled substances they must also have a Drug Enforcement Agency (DEA) number. Nurse practitioners may choose not to apply for a DEA number. Consult your agency policy regarding who is allowed to write client orders for the nurse to carry out.
#### Faxed orders
The physician or nurse practitioner may choose to send a faxed order. Because this is a form of written order, it has been shown to decrease the number of errors that occur when transcripting verbal or telephone orders. However, there is the risk for violating client confidentiality when faxing health-related information. See the American Health Information Management Association's general guidelines for faxing medical orders (Hughes, 2001).
#### Verbal orders
Often, a change in client condition requires the nurse to telephone the primary physician or hospital staff resident to obtain new orders. Most primary providers work in group practices, so it is necessary to determine who is "on call" or who is covering your client when the primary provider is unavailable. It may be necessary to call for new orders if there is a significant change in the client's physical or mental condition as noted by vital signs, laboratory value reports, treatment or medication reactions, or response failure. Before calling for verbal orders, obtain the chart and familiarize yourself with current vital signs, medications, infusions, and other relevant data. Read Chapter 22 on using the SBAR format to communicate with doctors.
With the growth of unlicensed personnel, there is greater likelihood that a verbal order will be relayed through someone with this status. The legality is vague, but basically, if harm comes to the client through miscommunication of a verbal order, you (the licensed nurse) will be held responsible. The following case examples demonstrate typical scenarios you may encounter:
Case Example
Tracy, the secretary on your unit, answers the telephone. Dr. Uganda gives her an order for a medication for a client. Tracy asks him to repeat the order as soon as she gets a registered nurse to take the call. If you cannot answer the telephone immediately, have her tell him you will call back in 5 minutes to verify the order.
#### Charting for others
It is not acceptable to chart for others.
Case Example
Juanita Diaz worked day shift. At 6 p.m. she calls you and says she forgot to chart Mr. Reft's preoperative enema. She asks you to chart the procedure and his response to it. Can you just add it to your notes? In court this would be portrayed as an inaccuracy. The correct solution is to chart "1800: Nurse Diaz called and reported..."
Developing an Evidence-Based Practice
Banner L, Olney CM: Automated clinical documentation: does it allow nurses more time for patient care? _CIN Comput Inform Nurs_ 27(2):75–81, 2009.
The purpose of this study was to compare time spent in nursing activities before and then 1 year after implementation of an electronic information system. The research question was whether automation would mean more time for direct patient care and less time spent on documentation. In this time-motion study, raters observed six categories of nurse work behavior on a progressive cardiac unit using a pretest and post-test design. The six categories were direct care, indirect care, documentation, administrative tasks, housekeeping, and personal.
_Results:_ There was a statistically significant 6% _increase_ in the amount of time nurses spent in direct care ( _P_ ≤ 0.05), work such as assessing and teaching.
There was a decrease in time spent in indirect activities ( _P_ = 0.008).
There was an increase in time spent documenting ( _P_ = 0.000).
There was a 12% decrease in time nurses spent on administrative tasks ( _P_ = 0.000), such as searching for charts, verifying all paper forms were completely filed in, and so on.
No change in time spent on housekeeping or personal tasks was noted.
_Application to Your Clinical Practice:_ Many studies support these results indicating EHR gives the nurse more time at the bedside interacting with his or her client. You can use this time to make more complete assessments, to reassure ill clients, but most importantly to educate them to promote maximal health. One Canadian study found HIT also improved communication-related activities such as time spent on the telephone, paging staff, or searching for a staff member, as well as improving work flow.
Vandenkerkhof EG, Wilson R, Gay A, Duhn L: Evaluation of an innovative communication technology in an acute care setting, _CIN Comput Inform Nurs_ 27(4):254–262, 2009.
## Applications
Computer literacy
To practice nursing in coming years, you will need to continually upgrade your technology skills. As students, you learn skills such as data entry, data transmission, word processing, Internet accessing, spreadsheet entry, and use of standard language and codes describing practice. Voice recognition software may eventually revolutionize clinical documentation, making documentation easier for nurses.
### Documenting on a client's health record
Documenting electronically requires learning the specific system at your agency. There is a learning curve; that is, initially it may take longer, but as you become familiar with the system, EHRs should increase your nursing efficiency. Use Exercise 25-1 to stimulate discussion of appropriate documentation.
EXERCISE 25-1 Documenting Nursing Diagnoses
Purpose: To clarify diagnoses.
Procedure:
Discuss in small groups which of the following examples help provide a direction for independent nursing interventions.
Example 1
_Incorrect:_ Inability to communicate related to deafness
_Suggested:_ Impaired social interaction (00052) related to anatomical (auditory), as evidenced by refusal to interact with others
Discussion:
What additional information is provided in the correct diagnosis? Why would the first statement be incorrect? Are all people who are deaf unable to communicate?
Example 2
_Incorrect:_ Acute lymphocytic leukemia
_Suggested:_ Acute pain (00132) during ambulation related to leukemia disease process, as evidenced by limping, grimacing, and increased pulse
Discussion:
Could a nurse make any independent intervention based on the information provided by the diagnosis "acute lymphocytic leukemia"?
### Confidentiality
Ethical and legal dilemmas inherent in use of computerized systems require continued vigilance, especially regarding the concern of protecting client privacy. As cases come to court, a body of case law will provide some guidance. HIPAA regulations mandating clients' right to privacy are the current guidelines. You need to become aware of threats to privacy and your obligation to protect your clients' privacy where possible. Discuss the ethical dilemma provided.
### Use of universal nursing languages and codes
The need to identify and analyze outcomes of nursing practice requires computer-compatible frameworks. Adoption allows us to gather and analyze large amounts of information to identify which nursing interventions produce positive client outcomes. Interoperable computer coding applications help do this across health settings. Think about this "bigger picture" as you learn use of nursing terminology in your clinical practice.
Dochterman and colleagues (2005) were among the first to demonstrate that NIC-coded patterns of nursing interventions can be analyzed. They examined three types of interventions for older adults in 13,758 acute care hospitalizations. Data were obtained for interventions for clients with diagnoses of heart failure and hip fracture, and for fall prevention interventions. Results demonstrated that interventions occurred throughout the hospitalization period, were individualized, and could be classified into daily patterns (and potentially could produce better health outcomes). Information describing the type and amount of nursing care delivered could also potentially help staff managers plan for amount and type of staff needed on a unit.
Standardization work is ongoing internationally, as evidenced by groups such as the Association for Common European Nursing Diagnoses, Interventions, and Outcomes. Try Exercise 25-2 to explore how you might apply information.
EXERCISE 25-2 Application of Nursing Intervention Classification Finding
Purpose: To make use of NIC meaningful.
Procedure:
Consider the following finding from Dochterman's 2005 study, then answer the questions.
On Day 3 of hospitalization, nurses averaged four intravenous therapy interventions for clients with a diagnosis of hip fracture but averaged only two interventions for (oral) fluid management.
1. How could you use this information to justify the need for skilled nursing care?
2. Suppose data showed that by Day 6, skilled care activities had been cut in half. How might the nurse manager readjust the client assignment for her nurse aides?
On Day 3, clients with hip fractures received three times as many nursing interventions encouraging proper coughing as were made for clients with congestive heart failure.
1. Speculate about why there was this difference.
2. Suppose hospital units with more nursing interventions to encourage coughing were shown to have greatly decreased rates of clients with pneumonia complications. Could this information be used to justify a better nurse-to-client ratio?
From Dochterman J, Titler M, Wang J, et al: Describing use of nursing interventions for three groups of patients, _J Nurs Scholarsh_ 37(1):57–66, 2005.
### Summary
This chapter focuses on electronic documentation of care in the nurse-client relationship. Documentation refers to the process of obtaining, organizing, and conveying information to others in the client record. Discussion of new HIT including the nurse's role in using EHRs emphasized their role in reducing redundancy, improving efficiency, reducing cost, decreasing errors, and improving compliance with standards of practice. Chapter 26 discusses technology that can facilitate communication among health care workers, increase client education, and assist the providers of health care with decision making.
Ethical Dilemma
What Would You Do?
You work in an organization with a computerized clinical documentation system. A coworker mentions that Alice Jarvis, RN, has been admitted to the medical floor for some strange symptoms and that her laboratory results have just been posted, showing she is positive for hepatitis C, among other things.
1. Identify at least two alternative ways to deal with this ethical dilemma. (What response would you make to your coworker who retrieved information from the computerized system? What else might you do?)
2. What ethical principle can you cite to support each answer?
From Sonya R. Hardin, RN, PhD, CCRN.
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CHAPTER 26
# Communicating at the Point of Care
## Application of eHealth Information Technology
Kathleen Underman Boggs
Objectives
At the end of the chapter, the reader will be able to:
1 Identify types of wireless technologies of use in decentralized "point of care" nursing.
2 Discuss the advantages and disadvantages of various assistive technologies for continual communication.
3 Describe advantages to staff nurses for using clinical decision support systems software, especially with regard to potential to increase communication in health care.
4 Discuss application of technology at the point of care.
Three major transformations are occurring in use of Health Information Technology [HIT] that will greatly change traditional patterns of nursing communication:
• Electronic health record (EHR) and accompanying ordering and taxonomy (discussed in Chapter 25)
• _Decentralized access_ to client information at the point of care
• Handheld wireless devices allowing continual real-time exchange of information
According to Dr. David Blumenthal, National coordinator for HIT in the United States, no healthcare provider can practice effectively without use of eHealth technology (2009). Nurses are expected to be competent in HIT use and keep abreast as innovations are introduced to help us meet professional standards (Fetter, 2009). Broad use of HIT can improve our communication, the quality and safety of our care, and our efficiency. At the same time, HIT can decrease costs of health care in the long term.
This chapter focuses on using electronic HIT to enhance communication between nurse and client or between nurse and other professional health care providers. Communication is the cornerstone for teamwork, safety, and support. New emerging technologies facilitate our communication. Portable electronic devices with Internet access small enough to be easily carried are referred to in this textbook as "handheld" devices. Decentralized access to information and ability to document at your client's location are referred to as "point of care" capability. You can use your handheld device to access nursing information databases or to document care while at your client's bedside and in his or her home. Content in this chapter also covers other HIT tools such as computerized clinical decision support programs (CDS), secure messaging, telehealth, remote monitoring, Internet client education and support, and Internet professional education. Discussion of these emerging technologies is limited to a focus on their relation to communication.
## Basic concepts
Decentralized access technology for communication at the point of care
Available electronic technology is revolutionizing our nursing care communication (Figure 26-1). In addition to the EHR discussed in Chapter 25, new handheld devices with Internet capability allow nurses decentralized access to client records. Nursing practice now incorporates Point of Care Information and Documentation, allowing continual use of updated client information and reference material at any client location via the Internet. Communication in a timely manner is one of four standards of effective communication (Table 26-1). Communication in "real time" is the new hallmark of bedside nursing in the age of new technology. With fiscal cutbacks, fewer nurses per client, and increased acuity of client situations, use of technology can enhance our critical thinking, clinical decision making, and delivery of safe, efficient care (Carter & Rukholm, 2008; HIT, <http://healthit.hhs.gov/portal/server.pt>, accessed 1/2/10).
TABLE 26-1
TeamSTEPPS: Standards of Effective Communication
Online: www.ahrq.gov/teamsteppstools/instructor/fundamentals/module6/
Figure 26-1 Health Information Technology: wireless technology has an impact on nursing care.
Development of technology is advancing hundreds of times faster than at any previous time in history. This chapter describes a few of the current choices. The goal is to improve health care outcomes and in the long range to decrease the cost of health care. Governmental agencies in many countries have been funding use of eHealth technology and giving incentives to providers. Government programs mandate use of aspects of HIT. For example, in the United States, the Medicare Modernization Act [MMA] requires that e-prescribing be done for Part D–covered clients. EHRs must be in use before 2014. Statutes address the delivery of information to the point of care to enable more informed decisions about appropriate, more cost-effective medications. Active electronic participation by clients is seen as a way to alleviate demands on staff. Among others, the American Academy of Family Physicians supports the concept of a "medical home" embodying active client participation via e-mail, client use of Internet portals, and remote monitoring.
#### Wireless devices in health care: access to information at the point of care
Unlike other industries such as banking, health care was slow to adopt new technology. But now that wireless handheld devices with Internet access are commonly used, the transition to HIT is making rapid progress. Box 26-1 presents a summary of advantages and disadvantages for use of wireless technology by nurses. As a new generation of wireless technology comes into common use, nurses have continual access
BOX 26-1 Use of Wireless Handheld Computers
Advantages
• Easily portable; can be used at the point of care (client's bedside, in the home, etc.)
• Quick charting when nurse enters information by tapping menu selections
• Can contain reference resources about treatment, for medication dosage, and so forth, if uploaded
• May provide dictionary, and reminders about standards of care
• When accompanied by Internet access, provides quick communication (e.g., nurse is signaled by beep regarding receipt of new orders)
• Provides quick access to client records
Disadvantages
• Possible threats to client's legal privacy rights
• Long learning curve; may take a while to become familiar with how to use
• Nurse does not have a printed copy of information (until downloaded to agency printer)
• Small screen does not allow you to view entire page of information
• Technical problem may result in dysfunction/downtime
Personal digital assistants (PDAs) are handheld electronic devices that may contain multiple databases, possibly including a language translator for use when interviewing a patient from another culture. With these devices, data can be entered at the point of care, whether it is in a clinic or a patient's home, then transmitted wirelessly to a central agency computer or printer. (Photo courtesy Adam Boggs.)
to client records. HIT will transform our nursing care, enhancing our ability to give quality care, reduce risk for making errors, and improve our communication competency.
Personal Digital Assistant: Personal digital assistant (PDA) is a generic term for any of several brands of small, handheld computerized electronic devices that fit in the palm of the nurse's hand. First introduced in the mid-1990s as the U.S. Robotics Pilot (Palm Pilot), PDAs organize and retrieve information. PDAs store assessment and diagnostic tools, best practice guidelines, and references for nursing and drug information. They reduce paperwork and help the nurse save time tracking client information, leaving more time to focus on client care (Stroud, Smith, & Erkel, 2009). PDA applications can check for drug interactions, calculate dosages, analyze laboratory results, schedule procedures, order prescriptions, serve as a dictionary, or provide language translation, among other functions. It is easy to upload reference sources, such as the latest medication information or disease treatment protocols, making them akin to a portable medical and nursing library. PDAs can be taken to wherever the client is located.
PDA operating systems incorporate various types of handwriting recognition, allowing the user to tap, draw, or write on the screen using a stylus. The great advantage of PDAs over laptop computers is they are small, lightweight, and easy to carry. Because they are wireless, they can be used in the client's hospital room, in an outpatient clinic, or in the community—even in the client's home. Most PDAs can send stored information to another PDA, to the agency computer, or directly to a printer.
PDAs are used to record client data. You can enter your client's history, your assessment of this client, compile a problem list, update data, and write nursing notes. Your wireless handheld device can also be used to track information such as client's medications and dosages or laboratory test results in a flow sheet format. In the community, PDAs with Internet capability can be used to access client records. For example, a nurse practitioner using a PDA can call up a client's previous prescriptions, renew them at a touch, record this new information in the agency mainframe computer, correctly calculate the dosage of a new medication, write the order, and send this prescription to the client's pharmacy instantly—all without writing anything on paper.
Nursing programs and agencies worldwide are beginning to require use of portable devices such as PDAs. For example, a survey of emergency department nurses in Australia showed they find PDAs a useful tool in their practice (Gururajan, 2004). Some study findings indicate that providers using PDAs make more accurate judgments and write more complete reports than do control groups without access to a PDA (Skeate, Wahi, Jessurum, & Connelly, 2007).
A number of brands of hardware are available to run operating systems like Palm OS or Windows CE Pocket PC. Downloadable health care information programs are available, as well as programs that support the documentation of client care data. Limited battery life and incompatibility of software uploadable programs are limitations that need to be considered before adoption.
Cellular (Mobile) Telephones or Pagers: Some staff nurses use tools of convenience such as cell phones or pagers in their daily work. Ordinary cell phones can be used to locate clinicians, or verify and clarify information. Some hospitals are issuing mobile phones to staff nurses to use at work so they can directly contact physicians or other hospital departments from the client's bedside, give condition updates, or obtain verbal orders. The major cost is not the actual phone device but the monthly service provider cost. Nurses working in the community use cellular phones to contact clients on the way to give home care. Phones provide easy access from the field back to the agency, to the client's primary physician, and to other resources.
In the United Kingdom, nurses making home visits use mobile phones to improve communication with agencies and community services and to transmit client data (Blake, 2008a, b). Some community nurses prefer pagers, which notify them of telephone messages so they can return calls. Cellular phones equipped with cameras and picture transmission capabilities have potential for long distance diagnosis, a "snapshot" version of telemedicine/telehealth interactive video and vocal transmissions.
Smartphones: Smartphones represent the convergence of cellular mobile phones and mobile computers. These devices, such as the Blackberry Storm, have three functions: They enable you to download and access PDA-type information resources, provide Internet access to client information (new laboratory results or physician orders), and make and receive telephone calls or instant messages. Some downloaded applications provide "alerts" by beeping when there are new orders or newly available test results. In addition to housing downloaded reference programs such as those described for the PDA, smartphones with large enough memory may even house computer-assisted decision support systems. Downloadable programs such as Epocrates, a free drug information program, not only provide drug information, but when you type in client information such as age, weight, and diagnosis, they provide you with guidelines for correct dosage, contraindications, and side effects. New information "alerts" are sent to your device in a timely manner. National guidelines for best practice can also be downloaded. Smartphones are now outselling PDAs by a wide margin. Busis (2010) suggests a barcode reader as an add-on application for a smartphone.
Phones may also increase direct access to health care for the client. Companies such as TelaDoc, provide access to a physician's advice or treatment by telephone to its members for a nominal annual fee.
Laptop Computers: Laptop computers are more powerful than PDAs, yet are still small and portable enough to be taken into the client's home. They are used to chart and transmit your client's care. If a laptop with a networking card is near a wireless Internet transmitter, information can be sent in a wireless fashion. Another option is to use a telephone to transmit your nursing documentation.
### Computerized clinical decision support systems
A most important asset of HIT adoption is the provision of computerized clinical decision support systems, which the authors refer to as CDS. A CDS is defined as an electronic information technology–based system designed to improve clinical decision making to enhance client care and safety. More sophisticated CDS systems give interactive advice, after comparing entries of your client data with a computerized knowledge base. The information offered to you is personalized to your client's condition (filtered) and is offered at appropriate times in your workday. Multiple research studies indicate that integrated decision support systems offer timely information, improve provider performance, and result in better outcomes for clients (Poissant, Taylor, Huang, & Tamblyn, 2010). Computerized physician order entry systems have been heavily promoted as assets in prescribing medications because they reduce the incidence of adverse outcomes. In addition to helping you provide safer care, outcomes include reduced costs, increased adoption of best-practice care, and improved treatment responses (Bertsche, 2009).
Since the Institute of Medicine and the Canadian Institutes of Health Research began advocating CDS programs or supporting research into CDS effect on client care, suggested types of data in the CDS system have come to include:
• Diagnosis and care information displays with care management priorities listed
• A method for communication, that is, for order entry and for entering client data (system offers prompts so you enter complete data; offers "smart" or model forms)
• Automatic checks for drug-drug, drug-allergy, and drug-formulary interactions
• Ability to send reminders to clients according to their stated preference
• Medication reconciliations and client summary of care at transitions of client care
• Ability to send you electronic "alerts" or prompts if problem occurs or you haven't acknowledged receipt of information, such as client's laboratory test results
The hardware can be a computer terminal on your hospital unit or wireless handheld device, such as a PDA or smartphone. A software database can be information residing in the agency server, or a central repository such as a disease registry or government database (Berner, 2009).
For the nurse, CDS software generates specific information for your client care including assessment guidelines and forms, analyses of their laboratory test results, and use of best practice protocols to make specific recommendations for safe care (Hayes & Wilczynski, 2010). Ideally, this is integrated into the EHR system you are using. Based on input about the current condition of your client (coded data), the system is programmed to provide you with appropriate reminders. For example, after you complete care for your first assigned client, specific information is presented to you if you have not yet documented a needed intervention. This assists you in preventing treatment errors or omissions and helps improve your documentation. Blaser and colleagues (2007) demonstrated that their computerized decision support system based on clinical pathways could also speed up the time to intervention. More timely interventions should lead to fewer client complications.
CDS technology is slowly being adopted. Early systems were "stand-alone"; but technology is rapidly advancing, leading to more user-friendly, integrated systems that provide timely, relevant content. Because the system stores your information about your activity, you can obtain reports about your overall compliance with standards of care or provide data for research. More studies on CDS effects on client health outcomes and client provider communication are needed. Current research results show better client outcomes and more accurate, complete documentation (Eslami, Abu-Hanna, de Jonge, & de Keizer, 2009; Gerard et al., 2008). Key CDS issues are speed and ease of access.
### Searchable references for nursing information
Nurses have the opportunity to search databases when they need information, using computers or smartphones. There are many free, downloadable guides to care. One example is "The Guide to Clinical Preventive Services," which has care recommendations. You can search by age, sex, and risk factors (U.S. Preventive Services Task Force: www.epss.ahrq.gov). Many regional nurse associations have or soon will have such databases. Most hospitals and larger agencies have resident experts such as medical librarians or clinical nurse specialists to help staff nurses access information about evidenced-based care guidelines.
### Remote client health monitoring
Rapid upgrades in electronic applications are changing the way we deal with our clients. A few examples are described here.
#### "Smart room" technology
"Telecare" programs have been implemented that communicate client vital signs, monitor whether nurses wash hands, or signal you if a client falls and does not get up via sensors embedded in the hospital room or client's house. Families in America and England are using such sensors placed throughout the client's home to monitor for potential problems such as stove burners left on, doors left open, a too cold house, or a client crisis, such as an epileptic seizure. In the literature, this is referred to as "Smart Rooms" a form of automated medical technology.
#### Remote monitoring
Wireless technology extends decision support into the client's home. Use allows for self-monitoring, reduces time client spends in physician offices, reduces demands on staff time, and promotes efficient monitoring of your client's status (Blake, 2008a,b). A variety of monitors worn by clients can periodically transmit data directly to a primary provider or nurse in a health agency via ground telephone lines or even using wireless technology (Yao, Schmitz, & Warren, 2005). Such devices include 24-hour heart monitors, pacemakers, uterine contraction monitors, and respiratory function peak flow readings, among others. Nurses are assuming increased responsibilities for interpretation of these data and for instituting interventions.
### Electronic communication
E-mail
According to the American Medical Association (AMA, 2004), e-mail can be a convenient, inexpensive method of communicating follow-up instructions, test results, and educational information to the client in his or her home. Almost all clients express a desire to communicate with their health care providers via e-mail, but only a small percentage of physicians actually use e-mail for scheduling appointments, providing prescription refills, and other routine tasks. Physicians express concern about lack of income generation, confidentiality, malpractice, and the belief that it would be too time-consuming (Gerstle & AAP Task Force on Medical Informatics, 2004). Yet, studies show e-mail access to physicians improves communication, is desirable, decreases phone calls, may improve health outcomes, and does not impede client satisfaction (Goldman, 2005; Stalberg et al., 2008). Nurses also use e-mail as a way to communicate with clients, for example, in tracking the response of clients who are on new medication, instead of waiting until their next office appointment. AMA guidelines (2004) suggest that electronic or paper copies be made of e-mail messages sent to clients.
#### Secure messaging
Text instant messaging (IM) is commonly used in daily life, but IM can also be used to improve communications between clients and providers as a part of eHealth. IM can be used by clients to communicate self-monitored information to their care provider. The provider can also text message reminders to the client. Nurses provide personalized IM to clients as one intervention in preventive or chronic care, such as weight management, smoking cessation, or drug rehabilitation. IMs are also used as interventions with clients managing their cancer, asthma, diabetes, or other chronic diseases (Blake, 2008a,b).
#### Electronic referrals and consultations
With computerization and Internet, making eReferrals is easy. The Internet provides a common platform among agencies, even those that do not have integrated systems. Technology offers great potential for nurses, nurse-practitioners, and physician assistants, especially those who comprise a significant portion of the rural health care labor force. Rural populations comprise 20% in the United States, and tend to be poorer and medically underserved. Use of HIT discussed in this chapter can increase resources available to rural providers (Effken & Abbott, 2009). This form of communication needs guaranteed privacy protection and reimbursement provisions for the professionals for time spent to become successful (Bodenheimer, 2008).
#### Telehealth
Telehealth is also called telemedicine, or occasionally, telenursing (eHealth in England). Telehealth is a broader term encompassing any use of the Internet for health purposes. Telecommunication technology is used for exchanging information across geographic distances with professional health care providers. It can be used to diagnose and treat illness, provide preventive health care, or provide medical consultation. It initially was used to provide care to clients in rural areas but is now also used in urban areas. The goal is to increase care to the underserved, while eliminating long trips to providers, especially to emergency departments. Many studies show use of this technology reduces hospitalizations, emergency department visits, and health care costs (Dansky, Vasey, & Bowles, 2008; McConnochie, Wood, Harendeen, Noyes, & Roghman, 2009).
Telehealth provides live, real-time audio and visual transmissions from one care provider to another or to a client. This technology is hailed as a boon to rural practitioners, facilitating long-distance consultations by expert specialists. Telehealth nursing communicates monitoring data to the nurse from the client (Prinz, 2008). There is some evidence that communication devices can improve client health outcomes, but more research is needed. It requires expensive hardware equipment at both ends of the transmission, as well as the infrastructure to support its use, but has the potential to reduce the cost of conventional health services (Wang, 2009). Privacy and information secuirty are concerns expressed by potential users (George, Hamilton, & Baker, 2009).
### Client health education and support
Consumer health information
People are willing to access the Internet for self-education to meet their health care needs. The Pew Internet and American Life Project (2005) found that about 80% of Internet users search for health information, especially on specific medical problems, wellness information, or treatment procedures. Many Web sites provide consumer health information. There is strong potential for improved health learning associated with interactive computer teaching programs.
#### Lifestyle management
Not only do these educational programs increase client knowledge about their disease and their role in health promotion and disease management, but computers have been shown to positively impact client outcomes. Support and reminders about health self-management have already been described. Many Web sites provide interactive management. Others provide access to client support groups, such as the National Institute of Health. Nurses frequently recommend Internet sites to clients.
Agency for Healthcare Research and Quality's analysis of 146 studies of the impact of computer health modules on client outcomes found that these programs succeeded in engaging client attention, but more significantly they improved client clinical health (AHRQ, a). Just as studies have documented positive health outcomes after telephone support from nurses, contact with providers using interactive computer programs for Client Health Education using Webcam technology real-time (synchronous) communication between nurse and client can deliver health maintenance information, provide answers to illness-related questions, and lead to positive health outcomes.
### Provider and client communication
Web portals for client education
Many health care systems use portals to allow their clients access to communicate both with physicians and nurses. Most major pharmaceutical companies have portals that provide consumer and health care provider access to drug information.
#### Alerts
Using the Internet, you can send electronic "alerts" to your clients who need medication renewals, screening examinations or other health services. A 2009 Kaiser Permanente study showed a marked decrease in primary care office visits after implementation of an electronic system with intensive provider-client communication via a secure Web site. They cite a separate Kaiser survey showing that 85% of users reported that being able to communicate electronically with their physicians improved their ability to manage their own health (Kaiser, 2004). A personalized Web site can be used by an agency for far broader functions than providing business hours or travel directions. In an American Hospital Association study report, O'Dell (2005) says that nearly all health care organizations now have their own Web sites. Such sites can include health assessment tools and allow clients to schedule appointments. Another primary function is to provide health information. Web sites can have hyperlinks embedded that clients can use to access general information about their condition, medications, or treatment. They can also contain an e-mail link so that clients can directly contact the nurse responsible for patient education.
#### Group communication as support
Computers are used to mediate support groups for families and clients with various health problems. These formal Internet groups provide information, but they also importantly have been shown to provide improved social support for the ill client. Rains and Young's 2009 analysis of 28 research studies showed Internet group participants report less depression, increases in quality of life, as well as improved ability to manage their disease condition. Technologies associated with providing support include e-mail, instant (text) messaging, chat rooms, and discussion forums. The chat rooms are usually synchronous, in real time, providing immediate feedback. Usually discussion forums are asynchronous with time delays between postings and responses, allowing for more reflection before posting. Communication with group members over the Internet has been shown to be associated with lower levels of reported stress, especially in older adults. More studies are needed before we can specify the needed frequency, duration, or quality of content for optimal client support.
### Professional education
In addition to the portals used by clients, most professional organizations and government agencies offer free access to health care information dealing with protocols, standards of practice, and medication information. The American Nurses Association provides a popular, useful resource (www.nursingworld.org).
Developing an Evidence-Based Practice
Vandenkerhof EG, Hall S, Wilson R, Gay A, Duhn L: Evaluation of an innovative communication technology in an acute care setting, _CIN Comput Inform Nurs_ 27(4):254–262, 2009.
_Purpose:_ To assess staff attitude toward use of wireless communications device (Vocera) and compare communication patterns before and after implementation.
This quasi-experimental prestudy and poststudy was conducted to measure nurses' use of a wireless communication system, called Vocera, at Kingston General Hospital in Canada. Vocera is a personal communication tool that uses voice-over-Internet protocol. Each nurse wears a communication badge the size of a small cell phone clipped to his or her uniform or on a lanyard around the neck. Except when initiating a call by pressing a button of this badge, all the rest of the communication is hands-free. You can designate the recipient of your communication by name, title, or function—eliminating the need to know a phone number. The badge can call within the hospital or outside.
_Results:_ Use of Vocera reduced the time for key communications, such as looking for the medication keys, looking for others, paging doctors, or walking to the telephone, by 25% overall. The distance each nurse walked to communicate was also reduced.
On average, each nurse reduced the time they spent attempting to communicate from 16.2 times per shift to 11.6 times. The most significant time savings were related to looking for other staff. There was a 45% reduction in the time spent looking for others ( _P_ ≤ 0.01). Attitudes were compared before and after implementation. The increase in efficiency after implementation alleviated most concerns, except those involving confidentiality issues.
_Application to Your Clinical Practice:_ Adoption of any innovative communication system needs to take into account nurses attitudes before implementation. Could your personal cell phone be used perhaps in its "texting" function for similar within-hospital communication? Should your employing agency provide such a device for all staff? These researchers believe their findings indicate that this communication system has the potential to improve client safety, as well as improve the general acute care work environment by improving work flow or eliminating some distractions. If further research should bear this out, employers might consider purchase of communications devices as economically prudent.
## Applications
In 2004, the U.S. National Coordinator for HIT set several goals, including the need to use new technology to improve health by facilitating quality of care monitoring and quickly disseminating research findings into practice. Competency in HIT use has broadly been cited by national nursing and policy organizations as an essential of basic nursing practice (Fetter, 2009). In addition to employers, regulatory agencies, professional agencies, and academic agencies, individual nurses themselves are responsible for attaining competency (ANA: role competency statement issued 3/12/09; accessed 1/11/10).
### Point of care
Wireless entry of data at the point of care can increase your access to and use of evidence-based resources in your practice. If smartphones are used for personal business, as well as in work situations, separate e-mail/messaging accounts would be needed. Study results suggest that after an initial learning period, you will save time spent documenting care. Handheld devices at point of care provide timely access to client information, are convenient, and are cost-effective in the long run. Their prompts should help you provide safer, more comprehensive care.
#### Wireless handheld computer use
Electronic Mail: Guidelines are available for physician use of e-mail to communicate with clients (AMA, 2004); these guidelines are also appropriate for nurses. No one knows how many nurses are accustomed to using wireless technology devices in their care of clients. Guidelines for their use in giving client care still need to be developed.
Personal Digital Assistants and Smartphones: Although just about every nursing student has seen or used a wireless or cellular telephone, not everyone has used them as an aid to giving client care. These devices can save time, decrease errors, and simplify information retrieval at the point of care. Nursing is just beginning to deal with guidelines. Ethically, you do not send personal, non-professional messages.
Electronic Messaging: Electronic provider-client IM can be used to communicate simple data. This may promote better quality care and improved client utilization. Multiple articles in the literature describe the efficacy of using personalized IM for helping clients manage their conditions. In one example, your hypertensive client taking a new medication could text message his blood pressures to you today after self-monitoring, or your diabetic client could send today's glucose results after testing his or her blood sugar. Potentially, this could lead to better control, as in Harris et al.'s 2009 study in which clients who sent electronic messages to providers had better glycemic control. In addition, you can use IM to send personalized reminders to your client to schedule an appointment or take a medication.
#### Clinical decision support systems
CDS systems were introduced in the 1970s but have not yet matured into widespread use. Various CDS systems include knowledge management, triage systems, assessment forms, prescribing systems, or systems for test ordering and analysis. Multiple studies show that CDS provision of information based on evidence-based best practice improves quality of care (Damiani et al., 2010). This is most likely to occur when the CDS system is integrated into existing EHR systems and automatically provides care recommendations. The "active" or automatic provision of suggestions or prompts to the nurse to support his or her decisions is more effective than "passive" systems, which wait for the user to request data. Access to CDS programs by staff nurses is improving but still limited in most countries, including the NHS agencies in England surveyed by Mitchell and colleagues (2009).
For staff nurses, suggestions about care are offered as "pop-ups" or "alerts" when you access the client's record. For example, when you access a medication order on your client's EHR, you can use the CDS system to verify the five rights before administering the drug (Table 26-2). This reveals whether there would be any possible harmful interactions with other medications your client is already taking. CDS "reminders" integrated with your work flow gives you suggestions about interventions that are based on researched best practice. Perhaps the CDS offers you a suggested alternative to the intervention you plan. In another example, nurses working with pediatric cancer clients have long used calculators to determine correct fractional dosage based on the child's weight. Now instead, they can use this automated support system because it automatically predetermines the correct doses.
TABLE 26-2
Five Rights of Medication Administration as Communicated by Clinical Decision Support
1 | Right information | • Use of this medication is evidence based, pertinent, and suitable for my client's current condition or circumstance, as well as cost-effective.
---|---|---
2 | Right person | • Was ordered by the appropriate provider. (Nurse will verify right client via coded ID bracelet on client, preferably with his or her picture attached; CDS matches this with bar code on the medication container.)
3 | Right format | • CDS does automatic check for contraindications, allergies, etc. Matches drug with laboratory data. Checks correct dose/amount, correct form for ordered route (oral, injection, rectal suppository, etc.), and verifies that there are no harmful interactions with other drugs client is receiving.
4 | Right channel | • Communicated to all via electronic health record disseminated through computer terminal, laptop, or handheld wireless device.
5 | At the Right time | • Order and drug received by nurse at the right time in her work flow; before administration, nurse is prompted to assess any needed information, such as the client's blood glucose level. (Nurse will document as administered at the approximate time specified in the order.)
_CDS_ , Clinical decision support programs.
Case Example
The following case is an example of how this technology is designed to assist us to deliver better and safer nursing care more efficiently.
Gail Myer, RN, is assigned to Mrs. Sanchez as one of her eight clients on an obstetrical unit. Mrs. Sanchez is in preterm labor. Gail's CDS automatically lists desired client outcomes based on her work assignment, lists "best practice" interventions, and then gives real-time feedback about client outcomes. Her handheld device receives electronic prompts to assist in clinical decision making. For example, the hospital's CDS program calculates expected delivery date for Mrs. Sanchez and supplies the correct dose of the prescribed medication based on her weight. It alerts Gail if the prescribed dose she intends to administer exceeds maximum standard safety margins, and also cross-checks this new drug for potential drug interactions with the drugs Mrs. Sanchez is already taking. It pops up a screening tool for Gail to use to assess Mrs. Sanchez's current status and then alerts Gail if she should forget to document today's results.
#### Barriers
Current handheld devices and CDS software programs are somewhat cumbersome to use. It may take too much time to input the data the program needs to make recommendations to you. Another problem is that the CSD system might send you clinically irrelevant information or it might send you so many alerts that you ignore them. Studies suggest that customizing alerts to your client assignment is more effective (Tamblyn et al., 2008). A number of studies show positive results, especially in areas of drug-dosing alerts or reminders about preventive care. More studies are needed to examine effects of CDSs on communication, but data suggest a positive effect. In a Canadian study, nurses used PDAs to access the Registered Nurses Association of Ontario best-practice guidelines specific to their assigned clients' outcome assessments. Overall study results indicated communication was improved and nurses were more likely to receive information in a timely manner when their client's condition changed (Doran & Mylopoulos, 2008). Interestingly, the majority of participating nurses had not accessed the best practice resource in the month before the Doran study when they began using PDAs.
Cost and usability are the main issues in adopting CDS technology. Of course, a nurse needs the hardware, as well as easy access to the CDS software program. Access needs to be user friendly, integrated into your work flow, relevant to your care, and provide information quickly at times that really fit into your existing work flow. Some current CDS systems are cumbersome to use, provide information that is irrelevant or in too much detail to be visualized on small handheld device screens. If your CDS requires separate access from your client EHRs, provides details you did not seek or want, or repeatedly sends you alerts that are not useful, you would probably not find it helpful. On the other hand, if CDS use improves your work environment and client care, you would probably support its use. Bakken and colleagues (2008) suggest that effective use begins when this technology is integrated into the student learning experience.
### Internet use
We are just beginning to realize the positive impact that Internet use can have on client health.
#### Cyber health care for health promotion
There is considerable evidence about the efficacy of providing health care education and information online. The Internet can be used to remind clients of appointments, replacing telephone calls. Limited areas of the client's EHR can be accessed for information. Clients could sign on and obtain results of laboratory tests. One advantage is that this information would be available at all times, rather than just during office hours. Appointments can be made and reminders given via the Internet.
#### Cyber education for client disease management
Disease self-management using computers will greatly change the way nurses deliver health education. Health information about preventive health or about controlling their chronic disease conditions can be provided to clients effectively, quickly, and inexpensively via the Internet. Van der Meer and colleagues (2009) studied outcomes of an Internet-based education program for asthma self-management and found that the Internet group had better quality-of-life scores and, more importantly, maintained better asthma control than did the traditional care group. Consider other conditions that might have similar outcomes.
Client education programs via the Internet are so popular that entire companies have sprung up to provide for this need. Commercial companies produce many software packages that nurses could use to supplement their own teaching. Client learning would need to be evaluated. Outcome studies show some clients learn more from computer-based programs than from traditional teaching. One example is the HIV/AIDS program described by Marsch and Bickel (2004). PDAs can be used to play videos to educate clients about their health care. In Brock and Smith's 2007 study, clients reported PDAs were an appropriate medium for learning, regardless of their literacy skills. They demonstrated increased knowledge after watching. One problem for clients accessing health information using general Web search engines is that not all online information is accurate or easy for the user to verify. Refer to Chapter 16 for in-depth discussion of health education.
#### Cyber support for clients
Caregivers or clients with chronic conditions can use Internet support groups, chat rooms, or direct communication with care providers to gain support. Also, nurses can gain insight and better understand the "lived experiences" of their clients by participating in these Internet opportunities. Clients are accustomed to accessing support from friends when they use Facebook, Twitter, and so on. Because support via telephone has been shown to be a cost-effective method for improving functioning and quality of life for diabetic clients, the same effects need to be documented for cyber support. For example, use of cyber support opportunities has been shown to empower asthma caregivers (Sullivan, 2008). Client use of CDS programs that provide information about treatment options and the benefits and risks for each option can help them clarify their choice and can improve nurse-client communication (O'Connor et al., 2009).
### Cautions or barriers to application of new technologies
User resistance
The transition to use of eHealth technology in nursing implies a learning curve. Some providers cite problems such as the time involved in use, equipment design limitations, access issues, and fears about losing handheld devices. Australian and Swedish studies suggest that administrators need to educate and support nurses while addressing the impact of computerization on nursing work flow (Dahm & Wadensten, 2008; Eley et al., 2008).
#### Outcomes
Is the cost involved in adopting new technology worth it? Measurable effects such as work efficiency and effects on client health need to be carefully evaluated to determine the effectiveness of use of these new communication technologies.
#### Illiteracy
Illiteracy could be a barrier to consumer use. For example, in some developed countries, one-fifth of the population may be reading below fifth-grade level. Although the number of citizens who have no access to the Internet is shrinking, there are those who have yet to learn use. Experts suggest that availability of technology will have a significant, widespread, positive impact on citizen health in Third World countries. In all cases, our communication needs to be tailored to the needs and literacy level of our client (Neuhauser & Kreps, 2008).
#### Liability issues
Use of the Internet presents many questions about how to maximize its communication potential with an increasingly diverse population. Liability and regulatory issues are outmoded, relevant to the century gone by. For example, if transmission (and treatment) crosses state lines, in which region does the provider need to be licensed? If malpractice occurs, in which region or state would legal action occur?
#### Privacy
As with any computer use, we are also concerned about _security_. Today, concerns about maintaining privacy are linked in people's minds with the ability of agencies to maintain secure records. Many surveys of consumer concerns cite breach of privacy as their biggest concern. See the Ethical Dilemma box at the end of this chapter for an exercise that explores this problem.
### Professional online nursing practice guidelines
A number of nursing organizations provide policy and procedure information to nurse users. One example is the Visiting Nurse Association (VNA) which offers telecare protocols used by more than 900 agencies.
### Professional online nursing education
Some nursing programs are offered entirely online, but most have incorporated at least some computer-enhanced courses in response to student demand. Students say they prefer asynchronous (not in real time) courses that they can access at their convenience. After graduation, would you prefer this method to earn continuing education credits as required for your relicensure or recertification? How about for work-related meetings? Gross and Gross (2005) have suggested using the asynchronous format for meetings, especially when content is controversial or has emotional aspects. This format may increase participation. Try Exercise 26-1 as practice.
EXERCISE 26-1 Critique of an Internet Nursing Resource Database
Purpose: To encourage students to gain familiarity with Internet resources.
Procedure:
As an out-of-class assignment, access any nursing resource database, preferably using a handheld wireless device. Many sites are listed in the online references.
Write a one-paragraph critique; rate the Web site from 0 = useless to 10 = excellent.
1. How quickly were you able to find a specific piece of information?
2. How applicable to your clinical practice?
3. To what degree was the information evidenced based?
Discussion:
Use results as a basis for a general in-class discussion.
## Summary
HIT is an emerging new technology transforming the way nurses communicate with other professionals, with clients, and with data. HIT provides nurses with new tools to deliver nursing at the client's point of care. Moreover, it is anticipated that use of HIT will improve the quality of care. Tools discussed in this chapter include CDS programs, messaging, telehealth, and remote monitoring. HIT gives clients new ways to educate themselves, to manage their health, and to communicate with health care professionals.
Ethical Dilemma
What Would You Do?
A large insurance company's medication service routinely fills 20 million prescriptions on the client's request transmitted over the Internet. The system contains client identification numbers, names, addresses, and diagnoses. After rebooting their system after a temporary shutdown to upgrade, a technician begins to reply to accumulated e-mails. Unfortunately, he sends these e-mail responses to the wrong recipients. Clients complain that they had been promised confidentiality of medical records as long as they did not give out their password, yet they were receiving e-mails containing other members' medical information.
In another case, a pharmacy chain replaced their computers, donating old computers to a local school system. However, they neglected to wipe out customer medical information from the hard drives. Users were able to access confidential information, such as which customers were taking AIDS-suppression medications.
1. What safeguards could have prevented these violations of confidentiality?
2. If you were the nurse sending the "e-mails gone astray," what would you do?
3. Are you responsible or is only the agency responsible?
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Glossary
Accommodation A desire to smooth over a conflict through cooperative but nonassertive responses. (ch. 14)
Acculturation Describes how a person from a different culture initially learns the behavior norms and values of the dominant culture, and begins to adopt its behaviors and language patterns. (ch. 11)
Active listening A dynamic process in which a nurse hears a client's message, decodes its meaning, and provides feedback to the client. (ch. 10)
Acute grief Somatic distress that occurs in waves with feelings of tightness in the throat, shortness of breath, an empty feeling in the abdomen, a sense of heaviness and lack of muscular power, and intense mental pain. (ch. 8)
Advance directive A legal document, executed by a competent client or legal proxy, specifically identifying individual preferences for level of treatment at end of life, should the client become unable to make valid decisions at that time. (chs. 2, 8)
Advanced practice nurses Registered nurses with a baccalaureate degree in nursing, and an advanced degree in a selected clinical specialty with relevant clinical experience. (ch. 7)
Advocacy Interceding or acting on behalf of the clients to provide the highest quality of care obtainable. (chs. 7, 19, 24)
Affective domain Domain concerned with emotional attitudes related to acceptance, compliance, and taking personal responsibility for health care. (ch. 16)
Aggregated Data Compilation of multiple bits of factual information into large groupings allowing analysis. (ch. 25)
Aggressive behavior A response in which the individual acts to defend the self and to deflect the emotional impact of the perceived threat to the self through personal attack, blaming, or an extreme reaction to a tangential issue. (ch. 14)
Aging A lifelong process, advancing through the life cycle, beginning at birth and ending at death. (ch. 19)
Andragogy Art and science of helping adults learn. (ch. 16)
Anticipatory grief An emotional response that occurs before the actual death around a family member with a degenerative, or terminal disorder. (ch. 8)
Anticipatory guidance Education which helps the client foresee health outcomes. (ch. 20)
Anxiety A vague, persistent feeling of impending doom. (ch. 6, 20)
Aphasia A neurological linguistic deficit that is most commonly associated with neurological trauma to the brain. (ch. 17)
Apraxia The loss of ability or the inability to take purposeful action even when the muscles, senses, and vocabulary seem intact. (ch. 19)
Art of nursing Nurse's mode of being knowing and responding; represents an attunement rather than an activity. It is the element of care that nurses and clients tend to remember best. (ch. 1)
Assertive behavior Setting goals, acting on those goals in a clear, consistent manner, and taking responsibility for the consequences of those actions. (ch. 14)
Assimilation A person's full adoption of the behaviors, customs, values, and language of the mainstream culture. (ch. 11)
Authenticity The capacity to be true to one's personality, spirit, and character in interacting with clients and others in the nurse-client relationship. (ch. 5)
Authoritarian leadership A leadership style in which leaders take full responsibility for group direction and control group interaction. (ch. 12)
Autonomy The client's right to self-determination. (chs. 3, 19)
Avoidance A withdrawal from conflict. (ch. 14)
Beneficence Ethical principle guiding decisions, based on doing the greatest good for the greatest number and avoiding malfeasance. (ch. 3)
Best practice Nursing interventions derived from research evidence demonstrating successful outcome for client. (ch. 22)
Biofeedback Immediate and continuous information about a person's physiological responses; auditory and visual signals that increase one's response to external events. (ch. 20)
Boards of nursing State governmental agencies that are responsible for the regulation of nursing practice in each respective state. Boards of Nursing are authorized to enforce the Nurse Practice Act, develop administrative rules/regulations and other responsibilities per state statutes. (ch. 2)
Body image The physical dimension of self-concept. (ch. 4)
Body language also kinesics Involving the conscious or unconscious body positioning or actions of the communicator. (ch. 9, 10)
Boundaries Invisible limits surrounding the family unit, protect the integrity of the family system. (chs. 2, 5, 12, 13)
Boundary crossings Boundary crossings are less serious infractions. They give the appearance of impropriety but do not actually violate prevailing ethical standards. (ch. 5)
Boundary violations Boundary violations take advantage of the client's vulnerability and represent a conflict of interest that usually is harmful to the goals of the therapeutic relationship. (ch. 5)
Burnout A state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that failed to produce an expected reward. (ch. 20)
Caring An intentional human action characterized by commitment and a sufficient level of knowledge and skill to allow the nurse to support the basic integrity of the client. (chs. 1, 6)
Case management A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. (ch. 24)
Catastrophic reactions Older adult tantrums that represent a completely disorganized set of responses. (ch. 19)
Chaining Linking single behaviors together in a series of steps leading to the targeted desired behavior. (ch. 16)
Channels Channels of communication through which a person receives messages are the five senses: sight, hearing, taste, touch, and smell. (ch. 1)
Charting by exception A type of charting in which normal data are charted using check marks on flow sheets, with only abnormal/significant findings, called exceptions, being charted in a descriptive format. (ch. 25)
Chronic sorrow An ill-defined form of grief, occurring while a person is still alive, in relation to a limiting disease, or as an ongoing loss of potential in a loved one. (ch. 8)
Circular questions Questions that focus on family interrelationships and the impact of a serious health alteration has on individual family members and the equilibrium of the family system. (chs. 10, 13)
Civil laws Developed through court decisions, which are created through precedents, rather than written statutes. (ch. 2)
Clarification A therapeutic active listening strategy designed to aid in understanding the message of the client by asking for more information or for elaboration on a point. (ch. 10)
Client education also patient education A set of planned educational activities, resulting in changes in health related behaviors and attitudes as well as knowledge. (ch. 16)
Clinical pathways **(also critical pathway)** A documentation tool based on standardized plans of care for a specific health condition, usually demonstrating predefined progress toward recovery. (chs. 2, 25)
Clinical preceptor An experienced nurse, chosen for clinical competence, and charged with supporting, guiding and participating in the evaluation of student clinical competence. (ch. 7)
Closed-ended questions A question that can be answered with yes, no, or another one-word syllable. (ch. 10)
Closed groups Groups that have a pre-defined selected membership with an expectation of regular attendance for an extended time period, usually at least 12 sessions. (ch. 12)
Coding systems Alphanumerics assigned to label each type of healthcare intervention, making computerization possible. (ch. 25)
Cognitive dissonance The holding of two or more conflicting values at the same time. (ch. 3)
Cognitive distortions Faulty or negative thinking that causes a person to interpret neutral situations in an unrealistic, exaggerated, or negative way. (ch. 1)
Cognitive domain The focus when the client has a knowledge deficit. (ch. 16)
Cognitive learning Knowledge obtained from information a person did not have before. (ch. 16)
Cohesion The value a group holds for its members and their investment in being a part of the group. (ch. 12)
Collaboration A solution-oriented response in which we work together cooperatively to problem solve. (chs. 7, 14)
Collaborative nursing interventions Interventions that are those performed by the nurse and other health care team members with the mutual goal of providing the most appropriate and effective care to clients (ch. 2)
Commendations The practice of noticing, drawing forth, and highlighting previously unobserved, forgotten, or unspoken family strengths, competencies or resources. (ch. 13)
Communication A combination of verbal and nonverbal behaviors integrated for the purpose of sharing information. (ch. 9)
Communication disability Includes any client who has any impairment in body structure or function that interferes with communication. (ch. 17)
Compassion fatigue A syndrome associated with serious spiritual, physical and emotional depletion related to caring for clients that can affect the nurse's ability to care for other clients. (ch. 8)
Competition A response style characterized by domination. (ch. 14)
Complicated grieving Represents a form of grief, distinguished by being unusually intense, significantly longer in duration, or incapacitating. (ch. 8)
Computerized Clinical Decision Support programs Software programs which input specific information about your client, analyze it, and make care recommendations based on standardized care practices to promote best care outcomes as derived from research evidence. (ch. 26)
Concrete operations period Piaget's developmental stage in which a child can play cooperatively and employ complex rules. (ch. 18)
Confidentiality The respect for another's privacy that involves holding and not divulging information given in confidence except in case of suspected abuse, commission of a crime, or threat of harm to self or others. (chs. 2, 6, 25)
Conflict A mental struggle, either conscious or unconscious, resulting from the simultaneous presence of opposing or incompatible thoughts, ideas, goals, or emotional forces, such as impulses, desires, or drives. (ch. 14)
Connotation A more personalized meaning of the word or phrase. (ch. 9)
Coping Any response to external life strains that serves to prevent, avoid, or control emotional distress (ch. 20)
Countertransference Feelings represent unconscious attitudes or exaggerated feelings a nurse may develop toward a client. (ch. 1)
Criminal laws Reserved for cases in which there was intentional misconduct, and/or the action taken by the health care provider represents a serious violation of professional standards of care. (ch. 2)
Crisis A crisis occurs when a stressful life event overwhelms an individual's ability to cope effectively in the face of a perceived challenge or threat. (ch. 21)
Crisis incident An event, which is outside the usual range of experience and challenges one's ability to cope. (ch. 21)
Crisis intervention The systematic application of problem-solving techniques, based on crisis theory, designed to help the client move through the crisis process as swiftly and painlessly as possible and thereby achieve at least the same level of pre-crisis functioning. (ch. 21)
Crisis state An acute normal human response to severely abnormal circumstances; it is not a mental illness. (ch. 21)
Critical incident stress debriefing **(CISD)** A type of crisis intervention, used to help a group of people who have witnessed or experienced a mass trauma event process its meaning and talk about feelings that otherwise might not surface. (ch. 21)
Critical thinking An analytical process in which you purposefully use specific thinking skills to make complex clinical decisions. (ch. 3)
Cultural competence A set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations. (ch. 11)
Cultural diversity Variations among cultural groups. (ch. 11)
Cultural relativism The belief that each culture is unique, and should be judged only on the basis of its own values, and standards. (ch. 11)
Cultural sensitivity The ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage. (ch. 11)
Culture A complex social concept that encompasses the entirety of socially transmitted communication styles, family customs, political systems, and ethnic identity held by a particular group of people. (ch. 11)
Decentralized access A nurse can use internet devices to view or document client information even when in the community or in the client's home. (ch. 26)
Delegation The transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome. (ch. 23)
Democratic leadership The leadership style in which the leader involves members in active discussion and decision making, encouraging open expression of feelings and ideas. (ch. 12)
Denial An unconscious refusal to allow painful facts, feelings, and perceptions into conscious awareness. (ch. 8)
Denotation The generalized meaning assigned to a word. (ch. 9)
Deontological model **(also duty-based model)** A duty based model for making ethical decisions. (ch. 3)
Dependent nursing interventions Interventions that require an oral or a written order from a physician to implement. (ch. 2)
Disaster A calamitous event of slow or rapid onset that results in large-scale physical destruction of property, social infrastructure, and human life. (ch. 21)
Discharge planning A process of concentration, coordination and technology integration, through the cooperation of healthcare professionals, clients and their families, to ensure that all patients receive continuing care after being discharged. (ch. 24)
Discipline A community of interest that is organized around the accumulated knowledge of an academic or professional group. (ch. 1)
Discrimination A legal statute refers to actions in which a person is denied a legitimate opportunity offered to others because of prejudice. (ch. 6)
Disease prevention A concept concerned with identifying modifiable risk and protective factors associated with diseases and disorders. (ch. 15)
Disenfranchised grieving The grief nurses can experience following the death of a client with whom they have had an important relationship. (ch. 8)
Distress A negative stress causes a higher level of anxiety, and is perceived as exceeding the person's coping abilities. (ch. 20)
Documentation The process of obtaining, organizing, and conveying client health information to others in print or electronic format. (ch. 25)
Dysfunctional conflict Conflict in which information is withheld, feelings are expressed too strongly, the problem is obscured by a double message, or feelings are denied or projected onto others. (ch. 14)
Ecomap A sociogram, illustrating the shared relationships between family members and the external environment. (ch. 13)
Ego defense mechanisms The conscious and unconscious coping methods used by people to change the meaning of a situation in their minds. (chs. 1, 20)
Ego despair The failure of a person to accept one's life as appropriate and meaningful. (ch. 19)
Ego integrity The capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. (ch. 19)
Electronic health record **(EHR):** Various types of computerized client health records. (ch. 25)
Emancipated minors Mentally competent adolescents under the age of 18, who petition the courts for adult status. (ch. 2)
Emotional Cutoff A person's withdrawal from other family members as a means of avoiding family issues that create anxiety. (ch. 13)
Emotion-focused coping (ch. 20)
Empathy The ability to be sensitive to and communicate understanding of the client's feelings. (chs. 5, 6)
Empowerment Helping a person become a self-advocate; an interpersonal process of providing the appropriate tools, resources, and environment to build, develop, and increase the ability of others to set and reach goals. (ch. 6)
End-of-life decision making The process that healthcare providers, patients and patients' families go through when considering what treatments will or will not be used to treat a life threatening illness. (ch. 8)
Environment The internal and external context of the client, as it shapes, and is affected by a client's health care situation. (ch. 1)
Ethical dilemma **(also moral dilemma):** The conflict of two or more moral issues; a situation in which there are two or more conflicting ways of looking at a situation. (ch. 3)
E-prescribing Prescriptions typed into the health record and transmitted as hardcopy, and electronically. (ch. 26)
Ethnicity A chosen awareness that reflects a person's commitment to a cultural identity; a personal awareness of certain symbolic elements that bind people together in a social context. (ch. 11)
Ethnic group A social grouping of people who share a common racial, geographical, religious, or historical culture. (ch. 11)
Ethnocentrism A belief that one's own culture should be the norm, because it is considered better or more enlightened than others. (ch. 11)
Eustress A short term mild level of stress. (ch. 20)
Facial expression Facial configurations convey feelings without words. Facial expression either reinforces or modifies the message the listener hears. (ch. 9, 10)
Familismo A strong value in the Hispanic community. The family is the center of Hispanic life, and serves as a primary source of emotional support. (ch. 11)
Family A self-identified group of two more or individuals whose association is characterized by special terms, who may or may not be related by bloodlines or law, but who function in such a way that they consider themselves to be a family. (ch. 13)
Family Projection Process An unconscious casting of unresolved family emotional issues, or attributes people in the past from the past onto a child. (ch. 13)
Feedback A message given by the nurse to the client in response to a message or observed behavior. (chs. 1, 10)
Flow sheets Charting on sheets with client's progress in preprinted in categories of information. (ch. 25)
Formal operations period Piaget's developmental stage in which abstract reality and logical thought processes emerge and independent decisions can be made. (ch. 18)
Functional similarity Choosing group members who have enough common intellectually, emotionally, and experientially to interact with each other in a meaningful way. (ch. 12)
Functional status A broad range of purposeful abilities related to physical health maintenance, role performance, cognitive or intellectual abilities, social activities, and level of emotional functioning. (ch. 19)
Genogram A standardized set of connections to graphically record basic information about family members and their relationships over three generations. (ch. 13)
Goals (ch. 17)
Good death One that is free from unavoidable distress and suffering for patients, families and caregivers; in general accord with patients and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards. (ch. 8)
Grand theories Addresses the key concepts and principles of the discipline as a whole. (ch. 1)
Grief Describes the personal emotions, and adaptive process a person goes through in recovering from loss. (ch. 8)
Group A gathering of two or more individuals who share a common purpose and meet over time in face-to-face interaction to achieve an identifiable goal. (ch. 12)
Group dynamics A term used to describe the communication processes and behaviors occurring during the life of the group. (ch. 12)
Group norms The behavioral rules of conduct expected of group members. (ch. 12)
Group process The identifiable structural development of the group that is needed for a group to mature. (ch. 12)
Group think A phenomena that occurs when loyalty and approval by other group members becomes so important that members are afraid to express conflicting ideas and opinions for fear of being excluded from the group. (ch. 12)
Handheld wireless communication devices Any small portable computer which uses the Internet to transmit client information. (ch. 26)
Handoffs Transfer process taking place when clients are reassigned to another team of health care providers. (chs. 22, 24)
Health A broad concept that is used to describe an individual's state of well-being and level of functioning. (chs. 1, 15)
Health disparities A chain of events signified by a difference in the environment, access to, utilization of, and quality of care, health status, or a particular health outcome that deserves scrutiny. (ch. 11)
Health Insurance Portability and Accountability Act **(HIPAA)** Federal privacy standards enacted in 2003, designed to protect client records and other health information provided to health plans and other health care providers. (chs. 2, 25)
Health Information Technology **(HIT)** Creation of a whole new electronic interactive system designed to support the multiple information needs required by today's complex client care. (ch. 25)
Health literacy The degree to which people have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. (ch. 15, 16)
Health promotion An interactive educational support process that enables people to reach their highest health potential by taking control of, and improving the circumstances pertaining to their health and well-being. (ch. 15)
Health teaching A specialized form of teaching, defined as a focused, creative, interpersonal nursing intervention in which the nurse provides information, emotional support, and health-related skill training. (ch. 16)
Hearing screening Includes testing for receptive acuity, pitch, and tone perception via use of whisper, tuning fork or an audiometry machine. (ch. 17)
Heterogeneous groups Groups that represent a wider diversity of human experience and problems. (ch. 12)
Homeostasis **(also dynamic equilibrium):** A person's sense of personal security and balance. (ch. 20)
Homogeneous groups Groups that share common characteristics, for example, diagnosis (e.g., breast cancer support group) or a personal attribute (e.g., gender or age). (ch. 12)
Human rights-based model Based on the belief that each client has basic rights. (ch. 3)
Independent nursing interventions Interventions that nurses can provide without a physician's order or direction from another health professional. (ch. 2)
Inference An educated guess about the meaning of a behavior or statement. (ch. 2)
Informed consent A focused communication process in which the professional nurse or physician discloses all relevant information related to a procedure or treatment, with full opportunity for dialogue, questions, and expressions of concern, prior to asking for the client's signed permission. (chs. 2, 16)
Interactive videodiscs Contain onscreen figures that sign words preprogrammed into bar codes that you select or that you speak into a microphone. (ch. 17)
Interagency Accessibility Transmission and availability of client information across departments in a healthcare agency. (ch. 25)
Intercultural communication Conversations between people from different cultures that embrace differences in perceptions, language and non-verbal behaviors, and recognition of dissimilar contexts for interpretations. (ch. 11)
Interpersonal communication A cyclic, reciprocal, interactive and dynamic process, with value, cultural, and cognitive variables influencing its transmission and reception. (ch. 1)
Interpersonal competence The ability to interpret the content of a message from the point of view of each of the participants and the ability to use language and nonverbal behaviors strategically to achieve the goals of the interaction. (ch. 9)
Interprofessional education Occasions when two or more professions learn from and about each other to improve collaboration and the quality of care. (ch. 7)
Intrapersonal communication Takes place within the self in the form of inner thoughts; beliefs are colored by feelings and influence behavior. (ch. 1)
Justice Ethical principle guiding decision making. Justice is actually a legal term; however, in ethics it refers to being fair or impartial. (ch. 3)
Laissez-faire A hands-off approach. (ch. 12)
Leadership Interpersonal influence that is exercised in situations and directed through the communication process toward attainment of a specified goal or goals. (ch. 12)
Learning readiness A person's mind-set and openness to engage in a learning or counseling process for the purpose of adopting new behaviors.
Lifestyle Patterns of choices made from the alternatives that are available to people according to their socioeconomic circumstances and the ease with which they are able to choose certain ones over others. (ch. 15)
Loss A generic term that signifies absence of an object, position, ability or attribute. (ch. 8)
Magnet Recognition Program ANA national program that recognizes quality patient care and nursing excellence in health care institutions and agencies and identifies them as work environments that act as a "magnet" for professional nurses desiring to work there because of their excellence. (ch. 7)
Maintenance functions Group role functions that foster the emotional life of the group. (ch. 12)
Medical home A community based delivery process involving a primary care team, led by an identified personal physician for the client. (ch. 24)
Mentoring A special type of professional relationship in which an experienced nurse or clinician (mentor) assumes a role responsibility for guiding the professional growth and advancement of a less-experienced person (protégé). (ch. 7)
Message Consists of the transmitted verbal or nonverbal expression of thoughts and feelings. (ch. 1)
Message competency The ability to use language and nonverbal behaviors strategically in the intervention phase of the nursing process to achieve the goals of the interaction. (ch. 9)
Metacommunication A broad term used to describe all of the verbal and nonverbal factors that influence how the message is perceived. (chs. 9, 10)
Mid-range theories Cover more discrete aspects of a phenomenon specific to professional nursing, exploring them in depth rather than exploring the full phenomena of nursing. (ch. 1)
Minimal cues The simple, encouraging phrases, body actions, or words that communicate interest and encourage clients to continue with their story. (ch. 10)
Modeling A behavioral strategy that describes learning by observing another person performing a behavior. (ch. 16)
Moral distress A feeling that occurs when one knows what is "right" but feels bound to do otherwise because of legal or institutional constraints. (ch. 3)
Moral uncertainty A difficulty in deciding which moral rules (e.g. values or beliefs) apply to a given situation. (ch. 3)
Motivation The forces that activate behavior and direct it toward one goal instead of another. (ch. 15)
Multiculturalism A term to describe a heterogeneous society in which diverse cultural world views can coexist with some general characteristics shared by all cultural groups and some perspectives that are unique to each group. (ch. 11)
Multigenerational transmission The emotional transmission of behavioral patterns, roles, and communication response styles from generation to generation. (ch. 13)
Mutuality An agreement on problems and the means for resolving them; a commitment by both parties to enhance well-being. (ch. 6)
NNN Abbreviation designating the combination of NANDA, NIC, and NOC. (ch. 25)
Nonmaleficence Avoiding actions that bring harm to another person. (ch. 3)
Nonverbal gesture A body movement that conveys a message without words. (ch. 9)
North American Nursing Diagnosis Association International **(NANDA-I)** A professional organization of registered nurses that promotes accepted nursing diagnoses. (chs. 25)
Nuclear Family Emotional System The way family members relate to one another within their immediate family, when stressed. (ch. 13)
Nurse Practice Acts Legal documents that communicate professional nursing's scope of practice, and outline nurses' rights, responsibilities, and licensing requirements in providing care to individual clients, families, and communities. (ch. 2)
Nursing Encompassing autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. (ch. 1)
Nursing Interventions Classification **(NIC)** A standardized language describing direct and indirect care that nurses perform. NIC and Nursing Outcomes Classification (NOC) attempt to quantify nursing care so that it becomes visible and defines professional practice. (chs. 2, 25)
Nursing outcomes classification **(NOC)** The measure of how nursing care affects client outcomes. NOC and Nursing Interventions Classifications (NIC) attempt to quantify nursing care so that it becomes visible and defines professional practice. (ch. 25)
Nursing's Social Policy Statement the discipline's covenant with society and contractual obligations for care (ch. 2)
Objective data Data that are directly observable or verifiable through physical examination or tests. (ch. 2)
Omaha System A comprehensive computerized information management system for documentation at the point of care (i.e., the client's location). (ch. 25)
Open-ended questions A question that is open to interpretation and that cannot be answered by yes, no, or another one-word response. (ch. 10)
Open groups Groups that do not have a defined membership. Individuals come and go depending on their needs. (ch. 12)
Optacon A reading device that converts printed letters into a vibration that can be felt by the client who is both deaf and blind. (ch. 17)
Orientation phase The period in the nurse-client relationship when the nurse and client first meet and set the tone for the rest of their relationship, assessing the client's situation and setting goals. (ch. 5)
Pager Converts voice mail into e-mail that can be read. (ch. 17)
Palliative care A clinical approach designed to improve the quality of life for clients and families coping with a life threatening illness. (ch. 8)
Paralanguage The oral delivery of a verbal message expressed through tone of voice and inflection, sighing, or crying. (ch. 9)
Paraphrasing Transforming the client's words into the nurse's words, keeping the meaning intact. (ch. 10)
Patterns of Knowing A unified form of knowledge embedded in nursing practice and grounded in empirical principles, intuitive personal responses, creative aesthetics used to connect with a client, and ethics, which the nurse uses to address the individualized needs of clients (ch. 1)
Pedagogy The processes used to help children learn. (ch. 16)
Perception A personal identity construct by which a person transforms external sensory data into personalized images of reality. (ch. 4)
Person A unitary concept that includes physiological, psychological, spiritual, and social elements. (ch. 1)
Personal digital assistant **(PDA)** A wireless electronic device containing databases that may also have the potential for electronic message transfer. (ch. 26)
Personal identity An intrapersonal psychological process consisting of a person's perceptions or images of personal abilities, characteristics and potential growth potential. (ch. 4)
Personal space The invisible and changing boundary around an individual that provides a sense of comfort and protection to a person and that is defined by past experiences and culture. (ch. 6)
Point of care Whatever location the nurse is in to provide care to the client, whether at the bedside in his hospital room, in an outpatient clinic, or even in the client's own home. (ch. 26)
Point of care information Client information and reference material that is updated via wireless Internet devices at any location. (ch. 26)
Possible selves Used to explain the future oriented component of self concept. (ch. 4)
Practice theories The most limited form of nursing theory. (ch. 1)
Prejudices Stereotypes based on strong emotions. (ch. 6)
Premack principle The choice of reinforcer should always be something of value to the individual learner. (ch. 16)
Preoperational period Piaget's developmental stage in which learning by the toddler is developed through concrete experiences and devices and the child is markedly egocentric. (ch. 18)
Primary prevention Actions taken to preclude illness or to prevent the natural course of illness from occurring; focus is on teaching people how to establish and maintain lifestyles conducive to optimal health. (ch. 15)
Privacy A client's right to have control over personal information whereas confidentiality refers to the obligation not to divulge anything said in a nurse-client relationship. (ch. 2)
Problem-oriented record **(POR)** A chart containing four basic sections: (1) a database, (2) a list of the client's identified problems, (3) a treatment plan, and (4) progress notes. (ch. 25)
Professional boundaries The invisible structures imposed by legal, ethical, and professional standards of nursing that respect nurse and client rights and protect the functional integrity of the alliance between nurse and client. (ch. 5)
Professional networking Establishing and using contacts for information, support, and other assistance in order to achieve career goals. (ch. 7)
Professional performance standards A competent level of professional role behavior related to quality of care, practice evaluation, continuing education, collegiality, collaboration, ethics, research, resource utilization and leadership. (ch. 2)
Professional standards of practice The knowledge and clinical skills required of nurses to practice competently and safely. (ch. 2)
Proxemics The study of an individual's use of space. (ch. 6, 9)
Psychomotor domain Learning a skill through hands-on practice. (ch. 16)
Quality of life A personal experience of subjective well-being, and general satisfaction with life that includes, but is not limited to, physical health. (ch. 1)
Real-time captioning devices Allow spoken words to be typed simultaneously onto a screen. (ch. 17)
Receiver The recipient of the message. (ch. 1)
Reflective appraisals The personalized messages received from others that help shape self-concepts, and contribute to self evaluations. (ch. 4)
Reframing Changing the frame in which a person perceives events in order to change the meaning. (ch. 10)
Reinforcement **(also conditioning)** The consequences of performing identified behaviors; positive reinforcement increases the probability of a response, and negative reinforcement decreases the probability of a response. (ch. 16)
Resilience Strength in the midst of change and stressful life events; the power of springing back or recovering readily from adversity. (ch. 15)
Safety The minimalization of risk of harm to clients and to providers; the avoidance of adverse outcomes or injuries stemming from the healthcare process. (chs. 14, 22)
SBAR A standardized communication format, used in handoffs and discharge/transfer of clients to communicate critical information about a client. (Ch. 2, 22, 24)
Scope of practice A broad term referring to the legal and ethical boundaries of practice for professional nurses established by each state; it is defined in written state statutes. (ch. 2)
Secondary prevention Interventions designed to promote early diagnosis of symptoms through health screening, or timely treatment after the onset of the disease, thus minimizing their effects on a person's life. (ch. 15)
Self-concept An acquired constellation of thoughts, feelings, attitudes and beliefs that individuals have about the nature and organization of their personality. (ch. 4)
Self-differentiation A person's capacity to define him/herself within the family system as an individual having legitimate needs and wants. (ch. 13)
Self-disclosure Intentional revealing of personal experiences or feelings that are similar to, or different from those of the client. (ch. 5)
Self-efficacy A term originally developed by Albert Bandura referring to a personal perceptual belief that a person has the capability to perform general or specific life tasks successfully. (ch. 4, 15)
Self-esteem The emotional value a person places on his or her personal self worth in relation to others and the environment. (ch. 4)
Self-talk A cognitive process people can use to lessen cognitive distortions. (ch. 4)
Sender The source or initiator of the message. (ch. 1)
Sensorimotor period Piaget's developmental stage in which the infant explores its own body as a source of information about the world. (ch. 18)
Shaping The reinforcement of successive approximations of the target behavior. (ch. 16)
Sibling Position A belief that sibling positions shape relationships and influence a person's expression of behavioral characteristics. (ch. 13)
Social cognitive competency The ability to interpret message content within interactions from the point of view of each of the participants. (ch. 9)
Social support The emotional comfort, advice, and instrumental assistance that a person receives from other people in their social network. (ch. 20)
Societal Emotional Process Parallels that Bowen found between the family system and the emotional system operating at the institutional level in society. (ch. 13)
Speech amplifiers Devices to assist hearing. (ch. 17)
Speech-generating devices Laptop computers, fax machines, and PDAs (ch. 17)
Spirituality A unified concept, closely linked to a person's worldview, providing a foundation for a personal belief system about the nature of God or a Higher Power, moral-ethical conduct, and reality. (chs. 4, 8, 11, 20)
Standard communication tools Uniformly used formats for communication of client information among all care providers, such as SBAR. (ch. 22)
Statutory laws Legislated laws, drafted and enacted at federal or state levels. (ch. 2)
Stereotyping The process of attributing characteristics to a group of people as though all persons in the identified group possessed them. (ch. 6)
Stress A natural physiologic, psychological, and spiritual response to the presence of a stressor. (ch. 20)
Stressor A demand, situation, internal stimulus, or circumstance that threatens a person's personal security or self-integrity. (ch. 20)
Subculture A smaller group of people living within the dominant culture who have adopted a cultural lifestyle distinct from that of the mainstream population. (ch. 11)
Subsystems Member unit relationships within the family such as spousal, sibling, and child-parent subsystems. (ch. 13)
Sundowning Episodic agitated behavior occurring in the late afternoon, or early evening with clients in the middle stages of dementia. (ch. 19)
Task functions The group role functions that facilitate goal achievement. (ch. 12)
TCAB An acronym for the program 'Transforming Care at the Bedside' which empowers nurses to make changes which improve client safety. (ch. 22)
TeamSTEPPS A program which emphasizes improving client outcomes by improving communication. (ch. 22)
Telehealth Any use of Internet transmitted visualization for health care diagnosis or treatment. Also known as Telemedicine, Telenursing, eHealth. (chs. 1, 26)
Tellatouch A portable machine into which the nurse types a message that emerges in Braille on a punched-out paper in Braille format. (ch. 17)
Termination phase **(also resolution)** A period in the nurse-client relationship when the nurse and client examine and evaluate their relationship and its goals and results; the time when they deal with the emotional content (if any) involved in saying good-bye. (ch. 5)
Tertiary prevention Rehabilitation strategies designed to minimize the handicapping effects of a disease or injury, once it occurs. (ch. 15)
Theme The underlying feeling associated with concrete facts a client presents (e.g. feelings of powerlessness, fear, abandonment, and helplessness). (ch. 10)
Theory A theorist's thoughtful examination of a phenomenon, defined as a concrete situation, event, circumstance, or condition of interest. (ch. 1)
Therapeutic communication An interactive active dynamic process entered into by nurse and client for the purpose of achieving identified health related goals. (ch. 10)
Therapeutic relationship A professional interpersonal alliance in which the nurse and client join together for a defined period of time to achieve health-related treatment goals. (ch. 5)
Touch Providing comfort and communication through purposeful contact. (ch. 9)
Transference Projecting irrational attitudes and feelings from the past onto people in the present. (ch. 1)
Triangles A defensive way of reducing, neutralizing or defusing heightened anxiety between two family members by drawing a third person, or object into the relationship. (ch. 13)
Trust A relational process, one that is dynamic and fragile, yet involving the deepest needs and vulnerabilities of individuals. (chs. 5, 6)
Uniform standards Guidelines of accepted practice. (ch. 25)
Universal client identifier numbers A unique series of digits assigned to each client, used by every health agent/agency. (This would replace use of identifying numbers such as social security number, which were not intended to be used for health care.) (ch. 25)
Utilitarian/goal-based model A framework for making ethical decisions in which the rights of the client and the duties of the nurse are determined by what will achieve maximum welfare. (ch. 3)
Validation A form of feedback involving verbal and nonverbal confirmation that both participants have the same basic understanding of the message. (chs. 1, 10)
Values A set of personal beliefs and attitudes about truth, beauty, and the worth of any thought, object, or behavior. Attitudes, beliefs, feelings, worries, or convictions that have not been clearly established are called value indicators. (ch. 3)
Values acquisitions The conscious assumption of a new value. (ch. 3)
Values clarification A process that encourages one to clarify one's own values by sorting them through, analyzing them, and setting priorities. (ch. 3)
Verbal responses The spoken words people use to communicate with each other. (ch. 10)
Violence A mental health emergency, which can create a critical challenge to the safety, well-being and health of the clients and others in their environment. (ch. 21)
Web portal An agency website that provides opportunities for consumers to use hyperlinks to access a variety of information, receive cyber support, or even make appointments. (ch. 26)
Well-being A person's subjective experience of satisfaction about his/her life related to six personal dimensions: intellectual, physical, emotional, social, occupational, and spiritual. (ch. 15)
Wireless text communication text messaging (ch. 17)
Wisdom The virtue associated with Erikson's 8th, and final stage of ego development, represents an integrated system of 'knowing' about the meaning and conduct of life. (ch. 19)
Working phase The period in the nurse-client relationship when the focus is on communication strategies, interventions for problem resolution, and enhancement of self-concept. (ch. 5)
World view The way people tend to look out upon their world or their universe to form a picture or value stance about life or the world around them. (ch. 11)
Photograph Credits
**Chapter 1**
Lowdermilk D, Perry S: Maternity and Women's Health Care, ed. 9, St. Louis, 2007, Mosby
Marriner Tomey A: Guide to nursing management and leadership, ed 8, Mosby, 2009.
Yoder-Wise PS:, Leading and Managing in Nursing, ed. 5, St. Louis, 2011, Mosby
**Chapter 2**
Sorrentino SA: Mosby's Textbook for Nursing Assistants, ed. 7, St. Louis, 2008, Mosby
**Chapter 3**
©2010, PhotoDisc, _Medicine Today_
**Chapter 4**
Courtesy Elizabeth Arnold
**Chapter 5**
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
©1996, Digital Stock, _Medicine and Health Care 2_
**Chapter 6**
Courtesy Adam Boggs
**Chapter 7**
©1996, Digital Stock, _Medicine and Health Care 2_
©2010, Comstock, _Medical 3_
**Chapter 9**
Sorrentino SA: Mosby's Textbook for Nursing Assistants, ed. 7, St. Louis, 2008, Mosby
**Chapter 10**
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
Potter PA, Perry AG: Fundamentals of Nursing, ed. 7, St. Louis, 2009, Mosby
**Chapter 11**
©2010, PhotoDisc, _Medicine Today_
Sorrentino SA: Mosby's Textbook for Nursing Assistants, ed. 7, St. Louis, 2008, Mosby
**Chapter 12**
Yoder-Wise PS:, Leading and Managing in Nursing, ed. 5, St. Louis, 2011, Mosby
**Chapter 14**
Yoder-Wise PS:, Leading and Managing in Nursing, ed. 5, St. Louis, 2011, Mosby
**Chapter 16**
©2010, Comstock, _Medical 3_
©2010, PhotoDisc, _Medicine Today_
©2010, Comstock, _Medical 3_
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
**Chapter 17**
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
Potter PA, Perry AG: Fundamentals of Nursing, ed. 7, St. Louis, 2009, Mosby
**Chapter 19**
Leake P: Community/Public Health Nursing Online for Stanhope and Lancaster Foundations of Nursing in the Community, ed. 3, St. Louis, 2010, Mosby.
**Chapter 20**
Potter PA, Perry AG: Fundamentals of Nursing, ed. 7, St. Louis, 2009, Mosby
**Chapter 22**
Yoder-Wise PS: Leading and Managing in Nursing, ed. 5, St. Louis, 2011, Mosby
Courtesy Endur ID Incorporated, Hampton, NH
**Chapter 24**
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
**Chapter 26**
Potter PA, Perry AG: Basic Nursing, ed. 7, St. Louis, 2011, Mosby
# Index
Note: Page numbers followed by _b_ indicate boxes, _f_ indicate figures and _t_ indicate tables.
A
Abuse, elder,
Acceptance stage, of dying,
Accommodation,
Accountability, , ,
Acculturation,
Acting-out behaviors, 361–362
Active listening
to child,
conflict resolution using,
definition of, , 179–180
language used in, 190–191
responses, 184–188
clarification, 185–186, 186 _b_
feedback, 191–192
minimal cues and leads, 184–185, 185 _b_
paraphrasing, , 187 _b_
reflection, , 187 _b_
restatement,
silence, 187–188, 188 _b_
summarization, 186–187, 187 _b_
validation,
Activities of daily living,
Acupressure,
Acute grief, 146–147
Adaptive functioning,
Adolescents
communication with, , 360–361
teaching strategies for, 318 _t_
Advance directives, 28–30, 29 _t_, 30 _b_,
Advance organizers,
Advance practice roles, 122–123, 123 _b_
Adventitious crisis,
Advocacy
children,
community, 484–486
description of, 134–136, 135 _b_, 137 _b_, ,
legal protections,
methods of, 486 _b_
older adults, 381–382
safety,
Aesthetic way of knowing,
Affect,
Affective domain of learning, 314–315
African American clients, cultural considerations, 212–213
Agency for Healthcare Research and Quality,
Aggression
behavior associated with,
clients showing, 287–288
by dementia patients, 388 _t_
Aging _See also_ Older adults
attitudes toward,
communication affected by,
concepts of, 369–371
definition of,
health affected by, 370–371
successful, ,
wisdom of, , 372 _b_
Agitation, 388 _t_
Aguilera, Donna,
Alerts, 514–515
Allostasis model of stress, , 395 _f_
Altruism, 126 _t_
Alzheimer's disease,
professional education models of,
safety and, ,
American Association of Critical Care Nurses,
American Health Information Management Association, 493–494
American Nurses Association
Bill of Rights for Registered Nurses, 131 _b_
Code of Ethics for Nurses, , , 28 _b_, , , ,
nursing standards,
Social Policy Statement,
American Nurses Credentialing Center,
Magnet Recognition Program, 131–132, 132 _f_
American Sign Language, , 341–343
Americans with Disabilities Act,
Andragogy, , 317 _f_
Anger, 273 _b_, 279–280, , 402 _b_,
Anger stage, of dying,
Angry clients, 285–287
Anticipatory grief,
Anticipatory guidance, , , 405–406
Anxiety
anger and, 402 _b_
behaviors associated with,
in children, ,
conflict effects on,
crisis-related,
description of, 279–280
family, 403 _t_
health teaching affected by,
nurse-client relationship affected by, 108–110, 109 _b_, 109 _t_, 110 _b_
separation,
Aphasia, ,
Apraxia, 383–385
Art of nursing, 5–7
Art therapy groups,
Articles, 5 _b_
Asian American clients, cultural considerations, , , , 213–216
Assertive behavior, , 275 _b_
Assertive skills, 283–285
Assertiveness, , 276 _b_
Assessment
case management,
client needs,
cognition, 71–72,
communication deficits and disabilities,
conflict, 277–278
cultural _See_ Cultural assessment
family _See_ Family assessment
nursing process, 31 _t_, 32–33
older adults, 373–377
pain, , 376–377
self-esteem, 74–76
social support, 401–402
spirituality, 78–80
stress, 399–404
Assessment summary,
Assimilation, 200–201
Attending behaviors,
Audiovisual aids, 359–360
Authenticity,
Authoritarian leadership, 240–241
Authority, , 458 _b_
Autonomy, 46–47, 53 _b_, 126 _t_, 208–209, , ,
Avoidance,
"Awfulizing, ",
Ayurveda,
B
Baby boomers, , 371 _b_
Bar-coded name bands, 447–448
Bargaining stage, of dying,
Beck, Aaron, 12–13
Behavioral cues, 178 _b_
Behavioral models, 316–319
Behavioral strategies
modeling,
premack principle,
reinforcement, , 317 _t_
shaping, ,
chaining,
Beneficence, 47–48, 53 _b_
Benner's stages of clinical competence, 128 _t_
Best practices
description of, , 439–440
evidence-based, 442–444
Bias
description of, 110–111
self-awareness of,
Bioethical principles, 46–47
autonomy, 46–47, 53 _b_
beneficence, 47–48, 53 _b_
justice, , 53 _b_
nonmaleficence, 47–48
paternalism, 46–47
Biofeedback,
Blaming,
Blended family, 247–248, 248 _t_
Blind self,
Bloom, Benjamin,
Body cues,
Body image
definition of,
disturbances of, 68–69
meaning of,
Body language,
Boundaries,
Boundary crossings,
Boundary violations,
Bowen's systems theory, 249–250
Brainstorming, , 243 _b_
Briefings,
Bullying,
Burnout, 409–412, 411 _f_, 411 _t_, 412 _b_
C
Canadian Nurses Association Code of Ethics for Registered Nurses,
Capacity building, 305–306
Caplan, Gerald, 417–418
Caregiver
family as, 267–268, 483–484
role as, 122 _t_
Caregiving skills, 329–332
Caring
communication improvement through, 104–105
description of, , 8 _b_
steps involved in, 113–114
Case finding,
Case management, 481–484
chronically medically ill clients,
definition of,
description of,
goal of,
implementation, 482–483
informal family caregivers, 483–484
populations served by,
principles and strategies for, 482–483
treatment planning,
Case manager, 122 _t_, , 482–483,
Catastrophic reactions, 387–388
Cellular telephones,
Center for the Advancement of Health, 330–331
Centers for Disease Control and Prevention,
Certified nurse-midwives,
Certified registered nurse anesthetists,
Charting by exception, 501–503
Children _See also_ Pediatric care
acting-out behaviors by, 361–362
active listening with,
adolescents
communication with, , 360–361
teaching strategies for, 318 _t_
advocacy for,
anticipatory guidance for, ,
anxiety in,
autonomy in,
cognition in
communication considerations, 350–351
developmental stages of, 350 _t_
impairments in,
communication by
hobbies used for, 360–361
play as, 353–357,
regression as form of,
communication with
active listening,
adolescents, , 360–361
age-appropriate considerations, 352–353, 354 _b_
assessments, 352–353, 353 _f_
authenticity in, 363–364
developmentally appropriate levels of, 350–351, 350 _t_
gender differences,
infants, 354–355,
interpersonal, 351–352
location for,
1- to 3-year-olds,
overview of,
physically ill child, 353–357, 354 _b_
preschoolers, 355–356, 357–364
respect in,
school-age children, , 358–360
3- to 5-year-olds, 355–356
toddlers,
veracity in, 363–364
disaster management for, 433–434
end-of-life care for, 155–158
family-centered care of, 351–352
hearing loss in,
hospitalization of, 351–352
infants, 354–355,
medical terminology usage with, 359 _b_
nurse as advocate for,
obesity in,
1- to 3-year old,
pain in,
physically ill
assessment of child's reaction, 352–353
communication with, 353–357, 354 _b_
needs of,
parents of, communication with, , 364–366
peers of, 352–353
preschoolers
communication with, 355–356, 357–364
teaching strategies for, 318 _t_
regressive behavior by,
school-age
communication with, , 358–360
teaching strategies for, 318 _t_
with special health care needs, ,
stress in,
supportive care for, 155–158, 157 _t_
teaching strategies for, 318 _t_
3- to 5-year old, 355–356
toddlers,
vision loss in,
Chronic conditions, 469–471
Chronic sorrow, 146–147
Circular questions, ,
Circular transactional model of communication, 14–15, 14 _f_, 15 _b_
Citizen Corps Program,
Citizen responders,
Civil laws, 26–27
Clarification, 185–186, 186 _b_
Clarifying feelings, 75 _f_
Client
advocacy _See_ Advocacy
aggressive, 287–288
angry, 285–287
coaching of, 331–332, 332 _b_, 332 _f_
culturally diverse _See_ Culturally diverse clients
definition of, 83–84
health literacy assessments,
medication administration rights for, 517 _t_
nurse and, relationship between _See_ Nurse-client relationship
physician communication with, ,
rights and responsibilities, , 135 _b_
violent, 287–288
Client advocate role, 122 _t_
Client education
client health literacy vs,
definition of,
Internet programs for,
Web portals for,
Client handoff, _See also_ Handoffs
Client needs
assessment of,
identifying of, 92–93
therapeutic relationships, 92–93
Client-centered care, 471–472, 473 _f_
Client-centered communication, 179–180
active listening in, 179–180
asking questions, 181–183
characteristics of,
description of,
goal of,
introductions,
nonverbal,
observation,
patterns of,
rapport building, 180–181
role-play exercise for, 181 _b_
themes, , 184 _b_
Client-centered health teaching, 315–316
Client-centered interactions, 89 _b_
Client-centered outcomes, 34–35
Client-centered partnership,
Clinical competence, 128 _t_
Clinical decision support systems, computerized, 511–512, 516–517
Clinical incompetence,
Clinical judgments, ,
Clinical nurse leader,
Clinical nurse specialists,
Clinical pathways, , , 502 _f_
Clinical practice, 7–8
Clinical research,
Clock drawing test,
Closed groups,
Closed-ended questions,
Clustering of information,
Coaching, 331–332, 332 _b_, 332 _f_
Code of Ethics for Nurses, , , 28 _b_, , , ,
Coding systems, 499–501
diagnosis-related groups,
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,
International Classification of Diseases, 499–500
Joint Commission computerized documentation guidelines,
Outcome and Assessment Information Set, 500–501
Cognition, 71–74
assessment of, 71–72,
definition of,
dementia-related changes in, 385 _b_
in older adults,
personal identity affected by, , 71–74
Cognitive behavioral communication strategies, , 194 _b_
Cognitive behavioral therapy, 12–13,
Cognitive dissonance,
Cognitive distortions, , , 73 _b_
Cognitive domain of learning,
Cognitive impairments
delirium, 384 _t_
dementia _See_ Dementia
description of, ,
older adults, 383–389
Co-leadership, 230–231
Collaboration, , 138–139,
Collaborative nursing interventions,
Colleagues _See also_ Peers
professional nursing roles with, 129–130
verbal communication with,
Collegiality culture, 452–453
Commendations, , 265 _b_
Commune,
Communication _See also_ Therapeutic communication
aging effects on,
barriers to,
channels of,
with children _See_ Children, communication with
circular transactional model of, 14–15, 14 _f_, 15 _b_
client involvement in,
cognitive behavioral strategies, , 194 _b_
colleagues,
concepts to improve,
caring, 104–105
empathy, 106–107
empowerment, 105–106,
mutuality,
respect,
trust, , 106 _b_, 107 _b_
veracity, 107–108
cross-cultural,
cultural influences on,
culturally competent,
culturally diverse clients, 208–209
definition of,
dementia patients, 385–387, 386 _b_
description of,
distortion in, 75 _f_
electronic health records benefits for, 492–493
electronic methods of, 513–514
end-of-life care, 151–154, 152 _b_
environment for,
group, ,
humor, 193–194
intercultural _See_ Intercultural communication
interpersonal,
interprofessional, 464 _b_
intrapersonal,
linear model of, , 15 _b_
malpractice claims prevented through,
metaphors,
negligence claims prevented through,
nonverbal, 166–169
behaviors used in, , ,
body cues,
body language, ,
congruent,
cultural differences,
description of, , 93 _b_,
function of,
silence,
styles of, 165 _t_, 166–169
touch, , 192–193
in nursing process, 30–31
with parents, , 364–366, 366 _b_
participant responsiveness, 172–173
personality characteristics that affect,
profession-specific differences in,
real-time,
reciprocity in, 172–173
reframing,
role relationships in,
safety _See_ Safety communication
self-esteem affected by,
sociocultural factors that affect, 169–170
culture, 169–170, 170 _b_
gender,
location,
specialized strategies for, 193–194
styles of, 165–166, 170–171
technology used in,
theories of, 13–15, 14 _b_
therapeutic _See_ Therapeutic communication
tips for improving, 172 _b_
touch as form of, , 192–193
unclear, 466 _t_
verbal, 164–166, 165 _t_,
violence defusing through,
voice inflection in,
Communication deficits and disabilities
assessment of,
cognitive impairments as cause of, ,
concepts associated with, 337–338
early recognition of,
environmental deprivation caused by illness, 340–341
hearing loss, , 341–343, 343 _b_
language deficits as cause of, , 344–345, 345 _b_
legal mandates,
mental disorders, 339–340, 345–346
nursing goals for,
speech deficits as cause of, , 344–345, 345 _b_
strategies for, 341–347
treatment-related, 346–347
types of, 338–341
vision loss, 338–339, 343–344
Community
advocacy in, 484–486
crisis interventions resources,
definition of,
disaster management response patterns,
empowerment in, , 305–306
family-centered relationships in, 267–268
health promotion, 301–303
stress management resources, , 403 _b_
Community education, 302–303, 303 _t_
Community engagement, 306 _b_
Community health agencies,
Compact state recognition model,
Compassion, 106–107
Compassion fatigue,
Competition,
Complaint procedures,
Complicated grieving,
Computer literacy,
Computerized clinical decision support systems, 511–512, 516–517
Concrete operations stage, 350 _t_
Confidentiality,
adolescent issues with,
definition of, ,
electronic health records, 494–495, ,
Health Insurance Portability and Accountability Act provisions for, 38–39, 39 _b_,
limits to,
mandatory reporting,
professional sharing of information,
violations of, 116–117
Conflict
anxiety affected by,
assessment of, 277–278
causes of,
covert,
cultural effects on,
de-escalation of, 278–279
definition of, 271–272,
dysfunctional,
escalation of, 286–287
features of,
functional uses of,
gender effects on,
in home health care settings,
interpersonal, ,
intrapersonal, , ,
lack of communication as cause of,
management of, 272–274
nature of,
in nurse-client relationship, 277–278
personal responses to, 272–274, 273 _b_
personal rights and responsibilities, 274 _b_
prevention of,
sources of, , 455 _b_
staff, 457–458
Conflict resolution
angry clients, 285–287
behavior change for,
cultural considerations, 281–282
demanding, difficult clients,
evaluation of,
health professionals, 461 _b_
"I" statements for,
nursing strategies to enhance, 278–283
options for,
principles of, 275–277
reasons for working toward,
tension-reducing actions for, 282–283
therapeutic communication for,
timing of,
in work environment, 454–459
barriers to, 455–456, 456 _b_
conflict sources, , 455 _b_
goal setting,
nurse-nurse, 457–458
physician-nurse, 456–457
Confrontation, 463 _b_
Connotation, 164–165,
Consent, informed, 40–41
Constructive criticism, 465 _b_
Constructive feedback,
Consultant role, 122 _t_
Consultations, electronic,
Consumer(s)
expectations of,
health information sources for,
roles of, 16–17
Consumer advocacy groups,
Continuity of care
case management _See_ Case management
for chronic conditions, 469–471
chronically medically ill clients,
community advocacy, 484–486
definition of,
description of, , ,
dimensions of, 469–470
discharge planning, 477–480, 478 _b_
functionality of, 470–471
handoffs, 477–481
hospitalist's role in,
informational, , 476–481
interdisciplinary teams for _See_ Interdisciplinary teams
management, , 480–481
medical home, 480–481
policy environment for, 485 _f_
relational,
transitions _See_ Transitions
Coping, 395–399
stress
adaptive strategies for, 396 _b_
assessment of,
defensive strategies for, 397–398, 397 _t_
definition of, 395–396
ego defense mechanisms for, , 64–65, 397–398, 397 _t_
emotion-focused,
maladaptive strategies for, 396 _b_
previously used strategies,
problem-focused strategies for,
purposes of, 395–396
strategies for, 396–398, 396 _b_
trauma, 433–434
Counseling role,
Countertransference, 8–9, ,
Criminal law,
Crisis
adventitious,
Burgess and Roberts continuum of, , 417 _t_
definition of, 415–416
developmental,
environmental,
existential,
feelings associated with,
mental health _See_ Mental health emergencies
powerlessness feelings,
private,
situational,
theoretical frameworks for, 417–418
types of,
Crisis intervention, 416–417
action plan for, ,
client's perception of,
community resources for,
critical incident debriefing as, 430–432
cultural influences, 431–432
definition of, 416–417
disaster and mass trauma crisis management, 428–432
family support in, , 424 _b_
follow-up protocol for, 423–425
goal setting for,
mental health emergencies _See_ Mental health emergencies
personal support systems, , 421 _b_
Robert's Stage Model for crisis intervention, 418–424
social support systems,
strategies for, 419–425
task selection for,
termination protocol for, 423–425
theoretical frameworks of, 416–418
Crisis state, 415–416
Critical incident,
Critical incident debriefing, 430–432
Critical thinkers, 49–50, 50 _t_
Critical thinking, 49–52
applications of, , 55–61
barriers to, 50–51
characteristics of,
clinical decision-making applications of, 55–61
in clinical judgments, ,
data integration, 57–58
definition of,
description of,
learning about,
summary of, 60–61
Criticisms,
Critiquing of nursing theory article, 5 _b_
Cross-cultural communication,
Cross-cultural dissonance,
Cultural assessment
client preferences, 206 _t_
guides to, , 206 _t_
Purnell's model, , 206 _t_
sample questions for, , 206 _t_
Cultural brokering,
Cultural care theory,
Cultural competence, , 202–204, , 206 _t_
Cultural diversity, 199–200
definition of,
in health care, 198 _b_
health teaching accommodations for, 328–329
in nursing, 201 _b_
Cultural identity,
Cultural relativism,
Cultural sensitivity, , 209 _b_
Culturally diverse clients
care of, 204–207
communication issues, , 208–209
family involvement,
health teaching principles,
interpreters for, 209–210, 210 _b_
rapport building with, 204–205
role relations, 207–208
time orientation,
Culture, 197–199 _See also specific cultural group_
acculturation,
assimilation, 200–201
communication affected by, 169–170, 170 _b_
conflict resolution affected by, 281–282
conflict responses affected by,
crisis management affected by, 431–432
decision making affected by,
definition of,
diagnoses affected by, 205–207
end-of-life care affected by, 154–155, 208–209
ethnicity,
ethnocentrism,
family experiences, 198 _b_
gender roles based on,
health promotion strategies affected by, 308–309
perceptions associated with, 200 _b_
poverty, 217–218
role relations affected by, 207–208
self-awareness assessments, 203 _b_
social behavior affected by,
stereotypes based on, 200 _b_
stress responses affected by,
subculture,
time orientation based on,
touch and,
values associated with, 200 _b_
verbal communication affected by,
worldview vs,
Curanderos,
Curative care, 151 _f_
D
Data cues, 32–33
Death _See also_ Dying End-of-life care
children and, 156–158
client care after,
good, 158–159
lifestyle factors,
as loss,
Muslims' beliefs about,
self-awareness about, 149 _b_
signs of approaching death, 158–159
stages of dying, 142–143
Debriefing
critical incident, 430–432
safety uses of,
Decision making
bioethical principles for, 46–48, 46 _f_
client-centered care,
computerized systems for, 511–512, 516–517
cultural differences,
end-of-life,
ethical, 48–49
models of, 45–48
mutuality in,
shared, , 473 _f_
Delegation of unlicensed personnel, , 460 _b_
Delusions, 345–346
Demanding, difficult clients,
Dementia
advanced, 388–389
aggression associated with, 388 _t_
agitation associated with, 388 _t_
catastrophic reactions by clients with, 387–388
characteristics of, 384 _t_
cognitive changes associated with, 385 _b_
communication difficulties associated with, 385–387, 386 _b_
description of, ,
neuropsychiatric symptoms associated with, , 388 _t_
sundowning,
touch considerations,
validation therapy for,
Democratic leadership, 240–241
Denial, 397 _t_
Denial stage, of dying,
Denotation, 164–165
Deontologic model,
Dependent nursing interventions,
Depression, 3–4, , , 384 _t_,
Depression stage, of dying,
Descriptive theory,
Development level
empowerment,
teaching strategies based on, 318 _t_
Developmental crisis,
Developmental family theory,
Diagnosis-related groups,
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,
Disaster management,
for children, 433–434
citizen responders in,
community response patterns,
critical incident debriefing, 430–432
in health care settings, 432–433
intervention protocols for,
for older adults, 433–434
planning for, 429–430
Discharge instructions,
Discharge planning, 477–480, 478 _b_
Discharge summary, 479–480
Discipline
characteristics of,
definition of, 1–2
Flexner's criteria of, 120 _b_
of nursing, 1–2
Disease prevention, 291–293
application of, 299–301
definition of,
goal of,
levels of, 291–292
lifestyle, 292–293
national agendas for, 293–294
well-being, , 292 _f_
Disenfranchised grieving, 159–160
Disengagement,
Displacement, 397 _t_
Disruptive behaviors, ,
Distraction,
Distress
behavioral observations associated with,
definition of,
moral,
spiritual, , 80 _b_,
Distributive justice,
Do not resuscitate order, 29 _t_,
Doctor of nursing practice,
Doctor-assisted suicide,
Documentation
charting formats, 501–503
client information, 489–490
definition of,
electronic health record _See_ Electronic health records
guidelines for, 504 _b_
health care outcome,
health teaching, 334–335
legal aspects of,
nursing process, 36–37
purposes of, , 490 _f_
tips for, 504 _b_
Domestic violence,
Drug Enforcement Agency,
DSM-IV-TR _See_ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
Durable mental health power of attorney, 29 _t_
Durable power of attorney, 29 _t_
Duty-based model,
Duvall's developmental framework, , 252 _t_
Dying _See also_ Death End-of-life care
caring environment during,
comfort care during, 158–159
communication during, 152 _b_
loss of appetite during,
as narrative, 151–152
presence during,
Dysfunctional conflict,
E
Ecomaps, , 259 _b_, 259 _f_
Education
client
client health literacy vs,
definition of,
Internet programs for,
Web portals for,
nursing, 123–124
interdisciplinary collaboration,
interprofessional, 124–125
models in, 124–125
online,
Effective groups, 233 _t_
Ego defense mechanisms, , 64–65, 397–398, 397 _t_
Ego despair,
Ego integrity,
Egocentrism, , 357–358
Elder abuse,
Electronic communication, 513–514
Electronic consultations,
Electronic health records
access benefits of,
advantages of, 490–493
aggregated data,
charting formats, 501–503
charting quality improved with,
client's rights, 493–494
communication benefits, 492–493
components of, , 491 _t_
confidentiality issues for, 494–495, ,
costs of, ,
description of,
disadvantages of, 493–495
ease of use,
efficiency of,
error reduction using,
ethical considerations,
example of, 491 _f_
interagency accessibility to, 491–492
legal considerations, ,
misuse of,
nursing classification systems, 495–499
advantages of,
development of, 495–499
disadvantages of,
goal for,
Nursing Interventions Classification, , 496 _t_, , 498 _b_, 506 _b_
Nursing Outcomes Classification, , 496 _t_,
Omaha System, 498–499
taxonomies, 495–499, 496 _t_, 497 _b_
nursing terminologies embedded in,
personal medical identification number,
privacy issues,
professional standards,
quality of care benefits, 492–493
regulatory considerations,
safety benefits of,
system function issues,
uniform standards lacking for,
universal client identifier numbers,
user frustration with,
Electronic records, 1–2
Electronic referrals,
E-mail, , ,
Emancipated minors,
Emblems,
Emergent informal leaders,
Emotional cutoff,
Emotional objectivity,
Emotion-focused coping,
Empathetic objectivity,
Empathy, 83–84, 84 _b_, , 106–107, 114–115,
Empirical way of knowing,
Empowerment
communication affected by, 105–106,
community, 305–306
description of,
developmental level effects,
health literacy for, 306–308, 307 _b_, 308 _t_
health promotion, , 305–309
learner involvement and,
strategies for, 305–309, 315–316
End-of-life care
advance directives, 28–30, 29 _t_, 30 _b_,
children, 155–158
communication in, 151–154, 152 _b_
cultural differences, 154–155, 208–209
decision making in,
family conversations about, 150 _b_, 152 _b_
guiding principles for, 153 _b_
pain control and management, 150–151
quality measures for, 144 _t_
spiritual needs, 154–155
transparent decision making in, 148–150
End-of-Life Nursing Education Consortium (ELNEC),
Engel, George,
Environment
concept of,
definition of,
illness-related deprivation of, 340–341
influence on relationship,
person and,
self-concept and, relationship between, 63–64
therapeutic communication affected by, 178–179
work _See_ Work environment
Environmental crisis,
Environmental hazards,
Equifinality, 248–249
Erikson, Erik
description of,
psychosocial development model, 65–67, 66 _t_, 67 _b_, , 371–372,
Essential values, 125–127, 126 _t_
Ethical decision making, 48–49
Ethical dilemmas
causes of,
definition of,
description of,
solving of, in nursing, 53–54, 53 _b_
Ethical reasoning, 45–49,
Ethical standards and issues, 28–30
advance directives, 28–30, 29 _t_
code of Ethics, , , 28 _b_
Ethical theories, 45–48
Ethnicity,
Ethnocentrism,
Eustress,
Euthanasia,
Evaluation phase of nursing process
description of, 31 _t_,
family application of,
health teaching application of,
Evidence-based practice, 17–18
best practices, 442–444
definition of, 17–18
elements of,
nursing theory and,
Existential crisis,
Explanatory theory,
Expressive aphasia,
Extended family,
Eye contact, ,
F
FACES Pain Rating Scale, 148 _f_,
Facial expressions, ,
Faith,
False inferences, 188 _t_
False reassurance, 188 _t_
Familismo,
Family
assessment of
data collection in
tools used in,
ecomaps, , 259 _b_, 259 _f_
genograms, 255–258, 256 _f_, 257 _b_, 257 _f_
time lines, 258–259, 260 _f_
in African American culture,
anxiety in, 403 _t_
in Asian American culture,
biological and blended, 247–248, 248 _t_
of chronically ill children,
common law,
composition of, 247–248, 247 _b_
conferences with, 153–154
crisis intervention support, , 424 _b_
of critically ill clients, 265–266, 265 _b_
culture experiences of, 198 _b_
definition of, 246–247,
dynamics of,
evaluation of,
extended,
health teaching participation by,
in Hispanic culture,
illness effects on, ,
informational needs of,
informational support for,
intervention skills with, 268 _b_
in Native American culture,
in palliative care, need of,
strategies for, 143–144
psychosocial support for, 254–255
stress effects on, ,
theoretical frameworks of, 248–254
Bowen's family systems theory, 249–250
Duvall's developmental framework, , 252 _t_
general systems theory, 248–249, 248 _f_
McCubbin's Resiliency Model of Family Coping, 251–254
Munchin's structural model, 250–251
types of, 247 _b_
Family assessment,
data collection, 260–262
framework for, 260–261, 261 _b_
interventive questioning, 262–263, 262 _b_
nursing process applied to, 260–266
Family assets,
Family boundaries,
Family caregiver, 267–268, 483–484
Family nursing care plan, 263 _b_
Family resilience, 253–254
Family strengths,
Family-centered care, 255–259
principles of, , 472 _b_
purpose of,
Faxed medical orders,
Feedback
active listening and, 191–192
constructive,
description of,
group leader, 242 _b_
health teaching, , 330 _b_
Feedback loops, 248–249
Feelings
crises and,
loss and,
stress and,
"Fight or flight" response, 393–394
First responders, 431–432
Flat affect,
Flow sheets,
Focus groups, 239–240
Focused questions, 182–183
Formal operations stage, 350 _t_
Freud, Sigmund
psychoanalytic theories of, ,
psychosexual stages of personality development, 10 _t_
Functional similarity,
Functional status
assessments of, 375–376
definition of, 375–376
G
Gaze aversion,
Gender
communication affected by, ,
conflict responses affected by,
nurse-client relationship affected by,
stress response differences based on,
Gender bias, 171 _b_
Gender roles
cultural influences on,
Gendergram, 258 _b_
General adaptation syndrome,
General systems theory, 248–249, 248 _f_
Generativity vs. stagnation stage, 66 _t_
Genograms, 255–258, 256 _f_, 257 _b_, 257 _f_
Gestures, ,
Gift giving, , 99 _b_
Global aphasia,
Goals
client-centered communication,
conflict resolution,
crisis intervention,
disease prevention,
group,
professional,
therapeutic relationships,
Good death, 158–159
Gordon's Functional Health Patterns, , 33 _b_
Grand theories,
Grass roots health promotion,
Grief, 145–146,
acute, 146–147
anticipatory,
definition of,
Lindemann's work on,
Grieving, 145–146
complicated,
contemporary models of,
disenfranchised, 159–160
patterns of, 146–147
personal inventory of, 146 _b_
reflections on, 147 _b_
theory-based frameworks of,
Group(s) _See also_ Therapeutic groups
adjourning phase of, 227–228, ,
closed,
cohesion of, , 234 _b_
definition of, 222–226
discussion groups, , 240 _t_
educational groups,
focus groups, 239–240
dynamics,
effective, 233 _t_
forming stage of, 226–227, 232–233,
functional roles of,
goals
heterogeneous,
homogeneous,
leader tasks applied to stage development of, 232–235
phases of, 226–228, 227 _f_
norming phase of, , 233–235,
open,
performing phase of, , 234–235, 235 _t_, 242–243
primary and secondary,
size of, 231–232
storming phase of, ,
structure and format of,
themes, , 184 _b_
therapeutic _See_ therapeutic groups
work _See_ professional work groups
Group communication characteristics, ,
Group dynamics, 223–226
definition of, 223–224
factors that affect, 224 _f_
functional similarity,
maintenance functions in, , 228 _b_, 229 _b_
monopolizing, 234–235
norms, , 225 _b_
task functions in, , 228 _b_, 229 _b_
Group family,
Group leader
feedback, 242 _b_
responsibilities of, 241–242
stage development-based tasks of, 242–244
Group leadership, 228–231
Group presentations, 332–334
Group process,
Group purpose,
Group think, 242–243, 243 _b_
Guided imagery,
Guilt,
H
Hallucinations, 345–346
Handbooks, 327–328
Handoffs, , 477–481
Hands-on training,
Health, 290–291
aging effects on, 370–371
definition of, , 290–291
as nursing concept, 3–4, 4 _b_
Health care
barriers to safety in,
cultural diversity in, 198 _b_
demographic changes in,
focus of, in 21st century, 18–19
reforms in,
Health care delivery
challenges in, 468–469
changes in, 15–17, 16 _f_,
community-based model of,
consumer roles, 16–17
continuity of care in,
hospital-based model of,
professional roles, 16–17
technological advances in, 19–20
Health care laws, 26–27
Health care outcome
definition of,
documentation of,
Health communication,
Health disparities, 203–204
Health information technology
advances in,
applications of, 515–517
barriers to, , 518–519
client communication using, 514–515
communication benefits of,
computerized clinical decision support systems, 511–512, 516–517
definition of,
description of,
electronic communication, 513–514
electronic health record _See_ Electronic health record
misuse of,
point of care uses of, 516–517
professional education uses of,
provider communication using, 514–515
remote client health monitoring, 512–513
searchable databases,
"Smart Rooms, ", 512–513
wireless devices, 509–511, 509 _f_, 510 _b_, 510 _f_,
Health Insurance Portability and Accountability Act
confidentiality protections, 39 _b_,
privacy protections of, 38–39, 39 _b_,
Health literacy, 306–308, 307 _b_, 308 _t_, ,
Health policy, 484–485
Health professionals
barriers to communication with, strategies for removing, 460–463
clarifying of communications,
constructive criticism, 465 _b_
destructive criticisms,
peer negotiation,
putdowns, ,
respect,
client and, collaboration between,
collaborations among, 444–445,
conflict resolution among, 461 _b_
interdisciplinary rounds, 446–447
Health profile, 300 _b_
Health promotion, 290–291
application of, 299–301
Centers for Disease Control and Prevention agenda for,
at community level, 301–303
counseling for,
cultural factors, 308–309
definition of,
education for,
empowerment strategies, 305–309
grass roots,
for individuals, 300–301
learner variables in education for, 304–309
national agendas for, 293–294
older adults, 382–383, 382 _b_
organized strategies for,
as population concept,
self-awareness,
theoretical frameworks for, 295–299
motivational interviewing, 297–298
Pender's model, 295–296, 295 _f_, 296 _b_,
social learning theory, 298–299
transtheoretical model of change, 296–297, 298 _b_
Health teaching, _See also_ Learning
accommodations for special learning needs, 328–329
advance organizers for,
anxiety effects on,
behavioral models of, 316–319
caregiving skills, 329–332
categories of, 320 _f_
client-centered, 315–316
coaching clients, 331–332, 332 _b_, 332 _f_
comorbid conditions that affect,
contexts of,
cultural diversity accommodations, 328–329
definition of,
documentation of, 334–335
ethical mandates for, 313–314
family support for,
feedback, , 330 _b_
format of, ,
group presentations, 332–334
handouts used in,
in home, 333–334
language used in, 326–327
learning domains, 314–315
legal mandates for, 313–314
medications, 330 _b_
nursing diagnoses amendable to, , 323 _b_
nursing process applied to, 319–332
assessment, 320–323
evaluation,
implementation, 326–329
planning, 323–326
older adults,
problem-solving approach used in, 330–331
self-management skills, 329–332
special learning needs accommodations, 328–329
teach-back method,
theoretical frameworks of, 315–319
andragogy, , 317 _f_
behavioral models, 316–319
client-centered health teaching, 315–316
pedagogy,
timing of, 325–326, 325 _b_
transitional cues,
visual aids used in, , 328 _f_
written handbooks used in, 327–328
Healthy lifestyle,
_Healthy People 2010_ , 3–4, , 136–137, 203–204, 293–294, 293 _b_, , , ,
_Healthy People 2020_ , 293–294
Hearing
loss of, , 341–343, 343 _b_, 374–375
screening of,
Helping relationships, 84 _t_
Henderson, Virginia, 2–3
Heterogeneous groups,
Hidden self,
Hispanic clients, cultural considerations, 210–212
Hobbies, 360–361
Holistic nursing theories,
Home care
conflict in,
health teaching, 333–334
Home health agencies,
Homeostasis, 248–249,
Homogeneous groups,
Hope,
Hopefulness,
Hospice,
Hospital
disaster planning for,
health care delivery in,
Hospitalist,
Hospitalization
of children, 351–352
stress caused by, 399–400
Hostility, , ,
Hot-cold balance,
Huddles, 475–476
Human dignity, 126 _t_
Human rights-based model,
Humor, 193–194, 282–283
Hypothalamic-pituitary-adrenal axis,
I
"I" statements,
ICD-9-CM,
ICD-10-PCS,
Identity, 63–64 _See also_ Personal identity
Ignoring, 318 _t_
Illiteracy, 306–307, 518–519
Illness-related environmental deprivation, 340–341
Illustrators,
Implementation phase of nursing process
description of, 31 _t_,
family assessment application of, 263–265
Independent nursing interventions,
Individualized education plan,
Infants, 354–355,
Inference,
Informal family caregivers, 483–484
Informational continuity, , 476–481
Informed consent, 40–41, 208–209
Inquiry,
Instant messaging, ,
Institute of Medicine, , , 199–200, , 294 _t_, , , , , 472 _b_,
Instrumental activities of daily living,
Intake assessment,
Integrity, 126 _t_
Intellectualization, 397 _t_
Intensive care unit
communication with clients in, 346 _b_
environmental deprivation associated with, 340–341
family needs in, 265–266, 265 _b_
Interactive videodiscs,
Intercultural communication, 201–202
definition of,
planning and intervention considerations,
principles of, 208–209
rapport building, 204–205
role relations, 207–208
Interdisciplinary collaboration, , 138–139
Interdisciplinary rounds, 446–447
Interdisciplinary teams
collaborative communication protocol, 479 _t_
description of,
meeting of, 474–475
sharing of critical information in,
International Classification of Diseases coding, 499–500
Internet
consumer health information on,
educational uses of,
health promotion uses of,
liability issues,
privacy issues,
support groups on,
Interpersonal communication
with children, 351–352
description of, ,
Interpersonal competence,
Interpersonal conflict
assertive skills, 283–285
description of, ,
escalation of, 286–287
interventions for, 283–288
Interpersonal relationships
Peplau's mid-range theory of,
trust and respect in, 171–172
Interpreters, 209–210, 210 _b_
Interprofessional collaboration, , 474 _f_
Interprofessional communication, 464 _b_
Interprofessional education, 124–125
Interventive questioning, 262–263, 262 _b_
Interview, assessment, , 373 _b_
Intrapersonal communication,
Intrapersonal conflict, , ,
Intuitive feelings,
Irrational beliefs, 13 _t_
J
James, William,
Jargon, , 190–191
Job maturity,
Johnson, Dorothy, 2–3
Joint Commission on Accreditation of Health Care Organizations
best practice guidelines,
computerized documentation guidelines,
nursing care plan requirements, 31 _b_
professional standards,
violence recommendations, 464–465
Jung, Carl,
Justice, , 53 _b_
K
Kinesics,
Kinesthetic communication, ,
Knowing, patterns of, ,
aesthetic way of,
empirical way of,
ethical way of,
personal way of,
L
Laissez-faire leadership, 240–241
Language deficits, , 344–345, 345 _b_
Language proficiency, limited, , 202 _b_,
Laptop computers,
Laughter, 193–194
Laws, 26–27
Leadership
authoritarian, 240–241
democratic, 240–241
group, 228–231
laissez-faire, 240–241
situational,
styles of, 240–242
Leadership role,
LEARN mnemonic,
Learning _See also_ Health teaching
domains of, 314–315
factors that affect ability for, 322–323
goal setting for, , 324 _b_, 325 _b_
physical barriers that affect,
styles of, 315 _b_
Learning delay,
Learning needs
at discharge, 333 _b_
questions for assessing, , 320 _b_
special, 328–329
Learning readiness, 306 _b_, 321–322
Legal advocacy,
Legal standards, 26–27
Leininger, Madeleine, ,
Licensure,
Lidocaine,
Life review, ,
Lifestyle, 292–293, ,
Limit setting, , , 362 _b_
Lindemann, Eric, ,
Linear model of communication, , 15 _b_
Listening _See_ Active listening
Literacy
computer,
health, 306–308, 307 _b_, 308 _t_, ,
Living will, 29 _t_
Logical Observation Identifiers Names and Codes,
LOINC _See_ Logical Observation Identifiers Names and Codes
Lose–lose situation, 273–274
Lose–win situation,
Loss
concept of, 141–142
death as, 142–143
definition of,
feelings associated with,
meaning of, 142 _b_
multiple,
M
Magnet Recognition Program, 131–132, 132 _f_
Malpractice, 26–27
Managed care,
Management continuity, , 480–481
Manager role, 122 _t_
Mandatory reporting,
Maslow's hierarchy of needs, 10–11, 11 _b_, 11 _f_, 12 _b_, , 34 _t_, 306 _b_, 372–373
Mass trauma, , 430 _t_
McCubbin's Resiliency Model of Family Coping, 251–254
Mead, George,
Mead, Margaret,
Medical home, 480–481
Medical jargon,
Medical orders
communication of, 503–505
faxed,
verbal,
written, 503–504
Medical power of attorney, 29 _t_
Medical terminology, 359 _b_
Medicare,
Medicare Modernization Act,
Medication administration rights, 517 _t_
Medication errors, , , 447–448,
Medication groups,
Medication support, for older adults, 380–381, 381 _b_
Meditation, , , 408 _b_
Mental disorders, 339–340, 345–346,
Mental health emergencies, 425–429
challenges associated with,
de-escalation tips for, 426 _b_
examples of,
psychotic clients,
suicide, 427–429
triage assessment system for,
types of, 426–429
violence, 426–427, 426 _b_, 427 _t_
Mental status
assessment of,
testing of, 376 _b_
mini-mental Status Examination, ,
Mentoring, 128–129
Message,
Message competency,
Metacommunication, 163–164, 164 _f_,
Metaparadigm, 3–4
nursing description of,
concept of environment,
concept of health, 3–4, 4 _b_
concept of person,
concept of nursing,
Metaphors,
Mid-range theories, ,
Mind reading,
Mind/body therapies, 407–409, 408 _b_, 409 _b_
Mindfulness,
Minorities,
Minors,
Mistrust,
Mnemonics,
Modeling,
Moral distress,
Moral uncertainty, 53–54
Moralizing, 188 _t_
Morphostasis, 248–249
Motivation,
Motivational interviewing, 297–298,
Multiculturalism,
Multidisciplinary teams,
Mutuality, ,
N
National Cancer Institute,
National Council of State Boards of Nursing, ,
National Library of Medicine,
Native American clients, cultural considerations, 216–217,
Negative feedback,
Negative reinforcement, 318 _t_
Negative stereotypes,
Negligence, 26–27, 27 _t_
Networking,
Newman, Margaret,
Nightingale, Florence, ,
Nonmaleficence, 47–48
Nonverbal communication, 166–169
of anger,
behaviors used in, , ,
body cues, ,
body language, ,
congruent,
cultural differences,
description of, , 93 _b_,
function of,
silence,
styles of, 165 _t_, 166–169
touch,
Nonverbal feedback,
Norms, , 225 _b_
North American Nursing Diagnosis Association, 33–34, , 495–497, 496 _t_, 497 _b_
Nurse _See also_ Registered nurse
accountability of, ,
core competencies, 121 _f_
legal liability of,
professional role of, 121–122 _See also_ Professional nursing roles
Nurse Practice Acts, 25–26,
Nurse practitioners,
Nurse-client relationship
advocacy roles in, 134–136
barriers to, 108–113
anxiety, 108–110, 109 _b_, 109 _t_, 110 _b_
bias, 110–111
cultural,
gender differences,
level of involvement, ,
caring as element of,
confidentiality in,
conflict in, 277–278
context of,
description of,
emotional integrity in, 85–86
interdependent nature of,
legal liability in,
limit setting in, , 362 _b_
nursing process application to, 30–41, 31 _t_
older adults, 377–383
professional role behaviors in, 133–134
termination of,
therapeutic _See_ Therapeutic relationships
Nurse-parent partnership,
Nursing
advocacy for,
art of, 5–7
core competencies, 121 _f_
concept of,
contemporary roles associated with,
core values of, 51 _b_
criteria for survival of, 20 _t_
discipline characteristics of, 1–7
definition of,
goal of,
knowledge base necessary for,
metaparadigm of _See_ Metaparadigm
professional standards of,
performance standards of,
role behaviors in,
roles of, 89 _b_
social policy statement of,
teamwork in,
themes of,
theoretical perspective of other disciplines in, 8–13
Nursing actions, 115 _t_
Nursing classification systems, 495–499
advantages of,
development of, 495–499
disadvantages of,
goal for,
Nursing Interventions Classification, , 496 _t_, , 498 _b_, 506 _b_
Nursing Outcomes Classification, , 496 _t_,
Omaha System, 498–499
taxonomies, 495–499, 496 _t_, 497 _b_
Nursing diagnoses, 33–34
definition of,
health teaching, , 323 _b_
role performance as, 136–138
self-concept as, 68–76
Nursing education, 123–124
interdisciplinary collaboration,
interprofessional, 124–125
models in, 124–125
online,
Nursing intervention
classification of,
collaborative,
definition of,
selection considerations for, 36 _b_
Nursing Interventions Classification, , 496 _t_, , 498 _b_, 506 _b_
Nursing licensure,
Nursing outcomes,
Nursing Outcomes Classification, , 496 _t_,
Nursing practice
online guidelines for,
political factors that affect,
Nursing process, 30–41
assessment _See_ Assessment
communication's role in, 30–31
definition of,
diagnosis, 31 _t_
documentation of, 36–37
evaluation _See_ Evaluation
family assessment use of, 260–266
health teaching application of _See_ Health teaching, nursing process applied to
implementation _See_ Implementation
nurse-client relationship application of, 30–41, 31 _t_
outcome identification, 31 _t_, 34–35
phases of, 30–31
planning _See_ Planning
values clarification and, 51–52
Nursing research,
Nursing rounds,
Nursing theory, 2–5
definition of,
development of, 2–3
evidence-based practice and,
frameworks of
clinical practice application of, 7–8
description of, , 7–8
grand,
as guide to practice, 5–7
historical development of, 2–3
holistic,
levels of, 4–5
mid-range,
practice,
types of,
O
OASIS _See_ Outcome and Assessment Information Set
Occupational stress, 409–412
Older adults _See also_ Aging
abuse of,
activities of daily living in,
advocacy support for, 381–382
assessment of, 373–377
autonomy of,
baby boomers, , 371 _b_
categories of,
cognitive assessments,
cognitive impairments, , 383–389
assessment and support interventions, 383–389
catastrophic reactions, 387–388
reality orientation groups,
comorbidities in,
contemporary,
delirium in, 384 _t_
dementia in _See_ Dementia
depression in, , 384 _t_
disaster management for, 433–434
discrimination against,
environmental supports for,
functional status assessments, 375–376
health promotion for, 382–383, 382 _b_
health teaching for,
hearing loss in, , 374–375
independence of, ,
individual differences among, 370–371
instrumental activities of daily living in,
interviews with, 373 _b_
legal advocacy for,
life review by,
medication support for, 380–381, 381 _b_
mental status testing in, 376 _b_
nurse-client relationships, 377–383
pain assessments in, 376–377
polypharmacy in,
population growth,
psychosocial assessments in,
psychosocial communication supports for, 377–378
reminiscence groups, , 378 _b_
rights of, , 381 _b_
safety supports for, 380–381
sensory changes in, 374–375
sensory function loss in, 342 _b_
social supports for, 378–379
spiritual supports for, 378–379
stress issues for,
teaching strategies for, 318 _t_
theoretical frameworks used in care of, 371–373
vision loss in, 338–339,
Omaha System, 498–499
Online nursing education,
Online nursing practice guidelines,
Open groups,
Open self,
Open-ended questions, 181–182, 182 _b_, ,
Opioids,
Optacon,
Organizational work groups, 464–465
_Ottawa Charter for Health Promotion_ ,
Outcome and Assessment Information Set, 500–501
Outcome identification, 31 _t_, 34–35
Overgeneralizing,
P
Pagers, ,
Pain
assessment of, , 376–377
behavioral indicators of, 150–151
in children,
in older adults, 376–377
Wong-Baker FACES Pain Rating Scale, 148 _f_,
Pain management
end-of-life care, 150–151
Joint Commission standards,
opioids for,
Palliative care, 143–144
definition of,
dimensions of, 143 _b_
hospice vs,
indications for, 143–144
model of, 151 _f_
nursing initiatives,
nursing roles in,
palliative care team,
principles of,
quality measures for, 144 _t_
stress issues for nurses in, 159–160
Paralanguage,
Paraphrasing, , 187 _b_
Parents of physically ill child
communication with, , 364–366, 366 _b_
nurse-parent partnership,
nurse's interactions with, 365–366
stress in,
support groups for,
Parse, Rosemarie,
Participant observation,
Paternalism, 46–47, 135–136
Patient education _See also_ Client education
definition of,
elements of, 319–320
Patient Protection and Affordable Care Act,
Patient Self-Determination Act, 28–30
Patient-centered care, , 471–472
Patterns of knowing,
PDAs _See_ Personal digital assistants
Pedagogy,
Pediatric care _See also_ Children
child's participation in,
location for,
Pediatric intensive care unit,
Peers _See also_ Colleagues
collaborations with, 458–459
delegation to,
negotiation with,
Pender's health promotion model, 295–296, 295 _f_, 296 _b_,
Peplau, Hildegard, , , ,
Perception, 70–71, 72 _b_
Person
client as,
concept of,
environment and,
Person centered models, 12–13
Personal digital assistants, 510–511, 510 _f_,
Personal identity, 69–70
body image and,
cognition effects on, , 71–74
definition of,
health status changes that affect,
interventions to enhance, , 72 _b_
perception effects on, 70–71
serious injury or illness effects on, 71–72
spiritual aspects of, 77–80
supportive nursing strategies for, 72–74
Personal medical identification number,
Personal space
respect for, 115–116
therapeutic conversation, 178–179
violation of, 111–112, 112 _b_
Personal support systems, , 421 _b_
Personal values, 50–51
Personality, 10 _t_,
Personalizing,
Person-centered care, 18–19
Person-centered models, 12–13
Pew Commission, 18 _b_
Pew Health Professions Commission,
Physician
client communication with, ,
disruptive behavior by,
nurse conflicts with, 456–457
Physiologic needs,
Piaget, Jean, , 350 _t_
Pictographs,
Planning phase of nursing process
description of, 31 _t_, 33–38
family assessment application of, 262–266
health teaching application of, 323–326
Play, 353–357,
Point of care
decentralized access technology for communication at, 509–511
health information technology applications, 516–517
Polypharmacy,
Positive reinforcement, 318 _t_
Possible selves,
Posture, , , 177 _f_
Poverty, 217–218
Powerlessness, ,
Practical wisdom,
Practice simulations, 441–442
Practice theories,
Prayer,
PRECEDE-PROCEED model, 302–303, 303 _t_
Preceptor,
Predictive theory,
Pregroup interview,
Pregroup tasks,
Premack principle,
Preoperational stage, 350 _t_
Presbycusis,
Preschoolers
communication with, 355–356, 357–364
play by,
storytelling, , 359 _b_
teaching strategies for, 318 _t_
Presence
during dying,
nursing,
Primary appraisal, , 396 _f_
Primary group,
Primary prevention, ,
Priority setting,
Privacy
confidentiality,
definition of,
Health Insurance Portability and Accountability Act protections for, 38–39, 39 _b_,
Internet,
protection of, 38–41
respect for,
for spiritual activities,
strategies for protecting, 39–40
Private crisis,
Problem-focused coping,
Problem-oriented record,
Prochaska's transtheoretical model of change, 296–297, 297 _t_, 298 _b_
Professional behaviors, 125–127
Professional boundaries, 85–86
Professional education,
Professional goals,
Professional licensure,
Professional nursing roles
advanced practice, 122–123, 123 _b_
behaviors, 129–130
with colleagues, 129–130
development of,
registered nurse, 127–129
types of, 121–122, 122 _t_
Professional performance standards,
Professional rights,
Professional role behaviors
with colleagues, 129–130
in nurse-client relationships, 133–134
Professional self-awareness, 177–178
Professional standards of care, 25–26
Professional values, 50–51, 54–55, 55 _b_
Professional work groups, 240–244
group maturity,
group think, 242–243
leadership styles, 240–241
leader and member responsibilities,
leader stage appropriate applications, 242–244
Professionalism, 126 _t_
Progressive relaxation, , 409 _b_
Projection, 397 _t_
Proxemics, , , 171–172 _See also_ Personal space
PSDA _See_ Patient Self-Determination Act
Psychiatric advance directives,
Psychodynamic models, 8–9
Psychological job maturity,
Psychomotor domain of learning,
Psychosexual development,
Psychosocial assessments,
Psychosocial development theories
description of, 9–11, 10 _t_
Erikson's, 65–67, 66 _t_, 67 _b_, 371–372,
Psychotherapy,
Psychotic clients, 236–237,
Punishment, 318 _t_
Purnell, Larry, , 206 _t_
Putdowns, ,
Q
Qi,
Quality of life, 3–4
R
Rapport
building of, 180–181, 204–205, 419–420,
humor and,
Rationalization, 397 _t_
Reaction formation, 397 _t_
Readiness to learn, 306 _b_, 321–322
Real-time captioning,
Real-time communication,
Reasoning, 55 _t_
Receiver,
Receptive aphasia,
Reciprocity, 172–173
Recognition role, 229 _t_
Reference terminologies,
Referrals, electronic,
Reflection, as listening response, , 187 _b_
Reflective appraisals,
Reframing,
Registered nurse _See also_ Nurse
American Nurses Association Bill of Rights for, 131 _b_
professional role development of, 127–129
Regression
by children,
as defense mechanism, 397 _t_
Regulatory bodies
nurse practice acts, 25–26
state boards of nursing,
Reinforcement, , 318 _t_
Relational continuity,
creation of,
definition of,
interprofessional collaboration, , 474 _f_
professional perspectives on, 473–477
team meetings, 474–475
Relationships _See_ Nurse-client relationship Therapeutic relationships
Religion
spirituality vs., _See also_ Spirituality
Reminiscence groups, , , 378 _b_
Remorse,
Remote client health monitoring, 512–513
Remotivation groups, , 237 _b_
Repression, 397 _t_
Researcher role, 122 _t_
Resilience, 253–254,
Resiliency Model of Family Coping, 251–254
Resocialization groups,
Resource role,
Respect
in communication with children,
for coworkers,
description of,
interpersonal conflict resolution and,
in interpersonal relationships, 171–172
organizational climate of,
for personal space, 115–116
for privacy,
in work environment, ,
Restatement,
Rightness, 45–46
Rogers, Carl, 12–13, ,
Role
definition of,
performance dimension of,
professional _See_ Professional nursing roles
Role disruption,
Role modeling, 381–382
Role performance
disturbance of,
as nursing diagnosis, 136–138
Role relationships, 119–129, , 138 _b_,
Role socialization
definition of, 125–126
nursing values,
professional, 125–129
S
Safety
advocacy for,
barriers to, in current health care system,
best practices for, , 439–440
checklists for improving,
client outcomes, 437–438
culture of
creation of,
error reporting and,
definition of,
electronic health record benefits for,
evidence-based best practices for, 442–444
initiatives to improve,
issues associated with, 437–438
medication errors, , ,
miscommunication during client handoff,
practice simulations for improving, 441–442
as priority,
reluctance to report errors,
standardization benefits for,
team training, ,
technology used for,
Safety communication
changes for improving,
checklists for,
competencies, 442 _f_
goals for, 438–439
health provider collaborations for, 444–445,
poor, ,
profession-specific differences in,
standardized tools for,
strategies for, 440 _b_
teaching strategies for nurses to improve, 441–444
SBAR format, 37–38, 38 _t_, 443–444, 444 _b_, 445 _t_, 446 _b_, , , 477 _b_, 478 _b_
Schemata,
Schizophrenia, , , 345–346, 346 _b_
School-age children
communication with, , 358–360
teaching strategies for, 318 _t_
Scope of practice,
Searchable databases,
Secondary appraisal, , 396 _f_
Secondary group,
Secondary prevention, ,
Secure messaging, ,
Self, therapeutic use of, 88–89
Self-actualization, , 11 _b_, 372–373
Self-awareness
about death, 149 _b_
culture, 203 _b_
description of, , 88–89, 89 _b_, , 177–178
health promotion through,
unintentional bias,
Self-concept
aspects of, ,
characteristics of, , 63 _f_
cultural identity,
definition of, 62–63,
environment and, relationship between, 63–64
features of, 63–64
functions of, 63–64
in infancy,
life experiences effect on, 70 _b_
as nursing diagnosis, 68–76
possible selves,
self-assessments, 64 _b_
spiritual, ,
theoretical models of, 64–65
Self-differentiation,
Self-disclosure, 96–97, 97 _b_
Self-efficacy, 77–81
definition of, ,
description of,
development of, , 300–301
Self-esteem, 74–76
assessment of, 74–76
communication effects on,
definition of,
evaluation of,
therapeutic strategies for,
Self-fulfilling prophecy, ,
Self-help groups, , 238–239
Self-management skills, 329–332
Self-roles, , 229 _t_
Self-talk, 73–74
Selye, Hans,
Sender,
Sensorimotor stage, 350 _t_
Sentinel events, 437–438
Separation anxiety,
Shaping, 316–317
Shared decision making, , 473 _f_
Sibling position, , ,
Sick role,
Silence, , 187–188, 188 _b_
Single-parent family,
Situational crisis,
Situational leadership,
Situational self-esteem,
Skinner, B.F.,
Slang,
"Smart Rooms, ", 512–513
Smartphones, ,
SNOMED-CT _See_ Systematized nomenclature of medical-clinical terms
Social cognitive competency,
Social isolation,
Social justice, , 126 _t_
Social learning theory, 298–299
Social networking, 485–486
Social policy statement,
Social relationships, 84 _t_
Social support
assessment of, 401–402
crisis intervention uses of,
description of, , 75 _b_
for older adults, 378–379
stress management with, 398–399, 401–402
Social worth,
Societal emotional process,
Sorrow, chronic, 146–147
Speech deficits, , 344–345, 345 _b_
Speech-generating devices,
Spiritual distress, , 80 _b_,
Spiritual growth,
Spiritual needs, 78–79
Spiritual rituals,
Spiritual self-concept,
Spiritual well-being, ,
Spirituality
assessment of, 78–80
description of,
end-of-life care, 154–155
evaluation of,
existential view of,
meditation,
in older adults, 378–379
prayer,
religion vs,
strategies for, 80–81
stress effects on,
Staff conflict, 457–458
Stages of dying, 142–143
State Board of Nursing,
Statutory laws,
Stereotypes/stereotyping, 110–111, 111 _b_, 200 _b_
Stimulus stress model,
Storytelling, , 359 _b_
Stranger anxiety,
Stranger role,
Stress
allostasis model of, , 395 _f_
anger associated with,
anticipatory guidance for, 405–406
anxiety associated with,
assessment of, 399–404
behavioral observations associated with,
biological models of, 393–395
burnout caused by, 409–412, 411 _f_, 411 _t_, 412 _b_
characteristics of,
children,
community resources for management of, , 403 _b_
coping with _See_ Coping, stress
cultural differences,
definition of,
expression of feelings during,
factors that affect, 399 _b_
family affected by, ,
gender differences in response to,
general adaptation syndrome,
health care sources of, 399–401
high levels of,
hostility caused by,
levels of,
mild,
moderate,
nurses in palliative care setting, 159–160
occupational, 409–412
older adults,
parents of physically ill child,
physiologic response models, 393–394
primary appraisal of, , 396 _f_
priority setting for,
psychosocial models of, 393–395
reduction strategies for, 404–407
secondary appraisal, , 396 _f_
social support for, 398–399, 401–402
sources of, 393 _b_, 399–401
spirituality affected by,
stimulus model of,
tolerance levels for, 392–393
transactional model of, 394–395
Stress management
biofeedback,
client efforts for, 406–407
community resources for, , 403 _b_
guided imagery for,
healthy lifestyle for,
meditation, , 408 _b_
mind/body therapies, 407–409, 408 _b_, 409 _b_
older adults,
progressive relaxation, , 409 _b_
social support for, 398–399, 401–402
tai chi for, 408–409
therapies for, 407–409
yoga for, 408–409
Stressor,
Subculture,
Sublimation, 397 _t_
Subsystems, 248–249,
Suicidal ideation,
Suicide, 427–429
adolescent,
demographics of,
precaution protocols for,
reporting of,
risk assessment,
statements about,
survivors of,
Sullivan, Harry Stack, ,
Summarization, 186–187, 187 _b_
Sundowning,
Supervision of unlicensed personnel,
Support groups
description of, 238–239, 238 _t_, 239 _b_
Internet,
parents of physically ill child,
Support system, 463–464
Suprasystems, 248–249
Surrogate role,
Symbolic interactionism,
System oriented continuity of care,
Systematized nomenclature of medical-clinical terms,
T
Tai chi, 408–409
Taxonomies, 495–499, 496 _t_, 497 _b_
Teach-back method,
Teaching role, , 122 _t_
Team culture,
Team meetings, , 474–475
Team training, ,
TeamSTEPPS, , , , 475 _b_, 509 _t_
Technology _See also_ Health information technology
communication uses of,
health care delivery use of, 19–20
medication error prevention using, 447–448
safety improvements using,
Teenagers _See_ Adolescents
Telecare, 512–513
Telehealth, , , , 513–514
Telemicroscopes,
Tellatouch,
Temper tantrums, ,
Tertiary prevention,
Text instant messaging, ,
Theory, 2–5
critiquing of articles, 5 _b_
definition of,
development of, 2–3
evidence-based practice and,
frameworks of
clinical practice application of, 7–8
description of, , 7–8
family _See_ Family, theoretical frameworks of
health promotion _See_ Health promotion, theoretical frameworks for
health teaching _See_ Health teaching, theoretical frameworks of
grand,
as guide to practice, 5–7
historical development of, 2–3
holistic,
levels of, 4–5
mid-range,
practice,
types of,
Therapeutic communication, 175–176 _See also_ Communication
characteristics of, 176 _f_
components of, 176–177
conflict resolution uses of,
definition of,
description of,
environmental effects on, 178–179
factors that affect,
environmental, 178–179
personal,
humor, 193–194
metaphors,
personal factors that affect,
professional self-awareness effects, 177–178
purpose of, 176–179
reframing,
specialized strategies for, 193–194
technology used in,
themes, , 184 _b_
timing of,
Therapeutic conversation
description of, 175–176
personal space in, 178–179
Therapeutic groups, , 225 _t_, _See also_ Group
activity groups, 236–238
in long-term settings,
in psychiatric settings,
communication characteristics of,
co-leadership,
format of,
self-help groups, 238–239
size of, 231–232
structure of,
support groups, 238–239, 238 _t_, 239 _b_
therapy groups, 236–237
types of, 235–240
Therapeutic relationships
barriers to, 108–113
anxiety, 108–110, 109 _b_, 109 _t_, 110 _b_
bias, 110–111
cultural,
gender differences,
overinvolvement, ,
personal space violation, 111–112, 112 _b_
reduction of,
stereotyping, 110–111, 111 _b_
summary of,
tips to reduce, 115 _b_
boundary crossings,
boundary violations,
characteristics of, 84–86
clarifying the purpose of, 91–92
clients
client-centered nature,
description of, 83–84,
needs of, 92–93
concepts in, 83–89
defining the problem, 93–94
definition of,
goals of,
improvement in, concepts for, ,
caring, 104–105
empathy, 106–107
empowerment, 105–106
mutuality,
respect,
trust, , 106 _b_, 107 _b_
veracity, 107–108
levels of involvement in, 87–88, 87 _f_
nurse's role in,
participant observation,
phases of, 89–100
orientation, 91–94
preinteraction, 90–91
termination, 97–98
working, 94–97
professional boundaries, 85–86,
self, 88–89
short-term, 98–100
trust,
Therapy groups, 236–237
Thinking
critical _See_ Critical thinking
types of, 44–45
Three-generational family,
Throughput,
Time lines, 258–259, 260 _f_
Time orientation, ,
Toddlers,
Token gifts,
Torts, 26–27
Touch, , 192–193, ,
Transactional model of stress, 394–395
Transcendent wisdom,
Transference,
Transforming Care At the Bedside,
Transition(s)
handoffs for, 477–481
planning of, 479 _t_
sending and receiving teams for, 480 _b_
Transitional cues,
Transitional objects,
Transparent decision making, 148–150
Transtheoretical model of change, 296–297, 298 _b_
Trauma _See also_ Disaster management
children and, 433–434
citizen responders to,
coping with, 433–434
mass, , 430 _t_
older adults and, 433–434
Triage assessment system,
Triangles,
Trust, , , 106 _b_, 107 _b_, 171–172, ,
Trust vs. mistrust stage, 66 _t_
Trustfulness,
U
Unclear communication, 466 _t_
Unconditional acceptance, 110–111
Uncooperative clients, 419 _t_
Undoing, 397 _t_
Uniform Emergency Volunteer Health Practitioners Act,
Universal client identifier numbers,
Universal norms,
Universal nursing languages and codes, 505–506
Universality, 224 _b_
Unknown self,
Unlicensed personnel, , 460 _b_, 504–505
U.S. Preventive Services Task Force, , , 304 _b_
Utilitarian/goal-based model, 45–46
V
Validation therapy,
Value judgments,
Values
clarification of, 51–52,
identifying of,
personal, 50–51
professional, 50–51, 54–55, 55 _b_
Veracity, , 107–108
Verbal communication, 164–166, 165 _t_,
Verbal medical orders,
Verbal responses, 176–177, 188–192
Violence, 426–427, 426 _b_, 427 _t_, 464–465
Violent clients, 287–288
Vision loss, 338–339, 343–344,
Visiting Nurse Association,
Visual aids
communication with school-age child using, 359–360
health teaching uses of, , 328 _f_
Voice pitch and tone,
Voice synthesizers,
W
Watson, Jean, , 8 _b_
Web portals for client education,
Well-being, , 292 _f_
Western cultures,
Win–win situation,
Wireless devices, 509–511, 509 _f_, 510 _b_, 510 _f_,
Wireless text communication,
Wisdom, , 372 _b_
Wong-Baker FACES Pain Rating Scale, 148 _f_,
Work environment, 131–132
bullying in,
code of behavior in,
collegiality culture in, 452–453
conflict resolution in, 454–459
barriers to, 455–456, 456 _b_
conflict sources, , 455 _b_
goal setting,
nurse-nurse, 457–458
physician-nurse, 456–457
culture of regard in,
definitions,
disruptive behaviors in, ,
group process, 464–465
healthy, standards for, 452–453
incivility in,
respect in, ,
support system, 463–464
Work groups
description of,
group concepts applied to, 240–242
leadership styles, 240–242
organizational, 464–465
stage development leader tasks applied to, 242–244
World Health Organization, , ,
Worldview
African American,
definition of,
Written handbooks, 327–328
Written medical orders, 503–504
Y
Yoga, 408–409
| {
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Back to skleleton Deadstein preparing for the Summer Tour.
Well with the summer tour under one month away Deadstein is doing its part to mae it a success. Looks like we are getting our Donna based singer and we should be set to do our best.
Cofffee-Boy somehow misplaced the fact we were to play on Monday and scheduled an install for that afternoon. With him out until 9:00 - 9:30 we were fortunate that Rich was able to get a hold of Russell so he could play with us for the first hour before he has to go to his preordained jam for the night.
So we get there and Rich's friend Kim X., something Greek, was there to drop off some video footage to Rich nd before we knew it, she was singing the first 6 songs of the night like it's Kariokie night at the local bowling alley. It was a fun time during that whole thing and it occupied the first part of the night when Russ was playing drums. IN addition, Stu was there for the first part of the night also.
Coffe Showed up and we played as a quartet thereafter. I think we played pretty well, ending with a Rhapsody in Red that didn't make the recoding cause Rich's Mac ran out of juice | {
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| {
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{"url":"http:\/\/math.stackexchange.com\/questions\/181984\/complete-course-of-self-study\/182191","text":"# Complete course of self-study\n\nI am about 16 years old and I have just started studying some college mathematics. I may never manage to get into a proper or good university (I do not trust fate) but I want to really study mathematics.\n\nI request people to tell me what topics an undergraduate may\/must study and the books that you highly recommend (please do not ask me to define an undergraduate).\n\nBackground:\n\n1. Single variable calculus from Apostol's book Calculus;\n\n2. I have started IN Herstein's topics in algebra;\n\n3. I have a limited knowledge of linear algebra: I only know what a basis is, a dimension is, a bit of transpose, inverse of a matrix, determinants defined in terms of co-factors, etc., but no more;\n\n4. absolutely elementary point set topology. I think open and closed balls, limit points, compactness, Bolzano-Weirstrass theorem (I may have forgotten this topology bit);\n\n5. binomial coefficients, recursions, bijections;\n\n6. very elementary number theory: divisibility, modular arithmetic, Fermat's little theorem, Euler's phi function, etc.\n\nI asked a similar question (covering less ground than this one) some time back which received no answers and which I deleted. Even if I do not manage to get into a good university, I wish to self-study mathematics. I thanks all those who help me and all those who give me their valuable criticism and advice.\n\nP.S.: Thanks all of you. Time for me to start studying.\n\n-\nThe most important thing is to focus your study around solving problems. Improving your ability to DO mathematics is much, much more important than increasing the amount of mathematical knowledge that you know. There will be plenty of time to learn all that you need to know. So pick topics that you enjoy and seek out resources that include challenging problems. \u2013\u00a0Michael Joyce Aug 13 '12 at 14:55\nI haven't got a clue if any of this is good material, but I found a list of free textbooks from various universities and colleges: openculture.com\/free_textbooks (Press ctrl+f and type 'mathematics' to jump to the mathematics part). If you like video courses, try this: openculture.com\/math_free_courses . The website also covers many other topics if you happen to be interested in them. \u2013\u00a0Simon Verbeke Aug 13 '12 at 17:58\n\nThis is a recapitulation and extension of what we talked about in chat.\n\nWhatever you do, I recommend that you try a variety of areas in order to find out what you like best. Don\u2019t feel obliged to stick to the most common ones, either; for instance, if you find that you\u2019ve a taste for set theory, give it a try.\n\nMy own interests are outside the undergraduate mainstream, so in mainstream areas others can probably give better recommendations. I do know that you\u2019re working through Herstein for algebra; although it\u2019s a little old-fashioned, it\u2019s still a fine book, and anyone who can do the harder problems in it is doing well.\n\nYou mentioned that you\u2019d prefer books and notes that are freely available. The revised version of Judy Roitman\u2019s Introduction to Modern Set Theory is pretty good and is available here as a PDF. You can also get it from Barnes & Noble for $8.99. Introduction to Set Theory by Hrbacek & Jech is also good, but it\u2019s not freely available (or at least not legitimately so). I\u2019ve not seen a freely available topology text that I like; in particular, I\u2019m not fond of Morris, Topology Without Tears, though I\u2019ve certainly seen worse. If you\u2019re willing to spend a little and like the idea of a book that proves only the hardest results and leaves the rest to the reader, you could do a lot worse than John Greever\u2019s Theory and Examples of Point-Set Topology. It\u2019s out of print, but Amazon has several very inexpensive used copies. (This book was designed for use in a course taught using the so-called Moore method. It\u2019s excellent for self-study if you have someone available to answer questions if you get stuck, but SE offers exactly that. In the interests of full disclosure I should probably mention that I first learned topology from this book when it was still mimeographed typescript.) If I were to pick a single undergraduate topology book to serve both as a text and a reference, it would probably be Topology, by James Munkres, but I don\u2019t believe that it\u2019s (legitimately) freely available. You might instead consider Stephen Willard, General Topology; it\u2019s at a very slightly higher level than the Munkres, but it\u2019s also well-written, and the Dover edition is very inexpensive. I can\u2019t speak to its quality, but Robert B. Ash has a first-year graduate algebra text available here; it includes solutions to the exercises, and it introduces some topics not touched by Herstein. He has some other texts available from this page; the algebra ones are more advanced graduate level texts, but the complex analysis text requires only a basic real analysis or advanced calculus course. This page has links to quite a collection of freely available math books, including several real analysis texts; I\u2019ve not looked at them, so I can\u2019t make any very confident recommendations, but if nothing else there may be some useful ancillary texts there. I will say that this analysis text by Elias Zakon and the companion second volume look pretty decent at first glance. For that matter, the intermediate-level book on number theory by Leo Moser available here looks pretty good, too, apart from having very few exercises. Oh, come to think of it there is one real analysis book that I want to mention: DePree and Swartz, Introduction to Real Analysis, if only for its wonderful introduction to the gauge integral. - Thank you in particular for pointing me to the set theory text by Judy Roitman. \u2013 user37450 Aug 13 '12 at 16:35 I am perhaps going to study(later) Munkres,Roitman and Rudin.It's Herstein for now before I am in a position to assess my self . \u2013 user37450 Aug 13 '12 at 16:51 Books may be available freely from public and academic libraries' own collections, and typically free or cheap via inter-library loans. WorldCat.org can help search library catalogues to find copies locally. \u2013 mctylr Aug 13 '12 at 19:22 \"The principle of Mathematic Analysis\" by Rudin is strongly recommended. Although it may be difficult for you, it will be very impressive if you can read through it. Although I don't know your interest, this book is critical for all students studying mathematics. - \"Understanding Analysis\" by Steven Abott is amazing. I think it is a good bridge if one wants to read Rudin. \u2013 Peter Tamaroff Aug 13 '12 at 16:51 Does that book have good examples ? Georges Elencwajg expressed some reservations about Rudin's style?(I have not yet bought anything but Herstein, so asking) \u2013 user37450 Aug 13 '12 at 19:01 The generality, breath-stopping elegance and economy of presentation of Rudin's Real and Complex Analysis (a bit more advanced text than The Principle of Mathematical Analysis) made me almost cry when I was using it as a self-found substitute to prepare for Complex Analysis examination as a second year student. If you like general way of presenting mathematics and want to learn mathematical thinking, I think Rudin is very very good. \u2013 FooF Aug 14 '12 at 4:56 I'd like to join in with Peter Tamaroff in recommending Abbott's book, which I called \"the best written introductory analysis book that's appeared in the past couple of decades\" back in January 2003. If you do wind up working through Abbott's book, a great follow-up to Abbott's book is Charles Chapman Pugh's Real Mathematical Analysis. \u2013 Dave L. Renfro Aug 14 '12 at 16:38 Lang's Undergraduate Analysis is richly illustrated, rigorous, very geometric (vector fields on spheres are discussed) and contains some juicy calculations (look at the treatment of the Fejer or the heat kernel ). Above all it prepares you to advanced modern analysis: Chapter XIV on the Fourier integral for example starts with a section on Schwartz space (again with some non-trivial calculations thrown in) which will ease the transition to distribution theory and partial differential equations. Don't forget that analysis is not a sterile exercise in axiomatics, despite what some boring books would make you believe, but one of the most useful and exciting subjects in mathematics (and physics). NB Lang was not an analyst (he was a student of the great arithmetician Emil Artin) but was capable of using quite tough analysis: just look at his book$SL_2(\\mathbb R)$and you will see Sobolev spaces, Mellin and zeta transforms, resolvants of Laplace operators,... at work. - Something that surprisingly has not been said, i find it amazing that at 16 years old you're into math that much and from the list stating your current knowledge, i see that you already acquired some overview on different fields of mathematics, which is great. Now since there have been some books recommended, i won't go into that anymore. But i would like to give you the following tips: If you look at the website of a university, often you can see a curriculum of the first few years in math. I'm pretty sure that you can find a university that has detailed course descriptions, including what literature they use. If you look further there might even be course notes online. This not only provides you some of the requested literature, but also can give you a good idea of what essential mathematical knowledge is, treated in the first years at uni. For example, my uni www.uva.nl has course descriptions, and you can select the language to be English. Also, if you look around and aren't afraid of rejections, i guess that if you email professors at some uni (anywhere around the world), there might be one enthousiastic and willing to help in some way. You might not realize it, but what you're doing is special. Maybe 1 out of 10 or 100 will actually respond, but hey, emailing is free. You might even have a better shot if you dont mail professors but graduate or post-graduate students. Lastly, considering your enthousiasm and the knowledge you already acquired, you should definitely go for a place at a uni. I have no idea where you live, but i believe some European universities offer grants to foreign students as well (i have NO personal experience with this though), so look around, there might be more possibilities then you think.. Good luck! Oh and by the way, Singh: Fermat's last theorem is a great popular math book! - I do not know in which field you are interested, though it is too early for you to select any field of interest, and rather learn all the basic techniques. Apart from Herstein, you should look at Artin's Algebra. Not only it is lucid, but also it clears several concepts from a practical (applied?) point of view. In particular, you should see the linear algebra portions. Also the exercises are important and should be attempted to make any real progress. Along with Rudin, you may try to work out Calculus I and II by Apostol. If these are too easy for you, then check differential geometry by Pressley. Some knowledge in probability theory is always useful. You can try Chung. All the best. - [Not a direct answer but may help in conjunction with the other answers that give topics and subjects of study] If you've not already checked it out then take a look at MITs \"OpenCourseWare\" site - I used this to brush up on my linear algebra when getting back into study around 3 years ago. As well as a wealth of lectures in many subjects the site also provides many, many references, including some that are out of print. If you pick through the courses carefully you will also find a number of assignments (with answers). http:\/\/ocw.mit.edu\/courses\/mathematics\/ Full disclosure: I am not associated with MIT or the OCW site in any way, I am just a (very) happy user of their site! - Here's a bunch of lesser known material I found really good. It may be a somewhat biased list though, since I tend to like reading \"easy\" books first to get the main idea, then solving hard problems and moving on to more difficult books later. So, some of this list is less textbook'y and more motivational. Linear Algebra: Numerical Linear Algebra: General techniques for solving mathematical problems: Abstract Algebra: Convex analysis and optimization: Real Analysis: Mathematical inequalities: Overview of mathematics from Courant: Topology: Overview of mathematical physics from Penrose: Differential topology\/geometry: - +1: Strang is a master expositor and his video lectures are indeed incredibly good . \u2013 Georges Elencwajg Aug 13 '12 at 20:22 I wouldn't call the Penrose book mathematical physics. \u2013 Nick Kidman Aug 14 '12 at 8:16 Well, it's not at the graduate or research level but it takes the mathematics seriously, which is to be expected since Penrose is a mathematical physicist himself. It certainly has a much more mathematical style than most physics textbooks which tend to handwave away difficulties. \u2013 Nick Alger Aug 14 '12 at 16:10 Benedict Gross's and Francis Su's video lectures seem amazing. \u2013 user37450 Aug 14 '12 at 17:06 Linear algebra is the most indispensable subject in all of mathematics: I can easily imagine someone getting a Fields medal without knowing what the sine function is, but I don't believe one could get that prize without being familiar with linear maps. Linear algebra is an easy subject and the main difficulty is choosing between the thousands of books on the subject and even between the tens of excellent ones. 1) My initiation was through Lang's Linear Algebra but I cannot guarantee that my genuine enthusiasm for that book is not nostalgia-tinted . 2) Lipschutz-Lipson's book in the Schaum series is very elementary, pleasant and richly illustrated, as befits the subject. As in all books in the series, the theory is kept to a minimum and the reader is encouraged to recreate the subject by solving judicious exercises (provided with complete solutions, just in case!) 3) Another excellent classic is Hoffman's-Kunze's Linear Algebra , which is very solid albeit a little austere. It is more advanced than the preceding two. - I would begin with the following: 1) Everyone has to learn multivariable calculus. There are many books to choose from here. The one I liked best was Calculus: A Complete Course by Adams. 2) You should be comfortable with linear algebra. I see that you know something about it, but you should really learn more. I'm not really sure which book you should use here (I used Elementary Linear Algebra by Edwards and Penney which was ok). Any suggestions? Then you can learn more advanced mathematics like the text by Rudin which user37787 recommended. For topology I would recommend Topology by Munkres. You could also look into applied mathematics like statistics and numerical mathematics. I don't know much about these fields so I cannot recommend anything in particular here. - I think the following subjects are absolute minimum. IMO, you should learn those before you learn other subjects(PDE, algebraic topology, differential geometry, algebraic geometry, etc.). Perhaps other people will recommend good books on each subject. - Linear algebra - Calculus(single and multivariable) - General topology - Abstract algebra(basics) - Naive set theory(basics) - This is precisely what I intend to study for now. \u2013 user37450 Aug 13 '12 at 16:38 When I was your age doing what you are doing, my Analysis professor said I should read Irving Kaplansky's book Set Theory and Metric Spaces. This was good advice. This book was my introduction to set theory, and ideas like well-orderings whose ideas underlie much of modern mathematics. I found it very readable and enjoyed it; it was an excellent supplement to Rudin, which others in this thread have recommended. - As many have said, Rudin's 'Principle of Mathematical Analysis' is a classic for Analysis. My personal recommendation for point-set topology would be Sutherland's 'Introduction to Metric and Topological Spaces'. It basically builds on from what we know in Analysis into more general spaces and the proofs inside are quite neat in my opinion. Apart from studying textbooks alone, have you considered reading books on mathematics itself? Books such as 'What is Mathematics' by Stewart and Courant, 'A very short introduction to Mathematics' by Tim Gowers are must reads, and I would also recommend 'The mathematical experience' by Hersh and Davis for a more philosophical insight. Happy reading! - This question is quite interesting and possibly deserves a big list of answers, so I would add my point of view. This is just an opinion. First of all, the goals should be set much clearer that it is done in the current version of the question. Even when studying at a proper University one needs to be very specific on what he or she wants to achieve. Examples are: \"I want to prepare for a course of General Relativity\", or \"I want to improve my mathematics for a Computer Graphics project\", or \"I want to contribute to ... and this is going to be my hobby\" etc. Secondly, I would recommend to find a challenging book that is not a leisure reading but rather a masterpiece in the area that you want to make your own. For instance, you could find one of S.Tabachnikov's books here as a motivating conundrum to start with. Just a hint. no more. Then, trying to work through the book you will encounter the parts of the story that are blurry or confusing. Thus you will get a good reason to learn more, and more and more. This is perhaps the way how to learn to ask right questions. (I believe that mathematics is all about that, and I feel that I still have to improve my question asking skills...) Of course, you will need to learn the cornerstones. Try to learn as much Linear Algebra as you can (this includes multilinear algebra). This will help you to master multivariable calculus to the level when it is done on smooth manifolds. A good knowledge of combinatorics is often an advantage and helps to master things like representation theory. My personal preference is geometry that is an enormous area but a course on differential geometry of curves and surfaces would dramatically expand the dimensionality of one's perception of mathematical problems. - The Foundations of Mathematics by Ian Stewart and David Tall (available second hand at Abe books). This is a great book on a variety of topics before \"more serious\" study, but considering what you say in you have already been reading it may be on the easy side, nevertheless I think it is worthy of a read. Definitely recommended is Galois Theory (3rd edition) by Ian Stewart, not only is it a beautiful story but beautiful mathematics, you can \"Look Inside\" a large part of it on the Amazon website before you buy. Something that is the upper end of undergraduate, but worth mentioning, is the free-online book Algebraic Topology by Allen Hatcher. Many tricky concepts, it's essentially an encyclopedia of the subject, and should be on everyone's bookshelf\/stored on their computer. - You can use this link to get Great Stuff like: free video lectures (from top Indian professors) along with Lecture Notes and Good References: http:\/\/nptel.iitm.ac.in\/ (Select \"Mathematics\" from the list of courses available). - I am not a mathematician, but when I was learning mathematics at the undergraduate level, a great professor recommended A Radical Approach to Real Analysis. I found it informative, full of interesting problems, and quite enlightening (it couches real analysis in the problems it was developed to solve, and as such added rich context to a subject I found otherwise difficult to access). - I would suggest some mathematical modeling or other practical application of mathematics. Also Finite automata and graph-theory is interesting as it is further away from \"pure math\" as I see it, it has given me another perspective of math. - I highly recommend The Princeton Companion to Mathematics - an encyclopedic overview of pure math and some theoretical physics with chapters on proof, many areas of math and biographies of famous mathematicians.Math blogs and personal websites. It is great for getting motivation and an overview on most subject areas so you can pick which to study further. It lists further reading for most topics. You should be able to read at your local library. As well as book there are some great math blogs, here are 3 that are a good start. Any many universities put course materials online so that you can both see what topics math undergraduates study and read the materials and problem sets for free. - On top of all helpful answers above I can add one very popular book:$\\mathit{Concrete \\ Mathematics}\\$ by Graham, Knuth and Patashnik (1995 edition). The main reasons are:\n\n1. This book is aimed at Computer Scientists that consider (or want to consider) themselves mathematicians through better understanding of mathematics behind programming and algorithms\n\n2. It has heaps of awesome problems in areas usually not very well covered by Discrete Math books: Generating functions, series, probability, asymptotics .\n\n3. Complexity of problems varies from easy high-school till PhD\/open problems. All have an answer or hints (not just 'odd-numbered').\n\n4. It blends continuous and discrete (hence 'concrete') math.\n\n5. It focuses a lot on recurrences, from very simple to very complicated.\n\n-\n\nI applaud you for taking the initiative to study on your own. I noticed the post was more than 6 months ago, so not sure if you are still looking for help. I recently started a website, www.redhoop.org, to help self learners like yourself. Search for math courses and see if you find any of them useful to you. Feel free to tell me what you think. Again, keep up your learning! Knowledge is the most important and only long lasting asset we have.\n\n-\n\nAt your age, it is more useful for you to socialise with friends, read good literature, watch TV, play sports and generally immerse yourself in hobbies. When you get to my age (I'm 22 so younger than you may think) you will not have that much time and if you now spend all your time worrying about undergraduate mathematics you may regret it. It's great to be young so don't waste it!!\n\n-\nIf this answer is meant as a joke, it is certainly not very funny. \u2013\u00a0Alex Nov 15 '12 at 2:36","date":"2013-05-19 19:37:32","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 1, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.34161376953125, \"perplexity\": 818.3646663720385}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2013-20\/segments\/1368698017611\/warc\/CC-MAIN-20130516095337-00057-ip-10-60-113-184.ec2.internal.warc.gz\"}"} | null | null |
Taking a Closer Look at What Made Pop Art Such a Special Movement For people who lived through the late 1950s through the early 1970s, it's quite likely that the pop art movement formed a huge part of their cultural exposure. The truth is that there are all kinds of ways in which pop art filtered its way into many fields of music, visual art, film making, and other areas. It's hard to find any piece of culture that wasn't somehow impacted by the existence and the spread of pop art. What you'll often find is that it can be tough to come to any consensus on what makes pop art its own movement in the broader art world, especially when you spend time asking different experts. You're going to find that there are few things that will prove to be consistent when it comes to defining pop art, but the projects that were done by Andy Warhol and his contemporaries tend to be the most firm starting place. In the article below, we'll look at a few of the most important things you should probably know about the work that was done in the name of pop art. The first thing you'll need to understand when dealing with the world of pop art is just what is part of the movement. In general, however, the definition of pop art simply involves any sort of art that takes subject matter from areas of culture that might not have traditionally been a part of art. Some of the most common areas where this is the case is the use of advertising or comic book imagery instead of subject matter that might have been more regularly considered acceptable in making visual art. This had a way of really increasing the democratic access to art in the modern world.
When you look at the world of pop art outside of the visual arts, you'll find that films and music also tended to incorporate this sort of popular imagery and thinking into what it created. What you'd often find is that film makers and songwriters would try to bring in common images that wouldn't ordinarily be found in these types of works. You may even find art historians who will argue that pop art is something that was designed to confused and conflate the line between actual art and imagery used for other purposes. | {
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Q: query solr without html tags? I have sent to Solr the following data:
{
"id":"kkk",
"name":"<div>book</div>"
}
after the solr receive data , if i search "div" , the result doesn't display, but when i search "book" , the result will display , how can i do ?
Here is my schema:
<field name="name" type="text_html" indexed="true" stored="true"/>
<fieldType name="text_html" class="solr.TextField" positionIncrementGap="100">
<analyzer>
<charFilter class="solr.HTMLStripCharFilterFactory"/>
<tokenizer class="solr.WhitespaceTokenizerFactory" />
<filter class="solr.LowerCaseFilterFactory" />
<filter class="solr.StopFilterFactory"
ignoreCase="true"
words="lang/stopwords_en.txt"
/>
</analyzer>
</fieldType>
The solr can only strip the html tags when i do the index , if i want to send solr the data directly , how can i strip the html tags?
A: What you see in the field name as result of your Solr query, is not what's is really indexed by Solr.
The <charFilter class="solr.HTMLStripCharFilterFactory"/> filter will remove the HTML tags.
Only after all the filters/tokenizers are execute the content is really indexed by Lucene.
Have a look at the Solr Admin Analysis Tool to better understanding what's going on.
In conclusion, for each field there are two contents:
*
*a stored content (stored="true") which is the source text passed to index (and that's is returned to the user when a document match the query constraints.
*an indexed content (indexed="true") which is the source content after being processed by the token/filters which is then used for the information retrieval part.
AFAIK, there is no way to modify the stored (source) content after processed, as said this is the source of field, so if you want modify the source just prepare it before submitting to Solr.
| {
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Coal mafia operates from jail
Picture Courtesy : wikimedia.org
Police have revealed that coal mafia and Jharkhand's most famous ganglord Fahim Khan, who inspired the Bollywood movie 'Gangs of Wasseypur', possesses 3G-enabled mobile phones which he uses to run his crime empire from the jail.
According to Ranchi Superintendent of Police Anup Birthray this fact came to light after interrogation of four sharp-shooters who were arrested from a posh locality of the capital. He said they were carrying out criminal activities on the directive of Khan. According to the call detail records of the mobile phones recovered from the shooters, they were in regular touch with Khan over phone.
Reportedly one prisoner, who served 4 months in jail, said that many inmates use 3G mobile phones. These phones are usually sneaked into the jail premises in food packets or provided by jail staff itself. The Ranchi SP, also revealed that sometimes inmates manage to get hold of mobile phones when brought out of jail for court hearings. | {
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<?php
class cancel_command extends base_command {
public $name = 'cancel';
public $description = 'لغو هر عملیاتی که در حال انجام آن هستید';
private function run($chat_id, $text, $message_id, $message, $state) {
global $telegram, $db;
reset_state('عملیات با موفقیت کنسل شد');
}
}
| {
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6.4 Local scale risk assessment for flashflooding in island countries
This Use Case uses the village of Dennery, Saint Lucia as an example to make the exercise tangible and reproducible. However, the data which is provided with the use case has been modified, complemented and generalized for the sake of this exercise. The results presented here cannot be used as basis for decision making. The authors do not accept any responsibility for the consequences that may result from any interpretation of this information beyond the purpose of this Use Case.
Flash floods, risk assessment, vulnerability
Spatial analist
Flash floods are floods that happen very suddenly and with little warning. They are caused by heavy or excessive rainfall in a short period of time, for instance thunderstorms or hurricanes, and occur within minutes or a few hours – usually less than six - after the peak of the rainfall event. Their severity may be aggravated by impermeable or saturated soils in the river's catchment and by the catchment's geometry. Flash floods can also occur after levee or dam failure, or after a sudden release of water by a debris or ice jam. Flash floods are very dangerous because they combine the destructive power of a flood with incredible speed and unpredictability and can be characterized as raging torrents that rip through an area sweeping everything before them. Another dangerous characteristic of flash floods is that they can transport large boulders and projectiles, such as uprooted trees and debris of destroyed buildings and structures, with high velocities downstream causing severe damage to whatever they collide with. The affected area is relatively small – especially when compared to e.g. fluvial floods. However, these phenomena are not included in this use case.
Flash flood risk assessment is the process to identify the harm that can be potentially caused by such a future flash flood event. This Use Case will give several examples how such an assessment can be done in a spatial manner, depending on the data that is available. To determine the risk of flash floods in a given area, one needs to 1) assess the nature and extent of the potential flash floods (flash flood hazard assessment) – see also Methodology Book chapter 3.3 - and 2) evaluate the existing conditions of vulnerability (exposure and vulnerability assessment) – see also chapter 7 of the Use Case book and chapter 5 of the Methodology Book. Together these two components determine the potential harm to exposed people, property, services, livelihoods and the environment – see chapter 5.5 of the Methodology Book.
Risk assessment is an important step towards disaster risk reduction (DRR) planning and risk management. Qualitative risk assessment approaches can be used to prioritize areas that require attention (which areas are 'worse off' than others), see examples 1 - 3, whereas quantitative approaches offer a basis for cost-benefit or cost effect evaluation of possible mitigation investments, e.g. by comparing the average annual loss before and after a proposed intervention, see examples 4 - 6.
The pictures below give a good impression of the raging power of flash floods in the Caribbean. The picture on the left shows the river at Roseau, Dominica during hurricane Dean in 2007, the picture on the right was taking during tropical storm Erika in 2015 in Dominica.
1 Source: http://www.themontserratreporter.com
2 Source: Mike Theiss; Instagram: @ExtremeNature
The objective of this Use Case is to give a number of practical examples on the assessment of flash flood risk at local scale using a GIS depending on the availability of data. This Use Case is accompanied by a GIS dataset with data from the village of Dennery, Saint Lucia, with instructions for hands-on practice. The target group of this Use Case are GIS experts who's task it is to integrate the data that is generated or collected by other experts into a (spatial) risk assessment.
Note: This use case requires data at local to medium scale, i.e. spatial data collected at a scale of 1:1000 to 1:10.000
Saint Lucia is highly exposed to tropical storms and hurricanes. These storms bring large amounts of rain that can result in flash floods. Notable storms include Hurricane Allen (1980), Tropical storm (later Hurricane) Debby (1994), Hurricane Tomas (2010), and the trough system that battered the island on Christmas Eve 2013. These storms (and others) and the consequent floods caused enormous damage. For instance, the 2013 Christmas Trough resulted in a total loss of almost 100 million US$, which is an equivalent of 8.3 percent of the island's GDP. Hurricane Tomas in 2010 caused an estimated US$ 336 million in damage or 34 percent of the island's GDP (Fisseha, 2014). Such losses seriously impede the growth and development of the country. The 2013 event led to widespread flooding in the country and in Dennery village in particular. Several people had to be evacuated from their flood-inundated houses because the water depth was up to five feet (1.5 meters) and some bridges where damaged or overrun by the flood waters (source: WordPress.com, 2013).
This Use Case presents a few examples of qualitative and quantitative risk assessment approaches for Dennery village. Which approach to use depends on the available data, on the preferences of the assessor and/or the requirements of the end user.
In general one can say that three types of data are necessary:
Flood hazard maps: These map contain the inundation depth information for different (at least three) flood return periods. Often the flood return periods are not so easy to define, so the return period of the causing event – in the case of St. Lucia hurricanes and tropical storms – is often used as a proxy. The return period is then obtained through a statistical analysis of the total daily precipitation amounts. Use Case 8.2 and chapter 2.3 of the Methodology Book give further details about this analysis. For the scale, please see Methodology Book, section 3.2. For local analysis, national scale assessments are not detailed enough; Assessments must be done at scales of 1:1000 to 1:10.000.
Exposure maps: These maps give the location of the assets that are (or could be) exposed to flash flood hazard. An introduction to the characterization of assets is given in chapter 5.2 of the Methodology Book. The Data Management Book gives further details about how to get e.g. building footprint maps (chapter 5.2), population distribution maps (chapter 5.3) and road maps (chapter 5.4).
Vulnerability: Vulnerability are the characteristics and circumstances of the assets (mapped in the expose maps) that make these assets susceptible to the damaging effects of the hazard. This term is further described in chapter 5.3 of the Methodology Book, exemplified in Use Cases 7.1 and 7.2. Vulnerability information is often collected as a list of attribute parameters of the assets in the exposure map – see also Data Management Book, chapter 5.2.
Especially the required vulnerability information is not well-defined as it depends on the hazard that is examined, on the type of assets that are mapped and on the resources available to carry out the exposure and vulnerability survey. In case of floods, buildings are most frequently characterized by the building materials (walls and roof), their use (residential, commercial, industrial, ..) and the number of floors. In detailed surveys one should also include mitigation and flood proofing measures, such as raised ground floor and the state of repair of the structure.
In these analysis steps we assume that certain layers of information are available. For instance, flood hazard maps are essential input. Chapters 3.3 and 3.4 of the Methodology Book provide background information regarding flood modeling and the flood hazard reports for Dominica, Grenada, St. Lucia and St. Vincent give an example on how to use flood model results for hazard assessment. Also the Super Use Case developed in this project may provide useful information about the modeling of hydrological and hydraulic processes in a river basin. Other layers may be absent or may not always contain the exact information that one would need for risk assessment. This is often the case for vulnerability data. As indicated in the previous paragraph this information is often linked to the assets in the exposure maps but it may be incomplete, absent or contain irrelevant attributes for our purpose. In this use case we will therefore present six examples: Three qualitative approaches based on flood hazard information only, and three qualitative approaches with one based on a combination of inundation depth and flow velocity, one on flood hazard information and exposure maps and a last one that integrates flood hazard, vulnerability and exposure (value) into a spatial flood risk assessment and that calculates the Average Annual Loss. All examples are linked to the GIS exercise and instructions are provided for the last two approaches.
It should also be noted that no single expert can prepare all three data layers by him/herself and do the GIS analysis described in this chapter. Risk assessment is a multi-disciplinary endeavour that requires input from various fields. Flood modeling should be carried out by a hydrology expert, mapping the elements at risk requires GIS and Remote Sensing and/or surveying skills. Selection and assessment of the attributes and their values to assess vulnerability requires engineering, social and economic expertise. The steps in this analysis require a GIS expert with a basic understanding of what the experts from the other disciplines deliver and integrate all this information into a final risk assessment.
Flood hazard
Most event-based flood models produce time series of maps with inundation depth and sometimes flow velocity and they usually produce aggregated maps such as maximum inundation depth and maximum flow velocity. Some models also produce other relevant output, such as e.g. maps that indicate the time a pixel was inundated for the first time. The exact outputs vary per flood model and the GIS expert should familiarize him/herself with what information the model expert can provide.
Maximum inundation depth is the most frequently used parameter in hazard and risk assessment. however in example 2 and 4 also flow velocity is used. Ideally the flood (inundation) maps should be calculated for events with a given return period, e.g. the 5 year flood, the 20 year flood and the 50 year flood. Figure 2 gives those three maps for Dennery. Figure 3 shows the same maps but now classified. An example for Dennery is given in Figure 4.
Figure 2: Three examples of maximum flood inundation depth maps (not classified) of Dennery, St. Lucia for the return periods 5, 20 and 5 years.
Figure 3: Three examples of maximum flood inundation depth maps (classified) of Dennery, St. Lucia for the return periods 5, 20 and 5 years.
Figure 4: The integration of the flood model results into a hazard map.
In October 2014 a survey was carried out in Dennery village in collaboration with a team of five members from the community. Some of them were Red Cross volunteers with experience in mapping and some of them had provided assistance during recent disasters in the community (e.g. in 2013). They received a short instruction before the field survey about the procedure of collecting and documenting the required data for exposure and vulnerability. In total, data was collected of 339 buildings. This Use Case uses that dataset but for the sake of example, it has been generalized and modified. The MSc thesis of Uwakwe (2015) is available here.
The identification of the elements at risk is an essential step for the characterization of physical vulnerability. Use Case 7.4, the Data Management Book chapter 5.2 and the Methodology Book chapter 5.2 give more information about elements at risk – or exposure maps. However, identification is useful (see e.g. example 5) but it is often not sufficient. For risk assessment an understanding of the characteristics of the asset (element at risk) is essential. Elements at risk, for example buildings and population, have specific characteristics that define their physical vulnerability, e.g. for buildings these characteristics include wall material, building height from the ground, number of floors, etc. For population vulnerability information about the number of people in a building, the age distribution, number of people in the building during day or night time, etc. are necessary. It should also be noted that the characteristics differ for different hazards. For example, the characteristic of a building's shape is important for earthquakes while it is not so important for floods.
Often the main limitations for risk assessment at local scale is the lack of such detailed data regarding the characteristics of the elements at risk, or if such data exists, it may either be inadequate or may not be suitable for the level (scale) or purpose of the assessment. For example, Papathoma-Köhle et al (2007) noted in an assessment of physical vulnerability of elements at risk that the main limitation was data availability and costs. They suggested that data to characterize the elements at risk can be collected by aerial-photograph analysis and remote sensing, local authorities, questionnaires and field surveys. Also Kappes et al. (2012) indicated during an assessment of the physical vulnerability of multi-hazards (including flood) that lack of data was a problem. They suggested that complementary using alternative sources such as e.g. Google Street view (if available) or completion of questionnaires by people that reside in the hazardous areas, will considerably improve the vulnerability assessment.
Vulnerability information was collected during the survey through 39 interviews with people whose house was flooded during the December 2013 flood event – see also Use Case 7.2. Several parameters were recorded of which four are used in this Use Case, more specifically in example 6:
The degree of damage to the buildings, graded from No damage (0) to Total Loss (1),
The inundation depth,
the building materials, and
the number of floors.
Uwakwe (2015) plotted the inundation depth vs the degree of damage for four types of buildings. The results are shown in Figure 5. Such a graph is called a stage-damage curve, or depth-damage curve, or flood-vulnerability curve. These data formed the basis of the vulnerability curves used in example 6, although slightly modified: Buildings of structural type 1 can be characterized by the building materials wood and brick; Buildings of structural type 2 can be characterized by the building materials concrete blocks and concrete; Buildings of structural type 3 can be characterized by a mix of building materials; There were only two records of buildings of structural type 4 (concrete blocks wall with ceramic tiles on the floor), so this category was not included in example 6.
Figure 5: Vulnerability curves for the structural types (source: Uwakwe 2015)
Type 1: Wood and brick; Type 2: Concrete blocks and concrete; Type 3: Mix of building materials; Type 4: Concrete blocks wall with ceramic tiles on the floor.
The team members had experience with the December 2013 flood in Dennery and they drew a sketch map of the extent of the flood as they remembered. Figure 6a shows this sketch, Figure 6b shows the model results of the 5-year return period flood for comparison.
Figure 6a (left): Sketch of the extent of the December 2013 flood NF = Not Flooded, L = Low, M = Medium, H = High.
Figure 6b (right: Flood extent of the 5-year return period flood according to the modeling. | {
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class CreateWeightImports < ActiveRecord::Migration
def change
create_table :weight_imports do |t|
t.integer :user_id
t.float :weight
t.float :fat
t.date :weighed_at
end
add_index :weight_imports, :user_id
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#ifndef SkAutoPixmapStorage_DEFINED
# define SkAutoPixmapStorage_DEFINED
# include "include/core/SkPixmap.h"
# include "include/private/SkMalloc.h"
class SkAutoPixmapStorage : public SkPixmap
{
public:
SkAutoPixmapStorage();
~SkAutoPixmapStorage();
/**
* Leave the moved-from object in a free-but-valid state.
*/
SkAutoPixmapStorage& operator=(SkAutoPixmapStorage&& other);
/**
* Try to allocate memory for the pixels needed to match the specified Info. On success
* return true and fill out the pixmap to point to that memory. The storage will be freed
* when this object is destroyed, or if another call to tryAlloc() or alloc() is made.
*
* On failure, return false and reset() the pixmap to empty.
*/
bool tryAlloc(const SkImageInfo&);
/**
* Allocate memory for the pixels needed to match the specified Info and fill out the pixmap
* to point to that memory. The storage will be freed when this object is destroyed,
* or if another call to tryAlloc() or alloc() is made.
*
* If the memory cannot be allocated, calls SK_ABORT().
*/
void alloc(const SkImageInfo&);
/**
* Gets the size and optionally the rowBytes that would be allocated by SkAutoPixmapStorage if
* alloc/tryAlloc was called.
*/
static size_t AllocSize(const SkImageInfo& info, size_t* rowBytes);
/**
* Returns an SkData object wrapping the allocated pixels memory, and resets the pixmap.
* If the storage hasn't been allocated, the result is NULL.
*/
sk_sp<SkData> SK_WARN_UNUSED_RESULT detachPixelsAsData();
// We wrap these so we can clear our internal storage
void reset()
{
this->freeStorage();
this->INHERITED::reset();
}
void reset(const SkImageInfo& info, const void* addr, size_t rb)
{
this->freeStorage();
this->INHERITED::reset(info, addr, rb);
}
bool SK_WARN_UNUSED_RESULT reset(const SkMask& mask)
{
this->freeStorage();
return this->INHERITED::reset(mask);
}
private:
void* fStorage;
void freeStorage()
{
sk_free(fStorage);
fStorage = nullptr;
}
typedef SkPixmap INHERITED;
};
#endif
| {
"redpajama_set_name": "RedPajamaGithub"
} | 3,299 |
alias lart='ls -lart'
alias j='jobs'
alias gst='git status'
| {
"redpajama_set_name": "RedPajamaGithub"
} | 14 |
The Sunday of the Samaritan Woman
Metropolitan Basilios2020-05-15T19:20:48+10:00May 15th, 2020|
"Whoever drinks of this water will thirst again, but whoever drinks of the water that I shall give him will never thirst. But the water that I shall give him will become in him a fountain of water springing up into everlasting life," (John 4:14)
The Fifth Sunday of Pascha
May 17th, 2020 | By His Eminence, Metropolitan Basilios
Today's reading, considered one of the longest dialogues in this gospel, is from John 4:5-42.
As a preface, we should reflect on the verse that precedes the biblical passage specified for reading, which says: "He (Jesus) needed to go through Samaria," (John 4: 4). Here, the phrase "He needed" does not translate to coercion, but occurred because of His "divine providence" which we will witness towards the end of the evangelical passage when Jesus fulfilled this "divine mission".
Jesus was heading north from Judea to Galilee, and there he passed by Samaria to a city called Sychar where Jacob's well was. And the gospel says, "Jesus therefore, being wearied from His journey, sat thus by the well. It was about the sixth hour," (4: 6). Here we read that Jesus was tired, thirsty, and hungry. For this reason, "His disciples had gone away into the city to buy food," (4: 8). This mention of hunger bears as conclusive evidence that the Lord Jesus was indeed man, as man often hungers and thirsts in the face of heat and hard labour.
"It was about the sixth hour" when "a woman of Samaria came to draw water" (4: 6-7). The sixth hour in the Eastern reckoning is midday. This hour has biblical significance; Eve was expelled from Paradise at the sixth hour because of the seduction of the serpent. We read in the Vespers: "At the sixth hour Thou didst come to the well, O Fountain of wonder, to ensnare the fruit of Eve; for that one, at the very same hour, had been driven from paradise by the serpent's temptation. Then the Samaritan woman came to draw water."
This is when Jesus saw the Samaritan woman and requested that she give him a drink. Here we see the Creator asking His creature to give Him water to drink. He, who has created the seas and rivers, and suspended the land on the water and "gathered the waters into the places where they are gathered, and Who is of one throne with the Father and the Spirit;" was asking a sinful woman to give him a drink.
This represents the beginning of the dialogue that Jesus initiated. The Samaritan woman knew Him to be a Jew from His appearance and His accent, and she said: "How is it that You, being a Jew, ask a drink from me, a Samaritan woman? For Jews have no dealings with Samaritans?". At that time, we know there was great animosity between Jews and the Samaritans, based on religious disputes mainly about where God must be worshipped, in Jerusalem, or in the temple built on a mountain called Gerizim.
Despite this known animosity, the Samaritan woman did not keep silent, but out of her concern that the Lord was doing something unlawful, she attempted to correct Him. But Christ, who "desires all men to be saved and to come to the knowledge of the truth," (1 Tim 2:4) broke this custom, as it was He who initiated the dialogue first. By this simple request and initial contact, He broke down the barriers of hatred between Jews and Samaritans, seeking the salvation of this woman and the people of her city.
The woman's repulsion towards the Lord Jesus did not prevent Him from continuing His conversation with her, and therefore taking her to a higher level of divine understanding and revelation, He said to her: "If you knew the gift of God, and who it is who says to you, 'Give Me a drink,' you would have asked Him, and He would have given you living water," (4:10).
Here it appears that the woman did not understand the words of Jesus about "living water," just as His disciples later did not understand His words about "food and eating" when He said to them: "My food is to do the will of Him who sent Me and to complete His work," (4:34). We see the woman still remains confined within her understanding, still thinking of earthly spring water. She answers Him: "Sir, You have nothing to draw with, and the well is deep. Where then do You get that living water?"
Jesus' response sparked an arousal of curiosity within her and made her notice that she was lacking something. He said to her: "Whoever drinks of this water will thirst again, but whoever drinks of the water that I shall give him will never thirst. But the water that I shall give him will become in him a fountain of water springing up into everlasting life," (4:14).
Here, it must be made clear that the Lord Jesus calls the grace of the Holy Spirit "living water" and elsewhere, the Holy Spirit is "fire" (Matthew 3:11). St. John Chrysostom explains that "scripture calls the grace of the Spirit sometimes Fire, sometimes Water, showing that these names are not descriptive of its essence, but of its operation; for the Spirit, being invisible and simple, cannot be made up of different substances". The nature of both water and fire purifies, therefore, they were used to refer to the action of the Holy Spirit in the human soul (purification). St. Maximos the Confessor writes, "for the single identical Spirit takes His different names from the different ways in which He acts on each person".
The Samaritan woman's response to Jesus was earthly, "Sir, give me this water, that I may not thirst, nor come here to draw." Up until this point, the Samaritan woman had viewed Jesus as an ordinary Jewish man, calling Him "Sir". But throughout the dialogue, we witness a shift in her attitude towards Him as Christ gives her the opportunity to attain self-knowledge before later revealing Himself to her.
The Lord Jesus asked her to call her husband and bring him here, to which she confesses that the man she lives with is not her husband, and comes to the enlightened realisation that this 'Jewish man's' knowledge of her past can only mean that she was not standing in front of an ordinary Jewish person, but rather a Prophet, who knows the hidden parts of the heart. She asks, "Sir, I perceive that You are a prophet?" and is further prompted to ask Him a doctrinal question that represents the essence of the doctrinal dispute between the Jews and the Samaritans. St. John Chrysostom comments, "Do you see how much more elevated in mind she has become? She who was anxious that she might not be troubled for thirst, now questions concerning doctrines."
Jesus then avoids a direct answer to her question: "Our fathers worshiped on this mountain, and you Jews say that in Jerusalem is the place where one ought to worship?" In the same way he avoided answering her previous question: "Are You greater than our father Jacob, who gave us the well, and drank from it himself, as well as his sons and his livestock?" Jesus' goal was not to compare the worship of the Jews with that of the Samaritans as much as it was to lead the woman to true worship in "spirit and truth".
There are several references in the Old Testament which indicate that God was not pleased with a particular kind of worship. "The sacrifices of God are a broken spirit, a broken and a contrite heart, These, O God, You will not despise," says the prophet David in Psalm 50. Also, we read successively from the prophet Isaiah "I have had enough of burnt offerings of rams. And the fat of fed cattle. I do not delight in the blood of bulls, Or of lambs or goats," (Isaiah 1: 11-19). In the New Testament, Jesus rebukes the customs of the Pharisees and Scribes when He said to them, "Well did Isaiah prophesy of you hypocrites, as it is written: 'These people honour Me with their lips, But their heart is far from Me. And in vain they worship Me, teaching as doctrines the commandments of men," (Mark 7: 6).
The Lord's answer about worship in "spirit and truth" led the Samaritan woman to a higher level of divine revelation, to the point of inquiring about the coming of the Messiah. "I know that Messiah is coming (who is called Christ). When He comes, He will tell us all things." And as the final divine revelation, Jesus says to her: "I who speak to you am He. And here I am telling you everything you need in order to save yourself." Christ does not show Who He is until the woman's virtue, humility, and repentance have been revealed. Then He begins to speak to her of more profound matters.
The arrival of the disciples coincides with the departure of the Samaritan woman from the well "where she left her waterpot," meaning that she had forgotten the initial reason for coming to the well. The encounter with Jesus altered her priorities and her life, and He became the centre and the goal, the "living water" that quenched her thirst. The woman returned to her hometown and revealed to her people, saying: "Come, see a Man who told me all things that I ever did. Could this be the Christ?"
Afterward, the lord conversed with His disciples about sowing and harvesting. "I sent you to reap that for which you have not laboured; others have laboured, and you have entered into their labours," (38: 4). The Prophets undertook the harder work, He says, while you are sent out merely to complete what has already been prepared. But in the end, "both he who sows and he who reaps may rejoice together" when they see the fruits of Eternal Life.
Jesus stayed with the Samaritans for two days. They came to believe in Him, but their faith was not based only on the words and experience of the Samaritan woman, but on their personal experience with Him, after their personal encounter with Him and hearing His words. "Now we believe, not because of what you said, for we ourselves have heard Him and we know that this is indeed the Christ, the Saviour of the world."
This Biblical passage represents the model of dialogue with God and how it leads to self-knowledge and to the knowledge of God. Evagrius of Pontus writes: "Do you want to know God? Learn first to know yourself." Saint Nilus also writes: "When you know yourself, you are able to know God."
The life of this Samaritan woman after encountering Jesus has been transformed. She showed repentance and acceptance of Him as a "Messiah" in her life, and after conversing with the Saviour, a ray of divine light illuminated her soul; she was baptised with her five sisters and two sons on the day of Pentecost and she became known as "Photini", the illumined one. She travelled to many places and preached about Christ with a fire in her heart that drew people to her faith. She proclaimed the good news, the Gospel, to her people even before the Apostles did. In the end, she suffered martyrdom in Rome after she had been thrown into a well for several weeks. The Orthodox Church commemorates St. Photini on February 26.
Every one of us, after his or her Baptism, becomes a Photios or Photini, illuminated by the divine rays of the Holy Trinity. If your life has been transformed, don't deprive your family, friend, or the people around you from encountering Christ and accepting Him as Saviour. Amen. | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 3,529 |
Przetrząsaczo-zgrabiarka – maszyna rolnicza służąca do przetrząsania (przetrząsacz) skoszonych roślin (traw) suszonych na siano w warunkach polowych oraz zgrabiania (zgrabiarka) suchego siana w zazwyczaj podłużne wały.
Istnieje kilka konstrukcji przetrząsaczo-zgrabiarek, najczęściej spotykane to:
kołowe – elementem roboczym są nienapędzane koła o poziomej osi obrotu wyposażone w druty przesuwające grabiony materiał, a obracające się w wyniku ruchu przetrząsaczo-zgrabiarki względem ziemi. Tryb pracy zmienia się, ustawiając kierunek osi obrotu kół względem kierunku jazdy. W trybie zgrabiania są one tak ustawione, że grabiony materiał z wcześniejszego koła jest przenoszony przed następne koło. W trybie przetrząsania materiał jest przerzucany w kierunku przeciwnym.
karuzelowe – elementem roboczym są zazwyczaj 2 koła napędzane z ciągnika. Oś obrotu ma kierunek zbliżony do pionowego. W trybie grabiarki koła mogą formować wał pośrodku między kołami lub dwa na zewnątrz.
pasowe – mechanizmem roboczym są sprężyny przymocowane do napędzanego pasa, który porusza się poziomo skośnie do kierunku jazdy. W zależności od ustawienia kierunku ruchu pasa maszyna przetrząsa lub zgrabia materiał.
Przetrząsaczo-zgrabiarki kołowe najczęściej mają 4, 5, 7, rzadziej spotykane 3, 6, 9.
Przetrząsaczo-zgrabiarki można podzielić na dwa rodzaje:
przyczepiane – wyposażone są w koła jezdne,
zawieszane (TUZ) – nie posiadają kół jezdnych.
Bibliografia
Przetrząsaczo-zgrabiarki – Zespół Szkół Agrotechnicznych i Ogólnokształcących im. Józefa Piłsudskiego w Żywcu {Praca dyplomowa: Barbara Kliś i Marzena Maryan, 2005)
Dobór parametrów technicznych przetrząsaczo-zagrabiarki beznapędowej
Maszyny rolnicze | {
"redpajama_set_name": "RedPajamaWikipedia"
} | 9,973 |
Domino's® Extends Partnership With Longtime Creative Agency CP+B
Ten years of collaboration to continue
Aug 21, 2017, 07:07 ET
ANN ARBOR, Mich., Aug. 21, 2017 /PRNewswire/ -- Domino's Pizza (NYSE: DPZ), the recognized world leader in pizza delivery and digital ordering platforms, has finalized a renewal agreement with its national agency of record, CP+B, to the end of 2020. The agency will handle creative, brand strategy, media planning and digital initiatives as it has through a decade-long partnership marked by ever-increasing business achievements.
"Lengthy creative agency partnerships are rare, to say the least. But after looking at what we've accomplished with CP+B, it should not be shocking," said Joe Jordan, chief marketing officer, Domino's. "Together we have built a legacy of creative work founded on uncommon honesty at every turn. In the process, we formed an unrivaled collaboration in which CP+B is a true extension of our team. We're looking forward to creating the next series of game-changing ideas together."
Alongside CP+B, Domino's began a landmark brand transformation with the 2010 "Pizza Turnaround" campaign, setting a precedent for corporate transparency and yielding record-setting sales. Ever since, the partners have embarked on a never-ending mission of improvement, continually exceeding consumer expectations for a pizza company and eclipsing the domain of an advertising agency – from building the DXP®, a purpose-built pizza delivery vehicle, to launching a wedding registry earlier this year.
Domino's has embarked on a journey to grow the brand as an e-commerce powerhouse with CB+P by its side. Since online ordering was first introduced nationwide, Domino's has launched numerous innovations including the brand's first digital customer loyalty program – Domino's Piece of the Pie Rewards® – and the AnyWare™ ordering platforms, allowing consumers to order anywhere they happen to be, whether through voice apps, Facebook Messenger, or simply tweeting or texting a pizza emoji. Domino's now generates 60 percent of orders via digital channels in the U.S.
The partnership has also resulted in some of advertising's highest honors. Within the last three years, the brand and agency won a Titanium Grand Prix at Cannes Lions and Grand at the Clio Awards, while recognized as "Best Partnership" at the 4A's Partner Awards and "Best Partnership Innovation" at the Adweek Project ISAAC Awards.
About Domino's Pizza®
Founded in 1960, Domino's Pizza is the recognized world leader in pizza delivery, with a significant business in carryout pizza. It ranks among the world's top public restaurant brands with a global enterprise of more than 14,200 stores in over 85 international markets. Domino's had global retail sales of nearly $10.9 billion in 2016, with more than $5.3 billion in the U.S. and more than $5.5 billion internationally. In the second quarter of 2017, Domino's had global retail sales of more than $2.7 billion, with over $1.3 billion in the U.S. and nearly $1.4 billion internationally. Its system is comprised of independent franchise owners who accounted for over 97% of Domino's stores as of the second quarter of 2017. Emphasis on technology innovation helped Domino's reach an estimated $5.6 billion in global digital sales in 2016, and has produced several innovative ordering platforms, including Google Home, Facebook Messenger, Apple Watch, Amazon Echo, Twitter and text message using a pizza emoji. In late 2015, Domino's announced the design and launch of the DXP®, a purpose-built pizza delivery vehicle, as well as Piece of the Pie Rewards™, its first digital customer loyalty program.
Order – dominos.com
AnyWare Ordering – anyware.dominos.com
Company Info – biz.dominos.com
Twitter – twitter.com/dominos
Facebook – facebook.com/dominos
Instagram – instagram.com/dominos
YouTube – youtube.com/dominos
SOURCE Domino's Pizza
http://www.dominos.com | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 9,381 |
Q: select from db sql query I have this query :
$query = mysql_query ("SELECT *
FROM saledb.application
WHERE app_id = (
SELECT app_id
FROM saledb.applicationdetails
WHERE is_hot = '1'
) LIMIT $Kvet,$Zet
");
And I have the following error:
Unable to save result set in
/home/lemondo/lemondosales.itnovations.ge/content/tpl/gtpl/main.php on
line 68
When I changing select item with MAX(app_id) it works but i need show all results. i know where is problem mysql cant choose in one query meny ID but i need alternativ query.
A: Use the IN predicate instead of = like os:
SELECT *
FROM saledb.application
WHERE app_id IN
(SELECT app_id
FROM saledb.applicationdetails
WHERE is_hot = '1');
A: $query = mysql_query ("SELECT * FROM saledb.application WHERE app_id IN (SELECT app_id FROM saledb.applicationdetails WHERE is_hot = '1') LIMIT $Kvet,$Zet");
That should do the trick. If you leave '=' and the subquery returns more than one row, you wil get that error. To match all the lines in saledb.application that have the app_id in the result set you need to use "IN" :)
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 6,053 |
\section{Introduction}
\label{sec:intro}
In supersymmetric models of particle physics,
$R$-parity is often imposed to avoid too rapid proton decay
which can be induced by superpotential terms which violate
baryon and lepton number conservation. One of the byproducts of
$R$-parity conservation is that the lightest supersymmetric particle
is absolutely stable, making it a good candidate particle to make up
the bulk of dark matter (DM) in the universe.
In gravity-mediated SUSY breaking models, dark matter candidate
particles include the lightest neutralino or the gravitino. Here we will
focus on the lightest neutralino $\widetilde Z_1$\cite{haim}; recent results on
TeV scale gravitino dark matter can be found in Ref.~\cite{gravitino}.
The relic density of neutralinos in supersymmetric models can be
straightforwardly calculated by solving the Boltzmann equation for the
neutralino number density\cite{griest}.
The central part of the calculation is to
evaluate the thermally averaged neutralino annihilation and
co-annihilation cross section times velocity.
The computation requires evaluating many thousands of Feynman diagrams.
Several computer codes are now publicly\cite{rdcodes,isared}
available which evaluate the
neutralino relic density $\Omega_{\widetilde Z_1}h^2$.
The dark matter density of the universe has recently been inferred
from the WMAP collaboration based on precision fits to
anisotropies in the cosmic microwave background radiation\cite{wmap}.
The WMAP collaboration result for the relic density of cold dark matter (CDM)
is that
\begin{equation}
\Omega_{CDM}h^2=0.113\pm 0.009 .
\end{equation}
This result imposes a tight constraint on supersymmetric models
which contain a dark matter candidate\cite{wmapcon}.
Many analyses have been
recently performed in the context of the paradigm minimal
supergravity model\cite{msugra} (mSUGRA), where the parameter space is given by
$m_0,\ m_{1/2},\ A_0,\ \tan\beta$ and $sign(\mu )$. The mSUGRA model
assumes the minimal supersymmetric model (MSSM) is valid between
the mass scales $Q=M_{GUT}$ and $Q=M_{SUSY}$. A common mass $m_0$ ($m_{1/2}$)
(($A_0$))
is assumed for all scalars (gauginos)
((trilinear soft breaking parameters)) at $Q=M_{GUT}$, while the bilinear
soft term $B$ is traded for $\tan\beta$, the ratio of Higgs vevs, via the
requirement of radiative electroweak symmetry breaking (REWSB). REWSB
also determines the magnitude, but not the sign, of the superpotential
Higgs mass term $\mu$. Weak scale couplings and soft parameters
can be computed via renormalization group (RG) evolution from $Q=M_{GUT}$ to
$Q=M_{weak}$. Once weak scale parameters are known, then sparticle masses
and mixings may be computed, and the associated relic density of
neutralinos can be determined.
In most of mSUGRA parameter space, the relic density $\Omega_{\widetilde Z_1}h^2$
turns out to be much larger than the WMAP value. Many analyses have found
just several allowed regions of parameter space:
\begin{itemize}
\item The bulk region occurs at low values of $m_0$ and $m_{1/2}$\cite{bulk}.
In this region, neutralino annihilation is enhanced by $t$-channel exchange of
relatively light sleptons. The bulk region, featured prominently in many early
analyses of the relic density, has been squeezed from below by the LEP2
bound on the chargino mass $m_{\widetilde W_1}>103.5$ GeV, and from above by the
tight bound from WMAP.
\item The stau co-annihilation region at low $m_0$ for almost any $m_{1/2}$
value where $m_{\tilde \tau_1}\simeq m_{\widetilde Z_1}$, so that $\tilde \tau_1-\widetilde Z_1$ and
$\tilde \tau_1^+\tilde \tau_1^-$ co-annihilation help to reduce the relic
density\cite{stau}.
\item The hyperbolic branch/focus point (HB/FP) region at large $m_0\sim$
several TeV, where $\mu$ becomes small, and neutralinos efficiently
annihilate via their higgsino components\cite{hb_fp}.
This is the case of mixed higgsino dark matter (MHDM).
\item The $A$-annihilation funnel occurs at large $\tan\beta$ values
when $2m_{\widetilde Z_1}\sim m_A$ and neutralinos can efficiently annihilate
through the broad $A$ and $H$ Higgs resonances\cite{Afunnel}.
\end{itemize}
In addition, a less prominent light Higgs $h$ annihilation corridor occurs at
low $m_{1/2}$\cite{drees_h}
and a top squark co-annihilation region occurs at
particular $A_0$ values when $m_{\tilde t_1}\simeq m_{\widetilde Z_1}$\cite{stop}.
Many analyses have also been performed for gravity-mediated SUSY breaking
models with non-universal soft terms. Non-universality of
SSB scalar masses can 1. pull various scalar masses to low values so that
``bulk'' annihilation via $t$-channel exchange of light
scalars can occur\cite{nmh},
or 2. they can bring in new near degeneracies of various sparticles with the
$\widetilde Z_1$ so that new co-annihilation regions open up\cite{auto,nuhm,sp},
or they can 3.
bring the value of $m_A$ into accord with $2m_{\widetilde Z_1}$ so that
funnel annihilation can occur\cite{ellis,nuhm},
or 4. they can pull the value of $\mu$
down so that higgsino annihilation can occur\cite{ellis,drees2,nuhm}.
It is worthwhile noting that
all these general mechanisms for increasing the neutralino annihilation rate
already occur in the mSUGRA model.
Moreover, in all these cases the lightest neutralino
is either bino-like, or a bino-higgsino mixture.
If non-universal gaugino masses are allowed, then a qualitatively new
possibility arises that is not realized in the mSUGRA model: that of mixed
wino dark matter (MWDM). In this case, if the $SU(2)$ gaugino mass $M_2$ is
sufficiently low compared to $U(1)_Y$ gaugino mass $M_1$, then the
$\widetilde Z_1$ can become increasingly wino-like. The $\widetilde Z_1-\widetilde W_{1,2}-W$
coupling becomes large when $\widetilde Z_1$ becomes wino-like,
resulting in enhanced $\widetilde Z_1\widetilde Z_1\rightarrow W^+W^-$ annihilations. Moreover, coannihilations with the lightest chargino and with the next-to-lightest neutralino help to further suppress the LSP thermal relic abundance.
Non-universal gaugino masses can arise in supersymmetric models in a
number of ways\cite{models}.
\begin{itemize}
\item In supergravity GUT models, the gauge kinetic
function (GKF) $f_{AB}$ must transform as the symmetric product of two
adjoints.
In minimal supergravity, the GKF transforms as a singlet. In $SU(5)$
SUGRA-GUT models, it can also transform as a 24, 75 or 200 dimensional
representation\cite{anderson}, while in $SO(10)$ models it can transform as
1, 54, 210 and 770 dimensional representations\cite{chamoun,nath}.
Each of these
non-singlet cases leads to unique predictions for the ratios of
GUT scale gaugino masses. Furthermore, if the GKF transforms as a
linear combination of these higher dimensional representations, then
essentially arbitrary gaugino masses are allowed.
\item Non-universal gaugino masses are endemic to heterotic superstring models
with orbifold compactification
where SUSY breaking is dominated by the moduli fields\cite{ibanez}.
\item Additionally, in extra-dimensional SUSY GUT models where SUSY breaking
is communicated from the SUSY breaking brane to the visible brane via gaugino
mediation, various patterns of GUT scale gaugino masses can occur,
including the case of completely independent gaugino masses\cite{dermisek}.
\end{itemize}
In this report, we will adopt a phenomenological approach, and regard the
three MSSM gaugino masses as independent parameters, with the constraint
that the neutralino relic density should match the WMAP measured value.
Much previous work has been done on evaluating the relic density in models with
gaugino mass non-universality.
In AMSB models\cite{amsb}, the
$\widetilde Z_1$ is almost pure wino, so that $\Omega_{\widetilde Z_1}h^2$ as predicted by
the Boltzmann equation is typically very low.
Moroi and Randall\cite{moroi} proposed moduli
decay to wino-like neutralinos in the early universe to account for the
dark matter density.
Already in 1991, Griest and Roszkowski had shown that a wide range of
relic density values could be obtained by abandoning
gaugino mass universality\cite{gr}.
Corsetti and Nath investigated dark matter relic density and detection rates
in models with non-minimal $SU(5)$ GKF and
also in O-II string models\cite{cor_nath}. Birkedal-Hanson and Nelson
showed that a GUT scale ratio $M_1/M_2\sim 1.5$ would bring the
relic density into accord with the measured CDM density via MWDM,
and also presented direct detection rates\cite{birkedal}.
Bertin, Nezri and Orloff showed variation of relic density and enhancement in
direct and indirect DM detection rates as non-universal gaugino masses
were varied\cite{nezri}. Bottino {\it et al.} performed scans
over independent weak scale parameters to show variation in indirect
DM detection rates, and noted that neutralinos as low as 6 GeV are
allowed\cite{bottino}. Belanger {\it et al.} presented relic density plots
in the $m_0\ vs. m_{1/2}$ plane for a variety of universal and
non-universal gaugino mass scenarios, and showed that large swaths
of parameter space open up when the $SU(3)$ gaugino mass $M_3$ becomes
small\cite{belanger}. Mambrini and Munoz and also Cerdeno and Munoz
showed direct and indirect detection rates for model with scalar and
gaugino mass non-universality\cite{munoz}.
Auto {\it et al.}\cite{auto} used non-universal gaugino masses to reconcile
the predicted relic density in models with Yukawa coupling unification
with the WMAP result.
Masiero, Profumo and Ullio
exhibit the relic density and direct and indirect detection rates
in split supersymmetry where $M_1$, $M_2$ and $\mu$ are taken as independent
weak scale parameters with ultra-heavy squarks and sleptons\cite{mpu}.
In this paper, we will adopt a model with GUT scale parameters
including universal scalar masses, but with
independent gaugino masses leading to MWDM.
We will assume all gaugino masses to be of the same sign. The opposite sign
situation leads to a distinct DM scenario and will be addressed
soon\cite{binodm}.
We will
adjust the gaugino masses such that $\widetilde Z_1$ receives just enough of a
wino component so that it makes up the entire CDM density as
determined by WMAP without the need for late-decaying moduli fields.
In fact, the wino component of the $\widetilde Z_1$ is usually of order
$0.1-0.2$, so that the $\widetilde Z_1$ is still mainly bino-like, but with a
sufficiently large admixture of wino as to match the WMAP result
on $\Omega_{CDM}h^2$.
In Sec. \ref{sec:pspace}, we present the parameter space for MWDM,
and show how the assumption of MWDM influences the spectrum of
sparticle masses.
In Sec. \ref{sec:ddet}, we show rates for direct and indirect
detection of MWDM. These rates are usually enhanced relative to mSUGRA
due to the enhanced wino component of the $\widetilde Z_1$.
In Sec. \ref{sec:col}, we investigate consequences of MWDM for the
CERN LHC and the international linear $e^+e^-$ collider (ILC).
The goal here is to devise a set
of measurements that can differentiate MWDM from the usual case of
bino-like DM or MHDM as expected in the mSUGRA model.
For MWDM,
the neutralino mass gap $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ is almost always less than
$M_Z$, so that two-body decays of $\widetilde Z_2$ are closed, and three
body decays are dominant. The $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ mass gap is directly
measurable at the CERN LHC via the well-known edge in the
$m(\ell^+\ell^- )$ distribution. The correlation of the $\widetilde Z_2 -\widetilde Z_1$
mass gap against direct and indirect detection rates provides
a distinction between the possible DM candidates.
Measurements of the $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ mass gap
at the LHC combined with measurements of chargino and neutralino masses and
production cross sections as a function of beam polarization
at the ILC would provide the ultimate determination of the presence of
MWDM in the universe.
In Sec. \ref{sec:conclude}, we present our conclusions.
\section{Relic density and sparticle mass spectrum}
\label{sec:pspace}
Our goal is to explore SUGRA models with non-universal gaugino masses
leading to MWDM with a neutralino relic density in accord with the WMAP
result. To do so, we adopt the subprogram Isasugra, which is a part of the
Isajet 7.72 event generator program\cite{isajet}. Isasugra allows
supersymmetric spectra generation using a variety of GUT scale non-universal
soft SUSY breaking terms. The Isasugra spectrum is generated using
2-loop MSSM RGEs for coupling and soft SUSY breaking term evolution.
An iterative approach is used to evaluate the supersymmetric spectrum.
Electroweak symmetry is broken radiatively, so that the magnitude,
but not the sign, of the superpotential $\mu$ parameter is determined.
The RG-improved 1-loop effective potential is minimized at an optimized scale
which accounts for leading 2-loop terms. Full 1-loop radiative corrections
are incorporated for all sparticle masses. To evaluate the neutralino
relic density, we adopt the IsaReD program\cite{isared},
which is based on CompHEP
to compute the several thousands of neutralino annihilation and co-annihilation
Feynman diagrams. Relativistic thermal averaging of the cross section
times velocity is performed\cite{gg}. The parameter space we consider is
given by
\be
m_0,\ m_{1/2},\ A_0,\ \tan\beta ,\ sign (\mu ),\ M_1\ {\rm or}\ M_2 ,
\ee
where we take either $M_1$ or $M_2$ to be free parameters, and in general
not equal to $m_{1/2}$.
In Fig. 1, we show our first result. Here, we take $m_0=m_{1/2}=300$ GeV,
with $A_0=0$, $\tan\beta =10$, $\mu >0$ with $m_t=178$ GeV. We plot the
neutralino relic density $\Omega_{\widetilde Z_1}h^2$ in frame {\it a}) versus
variation in the $U(1)$ gaugino mass $M_1$. At $M_1=300$ GeV,
we are in the mSUGRA case, and $\Omega_{\widetilde Z_1}h^2=1.3$, so that the
model would be excluded by WMAP. By decreasing $M_1$, the bino-like
neutralino becomes lighter until two dips in the relic density occur.
These correspond to the cases where $2m_{\widetilde Z_1}\simeq m_h$ and $M_Z$
as one moves towards decreasing $M_1$, {\it i.e.} one has either
light Higgs $h$ or $Z$ resonance annihilation. As $M_1$ increases past
its mSUGRA value, the $\widetilde Z_1$ becomes increasing wino-like, and the relic
density decreases. The $W-\widetilde W_{1,2}-\widetilde Z_1$ coupling is proportional to the
$SU(2)_L$ gaugino component of the neutralino,
(and also to the Higgsino components), and so
$\widetilde Z_1\widetilde Z_1\rightarrow W^+W^-$ annihilation becomes enhanced, and the relic
density is lowered. In this case, the WMAP $\Omega_{\widetilde Z_1}h^2$ value is reached
for $M_1=490$ GeV. For still higher $M_1$ values, $\Omega_{\widetilde Z_1}h^2$ drops
precipitously, so that other non-neutralino dark matter candidates would
have to exist to account for the dark matter density in the universe.
In frame {\it b}), we show the bino/wino fraction $R_{\widetilde B ,\widetilde W}$
of the $\widetilde Z_1$.
Here, we adopt the notation of Ref. \cite{wss}, wherein the lightest
neutralino is written in terms of its (four component Majorana)
Higgsino and gaugino components as
\be
\widetilde Z_1=v_1^{(1)}\psi_{h_u^0}+v_2^{(1)}\psi_{h_d^0}+v_3^{(1)}\lambda_3
+v_4^{(1)}\lambda_0 ,
\ee
where $R_{\widetilde W}=|v_3^{(1)}|$ and $R_{\widetilde B}=|v_4^{(1)}|$.
While $R_{\widetilde W}$ increases as $M_1$ increases, its value
when $\Omega_{\widetilde Z_1}h^2$ reaches the WMAP value is still only $\sim 0.25$,
while $R_{\widetilde B}\sim 0.9$. Thus, the $\widetilde Z_1$ is still mainly bino-like, with just
enough admixture of wino to give the correct relic density.
This corresponds to the case of MWDM.
A similar plot is obtained by lowering $M_2$, rather than raising $M_1$,
as shown in Fig. \ref{rd_bw2}.
\FIGURE[htb]{
\epsfig{file=nugm_rd_binowino.eps,width=6cm,angle=-90}
\caption{\label{rd_bw}
A plot of {\it a}) relic density $\Omega_{CDM}h^2$ and
{\it b}) bino/wino component of the lightest neutralino as a
function of $M_1$ for
$m_0=300$ GeV, $m_{1/2}=300$ GeV, $A_0=0$, $\tan\beta =10$, $\mu >0$
and $m_t=178$ GeV.}}
\FIGURE[htb]{
\epsfig{file=nugm_rdbinowino_m2.eps,width=6cm,angle=-90}
\caption{\label{rd_bw2}
A plot of {\it a}) relic density $\Omega_{CDM}h^2$ and
{\it b}) bino/wino component of the lightest neutralino as a
function of $M_2$ for
$m_0=300$ GeV, $m_{1/2}=300$ GeV, $A_0=0$, $\tan\beta =10$, $\mu >0$
and $m_t=178$ GeV.}}
By raising or lowering the GUT scale gaugino masses in SUGRA models,
the mass of the neutralinos will obviously change since $M_1$ and $M_2$
enter directly into the neutralino mass matrix. However, various other
sparticle masses will also be affected by varying the gaugino masses,
since these feed into the soft term evolution via the RGEs.
In Fig. \ref{mass_M1}, we show the variation of the sparticle
mass spectrum with respect to the GUT scale ratio
$M_1/m_{1/2}$ for the same parameters
as in Fig. \ref{rd_bw}. When $M_1/m_{1/2}=1$, there is a
relatively large mass gap between $\widetilde Z_2$ and $\widetilde Z_1$:
$m_{\widetilde Z_2}-m_{\widetilde Z_1}=106.7$ GeV. As $M_1$ is increased until
$\Omega_{\widetilde Z_1}h^2=0.11$, the mass gap shrinks
to $m_{\widetilde Z_2}-m_{\widetilde Z_1} =31.9$ GeV. The light chargino mass $m_{\widetilde W_1}$
remains essentially constant in this case, since $M_2$ remains fixed
at 300 GeV. However, we notice that as $M_1$ increases, the $\tilde e_R$,
$\tilde \mu_R$ and $\tilde \tau_1$ masses also increase, since $M_1$ feeds into their
mass evolution via RGEs.
As the coefficient appearing in front of $M_1$ in the RGEs is larger
(and with the same sign) for the right handed sfermions than
for the left handed ones, one expects, in general, a departure
from the usual mSUGRA situation where the lightest sleptons are right-handed.
As a matter of fact, whereas in mSUGRA $m_{\tilde e_L}>> m_{\tilde e_R}$, in the
case of MWDM, instead, for the particular parameter space slice
under consideration, we find that $m_{\tilde e_L}\sim m_{\tilde e_R}$.
As shown in the figure, the right-handed squark masses also increase
with increasing $M_1$, although the relative effect is less dramatic
than the case involving sleptons:
the dominant driving term in the RGEs is, in this case,
given by $M_3$ (absent in the case of sleptons),
hence variations in the GUT value of $M_1$ produce milder effects.
\FIGURE[htb]{
\epsfig{file=mass_300_m1.eps,width=12cm}
\caption{\label{mass_M1}
A plot of various sparticle masses {\it vs.} $M_1/m_{1/2}$ for
$m_0=300$ GeV, $m_{1/2}=300$ GeV, $A_0=0$, $\tan\beta =10$ and $\mu >0$.}}
In Fig. \ref{mass_M2}, we show a plot of sparticle masses for the same
parameters as in Fig. \ref{mass_M1}, but versus $M_2/m_{1/2}$. In this case,
as $M_2$ is decreased from its mSUGRA value of 300 GeV, the
$\widetilde W_1$ and $\widetilde Z_2$ masses decrease until $\Omega_{\widetilde Z_1}h^2$ reaches 0.11,
where now $m_{\widetilde Z_2}-m_{\widetilde Z_1}= 22.9$ GeV. In this case, with decreasing
$M_2$, the left- slepton and sneutrino masses also decrease, again
leading to $m_{\tilde e_L}\sim m_{\tilde e_R}$. The left-handed squark masses
similarly decrease. Right-handed sfermion masses are, instead, not affected, with the net result that the mSUGRA $m_{\tilde e_L}>> m_{\tilde e_R}$ hierarchy is again altered.
\FIGURE[htb]{
\epsfig{file=mass_300_m2.eps,width=12cm}
\caption{\label{mass_M2}
A plot of various sparticle masses {\it vs.} $M_2/m_{1/2}$ for
$m_0=300$ GeV, $m_{1/2}=300$ GeV, $A_0=0$, $\tan\beta =10$ and $\mu >0$.}}
The effect of varying gaugino masses on the allowed region of
parameter space is illustrated in Fig. \ref{planes}. Here, in frame
{\it a}), we show the case of the mSUGRA model in the $m_0\ vs.\ m_{1/2}$
plane for $A_0=0$, $\tan\beta =10$ and $\mu >0$. The red shaded regions
are disallowed by either a stau LSP (left side of plot) or lack of
REWSB (lower edge of plot). The blue shaded region has a chargino
with mass $m_{\widetilde W_1}<103.5$ GeV, thus violating bounds from LEP2. The dark
green shaded region has $0.094<\Omega_{\widetilde Z_1}h^2<0.129$, in accord with
the WMAP measurement. The light green shaded region has
$\Omega_{\widetilde Z_1}h^2<0.094$, so that additional sources of dark matter
would be needed. We see the stau co-annihilation region appearing along
the left edge of the allowed parameter space, and the bulk region
appearing at low $m_0$ and low $m_{1/2}$. The $h$ annihilation corridor
appears also at low $m_{1/2}$ along the edge of the LEP2 excluded region.
In frame {\it b}), we take $M_1/m_{1/2}=1.5$, so that the $\widetilde Z_1$ becomes more
wino-like. In response, we see that a large new bulk region has appeared
at low $m_0$ and low $m_{1/2}$. In frame {\it c}), we increase
$M_1/m_{1/2}$ to 1.75. In this case, most of the $m_0\ vs.\ m_{1/2}$
plane is now allowed, although much of it has $\Omega_{\widetilde Z_1}h^2$
below the WMAP central value for the CDM relic density.
\FIGURE[htb]{
\epsfig{file=oh2contour_sugra_nugm2.eps,width=13cm}
\caption{\label{planes}
WMAP allowed regions in the $m_0\ vs.\ m_{1/2}$ plane for
$\tan\beta =10$, $A_0=0$, $\mu >0$ and
{\it a}) $M_1/m_{1/2}=1$, {\it b}) $M_1/m_{1/2}=1.5$ and
{\it c}) $M_1/m_{1/2}=1.75$.}}
It should be apparent now that {\it any} point in the $m_0\ vs.\ m_{1/2}$ plane
can become WMAP allowed by either increasing $M_1$ or decreasing $M_2$ to a
suitable degree as to obtain MWDM.
To illustrate this, we plot in Fig. \ref{planes_r}
the ratio $r_{1}\equiv M_1/m_{1/2}$ in frame {\it a}) or
$r_2= M_2/m_{1/2}$ in frame {\it b}) needed to achieve a
relic density in accord with the WMAP central value.
We see in frame {\it a}) that $r_1$ increases as one moves from
lower-left to upper-right, reflecting the greater wino component of $\widetilde Z_1$
that is needed to overcome the increasing $\Omega_{\widetilde Z_1}h^2$ which is
expected in the mSUGRA model. We also see on the left side of the plot that
$r_1\le 1$ is allowed, since then $\Omega_{\widetilde Z_1}h^2\le 0.11$
already in the mSUGRA case. The structure at high $m_{1/2}$ and
$m_0\sim 400-500$ GeV results because increasing $M_1$ increases
$m_{\widetilde Z_1}$ until $2m_{\widetilde Z_1}\sim m_A$ and the $A$-funnel begins to come
into effect (even though $\tan\beta $ is small).
\FIGURE[htb]{
\mbox{\hspace{-0.5cm}\epsfig{file=nugm_tb10_r12_omega.eps,width=8cm}
\epsfig{file=nugm_tb10_r2_omega.eps,width=8cm}}
\caption{\label{planes_r}
Contours of {\it a}) $r_1$ and {\it b}) $r_2$ in the
$m_0\ vs.\ m_{1/2}$ plane for
$\tan\beta =10$, $A_0=0$, $\mu >0$. Each point has
$\Omega_{\widetilde Z_1}h^2 =0.11$.}}
\section{Direct and indirect detection of mixed wino dark matter}
\label{sec:ddet}
In this section, we turn to consequences of MWDM for direct and indirect
detection of neutralino dark matter\cite{eigen,fmw}.
We adopt the DarkSUSY code\cite{darksusy},
interfaced to Isajet, for the computation of the various rates, and resort
to the Adiabatically Contracted
N03 Halo model\cite{n03} for the dark matter distribution
in the Milky Way\footnote{For a comparison of the implications of
different halo model choices for indirect DM detection rates, see
{\it e.g.} Refs. \cite{bo,bbko,antimatter,nuhm}.}.
We evaluate the following neutralino DM detection rates:
\begin{itemize}
\item Direct neutralino detection via
underground cryogenic detectors\cite{direct}.
Here, we compute the spin independent neutralino-proton scattering
cross section, and compare it to expected sensitivities\cite{bbbo} for Stage 2
detectors (CDMS2\cite{cdms2}, Edelweiss2\cite{edelweiss},
CRESST2\cite{cresst}, ZEPLIN2\cite{zeplin})
and for Stage 3, ton-size detectors (XENON\cite{xenon},
Genius\cite{genius}, ZEPLIN4\cite{zeplin4} and WARP\cite{warp}).
We take here as benchmark experimental reaches of Stage 2 and Stage 3
detectors the projected sensitivities of, respectively,
CDMS2 and XENON 1-ton at the corresponding neutralino mass.
\item Indirect detection of neutralinos via neutralino annihilation to
neutrinos in the core of the Sun\cite{neut_tel}.
Here, we present rates for detection of $\nu_\mu \rightarrow \mu$ conversions
at Antares\cite{antares} or IceCube\cite{icecube}.
The reference experimental sensitivity we use is that of IceCube,
with a muon energy threshold of 25 GeV, corresponding to a flux
of about 40 muons per ${\rm km}^2$ per year.
\item Indirect detection of neutralinos via neutralino annihilations in the
galactic center leading to gamma rays\cite{gammas},
as searched for by EGRET\cite{egret}, and
in the future by GLAST\cite{glast}.
We evaluate the integrated continuum $\gamma$ ray flux above a
$E_\gamma=1$ GeV threshold, and assume a GLAST sensitivity
of 1.0$\times10^{-10}\ {\rm cm}^{-2}{\rm s}^{-1}$.
\item Indirect detection of neutralinos via neutralino annihilations in the
galactic halo leading to cosmic antiparticles, including
positrons\cite{positron} (HEAT\cite{heat}, Pamela\cite{pamela}
and AMS-02\cite{ams}), antiprotons\cite{pbar} (BESS\cite{bess},
Pamela, AMS-02) and anti-deuterons ($\bar{D}$s) (BESS\cite{bessdbar},
AMS-02, GAPS\cite{gaps}).
For positrons and antiprotons we evaluate the averaged differential
antiparticles flux in a projected energy bin centered at a kinetic
energy of 20 GeV, where we expect an optimal statistics and
signal-to-background ratio at space-borne antiparticles
detectors\cite{antimatter,statistical}. We use as benchmark
experimental sensitivity that of the Pamela experiment
after three years of data-taking.
Finally, the average differential antideuteron flux has been
computed in the $0.1<E_{\bar D}<0.4$ GeV range,
and compared to the estimated GAPS sensitivity\cite{gaps}.
\end{itemize}
In Fig. \ref{dmrates1}, we show various direct and indirect DM detection
rates for $m_0=m_{1/2}=300$ Gev, with $A_0=0$, $\tan\beta =10$ and $\mu >0$,
while $M_1$ is allowed to vary. The $M_1$ value corresponding to the mSUGRA model is
denoted by a dot-dashed vertical line, while the one where
$\Omega_{\widetilde Z_1}h^2=0.11$ by a dashed vertical line denoted
WMAP.
In frame {\it a}), we plot the spin-independent neutralino-proton
scattering cross section. Both the squark-mediated
and Higgs mediated neutralino-proton scattering amplitudes are
enhanced by more than one order of magnitude due to the
increasing wino nature of the $\widetilde Z_1$.
The reason for the enhancement is traced back to the structure
of the neutralino-quark-squark and neutralino-neutralino-Higgs couplings,
where the wino fraction is weighed by the $SU(2)$ coupling,
while the bino fraction by the (smaller) $U(1)$ coupling.
\FIGURE[htb]{
\mbox{\hspace{-1cm}\epsfig{file=nugm_allratestosugra_m1.ps,width=14cm,angle=-90} }
\caption{\label{dmrates1}
Rates for direct and indirect detection of neutralino dark matter
vs. $M_1$ for $m_0=m_{1/2}=300$ GeV, with
$\tan\beta =10$, $A_0=0$, $\mu >0$.
Frames {\it c}) -{\it f}) show the ratio of indirect detection rates
compared to the mSUGRA model.
In this plot, we adopt the
N03 distribution for halo dark matter.}}
In frame {\it b}), we show the flux of muons from neutralino
pair annihilations in the core of the Sun.
While the muon flux is below the reach of IceCube in the mSUGRA case, it has
climbed into the observable region when the $\widetilde Z_1$ has become sufficiently
wino-like as to fulfill the WMAP measured DM relic density.
In frames {\it c}), {\it d}), {\it e}) and {\it f}) we show the
flux of photons, positrons,
antiprotons and antideuterons, respectively.
The results here are plotted as ratios of fluxes normalized to the mSUGRA point,
in order to give results that are approximately halo-model independent.
(We do show the above described expected experimental reach lines as obtained by using
the Adiabatically Contracted
N03 Halo model\cite{n03}.) All
rates are enhanced, with respect to the mSUGRA case,
by 2 to 3 orders of magnitude, due to the increasing cross section for
$\widetilde Z_1\widetilde Z_1\rightarrow W^+W^- $ annihilation in the galactic halo.
In particular, antimatter fluxes are always below future sensitivities
for the mSUGRA setup, while they all rise to a detectable level when the WMAP point is reached.
In Fig. \ref{dmrates2}, we show the same direct and indirect DM detection
rates as in Fig. \ref{dmrates1}, except this time versus $M_2$ instead of
$M_1$. In this case, the various rates are all increasing as $M_2$ decreases,
entering the region of MWDM. Indirect detection rates again feature
enhancements as large as 2 orders of magnitude with respect to the mSUGRA
scenario, when the WMAP relic abundance is reached. The abrupt decrease
in the rates below $M_2\sim100$ GeV is due, instead, to the $m_{\widetilde Z_1}<m_W$ threshold.
\FIGURE[htb]{
\mbox{\hspace{-1cm}\epsfig{file=nugm_allratestosugra_m2.ps,width=14cm,angle=-90} }
\caption{\label{dmrates2}
Rates for direct and indirect detection of neutralino dark matter
vs. $M_2$ for $m_0=m_{1/2}=300$ GeV, with
$\tan\beta =10$, $A_0=0$, $\mu >0$.
Frames {\it c}) -{\it f}) show the ratio of indirect detection rates
compared to the mSUGRA model.
In this plot, we adopt the
N03 distribution for halo dark matter.}}
In Fig. \ref{dmplanes}, we show regions of the $m_0\ vs.\ m_{1/2}$ plane
for $A_0=0$, $\tan\beta =10$ and $\mu >0$ which are accessible to
various direct and indirect DM search experiments.
The visibility criteria we adopt here follow the same approach
outlined in Ref.~\cite{nuhm}.
The gray shaded regions in the plots are already excluded,
at 95\% C.L., by a $\chi^2$ analysis of the computed signal plus background
$\bar{p}$ flux compared to the available antiprotons data
(for details see\cite{antimatter}).
Observable rates for $\gamma$ detection by GLAST occur throughout all three planes,
due to the high DM density assumed at the galactic core in the N03 halo model.
In frame {\it a}), we show the case of the mSUGRA model. Only
small regions at low $m_0$ and low $m_{1/2}$ are accessible to $\bar{D}$
searches by GAPS and $\bar{p}$ searches by Pamela. A tiny region is also
accessible to CDMS2, and a much larger region is accessible to Stage 3 direct
detection experiments such as XENON. In frame {\it b}), we increase
$M_1(M_{GUT})$ at every point in the plane as in Fig. \ref{planes_r}
until $\Omega_{\widetilde Z_1}h^2=0.11$. The corresponding neutralino masses are
therefore accordingly increased with respect to the mSUGRA case.
Nevertheless, we see that the regions accessible to direct and indirect DM detection
have vastly increased. The $\bar{D}$ search by GAPS can cover
$m_{1/2}\lesssim 400-500$ GeV. The $e^+$ and $\bar{p}$ searches by Pamela
can see to $m_{1/2}\sim 250$ GeV and 350 GeV, respectively.
In addition, a region has opened up which is accessible to IceCube searches
for dark matter annihilation in the core of the Sun. The Stage 3 dark matter
detectors can see most of the $m_0\ vs.\ m_{1/2}$ plane, with the
exception of the region at large $m_{1/2}$ and low $m_0$ where a much lower
wino component of the $\widetilde Z_1$ is required to bring the relic density
into line with the WMAP measurement (here, early universe $\widetilde Z_1\widetilde Z_1$
annihilations are already somewhat enhanced by the proximity of the
$A$-pole and the stau co-annihilation region).
In frame {\it c}), we show again the $m_0\ vs.\ m_{1/2}$ plane,
but this time we have {\it reduced} $M_2$ until the $\Omega_{\widetilde Z_1}h^2=0.11$
value is reached. Again, many of the direct and indirect detection regions
are expanded compared to the mSUGRA case.
We remark that, although in this last case the neutralino mass is lower
than in the case shown in frame {\it b}), direct detection and neutrino fluxes
are somewhat less favored. This depends on the relative higgsino fraction,
which critically enters in the neutralino-proton scattering cross section
as well as in the neutralino capture rate in the Sun:
raising $M_1$ shifts the gaugino masses closer to $\mu$,
hence increasing the higgsino fraction and the resulting neutralino cross sections off matter.
\FIGURE[htb]{
\mbox{\epsfig{file=msugra_10_def.eps,width=8.5cm}\vspace*{1cm}}
\mbox{\hspace*{-1cm}\epsfig{file=mwdm_r1_10.eps,width=8.5cm}
\epsfig{file=mwdm_r2_10.eps,width=8.5cm}}
\caption{\label{dmplanes}
Regions of visibility for direct and indirect dark matter searches
in the $m_0\ vs.\ m_{1/2}$ plane for
$\tan\beta =10$, $A_0=0$, $\mu >0$. The upper frame {\it a}) shows the mSUGRA model, while frame {\it b}) corresponds to the MWDM model with non-universal $M_1$ and frame {\it c}) with non-universal $M_2$. In this plot, we adopt the
Adiabatically Contracted N03 Halo Model for the galactic dark matter
distribution. For this halo model, detection of $\gamma$s by GLAST should occur
over all three planes.}}
\section{Mixed wino dark matter at colliders}
\label{sec:col}
An important question is whether collider experiments would be able to
distinguish the case of MWDM from other forms of neutralino DM
such as bino-DM or MHDM as occur in the mSUGRA model. We have seen
from the plots of sparticle mass spectra that the squark and
gluino masses vary only slightly with changing $M_1$ or $M_2$. However, the
chargino and neutralino masses change quite a bit, and in fact
rather small mass gaps $m_{\widetilde W_1}-m_{\widetilde Z_1}$ and $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ are
in general expected in the case of MWDM as compared with the case from models
containing gaugino mass unification.
In Fig. \ref{z21gap}, we show contours of
the mass gap $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ in the $m_0\ vs.\ m_{1/2}$ plane for
$A_0=0$, $\tan\beta =10$ and $\mu >0$ for
{\it a}) the mSUGRA model, {\it b}) the case of MWDM where $M_1$ is
raised at every point until $\Omega_{\widetilde Z_1}h^2\rightarrow 0.11$ and {\it c})
the case of MWDM where $M_2$ is lowered until $\Omega_{\widetilde Z_1}h^2\rightarrow 0.11$.
In the case of the mSUGRA model, most of the parameter space has
$m_{\widetilde Z_2}-m_{\widetilde Z_1}>90$ GeV, which means that $\widetilde Z_2\rightarrow \widetilde Z_1 Z^0$ decay is
allowed. When this decay is allowed, its branching fraction is always large,
unless it competes with other two-body decays such as $\widetilde Z_2\rightarrow \widetilde Z_1 h$
or $\widetilde Z_2\rightarrow \bar{f}\tilde f$ or $f{\bar{\tilde f}}$ (where $f$ is
a SM fermion). In the case of MWDM in frames {\it b}) and {\it c}),
we see that (aside from the left-most portion of frame {\it b}), which is not a region of MWDM),
the mass gap is much smaller, so that
two-body decays of $\widetilde Z_2$ and $\widetilde W_1$ are closed and three-body decays
are dominant.
\FIGURE[htb]{
\epsfig{file=msugra_tb10_z21gap.eps,width=8.5cm}
\mbox{\hspace*{-1cm}\epsfig{file=nugm_tb10_r12_z21gap.eps,width=8.5cm}
\epsfig{file=nugm_tb10_r2_z21gap.eps,width=8.5cm} }
\caption{\label{z21gap}
Contours of $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ mass gap in
the $m_0\ vs.\ m_{1/2}$ plane for
$\tan\beta =10$, $A_0=0$, $\mu >0$ and
{\it a}) mSUGRA model, {\it b}) $M_1>m_{1/2}$ MWDM and
{\it c}) $M_2<m_{1/2}$ MWDM.}}
When the decays
$\widetilde Z_2\rightarrow\tilde\ell\bar{\ell},\ \bar{\tilde\ell}\ell\rightarrow \widetilde Z_1\ell\bar{\ell}$
or $\widetilde Z_2\rightarrow \widetilde Z_1 \ell\bar{\ell}$
are open ($\ell =e$ or $\mu$),
then prospects are good for measuring the $\widetilde Z_2 -\widetilde Z_1$ mass gap
at the CERN LHC and possibly at the Fermilab Tevatron.
If $\widetilde Z_2$'s are produced at large rates either directly or via gluino or
squark cascade decays\cite{cascade}, it should be possible to
identify opposite sign/ same flavor dilepton pairs, to reconstruct their
invariant mass, and extract the upper edge of the
invariant mass distribution\cite{mlldist}.
In Fig. \ref{bfs}, we show the branching fraction
$BF(\widetilde Z_2\rightarrow \widetilde Z_1 e^+e^-)$ versus $M_1$ (left-side) or versus
$M_2$ (right-side) for a variety of
choices of $m_0$, $m_{1/2}$ and $\tan\beta$. The mSUGRA model value
is denoted by the dot-dashed vertical line, while the $M_{1,2}$ value
at which $\Omega_{\widetilde Z_1}h^2\rightarrow 0.11$ is indicated by the dotted
vertical line. As one moves to higher $M_1$ (or lower $M_2$) values, in most cases
the leptonic three-body decays of $\widetilde Z_2$ become enhanced, usually
because as $M_1$ grows ($M_2$ decreases), the two-body decay modes become kinematically closed,
and only three-body decays are allowed.
Thus, while the mSUGRA model yields large rates for $\widetilde Z_2\rightarrow \widetilde Z_1 e^+e^-$
only when $m_{1/2}\stackrel{<}{\sim} 220$ GeV, this decay mode is almost always open in the
case of MWDM. The only exception occurs when the stau co-annihilation or the
$A$-funnel act to lower the relic density, so that a large $M_1$ or small
$M_2$ is not needed to obtain the correct relic density; this, however, is not the case
of MWDM.
\FIGURE[htb]{
\mbox{\hspace*{-1.5cm}\epsfig{file=nugm_3bodyBF.eps,width=14cm,angle=-90}}
\caption{\label{bfs}
The branching fraction for $\widetilde Z_2\rightarrow\widetilde Z_1 e^+e^-$ decay is plotted vs.
$M_1$ (left-side) or $M_2$ (right-side) for various points in the
MWDM model parameter space.
The $M_{1,2}$ value from mSUGRA is denoted by the dot-dashed lines, while
the $M_{1,2}$ value which gives $\Omega_{\widetilde Z_1}h^2=0.11$ is indicated by
dotted lines.
}}
\subsection{CERN LHC}
\label{ssec:lhc}
If the $R$-parity conserving MSSM is a good description of nature
at the weak scale, then
multi-jet plus multi-lepton plus $\not\!\!{E_T}$ events should occur at
large rates at the CERN LHC, provided that
$m_{\tilde g}\stackrel{<}{\sim} 2-3$ TeV.
The LHC reach for SUSY in the mSUGRA model has been calculated in
Ref. \cite{susylhc}. The mSUGRA reach results should also
apply qualitatively to the MWDM case, since the values of
$m_{\tilde g}$ and $m_{\tilde q}$ change little in going from mSUGRA to MWDM,
and the reach plots mainly depend on these masses.
For SUSY searches at the CERN LHC, Hinchliffe {\it et al.} have
pointed out\cite{frank} that an approximate value of $m_{\tilde q}$ or
$m_{\tilde g}$ can be gained by extracting the maximum in the
$M_{eff}$ distribution, where
$M_{eff}=\not\!\!{E_T} +E_T(jet\ 1)+E_T(jet\ 2)+E_T(jet\ 3)+E_T(jet\ 4)$.
This statement holds true in models with MWDM, as well as in
models with gaugino mass unification, so that the approximate
mass scale of strongly interacting sparticles will be known soon
after a supersymmetry signal has been established.
In mSUGRA, a dilepton mass edge should be
visible in SUSY signal events only if $m_{1/2}\stackrel{<}{\sim} 250$ GeV
or if $\widetilde Z_2\rightarrow \tilde\ell\bar{\ell},\ \bar{\tilde\ell}\ell$ decays are allowed.
In the case of MWDM, the dilepton mass edge should be visible over almost all
parameter space. We illustrate the situation for four case studies
listed in Table \ref{tab:mwdm}. The first case, labeled mSUGRA,
has $m_0=m_{1/2}=300$ GeV, with $A_0=0$, $\tan\beta =10$ and $\mu >0$.
In this case, $\tilde g\tg$, $\tilde g\tilde q$ and $\tilde q\tq$ production occurs with a
combined cross section of about 12 pb,
while the total SUSY cross section is around
13.4 pb (the additional 1.4 pb comes mainly from -ino pair production and
-ino-squark or -ino-gluino associated production).
The case of MWDM1, with $M_1=490$ GeV, has similar rates of
sparticle pair production. The case of MWDM2,
with lighter chargino and neutralino masses, has a total production cross
section of 19.2 pb, wherein strongly interacting sparticles are
pair produced at similar rates as in mSUGRA or MWDM1, but -ino pairs are
produced at a much larger rate $\sim 6.1$ pb.
We also show a case of MHDM from the HB/FP region of the mSUGRA model as
an alternative low $\widetilde Z_2 -\widetilde Z_1$ mass gap model to compare against MWDM
scenarios.
\begin{table}
\begin{tabular}{lcccc}
\hline
parameter & mSUGRA & MWDM1 & MWDM2 & MHDM \\
\hline
$M_1$ & 300 & 490 & 300 & 300 \\
$M_2$ & 300 & 300 & 187 & 300 \\
$\mu$ & 409.2 & 410.1 & 417.8 & 166.1 \\
$m_{\tilde g}$ & 732.9 & 732.8 & 733.0 & 854.6 \\
$m_{\tilde u_L}$ & 720.9 & 721.1 & 706.9 & 3467.2 \\
$m_{\tilde t_1}$ & 523.4 & 526.0 & 533.2 & 2075.8 \\
$m_{\tilde b_1}$ & 650.0 & 648.9 & 640.2 & 2847.0 \\
$m_{\tilde e_L}$ & 364.7 & 371.7 & 330.0 & 3449.7 \\
$m_{\tilde e_R}$ & 322.8 & 353.7 & 322.7 & 3449.4 \\
$m_{\widetilde W_2}$ & 432.9 & 433.8 & 435.9 & 288.9 \\
$m_{\widetilde W_1}$ & 223.9 & 224.0 & 138.3 & 146.6 \\
$m_{\widetilde Z_4}$ & 433.7 & 435.7 & 436.2 & 296.9 \\
$m_{\widetilde Z_3}$ & 414.8 & 415.6 & 424.1 & 179.0 \\
$m_{\widetilde Z_2}$ & 223.7 & 225.4 & 138.8 & 159.2 \\
$m_{\widetilde Z_1}$ & 117.0 & 193.5 & 115.9 & 101.5 \\
$m_A$ & 538.6 & 544.1 & 523.6 & 3409.9 \\
$m_{H^+}$ & 548.0 & 553.5 & 533.1 & 3433.3 \\
$m_h$ & 115.7 & 115.8 & 115.3 & 118.9 \\
$\Omega_{\widetilde Z_1}h^2$& 1.3 & 0.11 & 0.11 & 0.13 \\
$BF(b\rightarrow s\gamma)$ & $3.2\times 10^{-4}$ & $3.2\times 10^{-4}$ &
$3.3\times 10^{-4}$ & $3.4\times 10^{-4}$ \\
$\Delta a_\mu $ & $12.1 \times 10^{-10}$ & $11.8 \times 10^{-10}$ &
$15.9\times 10^{-10}$ & $3.9\times 10^{-11}$ \\
$\sigma_{sc} (\widetilde Z_1p )$ &
$2.6\times 10^{-8}\ {\rm pb}$ & $2.2\times 10^{-7}\ {\rm pb}$ &
$7.1\times 10^{-8}\ {\rm pb}$ & $1.8\times 10^{-8}\ {\rm pb}$\\
\hline
\end{tabular}
\caption{Masses and parameters in~GeV units
for mSUGRA, MWDM and MHDM models. In the first three cases,
$m_0=m_{1/2} =300$ GeV, $A_0=0$, $\tan\beta =10$ and $m_t=178$ GeV.
The case of MHDM has the same parameters, except $m_0=3451.8$ GeV,
with $m_t=175$ GeV.
}
\label{tab:mwdm}
\end{table}
We have generated 50K
LHC SUSY events for each of these cases using Isajet 7.72,
and passed them through
a toy detector simulation. The toy detector is divided into
calorimeter cells of
size $\Delta\eta \times\Delta\phi =0.05\times 0.05$ extending out to
$|\eta |<5$, with no transverse shower spreading. We invoke EM smearing with
$3\%/\sqrt{E}+.5\%$, hadronic smearing with $80\%/\sqrt{E}+3\%$ out
to $|\eta |=2.6$,
and forward calorimeter hadronic smearing with $100\%/\sqrt{E} +5\%$.
Jets are clustered using a UA1 type algorithm with cone size
$R=\sqrt{\Delta\eta^2+\Delta\phi^2}=0.7$, with $E_{jet}(min)=25$ GeV.
Leptons ($\ell =e\ {\rm or}\ \mu$) with $E_\ell >10$ GeV are classified
as isolated if $E_T(cone)<5$ GeV in a cone of $R=0.3$ about the lepton's
direction. Since gluino and squark masses of the three case studies
are similar to those
of LHC point 5 of the study of Hinchliffe {\it et al.}\cite{frank},
we adopt the same
overall signal selection cuts which gave rise to only a small background
contamination of mostly signal events:
$\not\!\!{E_T} >max(100\ {\rm GeV}, 0.2 M_{eff})$,
at least four jets with $E_T>50$ GeV, where the hardest jet has
$E_T>100$ GeV, transverse sphericity $S_T>0.2$ and $M_{eff}>800$ GeV.
In these events, we require at least two isolated leptons, and then plot
the invariant mass of all same flavor/opposite sign dileptons.
The results are shown in Fig. \ref{fig:mll}. In the case of the mSUGRA model,
frame {\it a}),
there is a sharp peak at $m(\ell^+\ell^- )\sim M_Z$, which comes
from $\widetilde Z_2\rightarrow \widetilde Z_1 Z^0$ decays where $\widetilde Z_2$ is produced in the gluino
and squark cascade decays. In the case of MWDM1 in frame {\it b}),
we again see a $Z^0$ peak,
although here the $Z^0$s arise from $\widetilde Z_3$, $\widetilde Z_4$ and $\widetilde W_2$ decays.
We also see the continuum distribution in
$m(\ell^+\ell^- )<m_{\widetilde Z_2}-m_{\widetilde Z_1}=31.9$ GeV. The cross section
plotted here is $\sim 0.05$ pb, which would correspond to
5K events in 100 fb$^{-1}$ of integrated luminosity (the sample
shown in the figure contains just 406 events).
In frame {\it c})-- with a cross section of $\sim 0.05$ pb
(but just 267 actual entries)-- we see again the $Z^0$ peak,
but also we see again the
$m(\ell^+\ell^- )<m_{\widetilde Z_2}-m_{\widetilde Z_1}=22.9$ GeV continuum.
In both these MWDM cases, the $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ mass edge should
be easily measurable. It should also be obvious that it is inconsistent
with models based on gaugino mass unification, in that the
projected ratios $M_1:M_2:M_3$ will not be in the order $1:\sim 2:\sim 7$ as in
mSUGRA. Although the $\widetilde Z_2 -\widetilde Z_1$ mass edge will be directly measurable,
the absolute neutralino and chargino masses will be difficult if not
impossible to extract at the LHC.
\FIGURE[htb]{
\epsfig{file=mll.eps,width=14cm}
\caption{\label{fig:mll}
Distribution of same flavor/opposite sign dileptons from SUSY
events at the CERN LHC
from {\it a}) mSUGRA, {\it b}) MWDM1, {\it c}) MWDM2
and {\it d}) MHDM cases
as in Table \ref{tab:mwdm}.}}
In frame {\it d}), we show the spectrum from MHDM in the HB/FP region of
the mSUGRA model. In this case, a $\widetilde Z_2 -\widetilde Z_1$ mass edge at
57.7 GeV should be visible. It will be accompanied by other continuum
contributions, since in the case of MHDM with a small $\mu$
parameter, the $\widetilde Z_3$, $\widetilde Z_4$ and $\widetilde W_2$ should all be relatively
light as well.
\subsection{Linear $e^+e^-$ collider}
\label{ssec:ilc}
At a $\sqrt{s}=500$ GeV ILC, the new physics reactions for the four
case studies shown in Table \ref{tab:mwdm} would
include $Zh$, $\widetilde W_1^+\widetilde W_1^-$,
$\widetilde Z_1\widetilde Z_2$ and $\widetilde Z_2\widetilde Z_2$ production. It was shown in Ref. \cite{nlc}
that, in the case of a small $\widetilde W_1 -\widetilde Z_1$ mass gap,
chargino pair production events could still be identified
above SM backgrounds.
The chargino and neutralino masses can be inferred from the resultant dijet
distribution in
$\widetilde W_1^+\widetilde W_1^-\rightarrow (\bar{\ell}\nu_\ell\widetilde Z_1 )+(q\bar{q}\widetilde Z_1 )$
events\cite{jlc,bmt,nlc}.
Alternatively, the chargino mass may be extracted
from threshold cross section measurements when the
CM energy of the accelerator is tuned to operate just above
$e^+e^-\rightarrow \widetilde W_1^+\widetilde W_1^-$ threshold.
These measurements should allow the absolute mass scale of the
sparticles to be pinned down, and will complement the $\widetilde Z_2 -\widetilde Z_1$
mass gap measurement from the CERN LHC.
The combination of $m_{\widetilde Z_2}$, $m_{\widetilde W_1}$,
$m_{\widetilde Z_1}$ and $m_{\widetilde Z_2} -m_{\widetilde Z_1}$ measurements
will point to whether or not gaugino
mass unification is realized in nature.
In addition, the $\widetilde W_1^+\widetilde W_1^-$, $\widetilde Z_1\widetilde Z_2$ and $\widetilde Z_2\widetilde Z_2$
production cross sections can all be measured as a function of beam
polarization at the ILC. In the mSUGRA model, since $\widetilde W_1$ and $\widetilde Z_2$
are mainly wino-like, they will be produced at high rates for
left-polarized electron beams, but at low rates for right-polarized
beams\cite{bmt}.
The $\widetilde Z_1\widetilde Z_2$ production cross section also has a significant
rise to it as
beam polarization parameter $P_L(e^-)$ is increased from -1 to +1.
These cross sections are plotted in frame {\it a}) of Fig. \ref{fig:ilc}.
In frame {\it b}), we show the same cross sections, except this time for
the case of MWDM1. The $\widetilde W_1$ is still mainly wino-like, and so has a
steeply rising cross section as $P_L(e^-)$ is increased.
However, in this case
$\widetilde Z_1$ and $\widetilde Z_2$ both have non-negligible bino components,
which enhances
their couplings to right-polarized electrons.
Thus, $\sigma (e^+e^-\rightarrow \widetilde Z_1\widetilde Z_2)$ in the case of MWDM is a
falling distribution $vs.\ P_L(e^-)$.
This is in fact borne
out in frame {\it b}), and would be a strong signal for MWDM!
In frame {\it c}), we plot the corresponding cross sections for the case of
MWDM2. Again, $\widetilde Z_1\widetilde Z_2$ has a (slightly)
falling cross section versus $P_L(e^-)$,
indicating once again the presence of MWDM.
In frame {\it d}), we show the corresponding cross sections for the case
of MHDM. In this case, numerous other reactions such as
$\widetilde W_1^+\widetilde W_2^-$, $\widetilde Z_1\widetilde Z_3$ and $\widetilde Z_2\widetilde Z_3$ should
likely be kinematically accessible, and their presence will help
serve to distinguish MHDM from MWDM.
\FIGURE[htb]{
\epsfig{file=ilc.eps,width=14cm}
\caption{\label{fig:ilc}
Plot of cross section for $e^+e^-\rightarrow \widetilde W_1^+\widetilde W_1^-$, $\widetilde Z_1\widetilde Z_2$ and
$\widetilde Z_2\widetilde Z_2$ versus electron beam polarization $P_L(e^-)$ for a
$\sqrt{s}=500$ GeV ILC for {\it a}) mSUGRA, {\it b}) MWDM1,
{\it c}) MWDM2 and {\it d}) MHDM with parameters as in table \ref{tab:mwdm}.}}
While a combination of mass measurements at LHC and ILC would help to pin down
the properties of MWDM, it is worth considering whether the case of MWDM
can be confused with the case of MHDM, such as occurs in the HB/FP region
of the mSUGRA model, or in models with non-universal
Higgs masses\cite{ellis,nuhm}.
To answer this, we plot in Fig. \ref{z2z1mw} the $\widetilde Z_2 -\widetilde Z_1$ mas gap
versus $m_{\widetilde W_1}$ for MWDM scenarios which yield $\Omega_{\widetilde Z_1}h^2=0.11$,
against mSUGRA models in the HB/FP region which also give
$\Omega_{\widetilde Z_1}h^2=0.11$. We see that the MWDM points can span the entire
range of $m_{\widetilde W_1}$ values shown, but that their $\widetilde Z_2 -\widetilde Z_1$ mass
gap is generally of order 15-40 GeV. Models with higher mass gaps are
usually due to an overlap of MWDM with stau co-annihilation or $A$-funnel
annihilation.
The general trend for $m_{\widetilde Z_2} -m_{\widetilde Z_1}$ in the
MWDM scenario is dictated by the interplay of wino coannihilations and
of the growing wino component, both functions of the mass gap,
which suppress $\Omega_{\widetilde Z_1}h^2$ to the required level.
In contrast, the $\widetilde Z_2 -\widetilde Z_1$ mass gap associated
with MHDM in the HB/FP region is generally or order 40-80 GeV,
at least until very large values of $m_{\widetilde W_1}\stackrel{>}{\sim} 600$ GeV are
generated. The largest mass gaps appear beyond the top quark mass
threshold, whose effect is greatly enhanced, with respect to the
MWDM case, due to $Z$ and Higgs $s$-channel exchanges.
At larger neutralino masses, the $\widetilde Z_2 -\widetilde Z_1$ mass gap
for MHDM shrinks to lower values, since a larger and larger
higgsino fraction and stronger neutralino/chargino coannihilations
are needed to fulfill the WMAP bound.
Eventually, a pure higgsino LSP (with $m_{\widetilde Z_2} -m_{\widetilde Z_1}$ of the
orders of few GeV) is needed to give $\Omega_{\widetilde Z_1}h^2=0.11$,
at $m_{\widetilde Z_1}\sim 1$ TeV. For
$m_{\widetilde W_1}\sim 600-800$ GeV, the MWDM and MHDM $\widetilde Z_2 -\widetilde Z_1$ mass gaps
overlap. In the large mass case, however,
the two scenarios could still be differentiated
by the remaining sparticle mass spectrum ({\it e.g.} $\widetilde Z_3$ would be light
in the case of MHDM and heavy in the case of MWDM) and by the dependences
of cross sections on electron beam polarization (if an energetic enough
$e^+e^-$ collider is built!).
\FIGURE[htb]{
\epsfig{file=deltam_mw.eps,width=11cm}
\caption{\label{z2z1mw}
Correlation between $m_{\widetilde Z_2}-m_{\widetilde Z_1}$ and $m_{\widetilde W_1}$
in models with MWDM and MHDM in the HB/FP region.}}
\section{Conclusions}
\label{sec:conclude}
In this paper, we have considered the phenomenological
consequences of mixed wino dark matter. MWDM occurs in models with gaugino
mass non-universality. MWDM may be obtained by modifying the
paradigm mSUGRA model by either increasing the GUT scale value of $M_1$
or by decreasing $M_2$ until a sufficiently wino-like LSP is obtained
as to fulfill the WMAP measured value of $\Omega_{CDM}h^2\sim 0.11$.
If DM in nature is indeed composed of MWDM, then a number of consequences
occur. In the sparticle mass spectrum,
the $\widetilde Z_2 -\widetilde Z_1$ and $\widetilde W_1 -\widetilde Z_1$
mass gaps are expected to be reduced compared to what is
expected in models
with gaugino mass unification and a large $\mu$ parameter. Also, left- and
right- sleptons are expected to be more nearly mass degenerate.
If MWDM comprises the dark matter of the universe,
then both direct and indirect dark matter detection rates are expected
to be enhanced compared to expectations from the mSUGRA model.
However, to really pinpoint the existence of a partially wino-like
$\widetilde Z_1$, collider experiments will be needed. The CERN LHC should be able
to measure approximately the value of $m_{\tilde g}$, and in MWDM scenarios,
also the $\widetilde Z_2 -\widetilde Z_1$ mass gap from the dilepton spectrum from
$\widetilde Z_2\rightarrow \ell\bar{\ell}\widetilde Z_1$ decay. These measurements should be enough
to establish whether gaugino mass unification holds. Ultimately, a
linear $e^+e^-$ collider, the ILC,
operating above $\widetilde W_1^+\widetilde W_1^-$ and $\widetilde Z_1\widetilde Z_2$
thresholds will be needed. The ILC should be able to measure the absolute
$\widetilde W_1$, $\widetilde Z_1$ and $\widetilde Z_2$ masses. The dependence of the associated
production cross sections on the electron beam polarization
will point conclusively to the existence of MWDM.
\section*{Acknowledgments}
We thank J. O'Farrill and X. Tata for conversations.
This research was supported in part by the U.S. Department of Energy
under contract number DE-FG02-97ER41022.
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 5,502 |
The Oppo F3 started selling in Kenya on May 23rd priced at Ksh 33,000. Since then, the phone's price hasn't changed, but this is no more thanks to Black Friday 2017.
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Note: This article has an affiliate link. For more info on how affiliate links work, click here. | {
"redpajama_set_name": "RedPajamaC4"
} | 4,382 |
Welcome to the KegMetrics Developer's Notes. This is a brief update with where we are at with development of KegMetrics. As you know KegMetrics is Keg Management Software that allows you to utilize your phone as a scanner to track your kegs. It does so much more than just track kegs though which is why we call it keg management software. We are a little different than your standard software developer. We are built and designed by brewers. We are craft just like you.
We've been plugging away at features and fixes for a few months now. We are now in a place where we are ready for rolling it out. In summary, we are up and running and taking orders. To build momentum our price is currently discounted, and we are still offering a 6 month 100% money back guarantee. There's virtually no risk.
We're staggering the rollout so we can give each customer our full attention and as part of it we're doing the labeling and tagging of all kegs you have onsite. We'd love to swing by your brewery or have a call to run you through the software to see if it is a good fit for your needs.
KegMetrics is up and running on Amazon Web Services, has daily back up of data and currently does the setup with each order. We run out of your browser and work on mobile and desktop/laptop platforms. You don't have to buy user licenses, and we are extremely cost effective.
Formatting and printing of Labels: We've spent an intense amount of effort making sure we got the right labels and printing technology. I won't bore you with all the tech but I'm really excited with the results. We print on 1″x 1.5″ polyester labels with a printing technique that won't fade and resists scratches. The KegMetrics app functionality allows for printing and reprinting labels of various quantities. The label is good from -40 to 302 degrees F and has been tested against mild acids, pressure washing and is permanent rated "outdoor durable". Currently, we handle all the printing for you so you don't even have to think about the labels. I'm seriously happy with our labeling.
KegMetrics was built from the ground up to utilize common mobile technology. This includes the asset scanning. Translation. You don't have to buy additional hardware to use KegMetrics on Android devices and iOS/laptop/desktop scanning can be done with an inexpensive scan gun. You get one for free if you order before the end of July.
Yes, we have also allowed for scanning gun functionality to work with KegMetrics, so when you're ready to move up in scan rates that functionality is built in.
CSV Keg Status import for initial keg set up: Yes. We offer a CSV import so you can take you spreadsheet and get it into KegMetrics easily.
Data Backups is proven to work: We use AWS (amazon web services) to back up once a day, and we can restore the database to any backup within the last week. We've run the system through getting corrupted and restoring it. All is well.
Digital Keg Collar Functionality: Yup this is online now. –This feature allows anyone who is not logged into the app to use a 3rd party QR scanning app to scan the KegMetrics QR code. The result is they will be taken to the public version of that specific Keg web page. There they will see anything you would put on a Keg Collar: For example: Beer Name, Batch No.,Batch Date, Keg Size, and Brewery. Nothing else (ie. no customer data).
Cooperage Metrics Calculations: This is where we specialize. Each Metric calculation is a "widget". We currently offer Available On-Site (showing clean, sanitized or dirty), Occupied On-Site, Off-Site (grouped by customer). Future rollouts are planned and we welcome your feedback for more ideas.
Email Notification: This is working. We are different because KegMetrics sends out email reports to your customer and distributors showing appreciation for purchasing your beer and also asking for the status so you can collect the kegs. It can be turned off as well. Note: We have also jumped through the hurdles to get the emails into the inbox (rather than the spam folder). We use Amazon services as the trusted sender which authenticates each email so it's not registered as spam.
Compatible Platform Status: Android = Awesome, iOS = Acceptable, Windows = Awesome, OSX = Awesome.
Clearly there's so much more to highlight. Please stay tuned for future updates as we roll out new features or fixes. Of course if you would like a demo, or would like to sign up please head over KegMetrics.com to get in touch with us. We'd love to hear from you. | {
"redpajama_set_name": "RedPajamaC4"
} | 9,489 |
{"url":"https:\/\/deepakbaby.in\/post\/kaldi-mkl\/","text":"# Installing Kaldi with MKL support without root access\n\nKaldi has recently switched to Intel Math Kernel Libraries (MKL) for linear algebra operations (as of April 2019). However, installing MKL (by running tools\/extras\/install_mkl.sh) requires root access. This post details how kaldi (with MKL) can be installed without root access.\n\n\u2022 Extract the contents and launch the installer by running install.sh.\n\u2022 When asked for the path to install, specify a location where you have write access (e.g., \/home\/<username>\/intel)\n\u2022 Complete the installation of MKL libraries\n3. Navigate to the kaldi folder kaldi\/tools\n4. Typically the first step is to run extras\/check_dependencies.sh. This will complain about the missing MKL libraries. This is because the script expects the MKL libraries to be located under \/opt\/intel directory. As of now (May 2019), there is no option to pass the mkl-root directory to this script. Therefore we will edit the extras\/check_dependencies.sh script by changing \/opt\/intel\/mkl\/include\/mkl.h to \/home\/<username>\/intel\/mkl\/include\/mkl.h. Then running extras\/check_dependencies.sh should work fine without any MKL related warnings.\n5. Then run make -j <numcpu> to install the tools required by kaldi\n6. Navigate to the kaldi\/src folder.\n7. Run .\/configure with the --mkl-root option.\n.\/configure --shared --mkl-root=\/home\/<username>\/intel\/mkl\n\n8. Then install kaldi using the usual steps\nmake depend -j <numcpu>\nmake -j <numcpu>\n\n\nThis will install Kaldi with MKL support without requiring any root privileges.\n\n##### Deepak Baby\n###### Applied Scientist\n\nMy research interests include speech recognition, enhancement and deep learning.","date":"2023-03-27 20:46:22","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 1, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.6288750171661377, \"perplexity\": 12502.274895200468}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2023-14\/segments\/1679296948684.19\/warc\/CC-MAIN-20230327185741-20230327215741-00682.warc.gz\"}"} | null | null |
Q: Plotting contours on a global map using ggplot and orthographic projection I am trying to plot a map like this one using ggplot and this dataset :
Using this code:
dev.off()
map.world <- map_data("world")
plot <- ggplot()
plot <- ggplot(data=DATASET, aes(V2,V1,fill=V3)) +
stat_density2d(aes(fill=..level..,alpha=..level..),
geom='polygon',colour='black') +
scale_fill_continuous(low="green",high="red") +guides(alpha="none")
plot <- plot + expand_limits(x = map.world$long, y = map.world$lat)
plot <- plot + theme(panel.grid=element_blank(),
panel.border=element_blank())
plot <- plot + theme(axis.ticks=element_blank(), axis.text=element_blank())
plot <- plot + theme(legend.position="right",plot.title = element_text(size =
10, face = "bold"))
plot <- plot + coord_map("ortho", orientation=c(90, -90, 0))
plot
I get this map:
As you see, in some locations, the contours are distorted. However, when I add the country maps:
dev.off()
map.world <- map_data("world")
plot <- ggplot()
plot <- ggplot(data=DATASET, aes(V2,V1,fill=V3)) +
stat_density2d(aes(fill=..level..,alpha=..level..),geom='polygon',
colour='black') +
scale_fill_continuous(low="green",high="red") +guides(alpha="none")
plot <- plot + geom_map(dat=map.world, map = map.world, aes(map_id=region),
fill="NA", color="black")
plot <- plot + expand_limits(x = map.world$long, y = map.world$lat)
plot <- plot + theme(panel.grid=element_blank(),
panel.border=element_blank())
plot <- plot + theme(axis.ticks=element_blank(), axis.text=element_blank())
plot <- plot + theme(legend.position="right",plot.title = element_text(size =
10, face = "bold"))
plot <- plot + coord_map("ortho", orientation=c(90, -90, 0))
plot
I get this message:
"Error in FUN(X[[i]], ...) : object 'V2' not found".
I would appreciate your help.
You can download the dataset here
A: This is only a partial answer, but the issue with object 'V2' not found is because when you first build the ggplot object, you map V2, V1, and V3 as aesthetics. These will carry through to all the layers, unless you override them or specify that a layer shouldn't inherit them. Adding inherit.aes = F to your geom_map fixes it.
library(tidyverse)
DATASET <- read.delim("https://www.dropbox.com/s/57qeekwm920lxbu/dataset.txt?dl=1", header = F)
map.world <- map_data("world")
plot <- ggplot()
plot <- ggplot(data=DATASET, aes(V2,V1,fill=V3)) +
stat_density2d(aes(fill=..level..,alpha=..level..),geom='polygon',
colour='black') +
scale_fill_continuous(low="green",high="red") +guides(alpha="none")
plot <- plot + geom_map(dat=map.world, map = map.world, aes(map_id=region),
fill="NA", color="black", inherit.aes = F)
# plot <- plot + expand_limits(x = map.world$long, y = map.world$lat)
plot <- plot + theme(panel.grid=element_blank(),
panel.border=element_blank())
# plot <- plot + theme(axis.ticks=element_blank(), axis.text=element_blank())
plot <- plot + theme(legend.position="right",plot.title = element_text(size =
10, face = "bold"))
plot <- plot + coord_map("ortho", orientation=c(90, -90, 0))
print(plot)
Created on 2018-04-13 by the reprex package (v0.2.0).
I turned the tick marks back on, just to try to figure out the limits issue, which I believe is what's making the stray lines. Some points are outside the coordinate limits, but I'm not sure how to fix that exactly. Maybe someone else has a suggestion on how to tweak expand_limits or lims---so far, I'm not getting quite there.
I did find this in the manual page for coord_map:
# Centered on New York (currently has issues with closing polygons)
worldmap + coord_map("ortho", orientation = c(41, -74, 0))
So this might be a known issue.
| {
"redpajama_set_name": "RedPajamaStackExchange"
} | 4,246 |
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Our Candlewood Suites hotel is centrally located at exit 58, off I-95 near I-85 & I-295; minutes from Fort Lee, Chester, Petersburg & Richmond, VA business & real estate districts. Our location offers access to Wathal Industrial Park, Meadowville Technology Park, Honeywell, Dominion Power, Phillip Morris, Dupont, SRMC, Xymid, Sunchem, Northrup Grumman, LMR, Fort Lee and Defense Supply Center.
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"redpajama_set_name": "RedPajamaC4"
} | 9,020 |
\section{Introduction}
Detection of binary black holes (BBHs) by LIGO/Virgo has opened a new era in astronomy.
Much effort has been focused on characterizing the formation scenario of these systems, whether they are born in the field or assembled dynamically.
There have been studies of the properties of the progenitors of these systems, largely based on the population synthesis models which rely on uncertain physics in large parts.
One of the key questions is whether there exists an upper mass limit for black holes formed through stellar evolution.
The theoretical models anticipate larger black hole masses to be formed at lower metallicities since the line-driven winds would be quenched, and therefore, a larger mass is available for collapse \citep{Kudritzki:2000cp,Vink:2001cs,Brott:2011fa,Fryer:2012jk}.
On the other hand, it is believed that pair-instability supernovae (PISN) creates a gap in BH mass distribution, with its location set by the pulsational pair instability supernovae (PPISN) that consequently determine an upper limit on the most massive BHs that can potentially form at the lowest metallicities \citep{Heger:2003ej,Belczynski:2016hj,Yoshida2016,Woosley:2017dj,2018arXiv181013412M,2019arXiv190111136L} due to the mass loss from pulsations pre-supernovae. This leads to the so-called second mass gap between $\approx$ 50 and 135 ${\rm\,M_\odot}$ for BHs formed from stellar core collapse. Given that the space-time volume that LIGO is sensitive to probe scales with the primary mass of the BBH as $m_1^{5/2}$, if there is a cut off at around 50 ${\rm\,M_\odot}$, the evidence for this should be there in the LIGO data.
There has been claims in the literature that the LIGO data so far suggest the presence of a strong upper mass cut for the black holes \citep{Fishbach:2017ic,Talbot:2018cj,Roulet:2019js}.
\citet{Fishbach:2017ic} conclude $M_{BH}^{\rm max}=40{\rm\,M_\odot}$, and a power law index of $\alpha<3$ based on about 6 early BBH systems detected by LIGO.
\citet{Roulet:2019js} arrive at $M_{BH}^{\rm max}=41^{+25}_{-10} {\rm\,M_\odot}$ and $\alpha\approx2$ by analyzing the ten observed systems.
LIGO collaboration analysis of the ten events suggests that no more than 1\% of black holes are more massive than 45${\rm\,M_\odot}$ \citep{Abbottetal:2018vb}.
Moreover, they constrain the power law index of the primary black hole to be $\alpha=1.6^{+1.5}_{-1.7}$(90\% credibility).
One caveat that has been missing in the literature with regards to the $M_{BH}^{\rm max}$ is the influence of the metallicity evolution of the universe.
If black holes close to the $M_{BH}^{\rm max}$ limit are born at the lowest metallicities of $\log(Z/Z_{\odot})<-3$, then in order to detect the limit, we need the universe to have
gone through such low metallicities for enough extended times to provide us with observables. In other words, if PISN is active at $\log(Z/Z_{\odot})<-3$, then if the universe lasted half of its age at such low metallicities, then
we would have ample evidence for the presence of the upper mass limit. However, if the universe spent only an insignificant lifetime at such low metallicities, then there would have been not much star formation at such
low metallicities, and therefore, our power to detect the evidence for the presence of such a mechanism would diminish.
In this paper, we parametrize the distribution of the BBHs with six different parameters, and investigate the constraining power in the ten observed events on them.
In our model, we tie the maximum black hole mass to the metallicity of the star forming gas, and we parametrize the star forming gas metallicity to evolve either rapidly or slowly with redshift.
The $M_{BH}^{\rm max}$ is considered to be the maximum mass born at zero metallicity and therefore how much time the universe is assumed to have spent at such low metallicities will determine the
expected birth rate of such massive black holes.
The structure of this paper is as follows: In \S\ref{sec:method} we describe our model in terms of how star forming gas metallicity evolution enters our calculation to set the maximum black hole mass,
and how the inference procedure is carried out. In \S\ref{sec:results} we provide our results, and in \S\ref{sec:summary} we discuss the caveats present in our model. Throughout this paper, we assume Planck 2013 cosmology.
\section{method}\label{sec:method}
\subsection{calculating the merger rate of the BBHs}
The BBH formation rate as a function redshift per comoving volume per source frame time is defined as:
\begin{align}
\frac{dN_{\rm form}}{dm_1 dm_2 dt_f dV_c}=\lambda_{BBH}m_1^{-\alpha} m_2^{-\beta} / C(\alpha,\beta) \psi(z),
\end{align}
where $C(\alpha,\beta)$ is the normalization constant given by:
\begin{equation}
C(\alpha,\beta)=\int m_1^{-\alpha} m_2^{-\beta} dm_1 dm_2
\end{equation}
$\psi(z)$ is the cosmic star formation rate density adopted from \citet{Madau:2014gtb}:
\begin{equation}
\psi(z)=0.015 \frac{(1+z)^{2.7}}{1+[(1+z)/2.9]^{5.6}}\,\, {\rm\,M_\odot}\, {\rm yr^{-1}\, Mpc^{-3}}.
\end{equation}
Here, $\lambda_{BBH}$ is the currently unknown BBH mass efficiency assumed not to evolve with redshift.
The corresponding merger rate is given by:
\begin{equation}
\frac{dN_{\rm merge}}{dm_1 dm_2 dt_m dV_c}= \int^{\infty}_{t_m(z_m)} P(t_m | t_f) \frac{dN_{\rm form}}{dm_1 dm_2 dt_f dV_c} dt_f
\end{equation}
$P(t_m | t_f)$ is the delay time distribution of the BBHs that sets the probability of merging after $t_m$ of time is past since the formation of the binary.
We set a minimum delay time, $t_{\rm min}=1$ Myr and impose a maximum delay time of 10 Gyr.
\begin{equation}
P(t_m | t_f)= t_m^{-\kappa} / C(\kappa)
\end{equation}
where $C(\kappa) $ is the normalization constant given by:
\begin{equation}
C(\kappa)=\int_{t_{\rm min}}^{t_{\rm max}} t_m^{-\kappa} dt.
\end{equation}
Subsequently the merger rate in the detector frame is:
\begin{equation}
\frac{dN_{\rm merge}}{dm_1 dm_2 dt_d dz} = \frac{dN_{\rm merge}}{dm_1 dm_2 dt_m dV} \frac{dV_c}{dz} \frac{1}{1+z}
\end{equation}
where the redshift derivative of the comoving volume is $dV_c/dz=(4\pi c/H_0)[D_L^2/(1+z)^2E(z)]$, where $D_L$ is the luminosity distance to the source, and $H_0$ is the Hubble constant.
In this framework, $M_{\rm min}<m_2<m_1<m_{1}^{\rm max}$, where $M_{\rm min}=5{\rm\,M_\odot}$ and $M_{BH}^{\rm max}$ is set by the metallicity as:
\begin{equation}
m_{1}^{\rm max}= (M_{BH}^{\rm max}-c) e^{-b Z(z,\gamma)} +c
\end{equation}
with constants $b=6.5$, and $c=17.5$. This is shown in the top panel of Figure \ref{f:fig1}. This parametrization matches the maximum mass of a blackhole as a function of metallicity as derived in \citet{Belczynski:2010iw} when
we consider the maximum black hole mass to be 80${\rm\,M_\odot}$. In later series of papers, \citet{Belczynski:2016hj} have included the impact of pair-instability mass loss on black hole binaries which creates
a second mass gap between 50-150${\rm\,M_\odot}$ for black holes. Our approach here is whether the presence of PISN could be inferred from the LIGO BBH systems.
$Z(z,\gamma)$ defines the metallicity evolution with redshift that we parametrize in two different ways: The first model is a metallicity evolution in which the metallicity drops exponentially with redshift, i.e., $Z/Z_{\odot}=e^{-\gamma z}$. In the second model the metallicity is modeled as $Z/Z_{\odot}=(1+z)^{-\gamma}$ where the metallicity evolution is much more modest.
While the impact of metallicity on the LIGO black holes has been explored recently in other works \citep{Kovetz2017,2019arXiv190608136N}, here we explore its impact on the maximum BH mass that LIGO would infer.
The bottom panel of Figure \ref{f:fig1} shows the different models for the metallicity evolution of the universe that is adopted in this work. The metallicity in this work
refers to the star formation rate weighted metallicity of the gas in the galaxies in which the BBHs are born.
From observational perspective, metallicity studies of damped Lyman alpha (DLA) systems at high redshifts suggest a modest evolution at redshifts between $1.5-5$ \citep{Pettini:1997jb,Prochaska:2000dk,Cen:2002fl,Kulkarni:2002eu,Prochaska:2003et,Berg:2016cu}. If the star forming gas metallicity evolves in a similar manner, then low values of $\gamma$ in our parametrization would be the closest model to the observed metallicity evolution.
\begin{figure}
\hspace{-0.15in}
\centering
\includegraphics[width=1.0\columnwidth]{max_mBH.pdf}
\includegraphics[width=1.0\columnwidth]{two_metal_evol_models.pdf}
\caption{\emph{Top panel:} the parametrized maximum black hole mass as a function of metallicity. The blue line shows the results of \citet{Belczynski:2010iw}. The green and red lines show the parametrized
$M_{BH}^{\rm max}$ curves when the $M_{BH}^{\rm max}$ is set to 80, and 40 ${\rm\,M_\odot}$ respectively. \emph{Bottom panel:} two different metallicity evolution models adopted in this work, one that drops exponentially with redshift (solid lines), and a power-law model (dashed lines).}
\label{f:fig1}
\end{figure}
The {\it observed} BBH merger rate is:
\begin{equation}
\frac{dN_{\rm obs}}{dm_1 dm_2 dt_d dz}= \frac{dN_{\rm merge}}{dm_1 dm_2 dt_d dz} P_{\text{det}}(m_1,m_2,z),
\end{equation}
where $P_{\text{det}}(m_1,m_2,z)$ is the detection probability of a BBH with masses of $m_1,m_2$, at redshift $z$.
We note that in this work we have assumed the mergers come from the same formation channel, and as such would follow the same $\lambda_{BBH}$ parameter.
\subsection{inference analysis}
To perform our inference analysis, we proceed as follows: Our model has 6 parameters that we fit for $\theta$=($\lambda_{BBH}$,$\alpha,\beta,\gamma,\kappa, M_{BH}^{\rm max}$).
The posterior distribution of these parameters given the data is:
\begin{equation}
P(\theta | data) = P (data | \theta) P(\theta)
\end{equation}
The prior on our parameter is such that they are bound between $1<\alpha,\beta,\gamma,\kappa<4$, and $ 30<M_{BH}^{\rm max}/{\rm\,M_\odot}<100$.
We approximate $P (data |\theta) $ which we call for brevity $P(d | \theta)$ as follow:
For each BBH event $i$, we have the $P(m_1^i,m_2^i,z^i | d^i )$ from the waveform analysis done by LIGO team.
We have
\begin{equation}
P(m_1^i,m_2^i,z^i | d^i )=P(d^i | m_1^i,m_2^i,z^i ) P(m_1^i,m_2^i,z^i )
\end{equation}
and
\begin{equation}
P(d^i | \theta) = P(d^i | m_1^i,m_2^i,z^i ) P(m_1^i,m_2^i,z^i | \theta)
\end{equation}
where by combining the last two equations we arrive at
\begin{equation}
P(d^i | \theta) \propto P(m_1^i,m_2^i,z^i | d^i ) P(m_1^i,m_2^i,z^i | \theta)
\end{equation}
Therefore, to compute $P(d^i | \theta)$, we draw $N_{\rm sample}$ of $(m_1^j,m_2^j,z^j)^i$ pairs from the posterior $P(m_1^i,m_2^i,z^i | d^i )$ and calculate $P(m_1^j,m_2^j,z^j | \theta)$.
For each event $i$, we have
\begin{equation}
P(d^i | \theta)=1/N_{\rm sample}\L\sum_{j=0}^{j=N_{\rm sample}} \frac{dN_{\rm merge}}{dm_1 dm_2 dt_d dz}(m_1^j,m_2^j,z^j )^i |_{\theta}
\end{equation}
The posterior distribution from $N_{\rm obs}$ events is:
\begin{equation}
P(\theta | d) \propto e^{-N_{\rm eff} |_{\theta}} \prod_{i=1}^{i=N_{\rm obs}} P(d^i | \theta) ,
\end{equation}
where $N_{\rm eff}|_{\theta}$ is the expected number of events given $\theta$ defined as :
\begin{equation}
N_{\rm eff}|_{\theta} = \int_5^{M_{BH}^{\rm max}} \int_{5}^{m_1}\int_0^{\infty} \int_0^{t_{\rm obs}} \frac{dN_{\rm obs}}{dm_1 dm_2 dt_d dz} |_{\theta}~dm_1 dm_2 dz dt
\end{equation}
Where $t_{\rm obs}$ is the total observing time by LIGO in O1 and O2 runs.
\section{results}\label{sec:results}
Figure \ref{f:result_exp} shows the posterior distribution for the six parameters of our model when the metallicity evolution is modeled as $Z/Z_{\odot}=e^{-\gamma z}$.
The median BBH efficiency is predicted to be $\approx 2\times10^{-7}/{\rm\,M_\odot}$. This birth rate is robust and is not affected by our metallicity evolution parametrization.
However, we note that we have assumed $\lambda_{BBH}$ to be constant in this work, but BBH formation is intrinsically tied to this parameter through the wind mass loss.
So the reader should note that the inferences on $\lambda_{BBH}$ in this work
is with the prior assumption that $\lambda_{BBH}$ is non-evolving with redshift itself.
While the simulation can not put stringent constraints on $\alpha$, $\beta$, and $\gamma$, one can say large values for $\beta$, and small values of $\gamma$ are disfavored.
The posterior on $\kappa$ is suggestive of a shallow slope and therefore a preference for long delay times for the BBHs.
The anti-correlation between the birth efficiency $\lambda_{BBH}$, and $\kappa$ is due to the fact that if a model with long delay times is chosen, then it should be balanced out with lower birth rate efficiency since long delays increase the number density of the BBH mergers in the local universe. Of all the parameters in our model, it is the $M_{BH}^{\rm max}$ that is very well constrained to be $M_{BH}^{\rm max}=44^{+9}_{-5}$ in this model.
Figure \ref{f:result_powerlaw} shows the same results but for the model with metallicity evolution modeled as $Z/Z_{\odot}=(1+z)^{\gamma}$. It appears that all the parameters expect $M_{BH}^{\rm max}$ have the same posterior distribution.
The bounds on the $M_{BH}^{\rm max}$ that is less constrained and is $M_{BH}^{\rm max}=52^{+16}_{-9}$. Not only the median value is larger, but the upper bound extends to a much larger value.
The impact of the assumptions about the metallicity evolution on the $M_{BH}^{\rm max}$ should be understood as follows: In our model, the maximum black hole mass enters our calculation in a non-trivial manner.
$M_{BH}^{\rm max}$ sets the maximum mass that a black hole can have at zero metallicity. If in one model, the metallicity evolution is modest, and barely touches very low metallicities, then to explain the LIGO black holes
one needs to push the $M_{BH}^{\rm max}$ to large values to open the room for the model to fit the massive LIGO systems such as GW170729, and GW170823. This is the case when the metallicity evolution follows $(1+z)^{-\gamma}$.
However, if the universe spends much of its cosmic time at very low metallicities, then one can easily explain GW170729 and GW170823 by the star formation at high redshifts.
The idea can be best seen in the anti-correlation between $\gamma$ and $M_{BH}^{\rm max}$ in Figure \ref{f:result_powerlaw}: Large values of $\gamma$ which translate into a faster drop in metallicity, leads to lower values of $M_{BH}^{\rm max}$ and vice versa.
\begin{figure*}
\includegraphics[width=1.0\linewidth]{Exp_z_tmax_10Gyr_nwalker_20_200_200_w_prior_high_res.pdf}
\caption{Results of MCMC simulation on six parameters in our model by fitting 10 LIGO events in O1 and O2 observing runs. In this model the metallicity evolution is modeled
as $Z/Z_{\odot}=e^{\gamma z}$.}
\label{f:result_exp}
\end{figure*}
\begin{figure*}
\includegraphics[width=1.0\linewidth]{new_range_Z_oneplusz_tmax_10Gyr_nwalker_20_200_200_w_prior_new.pdf}
\caption{Same as in Figure \ref{f:result_exp} but the metallicity evolution is modeled as $Z/Z_{\odot}=(1+z)^{-\gamma}$. Since in this parametrization the metallicity evolves more gradually with redshift, the impact is evident in the detail of the $M_{BH}^{\rm max}$ posterior as larger black hole masses would be allowed in this model. }
\label{f:result_powerlaw}
\end{figure*}
A different perspective on our results is provided in Figure \ref{f:mbhmax_evol}. In the left panel the thin black lines show posterior draws from the $M_{BH}^{\rm max}$ and $\gamma$ from the model with exponential metallicity evolution with redshift.
The thick red line shows the median predicted evolution. For each of the ten observed BBH systems, we show the bounds on the mass and redshift of the primary (more massive) black hole.
We are not fitting these data points, we are showing them to be compared to the maximum possible black holes that could be formed above a certain redshift range, such that after a delay time they merger in the local universe.
The right panel shows the same but for the model with power-law metallicity evolution with redshift.
The left panel of Figure \ref{f:metal_evol} shows the bounds on the metallicity evolution itself in the two models.
The solid lines and the shaded region of the same color show
the median and the 16th-84th percentile range for the each of the metallicity models. The evolution shown with blue is more consistent with the observations of the DLA systems at high redshifts which suggest a modest evolution of their metallicity with redshift \citep{Pettini:1997jb,Prochaska:2000dk,Cen:2002fl,Kulkarni:2002eu,Prochaska:2003et,Berg:2016cu}.
Right panel of Figure \ref{f:metal_evol} shows the
posterior BBH merger rate as a function of redshift for the model with $Z/Z_{\odot}\propto e^{-\gamma z}$ (red shaded region showing the 16th-84th percentile range. The blue line and shaded region show the same for the model with metallicity
evolution parametrized as $\propto (1+z)^{-\gamma}$. The dashed black line is the $\lambda_{BBH} \psi(z)$, which shows what the merger rate would be if there is no delay time for the BBHs. The different metallicity evolution models did not have a discernible impact on the merger rate of the binaries, and therefore on the maximum mass would be the best probe of the metallicity evolution in this picture.
\begin{figure*}
\includegraphics[width=1.0\columnwidth]{posterior_M_BH_Max_evol_Z_exp_tmax_10Gyr.pdf}
\includegraphics[width=1.0\columnwidth]{posterior_M_BH_Max_evol_Z_oneplusz_tmax_10Gyr_high_res.pdf}
\caption{{\it Left Panel:} thin black lines show posterior draws from the $M_{BH}^{\rm max}$ and $\gamma$ from the model with exponential metallicity evolution with redshift. The thick red line shows the median predicted evolution.
The heavier black hole mass and redshift of the ten observed BBH systems in O1 and O2 observing runs are plotted. The $M_{BH}^{\rm max}=44^{+9}_{-5}$ in this model. {\it Right panel:} The same as left panel, but for a metallicity
evolution parametrized as $\propto (1+z)^{\gamma}$. The bounds on the maximum mass in this model is less constrained and is predicted to be $M_{BH}^{\rm max}=52^{+16}_{-9}$.}
\label{f:mbhmax_evol}
\end{figure*}
\begin{figure*}
\includegraphics[width=1.0\columnwidth]{combined_posterior_metal_evol_tmax_10Gyr_high_res.pdf}
\includegraphics[width=1.0\columnwidth]{combined_posterior_merger_rate_tmax_10Gyr_high_res.pdf}
\caption{{\it Left Panel:} thin black lines show posterior draws of the metallicity evolution in the model with exponential metallicity evolution with redshift. The red line and the shaded region show
the median and the 16th-84th percentile range. {\it Right panel:} posterior BBH merger rate as a function of redshift for the model with $Z/Z_{\odot}\propto e^{-\gamma z}$ (red shaded region showing the 16th-84th percentile range. The blue line and shaded region show the same for the model with metallicity
evolution parametrized as $\propto (1+z)^{-\gamma}$. The dashed black line is the $\lambda_{BBH} \psi(z)$, which shows what the merger rate would be if there is no delay time for the BBHs.}
\label{f:metal_evol}
\end{figure*}
\section{summary \& discussion}\label{sec:summary}
Our results can be summarized as follows: If maximum black hole mass is set at close to zero metallicity, then in order to infer it from data, it is crucial to have a large part of the cosmic time to have
a metallicity close to zero to generate BBH systems that can probe the mass limit. In other words, if for example, we lived in a universe in which the metallicity never dropped below 0.1 $Z_{\odot}$, then there would have been little hope
to constrain a parameter that requires probing metallicities close to $10^{-4}Z_{\odot}$. In our two models, one prescription of the metallicity evolves rapidly with redshift and the other evolves rather smoothly.
The bounds on the $M_{BH}^{\rm max}$ are much more stringent in the model with a rapid drop of metallicity with redshift (i.e., $Z\propto e^{\gamma z}$), compared to the model in which metallicity is modeled as $Z\propto (1+z)^{-\gamma}$ .
Similarly, if we lived in a universe in which the very heavy black holes tend to be born in close binaries, and therefore merger rapidly, then we would be biased against finding them in the local universe. Such a parametrization is not considered in this work, but it would have resulted in the same conclusions that we have reached so far.
Therefore, any claim as to the presence of an upper limit on the $M_{BH}^{\rm max}$ should be taken with the caveat that we can be easily biased against them, and the bound on the $M_{BH}^{\rm max}$ depends on our
assumptions with regard to (i) how these systems are born (metallicity range) and how does the universe on average evolve in metallicity, and (ii) whether the more massive systems tend to cluster in a parameter
space in delay times that we would be biased against them.
\acknowledgements
This work was supported by the National Science Foundation under grant AST14-07835 and by NASA under theory grant NNX15AK82G as well as a JTF grant.
MTS is grateful to the Center for Computational Astrophysics for hospitality during the course of this work.
| {
"redpajama_set_name": "RedPajamaArXiv"
} | 6,485 |
Antonio's perfect hat-trick
Nottingham Forest winger Michail Antonio has been voted as The Bed Chambers Player of the Month for the third time this season.
The 24-year-old enjoyed a successful November at The City Ground as he added two more goals to his tally including the last-gasp winner over Norwich on Trentside.
Antonio's performances earned his 38% of the supporters' votes as he narrowly beat top scorer Britt Assombalonga to the prize with the popular striker taking second place with a 36% share of the vote.
Matty Fryatt impressed Forest fans with his all-action and hard-working displays as he finished in third spot with 14% of the vote.
Antonio wins a £100 voucher for The Bed Chambers along with a bottle of champagne. The winning fan, selected at random from those who voted for Michail, is Ken Dyson who also wins £100 to spend at The Bed Chambers.
Ken will also present Michail with his award at The Nigel Doughty Academy in the next few weeks.
Another winner is Susy Collins who voted for Antonio's last-minute winner over Norwich as her Dream Moment of the Month as she said: "The 2-1 win against Norwich was my Dream Moment.
"People had already started to leave when Assombalonga equalised in the 85th minute but we kept piling on the pressure and Antonio scored a winner in the 94th minute."
In all my years as a season ticket holder, there have been few times that I have experienced noise from the crowd quite as loud as this. An amazing feeling for what was such a desperately-needed win."
Susy wins a £50 voucher to spend at The Bed Chambers and a signed ball. News of how to vote for December's The Bed Chambers Player of the Month will appear on the website at the end of this month.
The award-winning The Bed Chambers are proud to sponsor Nottingham Forest's official Player of the Month competition. | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 5,640 |
You are here: Home / Texas / 20 of the Best Kid-Friendly Restaurants in San Antonio
20 of the Best Kid-Friendly Restaurants in San Antonio
San Antonio has all the best attributes of a city while still retaining a small-town feel, making it a true Texas gem for locals and tourists. Families will love visiting San Antonio for its abounding cultural and historical landmarks as well as entertainment for the whole family.
You can take a lazy boat tour or wander along Sant Antonio's famous Riverwalk, explore the historical Alamo for a lesson in Texas history, or marvel at the life-sized wax figures and other anomalous statues at Ripley's Believe It or Not Museum. The list of family-friendly attractions goes on and on.
You'll also find a long list of great kid-friendly restaurants in San Antonio that showcases Texas cuisine at its best while also providing an inviting and fun atmosphere.
If you're looking for the best kid-friendly restaurants in San Antonio, check out the following list of our favorite local spots around town to enjoy delicious food from a variety of cuisines served with plenty of Texas-style southern hospitality.
20 Best Family-Friendly Restaurants in San Antonio
1. The County Line
2. Mariscos El Paisa
3. Earth Burger
4. Burnwood '68
5. Zocca Cuisine D'Italia
6. Crepeccino USA
7. The Cove
8. Big Lou's Pizza
9. Magnolia Pancake Haus
10. La Haciendo de Los Barrios
11. Big'z Burger Joint
12. Nicha's Comida Mexicana
13. Antlers Lodge
14. Two Brother's Barbeque Market
15. The Bottling Department
16. Dough Pizzeria Napoletana
17. Pete's Tako House
18. The Guenther House
19. Mi Tierra Café and Bakery
20. The Magic Time Machine
No matter how picky your kids are, our list of the best kid-friendly restaurants in San Antonio will turn even the pickiest eater into a fan. Burger bars, pizzerias, bakeries, and barbeque joints with giant patios, playgrounds, and kid's menus abound on the following list of outstanding kid-friendly restaurants.
111 W. Crockett St. #104
Located in downtown San Antonio's famous Riverwalk, The County Line is a Texas institution, with locations in Austin, San Antonio, El Paso, and New Mexico. They have been serving Texas-style slow-cooked barbeque and hearty sides in a Texas Roadhouse-like atmosphere to happy customers since 1975. The County Line Riverwalk location has a giant outdoor patio with a bar for the adults and a great view of the river and surrounding downtown.
You don't want to miss out on their juicy brisket or their unique German sausages all served with homemade bread, pickles, and a sweet and spicy barbeque sauce. Kids have their own menu with all the same smoked meats served in smaller portions alongside pickles, fries, a fountain drink, and a bowl of homemade ice cream for dessert.
29094 U.S. Hwy 281 N,
Mariscos El Paisa is a neighborhood favorite seafood-centric Mexican food restaurant in the Encino Ranch neighborhood specializing in dishes from the Mexican Pacific coastal state of Sinaloa. They have some of the best ceviche in town, not to mention fresh seafood cocktails known as Campechanas and the freshest fried fish tacos you'll get this far from the coast.
Kids also have a menu they like with items like cheese quesadillas, chicken burritos, and chicken tenders. Plus, there is a playground on-site for your kids to blow off steam and work up an appetite.
818 NW Loop 410,
It's hard to believe that a guilt-free burger exists, but they do at Earth Burger, San Antonio's first and only plant-based burger stand. Not only are these burgers healthier than a fried beef patty, but they use sustainably sourced ingredients to make them. You can indulge in a decadent Beyond Burger or plant-based chicken tenders and fries without moral or gastrointestinal consequences.
See also 17 Fun Things to Do in Dallas with Kids
In addition to numerous kinds of plant-based burgers, wings, and delicious old-school crinkle fries, customers looking for even healthier options will find a wide selection of salads and grain bowls. Earth Burger is actually a fast-food drive-through joint that is delicious and nutritious.
18745 Redland Rd.
San Antonio, TX, 78259
Located in the Redland Ridge neighborhood on a large, beautiful property surrounded by greenery and woods, Burnwood '68 is a bar, grill, and music venue that the whole family will enjoy. They serve all your favorite local Texas draft beers and imported bottles along with fresh craft cocktails to cool you off on a hot Texas day or evening as you dine al fresco under a roofed patio.
There's live music on the weekends and multiple fire pits to make a full night of it at Burnwood '68. They serve a creative menu of barbeque dishes like brisket grilled cheese, Doritos nachos, and Frito pies. It's safe to say the menu is kid-approved.
Zocca Cuisine D'Italia is a refined yet family-friendly Italian restaurant located right on the Riverwalk in the fancy Westin Riverwalk Hotel, with a lovely outdoor patio on the river. The interior is also a beautiful rustic-chic space with beautiful Texas limestone walls, exposed brick ceilings, and comfy leather dining chairs.
There's something for everyone at Zocca Cuisine D'Italia, with classic Italian dishes for more sophisticated tastes like seafood pasta and filet mignon as well as a menu especially for the kids with dishes like grilled cheese, pizza, and spaghetti.
5500 Babcock Rd #104
Crepeccino USA is a neighborhood café and creperie in a cute, colorful space in the Villas of Babcock neighborhood. They serve a wide selection of sweet and savory crepes along with salads, sandwiches, waffles, milkshakes, gelato and sorbet, and so much more.
Whether you want a delectable snack for the kids and an artisanal espresso drink for the parents, or a sit-down meal in a whimsical, welcoming restaurant, Crepeccino has you covered.
606 W Cypress St,
Over the past 20 years, The Cove has become one of San Antonio's premier sol food restaurants, and by "sol," we mean sustainable, organic, and local. Locals and critics alike give rave reviews for this authentic and sustainable American food restaurant in a giant old car-wash space with a giant beer garden and its own little vegetable garden.
There are weekly live music performances to enjoy with a vast selection of artisanal beers, and with a dog-friendly patio, you can bring your human and canine children for a fun, delicious, sustainably-sourced meal. There's a wide variety of Tex-Mex favorites and burgers with vegetarian and vegan options to boot.
2048 S W White Rd
It's a good thing they put "big" in the title because Big Lou's Pizza serves gargantuan-sized pies and slices with a flavor to match. A large pizza is a whopping 42" pie that's enough to feed your family for a week.
Big Lou's has a fun and quirky dining room with all sorts of random memorabilia and friendly staff. Plus, they have creative specialty pies that would make Texas proud. Try the Barbeque Brisket Pizza!
606 Embassy Oaks
If you're looking for the best breakfast restaurant to lavish over a wonderful weekend brunch with the family, look no further than Magnolia Pancake Haus. Owned and operated by San Antonio-native couple Robert and Sheila Flemings, Magnolia Pancake Haus is located inside an old roller-rink that has been converted into a bright and airy country-style dining room with bright turquoise floors and chairs.
See also 16 of the Best Family Hotels in San Antonio
Their award-winning buttermilk pancakes aren't just a hit with the locals but have also been featured on the food network's Diners, Drive-ins, and Dives.
Your family is in for a special treat when you dine at this San Antonio favorite Mexican restaurant in an authentic Mexican-style Hacienda surrounded by exquisitely manicured lawns, giant oak trees, and flowering cactus gardens galore.
Hacienda Los Barrios comes from a multi-generational culinary passion that first started as a mom-and-pop Mexican joint called Los Barrios in 1979 that has since expanded to three different Mexican food restaurants. Whether you want sizzling fajitas or cheesy enchiladas, everything at Hacienda Los Barrios is steeped in generations of amazing family recipes.
With three locations in San Antonio, Big'z Burger Joint is a family-friendly burger joint serving the most over-the-top selection of burgers and franks in San Antonio. Burgers at Bigz is a life-changing experience with every combination of fresh ground patties, cheeses, and toppings stacked to epic heights.
You order your burger at the counter and can watch these amazing creations being made in real-time from an open kitchen while the kids play around in the playground out back. In addition to superb burgers and dogs, you'll love the fries, sweet potato fries, and extravagant milkshakes served in mason jars covered in whipped cream, sprinkles, and fudge.
Nicha's Comida Mexicana is another San Antonio Tex-Mex institution with a north location in Balcones Heights and its original southside location in Riverside South. A family-owned and operated business, Nicha's Comida Mexicana has been serving the San Antonio community the best Tex-Mex food in a family-oriented restaurant for the past 40 years.
Parents can enjoy various delicious margaritas, Mexican cocktails, or savor an imported Mezcal or Tequila straight-up. Bottomless baskets of chips and homemade salsa are the preludes to fantastic entrees like chiles rellenos, flautas, enchiladas, and more.
9800 Hyatt Resort Drive
San Antonio, Texas, United States, 78251
Located inside the beautiful Hyatt Hotel in Downtown San Antonio, Antlers Lodge is a family-friendly fine dining restaurant specializing in wild game and authentic Texan cuisine. Antlers Lodge sources all wild game, fish, and beef from Texan ranchers which they prepare with Southwestern and southern flavors that characterize Texas cuisine.
12656 West Ave
Two Brother's Barbeque Market is the creation of brothers Jason and Jake Dady who designed their own custom, open-fire pits to serve their award-winning Texas barbeque that has been featured in Texas Monthly, Andrew Zimmern's Bizarre Foods: Delicious Destinations, and USA Today.
All meats are smoked and grilled right in front of you, which acts as mesmerizing entertainment that culminates in one of the best meals you'll have in San Antonio. Succulent brisket, cherry-glazed baby back ribs, smoked turkey and pulled pork are some of their signature meats that you can have in sandwiches or as hearty combo plates with excellent sides like mac-n-cheese and coleslaw.
312 Pearl Pkwy
The Bottling Department is a Texas-sized food hall in an old warehouse that has been converted into a rustic, bustling food court with seven different restaurants offering everything from Ramen to Mexican food.
Restaurants inside The Bottling Department include Breakfast, Chilaquil, Fletcher's Hamburgers, Kineapple, Mi Roti, Park Bar, and Tenko Ramen. Each restaurant offers the very best street-food-style offerings from American, Mexican, Caribbean, and Japanese traditions. You can spend a whole week enjoying all the different meals offered at the Bottling Department.
See also 27 of the Best Zoos & Aquariums in Texas
518 S. Alamo St
Located a few blocks from the Riverwalk Park and the Alamo in Downtown San Antonio, Dough Pizzeria Napoletana is an authentic Neapolitan Pizzeria serving wood-fired pizzas, antipasti, salads, and house-made cheeses.
Their pizzas are gourmet, with authentic imported Italian ingredients like prosciutto and truffles, but kids will love the simpler Margarita or pepperoni pizzas. They'll also love the imported selection of delicious Italian sodas in colorful glass bottles.
502 Brooklyn Ave
Established in 1978, Pete's Tako House has been a neighborhood favorite for over 40 years, serving authentic Northern Mexican food cooked to order. Husband and wife owners and managers Pete and Dora Rios are there every day to welcome customers and rally their friendly staff, many of whom are family members themselves.
The family will love their utterly decadent gooey queso dip with ground beef or their fresh, made-to-order guacamole. They're famous for their different variations of tacos, with traditional soft corn tortillas, crispy, crunchy hard-shelled creations, and puffy, chalupa-like tacos.
205 East Guenther Street
Located along the beautiful San Antonio River in the Arsenal neighborhood, The Guenther House is a historic landmark, museum, shop, and breakfast and lunch restaurant. The building is a stunning Victorian and art nouveau-styled 19th century home built by the founder of Pioneer Flour Mills, which you and the family can tour before enjoying a delectable breakfast or lunch.
Whether you choose to sit in the indoor ballroom or the outdoor patio behind the house surrounded by immaculately landscaped grounds you'll be equally enchanted. The food is as amazing as the house, with Texas-sized platters of the most comforting southern dishes like biscuits and gravy, chicken and waffles, sweet cream pancakes, not to mention freshly baked pastries all served with a heaping scoop of vanilla ice cream.
218 Produce Row
Mi Tierra Café and Bakery is one of San Antonio's oldest Tex Mex restaurants and Mexican Bakeries, serving San Antonio for the past 80 years. Founders Pedro and Cruz Cortez opened in 1941 as a small corner café in downtown San Antonio that has since expanded to a 500-seat historical landmark with a gift shop, massive Mexican pastry and bread counter, and a full menu of Tex-Mex favorites. Mi Tierra is still a family-owned and run business by the founders' children and grandchildren.
Eating at Mi Tierra Café and Bakery feels like a historical event and the food is as memorable as the atmosphere. You can get all your favorite Tex Mex dishes like enchiladas, tacos, fajitas, chalupas, and tamales, along with traditional Mexican pastries like conchas and other delicacies like Mexican peanut brittle and coconut flags.
902 NE Loop 410
This whimsical, one-of-a-kind themed restaurant is a kid's dream! It's like a funhouse-turned restaurant with numerous themed rooms and wait staff dressed and acting like famous historical characters. This creative restaurant is the brainchild of Texas-native Jim Hasslocher, who created The Magic Time Machine in 1973 to enchant kids while filling their parents with nostalgia for decades past.
Not only will the theatrics of this magical restaurant leave you spellbound, but you'll also love the amazing selection of steakhouse-grade food like prime rib and fresh seafood. Kids can choose from a selection of pizza, chicken tenders, and popcorn shrimp plates to name a few. Save room for epic desserts like their strawberry shortcake or oreo Sunday. Neither you nor your kids will want your night to end! | {
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{"url":"https:\/\/stats.stackexchange.com\/questions\/97246\/can-i-trust-a-model-if-i-do-not-check-the-prediction-error?noredirect=1","text":"Can I trust a model if I do not check the prediction error?\n\nMy main field is machine learning and 90 % of what I do is to try to improve the prediction error.\n\nRecently I have started to work with a medical group. They are mainly doctors so I do not know how much I can trust their statistical knowledge.\n\nWhat they commonly do is to fit logistic regression and without any consideration of the model performance they start to look to the coefficient in order to understand which one is more important or stuff like that.\n\nIn a similar way I fitted a random forest model and the I have done the importance plot something like this even if the predicted performance was very poor.\n\nHow much can I trust these kind of results in model where the prediction performance is poor?\n\n\u2022 Models have more than one possible purpose. Is the purpose of the model prediction? \u2013\u00a0Glen_b May 11 '14 at 10:17\n\u2022 no necessarily. Now I was mainly interested in how much a variable influences the output. The random forest ranking was perfect but I do not know if I can trust it due the fact that the prediction error is so large \u2013\u00a0Donbeo May 11 '14 at 10:28\n\u2022 Related to Glen_b's comment: darden.virginia.edu\/web\/uploadedFiles\/Darden\/Faculty_Research\/\u2026 \u2013\u00a0boscovich May 11 '14 at 10:31\n\u2022 Is it possible that they are using a scoring rule or some likelihood measure like generalized $R^2$ instead of prediction accuracy? Different measures don't always agree on which model is the best. \u2013\u00a0user44764 May 24 '14 at 2:21","date":"2020-11-24 23:57:47","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 1, \"mathjax_display_tex\": 0, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.6234465837478638, \"perplexity\": 415.7623046076878}, \"config\": {\"markdown_headings\": false, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 20, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2020-50\/segments\/1606141177607.13\/warc\/CC-MAIN-20201124224124-20201125014124-00652.warc.gz\"}"} | null | null |
Oahu rainfall total on Monday sets December record
By Nina Wu nwu@staradvertiser.com
JAMM AQUINO / JAQUINO@STARADVERTISER.COM
A pedestrian crossed flooded Dillingham Boulevard, Monday, in Honolulu. The deluge of heavy rains brought by the "Kona low" set a record daily maximum rainfall of 7.92 inches at Honolulu on Monday, according to the National Weather Service, broaching the previous record of 4.11 inches set for the day in 1988.
The deluge of heavy rains brought by the "Kona low" set a record daily maximum rainfall of 7.92 inches at Honolulu on Monday, according to the National Weather Service, broaching the previous record of 4.11 inches set for the day in 1988.
It was also the wettest December day on record, NWS said, surpassing the previous single-day record of 7.89 inches for the month on Dec. 12, 1987.
But it still came in second to the overall record of rain in a single day in Honolulu — which still stands at 15.32 inches on March 5, 1958.
As of 8 a.m. today, NWS said 24-hour rainfall totals averaged around 5 to 10 inches across Oahu, with more than 10 inches at Makua Range and Makaha Stream. Across Kauai, an average of 1.5 to 3.5 inches fell during the same time period.
Preliminary 48-hour rainfall averages on Oahu up to the end of today include up to 11.68 inches in upper Nuuanu, 11.34 inches at Lyon Arboretum in Manoa, 7.31 inches in Waianae, and 8.46 inches at Aloha Tower.
On Hawaii island, meanwhile, the Nene Cabin rain gauge recorded 14.26 inches of rainfall. On Maui, the Kula 1 rain gauge recorded 12.86 inches.
Forecasters earlier today kept a flood watch in place for Oahu and Kauai due to the continued threat of heavy rain and thunderstorms, but canceled it for Oahu this evening.
A flood watch remains in effect for Kauai County through 6 a.m. Wednesday.
University of Hawaii football coach Todd Graham addresses criticism
Public's help sought locating suspect wanted in attempted murder in Kalihi
Southern U.S. braces for big blast of snow, ice
Flood advisory issued for Oahu until 9 p.m.
High surf advisory for north, west shores of smaller islands likely to last through weekend
Winter storm threatens disruption across wide stretch of the U.S.
High surf advisory in effect for north, west shores of smaller islands | {
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Better Business Bureau Rating: A+ BBB Rating: A+
The Wealth Management Gap
Why Realized
Realized Marketplace
"Secondary Sales" of Private Securities (And Tokens) in Crowdfunding
Posted by Drew Reynolds on May 15, 2018
Realized is fortunate to have Mark Roderick as its guest contributor for this week's blog. Mark is a well-respected, securities attorney with Flaster/Greenberg. He is also one of the thought leaders in the United States on crowdfunding, and the author of the Crowdfunding Attorney Blog.
Below, Mark shares his thoughts on individuals ability to sell their private securities (e.g. your investment in a Delaware Statutory Trust) to another person. If you are interested in selling your investment in a DST and want to learn about about the Realized DST Secondary Market, click here.
Thank you Mark for your continued support.
--David Wieland
We use the term "secondary sales" to refer to sales of securities by anyone other than the issuer, and the term "secondary market" to refer to a marketplace where those sales take place.
Suppose NewCo, LLC, a private (non-public) company, raises money by issuing limited liability company interests under Rule 506(c). One investor, Amanda Sakaguri, later sells her limited liability company interest to a third party. The sale by Ms. Sakaguri is what we refer to as "secondary sale." If Ms. Sakaguri sold her limited liability company interest on a marketplace – as opposed to a private sale – we call that a "secondary market."
The Basic Legal Rules for Secondary Sales
All offers of securities must be fully registered with the SEC, under section 5 of the Securities Act of 1933. If there were no exceptions to section 5, Ms. Sakaguri would have to register with the the SEC before selling her limited liability company interest. But of course, this being the securities laws, there are lots of exceptions. For example:
If Ms. Sakaguri bought her limited liability company interest in a Regulation A offering, she could sell it to anyone right away.
If Ms. Sakaguri bought her limited liability company interest in a Regulation CF offering, she could sell it to some buyers right away, and to anyone after one year.
Ms. Sakaguri bought her limited liability company interest under Rule 506(c), so she isn't eligible for either of those exceptions. For Ms. Sakaguri and other owners of private securities, the most likely potential exception is in section 4(a)(1) of the Securities Act, which exempts "[Sales] by any person other than an issuer, underwriter, or dealer."
We know Ms. Sakaguri isn't the issuer. How about a dealer or an underwriter?
A dealer is "[A]ny person engaged in the business of buying and selling securities . . . .for such person's own account. . . ." but does not include ". . . .a person that buys or sells securities. . . . but not as a part of a regular business." Provided she isn't buying and selling securities as a business, Ms. Sakaguri isn't a dealer.
Whether she's an underwriter is a harder question, believe it or not. We think of underwriters as big Wall Street firms in gleaming towers, but the definition is much broader than that: "[A]ny person who has purchased from an issuer with a view to. . . .the distribution of any security. . . ." If Ms. Sakaguri expected to sell her limited liability company interest from NewCo when she bought it, she might be an underwriter, ineligible for the exception.
Whether the seller of a security is an underwriter once caused so much confusion that the SEC adopted a long rule on that topic.
Rule 144 provides a "safe harbor" for sellers. If a seller satisfies all the conditions of Rule 144, the seller will definitely not be treated as an underwriter for purposes of section 4(a)(1). If a seller doesn't satisfy all the conditions, it doesn't mean she will be treated as an underwriter. It just means she's taking her chances.
Rule 144 imposes different requirements on sellers depending on whether:
The issuer is a private or a publicly-reporting company;
The seller is an "affiliate" of the issuer (generally meaning under common control); and
How the seller acquired the securities in the first place.
We're going to focus only on private companies, like NewCo, and situations where the seller acquired her interest directly from the issuer.
If Ms. Sakaguri were an affiliate of NewCo, she would be subject to four requirements:
She would have to provide current information about the issuer, including its name, its business, its CEO and Directors, and two years' of financial statements.
She would have to hold the securities for at least one year.
She would be limited in the volume of securities she could sell.
She would be limited in the manner in which she sells the securities.
On the other hand, because Ms. Sakaguri isn't an affiliate of NewCo, but just an ordinary investor, she's subject to only one requirement: she must hold her limited liability company in NewCo for at least one year. That means:
She's not required to provide any information about NewCo to the buyer.
She can sell as much of her limited liability company interest as she wants.
She can sell it to anyone, accredited or non-accredited.
She can sell it in any manner she want, including on a website.
(Remember, Rule 144 is a safe harbor, not a legal rule. If Ms. Sakaguri is a minority investor in a private company and sells her limited liability company interest after four months because she lost her job and needs the cash, nobody thinks she's an underwriter.)
Where are the Secondary Markets?
There are lots of investors in the same shoes as Ms. Sakaguri: everyone who owns an interest in a real estate limited partnership, or a tech startup, or even a family business. If it's so easy legally for them to sell their interests, why aren't there lots of places where they can sell them?
A place – a website, for example – where investors could sell their privately-owned securities would probably be treated as an "exchange" under the Securities Exchange Act of 1934 ("[A]ny organization. . . .which. . . .provides a market place. . . .for bringing together purchasers and sellers of securities. . . ."). Section 5 of the Exchange Act makes it illegal for any exchange to operate unless it is either a registered "national securities exchange" under section 6 of the Exchange Act (like NASDAQ or the NYSE) or exempt from registration under SEC rules. The typical private security couldn't qualify for listing on a national exchange, so Ms. Sakaguri and others in her shoes would be looking for something else.
Fortunately, that something else exists in the form of an "alternative trading system," or ATS, authorized by the SEC in 17 CFR 240.3a1-1(a)(2) and defined in 17 CFR 242.300 – 303. Today there are dozens of alternative trading systems operating in the United States for many different purposes, including several operated by OTC Markets, Inc. Any broker-dealer can create an ATS without much difficulty, and for that matter anyone can create a broker-dealer.
All the legal pieces of the puzzle are in place: Ms. Sakaguri is allowed to sell her limited liability company interest under Rule 144; and it's not hard to create an ATS where she can sell it. So why does everyone complain about the lack of liquidity in private securities?
The answer is that the legal pieces of the puzzle turn out not to be the most important. Ms. Sakaguri is allowed to sell her limited liability company interest, but finding someone who wants to buy it is another story. We can created all the legal mechanisms we want, but a secondary market needs lots of buyers and sellers, especially buyers.
Remember, Ms. Sakaguri is allowed to sell her limited liability company interest under Rule 144 without providing any information about NewCo. That's great, except there aren't a lot of people willing to buy that limited liability company interest without information about NewCo. Other characteristics of NewCo, if it's a typical privately-owned company, also make it unattractive:
It probably has a very limited business, possibly only one product or even one asset.
It probably has limited access to capital.
It probably lacks professional management.
Sakaguri probably has limited or no voting rights.
There are probably no independent directors.
The insiders of NewCo are probably allowed to pay compensation to themselves more or less free of limits, and have probably protected themselves from just about every kind of legal claim that investors could bring.
When Franklin Roosevelt and Sam Rayburn created the American securities laws in the 1930s, what emerged from all the new regulation was the most efficient, most transparent, most vibrant public capital market in the world. Eighty-five years later, you might say Americans have become spoiled by the safety of buying publicly-traded companies on national exchanges. When Ms. Sakaguri asks them to buy her limited liability company interest in NewCo on an alternative trading system, she's asking for a lot.
To create a more vibrant secondary market for private securities we need greater standardization, greater protections for investors, and greater transparency. Some of these things the industry can do by itself – for example, by using blockchain technology. Other things will probably require regulation.
To create a vibrant market in automobiles we didn't adopt laws protecting auto manufacturers. We adopted laws protecting consumers, e.g., lemon laws. My guess is that to create a vibrant secondary market for private securities the law should focus on buyers, not sellers.
What About Tokens?
More companies than I can remember have said they want to convert their limited liability company interests or preferred stock to token form because "There's a secondary market for tokens."
From a legal point of view that's not true. The laws governing secondary sales of securities apply equally to the most boring share of common stock, represented by a paper certificate stored in a battered aluminum filing cabinet, and the most interesting token treated as a security under the Howeytest, residing only in the cloud on a public blockchain.
But it is true in two other senses:
The rules I've talked about above apply only to tokens that are securities under the Howey test. A token that is a currency and not a security is not subject to those rules. I would also say that a true utility token isn't subject to the rules, either, except a token being traded is probably a security under the Howey test, i.e., it probably isn't a true utility token.
The reason there isn't a vibrant market in private securities isn't the legal restrictions, but the risk inherent in private securities. The frenzy over anything called a token in the last 12 months has overridden investor fears of private securities. Whether that frenzy will continue is impossible to predict (it won't).
The same people ask "What about all those crypto exchanges?" There are two answers to that question as well. One, many or all of them have become alternative trading systems controlled by broker-dealers, or are in the process of doing so. Two, many got in trouble. Some are being sued privately and some are being sanctioned by the SEC.
Interested in learning more about secondary markets or secondary transactions for real estate securities? Log on to www.realized1031.com or call us at 877-797-1031.
Mark Roderick's Bio
Markley S. Roderick concentrates his practice on the representation of entrepreneurs and their businesses. He represents companies across a wide range of industries, including technology, real estate, and healthcare. Expanding on his in-depth knowledge of capital raising and securities law, Mr. Roderick spearheads the firm's Crowdfunding practice and is one of the leading Crowdfunding lawyers in the United States. He maintains a Crowdfunding blog at www.crowdfundattny.com, which contains news, updates and links to important information on the Crowdfunding industry. Mr. Roderick also speaks regularly at Crowdfunding events.
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SECURITIES DISCLOSURE
Realized1031.com is a website operated by Realized Technologies, LLC, a wholly owned subsidiary of Realized Holdings, Inc. ("Realized"). Securities offered on this website are offered exclusively through Thornhill Securities, Inc., a registered broker/dealer and member of FINRA/SIPC("Thornhill"). Investment advisory services are offered through Thornhill Securities, Inc. a registered investment adviser. Thornhill Securities, Inc. is a subsidiary of Realized. Check the background of this firm on FINRA's BrokerCheck.
Hypothetical example(s) are for illustrative purposes only and are not intended to represent the past or future performance of any specific investment.
Investing in alternative assets involves higher risks than traditional investments and is suitable only for sophisticated investors. Alternative investments are often sold by prospectus that discloses all risks, fees, and expenses. They are not tax efficient and an investor should consult with his/her tax advisor prior to investing. Alternative investments have higher fees than traditional investments and they may also be highly leveraged and engage in speculative investment techniques, which can magnify the potential for investment loss or gain and should not be deemed a complete investment program. The value of the investment may fall as well as rise and investors may get back less than they invested.
This site is published for residents of the United States who are accredited investors only. Registered Representatives and Investment Advisor Representatives may only conduct business with residents of the states and jurisdictions in which they are properly registered. Therefore, a response to a request for information may be delayed until appropriate registration is obtained or exemption from registration is determined. Not all of services referenced on this site are available in every state and through every representative listed. For additional information, please contact 877-797-1031 or info@realized1031.com.
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© 2020 Realized Holdings, Inc. | {
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If you or someone you know has survived a heart attack, chances are good that beta blockers were prescribed afterwards to help lower blood pressure and help the heart work more effectively. But a recent study suggests that these medicines aren't always the best choice in every situation.
Researchers from the University of Leeds say that beta blockers are best used when patients suffer a heart attack and heart failure, a complication from the event that damages heart muscle and stops it from functioning properly. However, their findings show that the vast majority of patients who did not suffer from heart failure were given the medicines anyway, and that it did not improve patient outcomes.
"There is uncertainty in the evidence as to the benefit of beta-blockers for patients with heart attack and who do not have heart failure. This study suggests that there may be no mortality advantage associated with the prescription of beta-blockers for patients with heart attack and no heart failure," said Chris Gale, a consultant cardiologist and professor of cardiovascular medicine at the University of Leeds.
The study analyzed anonymized data from over 179,000 patients who had a heart attack but did not suffer from heart failure. The researchers found that 95% of the sample were given beta blockers after their cardiac event, but that the mortality rate one year later was statistically similar between those who received the medicines and those who did not.
"If you look at the patients who had a heart attack but not heart failure -- there was no difference in survival rates between those who had been prescribed beta blockers and those that had not," said lead investigator Dr. Marlous Hall, a senior epidemiologist at the Leeds Institute of Cardiovascular and Metabolic Medicine.
The findings raise the question of whether beta blockers are over-prescribed or medically necessary for certain patients, since some people experience side effects such as dizziness and fatigue from taking them. The researchers say their next step will be to conduct a randomized, controlled trial to corroborate their results. | {
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Unterfranken (of Neder-Franken) is zowel een Bezirk als een Regierungsbezirk (regio) van Beieren, een deelstaat van Duitsland.
Geografie
Aangrenzende Regierungsbezirke of deelstaten in wijzerzin zijn:
in het noorden: Regierungsbezirk Kassel en deelstaat Thüringen
in het oosten: Regierungsbezirk Oberfranken en Regierungsbezirk Mittelfranken
in het zuiden: Regierungsbezirk Stuttgart en Regierungsbezirk Karlsruhe
in het westen: Regierungsbezirk Darmstadt
Politiek
Parlement (Bezirkstag)
Verkiezingsuitslagen
President
Erwin Dotzel (CSU) is sinds 30 januari 2007 Bezirkstagspresident.
Indeling
Unterfranken wordt gevormd door 9 Landkreise en 3 Kreisfreie steden.
Zie ook
Franken (gebied)
Franken (wijnstreek)
Referenties
Regierungsbezirk in Beieren
Bezirk in Beieren
NUTS-2-regio | {
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\section{Introduction}
A Delsarte surface $S$ is a surface of ${\mathbf{P}}^3$ defined by the vanishing of a polynomial $F$ consisting of four monomials. Let $A$ be the exponent matrix of $F$, then a Delsarte surface is the quotient of a Fermat surface if and only if $\det(A)\neq 0$. Shioda used this observation in \cite{ShiodaPic} to present an algorithm to determine the Lefschetz number of any smooth surface that is birationally equivalent with $S$.
Fix now two disjoint lines $\ell_1,\ell_2$ in ${\mathbf{P}}^3$. The projection with center $\ell_1$ onto $\ell_2$ yields a rational map $S\dashrightarrow {\mathbf{P}}^1$. Resolving the indeterminancies of this map yields a fibration $\tilde{S} \to {\mathbf{P}}^1$.
If the genus of the general fiber is one and this morphism has a section then Shioda's algorithm together with the Shioda-Tate formula allows one to determine the Mordell-Weil rank of the group of sections. Shioda applied this to the surface
\[ y^2+x^3+1+t^n\]
and showed in \cite{ShiodaAstr} that the maximal Mordell-Weil rank (by varying $n$) is 68.
If both lines $\ell_i$ are intersections of two coordinate hyperplane then we call the obtained fibration a \emph{Delsarte fibration}. We will introduce the notion of a \emph{Delsarte base change}. Roughly said, this is a base change ${\mathbf{P}}^1\to{\mathbf{P}}^1$ completely ramified over $0$ and $\infty$. In particular, the pullback of a Delsarte fibration under a Delsarte base change is again a Delsarte fibration.
The first author determined in his PhD thesis \cite{HeijnePhD} the maximal Mordell-Weil rank under Delsarte base changes of any Delsarte fibration such that the general fiber has genus one. In this way he showed that Shioda's example has the highest possible rank among Delsarte fibration of genus one.
In \cite{FastExtremal} and \cite{FastLongTable} Fastenberg calculated the maximal Mordell-Weil rank under base changes $t\mapsto t^n$ for a special class of elliptic surface, i.e., elliptic curves over ${\mathbf{C}}(t)$ with nonconstant $j$-invariant such that a certain invariant $\gamma$ is smaller than $1$. It turned out that all the ranks that occur for Delsarte surfaces with nonconstant $j$-invariant also occur in Fastenberg's list. In \cite[Ch. 6]{HeijnePhD} it is shown that for every Delsarte fibration of genus one, there exist integers $m,n$ such that the Delsarte base change of degree $m$ of the Delsarte fibration is isomorphic to a base change of the form $t\mapsto t^n$ of one of the surfaces in Fastenberg's list.
In this paper we present a more conceptual proof for this phenomenon: First we study the configuration of singular fibers of a Delsarte fibration. We show that for any Delsarte fibration each two singular fibers over points $t\neq0,\infty$ are isomorphic. Then we show that after a base change of the form $t\mapsto t^n$ the Delsarte fibration is a base change of the form $t\mapsto t^m$ of a fibration with at most one singular fiber away from $0,\infty$.
If there is no singular fiber away from $0,\infty$, then the fibration becomes split after a base change of $t\mapsto t^m$. If there is at least one singular fiber then we show that there are three possibilities, namely the function field extension $K(S)/K({\mathbf{P}}^1)=K(x,y,t)/K(t)$ is given by $m_1+m_2+(1+t)m_3$, where the $m_i$ are monomials in $x$ and $y$, or this extension is given by $y^a=x^b+x^c+tx^d$, where $b,c,d$ are mutually distinct, or the singular fiber away from $0$ and $\infty$ has only nodes as singularities and is therefore semistable. See Proposition~\ref{propStandardForm}.
In the case of a genus one fibration we can use this classification to check almost immediately that any Delsarte fibration of genus one admits a base change of the form $t\mapsto t^n$ such that the pulled back fibration is the pull back of a fibration with $\gamma<1$ or has a constant $j$-invariant. See Corollary~\ref{corGamma}. This procedure is carried out in Section~\ref{secDes}.
The techniques used in the papers by Fastenberg use the fact that the fibration is not isotrivial and it seems very hard to extend these techniques to isotrivial fibrations.
In Section~\ref{secIsoTrivial} we consider an example of a class of isotrivial Delsarte fibrations. Shioda's algorithm yields the Lefschetz number of any Delsarte surface with $\det(A)\neq 0$. Hence it is interesting to see how it works in the case where Fastenberg's method breaks down. Let $p$ be an odd prime number, and $a$ a positive integer. We consider the family of surfaces
\[ S:y^2=x^p+t^{2ap}+s^{2ap}\]
in ${\mathbf{P}}(2a,ap,1,1)$. Then $S$ is birational to a Delsarte surface. After blowing up $(1:1:0:0)$ we obtain a smooth surface $\tilde{S}$ together with a morphism $\tilde{S}\to {\mathbf{P}}^1$. The general fiber of this morphism is a hyperelliptc curve of genus $(p-1)/2$. We show that if $p>7$ then $\rho(\tilde{S})=2+6(p-1)$, in particular the Picard number is independent of $a$. Two of the generators of the N\'eron-Severi group of $S$ can be easily explained: the first one is the pullback of the hyperplane class on $S$, the second class is the exceptional divisor of the morphism $\tilde{S}\to S$. In Example~\ref{exaIso} we give also equations for some other classes.
If we take $p=3$ then we find back Shioda's original example. However, in Shioda's example one has that $\rho(\tilde{S})$ is not completely independent of $a$, it depends namely on $\gcd(a,60)$. Similarly one can show that if $p=5$ and $p=7$ then $\rho(\tilde{S})$ depends on $a$. Our result shows that these cases are exceptions, i.e., for $p>7$ we have that $\rho(\tilde{S})$ is completely independent of $a$.
\section{Delsarte surfaces}\label{secDes}
In this section we work over an algebraically closed field $K$ of characteristic zero.
\begin{definition} \label{defBasic} A surface $S\subset {\mathbf{P}}^3$ is called a \emph{Delsarte surface} if $S$ is the zero-set of a polynomial of the form
\[F:=\sum_{i=0}^3 c_i \prod_{j=0}^3 X_i^{a_{i,j}},\]
with $c_i\in K^*$ and $a_{i,j}\in {\mathbf{Z}}_{\geq0}$. The $4\times 4$ matrix $A:=(a_{i,j})$ is called the \emph{exponent matrix} of $S$.
A \emph{Delsarte fibration of genus $g$} on a Delsarte surface $S$ consists of the choice of two disjoint lines $\ell_1,\ell_2$ such that both the $\ell_i$ are the intersection of two coordinate hyperplanes and the generic fiber of the projection $S\dashrightarrow \ell_2$ with center $\ell_1$ is an irreducible curve of geometric genus $g$.
A \emph{Delsarte birational map} is a birational map $\varphi:{\mathbf{P}}^3\dashrightarrow {\mathbf{P}}^3$ such that $\varphi(X_0:\dots:X_3)= (\prod X_j^{b_{0j}}:\dots: \prod X_j^{b_{3j}})$, i.e., $\varphi$ is a birational monomial map.
\end{definition}
\begin{remark} \label{rmkCoeff} Since $K$ is algebraically closed, we can multiply each of the four coordinates $X_i$ by a nonzero constant such that all four constants in $F$ coincide, hence without loss of generality we may assume that $c_i=1$.
After permuting the coordinates, if necessary, we may assume that $\ell_1$ equals $V(X_2,X_3)$ and $\ell_2$ equals $V(X_0,X_1)$. Then the projection map $S\dashrightarrow \ell_2$ is just the map $[X_0:X_1:X_2:X_3]\to [X_2:X_3]$. Let $f(x,y,t):=F(x,y,t,1)\in K(t)[x,y]$.
Then the function field extension $K(S)/K(\ell_2)$ is isomorphic to the function field extension $K(x,y,t)/f$ over $K(t)$.
We call a Delsarte fibration with $\ell_1=V(X_2,X_3)$ and $\ell_2=V(X_0,X_1)$ the \emph{standard fibration} on $S$.
\end{remark}
\begin{definition}\label{defBaseChange}
Let $n$ be a nonzero integer. A \emph{Delsarte base change of degree $|n|$} of a Delsarte fibration $\varphi :S\dashrightarrow {\mathbf{P}}^1$ is a Delsarte surface $S_n$, together with a Delsarte fibration $\varphi_n: S_n\dashrightarrow {\mathbf{P}}^1$ and a Delsarte rational map $S_n\dashrightarrow S$ of degree $n$, such that there exists a commutative diagram
\[
\xymatrix{S_n\ar@{-->}[r] \ar@{-->}[d] &S\ar@{-->}[d] \\\
{\mathbf{P}}^1 \ar[r]&{\mathbf{P}}^1}
\]
and $K(S_n)/K({\mathbf{P}}^1)$ is isomorphic to the function field extension $K(x,y,s)/(f(x,y,s^n)$ over $K(s)$.
\end{definition}
\begin{remark}
Note that $n$ is allowed to be negative. If $n$ is negative then a base change of degree $-n$ is the composition of the automorphism $t\mapsto 1/t$ of ${\mathbf{P}}^1$ with the usual degree $-n$ base change $t\mapsto t^{-n}$. In many cases we compose a base change with a Delsarte birational map which respects the standard fibration. In affine coordinates such a map is given by $(x,y,s)\mapsto (xs^a,ys^b,s^n)$ for some integers $a,b$.
\end{remark}
\begin{lemma}\label{lemRatFib} Let $S$ be a Delsarte surface. Suppose there is a nonzero vector ${\mathbf{v}}=(a,b,0,0)^T$ in ${\mathbf{Z}}^4$ such that $A{\mathbf{v}}\in \spa(1,1,1,1)^T$. Then the generic fiber of the standard fibration $\varphi:S\to {\mathbf{P}}^1$ is a rational curve.
\end{lemma}
\begin{proof}
After interchanging $x$ and $y$, if necessary, we may assume that $a$ is nonzero. Consider now $f_0:=f(x^a,x^by,t)$. The exponents of $x$ in the four monomials of $f_0$ are precisely the entries of $A{\mathbf{v}}$. Since $A{\mathbf{v}}=e(1,1,1,1)^T$ for some integer $e$ we have that $f_0=x^eg(y,t)$. This implies that the generic fiber of $\varphi$ is dominated by a finite union of rational curves. Since the generic fiber is irreducible it follows that the generic fiber of $\varphi$ is a rational curve.
\end{proof}
\begin{lemma} \label{lemProd} Let $S$ be a Delsarte surface. Suppose there is a nonzero vector ${\mathbf{v}}=(a,b,c,0)^T$ in ${\mathbf{Z}}^4$ such that $c\neq 0$ and $A{\mathbf{v}}\in \spa(1,1,1,1)^T$. Then there is a Delsarte base change of degree $|c|$ such that the pull back of the standard fibration on $S$ is birational to a product $C\times {\mathbf{P}}^1\to{\mathbf{P}}^1$.
\end{lemma}
\begin{proof}
Consider now $f_0:=f(xt^a,yt^b,t^c)$. The exponents of $t$ in the four monomials of $f_0$ are precisely the entries of $A{\mathbf{v}}$.
Since $A{\mathbf{v}}=e(1,1,1,1)^T$ for some integer $e$ we have that $f_0=t^eg(x,y)$. Let $S'$ be the projective closure of $g=0$ in ${\mathbf{P}}^3$. Then $S'$ is a cone over the plane curve $g=0$, in particular $S'$ is birational to $C\times {\mathbf{P}}^1$ and the standard fibration on $S'$ is birational to the projection $C\times {\mathbf{P}}^1\to {\mathbf{P}}^1$.
Now $S'$ is birational to the surface $S_c$, the projective closure of $f(x,y,t^c)=0$. Hence $S_c \to {\mathbf{P}}^1$ is birational to $C\times {\mathbf{P}}^1\to {\mathbf{P}}^1$.
\end{proof}
\begin{lemma}\label{lemDetA} Let $A$ be the exponent matrix of a Delsarte surface. There exists a nonzero vector ${\mathbf{v}}=(a,b,c,0)^T$ in ${\mathbf{Z}}^4$ such that $A{\mathbf{v}}\in \spa(1,1,1,1)^T$ if and only if $\det(A)=0$.
\end{lemma}
\begin{proof}
Since each row sum of $A$ equals $d$, the degree of the $i$-th monomial in $F$, it follows that $A(1,1,1,1)^T =d(1,1,1,1)^T$. Suppose first that $\det(A)\neq 0$. Then from $A(1,1,1,1)^T =d(1,1,1,1)^T$ it follows that $A^{-1}(1,1,1,1)^T\in\spa (1,1,1,1)^T$, which does not contain a nonzero vector with vanishing fourth coordinate.
Suppose now that $\det(A)=0$. Denote with $A_i$ the $i$-th column of $A$. From the fact that each row sum of $A$ equals $d$ we get that $A_1+A_2+A_3+A_4=d(1,1,1,1)^T$.
Since $\det(A)=0$ there exists a nonzero vector $(a_1,a_2,a_3,a_4)$ such that $\sum a_iA_i=0$. From this we obtain
\[ (a_4-a_1)A_1+(a_4-a_2)A_2+(a_4-a_3)A_3=a_4(A_1+A_2+A_3+A_4)= a_4d(1,1,1,1)^T.\]
I.e., ${\mathbf{v}}=(a_4-a_1,a_4-a_2,a_4-a_3,0)^T$ is a vector such that $A{\mathbf{v}}\in \spa (1,1,1,1)^T$. We need to show that ${\mathbf{v}}$ is nonzero. Suppose the contrary, then also $A{\mathbf{v}}=a_4d(1,1,1,1)^T$ is zero and therefore $a_4=0$. Substituting this in ${\mathbf{v}}$ yields that ${\mathbf{v}}=(-a_1,-a_2,-a_3,0)=(0,0,0,0)$ holds, which contradicts our assumption that $(a_1,a_2,a_3,a_4)$ is nonzero.
\end{proof}
\begin{remark} \label{rmkDet}
We want to continue to investigate the singular fibers of a Delsarte fibration, in particular the singular fibers over points $t=t_0$ with $t_0\neq 0,\infty$.
If $\det(A)=0$ then either the generic fiber has geometric genus 0 or after a Delsarte base change the fibration is split, i.e., the fibration is birational to a product. In the latter case all the fibers away from $0$ and $\infty$ are smooth. Hence from now on we restrict to the case where $\det(A)\neq 0$.
\end{remark}
\begin{lemma} \label{lemOneT} Let $S$ be a Delsarte surface with $\det(A)\neq0$, such that the generic fiber has positive geometric genus. Let $\varphi: S \to {\mathbf{P}}^1$ be the standard Delsarte fibration. Then there exists a Delsarte base change of $\varphi$ that is birational to the standard fibration on a Delsarte surface $S'$ with affine equation of the form $m_1+m_2+m_3+t^nm_4$, where each $m_i$ is a monomial in $x$ and $y$.
\end{lemma}
\begin{proof}
Let $\mathbf{e}_0=(1,1,1,1)^T$ and $\mathbf{e}_i$ be the $i$-th standard basis vector of ${\mathbf{Q}}^4$.
Let $V_i$ be the vector space spanned by $\mathbf{e}_0$ and $\mathbf{e}_i$. Since $A^{-1}\mathbf{e}_0=\frac{1}{d}\mathbf{e}_0$ it follows that $A^{-1}V_i$ is not contained in $\spa \{\mathbf{e}_1,\mathbf{e}_2,\mathbf{e}_3\}$.
In particular, $\dim A^{-1}V_i\cap \spa \{\mathbf{e}_1,\mathbf{e}_2,\mathbf{e}_3\}=1$.
Let $\ell_i$ be the line $A^{-1}V_i\cap \spa \{\mathbf{e}_1,\mathbf{e}_2,\mathbf{e}_3\}$ and let ${\mathbf{v}}_i$ be a vector spanning $\ell_i$.
We can scale ${\mathbf{v}}_i$ such that $A{\mathbf{v}}_i=\mathbf{e}_i+t_i\mathbf{e}_0$ for some $t_i \in K$. Since $\mathbf{e}_0,\mathbf{e}_1,\mathbf{e}_2,\mathbf{e}_3$ are linearly independent it follows that $\{\mathbf{e}_i+t_i\mathbf{e}_0\}_{i=1}^3$ are linearly independent and therefore ${\mathbf{v}}_1,{\mathbf{v}}_2,{\mathbf{v}}_3$ are linearly independent. Hence $\spa \{{\mathbf{v}}_1,{\mathbf{v}}_2,{\mathbf{v}}_3\}$ is three-dimensional and there is at least one ${\mathbf{v}}_i=(a_i,b_i,c_i,0)$ with $c_i\neq0$. Then the rational map defined by $(x,y,t)\mapsto (xt^{a_i},yt^{b_t},t^{c_i})$ is a composition of a Delsarte base change and a Delsarte rational map.
Now three of the four entries of $A{\mathbf{v}}_i$ coincide, say they equal $e$. The exponent of $t$ in the four monomials of $f_0:=f(xt^{a_i},yt^{b_i},t^{c_i})$ are the entries of $A{\mathbf{v}}_i$. In particular, in precisely three of the four monomials the exponents of $t$ equal the same constant $e$. Therefore $g:=f_0/t^e$ consists of four monomials of which precisely one contains a $t$. If the exponent of $t$ in this monomial is negative then we replace $t$ by $1/t$ in $g$. Then $g=0$ is an affine polynomial equation for the surface $S'$.
\end{proof}
Recall that we investigate the singular fibers of a Delsarte fibration, in particular the singular fibers over points $t=t_0$ with $t_0\neq 0,\infty$.
If we have a Delsarte fibration and take a Delsarte base change then the type of singular fiber over $t=0,\infty$ may change, since the base change map is ramified over these points. Over points with $t\neq 0,\infty$ the base change map is unramified and therefore the type of singular fibers remains the same.
Hence to describe the possible types of singular fibers over points with $t\neq0,\infty$ it suffices by Lemma~\ref{lemOneT} to study Delsarte surfaces such that only one monomial contains a $t$, i.e.,
we may restrict ourselves to Delsarte surfaces with affine equation $m_1+m_2+m_3+t^nm_4$. If $n=0$ then the fibration is split and there are no singular fibers. If $n\neq 0$ then the possible types of singular fibers are already determined at $n=1$, i.e., it suffices to consider Delsarte surfaces with affine equation $m_1+m_2+m_3+tm_4$.
\begin{definition}\label{defMinFib}
We call the standard fibration on a Delsarte surface a \emph{minimal Delsarte fibration} if the following conditions hold:
\begin{enumerate}
\item The affine equation for the standard fibration is of the form $m_1+m_2+m_3+tm_4$, where the $m_i$ are monomials in $x$ and $y$.
\item The exponent matrix $A$ of the corresponding surface $S\subset {\mathbf{P}}^3$ satisfies $\det(A)\neq 0$.
\end{enumerate}
\end{definition}
\begin{remark}\label{remMinFib} In the function field $K(S)=K(x,y,t)/f$ we have the relation $t=(-m_1-m_2-m_3)/m_4$. In particular $K(S)=K(x,y)$ and therefore $S$ is a rational surface.
Consider now the defining polynomial for $S$, i.e., $M_1+M_2+M_3+X_2M_4$, where the $M_i$ are monomials in $X_0,X_1,X_3$, the degrees of $M_1, M_2$ and $M_3$ are the same, say $d$ and the degree of $M_4$ equals $d-1$.
The Delsarte fibration is induced by the map $(X_0:X_1:X_2:X_3)\mapsto (X_2:X_3)$.
If $S$ contains the line $\ell_1:X_2=X_3=0$ then this rational map can be extended to a morphism on all of $S$, otherwise we blow-up the intersection of this line with $S$ and obtain a morphism $\tilde{S}\to{\mathbf{P}}^1$, such that each fiber is a plane curve of degree $d$.
There is a different way to obtain this family of plane curves. Define $N_i'$ as follows:
\[ N_i':=M_i(X_0,X_1,X_2,X_2) \mbox{ for } i=1,2,3 \mbox{ and } N_4'=X_2M_4(X_0,X_1,X_2,X_2)\]
Now the four $N_i'$ have a nontrivial greatest common divisor if and only if $X_3\mid M_i$ for $i=1,2,3$. The later condition is equivalent to the condition that the line $\ell_1$ is contained in $S$. Moreover, if the greatest common divisor is nontrivial then it equals $X_2$.
Now set $N_i=N'_i$ if $\ell_1\not \subset S$ and set $N_i=N'_i/X_3$ if $\ell_1\subset S$.
Then $\lambda(N_1+N_2+N_3)+\mu N_4$ is a pencil of plane curves of degree $d$ or $d-1$ and the generic member of this pencil is precisely the generic fiber of the standard fibration on $S$.
We can consider the generic member of this family as a projective curve $C$ over $K(t)$ with defining polynomial $G:=N_1+N_2+N_3+tN_4\in K(t)[X_0,X_1,X_2]$. Let $A'$ be the exponent matrix of $C$ (considered as a curve in ${\mathbf{P}}^2_{K(t)}$). Set
\[ B:=\left(\begin{matrix} 1&0&0\\0&1&0\\0&0&1\\ 0&0&1\end{matrix}\right) \mbox{ if } \ell_1\not\subset S \mbox{ and } B:=\left(\begin{matrix} 1&0&\frac{-1}{d}\\0&1&\frac{-1}{d}\\0&0&\frac{d-1}{d}\\ 0&0&\frac{d-1}{d}\end{matrix}\right) \mbox{ otherwise.}\]
Then $A'=AB$. Since $A$ is invertible and $B$ has rank $3$ it follows that $\rank A'=3$. Moreover the first three rows of $A'$ are linearly independent, since the upper $3\times 3$-minor of $A'$ equals the upper $3\times 3$-minor of $A$ times the upper $3\times 3$ minor of $B$.
In particular, there is a vector $\mathbf{k}$, unique up to scalar multiplication, such that $\mathbf{k} A'=0$. Since the upper three rows of $A'$ are linearly independent it follows that the fourth entry $k_4$ of $\mathbf{k}$ is nonzero. We can make the vector $\mathbf{k}$ unique, by requiring that $k_4>0$, $k_i\in {\mathbf{Z}}$ for $i=1,\dots, 4$ and $\gcd(k_1,k_2,k_3,k_4)=1$.
Moreover from $\rank A'=3$ and the fact that $(0,0,1,-1)B$ vanishes it follows that $\mathbf{k}\in \spa \{(0,0,1,-1)A^{-1}\}$.
Since none of the rows of $A'$ is zero there are at least two nonzero entries in $\mathbf{k}$. Suppose that there are precisely two nonzero entries, say $k_i$ and $k_4$. Then $-k_i$ times the $i$-th row of $A'$ equals $k_4$ times the fourth row of $A'$. Each row sum of $A'$ equals the degree of $C$, say $d$. From this it follows that $k_id=-k_4d$ and hence that $k_i=-1,k_4=1$. In particular, the $i$-th row and the fourth row coincide. After permuting $m_1,m_2,m_3$, if necessary, we may assume that the affine equation for the standard fibration is of the form $m_1+m_2+(1+t)m_3$.
Hence if the four monomials $m_1,m_2,m_3,m_4$ (in $x,y$) are distinct then at least three of the four entries of $\mathbf{k}$ are nonzero.
Let $A'_i$ be the $i$-th row of $A'$. Recall that each row sum of $A'_i$ equals $d$. Since $\sum k_iA_i$ equals zero it follows that $0=\sum_i k_i\sum_j A'_{i,j}=\sum_i k_id$ and hence $\sum k_i=0$. Let $p$ be a prime number dividing one of the $k_i$. Since $\gcd(k_1,\dots,k_4)=1$ there is a $j$ such that $p\nmid k_j$. From $\sum k_i=0$ it follows that there is a $j'\neq j$ such that $p\nmid k_{j'}$. Hence each prime number $p$ does not divide at least two of the entries of $\mathbf{k}$.
\end{remark}
\begin{proposition}\label{propDiscrim} Let $S\to {\mathbf{P}}^1$ be a minimal Delsarte fibration. Let $A'$, $\mathbf{k}$ and $N_i$ be as above. Suppose that the fiber over $t=t_0$ is singular and $t_0\neq0,\infty$ then
\[ t_0^{k_4}-\prod_{i: k_i\neq 0} k_i^{k_i}=0\]
or two of the $N_i$ coincide.
\end{proposition}
\begin{proof}
Let $G\in K(t)[X_0,X_1,X_2]$ be as above. Then $G$ defines a pencil of plane curves in ${\mathbf{P}}^2_K$. Assume that no two of the $N_i$ coincide. We aim at determining the singular members of the pencil defined by $G$.
Let $B_t$ be the matrix obtained from $A'$ by multiplying the fourth row by $t$. Let us consider the matrix $B_{t_0}$ for some $t_0\in K^*$.
Since the upper $3\times 3$ minor of $B_{t_0}$ equals the upper $3\times 3$ minor of $A'$, and this minor is nonzero, it follows that $\rank B_{t_0}=3$. Hence the kernel of right-multiplication by $B_{t_0}$ is one-dimensional and is generated by $(k_1,k_2,k_3,\frac{k_4}{t_0})$.
Consider now the closure of the image of the rational map $M:K^3\dashrightarrow K^4$ sending $(x,y,z)$ to $(N_1,N_2,N_3,N_4)$. Let $z_1,z_2,z_3,z_4$ be the coordinates on $K^4$. Then by the definition of the vector $(k_1,k_2,k_3,k_4)$ one has that $\prod N_i^{k_i}=1$ holds, i.e., on the image of $M$ one has
\[ \prod z_i^{k_i}=1\]
Since the greatest common divisor of the $k_i$ equals one, this defines an irreducible hypersurface $\overline{V}$ in $K^4$. Moreover, from the fact that $\rank A'$ equals 3 it follows that $M$ has finite fibers, hence the image of $M$ is three-dimensional and the closure of the image of $M$ is precisely the closure of $ \prod z_i^{k_i}=1$.
We want now to determine the values for which $t_0$ the corresponding member of the pencil of plane curves is singular. Hence we want to find $(x_0:y_0:z_0)\in {\mathbf{P}}^2$ and $t_0\in K^*$ such that for $(t,X_0,X_1,X_2)=(t_0,x_0,y_0,z_0)$ the vector $(G_{X_0},G_{X_1},G_{X_2})$ is zero. In particular, the vector $(X_0G_{X_0},X_1G_{X_1},X_2G_{X_2})$ is zero. A direct calculation shows that the latter vector equals $(N_1,N_2,N_3,tN_4)A'$, which in turn equals $(N_1,N_2,N_3,N_4)B_t$.
Hence if $(x_0,y_0,z_0)$ is a singular point of a fiber over $t=t_0$ then $M(x_0,y_0,z_0)$ is contained in $\ker B_{t_0}\cap \overline{V}$.
We consider first the case where $M(x_0,y_0,z_0)$ is nonzero and $t_0\neq 0$. Then $ \prod_{i:k_i\neq 0} z_i^{k_i}=1$ and $(z_1,z_2,z_3,z_4)$ is a multiple of $(k_1,k_2,k_3,k_4/t_0)$. In particular,
\[ \frac{\prod_{i:k_i\neq 0} k_i^{k_i}}{t_0^{k_4}}=1\]
holds, which finishes the case where $M(x_0,y_0,z_0)$ is nonzero.
To finish we show that if $t_0\neq 0$ and $\ker B_{t_0}\cap \overline{V}$ consists only of $(0,0,0,0)$ then the fiber over $t_0$ is smooth. Since $\ker B_{t_0}\cap \overline{V}$ consists only of $(0,0,0,0)$ each singular point of the fiber satisfies $N_1=N_2=N_3=N_4=0$. In particular at least two of the $X_i$ are zero. Without loss of generality we may assume that the point $(0:0:1)$ is singular. Consider now $G(x,y,1)$ and write this as $m_1+m_2+m_3+tm_4$.
Since all the four $N_i$ are distinct we have that $m_1+m_2+m_3+tm_4=0$ is an equisingular deformation of $m_1+m_2+m_3+t_0m_4$ for $t$ in a small neighborhood of $t_0$. Hence we can resolve this singularity simultaneously for all $t$ in a neighborhood of $t_0$. Therefore all fibers in a neighborhood of $t_0$ are smooth and, in particular, the fiber over $t_0$ is smooth.
\end{proof}
\begin{lemma}\label{lemBaseAuto} Let $\varphi: S\to {\mathbf{P}}^1$ be a minimal Delsarte fibration. Then there is an automorphism $\sigma:S\to S$, mapping fibers of $\varphi$ to fibers, such that its action on the base curve is $t\mapsto \zeta_{k_4} t$.
\end{lemma}
\begin{proof}
Let $d$ be the smallest integer such that $D:=dA^{-1}$ has integral coefficients.
Let $T=\{\sum X_i^d=0\}\subset {\mathbf{P}}^3$ be the Fermat surface of degree $d$. Then there is a rational map $T\dashrightarrow S$ given by $(X_0:X_1:X_2:X_3)\mapsto ( \prod X_j^{d_{0j}}: \dots: \prod X_j^{d_{3j}})$. On $T$ there is a natural action of $({\mathbf{Z}}/d{\mathbf{Z}})^3$, given by $(X_0:X_1:X_2:X_3)\mapsto (\zeta_d^{a_1}X_0:\zeta_d^{a_2}X_1:\zeta_d^{a_3}X_2:X_3)$. On the affine chart $X_3\neq 0$ with coordinates $x,y,t$ this action is given by $(x,y,t)\mapsto (\zeta_d^{a_1}x,\zeta_d^{a_2}y,\zeta_d^{a_3}t)$.
The rational map $T\dashrightarrow S$ is given (in affine coordinates) by
\[(x,y,t)\mapsto \left(\frac{x^{d_{00}}y^{d_{01}}t^{d_{02}}}{x^{d_{30}}y^{b_{31}}t^{b_{32}}},\frac{x^{d_{10}}y^{d_{11}}t^{d_{12}}}{x^{d_{30}}y^{d_{31}}t^{d_{32}}},\frac{x^{d_{20}}y^{d_{21}}t^{d_{22}}}{x^{d_{30}}y^{d_{31}}t^{d_{32}}}\right).\]
The action of $({\mathbf{Z}}/d{\mathbf{Z}})^3$ descents to $S$ and respects the standard fibration. Let $t=X_2/X_3$ be a coordinate on the base of the standard fibration. Then $(a_1,a_2,a_3)\in ({\mathbf{Z}}/d{\mathbf{Z}})^3$ acts as $t \mapsto \zeta_d^e t$ with $e\equiv (d_{20}-d_{30})a_1+(d_{21}-d_{31})a_2+(d_{22}-d_{32})a_3\bmod d$.
Since $\mathbf{k}$ as defined in Remark \ref{remMinFib} is proportional to $(0,0,1,-1)A^{-1}$ it follows that $\mathbf{k}$ is proportional to $(d_{20}-d_{30},d_{21}-d_{31},d_{22}-d_{32},d_{23}-d_{33})$, i.e., there is an $m\in {\mathbf{Z}}$ such that $mk_i=d_{2i}-d_{3i}$. In particular, setting $d'=d/m$ it follows that $(a_0,a_1,a_2)$ acts as $t \mapsto \zeta_{d'}^e t$ with $e\equiv k_1a_1+k_2a_2+k_3a_3\bmod d'$.
Let $p$ be a prime number and suppose that $p^m$ divides $k_4$. Since $k_4$ is a divisor of $d$ and the greatest common divisor of the $k_i$ equals one it follows that $p^m$ also divides $d'$. Since the greatest common divisor of the $k_i$ equals one it follows that at least one of the $k_i$ is not divisible by $p$. Without loss of generality we may assume that $k_1$ is invertible modulo $p$. From this it follows that we can choose $a_1$ in such a way that $a_1k_1+a_2k_2+a_3k_3\equiv 1 \bmod p^m$.
The corresponding automorphism $\sigma'_{p^m}$ of $S$ maps $t$ to $t\times \zeta t$ where $\zeta$ is a primitive $p^tn$-th root of unity. Take now $\sigma_{p^m}:=(\sigma'_{p^m})^n$. Then $\sigma_{p^m}$ multiplies $t$ with a primitive $p^t$-root of unity.
Write now $k_4=\prod p_i^{t_i}$. Then $\sigma:=\prod_i \sigma_{p_i^{t_i}}$ multiplies $t$ with a primitive $k_4$-th root of unity.
\end{proof}
\begin{proposition}\label{propBaseChangeOneSingFib} Let $S\to {\mathbf{P}}^1$ be a Delsarte fibration with $\det(A)\neq 0$ then there exists a Delsarte base change $S_n\to {\mathbf{P}}^1$ of $S\to {\mathbf{P}}^1$ which is isomorphic to the base change of a genus $g$ fibration $S_0\to {\mathbf{P}}^1$ with at most one singular fiber outside $0,\infty$.
\end{proposition}
\begin{proof}
From Lemma~\ref{lemOneT} it follows that we may assume that the Delsarte fibration is a minimal Delsarte fibration, i.e., we have an affine equation for the generic fiber of the form $m_1+m_2+m_3+tm_4$, where the $m_i$ are monomials in $x$ and $y$.
On a minimal Delsarte fibration $\varphi :S\to {\mathbf{P}}^1$ there is an automorphism of order $k_4$ that acts on the $t$-coordinate as $t\mapsto \zeta_{k_4}t$. In particular, all the fixed points of this automorphism are in the fibers over 0 and $\infty$.
Consider next $\psi:S/\langle\sigma\rangle\to {\mathbf{P}}^1/\langle\sigma\rangle\cong {\mathbf{P}}^1$. Now the singular fibers of $\varphi$ are possibly at $t=0, \infty$ and at $t^{k_4}=\prod k_i^{k_i}$, hence the singular fibers of $\psi$ are possibly at $t=0,\infty$ and $t=\prod k_i^{k_i}$.
\end{proof}
\begin{proposition}\label{propStandardForm} Let $\varphi: S\to {\mathbf{P}}^1$ be a minimal Delsarte fibration with affine equation $m_1+m_2+m_3+tm_4$ such that the general fiber has positive geometric genus. Then one of the following happens
\begin{itemize}
\item $m_4$ equals one of $m_1,m_2,m_3$. In this case the fibration is isotrivial.
\item $S$ is Delsarte-birational to a Delsarte surface with equation of the form $y^a=f(x,t)$.
\item every singular fiber over $t=t_0$ with $t_0\neq 0,\infty$ is semistable.
\end{itemize}
\end{proposition}
\begin{proof} Assume that all four $m_i$ are distinct. Let $N_i$ be as in Remark~\ref{remMinFib}.
Let $t_0\in K^*$ be such that the fiber over $t=t_0$ is singular. Let $P=(X_0:X_1:X_2)\in {\mathbf{P}}^2$ be a singular point of the fiber.
From the proof of Proposition~\ref{propDiscrim} it follows that at least one of the $N_i$ is nonzero and that $(N_1:N_2:N_3:N_4)=(k_1:k_2:k_3:\frac{k_4}{t_0})$ holds.
From Remark~\ref{remMinFib} it follows that at most one of the $k_i$ is zero.
Suppose first that one of the $k_i$, say $k_1$ is zero. This implies that $N_1$ vanishes and that the other $N_i$ are nonzero. Therefore one of the coordinate of $P$ has to be zero (in order to have $N_1=0$). If two of the coordinates of $P$ are zero then from $\det(A)\neq0$ it follows that there is some $i\neq 1$ such that $N_i=0$, which contradicts the fact that at most one $N_i$ vanishes. Hence without loss of generality we may assume $P=(\alpha:0:1)$ with $\alpha\neq 0$, $X_1\mid N_1$ and $X_1\nmid N_i$ for $i=1,2,3$. In particular, we have an affine equation for the fibration of the form $m_1+m_2+m_3+tm_4$, where $y$ divides $m_1$, and $m_2,m_3,m_4$ are of the form $x^{a_i}$.
Multiply the equation with a power of $x$ such that $m_1$ is of the form $x^{ab}y^{b}$ and set $y_1=y/x^a$. Then we obtain an equation of the form $y_1^b=f(x,t)$, where $f(x,t)$ is of the form $x^a+x^b+tx^c$. This yields the second case.
It remains to consider the case where all the $N_i$ are nonzero. Let $P\in S$ be a point where the fiber over $t=t_0$ singular. Let $f$ be an affine equation for $S$. We prove below that if we localize $K[x,y,z,t]/(f_x,f_y,f_z,t-t_0)$ at $P$ then this ring is isomorphic to $k[x]$. Hence the scheme defined by the Jacobian ideal of fiber at $t=t_0$ has length one at the point $P$. Equivalently, the Milnor number of the singularity of the fiber at $t=t_0$ at the point $P$ equals one. In particular, the singularity of the fiber at $P$ is an ordinary double point.
Consider now the rational map $\tau:{\mathbf{P}}^2\setminus V(X_0X_1X_2) \to {\mathbf{P}}^3$ given by $(X_0:X_1:X_2)\mapsto (N_1:N_2:N_3:N_4)$. The map $\tau$ is unramified at all points $Q\in {\mathbf{P}}^2$ such that $\tau (Q)\not \in V(X_0X_1X_2X_3)$.
Since we assumed that all the $N_i$ are nonzero it follows that also all the $X_i$ are nonzero. Hence the length of $V(f_{X_0},f_{X_1},f_{X_2},t-t_0)$ at $P$ equals the length of $V(X_0f_{X_0},X_1f_{X_1},X_2f_{X_2},t-t_0)$ at $P$. From the proof of Proposition~\ref{propDiscrim} it follows that $V(X_0f_{X_0},X_1f_{X_1},X_2f_{X_2},t-t_0)$ is the scheme-theoretic intersection of $\ker B_{t_0}$ and $V(\prod z_i^{k_i}-1)$ and that this intersection is locally given by
$V(k_4Z_0-t_0k_1Z_3,k_4Z_1-t_0k_2Z_3,k_4Z_2-t_0k_3Z_4, Z_2-t_0Z_4)$, whence the length of the scheme equals one, and therefore the local Milnor number equals one, and the singularity is an ordinary double point.
\end{proof}
\begin{theorem}\label{thmSingFib} Suppose $S\to {\mathbf{P}}^1$ is a Delsarte fibration of genus $1$ with nonconstant $j$-invariant. Then every singular fiber at $t\neq 0,\infty$ is of type $I_\nu$.
\end{theorem}
\begin{proof}
Without loss of generality we may assume the fibration is a Delsarte minimal fibration. In particular we have an affine equation for this fibration of the form described in the previous Proposition.
In the first case the fibration is isotrivial and therefore the $j$-invariant is constant, hence we may exclude this case. If we are in the third case then each singular fiber at $t=t_0$ is semistable and, in particular, is of type $I_\nu$.
It remains to consider the second case. In this case we have an affine equation of the form $y^a=f(x,t)$. Suppose first that $a>2$ holds. Then the generic fiber has an automorphism of order $a$ with fixed points. This implies that the $j$-invariant of the generic fiber is either $0$ or $1728$. In particular, the $j$-invariant is constant and that the fibration is isotrivial. Hence we may assume $a=2$. In this case we have an affine equation $y^2=f(x,t)$. Without loss of generality we may assume $x^2\nmid f$. Since the generic fiber has genus $1$ it follows that $\deg_x(f)\in \{3,4\}$. Since $S$ is a Delsarte surface it follows that $f$ contains three monomials.
Suppose first that $\deg_x(f)=3$ and that at $t=t_0$ there is a singular fiber of type different from $I_v$. Then $f(x,t_0)$ has a triple root, i.e., $f(x,t_0)=(x-t_0)^3$. This implies that $f(x,t_0)$ consists of either one or four monomials in $x$. This contradicts the fact that $f(x,t)$ consists of three monomials and $t_0\neq 0$.
If $\deg_x(f)=4$ then we may assume (after permuting coordinates, if necessary) that $f=x^4+x^a+t$ or $f=x^4+tx^a+1$.
If the fiber type at $t=t_0$ is different from $I_v$ then $f(x,t_0)$ consists of three monomials and $y^2=f(x,t_0)$ has at singularity different from a node. In particular, $f(x,t_0)$ has a zero or order at least 3 and therefore $f(x,t_0)=(x-a)^4$ or $f(x,t_0)=(x-a)(x-b)^3$. In the first case $f(x,t_0)$ contains five monomials, contradicting the fact that is has three monomials. In the second case note that the constant coefficient of $f(x,t_0)$ is nonzero and hence $ab\neq 0$. Now either the coefficient of $x$ or of $x^3$ is zero. From this it follows that either $b=-3a$ or $a=-3b$ holds. Substituting this in $f(x,t_0)$ and the the fact that $f(x,t_0)$ has at most three monomials yields $b=0$, contradicting $ab\neq 0$.
\end{proof}
\begin{corollary}\label{corSingFib} Let $\varphi: S\to {\mathbf{P}}^1$ be an elliptic Delsarte surface, then there exists a cyclic base change of $\varphi$ ramified only at 0 and $\infty$
that is isomorphic to a cyclic base change, ramified only at $0$ and $\infty$, of an elliptic surface with at most one singular fiber away from 0 and $\infty$ and this fiber is of type $I_v$.
\end{corollary}
Let $\pi:E\to {\mathbf{P}}^1$ be an elliptic surface (with section). Define $\gamma(\pi)$ to be
\[ \gamma(\pi):=\sum_{t\neq0,\infty} \left( f_t-\frac{e_t}{6}\right)-\frac{n_0}{6}-\frac{n_\infty}{6},\]
where $f_t$ is the conductor of $\pi^{-1}(t)$, $e_t$ the Euler number of $\pi^{-1}(t)$ and $n_p$ is zero unless the fiber at $p$ is of type $I_n$ or $I_n^*$ and in this cases $n_p=n$.
In \cite{FastExtremal} and \cite{FastLongTable} Fastenberg studies rational elliptic surfaces with $\gamma<1$. She determines the maximal Mordell-Weil rank of such elliptic surfaces under cyclic base changes of the form $t\mapsto t^n$.
We will now show that each Delsarte fibration of genus 1 with nonconstant $j$-invariant becomes after a Delsarte base change the base change of a rational elliptic surface with $\gamma<1$. In particular, the maximal Mordell-Weil ranks for Delsarte fibrations of genus 1 under cyclic base change (as presented in \cite[§3.4]{HeijnePhD} and \cite{HeijneMoC}) can also be obtained from \cite{FastLongTable}.
\begin{corollary}\label{corGamma} Let $\pi: S\to {\mathbf{P}}^1$ a minimal Delsarte fibration of genus $1$ with nonconstant $j$-invariant. Then $S$ is the base change of a rational elliptic surface with $\gamma<1$.
\end{corollary}
\begin{proof}
From Theorem~\ref{thmSingFib} it follows that $\pi$ is the base change of an elliptic fibration $\pi':S'\to {\mathbf{P}}^1$ with at most one singular fiber away from $0$ and $\infty$ and this fiber is of type $I_v$.
Since the $j$-invariant is nonconstant it follows that $\pi'$ has at least three singular fibers, hence there is precisely one singular fiber away from $0$ and $\infty$.
Since this fiber is of type $I_\nu$ it follows that $f_t=1$ for this fiber. Hence
\[ \gamma=1-\frac{e_t+n_0+n_\infty}{6}<1.\]
\end{proof}
\begin{remark} The converse statement to this results holds also true: let $\pi:S\to {\mathbf{P}}^1$ be a rational elliptic surface with $\gamma<1$, only one singular fiber away from $0$ and $\infty$ and this fiber is of type $I_\nu$. Then there exists a base change of the form $t\mapsto t^n$ such that the pullback of $\pi:S\to{\mathbf{P}}^1$ along this base change is birational to the standard fibration on a Delsarte surface. One can obtain this result by comparing the classification of elliptic Delsarte surfaces from \cite[Chapter 3]{HeijnePhD} with the tables in \cite{FastExtremal} and \cite{FastLongTable}.
\end{remark}
\begin{example}
According to \cite{FastLongTable} there is an elliptic surface with a $IV$-fiber at $t=0$, an $I_1$-fiber at $t=\infty$ and one further singular fiber that is of type $I_1^*$, such that the maximal rank under base changes of the form $t\mapsto t^n$ is $9$. Such a fibration has a nonconstant $j$-invariant. Corollary~\ref{corSingFib} now implies that this fibration is not a Delsarte fibration.
If we twist the $I_1^*$ fiber and one of the fibers at $t=0$ or $t=\infty$ then we get the following fiber configurations $IV;I_1^*;I_1$ or $II^*;I_1;I_1$. Then maximal rank under base changes of the form $t\mapsto t^n$ equals 9 in both cases. Now $y^2=x^3+x^2+t$ has singular fibers of type $I_1$ at $t=0$ and $t=-4/27$ and of type $II^*$ at $t=\infty$ and $y^2=x^3+tx+t^2$ has a $IV$-fiber at $t=0$, a $I_1$ fiber at $t=-4/27$ and a $I_1^*$ fiber at $t=\infty$. Hence both fibration occur as Delsarte fibrations.
\end{example}
\begin{example}
Consider the elliptic Delsarte surface that corresponds to
\[Y^2=X^3+X^2+tX.\]
We can easily compute the discriminant and $j$-invariant of this fibration:
\[ \Delta=-64t^3-16t^2 \mbox{ and } j=256\frac{(3t-1)^3}{4t^3-t^2}.\]
From this we can see that there are three singular fibres. Over $t=0$ there is $I_2$-fiber, over $t=\infty$ there is a $III$-fiber and over $t=-1/4$ there is a $I_1$-fiber.
We then check that this corresponds to the second entry in the list of \cite{FastLongTable}.
\end{example}
\begin{remark}\label{rmkDifference} The approaches to determine the maximal Mordell-Weil ranks under cyclic base change in \cite{FastLongTable} and in \cite{HeijnePhD} are quite different. The former relies on studying the local system coming from the elliptic fibration, whereas the latter purely relies on Shioda's algorithm to determine Lefschetz numbers of Delsarte surfaces. This explains why Fastenberg can deal with several base changes where the ``minimal" fibration has four singular fibers (which cannot be covered by Shioda's algorithm because of Proposition~\ref{propBaseChangeOneSingFib}) but cannot deal with fibration with constant $j$-invariant. Instead Shioda's algorithm can handle some of them.
\end{remark}
\section{Isotrivial fibrations}\label{secIsoTrivial}
Using Proposition~\ref{propStandardForm} one easily describes all possible isotrivial minimal Delsarte fibrations.
\begin{proposition} Suppose the standard fibration on $S$ is isotrivial and that the genus of the generic fiber is positive. Then there is a Delsarte base change and a Delsarte birational map such that the pull back of the standard fibration is of the form $m_1+m_2+(1+t^n)m_3$, $y^3+x^3+x^2+t^n$, or $y^a+x^2+x+t^n$.
\end{proposition}
\begin{proof} Suppose the affine equation for $S$ is of the third type of Proposition~\ref{propStandardForm}. Then $S$ admits a semistable fiber and in particular the fibration cannot be isotrivial.
If the affine equation for $S$ is of the first type of Proposition~\ref{propStandardForm}, then the generic fiber is (after an extension of the base field) isomorphic to $m_1+m_2+m_3$, in particular each two smooth fibers of the standard fibration are isomorphic and therefore this fibration is isotrivial. In this case $S$ is the pull back of $m_1+m_2+(1+t^n)m_3$.
Hence we may restrict ourselves to the case where we have an affine equation of the form $y^a=x^bf(x,t)$ where $f$ consists of three monomials, $f(0,t)$ is not zero and the exponent of $x$ in each of the three monomials in $f$ is different. Moreover, after a Delsarte birational map we may assume that $b<a$.
The surface $S$ is birational to a surface $y^a=x^bz^{c+\deg(f)}f(x/z,t)$ in ${\mathbf{P}}(1,w,1)$, with $0\leq c<a$ and $w=(b+c+\deg(f))/a\in {\mathbf{Z}}$.
The standard fibration on $S$ is isotrivial if and only if the moduli of the zero-set of $x^bz^{c+\deg(f)}f(x/z,t)$ in ${\mathbf{P}}^1_{(x:z)}$ is independent of $t$. We will now consider this problem.
We cover first the case where $d':=\deg_x(f)>2$ holds.
After swapping the role of $x$ and $z$, if necessary, we may assume that the coefficient of $xz^{d'-1}$ is zero.
We claim that after a map of the form $y=t^{c_1}y, x=t^{c_2}x,z=z,t=t^{c_3}$ we may assume that $f=x^{d'}+x^{c'}z^{d'-c'}+tz^{d'}$. To see this, take an affine equation for $S$ of the form
$y^a=x^b(a_1x^{d'}+a_2x^{c'}+a_3)$, where $a_i\in\{1,t\}$, and two of the $a_i$ equal $1$. If $a_1=t$ then we need to take an integer solution of $ac_1=bc_2+d'c_2+c_3=bc_2+c'c_2$, if $a_2=t$ then we need to take an integer solution of $ac_1=bc_2+d'c_2+c_3=bc_2+c'c_2$. In both cases we obtain an affine equation of the form $y^a=x^b(x^{d'}+x^{c'}+t^n)$. This fibration is isotrivial if and only if $y^a=x^b(x^{d'}+x^{c'}+t)$ is isotrivial, which proves the claim.
Hence from now on we assume that $f$ is of the form $x^{d'}+x^{c'}z^{d'-c'}+tz^{d'}$ with $d'>2$ and $c'>1$.
Let $s$ denote the number of distinct zeroes of $g(x,z):=x^bz^{c+\deg(f)}f(x/z,t)$ for a general $t$-value.
We say that fiber at $t=t_0$ is bad if $x^bz^{c+\deg(f)}f(x/z,t)$ has at most $s-1$ distinct zeroes.
The main result from \cite{KT} yields that if the fiber a $t=t_0$ is bad then $g(x,z)$ has at most $3$ distinct zeroes. We are first going to classify all $g$ satisfying this condition. Then we will check case-by-case whether the moduli of the zeroes of $g$ are independent of $t$.
Consider the fiber over $t=0$. From $c'>1$ it follows that $x=0$ is a multiple zero of $f(x,0)$. Hence that the fiber over $t=0$ is bad. If $c$ is positive then the criterion from \cite{KT} implies that $g(x,0)$ can have at most one further zero and hence $d'=c'+1$. If $c=0$ then $g$ can have at most two further zeroes and therefore $d'-c'\in \{1,2\}$.
Suppose first $d'=c'+1$.
Consider $f'(x,t):=\frac{\partial}{\partial x}f(x,t)$. Our assumption on $f$ implies that $f'(x,t)$ is a polynomial only in $x$. The fiber at $t=t_0$ is bad if and only if $f'(x,t_0)$ and $f(x,t_0)$ have a common zero. From $c'=d'-1$ it follows that $f'(x,t)$ has a unique zero different from $0$, say $x_0$, and $x_0$ is a simple zero of $f'(x,t)$. Now $f(x_0,t)$ is a linear polynomial in $t$. Hence there is a unique nonzero $t$-value $t_0$ over which there is a bad fiber. Since $x_0$ is a simple zero of $f'(x,t_0)$ it follows that $(x-x_0)^2$ divides $f(x,t_0)$ and that there are $d'-2$ further distinct zeroes, all different from $0$. Using that $g$ has at most $3$ zeroes it follows that if both $b$ and $c$ are nonzero then $d'-2=0$, if one of $b,c$ is zero then $d'-2\leq 1$ and if both $b$ and $c$ are zero then $d'-2\leq 2$. Using that we assumed that $d'$ is at least $3$ we obtain the following possibilities for $g$:
$x^b(x^3+x^2z+tz^3)$, $z^c(x^3+x^2z+tz^3)$, $x^3+x^2z+tz^3$ and $x^4+x^3z+tz^4$.
Suppose now $c=0$ and $d'=c'+2$. Then $f'$ is of the form $\beta(x^2+\alpha)x^{d'-3}$. In particular, there are two possible $x$-values for a bad point in a bad fiber. If they occur in the same fiber and $b=0$ then $d'\in \{4,5\}$, otherwise $d'\in \{3,4\}$. Since $2\leq c'=d'-2$ we may exclude $d'=3$ and we obtain that the two polynomials $x^4+x^2+t$ and $x^5+x^3+t$ are the only possibilities for $f$. We can exclude $x^5+x^3+t$, since it has bad fibers at $t^2=\frac{-3125}{108}$ and a necessary condition to have $d'=5$ is that there is at most one bad fiber with $t\neq0,\infty$.
If $b>0$ then $d'\leq 4$; in particular we have only $x^b(x^4+x^2+t)$ to check.
Actually only in one of the above cases the moduli are independent of $t$, namely $g=x^3+x^2z+tz^3$:
Note that the $j$-invariants of the elliptic curves $y^2=x^3+x^2+t$ and $y^2=tz^3+z+1$ are not constant, hence the moduli of the zeros of $x^b(x^3+x^2z+tz^3)$ and of $z^c(x^3+x^2z+tz^3)$ depend on $t$ (if $b>0$ resp. $c>0$ holds). Since $x^3+x^2z+tz^3$ has degree 3, the moduli of its zeroes are obviously constant.
The family of genus one curves $y^2=x^4+x^2+t$ has a semistable fiber at $t=\frac{1}{4}$ and the family of genus one curves $y^2=x^4+x^3z+tz^4$ has a semistable fiber at $t=\frac{27}{256}$. Hence the moduli of the zeroes of $x^b(x^4+x^2+t)$ for $b\geq 0$ and of $x^4+x^3z+tz^4$ depend on $t$.
Consider now the final case $d'=2$. Then $f=x^2+x+t$, and therefore automatically two of the three possibilities for $g$, namely $z^c(x^2+xz+tz^2)$ and $x^b(x^2+xz+tz^2)$ have constant moduli since they define 3 points in ${\mathbf{P}}^1$.
Now $y^{b+2}=z^b(x^2+xz+tz^2)$ and $y^{b+2}=x^b(x^2+xz+tz^2)$ are birationally equivalent up to a Delsarte base change, e.g., take $((x:y:z),t)\mapsto ((z:\frac{y}{t}:\frac{x}{t^{b+2}}),t^{b+2})$. Hence these two cases yield only one case up to isomorphism. We may assume that the affine equation equals $y^b+x^2+x+t^n$.
If $b=c=0$ holds, then the generic fiber is a cyclic cover of ${\mathbf{P}}^1$ ramified at two points, and in particular has genus 0. Hence we can exclude this case.
Finally, $x^bz^c(x^2+xz+tz^2)$ does not have constant moduli since the $j$-invariant of $y^2=x^3+x^2+tx$ is nonconstant.
\end{proof}
\begin{remark} In the case of $y^a+x^2+x+t$ we may complete the square. This yields a surface that is isomorphic to $y^a+x^2+1+t$, in particular the fibration is birationally equivalent to a fibration of the first kind. However, they are not Delsarte birational.
In \cite[Section 3.5.1]{HeijnePhD} it is shown that $y^3+x^3+x^2+t$ is birational to $y^2+x^3+t^3+1$, however the given birational map is not a Delsarte birational map.
Hence both exceptional case are fibration that are birational to a fibration of the first type.
\end{remark}
From the previous discussion it follows that almost all minimal isotrivial Delsarte fibrations are of the form $m_1+m_2+(1+t)m_3$.
We will calculate the Picard numbers for one class of such fibration and consider the behavior of the Picard number under Delsarte base change, i.e., base changes of the form $t\mapsto t^a$.
\begin{example}\label{exaIso}
Let $p=2g+1$ be a prime number.
Consider the isotrivial fibration $y^2=x^{p}+t^{2ap}+s^{2ap}$ of genus $g$-curves over ${\mathbf{P}}^1_{(s:t)}$. This equation defines a quasi-smooth surface $S$ of degree $2ap$ in $ {\mathbf{P}}(2a,ap,1,1)$. The surface $S$ has one singular point, namely at $(1:1:0:0)$. A single blow-up of this suffices to obtain a smooth surface $\tilde{S}$. The Lefschetz number of $\tilde{S}$ can be computed by using Shioda's algorithm, which we do below. The exceptional divisor of $\tilde{S}\to S$ is a smooth rational curve. In particular, using the Mayer-Vietoris sequence one easily obtains that $h^2(\tilde{S})=h^2(S)+1$ and $\rho(\tilde{S})=\rho(S)+1$.
Since $S$ is quasi-smooth one has a pure weight 2 Hodge structure on $H^2(S)$. To determine the Hodge numbers of this Hodge structure we use a method of Griffiths and Steenbrink. Note first that $\dim H^2(S)_{\prim}=h^2(S)-1=h^2(\tilde{S})-2$.
Let $R$ be the Jacobian ring of $S$, i.e.,
\[ R={\mathbf{C}}[x,y,t,s]/\left(\frac{\partial f}{\partial x},\frac{\partial f}{\partial y},\frac{\partial f}{\partial s},\frac{\partial f}{\partial t}\right)={\mathbf{C}}[x,y,s,t]/(x^{p-1},y,t^{2p-1},s^{2p-1})\]
This is a graded ring with weights $(2a,ap,1,1)$. Let $d=2ap$ be the degree of $S$ and $w=ap+2a+2$ the sum of the weights.
From Griffiths-Steenbrink \cite{SteQua} it follows that
$H^{2-q,q}(S)_{\prim}$ is isomorphic with
\begin{eqnarray*} R_{qd-w}&=&\spa \{ x^it^js^k\mid 2ai+j+k=qd-w, 0\leq i<p-1, 0\leq j,k< 2p-1\}\\ &=& \spa\{ yx^it^js^k \mid 2ai+j+k=qd, 0< i\leq p-1, 0<j,k\leq 2p-1\}. \end{eqnarray*}
In other words the basis elements of $R_{qd-w}$ correspond one-to-one to vectors
\[\left\{ \left( \frac{1}{2},\frac{i}{p},\frac{j}{2ap},\frac{k}{2ap}\right) \in ({\mathbf{Q}}/{\mathbf{Z}})^4 \left| \begin{array}{c} i,j,k\in {\mathbf{Z}};0<i<p; 0<j,k<2ap; \\ \frac{1}{2}+\frac{i}{p}+\frac{j}{2ap}+\frac{k}{2ap}=q\end{array} \right. \right\}.\]
In \cite[Section 2.1]{HeijnePhD} a variant of Shioda's algorithm \cite{ShiodaPic} is presented. This algorithm calculates the Lefschetz number of a resolution of singularities of a Delsarte surface in ${\mathbf{P}}^3$. In our case we apply this algorithm to the surface $T\subset {\mathbf{P}}^4$ given by
\[-Y^2Z^{2ap-2}+X^pZ^{2ap-p}+W^{2ap}+Z^{2ap}\]
Since the Lefschetz number is a birational invariant, one has that the Lefschetz number of $\tilde{S}$ and $\tilde{T}$ coincide.
Following \cite{HeijnePhD} we need to take the exponent matrix
\[A=
\left(
\begin{array}{cccc}
0&2&0&2ap-2\\
p&0&0&(2a-1)p\\
0&0&2ap&0\\
0&0&0&2ap\\
\end{array}
\right)
\]
and then to determine the three vectors \[{\mathbf{v}}_1:=A^{-1}(1,0,0,-1)^T, {\mathbf{v}}_2:=A^{-1}(1,0,0,-1)^T\mbox{ and }{\mathbf{v}}_3:=A^{-1}(0,0,1,-1)^T.\]
In our case this yields the vectors \[{\mathbf{v}}_1=\left(0,\frac{1}{p},0,\frac{-1}{p}\right) , {\mathbf{v}}_2=\left(\frac{1}{2},0,0,\frac{-1}{2}\right)\mbox { and }{\mathbf{v}}_3=\left(0,0,\frac{1}{2ap},\frac{-1}{2ap}\right).\]
Consider now the set $L:=i{\mathbf{v}}_1+k{\mathbf{v}}_2+j{\mathbf{v}}_3\in {\mathbf{Q}}/{\mathbf{Z}}$. This are precisely the vectors of the form
\[\left\{\left( \frac{k}{2},\frac{i}{p},\frac{j}{2ap},\frac{-apk-2ai-j}{2ap} \right)\in ({\mathbf{Q}}/{\mathbf{Z}})^4\left| i,j,k\in {\mathbf{Z}}\right.\right\} \]
Let $L_0\subset L$ be the set of vectors $v\in L$ such that none of the entries of $v$ equals $0$ modulo ${\mathbf{Z}}$, i.e.,
\[ \left\{\left( \frac{1}{2},\frac{i}{p},\frac{j}{2ap},\frac{-ap-2ai-j}{2ap} \right)\in ({\mathbf{Q}}/{\mathbf{Z}})^4\left| \begin{array}{l} i,j\in {\mathbf{Z}}, 0<i<p,0<j<2ap, \\ j \not \equiv -ap-2ai \bmod 2ap \end{array}\right.\right\} \]
Note that $\#L_0$ is precisely $h^2(S)_{\prim}$.
For an element $\alpha\in {\mathbf{Q}}/{\mathbf{Z}}$ denote with $\fr{\alpha}$ the fractional part, i.e., the unique element $\beta\in {\mathbf{Q}}\cap [0,1)$ such that $\alpha-\beta\equiv 0 \bmod {\mathbf{Z}}$ and with $\ord_{+}(\alpha)$ the smallest integer $k>0$ such that $k\alpha\in {\mathbf{Z}}$.
Define the following $\Lambda\subset L_0$ consisting of elements $(\alpha_1,\alpha_2,\alpha_3,\alpha_4)\in L_0$ such that there is a $t\in {\mathbf{Z}}$ for which $\ord_+(\alpha_kt)=\ord_+(\alpha_k)$ holds for $k=1,2,3,4$ and $\fr{t\alpha_1}+\fr{t\alpha_2}+\fr{t\alpha_3}+\fr{t\alpha_4}\neq 2$. The condition $\ord_+(\alpha_kt)=\ord_+(\alpha_k)$ for $k=1,2,3,4$ is equivalent with $t$ being invertible modulo $2a'p$, where $a'=a/\gcd(a,j)$.
Then the Lefschetz number $\lambda=h^2(\tilde{T})-\rho(\tilde{T})$ equals $\#\Lambda$.
Since $\lambda(\tilde{S})=\lambda(\tilde{T})$ and $h^2(\tilde{S})=2+\# L_0$ it follows that $\rho(S)$ equals
\[2+\# \left\{ (\alpha_1,\alpha_2,\alpha_3,\alpha_4)\in L_0 \mid\begin{array}{l} \frd{t\alpha_1}+\frd{t\alpha_2}+\frd{t\alpha_3}+\frd{t\alpha_4}=2 \mbox{ for } t\in {\mathbf{Z}} \\\mbox{ such that } \ord_{+}(t\alpha_k)=\ord_{+}(\alpha_k), k=1,2,3,4\end{array}\right \}.\]
We now determine this set.
Consider now a vector ${\mathbf{v}}$ from $L_0$, i.e., a vector
\[ \left(\frac{1}{2},\frac{i}{p},\frac{j}{2ap},\frac{ap-2ai-j}{2ap}\right) \]
with $i,j\in {\mathbf{Z}}$, $i\nequiv 0 \bmod p, j\nequiv 0 \bmod 2ap, ap-2api-j \nequiv 0 \bmod 2ap$.
Take $t\in \{1,\dots, 2a'p-1\}$ such that $\gcd(t,2a'p)= 1$ and $t\equiv i^{-1} \bmod p$. Then $v\in \Lambda$ if and only if $t{\mathbf{v}} \in \Lambda$. Hence to determine whether a vector is in $\Lambda$ it suffices to assume $i\equiv 1 \bmod p$.
Suppose now that $p>7$.
In Lemma~\ref{lemExcl} we show that ${\mathbf{v}}\not \in \Lambda$ if and only if the fractional part $\fr{\frac{j}{2ap}}$ is in the set $ \left\{ \frac{p-1}{2p}, \frac{1}{2}, \frac{p+2}{2p},\frac{2p-4}{2p}, \frac{2p-2}{2p}, \frac{2p-1}{2p}\right\}$. Each of the six values for $j$ yields $(p-1)$ elements in $L_0\setminus \Lambda$, hence $\rho(\tilde{S})=2+6(p-1)$.
One can easily find several divisors on $\tilde{S}$. We remarked in the introduction that the pull back of the hyperplane class and the exception divisor yield two independent classes in $NS(\tilde{S})$. We give now $2(p-1)$ further independent classes:
Let $\zeta$ be $p$-th root of unity. Let $C_{1,i}$ be $x=t^{2a}\zeta^i$, $y=s^{ap}$, $C_{2,i}$ be $x=s^{2a}\zeta^i$, $y=t^{ap}$. Then $\sum_i C_{1,i}$ and $\sum C_{2,i}$ equal the hyperplane class in $Pic(S)$. However each $C_{i,j}$ is nonzero in $\Pic(S)$: Let $\sigma$ be the automorphism of $S$ sending $t$ to $t$ times a $2ap$-th root of unity and leaving the other coordinates invariant. Then the characteristic polynomial of $\sigma$ on the image of $C_{1,i}$, $i=1,\dots,p-1$ is $(t^p-1)/(t-1)$. In particular the image of $\spa \{[C_{1,j}]\}$ is either 0 or $p-1$ dimensional. (One can exclude the former possibility by checking intersection numbers.)
Similarly using the automorphism $s$ is mapped to $s$ times a $2ap$-th root of unity it follows that $\spa\{[C_{2,i}]\}$ has dimension $p-1$ and that $\spa\{ [C_{i,j}]\}$ is $2(p-1)$ dimensional.
\end{example}
\begin{lemma}\label{lemExcl} Suppose $p>7$.
Let
\[{\mathbf{v}}=\left( \frac{1}{2},\frac{1}{p},\frac{j}{2ap},\frac{-2a-ap-j}{2ap} \right)\in ({\mathbf{Q}}/{\mathbf{Z}})^4\]
such that $j\nequiv 0 \bmod 2ap, 2a+j+ap\nequiv 0 \bmod 2ap$.
Then ${\mathbf{v}}\not \in\Lambda$ if and only if
\[ \frac{j}{2ap} \in\left\{\frac{p-1}{2p}, \frac{1}{2},\frac{p+2}{2p}, \frac{2p-4}{2p},\frac{2p-2}{2p},\frac{2p-1}{2p}\right\}.\]
\end{lemma}
\begin{proof}
Without loss of generality we may assume that $\gcd(a,j)=1$.
We start by proving that if a prime $\ell\geq 5$ divides $a$ then $v \in \Lambda$. For this it suffices to give a $t$, invertible modulo $2ap$ such that
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2ap}}+\frd{\frac{(-2a-ap-j)t}{2ap}}=1.\]
Since the left hand side is an integer for any choice of $t$, and each summand is smaller than one it suffices to prove that
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2ap}} \leq 1.\]
Consider the value
\[t=1+ck\frac{2ap}{\ell},\]
with $c\equiv j^{-1}\bmod \ell$ and $k\in {\mathbf{Z}}$ such that $k\not\equiv (c\frac{2ap}{\ell})^{-1} \bmod \ell$ and $k$ in the interval
\[\left(-\frac{\ell j}{2ap},-\frac{\ell j}{2ap}+\frac{\ell(p-2)}{2p}\right).\]
Note that we have to assume $p>7$ or $\ell\geq 5$ to ensure the existence of such a $k$.
Then $\fr{\frac{t}{2}}=\frac{1}{2}$ and
\[ \frd{\frac{t}{p}} = \frd{\frac{1}{p}+ck \frac{2a}{\ell}} =\frac{1}{p}.\]
Moreover, we have that
\[\frd{\frac{tj}{2ap}}= \frd{\frac{(1+ck\frac{2ap}{\ell})j}{2ap}}=\frd{\frac{j}{2ap}+\frac{k}{\ell}}\leq \frac{(p-2)}{2p}.\]
From this it follows that
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2ap}}\leq 1\]
holds, which finishes this case.
Suppose now that the only primes dividing $a$ are $2$ or $3$. If $p=11,13,17$ and $a=3$ then one can find easily by hand a $t$-value such that
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2ap}}+\frd{\frac{(-2a-ap-j)t}{2ap}}=1\]
holds. For all other combinations $(a,j,p)$ with $a>1$ we give a value for $t$ in Table~\ref{TabTVal} such that the above formula holds.
\begin{table}[hbtp]\label{TabTVal}
\begin{tabular}{|c|c|c|c|}
\hline
$a$ & $\frac{j}{2ap} \in I $& & $t$ \\
\hline
$4\mid a$& $(0,\frac{p-2}{2p})$ &&$1$\\
$p>3$ & $ (\frac{1}{2},\frac{p-1}{p})$& & $1+ap$\\
& $ (0,\frac{p-4}{4p})\cup(\frac{3}{4},1)$& $j\equiv 1 \bmod 4$ & $1+\frac{ap}{2}$\\
& $ (\frac{1}{4},\frac{3p-4}{4p})$ & $j\equiv 1 \bmod 4$ & $1+\frac{3ap}{2}$\\
& $(0,\frac{p-4}{4p})\cup(\frac{3}{4},1)$ & $j\equiv 3 \bmod 4$ & $1+\frac{3ap}{2}$\\
& $(\frac{1}{4},\frac{3p-4}{4p})$ & $j\equiv 3 \bmod 4$ & $1+\frac{ap}{2}$\\
\hline
$2\mid a$, $4\nmid a'$ & $(0,\frac{p-2}{2p})$ &&$1$\\
$p>7$ & $ (\frac{1}{2},\frac{p-1}{p})$ && $1+ap$\\
& $(0,\frac18-\frac1p)\cup(\frac{3}{8},\frac{5}{8}-\frac{1}{p})\cup (\frac78,1)$ & $j\equiv 1 \bmod 4$ & $2+\frac{ap}{2}$\\
& $ (\frac{3}{8},\frac{5}{8}-\frac{1}{p})$&$j\equiv 3 \bmod 4$ & $2+\frac{3ap}{2}$\\%aanname 1/p<1/8 Gaat dus nog fout bij p=7.
\hline
$9\mid a$& $ (0,\frac{p-2}{2p})$ &&$1$\\
$p>5$ & $(\frac{1}{3},\frac{5}{6}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ & $1+\frac{2ap}{3}$\\
& $(0, \frac{1}{3}-\frac{1}{p})\cup (\frac{2}{3},1)$ & $j\equiv 2 \bmod 3$ & $1+\frac{4ap}{3}$\\
& $(\frac{1}{3},\frac{5}{6}-\frac{1}{p})$ & $j\equiv 1 \bmod 3$ & $1+\frac{4ap}{3}$\\
& $(0, \frac{1}{3}-\frac{1}{p})\cup (\frac{2}{3},1)$ & $j\equiv 1 \bmod 3$ &$1+\frac{2ap}{3}$\\
\hline
$a=3$ & $ (0,\frac{p-2}{2p})$ &&$1$\\
$p\equiv 1\bmod 3$ & $ (\frac{1}{3},\frac{5}{6}-\frac{1}{p})$ &$j\equiv 1 \bmod 3$ & $1+4p$ \\
$p>18$ & $ (\frac{8}{9},\frac{19}{18}-\frac{1}{p})$& $j\equiv 1 \bmod 3$ &$3+2p$ \\
& $ (\frac{7}{9},\frac{17}{18}-\frac{1}{p})$ &$j\equiv 1 \bmod 3$ &$3+4p$ \\
& $(\frac{2}{3},1)$ & $j\equiv 2 \bmod 3$ & $1+4p$ \\
& $ (\frac{4}{9},\frac{11}{18}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ &$3+2p$ \\
& $ (\frac{5}{9},\frac{13}{18}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ &$3+4p$ \\
\hline
$a=3$ & $ (0,\frac{p-2}{2p})$ &&$1$\\
$p\equiv 2\bmod 3$ & $(\frac{2}{3},1)$ & $j\equiv 1 \bmod 3$ & $1+2p$ \\
$p>18$ & $(\frac{5}{9},\frac{13}{18}-\frac{1}{p})$ & $j\equiv 1 \bmod 3$ &$3+2p$ \\
& $ (\frac{4}{9},\frac{11}{18}-\frac{1}{p})$ & $j\equiv 1 \bmod 3$ &$3+4p$ \\
& $ (\frac{1}{3},\frac{5}{6}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ &$1+2p$ \\
& $ (\frac{7}{9},\frac{17}{18}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ &$3+2p$ \\
& $ (\frac{8}{9},\frac{19}{18}-\frac{1}{p})$ & $j\equiv 2 \bmod 3$ &$3+4p$ \\
\hline
\end{tabular}
\caption{$t$-values for the case $a=2^{v_2}3^{v_3}$, $a\neq 1$}
\end{table}
The only case left to consider is the case $a=1$. If $p\leq 30$ then one can easily find an appropriate $t$-value by hand. Hence we
may assume that $p>30$.
If we take $t=1$ then we see that $v\in\Lambda$ whenever
\[\frac{j}{2ap}=\frac{j}{2p}\in \left(0,\frac{1}{2}-\frac{1}{p}\right).\]
We will consider what happens if $\frac{j}{2p}>\frac{p-2}{2p}$.
Suppose $t<p$ is an odd integer, and $k$ is an integer such that $k \leq \frac{tj}{2p}< k+1$. Then we have
\[ \frd{\frac{t}{2}}+\frd{\frac{t}{p }}+\frd{\frac{tj}{2p}} = \frac{1}{2}+\frac{t}{p}+\frac{tj}{2p}-k\]
The right hand side is at most $1$ if
\[ \frac{j}{2p} \leq \frac{1+2k}{2t}-\frac{1}{p}\]
Hence if
\[ \frac{j}{2p} \in \left( \frac{k}{t},\frac{1+2k}{2t}-\frac{1}{p} \right)\]
Then ${\mathbf{v}}\in \Lambda$.
If we take $k=t-1$ then we get the interval
\[ I_t:=\left( 1-\frac{1}{t},1-\frac{1}{2t}-\frac{1}{p}\right)\]
and if we take $k=(t+1)/2$ then we get
\[ I'_t:=\left(\frac{1}{2}+\frac{1}{2t},\frac{1}{2}+\frac{1}{t}-\frac{1}{p}\right).\]
Note that $I_3=I'_3$.
We claim that if $p>30$ and $5\leq t\leq \frac{p-1}{2}-3$ then $I'_t\cap I'_{t-2}\neq \emptyset$ and $I_t\cap I_{t-2}\neq \emptyset$.
For this it suffices to check that
\[ \frac{1}{2}+\frac{1}{2(t-2)} < \frac{1}{2}+\frac{1}{t}-\frac{1}{p} \mbox{ and }1-\frac{1}{2(t-2)}-\frac{1}{p} >1-\frac{1}{t} \]
Both conditions are equivalent with
\begin{equation}\label{eqnBoundPnt} 2t^2-(p+4)t+4p<0\end{equation}
The smallest value to check is $t=5$ then the above formula yields that $p>30$, which is actually the case. For fixed $p$ we have that the above bound is equivalent with $t\in (\frac{1}{4}p+1-\frac{1}{4} \sqrt{p^2-24p+16}, \frac{1}{4}p+1+\frac{1}{4} \sqrt{p^2-24p+16})$.
The previous argument already shows that the left boundary of this interval is smaller than $5$. Substituting $t=\frac{p-1}{2}-3$ in (\ref{eqnBoundPnt}), yields that for $p>77/3$ the boundary point on the right is at bigger than $\frac{p-1}{2}-3$. In particular, if $p>30$, $t$ is odd then $I'_t\cap I'_{t-2}\neq \emptyset$ and $I_t\cap I_{t-2}\neq \emptyset$.
Take now the union of $I'_t$ and $I_t$ for all odd $t$ between $3$ and $\frac{p-1}{2}-5$. This yields an interval $I=(\alpha,\beta)$ such that for all $\frac{j}{2p}\in I$ we have that ${\mathbf{v}} \in \Lambda$.
The maximal $t$-value is either $\frac{p-1}{2}-3$ or $\frac{p-1}{2}-4$ (depending on $p\bmod 4$). Hence we know only that the maximal $t$ is at least $\frac{p-1}{2}-4$. From this it follows that
\[I\supset \left( \frac{1}{2}+\frac{1}{p-9} , 1-\frac{1}{p}-\frac{1}{p-9}\right).\]
Note that $p-9>\frac{2}{3}p$ and hence $\frac{1}{p}+\frac{1}{p-9}\leq \frac{5}{2p}$. Hence the only possibilities for $\frac{j}{2p} \not \in I$ and $p-2<j <2p$ are
\[ \left\{\frac{p-1}{2p} ,\frac{p}{2p},\frac{p+1}{2p},\frac{p+2}{2p}, \frac{2p-4}{2p}. \frac{2p-3}{2p},\frac{2p-2}{2p},\frac{2p-1}{2p}\right\}.\]
If $\frac{j}{2p}\in \{\frac{p+1}{2p},\frac{2p-3}{2p}\}$ then we have that ${\mathbf{v}}$ is in $\Lambda$. This can be verified by taking $t=p-2$. Hence we have shown that for all but six values for $\frac{j}{2p}$ the corresponding vector is in $\Lambda$.
It remains to show that for the remaining values of $\frac{j}{2p}$ we have that ${\mathbf{v}} \not\in \Lambda$.
If $\frac{j}{2p}\in \{\frac{1}{2},\frac{2p-2}{2p}\}$ then two coordinates $\alpha,\beta$ of ${\mathbf{v}}$ equal $\frac{1}{2}$. Hence for any admissible $t$ we have
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2ap}}+\frd{\frac{(-2a-ap-j)t}{2ap}}> \frac{1}{2}+\frac{1}{2} =1\]
Since the left hand side is an integer, it is at least 2.
In the other four cases we have two entries $\alpha,\beta$ such $\alpha=\beta+\frac{1}{2}$. Since $t$ is odd we have then that $|\fr{t\alpha}-\fr{t\beta}|=\frac{1}{2}$ and therefore
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2p}}+\frd{\frac{(-2-p-j)t}{2p}}>\frd{\frac{1}{2}} +\frd{t\alpha}+\frd{t\beta}>1.\]
Summarizing we have that for all $t$ that are invertible modulo $2p$ that
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2p}}+\frd{\frac{(-2-p-j)t}{2p}}\geq 2\]
holds. Using the symmetry of the coordinates it follows that for all $t$ that are invertible modulo $2p$ we have
\[\frd{\frac{t}{2}}+\frd{\frac{t}{p}}+\frd{\frac{tj}{2p}}+\frd{\frac{(-2-p-j)t}{2p}}\leq 2\]
hence ${\mathbf{v}} \not \in \Lambda$, which finishes the proof.
\end{proof}
\begin{remark}
If we had taking $p$ to be a non-prime the result would be different.
This would restrict the number of possible $t$'s that can be used.
As a consequence the Picard number will probably be slightly higher.
The cases for $p=7$, $p=5$ and $p=3$ can also be computed.
If $p=7$ and $3|a$ we get $\rho(\tilde{S})=2+14(p-1)$.
For $p=5$ and $6|a$ we get $\rho(\tilde{S})=2+18(p-1)$.
For $p=3$ and $60|a$ we get $\rho(\tilde{S})=2+30(p-1)$.
Also for small $p$ the result would be higher.
\end{remark}
\bibliographystyle{plain}
| {
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From Target to Patient: How Machine Learning Can Deliver on the Promise of Value
Session Synopsis: In order to facilitate the identification of targets or to provide individualized patient care, the ultimate practice of precision medicine, optimal use of the wide variety of translational data collected on patients is of critical importance. Yet, it is difficult to identify biomarkers with traditional methods given the much larger number of variables measured, compared to the number of patients enrolled in a clinical trial. As a result, very few organizations are leveraging all their data assets to identify what treatments work best for individual patients in an unbiased manner. As the data collected in clinical trials and during a patients' life journey increases exponentially, this session aims to showcase how machine learning is a critical component to making personalized medicine a reality at the example of predictive biomarker identification, the development of holistic solutions for patients with complex diseases and its potential to impact value based pricing strategies.
Session Chair Profile
Ph.D., Associate Director, Precision Medicine Initiatives, GNS Healthcare, Inc.
Diane Wuest
Dr. Diane Wuest develops strategic relationships with precision medicine partners to develop and commercialize computer models capable of elucidating disease mechanisms, advancing drug discovery and development, and improving patient care. Diane manages ongoing alliances and leverages internal analytic and product development teams to implement company-wide initiatives. Prior to GNS Healthcare, Diane worked at Genentech and obtained a Ph.D. in chemical and biomolecular engineering from the University of Delaware. Diane holds a B.S. in chemical engineering from Cornell University.
Ph.D., Senior Vice President, DPU Head, ln Silico Discovery, GSK Pharmaceuticals
John Baldoni
John Baldoni heads a newly formed drug discovery unit dedicated to explore and apply in silico methodology to drug discovery and development at GSK. This new appointment follows his role as Senior Vice President, Platform Technology and Science (PTS), GSK Pharma R&D. Baldoni joined GSK in 1989 and has worked in the pharmaceutical industry for 37 years. His experience spans new chemical entity design, development and commercialization, and biopharmaceutical development. In progressing to his current role, Baldoni has held various positions at GSK including Senior Vice President, Preclinical Development; Vice President, Product Development; Director, Product Development; and Assistant Director, Biopharmaceutical Formulation Development, among others. He has led several key cross-functional problem solving and strategic initiatives. Baldoni has a BS in biochemistry (1974), and MS and Ph.D. degrees in chemistry (1980) from Penn State University.
Ph.D., Executive Director, Computational Biology, MRL at Merck
Joseph Lehar
Dr. Joseph Lehar is an executive director of computational biology at Merck Research Laboratories. Before MRL, Joseph built computational biology teams at Google/Verily, Novartis, and CombinatoRx, a biotech focused on drug combinations. Joseph holds a Ph.D. in physics, and his original career was astrophysics, which he pursued at MIT, Cambridge University, and Harvard. Joseph's experience includes systems biology, high-throughput screening, clinical investigations, and digital phenotypes across multiple disease areas. In his current role, Joseph is involved with external collaborations and digital health.
Ph.D., Chief Computing Officer, Calico Labs
Daphne Koller
Daphne Koller is one of the world's foremost experts in machine learning and its application to biology and human health. She is Calico's Chief Computing Officer. She was previously Co-founder and President at Coursera, a leading online educational platform, following 18 years on the Computer Science faculty at Stanford University. Koller is the recipient of the Presidential Early Career Award for Scientists and Engineers (PECASE), the MacArthur Foundation Fellowship, the ACM Prize in Computing, and membership in the U.S. National Academy of Engineering and the American Academy of Arts and Sciences. She was recognized as one of Fast Company's Most Creative People in 2014, Time Magazine's 100 Most Influential People for 2012, Newsweek's 10 Most Important People in 2010 and Huffington Post 100 Game Changers for 2010. She received her bachelor's and master's from the Hebrew University of Jerusalem, and her Ph.D. in computer science from Stanford. | {
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nice idea, shame about the execution
The revolution will be televised in low-resolution
One thing that's always bothered me about sci-fi movies is how bad everybody's communications technology is. Well, that and the costumes. Seriously, if the future is Spandex, I take back what I said about never wanting to die. But anyway, every brave new vision of the future you see, the phone system has gone to hell. Alien, Star Wars, Battlestar Galactica, you name it: people are flying around, firing laser guns, and talking through intercoms that make them sound like Stephen Hawking gargling. Even a simple video link spits and fuzzes as if they're tuning it through a coathanger. Will the future really be filled with technological marvels that enhance every area of our lives but this?
Now I realize: yes. We're already on the way. I used to listen to music on CD, watch TV on a television, take photos with a camera, and talk to people on a phone with a cord. Now I have internet radio, MP3s, YouTube, VoIP and a cellphone. Even my home landline is a wireless thing that makes people sound as if they're calling from inside an empty beer can. I don't yet watch TV on my cellphone, but my phone company wants me to, even though the screen is one inch wide. I do take photos and videos on it, and that's what I'll have to look back on: a bunch of 8x6 pixel images and footage so jerky everyone seems to be having a seizure.
You know where this started? Vinyl. Oh yes, we laughed, when the purists said CDs didn't sound as good. Well, maybe you didn't, you weren't born. But ask your Dad. Those long-haired freaks were right.
18 comments | MaxBarry.com › Max › The revolution will be televised in low-resolution
Free Money for Everyone
I was going to let this slide, because calls for schools to chase the corporate dollar are nothing new. And I like to reserve my outrage for really odious new forms of marketing. Not just whacking ads on anything that moves, but the truly insidious slime you don't really notice until it's smiling you in the face. Like the "charm offensive" aimed at making the French more polite to tourists: now that gives me the heebie-jeebies. Polite French people? That's just wrong. I like my French arrogant. If I ever step off a French airplane and hear, "Missing you already!," I will take that as a sign of the Apocalypse.
But to schools. This particular push for big business to step in to educate young minds comes from Professor Brian Caldwell, who calls the public funding model "outdated thinking":
He says partnerships with business could be valuable for both parties, for example in areas of science and technology.
"With a company like Rolls Royce you're getting not only cash support but you're also getting the opportunity of having top engineers work side by side with your teachers and your students and who also can provide marvellous work experience so yes there is self interest but it's a self interest that matches the public interest," he said.
Phew, that's lucky. For a minute I was worried that the public interest in delivering quality education to children might not completely overlap with Rolls-Royce's interest in stuffing great wads of cash into the pockets of its shareholders. Actually, I had thought that if we were brainstorming for large organizations with scads of money and an interest in public education, we might have thought of, you know, the frickin' government. I mean, I don't want to blow their cover, but government does occasionally provide services for the national good. Roads, bombing things, education; there's a whole package.
What really bothers me here is the persistent idea that you can get money from companies for nothing:
Professor Caldwell doesn't believe there is danger of too much interference, such as for example fast food companies influencing students' diets.
Corporations are the most ruthlessly rational economic entities on the planet. They have to be, because if they aren't, they die. They are subject to intense competitive pressure, and the evolutionary effect is that today's corporate giants are the sharpest, most efficient wealth-generators in history. Anything they do, it's because there's a return.
I'm fine with that. But I'm not letting one loose in a school without asking: What does it get out of this? Or put another way: What are we selling?
Advertising is so pervasive is because everyone thinks it's money for nothing: you put up some ads, you get paid, what's the harm? The non-monetary side of the transaction can't be measured. What's the undivided attention of a twelve-year old worth? What's the real cost of making our police dependent on ad revenue? What's the final invoice on installing corporate patriotism in our kids?
I don't know. But I bet it ends with smiling French people.
17 comments | MaxBarry.com › What Max Reckons › Free Money for Everyone
Killer phone
Regular site defacer Shahab writes:
We need Max's comments about the iPhone launch!
I think if I was writing Jennifer Government today, it would be phones, not sneakers.
15 comments | MaxBarry.com › What Max Reckons › Killer phone | {
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Ma Tianyu (; born 12 July 1986), also known as Ray Ma, is a Chinese Mandopop singer and actor of Hui ethnicity. He graduated from the Beijing Film Academy.
Career
2006–2008: Debut as a singer
In 2006, Ma Tianyu entered the My Hero competition. He was the regional champion for the province of Wuhan and came sixth in the final round, and was chosen as the most popular contestant.
In 2007, Ma released his first album Beautiful Light. The album was well-received, and topped the Asia Music Chart for Chinese albums. Ma won two newcomer awards at the China Billboard Award Ceremony, and Most Popular Singer awards at the 5th Southeast Music Chart Awards and 11th Tencent Star Award Ceremony. The title song of the album, "The Death of Gentleness" was also chosen as the Top Ten Songs of the Year.
2009–2013: Acting debut and breakthrough
Ma made his acting debut in the film Evening of Roses, based on a novel of the same name by Cai Zhiheng. In 2010, he played the character Jia Baoyu in the historical television series The Legend of Daiyu.
Ma first gained public attention in 2011 when he starred in wuxia drama The Vigilantes in Masks alongside Wallace Huo and Cecilia Liu. He won the Breakthrough Actor award at the 2011 Youku Television Index Awards. He then starred in Hunan TV's family drama Treasure Mother Treasure Girl (2012), which topped viewership ratings. The same year, he had a guest starring role in Xuan-Yuan Sword: Scar of Sky, which was well received by the audience.
In 2013, Ma starred in the comedy film, The Cosplayers, and was chosen as the Most Promising Film Actor for his performance.
2014–present: Rising popularity
Ma gained an increase in popularity after starring in the wuxia drama Young Sherlock (2014). His portrayal of the elegant and dandy Wang Yuanfang was praised. He continued his success streak with dual roles in Swords of Legends (2014), which was a huge commercial success. The same year he released a single titled "Narcissus". The song received positive reviews from both the media and fans and topped various music charts in China.
In 2015, Ma joined the cast of travel-reality show Sisters Over Flowers, and sung the theme song titled "Let Time Rewind in the Wind" for the show. The same year, he starred in the comedy film Surprise. The film broke a million admissions and Ma received acclaim for his dynamic portrayal of a "tragic hero". Ma received the "Outstanding Male Artist" award at the Esquire Man at His Best Award.
In 2016, Ma starred in the epic fantasy drama Ice Fantasy, based on Guo Jingming's best-selling novel City of Fantasy, playing the role of the silent and mysterious ice prince, Ying Kongshi. He became known to wider international audience following the airing of the drama. The same year, he released the album Flower in Hand to celebrate his 10th anniversary since debut.
In 2017, Ma ranked 95th on Forbes China Celebrity 100 list.
In 2018, Ma starred in the crime action film A Better Tomorrow 2018 by Ding Sheng. The same year, he starred in the television series historical drama Secret of the Three Kingdoms, playing Liu Xie; and romance melodrama All Out of Love.
In 2019, Ma starred in romance melodrama River Flows To You alongside Zheng Shuang, and romance environmental drama My Mowgli Boy alongside actress Yang Zi.
Personal life
Ma Tianyu was born in Wucheng County, Dezhou City, Shandong Province. His mother committed suicide on the night of Mid-Autumn Festival when he was 5 years old. His father also left because of debts. He and his two sisters lived with their elderly grandparents. In order to make a living, he took on the burden of supporting his family, Bei Piao, and went to work, when he was less than 16 years old. He met a group of "people closer to this circle" when he was a waiter at a bar, and they told Ma Tianyu that he should be an actor and take the Beijing Film Academy. At that time he had not found his proper career direction yet, so he accepted this suggestion from a friend. But because he was extremely timid, he least liked the atmosphere of the exam. In order to practice courage, he signed up for "Come on! Good man".
Discography
Albums
Singles
Soundtracks and promotional songs
Other appearances
Filmography
Film
Television series
Variety show
Awards and nominations
References
External links
Ma Tianyu's Weibo
1986 births
Living people
Chinese Mandopop singers
Hui male actors
Hui singers
Male actors from Shandong
People from Dezhou
Musicians from Shandong
Singers from Shandong
Chinese male television actors
Chinese male film actors
21st-century Chinese male actors
Beijing Film Academy alumni
21st-century Chinese male singers | {
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# TABLE OF CONTENTS
**INTRODUCTION**
**CHAPTER 1**
**MEET THE SPANISH LANGUAGE—Spanish Is Not a Complete Stranger, Spanish Is Not Difficult to Pronounce or Spell, Our Neighbors to the South Speak Spanish.**
**CHAPTER 2**
**SPANISH PRONUNCIATION** — **Numbers 1 to 21; Days of the Week and Months of the Year; Useful Expressions for the Traveler; Some Useful Words:** how much...?; where is...?; I want...; My name is...; numbers 20 to 100. **Summary of Spanish Consonants, The Stress in Spanish Words, Dialogues for Pronunciation Practice:** How Are You?; Days of the Week; Do You Speak Spanish?; What Is Your Name?
**CHAPTER 3**
**¿QUIÉN ES EL SEÑOR ADAMS?** -WHO IS MR. ADAMS?— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes** (Important Expressions), **Completion of Text, Grammar Notes:** definite articles, gender of nouns, plural nouns, indefinite articles, some common verbs. **Ejercicios**
**CHAPTER 4**
**¿POR QUÉ ESTUDIA EL SEÑOR ADAMS ESPANOL?** —WHY IS MR. ADAMS STUDYING SPANISH?— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** **_es, está_** , and **_hay_**; some common verbs, special uses for indefinite articles. **Ejercicios y Preguntas**
**CHAPTER 5**
**EN LA SALA DEL SEÑOR ADAMS** —IN MR. ADAMS'S LIVING ROOM— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** contractions **_del_** and **_al_**, possession, omission of indefinite article. **Ejercicios y Preguntas**
**CHAPTER 6**
**REPASO** — REVIEW CHAPTERS 1–5— **Repaso de Palabras** (Review of Words): nouns, verbs, adjectives, adverbs, prepositions, question words, conjunctions, important expressions. **Grammar Notes, Diálogos**: ¿Dónde está la calle Lerma?; ¿Dónde para el camión (autobús)? **Lectura** : El señor Adams, comerciante de Nueva York.
**CHAPTER 7**
**LOS VERBOS SON IMPORTANTES, SEÑOR** —VERBS ARE IMPORTANT, SIR— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** about verb endings; present tense of **_hablar_** , a model **_-ar_** verb;, polite and familiar _you_; negative and interrogative. **Ejercicios y Preguntas**
**CHAPTER 8**
**LA FAMILIA DEL SEÑOR ADAMS** —THE FAMILY OF MR. ADAMS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_ser, ir_** , and **_estar_**; use of **_ir_** to indicate future time, the personal **_a_**, possessive adjectives **_mi_** and **_su._** **Ejercicios y Preguntas**
**CHAPTER 9**
**EN LA OFICINA DEL SEÑOR ADAMS** —IN THE OFFICE OF MR. ADAMS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** agreement of adjectives, more about the uses of **_ser_** and **_estar._** **Ejercicios y Preguntas**
**CHAPTER 10**
**UN AMIGO VISITA LA OFICINA DEL SEÑOR ADAMS** —A FRIEND VISITS THE OFFICE OF MR. ADAMS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_aprender_** and **_vivir_** , model **_-er_** and **_-ir_** verbs; verbs followed by an infinitive with **_a._** **Ejercicios y Preguntas**
**CHAPTER 11**
**REPASO** — REVIEW CHAPTERS 7–10— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, prepositions, question words, conjunctions, important expressions. **Grammar Notes, Diálogos**: ¿Quién es Ud.?; ¿Qué camión (autobús) tomo...?; ¿Qué tranvía va a...? **Lecturas** : Dos amigos del señor Adams; El señor Adams se enferma.
**CHAPTER 12**
**EN EL COMEDOR** —IN THE DINING ROOM— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** demonstrative adjectives, present tense of **_tener_** and **_vivir._** **Ejercicios y Preguntas**
**CHAPTER 13**
**NÚMEROS, NÚMEROS, SIEMPRE NÚMEROS** —NUMBERS, NUMBERS, ALWAYS NUMBERS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** verbs with stem changes, números de uno a cien (numbers from one until one hundred). **Ejercicios y Preguntas**
**CHAPTER 14**
**EL SISTEMA MONETARIO DE MÉXICO** —THE MONETARY SYSTEM OF MEXICO— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_dar_** and **_saber_**; números de cien a mil (numbers from one hundred until one thousand); more about object pronouns. **Ejercicios y Preguntas**
**CHAPTER 15**
**PROBLEMAS DE ARITMÉTICA, EN EL RESTAURANTE, EN EL AEROPUERTO, EN LA TIENDA** —MATH PROBLEMS IN A RESTAURANT, IN THE AIRPORT, IN A STORE— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Grammar Notes:** present tense of **_hacer, decir, poner, salir, valer, traer_** , and **_caer_**; possessive adjectives; **_pero_** and **_sino._** **Ejercicios y Preguntas**
**CHAPTER 16**
**¿QUÉ HORA ES?** —WHAT TIME IS IT?— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** verbs with stem changes, time of day. **Ejercicios y Preguntas**
**CHAPTER 17**
**REPASO** — REVIEW CHAPTERS 12–16— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, prepositions, important expressions. **Grammar Notes, Diálogos:** Un turista pide información acerca de la cerámica mexicana. **Lecturas:** La familia del señor Adams viene a visitar su oficina; Una fábula moderna.
**CHAPTER 18**
**EL CINE** —THE MOVIES— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Direct Object Pronouns, Ejercicios y Preguntas**
**CHAPTER 19**
**LAS CALLES Y LAS FECHAS** —THE STREETS AND THE DATES— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_recordar_** and **_oír_**, ordinal numbers, dates, pronouns with prepositions. **Ejercicios y Preguntas**
**CHAPTER 20**
**CALLES, RÍOS, Y MONTAÑAS** —STREETS, RIVERS, AND MOUNTAINS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** comparison of adjectives, irregular comparisons, the ending - ** _ísitmo(a)_.** **Ejercicios y Preguntas**
**CHAPTER 21**
**EL DÍA DEL SEÑOR ADAMS** —MR. ADAMS'S DAY— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of model reflexive verbs, present tense of **_sentarse_** and **_verstirse_**, other reflexive verbs. **Ejercicios y Preguntas**
**CHAPTER 22**
**REPASO** —REVIEW CHAPTERS 18–21— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, prepositions, important expressions. **Ejercicios, Diálogo:** En el mercado. **Lectura:** Una visita al distrito puertorriqueño de Nueva York.
**CHAPTER 23**
**UNA NOCHE LLUVIOSA** —A RAINY NIGHT— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** imperative (command) forms of verbs, irregular imperatives, imperatives with object pronouns. **Ejercicios y Preguntas**
**CHAPTER 24**
**EL CLIMA DE MÉXICO** —THE CLIMATE OF MEXICO— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_seguir_** and **_servir_**, present participle of some common verbs, position of object pronouns with present participles. **Ejercicios y Preguntas**
**CHAPTER 25**
**EL CLIMA DE MÉXICO (CONTINUACIÓN)** —THE CLIMATE OF MEXICO (CONTINUATION)— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** negative words, infinitives after prepositions. **Ejercicios y Preguntas**
**CHAPTER 26**
**LA COMIDA MEXICANA** —MEXICAN FOOD— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_sentir_**, special uses of the pronoun **_se, conocer_** and **_saber._** **Ejercicios y Preguntas**
**CHAPTER 27**
**REPASO** —REVIEW CHAPTERS 23–26— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, prepositions, pronouns, negatives, important expressions. **Ejercicios, Diálogo** : En el mercado. **Lectura** : A Felipe no le gusta estudiar aritmética.
**CHAPTER 28**
**EL PUEBLO DE MEXICO** —THE TOWN OF MEXICO— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_volver, volver + a +_** infinitive, present tense of **_acabar, acabar + de +_** infinitive. **Ejercicios y Preguntas**
**CHAPTER 29**
**LAS ARTES POPULARES** —POPULAR ARTS (FOLK ARTS)— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** demonstrative pronouns, the closer and the farther. **Ejercicios y Preguntas**
**CHAPTER 30**
**LOS DIAS DE FIESTA** —THE FESTIVE DAYS— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present tense of **_coger_** and **_escoger_** , present participle of stem changing verbs. **Ejercicios y Preguntas**
**CHAPTER 31**
**¿QUÉ LUGARES QUIERE VISITAR, SEÑOR ADAMS?** —WHAT PLACES DO YOU WISH TO VISIT, MR. ADAMS?— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** future tense, the irregular future. **Ejercicios y Preguntas**
**CHAPTER 32**
**REPASO** —REVIEW CHAPTERS 28–31—Repaso de Palabras: nouns, verbs, adjectives, adverbs, prepositions, important expressions. **Ejercicios, Diálogos** : En el camión (autobús), sobre el correo. Lectura: El cumpleaños de la señora Adams.
**CHAPTER 33**
**EL SEÑOR ADAMS ESCRIBE UNA CARTA A SU AGENTE** —MR. ADAMS WRITES A LETTER TO HIS AGENT— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** the indirect object, indirect object pronouns, familiar verbs that may take indirect objects, indirect objects with **_gustar, parecer_** , and **_importar._** **Ejercicios, Preguntas**
**CHAPTER 34**
**EL SEÑOR ADAMS RECIBE UNA CARTA** —MR. ADAMS RECEIVES A LETTER— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** use of **_hacer_** in time expressions, use of definite articles in place of possessive adjectives, reflexive pronouns with reciprocal meaning. **Ejercicios y Preguntas**
**CHAPTER 35**
**LOS CONSEJOS DEL SEÑOR LÓPEZ** —MR. LOPEZ'S ADVICE— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** present perfect tense, past participles with accent marks, irregular past participles, **_haber_** and **_tener._** **Ejercicios y Preguntas**
**CHAPTER 36**
**EL SEÑOR ADAMS SALE PARA MÉXICO** —MR. ADAMS LEAVES FOR MEXICO— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** the present tense of **_dormir_** and **_despedirse_** , the present perfect tense of **_dormir_** and **_despedirse_** , past participles used as adjectives. **Ejercicios y Preguntas**
**CHAPTER 37**
**REPASO** — REVIEW CHAPTERS 33–36— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, important expressions. **Ejercicios, Diálogo** : En el aeropuerto. **Lectura** : Un programa extraordinario en el cine.
**CHAPTER 38**
**EL SEÑOR ADAMS LLEGA A MÉXICO** —MR. ADAMS ARRIVES IN MEXICO— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** the preterite tense, preterites of **_leer, creer, caerse_** , and **_oír._** **Ejercicios y Preguntas**
**CHAPTER 39**
**UNA VISITA A LA FAMILIA CARRILLO** —A VISIT TO THE CARRILLO FAMILY— **Pronunciation and Spelling Aids, Building Vocabulary, Expresiones Importantes, Completion of Text, Grammar Notes:** irregular preterites with -i- stems, preterite tense of stem changing verbs like **_pedir._** **Ejercicios y Preguntas**
**CHAPTER 40**
**EL PASEO DE LA REFORMA** —THE PASEO DE LA REFORMA— **Pronunciation and Spelling Aids, Building Vocabulary, Completion of Text, Grammar Notes:** irregular preterites with **_-u-_** stems, more irregular preterites, the personal **_a._** **Ejercicios y Preguntas**
**CHAPTER 41**
**EL MERCADO DE TOLUCA** —THE TOLUCA MARKET— **Pronunciation and Spelling Aids, Building Vocabulary, Completion of Text, Grammar Notes:** the imperfect tense; the imperfect of model verbs **_hablar, aprender_** , and **_vivir_** ; the imperfect of **_ver, ser_** , and **_ir._** **Ejercicios y Preguntas**
**CHAPTER 42**
**SOBRE EL DESCANSO** —ABOUT LEISURE TIME— **Completion of Text, Grammar Notes:** possessive pronouns, definite articles as pronouns. **Ejercicios y Preguntas**
**CHAPTER 43**
**REPASO** —REVIEW CHAPTERS 38–42— **Repaso de Palabras:** nouns, verbs, adjectives, adverbs, prepositions, conjunctions, important expressions. **Ejercicios, Diálogo:** En la gasolinera. **Lecturas:** Una visita a Xochimilco, En la Avenida Juárez.
**CHAPTER 44**
**LA PLAZA** —THE SQUARE— **Vocabulario, Test of Reading Comprehension, Completion of Text, Grammar Notes:** present and preterite of **_dormir_** , relative pronouns. **Ejercicios**
**CHAPTER 45**
**UN PASEO A TEOTIHUACÁN** —A WALK TO TEOTIHUACAN— **Vocabulario, Expresiones Importantes, Test of Reading Comprehension, Completion of Text, Grammar Notes:** past perfect tense of model verbs **_hablar, aprender_ , and _vivir_** ; verbs with spelling changes. **Ejercicios**
**CHAPTER 46**
**EL SEÑOR ADAMS COMPRA UN BILLETE DE LOTERÍA** —MR. ADAMS BUYS A LOTTERY TICKET— **Vocabulario, Test of Reading Comprehension, Completion of Text, Grammar Notes:** present conditional of model verbs **_hablar, aprender_** , and **_vivir_** ; the irregular conditional. **Ejercicios**
**CHAPTER 47**
**EL SEÑOR ADAMS NO ES AFICIONADO A LOS TOROS** —MR. ADAMS IS NOT A FAN OF BULLS— **Vocabulario, Expresiones Importantes, Test of Reading Comprehension, Completion of Text, Grammar Notes:** two object pronouns. **Ejercicios**
**CHAPTER 48**
**EL SEÑOR ADAMS SALE DE MÉXICO** —MR. ADAMS LEAVES MEXICO— **Vocabulario, Expresiones Importantes, Test of Reading Comprehension, Grammar Notes:** **_saber_** and **_poder_** , the untranslated **_que._** **Ejercicios**
**CHAPTER 49**
**REPASO** — REVIEW CHAPTERS 44–48— **Repaso de Palabras:** nouns, verbs, prepositions, important expressions. **Ejercicios, Lecturas:** Las Pirámides de Teotihuacán, En el Zócalo.
**CHAPTER 50**
**DICCIONARIO— Spanish-English**
DICTIONARY— English-Spanish
**CHAPTER 51**
**RESPUESTAS Y TRADUCCIONES** —ANSWERS AND TRANSLATIONS
# INTRODUCTION
# ¡BIENVENIDOS!
Welcome!
Do you wish to acquire enough knowledge of Spanish to meet your needs as tourist or business traveler in a Spanish-speaking country? Do you wish to be able to read simple Spanish texts? Do you wish to build a foundation in the Spanish language for further study in secondary school or college? SPANISH MADE SIMPLE meets the needs of the self-learner, whether the aim is the practical conversation and comprehension ability needed by a tourist or businessperson, or the wish to read in Spanish. It can also serve as an excellent refresher course for those who already have had some study of the language.
SPANISH MADE SIMPLE will enable you to attain your goal. The essential grammatical facts of Spanish grow naturally out of conversation and reading texts. The concepts are clearly explained. Nonessentials are omitted. The illustrative drills and exercises will help you gain a practical knowledge of the elements of Spanish and lay the foundation for a more advanced study of the language.
SPANISH MADE SIMPLE has several features that will help you to learn. Each chapter begins with a parallel, bilingual text, which eliminates the burdensome and time-consuming need to look up words in the dictionary. Each chapter also includes dialogues that deal with common topics, vocabulary building exercises, and Spanish practice questions. To reinforce your comprehension, there are examples provided for selected exercises. Every few chapters, you'll find a review chapter, which provides easy reference to the terms and rules covered so far. This will help you to gauge your progress as you go.
Important words, expressions, and cultural facts are presented through a series of conversations between a Mexican teacher, Mr. López, and his pupil, Mr. Adams. Mr. Adams is a businessman from New York who is about to take a trip to Latin America. He hopes to learn enough Spanish to meet his needs as both a tourist and a business traveler in a Spanish-speaking country. As you follow him through his lessons, you will also be learning to speak, read, and understand Spanish.
In the revision of this classic and popular Spanish textbook, I have removed outdated or archaic words and phrases and added idiomatic expressions. I also included new words and phrases that correspond with advancements in technology, and updated words and grammatical forms to follow new rules of spelling and written accents. I updated some of the statistical information and modernized the content of several readings. I also added some explanations of the grammatical rules, to help you better understand the structure of Spanish.
This new edition also features illustrations that. highlight some of the expressions and grammatical rules covered in the chapters in which they appear. They will help you apply the information to a visual and tangible situation. For quick reference, you'll find a Spanish to English dictionary and an English to Spanish dictionary located at the back of the book. There is also an answer key, so you can check your answers and track your progress.
The most important advice I can offer is this: practice aloud, memorize the new words and expressions of each chapter, write out the exercises, and you will enjoy the process of learning a new language!
— _Dr. Judith Némethy is the Director of Spanish Language Studies, Department of Spanish and Portuguese Languages and Literatures at New York University._
# CHAPTER 1
CAPÍTULO 1 (UNO)
# MEET THE SPANISH LANGUAGE
## 1. SPANISH IS NOT A COMPLETE STRANGER.
On your introduction to the Spanish language you will be glad to learn that you already know or can guess the meaning of many Spanish words.
First of all, there are those words that are spelled alike and have the same meaning in Spanish and English. For example:
**actor** | **color** | **doctor** | **gratis** | **canal** | **conductor** | **hospital**
---|---|---|---|---|---|---
**hotel** | **error** | **piano** | **animal** | **auto** | **principal** | **director**
Then there are many Spanish words whose spelling is only a bit different from like words in English, and whose meaning is easily recognized. Thus:
**aire** | **arte** | **centro** | **barbero** | **mula** | **profesor** | **conversación**
---|---|---|---|---|---|---
_air_ | _art_ | _center_ | _barber_ | _mule_ | _professor_ | _conversation_
Many Spanish verbs differ from corresponding English verbs only in the matter of ending. Thus:
**declarar** | **adorar** | **admirar** | **usar** | **informar** | **defender** | **dividir**
---|---|---|---|---|---|---
_declare_ | _adore_ | _admire_ | _use_ | _inform_ | _defend_ | _divide_
English has borrowed words directly from Spanish with or without changes in spelling. Thus:
**adobe** | **rodeo** | **fiesta** | **lazo** | **patio** | **tomate** | **siesta** | **rancho**
---|---|---|---|---|---|---|---
_adobe_ | _rodeo_ | _fiesta_ | _lasso_ | _patio_ | _tomato_ | _siesta_ | _ranch_
Spanish has borrowed words directly from English. This is especially true in the field of sports. You will recognize these words even in their strange spellings.
**rosbif** | **mitin** | **pudín** | **tenis** | **béisbol** | **fútbol** | **básquetbol**
---|---|---|---|---|---|---
_roast beef_ | _meeting_ | _pudding_ | _tennis_ | _baseball_ | _football_ | _basketball_
The similarities between the Spanish and English vocabularies will be a great help to you in learning Spanish. However, you must bear in mind that words of the same or similar spelling in the two languages are pronounced differently. Also you must be on the lookout for some Spanish words that are alike or similar in spelling to English words, but different in meaning.
## 2. SPANISH IS NOT DIFFICULT TO PRONOUNCE OR SPELL.
Spanish is a phonetic language. This means that words are spelled as they are pronounced. There are no silent letters in Spanish except h, which is always silent, and u, which is silent under certain circumstances. How much simpler this is than English, where such words as _height, knight, cough, rough, rogue, weigh, dough_ , and a host of others, give so much difficulty to the foreigner learning English.
When you see the letter a in Spanish words like **Ana, mapa, sala** , you know it is pronounced like a in _father_ , because Spanish a is always like _a_ in _father._ It is never like _a_ in _cat, all, ox fame._ Like a, the other letters of the Spanish alphabet are an accurate guide to the pronunciation of the words.
In Chapter 2, the pronunciation of the Spanish sounds—and their spelling—is explained in detail. Most of the Spanish sounds have like sounds in English, or sounds so similar that they are easy to learn. The description of the sounds should enable you to pronounce them quite well. If possible, you should get some Spanish-speaking person to help you with your pronunciation, for it is important for you to hear the sounds correctly spoken and to have your own pronunciation checked.
You can improve your pronunciation and understanding of the spoken word by listening to Spanish recordings, radio broadcasts, and TV programs. The "commercials" are particularly valuable for this purpose, because they contain so much repetition and emphatic expression. At first a few minutes of listening each day will suffice. As you progress in your study of Spanish you should increase the amount.
## 3. OUR NEIGHBORS TO THE SOUTH SPEAK SPANISH
Spanish-speaking countries of the Western Hemisphere include: all the republics of South America (with the exception of Brazil, Guyana, Surinam, and French Guiana); all the republics of Central America (except Belize, formerly British Honduras); Cuba, Puerto Rico, and the Dominican Republic in the West Indies; and our nearest southern neighbor, Mexico. They include some 300 million people. The Spanish that they speak differs in some respects from Castilian Spanish, the official language of Spain. The chief differences are in the pronunciation of **z** , and **c** (before **e** and **i** ). In Castilian these letters are pronounced like _th_ in _think._ In the Spanish of Latin America they are pronounced like _s_ in _see._
This book teaches the pronunciation of our Spanish-speaking neighbors. This is desirable because of the ever-growing business and cultural intercourse between our country and the people in the southern half of our hemisphere. Mexico in particular has become a favorite country for businesspeople and tourists from the United States, thousands of whom visit it every year.
# CHAPTER 2
CAPÍTULO 2 (DOS)
# SPANISH PRONUNCIATION
This chapter contains many useful words and expressions. If you follow the instructions for pronunciation practice carefully, you will acquire many of these without difficulty. It is not necessary to try to memorize all of them at this point, as they will appear again in later chapters when you will have opportunity to learn them thoroughly. However, it is desirable to memorize at once the numbers and the days of the week, as these serve to illustrate most of the Spanish sounds.
## PRIMERA PARTE
### The Numbers 1 to 21
Among the most important words in any language are the numbers. Let us start by learning the Spanish numbers 1 to 21. These numbers illustrate many of the Spanish sounds. Pronounce each number aloud five times. Stress (emphasize) the syllables in heavy type.
1. **uno** ( ** _oo_ -noh**) Spanish **u** is like _oo_ in _booth._ Symbol, _oo._
Spanish **o** is like _o_ in _bone._ Symbol _oh._
2. **dos** ( _dohs_ ) Spanish **s** is like 5 in _see._
3. **tres** ( _trays_ ) Spanish **e** is like _ay_ in _day._ Symbol, _ay._
Remember: **s** is like s in _see._
4. **cuatro** ( ** _kwah_ -troh**) In the combination ua, the **u** is pronounced like _w._ **ua** = _wah._ There is no letter _w_ in Spanish.
Spanish **r** is like _r_ in _three._ It has a slight trill.
5. **cinco** ( ** _seen_ -koh**) Spanish **i** is like _ee_ in _seen._ Symbol, _ee._
**c** is pronounced as in English; like s,
before _e_ or _i_ ( _ceiling, cinder_ ); like _k_ ,
before any other letter. There is no letter
_k_ in Spanish.
6. **seis** ( _sayees_ ) The combination ei is pronounced _ayee._ Pronounce the first part ( _ay_ ) stronger than the second part ( _ee_ ).
7. **siete** ( _syay-tay_ ) In the combination **ie** , the **i** is pronounced like _y_ in _yes._ Thus **ie** = yay.
8. **ocho** ( ** _oh_ -choh**) **ch** is like the English _ch_ in _choke._ In Spanish, **ch** is considered a single letter and follows **c** in the alphabet and dictionary.
9. **nueve** ( ** _nway_ -vay**) The combination **ue** is pronounced _way._
10. **diez** ( _dyays_ ) Spanish **z** equals _s_ as in _see._ It is not like English _z._
11. **once** ( ** _ohn_ -say**)
12. **doce** ( ** _doh_ -say**)
13. **trece** ( ** _tray_ -say**)
14. **catorce** ( _kah- **tor** -say_) The letter o is some-times pronounced as in the English word _for._ In such cases o is used as a symbol instead of _oh._
15. **quince** ( ** _keen_ -say**) **qu** always equals _k._ **qu** is found only before **e** and **i.**
16. **dieciséis** ( _dyays-ee-sayees_ )
17. **diecisiete** ( _dyays-ee- **syay** -tay_)
18. **dieciocho** ( _dyays-ee-oh-choh_ )
19. **diecinueve** ( _dyays ee **nway** -vay_)
20. **veinte** ( _yayeen-tay_ )
21. **veintiuno** ( ** _vayeen_ -t-ee-oo-noh**)
Practice aloud and memorize:
1. **uno** ( _ **oo** -noh_)
2. **dos** ( _dohs_ )
3. **tres** ( _trays_ )
4. **cuatro** ( ** _kwah_ -troh**)
5. **cinco** ( ** _seen_ -koh**)
6. **seis** ( _sayees_ )
7. **siete** ( ** _syay_ -tay**)
8. **ocho** ( ** _oh_ -choh**)
9. **nueve** ( ** _nway_ -vay**)
10. **diez** ( _dyays_ )
11. **once** ( ** _ohn_ -say**)
12. **doce** ( ** _doh_ -say**)
13. **trece** ( ** _tray_ -say**)
14. **catorce** ( _kah-tor-say_ )
15. **quince** ( _keen-say_ )
16. **dieciséis**
17. **diecisiete**
18. **dieciocho**
19. **diecinueve**
20. **veinte** ( ** _vayeen_ -tay**)
21. **veintiuno**
Summary of Spanish Vowels and Vowel Combinations Learned Thus Far
| **VOWELS** | **VOWEL COMBINATIONS**
---|---|---
Spanish letters | **a** | **e** | **i(y)** | **o** | **u** | **ua** | **ue** | **ie** | **ei**
Symbols | _ah_ | _ay_ 1 | _ee_ | _oh_ 1 | _oo_ | _wah_ | _way_ | _yay_ | _ayee_
**NOTE** : 1. **_oh_** and **_ay_** are not exact equivalents of Spanish **o** and **e** but they are near enough for practical purposes.
### Days of the Week and Months of the Year
Practice aloud and memorize. The names of the days and months contain only one sound not found in the numbers 1–21; namely **j.** Spanish **j** is something like a strong English _h._
**domingo** ( _doh- **meen** -goh_) | Sunday
---|---
**lunes** ( ** _loo_ -nays**) | Monday
**martes** ( ** _mahr_ -tays**) | Tuesday
**miércoles** ( _myayr-koh-lays_ ) | Wednesday
**jueves** ( ** _hway_ -vays**) | Thursday
**viernes** ( ** _vyayr_ -nays**) | Friday
**sábado** ( ** _sah_ -bah-doh**) | Saturday
**enero** ( _ay- **nay** -roh_) | January
---|---
**febrero** ( _fay- **bray** -roh_) | February
**marzo** ( ** _mahr_ -soh**) | March
**abril** ( _ah- **breel**_ ) | April
**mayo** ( ** _mah_ -yoh**) | May
**junio** ( ** _hoo_ -nyoh**) | June
**julio** ( ** _hoo_ -lyoh**) | July
**agosto** ( _ah-gos-toh_ ) | August
**septiembre** ( _say- **tyaym** -bray_) | September
**octubre** ( _ok- **too** -bray_) | October
**noviembre** ( _noh- **vyaym** -bray_) | November
**diciembre** ( _dee- **syaym** -bray_) | December
**NOTE** : The combination **io** is pronounced **yoh**.
## SEGUNDA PARTE
### Useful Expressions for the Traveler
Here are some key words which every traveler needs:
1. **por favor** ( ** _por_ fah-vor**) please. This is most handy for introducing a question or request.
2. **señor** ( _say- **ñor**_ ) Mr., sir; **señora** ( _say- **ño** -rah_) Mrs., madame; **señorita** ( _say- **ño-ree** -tah_) Miss. It's polite to follow your por favor with one of these. **Por favor, señor** , etc.
**NOTE** : **ñ** is like n in onion. Everyone knows this sound in **mañana** , tomorrow, **ñ** follows **n** in the alphabet and dictionary.
3. **¿Cuánto cuesta?** ( ** _kwahn_ -toh **kways** -tah**) How much does it cost? For short, ¿ **Cuánto**? will do.
The following are appropriate answers: **Es**
**caro** ( _ays kah-roh_ ) It is expensive. **Es más**
**barato** ( _ays mahs bah-rah-toh_ ) It is cheaper.
**NOTE** : Spanish questions begin with an inverted question mark.
4. **¿Dónde está** —? ( _dohn-day ays- **tah**_ ) Where is—?
5. **Quiero** ( _kyay-roh_ ) I want. **Deseo** ( _day- **say** -oh_) I want. If you begin with **Por favor** , you won't sound too abrupt.
6. **¿A qué hora?** ( _ah kay **oh** -rah_) At what time? The Spanish says: At what hour?
**NOTE** : **h** in Spanish is always silent
7. **Muchas gracias** ( _moo-chahs **grah** -syahs_) Many thanks. Thank you very much.
**NOTE** : The combination **ia** is pronounced yah.
8. **De nada** ( _day **nah** -thah_) or No hay **de qué** ( _ahee day **kay**_ ). Don't mention it or you're welcome. You'll hear either of these in reply to your **gracias.**
9. ¿ **Cómo se llama usted**? ( ** _koh_ -moh say **yah** -mah oos- **tayd**** ) What's your name? The Spanish says: What do you call yourself?
**NOTE** : **II** is pronounced like y in you. **II** is considered a single letter in Spanish and follows **I** in the alphabet and dictionary.
10. **Me llamo**... ( _may **yah** -moh_) My name is... The Spanish say: I call myself...
### Some Useful Words
Repeat aloud, three times, the words listed under each heading. Then repeat each word with the heading under which it is listed. Thus:
**Ejemplo: 1. ¿Cuánto cuesta el 1 sarape? etc.** | **¿Dónde está la calle Gante? etc.**
---|---
**¿Cuánto cuesta...?**
1. **el sarape** ( _sah- **rah** -pay_) or la **cobija** ( _coh- **bee** -hah_) blanket
2. **el rebozo** 2 ( _rray- **boh** -soh_) or **la chal** ( _chal_ ) shawl
3. **el sombrero** ( _sohm- **bray** -roh_) hat
4. **la blusa** ( ** _bloo_ -sah**) blouse
5. **la camisa** ( _kah- **mee** -sah_) shirt
6. **el vestido** ( _vays- **tee** -doh_) dress
7. **la cesta** ( ** _says_ -tah**) basket
8. **el plato** ( ** _plah_ -toh**) plate
9. **el jarro** ( ** _hah_ -rroh**) or **la jarra** ( ** _hah_ -rrah**) pitcher
10. **el automóvil** 3 ( _ow-toh- **moh** -veel_) automobile
NOTE:
1. Pronounce **el** like _ell_ in _bell_ , **el** = _the_ before a masculine noun and **la** = _the_ before a feminine noun. You will learn more about these later
2. **r** at the beginning of a word, and **rr** are strongly trilled, like the _r_ of the telephone operator in _thrrr-ee. rr_ is a letter in Spanish but no word begins with **rr.**
3. **au** = _ow_ as in _how._
**¿Dónde está...?**
1. **la calle Gante** ( _kah-yay **gahn** -tay_) Gante Street
2. **la avenida Juárez** ( _ah-vay- **nee** -dah **hwah** -rays_) Juarez Avenue
3. **el hotel** ( _oh- **tel**_ ) hotel
4. **el lavabo** ( _lah- **vah** -boh_) washroom
5. **el baño** ( ** _bahn_ -yoh**) bathroom
6. **el correo** ( _koh- **rray** -oh_) post office
7. **el museo** ( _moo- **say** -oh_) museum
8. **el agente** ( _ah- **hayn** -tay_) agent
9. **la oficina** ( _oh-fee- **see** -nah_) office
10. **el garage** ( _gah- **rah** -hay_) garage
**NOTE** : **g** , before **e** or i, is pronounced like Spanish **j.** Before any other letter it is hard as in _goat_
### Quiero... Deseo...
1. **un cuarto con baño** ( ** _kwahr_ -toh kon **bah** -ñoh**) a room with bath
2. **agua caliente** ( ** _ah_ -gwah kah **lyayn** -tay**) hot water
3. **el jabón** ( _hah- **bohn**_ ) soap
4. **toallas** ( _toh- **ah** -yahs_) towels
5. **el mené** ( _may- **noo**_ ) mené
6. **la cuenta** ( ** _kwayn_ -tah**) bill
7. **la revista** ( _rray- **vees** -tah_) magazine
8. **el diario** ( ** _dyahr_ -yoh**) newspaper
9. **telefonear** ( _tay-lay-foh-nay- **ahr**_ ) to telephone
10. **cambiar dinero** ( _kahm- **byahr** dee- **nay** -roh_) to change money
### Me llamo...
1. **el señor Gómez** ( ** _goh_ -mays**) Mr. Gomez
2. **la señora de Gómez** Mrs. Gomez
3. **Pablo** ( ** _pah_ -bloh**) Paul
4. **Felipe** ( _fay- **lee** -pay_) Philip
5. **Roberto** ( _rroh- **ber** -to_) Robert
6. **José** ( _hoh- **say**_ ) Joseph
7. **Juan** ( _hwahn_ ) John
8. **Isabel** ( _ee-sah- **bel**_ ) Isabelle
9. **Ana** ( ** _ah_ -nah**) Anna
10. **María** ( _mah- **ree** -ah_) Mary
### The Numbers 20 to 100
Practice aloud:
* 20 **veinte** ( ** _vayeen_ -tay**)
* 22 **veintidós**
* 30 **treinta** ( ** _trayeen_ -tah**)
* 33 **treinta y tres**
* 40 **cuarenta** ( _kwah- **rayn** -tah_)
* 44 **cuarenta y cuatro**
* 50 **cincuenta** ( _seen- **kwayn** -tah_)
* 55 **cincuenta y cinco**
* 60 **sesenta** ( _say- **sayn** -tah_)
* 66 **sesenta y seis**
* 70 **setenta** ( _say- **tayn** -tah_)
* 77 **setenta y siete**
* 80 **ochenta** ( _oh- **chayn** -tah_)
* 88 **ochenta y ocho**
* 90 **noventa** ( _noh- **vayn** -tah_)
* 99 **noventa y nueve**
* 100 **cien** ( _syayn_ )
* 101 **ciento uno** ( ** _syayn_ -toh oo-noh**)
Practice aloud:
* 10 **diez sarapes**
* 20 **veinte rebozos**
* 30 **treinta sombreros**
* 40 **cuarenta blusas**
* 50 **cincuenta camisas**
* 60 **sesenta vestidos**
* 70 **setenta cestas**
* 80 **ochenta platos**
* 90 **noventa jarros**
* 100 **cien garages**
**NOTE** : **cien** is used instead of **ciento** before a noun.
## SUMMARY OF THE SPANISH CONSONANTS
Most of the Spanish consonants are pronounced like or almost like corresponding English consonants. The following however deserve special attention:
**b, v** | There is no difference between these sounds. Both are made with the lips slightly open, **sábado** , **lavabo**
---|---
**c 1** | is like English _c_ , that is, it is pronounced like a hissing _s_ before **e** or **i** , and like _k_ before any other letter.
**cinco** ( ** _seen_ -ko**h). **cc** = _ks._ **lección** = _layk- **syohn**_
**d, t** | like the English sounds, but tongue is against the teeth. Between vowels, d is more like th in this. **nada** ( _nah-thah_ )
**h** | always silent. **hay, hoy**
**j** | like a strong English _h._ **jueves** ( ** _hway_ -vays**)
**g** | like hard _g_ in _go._ Before **e** or **i** it is like Spanish **j. garage** ( _gah- **rah** -hay_)
**ll 1** | like _y_ in _you._ **llamo** ( ** _yah_ -moh**)
**ñ** | like _n_ in onion, **mañana** ( _man- **yah** -nah_)
**rr** | pronounced with a strong trill as in thrrrr-ee. **jarro** ( ** _hah_ -rroh**)
**r** | pronounced like **rr** , at the beginning of a word. At other times it has a slight trill. **rebozo** ( _rray- **boh** -soh_) **sombrero** ( _sohm- **bray** -roh_)
**s, z** 1 | like hissing s in see. **sesenta** ( _say- **sayn** -tah_) **diez** ( _dyays_ )
**qu** | like k. quince ( ** _keen_ -say**)
**NOTE** : 1. In Castilian Spanish, **c** (before **e** and **i** ) and **z** , are like _th_ in _think_ : and **ll** is like _lli_ in _million._
## TERCERA PARTE
### The Stress in Spanish Words
The stressed syllable of a word is the syllable that is emphasized. In the word _father_ , the syllable _fa-_ gets the stress; in _alone, -lone_ gets the stress; in _education_ , the stressed syllable is _-ca._ There are no good rules for stress in English.
In Spanish there are three simple rules by means of which you can tell which syllable of a word is stressed. They are:
**RULE 1.** If a word ends in **a e i o u n** or **s** , the next to the last syllable is stressed.
---
som- **bre** -ro | a-ve- **ni** -da | **sie** -te | **quin** -ce | lu- **nes** | se- **ño** -ra | re- **bo** -zo
**RULE 2.** If a word ends in any consonant, except n or s, the last syllable is stressed.
se- **ñor** | ho- **tel** | fa- **vor** | I-sa- **bel** | us- **ted** | cam- **biar** | te-le-fo-ne- **ar**
**RULE 3.** If the stress does not follow Rules 1 or 2, an accent mark shows which syllable is stressed.
**sá** -ba-do | **miér** -co-les | **Gó** -mez | ja- **bón** | Jo- **sé** | au-to- **mó** -vil |
### Dialogues for Pronunciation Practice
Directions for Study of Dialogues
1. Read the Spanish text silently, sentence by sentence, using the English translation to get the meaning.
2. Practice aloud the words that follow the text under the heading "Practice These Words."
3. Finally read the whole Spanish text aloud several times.
**Diálogo 1** ( _dee **-ah** -loh-goh_)
---
**¿Cómo Está listed?** | How Are You?
1. **Buenos días, señor López. ¿Cómo está usted?** | 1. Good day, Mr. Lopez. How are you?
2. **Muy bien, gracias. ¿Y usted?** | 2. Very well, thank you. And you?
3. **Muy bien, gracias. ¿Y cómo está la señora de López?** | 3. Very well, thank you. And how is Mrs. Lopez?
4. **Muy bien, gracias. ¿Y cómo están su papá y su mamá?** | 4. Very well, thank you. And how are your father and mother?
5. **Muy bien, gracias. Hasta la vista, señor López.** | 5. Very well, thank you. Good-bye, Mr. Lopez.
6. **Hasta mañana, Felipe.** | 6. Until tomorrow, Philip.
### Practice These Words
1. **buenos días** ( ** _bway_ -nohz **dee** -ahs**). Pronounce the **s** of **buenos** like the English _z_ instead of like the usual _s_ sound.
2. **muy bien** ( _mwee **byayn**_ ) gracias ( _grah-syas_ )
3. **cómo** ( ** _koh_ -moh**) **están** ( _ays- **tahn**_ )
4. **papá** ( _pah- **pah**_ ) **mamá** ( _mah- **mah**_ )
5. **hasta la vista** ( ** _ahs_ -tah lah **vees** -tah**)
6. **usted** ( _oos- **tayd**_ )
7. **hasta** ( _ahs-tah_ )
**Diálogo 2**
---
**Los días de la semana** | The Days of the Week
**1. ¡Oiga, Jaime! ¿Cuántos días hay en una semana?** | 1. Listen, James. How many days are there in one week?
**2. Hay siete días en una semana.** | 2. There are seven days in one week.
**3. Bueno. Dígame, por favor, los siete días.** | 3. Good. Tell me, please, the seven days.
**4. Los siete días de la semana son lunes, martes, miércoles, jueves, viernes, sábado y domingo.** | 4. The seven days of the week are Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday.
**5. Muy bien. ¡Oiga, Jorge! ¿Qué día es hoy?** | 5. Very good. Listen, George, what day is today?
**6. Hoy es lunes. Mañana es martes.** | 6. Today is Monday. Tomorrow is Tuesday.
**7. Carlos, ¿sabe usted los números desde uno hasta doce?** | 7. Charles, do you know the numbers from one to twelve?
**8. Sí, señor, los números son uno, dos, tres, cuatro, cinco, seis, siete, ocho, nueve, diez, once, doce.** | 8. Yes, sir, the numbers are one, two, three, four, five, six, seven, eight, nine, ten, eleven, twelve.
**9. Muy bien, Carlos.** | 9. Very good, Charles.
### Practice These Words
1. **oiga** ( ** _oi_ -gah**) oi in Spanish is like oi in oil.
2. **hoy** ( _oy_ ) oy in Spanish is like oy in boy.
3. **hay** ( _ay_ ) ay and ai are like ai in aisle.
4. **semana** ( _say-mah-nah_ )
5. **dígame** ( ** _dee_ -gah-may**)
6. **Jorge** ( ** _hor_ -hay**)
7. **sabe** ( ** _sah_ -bay**)
8. **desde** ( ** _dayz_ -day**)
**Diálogo 3**
---
**¿Habla listed Español?** | Do You Speak Spanish?
1. **¿Habla usted español, Claudio?** | 1. Do you speak Spanish, Claude?
2. **Sí, señor, yo hablo español.** | 2. Yes, sir, I speak Spanish.
3. **¿Habla Pancho español?** | 3. Does Frank speak Spanish?
4. **Sí, señor, él habla español bien.** | 4. Yes, sir, he speaks Spanish well.
5. **¿Habla Paulina español?** | 5. Does Pauline speak Spanish?
6. **Sí, señor, ella habla español bien.** | 6. Yes, sir, she speaks Spanish well.
7. **¿Habla ella inglés también?** | 7. Does she speak English also?
8. **No, señor, ella no habla inglés.** | 8. No, sir, she does not speak English.
9. **¿Es Pablo de México?** | 9. Is Paul from Mexico?
10. **Sí, señor, él es de México. Es mexicano.** | 10. Yes, sir, he is from Mexico. He is a Mexican.
**NOTE** : The subject pronouns— **yo** , I; **el** , he; and **ella** , she—are usually omitted in Spanish. They are used here for emphasis.
### Practice These Words
1. **español** ( _ays-pah-ñol_ )
2. **hablo** ( ** _ah_ -bloh**), **habla** ( ** _ah_ -blah**)
3. **yo** ( _yoh_ ), **él** ( _el_ ), **ella** ( _ay-yah_ ), **usted** ( _oos- **tayd**_ ) or ( _oos- **stay**_ )
4. **Paulina** ( _pow- **lee** -nah_)
5. **México** ( ** _may_ -hee-coh**). The **x** in México is pronounced like Spanish **j.** Outside the country of México the name is often spelled **Méjico.** The usual pronunciation of Spanish **x** is as in English.
**Diálogo 4**
---
**¿Cómo Se Llama Ud.?** | What Is Your Name?
1. **¿Cómo se llama Ud., joven?** | 1. What is your name, young man?
2. **Me llamo Pablo Rivera.** | 2. My name is Paul Rivera.
3. **¿Dónde vive Ud.?** | 3. Where do you live?
4. **Vivo en la calle 23 (veintitrés).** | 4. I live on 23rd Street.
5. **¿Cuántas personas hay en su familia?** | 5. How many persons are there in your family?
6. **Hay cinco personas: mi padre, mi madre, mi hermano Carlos, mi hermana Ana y yo.** | 6. There are five persons, my father, my mother, my brother Charles, my sister Anna, and I.
7. **Ud. habla bien español. ¿Estudia Ud. esta lengua en la escuela?** | 7. You speak Spanish well. Are you studying the language in school?
8. **Sí, señor. Además hablamos Español en casa. Mis padres son puertorriqueños.** | 8. Yes, sir. Besides, we speak Spanish at home. My parents are Puerto Ricans.
9. **Adiós, Pablo.** | 9. Good-bye, Paul.
10. **Adiós, señor.** | 10. Good-bye, sir.
**NOTE** : 1. **Ud.** or **Vd.** are abbreviations of usted.
### Practice These Words
1. **llama** ( ** _yah_ -mah**) **calle** ( ** _kah_ -yay**)
2. **joven** ( ** _hoh_ -vayn**) **Rivera** ( _rree- **vay** -rah_)
3. **vive** ( ** _vee_ -vay**) **vivo** ( ** _vee_ -voh**)
4. **personas** ( _per- **soh** -nahs_) **familia** ( _fah- **mee** -lyah_)
5. **padre** ( ** _pah_ -dray**) **madre** ( ** _mah_ -dray**)
6. **mi hermana** ( _mee er- **mah** -nah_)
7. **estudia** ( _ays- **too** -dyah_) **lengua** ( ** _layn_ -gwah**)
8. **en la escuela** ( _ayn lah ays- **kway** -lah_)
9. **hablamos** ( _ah- **blah** -mohs_)
10. **además** ( _ah-day- **mahs**_ )
11. **puertorriqueños** ( _pwer-toh-rree- **kay** -ñohs_)
12. **adiós** ( _ah- **dyohs**_ )
# CHAPTER 3
CAPÍTULO 3 (TRES)
You now have a good working knowledge of Spanish pronunciation and are ready for a more intimate study of the language. However, pronunciation must at no time be neglected. Practice conscientiously the pronunciation aids after each conversational text and follow all directions for reading aloud and speaking. Remember: the only way you can learn to speak a language is by speaking it.
This chapter will introduce you to Mr. Adams, a New York businessman who is as eager as you are to learn Spanish. You will also meet his congenial teacher, el Señor López, a Mexican living in New York. As he teaches Mr. Adams he will also teach you in a pleasant and interesting way.
So buena suerte (good luck) and buen viaje (happy voyage) as you accompany Mr. Adams on the road which leads to a practical knowledge of the Spanish language.
## PRIMERA PARTE
### ¿Quién es el señor Adams? Who Is Mr. Adams?
**Instrucciones para estudiar.** Instructions for study.
1. Read the Spanish text silently referring to the English only when necessary to get the meaning.
2. Cover up the English text and read the Spanish text silently.
3. Study the Pronunciation and Spelling Aids which follow the text. Then read the Spanish text aloud, pronouncing carefully.
4. Study the section "Building Vocabulary."
5. Do the exercise "Completion of Text."
6. Proceed to Segunda Parte.
7. Follow these instructions with the conversational texts in succeeding chapters.
1. **El señor Adams es un comerciante de Nueva York. Es norteamericano** | 1. Mr. Adams is a businessman of New York. He is a North American.
---|---
2. **Vive con su familia en uno de los suburbios de la ciudad.** | 2. He lives with his family in one of the suburbs of the city.
3. **En la familia Adams hay seis personas: el padre, el señor Adams; la madre, la señora Adams; dos hijos y dos hijas. El señor Adams es un hombre de cuarenta años de edad. La señora Adams es una mujer de treinta y cinco años.** | 3. In the Adams family there are six persons: the father, Mr. Adams; the mother, Mrs. Adams; two sons, and two daughters. Mr. Adams is a man forty years of age. Mrs. Adams is a woman of thirty-five years.
4. **Los hijos se llaman Felipe y Guillermo. Las hijas se llaman Rosita y Anita.** | 4. The sons are named Philip and William. The daughters are named Rosie and Annie.1
5. **La casa del señor Adams tiene siete cuartos: el comedor, la sala, la cocina, tres dormitorios y un cuarto de baño. Hay también un zaguán.** | 5. Mr. Adams's house has seven rooms: the dining room, the living room, the kitchen, three bedrooms, and a bathroom. There is also a vestibule.
6. **Es una casa particular, y todos los cuartos están en un piso.** | 6. It is a private house and all the rooms are on one floor.
7. **La oficina del señor Adams está en la calle Whitehall.** | 7. Mr. Adams's office is on Whitehall Street.
8. **Está en el décimo piso de un edificio muy grande.** | 8. It is on the tenth floor of a very big building.
9. **El lunes, el martes, el miércoles, el jueves y el viernes, el señor Adams va en tren a su oficina en la ciudad.** | 9. On Monday, Tuesday, Wednesday, Thursday, and Friday, Mr. Adams goes by train to his office in the city.
10. **Allí trabaja diligentemente todo el día.** | 10. There he works diligently all day.
**NOTE** : 1. Literally (word for word):The sons call themselves Philip and William. The daughters call themselves Rosie and Annie. Lit. will be used hereafter as an abbreviation for literally.
### Prounciation and Spelling Aids
1. Practice Aloud:
ins-truc- **cio** -nes | su- **bur** -bios | par-ti-cu- **lar**
---|---|---
co-mer- **cian** -te | co-me- **dor** | o-fi- **ci** -na
fa- **mi** -lia | dor-mi- **to** -rios | ca-lle ( **cah** -yay)
nor-te-a-me-ri- **ca** -no | Gui- **ller** -mo (gee-yer-moh) | za- **guán** (sah- **gwahn** )
2. The **u** in **gui** (Gui- **ller** -mo) is silent. Its purpose is to show that the g is hard as in gold. Without silent **u** , it would be like **g** in **gente** ( **hayn** -tay). Remember: **g** before **e** or **i** is pronounced like Spanish **j.**
**NOTE** : Span, will be used hereafter as an abbreviation for Spanish.
### Building Vocabulary
A. **La familia** The Family
**el padre** the father | **la madre** the mother | **el hijo** the son **la hija** the daughter
---|---|---
**el niño** the child (little boy) | **la niña** the child (little girl) | **el muchacho** the boy (teenage)
**la muchacha** the girl (teenage) | **el hermano** the brother | **la hermana** the sister
**el tío** the uncle | **la tía** the aunt | **el señor** the gentleman
**la señora** the lady, Mrs. | **el hombre** the man | **la mujer** the woman
B. **Los cuartos de la casa** The Rooms of the House
**el comedor** the dining room | **la sala** the living room
---|---
**la cocina** the kitchen | **el cuarto** the room
**el dormitorio** the bedroom | **la recámara (Mex.)** the bedroom
**el baño** the bathroom | **el zaguán** the vestibule
**NOTE** : Mex. will be used hereafter as an abbreviation for expressions particular to Mexico.
**Expresiones Importantes** | | | Important Expressions
---|---|---|---
**por tren** by train | | | | **todo el día** all day
### Exercise No. 1—Completion of Text
For maximum benefit follow these instructions carefully in all "Completion of Text" exercises.
1. Complete each sentence by putting the English words into Spanish. Where you can, do this from memory.
2. If you do not remember the words, refer to the Spanish text. There you will find the words in the order of their appearance in the sentences. You have only to reread the text to find them easily.
3. When you have completed the sentence with the needed words, read the complete sentence aloud in Spanish.
4. Write down and read aloud each completed sentence. This is true for all exercises.
5. The correct Spanish words for the "Completion of Text Exercises" are in the Answer Section of this book, along with the answers to all other exercises. Check all your answers.
**WARNING** : Never refer to the English text when you do the Completion of Text Exercise.
Replace the English word with its Spanish equivalent.
### Ejemplo (Example): 1. El señor Adams es un comerciante de Nueva York.
1. **El señor Adams es un** (businessman) **de Nueva York.**
2. ¿(Who) **es el señor Adams**?
3. **Vive** (with) **su familia.**
4. **El señor Adams es el** (father).
5. **La señora Adams es la** (mother).
6. (There are) **seis personas.**
7. **En** (his) **familia hay seis personas.**
8. **Los hijos** (are named) **Felipe, Guillermo, Rosita y Anita.**
9. **Es una casa** (private).
10. (All the rooms) **están en un piso.**
11. **La oficina está en el décimo** (floor).
12. **Está en la** (street) **Whitehall.**
13. **El edificio es** (big).
14. (There) **trabaja el señor Adams** (all day).
15. **Su oficina está en la** (city).
## SEGUNDA PARTE
### Grammar Notes
1. _The Definite Article._ Note the four forms of the definite article. | MASCULINE | FEMININE
---|---|---
Singular: | **el padre** _the_ father | **la madre** _the_ mother
Plural: | **los padres** _the_ fathers/ _the_ parents | **las madres** _the_ mothers
The definite article has four forms. These agree with their nouns in number and gender.
2. _The Gender of Nouns._
1. Nouns are either masculine or feminine in gender. This is true for thing-nouns as well as person-nouns. Thus: **el señor** | **el hijo** | **el cuarto** | **el piso** | **el comedor**
---|---|---|---|---
**la señora** | **la hija** | **la sala** | **la calle** | **la casa**
2. Nouns ending in **-o** are usually masculine. Nouns ending in **-a** are usually feminine.
3. The definite article must be repeated before each noun to which it refers. Thus: **el padre y la madre** the father and mother.
4. Many nouns for persons have a masculine form in **-o** and a feminine form in **-a.** Thus: **el hermano** the brother, **la hermana** the sister; **el muchacho** the boy **la muchacha** the girl; **el tío** the uncle, **la tía** the aunt; **el esposo** the husband, **la esposa** the wife.
3. _The Plural of Nouns._ Note the singular and plural of the following nouns. **el padre** | **el hermano** | **la casa la mujer** | **el señor** | **la ciudad** |
---|---|---|---|---|---
**los padres** 1 | **los hermanos** | **las casas** | **las mujeres** | **los señores** | **las ciudades**
To form the plural of nouns add **-s** if the nouns end in **a** vowel. Add **-es** if the nouns end in a consonant.
**NOTE** : 1. **los padres** means either _the fathers_ , or _the parents_ ; **los hermanos** _the brothers_ , or _brother(s) and sister(s)_ ; **los hijos** _the sons, son(s) and daughter(s), or children._ In such words the plural masculine may include both genders.
4. _The Indefinite Article._ Note the four forms of the indefinite article. **un cuarto** _a_ room | **una casa** _a_ house
---|---
**unos cuartos** _some_ rooms | **unas casas** _some_ houses
**un** _a_ or _one_ , is used before a masculine noun; **una** _a_ or _one_ , before a feminine noun; **unos** , _some_ , before a masculine plural; **unas** _some_ , before a feminine plural.
5. _Some Common Verbs._
**es** (he, she, it) is
**son** (they) are
**está** (he, she, it) is (located)
**están** (they) are (located)
**hay** there is, there are
**vive** (he, she, it) lives
**tiene** (he, she, it) has
**se llama** (he, she, Ud.) is named ( _Lit._ they call themselves)
**NOTE** : The subject pronouns corresponding to he, she, it, and they are usually omitted in Spanish, since the ending of the verb indicates the subject pronoun quite clearly. Subject pronouns are used only to contrast or emphasize the person being referred to.
## TERCERA PARTE
### Ejercicios (Exercises) No. 2A-2B-2C
2A. Replace the English articles by the correct Spanish articles.
**Ejemplo: La familia Adams vive en Nueva York.**
1. (The) **familia Adams vive en Nueva York.**
2. **Nueva York es** (a) **ciudad grande.**
3. (The) **casa está en** (the) **suburbios.**
4. (The) **padre es el señor Adams** ; (the) **madre es la señora Adams.**
5. **Anita es** (a) **hija; Felipe es** (a) **hijo.**
6. (The) **dormitorio es grande.**
7. (The) **cuartos están en** (one) **piso.**
8. (Some) **muchachos están en** (the) **sala** ; (some) **muchachas están en** (the) **cocina.**
9. (The) **niños están en** (the) **calle.**
10. (The) **hermanos y** (the) **hermanas están en** (the) **ciudad.**
2B. Change the following nouns into the plural.
1. **la calle**
2. **el comedor**
3. **el cuarto**
4. **el señor**
5. **la recámara**
6. **la cocina**
7. **la madre**
8. **el padre**
9. **la sala**
10. **la hija**
11. **la ciudad**
12. **el año**
13. **la mujer**
14. **el hombre**
15. **el tío**
2C. Translate into Spanish.
1. Mr. Adams is a North American.
2. He lives in New York.
3. There are six persons in the family.
4. The house has six rooms.
5. It is a private house.
6. Mrs. Adams is the mother.
7. Mr. Adams is the father.
8. The office is in Whitehall Street.
9. He goes by train to the city.
10. There he works all day.
### Ejercicio No. 3
Study and read aloud the questions and answers. Note: a) the question words, b) the inverted question mark which begins all Spanish questions, and c) the omission of subject pronouns in Spanish
**Preguntas** Questions | **Respuestas** Answers
---|---
1. **¿Quién es el señor Adams?**
**Es un comerciante de Nueva York.** | 1. Who is Mr. Adams?
He is a New York businessman.
2. **¿Es norteamericano?**
**Sí, señor, es norteamericano.** | 2. Is he a North American?
Yes, sir, he is a North American.
3. **¿Dónde vive el señor Adams?**
**Vive en los suburbios de la ciudad.** | 3. Where does Mr. Adams live?
He lives in the suburbs of the city.
4. **¿Cuántas personas hay en su familia?**
**Hay seis personas en su familia.** | 4. How many persons are there in his family?
There are six persons in his family.
5. **¿Cómo se llaman sus hijos?**
**Se llaman Felipe y Guillermo.** | 5. What are the names of his sons?
They are named Philip and William.
6. **¿Cómo se llaman sus hijas?**
**Se llaman Rosita y Anita.** | 6. What are the names of his daughters?
They are named Rosie and Annie.
7. **¿Cuántos cuartos tiene la casa del señor Adams?**
**Tiene siete cuartos.** | 7. How many rooms has the house of Mr. Adams?
It has seven rooms.
8. **¿Dónde están todos los cuartos?**
**Están en un piso.** | 8. Where are all the rooms?
They are on one floor.
9. **¿En qué calle está la oficina del señor Adams?**
**Está en la calle Whitehall.** | 9. On what street is the office of Mr. Adams?
It is on Whitehall Street.
10. **¿Es grande el edificio?**
**Sí, señor, es muy grande.** | 10. Is the building big?
Yes, sir, it is very big.
# CHAPTER 4
CAPÍTULO 4 (CUATRO)
## PRIMERA PARTE
### ¿Por qué estudia el Sr. Adams Español?
#### Why is Mr. Adams studying Spanish?
**Instrucciones para estudiar.** (See Chapter 3)
1. **El Sr. Adams es importador.** | 1. Mr. Adams is an importer.
---|---
2. **Importa objetos de arte y otros artículos de México y de Guatemala.** | 2. He imports art objects and other articles from Mexico and Guatemala.
3. **En la primavera el Sr. Adams va a hacer un viaje a México. Desea visitar a su agente en la ciudad de México. Desea hablar con él en español.** | 3. In the spring Mr. Adams is going to make a trip to Mexico. He wants to visit his agent in Mexico City. He wants to speak with him in Spanish.
4. **También desea ver unos lugares de interés en México. Espera además ir a Guatemala, y tal vez a Colombia.** | 4. He also wants to see some places of interest in Mexico. He expects, moreover, to go to Guatemala, and perhaps to Colombia.
5. **El Sr. Adams sabe leer el español un poco. Pero no habla español. Por eso estudia la lengua.** | 5. Mr. Adams knows how to read Spanish a little. But he does not speak Spanish. Therefore he is studying the language.
6. **Su maestro es el Sr. López.** | 6. His teacher is Mr. Lopez.
7. **El Sr. López, amigo del Sr. Adams, es mexicano. Es un hombre de cuarenta y cinco años de edad.** | 7. Mr. Lopez, a friend of Mr. Adams, is a Mexican. He is a man forty-five years old.
8. **Los martes y los jueves los dos señores tienen una cita, casi siempre en la casa del Sr. Adams. Allí hablan español.** | 8. On Tuesdays and Thursdays the two gentlemen have an appointment, almost always in the house of Mr. Adams. There they speak Spanish.
9. **El Sr. López es un maestro bueno.** | 9. Mr. Lopez is a good teacher.
10. **El Sr. Adams es muy inteligente y aprende rápidamente.** | 10. Mr. Adams is very intelligent and learns rapidly.
11. **En la primera conversación aprende de memoria este diálogo** : | 11. In the first conversation he learns this dialogue by heart.
12. — **Buenos días, Sr. López. ¿Cómo está Ud.?**
— **Muy bien, gracias. ¿Y Ud.?**
— **Yo también, gracias.** | 12. Good day, Mr. Lopez. How are you?
Very well, thank you. And you?
Me too, thank you.
13. **El Sr. Adams aprende también unos saludos y unas despedidas.** | 13. Mr. Adams also learns some greetings and farewells.
14. **Buenos días. Buenas tardes. Buenas noches.** | 14. Good morning. Good afternoon. Good night.
15. **Adiós. Hasta la vista. Hasta luego. Hasta mañana.** | 15. Good-bye. Until I see you. Until later. Until tomorrow.
**NOTE** : All the expressions in sentence 15 are ways of saying "Good-bye."
### Pronunciation and Spelling Aids
1. Practice: im-por-ta- **dor** | Gua-te- **ma** -la | **rá** -pi-da-men-te
---|---|---
a- **llí** (ah-yee) | a-de- **más** | im- **por** -ta
de- **se** -a | ar- **tí** -cu-los | Co- **lom** -bia
es- **tu** -dia | sa- **lu** -dos | a- **gen** -te pri-ma- **ve** -ra
es- **pe** -ra | ciu- **dad** ( _syoo-dahd_ ) | des- **pe** -di-das
**lue** -go | ma- **es** -tro | in-te-li- **gen** -te ( _in-tay-lee- **hayn** -tay_)
2. **el** = the **él** = he or him
3. The names of countries are capitalized. The names of nationalities, languages (español, Spanish), days of the week, and months are written with small letters.
### Building Vocabulary
1. Synonyms (Words of the Same Meaning)
1. **el negociante = el comerciante** businessman
2. **también = además** also, moreover
3. **el maestro = el profesor** teacher ( _m_ )
**la maestra = la profesora** teacher ( _f_ )
2. Antonyms (Words of Opposite Meaning)
1. **grande** big, **pequeño** small
2. **bueno** good, **malo** bad
3. **allí** there, **aquí** here
4. **importador** importer, **exportador** exporter
5. **el saludo** greeting, **la despedida** farewell
3. **Lenguas** (Languages)
1. **el español** Spanish
2. **el inglés** English
3. **el francés** French
4. **el portugués** Portuguese
5. **el alemán** German
6. **el italiano** Italian
### Expresiones Importantes
1. **buenos días** Good morning (day)
2. **buenas tardes** Good afternoon
3. **buenas noches** Good evening (night)
4. **adiós** good-bye
5. **hasta la vista** until we meet again
6. **hasta luego** so long
7. **hasta mañana** until tomorrow
8. **de memoria** by heart
9. **por eso** therefore
10. **tal vez** perhaps
### Ejercicio No. 4—Completion of Text
Follow carefully the instructions given in Exercise No. 1.
1. ¿(Who) **es el Sr. Adams**?
2. **Es** (a businessman of New York).
3. (His office) **está en Nueva York.**
4. **Importa objetos de arte y** (other) **artículos.**
5. **En la primavera** (he is going) **a hacer un viaje.**
6. (He wants) **visitar la ciudad de México.**
7. **Espera** (moreover) **ir a Guatemala.**
8. (But) **no habla español.**
9. (He is studying) **la lengua.**
10. **Los** (Tuesdays) **y los** (Thursdays) **tienen una cita.**
11. **El Sr. Adams aprende** (rapidly).
12. **Es** (very intelligent).
13. **El Sr. López es** (Mexican).
14. **Es** (a good teacher).
15. **El Sr. Adams aprende un diálogo** (in the first conversation).
## SEGUNDA PARTE
### Grammar Notes
1. The Use of **es** — **está** — **hay.**
In Spanish there are three words for to be, **ser** — **estar—haber** (always in third person: **hay** ). The form **es** comes from **ser.** The form **está** comes from estar. Both mean _he, she_ , or _it is._ **Hay** is impersonal: it means _there is, there are._
1. The form **es** and other forms of **ser** are used in such questions and answers as: **¿Quién es el Sr. Adams?** | Who is Mr. Adams?
---|---
**Es un comerciante de Nueva York.** | He is a New York businessman.
**¿Qué es el Sr. López?** | What is Mr. Lopez?
**Es un maestro de español.** | He is a Spanish teacher.
2. The form **está** , and other forms of **estar** , are used in questions and answers that have to do with place. They really mean **_is_** or _are located._ Thus: **¿Dónde está la Sra. Adams?** | Where is Mrs. Adams?
---|---
**Está en casa.** | She is at home.
3. The form **hay** for _to be_ is used similarly to the English _there is, there are._ **Hay un niño en el cuarto.** | There is a boy in the room
---|---
Later you will learn more about the uses of **ser, estar** , and **haber.**
2. Some Common Verbs.
**habla** (he, she, it) speaks
**hablan** they speak
**no habla** (he, she, it) does not speak
**importa** (he, she, it) imports
**estudia** (he, she, it) studies
**desea** (he, she, it) wants
**espera** (he, she, it) expects
**aprende** (he, she, it) learns
**sabe** (he, she, it) knows
**hablar** to speak
**visitar** to visit
**leer** to read
**ver** to see
**ir** to go
**va a hacer** he is going to make
**NOTE** : The verb endings **-a** and **-e** correspond to **he, she** , or **it.** The ending **-n** corresponds to **they** , while **-ar, -er** , and **-ir** denote the infinitive form of the verb.
3. Special Uses of the Definite Article
1. Use the definite article before titles when speaking about a person. Omit it when speaking to a person. **El Sr. Adams va a México.** | Mr. Adams is going to Mexico.
---|---
**Buenos días, Sr. Adams.** | Good day, Mr. Adams.
2. Use the definite article before a language. Omit it if the language is used after the verb **hablar** or after **en.** **_El_ francés es la lengua de Francia.** | French is the language of France.
---|---
**_El_ Sr. Adams no habla francés.** | Mr. Adams does not speak French.
**_en_ español _en_ francés _en_ inglés** | _in_ Spanish _in_ French _in_ English
## TERCERA PARTE
### Ejercicios (Exercises) No. 5A-5B-5C
5A. Complete the sentences with **es, está** or **hay** as the sense requires.
**Ejemplo: 1. El Sr. Adams es importador.**
1. El Sr. Adams_______________importador.
2. ¿Dónde_______________su oficina?
3. ¿Qué_______________el Sr. López?
4. La familia_______________en la sala.
5. ¿Quién_______________norteamericano?
6. ¿Carlos mexicano?
7. Su agente _______________en México.
8. La ciudad de Nueva York no_______en México.
9. ¿Qué_______________el Sr. Adams?
10. ________una computadora nueva en la oficina
5B. Select from Column II the word groups that best complete the sentences begun in Column I.
**Ejemplo: 1. El Sr. Adams desea hablar con su agente en español.**
Column I | Column II
---|---
1. **El Sr. Adams desea hablar** | a) **aprende rápidamente.**
2. **El Sr. Adams sabe leer** | b) **de México y Guatemala.**
3. **Es muy inteligente y por eso** | c) **en la casa del Sr. Adams.**
4. **Importa objetos de arte** | d) **con su agente en español.**
5. **Los dos señores tienen una cita** | e) **de cuarenta y cinco años de edad.**
6. **El Sr. López es un hombre** | f) **el español un poco.**
5C. Find the corresponding Spanish words in the text or in "Building Vocabulary" and write them.
1. and
2. in
3. with
4. also
5. to
6. perhaps
7. but
8. therefore
9. there
10. here
11. almost
12. always
13. How are you?
14. very well
15. thank you
16. big
17. small
18. good
19. bad
20. rapidly
### Ejercicio No. 6—Preguntas y Respuestas
Study and read aloud the questions and answers. Note: a) the word order, b) the omission of subject pronouns, and c) that all question words have an accent mark.
1. **¿Quién es el maestro?**
**El maestro es el Sr. López.** | 1. Who is the teacher?
Mr. Lopez is the teacher.
---|---
2. **¿Habla español?**
**Sí, señor, habla español.** | 2. Does he speak Spanish?
Yes, sir, he speaks Spanish.
3. **¿Quién es el comerciante?**
**El comerciante es el Sr. Adams.** | 3. Who is the businessman?
Mr. Adams is the businessman.
4. **¿Habla español?**
**No, señor, no habla español.** | 4. Does he speak Spanish?
No, sir, he does not speak Spanish.
5. **¿Dónde está la oficina del Sr. Adams?**
**Está en la calle Whitehall.** | 5. Where is the office of Mr. Adams?
It is on Whitehall Street.
6. **¿Importa automóviles?**
**No, no importa automóviles.** | 6. Does he import automobiles?
No, he does not import automobiles.
7. **¿Aprende rápidamente?**
**Sí, señor, aprende rápidamente.** | 7. Does he learn rapidly?
Yes, sir, he learns rapidly.
8. **¿Cuándo tienen los señores una cita?**
**Los martes y los jueves tienen una cita.** | 8. When do the gentlemen have an appointment?
On Tuesdays and Thursdays they have an appointment.
9. **¿Es inteligente el Sr. Adams?**
**Es muy inteligente.** | 9. Is Mr. Adams intelligent?
He is very intelligent.
10. **¿Por qué 1 estudia español?**
**Porque desea hacer un viaje a México.** | 10. Why is he studying Spanish?
Because he wants to make a trip to Mexico.
**NOTE** : 1. **por qué** means _why_ , **porque** means _because._
# CHAPTER 5
CAPÍTULO 5 (CINCO)
## PRIMERA PARTE
### En la sala del señor Adams
1. **Es martes, 5 (cinco) de enero de 2003 1.** | 1. It is Tuesday, January 5, 2003.
---|---
2. **Son las 8 (ocho) de la noche.** | 2. It is eight o'clock in the evening.
3. **El señor Adams está sentado en la sala de su casa. El señor López está sentado a su lado.** | 3. Mr. Adams is seated in the living room of his house. Mr. Lopez is seated near him.
4. **El señor López le dice al señor Adams:—Alrededor de nosotros hay muchas cosas; en la casa, en la calle, en la oficina, en el parque, en la ciudad y en el campo.** | 4. Mr. Lopez says to Mr. Adams, "Around us there are many things: in the house, in the street, in the office, in the park, in the city, and in the country."
5. — **Sr. López, dígame, por favor. ¿Qué es esto?** | 5. Mr. Lopez, tell me, please, what is this?
6. — **Es un hifi. Mi esposa escucha mucha música clásica.** | 6. It is a hi-fi. My wife listens to a lot of classical music.
7. — **Bueno. ¿Y qué libros hay en el estante?** | 7. Good. And what books are there on the shelf?
8. — **Hay libros de música y de arte.** | 8. There are music and art books.
9. — **¿Y qué hay en la pared encima del estante?** | 9. And what is there on the wall over the bookcase?
10. — **Es un cuadro de Frida Kahlo.** | 10. It is a painting by Frida Kahlo.
11. — **¡Qué fantástico! Dígame, por favor, los nombres en español de otros objetos en la sala y dónde están.** | 11. Wow! Tell me, please, the names in Spanish of other objects in the living room and where they are.
12. — **El otro estante está delante de una ventana. El escritorio está cerca de la puerta. La silla está cerca del escritorio. Encima del escritorio hay un lápiz, un bolígrafo, unos papeles y unas cartas. Hay unos libros en la mesita. La lámpara está en el rincón, entre el sillón y el sofá.** | 12. The other bookcase is in front of a window. The desk is near the door. The chair is near the desk. There are a pencil, a pen, some papers, and some letters on the desk. There are some books on the little table. The lamp is in the corner, between the armchair and the couch.
13. — **Bueno. Basta por hoy. Hasta luego, señor Adams.** | 13. Good. Enough for today. So long, Mr. Adams.
14. **Hasta el jueves, señor López.** | 14. Until Thursday, Mr. Lopez.
**NOTE** : 1. 2003 = dos mil tres
### Pronunciation and Spelling Aids
1. Pronounce carefully. al-re-de- **dor** | a- **quí** (ah-kee) | es- **ta** -mos | es- **tan** -te | **lá** -piz
---|---|---|---|---
es-cri- **to** -rio | ne-ce- **sa** -rio | ex-ce- **len** -te | **dí** -ga-me | **via** -ja
2. All question words in Spanish have an accent mark. **¿quién?** (sing.) | who
---|---
**¿quiénes?** (plur.) | who
**¿dónde?** | where
**¿cuándo?** | when
**¿qué?** | what
**¿cómo?** | how
**¿cuánto?** | how much
**¿cuántos?** | how many
**¿por qué?** | why
### Building Vocabulary
1. **En la sala** In the Living Room **la carta** | letter
---|---
**el escritorio** | desk
**el estante** | bookcase
**la lámpara** | lamp
**el libro** | book
**el lápiz** | pencil
**la mesa** | table
**la mesita** | little table
**el papel** | paper
**la pared** | wall
**el bolígrafo** | pen
**el rincón** | corner
**la puerta** | door
**el cuadro** | block
**la silla** | chair
**el sillón** | armchair
**la ventana** | window
**el sofá** | couch
2. Some Common Prepositions **a** | to, at
---|---
**de** | of, from
**alrededor de** | around
**acerca de** | near
**debajo de** | under
**delante de** | in front of
**detrás de** | behind
**encima de** | on top of
**con** | with
**en** | in, on, at
**entre** | between
**sobre** | over, above
### Expresiones Importantes
**está sentado** is seated | **cinco de enero** January 5
---|---
**dígame** tell me | **basta por hoy** enough for today
**por favor** please | **son las ocho** it's eight o'clock
### Ejercicio No. 7—Completion of Text
1. **El señor** (is seated) **en la sala.**
2. (There are) **muchas cosas en la calle.**
3. **Es necesario** (to know) **los nombres.**
4. (Tell me)— **¿Qué es esto?**
5. (My wife) **escucha música.**
6. **La pintura está** (over the bookcase).
7. **En el escritorio hay** (a pencil, a pen, and some paper).
8. (There are) **unos libros** (on the little table).
9. (Enough) **por hoy.**
10. (Until Thursday), **Sr. López.**
## SEGUNDA PARTE
### Grammar Notes
1. The Contractions **del** and **al**
1. The preposition **de** ( _of, from_ ) contracts with **el** and forms **del** ( _of, from the_ ). **¿Dónde está la oficina _del_ comerciante?** | Where is the office _of the_ businessman?
---|---
2. The preposition **a** ( _to_ ) contracts with **el** , and forms **al** ( _to the_ ). **El maestro habla _al_ comerciante.** | The teacher speaks _to the_ businessman.
---|---
3. The other forms of the definite article do not contract with **de** or **a.** **El padre _de los_ niños está aquí.** | The father _of the_ children is here.
---|---
**Los niños van _a la_ escuela.** | The children go _to_ school.
4. Possession
1. Possession is indicated by a phrase with **de** , never by means of an apostrophe. la casa **del maestro** | the house _of the teacher_ | the teacher's house
---|---|---
el tío **de María** | the uncle _of Mary_ | Mary's uncle
2. **de quién, de quiénes** whose, of whom **¿De quién es la oficina?** | Whose office is it?
---|---
**Es la oficina del Sr. Adams.** | It is Mr. Adams's office.
**¿De quiénes son estos libros?** | Whose are these books?
**Son los libros de los alumnos.** | They are the students' books.
3. Omission of the Indefinite Article
Omit the indefinite article with words indicating professions and occupations after the verb ser to be. If such words are modified, the indefinite article is not omitted. **El Sr. Adams es negociante.** | Mr. Adams is a businessman.
---|---
**Es un negociante bueno.** | He is a good businessman.
## TERCERA PARTE
### Ejercicios No. 8A-8B-8C-8D
8A. Write the singular, plural, and meaning of the following nouns. Use the definite article.
**Ejemplo: el edificio, los edificios building**
1. **calle**
2. **oficina**
3. **pared**
4. **silla**
5. **señor**
6. **mesa**
7. **papel**
8. **puerta**
9. **estante**
10. **ventana**
8B. Complete in Spanish. First review "Building Vocabulary B."
**Ejemplo: 1. El lápiz está debajo de los papeles.**
1. **El lápiz está** (under) **los papeles.**
2. **Hay un parque** (near) **la casa.**
3. (On top of the) **escritorio hay muchas cartas.**
4. **La pintura está** (above) **el estante.**
5. **Hay un sillón** (between) **las ventanas.**
6. **Hay un automóvil** (in front of the) **edificio.**
7. **Las sillas están** (around) **la mesa.**
8. **¿Qué hay** (behind) **la puerta?**
9. **¿Qué hay** (under) **la mesa?**
10. **¿Qué hay** (near the) **escritorio?**
8C. Use **del, de la, de los, de las, al, a la, a los** , or **a las** as required. First review "Grammar Notes 1."
**Ejemplo: 1. La sala de la casa es grande.**
1. **La sala** (of the) **casa es grande.**
2. **María habla** (to the) **maestro.**
3. **La señora Gómez es la maestra** (of the) **muchachas.**
4. **El Sr. López es un amigo** (of the) **negociante.**
5. **Los señores van** (to the) **puerta.**
6. **Felipe es un amigo** (of the) **niños.**
7. **El maestro habla** (to the) **alumnos.**
8. **El negociante va por tren** (to the) **ciudad.**
9. ¿ **Quién habla** (to the) **padre**?
10. ¿ **Quién habla** (to the) **alumnas**?
8D. Practice the Spanish aloud.
1. **¿De quién es este sombrero?**
**Es el sombrero de Juan.** | 1. Whose hat is this?
It is John's hat.
---|---
2. **¿Es este estante de Carlos o de María?**
**Es de María.** | 2. Is this bookcase Charles's or Mary's?
It is Mary's.
3. **¿Es este bolígrafo de él o de ella?**
**Es de ella.** | 3. Is this fountain pen his or hers?
( _Lit._ of him or of her)
It is hers. ( _Lit._ of her)
4. **¿De quién es la pintura?**
**Es la pintura de Frida Kahlo.** | 4. Whose portrait is it?
It is Frida Kahlo's portrait.
5. **¿De quiénes son estos papeles?**
**Son los papeles de los maestros.** | 5. Whose are these papers?
They are the teachers' papers.
### Ejercicio No. 9—Preguntas
Answer in complete Spanish sentences. Consult the text for your answers. The correct answers to these questions and those in all later lessons are given in the Answer Section of the Appendix. Check all your answers.
1. **¿Dónde está sentado el Sr. Adams?**
2. **¿Quién está sentado cerca de él?**
3. **¿Hay muchas cosas alrededor de nosotros?**
4. **¿Hay muchas cosas en la calle?**
5. **¿Quién escucha mucha música?**
6. **¿Dónde hay libros de música y arte?**
7. **¿Dónde está la pintura de Frida Kahlo?**
8. **¿Qué hay delante de una ventana?**
9. **¿Dónde está el escritorio?**
10. **¿Qué hay cerca del escritorio?**
11. **¿Dónde están las cartas?**
12. **¿Dónde están los libros?**
# CHAPTER 6
REVIEW, CHAPTERS 1–5
REPASO, CAPÍTULOS 1–5
## PRIMERA PARTE
Each Review Chapter will begin with a summary of the most important words and expressions that have occurred in the chapters reviewed. Check yourself as follows:
1. Cover up the English words on the right of the page with a piece of paper or blotter. Read one Spanish word at a time aloud and give the English meaning. Uncover the English word of the same number in order to check.
2. Cover up the Spanish words. Say aloud, one at a time, the Spanish for each English word. Uncover the Spanish word to check.
3. Write the words you have difficulty in remembering, three or four times.
### Repaso de palabras (Word Review)
**NOUNS**
**1. el alumno** | 1. student (m)
---|---
**2. la alumna** | 2. student (f)
**3. el amigo** | 3. friend (m)
**4. el automóvil** | 4. automobile
**5. el bolígrafo** | 5. pen
**6. la calle** | 6. street
**7. la casa** | 7. house
**8. el campo** | 8. country
**9. la carta** | 9. letter
**10. la ciudad** | 10. city
**11. el comedor** | 11. dining room
**12. la cosa** | 12. thing
**13. el cuarto** | 13. room
**14. el día** | 14. day
**15. el edificio** | 15. building
**16. el escritorio** | 16. desk
**17. la esposa** | 17. wife
**18. la familia** | 18. family
**19. el hermano** | 19. brother
**20. la hermana** | 20. sister
**21. el hijo** | 21. son
**22. la hija** | 22. daughter
**23. el hombre** | 23. man
**24. el lápiz** | 24. pencil
**25. la lengua** | 25. language
**26. el lugar** | 26. place
**27. el libro** | 27. book
**28. la madre** | 28. mother
**29. la mesa** | 29. table
**30. la mujer** | 30. woman
**31. el maestro** | 31. teacher (m)
**32. el muchacho** | 32. boy
**33. la muchacha** | 33. girl
**34. el niño** | 34. child (m)
**35. la niña** | 35. child (f)
**36. el objeto** | 36. object
**37. el padre** | 37. father
**38. el papel** | 38. paper
**39. la puerta** | 39. door
**40. la sala** | 40. living room
**41. el señor** | 41. Mr.
**42. la señora** | 42. Mrs.
**43. la silla** | 43. chair
**44. el tío** | 44. uncle
**45. la tía** | 45. aunt
**46. el tren** | 46. train
**47. la ventana** | 47. window
**48. el viaje** | 48. trip
**VERBS**
**1. es** | 1. he is
---|---
**2. está** | 2. he is (place)
**3. estamos** | 3. we are (place)
**4. están** | 4. they are (place)
**5. espera** | 5. he expects
**6. estudia** | 6. he studies
**7. habla** | 7. he speaks
**8. va** | 8. he goes
**9. aprende** | 9. he learns
**10. sabe** | 10. he knows (how)
**11. tiene** | 11. he has
**12. vive** | 12. he lives
**13. hablar** | 13. to speak
**14. visitar** | 14. to visit
**15. hacer** | 15. to make (do)
**16. leer** | 16. to read
**17. saber** | 17. to know
**18. ver** | 18. to see
**19. ir** | 19. to go
**20. pedir** | 20. to ask for
**21. hay** | 21. there is
**22. dígame** | 22. tell me
**NOTE** : The same form of the verb is good for _he, she, it_ , and _you_ ( **usted** ).
Thus: **es** = _he, she, it_ is, _you (formal)_ are **espera** = _he, she, it_ expects, _you (formal)_ expect.
**ADJECTIVES**
**1. bueno** | 1. good
---|---
**2. excelente** | 2. excellent
**3. grande** | 3. great, big
**4. importante** | 4. important
**5. malo** | 5. bad
**6. mi** | 6. my
**7. mucho** | 7. much
**8. necesario** | 8. necessary
**9. otro** | 9. other
**10. pequeño** | 10. small
**11. sentado** | 11. seated
**12. su** | 12. his, her, its
**13. todos** | 13. all
**14. un poco** | 14. a little
**ADVERBS**
**1. allí** | 1. there
---|---
**2. aquí** | 2. here
**3. basta** | 3. enough
**4. bien** | 4. well
**5. casi** | 5. almost
**6. diligentemente** | 6. diligently
**7. muy** | 7. very
**8. rápidamente** | 8. rapidly
**9. siempre** | 9. always
**10. también** | 10. also
**11. además** | 11. moreover
**12. si** | 12. if
**13. sí** | 13. yes
**14. ya** | 14. now, already
**PREPOSITIONS**
**1. a** | 1. to, at
---|---
**2. al** | 2. to the
**3. con** | 3. with
**4. en** | 4. in, on
**5. de** | 5. of, from
**6. del** | 6. of the
**7. sobre** | 7. above
**8. alrededor de** | 8. around
**9. cerca de** | 9. near
**10. debajo de** | 10. under
**11. delante de** | 11. in front of
**12. detrás de** | 12. behind
**13. encima de** | 13. on top of
**14. por** | 14. for, by, through
**QUESTION WORDS**
1. **¿cómo?** | 1. how?
---|---
2. **¿qué?** | 2. what?, which?
3. **¿por qué?** | 3. why?
4. **¿dónde?** | 4. where?
5. **¿quién?** | 5. who?
6. **¿cuánto?** | 6. how much?
7. **¿cuántos (as)?** | 7. how many?
**CONJUNCTIONS**
1. **o** | 1. or
---|---
2. **pero** | 2. but
3. **porque** | 3. because
4. **y** | 4. and
**IMPORTANT EXPRESSIONS**
**1. basta** | 1. enough
---|---
**2. por hoy** | 2. for today
**3. buenos días** | 3. good day
**4. buenas noches** | 4. good night
**5. buenas tardes** | 5. good afternoon
**6. adiós** | 6. good-bye
**¿Cómo está Ud.?** | 7. How are you?
**8. ¡Qué fantástico!** | 8. How fantastic!
**9. muy bien** | 9. very well
**10. gracias** | 10. thanks
**11. en casa** | 11. at home
**12. es necesario** | 12. it is necessary
**13. hasta luego** | 13. until later
**14. hasta mañana** | 14. until tomorrow
**15. hasta la vista** | 15. until I see you again
**16. por eso** | 16. therefore
**17. por favor** | 17. please
**18. ¿Qué es esto?** | 18. What is this?
**19. todo el día** | 19. all day
**20. tal vez** | 20. perhaps
## SEGUNDA PARTE
### Grammar Notes
**Ejercicio 10.** From Group II select the antonym (opposite) for each word in Group I.
Group I | Group II
---|---
1. **bueno** | a. **delante de**
2. **sí** | b. **el campo**
3. **allí** | c. **la muchacha**
4. **pequeño** | d. **buenas noches**
5. **encima de** | e. **no**
6. **padre** | f. **el hombre**
7. **mucho** | g. **malo**
8. **detrás de** | h. **grande**
9. **buenos días** | i. **aquí**
10. **el muchacho** | j. **debajo de**
11. **la ciudad** | k. **poco**
12. **la mujer** | l. **madre**
**Ejercicio 11.** Complete the following sentences in Spanish.
1. **Trabajo** (all day).
2. **Dígame** (please).
3. (Perhaps) **está en la oficina.**
4. (Good afternoon) **señor.**
5. **Aprende los saludos** (with pleasure).
6. (Therefore) **estudia español.**
7. ¿(How) **está Ud.**?
8. ¿(Where) **vive el señor**?
9. ¿(What) **es esto**?
10. ¿(Who) **es negociante**?
**Ejercicio 12.** Select the group of words in the right-hand column which best completes each sentence begun in the left-hand column.
**Ejemplo: 1. En la familia Adams (d) hay seis personas.**
1. **En la familia Adams** | a. **aprende los saludos y las despedidas.**
---|---
2. **La casa del Sr. Adams** | b. **toca bien el piano.**
3. **El Sr. Adams va en tren** | c. **porque es muy inteligente.**
4. **Estudia español** | d. **hay seis personas.**
5. **Trabaja todo el día** | e. **un viaje a México.**
6. **Sabe leer español** | f. **está en los suburbios.**
7. **Aprende rápidamente** | g. **pero no habla la lengua.**
8. **Los martes y los jueves** | h. **en su oficina.**
9. **En la primera conversación** | i. **a la ciudad.**
10. **La esposa del Sr. Adams** | j. **los señores tienen una cita.**
11. **El Sr. Adams va a hacer** | k. **porque desea hablar la lengua.**
**Ejercicio 13.** Complete these sentences in Spanish.
1. **El automóvil está** (in front of the house).
2. **Las sillas están** (near the door).
3. **Los suburbios están** (around the city).
4. **El Sr. Adams está sentado** (behind the desk).
5. **Las lámparas están** (on top of the piano).
6. (The boy's books, the books of the boy) **están en la mesa.**
7. (The girls' mother, the mother of the girls) **está en casa.**
8. (Philip's brother) **es médico.**
9. (Mary's father) **es profesor.**
10. (The children's teacher) **es mexicano.**
## TERCERA PARTE
Practice all Spanish dialogues aloud:
### Diálogo 1
**¿Dónde está la calle Lerma?**
1. **Por favor, señor, ¿Dónde está la calle Lerma?** | 1. Please sir, where is Lerma Street?
---|---
2. **Siga adelante, señorita.** | 2. Continue straight ahead, Miss.
3. **¿Cuántas cuadras?** | 3. How many blocks?
4. **Cinco cuadras, señorita.** | 4. Five blocks, Miss.
5. **Muchas gracias.** | 5. Many thanks.
6. **De nada.** | 6. Don't mention it. (You're welcome.)
### Diálogo 2
**¿Dónde para el camión (autobús)?**
1. **Señor, ¿me podría decir dónde para el camión (autobús)?** | 1. Could you please tell me, sir, where does the bus stop?
---|---
2. **Para en la esquina allá, señorita.** | 2. It stops at the corner over there, Miss.
3. **Muchas gracias, señor.** | 3. Many thanks, sir.
4. **No hay de qué. (De nada.)** | 4. You're welcome.
## LECTURA (READING SELECTION)
### Ejercicio No. 14—How to Read the Lecturas
1. Read the passage silently from beginning to end to get the meaning as a whole.
2. Reread the passage, looking up any words you may have forgotten in the Spanish-English dictionary at the end of this book. There are few new words in the Lecturas of the Review Chapters, and the meaning of these is given in parentheses.
3. Read the passage a third time, this time aloud. Then translate it and check your translation with that given in the Answer Section of the Appendix.
4. Follow this procedure in all succeeding Lecturas.
### Ejercicio No. 14A—El señor Adams, comerciante de Nueva York
**El señor Adams es un comerciante norteamericano que** (who) **importa objetos de arte de México. Por eso desea hacer un viaje a México en la primavera. Desea hablar con su agente y visitar unos lugares de interés en México. Pero no sabe hablar español.**
**El señor Adams tiene un maestro bueno. Es un mexicano que vive en Nueva York y se llama señor López. Los martes y los jueves el maestro va por tren a la casa de su estudiante. Allí los dos señores hablan un poco en español. El señor Adams es muy inteligente y aprende rápidamente.**
**Por ejemplo** (For example), **en la primera conversación aprende de memoria los saludos y las despedidas. Ya** (already) **sabe decir** (to say) **«Buenos días», «¿Cómo está Ud.?», «Hasta la vista» y «Hasta mañana». Ya sabe decir en español los nombres de muchas cosas que** (which) **están en su sala, y sabe contestar** (to answer) **bien a las preguntas «¿Qué es esto?» y «¿Dónde está...?»** ;
**El señor López está muy satisfecho** (satisfied) **con el progreso de su estudiante y dice** (says)— **Bueno. Basta por hoy. Hasta luego.**
# CHAPTER 7
CAPÍTULO 7 (SIETE)
## PRIMERA PARTE
### Los verbos son importantes, señor.
1. **Los señores Adams y López están sentados en la sala del señor Adams. El Sr. López explica con entusiasmo. El Sr. Adams lo 1 escucha con atención.** | 1. Mr. Lopez and Mr. Adams are seated in the living room of Mr. Adams. Mr. Lopez explains with enthusiasm. Mr. Adams listens to him attentively.
---|---
2. — **Ya sabe Ud. que los nombres de las cosas y de las personas son importantes. Pero los verbos son importantes también, señor. No es posible formar una oración sin verbos. Tampoco es posible conversar sin verbos.** | 2. You already know that the names of things and of persons are important. But verbs are important, too, sir. It is not possible to make a sentence without verbs. Neither it is possible to converse without verbs.
3. — **Vamos a practicar unos verbos corrientes. Voy a hacer unas preguntas. Yo pregunto y Ud. contesta. Si no sabe la respuesta, diga, por favor «No sé».** | 3. We are going to practice some common verbs. I am going to ask some questions. I ask and you answer. If you do not know the answer, please say "I do not know."
4. — **Bueno—dice el señor Adams.—Si no sé la respuesta le voy a decir «No sé».** | 4. "Good," says Mr. Adams. "I will say I don't know if I don't know the answer."
5. — **¿Es Ud. comerciante?** | 5. Are you a businessman?
6. — **Sí, señor, soy comerciante, importador de objetos de arte y otros artículos de varios países hispano americanos y sobre todo de México.** | 6. Yes, sir, I am a businessman, importer of art objects and other things from various Spanish-American countries and especially from Mexico.
7. — **¿Y por qué estudia español?** | 7. And why are you studying Spanish?
8. — **Estudio español porque deseo hacer un viaje a México para visitar a mi agente allí. Deseo hablar con él en español. Él no habla inglés.** | 8. I am studying Spanish because I want to take a trip to Mexico to visit my agent there. I want to speak with him in Spanish. He does not speak English.
9. — **¿Espera visitar otros países?** | 9. Do you expect to visit other countries?
10. — **Sí, espero ir además a Guatemala, y tal vez a Colombia.** | 10. I expect to go besides to Guatemala, and perhaps Colombia.
11. — **¿Cuándo sale de Nueva York para México?** | 11. When do you leave New York for Mexico?
12. — **Salgo el 31 (treinta y uno) de mayo.** | 12. I am leaving on May 31.
13. — **¿Viaja en tren, por barco o en avión?** | 13. Are you traveling by train, by boat, or by plane?
14. — **Viajo por avión porque es el modo más rápido.** | 14. I am traveling by plane because it is the quickest way.
15. — **¿Cuánto cuesta el vuelo?** | 15. How much does the flight cost?
16. — **No sé. Mañana voy a pedir información y una reservation.** | 16. I do not know. Tomorrow I am going to ask for information and make a reservation.
17. — **Excelente, señor. Ud. aprende el español muy rápidamente.** | 17. Excellent sir. You are learning Spanish very quickly.
18. — **Gracias, pero Ud. exagera.** | 18. Thank you, but you exaggerate.
19. — **No, es verdad. Pues, basta por hoy. Hasta luego.** | 19. No, it is the truth. Well, enough for today. So long.
20. — **Hasta el próximo jueves.** | 20. Until next Thursday
**NOTE** : 1. **lo** _him._ It is an object pronoun. Object pronouns usually precede the verb.
### Pronunciation and Spelling Aids
1. Practice: a-ten- **ción** | ha- **cer** | es- **tu** -dio | **via-** jo | a- **pren** -de | es- **tán**
---|---|---|---|---|---
re-ser-va- **ción** | prac-ti- **car** | de- **se** -o | es- **tu** -dia | **sa** -le | co- **rrien** -tes
con-ver- **sar** | de- **cir** | es- **pe** -ro | es- **pe** -ra | es- **tá** | **via** -ja
2. **pa-í-ses** ( _pah- **ee** -says_). The accent mark over the **í** shows that the **í** is a separate syllable. Otherwise **_ai_** would be pronounced like **_ai_** in the English word _aisle_ and in the Spanish word **_ai-re._**
### Building Vocabulary
1. **Los países de Sudamérica.** The countries of South America.
1. **la Argentina**
2. **Bolivia**
3. **Colombia**
4. **Chile**
5. **el Ecuador**
6. **el Paraguay**
7. **el Perú**
8. **el Uruguay**
9. **Venezuela**
10. **el Brasil**
**Los habitantes** (inhabitants) **del Brasil hablan portugués. Los habitantes de los otros países de Sudamérica hablan español.**
2. **Algunos países de Europa** ( _ayoo_ - **roh** - _pah_ ). Some Countries of Europe.
1. **Inglaterra** England
2. **Francia** France
3. **Alemania** Germany
4. **Italia** Italy
5. **España** Spain
6. **Portugal** Portugal
3. **Los países de Norteamérica.** The Countries of North America.
1. **Los Estados Unidos** The United States
2. **México** Mexico
3. **el Canadá** Canada
### Expresiones Importantes
1. **con entusiasmo** | with enthusiasm
---|---
2. **hacer preguntas** | to ask questions
3. **hacer un viaje** | to take a trip
4. **por avión (tren, barco)** | by plane (train, boat)
5. **sobre todo** | above all, especially
### Ejercicio No. 15—Completion of Text
Complete the following sentences based on the text.
1. **Los verbos** (are important) **señor.**
2. **Vamos a practicar** (some common verbs).
3. ¿(Why) **estudia Ud. el español**?
4. (Because) **deseo visitar a** (my) **agente.**
5. **Deseo hablar** (with him in Spanish).
6. **Espero ir** (to other countries).
7. **¿Viaja Ud.** (by train or by plane)?
8. ¿(How much) **cuesta el vuelo**?
9. **Ud. aprende** (very rapidly).
10. (Enough for today.)
## SEGUNDA PARTE
### Grammar Notes
1. About Verb Endings
The infinitive is the base form of the verb. In English it is expressed by _to._ Thus: _to_ speak, _to_ learn, _to_ live, etc. In Spanish there are infinitive endings which mean _to._ Thus: hablar _to_ speak | aprender _to_ learn | vivir _to_ live
---|---|---
The infinitives of all Spanish verbs end in **-ar, -er** , or **-ir.** That part of the verb which is left after the ending is removed is called the stem. Thus **habl-, aprend-, viv-** , are the stems of **hablar, aprender** , and **vivir.**
The infinitive endings of the verb are dropped and other endings added to the stem as the verb is used in various persons and tenses. Let us see how the endings change, and what they mean, in the present tense of the verb **hablar.**
2. Present Tense of **hablar.** Model Regular **-ar** Verb (yo) | **habl-o** | I speak
---|---|---
(tú) | **habl-as** | you speak (fam.)
usted | **habl-a** | you speak
(él) | **habl-a** | he, it speaks
(ella) | **habl-a** | she, it speaks
(nosotros) | **habl-amos** | we speak
(vosotros) | **habl-áis** | you speak (fam.)
ustedes | **habl-an** | you speak
(ellos) | **habl-an** | they (m) speak
(ellas) | **habl-an** | they (f) speak
1. The endings of a regular -ar verb in the present tense are: SINGULAR **-o -as -a** | PLURAL **-amos -áis -an**
---|---
**NOTE** : The verb ending -a is used with usted, él, and ella. The verb ending -an is used with ustedes, ellos, and ellas.
2. Since the ending indicates the subject pronoun quite clearly, subject pronouns are usually omitted [ **usted (Ud.)** and **ustedes (Uds.)** less frequently]. They may be used for emphasis or to make the meaning clear. Yo hablo inglés. **Ella** habla francés. | _I_ speak English. _She_ speaks French.
---|---
3. The present tense may be translated: I speak, I do speak, I am speaking, etc.
4. **nosotros** and **vosotros** have feminine forms **nosotras, vosotras.**
3. Polite and Familiar _you._
1. **usted** ( _you, sing._ ) and **ustedes** ( _you, plur._ ) are the polite forms of address. They are used most of the time. **¿Habla Ud. francés, Sr. Muñoz?** | Do you speak French, Mr. Munoz?
---|---
**Uds. hablan muy bien, señoras.** | You speak very well, ladies.
2. **tú** ( _you, sing._ ) and **vosotros** ( **as** ) ( _you, plur._ ) are the familiar forms of address. They are used with members of the family, with good friends, and with children. In Latin America (L.A.) the **vosotros** form is not used; **ustedes** takes its place. **¿Hablas (tú) inglés, papá?** | Do you speak English, papa?
---|---
**(Vosotros) habláis demasiado alto, niños.** | You speak too loudly, children.
**L.A.—Ustedes hablan demasiado alto, niños.** | You speak too loudly, children.
4. The Negative and Interrogative.
1. To form the negative, put the word **no** ( _not_ ) directly before the verb. **No hablamos portugués.** | We do not speak Portuguese.
---|---
2. To form a question, place the subject after the verb. If the subject is not expressed, the double question mark is sufficient. **¿Platican los alumnos?** | Are the students chatting?
---|---
**¿No van a hacer un viaje?** | Are they not going to make a trip?
## TERCERA PARTE
### Ejercicios No. 16A-16B-16C-16D
16A. Translate the following **-ar** verbs. They take the same endings as the model **-ar** verb, **hablar.**
1. **escuchar**
2. **desear**
3. **visitar**
4. **formar**
5. **esperar**
6. **conversar**
7. **practicar**
8. **viajar**
9. **preguntar**
10. **contestar**
11. **platicar**
12. **estudiar**
13. **importar**
14. **tocar** (an instrument)
15. **entrar**
16B. Practice aloud the following brief dialogues. Translate them.
1. **¿Habla Ud. español?**
**Sí, hablo español.**
**¿Qué lenguas habla su maestro?**
**Habla inglés, español y francés.**
2. **¿Quién toca el piano?**
**María toca el piano.**
**¿No tocas tú el piano, Rosita?**
**No, no toco el piano.**
3. **¿Estudian los alumnos la lección?**
**No, no estudian la lección.**
**¿Platican en español?**
**Sí, platican en español.**
4. **¿Escuchan Uds. con atención**
**cuando el maestro habla?**
**Sí, escuchamos con atención**
**cuando el maestro habla.**
16C. Copy each sentence filling in the correct verb endings.
**Ejemplo: El Sr. Adams no habla español.**
1. **El Sr. Adams no habl_________________español.**
2. **Nosotros estudi_________________la lección.**
3. **¿Quién import_________________objetos de arte?**
4. **¿Dese_________________Ud. aprender a hablar Español?**
5. **Yo esper_________________ir a Cuba.**
6. **Uds. platic_________________mucho.**
7. **Juan y Carlos (ellos) practic_________________la pronunciación.**
8. **¿Viaj_________________el señor en tren o en avión?**
9. **Pablo y yo (nosotros) esper_________________salir mañana.**
10. **Eva y Ana (ellas) escuch_________________música.**
16D. Complete with the form of the verb that fits the pronoun.
**Ejemplo: yo miro**
1. **yo (mirar)**
2. **él no (escuchar)**
3. **tú (formar)**
4. **ella (conversar)**
5. **ellos (practicar)**
6. **¿(preguntar) Ud.?**
7. **ellas (contestar)**
8. **¿(estudiar) nosotros?**
9. **Uds. (desear)**
10. **yo no (visitar)**
11. **yo (viajar)**
12. **¿(esperar) Ud.?**
### Ejercicio No. 17—Preguntas
Answer in complete Spanish sentences.
1. **¿Dónde están sentados los señores?**
2. **¿Quién explica?**
3. **¿Quién escucha con atención?**
4. **¿Quién pregunta?**
5. **¿Quién contesta?**
6. **¿Son importantes los verbos?**
7. **¿Es comerciante el Sr. Adams?**
8. **¿Habla (él) español?**
9. **¿Por qué desea hablar español?**
10. **¿Qué países espera visitar?**
11. **¿Viaja en tren, en avión o por barco?**
12. **¿Aprende el Sr. Adams rápidamente o despacio** (slowly)?
# CHAPTER 8
CAPÍTULO 8 (OCHO)
## PRIMERA PARTE
### La familia del señor Adams
1. **Es jueves, el 14 (catorce) de enero a las 8 (ocho) de la noche.** | 1. It is Thursday January 14, at 8 o'clock in the evening.
---|---
2. **El señor López toca el timbre de la casa de la familia Adams. La criada abre la puerta y dice:—Pase Ud. a la sala, por favor.** | 2. Mr. Lopez rings the bell of the Adams house. The maid opens the door and says, "Go to the living room, please."
3. **En la sala el señor Adams espera al señor López, y cuando éste entra, dice:—Buenas noches. ¿Cómo está Ud.?** | 3. In the living room Mr. Adams is awaiting Mr. Lopez, and when the latter enters, he says, "Good evening. How are you?"
4. — **Regular. ¿Y cómo está Ud.? ¿Y su familia?** | 4. So so. And how are you and your family?
5. — **Yo estoy muy bien, gracias. Pero mi niña Anita está enferma. Tiene un resfriado.** | 5. I am very well, thank you. But my child Annie is ill. She has a cold.
6. — **Lo siento mucho. ¿Tiene Ud. otros hijos?** | 6. I'm very sorry. Do you have other children?
7. — **Por supuesto. Tengo cuatro hijos, dos muchachos y dos muchachas. Somos una familia de seis personas.** | 7. Of course. I have four children, two boys and two girls. We are a family of six people.
8. — **¿Y cómo se llaman sus hijos?** | 8. And what are the names of your children?
9. — **Se llaman Felipe, Guillermo, Rosita y Anita.** | 9. Their names are Philip, William, Rosie, and Annie.
10. — **¿Cuántos años tienen?** | 10. How old are they?
11. — **Felipe tiene diez años. Es el mayor. Guillermo tiene ocho años. Rosita tiene seis años. Anita es la menor. Tiene cinco años.** | 11. Philip is ten years old. He is the oldest. William is eight years old. Rosie is six years old. Annie is the youngest. She is five years old.
12. — **Todos menos Anita van a la escuela.** | 12. All except Annie go to school.
13. **Los señores platican un rato más. Entra la señora Adams. — Le presento a mi esposa —dice el señor Adams. — ¡Mucho gusto, Sra. Adams! — El gusto es mío. — responde la señora Adams.** | 13. The two gentlemen chat a while longer. Mrs. Adams comes in. "May I introduce my wife?" says Mr. Adams. — "Nice to meet you, Mrs. Adams." — "Nice to meet you too," Mrs. Adams replies.
14. **Entonces el señor Adams invita al señor López a visitar su oficina el próximo lunes, a las doce** y **media de la tarde.** | 14. Then Mr. Adams invites Mr. Lopez to visit his office the following Monday at 12:30 p.m.
15. **A las nueve el señor López dice:—Hasta la vista.** | 15. At nine o'clock Mr. Lopez says, "So long."
16. **El señor Adams responde:—Hasta el lunes a las doce y media de la tarde.** | 16. Mr. Adams answers, "Till Monday at 12:30 p.m."
### Pronunciation and Spelling Aids
1. Practice:
**jue** -ves | en- **fer** -ma | in-vi- **tar** | a-cep- **tar** | **lue-go**
---|---|---|---|---
fa- **mi** -lia | **sien** -to | in-vi-ta- **ción** | **tie** -nen | **lla** -man ( ** _yah_ -mahn**)
res- **fria** -do | Gui- **ller** -mo | res- **pon** -de | se-gu-ra- **men** -te |
### Building Vocabulary
1. Most Spanish words ending in **-ción** have corresponding English words ending in _-tion._ Words ending in -ción are feminine.
1. **la invitación**
2. **pronunciación**
3. **elección**
4. **continuación**
5. **atención**
6. **dirección**
7. **aplicación**
8. **invención**
9. **prevención**
10. **solución**
11. **revolución**
12. **reservación**
2. The ending **-mente** is equal to the ending _-ly_ in English.
1. **seguramente** surely
2. **generalmente** generally
3. **atentamente** attentively
4. **rápidamente** rapidly
5. **ciertamente** certainly
6. **probablemente** probably
### Expresiones Importantes
1. **¿Cómo se llama Ud.?** | 1. What is your name?
---|---
2. **Me llamo Felipe.** | 2. My name is Philip.
3. **¿Cómo se llama su amigo?** | 3. What is your friend's name?
4. **Mi amigo se llama Pablo.** | 4. My friend's name is Paul.
5. **¿Cuántos años tiene Ud.? 1** | 5. How old are you?
6. **Tengo 13 (trece) años. 1** | 6. I am thirteen years old.
7. **¿Cuántos años tiene Pablo?** | 7. How old is Paul?
8. **Tiene 15 (quince) años.** | 8. He is fifteen years old.
9. **¡Mucho gusto! 2** | 9. Nice to meet you.
10. **El gusto es mío. 3** | 10. Nice to meet you too.
### Ejercicio No. 18—Completion of Text
Complete the following sentences based on the text.
1. **La esposa** (opens) **la puerta.**
2. **Dice—** (Go) **a la sala, por favor.**
3. (Good evening). **¿Cómo está (your) familia?**
4. **Ella tiene** (a cold).
5. **¿Tiene Ud.** (other) **hijos?**
6. (I have) **cuatro hijos.**
7. (We are) **una familia de seis personas.**
8. **¿Cuántos** (years) **tienen sus hijos?**
9. **Anita es** (the youngest).
10. **Felipe es** (the oldest).
11. **Platican** (a while longer).
12. **El Sr. Adams invita** (Mr. Lopez).
**NOTE** : 1. _Lit._ How many years have you? I have 13 years. 2. _Lit_ It is a pleasure. 3. _Lit._ The pleasure is mine.
## SEGUNDA PARTE
### Grammar Notes
1. Present Tense of **ser** _to be_ , **estar** _to be_ , and **ir** _to go._ SINGULAR | SINGULAR | SINGULAR
---|---|---
**soy** | I am | **estoy** | I am | **voy** | I go
**eres** | you are (fam.) | **estás** | you are (fam.) | **vas** | you go (fam.)
**Ud. es** | you are | **Ud. está** | you are | **Ud. va** | you go
**es** | he, she, it is | **está** | he, she, it is | **va** | he, she, it goes
PLURAL | PLURAL | PLURAL
**somos** | we are | **estamos** | we are | **vamos** | we go
**sois** | you are (fam.) | **estáis** | you are (fam.) | **ais** | you go (fam.)
**Ud. son** | you are | **Uds. están** | you are | **Uds. van** | you go
**son** | they are | **están** | they are | **van** | they go
**NOTE** : All forms of **estar** except **estamos** are stressed on the last syllable.
2. Use of **ir** to Indicate Future Time a. **Voy a hacer un viaje a Cuba.**
**¿Van Uds. a aprender el francés?** | I am going to take a trip to Cuba.
Are you going to learn French?
---|---
b. **Vamos** may be translated: _Let us_ , or _We are going to_ , whichever makes best sense.
**Vamos a comenzar. Vamos a ver.** | Let us begin. Let's see.
**Vamos a visitar a nuestro amigo.** | We are going to visit our friend.
3. The Personal a. This is placed before the direct object, if the direct object is a person or proper name. The personal **a** is not translated, **¿a quién**? and **¿a quiénes?** (as a question) equal _whom._ **¿A quién espera Ud.?** | Whom are you expecting?
---|---
**Espero a Juan.** | I am expecting John.
4. The Possessive adjectives **mi** and **su.** Observe the forms and meanings of **mi** and **su** : a. **_Mi_ niña está enferma.** | _My_ child is ill.
---|---
b. **_Mis_ niños van a la escuela.** | _My_ children go to school.
c. **Ana, ¿dónde está _su_ madre?** | Anna, where is _your_ mother?
d. **Juan, ¿dónde están _sus_ libros?** | John, where are _your_ books?
e. **María está aquí. _Su_ amiga está ausente.** | Mary is here. _Her_ friend is absent.
f. **Felipe está aquí. _Su_ amigo está ausente.** | Philip is here. _His_ friend is absent.
g. **Los alumnos están aquí. _Su_ maestro está ausente.** | The pupils are here. _Their_ teacher is absent.
**mi** ( _my_ ) is used with a sing. noun: **mis** ( _my_ ) with a plur. noun.
**su** ( _his, her, its, their, your_ ) is used with a sing. noun.
**sus** ( _his, her, its, their, your_ ) is used with a plur. noun.
The sense of the sentence determines which meaning of **su** ( **sus** ) applies.
### Ejercicios No. 19A-19B-19C
19A. Fill in the correct forms of **ser** and **estar.**
Remember: **ser** is used to express _Who is?_ or _What is?_ **estar** is used to express _place, location (where someone or something is)_ , or _health._
1. **¿Quién** (is) **el señor López?** (He is) **maestro.**
2. **¿Cómo** (are) **Ud.?** (I am) **muy bien.**
3. **¿Dónde** (are) **Uds.?** (We are) **en la sala.**
4. **¿** (Are) **Ud. negociante? Sí** , (I am) **negociante.**
5. ¿(Is) **enferma su hija**? **Sí, mi hija** (is) **enferma.**
6. **¿Cómo** (are) **Uds.?** (We are) **muy bien, gracias.**
7. **¿Dónde** (are) **los libros?** (They are) **en el estante.**
8. **¿** (Are) **Uds. mexicanos? No** , (we are) **norteamericanos.**
9. **¿Quiénes** (are) **en la sala? Los dos señores** (are) **allí.**
10. **¿** (Are) **Uds. amigos del maestro? Sí** , (we are) **sus amigos.**
19B. Complete the following sentences with the words in parentheses, using the personal **a** whenever necessary.
**Ejemplo: Hoy invitamos _al_ señor Adams.**
1. **Hoy invitamos (el señor Adams).**
2. **No voy a visitar (la escuela).**
3. **Carlos espera (su amigo) Pablo.**
4. **Estudian (la lección).**
5. **Vamos a visitar (la señora de López).**
6. **Esperan Uds. (el tren)?**
7. **No, esperamos (Isabel).**
8. **El Sr. Adams desea ver (su agente).**
9. **Ellos no visitan (el parque).**
10. **Hoy visitamos (José).**
19C. Translate into Spanish.
1. How are you?
2. So so, thank you.
3. My daughter is sick.
4. I am very sorry.
5. You are a family of six people.
6. Do your children go to school?
7. Do you speak Spanish?
8. No. I do not speak Spanish.
9. I invite Charles to visit my house.
10. We are going to chat a while.
11. Let's begin.
12. I want to study Spanish.
## TERCERA PARTE
### Ejercicio No. 20—Preguntas
1. **¿Quién abre la puerta?**
2. **¿Quién toca el timbre?**
3. **¿Dónde espera el Sr. Adams al Sr. López?**
4. **¿Quién está enferma?**
5. **¿Qué tiene ella?**
6. **¿Cuántos hijos tiene el comerciante?**
7. **¿Cuántas personas hay en su familia?**
8. **¿Cómo se llaman sus hijos?**
9. **¿Cuántos años tiene Felipe?**
10. **¿Platican los señores un rato más?**
11. **¿A quién** (whom) **invita el negociante a visitar su oficina?**
12. **¿Acepta el maestro la invitación?**
# CHAPTER 9
CAPÍTULO 9 (NUEVE)
## PRIMERA PARTE
### En la oficina del señor Adams
1. **La oficina del señor Adams está en el décimo piso de un edificio alto, en un rascacielo. No es grande, pero es muy cómoda. Hay dos ventanas grandes que dan a la calle. En las paredes grises hay algunos carteles de México en colores vivos y un mapa de México.** | 1. Mr. Adams's office is on the tenth floor of a tall building. It is not large, but it is very comfortable. There are two large windows that face the street. On the gray walls there are some posters of Mexico in bright colors and a map of Mexico.
---|---
2. **En el escritorio, cerca de la puerta azul, hay una computadora. Al lado está el ratón rojo y una impresora con muchos papeles blancos. Entre las dos ventanas hay una mesa larga y verde. En la mesa hay periódicos y revistas.** | 2. On the desk, near the blue door, there is a computer. Next to it are the red mouse and the printer with a lot of white papers. Between the two windows there is a long green table. On the table there are newspapers and magazines.
3. **El señor Adams, que está sentado detrás de su escritorio cuando el señor López entra en la oficina, se levanta y va a saludarlo.** | 3. Mr. Adams, who is seated behind his desk when Mr. Lopez enters the office, gets up and goes to greet him.
4. — **Buenas tardes, señor López. Mucho gusto en verlo.** | 4. Good afternoon, Mr. Lopez. I am very glad to see you.
5. — **El gusto es mío. ¿Cómo está Ud.?** | 5. The pleasure is mine. How are you?
6. — **Muy bien, gracias.** | 6. Very well, thank you.
7. — **Su oficina es hermosa. ¡Qué colores más fantásticos! Me gusta este moderno teléfono negro con su contestador amarillo.** | 7. Your office is beautiful. What great colors! I like this modern black telephone with its yellow answering machine.
8. — **Sí, hay tres mensajes en el contestador, los contesto por correo electrónico.** | 8. Yes, there are three messages on the answering machine. I answer them by e-mail.
9. — **A propósito, ¿cuál es su dirección electrónica?** | 9. By the way, what is your e-mail address?
10. — **adams-arroba – arul – punto – com (adams@arul.com)** | 10. adams@arul.com
11. — **¡Dios mío, es la una! ¡Por eso tengo hambre! ¿No tiene Ud. hambre?** | 11. My goodness, it's one o'clock! That's why I am so hungry. Are you not hungry?
12. — **Sí. Tengo hambre también.** | 12. Yes, I am also hungry.
13. — **Bueno. No lejos de aquí hay un restaurante bueno.** | 13. Good. Not far from here there is a good restaurant.
14. — **Pues, ¡vámonos!** | 14. Well, let's go!
### Pronunciation and Spelling Aids
1. Practice: | e-di- **fi** -cio | re- **vis** -tas | pro- **pó** -si-to | **bas** -ta | **má** -qui-na
---|---|---|---|---|---
| pe- **rió** -di-cos | mu- **chí** -si-mo | a-ma- **ri** -llo | ce-ni- **ce** -ro |
2. **¿quién?, ¿cuándo?, ¿qué?** and other question words drop the accent mark when they are not used as question words. Thus: **El Sr. Adams, que está sentado cuando el Sr. López entra en la sala, se levanta.**
### Building Vocabulary
1. Common Descriptive Adjectives **amarillo** | yellow
---|---
**azul** | blue
**blanco** | white
**negro** | black
**gris** | gray
**rojo** | red
**verde** | green
**vivo** | lively
**enfermo** | sick
**bueno** | good
**Malo** | bad
**Barato** | cheap
**caro** | dear, expensive
**bonito** | pretty
**hermoso** | beautiful
**simpático** | nice
**alto** | high, tall
**bajo** | low
**grande** | big
**pequeño** | little
**corto** | short
**largo** | long
**pobre** | poor
**rico** | rich
**fácil** | easy
**difícil** | hard
**cómodo** | comfortable
**inteligente** | intelligent
**importante** | important
**interesante** | interesting
2. New Nouns in Technology **computadora** | computer
---|---
**correo electrónico** | e-mail
**dirección electrónica** | e-mail address
**ratón** | mouse
**contestador** | answering machine
**mensaje** | message
**impresora** | printer
**arroba** | @
**punto** | dot
3. **-ísimo** This ending means _very._ Thus:
1. **muchísimo** very much
2. **altísimo** very high
3. **pobrísimo** very poor
4. **hermosísimo** very beautiful
5. **larguísimo** very long
6. **bonísimo** very good
### Expresiones Importantes
1. **dan a la calle** they face the street. The usual meaning of **dan** is _they give._
2. **¿Tiene Ud. hambre?** Are you hungry? ( _Lit._ Have you hunger?) **Tengo hambre.** I am hungry. ( _Lit._ I have hunger.)
3. **a propósito** by the way.
4. **¿De qué color es el papel?** What color ( _Lit._ of what color) is the paper?
5. Expressions of liking: In Spanish the idea of liking is expressed by means of the verb **gustar** _to be pleasing to._ The person to whom something is pleasing begins the sentence. The thing which is pleasing follows the verb. Thus: **Me gusta el libro.** I like the book. ( _Lit._ To me is pleasing the book.) **Me gustan los carteles**. I like the posters. ( _Lit._ To me are pleasing the posters.)
6. **¡Dios mío! My** God!
7. **Dirección electrónica** e-mail address, **arroba @, punto** dot
### Ejercicio No. 21—Completion of Text
1. **Dos ventanas** (face the street).
2. **En la mesa hay** (newspapers).
3. **El Sr. Adams está sentado** (behind his desk).
4. **El Sr. López** (enters the office).
5. (I'm very glad to see you).
6. (The pleasure is mine).
7. (I like = to me is pleasing) **ese mapa.**
8. (By the way), **¿ve Ud. ese cartel?**
9. (I see) **la computadora y el ratón.**
10. ¿(What color) **es el ratón**?
11. ¿(What colors) **la mesa y la puerta**?
12. (My goodness!) **Es la una.**
13. (I am hungry).
14. (Not far from here) **hay un restaurante.**
15. (Let's go!)
## SEGUNDA PARTE
### Grammar Notes
1. Agreement of Adjectives
Observe the position of the adjectives in the following examples and how they agree with the nouns they modify. **el hombre bueno** | the good man
---|---
**la mujer buena** | the good woman
**los hombres buenos** | the good men
**las mujeres buenas** | the good women
**el libro azul** | the blue book
**la casa azul** | the blue house
**los libros azules** | the blue books
**las casas azules** | the blue houses
**El edificio es grande y hermoso.** | The building is large and beautiful.
---|---
**La ciudad es grande y hermosa.** | The city is large and beautiful.
**Los edificios son grandes y hermosos.** | The buildings are large and beautiful.
**Las ciudades son grandes y hermosas.** | The cities are large and beautiful.
**El moderno teléfono negro** | The modern black telephone
1. Adjectives agree with the nouns they modify in number and gender.
2. Adjectives ending in **-o** change to **-a** in the feminine. **(bueno buena; hermoso hermosa)**
3. Adjectives not ending in **-o** do not change in the feminine. **(grande grande; azul azul)**
4. Adjectives, like nouns, form their plurals by adding **-s** if they end in a vowel **(bueno buenos) (verde verdes)** ; and by adding **-es** if they end in a consonant. **(azul azules; gris grises)**
5. Descriptive adjectives usually follow the noun. Adjectives of quantity precede it. **una mesa larga** | a long table
---|---
**muchas hijas bonitas** | many pretty daughters
6. If you use two adjectives you have two possibilities:—add both adjectives after the noun, with the conjunction **y** —or place the noun between the two adjectives.
2. More About the Uses of **ser** and **estar.**
1. You have learned:
**ser** is used in answer to such questions as _Who is? What is_?
**¿Quién es el maestro? El Sr. López es el maestro.**
**¿Qué es esto? Es el retrato de mi esposa.**
**estar** is used in expressions of _place and health._
**¿Dónde está la oficina? Está en la calle Whitehall.**
**¿Cómo está su niño? Mi niño está enfermo.**
2. Study the following sentences and note:
**ser** is used with adjectives that indicate _lasting qualities_ , that is, qualities not likely to change, such as color, size, shape, personal characteristics.
**estar** is used with adjectives that indicate _non-lasting qualities_ , that is, qualities quite subject to change.
Among these are adjectives of health. Adjectives with **ser**
( _Lasting Qualities_ ) | Adjectives with **estar**
( _Non-lasting Qualities_ )
---|---
1. **La oficina es pequeña.** | 1. **La cocina está caliente** (hot).
2. **Los libros son azules.** | 2. **La sala está fría** (cold).
3. **La lección es fácil.** | 3. **Estamos listos** (ready).
4. **Mis amigos son inteligentes.** | 4. **¿Están Uds. contentos** (happy)?
5. **Las cestas son baratas.** | 5. **Las ventanas están limpias** (clean).
6. **María es simpática.** | 6. **El jarro está lleno** (full).
7. **El niño es bueno.** | 7. **Estoy bueno (bien)** (well).
8. **Los cuartos no son malos.** | 8. **Jorge está malo** (sick).
**NOTE: bueno** and **malo** go with **ser** when they mean _good_ and _bad._ | **NOTE** : **bueno** and **malo** go with **estar** when they mean _well_ and _sick._
3. **estar** is also used with adjectives indicating a finished action, like **sentado** seated, or **escrito** written. **Los señores están sentados. La carta está escrita.**
## TERCERA PARTE
### Ejercicios No. 22A-22B-22C
22A. Fill in the correct form of the adjective in parentheses.
**Ejemplo: Los colores de los carteles son vivos.**
1. **Los colores de los carteles son** (lively).
2. **La oficina es** (comfortable).
3. **Veo las casas con tejados** (red).
4. **¿Dónde están las montañas** (green)?
5. **Los edificios de mi ciudad son muy** (high).
6. **Hay** (many) **carteles en la pared.**
7. **Las casas son** (white).
8. (Many) **ventanas dan a la calle.**
9. **La puerta es** (blue).
10. **Es una señorita muy** (nice).
22B. Fill in the correct form of **ser** or **estar** as needed.
1. **Los niños________simpáticos.**
2. **El auto azul________en la esquina.**
3. **El color de los tejados________rojo.**
4. **¿Cómo________Ud.?**
5. **________muy bien.**
6. **Mis niños________enfermos.**
7. **Nosotros________sentados en el comedor.**
8. **Nosotros________los amigos de Felipe.**
9. **Los alumnos________muy inteligentes.**
10. **¿________muy altos los edificios?**
22C. Translate:
1. The office of Mr. Adams is very nice.
2. The windows of the office are large.
3. There are many papers in the printer.
4. The walls of the office are grey.
5. The table is green.
6. The answering machine is yellow.
7. The building is very high.
8. How are you, Mr. Adams?
9. I am very well, thank you.
10. The posters are beautiful.
### Ejercicio No. 23—Preguntas
Answer in complete Spanish sentences.
1. **¿Dónde está la ofícina del Sr. Adams?**
2. **¿Es grande la ofícina?**
3. **¿Es cómoda la ofícina?**
4. **¿Dónde hay algunos carteles de México?**
5. **¿Dónde hay muchos papeles?**
6. **¿Dónde está el ratón?**
7. **¿Qué hay entre las dos ventanas?**
8. **¿Quién está sentado?**
9. **¿De qué color es el ratón?**
10. **¿De qué color es el contestador?**
11. **¿De qué color son los papeles?**
12. **¿Es azul el teléfono?**
13. **¿De qué color son las paredes?**
14. **¿Es verde la mesa?**
15. **¿De quién** (whose) **es la ofícina?**
**Es la ofícina del** ________.
# CHAPTER 10
CAPÍTULO 10 (DIEZ)
## PRIMERA PARTE
### Un amigo visita la oficina del señor Adams
1. **El señor Gómez, amigo del señor Adams, es un habitante de Nueva York. Sin embargo, habla bien el español, porque sus padres son puertorriqueños. Es un caballero de treinta y cinco años de edad.** | 1. Mr. Gomez, a friend of Mr. Adams, is an inhabitant of New York. Nevertheless, he speaks Spanish well because his parents are Puerto Ricans. He is a gentleman of thirty-five years of age.
---|---
2. **Sabe que su amigo Adams aprende el español. Desea saber cómo su amigo adelanta. Por eso entra un día en la oficina del señor Adams y lo saluda en español. Sigue la conversación.** | 2. He knows that his friend Adams is learning Spanish. He wants to find out how his friend is progressing. Therefore he enters the office of Mr. Adams one day and greets him in Spanish. The conversation follows.
3. — **¿Qué tal, amigo?** | 3. How do you do, friend?
4. — **Muy bien, gracias. ¿Y Ud.?** | 4. Very well, thank you. And you?
5. — **Más o menos. A propósito, ¿Ud. aprende el español, verdad?** | 5. So, so. By the way, you are learning Spanish, aren't you?
6. — **¡Cómo no! Aprendo a hablar, a leer y a escribir español.** | 6. Of course. I am learning to speak, read, and write Spanish.
7. — **¿Es difícil el español?** | 7. Is Spanish difficult?
8. — **Pues, no es difícil. Me gusta la lengua y estudio diligentemente.** | 8. Well, it's not difficult. I like the language and I study diligently.
9. — **¿Quién es su maestro de español?** | 9. Who is your Spanish teacher?
10. — **El señor López. Es un maestro muy bueno, y día por día hablo, leo y escribo mejor. Aprendo las palabras y las expresiones de la vida diaria. Yo comprendo al señor López cuando él habla español, y él me 1 comprende cuando yo hablo la lengua. Me gusta mucho el español.** | 10. Mr. Lopez. He is a very good teacher and day by day I speak, read, and write better. I learn the words and expressions of daily life. I understand Mr. Lopez when he speaks Spanish, and he understands me when I speak it. I like Spanish very much.
11. — **Amigo mío, Ud. habla estupendamente bien.** | 11. My friend, you speak stupendously well.
12. — **Es favor que Ud. me hace.** | 12. You flatter me.
13. — **No es favor. Es verdad. Mis amigos me dicen que Ud. va a hacer un viaje a México el verano que viene.** 2 | 13. It is not flattery. It is the truth. My friends tell me that you are going to take a trip to Mexico the coming summer.
14. — **Espero ir en la primavera, el 31 de mayo. Voy a viajar por avión. Quiero llegar a México cuanto antes.** | 14. I hope to go in the spring, the 31st of May. I am going to travel by plane. I want to arrive in Mexico as soon as possible.
15. — **¡Buen viaje! ¡Y buena suerte! Hasta luego, amigo.** | 15. Happy voyage! And good luck! So long, friend.
16. — **Hasta la vista.** | 16. So long.
**NOTE** : 1. **me** me. Object pronouns usually precede the verb. 2. _Lit_ the summer that is coming.
### Pronunciation and Spelling Aids
1. Practice: | ha-bi- **tan** -te | con-ver-sa- **ción** | es-tu-pen-da- **men** -te | **bue** -na
---|---|---|---|---
| puer-to-rri- **que** -ño | di-li-gen-te- **men** -te | **fá** -cil | **suer** -te
| a-de- **lan** -te | ex-pre- **sio** -nes | di- **fí** -cil | buen **via** -je
### Building Vocabulary
1. **Palabras relacionadas** (Related Words) 1. **habitar** | to inhabit | **el habitante** | the inhabitant | |
---|---|---|---|---|---
2. **conversar** | to converse | **la conversación** | the conversation | |
3. **estudiar** | to study | **el estudiante** | the student | **el estudio** | the study
4. **comprender** | to comprehend/to understand | **la comprensión** | the comprehension, the understanding | |
5. **viajar** | to travel | **el viaje** | the voyage | **el viajero** | the traveler
2. More Adverbs Ending in **-mente** 1. **diligentemente** | diligently
---|---
2. **estupendamente** | wonderfully
3. **rápidamente** | rapidly
4. **seguramente** | surely
5. **ciertamente** | certainly
6. **posiblemente** | possibly
### Expresiones Importantes
1. **sin embargo** | nevertheless
---|---
2. **por eso** | therefore
3. **¿Qué tal?** | How goes it?
4. **¿Cómo no?** | Of course, why not?
5. **día por día** | day by day
6. **cuanto antes** | as soon as possible
7. **¿verdad?, ¿no es verdad?** is it not true?
Translated in various ways, such as: Isn't he, she, it? Aren't you? etc.
8. **el verano que viene** next summer
( _Lit._ the summer that is coming).
### Ejercicio No. 24—Completion of Text
1. (His parents) **son puertorriqueños.**
2. **Su amigo** (is progressing).
3. **Cuando el Sr. Gómez entra, dice** :—¿(How goes it?)
4. (By the way) **Ud. aprende el español** , (aren't you)?
5. (Of course).
6. (I am learning) **a hablar, a leer y a escribir el español.**
7. **Es** (easy). **No es** (difficult).
8. (I am studying) **diligentemente, porque**
(I want) **ir a México.**
9. **Cuando él habla** , yo (understand).
10. **¿Aprende Ud. las** (words) **de la vida** (daily)?
11. **Sí, y aprendo las** (expressions) **también.**
12. (I like = to me is pleasing) **la lengua.**
## SEGUNDA PARTE
### Grammar Notes
1. Present Tense of **aprender** and **vivir.** Model **-er** and **-ir** Verbs. | SINGULAR | | | SINGULAR |
---|---|---|---|---|---
| **aprend-o** | I learn | | **viv-o** | I live
| **aprend-es** | you learn (fam.) | | **viv-es** | you live (fam.)
Ud. | **aprend-e** | you learn | Ud. | **viv-e** | you live
| **aprend-e** | he, she, it learns | | **viv-e** | he, she, it lives
| PLURAL | | | PLURAL |
| **aprend-emos** | we learn | | **viv-imos** | we live
| **aprend-éis** | you learn (fam.) | | **viv-ís** | you live (fam.)
Ud. | **aprend-en** | you learn | Uds. | **viv-en** | you live
| **aprend-en** | they learn | | **viv-en** | they live
1. The endings of **aprender** are like the endings of **hablar** , except that the letter **-e** replaces the letter **-a.** The endings of **aprender** are the same as those of **vivir** , except in the **nosotros (** _we_ ) and **vosotros** ( _you, fam._ ) forms.
2. Some common **-er** and **-ir** verbs like **aprender** and **vivir.** **beber** | to drink
---|---
**comer** | to eat
**comprender** | to understand
**leer** | to read
**responder** | to answer
**ver 1** | to see
**abrir** | to open
**escribir** | to write
**dividir** | to divide
**recibir** | to receive
**permitir** | to permit
**prohibir** | to prohibit
**NOTE** : 1 The present tense of **ver** : Sing.= **veo, ves, ve.** Plur. = **vemos, veis, ven.**
2. Verbs followed by an Infinitive with **a** **Va a hacer un viaje.** | He is going to make a trip.
---|---
**Aprende a leer.** | He learns to read.
**Empezamos a hablar.** | We begin to speak.
**Comenzamos a comer.** | We begin to eat.
After the verbs **ir, aprender, comenzar** , and **empezar** , a complementary infinitive must be preceded by **a.**
## TERCERA PARTE
### Ejercicios No. 25A-2SB
25A. Practice these short dialogues aloud. They will give you a "feeling" for the correct use of verbs in the present tense.
1. **¿Aprenden Uds. español?**
**Sí, aprendemos español.**
**¿Aprende Carlos español?**
**No, no aprende español.**
2. **¿Escribe Ud. una carta?**
**No, no escribo una carta.**
**¿Qué escribe Ud.?**
**Escribo los ejercicios.**
3. **¿Qué lee Ud.?**
**Leo el diario.**
**¿Qué lee Ana?**
**Ella lee una revista.**
4. **¿Quién abre la puerta?**
**La criada abre la puerta.**
**¿Quién entra en la casa?**
**El Sr. López entra en la casa.**
5. **¿Quéve Ud.?**
**Veo el mapa.**
**¿Ve Ud. los carteles?**
**No, no veo los carteles.**
6. **¿Dónde viven Uds.?**
**Vivimos en Nueva York.**
**¿Dónde viven los mexicanos?**
**Viven en México.**
25B. Fill in the missing endings, **-ar, -er** and **-ir** verbs are included in this exercise.
### Ejemplo: Aprendo el español.
1. **(Yo) aprend—español.**
2. **El señor López toc— el timbre.**
3. **(Nosotros) estudi— diligentemente.**
4. **(Ellos) no comprend— al maestro.**
5. **¿Le— Uds. los periódicos?**
6. **Los niños beb— leche.**
7. **¿Escrib— Ud. los ejercicios?**
8. **¿Viv— (ella) en la ciudad?**
9. **Niño, ¿por qué no beb— la leche?**
10. **Papa, ¿dese— (tú) la revista?**
11. **(Ellas) no viaj— en la primavera.**
12. **La esposa abr— la puerta.**
### Ejercicio No. 26—Preguntas
1. **¿Quién es un habitante de Nueva York?**
2. **¿Habla el Sr. Gómez bien el español?**
3. **¿Son sus padres norteamericanos?**
4. **¿Qué sabe el señor Gómez?**
5. **¿En dónde entra un día?**
6. **¿A quién saluda el Sr. Gómez en español?**
7. **¿Quién aprende a hablar, a leer y a escribir el español?**
8. **¿Cómo estudia el Sr. Adams?**
9. **¿Quién es su maestro de español?**
10. **¿Es un maestro bueno?**
11. **¿Comprende el señor Adams cuando el maestro habla español?**
12. **¿Qué clase de** (what kind of) **palabras aprende el señor Adams?**
13. **¿Quién va a hacer un viaje a México?**
14. **¿Cuándo espera ir a México?**
15. **¿Quién dice—Buen viaje y buena suerte?**
# CHAPTER 11
REVIEW, CHAPTERS 7–10
REPASO, CAPÍTULOS 7–10
## PRIMERA PARTE
### Repaso de palabras (Word Review)
**NOUNS**
**1. el año** | 1. year
---|---
**2. el avión** | 2. airplane
**3. el caballero** | 3. gentleman
**4. el cartel** | 4. poster
**5. la noche** | 5. night
**6. el contestador** | 6. answering machine
**7. la escuela** | 7. school
**8. el estudiante** | 8. student
**9. el habitante** | 9. inhabitant
**10. la lección** | 10. lesson
**11. la manera** | 11. manner
**12. la computadora** | 12. computer
**13. el ratón** | 13. mouse
**14. arroba** | 14. @
**15. el país** | 15. country
**16. el parque** | 16. park
**17. el periódico** | 17. newspaper
**18. la plaza** | 18. square
**19. la pregunta** | 19. question
**20. la respuesta** | 20. answer
**21. el restaurante** | 21. restaurant
**22. la revista** | 22. magazine
**23. el sol** | 23. sun
**24. la suerte** | 24. luck
**25. la tarde** | 25. afternoon
**26. la verdad** | 26. truth
**27. el viaje** | 27. voyage
**28. la vida** | 28. life
**29. el vuelo** | 29. flight
**VERBS**
**1. aceptar** | 1. to accept
---|---
**2. adelantar** | 2. to progress
**3. contestar** | 3. to answer
**4. desear** | 4. to want
**5. entrar (en)** | 5. to enter
**6. escuchar** | 6. to listen
**7. esperar** | 7. to expect
**8. estudiar** | 8. to study
**9. hablar** | 9. to speak
**10. invitar** | 10. to invite
**11. llegar** | 11. to arrive
**12. pasar** | 12. to pass
**13. platicar** | 13. to chat
**14. practicar** | 14. to practice
**15. preguntar** | 15. to ask
**16. empezar** | 16. to begin
**17. saludar** | 17. to greet
**18. tocar** | 18. to play (music)
**19. trabajar** | 19. to work
**20. viajar** | 20. to travel
**21. visitar** | 21. to visit
**22. aprender** | 22. to learn
**23. beber** | 23. to drink
**24. comprender** | 24. to understand
**25. hacer** | 25. to make
**26. leer** | 26. to read
**27. responder** | 27. to answer
**28. tener** | 28. to have
**29. saber** | 29. to know
**30. ver** | 30. to see
**31. abrir** | 31. to open
**32. escribir** | 32. to write
**33. ir** | 33. to go
**34. pedir** | 34. to ask for
**35. seguir** | 35. to follow
**36. salir (de)** | 36. to leave, go out of
**37. salgo** | 37. I leave
**38. no sé** | 38. I don't know
**39. voy a** | 39. I am going to
**ADJECTIVES**
**1. alto** | 1. high
---|---
**2. amarillo** | 2. yellow
**3. azul** | 3. blue
**4. bajo** | 4. low
**5. barato** | 5. cheap
**6. caro** | 6. expensive
**7. caliente** | 7. hot
**8. cómodo** | 8. comfortable
**9. corriente** | 9. common
**10. difícil** | 10. difficult
**11. enfermo** | 11. sick
**12. fácil** | 12. easy
**13. frío** | 13. cold
**14. gris** | 14. gray
**15. hermoso** | 15. beautiful
**16. importante** | 16. important
**17. inteligente** | 17. intelligent
**18. largo** | 18. long
**19. listo** | 19. ready
**20. limpio** | 20. clean
**21. lleno** | 21. full
**22. próximo** | 22. next
**23. rápido** | 23. rapid
**24. rico** | 24. rich
**25. rojo** | 25. red
**26. sucio** | 26. dirty
**27. verde** | 27. green
**ADVERBS**
1. **alto** | 1. loudly
---|---
2. **despacio** | 2. slowly
3. **hoy** | 3. today
4. **tan** | 4. such, so
5. **tampoco** | 5. neither
6. **demasiado** | 6. too much
**PREPOSITIONS**
1. **para** | 1. for, in order to
---|---
2. **sin** | 2. without
3. **lejos de** | 3. far from
4. **por** | 4. for, by
5. **menos** | 5. except
6. **cerca de** | 6. near, through
**NOTE** : The uses of **por** and **para** offer some difficulty in Spanish. You can best get a feeling for their correct use by memorizing **por** and **para** phrases as you meet them. Thus: **por favor, por barco, por avión, etc.; basta por; para visitar** (in order to visit); **Sale para México.** He leaves for Mexico.
In general, **para** is used to indicate _purpose, destination_ , **por** is used to indicate _price_ **(por peso)** ; _duration of time_ **(por dos meses)** ; _through_ **(por la calle).**
**QUESTION WORDS**
1. **quién** | 1. who
---|---
2. **cuál** | 2. which (one)
3. **a quién** | 3. whom, to whom
4. **cuáles** | 4. which (ones)
5. **de quién** | 5. of whom, whose
6. **cuándo** | 6. when
**CONJUNCTIONS**
1. **pues** | 1. then, since
---|---
2. **si** | 2. if
3. **cuando** | 3. when
4. **porque** | 4. because
**IMPORTANT EXPRESSIONS**
**1. buena suerte** | 1. good luck
---|---
**2. buen viaje** | 2. happy voyage
**3. a propósito** | 3. by the way
**4. ¿Cómo no?** | 4. Of course, why not?
**5. con su permiso** | 5. if you please
**6. con mucho gusto** | 6. with great pleasure
**7. ¿Cuánto cuesta?** | 7. How much does it cost?
**8. ¿Cuántos años tiene?** | 8. How old are you?
**9. Tengo quince (15) años.** | 9. I am 15 years old.
**10. ¿De qué color?** | 10. What color is it?
**11. ¿(No es) verdad?** | 11. Isn't it so?
**12. hacer un viaje** | 12. to take a trip
**13. hacer preguntas** | 13. to ask questions
**14. mucho gusto en verlo** | 14. very glad to see you
**15. lo siento mucho** | 15. I am very sorry
**16. pedir información** | 16. to ask for information
**17. en/por tren** | 17. by train
**18. por barco** | 18. by boat
**19. en/por avión** | 19. by airplane
**20. ¿Qué tal?** | 20. How goes it?
**21. Tengo hambre.** | 21. I am hungry.
**22. sin embargo** | 22. nevertheless
**23. sobre todo** | 23. especially
**24. Vámonos.** | 24. Let's go.
**25. un rato más** | 25. a while longer
**26. contestador automático** | 26. answering machine
**27. correo electrónico** | 27. e-mail
## SEGUNDA PARTE
### Grammar Notes
**Ejercicio 27.** Give the Spanish words that correspond to these English words. The ending _-tion_ becomes **_-ción_**
**Ejemplo: atención** attention
1. civilization
2. reservation
3. instruction
4. exception
5. revolution
6. observation
7. application
8. election
9. invention
10. solution
**Ejercicio 28.** Answer each of the following questions in complete sentences, using the suggested words in the answer.
**Ejemplo: ¿De qué color es el jarro? (azul). El jarro es azul. or Es azul.**
1. **¿De qué color es la puerta? (azul)**
2. **¿Qué lengua hablan los mexicanos? (español)**
3. **¿Quién tiene hambre? (El Sr. Adams)**
4. **¿De qué color es la revista? (blanco-y negro)**
5. **¿Dónde vive Ud.? (en Estados Unidos)**
6. **¿De qué color son los papeles? (bianco)**
7. **¿Qué beben los niños? (leche)**
8. **¿A quién saluda el Sr. Adams? (a su amigo)**
9. **¿Cuántos años tiene Ud.? (treinta años)**
10. **¿Cómo se llama Ud.?** (your own name)
**Ejercicio 29.** Select the words in the right-hand column which best complete the sentence begun in the left-hand column.
**Ejemplo: 1. No comprendo bien al maestro (e) cuando habla rapidamente.**
1. **No comprendo bien al maestro** | a. **diga:—No sé.**
---|---
2. **El señor dice:—Con su permiso—** | b. **es el modo más rápido.**
3. **Si Ud. no sabe la respuesta** | c. **voy al restaurante.**
4. **El profesor dice:—Lo siento mucho** | d. **dan a la calle.**
5. **Vamos por avión porque** | e. **cuando habla rápidamente.**
6. **Si estudiamos diligentemente** | f. **el vuelo a México.**
7. **Cuando tengo hambre** | g. **cuando pasa delante de una persona.**
8. **Las ventanas de la oficina** | h. **vamos a adelantar día por día.**
9. **El amigo saluda al señor Adams y dice:—** | i. **porque la niña está enferma.**
10. **No sé cuánto cuesta** | j. **Mucho gusto en verlo.**
**Ejercicio 30.** Complete each verb with the correct ending.
**Ejemplo: nosotros vivimos.**
1. **nosotros viv** _______________
2. **ellos aprend** _______________
3. **él trabaj** _______________
4. **Ud. sab** _______________
5. **Uds. escrib** _______________
6. **tú abr** _______________
7. **yo permit** _______________
8. **Ud. beb** _______________
9. **nosotros adelant** _______________
10. **yo ve** _______________
**Ejercicio 31.** Answer each of the following questions in the affirmative:
**Ejemplo: ¿Habla Ud. ingles? Sí, hablo inglés.**
1. **¿Aprende Ud. español?**
2. **¿Estudia Ud. la lección?**
3. **¿Trabaja Ud. diligentemente?**
4. **¿Espera Ud. viajar?**
5. **¿Ve Ud. los carteles?**
6. **¿Lee Ud. el periódico?**
7. **¿Comprende Ud. la pregunta?**
8. **¿Acepta Ud. la invitación?**
9. **¿Visita Ud. al maestro?**
**Ejercicio 32.** Complete with the correct forms of **ser** or **estar** ( _See grammar notes_ 2a, b, c).
**Ejemplo: El padre es profesor. or Es profesor.**
1. **El padre** (is) **profesor.**
2. **¿Cómo** (are) **Ud.?**
3. (I am) **enfermo.**
4. (We are) **contentos.**
5. **La casa** (is) **blanca.**
6. (He is) **sentado.**
7. **Los niños** (are) **buenos.**
8. **Ella** (is) **inteligente.**
9. **Los muchachos** (are) **simpáticos.**
10. **La sala** (is) **fría.**
11. (They are) **importantes.**
12. **Tú** (are) **bonito, niño.**
13. **Ud.** (are) **alto.**
14. **Uds. no** (are) **ricos.**
15. (I am) **bien.**
## TERCERA PARTE
### Diálogo 1
Practice the Spanish aloud.
**¿Ouién es Ud.?** | Who Are You?
---|---
1. **¿Cómo se llama Ud.?** | 1. What is your name?
2. **Me llamo Carlos Sánchez.** | 2. My name is Charles Sanchez.
3. **¿Cuántos años tiene Ud.?** | 3. How old are you?
4. **Tengo veinte años.** | 4. I am 20 years old.
5. **¿Dónde vive Ud.?** | 5. Where do you live?
6. **Vivo en la calle Orizaba 50.** | 6. I live at 50 Orizaba St.
7. **¿Dónde trabaja Ud.?** | 7. Where do you work?
8. **Trabajo en la casa Velarde y Cía. (Compañía).** | 8. I work for the firm Velarde & Company.
### Diálogo 2
**¿Oué camión (autobus) tomo?** | What Bus Do I Take?
---|---
1. **Dispénseme, señor, ¿qué camión (autobús) tomo para el Zócalo? (para Coyoacán)? (para el centro)?** | 1. Excuse me, sir, what bus do I take for the Zocalo? (for Coyoacán?) (for downtown?)
2. **Tome Ud. el camión (autobús) número 24. Para aquí mismo en la esquina.** | 2. Take bus number 24. It stops right here on the corner.
3. **Muchas gracias, señor.** | 3. Thank you very much, sir.
4. **De nada.** | 4. You're welcome.
### Diálogo 3
**¿Qué tranvía va a...?** | What Streetcar Goes to...?
---|---
1. **Dispénseme, señor, ¿me hace el favor de decirme, qué tranvía va al parque de Chapultepec? (al Palacio de Bellas Artes)? (al Jardín Zoológico)?** | 1. Excuse me, sir, would you please tell me, what street car goes to Chapultepec Park? (to the Palace of Fine Arts)? (to the Zoo)?
2. **No sé, señor. Pero aquel policía en la esquina puede decide, estoy seguro.** | 2. I do not know, sir. But that policeman on the corner can tell you, I am sure.
3. **Muchas gracias, señor. Voy a preguntarle.** | 3. Thank you very much, sir. I am going to ask him.
## LECTURA I
**Follow the instructions given in Ejercicio No. 14.**
### Ejercicio No. 33—Dos amigos del señor Adams
**El señor Adams ya sabe los nombres de todos los objetos de su casa. Ahora empieza a estudiar los verbos porque desea aprender a leer, a escribir y a conversar en español. También desea saber los números en español. Siendo** (being) **un comerciante que espera visitar a su agente en México, necesita** (he needs) **la práctica de charlar** (chatting) **con españoles o hispanoamericanos. Afortunadamente** (Luckily) **tiene dos amigos que son de México y que trabajan cerca de su oficina en la calle Whitehall.**
**Un día el señor Adams va a visitar a estos** (these) **mexicanos. Los dos señores escuchan con aten-ción al señor Adams mientras** (while) **habla con ellos en español. Después de** (After) **diez minutos de conversación, los mexicanos hacen muchas preguntas a su** (their) **amigo y están muy contentos** (pleased) **de sus** (his) **respuestas.**
## LECTURA 2
### Ejercicio No. 34—El Sr. Adams se enferma (gets sick).
**El jueves veintidós de abril, a las nueve de la noche, llega** (arrives) **el señor López 1 a la casa de su estudiante, el señor Adams. El hijo mayor, un muchacho de diez años, abre la puerta y saluda al maestro. Entran en la sala donde el señor Adams general-mente espera a su profesor.**
**Pero esta** (this) **noche no está en la sala. Tampoco** (Neither) **está allí la señora Adams. El señor López está muy sorprendido** (surprised) **y le pregunta al muchacho:—¿Dónde está tu papá? El hijo responde tristemente:— Mi papá está enfermo y no puede** (cannot) **salir de su dormitorio. Está en cama** (bed) **porque está muy resfriado. También tiene dolor de cabeza** (headache).
**El profesor se pone** (becomes) **muy triste y dice: —¡Qué lástima!** (What a pity!) **Entonces hoy no podemos tener clase, pero la semana próxima vamos a estudiar dos horas. Hasta el martes próximo.**
**NOTE** : 1. Quite frequently the subject is placed after the verb in Spanish, even when the sentence is not a question. Thus: **llega el Sr. Adams = el Sr. Adams llega.** Watch out for this inverted word order
# CHAPTER 12
CAPÍTULO 12 (DOCE)
## PRIMERA PARTE
### En el comedor
1. **Los señores Adams y López están sentados en el comedor de la casa Adams. Toman café y comen pan dulce.** | 1. Mr. Adams and Mr. Lopez are seated in the dining room of the Adams house. They are having coffee and sweet rolls.
---|---
2. **Dice el señor Adams:—¿Le gustan estas tazas y estos platillos?** | 2. Mr. Adams says, "Do you like these cups and saucers?"
3. — **¡Qué bonitos son!—contesta el señor López.—Esta taza blanca con dibujos azules es de Puebla, ¿verdad?** | 3. "How pretty they are!" answers Mr. Lopez. "This white cup with the blue designs is from Puebla, is it not?"
4. — **Sí, este tipo de cerámica se llama Talavera de Puebla. Es conocida por todas partes. Es interesante ver que cada distrito tiene su propio estilo de cerámica.** | 4. Yes, this kind of pottery is called Puebla Talavera. It is known everywhere. It is interesting to see that each district has its own style of pottery.
5. — **¿De dónde es ese jarro verde y blanco?** | 5. Where does that green-and-white pitcher come from?
6. — **Este jarro para crema es de Oaxaca. Mire los dibujos de pájaros y flores. Ese otro para agua es de Michoacán.** | 6. This cream pitcher is from Oaxaca. Look at the designs of birds and flowers. That other one for water is from Michoacán.
7. — **Ya sabe Ud., señor Adams, que los indios son verdaderos artistas. Trabajan despacio. Como cualquier artista, no tienen prisa.** | 7. You already know, Mr. Adams, that the Indians are true artists. They work slowly. Like any artist, they are not in a hurry.
8. — **Sí, es difícil hoy día obtener un surtido adecuado para el mercado norteamericano.** | 8. Yes, it is hard nowadays to obtain an adequate assortment for the North American market.
9. — **Pobre artista—dice el señor López—. Para aquel mercado lejano tiene que trabajar de prisa. Así no es fácil mantener la calidad artística.** | 9. "Poor artist," says Mr. Lopez. "For that distant market he has to work fast. Thus it is not easy to maintain artistic quality."
10. — **Es verdad—responde el señor Adams—. Pero de todos modos veo mucha cerámica de interés artístico.** | 10. "It is true," answers Mr. Adams. "But anyway, I see much pottery of artistic interest."
11. — **¡Ya lo creo!—contesta el señor López—. Me gustan mucho aquellos platos para frutas en el aparador. ¡Qué finos son los dibujos amarillos y azules en el fondo blanco!** | 11. "I should say so!" answers Mr. Lopez. "I like very much those fruit dishes on the sideboard. How fine the yellow-and-blue designs are on the white background!"
12. **—¡Tengo también ejemplares de cerámica corriente. Es muy sencilla. Como ese plato cerca de Ud., muchas veces es color café.** | 12. I also have samples of ordinary pottery. It is very simple. Like that plate near you, it is often brown.
13. — **Es para el uso—dice el señor López—. Pero también tiene dibujos.** | 13. "It is for use" says Mr. Lopez. "But it also has designs."
14. — **¿Quiere más café? ¿No quiere también esa torta?** | 14. Do you want more coffee? Do you want that cake, too?
15. — **Gracias. Todo está muy sabroso,—contesta el señor López.** | 15. "Thank you. Everything is very tasty," answers Mr. Lopez.
### Pronunciation and Spelling Aids
1. Practice: pla- **ti** -llo | co-no- **ci** -do | ar-te- **sa** -no | cu-cha- **ri** -ta | Michoacán (mee-chwah- **cahn** )
---|---|---|---|---
di- **bu** -jo | **pá** -ja-ro | a-pa-ra- **dor** | le- **ja** -no | Oaxaca (wah- **hah** -cah)
ce- **rá** -mi-ca | a-zu-ca- **re** -ro | sen- **ci** -llo | Taxco ( **tahs** -koh)
2. Exclamations begin with a reversed exclamation point. **¡Qué finos son los dibujos!** | How fine the designs are!
---|---
3. When a feminine noun begins with a stressed a, the masculine article **el** is used for the sake of the sound. Thus: **el agua** , but **las aguas; el arte, las artes**
### Building Vocabulary
1. **En el comedor** In the Dining Room **el aparador** | buffet
---|---
**el azucarero** | sugar bowl
**la cuchara** | spoon
**la cucharita** | teaspoon
**el cuchillo** | knife
**la mesa** | table
**el jarro para crema** | cream pitcher
**el jarro para agua** | water pitcher
**el plato** | plate
**el platillo** | saucer
**el sillón** | armchair
**el vaso** | glass
2. The endings **-ito, -ita, -illo, -illa** , when added to a noun, have the meaning _small._ They are also used to indicate affection, friendliness, sympathy, or informality. The Mexicans are very fond of these endings and use them even on adjectives and adverbs. **cuchara** | spoon
---|---
**cucharita** | little (tea) spoon
**plato** | plate
**platillo** | saucer
**hijo (a)** | son, daughter
**hijito (a)** | sonny, girlie
**Ana** | Anna
**Anita** | Annie
**Juan** | John
**Juanito** | Johnny, Jack
**ahora** | now
**ahorita** | right away
### Expresiones Importantes
1. **cada artista** | each artist
---|---
2. **de todos modos** | anyway
3. **hoy día** | nowadays
4. **muchas veces** | many times, often
5. **por todas partes** | everywhere
6. **tener que** | to have to
7. **Tiene que trabajar.** | He has to work.
8. **tener prisa** | to be in a hurry
9. **tengo prisa** | I am in a hurry
10. **¡Ya lo creo!** | Of course! I should say so!
11. **tomar una bebida, tomar café** | to have a drink, to have coffee
12. **comer un pastel** | to eat a cake
### Ejercicio No. 35—Completion of Text
1. (They are having) **café** y **pan dulce.**
2. **¡Qué bonitos son estos** (designs)!
3. **Este tipo de cerámica es conocido** (everywhere).
4. (Each) **distrito tiene su** (own) **estilo.**
5. **Este jarro es** (for cream).
6. **Ese otro es** (for water).
7. **Cualquier artista trabaja** (slowly).
8. (He has to) **trabajar de prisa.**
9. **Pero** (anyway) **veo mucha cerámica.**
10. (I have) **ejemplares de cerámica corriente.**
11. **Ese plato es** (very simple).
12. (Often) **es color de café.**
13. **Es** (for use), **pero tiene dibujos.**
14. ¿(Do you wish) **más café**?
15. ¿(Do you not wish) **esta torta?**
## SEGUNDA PARTE
### Grammar Notes
1. The Demonstrative Adjectives. Note the forms and meanings of **este, ese** , and **aquel** in the following sentences. **Este** jarro es de Puebla.
**Esta** taza es de Oaxaca.
**Estos** jarros son de Puebla.
**Estas** tazas son de Oaxaca. | _This_ pitcher is from Puebla.
_This_ cup is from Oaxaca.
_These_ pitchers are from Puebla.
_These_ cups are from Oaxaca.
---|---
**Ese** plato es de Puebla.
**Esa** cuchara es de Taxco.
**Esos** platos son de Puebla.
**Esas** cucharas son de Taxco. | _That_ plate is from Puebla.
_That_ spoon is from Taxco.
_Those_ plates are from Puebla.
_Those_ spoons are from Taxco.
Mire Ud. **aquel** tejado rojo.
Mire Ud. **aquella** montaña alta.
Mire Ud. **aquellos** tejados rojos.
Mire Ud. **aquellas** montañas altas. | Look at _that_ red roof.
Look at _that_ high mountain.
Look at _those_ red roofs.
Look at _those_ high mountains.
1. Demonstrative adjectives agree in number and gender with the nouns they modify.
2. ese, esa, esos, esas ( _that, those_ ) are used to point out persons or things near the persons spoken to; **aquel, aquella, aquellos, aquellas** ( _that, those_ ) are used to point out distant persons or things.
2. Present Tense of **tener** to have, **venir** to come SINGULAR | SINGULAR
---|---
**tengo** | I have | **vengo** | I come
**tienes** | you have ( _fam._ ) | **Ud. vienes** | you come ( _fam._ )
**Ud. tiene** | you have | **viene** | you come
**tiene** | he, she, it has | **viene** | he, she, it comes
PLURAL | PLURAL
**tenemos** | we have | **venimos** | we come
**tenéis** | you have ( _fam._ ) | **venís** | you come ( _fam._ )
**Uds. tienen** | you have | **Uds. vienen** | you come
**tienen** | they have | **vienen** | they come
**NOTE** : Memorize the proverb **(el refrán)** : **Quien primero viene primero tiene.** First come first served. ( _Lit_ Who comes first has first.)
## TERCERA PARTE
### Ejercicios No 36A-36B-36C
36A. Complete with the correct form of **este, ese, aquel.** The abbreviation, _dist. (distant)_ after _that_ and _those_ , means use the correct form of **aquel** , not **of ese.**
**Ejemplo: ¿Ven Uds. _aquellas_ montañas verdes?**
1. **¿Ven Uds.** (those- _dist._ ) **montañas verdes?**
2. (This) **taza es de Puebla.**
3. (These) **señores toman café.**
4. (These) **sillas son nuevas.**
5. (Those) **revistas son muy interesantes.**
6. (Those) **dibujos son muy finos.**
7. (That- _dist._ ) **casa es gris.**
8. (This) **retrato es de mi esposa.**
9. **Vamos a visitar** (those _-dist._ ) **ciudades.**
10. (This) **camisa es de Juan.**
11. (That) **blusa es de Maria.**
12. **Me gustan** (these) **dibujos.**
36B. Read each question and answer aloud several times.
1. **¿Tiene Ud. que escribir una carta? Sí, tengo que escribir una carta.**
2. **¿Tienen Uds. que hacer un viaje? No, no tenemos que hacer un viaje.**
3. **¿Tienes hambre, hijito? Sí, tengo hambre.**
4. **¿Tienes prisa, Carlitos? No, no tengo prisa.**
5. **¿De dónde viene Ud.? Vengo del cine.**
6. **¿De dónde vienen Uds.? Venimos del parque.**
36C. Translate into Spanish.
1. These gentlemen are seated in the dining room
2. These cups are from Puebla.
3. I like **(me gustan)** these designs.
4. Those plates are from Oaxaca.
5. Do those ( _dist._ ) artists work slowly?
6. Has this family five children?
7. Are you hungry sonny?
8. No, I am not hungry.
9. Do you have to write a letter, Mr. Adams?
10. Yes, I have to write a letter.
## CUARTA PARTE
### Ejercicio No. 37—Preguntas
Answer in complete Spanish sentences.
1. **¿Dónde están sentados los señores Adams y López?**
2. **¿Qué toman?**
3. **¿Qué dice el Sr. Adams?**
4. **¿De dónde es la taza blanca con los dibujos azules?**
5. **¿Tiene cada distrito su propio estilo?**
6. **¿De dónde es el jarro para crema?**
7. **¿De dónde es el jarro para agua?**
8. **¿Son verdaderos artistas los indios?**
9. **¿Cómo trabajan los artesanos indios, despacio o de prisa?**
10. **¿Tienen prisa los artistas?**
11. **¿Para qué mercado es difícil obtener un surtido adecuado?**
12. **¿Quién ve mucha cerámica de interés artístico?**
13. **¿Dónde están los platos para frutas?**
14. **¿De qué color son los dibujos en los platos para frutas?**
15. **¿Tiene el Sr. Adams ejemplares de cerámica corriente?**
# CHAPTER 13
CAPÍTULO 13 (TRECE)
## PRIMERA PARTE
### Números, números, siempre números
1. — **Ya sabe que los nombres de cosas y de personas son importantes. Ya sabe que no es posible hacer una frase sin verbos.** | 1. You already know that the names of things and of persons are important. You already know that it is not possible to make a sentence without verbs.
---|---
2. — **Es verdad, Sr. López.** | 2. It's true, Mr. Lopez.
3. — **Pues, hay palabras, señor, que son tan importantes como los nombres y los verbos. En efecto, no es posible imaginar nuestra civilización moderna sin estas palabras. ¿Puede adivinar en qué pienso?** | 3. Well, there are words, sir, that are as important as nouns and verbs. In fact, it is not possible to imagine our modern civilization without these words. Can you guess what I am thinking of?
4. — **Creo que sí. Ud. quiere decir 1 los números.** | 4. I think so. You mean numbers.1
5. — **Tiene razón. ¿Puede decirme cuándo usamos números hoy en día?** | 5. You are right. Can you tell me when do we use numbers nowadays?
6. — **Por supuesto. Nada es más fácil. Necesitamos números para comprar y vender.** | 6. Of course. Nothing is easier. We need numbers for buying and selling.
7. — **¡Ja, Ja, Ja! El comerciante piensa primero en comprar y vender. Pero sin dinero no valen mucho los números ¿no es verdad?** | 7. Ha, ha, ha! The businessman thinks first of buying and selling. But without money numbers are not worth much, are they?
8. — **¿Cómo no? Pues, necesitamos números para indicar la fecha, las horas del día, la temperatura; para expresar medidas y cantidades; para telefonear; para la radio; para la computadora; para todas las ciencias, y para mil cosas más.** | 8. Of course. Well, we need numbers to indicate the date, the time of day, the temperature; to express measures and quantities; to telephone; for the radio; for the computer; for all the sciences, and for a thousand more things.
9. — **Números, números, siempre números. Sí, Sr. Adams, no es posible vivir sin números. Pero una cosa es saber los números. Otra cosa es usarlos 2 correctamente en la vida diaria.** | 9. Numbers, numbers, always numbers. Yes, Mr. Adams, it is not possible to live without numbers. But it is one thing to know numbers. It is another thing to use them correctly in daily life.
10. — **Ud. tiene razón. Yo voy a hacer todo lo posible para usarlos perfectamente.** | 10. You are right. I am going to do everything possible to use them perfectly.
11. — **Entretanto quiero decir que día por día Ud. adelanta mucho.** | 11. Meanwhile I want to say that day by day you are making much progress.
12. — **Es favor que me hace, señor López.** | 12. You flatter me, Mr. Lopez.
13. — **No es favor. Es verdad. Pues basta por hoy. Hasta luego.** | 13. It is not flattery. It is the truth. Well, enough for today. So long.
14. — **Hasta el jueves próximo, señor.** | 14. Until next Thursday, sir.
**NOTE** : 1. _Lit_ you wish to say. 2. **los** them. Pronouns which are objects of infinitives follow the verb and are attached to it.
### Pronunciation and Spelling Aids
1. Practice: | ci-vi-li-za- **ción** | ne-ce-si- **tar** | se-gu-ra- **men** -te | en-tre- **tan** -to | can-ti- **da** -des
---|---|---|---|---|---
| e-nu-me- **rar** | a-di-vi- **nar** | tem-pe-ra- **tu** -ra | **cien** -cias | per-fec-ta- **men** -te
### Building Vocabulary
1. **Palabras relacionadas** (Related Words) 1. **necesitar** | to need | **necesario** | necessary | **la necesidad** | necessity
---|---|---|---|---|---
2. **civilizar** | to civilize | **la civilización** | civilization | |
3. **indicar** | to indicate | **la indicación** | indication | |
2. **El día** and **el mapa** are among the exceptions to the rule that nouns ending in **a** are feminine.
### Expresiones Importantes
1. **basta por hoy** | enough for today
---|---
2. **Creo que sí.** | I think so.
3. **Creo que no.** | I think not.
4. **Ud. tiene razón.** | You are right.
5. **en efecto** | in fact
6. **pensar en** | to think of
7. **Favor que me hace.** | You flatter me.
8. **no valen mucho** | are not worth much
9. **en la vida diaria** | in daily life
10. **todo lo posible** | everything possible
### Ejercicio No. 38—Completion of Text
1. ¿(Do you know) **los números**?
2. **¿Hay palabras que son** (as important as) **los verbos?**
3. (Our civilization) **no es posible sin números.**
4. (You are right.)
5. ¿(Can you) **decirme cuándo usamos números**?
6. **Los números sin dinero** (are not worth) **mucho.**
7. (We need) **números para indicar** (the date).
8. **No es posible** (to get along) **sin números.**
9. (In the meantime) **quiero decir** (that) **Ud. adelanta mucho.**
10. ¿(What is the meaning of) **esta palabra**?
## SEGUNDA PARTE
### Grammar Notes
1. Verbs with Stem Changes: **pensar** to think, **querer** to wish, **contar** to count, **poder** to be able.
The stem of a verb is that part that remains after the infinitive ending **-ar, -er** , or **-ir** has been removed. Note the stem changes in the following verbs. The endings are regular. I think, etc. | I wish, etc. | I count, etc. | I am able, etc.
---|---|---|---
**pienso** | **quiero** | **cuento** | **puedo**
**piensas** | **quieres** | **cuentas** | **puedes**
**piensa** | **quiere** | **cuenta** | **puede**
**pensamos** | **queremos** | **contamos** | **podemos**
**pensáis** | **queréis** | **contáis** | **podéis**
**piensan** | **quieren** | **cuentan** | **pueden**
Many verbs have stem changes from **e** to **ie** , like **pensar** and **querer.**
Many verbs have stem changes from **o** to **ue** , like **contar** and **poder.**
They will be indicated in the vocabulary as follows: **pensar(ie), querer(ie), poder(ue), contar(ue).**
**NOTE** : The stem changes do not occur in the **nosotros-as** (we) and the **vosotros-as** ( _you, fam._ ) forms.
2. **Los números desde uno (1) hasta cien (100)**
* 0 **cero**
* 1 **uno**
* 2 **dos**
* 3 **tres**
* 4 **cuatro**
* 5 **cinco**
* 6 **seis**
* 7 **siete**
* 8 **ocho**
* 9 **nueve**
* 10 **diez**
* 11 **once**
* 12 **doce**
* 13 **trece**
* 14 **catorce**
* 15 **quince**
* 16 **dieciséis**
* 17 **diecisiete**
* 18 **dieciocho**
* 19 **diecinueve**
* 20 **veinte**
* 21 **veintiuno**
* 22 **veintidós**
* 23 **veintitrés**
* 24 **veinticuatro**
* 25 **veinticinco**
* 26 **veintiséis**
* 27 **veintisiete**
* 28 **veintiocho**
* 29 **veintinueve**
* 30 **treinta**
* 31 **treinta y uno**
* 32 **treinta y dos**
* 40 **cuarenta**
* 43 **cuarenta y tres**
* 50 **cincuenta**
* 54 **cincuenta y cuatro**
* 60 **sesenta**
* 65 **sesenta y cinco**
* 70 **setenta**
* 76 **setenta y seis**
* 80 **ochenta**
* 87 **ochenta y siete**
* 90 **noventa**
* 99 **noventa y nueve**
* 100 **cien**
* 101 **ciento uno**
* 102 **ciento dos**
1. Before a masculine noun **uno** becomes **un.** Before a feminine noun **una** becomes **un** **un amigo** | **una amiga** | **veintiún amigos** | **veintiuna amigas**
---|---|---|---
2. Like any other adjective, **cuánto** (sing, _how much_ , plur. _how many_ ) must agree with the noun it modifies: **cuánto dinero cuánta tinta** (ink) **cuántos niños cuántas niñas**
## TERCERA PARTE
### Ejercicios No. 39A-39B-39C-39D
39A. Read aloud, saying the numbers in Spanish.
**Ejemplo: treinta palabras españolas**
1. **30 palabras españolas**
2. **10 lecciones fáciles**
3. **50 personas buenas**
4. **49 carteles mexicanos**
5. **16 colores vivos**
6. **78 señoritas inteligentes**
7. **17 casas blancas**
8. **15 niños bonitos**
9. **62 papeles verdes**
10. **97 libros azules**
11. **84 ciudades grandes**
12. **13 plumas negras**
39B. Read aloud and write in Spanish.
1. 2 + 6 = 8 **dos mas seis son ocho**
2. 10 – 7 = 3 **diez menos siete son tres**
3. 5 × 4 =20 **cinco por cuatro son veinte**
4. 12 ÷ 4 = 3 **doce dividido por cuatro son tres**
5. 4 + 9 = 13
6. 7 × 8 = 56
7. 8 × 3 = 24
8. 8. 80 ÷ 20 = 4
9. 9. 19 – 8=11
10. 16 – 3 = 13
11. 8 + 7=15
12. 50 ÷ 10 = 5
39C. Read questions and answers aloud, saying all numbers in Spanish.
**Ejemplo: ¿Cuántos días hay en enero? (31) treinta y un días.**
1. **¿Cuántos días hay en junio? (30 días)**
2. **¿Cuántos meses tiene el año? (12 meses)**
3. **¿Cuántos días hay en la semana? (7 días)**
4. **¿Cuántas horas tiene un día? (24 horas)**
5. **¿Cuántos minutos hay en una hora? (60 minutos)**
6. **¿Cuántos segundos tiene un minuto? (60 segundos)**
7. **¿Cuántos libros hay en el estante? (75 libros).**
8. **¿Cuántos alumnos hay en la clase? (36 alumnos).**
9. **¿Cuántos años tiene Ud.? Tengo (35 años).**
10. **¿Cuántos años tiene Carlos? Tiene (16 años).**
39D. Substitute the correct form of the verb for the infinitive in parentheses.
**Ejemplo: Yo quiero aprender los números.**
1. **Yo (querer) aprender los números.**
2. **Yo no (poder) ir a casa.**
3. **Nosotros (pensar) en los números.**
4. **¿(Pensar) Ud. en su maestro?**
5. **¿Qué (querer) decir esta palabra?** 2
6. **Rosa no (querer) ir a la escuela.**
7. **¿(Querer) Uds. hablar español?**
8. **Ellos no (poder) comprar el automóvil.**
9. **¿(Poder) tú adivinar la respuesta?**
10. **Ellas (pensar) en comprar y vender.**
11. **Este radio 1 (valer) mucho.**
12. **Yo (contar) en español.**
13. **Tú (contar) en inglés.**
14. **¿(Contar) ella bien en español?**
**NOTE** : 1. **el radio** = the radio apparatus, **la radio** = the radio system, broadcasting.
2. What does this word mean? ( _Lit_ What does this word wish to say?)
### Ejercicio No. 40—Preguntas
Answer each question in a complete Spanish sentence.
1. **¿Son importantes los números?**
2. **¿Son los números tan importantes como los nombres?**
3. **¿Qué necesitamos para comprar y vender?**
4. **¿En qué piensa primero el negociante?**
5. **¿Valen mucho los números sin dinero?**
6. **¿Es posible comprar y vender sin dinero?**
7. **¿Vende y compra un comerciante?**
8. **¿Es un comerciante comprador y vendedor?**
9. **¿Quién adelanta día por día?**
10. **Dígame estos números en español: 10, 20, 30, 40, 50, 100.**
# CHAPTER 14
CAPÍTULO 14 (CATORCE)
## PRIMERA PARTE
### El sistema monetario de México
1. — **En nuestra última conversación dijimos que no es posible imaginar nuestra civilización moderna sin números, es decir sin matemáticas. Igualmente, no es posible imaginar un viaje sin matemáticas.** | 1. In our last conversation we said that it is not possible to imagine our modern civilization without numbers, that is to say, without mathematics. Likewise, it is not possible to imagine a trip without mathematics.
---|---
2. — **¿Sabe cuántas veces se usan las matemáticas en un viaje?** | 2. Do you know how many times one uses mathematics on a trip?
3. — **Creo que sí. Se usan para cambiar dinero, para comprar boletos y comida, para pesar maletas, para medir distancias y tamaños y para ir de compras en tiendas, mercados y almacenes.** | 3. I think so. One uses it in order to change money, buy tickets and food, to weigh suitcases, to measure distances and sizes, and to make purchases in shops, markets, and department stores.
4. — **¿Conoce el sistema monetario de México?** | 4. Do you know the monetary system of Mexico?
5. — **¡Qué cosa! Por supuesto lo conozco! Yo soy un negociante que importa artículos mexicanos, ¿no es verdad? El peso es el «dólar» de México, pero no sé cuánto vale en dólares.** | 5. What a question! I certainly do know it. I am a businessman who imports Mexican things, am I not? The peso is the "dollar" of Mexico, but I don't know what its value is in dollars.
6. **Obviamente debe fijarse en el cambio oficial del día. Digamos que el dólar vale 9 pesos y Ud. quiere cambiar quinientos (500) dólares...** | 6. Obviously you have to check the current exchange rate. Let's say the exchange rate is 9 dollars per peso and you want to change 500 dollars.
7. — **Entonces voy a recibir cuatro mil quinientos (4500) pesos.** | 7. Then I'll get 4,500 pesos.
8. — **¿Y si quiere cambiar cincuenta dólares en pesos?** | 8. And if you want to change 50 dollars in pesos?
9. — **Voy a recibir cuatrocientos cincuenta (450).** | 9. I'll get 450.
10. — **Otro ejemplo. Ud. va a la estación de ferrocarril. Quiere comprar dos boletos para Guadalajara. Cada boleto cuesta 45 pesos. Ud. le da al vendedor 100 pesos. ¿Cuánto recibe Ud. de cambio?** | 10. Another example. You go to the railroad station. You want to buy two tickets for Guadalajara. Each ticket costs 45 pesos and you give the ticket agent 100 pesos. How much do you receive in change?
11. — **Recibo 10 (diez) pesos de cambio.** | 11. I receive 10 pesos in change.
12. — **Está bien. En nuestra próxima conversación vamos a continuar este tema importante. El ejercicio hace al maestro.** | 12. O.K. In our next conversation let us continue this important topic. Practice makes perfect. ( _Lit._ Practice makes the master.)
**NOTE** : **lo** (m) it. Object pronouns usually precede the verb.
### Pronunciation and Spelling Aids
1. Practice: i-gual- **men** -te | dis- **tan** -cias | Gua-da-la- **ja** -ra | es-ta- **ción** de fe-rro-ca- **rril** | con-ti- **nuar**
---|---|---|---|---
2. Una vez, dos veces. Since the letter **z** is unusual before **e** or **i** , words ending in **z** change **z** to **c** in the plural. Other examples are: **el lápiz** (pencil) **los lápices; la voz** (voice) **las voces; la actriz** (actress) **las actrices**
### Building Vocabulary
A. 1. **la maleta, la valija** suitcase | 2. **el equipaje** baggage | 3. **el baúl trunk**
---|---|---
B. **El sistema monetario de México**
The dollar sign ($) is used in Mexico to indicate **pesos.** Thus $25 (Mex.) means **25 pesos** ; but it's a good idea to ask whether pesos are meant or U.S. dollars.
### Expresiones Importantes
1. **es decir** | that is to say
---|---
2. **¡Qué cosa!** | The idea!
3. **de cambio** | in change
4. **ir de compras** | to go shopping
5. **El ejercicio hace al maestro.** | Practice makes perfect.
6. **por supuesto** | of course
7. **digamos que** | let's say
### Ejercicio No. 41—Completion of Text
1. **Nuestra civilización no es posible sin números** (that is to say) **sin matemáticas.**
2. ¿(How many times) **usa Ud. las matemáticas en un día**?
3. **Compro** (tickets and meals).
4. **Ud. no puede pesar** (suitcases) y **saber los** (sizes) y **las** (distances).
5. (The monetary system) **de México no es difícil.**
6. (Let's say each) **dólar norteamericano vale pesos.**
7. **En cada peso hay cien** (cents).
8. (Of course). **Ud. va a recibir ocho pesos** (in change).
9. **Dos boletos para Guadalajara cuestan** (ninety) **pesos.**
10. **En nuestra** (next) **conversación vamos a continuar** (this) **tema.**
## SEGUNDA PARTE
### Grammar Notes
1. Present tense of **dar** 1 to give, and **saber** 2 to know, to know how. I give, etc. | I know, etc.
---|---
**doy** | **damos** | **sé** | **sabemos**
**das** | **dais** | **sabes** | **sabéis**
**Da** | **dan** | **sabe** | **saben**
**NOTE** : 1. Spanish verbs in the **yo** ( _l_ ) form, present tense, end in **-o.** There are only six exceptions: **soy, estoy, voy, doy, he** and **sé.** 2. Spanish verbs **conocer** and **saber** both mean "to know" but are used differently.
2. **Los numeros desde el den (100) hasta un mil (1,000).** 100 **cien** | 200 **doscientos (as)** | 500 **quinientos (as)** | 800 **ochocientos (as)**
---|---|---|---
101 **ciento uno (un, una)** | 300 **trescientos (as)** | 600 **seiscientos (as)** | 900 **novecientos (as)**
102 **ciento dos** | 400 **cuatrocientos (as)** | 700 **setecientos (as)** | 1,000 **mil**
1. **Ciento** is used only connected to another number. Ex.: **ciento tres, ciento cuarenta** , etc.
2. **y** is never used between the hundreds and tens. Thus: 342 **(trescientos cuarenta y dos)**
3. Note the formation of numbers over one thousand: 1998 **mil novecientos noventa y ocho** | 2662 **dos mil seiscientos sesenta y dos**
---|---
4. The hundreds agree in gender with the nouns they modify. Thus: **trescientos libros** | **trescientas plumas**
---|---
3. More about Object Pronouns.
1. **lo** ( _it_ ), direct object pronoun, stands for a thing in the masculine gender.
2. **la** ( _it_ ), direct object pronoun, stands for a thing in the feminine gender. **¿Sabe Ud. el cambio de hoy? Lo sé.** | Do you know today's exchange rate? I know it.
---|---
**¿Sabe Ud. la respuesta? La sé.** | Do you know the answer? I know it.
### Ejercicios No. 41A-41B-41C
41A. Write out the numbers in Spanish.
**Ejemplo: 250 = doscientos cincuenta**
1. 400
2. 350
3. 525
4. 860
5. 627
6. 490
7. 560
8. 780
9. 200
10. 970
41B. Practice the following table aloud ( **1 dólar = 9 pesos** ):
$ 10.00 **Diez dólares valen** | **$ 90 noventa pesos**
---|---
$ 20.00 **Veinte dólares valen** | **$ 180 ciento ochenta pesos**
$ 30.00 **Treinta dólares valen** | **$ 270 doscientos setenta**
$ 40.00 **Cuarenta dólares valen** | **$ 360 trescientos sesenta pesos**
$ 50.00 **Cincuenta dólares valen** | **$ 450 cuatrocientos cincuenta pesos**
$ 60.00 **Sesenta dólares valen** | **$ 540 quinientos cuarenta pesos**
$ 70.00 **Setenta dólares valen** | **$ 630 seiscientos treinta pesos**
$ 80.00 **Ochenta dólares valen** | **$ 720 setecientos veinte pesos**
$ 90.00 **Noventa dólares valen** | **$ 810 ochocientos diez pesos**
$100.00 **Diez dólares valen** | **$ 900 novecientos pesos**
$150.00 **Ciento cincuenta dólares valen** | **$1500 mil quinientos pesos**
**NOTE** : The exchange rate of the peso as of 2003 is 9 pesos to the dollar.
41C. Translate.
1. I know the numbers.
2. Do you ( **Ud.** ) know where he lives?
3. We know what **(que)** he wants.
4. We do not give the money.
5. Do they give the tickets?
6. What does John give?
7. She does not know the answer.
8. We are not giving our books.
9. Do you ( **tú** ) know the questions?
10. They do not know who **(quién)** lives here.
### Ejercicio No. 42—Preguntas
Answer each question giving the numbers in full in Spanish.
**Ejemplo: Recibo cuarenta pesos de cambio.**
1. **Si una cosa cuesta 10 pesos y Ud. da un billete de 50 pesos, ¿cuánto recibe Ud. de cambio?**
2. **Si un boleto cuesta 250 pesos, ¿cuánto da por tres boletos?**
3. **Si una revista cuesta 25 pesos, ¿cuánto da por dos revistas?**
4. **Si un diario cuesta 10 pesos y Ud. le 1 da al vendedor un billete de cincuenta pesos, ¿cuánto recibe Ud. de cambio?**
5. **Si Ud. tiene un billete de cincuenta pesos, dos billetes de cien pesos, y veinte billetes de un peso, ¿cuánto dinero tiene Ud. en el bolsillo** (pocket)?
6. **Si un hombre tiene un millón de pesos, ¿es millonario?**
7. **¿Qué vale más, $20 (veinte dólares) norteamericanos o 2800 (dos mil ochocientos) pesos?**
8. **¿Sabe Ud. cuánto dinero hay en el banco de México?**
9. **¿Sabe Ud. quién es el presidente de México?**
10. **¿Cuándo vamos a continuar este tema?**
**NOTE** : 1. **le** = to _him._ Do not translate it. The Spanish often uses a pronoun object, even when the noun object (in this case **al vendedor** ) is expressed.
# CHAPTER 15
CAPÍTULO 15 (QUINCE)
## PRIMERA PARTE
### Problemas de aritmética. En el restaurante. En el aeropuerto. En la tienda.
1. — **Vamos a continuar nuestro estudio de los usos de las matemáticas en un viaje.** | 1. We are going to continue our study of the uses of mathematics on a trip.
---|---
2. — **En el restaurante cenamos. Somos cuatro. Las cenas cuestan $200 (doscientos pesos), $105 (ciento cinco pesos), $120 (ciento veinte pesos), y $135 (ciento treinta y cinco pesos). Le damos al mesero una propina de quince por ciento. ¿Cuánto es la cuenta? ¿La propina?** | 2. In the restaurant we have dinner. We are four. The dinners cost $200 (Mex.), $105, $120, and $135. We give the waiter a 15 percent tip. How much is the bill? The tip?
3. — **La cuenta es de $560 (quinientos sesenta pesos). La propina es $84 (ochenta y cuatro).** | 3. The bill is $560 (Mex.). The tip is $84.
4. — **Está bien. En el aeropuerto pongo la maleta en la balanza. Pesa 30 kilos. ¿Qué hago para saber cuánto pesa la maleta en libras?** | 4. That is good. In the airport I put the suitcase on the scale. It weighs 30 kilos. What do I do to find out how much the suitcase weighs in pounds?
5. — **No es difícil. En un kilo hay aproximadamente 2.2 (dos punto dos) libras. Ud. multiplica 30 (treinta) por 2.2. La maleta pesa 66 (sesenta y seis) libras.** | 5. It is not difficult. In one kilo there are approximately 2.2 pounds. You multiply 30 by 2.2. The suitcase weighs 66 pounds.
6. — **Correcto. En México y en los otros países de Hispanoamérica, no se usan millas sino kilómetros para medir las distancias. ¿Sabe Ud. cambiar kilómetros en millas?** | 6. Correct. In Mexico and in the other countries of Latin America, not miles but kilometers are used to measure distances. Do you know how to change kilometers into miles?
7. — **Por cierto. Divido por ocho y multiplico por cinco. De este modo ochenta kilómetros son iguales a cincuenta millas. En el taxi pagamos por kilómetro.** | 7. Certainly. I divide by eight and multiply by five. Thus eighty kilometers are equal to fifty miles. In the taxi we pay by kilometer.
8. — **Ud. calcula muy rápido. Solamente un problema más. En una tienda Ud. compra un sarape a 105 (ciento cinco) pesos, dos rebozos a 90 (noventa) pesos, tres cestas a 75 (setenta y cinco) pesos y cuatro cinturones a 45 (cuarenta y cinco) pesos. 1 ¿Cuál es el precio total?** | 8. You figure very fast. Only one more problem. In a store you buy one sarape for 105 pesos, two shawls at 90 pesos, three baskets at 75 pesos, and four belts at 45 pesos. What is the total price?
9. — **$690 (seiscientos noventa pesos). Y si le doy al comerciante $700 voy a recibir 10 pesos de cambio.** | 9. 690 pesos. And if I give the merchant $700, I will receive 10 pesos in change.
10. **Bueno. No hablemos más de matemáticas por hoy. El jueves vamos a platicar sobre la hora. Es un tema de inmensa importancia.** | 10. Good. We won't speak of mathematics any more today. On Thursday we are going to talk about the time of day. It is a topic of great importance.
11. **Seguramente. Espero una conversación interesante.** | 11. Surely I am expecting an interesting conversation.
12. — **A propósito, Sr. Adams, el próximo jueves no puedo llegar antes de las ocho y media de la noche.** | 12. By the way, Mr. Adams, next Thursday I cannot arrive before 8:30 p.m.
13. — **Bien. Más vale tarde que nunca.** | 13. That's all right. Better late than never.
14. — **Bien dicho. Hasta la vista, Sr. Adams.** | 14. Well said. Good-bye, Mr. Adams.
15. — **Hasta el jueves, Sr. López.** | 15. Until Thursday, Mr. Lopez.
**NOTE** : 1. These numbers may not reflect today's current prices. Prices change often.
### Pronunciation and Spelling Aids
1. Practice: res-tau- **ran** -te | mul-ti-pli- **car** | cin-tu- **ro** -nes | mul-ti- **pli** -co | co-mer- **cian** -te | pa- **í** -ses
---|---|---|---|---|---
Remember: **au** is pronounced like _ow_ in _cow._
2. **kilómetro.** A few foreign words borrowed by Spanish are spelled with **k.**
### Building Vocabulary
1. **el día, el mapa, el sistema, el problema** , and **el tema** are masculine. Remember: Most nouns ending in **-a** are feminine.
2. Synonyms (words of about the same meaning)
1. **rápido, rápidamente** rapidly fast
2. **el negociante, el comerciante** the businessman
3. **despacio, lentamente** slowly
4. **de este modo, de esta manera** in this way
3. Antonyms (opposites) 1. **rápidamente** rapidly | **despacio** slowly
---|---
2. **comprador** buyer | **vendedor** seller
3. **dar** to give | **recibir** to receive
4. **multiplicar** to multiply | **dividir** to divide
### Expresiones Importantes
1. **por ciento** | percent
---|---
2. **de este modo** | thus, in this way
3. **nada más** | nothing more, that's all
4. **kilómetro** | about 5/8 mile
5. **por cierto** | certainly, surely
6. **cenamos** | we have dinner
7. **¿Cuánto es la cuenta?** | How much is the bill?
8. **está bien** | good, that's right
9. **Refrán** (proverb):
**Más vale tarde que nunca.** | Better late than never.
## SEGUNDA PARTE
### Grammar Notes
1. The Present Tense of hacer to make, to do; **decir** to say; **poner** to put. I make, etc. | I say, etc. | I put, etc.
---|---|---
**hago** | **hacemos** | **digo** | **decimos** | **pongo** | **ponemos**
**haces** | **hacéis** | **dices** | **decís** | **pones** | **ponéis**
**hace** | **hacen** | **dice** | **dicen** | **pone** | **ponen**
1. **salir** to leave, **valer** to **be** worth, **traer** to bring, and **caer** to fall have a **g** in the first person, but are regular in other forms of the present tense. SING. | **Salgo** | **sales** | **sale** | PLUR. | **salimos** | **salís** | **salen**
---|---|---|---|---|---|---|---
SING. | **valgo** | **vales** | **vale** | PLUR. | **valemos** | **valéis** | **valen**
SING. | **traigo** | **traes** | **trae** | PLUR. | **traemos** | **traéis** | **traen**
SING. | **caigo** | **caes** | **cae** | PLUR. | **caemos** | **caéis** | **caen**
2. Possessive Adjectives—Summary. You are familiar with the possessive adjective **mi** (mis) and **su** ( **sus** ). Learn the meaning and forms of all the possessive adjectives. SINGULAR | PLURAL
---|---
| _masc._ | _fem._ | _masc._ | _fem._
(my) | **mi hijo** | **mi hija** | **mis hijos** | **mis hijas**
(your— _fam._ ) | **tu hijo** | **tu hija** | **tus hijos** | **tus hijas**
(your, his, her) | **su hijo** | **su hija** | **sus hijos** | **sus hijas**
(its, their) | | | |
(our) | **nuestro hijo** | **nuestra hija** | **nuestros hijos** | **nuestras hijas**
(your— _fam._ ) | **vuestro hijo** | **vuestra hija** | **vuestros hijos** | **vuestras hijas**
(your, their) | **su hijo** | **su hija** | **sus hijos** | **sus hijas**
1. Possessive adjectives agree with the nouns they modify in number and gender.
2. **tu (tus)** _your_ is used to show possession when one person is addressed familiarly, tú ( _you_ ) has an accent mark, **tu** ( _your_ ) has not. **¿Y tú, tienes ya tu visa?** | And you, do you have your visa yet?
---|---
3. **Vuestro, (-a,-os,-as)** ( _your_ ) is used to show possession when more than one person is addressed familiarly. However, use this possessive adjective only in Spain. Like the subject pronoun **vosotros** , it is rarely used in Latin America. Use **su (sus)** _your_ instead. **Uds. no tienen sus pasaportes** | You don't have your passports.
---|---
4. **su** (sus) means _your, his, her, its_ , or _their_ , according to the sense of the sentence. In cases where the meaning would be in doubt, the definite article is used before the noun, and the phrase **de Ud., de él, de ella, de Uds., de ellos** , or **de ellas** after the noun. **el padre de él** | his father
---|---
**la madre de ella** | her mother
**la casa de Ud.** | your house
**la familia de ellos** | their family
**la clase de ellas** | their class
**los hijos de Uds.** | your sons
3. **pero** and **sino.** After a negative, **sino** is used instead of **pero** in the sense of "but on the contrary," "but rather." **No es rico _sino_ pobre.** | He is not rich, _but_ poor.
---|---
**No se usan libras _sino_ kilos.** | Not pounds, _but_ kilos are used.
However, **pero** must be used if the subject changes.
**Él no es rico, _pero_ su tío sí.** | He is not rich, _but_ his uncle is. ( _Lit._ but his uncle is yes)
---|---
### Ejercicios No. 43A-43B-43C-43D
43A. Complete the following sentences, substituting the correct form of **mi, tu, su** , or **nuestro** for the words in parentheses.
**Ejemplo: No tenemos nuestros boletos.**
1. **No tenemos** (our) **boletos.**
2. **¿Cuánto cuesta** (your) **cena, señor?**
3. **¿Son muy pesadas** (your) **maletas, señorita?**
4. **No** , (my) **maletas no son muy pesadas.**
5. **¿Es muy interesante** (their) **conversación?**
6. **¿Hay cien pesos en** (his) **escritorio?**
7. (Our) **equipaje está en la estación.**
8. **¿Dónde está** (your) **madre, niño?**
9. ¿(My) **amigos están en el restaurante**?
10. ¿(Our) **civilización no es posible sin números**?
43B. Read the following, giving the numbers in Spanish.
**Ejemplo: Diez kilos son iguales a veintidós libras.**
1. **10 kilos = 22 libras**
2. **20 kilos = 44 libras**
3. **30 kilos = 66 libras**
4. **40 kilos = 88 libras**
5. **50 kilos = 110 libras**
6. **16 kilómetros = 10 miles**
7. **32 kilómetros = 20 miles**
8. **48 kilómetros = 30 miles**
9. **64 kilómetros = 40 miles**
10. **80 kilómetros = 50 miles**
43C. Translate into Spanish.
1. I say
2. I do
3. I am going out
4. I have
5. we say
6. we do not put
7. they make
8. they put
9. do you ( **Ud.** ) make?
10. do you ( **Uds.** ) go out?
11. do you ( **Uds.** ) say?
12. you ( **tú** ) make
13. do you ( **Ud.** ) put?
14. I put
15. it is worth
43D. Complete the following sentences with pero or sino as the sense requires.
1. **El señor no estudia francés** (but) **español.**
2. **No es comerciante** (but) **profesor.**
3. **Yo no estudio español** , (but) **mi hermano lo estudia.**
4. **No ponemos los libros en la mesa** (but) **en el estante.**
5. **Es un muchacho inteligente** , (but) **es perezoso** (lazy).
### Ejercicio No. 44—Preguntas
1. **¿Dónde cenan Uds.?**
2. **¿Qué por ciento le dan Uds. al mesero como propina?**
3. **¿Qué por ciento se le da al mesero de propina?**
4. **¿Dónde hace Ud. pesar su maleta?**
5. **¿Cuánto pesa la maleta en kilos? ¿En libras?**
6. **¿Qué se usa en México para medir las distancias, kilómetros o millas?**
7. **¿Quién sabe cambiar kilómetros en millas?**
8. **¿Qué artículos compra el Sr. Adams en una tienda?**
9. **¿Cuál es el tema de la próxima conversación?**
10. **¿Qué refrán (proverb) usa el Sr. Adams?**
# CHAPTER 16
CAPÍTULO 16 (DIECISÉIS)
## PRIMERA PARTE
### ¿Qué hora es?
1. **¡La hora! Todo el mundo quiere saben¿Qué hora es? ¿A qué hora llega el avión? ¿A qué hora sale el tren? ¿A qué hora comienzan los exámenes? ¿A qué hora comienza la película? ¿A qué hora comienza la función? Y un millón de otras preguntas.** | 1. The time! Everybody wants to know: What time is it? At what time does the plane arrive? At what time does the train leave? At what time do the examinations begin? At what time does the film begin? At what time does the performance begin? And a million other questions.
---|---
2. — **Sr. Adams, yo voy a hacer el papel de boletero en la taquilla de la estación del ferrocarril. Ud. va a hacer el papel de viajero que quiere comprar un boleto y pide inform ación. Favor de comenzar.** | 2. Mr. Adams, I am going to play the role of ticket agent at the window in the railroad station. You are going to take the part of a traveler who wants to buy a ticket and is asking for information. Please begin.
3. — **Buenos días, señor. Quiero comprar un boleto para Puebla.** | 3. Good day, sir. I wish to buy a ticket for Puebla.
4. — **¿De primera o de segunda clase?** | 4. First or second class?
5. — **De primera, por favor. ¿Cuánto vale el pasaje?** | 5. First class, please. How much is the fare?
6. — **Cincuenta pesos el boleto sencillo y 95 (noventa y cinco) el de ida y vuelta.** | 6. Fifty pesos for a one-way ticket or 95 pesos for a round trip.
7. — **Déme por favor un boleto de ida y vuelta. Quiero salir el lunes.** | 7. Please give me a round-trip ticket. I want to leave on Monday.
8. — **Aquí tiene Ud. el boleto. Cuesta 95 pesos.** | 8. Here is the ticket. It costs 95 pesos.
9. — **Gracias. ¿A qué hora sale el tren y cuándo llega a Puebla?** | 9. Thanks. At what time does the train leave and when does it arrive at Puebla?
10. — **Sale a las cuatro menos diez de la tarde y llega a las diez menos doce de la noche.** | 10. It leaves at 3:50 in the afternoon and arrives at 9:48 in the evening.
11. — **Muchas gracias, señor.** | 11. Many thanks, sir.
12. — **De nada.** | 12. You're welcome.
13. — **Excelente, Sr. Adams. Ud. va a hacerse entender bien en México.** | 13. Excellent, Mr. Adams. You can get along in Mexico.
______________________________ | ______________________________
1. — **Ahora yo hago el papel de boletero de un cine. Ud., Sr. Adams, pide información sobre la función. Favor de comenzar.** | 1. Now I am playing the part of the ticket agent at a cinema. You, Mr. Adams, ask for information about the show. Please begin.
---|---
2. — **Por favor, señor, ¿a qué hora comienzan las funciones del cine?** | 2. Please, sir, at what time do the performances begin?
3. — **Hay tres funciones. La primera comienza a las 4:20 (las cuatro y veinte) de la tarde, la segunda a las 6:50 (a las siete menos diez), y la tercera a las 9:10 (las nueve y diez) de la noche.** | 3. There are three showings. The first begins at 4:20 in the afternoon. The second at 6:50, and the third at 9:10 in the evening.
4. — **¿Hay noticiero?** | 4. Is there a newsreel?
5. — **¿Cómo no? Veinte minutos antes de cada película.** | 5. Of course. Twenty minutes before each picture.
6. — **¿Cuánto cuestan los boletos?** | 6. How much do the tickets cost?
7. — **Tres pesos cada uno. Si Ud. viene temprano va a obtener asientos buenos.** | 7. Three pesos each. If you come early you will get good seats.
8. — **Favor de darme dos boletos para la tercera función.** | 8. Please give me two tickets for the third showing.
9. — **Aquí los tiene. Muchas gracias.** | 9. Here they are. Thank you very much.
10. — **Admirable, Sr. Adams. ¡Ud. sí que se va a hacer entender en México!** | 10. Admirable, Mr. Adams. You will certainly get along well in Mexico.
### Pronunciation and Spelling Aids
1. Practice: co- **mien** -za | cual- **quie** -ra | **mi** -llas | cum-ple- **a** -ños | ta- **qui** -lla
---|---|---|---|---
e- **xá** -me-nes | va-ca- **cio** -nes | co-rrec-ta- **men** -te | Oa- **xa** -ca (wah- **hah** -kah) |
Remember: **au** is pronounced like _ow_ in _cow._
### Building Vocabulary
1. **Sinónimos** (Synonyms): 1. **comenzar (ie)** | **empezar (ie)** | to begin
---|---|---
2. **la taquilla** | **la boletería (Mex.)** | ticket office
3. **el billete** | **el boleto** | the ticket
4. **de nada** | **no hay de qué** | don't mention it
5. **el diario** | **el periódico** | newspaper
2. Words Dealing with Trains:
1. **¿A qué hora sale el tren para** —?
At what time does the train leave for—?
2. **¿Cuándo llega el tren de** —?
When does the train arrive from—?
3. **El tren sale (llega) a las dos.**
The train leaves (arrives) at 2 o'clock.
4. **un boleto sencillo**
a one-way ticket
5. **un boleto de primera (segunda)**
a first (second) class ticket
6. **un boleto de pullman**
a pullman ticket
7. **un boleto de ida y vuelta**
a round-trip ticket
8. **¿Cuánto cuesta (vale) el pasaje?**
How much is the fare?
### Expresiones Importantes
1. **todo el mundo** everybody
2. **desde uno hasta cien** from 1 to 100
3. **hacer el papel de** to play the part (role) of
4. **pedir información** to ask for information
5. **favor de comenzar** please begin
6. **Aquí tiene Ud. el boleto.** Here is the ticket.
7. **(Ud.) puede ir pasando** you can get along
8. **la próxima vez** next time
9. **hacerse entender** get along
### Ejercicio No. 45—Completion of Text
1. **¿A qué hora comienza** (the film)?
2. **¿A qué hora comienza** (the performance)?
3. **¿Tienen Uds.** (other questions)?
4. **El boletero está en la** (ticket office).
5. **¿Dónde está** (the railroad station)?
6. **Ud. es un viajero que** (is asking for information).
7. **Favor de darme** (a round-trip ticket).
8. **¿A qué hora** (does the train leave)?
9. **¿Llega** (at nine in the evening)?
10. (Many thanks.)
11. You're welcome.
12. **Ahora** (I play the role) **de boletero**
## SEGUNDA PARTE
### Grammar Notes
1. Verbs with Stem Changes **e** to **i** — **pedir** to ask for, **repetir** to repeat I ask for, you ask for, etc. | |
---|---|---
**pido** | **pedimos** | **repito** | **repetimos**
**pides** | **pedís** | **repites** | **repetís**
**pide** | **piden** | **repite** | **repiten**
1. The stem change **e** to **i** does not occur in the **nosotros-as** ( _we_ ) and the **vosotros-as (** _you, fam._ ) forms.
2. Verbs with stem changes from **e** to **i** , like **pedir** and **repetir** , will be indicated in the vocabulary as follows: **pedir(i), repetir(i).**
2. Time of Day **¿Qué hora es?** | What time is it?
---|---
**Es la una.** | It is one o'clock.
**Son las dos.** | It is two o'clock.
**Son las tres.** | It is three o'clock.
**Son las cuatro.** | It is four o'clock.
**Son las cinco y media.** | It is half past five.
**Son las seis y cuarto.** | It is a quarter past six.
**Son las seis y veinte.** | It is twenty minutes past six.
**Son las siete menos cuarto.** | It is a quarter to seven.
**Son las siete menos veinte.** | It is twenty minutes to seven.
**¿A qué hora? A la una en punto.** | At what time? At one o'clock sharp.
---|---
**A las ocho de la mañana.** | At eight o'clock in the morning (A.M.).
**A las cinco de la tarde.** | At five o'clock in the afternoon (P.M.).
**A las nueve de la noche.** | At nine o'clock at night (P.M.).
**A mediodía. A medianoche.** | At noon. At midnight.
1. Use the singular verb **es** in all time expressions involving **la una.** (1:12) Es **la una y doce.** | (1:30) Es **la una y media.**
---|---
2. Use the plural verb **son** for all other time expressions.
3. **y** ( _and, after_ ) is used for time after the hour **(cuarto, media, minutos)**
**Menos** ( _less, to_ ) is used for time before the hour.
4. Base time expressions after the half hour on the following hour.
(6:40) **Son las siete menos veinte.** It is twenty minutes to seven.
5. If no clock time is mentioned, use **por la mañana, por la tarde** , and **por la noche** for in the morning, in the afternoon, and at night. With clock time use **de la mañana, de la tarde** , and **de la noche.** **Trabajo por la mañana.** | I work in the morning.
---|---
**Trabajo a las ocho de la mañana.** | I work at 8 o'clock in the morning.
## TERCERA PARTE
### Ejercicios No. 46A-46B-46C
46A. Read these sentences giving the time in Spanish.
**Ejemplo: El tren de Oaxaca llega a las cinco y media de la tarde.**
1. **El tren de Oaxaca llega a** (5:30 P.M.).
2. **El tren llega a Puebla a** (8:15 P.M.).
3. **El tren para Cuernavaca sale a** (9:55 A.M.).
4. **El tren para Guadalajara sale a** (10:50 A.M.).
5. **La primera función comienza a** (2:20 P.M.).
6. **La segunda función comienza a** (4:40 P.M.).
7. **La tercera función comienza a** (7:10 P.M.).
8. **El noticiero comienza a** (6:50 P.M.).
9. **Vamos a cenar a** (7:45 P.M.).
10. **Almorzamos** (at noon).
43B. Fill in the correct forms of the verbs in parentheses.
**Ejemplo: Yo pido información.**
1. **Yo (pedir) información.**
2. **Nosotros (comenzar) a comer.**
3. **Ellos (repetir) las preguntas.**
4. **¿Quién (pedir) información?**
5. **Yo (comenzar) a trabajar.**
6. **¿(Empezar) Ud. a trabajar ahora?**
7. **¿Qué (pedir) tú, niña?**
8. **¿Qué (pedir) Uds.?**
9. **El maestro (repetir) la respuesta.**
10. **¿Por qué no (comenzar) la función?**
46C. Translate into Spanish.
1. I want a round-trip ticket.
2. He is asking for information.
3. When does the train for Oaxaca leave?
4. Do you know when the train arrives from Puebla?
5. It arrives at 5:30 in the afternoon.
6. At what time does the first performance begin?
7. It begins at 3:20 in the afternoon.
8. Do they repeat the performance?
9. Yes, they repeat the performance two times.
10. Here you have two tickets.
### Ejercicio No. 47—Preguntas
1. **¿Qué quiere saber todo el mundo?**
2. **¿Quién hace el papel de viajero?**
3. **¿Quién hace el papel de boletero?**
4. **¿Qué clase de boleto quiere comprar?**
5. **¿Cuánto cuesta un boleto de ida y vuelta?**
6. **¿Quién hace el papel de boletero de un cine?**
7. **¿Quién pide información?**
8. **¿Cuántas funciones tiene este cine?**
9. **¿Para qué función compra el señor dos boletos?**
10. **¿Cuánto paga por los dos boletos?**
# CHAPTER 17
REVIEW, CHAPTERS 12–16
REPASO, CAPÍTULOS 12–16
## PRIMERA PARTE
### Repaso de palabras
**NOUNS**
**1. el agua** | 1. water
---|---
**2. el boleto** | 2. ticket
**3. el bolsillo** | 3. pocket
**4. la cesta** | 4. basket
**5. la cena** | 5. dinner
**6. el cine** | 6. movies
**7. la dase** | 7. class
**8. la comida** | 8. meal
**9. el comprador** | 9. buyer
**10. el dibujo** | 10. drawing
**11. la cuenta** | 11. bill
**12. el cumpleaños** | 12. birthday
**13. el dinero** | 13. money
**14. el dólar** | 14. dollar
**15. el equipaje** | 15. baggage
**16. la estación** | 16. station
**17. la fecha** | 17. date
**18. la flor** | 18. flower
**19. la fruta** | 19. fruit
**20. la función** | 20. performance
**21. la hora** | 21. hour
**22. el jarro** | 22. jar, pitcher
**23. la llegada** | 23. arrival
**24. la maleta** | 24. suitcase
**25. el mercado** | 25. market
**26. el mesero** | 26. waiter
**27. el modo** | 27. way
**28. el número** | 28. number
**29. el pájaro** | 29. bird
**30. el pan** | 30. bread
**31. el pasaje** | 31. fare
**32. el platillo** | 32. saucer
**33. el plato** | 33. plate
**34. la propina** | 34. tip
**35. el pueblo** | 35. people, town
**36. el rebozo** | 36. shawl
**37. el sarape** | 37. blanket
**38. el tamaño** | 38. size
**39. la taquilla** | 39. ticket window
**40. el tipo** | 40. type
**41. la tienda** | 41. store
**42. el vendedor** | 42. seller
**43. el viajero** | 43. traveler
**44. el vaso** | 44. glass
**45. el uso** | 45. use
**46. la bebida** | 46. drink
**VERBS**
**1. caer** | 1. to fall
---|---
**2. cambiar** | 2. to change
**3. contar (ue)** | 3. to count
**4. comprar** | 4. to buy
**5. continuar** | 5. to continue
**6. comer** | 6. to eat
**7. comenzar (ie)** | 7. to begin
**8. creer** | 8. to believe
**9. dar** | 9. to give
**10. decir** | 10. to say
**11. cenar** | 11. to have dinner
**12. empezar (ie)** | 12. to begin
**13. hacer** | 13. to make, do
**14. llegar** | 14. to arrive
**15. mirar** | 15. to look at
**16. necesitar** | 16. to need
**17. obtener** | 17. to obtain
**18. pagar** | 18. to pay
**19. pensar (ie)** | 19. to think
**20. poder(ue)** | 20. to be able
**21. poner** | 21. to put
**22. venir** | 22. to come
**23. pedir (i)** | 23. to ask for
**24. querer (ie)** | 24. to want, wish
**25. saber** | 25. to know (how)
**26. tomar** | 26. to take
**27. traer** | 27. to bring
**28. telefonear** | 28. to telephone
**29. repetir (i)** | 29. to repeat
**30. recibir** | 30. to receive
**31. saber** | 31. to know
**32. salir (de)** | 32. to leave
**33. tener** | 33. to have
**34. valer** | 34. to be worth
**35. vender** | 35. to sell
**36. hemos dicho** | 36. we have said
**37. hacerse entender** | 37. make oneself understood
**ADJECTIVES**
**1. alguno** | 1. some
---|---
**2. antiguo** | 2. old
**3. cada** | 3. each
**4. cierto** | 4. certain
**5. conocido** | 5. known
**6. correcto** | 6. correct
**7. corriente** | 7. ordinary
**8. cualquier** | 8. any
**9. diario** | 9. daily
**10. diligente** | 10. diligent
**11. fino** | 11. fine
**12. igual** | 12. equal
**13. ligero** | 13. light
**14. más** | 14. more
**15. mismo** | 15. same
**16. necesario** | 16. necessary
**17. nuestro** | 17. our
**18. pesado** | 18. heavy
**19. propio** | 19. own
**20. sencillo** | 20. simple
**21. todo** | 21. all
**ADVERBS**
**1. ahora** | 1. now
---|---
**2. ahorita** | 2. now, right away
**3. correctamente** | 3. correctly
**4. entretanto** | 4. meanwhile
**5. lentamente** | 5. slowly
**6. más** | 6. more
**7. rápidamente** | 7. quickly, fast
**8. solamente** | 8. only
**9. tan** | 9. so, as
**10. tan rico como** | 10. as rich as
**PREPOSITIONS**
1. **antes de** | 1. before
---|---
2. **desde** | 2. from
3. **hasta** | 3. to, until
4. **sobre** | 4. on, upon
5. **acerca de** | 5. about, concerning
**IMPORTANT EXPRESSIONS**
**1. aquí tiene Ud.** | 1. here is, are
---|---
**2. creo que sí** | 2. I think so.
**3. creo que no** | 3. I think not.
**4. de cambio** | 4. in change
**5. de este modo** | 5. in this way
**6. de la misma manera** | 6. in the same way
**7. ¿Qué quiere decir...?** | 7. What do you mean?
**8. ¡Qué cosa!** | 8. What an idea!
**9. tener prisa** | 9. to be in a hurry
**10. tener que...** | 10. to have to
**11. tener razón** | 11. to be right
**12. en efecto** | 12. in fact
**13. es decir** | 13. that is to say
**14. favor de darme** | 14. please give me
**15. hoy día** | 15. nowadays
**16. ir de compras** | 16. to go shopping
**17. ir pasando** | 17. to get along
**18. nada más** | 18. nothing more
**19. pasar sin** | 19. to get along without
**20. pensar en** | 20. to think of
**21. por cìerto** | 21. indeed, certainly
**22. todas partes** | 22. everywhere
**23. todo el mundo** | 23. everybody
**24. todo lo posible** | 24. everything possible
**25. ¡Ya lo creo!** | 25. yes indeed!
**26. Más vale tarde que nunca.** | 26. Better late than never.
**27. El ejercicio hace al maestro.** | 27. Practice makes perfect.
**28. boleto de ida y vuelta** | 28. round-trip ticket
**29. pedir información** | 29. to ask for information
## SEGUNDA PARTE
### Grammar Notes
**Ejercicio 48.** Answer the following questions in the affirmative in complete sentences.
**Ejemplo: 1. Sí, pienso en mi amigo.**
1. **¿Piensa Ud. en su amigo?**
2. **¿Quiere Ud. hacer un viaje a México?**
3. **¿Puede Ud. comprar un automóvil?**
4. **¿Pone Ud. la lámpara en el piano?**
5. **¿Sale Ud. mañana de la ciudad?**
6. **¿Cuenta Ud. siempre el cambio?**
7. **¿Dice Ud. las palabras dos veces?**
8. **¿Continúa Ud. la lección?**
9. **¿Le 1 da Ud. una propina al mesero?**
10. **¿Sabe Ud. contar en español?**
**NOTE** : 1. **le** _to him_ , is not translated here.
**Ejercicio 49.** Answer the following questions in the negative in complete sentences. Be sure to use the **nosotros** ( _we_ ) form.
**Ejemplo: 1. No, no repetimos las respuestas.**
1. **¿Repiten Uds. las respuestas?**
2. **¿Hacen Uds. muchas preguntas?**
3. **¿Piden Uds. información?**
4. **¿Tienen Uds. prisa?**
5. **¿Vienen Uds. temprano a casa?**
6. **¿Creen Uds. el cuento (story)?**
7. **¿Traen Uds. el equipaje?**
8. **¿Toman Uds. la cena?**
9. **Necesitan Uds. dinero?**
10. **¿Tienen Uds. que trabajar?**
**Ejercicio 50.** Select the phrase in the right-hand column which best completes the sentence begun in the left-hand column.
**Ejemplo: 1. Este Tipo de cerámica (b) es conocida por todas partes.**
1. **Este tipo de cerámica** | a. **hace al maestro.**
---|---
2. **Estos dibujos son de flores** | b. **es conocida por todas partes.**
3. **Cada negociante piensa** | c. **antes de las nueve.**
4. **Ud. sabe que el ejercicio** | d. **y ésos son de animalitos.**
5. **Vamos a continuar** | e. **para comprar dos boletos.**
6. **No puedo llegar** | f. **cuando hablo español.**
7. **Voy a la boletería** | g. **primero tiene.**
8. **Sé a qué hora** | h. **en comprar y vender.**
9. **Él me comprende** | i. **este tema interesante.**
10. **Quien primero viene** | j. **comienza la función.**
**Ejercicio 51.** Complete the following sentences by choosing the proper expression from those listed below.
1. (How much does it cost?) **Cada turista** (must know) **esta expresión.**
2. **El turista** (asks for information) **en la estación del ferrocarril.** —¿(At what time) **llega el tren de Oaxaca? Dice el empleado** :—(At 7:30) **de la noche.**
3. **El turista** (is hungry). **Toma una** (drink) **en un restaurante.** (He pays the bill) **con un billete de diez pesos. Recibe cuatro pesos** (in change). **Le da al mesero** (a tip) **de sesenta centavos** , (that is to say), **diez por ciento.**
**Ejercido 52.** Translate the demonstrative adjectives in parentheses.
1. (this) **cena**
2. (these) **rebozos**
3. (that) **viajero**
4. (those) **vasos**
5. (this) **tipo**
6. (that) **estación**
7. (that-dist.) **computadora**
8. (those) **papeles**
9. (these) **casas**
10. (those) **fechas**
11. (that-dist.) **cielo**
12. (those-dist.) **puertas**
**Ejercicio 53.** From group II select antonyms for each word in group 1.
**I** | **II**
---|---
1. **comprar** | a. **recibir**
2. **venir** | b. **tarde**
3. **dar** | c. **rápidamente**
4. **antes de** | d. **salir de**
5. **temprano** | e. **vender**
6. **dividir** | f. **ir**
7. **llegar a** | g. **después de**
8. **más** | h. **multiplicar**
9. **lentamente** | i. **comprador**
10. **vendedor** | j. **menos**
## TERCERA PARTE
### Diálogo
Practice the Spanish Aloud.
**Un turista pide información acerca de la cerámica mexicana**
---
1. — **Por favor, señor, ¿de qué distritos de México son las mejores cerámicas mexicanas? Deseo comprar un juego de tazas, platillos y platos.** | 1. Please tell me, sir: From which districts of Mexico come the best examples of Mexican pottery? I want to buy a set of cups, saucers, and plates.
2. — **Pues, cada distrito tiene su propio estilo. La cerámica de Puebla, Oaxaca y Michoacán es bien conocida por todas partes.** | 2. Well, each district has its own style. The pottery of Puebla, Oaxaca, and Michoacán is well known everywhere.
3. — **¿Tengo que ir a aquellos distritos para obtener los mejores ejemplares?** | 3. Do I have to go to those districts to buy the best items?
4. — **De ninguna manera. Ud. puede comprar cerámica de todos los distritos aquí mismo en la capital.** | 4. By no means. You can buy pottery from all the districts right here in the capital.
5. — **¿Cuesta más aquí?** | 5. Does it cost more here?
6. — **Por supuesto cuesta más. Pero hay un surtido excelente.** | 6. Of course it costs more. But there is an excellent assortment.
7. — **¿Me puede dar el nombre de algunas tiendas de cerámica?** | 7. Please tell me the names of a few pottery shops.
8. — **Hay muchas en la Avenida Juárez. En aquella avenida está también el Museo Nacional de Artes e Industrias Populares.** | 8. There are many on luarez Avenue. On the same avenue you'll find also the National Museum of Popular Arts and Industries.
9. — **¿Se vende cerámica allí?** | 9. Do they sell pottery there?
10. — **¡Ya lo creo! La mejor de México.** | 10. I should say so! The best in Mexico.
11. — **Muchas gracias, señor.** | 11. Many thanks, sir.
12. — **De nada.** | 12. You are welcome.
## LECTURA
### Ejercicio No. 54—La familia del señor Adams viene a visitar su oficina
**Es la primera vez que la familia Adams viene a visitar la oficina del señor Adams. La señora Adams y sus** (her) **cuatro hijos entran en un edificio muy grande y suben** (go up) **al décimo piso por ascensor** (elevator). **Anita, la hija menor, que tiene solamente cinco años, está muy curiosa, y hace muchas preguntas a su mamá sobre la oficina.**
**Cuando llegan a la oficina, el padre se levanta y dice:—Me gusta mucho verlos** (to see you) **a todos aquí. ¡Qué sorpresa más agradable** (pleasant)!
**Los niños admiran los objetos que ven en la oficina: la computadora, la máquina de fax, las revistas mexicanas y los carteles de muchos colores. Todos están muy contentos.**
**Felipe, el hijo mayor, mira por la ventana alta. Abajo** (below) **ve los automóviles que pasan por la calle. Desde el décimo piso parecen** (they seem) **muy pequeños.**
**Después de** (after) **la visita toda la familia va a un restaurante que no está lejos de la oficina. Comen con mucho gusto, sobre todo los hijos, porque tienen mucha hambre.**
### Ejercicio No. 55—Una fábula moderna
**A Anita, la menor de los hijos del Sr. Adams, le gustan mucho los chistes. El Sr. López le ha escrito uno. Su título es «La fábula del automóvil y del burro».**
**Un automóvil pasa por el camino y ve un burro. El pobre burro lleva una carga grande y pesada (heavy) de madera.**
**El automóvil para** (stops) **y le dice al burro —Buenos días. Ud. anda muy despacio. ¿No desea correr rápidamente como yo?**
— **Sí, sí, señor! Pero dígame, ¿cómo es posible?**
— **No es difícil—dice el automóvil.—En mi tanque hay mucha gasolina. Ud. tiene que beber un poco.**
**Entonces el burro bebe la gasolina. Ahora no anda despacio. No corre rápidamente. No va al mercado. Se echa** (he stretches out) **en el camino. Tiene dolor de estómago.**
**¡Pobre burro! No es muy inteligente, ¿verdad? No sabe que la gasolina es buena para un automóvil, pero no vale nada para un burro.**
**A Anita no le gusta la fábula moderna y comenta al final: «¡Qué chiste más tonto, Sr. López!»**
# CHAPTER 18
CAPÍTULO 18 (DIECIOCHO)
## PRIMERA PARTE
### El cine
1. — **Sr. Adams, Ud. sabe pedir información sobre las funciones del cine. ¿Le gusta el cine?** | 1. Mr. Adams, you know how to ask for information about the performances of the movies. Do you like movies?
---|---
2. — **Pues, algunas películas buenas me gustan, pero la mayoría no me interesa.** | 2. Well, I like some good pictures, but most films do not interest me.
3. — **¿Le gusta más el teatro?** | 3. You prefer the theater?
4. — **Sí. Mi esposa y yo lo preferimos. Vamos a menudo al teatro para ver un buen drama o una producción musical.** | 4. Yes. My wife and I prefer it. We often go to the theater to see a good play or musical.
5. — **¿Y sus hijos? ¿Prefieren el teatro?** | 5. And your children? Do they prefer the theater?
6. — **¡Claro que no! Les encantan las películas de acción y las musicales en colores, que a nosotros nos aburren.** | 6. Of course not! They like action movies and animated musicals, which bore us.
7. — **Ellos conocen 1 a todas las estrellas de cine, ¿verdad?** | 7. They know all the stars, don't they?
8. — **Claro está, las conocen. Conocen también a las estrellas de la televisión y de la radio.** | 8. Of course, they know them. They also know the stars of television and radio.
9. — **Uds. viven en los suburbios. ¿Hay un cine cerca de su casa?** | 9. You live in the suburbs. Is there a movie theater near your house?
10. — **Sí, a unas ocho cuadras. Se puede ir a pie, pero si hay mucha cola regreso a casa. No me gusta estar de pie por más de cinco minutos.** | 10. Yes, about eight blocks. We can walk there but if there is a line I go home. I don't like to stand for more than five minutes.
11. — **¿Dónde prefieren Uds. sentarse, en las primeras filas o atrás?** | 11. Where do you prefer to sit, in the first rows or in the back?
12. — **Nos gusta más sentarnos en las filas catorce o quince. Desde allí es posible ver y oír bien. Desde allí la luz y los movimientos en la pantalla no hacen daño a los ojos.** | 12. We prefer to sit in rows fourteen or fifteen. From there it is possible to see and hear well. From there the light and the movements on the screen do not harm the eyes.
13. — **¿Qué hacen Uds. si la mayor parte de los asientos están ocupados?** | 13. What do you do if most of the seats are taken?
14. — **Entonces pido ayuda al acomodador. Nos sentarnos en cualquier asiento desocupado, delante, atrás o al lado.** | 14. Then I ask the usher for help. We sit in any unoccupied seats, in front, in back, or at the side.
15. — **¡Estupendo, Sr. Adams!** | 15. Marvelous, Mr. Adams!
**NOTE** : 1. **conocer** to know (to be acquainted with persons or things), **saber** to know (facts).
### Pronunciation and Spelling Aids
1. Practice: | bo-le- **te** -ro | a- **sien** -tos | a-co-mo-da- **dor** | es- **tre** -lla
---|---|---|---|---
| bo-le-te- **rí** -a | pan- **ta** -lla | pe- **lí** -cu-la | pre- **fie** -ro
2. Nouns ending in -ción drop the accent in the plural: **la función, las funciones; la lección, las lecciones; la estación, las estaciones.**
### Vocabulary Building
1. **Sinónimos** : 1. **el noticiero, las actualidades** | the newsreel
---|---
2. **por eso, por consiguiente** | therefore
3. **prefiero, me gusta más** | I prefer
4. **la cinta, la película** | film
5. **a menudo, muchas veces** | often
2. Antónimos: 1. **antes de** | before (time) | **después de** | after
---|---|---|---
2. **delante de** | in front of | **detrás de** | behind
3. **ocupado** | occupied | **desocupado** | unoccupied
3. Words Dealing with the Movies: 1. **el cine** | the movie theater
---|---
2. **la película** | the picture
3. **la función** | the performance
4. **el noticiero** | the newsreel
5. **la taquilla, la boletería (Mex.)** | the ticket office
6. **el papel** | the part, role
7. **la estrella** | the star
8. **la pantalla** | the screen
9. **el asiento** | the seat
10. **la fila** | the row
11. **el acomodador** | the usher
### Expresiones Importantes
1. **tener que: tener** to have, followed by **que** means to have to, must. **Tengo que repetir.** | I have to (must) repeat.
---|---
**Ud. tiene que aprender.** | You have to (must) learn.
**¿Tiene él que escribir?** | Does he have to (must he) write?
**Ella no tiene que ir.** | She does not have to go.
2. **ir a pie** | to go on foot
---|---
3. **estar de pie** | to stand
4. **más de cinco minutos** | more than five minutes
5. **película de acción** | action movie
## SEGUNDA PARTE
### Grammar Notes
1. Direct Object Pronouns—Summary. Study the following sentences, which summarize the direct object pronouns. Note their meanings and position in relation to the verb. 1. **¿Compra Pablo el pan? _Lo_ compra.** | 1. Does Paul buy the bread? He buys _it._
---|---
2. **¿Compra Ana la crema? _La_ compra.** | 2. Does Anna buy the cream? She buys _it._
3. **¿Ve Ud. al padre? _Lo_ veo (a él).** | 3. Do you see the father? I see _him._
4. **¿Ve Ud. al la madre? _La_ veo (a ella).** | 4. Do you see the mother? I see _her._
5. **¿Ve Ud. a los padres? _Los_ veo (a ellos).** | 5. Do you see the parents (fathers)? I see _them._
6. **¿Ve Ud. a las madres? _Las_ veo (a ellas).** | 6. Do you see the mothers? I see _them._
7. **¿Tiene Ud. los boletos? _Los_ tengo.** | 7. Have you the tickets? I have _them._
8. **¿Tienen Uds. las cartas? _Las_ tenemos.** | 8. Have you the letters? We have _them._
9. **_Lo_ esperamos, Sr. Adams.** | 9. We are expecting _you_ , Mr. Adams.
10. **_La_ esperamos, Sra. López.** | 10. We are expecting _you_ , Mrs. Lopez.
11. **_Los_ esperamos, señores.** | 11. We are expecting _you_ , gentlemen.
12. **_Las_ esperamos, señoras.** | 12. We are expecting _you_ , ladies.
13. **¿ _Me_ buscas, mamá?** | 13. Are you looking for _me_ , mother?
14. **_Te_ busco, hijito.** | 14. I am looking for _you_ , sonny.
15. **¿Quién _nos_ busca?** | 15. Who is looking for _us_?
### Chart of Direct Object Pronouns
**SINGULAR** | **PLURAL**
---|---
**me** | me | **nos** | us
**te** | you ( _fam._ ) | **os** | you ( _fam._ ) ( _Spain only_ )
**lo** (m) | it, him, you | **los** ( _m_ ) | them, you
**le** (m) | him, you ( _Spain only_ ) | **les** ( _m_ ) | them, you ( _persons only_ )
**la** ( _f_ ) | it, her, you | **las** ( _f_ ) | them, you
1. Object pronouns usually stand directly before the verb.
2. When the pronoun is the object of an infinitive or of an affirmative command, it follows the verb and is attached to it. **El Sr. Adams va a saludar _lo._** | Mr. Adams is going to greet _him._
---|---
**Díga _me._** | Tell _me._
3. **a Ud.** and **a Uds.** are usually added after the verb to distinguish the meaning you from the other meanings of **lo, la, (les-Spain), los, las (les-Spain), a él, a ella, a ellos** and **a ellas** may also be added to make the meaning clear.
4. **os** (object _you_ , fam. plur.) is only used in Spain. Use **los** ( _you_ ) and **las** ( _you_ ) instead.
## TERCERA PARTE
### Ejercicios No. 56A-56B-56C
56A. Read each Spanish question. Then read the answer, using the correct direct object pronoun in place of the dash. Be sure the object pronouns have the same number and gender as the nouns for which they stand.
**Ejemplo: Sí, _los_ compro.**
1. **¿Compra Ud. los boletos?** | **Sí,________compro.**
---|---
2. **¿Comienza Ud. el ejercicio?** | **Sí,________comienzo.**
3. **¿Quiénes tienen el radio?** | **Los niños_______tienen.**
4. **¿Ven Uds. bien la pantalla?** | **No, no_______vemos bien.**
5. **¿Espera el señor a su amigo?** | **Sí,_______espera.**
6. **¿Prefieren Uds. las primeras filas?** | **No, no ___________preferimos.**
7. **¿Conocen los niños a la estrella?** | **Sí,___________conocen.**
8. **¿Conocen Uds. a estos hombres?** | **Sí,___________conocemos.**
9. **¿Conocen Uds. a estas mujeres?** | **Sí,___________conocemos.**
10. **¿Quiénes esperan al maestro?** | **Los niños ___________esperan.**
56B. Read each Spanish sentence. Then put the corresponding English sentence into Spanish. Where do the object pronouns go?
**Ejemplo: El camarero la lleva.**
1. **El camarero trae la cuchara.** | 1. The waiter brings it.
---|---
2. **Los niños comen el azúcar.** | 2. The children eat it.
3. **Pongo los platillos en la mesa.** | 3. I put them on the table.
4. **Digo las frases al estudiante.** | 4. I tell them to the student.
5. **¿Por qué no saluda Ud. al hombre?** | 5. Why don't you greet him?
6. **¿Visitas a tu hermana?** | 6. Do you visit her?
56C. Translate into Spanish.
1. I see you, Mr. Adams.
2. Do you see me?
3. Who sees us?
4. The teacher sees you (pl.), boys.
5. We see the house. We see it.
6. I take the plate. I take it.
7. She writes the verbs. She writes them.
8. We have the chairs. We have them.
9. I expect you, ladies.
10. We expect you, gentlemen.
### Ejercicio No. 57—Preguntas
1. **¿Quién sabe pedir información?**
2. **¿Qué prefieren los señores Adams, el teatro o el cine?**
3. **¿Qué prefieren los niños?**
4. **¿Conocen los niños a las estrellas del cine?**
5. **¿Dónde vive la familia Adams?**
6. **¿A qué distancia está el cine de la casa de ellos?**
7. **¿Qué filas del cine prefieren?**
8. **¿Es posible ver y oír desde allí?**
9. **¿A quién piden ayuda en el cine?**
10. **¿Vienen temprano o tarde?**
# CHAPTER 19
CAPÍTULO 19 (DIECINUEVE)
## PRIMERA PARTE
### Las calles y las fechas
1. **Si el turista no sabe nada de la historia de México, los nombres de las calles pueden enseñarle mucho. Como en todas las ciudades del mundo, en la ciudad de México hay calles nombradas en memoria de los grandes héroes de la patria.** | 1. If the tourist knows nothing about the history of Mexico, the names of the streets can teach him a great deal. As in all the cities in the world, so in Mexico there are streets named in memory of the great heroes of the fatherland.
---|---
2. **Dos de las avenidas más importantes de la ciudad son las Avenidas Juárez y Francisco I. Madero. Ud. sabe bien que Benito Juárez es el Abraham Lincoln de México, presidente de México desde 1857 (mil ochocientos cincuenta y siete) hasta 1872 (mil ochocientos setenta y dos), el alma de la resistencia al emperador Maximiliano. Francisco I. Madero fue uno de los líderes contra el dictador Porfirio Díaz en 1910 (mil novecientos diez).** | 2. Two of the city's most important avenues are Avenue Juarez and Avenue Francisco I. Madero. You know that Benito Juarez is the Abraham Lincoln of Mexico, president of Mexico from 1857 to 1872, the soul of the resistance to Emperor Maximilian. Francisco I. Madero was one of the leaders who fought against dictator Porfirio Diaz.
3. **Pero en el centro de la ciudad hay otras calles muy interesantes desde el punto de vista histórico. Sus nombres son fechas:—16 de septiembre, 20 de noviembre, 5 de febrero y 5 de mayo. ¿Qué significan estas fechas?** | 3. But in the center of the city there are other streets, very interesting from a historical point of view Their names are dates—September 16, November 20, February 5, and May 5. What do these dates mean?
4. **El 16 de septiembre es el Día de la Independencia de México. Recuerda el año 1810 (mil ochocientos diez) y la lucha contra España. El iniciador de esta revolución fue el cura Hidalgo, el George Washington de México.** | 4. September 16 is Mexico's Independence Day. It recalls the year 1810 and the struggle against Spain. The initiator of this revolution was the priest Hidalgo, the George Washington of Mexico.
5. **El 20 de noviembre se celebra el comienzo de la revolución de 1910 (mil novecientos diez) contra el dictador Porfirio Díaz.** | 5. November 20 marks the beginning of the revolution in 1910 against the dictator Porfirio Diaz.
6. **El 5 de mayo es el aniversario de la victoria contra los franceses, partidarios de Maximiliano, en Puebla en el año 1861 (mil ochocientos sesenta y uno).** | 6. The 5th of May is the day of victory against the French, supporters of Maximilian, at Puebla in the year 1861.
7. **El 5 de febrero es una fiesta también. Esta fiesta se llama el Día de la Constitución** | 7. The 5th of February is a holiday, too. This holiday is called Constitution Day.
8. — **Sr. Adams, ¿le interesan estos sucesos de la historia de México?** | 8. Mr. Adams, do these events of Mexican history interest you?
9. — **Sí, sí. Me interesan mucho. Un día voy a caminar por las calles cuyos nombres son fechas, y voy a recordar las palabras de mi maestro y amigo, el señor López.** | 9. Yes, yes. They interest me very much. Some day I am going to walk along the streets the names of which are dates, and I will recall the words of my teacher and friend, Mr. Lopez.
10. — **Ahora es favor que Ud. me hace a mí. 1** | 10. Now you flatter me.
11. — **No es favor. Es verdad. ¿No quiere pasear hoy?** | 11. It is not flattery. It is the truth. Would you like to talk a walk today?
12. — **¿Qué día es hoy?** | 12. What day is it today?
13. — **Hoy es martes.** | 13. Today is Tuesday.
14. — **Lamentablemente, hoy no puedo, tengo un compromiso.** | 14. Unfortunately I cannot today, I have an engagement.
15. — **Bueno, entonces será otro día.** | 15. OK. We'll do it some other day.
**NOTE** : 1. **a mí** _to me_ , added for emphasis.
### Pronunciation and Spelling Aids
1. Practice: | his- **to** -ria | Fran- **cis** -co Ma- **de** -ro | **Ií** -de-res | re-cor- **dar**
---|---|---|---|---
| **hé** -ro-es | Por- **fi** -rio **Dí** -az | sig-ni- **fi** -can | re- **cuer** -da
| Mi- **guel** Hi- **dal** -go | em-per-ra- **dor** | in-de-pen- **den** -cia | vic- **to** -ria
| Be- **ni** -to **Juá** -rez | Ma-xi-mi- **lia** -no | re-vo-lu- **ción** | **Jor** -ge
### Building Vocabulary
1. **Antónimos** : 1. **contra** against | **por** for
---|---
2. **enseñar** to teach | **aprender** to learn
2. **Palabras Relacionadas** : 1. **interesar** | to interest | **interesante** | interesting
---|---|---|---
2. **la historia** | history | **histórico** | historical
3. **dictar** | to dictate | **el dictador** | the dictator
4. **luchar** | to fight | **la lucha** | the fight
5. **caminar** | to walk | **el camino** | the road
6. **recordar** | to recall, remember | **el recuerdo** | the remembrance
7. **resistir** | to resist | **la resistencia** | resistance
8. **comenzar** | to begin | **el comienzo** | beginning
3. **Los grandes héroes** the great heroes. The adjective **grande** placed before a noun means _great._ After a noun it means _big._ Thus: **un hombre grande** | a _big_ man
---|---
**un gran hombre** | a _great_ man
**NOTE** : **grande** (not **grandes** ) before a noun becomes **gran.**
### Expresiones Importantes
1. **en memoria de** | in memory of
---|---
2. **desde...hasta** | from... to, until
3. **el Día de la Independencia** | Independence Day
4. **tener un compromiso** | to have an engagement
5. **¿Qué día es hoy? Es martes.** | What day is it today? It is Tuesday.
6. **¿Cuál es la fecha de hoy? Hoy es el 23 de marzo.** | What is today's date? Today is March 23.
### Ejercicio No. 58—Completion of Text
1. (They know nothing) **de la historia de México.**
2. **Las calles (can) enseñarles mucho.**
3. **Hay calles nombradas** (in memory of) **los héroes de la** (fatherland).
4. **Una de las avenidas** (most important) **es la Avenida Juárez.**
5. **Benito Juárez fine presidente de México** (from) **1857** (until) **1872.**
6. **Los** (names) **de estas calles son** (dates).
7. **Son interesantes** (from the point of view) **histórico.**
8. **¿Qué** (signify) **estas fechas?**
9. **El** (priest) **Hidalgo fue el** (initiator) **de la revolución contra España en 1810.**
10. (These events) **me interesan mucho.**
11. **Voy a** (walk) **por las calles** (whose) **nombres son fechas.**
12. **Voy a** (recall) **las palabras de mi maestro.**
## SEGUNDA PARTE
### Grammar Notes
1. The Present Tense of **recordar(ue)** to remember and **oír** to hear I remember, you remember, etc. | I hear, vou hear, etc.
---|---
**recuerdo** | **recordamos** | **oigo** | **oímos**
**recuerdas** | **recordáis** | **oyes** | **oís**
**recuerda** | **recuerdan** | **oye** | **oyen**
2. Ordinal Numbers **primero (a)** first | **quinto (a)** fifth | **noveno (a)** ninth
---|---|---
**segundo (a)** second | **sexto (a)** sixt | **décimo (a)** tenth
**tercero (a)** third | **séptimo (a)** seventh |
**cuarto (a)** fourth | **hoctavo (a)** eighth |
1. Ordinal numbers are used much less in Spanish than in English. After the tenth they are seldom used.
2. Like other adjectives, ordinal numbers agree with their nouns in number and gender. **la prin aera fila** | **la see unda fila** | **el décimo piso**
---|---|---
3. Before a masculine singular noun, **primero** and **tercero** , drop the **-o.** **el primer año** | **el primero** | **el tercer mes** | **el tercero**
---|---|---|---
3. Dates. 1 **de mayo de 2003 (el primero de mayo)** | May 1, 2003
---|---
5 **de mayo de 1861 (el cinco de mayo)** | May 5, 1861
1. **Primero** is used for the first day of the month. After that the cardinal numbers **dos, tres** , etc., are used.
2. The order for a date is: (day) **de** (month) **de** (year)
3. The numbers in the year are read like numbers in general. 2003 **(dos mil tres)** | **1861 (mil ochocientos sesenta y uno)**
---|---
4. Pronouns with Prepositions **para mí** | for me
---|---
**para ti** | for you ( _fam. sing._ )
**para Ud.** | for you
**para él** | for him
**para ella** | for her
**para nosotros (-as)** | for us
**para vosotros (-as)** | for you ( _fam. plur._ )
**para Uds.** | for you
**para ellos** | for them ( _masc. pl._ )
**para ellas** | for them ( _fem. pl._ )
1. Pronouns with prepositions, except **mi** ( _me_ ) and **ti** ( _you_ ) are the same as the subject pronouns.
2. With the preposition **con, mí** and **ti** become **conmigo** _with me_ , and **contigo** _with you._
3. The accent mark on **mí** ( _me_ ) distinguishes it from **mi** ( _my_ ).
## TERCERA PARTE
### Ejercicios No. 59A-59B
59A. Complete the Spanish sentences so that they correspond fully to the English sentences.
**Ejemplo: 1. Hablamos de Ud., señor.**
1. We are speaking of you, sir. | 1. **Hablamos de________________señor.**
---|---
2. They do not work for us (m.). | 2. **No trabajan para_________________.**
3. He is standing near them (f.). | 3. **Está de pie cerca de_______________.**
4. They are seated behind me. | 4. **Están sentados detrás de_______________.**
5. You can go with me. | 5. **Ud. puede ir_______________.**
6. I want to go with you, Johnny. | 6. **Quiero ir_________________, Juanito.**
7. We are for them, not against them. | 7. **Estamos por_______, no contra_______**
8. We prefer to go without you, Anna. | 8. **Preferimos ir sin____________, Ana.**
9. The ashtray is in front of her. | 9. **El cenicero está delante de**
10. We are going to have dinner with him. | 10. **Vamos a cenar con__________________.**
59B. Translate in two ways.
**Ejemplo** : Where is your book, Anna? **¿Dónde está su libro (el libro de Ud.), Ana?**
1. Where is her book?
2. Where is his book?
3. Where are her books?
4. Where are his books?
5. Where are your parents, boys?
6. Where is your house, Mr. Adams?
7. Where are their chairs?
8. Where is their room?
### Ejercicio No. 60—Preguntas
1. **¿Cuál es la fecha del Día de la Independencia de México?**
2. **¿Quién fue el iniciador de la revolución de 1810 contra España?**
3. **¿Quién es el George Washington de México?**
4. **¿Cuál es la fecha del aniversario de la victoria contra los franceses en Puebla en 1861?**
5. **¿Quién es el Abraham Lincoln de México?**
6. **¿Cuándo fue presidente?**
7. **¿Qué fecha celebra el comienzo de la revolución contra el dictador Porfirio Díaz?**
8. **¿Quién fue uno de los líderes de esa revolución?**
9. **¿Qué avenidas importantes de la ciudad de México están nombradas en memoria de dos grandes héroes?**
10. **¿Cuál es la fecha del Día de la Constitución?**
11. **¿Le interesan estos sucesos de la historia de México al Sr. Adams?**
12. **¿Por dónde va a caminar un día el Sr. Adams?**
13. **¿Qué palabras va a recordar?**
14. **¿Cuál es la fecha del aniversario del Día de la Independencia de los Estados Unidos?**
# CHAPTER 20
CAPÍTULO 20 (VEINTE)
## PRIMERA PARTE
### Calles, ríos y montañas
1. — **Ya sabe Ud., señor Adams, que hay muchas calles en México cuyos nombres recuerdan los grandes héroes de México y otras cuyos nombres son fechas. Estos recuerdan los acontecimientos más notables de la historia de México. Además, en un barrio las calles tienen los nombres de algunos de los escritores franceses más conocidos, por ejemplo Victor Hugo, Anatole France y Eugenio Sue. En otro barrio los nombres de las calles celebran algunos de los científicos más famosos, como por ejemplo, Copérnico, Kepler y Galileo.** | 1. You already know, Mr. Adams, that there are many streets in Mexico whose names recall the great heroes of Mexico and others whose names are dates. The latter recall the most outstanding accomplishments of the history of Mexico. Besides, in one district the streets have the names of some of the most well-known French writers—Victor Hugo, Anatole France, and Eugene Sue, for example. In another district, the names of the streets honor some of the most famous scientists—for example, Copernicus, Kepler, and Galileo.
---|---
2. — **Al sur del Paseo de la Reforma, una de las avenidas más hermosas de México, podemos dar un paseo por algunas de las «ciudades más importantes del mundo» Liverpool, Hamburgo, Florencia, Londres, etc. Al norte del Paseo se encuentran «los ríos» Misisipí, Tiber, Rhin, Danubio, etc. Por cierto, una persona que tiene la costumbre de caminar por las calles de México puede educarse bien y barato.** | 2. South of the Paseo de la Reforma, one of the most beautiful avenues of Mexico, we can take a walk through some of the "most important cities in the world"—Liverpool, Hamburg, Florence, London, etc. North of the Paseo are "the rivers" Mississippi, Tiber, Rhine, Danube, etc. Indeed, a person who has the habit of walking through the streets of Mexico can obtain a good and inexpensive education.
3. — **A propósito, señor Adams, ¿me permite hacerle algunas preguntas sobre la geografía del Hemisferio Occidental?** | 3. By the way, Mr. Adams, will you permit me to ask you a few questions about the geography of the Western Hemisphere?
4. — **Desde luego. ¿Y voy a recibir un premio por las respuestas correctas?** | 4. Certainly. And will I receive a prize for correct answers?
5. — **No, señor Adams, éste no es un programa de radio. Vamos a empezar. ¿Cuál es el río más largo del Hemisferio Occidental?** | 5. No, Mr. Adams, this is not a radio program. Let's begin. Which is the longest river in the Western Hemisphere?
6. — **Por supuesto, el Misisipí es el río más largo.** | 6. Of course the Mississippi is the longest river.
7. — **Ud. está equivocado. El Misisipí es mucho más pequeño que el río Amazonas. Éste es el más largo y el más grande, no solamente de nuestro hemisferio, sino también del mundo entero. Tiene más de 4600 millas de largo y cruza todo el Brasil. ¿Y cuál es el pico más alto de la América del Sur?** | 7. You are mistaken. The Mississippi is much smaller than the Amazon River. The latter is the longest and the biggest, not only in our hemisphere, but also in the whole world. It is more than 4600 miles long and crosses all of Brazil. And which is the highest peak in South America?
8. — **No me acuerdo del nombre pero está en los Andes. Es más alto que cualquier pico de la América del Norte, de Europa o de África. Pero sí hay picos más altos en el Himalaya de Asia.** | 8. I do not remember the name but it is in the Andes. It is higher than any mountain in North America, Europe or Africa. But indeed, there are higher peaks in the Himalayas of Asia.
9. — **Aquel pico altísimo se llama Aconcagua. Pues bien, una pregunta más. ¿Sabe Ud. los nombres de los dos picos no lejos de México, D.F.?** | 9. That very high peak is called Aconcagua. Well then, one more question. Do you know the names of the two peaks not far from Mexico City?
10. — **Creo que sí, pero no sé pronunciarlos.** | 10. I think so, but I do not know how to pronounce them.
11. — **No es difícil. Repita, por favor. Po-po-ca-té-petl. Ix-tac-cí-huatl.** | 11. It is not difficult. Repeat, please. Po-po-ca-te-petl. Ix-tac-ci-huatl.
12. — **Po-po-ca-té-petl. Ix-tac-cí-huatl (poh-poh-ca- _tay_ -petl, ees-tah- _see_ -wahtl). Ud. tiene razón. No es difícil pronunciarlos sílaba por sílaba.** | 12. Po-po-ca-te-petl. Ix-tac-ci-huatl. You are right. It is not difficult to pronounce them syllable by syllable.
### Pronunciation and Spelling Aids
1. Practice: | **cu** -yos | Co- **pér** -ni-co | Mi-si-si- **pí** | **cru** -za
---|---|---|---|---
| re- **cuer** -dan | **Kep** -ler | Da- **nu** -bio | a- **cuer** -do
| a-con-te-ci- **mien** -tos | Ga-li- **le** -o | Ti- **ber** | cual- **quie** -ra
| **ba** -rrio | Pa- **se** -o | cos- **tum** -bre | **A** -sia
| fran- **ce** -ses | de la Re- **for** -ma | con- **se-guir** | Hi-ma- **la** -ya
| es-cri- **to** -res | en- **cuen** -tran | **ge** -o-gra- **fí** -a | A-con- **ca** -gua
| Eu- **ge** -nio | Flo- **ren** -cia | he-mis- **fe** -rio | pro-nun- **ciar** -los
| ce-le- **brar** | Ham- **bur** -go | oc-ci-den- **tal** | Po-po-ca- **té** -petl
| cien- **tí** -fi-cos | Li-ver- **pool** | el **rí** -o A-ma- **zo** -nas | Ix-tac- **cí** -huatl
2. **francés, franceses; inglés, ingleses; portugués, Portugueses.** The accent mark is dropped in the plural.
3. In the combination **-guir (conseguir)** the **u** is silent. In the combination **-gua (Aconcagua)** the **u** is pronounced like Eng. _w._
### Building Vocabulary
1. **Sinónimos** : 1. **por cierto** | **de veras** | **claro está** | indeed
---|---|---|---
2. **el sabio** | **el hombre de ciencia** | **el científico** | the scientist
3. **conseguir** | **obtener** | **adquirir** | to obtain
2. **Antónimos** : 1. **barato** cheap | **caro** dear
---|---
2. **alto** high | **bajo** low
3. **el más largo** the longest | **el más corto** the shortest
4. **fácil** easy | **difícil** hard
3. **Palabras relacionadas** : 1. **educar** | to educate
---|---
**educación** | education
2. **la ciencia** | science
**el científico** | the scientist
3. **historia** | history
**histórico** | historical
### Expresiones Importantes
1. **dar un paseo** to take a walk
2. **hacer preguntas** to ask questions
3. **cualquier montaña** any mountain
4. **por cierto** indeed
### Ejercicio No. 61—Completion of Text
1. **Hay muchas calles** (whose) **nombres** (recall) **a grandes héroes.**
2. **Otras calles recuerdan** (the most notable events) **de nuestra historia.**
3. **Otras calles tienen los nombres de los escritores franceses** (most well-known).
4. **En un barrio las calles llevan los nombres de los científicos** (most famous).
5. **Podemos dar un paseo por algunas de las ciudades** (most important in the world).
6. (Indeed) **una persona puede** (get a good and inexpensive education) **en las calles de México.**
7. (By the way) **Sr. Adams, quiero hacerle algunas preguntas** (about) **la geografía del Hemisferio** (Western).
8. **Ud. no va a** (receive) **un premio.**
9. **¿Es** (larger) **el Misisipí que el Amazonas?**
10. **El Misisipí es** (smaller) **que el Amazonas.**
11. **Este río es** (the largest) **y** (the longest) **del mundo.**
12. **El pico de Aconcagua es** (higher) **que cualquier pico de la América del Norte.**
13. **Hay picos** (higher) **en el Himalaya.**
14. **Dos picos** (high) **se encuentran** (not far from) **la capital.**
15. (You are right). **La pronunciación no es difícil.**
## SEGUNDA PARTE
### Grammar Notes
1. Comparison of adjectives in Spanish. **grande** large | **más grande** larger | **el (la) más grande** largest
---|---|---
**notable** notable | **más notable** more notable | **el (la) más notable** most notable
**notable** notable | **menos notable** less notable | **el (la) menos notable** least notable
1. These adjectives follow and agree with their nouns as usual. In the superlative and sometimes in the comparative, the definite article or a possessive adjective precedes the noun. Context usually indicates the meaning desired.
**las avenidas más hermosas** the most beautiful avenues
**mi maestro más amable** my kindest teacher
2. After a superlative use de not en for in.
**el río más largo del mundo** the longest river in the world
3. _as... (adj.)... as_ , is expressed in Spanish as **tan... ( _adj._ )... como.**
**Carlos es tan alto como Ana.** Charles is as tall as Anna.
**El Tiber no es tan largo como el Rhin.** The Tiber is not as long as the Rhine.
4. In comparisons, _than_ is usually **que.** Before a number _than_ is **de.**
**Londres es más grande que Nueva York.** London is larger than New York.
**Tenemos más de cien dólares.** We have more than $100.
2. Irregular Comparisons **bueno** | good
---|---
**malo** | bad
**grande** | big
**pequeño** | small
**mejor** | better
**peor** | worse
**más grande** | bigger
**mayor** | older
**más pequeño** | smaller
**menor** | younger
**el (la) mejor** | best
**el (la) peor** | worst
**el (la) más grande** | biggest
**el (la) mayor** | oldest
**el (la) más pequeño** | smallest
**el (la) menor** | youngest
1. The irregular forms of **grande** and **pequeño** refer to age.
The regular forms of **grande** and **pequeño** refer to size. **Felipe es mayor que Guillermo.** | Philip is older than William.
---|---
**Felipe es más grande que Guillermo.** | Philip is bigger than William.
**Es el mayor de la familia.** | He is the oldest in the family.
**Es el más grande de la familia.** | He is the biggest in the family.
**Anita es menor que Rosita.** | Annie is younger than Rosie.
**Anita es más pequeña que Rosita.** | Annie is smaller than Rosie.
**Es la menor de la familia.** | She is the youngest in the family.
**Es la más pequeña de la familia.** | She is the smallest in the family.
3. The ending **-ísimo(a)** may be used instead of **muy.** **alto** | tall | **altísimo** | very tall
---|---|---|---
**largo** | long | **larguísimo** | very long
**bueno** | good | **bonísimo** | very good
**rico** | rich | **riquísimo** | very rich
**Aconcagua es un pico altísimo.** | Aconcagua is a very high peak.
## TERCERA PARTE
### Ejercicio No. 62
**Ejemplo: 1. Pablo es tan alto como Juan.**
1. Paul is as tall as John. | 1. **Pablo es_____alto_____Juan.**
---|---
2. My pen is better than John's. | 2. **Mi pluma es_____que la de Juan.**
3. Mary is nicer than Elsie. | 3. **María es_____simpática_____Elsa.**
4. I have the best pen of all. | 4. **Tengo la_____bolígrafo de todas.**
5. The black ink is not as good as the blue. | 5. **La tinta negra no es____buena_____la tinta azul.**
6. I want the newest book. | 6. **Quiero el libro____nuevo.**
7. My exercises are more difficult than yours. | 7. **Mis ejercicios son____difíciles____los de Ud.**
8. Jane is tall. Marie is taller than Jane. | 8. **Juana es alta. María es_____alta_____Juana.**
9. Isabel is the tallest girl of the three. | 9. **Isabel es la muchacha________de las tres.**
10. Mr. García has the worst luck. | 10. **El señor García tiene la____________ 1 suerte.**
11. Philip is the oldest child. | 11. **Felipe es el hijo________.**
12. The capital has the most modern buildings. | 12. **La capital tiene los edificios________.**
13. The pen is bad but the pencil is worse. | 13. **La pluma es mala, pero el lápiz es________.**
14. Why are you not as happy as he? | 14. **¿Por qué no está Ud._____contento_____él?**
15. He is the laziest man in the office. | 15. **El es el hombre más perezoso______la oficina.**
16. Annie is the youngest child. | 16. **Anita es la hija______________.**
**NOTE** : 1. **mejor** and **peor** often precede the noun.
### Ejercicio No. 63—Preguntas
1. **¿Cuál es el río más largo de Sudamérica?**
2. **¿Cuál es una de las ciudades más importantes del mundo?**
3. **¿Cuál es el pico más alto de Sudamérica?**
4. **¿Qué ciudad es más grande que Nueva York?**
5. **¿Es Madrid tan grande como Nueva York?**
6. **¿Es Nueva York tan antigua como Madrid?**
7. **¿Qué ciudad es más Antigua, Plymouth o San Agustín?**
8. **¿Qué ciudad tiene los edificios más altos del mundo?**
9. **¿Cuál es el país más pequeño de Centroamérica?**
10. **El Sr. García es un hombre de cuarenta y cinco años de edad. Tiene $100,000 (cien mil dólares). El Sr. Rivera es un hombre de cincuenta años. Tiene $80,000 (ochenta mil dólares). El Sr. Torres es un hombre de sesenta años. Tiene $50,000 (cincuenta mil dólares).**
1. **¿Quién es el menor de los tres?**
2. **¿Quién es el mayor de los tres?**
3. **¿Es el Sr. Rivera mayor que el Sr. García?**
4. **¿Quién es el más rico?**
5. **¿Quién es el menos rico?**
6. **¿Es el Sr. Torres tan rico como el Sr. García?**
# CHAPTER 21
CAPÍTULO 21 (VEINTIUNO)
## PRIMERA PARTE
### El día del señor Adams
1. — **Sr. Adams, ¿me permite preguntarle cómo pasa un día típico?** | 1. Mr. Adams, may I ask you how you spend a typical day
---|---
2. — **Cómo no. Cuando voy a la oficina, me levanto a las seis y media. Ud. ve que soy madrugador. Me lavo y me visto en treinta minutos más o menos. A eso de las siete me siento a la mesa en el comedor para tomar el desayuno. Mi esposa, que también es madrugadora, se levanta temprano y nos desayunamos juntos. Naturalmente me gusta mucho esta costumbre. Tenemos la oportunidad de platicar de los niños y de otras cosas de interés.** | 2. Certainly. When I go to the office, I get up at six-thirty. You see that I am an early riser. I wash and dress in thirty minutes more or less. At about seven, I sit down at the table in the dining room to have breakfast. My wife, who is also an early riser, gets up early and we have breakfast together. Naturally I like this custom very much. We have an opportunity to talk about the children and other interesting things.
3. — **¿Qué desayuna Ud?** | 3. What do you have for breakfast?
4. — **Para el desayuno tomo jugo de naranja, café, panecillos y huevos. De vez en cuando como panqueques en vez de huevos.** | 4. For breakfast I have orange juice, coffee, rolls, and eggs. Sometimes I have pancakes instead of eggs.
5. — **¿Y después del desayuno?** | 5. And after breakfast?
6. — **A las siete y media estoy listo para salir a tomar el tren. Ud. sabe que vivo fuera de la ciudad. Voy en coche a la estación. Dejo allí el automóvil hasta la tarde cuando vuelvo de la ciudad. El tren sale para la ciudad a las ocho menos cuarto en punto. Raras veces sale tarde. Llega a la ciudad a las nueve menos cuarto en punto. Casi siempre llega a tiempo. Desde la estación de ferrocarril voy a la oficina en subterráneo. Llego a eso de las nueve. En la oficina leo mi correo electrónico, lo contesto inmediatamente, escucho mi contestador, hago algunas llamadas a varios dientes, y hablo con la secretaria para ver si tengo otros compromisos.** | 6. At seven-thirty I am ready to leave to catch the train. You know that I live outside the city. I go by car to the station. I leave the automobile there until the afternoon, when I return from the city. The train leaves for the city at a quarter to eight sharp. It seldom leaves late. It arrives at the city at quarter to nine sharp. It almost always arrives on time. From the railroad station, I go to my office by subway. I arrive at about nine. In the office I read my e-mail, I answer it immediately, I listen to my answering machine, I make a few phone calls to various clients, and I talk to my secretary to see if I have other engagements.
7. — **¿Y cuándo almuerza?** | 7. And when do you have lunch?
8. — **Casi siempre a la una. Es cosa de 20 minutos.** | 8. Almost always at one. It takes me about 20 minutes.
9. — **Es muy poco tiempo. En México va a ver que son muy distintas las costumbres. El negociante mexicano pasa mucho más tiempo en comer. Pero en otra ocasión vamos a hablar más de esto. ¿Qué suele almorzar?** | 9. It is very little time. In Mexico you will see that customs are very different. The Mexican businessman spends much more time at meals. But another time we will speak more of this. What do you have for lunch?
10. — **Generalmente como un sandwich, tomo café y de postre una manzana cocida, una torta o un helado.** | 10. Usually I have a sandwich and coffee and for dessert a baked apple, a cake, or ice cream.
11. — **¿Qué hace Ud. después del almuerzo?** | 11. What do you do after lunch?
12. — **Hago lo mismo que por la mañana. Muchas veces algunos clientes vienen a visitarme por la tarde y de vez en cuando salgo a visitar a otros clientes.** | 12. I do the same as in the morning. Often some clients come to visit me in the afternoon and from time to time I go out to visit other clients.
13. — **¿A qué hora termina Ud. el trabajo?** | 13. At what time do you stop work?
14. — **A las cinco en punto salgo de la oficina y tomo el tren de las cinco y media. Llego a casa a eso de las siete menos cuarto y me siento a la mesa para cenar.** | 14. At five o'clock sharp I leave the office and take the five-thirty train. I arrive home at about a quarter to seven and I sit down at table to have dinner.
15. — **Ud. debe de estar cansado después de tal día.** | 15. You must be tired after such a day.
16. — **¡Ya lo creo! —responde el señor Adams.** | 16. "Yes, indeed!" answers Mr. Adams.
### Pronunciation and Spelling Aids
1. Practice: | pre-gun- **tar** | de-sa-yu- **nar** -se | pan- **que** -ques | ta- **quí** -gra-fa
---|---|---|---|---
| ma-dru-ga- **dor** | de-sa-yu- **na** -mos | **hue** -vos-( _way-vos_ ) | te- **lé** -fo-no
| ma-dru-ga- **do** -ra | o-por-tu-ni- **dad** | a- **fue** -ra | **clien** -tes
| de-sa- **yu** -no | pa-ne- **ci** -llos | sub-te- **rrá** -ne-o | **sand** -wich ( ** _sand_ -weech**)
2. **panqueques, sandwich.** These have been borrowed from English. Note the Spanish spelling of the first. The second has retained the English _w._
### Building Vocabulary
1. **Sinónimos** : 1. **en general** | **generalmente** | in general
---|---|---
2. **naturalmente** | **por supuesto** | of course
3. **platicar** | **charlar** | to chat
4. **en coche** | **en auto** | by auto
5. **algunas veces** | **de vez en cuando** | sometimes
6. **panecillos** | **bolillos (Mex.)** | rolls
2. **Antónimos** : 1. **después del desayuno** | after breakfast | **antes del desayuno** | before breakfast
---|---|---|---
2. **poco tiempo** | little time | **mucho tiempo** | much time
3. **Palabras relacionadas** : 1. **comer** | to eat | **comedor** | dining room | **la comida** | the meal
---|---|---|---|---|---
2. **el desayuno** | the breakfast | **desayunarse** | to have breakfast |
4. **Jugos** (juices) 1. **jugo de naranja** | orange juice
---|---
2. **jugo de tomate** | tomato juice
3. **jugo de toronja** | grapefruit juice
4. **jugo de uvas** | **grape** juice
5. **jugo de piña** | pineapple juice
6. **jugo de limón** | lemon juice
### Expresiones Importantes
1. **a eso de las siete** | at about seven
---|---
2. **a las cinco en punto** | at five o'clock sharp
3. **de costumbre** | generally
4. **ponerse** | to become
5. **Me enfermo.** | I become sick.
6. **¿Qué suele** (+ _inf._ ) | What do you usually (+ _verb_ )?
Expressions with **vez** :
1. **una vez** | one time
---|---
2. **dos veces** | two times
3. **otra vez** | another time
4. **algunas veces** | sometimes
5. **muchas veces** | many times
6. **raras veces** | seldom
7. **en vez de** | instead of
8. **¿Cuántas veces?** | How many times?
9. **cada vez** | each time
10. **de vez en cuando** | from time to time
### Ejercicio No. 64—Completion of Text
1. **Sr Adams, ¿me permite** (to ask you at what time) **se levanta?**
2. **Me levanto** (at 6:30)
3. **Soy** (an early riser). **Mi esposa es también** (an early riser).
4. **Siempre se levanta** (early).
5. **A las siete y media** (I am ready to leave).
6. (I read) **el correo electrónico y** (answer it)
7. **Para el almuerzo como** (a sandwich and some dessert).
8. (Often) **algunos clientes vienen** (to visit me).
9. **Termino el trabajo** (at five o'clock sharp).
10. (The customs) **son muy distintas en México.**
## SEGUNDA PARTE
### Grammar Notes
1. Present tense of Model Reflexive verb. **lavarse** to wash oneself | **me lavo** | **I** wash myself
---|---|---
| **te lavas** | you wash yourself (fam.)
**Ud.** | **se lava** | you wash yourself
| **se lava** | he washes himself
| | she washes herself, it washes itself
| **nos lavamos** | we wash ourselves
| **os laváis** | you wash yourselves (fam.)
**Uds.** | **se lavan** | you wash yourselves
| **se lavan** | they wash themselves
1. Observe that the reflexive pronoun **se** means _oneself, yourself, himself, herself, itself, yourselves_ , and _themselves._
2. Like other object pronouns, reflexives usually precede the verb. Used with the infinitive, they follow the verb and are attached to it. **lavarse** to wash oneself | **Quiero lavarme** I want to wash myself
---|---
2. Present Tense of **sentarse(ie)** to sit down (seat oneself), **vestirse(i)** to dress oneself I sit down, etc | I dress myself, etc
---|---
**me siento** | **nos sentamos** | **me visto** | **nos vestimos**
**te sientas** | **os sentáis** | **te vistes** | **os vestís**
**Ud. se sienta** | **Uds. se sientan** | **Ud. se viste** | **Uds. se visten**
**se sienta** | **se sientan** | **se viste** | **se visten**
3. Other Reflexive Verbs
Some Spanish reflexive verbs are not translated by a reflexive verb in English **sentarse** | to sit down (to seat oneself)
---|---
**levantarse** | to get up (to raise oneself)
**acostarse(ue)** | to go to bed
**llamarse** | to be called (to call oneself)
**encontrarse(ue)** | to be (to find oneself)
**llevarse** | to take away
**irse** | to go away
**acordarse** | to remember
**ponerse** | to become
**Me siento** | I sit down
**Me levanto** | I get up
**Me acuesto** | I go to bed
**Me llamo** | My name is
**Me encuentro** | I am (somewhere)
**Se lleva el sarape.** | He takes away the sarape.
**Me voy de esta ciudad.** | I am going away from this city.
**Nos acordamos de él.** | We remember him.
**Se ponen nerviosos.** | They become (get) nervous.
## TERCERA PARTE
### Ejercicios No. 65A-65B
65A. Translate the following questions and answers. Then practice the Spanish aloud.
1. ¿A **qué hora se acuesta Ud.**?
**Me acuesto a las once de la noche**
2. **¿A qué hora se levanta Ud.**
**Me levanto a las siete de mañana.**
3. **¿Se lava antes de vestirse?**
**Sí, me lavo antes de vestirme.**
4. **¿Dónde se encuentra al mediodía?**
**Me encuentro en mi oficina.**
5. **¿Cuándo se va Ud. de aquí?**
**Mañana me voy de aquí.**
6. **¿Se pone Ud. nervioso cuando no funciona el correo electrónico?**
**Sí, me pongo nervioso.**
7. **¿En qué fila del cine se sientan Uds.?**
**Nos sentamos en la fila catorce o quince.**
8. **¿Se acuerdan Uds. de nuestras conversaciones?**
**Sí, nos acordamos.**
65B. Insert the correct form of the reflexive pronoun to make the Spanish sentences match the English.
**Ejemplo: 1. El Sr. Adams se sienta en el comedor.**
1. Mr. Adams sits down in the dining room. | 1. **El Sr. Adams_______sienta en el comedor.**
---|---
2. He gets up at seven o'clock. | 2. **________________levanta a las siete.**
3. He washes and dresses himself. | 3. **______________lava y_____________viste.**
4. At what time do you go to bed? | 4. **¿A qué hora________________acuesta Ud.?**
5. I go to bed at 10 o'clock. | 5. **__________________acuesto a las diez.**
6. What is his name? | 6. **¿Cómo_________________llama él?**
7. Mr. and Mrs. Adams are (find themselves) in the living room. | 7. **El Sr. y la Sra. Adams___________encuentran en la sala.**
8. When do you get up? | 8. **¿Cuándo_________________levantan Uds.?**
9. We get up about seven. | 9. **______________levantamos a eso de las siete.**
10. I don't remember the name. | 10. **No________________acuerdo del nombre.**
### Ejercicio No. 66—Preguntas
66. Answer the following in complete sentences.
1. **¿A qué hora se levanta el Sr. Adams?**
2. **¿Qué hace después?**
3. **¿En cuántos minutos se viste?**
4. **¿Qué hace a eso de las siete?**
5. **¿Se levanta su esposa temprano?**
6. **¿Se desayunan ellos juntos?**
7. **¿Qué desayunoa?**
8. **¿Qué come de vez en cuando en vez de huevos?**
9. **¿A qué hora está listo para salir?**
10. **¿Cómo va el Sr. Adams a la estación?**
11. **¿A qué hora llega a su oficina?**
12. **¿Cuándo almuerza?**
13. **¿Qué come y toma para el almuerzo?**
14. **¿Vienen clientes a visitarlo por la tarde?**
15. **¿A qué hora termina el trabajo?**
# CHAPTER 22
REVIEW, CHAPTERS 18–21
REPASO, CAPÍTULOS 18–21
## PRIMERA PARTE
### Repaso de palabras (Word Review)
**NOUNS**
**1. el almuerzo** | 1. lunch
---|---
**2. el asiento** | 2. seat
**3. la cara** | 3. face
**4. el camino** | 4. road
**5. el cliente** | 5. customer
**6. el coche** | 6. car, auto
**7. el comienzo** | 7. beginning
**8. la costumbre** | 8. custom
**9. el cura** | 9. priest
**10. el desayuno** | 10. breakfast
**11. la estrella** | 11. star
**12. la fiesta** | 12. holiday
**13. la historia** | 13. history
**14. el huevo** | 14. egg
**15. el jugo** | 15. juice
**16. la luz** | 16. light
**17. la manzana** | 17. apple
**18. la naranja** | 18. orange
**19. el norte** | 19. north
**20. el ojo** | 20. eye
**21. el panecillo** | 21. roll
**22. los panqueques** | 22. pancakes
**23. la película** | 23. film
**24. la pluma** | 24. pen
**25. el postre** | 25. dessert
**26. el recuerdo** | 26. remembrance
**27. el río** | 27. river
**28. el sur** | 28. south
**29. el turista** | 29. tourist
**30. el teléfono** | 30. telephone
**VERBS**
**1. acordarse** | 1. to remember
---|---
**2. buscar** | 2. to look for
**3. caminar** | 3. to walk
**4. celebrar** | 4. to celebrate
**5. comer** | 5. to eat
**6. comerse** | 6. to eat up
**7. cruzar** | 7. to cross
**8. deber** | 8. to owe, ought to
**9. dejar** | 9. to let, to leave
**10. desayunarse** | 10. to eat breakfast
**11. dormir(ue)** | 11. to sleep
**12. dormirse** | 12. to fall asleep
**13. encontrar(ue)** | 13. to meet, to find
**14. encontrarse** | 14. to be
**15. irse** | 15. to go away
**16. hallar** | 16. to find
**17. lavar** | 17. to wash (something)
**18. lavarse** | 18. to wash (oneself)
**19. levantar** | 19. to raise
**20. levantarse** | 20. to get up
**21. llevar** | 21. to carry, wear
**22. llevarse** | 22. to take away
**23. llamar** | 23. to call
**24. llamarse** | 24. to be named
**25. poner** | 25. to put
**26. ponerse** | 26. to become
**27. oír** | 27. to hear
**28. permitir** | 28. to permit
**29. preferir(ie)** | 29. to prefer
**30. reír(i)** | 30. to laugh
**31. sonreír(i)** | 31. to smile
**32. recordar(ue)** | 32. to recall (oneself)
**33. sentarse(ie)** | 33. to sit down
**34. sentir(ie)** | 34. to feel, regret
**35. sentirse(ie)** | 35. to feel (sad, weak, etc.)
**36. significar** | 36. to mean (signify)
**37. tratar** | 37. to try
**38. terminar** | 38. to end
**39. vestir(i)** | 39. to dress
**40. vestirse** | 40. to dress oneself
**41. volver(ue)** | 41. to return
**42. ser** — **fue** | 42. to be—he (she) was
**ADJECTIVES**
**1. ancho** | 1. wide
---|---
**2. barato** | 2. cheap
**3. caro** | 3. dear, expensive
**4. conocido** | 4. well-known
**5. chico** | 5. small
**6. desocupado** | 6. unoccupied
**7. junto** | 7. together
**8. mayor** | 8. older
**9. ocupado** | 9. busy, occupied
**10. oscuro** | 10. dark
**11. raro** | 11. rare
**12. tal** | 12. such
**ADVERBS**
1. **generalmente** | 1. ordinarily
---|---
2. **naturalmente** | 2. naturally
3. **temprano** | 3. early
**PREPOSITIONS**
1. **contra** | 1. against
---|---
2. **lejos de** | 2. far from
3. **en vez de** | 3. instead of
**IMPORTANT EXPRESSIONS**
**1. a pie** | 1. on foot
---|---
**2. a eso de** | 2. at about
**3. a ver** | 3. let's see
**4. a tiempo** | 4. on time
**5. acabo de (+ _5. infin._ )** | I have just
**6. por supuesto** | 6. of course
**7. estar de pie** | 7. to stand
**8. desde luego** | 8. of course
**9. de vez en cuando** | 9. from time to time
**10. en punto** | 10. sharp, on the dot
**11. dar un paseo** | 11. to take a walk
**12. más o menos** | 12. more or less
**13. me gusta más** | 13. I prefer
**14. no solamente** | 14. not only
**15. sino también** | 15. but also
**16. por eso** | 16. therefore
**17. Ud. debe de estar cansado.** | 17. You must be tired.
## SEGUNDA PARTE
### Grammar Notes
**Ejercicio 67**. Select the group of words in the right-hand column which best completes the sentence begun in the left-hand column.
1. **Los niños Adams conocen** | a. **muy temprano.**
---|---
2. **Desde la fila catorce** | b. **es el Paseo de la Reforma.**
3. **En la ciudad de México hay calles** | c. **es el Amazonas.**
4. **El 16 de septiembre es** | d. **el Día de la Independencia de México.**
5. **Una de las avenidas más hermosas de México** | e. **se puede ver y oír bien.**
6. **El río más largo del mundo** | f. **en tren, en subterráneo y a pie.**
7. **La ciudad más antigua de los EE.UU.** | g. **toma jugo de naranja.**
8. **Un madrugador se levanta** | h. **es San Agustín en la Florida.**
9. **Para comenzar el desayuno el señor** | i. **a las estrellas de la pantalla.**
10. **Para llegar a la oficina viaja** | j. **nombradas en memoria de los grandes héroes de México.**
**Ejercicio 68.** Read the Spanish questions and then make your answer in Spanish correspond to the English answer following the question:
1. **¿lnvita Ud. a sus amigos a su casa?** | Yes, I invite them from time to time.
---|---
2. **¿Prefiere Ud. el cine?** | No, I do not prefer it.
3. **¿Conocen los niños a las estrellas del cine?** | Yes, they know them well.
4. **¿Nos esperan Uds.?** | Yes, we are waiting for you.
5. **¿Dónde pone la criada las tazas?** | She puts them on the table.
6. **¿Me busca Ud.?** | No, I am not looking for you, sir.
7. **¿A qué hora se levanta Ud.?** | I get up at eight o'clock.
8. **¿Se lavan Uds. antes de comer?** | Yes, we wash ourselves before eating.
9. **¿En qué fila se sientan los Adams?** | They sit in row fifteen.
10. **¿Cómo se llama su padre?** | My father's name is_________________.
**Ejercicio 69**. Complete these sentences by writing all English words in Spanish.
1. **El Amazonas es el río** (the largest in the world).
2. **Nueva York es** (bigger than) **Los Angeles.**
3. **Mi padre es** (older than) **mi madre.**
4. **No soy** (as tall as) **mi hermano.**
5. **Anita es** (the youngest in) **la familia.**
6. **El lunes es** (the first day) **de la semana.**
7. **Hoy es el** (January 30, 2003).
8. **¿Desea Ud. ir** (with me) **al teatro?**
9. **Pablo prefiere ir** (without me).
10. **Cuando** (I hear) **una palabra española** (I remember it).
**Ejercicio 69.** The following expressions are used in the sentences below. See if you can apply them correctly.
**tener que + infinitive** | **hacer preguntas** | **a eso de** | **de vez en cuando**
---|---|---|---
**darse la mano** | **dar un paseo** | **deber de + infinitive** | **otra vez**
| **acostarse** | **por eso** |
1. **Los amigos** (shake hands).
2. (We must study) **todos los días.**
3. (I go to bed) **a las once.**
4. **El profesor** (asks many questions).
5. **El niño está enfermo.** (Therefore) **no puede ir a la escuela.**
6. **Voy al teatro** (from time to time).
7. **Me gusta** (to take a walk) **por la noche.**
8. (You must be) **muy cansado, señor.**
9. **Dígame su nombre** (again), **por favor.**
10. **Me levanto** (at about 7:30 a.m.).
## TERCERA PARTE
### Diálogo
**En el mercado**
Practice the Spanish Aloud:
**Estamos cerca de un puesto donde se venden sarapes.** | We are near a stand where sarapes are sold.
---|---
**_Comprador_ : ¿Cuánto cuesta éste blanco y negro?** | _Buyer_ : How much does this black-and-white one cost?
**_Vendedor_ : 35 (treinta y cinco) pesos.** | _Seller_ : 35 pesos.
**_Comprador_ : Es demasiado. Le doy 25 (veinticinco).** | _Buyer_ : It's too much. I'll give you 25.
**_Vendedor_ : Pues no, señor. Éste es muy fino. Por 34 (treinta y cuatro) pesos es suyo.** | _Seller_ : Well, no sir. It's very fine. For 34 pesos it's yours.
**_Comprador_ : Es mucho. Le doy 26 (veintiséis).** | _Buyer_ : It's too much. I'll give you 26.
**_Vendedor_ : Es barato, señor. Mire Ud. Es muy grande. Es para cama de matrimonio. Déme 31 (treinta y uno).** | _Seller_ : It is cheap, sir. Look. It's very big. It's for a double bed. Give me 31.
**_Comprador_ : Yo soy soltero. No voy a casarme. Le doy 27 (veintisiete).** | _Buyer_ : I am a bachelor. I'm not going to get married. I'll give you 27.
**_Vendedor_ : No puedo, señor. Tengo mujer y seis niños. Tenemos que vivir. 29 (veintinueve) Es el ultimo precio.** | _Seller_ : I cannot do it, sir. I have a wife and six children. We have to live. 29. It's the final price (offer).
**_Comprador_ : Muy bien.** | _Buyer_ : Very well.
**Le da al vendedor 29 (veintinueve) pesos y se lleva el sarape negro y blanco. Es costumbre regatear y los dos se quedan muy contentos.** | He gives the seller 29 pesos and takes away the black-and-white sarape. It is customary to bargain and both are (remain) pleased.
## LECTURA
### Ejercicio No. 71—Una visita al distrito puertorriqueño de Nueva York
**Es sábado. El señor Adams se levanta a las ocho y mira por la ventana. El cielo es azul. Hace un sol brillante. Le dice a su esposa:—Hoy vamos a visitar el distrito** (district) **puertorriqueño que está cerca del Parque Central en Nueva York.**
— **Está bien—dice la señora Adams.**
**A las nueve suben a** (get into) **su auto y después de una hora de viaje llegan a la calle 116 (ciento dieciséis). Bajan** (they get out of) **del auto y comienzan a pasearse** (to walk) **por la calle. Dentro de poco** (In a little while), **cerca de una tienda, ven un grupo de muchachos puertorriqueños que platican muy rápido en español.**
**El señor Adams saluda a los muchachos y comienza a charlar con uno de ellos. Sigue la conversación.**
— **¡Hola, joven!** (young man) **¿Es Ud. puertorriqueño?**
— **No, señor, soy norteamericano, pero sé hablar bien español. Tengo muchos amigos puertorriqueños y ellos son mis maestros. En casa tengo un libro de español y todas las tardes estudio un poco. A propósito, ¿es Ud. español?**
— **No, joven, también yo soy norteamericano, y como Ud., estudio español. Me gusta mucho la lengua. Parece** (It seems) **que en Nueva York hay muchas personas que estudian español. Hasta la vista, amigo.**
— **Hasta luego, señor,—dice el muchacho—y en pocos minutos desaparece** (he disappears) **entre su grupo de amigos que siguen platicando** (continue talking) **en español.**
**¡Qué muchacho tan simpático!—dice el Sr. Adams a su esposa. Y entonces traduce** (then he translates) **la frase, porque ésta** (the latter) **no comprende el español** : "What a nice boy!"
# CHAPTER 23
CAPÍTULO 23 (VEINTITRÉS)
## PRIMERA PARTE
### Una noche lluviosa
1. **Está lloviendo mucho. La Sra. Adams abre la puerta. Entra el señor López.** | 1. It is raining hard. Mrs. Adams opens the door. Mr. Lopez enters.
---|---
2. **La señora dice:—Buenas noches, señor López. ¡Qué tiempo tan lluvioso! Pase Ud., pase. Está bastante mojado. Por favor, déme el impermeable y el sombrero. Ponga el paraguas en el paragüero.** | 2. The lady says, "Good evening, Mr. Lopez. What rainy weather! Come in, come in. You are quite wet. Give me, please, your raincoat and hat. Put your umbrella in the umbrella stand."
3. **El señor López responde:—Gracias. Ahora estoy bien. Llueve a cántaros, pero no hace frío. Estoy seguro de que no me voy a pescar un catarro. ¿Está en casa el señor Adams?** | 3. Mr. Lopez answers, "Thank you. Now I feel all right. It is raining buckets, but it is not cold. I am sure that I will not catch cold. Is Mr. Adams at home?"
4. — **Sí, sí. Lo espera en la sala. Aquí está él mismo.** | 4. Yes, yes. He is waiting for you in the living room. Here he is himself.
5. — **Buenas noches, señor López. Mucho gusto en verlo, pero Ud. no debe salir de su casa con este tiempo. Venga conmigo al comedor y tome una taza de té con ron para calentarse un poquito.** | 5. Good evening, Mr. Lopez. I am very glad to see you, but you should not go out of your house in weather like this. Come with me to the dining room and drink a cup of tea with rum to warm yourself a bit.
6. — **Gracias, gracias, con mucho gusto, señor Adams. Tengo un poco de frío. Mientras tomamos el té con ron vamos a charlar sobre el tiempo. Es un tema de conversación común y en este momento es muy apropiado.** | 6. Thank you, thank you, Mr. Adams, with pleasure. I am a little cold. While we drink the tea with rum, we will chat about the weather. It is a common topic of conversation and just now is very appropriate.
7. **Los señores pasan al comedor charlando en voz animada. Se sientan a la mesa y la señora Adams les trae una bandeja con dos tazas y platillos, una tetera con té caliente, un azucarero y unas cucharitas. Los pone en la mesa junto con una botella de ron que toma del aparador.** | 7. The gentlemen go into the dining room chatting in an animated voice. They sit down and Mrs. Adams brings them a tray with two cups and saucers, a teapot with hot tea, a sugar bowl, and some teaspoons. She puts them on the table together with a bottle of rum which she takes from the sideboard.
8. **La señora Adams le dice a su esposo: — John, ¿quieres servirle el té al señor López?** | 8. Mrs. Adams tells her husband: "John, would you serve some tea to Mr. Lopez?"
9. — **Sí, por supuesto. Permítame servirle, Sr. López—Luego echa el té y un poco de ron en la taza del Sr. López. La señora Adams sale del comedor.** | 9. "Sure. Allow me to serve you, Mr. Lopez." He then pours tea and a little rum in Mr. Lopez's cup. Mrs. Adams leaves the dining room.
10. **Mientras toman el té con ron los señores siguen charlando en voz animada.** | 10. While they are drinking the tea with rum the gentlemen continue chatting in an animated voice.
11. **Afuera sigue lloviendo.** | 11. Outside it continues raining.
### Pronunciation and Spelling Aids
1. In the combinations **gua, guo** ( _gwah, guo_ ), the **u** is pronounced: pa-ra-guas ( _pah- **rah** -gwahs_).
2. In the combinations **gue, gui** , the **u** is silent. It is there to show that the **g** is hard (not like **g** in **gente** ). **si** -guen, se- **guir** ( _say- **geer**_ ).
3. In the combinations güe, **güi** ( _gway, gwee_ ), the" (diaeresis) over the **u** shows that the **u** is pronounced: **paragüero** ( _pah-rah- **gway** -roh_).
### Building Vocabulary
1. **él mismo** | he himself
---|---
**ella misma** | she herself
**ellos mismos** | they themselves (m)
**ellas mismas** | they themselves (f)
2. **tomar** may mean _to take, to eat_ , or _to drink_
### Expresiones Importantes
1. Expressions of Weather.
In Spanish we say: What weather does it _make_ ( **hace** )? It _makes_ **(hace)** heat, cold, etc.; not What _is_ the weather? It _is_ hot, cold, etc.
In Spanish we say _I have_ ( **tengo** ) warmth, cold, etc.; not _I am_ warm, cold, etc. 1. **¿Qué tiempo hace?** | What's the weather?
---|---
2. **Hace buen (mal) tiempo.** | The weather is (bad) nice.
3. **Hace calor, hace frío, hace fresco.** | It is warm (hot), it is cold, it is cool.
4. **Hace mucho calor. Hace mucho frío.** | It is very hot. It is very cold.
5. **Hace viento. Hace sol (hay sol).** | It is windy. It is sunny.
6. **Truena.** | It is thundering.
7. **Llueve (está lloviendo).** | It is raining.
8. **Nieva (está nevando).** | It is snowing.
9. **Tengo calor, frío.** | I am warm (hot), cold.
10. **Tengo mucho calor, mucho frío.** | I am very warm (hot), very cold
### Ejercicio No. 72—Completion of Text
1. **La señora dice** :—¡(What rainy weather)!
2. (Come in, come in). **Ud. está bastante** (wet).
3. (Give me) **el impermeable y el sombrero.**
4. (Put) **el paraguas en el paragüero.**
5. **Estoy seguro de que no me voy a** (catch a cold).
6. (Come with me) **al comedor.**
7. (Drink) **una taza de** té **con ron.**
8. (Allow me) **servirle.**
9. (While they are drinking) **el té siguen charlando.**
10. **Afuera** (it continues raining).
## SEGUNDA PARTE
### Grammar Notes
1. The Imperative or Command Forms of the Verb.
1. To form the imperative, take these steps:
1. Formal: Drop the **-o** from the first person singular indicative.
2. For the imperative singular, add **-e** to the stem of **-ar** verbs, and **-a** to the stem of **-er** and **-ir** verbs.
3. For the imperative plural, add **-en** to the stem of **-ar** verbs, and **-an** to the stem of **-er** and **-ir** verbs. Thus, the endings of the imperative are the reverse of the endings of the present tense, where **-ar** verbs have **-a** and **-an** , and **-er** and **-ir** verbs have **-e** and **-en.**
4. You may use **Ud.** and **Uds.** after the verb. They are, however, usually omitted like _you_ in English.
5. The informal ( **tú** ) form of the imperative is the same as the third person singular of the indicative. There are exceptions; for example: **pon, ven.**
2. Irregular Imperatives INFINITIVE | IMPERATIVE SINGULAR | IMPERATIVE PLURAL
---|---|---
**dar** | **dé (Ud.)** | give | **den (Uds.)** | give
**estar** | **esté (Ud.)** | be | **estén (Uds.)** | be
**ser** | **sea (Ud.)** | be | **sean (Uds.)** | be
**ir** | **vaya (Ud.)** | go | **vayan (Uds.)** | go
3. The Imperative with Object Pronouns.
1. Object pronouns follow and are attached to the affirmative imperative form.
An accent mark must be added to hold the verb stress where it was before the pronoun was added. **Abra la puerta.** | Open the door.
---|---
**Dejen los platos.** | Leave the plates.
**Óigame.** | Hear me.
**Ábrala (Ud.)** | Open it.
**Déjenlos (Uds.)** | Leave them.
**Dígame.** | Tell me.
2. In the negative imperative, object pronouns precede the verb. **No abra la puerta.** | Do not open the door.
---|---
**No tomen los platos.** | Do not take the plates.
**No la abra.** | Do not open it.
**No los tomen.** | Do not take them.
### Ejercicios No. 73A-73B
73A. Rewrite each sentence, changing the direct object noun into an object pronoun. First, review "Grammar Notes 3."
**Ejemplo: Póngala en la mesa.**
1. **Ponga la tetera en la mesa.**
2. **No abra la puerta.**
3. **Repita las preguntas.**
4. **No deje el paraguas en la puerta.**
5. **Traiga los platos al comedor.**
6. **No tomen el pan.**
7. **Saluden a sus amigos.**
8. **Compren los boletos.**
9. **Inviten a maestro.**
10. **Hagan el ejercicio.**
73B. Write the first person singular, present; and the imperative, singular and plural formal, and the singular informal ( **tú** ) of the following verbs. Give the meaning of each form.
**Ejemplo: entrar** , to enter; **entro** , I enter; **entre Ud., entren Uds., entra (tú)** enter.
1. **escribir**
2. **leer**
3. **tener**
4. **ver**
5. **preguntar**
6. **recibir**
7. **repetir**
8. **ir**
9. **dar**
10. **ser**
### Ejercicio No. 74-Preguntas
1. **¿Hace buen o mal tiempo?**
2. **¿Quién abre la puerta?**
3. **¿Dónde pone el Sr. López el paraguas?**
4. **¿Qué tiempo hace afuera?**
5. **¿A dónde pasan los señores Adams y López?**
6. **¿Qué toman en el comedor?**
7. **¿Qué pone la señora en la mesa?**
8. **¿Qué hace ella entonces?**
9. **¿Quién le sirve al Sr. López?**
10. **¿Qué echa el Sr. Adams en las tazas?**
**En las palabras con «gua» y «guo» la «u» se pronuncia.**
**Eso me recuerda que tengo que tomar agua.**
# CHAPTER 24
CAPÍTULO 24 (VEINTICUATRO)
## PRIMERA PARTE
### El clima de México
1. **Todavía están sentados los dos señores en el comedor. Todavía están charlando y tomando el té con ron. Todavía está lloviendo afuera. Pero el Sr. López ya no tiene frío.** | 1. The two gentlemen are still seated in the dining room. They are still chatting and drinking tea with rum. It is still raining outside. But Mr. Lopez is no longer cold.
---|---
2. **El señor Adams dice:—El clima de los Estados Unidos y el de México son muy distintos ¿verdad? Aquí en Estados Unidos tenemos cuatro estaciones y cada estación es diferente.** | 2. Mr. Adams says, "The climate of the United States and that of Mexico are very different, are they not? Here in the United States we have four seasons and each season is different."
3. — **Es cierto. En el verano hace calor; muchas veces hace mucho calor. En el invierno hace frío; muchas veces hace mucho frío y de vez en cuando nieva. En la primavera comienza a hacer buen tiempo pero a menudo llueve como esta noche. En general hace un tiempo agradable y hay mucho sol. En el otoño hace fresco y hace viento. ¿Qué estación prefiere Ud.?** | 3. That's true. In the summer it is hot; often it is very hot. In the winter it is cold; often it is very cold and from time to time it snows. In the spring the weather begins to be good but often it rains like tonight. Usually the weather is pleasant and the sun shines a great deal. In autumn it is cool and windy. Which season do you prefer?
4. — **Prefiero la primavera cuando toda la naturaleza se pone verde; pero me gusta también el otoño con sus colores vivos. Pues, basta del clima de Estados Unidos. Dígame algo del clima de México.** | 4. I prefer the spring when all nature turns green; but I also like autumn with its bright colors. Well, enough of the climate of the United States. Tell me something about the climate of Mexico.
5. — **Bueno. Acabamos de hablar del clima de Estados Unidos. Ahora vamos a hablar del clima de México. Ud. va a viajar en avión. Desde allí va a ver el gran panorama de sierras y picos altos. México le va a parecer una tierra de montañas y volcanes. Es verdad. Al cruzar México en coche por la Carretera Panamericana, se sube hasta una altura de casi 8000 pies cerca de México, D.F. La ciudad está situada en la Mesa Central, una mesa inmensa cuya altura varía desde 4000 (cuatro mil) hasta 8000 (ocho mil) pies más o menos. Desde esta mesa se elevan grandes montañas y volcanes como Ixtaccíhuatl y Popocatépetl. En el estado de Veracruz está el Pico de Orizaba, la cima más alta de México.** | 5. Okay. We have just talked about the climate of the United States. Now we are going to talk about the climate of Mexico. You are going to travel by plane. From there you will see the great panorama of ranges and high peaks. Mexico will seem a land of mountains and volcanoes. It is a fact. In crossing Mexico by car along the Pan American Highway, one climbs to an altitude of almost 8000 feet near Mexico City. The city is located on the Central Plateau, an immense elevated plain whose altitude varies from 4000 to 8000 feet more or less. From this plateau rise up great mountains and volcanoes like Ixtaccihuatl and Popocatepetl. In the state of Veracruz is the peak of Orizaba, the highest summit in Mexico.
6. **El señor Adams dice:— ¡De veras! México sí es una tierra de montañas. Y este hecho en gran parte determina el clima de México, ¿verdad?** | 6. Mr. Adams says, "Really! Mexico is indeed a land of mountains. And this fact in large part determines the climate of Mexico, does it not?"
7. — **Ud. tiene razón—responde el señor López. La mitad de México está situada en la zona tórrida. Solo las costas tienen un clima caliente y húmedo. En la Mesa Central siempre es primavera. En las montañas altas naturalmente hace mucho frío y el Pico de Orizaba está coronado de nieve todo el año.** | 7. "You are right," answers Mr. Lopez. "Half of Mexico is located in the torrid zone. Only the coasts have a hot and humid climate. On the Central Plateau there is always spring. In the high mountains naturally it is very cold, and the peak of Orizaba is crowned with snow all year."
8. — **De hecho, hay tres climas en México—el de las tierras frías en las sierras altas, el de las tierras calientes en las costas, y el de lastierras templadas en la Mesa Central.** | 8. So there are in fact three climates in Mexico—that of the frigid zone in the high ranges, that of the torrid zone on the coasts, and that of the temperate zone on the Central Plateau.
9. — **¿Y las estaciones?** | 9. And the seasons?
10. — **Ya es tarde. Vamos a continuar este tema la próxima vez.** | 10. It's already late. We shall continue this topic next time.
### Pronunciation and Spelling Aids
Practice: | pa-no- **ra** -ma | Ix-tac- **cí** -huatl (ees-tah- **see** -wahtl) | O-ri- **za** -ba
---|---|---|---
| Po-po-ca- **té** -petl | Ve-ra - **cruz** | na-tu-ra- **le** -za
### Building Vocabulary
1. Las cuatro estaciones (the four seasons) **La primavera** spring | **el verano** summer | **el otoño** autumn | **el invierno** winter
---|---|---|---
2. **Los E.E.U.U.** is the abbreviation for **Estados Unidos.**
### Expresiones Importantes
1. **no importa** | it doesn't matter
---|---
2. **de hecho** | in fact
3. **ponerse** | to become
4. **todavía** | still
5. **ya no** | no longer
6. **Ya no tiene frío** | He is no longer cold.
7. **La naturaleza se pone verde** | Nature becomes green
### Ejercicio No. 75—Completion of Text
1. (It is raining) **afuera.**
2. **Todavía los señores** (are chatting and drinking) **té con ron.**
3. **En el verano** (it is hot); **en el invierno** (it is cold).
4. **¿Qué estación** (do you prefer)?
5. (Tell me) **algo del clima de México.**
6. (We have just spoken) **del clima de los E.E.U.U.**
7. (In crossing) **México** (one climbs) **hasta una altura de ocho mil** (8000) **pies.**
8. **Desde la mesa central** (rise) **grandes montañas.**
9. **El Pico de Orizaba es la cima** (highest in Mexico).
10. (Half) **de México está situada en la zona** (torrid).
## SEGUNDA PARTE
### Grammar Notes
1. The Present Tense of **seguir(i)** to follow, **servir(i)** to serve I follow, continue, etc. | I serve, etc.
---|---
**sigo** | **seguimos** | **sirvo** | **servimos**
**sigues** | **seguís** | **sirves** | **servís**
**sigue** | **siguen** | **sirve** | **sirven**
IMPERATIVE | IMPERATIVE
---|---
**siga (Ud.)** | **sigan (Uds.)** | **sirva(Ud.)** | **sirvan (Uds.)**
**sigue (tú)** | | **sirve (tú)** |
1. Verbs ending in **-guir** , like **seguir** , drop the silent **u** before the ending **-o** and **-a.**
2. **seguir(i)** and **servir(i)** belong in the same stem-changing group as **pedir(i), repetir(i).**
2. The Present Progressive Tense of **hablar, aprender, vivir.** | SINGULAR |
---|---|---
| **estoy hablando (aprendiendo, viviendo)** | I am speaking (learning, living)
| **estás hablando (aprendiendo, viviendo)** | you are speaking (learning, living)
**Ud.** | **está hablando (aprendiendo, viviendo)** | you are speaking (learning, living)
| **está hablando (aprendiendo, viviendo)** | he, she, it is speaking (learning, living)
| PLURAL |
| **estamos hablando (aprendiendo, viviendo)** | we are speaking (learning, living)
| **estáis hablando (aprendiendo, viviendo)** | you are speaking (learning, living)
**Uds.** | **están hablando (aprendiendo, viviendo)** | you are speaking (learning, living)
| **están hablando (aprendiendo, viviendo)** | they are speaking (learning, living)
1. The present progressive tense in Spanish is formed by the present tense of **estar** and the present participle of a verb.
2. To form the present participle: remove the infinitive ending **-ar, -er** , or **-ir.** Add **-ando** to the remaining stem of **-ar** verbs; add **-iendo** to the stem of **-er** verbs and **-ir** verbs. The endings **-ando** and **-iendo** are equivalent to the English ending **-ing.** **hablando** speaking | **aprendiendo** learning | **viviendo** living
---|---|---
3. The simple present tense in Spanish may be translated into the English progressive form. However, to stress continuing action use the progressive tense: **No están hablando ahora.** | They are not talking now.
---|---
3. Present Participle of Some Common Verbs **desear** | to want
---|---
**estudiar** | to study
**pensar(ie)** | to think
**contar(ue)** | to count
**hacer** | to make, do
**repetir(i)** | to repeat
**pedir(i)** | to ask for
**ser** | to be
**deseando** | wanting
**estudiando** | studying
**pensando** | thinking
**contando** | counting
**haciendo** | making, doing
**repitiendo** | repeating
**pidiendo** | asking for
**siendo** | being
**leer** | to read
**leyendo** | reading
**creer** | to believe
**creyendo** | believing
**traer** | to bring
**trayendo** | bringing
**caer** | to fall
**cayendo** | falling
**ir** | to go
**yendo** | going
**poner** | to put
**poniendo** | putting
**querer(ie)** | to wish
**queriendo** wishing
**abrir** | to open
**abriendo** | opening
1. The Spanish does not permit an unaccented **i** between two vowels. Therefore, **-iendo** becomes **-yendo** in the following verbs. **leer, leyendo** | **creer, creyendo** | **oír, oyendo** | **caer, cayendo** | **traer, trayendo**
---|---|---|---|---
2. No Spanish word may begin with **ie.** Therefore: **yendo** , going.
4. Position of Object Pronouns with Present Participles
Object pronouns follow the present participle and are attached to it, as in the case of the infinitive. An accent mark must be added to hold the stress on the first syllable of **-ando** and **-iendo** : **Está escribiendo la carta.** | He is writing the letter.
---|---
**Está escribiéndola.** | He is writing it.
**Estamos esperando al maestro.** | We are expecting the teacher.
**Estamos esperándolo.** | We are expecting him.
**Estoy sentándome.** | I am sitting down.
### Ejercicios No. 76A-76B-76C
76A. Rewrite each sentence, changing the direct object noun into an object pronoun.
**Ejemplo: Estamos estudiándolas.**
1. **Estamos estudiando _las lecciones._**
2. **Carlos está escribiendo _la carta._**
3. **¿Estás leyendo _el cuento_ , niño?**
4. **La criada está poniendo _la mesa._**
5. **Los señores están tomando _el té._**
6. **Juan y yo estamos contando _el dinero._**
7. **¿Están comprando Uds. _los boletos_?**
8. **No estoy leyendo _las revistas._**
9. **¿Quién está escribiendo _las cartas_?**
10. **Están vendiendo _los rebozos._**
76B. Answer the questions in the negative form.
**Ejemplo: No, no la estoy leyendo.**
1. **¿Estás leyendo la revista?**
2. **¿Está Ud. esperando a la señora?**
3. **¿Está Ud. esperando al señor?**
4. **¿Está el señor mirando las noticias en la tele?**
5. **¿Está la muchacha comiendo un sandwich?**
6. **¿Estamos aprendiendo los colores?**
76C. Translate, using the present progressive tense. Omit all subject pronouns except **Ud.** and **Uds.**
1. We are studying
2. He is putting
3. We are opening
4. Are you ( **Ud.** ) reading?
5. She is bringing
6. Who is waiting?
7. Are you ( **Ud.** ) taking?
8. You ( **tú** ) are speaking
9. I am not writing
10. Is Mary working?
11. He is looking for
12. They are teaching
### Ejercicio No.77—Preguntas
1. **¿De qué están hablando los señores?**
2. **¿Qué tiempo hace en general en la primavera?**
3. **¿Se pone verde la naturaleza en el invierno?**
4. **¿Qué ve un viajero desde el avión en México?**
5. **¿Dónde está situada México, D.F.?**
6. **¿Qué altura tiene la Mesa Central?**
7. **¿Cuál es la cima más alta de México?**
8. **¿Qué determina en gran parte el clima de México?**
9. **¿En qué zona está situada la mitad de México?**
10. **¿En qué zona hace mucho calor?**
# CHAPTER 25
CAPÍTULO 25 (VEINTICINCO)
## PRIMERA PARTE
### El clima de México (continuación)
1. **Esta noche seguimos charlando del clima de México. Comenzamos con las estaciones.** | 1. Tonight, we continue chatting about the climate of Mexico. We'll start with the seasons.
---|---
2. **En México hay solamente dos estaciones, la estación de lluvias y la estación seca. La estación de lluvias comienza en el mes de junio y termina en el mes de septiembre.** | 2. In Mexico there are only two seasons, the rainy season and the dry season. The rainy season begins in the month of June and ends in the month of September.
3. **Voy a llegar a México el primero o el dos de junio, es decir, al comienzo de la estación de lluvias.** | 3. I will arrive in Mexico the first or second of June, that is to say, at the beginning of the rainy season.
4. **No importa. Todas las estaciones allí son agradables.** | 4. It doesn't matter. All the seasons there are pleasant.
5. **¿Y es posible ser sorprendido por la lluvia?** | 5. And may one be surprised by the rain?
6. **A veces. Pero en la estación de lluvias suele llover más o menos a la misma hora cada día, es decir, a eso de las cuatro de la tarde. Por lo tanto vale la pena llevar un impermeable o un paraguas si uno quiere pasearse durante esas horas.** | 6. Sometimes. But in the rainy season it usually rains at more or less the same time every day, that is to say, at about four in the afternoon. Therefore it is worth the trouble to take a raincoat or umbrella if you want to go for a walk during those hours.
7. **¿Y nunca hace frío?** | 7. And it is never cold?
8. **Por la noche hace fresco a veces, y un abrigo ligero o un suéter vienen bien. Nunca hace frío excepto en las montañas altas. Pero tenga cuidado con el sol tropical. Es muy fuerte y es peligroso caminar o quedarse al sol sin sombrero.** | 8. At night it is cool at times, and a light overcoat or a sweater is useful. It is never cold except in the high mountains. But watch out for the tropical sun. It is very strong and it is dangerous to walk or remain in the sun without a hat.
9. **Muchas gracias por estos consejos. 1 Voy a acordarme de ellos. Y al hacer la maleta no voy a olvidarme del impermeable, un suéter y un abrigo ligero.** | 9. Many thanks for this advice. I am going to remember it. And on packing my bag I am not going to forget my raincoat, a sweater, and a light overcoat.
10. **La próxima vez vamos a hablar de los efectos de la altura, de los alimentos, y de las bebidas.** | 10. Next time we will talk about the effects of the altitude, of food, and of drink.
**NOTE** : 1. In Spanish one says: advices.
### Pronunciation and Spelling Aids
Practice: | **llu** -vias ( ** _yoo_ -vyahs**) | sor-pren- **di** -do | **ve** -ces | cui- **da** -do
---|---|---|---|---
| llo- **ver** | es-ta- **cio** -nes | a-cos- **tum** -bra | li- **ge** -ro
### Building Vocabulary
1. **Antónimos** : 1. **algo** | something | **nada** | nothing
---|---|---|---
2. **antes de mi llegada** | before my arrival | **después de mi llegada** | after my arrival
3. **comenzar** | to begin | **terminar** | to end
4. **siempre** | always | **nunca** | never
5. **alguien** | somebody | **nadie** | nobody
### Expresiones Importantes
1. **no importa** | it doesn't matter
---|---
2. **por lo tanto, por eso** | therefore
3. **esta noche** | tonight
4. **tenga cuidado** (con) | be careful (of)
5. **al hacer mi maleta** | on packing my valise
6. **suele (+ inf.)** | he, it usually does (+ inf.)
7. **viene bien** | useful
8. **Refrán** (Proverb) **Más vale algo que nada.**
_Literally: Something is worth more than nothing._
### Ejercicio No. 78—Completion of Text
1. **Esta noche** (we continue speaking) **del clima.**
2. **La estación de lluvias comienza** (in the month of **June** ).
3. **Suele llover** (at the same hour) **cada día.**
4. (Therefore) **lleve Ud. un paraguas.**
5. (It's useful) **llevar un impermeable.**
6. (Never) **hace frío** (except) **en las montañas.**
7. (Be careful of) **el sol tropical.**
8. **Es peligroso** (to remain) **al sol** (without) **sombrero.**
9. **Voy a** (remember) **de estos consejos.**
10. (On packing) **mi maleta no voy** (to forget) **del paraguas.**
## SEGUNDA PARTE
### Grammar Notes
1. Negative Words.
1. Common negative words are: **nadie** | Nobody
---|---
**ninguno** | no, none, not any
**nada** | Nothing
**nunca (jamás)** | never
**ni... ni** | neither... nor
**tampoco** | neither, not... either
2. If these negative words follow the verb, **no** must precede the verb. If the negative words precede the verb or stand alone, **no** is not required. **_Nadie_ viene hoy.** | **_No_ viene _nadie_ hoy.** | _Nobody_ is coming today.
---|---|---
**_Ningún_ cliente viene.** | **_No_ viene _ningún_ cliente.** | _No_ customer is coming.
**_Nunca_ (jamás) hace frío.** | **_No_ hace _nunca_ ( _jamás_ ) frío.** | It is _never_ cold.
**_Nada_ es difícil.** | _Nothing_ is difficult
---|---
**_No_ tengo _nada._** | I have _nothing._
**_No_ tiene _ni_ amigos _ni_ dinero.** | He has _neither_ friends _nor_ money.
**¿Qué quiere Ud.? _Nada._** | What do you want? _Nothing._
**Pablo _no_ desea ir. Yo _tampoco._ ( _Ni_ yo _tampoco_ )** | Paul _doesn't_ want to go. _Neither_ do I.
**NOTE** : **ninguno** becomes **ningún** before a masculine singular noun.
**Ningún, ninguno** , and **ninguna** have no plural. **Nada** can precede only the verb **ser** , when used with adjectives.
2. Infinitives after Prepositions.
After prepositions the Spanish uses an infinitive where the English uses a present participle. **al cruzar México** | on crossing Mexico
---|---
**sin trabajar** | without working
**después de comer** | after eating
**antes de comer** | before eating
### Ejercicio No. 79
Complete the following, replacing the English words with **nadie, ningún (o, a, os, as), nunca, nada, ni... ni, or tampoco** , as needed.
1. **Muchos turistas no saben** (nothing) **de la historia de México.**
2. (Nothing) **es más fácil.**
3. (Never) **hace frío en la capital.**
4. **No es posible pasar sin números.** (Nor) **es posible comprar sin dinero.**
5. (Nobody) **puede vivir sin comer.**
6. **No hay** (nobody) **en la taquilla.**
7. **Más vale tarde que** (never).
8. **No anda** (never) **al sol sin sombrero.**
9. **El hombre no está bien.** (Neither) **está contento.**
10. **No tenemos** (neither) **tiempo** (nor) **dinero.**
11. (Nobody) **puede vivir sin comer.**
12. **No vemos a** (no) niño **en la calle.**
13. **¿Qué quieres decir? —No tengo** (anything) **que decir.**
14. **Más vale algo que** (nothing).
### Ejercicio No. 80—Preguntas
1. **¿Cuáles son las dos estaciones en México?**
2. **¿Cuándo comienza la estación de lluvias?**
3. **¿Cuándo termina la estación de lluvias?**
4. **¿A qué hora suele llover cada día?**
5. **¿Hace frío en la ciudad?**
6. **¿Por qué viene bien un abrigo ligero?**
# CHAPTER 26
CAPÍTULO 26 (VEINTISÉIS)
## PRIMERA PARTE
### La comida mexicana
1. **México D.F. está situada a una altura de cerca de 7500 (siete mil quinientos) pies sobre el nivel del mar. Mucha gente no acostumbrada a la altura se siente un poco débil y sin ambición.** | 1. Mexico City has an altitude of about 7500 feet above sea level. Many people who are not used to the altitude may feel a little weak and lacking in ambition.
---|---
2. **Es costumbre echarle la culpa a la altura de todos los malestares. ¿Tiene un turista un dolor de cabeza? Se dice es la altura. ¿Tiene dolor de estómago? Se dice es la altura. ¿Tiene dolor de muelas? Otra vez, es la altura.** | 2. It is the custom to place the blame for all discomfort on the altitude. Does a tourist have a headache? They say it's the altitude. Does he have a stomachache? They say it's the altitude. Does he have a toothache? Again, it's the altitude.
3. — **Pero ¿qué se puede hacer para acostum-brarse a la altura?** | 3. But what can one do to get used to the altitude?
4. — **No se preocupe. Al principio es mejor no apresurarse. Camine despacio. Descanse varias horas por la tarde.** | 4. Don't worry. At first it is better not to hurry. Walk slowly. Rest several hours in the afternoon.
5. — **¿Y qué me aconseja sobre los alimentos?** | 5. And what do you advise me about the food?
6. — **Tenga cuidado con las frutas típicas de México: el mango, la papaya, el zapote, etc. Son muy sabrosas pero al principio es mejor comer frutas ordinarias, como naranjas, plátanos, peras, melones y manzanas, que se venden en todos los mercados. Acostúmbrese poco a poco a las otras.** | 6. Be careful with the typical fruits of Mexico—mangos, papayas, zapotes, etc. They are very tasty but at first it is better to eat ordinary fruits—oranges, bananas, pears, melons, and apples which are sold in all the markets. Get used to the others little by little.
7. — **¿Hay muchos alimentos típicos de México?** | 7. Are there many foods typical of Mexico?
8. — **Claro que sí. Hay muchos. Estos alimentos no nos parecen raros a nosotros los mexicanos. El hot dog, en cambio, sí. ¿Conoce el pan de México?** | 8. Of course. There are many. These foods don't seem strange to us Mexicans. Hot dogs on the other hand do. Do you know the bread of Mexico?
9. — **Sí, lo conozco. Hay dos tipos: el taco y la tortilla.** | 9. Yes, I know it. There are two kinds: the taco and the tortilla.
10. — **La tortilla se parece al panqueque. La preparan del maíz. La usan para hacer enchiladas. El taco es parecido pero más duro.** | 10. The tortilla looks like a pancake. They make it of corn. They use it to make enchiladas. The taco is similar but harder.
11. — **¿Qué clase de carne comen los mexicanos?** | 11. What kind of meat do Mexicans eat?
12. — **Comen filete, jamón, polio, guajalote, varias clases de chuletas, etc. Comen también varias clases de pescado. Les gusta mucho la salsa picante. Y casi no hay comida sin arroz y frijoles.** | 12. They eat steak, ham, chicken, turkey, several kinds of chops, etc. They also eat several kinds of fish. They like a hot sauce very much. And there is almost no meal without rice and beans.
13. — **¿Y hay muchas clases de postres?** | 13. And are there many kinds of desserts?
14. — **A los mexicanos les gusta comer un dulce, un flan o una de las muchas frutas que se venden en el mercado.** | 14. Mexicans like to eat a candy, a custard, or one of the many fruits that are sold in the market.
15. — **Debo saber leer el menú en un restaurante, ¿verdad?** | 15. I should know how to read the menu in a restaurant, shouldn't I?
16. — **Sí, y también debe probar la comida mexicana. Pero todo con moderación. El estómago norteamericano no se acostumbra rápidamente a los alimentos picantes de México. Recuerde comemos para vivir; no vivimos para comer.** | 16. Yes, and you should also try the Mexican foods. But everything in moderation. The North American stomach does not quickly get used to the hot foods of Mexico. Remember. We eat to live; we do not live to eat.
17. **No lo voy a olvidar. Tampoco voy a olvidar ninguno de sus buenos consejos.** | 17. I will not forget. And I will not forget any of your good advice.
### Pronunciation and Spelling Aids
1. Practice: | a-cos-tum- **bra** -da | a-con- **se** -ja | pa- **re** -cen | fri- **jo** -les
---|---|---|---|---
| ma-les- **ta** -res | gua-ja- **lo** -te | res-tau- **ran** -te | es- **pá** -rra-gos
| a-cos-tum- **brar** -se | es- **tó** -ma-go | ma- **íz** | le- **gum** -bres
| a-pre-su- **rar** -se | | |
### Building Vocabulary
**A. Frutas** Fruits
**la banana** | banana
---|---
**el plátano** | banana (Mex.)
**la cereza** | cherry
**el melocotón** | peach
**la lima** | lime
**el limón** | lemon
**la naranja** | orange
**la pera** | pear
**la piña** | pineapple
**la toronja** | grapefruit
**la uva** | grape
### Expresiones Importantes
B. **Carne** Meat and **Pescados** Fish
**la chuleta** | chop
---|---
**el cordero** | lamb
**la hamburguesa** | hamburger
**el jamón** | ham
**la langosta** | lobster
**el pato** | duck
**el pavo** | turkey
**el guajalote** | turkey (Mex.)
**el pescado** | fish
**el polio** | chicken
**el puerco** | pork
**el rosbif** | steak
**el filete** | steak (Mex.)
**la ternera** | veal
**el tocino** | bacon
C. **Legumbres y verduras** Vegetables ( _Lit._ legumes and greens)
**el camote** | sweet potato (Mex.)
---|---
**la cebolla** | onion
**la col** | cabbage
**la coliflor** | cauliflower
**el elote** | ear of corn (Mex.)
**los chícharos** | peas
**los espárragos** | asparagus
**los frijoles** | beans
**la lechuga** | lettuce
**la patata** | potato (Esp.)
**la papa** | potato
**el pepino** | cucumber
### Expresiones Importantes
1. **dolor de cabeza** | headache
---|---
2. **dolor de muelas** | toothache
3. **dolor de estómago** | stomachache
4. **eso es** | that's right
### Ejercicio No. 81—Completion of Text
1. **Mucha gente** (feel a bit weak) **a causa de la altura.**
2. ¿ **Tiene Ud.** (a headache)? (a toothache)? (a stomachache)?
3. (People say): **Es la altura.**
4. ¿(What can one do) **si se siente un poco débil?**
5. (Rest) **varias horas cada día.** (Walk slowly).
6. ¿(What do you advise me) **sobre los alimentos?**
7. (Be careful) **con las frutas típicas de México.**
8. **Estas frutas** (are sold) **en todos los mercados.**
9. **Estos alimentos no nos** (seem) **raros a nosotros.**
10. **La tortilla** (is like) **al panqueque.**
11. ¿ **Sabe Ud.** (what kind of meat) **comen los mexicanos?**
12. (They like) **mucho la salsa picante.**
13. **Ud.** (should) **probar la comida.**
14. (We eat) **para vivir.** (We do not live) **para comer.**
15. **No voy** (to forget) **sus consejos.**
## PARTE SEGUNDA
### Grammar Notes
1. The Present Tense of **sentir** (ie) to feel, to regret, **conocer** to know I feel, etc.
---
**siento** | **sentimos**
**sientes** | **sentís**
**siente** | **sienten**
I know, etc.
---
**conozco** | **conocemos**
**conoces** | **conocéis**
**conoce** | **conocen**
1. **parecer** to seem, and **traducir** to translate, are irregular in the first person singular, like **conocer.** Thus: **parezco, pareces** , etc.; **traduzco, traduces** , etc.
2. Special Uses of the pronoun **se.** It has the meaning of the English _they._
1. The pronoun **se** is used for an impersonal subject. **Se venden frutas.** | Fruits are sold (They sell fruits).
---|---
**Se abre la puerta.** | The door is opened.
**Aquí se habla español.** | Here Spanish is spoken.
**Se ve mucha gente en el parque.** | Many people are seen in the park.
2. The pronoun **se** is also used with the verb, but without the direct object. It means: _one, people, they_ or _you._ **se dice** | one says | people say | they say | it is said
---|---|---|---|---
**¿cómo se dice?** | how does one say? | how do you say?
**se puede** | one may | can
**se sube** | one goes up
3. Some verbs change their meaning if the pronoun **se** is added. **comer** | to eat
---|---
**comerse** | to eat up
**parecer** | to seem
**parecerse** | to resemble
**ir** | to go
**irse** | to go away to leave
**encontrar** | to find
**encontrarse** | to be (somewhere), to meet
3. **conocer, saber**
1. **saber** means to know facts and things (never persons) by means of the mind. **Saber** also means to know how. **Sabemos dónde vive Juan.** | We know where John lives.
---|---
**Sabemos cuántos años tiene.** | We know how old he is.
**Sabemos los números en español.** | We know the numbers in Spanish.
**Sé cantar esta canción.** | I know how to sing this song.
2. **conocer** means to know in the sense of to be acquainted with a person or thing; to recognize; to know by sight, hearing, or any of the senses. **Conozco a Juan.** | I know (am acquainted with) John.
---|---
**Conozco esta casa.** | I know (recognize by sight) this house.
**Conocemos este restaurante. Es muy bueno.** | We know this restaurant. It is very good.
**Conozco esta canción.** | I know (recognize on hearing) this song.
### Ejercicios No. 82A-82B
82A. Replace the English words with the correct Spanish ones.
1. ¿(May one) **entrar en el parque?**
2. ¿(How does one say) **en inglés—Permítame?**
3. **Aquí** (are sold) **flores.**
4. (Are seen) **muchos burros en los caminos.**
5. (People say) **que el presidente viene hoy.**
6. **Aquí** (Spanish is spoken).
7. (They eat up) **todas las frutas.**
8. ¿(Do you know) **a aquellos profesores**?
9. (I do not know them).
10. ¿(Do you know how) **contar hasta cien?**
11. **Mañana** (I go away).
12. (We know how) **cantar estas canciones.**
13. **La tortilla** (resembles) **a nuestros panqueques.**
82B. Match up the Spanish words in Group II with the English words in Group I.
**Group I** | **Group II**
---|---
1. the banana | a. **el postre**
2. the steak | b. **los frijoles**
3. the pear | c. **el arroz**
4. the corn | d. **la carne**
5. the dessert | e. **el jamón**
6. the rice | f. **la pera**
7. the beans | g. **el pan**
8. the ham | h. **la salsa**
9. the meat | i. **el plátano**
10. the chicken | j. **las chuletas**
11. the bread | k. **el maíz**
12. the sauce | l. **la naranja**
13. the chops | m. **el filete**
14. the foods | n. **el polio**
15. the orange | o. **la manzana**
16. the apple | p. **los alimentos**
### Ejercicio No. 83—Preguntas
1. **¿A qué altura está México D.F.?**
2. **Nombre dos frutas típicas de México.**
3. **Nombre cuatro frutas ordinarias.**
4. **¿Dónde se vende toda clase de frutas?**
5. **Al principio ¿qué es mejor, comer frutas ordinarias o frutas típicas de México?**
6. **¿Cuál es el pan de México?**
7. **¿De qué se hace la tortilla?**
8. **¿Qué se usa para hacer tacos y enchiladas?**
9. **¿Qué clase de postres comen los mexicanos?**
10. **¿Por qué es mejor probar la comida mexicana con moderación?**
11. **¿Por qué es peligroso caminar al sol sin sombrero?**
12. **¿De qué no va a olvidarse el Sr. Adams al hacer su maleta?**
13. **¿De qué van a platicar la próxima vez?**
# CHAPTER 27
REVIEW, CHAPTERS 23–26
REPASO, CAPÍTULOS 23–26
## PRIMERA PARTE
### Repaso de palabras (Word Review)
#### NOUNS
1. **el abrigo** | 1. coat
---|---
2. **la altura** | 2. height
3. **el arroz** | 3. rice
4. **la botella** | 4. bottle
5. **la bebida** | 5. drink
6. **la carne** | 6. meat
7. **el clima** | 7. climate
8. **el consejo** | 8. advice
9. **las chuletas** | 9. chops
10. **el estado** | 10. state
11. **la estación** | 11. season
12. **el filete** | 12. steak
13. **el flan** | 13. custard
14. **los frijoles** | 14. beans
15. **la gente** | 15. people
16. **el hecho** | 16. fact
17. **el impermeable** | 17. raincoat
18. **el invierno** | 18. winter
19. **el jamón** | 19. ham
20. **el menú** | 20. menu
21. **la lluvia** | 21. rain
22. **el maíz** | 22. corn
23. **el mar** | 23. sea
24. **el meloó** | 24. melon
25. **la naturaleza** | 25. nature
26. **la nieve** | 26. snow
27. **el otoño** | 27. autumn
27. **el paraguas** | 27. umbrella
28. **la pera** | 28. pear
29. **el pie** | 29. foot
30. **el plátano** | 30. banana
31. **el polio** | 31. chicken
32. **el pico** | 32. peak
33. **la primavera** | 33. spring
34. **la tortilla** | 34. tortilla
35. **la sierra** | 35. mountain range
36. **el sombrero** | 36. hat
37. **el verano** | 37. summer
38. **el trueno** | 38. thunder
#### VERBS
1. **acostumbrarse** | 1. to accustom oneself
---|---
2. **aconsejar** | 2. to advise
3. **apresurarse** | 3. to hurry
4. **conocer** | 4. to know
5. **charlar** | 5. to chat
6. **descansar** | 6. to rest
7. **llover(ue)** | 7. to rain
8. **olvidar** | 8. to forget
9. **parecer** | 9. to seem
10. **parecerse** | 10. to resemble
11. **ponerse** | 11. to become
12. **preocuparse** | 12. to worry
13. **probar** | 13. to try
14. **quedar** | 14. to remain
15. **seguir(i)** | 15. to follow, continue
16. **servir(i)** | 16. to serve
17. **sentirse(ie)** | 17. to feel (weak, ill, etc.)
18. **subir** | 18. to go up
19. **traer** | 19. to bring, carry
20. **tronar (truena)** | 20. to thunder, it is thundering
#### ADJECTIVES
1. **agradable** | 1. pleasant
---|---
2. **caliente** | 2. hot
3. **común** | 3. common
4. **débil** | 4. weak
5. **diferente** | 5. different
6. **distinto** | 6. different
7. **frío** | 7. cold
8. **fuerte** | 8. strong
9. **húmedo** | 9. damp
10. **ligero** | 10. light
11. **lluvioso** | 11. rainy
12. **mojado** | 12. wet
13. **mismo** | 13. same
14. **peligroso** | 14. dangerous
15. **picante** | 15. hot, spicy
16. **sabroso** | 16. tasty
17. **seguro** | 17. certain
18. **seco** | 18. dry
#### ADVERBS
1. **afuera** | 1. outside
---|---
2. **abajo** | 2. below
3. **entonces** | 3. then
4. **solamente** | 4. only
5. **todavía** | 5. still
6. **todavía no** | 6. not yet
#### PREPOSITIONS
1. **junto con** | 1. together with
---|---
2. **antes de** | 2. before
3. **cerca de** | 3. near
#### PRONOUNS
1. **algo** | 1. something
---|---
2. **alguien** | 2. somebody
3. **consigo** | 3. with himself, herself, themselves
#### NEGATIVES
1. **nada** | 1. nothing
---|---
2. **nadie** | 2. nobody
3. **ninguno** | 3. no, none, not any
4. **nunca** | 4. never
5. **ni... ni** | 5. neither... nor
6. **tampoco** | 6. neither, not... either
7. **jamás** | 7. never
8. **todavía no** | 8. not yet
#### IMPORTANT EXPRESSIONS
1. **a menudo** | 1. often
---|---
2. **acabar de** | 2. to have just
3. **con su permiso** | 3. with your permission
4. **de veras** | 4. indeed
5. **en coche** | 5. by automobile
6. **es cierto** | 6. it is true
7. **dolor de cabeza** | 7. headache
8. **dolor de muelas** | 8. toothache
9. **hacer la maleta** | 9. to pack the suitcase
10. **no importa** | 10. it doesn't matter
11. **por lo tanto** | 11. therefore
12. **tener cuidado** | 12. to be careful
13. **vale la pena** | 13. it is worth the trouble
14. **eso es** | 14. that's right
## SEGUNDA PARTE
### Grammar Notes
**Ejercicio** 84. From Group 2 select the opposite for each word in Group 1.
Group 1 | Group 2
---|---
1. **antes de comer** | a. **cahente**
2. **frío** | b. **después de comer**
3. **siempre** | c. **nada**
4. **alguien** | d. **de prisa**
5. **comenzar** | e. **seco**
6. **recordar** | f. **descansar**
7. **fuerte** | g. **nunca**
8. **trabajar** | h. **olvidar**
9. **lluvioso** | i. **débil**
10. **despacio** | j. **terminar**
11. **algo** | k. **nadie**
**Ejercicio 85.** Complete the following sentences in Spanish.
1. **Cuando hace frío** (I am cold).
2. **Cuando hace calor** (I am warm).
3. **En el verano** (the weather is nice).
4. **En la primavera** (it rains a great deal).
5. **En el otoño** (it is cool).
6. **En el invierno** (it is cold).
7. **Cuando llueve** (I wear a raincoat).
8. **Cuando nieva** (I wear an overcoat).
9. **Cuando hace calor** (it is dusty).
10. **Me gustan** (all the seasons).
**Ejercicio 86.** Select the group words in the right-hand column which best complete the sentences begun in the left hand column.
**Ejemplo: 1. Prefiero la primavera** (d) **porque hace buen tiempo.**
1. **Prefiero la primavera** | a. **el clima de México.**
---|---
2. **No me gusta el invierno** | b. **es una tierra de montañas.**
3. **Voy a decir algo sobre** | c. **en todos los mercados.**
4. **Es verdad que México** | d. **porque hace buen tiempo.**
5. **Se venden frutas** | e. **comer mangos y plátanos.**
6. **Lleve Ud. un paraguas consigo** | f. **porque hace mucho frío.**
7. **A los mexicanos les gusta** | g. **contar en español.**
8. **No voy a olvidar** | h. **porque está lloviendo.**
9. **Sabemos** | i. **a los alumnos de esta clase.**
10. **Conocemos bien** | j. **ninguno de sus consejos.**
**Ejercicio 87.** Read each command. Then translate the sentence that follows it. Watch out for the position of the object pronoun!
**Ejemplo: Cuente (Ud.) el dinero.** I count it. **_Lo cuento._**
1. **Abra (Ud.) la puerta.** I open it.
2. **Cuente los picos. I** count them.
3. **Coma la carne. I** eat it.
4. **Ponga la mesa. I** set it.
5. **Repita las preguntas.** I repeat them.
6. **Dejen (Uds.) los platos.** We leave them.
7. **Tomen las tazas.** We take them.
8. **Aprendan las lecciones.** We learn them.
9. **Escriban el ejercicio.** We write it.
10. **Lean el periódico.** We read it.
**Ejercicio 88.** Substitute the present participle for the infinitive in parentheses to make the present progressive tense.
**Ejemplo: 1. Está lloviendo a cántaros.**
1. **Está (llover) a cántaros.**
2. **Estamos (echar) el café en la taza.**
3. **Están (pedir) informes.**
4. **Estoy (leer) las cartas.**
5. **¿Está (pensar) Ud. en su viaje?**
6. **¿Quién está (traer) la tetera?**
7. **¿Quiénes están (escribir) el mensaje?**
8. **¿No están (contar) el dinero?**
9. **¿La criada está (poner) la mesa?**
10. **¿Qué está (hacer) Carlos?**
## TERCERA PARTE
### Diálogo
#### En el mercado
Practice the Spanish Aloud:
— **¿Puede traerme el menú, por favor?—le pregunta el Sr. Adams al mozo.** | Can I have the menu, please? Mr. Adams asks the waiter.
---|---
— **¡Cómo no! ¿Quiere Ud. probar algún plato típico mexicano?** | Of course! Do you want to eat some typical Mexican dish?
— **Pues, todavía no. Acabo de llegar a México y es mejor, al principio, comer algo a lo que acostumbrado.** | Well, not yet. I have just arrived in Mexico and it is better, at first, to eat something familiar.
— **¿Me permite Ud. recomendar el filete mignon a la parrilla?** | Can I recommend the broiled filet mignon?
— **Debe de estar muy bueno pero prefiero probar las chuletas.** | It must be very good but I prefer to try the chops.
— **Chuletas de ternera, entonces. ¿Con arroz o legumbres?** | Veal chops, then. With rice or vegetables?
— **Con arroz y zanahorias. De postre, déme flan, por favor. Es un postre que me gusta mucho.** | With rice and carrots. For dessert, give me custard, please. It is a dessert that I like very much.
— **¿Y de beber?** | And to drink?
— **Café con leche, por favor.** | Coffee with milk, please.
— **Muy bien, señor.** | Very well, sir.
— **Y favor de traer la cuenta.** | And please bring me the check.
— **Aquí la tiene, señor.** | Here it is, sir.
— **Muchas gracias.** | Many thanks.
— **A Ud., señor.** | Thanks to you, sir.
## LECTURA
### Ejercicio No. 89—A Felipe no le gusta estudiar aritmética
**Un día, al volver** (upon returning) **de la escuela, le dice Felipe a su madre:—No me gusta estudiar aritmética. Es tan difícil. ¿Para qué necesitamos tantos** (so many) **ejercicios y problemas hoy día? ¿No es verdad que tenemos calculadoras?**
**La señora Adams mira a su hijo y dice:—No tienes razón, hijito. No es posible pasar sin números. Por ejemplo, siempre es necesario cambiar dinero, hacer compras, calcular distancias y...**
**La madre deja de** (stops) **hablar al ver** (on seeing) **que Felipe no presta atención a lo que** (what) **ella dice.**
— **A propósito—continúa la madre con una sonrisa** (smile)— **el béisbol no te interesa tampoco** (either), **hijo mío?**
— **Ya lo creo, mamacita.**
— **Pues, si los Dodgers han ganado** (have won) **ochenta juegos** (games) **y han perdido** (have lost) **treinta, ¿sabes qué por ciento de los juegos han ganado?**
**Al oír** (On hearing) **esto Felipe abre la boca y exclama:—Tienes razón, mamá. Los números, la aritmética y las matemáticas son muy importantes. Creo que voy a estudiar mucho más.**
# CHAPTER 28
CAPÍTULO 28 (VEINTIOCHO)
## PRIMERA PARTE
### El pueblo de México
1. — **Voy a hacerle algunas preguntas sobre el pueblo de México—dice el señor Adams.—¿Está Ud. listo? ¿Quiere un café o un té?** | 1. "I am going to ask you some questions about the people of Mexico," says Mr. Adams. "Are you ready? Do you want coffee or tea?"
---|---
2. — **Gracias, señor Adams. Estoy muy bien. Continúe, por favor.** | 2. Thank you, Mr. Adams. I am very well. Continue, please.
3. — **Ante todo, ¿quiénes son los mexicanos?** | 3. First of all, who are the Mexicans?
4. — **Son los descendientes de los indios indíge-nas y de los españoles, conquistadores de México y de la America del Sur.** | 4. They are descendants of the native Indians and of the Spaniards, conquerors of Mexico and of South America.
5. — **¿Cuántos habitantes tiene México?** | 5. How many inhabitants does Mexico have?
6. — **México tiene actualmente más o menos 100 millones de habitantes. No todos hablan español. De los muchos millones llamados «indios» muchos todavía hablan varias lenguas indígenas.** | 6. Today about 100 million people live in Mexico. Not all speak Spanish. Of the many million called "Indians" a great number still speak various native languages.
7. — **¿Dónde vive la mayor parte de los habitantes, en la ciudad o en el campo?** | 7. Where do the majority of the inhabitants live, in the city or in the country?
8. — **Hay ciudades grandes muy modernas e industrias grandes. Unas 20 millones de personas viven en el Distrito Federal, una ciudad hermosa y cosmopolita. Pero la mayor parte vive en el campo y trabaja en la agricultura.** | 8. There are big, very modern cities and big industries. About twenty million people live in the Federal District, a beautiful and cosmopolitan city. But the majority live in the country and work in agriculture.
9. — **¿Cuáles son los productos más importantes?** | 9. What are the most important products?
10. — **A causa de la variedad de climas y la extension del territorio, México produce una variedad de productos, desde el trigo hasta la caña de azúcar. Pero el maíz es el producto más importante de todos.** | 10. Because of the variety of climates and the extent of territory, Mexico produces a variety of products from wheat to sugar cane. But corn is the most important product of all.
11. — **Además de ser agricultures, los mexicanos son artistas y artesanos, ¿verdad?** | 11. Besides being agriculturists, Mexicans are artists and craftsmen, are they not?
12. — **Tratan siempre de embellecer una vida dura. Son muy trabajadores pero saben también vivir bien. La artesanía mexicana es famosa.** | 12. They always try to beautify a hard life. They are very hardworking but they also know how to live. The Mexican folk art is famous.
13. — **¿De qué artes se ocupan?** | 13. What arts are they engaged in?
14. — **Mucha gente se ocupa de las artes populares, la cerámicay el tejido; hace cestas, artículos de cuero, de cobre, de hojalata, de oro, de plata y de laca.** | 14. Many people are engaged in the folk arts—ceramics, weaving; they make baskets, leather goods, things of copper, tin, gold, silver, and lacquer.
15. — **A propósito, acabo de recibir un envío de algunos artículos de México. ¿Quiere Ud. venir a mi oficina el jueves a las tres de la tarde para verlos? Entonces volvemos a platicar de las artes populares.** | 15. By the way, I have just received a shipment of some articles from Mexico. Do you want to come to my office Thursday at three in the afternoon to look at them? Then we will talk again about the popular arts.
16. — **Con todo gusto, Sr. Adams. Tenemos cita para el jueves a las tres, ¿verdad?** | 16. With pleasure, Mr. Adams. We have an appointment for Thursday at three, right?
17. — **Hasta el jueves, entonces.** | 17. Until Thursday, then.
18. — **Hasta luego. Que lo pase bien.** | 18. So long. Good luck to you.
### Pronunciation and Spelling Aids
1. Practice: | con-ti- **nen** -te | Fe-de- **ral** | em-be-lle- **cer** | las **Ar** -tes | en- **ví** -o
---|---|---|---|---|---
| con-ti- **nú** -e | in- **dí** -ge-nas | cos-mo-po- **li** -ta | tra-ba-ja- **do** -res | Po-pu- **la** -res
| ho-ja- **la** -ta | des-cen- **dien** -tes | in- **dus** -trias | ex-ten- **sión** | a-gri-cul- **to** -res
| ce- **rá** -mi-ca | **cue** -ro | con-quis-ta- **do** -res | Dis- **tri** -to | va-rie- **dad**
| ar- **tís** -ti-cos | te- **ji** -do | **co** -bre
2. y and **e** mean _and._ **e** is used instead of **y** when the next word begins with the letter **i** , to avoid repetition of the **i** ( **ee** ) sound; **agricultura e industria.**
**o** and **u** mean _or._ **u** is used instead of **o** when the next word begins with **o** to avoid repetition of the **o** sound. **septiembre u octubre.**
### Building Vocabulary
A. **Materias primas** (Raw Materials)
**el algodón** | cotton
---|---
**el cobre** | copper
**el cuero** | leather
**el hierro** | iron
**la lana** | wool
**la madera** | wood
**el oro** | gold
**la paja** | straw
**el petróleo** | petroleum
**la plata** | silver
**el plomo** | lead
**la seda** | silk
B. **Sinónimos**
**el idioma** | **la lengua** | language
---|---|---
**acabar** | **terminar** | to finish
**con todo gusto** | **con mucho gusto** | with great pleasure
### Expresiones Importantes
**a causa de** | because of
---|---
**ante todo** | first of all
**acostumbrarse a** | to get used to
**hacer preguntas** | to ask questions
**ocuparse de** | to be engaged in (to busy oneself with)
**que la pase bien** | good luck to you (may you get along well)
### Ejercicio No. 90—Completion of Text
1. **Voy a** (ask you) **algunas preguntas.**
2. **Son** (about the people) **de México.**
3. (Here is) **el café.** (Continue), **por favor.**
4. ¿(Who) **son los mexicanos?**
5. **¿Cuántas personas viven** (nowadays) **en México?**
6. **El Distrito Federal es una ciudad** (beautiful and cosmopolitan).
7. (Because of the variety) **de dimas, hay** (a variety) **de productos.**
8. **El maíz es** (the most important product) **de todos.**
9. **Son** (artists and artisans).
10. **¿De qué artes** (are they engaged)?
11. (They are engaged) **de las artes populares.**
12. **Hacen** (baskets and leather articles).
13. (I have just received) **un envío de México.**
14. (We will talk again) **de las artes populares.**
15. (Good luck to you).
## SEGUNDA PARTE
### Grammar Notes
1. Present tense of **volver (ue)** to return, go back
**Vuelvo a casa.** I return home. **Volvemos al cine.** We return to the movies. **vuelvo** I return | **vuelves** you return | **vuelve** he, she, it returns
---|---|---
**volvemos** we return | **volvéis** you return | **vuelven** they return
2. **Volver a+** an infinitive, means to do something again; **volver a hablar** , to speak again **vuelvo a hablar** I speak again | **volvemos a hablar** we speak again
---|---
**vuelves a hablar** you speak again | **volvéis a hablar** you speak again
**vuelve a hablar** he, she, it speaks again | **vuelven a hablar** they speak again
**Vuelvo a escribir la carta.** | I am writing the letter again.
**Hoy volvemos a platicar de las artes.** | Today we shall speak again of the arts.
Another way of expressing the same idea: |
**Hoy platicamos de las artes otra vez.** | Today we are speaking of the arts again.
3. Present tense of **acabar** to finish **Acabo el trabajo.** I finish the work. | **¿Acaban Uds. la lección?** Are you finishing the lesson?
---|---
4. **Acabar de +** infinitive, means to have just done something; **acabar de recibir** to have just received **Acabo de recibir un envío.** | I have just received a shipment.
---|---
**Acaba de enseñar la lección.** | He has just taught the lesson.
### Ejercicios No. 91A-91B
91A. Repeat aloud the Spanish sentences many times.
1. **¿Acaba Ud. de comer?** | Have you just eaten?
---|---
2. **Sí, acabo de comer.** | Yes, I have just eaten.
3. **¿Acaba de dormir el niño?** | Has the child just slept?
4. **No, no acaba de dormir.** | No, he has not just slept.
5. **¿Acaban de tomar la cena?** | Have they just eaten supper?
6. **Sí, acaban de tomarla.** | Yes, they have just eaten it.
7. **¿Cuándo vuelve Ud. a casa?** | When do you return home?
8. **Vuelvo a casa a las siete.** | I return home at seven.
9. **Vuelven a leer el libro.** | They are reading the book again.
10. **Carlos vuelve a venir acá.** | Charles is coming here again.
**NOTE** : **acá** here, and **allá** _there_ , are used instead of **aquí** and **allí** with verbs of motion.
91B. Translate:
1. When do they return home?
2. They return home at ten o'clock in the evening.
3. The students are writing the exercises again.
4. I am reading the guide book **(la guía de viajero)** again.
5. We have just received a shipment of merchandise **(mercancía).**
6. I have just spoken about the climate.
7. She has just returned from the jewelry shop **(joyería).**
8. They have just bought silver earrings **(aretes de plata).**
9. Have you just come from the movies?
10. We are finishing the work **(el trabajo** ).
### Ejercicio No. 92—Preguntas
1. **¿Quién va a hacer algunas preguntas?**
2. **¿Cuál es la primera pregunta?**
3. **¿De quiénes son descendientes los mexicanos de hoy?**
4. **¿Cuántos habitantes tiene México?**
5. **¿Quién acaba de recibir un envío de mercancía de México?**
6. **¿Dónde vive la mayor parte de los habitantes, en la ciudad o en el campo?**
7. **¿Cuál es el producto más importante de México?**
8. **¿De qué artes se ocupan muchas personas?**
9. **¿Qué materiales usan para hacer cosas artísticas?**
# CHAPTER 29
CAPÍTULO 29 (VEINTINUEVE)
## PRIMERA PARTE
### Las artes populares
1. **El Sr. Adams acaba de recibir en su oficina una caja de mercancía de México y ha invitado al Sr. López a ver el contenido con él.** | 1. Mr. Adams has just received in his office a box of merchandise from Mexico and has invited Mr. Lopez to look at its contents with him.
---|---
2. — **Vamos a ver los artículos de México, Sr. López. Acabo de recibirlos.** | 2. Let us look at the things from Mexico, Mr. Lopez. I have just received them.
3. — **Con mucho gusto. Y entretanto podemos hablar de las artes populares.** | 3. With pleasure. And meanwhile we can talk about the popular arts.
4. — **Sabemos, Sr. López, que algunos de los artículos más artísticos que hacen los artesanos mexicanos son los de uso diario. Así es que el vestido típico es también un arte popular, ¿verdad?** | 4. We know, Mr. Lopez, that some of the most artistic articles that the Mexican craftsmen make are those of daily use. So clothing is also a popular art, is it not?
5. — **Es cierto. El vestido típico da a los indios un aspecto pintoresco. Las mujeres llevan faldas largas y blusas con bordados sencillos. Lejos de las ciudades se visten todavía de blusas, faldas y fajas de antes. Los hombres llevan traje bianco o de color claro. El sombrero de paja es de uso general.** | 5. Yes, indeed. The typical dress gives the Indians a picturesque appearance. The women wear long skirts and blouses with simple embroidery. Far from the cities they still dress in the blouses and skirts and sashes of olden times. The men wear a white or light-colored suit. The straw hat is in general use.
6. — **¿Aquí tiene Ud. algunos sarapes de lugares distintos. El sarape es un artículo de ropa, ¿verdad?** | 6. Here are some sarapes from different places. The sarape is an article of clothing, is it not?
7. — **Sí, los hombres llevan el sarape de abrigo o de adorno. Sirve también de manta. ¡Qué tejidos más bonitos son estos sarapes grises! ¡Me gustan los dibujos geométricos! Son de Oaxaca, ¿verdad?** | 7. Yes, the men wear the sarape as an overcoat or for adornment. It serves also as a blanket. How beautifully woven these gray sarapes are! I like the geometric designs! They are from Oaxaca, are they not?
8. — **Sí. Y mire Ud. las fajas. Estas rojas son de Toluca. Tanto los hombres como las mujeres llevan faja. Es tejida de lana o de algodón.** | 8. Yes. And look at the sashes. These red ones are from Toluca. The men as well as the women wear sashes. It is woven of wool or cotton.
9. — **¡Qué graciosos son los dibujos!—éstos de pájaros y ésos de animalitos que adornan la bolsa que tiene Ud. en la mano. ¿Y le mandan también chales?** | 9. How pleasing the designs are!—these of birds and those of little animals which adorn the purse that you have in your hand. And they also sent you shawls?
10. — **Desgraciadamente, no.** | 10. Unfortunately, no.
11. — **¿Ud. sabe que el rebozo es para la mujer lo que es el sarape para el hombre. Sirve para todo, sombrero, abrigo, para envolver bultos; para manta y cuna del nene.** | 11. You know that the shawl is to the woman what the sarape is to the man. It serves all purposes: as a hat and an overcoat; to wrap packages; as a blanket and cradle for the baby.
12. — **Van a mandarme también cestas de varios tamaños y estilos y, desde luego, toda clase de cerámica—dice el señor Adams.** | 12. "They are also going to send me baskets of various sizes and styles and, of course, all kinds of pottery," says Mr. Adams.
13. — **¿Ha visto Ud. las máscaras que llevan los indios durante las fiestas?** | 13. Have you seen the masks that the Indians wear during the fiestas?
14. — **No las he visto. Y sé muy poco de las fiestas.** | 14. I have not seen them. And I know very little about fiestas.
15. — **Entonces tenemos que hablar de las fiestas la próxima vez. ¿Le parece bien el martes a las ocho?** | 15. Then, we must talk about fiestas the next time. Is Tuesday at eight all right with you?
16. — **Me parece bien** | 16. It is all right with me.
17. — **Hasta el martes, Sr. Adams.** | 17. Until Tuesday, Mr. Adams.
18. — **Hasta la vista, Sr. López.** | 18. See you soon, Mr. Lopez
### Pronunciation and Spelling Aids
1. Practice: | en-tre- **tan** -to | des-gra-cia-da- **men** -te | ge-o- **mé** -tri-co | as- **pec** -to
---|---|---|---|---
| pin-to- **res** -co | ves- **ti** -do | **más** -ca-ra | gra- **cio** -so
### Building Vocabulary
1. **la mano** , the hand. Nouns ending in **-o** are usually masculine. **La mano** is an exception.
2. **La Rop** **a** Clothing, Wearing Apparel **el abrigo** | coat
---|---
**la blusa** | blouse
**los calcetines** | socks
**la camisa** | shirt
**la corbata** | tie
**la faja** | sash
**la falda** | skirt
**los guantes** | gloves
**el impermeable** | raincoat
**las medias** | stockings
**los pantalones** | pants
**el pañuelo** | handkerchief
**el rebozo** | shawl
**el sarape** | shawl, blanket
**el sombrero** | hat
**el traje** | suit
**el vestido** | dress
**los zapatos** | shoes
3. **Sinónimos** **el idioma** | **la lengua** | language
---|---|---
**acabar** | **terminar** | to finish
**con todo gusto** | **con mucho gusto** | with great pleasure
### Expresiones Importantes
1. **entretanto** | meanwhile
---|---
2. **seguro** | certainly
3. **¿Le parece (a Ud.) bien?** | Is it all right with you?
4. **Me parece bien.** | It's all right with me.
5. **Se visten de blusas.** | They dress in blouses.
6. **El sarape sirve de abrigo.** | The sarape is used as a coat.
### Ejercicio No. 93—Completion of Text
1. **Vamos** (to see) **los artículos de México.**
2. (In the meanwhile) **vamos a hablar de** (the folk arts).
3. **Estos artículos son** (in daily use).
4. (The typical dress) **les da a los indios un aspecto** (picturesque).
5. **Las mujeres se visten de** (long skirts).
6. **Los hombres llevan** (a white suit).
7. (The straw hat) **es de uso general.**
8. **El sarape es** (an article of clothing).
9. (I like) **los dibujos geométricos.**
10. **La faja es tejida** (of wool or cotton).
11. **El rebozo** (serves for everything).
12. (Of course) **van a mandarme** (baskets of various sizes).
13. (We must talk) **de las fiestas.**
14. (Is Tuesday all right with you?)
15. (It's all right with me.)
## SEGUNDA PARTE
### Grammar Notes
1. Demonstrative Pronouns a. **este** dibujo y **ése** | _this_ sketch and _that_ ( _one_ )
---|---
**esta** casa y **aquélla** | _this_ house and _that_ ( _one_ )
**esos** trajes y **éstos** | _those_ costumes and _these_
**esa** tienda y **ésta** | _that_ shop and _this_ ( _one_ )
**estos** libros y **ésos** | _these_ books and _those_
**aquel** coche y **éste** | _that_ car and _this_ ( _one_ )
The demonstrative adjective must agree in gender and number with the noun it precedes.
When the noun is omitted after a demonstrative adjective, the adjective becomes a demonstrative pronoun. The demonstrative pronoun takes an accent mark.
b. **esto, eso, aquello.** These are neuter forms of the demonstrative pronoun. They are used to point out a thing not yet mentioned, and to refer to a whole sentence or idea. They do not have an accent mark.
**¿Qué es esto?** What's this? (pointing to it) **Es perezoso. _Eso es verdad._** He is lazy. That is true.
**¡OJO!** (Watch out!) Do not confuse with the masculine demonstrative adjective **este** , plural **estos.**
2. The Closer, the Farther
In both adjectives and pronouns, **este** , and **éste** mean the closer; **ese** , and **ése** refer to nouns that are not close to the speaker, while **aquel** , and **aquél** refer to nouns that are even farther away. They agree in number and gender with the nouns to which they refer. The accent mark is usually omitted over capitals. **El Sr. Adams y su esposa están en casa.** | Mr. Adams and his wife are at home.
---|---
**_Ésta_ lee una revista.** | _The latter_ is reading a magazine.
**_Aquél_ escribe una carta.** | _The former_ is writing a letter.
### Ejercicios No. 94A-94B-94C
94A. Write each sentence putting the verbs into Spanish. Remember: **vestir(i)** _to dress_ , **vestir de** _to dress in_ , **vestirse** _to dress oneself_ , **llevar** _to wear._
1. (I dress) **al niño.**
2. (I dress myself)
3. (They dress in) **faldas bordadas.**
4. (We dress) **a los niños.**
5. **Las niñas** (dress themselves).
6. **¿Qué** (do you wear) **los domingos?**
7. (I wear) **mi vestido nuevo.**
8. **¿Quiénes** (wear) **sarapes?**
9. **Las señoritas** (wear) **guantes.**
10. (We are wearing) **zapatos nuevos.**
94B. Complete these sentences using the correct demonstrative adjectives and pronouns.
**Ejemplo: Este dibujo es antiguo, ése es moderno.**
1. (This) **dibujo es antiguo** , (that one) **es moderno.**
2. (These) **sarapes tienen dibujos de animalitos** , (those) **tienen dibujos de pájaros.**
3. (Those) **faldas son de lana** , (these) **son de algodón.**
4. (This) **blusa tiene bordados sencillos** , (that one) **es moderna.**
5. (That- _distant_ ) **casa es antigua** , (this one) **es moderna.**
6. **El Sr. López llega a la casa del Sr. Adams cuando** (this one) **sale.**
7. **Felipe trabaja diligentemente. Todos saben** (that).
8. **¿Qué es** (this)? **¿Qué es** (that)?
9. **El hombre es rico.** (That) **es verdad.**
94C. Repeat the Spanish sentences aloud many times.
1. **¿Qué está comprando Ud.?** | 1. What are you buying?
---|---
2. **Estoy comprando un sombrero.** | 2. I am buying a hat.
3. **¿Qué está comprando su hermana?** | 3. What is your sister buying?
4. **Está comprando una faja.** | 4. She is buying a sash.
1. **¿Tiene Ud. un rebozo?** | 1. Have you a shawl?
2. **No, no tengo rebozo.** | 2. I have no shawl.
3. **¿Tiene Ud. un pañuelo?** | 3. Have you a handkerchief?
4. **No, no tengo pañuelo.** | 4. I have no handkerchief
1. **¿Lleva Ud. guantes en el invierno?** | 1. Do you wear gloves in winter?
2. **Sí, llevo guantes en el invierno.** | 2. Yes, I wear gloves in winter.
3. **¿Lleva Ud. abrigo?** | 3. Do you wear a coat?
4. **Llevo abrigo cuando hace frío.** | 4. I wear a coat when it is cold.
### Ejercicio No. 95—Preguntas
1. **¿Quién acaba de recibir una caja de mercancía de México?**
2. **¿Quiénes llevan sarape, los hombres o las mujeres?**
3. **¿De dónde son los sarapes con los dibujos geométricos?**
4. **¿De dónde son las fajas rojas?**
5. **¿Qué llevan tanto los hombres como las mujeres?**
6. **¿Qué clase de dibujos adornan la bolsa?**
7. **¿Qué artículo sirve de manta y cuna del nené?**
8. **¿Qué llevan los indios en las fiestas?**
9. **¿De qué sabe muy poco el Sr. Adams?**
10. **¿Qué le dice el Sr. Adams al Sr. López cuando éste sale de su casa?**
# CHAPTER 30
CAPÍTULO 30 (TREINTA)
## PRIMERA PARTE
### Los días de fiesta
1. — **¿Cuáles son los días de fiesta en México?—le pregunta el Sr. Adams al Sr. López.** | 1. "What are the fiesta days in Mexico?" Mr. Adams asks Mr. Lopez.
---|---
2. — **Hay fiestas casi todos los días en algún pueblo u otro. Hay fiestas nacionales y fiestas dedicadas a varios santos. Todas se celebran con bailes, cohetes, juegos, y dramas.** | 2. There are fiestas almost every day in some town or other. There are national fiestas and fiestas dedicated to various saints. All are celebrated with dances, fireworks, games, and plays.
3. — **Por supuesto, celebran la Navidad.** | 3. Of course, they celebrate Christmas.
4. — **Sí, la celebración de la Navidad dura diez días, desde el 16 de diciembre hasta el 25. Las personas van en grupos de casa en casa cantando canciones y pidiendo «posada». Entran en las casas y allí la pasan bien. Cantan, bailan y rompen la piñata tradicional.** | 4. Yes, the celebration of Christmas lasts ten days, from the 16th of December until the 25th. The people go in groups from house to house singing songs and asking for "lodging." They enter the houses and there spend a pleasant time. They sing, they dance, and they break the traditional piñata.
5. — **¿Qué es la piñata?** | 5. What is the piñata?
6. — **Es un olla grande cubierta de papel de colores vivos. Puede representar un animalito o un pájaro. Contiene dulces y juguetes. Un niño con los ojos vendados trata de romperla con un palo. Al final logra romperla. Todos se apresuran a agarrar los dulces y juguetes.** | 6. It is a big pot covered with paper in bright colors. It may represent an animal or bird. It contains candy and toys. A child, with his eyes blindfolded, tries to break it with a stick. At the end he succeeds in breaking it. Everybody rushes to gather up the candy and toys.
7. — **¿Reciben regalos los niños?** | 7. Do the children receive presents?
8. — **Los reciben el seis de enero, el Día de los Reyes Magos.** | 8. They receive them on the sixth of January, the Day of the Wise Kings.
9. — **¿Qué fiestas hay en la primavera?** | 9. What fiestas are there in spring?
10. — **Ud. debe ver la fiesta de la Semana Santa en Tzintzuntzán, cerca de Pátzcuaro. Es el drama de la Pasión y dura tres días. Lo interpretan los habitantes del pueblo. Hacen los papeles con mucha emoción.** | 10. You should see the fiesta of Holy Week in Tzintzuntzán, near Pátzcuaro. It is the Passion Play and it lasts three days. It is interpreted by the inhabitants of the town. They act the roles with much feeling.
11. — **¿Cómo celebran el 5 de mayo?** | 11. How do they celebrate the fifth of May?
12. — **Hay una gran batalla simulada cerca de Puebla para celebrar la victoria de los mexicanos sobre los franceses.** | 12. There is a great simulated battle near Puebla to celebrate the victory of the Mexicans over the French.
13. — **He oído hablar también del Día de los Difuntos.** | 13. I have also heard talk of the Day of the Dead.
14. — **Sí, el 2 de noviembre es el Día de los Difuntos. Los panaderos venden «panes de los muertos». Se pueden comprar en los mercados toda clase de juguetes apropriados, como esqueletos danzantes, máscaras, etc. La gente visita los cementerios y prepara ofrendas de comida para los muertos de la familia.** | 14. Yes, November 2 is the Day of the Dead. The bakers sell "cakes of the dead." One can buy in the markets all kinds of appropriate toys: dancing skeletons, masks, etc. People visit the cemeteries and prepare offerings of food for the dead of the family.
15. — **¿Hay fiestas en el Día de Corpus Christi?** | 15. Are there fiestas on Corpus Christi Day?
16. — **¡Claro! En los pueblos cerca de Pátzcuaro, Michoacán, hay ferias. Cada vendedor vende miniaturas de la mercancía que vende en el mercado regularmente, como tortillas, ropa o cualquier otra cosa. Los compradores usan dinero de mentira, hecha por los panaderos.** | 16. Yes indeed! In the towns near Patzcuaro, Michoacán, there are fairs. Each seller sells miniatures of the merchandise that he ordinarily sells in the market, like tortillas, clothing, or whatever other things. The buyers use fake money—made by the bakers.
17. — **Me acuerdo de otra fecha importante. Es el 16 de septiembre, el Día de la Independencia.** | 17. I remember another important date. It is the 16th of September, Independence Day.
18. — **Sí, es el día del Grito de Dolores, pronunciado por el padre Miguel Hidalgo para dar comienzo a la revolución de 1810 contra España.** | 18. Yes, it is the day of the Proclamation ( _Lit_ Shout) of Dolores made by Father Miguel Hidalgo to set off the revolution of 1810 against Spain.
19. — **Yo sé muy poco de la historia de México.** | 19. I know very little about the history of Mexico.
20. — **Pero Ud. sí va aprendiendo 1 Sr. Adams.** | 20. But you are certainly learning, Mr. Adams.
**NOTE** : 1. **ir** may be used instead of **estar** to express the progressive tense, **va aprendiendo** = **está aprendiendo.**
### Pronunciation and Spelling Aids
1. Practice: | Na-vi- **dad** | a-pro- **pia** -pos | Mi-choa- **cán** ( _meech-wah- **cahn**_ )
---|---|---|---
| di- **ciem** -bre | ce-men- **te** -rios | Tzin-tzun- **tzán** ( _seen-soon- **sahn**_ )
| ce-re- **mo** -nia | mi-nia- **tu** -ras | **Pátz** -cua-ro ( ** _pahts_ -kwah-roh**)
| a-pre- **su** -ran | or-di-na-ria- **men** -te | Mi- **guel** ( _mee- **gel**_ )
| e-mo- **ción** | in-de-pen- **den** -cia | Hi- **dal** -go ( _ee- **dahl** -goh_)
| ju- **gue** -tes | |
### Building Vocabulary
1. **Palabras Relacionadas** 1. **pan** | bread
---|---
**panadero** | baker
**panadería** | bakery
2. **zapato** | shoe
**zapatero** | shoemaker
**zapatería** | shoe store, shoe repair shop
3. **plata** | silver
**platero** | silversmith
**platería** | silversmith's shop
4. **sastre** | tailor
**sastrería** | tailor's shop
2. **Partes de la cara** Parts of the Face **la boca** | mouth
---|---
**los dientes** | teeth
**los labios** | lips
**la nariz** | nose
**los oídos** | ears (internal)
**las orejas** | ears (external)
**los ojos** | eyes
**las mejillas** | cheeks
### Expresiones Importantes
1. **al final** | finally
---|---
2. **al principio** | at first
3. **Ud. debe ver** | you should see
5. **Logra romper.** | He succeeds in breaking.
6. **La pasan bien.** | They have a good time.
### Ejercicio No. 96—Completion of Text
1. **Hay fiestas** (in some town or other).
2. **Todos** (are celebrated) **con danzas y juegos.**
3. (Of course) **celebran la Navidad.**
4. **Van de casa en casa** (singing songs and asking for lodging).
5. **En las casas** (they have a good time).
6. **La piñata es un olla** (covered with paper).
7. **Un niño** (tries to break it).
8. **Llega** (in breaking it).
9. (You should see) **el drama de la Pasión.**
10. **El 2 de noviembre es** (the Day of the Dead).
11. (The bakers sell) **«panes de los muertos».**
12. (One may buy) **toda clase de juguetes.**
13. **Hay** (markets) **en el Día de Corpus Christi.**
14. (The buyers) **emplean dinero de mentira** (made by) **los panaderos.**
15. (The 16th of September) **es el día del** (Proclamation of Dolores).
## SEGUNDA PARTE
### Grammar Notes
1. Present Tense of **agarrar** to catch, pick up **escoger** to choose I catch, etc. | I choose, etc. | IMPERATIVE
---|---|---
**agarro** | **agarramos** | **escojo** | **escogemos** | **agarre Ud.** | **escoja Ud.**
**agarras** | **agarrais** | **escoges** | **escogéis** | **agarren Uds.** | **escojan Uds**
**agarra** | **agarran** | **escoge** | **escogen**
**NOTE: algún** and **ningún** have an accent mark to hold the stress on the syllable **-gún.**
2. Present Participle of Stem-Changing Verbs. **pedir (i)** , and verbs like it, which have the stem change **e** to **i** in the present tense, have the same change in the present participle. INFINITIVE | PRESENT TENSE | PRESENT PARTICIPLE
---|---|---
**pedir** | **(yo) pido** | **pidiendo**
**repetir** | **(yo) repito** | **repitiendo**
**servir** | **(yo) sirvo** | **sirviendo**
**despedirse** | **(yo) me despido** | **despidiéndome**
### Ejercicios No. 97A-97B
97A. Complete these sentences in Spanish.
1. **Enero es el** (first) **mes del año.**
2. **Marzo es el** (third) **mes del año.**
3. **Vamos a pasarla** (well).
4. **Tenemos un maestro** (good).
5. **El científico Einstein es un** (great) **hombre.**
**No es un hombre** (big, tall).
6. **Tenemos asientos en la** (third) **fila.**
7. **Hace** (bad) **tiempo en el invierno.**
8. **El** (first) **de enero.**
9. **Ellos tienen asientos** (good).
10. (Some) **día Ud.** **irá a México.**
97B. Write each sentence translating all verbs into Spanish.
1. (They sing) **canciones.**
2. (We celebrate) **la Navidad.**
3. (They visit) **los cementerios.**
4. **La celebración** (lasts) **diez días.**
5. (I am preparing) **la comida.**
6. ¿(Do you use) **moneda falsa**?
7. **La piñata** (contains) **dulces y juguetes.**
8. **Un niño** (tries) **de romper la piñata.**
9. **Todos** (pick up) **los dulces.**
10. **Los Reyes Magos** (bring) **los regalos.**
### Ejercicio No. 98—Preguntas
1. ¿ **Cómo se titula** (titled) **esta lectura** (reading selection)?
2. **¿Qué clase de fiestas hay en México?**
3. **¿Cómo se celebran estas fiestas?**
4. **¿Cuántos días dura la celebración de la Navidad?**
5. **¿Quiénes van de casa en casa?**
6. **¿Qué piden?**
7. **¿Cómo la pasan ellos en las casas?**
8. **¿Qué es la piñata?**
9. **¿Qué contiene?**
10. **¿Quién trata de romperla con un palo?**
11. **¿Qué agarran todos cuando un niño logra romperla?**
12. **¿De quiénes reciben los niños regalos?**
13. **¿Qué fiesta debe ver el Sr. Adams?**
14. **¿Quiénes interpretan el drama de la Pasión?**
15. **¿Cuál es la fecha del «Grito de Dolores»?**
# CHAPTER 31
CAPÍTULO 31 (TREINTA Y UNO)
## PRIMERA PARTE
### ¿ Qué lugares quiere visitar, Sr. Adams?
1. — **Pronto va a salir para México, Sr. Adams. ¿Ha decidido qué lugares quiere visitar?** | 1. Soon you are going to leave for Mexico, Mr. Adams. Have you decided what places you want to visit?
---|---
2. — **No pienso en nada más y estoy leyendo mucho en las varias guías de viaje.** | 2. I think of nothing else and I am reading a great deal in the various travel guides.
3. — **Viajaré por avión a la capital. Usando el centro de la ciudad como punto de partida, visitaré lugares de interés en el Distrito Federal, en los alrededores y en otras partes del país.** | 3. I will travel by plane to the capital. Using the center of the city as a point of departure, I will visit places of interest in the Federal District, in the surrounding areas, and in other parts of the country.
4. — **En la capital, veré la Alameda con sus grandes árboles; muy cerca está el Museo Nacional de Artes e Industrias Populares. Visitaré la Secretaria de Educación Publica y la Escuela Nacional Preparatoria para ver las pinturas murales. Voy a ver el Zócalo, donde están situados la Catedral, el Palacio Nacional y muchas cosas más de interés. Pasaré un día en el parque de Chapultepec. Tengo ganas también de ir a ver los mercados. Oigo hablar a mucha gente del mercado de la Merced y del mercado de Lagunilla.** | 4. In the capital, I will see the Alameda with its great trees; very near is the National Museum of Popular Arts and Industries. I will visit the Secretary of Public Education and the National Preparatory School to see the painted murals. I will see the Zocalo, where the Cathedral, the National Palace, and many more things of interest are located. I will spend a day in Chapultepec Park. I also have a desire to go to see the markets. I hear many people speak of the Merced market and the market of Lagunilla.
5. — **En los alrededores visitaré las pirámides de Teotihuacán. Veré la gran pirámide del Sol y la de la Luna. Se dice que son tan imponentes como las de Egipto. Y mientras estoy en la capital visitaré los suburbios como, por ejemplo, Coyoacán, y algunos de los pueblos cercanos.** | 5. In the surrounding areas I will visit the pyramids of Teotihuacán. I will see the great pyramid of the Sun and that of the Moon. It is said that they are as impressive as those of Egypt. And while I am in the capital, I will visit the suburbs like, for example, Coyoacán, and some of the nearby towns.
6. — **¿No quiere ir a una corrida de toros, Sr. Adams?** | 6. Do you not want to go to a bullfight, Mr. Adams.
7. — **Sí, y no—responde el señor Adams.—Tal vez.** | 7. "Yes and no," answers Mr. Adams. "Maybe."
8. — **Estoy seguro de que irá al mercado de Toluca y a Cuernavaca. Esta ciudad tiene siempre un clima de primavera, edificios bonitos con jardines y patios llenos de flores, muchos árboles y hermosas vistas de las montañas. Ud. irá a Taxco, el pueblo de los plateros y de casas antiguas.** | 8. I am sure that you will go to the market of Toluca and to Cuernavaca. That city always has a spring climate, pretty buildings with gardens and patios full of flowers, many trees and beautiful views of the mountains. You will go to Taxco, the town of the silversmiths and of ancient houses.
9. — **Sí, e iré a Pátzcuaro y a los otros pueblos conocidos por sus artes populares.** | 9. Yes, and I will go to Pátzcuaro and to other towns known for their popular arts.
10. — **Ud. es siempre el negociante, Sr. Adams.** | 10. You are always the businessman, Mr. Adams.
11. — **No es eso. Me interesa la gente que vive fuera de los grandes centros. Pero claro está que también quiero visitar Guadalajara y otros lugares bien conocidos.** | 11. It is not that. I am interested in the people who live outside the great centers. But of course I also want to visit Guadalajara and other well-known places.
12. — **No deje de ver Guanajuato, una ciudad colonial con callejones tortuosos que suben las montañas entre casas chicas de varios colores.** | 12. Do not fail to see Guanajuato, a colonial city with winding lanes that climb the mountains among small houses of various colors.
13. — **Y he leído que en Oaxaca también hay una cantidad de cosas interesantes, los restos de las culturas de los mixtecas y los zapotecas, el pueblo de Mitla y la zona arqueológica de Monte Albán.** | 13. And I have read that in Oaxaca also there are a number of interesting things—the remains of the cultures of the Mixtec and the Zapotec Indians, the town of Mitla, and the archeological zone of Monte Albán.
14. **Tengo ganas de acompañarlo, Sr. Adams, pero no es posible.** | 14. I have a desire to go with you, Mr. Adams, but it is not possible.
15. — **¡Qué lástima, Sr. López!** | 15. What a pity, Mr. Lopez.
### Pronunciation and Spelling Aids
1. Practice: | na-cio- **nal** | ca-lle- **jo** -nes | Cuer-na- **va** -ca
---|---|---|---
| se-cre- **ta** -ria | tor- **tuo** -so | **Tax** -co ( ** _tahs_ -coh**)
| ca-te- **dral** | ar-que-o- **ló** -gi-co | Oa- **xa** -ca ( _wah- **hah** -cah_)
| pi- **rá** -mi-de | Te-o-ti-hua- **cán** ( _tay-oh-tee-wah- **cahn**_ ) | Mix- **te** -cas ( _mees- **tay** -cahs_)
| im-po- **nen** -te | Za-po- **te** -cas | co- **rri** -da
| E- **gip** -to | Gua-na- **jua** -to |
### Building Vocabulary
1. The **Alameda** is a park along the **Avenida Juárez** , the most important shopping center for the tourist in Mexico City. Most towns have an **Alameda** , named for the **álamo** tree that gives them shade.
2. **Sinónimos** 1. **contestar** | **responder** | to answer
---|---|---
2. **desear** | **querer** | to wish, want
3. **el lugar** | **el sitio** | place
3. Expressions of Future 1. **mañana** | tomorrow
---|---
2. **pasado mañana** | day after tomorrow
3. **la próxima vez (semana)** | next time (week)
4. **el próximo año** | next year
5. **el año que viene** | the coming year
6. **mañana por la mañana** | tomorrow morning
### Expresiones Importantes
1. **estoy seguro** | I am sure
---|---
2. **No deje Ud. de (ver, etc.)** | do not fail to (see, etc)
3. **pensar en** | to think of
4. **tengo ganas de** | I feel like
### Ejercicio No. 99—Completion of Text
1. (I am reading) **en las varias guías.**
2. (I shall travel) **por avión.**
3. (I shall visit) **lugares de interés.**
4. (I shall see) **la Alameda.**
5. (I shall spend) **un día en el parque de Chapultepec.**
6. (I am sure) **que Ud. irá al mercado de Toluca.**
7. **Tiene siempre** (a spring climate).
8. **Los edificios son** (pretty) **y los jardines están** (full of flowers).
9. Hay (many trees) **y** (beautiful views) **de las montañas.**
10. **Le gustará a Ud. Taxco** (the town of the silversmiths).
11. (I shall go) **a Pátzcuaro.**
12. **Me interesa más el pueblo que vive** (outside of the great centers).
13. (Do not fail) **de ver a Guanajuato, una ciudad** (with winding lanes).
14. **En Oaxaca hay** (a number of interesting things).
15. (I have a desire) **de acompañarlo, Sr. Adams.**
## SEGUNDA PARTE
### Grammar Notes
1. The Future Tense. Model Verb, **hablar.** **hablar-é** | I shall speak
---|---
**hablar-ás** | you ( _familiar_ ) will speak
**hablar-á** | you ( _formal_ ), he, she, it will speak
**hablar-emos** | we shall speak
**hablar-éis** | you ( _familiar, pl._ ) will speak
**hablar-á** | you ( _formal pl._ ), they will speak
1. The future endings of all verbs are: SINGULAR | **-é** | **-ás** | **-á**
---|---|---|---
PLURAL | **-emos** | **-éis** | **-án**
2. To form the regular future add these endings to the whole infinitive as a base. **hablaré** | **hablarás** | **hablará** | **hablaremos** | **hablaréis** | **hablarán**
---|---|---|---|---|---
**aprenderé** | **aprenderás** | **aprenderá** | **aprenderemos** | **aprenderéis** | **aprenderán**
**seré** | **serás** | **será** | **seremos** | **seréis** | **serán**
**estaré** | **estarás** | **estará** | **estaremos** | **estaréis** | **estarán**
**viviré** | **vivirás** | **vivirá** | **viviremos** | **viviréis** | **vivirán**
**abriré** | **abrirás** | **abrirá** | **abriremos** | **abriréis** | **abrirán**
2. The Irregular Future.
In a few common verbs there is a change in the infinitive base when the future endings are added. Thus: **saber** to know | **tener** to have | **salir** to leave
---|---|---
I shall know, etc. | I shall have, etc. | I shall leave, etc.
**sabré** | **sabremos** | **tendré** | **tendremos** | **saldré** | **saldremos**
**sabrás** | **sabréis** | **tendrás** | **tendréis** | **saldrás** | **saldréis**
**sabrá** | **sabrán** | **tendrá** | **tendrán** | **saldrá** | **saldrán**
**querer** to wish | **venir** to come | **valer** to be worth
---|---|---
I shall wish, etc. | I shall come, etc. | I shall be worth, etc.
**querré** | **querremos** | **vendré** | **vendremos** | **valdré** | **valdremos**
**querrás** | **querréis** | **vendrás** | **vendréis** | **valdrás** | **valdréis**
**querrá** | **querrán** | **vendrá** | **vendrán** | **valdrá** | **valdrán**
**poder** to be able | **decir** to say | **hacer** to do, to make
---|---|---
I shall be able, etc. | I shall say, etc. | I shall do, make, etc.
**podré** | **podremos** | **diré** | **diremos** | **hare** | **haremos**
**podrás** | **podréis** | **dirás** | **diréis** | **harás** | **haréis**
**podrá** | **podrán** | **dirá** | **dirán** | **hará** | **harán**
### Ejercicios No. 100A-100B-100C
100A. Translate:
1. **Visitaremos Taxco.**
2. 2. **Pasaré una semana allí.**
3. **Me gustará ver las pinturas murales.**
4. **¿Quién viajará a México?**
5. **Ellos no trabajarán mucho.**
6. **¿Estudiarán (Uds.) la lección?**
7. **¿Tomará Ud. café?**
8. **Felipe no escribirá la carta.**
9. **No tendré frío.**
10. **Él no vendrá acá.**
11. **Saldremos a las ocho.**
12. **Haré este papel con entusiasmo.**
13. **Querrán comer.**
14. **Ella lo pondrá en la mesa.**
15. **No podré ir allá.**
100B. Answer these questions in complete sentences (in the future), with the help of the words in parentheses.
**Ejemplo: Adónde irá Ud. esta noche? (al cine) Esta noche iré al cine.**
1. **¿Qué comprará Ud.? (una corbata)**
2. **¿Cuánto costará? (cinco pesos)**
3. **¿Adónde irá Ud. en el verano? (al campo)**
4. **¿Quién irá con Ud.? (mi hermano)**
5. **¿A qué hora volverá Ud. del cine? (a las nueve de la noche)**
6. **¿A quién verá Ud. en la estación? (a mi amigo Guillermo)**
7. **¿A qué hora saldrá Ud. de su casa? (a las ocho de la mañana)**
8. **¿A qué hora cenarán Uds.? (a las siete)**
9. **¿A quiénes visitarán Uds. en la ciudad? (a nuestros amigos)**
10. **¿Qué estudiarán Uds. esta tarde? (nuestras lecciones de español)**
100C. Translate:
1. I shall learn.
2. He will write.
3. They will go.
4. We shall eat.
5. She will speak.
6. Will you work?
7. Will John see?
8. Who will visit?
9. I shall not travel.
10. Will they study?
11. I shall make.
12. He will come.
13. You ( **Ud.** ) will put.
14. They will not want.
15. Will you ( **Ud.** ) go out?
16. I shall have.
17. They will be here.
18. Will you ( **Uds.** ) go?
### Ejercicio No. 101—Preguntas
1. **¿Cómo'se titula esta lectura?**
2. **¿Quién va a salir pronto para México?**
3. **¿Qué clase de libros está leyendo él?**
4. **¿Cómo viajará?**
5. **¿Qué lugar usará como punto de partida?**
6. **¿Dónde está el Museo Nacional de Artes e Industrias Populares?**
7. **¿Qué verá el Sr. Adams en la Secretaría de Educación Pública?**
8. **¿En qué parque pasará un día?**
9. **¿Qué pirámides verá en Teotihuacán?**
10. **¿Qué se dice acerca de estas pirámides?**
11. **¿Irá el Sr. Adams a una corrida de toros?**
12. **¿Qué ciudad tiene un clima de primavera?**
13. **¿Cuál es el pueblo de los plateros?**
14. **¿Qué le interesa más al Sr. Adams, la gente de las ciudades o la gente del campo?**
15. **¿Quién tiene ganas de acompañar al Sr. Adams?**
# CHAPTER 32
REVIEW, CHAPTERS 28–31
REPASO, CAPÍTULOS 28–31
## PRIMERA PARTE
### Repaso de palabras (Word Review)
#### NOUNS
1. **el artista** | 1. artist
---|---
2. **el árbol** | 2. tree
3. **el arte** | 3. art
4. **el algodón** | 4. cotton
5. **el baile** | 5. dance
6. **la blusa** | 6. blouse
7. **la boca** | 7. mouth
8. **la caña de azúcar** | 8. sugar cane
9. **la camisa** | 9. shirt
10. **la canción** | 10. song
11. **los calcetines** | 11. socks
12. **la cara** | 12. face
13. **la corbata** | 13. necktie
14. **el cuero** | 14. leather
15. **la falda** | 15. skirt
16. **la guía** | 16. guidebook
17. **el idioma** | 17. language
18. **el juego** | 18. game
19. **el juguete** | 19. toy
20. **el jardín** | 20. garden
21. **la lana** | 21. wool
22. **la madera** | 22. wood
23. **la mano** | 23. hand
24. **las medias** | 24. stockings
25. **la moneda** | 25. coin
26. **la nariz** | 26. noise
27. **la feria** | 27. market
28. **el ojo** | 28. eye
29. **el oro** | 29. gold
30. **la plata** | 30. silver
31. **el panadero** | 31. baker
32. **los pantalones** | 32. trousers
33. **el pañuelo** | 33. handkerchief
34. **el platero** | 34. silversmith
35. **la ropa** | 35. clothing
36. **el sastre** | 36. tailor
37. **el tejido** | 37. cloth
38. **el traje** | 38. suit
39. **el vestido** | 39. dress
40. **el zapato** | 40. shoe
#### VERBS
1. **bailar** | 1. to dance
---|---
2. **cantar** | 2. to sing
3. **celebrar** | 3. to celebrate
4. **coger** | 4. to pick up, to catch
5. **contener** | 5. to contain
6. **cubrir** | 6. to cover
7. **decidir** | 7. to decide
8. **durar** | 8. to last
9. **emplear** | 9. to employ
10. **escoger** | 10. to choose
11. **llevar** | 11. to bring, wear
12. **mandar** | 12. to send
13. **mirar** | 13. to look at
14. **observar** | 14. to observe
15. **ocuparse de** | 15. to be busy with
16. **representar** | 16. to represent
17. **romper** | 17. to break
18. **vestir** | 18. to dress
19. **vestirse** | 19. to dress oneself
20. **volver** | 20. to return
21. **interpretar** | 21. to act
#### ADJECTIVES
1. **cubierto** | 1. covered
---|---
2. **cercano** | 2. near
3. **chico** | 3. little
4. **falso** | 4. false
5. **hecho** | 5. made
6. **imponente** | 6. impressive
7. **lleno** | 7. full
8. **pintoresco** | 8. picturesque
9. **precioso** | 9. precious
10. **popular** | 10. folk, popular
11. **rosado** | 11. pink
12. **tejido** | 12. woven
#### ADVERBS
1. **de antemano** | 1. beforehand
---|---
2. **entretanto** | 2. in the meantime
3. **todavía** | 3. still
#### PREPOSITIONS
1. **acerca de** | 1. concerning
---|---
2. **a causa de** | 2. because of
3. **fuera de** | 3. outside of
#### IMPORTANT EXPRESSIONS
1. **acabar de (+ infin.)** | 1. to have just
---|---
2. **al fin** | 2. finally
3. **al principio** | 3. at first
4. **llegar a (+ infin.)** | 4. to succeed in
5. **¿Le parece bien?** | 5. Is it all right with you?
6. **Me parece bien.** | 6. It's all right with me
7. **pasarla bien** | 7. to have a good time
8. **vestir de** | 8. to dress in
9. **volver a (+ infin.)** | 9. to do again
10. **a la derecha** | 10. to the right
11. **a la izquierda** | 11. to the left
## SEGUNDA PARTE
**Ejercicio** 102. From Group 2 select the synonym for each word or expression in Group 1.
**Ejemplo: Me pongo la camisa (not mi camisa). I put on my shirt.**
Group 1 | Group 2
---|---
1. **contestar** | 1. **terminar**
2. **desear** | 2. **lengua**
3. **acabar** | 3. **responder**
4. **llevar** | 4. **lugar**
5. **sitio** | 5. **querer**
6. **el año próximo** | 6. **por lo tanto**
7. **me acuerdo** | 7. **vestir de**
8. **vuelvo a escribir** | 8. **el año que viene**
9. **por eso** | 9. **recuerdo**
10. **idioma** | 10. **escribo otra vez**
11. **por supuesto** | 11. **prefiero**
12. **me gusta más** | 12. **claro**
**Ejercicio 103.** Complete the following sentences by translating the given words.
Remember: 1. **ponerse** = to put on. 2. Use the definite article (el, **la, los, las)** instead of the possessive adjective ( **mi, tu, su** , etc.) with clothing, when the meaning is clear.
**Ejemplo: 1. Me pongo los pantalones.**
1. **Me pongo** (my trousers).
2. **Te pones** (your hat).
3. **Él se pone** (his suit).
4. **Ud. se pone** (your tie).
5. **Ella se pone** (her sash).
6. **Nos ponemos** (our shoes).
7. **Uds. se ponen** (your gloves).
8. **Ellos se ponen** (their shirts).
9. **Ellas se ponen** (their dresses).
10. **Póngase** (your coat).
**NOTE** : Another meaning of **ponerse** is _to become._ **Los árboles de ponen verdes.** The trees become green.
**Ejercicio 104.** Select the group of words in the right-hand column that best completes the sentence begun in the left-hand column.
Remember: **se lleva** = is worn, one wears | **Se llevan** = are worn, one wears
---|---
1. **Se lleva abrigo** | a. **cuando se juega al tenis.**
2. **Se lleva impermeable** | b. **para proteger la cabeza.**
3. **Se lleva sombrero** | c. **cuando hace frío.**
4. **Se llevan zapatos** | d. **para proteger las manos.**
5. **Se llevan guantes** | e. **cuando llueve.**
6. **Se lleva traje de deporte** | f. **para proteger los pies.**
**Ejercicio 105.** Complete these sentences, putting all the English words into Spanish.
1. (The baker) **vende pan en la** (bakery).
2. (The silversmith) **hace artículos de plata en** (the silversmith's shop).
3. (The shoemaker) **vende zapatos en la** (shoe shop).
4. **El** (tailor) **hace trajes en la** (tailor shop).
5. **Quien vende es** (a seller).
6. **Quien compra es** (a buyer).
7. **Comemos** y **hablamos con la** (mouth).
8. **Oímos con los** (ears).
9. **Vemos con los** (eyes).
10. **Otras partes de la** (face) **son** (the nose) **y** (the lips).
## TERCERA PARTE
### Diálogo 1
Practice the Spanish Aloud
**En el camión** | On the Bus
---|---
1. — **Discúlpeme, señor, ¿dónde me bajo para el Correo Central? (para la Avenida Juárez)? (para la Alameda)? (para la embajada de los EE. UU.)? (para la estación de ferrocarril)? (para el mercado de la Merced)? etc.** | 1. Excuse me, sir, where do I get off for the Main Post Office? (for Juarez Avenue)? (for the Alameda)? (for the United States embassy)? (for the railway station)? (for the Merced market)? etc.
2. — **Ud. se baja en la esquina de Madero y San Juan de Letrán (etc.).** | 2. You get off at the corner of Madero and San Juan de Letran (etc.).
3. — **¿A cuántas cuadras de aquí?** | 3. How many blocks from here?
4. — **Más o menos diez (cinco, etc.) cuadras, señor.** | 4. More or less ten (five, etc.) blocks, sir.
5. — **¿En cuántos minutos llegaremos?** | 5. In how many minutes will we get there?
6. — **Como en quince minutos.** | 6. In about fifteen minutes.
7. — **Muchas gracias, señor.** | 7. Thank you very much, sir.
### Diálogo 2
**Sobre el correo.** | About the mail
---|---
1. — **Sr. Adams, por supuesto tiene Ud. mucha correspondencia. ¿Hay un buzón en su edificio?** | 1. Mr. Adams, of course you have much correspondence. Is there a mailbox in your building?
2. — **Naturalmente. Tenemos un buzón en donde echamos nuestras cartas. Pero llevamos los paquetes al Correo Central.** | 2. Naturally. We have a mailbox where we mail our letters. But we take parcels to the main post office.
3. — **¿Quién los lleva allá?** | 3. Who takes them there?
4. — **Nuestro mandadero. Él nos compra también las muchos estampillas que necesitamos, estampil-las de correo aéreo, de entrega inmediata, etc.** | 4. Our office boy. He also buys us the many stamps that we need—air mail stamps, special delivery etc.
5. — **¿Dónde está el Correo Central?** | 5. Where is the main post office?
6. — **No está lejos de aquí.** | 6. It is not far from here.
## LECTURA
### Ejercicio No. 106—El cumpleaños de la señora Adams
**Es el veintidós de marzo, día del cumpleaños** (birthday) **de la señora Adams. Hoy cumple** (she is) **treinta** y **cinco años. Para celebrar este día, la familia Adams va a cenar** (dine) **en un restaurante elegante en la calle Cincuenta y Dos** (52) en **la ciudad de Nueva York.**
**Cuando entran en el restaurante ven una hermosa canasta llena de** (basket full of) **rosas rojas en el centro de la mesa reservada para los Adams. Naturalmente la señora Adams está muy sorprendida y le da mil gracias y besos** (kisses) **a su esposo.**
**Después de una comida sabrosa, Anita, la hija menor, dice en voz baja** (in a low voice) **a sus hermanos:—**
**¡Ya!** (Now!) **Y cada uno de los cuatro hijos saca** (take out) **de debajo de la mesa una cajita bonita. Son regalos para su madre.**
**Anita le da un pañuelo de seda; Rosita, una blusa de algodón; Guillermo, un par de guantes y Felipe, un rebozo (una chal) de lana.**
# CHAPTER 33
CAPíTULO 33 (TREINTA Y TRES)
## PRIMERA PARTE
### El Sr. Adams escribe una carta a su agente
1. **El Sr. Adams y el Sr. López están sentados en la sala del primero. Es la última cita antes de la salida del Sr. Adams para México. El Sr. Adams tiene en la mano una copia de su carta a su agente, el Sr. Carrillo, y la respuesta de éste, que acaba de llegar.** | 1. Mr. Adams and Mr. Lopez are seated in the living room of the former. It is the last appointment before the departure of Mr. Adams for Mexico. Mr. Adams has in his hand a copy of his letter to his agent, Mr. Carrillo, and the latter's answer, which has just arrived.
---|---
2. — **Sr. López, voy a leerle mi carta al Sr. Carrillo.** | 2. Mr. Lopez, I am going to read you my letter to Mr. Carrillo.
3. — **Me gustará mucho oírla.** | 3. I will like very much to hear it.
4. **El Sr. Adams lee la carta siguiente** : | 4. Mr. Adams reads the following letter:
**Nueva York, 4 de mayo de 2004** | New York, May 4, 2004
**Sr. Rufino Carrillo
Gante 40
México, D.E, México
Estimado Sr. Carrillo:** | Mr. Rufino Carrillo
Gante 40
Mexico. D.E, Mexico
Dear Mr. Carrillo:
**Tengo el gusto de informarle que voy a hacer un viaje a México. Saldré de Nueva York por avión el 31 de mayo a las ocho menos cuarto de la mañana y llegaré al aeropuerto de México D.E a las siete menos cuarto de la tarde. Tengo la intención de quedarme en la capital dos meses. Será un viaje de recreo y también de negocios. Usando la capital como punto de partida, haré viajes a lugares de interés en México. Espero también ir por avión a Guatemala, y tal vez a Colombia.** | I am pleased to inform you that I am going to make a trip to Mexico. I will leave New York by plane May 31 at 7:45 A.M. and will arrive at the airport of Mexico City at 6:45 P.M. I intend to remain in the capital two months. It will be a trip for recreation and also for business. Using the capital as a point of departure, I will take trips to places of interest in Mexico. I also hope to go by plane to Guatemala and perhaps to Colombia.
**Siempre lo he apreciado mucho a causa de sus servicios excelentes para nuestra casa y ahora espero aprovechar la oportunidad de conocerlo personalmente. Tenga la bondad de informarme la fecha más conveniente para una cita. Sé que está muy ocupado y que viaja mucho. Por eso le escribo de antemano esperando tener el gusto de verlo.** | I have always appreciated you very much because of your excellent services for our firm and now I hope to take advantage of the opportunity to meet you personally. I beg you to let me know the most convenient date for an appointment. I know that you are very busy and that you travel a great deal. For that reason I am writing you beforehand, hoping to have the pleasure of seeing you.
**Estará sorprendido de saber que desde hace cinco meses tomo lecciones de conversación española. Ud. sabe que yo sabía leer el español bastante bien pero no sabía ni escribirlo ni hablarlo. Esta carta, espero, le mostrará que mi escritura ha mejorado un poco. Espero poder conversar con Ud. en su hermoso idioma. Creo que no tendrá mucha dificultad en entenderme. Mi maestro es el Sr. Eugenio López, compatriota de Ud. Por eso verá que uso muchos mexicanismos típicos.** | You will be surprised to learn that for five months I have been taking lessons in Spanish conversation. You know that I could read Spanish fairly well but I could neither write it nor speak it. This letter, I hope, will show you that I have made a little progress in writing. I hope to be able to talk with you in your beautiful language. I think you won't have much difficulty in understanding me. My teacher is Mr. Eugene Lopez, a compatriot of yours. For that reason, you will see that I use many typical Mexicanisms.
**En espera de sus noticias, lo saludo atentamente. Juan Adams** | Looking forward to hearing from you, John Adams
5. — **Estupendo, Sr. Adams. No hay ninguna falta en toda la carta.** | 5. Wonderful, Mr. Adams. There is not a single error in the whole letter.
6. — **Sr. López, tengo que confesarle algo. Hay un libro titulado _Correspondencia Comercial._ Me ayuda mucho este libro en todas las cosas relacionadas con encabezamientos, saludos, conclusiones y diversas formulas y expresiones de cortesía. Desde luego, tengo que darle mis gracias más sinceras.** | 6. Mr. Lopez, I must confess something to you. There is a book entitled _Commercial Correspondence._ This book helps me a great deal in all matters relating to headings, salutations, conclusions, and various forms and expressions of courtesy. Of course, I must give my most sincere thanks to you.
7. — **Ud. es muy amable. ¿Y ahora me hará el favor de leerme la respuesta que ha recibido del Sr. Carrillo?** | 7. You are very kind. And now, will you kindly read me the answer you have received from Mr. Carrillo?
8. — **Con todo gusto, señor.** | 8. With great pleasure, sir.
**Continúa en el capítulo 34** | Continued in Chapter 34
### Pronunciation and Spelling Aids
1. Practice: a-e-ro- **puer** -to | per-so-nal- **men** -te | en-ten- **der** -me | con-ver- **sar** | o-por-tu-ni- **dad** | co-rres-pon- **den** -cia
---|---|---|---|---|---
a-pre- **cia** -do | con-ve- **nien** -te | com-pa- **trio** -ta | si- **guien** -te | an-te- **ma** -no | en-ca-be-za- **mien** -to
a-pro-ve- **char** | sor-pren- **di** -do | co-mer- **cial** | ser- **vi** -cios | a-de-lan- **ta** -do | con-clu- **sio** -nes
### Building Vocabulary
1. **Sinónimos** : 1. **bello** | **hermoso** | beautiful
---|---|---
2. **comprender** | **entender(ie)** | to understand
3. **el idioma** | **la lengua** | language
4. **mostrar(ue)** | **enseñar** | to show
5. **por eso** | **por lo tanto** | therefore
6. **Tenga la bondad de...** | please
**Hágame el favor de...** | please
( _Lit._ have the kindness to; do me the favor to)
2. **Palabras Relacionadas** 1. **la mano** | the hand
---|---
2. **la mano derecha** | the right hand
3. **la mano izquierda** | the left hand
4. **a la derecha** | to the right
5. **a la izquierda** | to the left
6. **de antemano** | beforehand
7. **hecho a mano** | handmade
### Expresiones Importantes
1. Salutation: Business Letters
1. **Estimado Sr. Adams** : Dear Mr. Adams:
2. **Estimados señores** : Dear Gentlemen:
3. **Estimada señora** : Dear Madame:
2. Conclusion: Business Letters **En espera de sus gratas noticias, quedo de Ud.** | Awaiting your kind reply, I remain yours
---|---
### Ejercicio No. 107—Completion of Text
1. **Voy** (to read to you) **mi carta.**
2. (I will be very glad) **oírla.**
3. **Tengo el gusto** (to inform you) **que saldré el 31 de mayo.**
4. **Siempre** (I have appreciated you).
5. (Kindly) **informarme de la fecha** (most convenient).
6. **Sé que Ud. está** (very busy).
7. (Therefore) **le escribo** (in advance).
8. **Espero tener el gusto** (of seeing you).
9. **Esta carta** (will show you) **que he adelantado.**
10. **Ud. no tendrá dificultad** (in understanding me).
11. (There is not any) **falta en la carta.**
12. **Un libro** (called) **Correspondencia Comercial** (helps me) **mucho.**
13. **Tengo que** (give my sincere thanks to you).
14. (You are very kind.)
15. ¿(Will you kindly) **leerme la respuesta?**
## SEGUNDA PARTE
### Grammar Notes
1. The Indirect Object.
As in English, the indirect object is the _to_ (sometimes _for_ ) object. It indicates the person or persons _to_ whom, sometimes _for_ whom, the action is performed. **Escribo una carta _a_ mi agente.** | I write a letter _to_ my agent.
---|---
2. The Indirect Object Pronouns.
Observe the indirect object pronouns in the following sentences. **Carlos _me_ da el vaso.** | Charles gives _me_ the glass.
---|---
**Juan _te_ escribe una carta.** | John writes _you_ ( _fam._ ) a letter.
**Pablo _le_ da ( _a Ud._ ) el dinero.** | Paul gives _you_ the money.
**Ana _le_ lleva ( _a él_ ) la silla.** | Anna brings _him_ the chair.
**Yo _le_ leo ( _a ella_ ) el cuento.** | I read _her_ the story.
**El maestro** _nos_ **da la lección.** | The teacher gives _us_ the lesson.
**La criada _les_ da ( _a Uds._ ) los platos.** | The servant gives _you_ the plates.
**Nosotros _les_ vendemos ( _a ellos_ ) el auto.** | We sell _them_ ( _m._ ) the auto.
**Los niños _les_ traen ( _a ellas_ ) las flores.** | The children bring _them_ ( _f._ ) the flowers.
1. The Indirect Object Pronouns Are: **me** ( _to_ ) me | **le... a Ud.** ( _to_ ) you | **les... a Uds.** ( _to_ ) you
---|---|---
**te** ( _to_ ) you ( _fam._ ) | **le... a él** ( _to_ ) him | **les... a ellos** ( _to_ ) them (m.)
**nos** (to) us | **le... a ella** ( _to_ ) her | **les... a ellas** ( _to_ ) them ( _f._ )
**os** ( _to_ ) you (fam. _pl._ )
2. The Indirect Object Pronouns, **me, te, nos** , and **os** are like the direct object pronouns.
3. The indirect object pronoun **le** can mean _to you, to him_ , or _to her._ The indirect object pronoun **les** can mean _to you_ ( _pl._ ) _, to them_ ( _m._ ), or _to them_ ( _f._ ).
If necessary to make the meaning clear, add: **a Ud., a él, a ella, a Uds., a ellos** , or **a ellas** , immediately after the verb.
4. Like the direct object, the indirect object precedes the verb, except when used with the infinitive, the present participle, or the affirmative imperative.
**¡OJO!** Direct and indirect object pronouns, as well as reflexive pronouns, must follow affirmative commands and present participle or infinitive, and be attached to them. In order to maintain the original stress of the verb form, an accent mark is added to the stressed vowel if the original command has two or more syllables.
**Example: Está comprando un abrigo para Juan = está comprándole un abrígo.**
**¡Compre un abrigo para Juan! = ¡Cómprele un abrigo!**
3. Familiar Verbs Which May Take Indirect Objects **dar** | to give
---|---
**enseñar** | to show, teach
**mostrar (ue)** | to show
**enviar** | to send
**mandar** | to send
**llevar** | to bring
**traer** | to bring
**entregar** | to deliver
**leer** | to read
**escribir** | to write
**decir** | to say
4. Indirect Objects with **gustar, parecer, importar.**
1. **gustar** , to be pleasing to, to like **Me gusta el cuento.** | I like the story. ( _Lit._ To me is pleasing the story.)
---|---
**¿Les gustan a Uds. los cuentos?** | Do you like the stories?
2. **parecer** to seem
**Me parece bien.** It seems (is) all right to me. **Le parece bien a ella.** It seems (is) all right to her.
3. **importar** to be important to (another meaning of **importar** ) **No nos importa.** | It is not important to us. It does not concern us.
---|---
**No les importa (a ellos).** | It is not important to them. It does not concern them.
### Ejercicios No. 108A-108B
108A. Translate:
1. **Le dará Ud. las naranjas (a él).**
2. **Lléveme los zapatos a la zapatería.**
3. **Tenga la bondad de leernos la carta.**
4. **Cuanto antes le escribiré a ella una carta.**
5. **¿Me enseñará Ud. las palabras nuevas?**
6. **No podemos mandarles a Uds. el dinero.**
7. **¿Quién nos leerá el cuento?**
8. **Dígame, ¿qué hace María en la cocina?**
9. **No me gustará la corrida de toros.**
10. **¿Le parece bien esa fecha?**
11. **Me parece bien.**
12. **No me importan estas cosas.**
108B. Complete the Spanish sentences, filling in the correct indirect object pronouns, so that the Spanish sentences correspond exactly to the English.
Remember: **le** = to you ( _sing._ ), to him, to her; **les** = to you ( _plur._ ), to them ( _m._ and _f._ )
**Ejemplo** : I am writing _you_ a letter. | **_Le_ escribo una carta.**
---|---
1. Will you give _him_ the money? | 1. **¿__________dará Ud. el dinero?**
2. They bring _us_ the clothing. | **2.___________traen la ropa.**
3. Will you teach _her_ the lesson? | **3.¿_________enseñará Ud. la lección?**
4. I like _your_ hats. | **4.___________gustan tus sombreros.**
5. They like _your_ garden. | **5.___________gusta (a ellos) su jardín.**
6. Tell _me_ the truth. | **6. Díga___________la verdad.**
7. It's of no concern _to them._ | **7. No____________importa (a ellos).**
8. The ticket-seller will give _you_ ( _pl._ ) the tickets. | **8. El boletero dará los boletos.**
9. I like sweets. | **9.___________gustan los dukes.**
10. Their parents are buying _them_ the toys. | **10. Sus padres están comprando______los juguetes.**
11. I shall speak to _you_ on the telephone, Henry. | **11.___________hablaré por teléfono, Enrique.**
12. I am bringing _you_ the umbrella, sir. | **12. Estoy trayendo_______a Ud. el paraguas, señor.**
13. Bring _us_ the coffee, please. | **13. Tráiga____________el café, por favor.**
14. It seems good _to me._ | **14.____________parece bien.**
15. They seem good _to us._ | **15.____________parecen bien.**
### Ejercicio No. 109—Preguntas
1. **¿Dónde están sentados los dos señores?**
2. **¿Qué tiene en la mano el señor Adams?**
3. **¿Qué va a leerle al Sr. López?**
4. **¿A quién le gustará mucho oírla?**
5. **¿Cuál es la fecha de la carta?**
6. **¿A quién le escribe la carta el Sr. Adams?**
7. **¿Qué forma de saludo usa el Sr. Adams?**
8. **¿Quién irá de viaje a México?**
9. **¿Cuándo saldrá el Sr. Adams de Nueva York?**
10. **¿Cuándo llegará al aeropuerto de México D. F.?**
11. **¿Cuánto tiempo se quedará en la capital?**
12. **¿Adónde hará viajes?**
13. **¿Adónde irá tal vez por avión?**
14. **¿De quién ha apreciado los servicios el Sr. Adams?**
15. **¿A quién quiere conocer personalmente?**
# CHAPTER 34
CAPÍTULO 34 (TREINTA Y CUATRO)
## PRIMERA PARTE
### El señor Adams recide una carta.
**El Sr. Adams tiene en la mano la respuesta que acaba de recibir de su agente, el Sr. Carrillo. Está leyéndola.** | Mr. Adams has in his hand the reply that he has just received from his agent, Mr. Carrillo. He is reading it.
---|---
1. **Estimado señor** : | 1. Dear Sir:
2. **Le agradezco mucho su carta del 4 de mayo en la que me informa de su visita a México.** | 2. Thank you for your letter of May 4 in which you inform me of your visit to Mexico.
3. **Tengo el gusto de informarle que estaré en la capital durante los meses de junio y julio y quiero aprovechar la oportunidad de ponerme enteramente a sus órdenes.** | 3. I take pleasure in informing you that I shall be in the capital during the months of June and July and I want to take advantage of the opportunity to put myself entirely at your service.
4. **Tendré el gran placer de recibirlo en el aeropuerto el 31 de mayo a las siete menos cuarto de la tarde. Espero poder facilitar su estancia en esta capital tanto en las diversiones como en los negocios.** | 4. I will take great pleasure in greeting you at the airport on May 31 at 6:45 P.M. I hope to be able to facilitate your stay in this capital in matters of diversion as well as in matters of business.
5. **Con mucho gusto conversaré con Ud. en español y estoy seguro de que Ud. lo habla perfectamente. Por cierto, lo escribe sumamente bien. Quiero felicitarlos a Ud. y a su maestro, el Sr. López. Puesto que es mexicano, entiendo bien que Ud. usará muchos modismos mexicanos. ¿Y por qué no?** | 5. With much pleasure, I will talk with you in Spanish and I am sure that you speak it perfectly. Indeed you write it extremely well. I want to congratulate you and your teacher, Mr. Lopez. Since he is Mexican, I understand very well that you will use many Mexican idioms. And why not?
6. **Esperando la pronta oportunidad de conocer-lo, lo saludo muy atentamente.** | 6. Looking forward to meeting you soon, I remain, sincerely yours.
**Rufino Carrillo** | Rufino Carrillo
7. — **Es una carta muy amable—dice el señor López. —Hasta ahora Ud. ha conocido y ha apreciado al señor Carrillo solamente como un buen representante. Sin duda alguna, Ud. verá que es también muy simpático, como tantos mexicanos. Perdóneme si estoy orgulloso de mi pueblo. Pero Ud. verá por sí mismo.** | 7. "It is a very kind letter," says Mr. Lopez. "Until now you have known and appreciated Mr. Carrillo only as a good representative. Without any doubt, you will find that he is also very nice like so many Mexicans. Pardon me if I am proud of my people. But you will see for yourself."
8. — **Estoy seguro de que estaré muy contento entre la gente de México. Y lo mejor es que podré hablar con ellos en su propio idioma.** | 8. I am sure that I will be very happy among the people of Mexico. And the best is that I shall be able to speak to them in their own language.
9. — **Claro está. Pues, Sr. Adams, el martes que viene es nuestra última cita antes de su salida para México. Nos veremos en su oficina, ¿verdad?** | 9. Very true. Well, Mr. Adams, next Tuesday is our last appointment before your departure for Mexico. We shall meet in your office, shall we not?
10. — **Sí. ¿Y me dará algunos últimos consejos?** | 10. Yes, and will you give me some final advice?
11. — **Con mucho gusto, Sr. Adams.** | 11. With great pleasure, Mr. Adams.
### Pronunciation and Spelling Aids
1. Practice: | a-gra-de- **ci** -do | es- **tan** -cia | su-ma- **men** -te | re-pre- **sen** -to
---|---|---|---|---
| a-pro-ve- **char** | di-ver- **sio** -nes | fe-li-ci- **tar** -los | per- **dó** -ne-me
| en-te-ra- **men** -te | per-fec-ta- **men** -te | a-pre- **cia** -do | or-gu- **llo** -so
### Building Vocabulary
**Sinónimos** :
1. **informar—avisar** | to inform
---|---
2. **enteramente—completamente** | entirely
3. **tendré gran placer en—me gustará mucho** | I shall be pleased to
4. **discúlpeme—perdóneme** | pardon me
### Expresiones Importantes
1. 1. **aprovechar la oportunidad de** | to take advantage of the opportunity to
---|---
2. **esperando la pronta oportunidad de conocerlo** | looking forward to meeting you soon
3. **Lo/la saludo atentamente** | Sincerely yours
4. **le agradezco mucho** | I thank you very much
5. **lo mejor es, lo peor es** | the best is, the worst is
6. **quiero felicitarle** | I want to congratulate you
7. **sin duda alguna** | without any doubt
8. **Tengo el gusto de informarle** | I am pleased to inform you
2. Greetings: Letters to Friends **Querido Pablo; Querida Elena** | Dear Paul; Dear Ellen
---|---
**Querido amigo; Querida amiga** | Dear Friend
**Estimada amiga Estimado amigo** | Esteemed Friend
3. Conclusions: Letters to Friends **Su sincero amigo, Su sincera amiga** | Your sincere friend
---|---
**Sinceramente, Afectuosamente** | Sincerely, Affectionately
**Lo saluda cordialmente su amigo(a)** | Cordial greetings from your friend
**Reciba un abrazo de su amigo (a)** | Receive an embrace from your friend
**NOTE** : **Querido(a)** is for relatives and very intimate friends. It is not used freely like the English _Dear_ , which is the form of address even for business letters.
### Ejercicio No. 110—Completion of Text
A. Complete these sentences by translating all English words into Spanish.
1. **El Sr. Adams tiene** (a letter in his hand).
2. (I am much obliged) **por su carta del 4 de mayo.**
3. **Ud. tiene la bondad** (to inform me) **de su visita a México.**
4. (I shall take great pleasure) **en recibirlo en el aeropuerto.**
5. (I shall converse) **con Ud. en español.**
6. **Quiero** (to congratulate you) **a Ud. y a su maestro.**
7. (I understand very well) **que Ud. usará modismos mexicanos.** (Why not?)
8. (Without any doubt) **Ud. verá que el Sr. Carrillo es** (very congenial).
9. (Pardon me). **Estoy muy** (proud) **de mi pueblo.**
10. **Ud. verá** (for yourself) **que los mexicanos son** (very nice).
11. (I am sure) **de que** (I will be able) **hablar con ellos en su propio idioma.**
12. (The best is) **que puedo hablar español.**
13. (The worst is) **que Ud. no puede ir conmigo.**
14. (Each other) **veremos en su oficina.**
15. **Le daré a Ud.** (some final advice).
## SEGUNDA PARTE
### Grammar Notes
1. Use of **hacer** in Time Expressions. a. **¿Cuanto tiempo hace que Ud. estudia español?** | How long have you been studying Spanish?
---|---
( _Lit._ How much time does it make that you are studying Spanish?)
b. **Hace cinco meses que estudio español.**
(It makes five months that I am studying Spanish.) | I have been studying Spanish for five months.
c. **Estudio español hace cinco meses.**
(I am studying Spanish it makes five months.) | I have been studying Spanish for (since) five months.
To express an action which began in the past and is still going on, the Spanish uses **hace** (it makes), plus an expression of time, plus **que** , plus the present tense of the verb (ex. b).
If the hace expression comes after the verb, **que** is omitted (ex. c).
2. Use of the Definite Article in Place of the Possessive Adjective. 1. **El señor tiene una carta en la mano.** | The gentleman has a letter in his hand.
---|---
2. **Ana se pone el sombrero en la cabeza.** | Anna puts her hat on her head.
The definite article is used instead of the possessive adjective with parts of the body and clothing when there is no doubt who is meant.
3. Reflexive Pronouns with a Reciprocal Meaning. **Nos veremos.** | We shall see each other.
---|---
**No se conocen el uno al otro.** | They do not know each other.
**Juana y Ana se admiran la una a la otra.** | Jane and Anna admire each other.
a. When the reflexive pronoun is used with a reciprocal meaning, **el uno al otro (la una a la otra)** , _one another_ , may be added for clarity.
### Ejercicios No. 111A-111B-111C
111A. Complete these sentences by putting the English words into Spanish.
#### Ejemplo: 1. ¿Cuánto tiempo hace que Ud. estudia el español?
1. ¿(How long) **hace que Ud. estudia español**?
2. (For six months) **que estudio español.**
3. (For ten years) **que el Sr. López es profesor.**
4. (For 45 minutes) **que esperamos.**
5. (For three days) **que mi madre está enferma.**
6. **Hace seis meses que** (I have known him).
7. **Hace cinco semanas que** (they have lived in this house).
8. **Hace tres horas que los niños** (have been in the cinema).
9. **Hace diez años que** (he has been in this country).
10. **Hace cinco días que** (I have been here).
111B. Change the following affirmative commands into negative commands.
**Remember** : 1. In affirmative commands object pronouns follow the verb.
2. In negative commands they precede it.
#### Ejemplo: Déme el libro. No me dé el libro.
1. **Pónganlos en la mesa.**
2. **Escríbales las cartas.**
3. **Tráiganlos a la casa.**
4. **Dígame las respuestas.**
5. **Mándele los artículos.**
6. **Lléveme la carne y el pescado.**
7. **Déme un boleto de ida y vuelta.**
8. **Cómpreme una bolsa de cuero.**
9. **Léanles todos los cuentos.**
10. **Véndale el automóvil.**
**Remember** : 1. The singular imperative of **dar, dé Ud.** , takes an accent mark to distinguish it from **de** (of).
2. When writing the negative form of the imperative, remember to drop the accent mark.
111C. Answer the following questions in the future with both **sí** and **no.** Use an object pronoun in each answer.
**Remember** : If the question has **Ud**. as subject, the answer has ( **yo** ) as subject; if the question has **Uds.** , the answer has **(nosotros).**
**Ejemplos** : | **¿Comerá Ud. la carne?** | **Sí, la comeré** | **No, no la comeré.**
---|---|---|---
| **¿Comerán Uds. la carne?** | **Sí, la comeremos.** | **No, no la comeremos.**
1. **¿Visitará Ud. el museo?**
2. **¿Escribirá Ud. la carta?**
3. **¿Comprará Ud. el coche?**
4. **¿Traerá Ud. los cestos?**
5. **¿Tomará Ud. el té?**
6. **¿Pedirán Uds. los boletos?**
7. **¿Venderán Uds. la casa?**
8. **¿Querrán Uds. las frutas?**
9. **¿Seguirán Uds. a sus amigos?**
10. **¿Repetirán Uds. las preguntas?**
### Ejercicio No. 112—Preguntas
1. **¿Qué acaba de recibir el Sr. Adams?**
2. **¿Cuándo estará en la capital el Sr. Carrillo?**
3. **¿Dónde esperará al Sr. Adams?**
4. **¿En qué idioma conversará con él?**
5. **¿A quiénes quiere felicitar el Sr. Carrillo?**
6. **¿Qué entiende bien?**
7. **¿Quién está orgulloso de su pueblo?**
8. **¿Qué verá el Sr. Adams por sí mismo?**
9. **¿Cuándo será la última cita de los dos señores?**
10. **¿Dónde se verán?**
# CHAPTER 35
CAPÍTULO 35 (TREINTA Y CINCO)
## PRIMERA PARTE
### Los consejos del señot López
1. **Hace calor en la oficina del señor Adams. No hace viento. Por la ventana abierta se oye el ruido de la calle.** | 1. It is hot in Mr. Adams's office. There is no wind. Through the open window are heard the noises of the street.
---|---
2. — **Me alegro de salir de la ciudad—le dice el señor Adams al señor López.** | 2. "I am happy to leave the city," says Mr. Adams to Mr. Lopez.
3. — **Tengo ganas de acompañarlo—contesta el señor López.** | 3. "I feel like going with you," answers Mr. Lopez.
4. — **¿No puede ir conmigo?** | 4. Can you not go with me?
5. — **Desgraciadamente, no es posible.** | 5. Unfortunately, it is not possible.
6. — **Por lo menos, ¿me hace el favor de darme algunos últimos consejos? ¿Es muy distinta la vida en México de la vida en los EE.UU.?** | 6. At least, will you please give me some final advice? Is life in Mexico very different from life in the United States?
7. — **Sí, señor Adams, hay muchas costumbres diferentes. En general, la vida en México es más formal. Son muy importantes las formalidades. Y eso de la cortesía, yo creo, tiene un significado profundo. Quiere decir que cada hombre es digno de respeto.** | 7. Yes, Mr. Adams, there are many different customs. In general, life in Mexico is more formal. The formalities are very important. And the matter of courtesy, I think, has a profound significance. It means that every man is worthy of respect.
8. — **Es verdad—responde el señor Adams.** | 8. "That is true," answers Mr. Adams.
9. — **He notado que entre los negociantes también hay más formalidad en México que en los EE.UU. Les gusta platicar un rato acerca de otras cosas antes de emprender un nego-cio. Quieren llegar a conocerse el uno al otro.** | 9. I have noticed that among businessmen too there is more formality in Mexico than in the United States. They like to chat a little about other things before taking up business. They want to get to know one another.
10. — **Estaré muy contento allí.** | 10. I shall be very happy there.
11. — **Como le he dicho hace algún tiempo, hay que acostumbrarse a la altura. Al principio es mejor no apresurarse.** | 11. As I told you some time ago, one must get used to the altitude. At first it is better not to hurry.
12. — **Se dice que en general la vida es más tranquila allí. Espero que sí. Estoy cansado de estar de prisa.** | 12. They say that in general life is more tranquil there. I hope so. I am tired of being in a hurry.
13. — **A propósito, Sr. Adams, ¿ha leído los libros sobre México que le he recomendado?** | 13. By the way, Mr. Adams, have you read the books on Mexico which I have recommended to you?
14. — **Sí, los he leído todos. Me han sido muy útiles e interesantes. Pero me gusta sobre todo «Mexican Folkways» por Frances Toor. También he leído el excelente librito «México por Motor» publicado por la Asociación Automovilística de América.** | 14. Yes, I have read them all. They have been very useful and interesting to me. But I like most of all "Mexican Folkways" by Frances Toor. I have read the excellent booklet _Mexico by Motor_ , published by the Automobile Association of America.
15. — **Bueno. Le he dicho muchas veces que Ud. se harà entender bien en México. En cuanto a mí, pasaré el verano en Nueva York. He gozado de nuestras conversaciones y voy a echarlo de menos.** | 15. Good. I have said many times that you will get along well in Mexico. As for me, I shall spend the summer in New York. I have enjoyed our conversations and I am going to miss you.
16. — **Pensaré en Ud. a menudo y le escribiré de vez en cuando.** | 16. I shall think of you often and I shall write you from time to time.
17. — **Me gustará mucho recibir sus cartas desde México. Pues bien, tenemos que despedirnos. Hágame el favor de saludar de mi parte a la señora Adams y a sus hijos.** | 17. I shall be glad to receive your letters from Mexico. Well then, we have to take leave of each other. Kindly give my regards to Mrs. Adams and to your children.
18. — **Gracias y mucha suerte, Sr. López.** | 18. Thank you and good luck, Mr. Lopez.
19. — **Buen viaje, Sr. Adams.** | 19. Happy voyage, Mr. Adams.
**Se dan la mano.** | They shake hands.
### Pronunciation and Spelling Aids
1. Practice: | **vien** -to | des-gra-cia-da- **men** -te | for-ma-li- **dad** | des-pe- **dir** -nos | cre- **í** -do
---|---|---|---|---|---
| **rui** -dos | cor-te- **sí** -a | a-cos-tum- **brar** -se | le- **í** -do | o- **í** -do
| a-com-pa- **ñar** -lo | sig-ni-fi- **ca** -do | a-pre-su- **rar** -se | ca- **í** -do
2. The combinations (diphthongs) **ai, oi** , and **ei** become separate vowels, **a-í, o-í** , and **e-í** , when the **í** has an accent mark.
### Building Vocabulary
A. **Sinónimos**
1. **alegrarse (de)** | **estar contento (de)** | to be happy (to)
---|---|---
2. **a menudo** | **muchas veces** | often
3. **estar de prisa** | **tener prisa** | to be in a hurry
4. **hay que** | **es necesario** | it is necessary, one must
### Expresiones Importantes
1. **en cuanto a mí** | as for me
---|---
2. **Espero que sí.** | I hope so.
3. **Espero que no.** | I hope not.
4. **He gozado de nuestras conversaciones.** | I have enjoyed our conversations.
5. **Voy a echarlo de menos.** | I am going to miss you.
6. **hacerse entender** | to get along
### Ejercicio No. 113—Completion of Text
1. (I am glad) **salir de la ciudad.**
2. (I feel like) **de acompañarlo.**
3. (At least) **hágame el favor de** (to give me) **algunos consejos.**
4. (The matter of courtesy) **tiene un significado profundo.**
5. (It means) **que cada hombre** (is worthy) **de respeto.**
6. (They like) **platicar un rato** (about) **otras cosas.**
7. **Quieren llegar a** (to know each other).
8. (As I have told you) **es mejor no apresurarse.**
9. (People say) **que en general la vida es más tranquila.** (I hope so).
10. **Estoy cansado** (of being in a hurry).
11. ¿(Have you read) **los libros sobre México?**
12. (As for me) **me quedaré aquí en Nueva York.**
13. (I have enjoyed) **de nuestras conversaciones.**
14. **Tenemos que** (take leave of each other).
15. **They shake hands.**
## SEGUNDA PARTE
### Grammar Notes
1. The Present Perfect Tense—Model Verbs: **hablar, aprender, vivir.** This is one of the tenses used to indicate past time. | SINGULAR |
---|---|---
| **he hablado (aprendido, vivido)** | I have spoken (learned, lived)
| **has hablado (aprendido, vivido)** | you have spoken (learned, lived)
**Ud.** | **ha hablado (aprendido, vivido)** | you have spoken (learned, lived)
| **ha hablado (aprendido, vivido)** | he, she, it has spoken (learned, lived)
| PLURAL
| **hemos hablado (aprendido, vivido)** | we have spoken (learned, lived)
| **habéis hablado (aprendido, vivido)** | you have spoken (learned, lived)
**Uds** | **. han hablado (aprendido, vivido)** | you have spoken (learned, lived)
| **han hablado (aprendido, vivido)** | they have spoken (learned, lived)
1. As in English, the present perfect tense in Spanish is formed by the present tense of the auxiliary (helping) verb, **haber** ( _to have_ ) plus the past participle of the verb.
2. The endings of the auxiliary verb **haber** are: singular **-e, -as, -a** ; plural **-emos, -éis, -an.** You have learned that these are also the endings in the future tense (See **Capítulo 31** ). In the future, however, all the endings except **-emos** have an accent mark.
3. To form the regular past participle of an **-ar** verb, drop the **-ar** and add **-ado.** To form the past participle of an **-er** or **-ir** verb, drop the **-er** or **-ir** and add **-ido.** Example: **hablar- > hablado; vender-> vendido; vivir-> vivido.**
4. The subject may never, as in English, come between the auxiliary verb and the past participle. Object pronouns precede the auxiliary verb.
**¿Ha escrito Carlos la carta?** | Has Charles written the letter?
---|---
**Sí, la ha escrito.** | Yes, he has written it.
2. The Past Participles of Some Familiar Verbs **he comprado** | I have bought | **he querido** | **I** have wished
---|---|---|---
**he enseñado** | I have taught | **he vendido** | I have sold
**he tornado** | I have taken | **he comido** | I have eaten
**he trabajado** | I have worked | **he bebido** | I have drunk
**he andado** | I have walked | **he tenido** | I have had
**he deseado** | I have wanted | **he sido** | I have been
**he pasado** | I have passed | **he ido** | I have gone
**he estado** | I have been | **he venido** | I have come
3. Past Participles with an Accent Mark
When the stem of the verb ends in a vowel, the i of -ido has an accent mark. **he leído (le- _í_ -do)** | I have read | **he traído (tra- _í_ -do)** | **I** have brought
---|---|---|---
**he caído (ca- _í_ -do)** | I have fallen | **he creído (cre- _í_ -do)** | I have believed
**he oído (o- _í_ -do)** | I have heard
4. Irregular Past Participles
Most past participles are regular. The most common irregulars are: **abrir** | **he _abierto_** | I have opened | **poner** | **he _puesto_** | I have put
---|---|---|---|---|---
**cubrir** | **he _cubierto_** | I have covered | **ver** | **he _visto_** | I have seen
**decir** | **he _dicho_** | I have said | **volver** | **he _vuelto_** | I have returned
**escribir** | **he _escrito_** | I have written | **morir** | **ha _muerto_** | he has died
**hacer** | **he _hecho_** | I have done | **romper** | **he _roto_** | I have broken
**NOTE** : the proverb ( **refrán** ): **Dicho y hecho** —No sooner said than done. _Lit_ Said and done.
5. **haber** and **tener**
**haber** , to have, as you have seen, is used as an auxiliary verb to form the present perfect tense.
**tener** , to have, means _to possess._ It is never used as an auxiliary verb. **He vendido la casa.** | I have sold the house. | **Tengo una casa.** | I have (possess) a house.
---|---|---|---
**He tenido una casa.** | I have had (possessed) a house.
### Ejercicios No. 114A-114B-114C
114A. Translate:
1. **Hemos tenido un buen viaje.**
2. **Los jarros han caído en el suelo.**
3. **No han dicho nada.**
4. **¿Qué ha hecho Pablo con el dinero?**
5. **Nadie ha abierto las puertas.**
6. **No hemos leído esos diarios.**
7. **¿Han estado Uds. en el cine?**
8. **¿Ha estado enferma la niña?**
9. **Nunca he creído ese cuento.**
10. **¿Qué han dicho ellos?**
114B. Translate:
1. I have noticed
2. He has said
3. They have not read
4. ( **ser** ) They have been
5. ( **estar** ) We have been
6. I have not worked
7. Have you taught ( **Ud.** )?
8. Who has not written?
9. What have you done ( **Uds.** )?
10. You ( **tú** ) have opened.
11. What has John said?
12. She has taken
13. I have not believed
14. We have heard
15. Have you ( **Uds.** ) heard?
114C. Change the following sentences 1. to the future. 2. to the present perfect. Do not change the subject.
**Ejemplo: Compro un sombrero. Compraré un sombrero. He comprado un sombrero.**
1. **El Sr. García vende su casa.**
2. **Trabajo en la ciudad.**
3. **Escribimos una carta.**
4. **Leen las revistas.**
5. **¿Cena Ud. a las ocho?**
6. **Tú no aprendes la lección.**
7. **¿Busca el niño a su madre?**
8. **¿Compran Uds. zapatos nuevos?**
9. **Salgo de la ciudad.**
10. **Entran en la casa.**
### Ejercicio No. 115—Preguntas
1. **¿Dónde se encuentran los señores Adams y López?**
2. **¿Qué tiempo hace?**
3. **¿Qué se oye por la ventana?**
4. **¿Quién se alegra de irse de la ciudad?**
5. **¿Quién tiene ganas de acompañar al Sr. Adams?**
6. **¿Qué responde el Sr. López a la pregunta: ¿No puede Ud. ir conmigo?**
7. **¿Es la vida en México más formal que la vida en Estados Unidos?**
8. **¿Qué quiere decir la importancia de la cortesía en México?**
9. **¿Qué ha notado el Sr. López entre los negociantes?**
10. **¿Quién está cansado de estar de prisa?**
11. **¿Quién ha leído libros sobre México?**
12. **¿Quién ha recomendado estos libros?**
13. **En cuanto al Sr. López, ¿dónde pasará el verano?**
14. **¿En quién pensará a menudo el Sr. Adams?**
15. **¿Le escribirá cartas al Sr. López de vez en cuando?**
# CHAPTER 36
CAPÍTULO 36 (TREINTA Y SEIS)
## PRIMERA PARTE
### El señor Adams sale para México
1. **Hace cinco meses que el señor Adams estudia español. Ha pasado muchas horas en conversación con su maestro, el señor López. También ha aprendido la gramática necesaria y ha leído mucho sobre México e Hispanoamérica. Verdaderamente ha trabajado mucho. Ahora habla español bastante bien y espera hacerse entender muy bien en México.** | 1. Mr. Adams has been studying Spanish for five months. He has spent many hours in conversation with his teacher, Mr. Lopez. He has also learned the necessary grammar and has read a great deal about Mexico and Hispanic-America. He really has worked very hard. Now he speaks Spanish well enough and he expects to make himself understood very well in Mexico.
---|---
2. **El señor Adams ha conseguido los boletos para el vuelo, el pasaporte, y el permiso de entrada mexicano. Necesita todo esto porque está en viaje de negocios así como en viaje de recreo. Un turista necesita solamente el pasaporte. Desde luego, el señor Adams ha escrito una carta a su agente en México haciéndole saber la hora de llegada del avión en la capital. Este ha prometido recibirlo en el aeropuerto.** | 2. Mr. Adams has obtained the tickets for the flight, his passport, and the Mexican entry permit. He needs all this because he is on a business trip as well as a recreational trip. A tourist needs only a passport. Of course, Mr. Adams has written a letter to his agent in Mexico letting him know the time of arrival of the plane at the capital. The latter has promised to meet him at the airport.
3. **Al fin llega el 31 de mayo, día de la salida. El avión del señor Adams sale del Aeropuerto Internacional a las ocho menos cuarto de la mañana. El tiene que estar en el aeropuerto dos horas antes para pasar por la seguridad y el control de pasaportes, mostrar su boleto y hacer pesar su equipaje. La familia no va a acompañarlo a México porque los hijos tienen que terminar el año escolar y su esposa tiene que quedarse en casa para cuidarlos. Además, viajar con cuatro niños de cinco a diez años de edad no es solamente difícil sino también bastante caro.** | 3. At last May 31st, the day of departure, arrives. Mr. Adams's plane leaves the International Airport at a quarter to eight in the morning. He must be at the airport two hours earlier to go through the security and passport control, show his ticket, and have his baggage weighed. His family is not going with him to Mexico because his children have to finish the school year and his wife has to remain at home to take care of them. Besides, traveling with four children from five to ten years of age is not only difficult but quite expensive.
4. **Por supuesto, toda la familia está muy animada. Los niños no han dormido mucho y a las cinco de la mañana todos están despiertos.** | 4. Of course the whole family is very excited. The children have not slept very much and at five in the morning all are awake.
5. **A las seis de la mañana la familia entera está lista para salir para el aeropuerto. El señor Adams ha hecho dos maletas y las pone en el auto. Entonces todos suben al automóvil, que se pone en marcha y llega al aeropuerto a eso de las siete.** | 5. At six in the morning the whole family is ready to leave for the airport. Mr. Adams has packed two valises and puts them in the auto. Then all get into the automobile which starts off and arrives at the airport at about seven.
6. **Entonces el señor Adams se despide de su esposa y de sus hijos, que le desean un buen viaje. El señor Adams hace revisar su boleto y hace pesar su equipaje. Tiene que pagar setenta dólares de exceso porque el peso total excede las 66 libras permitidas gratis. Sube al avión A las ocho menos cuarto en punto éste se despega.** | 6. Then Mr. Adams says good-bye to his wife and children, who wish him a happy voyage. Mr. Adams has his ticket checked and has his baggage weighed. He has to pay seventy dollars extra because the total weight exceeds the 66 pounds allowed free. He boards the plane. At 7:45 sharp, it departs.
7. **El señor Adams está en camino.** | 7. Mr. Adams is on his way.
### Pronunciation and Spelling Aids
1. Practice:
ver-da-de-ra- **men** -te | le- **í** -do | pro-me- **ti** -do | cer-ti-fi- **ca** -do | re-vi- **sar** | se des- **pi** -de
---|---|---|---|---|---
pa- **sa** -do | **he** -cho | dor- **mi** -do | re-qui- **si** -to | ha- **cién** -do-le | e-qui- **pa** -je
a-pren- **di** -do | con- **se-gui** -do | des- **pier** -to | va- **cu** -na | des-pe- **dir** -se | ae-ro- **puer** -to
### Building Vocabulary
**Antónimos**
1. **empezar (ie)** | to begin | **acabar, terminar** | to finish
---|---|---|---
2. **abrir** | to open | **cerrar** | to close
3. **abierto** | open | **cerrado** | closed
4. **acostarse (ue)** | to go to bed | **levantarse** | to get up
5. **dormir** | to sleep | **estar despierto** | to be awake
6. **dormirse** | to go to sleep | **despertarse** | to wake up
7. **despedirse(i) (de)** | to take leave (of) | **saludar (a)** | to greet
8. **llegar (a)** | to arrive (at) | **salir (de)** | to leave (from)
9. **la llegada** | the arrival | **la salida** | the departure
10. **suben al auto** | they get into the auto | **bajan del auto** | they get out of the auto
### Expresiones Importantes
1. **cuidar a los niños** | to take care of the children
---|---
2. **haciéndole saber** | letting him know
3. **hacer una maleta** | to pack a suitcase
4. **no solamente... sino también** | not only... but also
5. **quedarse en casa** | to remain at home
6. **hacerse entender** | to get along
### Ejercicio No. 116-Completion of Text
1. (For five months) **que el Sr. Adams estudia el español.**
2. **El Sr. Adams** (has obtained) **los boletos.**
3. (Of course) **el Sr. Adams ha escrito a su agente.**
4. (Finally) **llega el 31 de mayo.**
5. **La familla no va** (to accompany him).
6. **Viajar con cuatro niños** (is not only) **difícil** (but also) **bastante caro.**
7. **La familia** (is ready) **para salir**
8. **El Sr. Adams** (has packed two suitcases).
9. **Todos** (get into the automobile).
10. (It starts off) **y llega al aeropuerto** (at about) **las diez.**
11. **El peso total** (of his baggage) **excede 66** (pounds).
12. **Por eso** (he has to) **pagar setenta dólares extra.**
13. **El negociante** (takes leave of) **su esposa y de sus hijos.**
14. (At 11 o'clock sharp) **se despega el avión.**
15. Mr. Adams is on his way.
## SEGUNDA PARTE
### Grammar Notes
1. Present Tense of **dormir** (ue) to sleep, **despedirse (i)** to take leave I sleep, etc. | I take leave, etc.
---|---
**duermo** | **dormimos** | **me despido** | **nos despedimos**
**duermes** | **dormís** | **te despides** | **os despedís**
**duerme** | **duermen** | **se despide** | **se despiden**
IMPERATIVE | IMPERATIVE
**duerma Ud.** | **duerman Uds.** | **despídase Ud.** | **despídanse Uds.**
2. Present Perfect of **dormir (ue)** and **despedirse (i)** I have slept, etc. | I have taken leave, etc.
---|---
**he dormido** | **hemos dormido** | **me he despedido** | **nos hemos despedido**
**has dormido** | **habéis dormido** | **te has despedido** | **os habéis despedido**
**ha dormido** | **han dormido** | **se ha despedido** | **se han despedido**
In the present perfect tense of a reflexive verb, the reflexive pronoun must precede the auxiliary verb.
**No me he lavado.** | I have not washed myself. | **¿Se ha lavado Ud.?** | Have you washed yourself?
---|---|---|---
3. Past Participles Used as Adjectives.
Study the following expressions, noting in each a past participle used as an adjective. 1. **el libro abierto** | the open book
---|---
2. **el libro está abierto.** | The book is open.
3. **la ventana cerrada** | the closed window
4. **La ventana está cerrada.** | The window is closed.
1. Past participles may be used as adjectives. Like other adjectives they agree in number and gender with the nouns they modify.
2. Past participles as predicate adjectives are generally used with **estar.**
### Ejercicios No. 117A-117B-117C
117A. Translate:
1. **Estamos comenzando la lección.**
2. **Hemos comenzado el ejercicio.**
3. **No me acuerdo de él.**
4. **Me he acordado de ella.**
5. **¿Están sentándose?**
6. **¿Se han sentado?**
7. **¿Están repitiendo Uds. las palabras?**
8. **¿Han repetido Uds. las palabras?**
9. **La criada está poniendo la mesa.**
10. **La criada no ha puesto la mesa.**
11. **La mesa está puesta.**
12. **Ella está sirviendo el café.**
13. **Ella ha servido el té.**
14. **¿Qué frutas prefiere Ud.?**
15. **¿Qué frutas ha preferido Ud.?**
16. **Los niños están acostándose.**
117B. Complete by translating the English words into Spanish.
1. **La ventana está** (open).
2. **La puerta está** (closed).
3. **Los niños están** (awake).
4. **La mesa está** (set).
5. **La casa está** (sold).
6. **Los muchachos están** (dressed).
7. **Los señores están** (seated).
8. **Las cartas están** (written).
9. **El año escolar está** (finished).
10. **El traje está** (made) **a mano.**
117C. Translate:
1. I sleep.
2. He is sleeping (prog. tense).
3. They sleep.
4. Do you (Ud.) sleep?
5. I am leaving.
6. They are leaving.
7. We do not say good-bye.
8. I have slept.
9. Have you slept?
10. We have not slept.
11. I have taken leave.
12. They have not said good-bye.
13. Have you (Uds.) taken leave?
14. Sleep (Ud.).
15. Do not sleep (Uds.).
### Ejercicio No. 118—Preguntas
1. **¿Cuánto tiempo hace que el Sr. Adams estudia español?**
2. **¿Con quién ha pasado muchas horas en conversación?**
3. **¿Qué ha aprendido?**
4. **¿Cómo ha trabajado?**
5. **¿Cómo habla español ahora?**
6. **¿Qué ha conseguido el Sr. Adams?**
7. **¿Qué certificado ha obtenido?**
8. **¿A quién le ha escrito el Sr. Adams?**
9. **¿Qué le ha prometido su agente?**
10. **¿A qué hora están despiertos todos los niños?**
11. **¿A qué hora sale el avión del aeropuerto?**
12. **¿Qué tiene que mostrar cada pasajero?**
13. **¿Va a acompañarlo al Sr. Adams su familia?**
14. **¿Qué tienen que terminar sus niños?**
15. **¿Para qué tiene que quedarse en casa la señora Adams?**
# CHAPTER 37
REVIEW, CHAPTERS 33–36
REPASO, CAPÍTULOS 33–36
## PRIMERA PARTE
### Repaso de palabras (Word Review)
NOUNS
1. **el aeropuerto** | 1. airport
---|---
2. **el aire** | 2. air
3. **los alrededores** | 3. surrounding areas
4. **los suburbios** | 4. suburbs
5. **el cariño** | 5. affection
6. **la cortesía** | 6. courtesy
7. **la corrida de toros** | 7. bullfight
8. **la cultura** | 8. culture
9. **la dirección** | 9. address
10. **la entrada** | 10. entrance
11. **la luna** | 11. moon
12. **el modismo** | 12. idiom
13. **las noticias** | 13. news
14. **el negocio** | 14. business
15. **la partida** | 15. departure
16. **el pasaporte** | 16. passport
17. **el placer** | 17. pleasure
18. **el punto** | 18. point
19. **un rato** | 19. a while, time
20. **el ruido** | 20. noise
21. **el servicio** | 21. service
22. **tarjeta de turista** | 22. tourist card
23. **el sitio** | 23. place
24. **la visita** | 24. visit
25. **la vista** | 25. view
26. **la bondad** | 26. kindness
### VERBS
1. **acompañar** | 1. to accompany
---|---
2. **alegrarse** | 2. to be glad
3. **aprovechar** | 3. to take advantage of
4. **apreciar** | 4. to appreciate
5. **ayudar** | 5. to help
6. **cansarse** | 6. to get tired
7. **confesar(ie)** | 7. to confess
8. **cuidar** | 8. to take care of
9. **despedirse(i) de** | 9. to take leave of
10. **extender(ie)** | 10. to extend
11. **envidiar** | 11. to envy
12. **informar** | 12. to inform
13. **faltar** | 13. to be lacking
14. **facturar** | 14. to check (baggage)
15. **felicitar** | 15. to congratulate
16. **gozar de** | 16. to enjoy
17. **irse** | 17. to go away
18. **mostrar(ue)** | 18. to show
19. **pesar** | 19. to weigh
20. **prometer** | 20. to promise
21. **usar** | 21. to use
### ADJECTIVES
1. **abierto** | 1. open
---|---
2. **amable** | 2. friendly
3. **bello** | 3. beautiful
4. **digno** | 4. worthy
5. **caro** | 5. expensive
6. **cierto** | 6. certain
7. **conveniente** | 7. convenient
8. **despierto** | 8. awake
9. **entero** | 9. entire
10. **ocupado** | 10. busy
11. **orgulloso** | 11. proud
12. **siguiente** | 12. following
13. **sorprendido** | 13. surprised
14. **ultimo** | 14. final
### ADVERBS
1. **atentamente** | 1. attentively
---|---
2. **desgraciadamente** | 2. unfortunately
3. **enteramente** | 3. entirely
4. **entretanto** | 4. meanwhile
5. **perfectamente** | 5. perfectly
6. **sumamente** | 6. completely
### IMPORTANT EXPRESSIONS
1. **a menudo** | 1. often
---|---
2. **bastante bien** | 2. quite well
3. **de antemano** | 3. beforehand
4. **de seguro** | 4. surely
5. **discúlpeme** | 5. pardon me
6. **echar de menos** | 6. to miss
7. **en cuanto a mí** | 7. as for me
8. **Espero que sí.** | 8. I hope so.
9. **Espero que no.** | 9. I hope not.
10. **estar de prisa** | 10. to be in a hurry
11. **estar en camino** | 11. to be on the way
12. **hace algún tiempo** | 12. sometime ago
13. **hay que** | 13. it is necessary
14. **hecho a mano** | 14. handmade
15. **por lo menos** | 15. at least
16. **que lástima** | 16. what a pity
17. **ponerse en marcha** | 17. to put in motion
18. **sin duda alguna** | 18. without any doubt
19. **tener la intención** | 19. to intend
20. **la mano izquierda** | 20. the left hand
21. **la mano derecha** | 21. the right hand
## SEGUNDA PARTE
**Ejercico 119.** From Group II select the antonyms for each word in Group I.
Group I | Group II
---|---
1. **me acuesto** | a. **comienzo**
2. **me despido** | b. **cierro**
3. **duermo** | c. **saludo**
4. **acabo** | d. **vendo**
5. **compro** | e. **estoy despierto**
6. **abro** | f. **me levanto**
7. **aprendo** | g. **enseño**
8. **mando/envio** | h. **recibo**
9. **subo a** | i. **bajo de**
10. **llego a** | j. **salgo de**
**Ejercicio 120.** Complete the following sentences by selecting expressions from those listed (a to j). Be sure to use the correct forms of the verbs.
1. (Pardon me), **señor, tengo que despedirme.** | a. **tener la intención de**
---|---
2. (It is necessary) **conseguir un pasaporte.** | b. **a menudo**
3. **Estudiamos español** (for some time). | c. **discúlpeme**
4. (They intend to) **salir para México mañana.** | d. **estar de prisa**
5. (Often) **he pensado en Ud.** | e. **por lo menos**
6. **No puedo hablar más porque** (I am in a hurry). | f. **hay que**
7. **María** (will remain at home) **porque está en-ferma.** | g. **quedarse en casa**
8. ¿(At least) **me dará Ud. algunos consejos**? | h. **bastante bien**
9. (As for me) **pasaré todo el verano en la ciudad.** | i. **hace algún tiempo**
10. **Me haré entender en México porque hablo español** (quite well). | **J. en cuanto a mí**
**Ejercicio 121.** Select the group of words in the right-hand column that best completes each sentence begun in the left-hand column.
1. **Ahora espero aprovechar la oportunidad** | a. **lea Ud. algo de sus costumbres.**
---|---
2. **El Sr. Adams no es solamente un buen negociante** | b. **pero tiene que quedarse en Nueva York.**
3. **Ha aprendido a hablar español** | c. **porque estoy de prisa.**
4. **La carta que he recibido** | d. **de conocerlo personalmente.**
5. **Si Ud. quiere viajar en México** | e. **sino también un hombre de cultura.**
6. **Después de despedirse de su familia** | f. **de mi agente es muy amistosa** (friendly).
7. **El Sr. López tiene ganas de acompañar a su amigo** | g. **porque quiere visitar a su agente.**
8. **Pensaré a menudo en Ud.** | h. **el Sr. Adams entra en el avión.**
9. **Ya no puedo quedarme aquí** | i. **que estudio el español.**
10. **Hace cinco meses** | j. **porque voy a echarlo de menos.**
**Ejercicio 122.** Complete the Spanish sentences so that they correspond to the English sentences. Be careful to use the correct indirect object pronouns.
#### Ejemplo: Me gusta la carta.
1. I like the letter. | 1. **________gusta la carta.**
---|---
2. They like to travel. | 2. **________ gusta viajar.**
3. We like the airplanes. | 3. **________ gustan los aviones.**
4. Do you like the paintings, Madame? | 4. **________ gustan las pinturas, señora?**
5. He does not like tomatoes. | 5. **No________ gustan los tomates.**
6. She does not like this style. | 6. **No________ gusta esta moda.**
7. Do you like to dance, gentlemen? | 7. **¿________gusta bailar, caballeros?**
8. Don't you like to play, Anita? | 8. **¿No________ gusta jugar, Anita?**
9. It seems all right to us. | 9. **________ parece bien.**
10. It doesn't concern me. | 10. **No________ importa.**
**Ejercicio 123.** In the following sentences fill in the past participle of the verbs in parentheses.
1. **Los pájaros han** (cantar) **todo el día.**
2. **¿Por qué no han** (volver) **Uds. a casa?**
3. **¿Ha** (llegar) **el tren ya?**
4. **¿Han** (poner) **Uds. los objetos de arte en la mesa?**
5. **El señor ha** (hacer) **un viaje de recreo.**
6. **Los empleados han** (abrir) **las cajas.**
7. **Hemos** (recibir) **una caja de mercancía.**
8. **Le he** (decir) **a Ud. la verdad.**
9. **¿Han** (leer) **Uds. muchos libros sobre México?**
10. **¿Se han** (despedir) **todos los viajeros?**
**Ejercicio 124.** Complete the following sentences with a past participle.
Remember: In these sentences the past participle is used as an adjective and therefore must agree with the noun it modifies.
#### Ejemplo: 1. Las señoritas están sentadas en la sala.
1. **Las señoritas están** (sentar) **en la sala.**
2. **La tierra está** (cubrir) **de nieve** (snow).
3. **El viento viene por la puerta** (abrir).
4. **Todos los cuartos están** (cerrar).
5. **Los rebozos están** (hacer) **a mano.**
6. **Estas cartas están** (written) **en español.**
7. **La mesa está** (poner).
8. **No hemos visto el ejercicio** (escribir).
9. **El trabajo está** (acabar).
10. **Tiene un libro** (abrir) **en la mano.**
**Ejercicio** 125. Translate the English sentences. Be careful to use the correct direct object pronouns.
#### Ejemplo: 1. ¿Ha comprado Ud. la cesta? Sí, la he comprado.—No, no la he comprado
1. **¿Ha comprado Ud. la cesta?** | 1. Yes, I have bought it.
---|---
2. **¿Ha abierto Ud. la ventana?** | 2. Yes, I have opened it.
3. **¿Ha oído Ud. el ruido?** | 3. No, I haven't heard it.
4. **¿Ha conseguido Ud.el pasaporte?** | 4. No, I haven't obtained it.
5. **¿Ha ayudado Ud. a sus amigos?** | 5. Yes, I have helped them.
6. **¿Han visto Uds. los rebozos?** | 6. Yes, we have seen them.
7. **¿Han vendido Uds. los boletos?** | 7. Yes, we have sold them.
8. **¿Han completado Uds. el ejercicio?** | 8. No, we haven't completed it.
9. **¿Han escrito Uds. las cartas?** | 9. No, we haven't written them.
10. **¿Han leído Uds. la revista?** | 10. Yes, we have read it.
## TERCERA PARTE
### Diálogo
#### En el aeropuerto
Practice the Spanish Aloud:
— **Buenos días, Sr. Carrillo. ¿Espera Ud. a alguien en el próximo avión?** | Good day, Mr. Carrillo. Are you waiting for someone on the next plane?
---|---
— **Sí, estoy esperando al Sr. Adams de Nueva York, jefe de la casa que represento en México.** | Yes, I am waiting for Mr. Adams from New York, head of the firm which I represent in Mexico.
— **¿Lo conoce personalmente?** | Do you know him personally?
— **Lo conozco solamente por correspondencia. Pero tengo su fotografía y debo reconocerlo. Es un hombre de cerca de cuarenta años de edad.** | I know him only by correspondence. But I have his photograph and I should recognize him. He is a man of about forty years of age.
— **¿Cuándo llega el vuelo 225 de Houston?** | When does flight 225 arrive from Houston?
— **Debe de llegar a las once y cuarto.** | It should arrive at 11:15.
— **¿Llega atrasado?** | Is it late?
— **No, llega a tiempo. ¡Ah! Ya llega. Está acercándose. Está bajando. Ya está aterrizando.** | No, it is on time. Ah! It is arriving now. It is approaching. It is coming down. It is landing now.
— **Discúlpeme, señor, voy a saludar al Sr. Adams.** | Excuse me, sir, I am going to greet Mr. Adams.
— **Bienvenido a México, Sr. Adams. ¿Ha tenido Ud. un buen viaje?** | Welcome to Mexico, Mr. Adams. Have you had a good trip?
— **¡Estupendo! Me alegro mucho de estar en México. A menudo he soñado con este momento.** | Stupendous! I am very happy to be in Mexico. I have often dreamed of this moment.
— **Bueno. Estoy seguro de que estará muy contento aquí.** | Good. I am sure that you will be very happy here.
## LECTURA
### Ejercicio No. 126—Un programa extraordinario en el cine
**Esta tarde el señor Adams y su esposa van al cine. Al señor Adams no le gusta la mayoría de las peliculas de Hollywood, sobre todo aquéllas en que los vaqueros americanos se disparan tiros** (fire shots) **los unos a los otros. Tampoco le interesan las películas policíacas.**
**Pero esta tarde se pone** (is being shown) **un programa extraordinario en un teatro que está a cosa de cuatro cuadras de su casa. La película se llama «Un Viaje Por México». Es una película sobre el país que nuestro amigo Adams va a visitar dentro de unos meses y que trata de** (deals with) **su historia, su geografía, sus ríos, montañas, ciudades, etc.; es decir, una película que debe interesar mucho a los turistas.**
**Los Adams entran en el teatro a las ocho y media. Casi todos los asientos están ocupados y por eso tienen que sentarse en la tercera fila. Esto no le gusta al señor Adams porque los movimientos en la pantalla le hacen daño a los ojos. Afortunadamente pueden cambiar de asientos después de quince minutos y se cambian** (move) **a la fila trece.**
**Los Adams gozan mucho de esta película y también aprenden mucho acerca de las costumbres de México. Al salir** (On leaving) **del teatro, el señor Adams le dice a su esposa—¿Sabes, Carlota? Creo que me haré entender muy bien en México. He entendido** (I have understood) **casi todas las palabras de los actores y las actrices de esta película.**
# CHAPTER 38
CAPÍTULO 38 (TREINTA Y OCHO)
## PRIMERA PARTE
### Foreword
Mr. Adams is now in Mexico and writes ten letters to Mr. Lopez, about some of the places he visits and about some of his experiences and impressions.
There are many references in his letters to things he has discussed with his teacher so that much of the vocabulary of Chapters 3 to is repeated in the letters.
It is therefore very desirable that you reread all the texts and dialogues of the previous chapters before proceeding with Chapter 38. You will be able to do this easily and rapidly with little or no reference to the English translation. Thus you will in a pleasant manner review the vocabulary and important expressions.
Chapters 2 to are in the present tense, which is by far the most important and most used tense in the affairs of daily life. In Chapters 31 to the future and present perfect tenses were introduced. In Chapters 38, Mr. Adams begins to relate his experiences, that is to say, what _happened_ to him. He will begin to use the preterite tense, which is the chief tense for relating what _happened_ in definite past time.
Thus in Chapter 38, you will accompany Mr. Adams not only into the interesting and fascinating country of Mexico, but also into the realm of the preterite tense, which you will find interesting and useful.
You should continue your pronunciation practice by reading aloud as often as possible dialogues and parts of conversational texts from previous chapters.
**El ejercicio hace al maestro.**
### El señor Adams llega a México
#### Primera carta de México
**México D.F., 4 de junio de 2004** | Mexico City, June 4, 2004
---|---
**Estimado amigo** : | Dear (Esteemed) Friend:
1. **Después de que llegó el avión al aeropuerto de México** y **me revisaron el equipaje en la aduana, fui a la sala de espera.** | 1. After the airplane arrived at the airport of Mexico and they examined my luggage in the customshouse, I went to the waiting room.
2. **De repente un señor guapo se acercó a mí y dijo—Discúlpeme, ¿es Ud. el señor Adams?** | 2. Suddenly a handsome gentleman approached me and asked, Excuse me, are you Mr. Adams?
3. — **A sus órdenes—contesté yo.— Y Ud. es el señor Carrillo, ¿verdad? Mucho gusto en conocerlo. (Se dan la mano.)** | 3. At your service, I answered. And you are Mr. Carrillo, are you not? I am very pleased to meet you. (They shake hands.)
4. — **El gusto es mío—respondió el señor Carrillo.** | 4. The pleasure is mine, answered Mr. Carrillo.
5. **Ud. recordará, Sr. López, que el Sr. Carrillo es el agente de nuestra casa en Nueva York y que prometió recibirme en el aeropuerto.** | 5. You will remember, Mr. Lopez, that Mr. Carrillo is the agent of our firm in New York and that he promised to meet me at the airport.
6. **Cuando salimos juntos a la calle el señor Carrillo llamó un libre (un taxi mexicano). Le dijo al chófer—Al Hotel Luma, por favor.** | 6. When we went outside together Mr. Carrillo called a "libre" (a Mexican taxi). He said to the driver, "To the Hotel Luma, please."
7. **Salimos del aeropuerto. Andando a una velocidad espantosa por una gran avenida, pensé:—López está muy equivocado en cuanto a la tranquila vida mexicana.** | 7. We left the airport. Traveling with frightful speed along the great avenue, I thought Lopez is very mistaken as regards the quiet life of Mexico!
8. **Por la ventanilla del libre vi correr por todas partes a la misma velocidad espantosa, camiones, autos, tranvías y ¿quién sabe qué más?** | 8. Through the window of the taxi I saw on all sides, dashing at the same frightening speed, buses, automobiles, streetcars, and who knows what else?
9. **Traté de decide al chófer:—¡Por favor, más despacio! Pero olvidé por entero el español.** | 9. I tried to say to the driver, "Please, more slowly." But I forgot my Spanish completely.
10. — **Yo no tengo prisa—le grité al fin al chófer.** | 10. "I am not in a hurry," at last I shouted to the driver.
11. — **Yo tampoco, señor—me contestó, doblando la calle a toda velocidad.** | 11. "Neither am I, sir," he answered me, turning a corner at full speed.
12. **Pues, al fin llegamos sanos y salvos al hotel. El automóvil paró y bajamos. El Sr. Carrillo y yo entramos en el hotel. Le dije al dependiente—Buenas tardes. ¿Tiene Ud. un cuarto con baño?** | 12. Well, at last we arrived safe and sound at the hotel. The automobile stopped and we got out. Mr. Carrillo and I entered the hotel. I said to the clerk, "Good day. Have you a room with bath?"
13. — **Tenemos un cuarto en el segundo piso. Da a la plaza. Es el número 25.** | 13. We have a room on the second floor. It opens onto the plaza. It is number 25.
14. — **¿Cuánto es?** | 14. How much is it?
15. — **Quinientos pesos al día, señor.** | 15. Five hundred pesos a day, sir.
16. — **Muy bien. Voy a quedarme aquí varias semanas. Favor de mandar a un muchacho por mis maletas.** | 16. Very well. I am going to remain here several weeks. Please send a bellboy to get my bags.
17. — **Ahorita, señor. Ud. habla español muy bien. ¿Hace mucho tiempo que está aquí en México?** | 17. Right away, sir. You speak Spanish very well. You have been in Mexico a long time?
18. — **Acabo de llegar—contesté yo, un tanto orgulloso.** | 18. "I have just arrived," I answered, somewhat proud.
19. — **¿Ud. está aquí de turista?—preguntó el dependiente.** | 19. "You are here as a tourist?" asked the clerk.
20. — **Estoy aquí de viaje de recreo y de negocios.** | 20. I am here on a pleasure and business trip.
21. **El Sr. Carrillo y yo conversamos un rato más y después nos despedimos. Prometió llamarme por teléfono para hacer una cita.** | 21. Mr. Carrillo and **I** chatted a while longer and then we said good-bye. He promised to telephone me to make an appointment.
22. **Subí en el ascensor al cuarto número 25. Es muy cómodo. No me falta nada. Vuelvo a decide, señor López, que voy a estar muy contento en México.** | 22. I went up in the elevator to room number 25. It is very comfortable. I lack nothing. I tell you again, Mr. Lopez, that I am going to be very happy in Mexico.
**Un cordial saludo de su amigo** , | Cordial greetings from your friend,
**Juan Adams** | John Adams
**NOTE** : **libre** really means _free._ It is the name given to Mexican taxis because they show the sign **"Libre"** when unoccupied.
### Pronunciation and Spelling Aids
1. Practice: | **chó** -fer | es-pan- **to** -sa | co- **rrien** -do | ve-lo-ci- **dad** | or-gu- **llo** -so
---|---|---|---|---|---
2. Be sure to stress these verbs on the last syllable.
**sa- _lió_** | **res-pon- _dió_** | **pro-me- _tió_** | **ba- _jé_** | **con-tes- _té_** | **gri- _té_**
---|---|---|---|---|---
**con-tes- _tó_** | **se a-cer- _có_** | **en- _tré_** | **pre-gun- _té_** | **ol-vi- _dé_**
### Building Vocabulary
A. **Words Indicating Past Time**
1. **ayer** | yesterday
---|---
2. **anteayer** | day before yesterday
**3.anoche** | last night
4. **el año (mes) pasado** | last year (month)
5. **la semana pasada** | last week
6. **el verano pasado** | last summer
### Expresiones Importantes
1. 1. **acercarse a** to approach | **Se acercó a mí** He approached me
---|---
2. **doblando la calle** | making a turn
3. **de repente** | suddenly
4. **tratar de** | to try to
5. **pienso visitar** | I intend to visit
6. **por entero** | completely
7. **revisar el equipaje** | to examine the luggage
8. **sano y salvo** | safe and sound ( _Lit._ sound and safe)
9. **se dan la mano** | they shake hands ( _Lit._ give the hand to each other)
2. **Presentaciones** (Introductions) 1. **_Sr. Carrillo_ : Quiero presentarle a un amigo mío.** | 1. _Mr. Carrillo_ : I want to present to you a friend of mine.
---|---
2. **_Sr. Sanchez_ : Pedro Sánchez, a sus órdenes. Tengo mucho gusto en conocerlo.** | 2. _Mr. Sanchez_ : Peter Sanchez, at your service. I'm very glad to meet you.
3. **_Sr. Adams_ : Juan Adams. El gusto es mío. (Se dan la mano)** | 3. _Mr. Adams_ : John Adams. The pleasure is mine. (They shake hands)
Notice that the introducer lets the persons introduced say their own names.
### Ejercicio No. 127—Completion of Text
1. **Fui a** (the waiting room).
2. (Suddenly) **un señor se acercó a mí.**
3. (Excuse me), **¿es Ud. el Sr. Adams?**
4. **Yo contesté** —(I am pleased to meet you).
5. —(The pleasure is mine)— **respondió el Sr. Carrillo.**
6. **El Sr. Carrillo llamó** (a taxi).
7. **Pensé** —(Lopez is very mistaken).
8. (Who knows what else?)
9. —(I am not in a hurry!)— **le grité al chófer.**
10. —(Neither am I), **señor** — **me contestó.**
11. **Tenemos un cuarto que** (faces the plaza).
12. **¿Cuánto es?** (Five hundred pesos a day).
## SEGUNDA PARTE
### Grammar Notes
1. The Preterite Tense. Model Verbs— **hablar, aprender, vivir**
The preterite tense is used in Spanish to tell of things that happened at a definite time in the past. **hablar** , to speak | **aprender** , to learn | **vivir** , to live
---|---|---
I spoke (did speak), etc. | I learned (did learn), etc. | I lived (did live), etc.
SINGULAR | SINGULAR | SINGULAR
**habl-é** | **aprend-í** | **viv-í**
**habl-aste** | **aprend-iste** | **viv-iste**
**habl-ó** | **aprend-ió** | **viv-ió**
PLURAL | PLURAL | PLURAL
**habl-amos** | **aprend-imos** | **viv-imos**
**habl-asteis** | **aprend-isteis** | **viv-isteis**
**habl-aron** | **aprend-ieron** | **viv-ieron**
1. To form the regular preterite tense of **-ar** verbs 1. Drop **-ar** from the infinitive | 2. Add to the remaining stem the endings:
---|---
SINGULAR: **-é, -aste, -ó** | PLURAL **-amos, -asteis, -aron**
2. To form the regular preterite tense of **-er** and **-ir** verbs 1. Drop **-er** or **-ir** from the infinitive. | 2. Add to the remaining stem the endings:
---|---
SINGULAR: **-í, -iste, -ió** | PLURAL **-imos, -isteis, -ieron**
The preterite endings of **-er** and **-ir** verbs are exactly the same.
3. **-ar** and **-ir** verbs have **-amos** and **-imos** respectively in the **nosotros** ( _we_ ) form of both the present and preterite.
The sense of the sentence will tell you which is meant. **Hoy hablamos.** | Today we speak. | **Hoy vivimos.** | Today we live.
---|---|---|---
**Ayer hablamos.** | Yesterday we spoke. | **Ayer vivimos.** | Yesterday we lived.
4. **dije** , _I said_ and **dijo** , _he said_ are irregular preterites. You will learn more about these and other irregular preterites later.
2. Preterite of **leer, creer, caerse** , and **oír** I read (did read), etc. | I believed, etc. | I fell, etc. | I heard, etc.
---|---|---|---
**lei** | **creí** | **me caí** | **oí**
**leíste** | **creíste** | **te caíste** | **oíste**
**leyó** | **creyó** | **se cayó** | **oyó**
**leímos** | **creímos** | **nos caímos** | **oímos**
**leísteis** | **creísteis** | **os caísteis** | **oísteis**
**leyeron** | **creyeron** | **se cayeron** | **oyeron**
Note carefully the forms:
**leyó, leyeron** | **creyó, creyeron** | **cayó, cayeron** | **oyó, oyeron**
### Ejercicios No. 128A.128B-128C-128D
128A. Conjugate the following verbs in the preterite tense:
1. **entrar**
2. **comer**
3. **salir**
4. **ver**
5. **sentarse**
128B. Translate:
1. **¿Quién olvidó los boletos?**
2. **Ayer recibimos las cartas.**
3. **El hombre compró un vestido nuevo.**
4. **Anoche no oímos el timbre.**
5. **¿Llegó a tiempo el tren?**
6. **Buscaron el equipaje.**
7. **El niño se cayó delante de la casa.**
8. **Salieron del aeropuerto en un libre.**
9. **¿Dónde esperó el Sr. Adams a su amigo?**
10. **¿Cuánto costó el impermeable?**
128C. Answer in the negative in complete Spanish sentences. Use the preterite.
Remember: A question with **Ud.** requires an answer in the singular (yo).
A question with **Uds.** requires an answer in the plural ( **nosotros** ).
**Ejemplo: ¿Trabajó Ud. anoche?** Did you work last night?
**No, no trabajé anoche.** No, I did not work last night.
1. **¿Compró Ud. ayer un sombrero nuevo?**
2. **¿Volvieron Uds. tarde del teatro anoche?**
3. **¿Escribió Ud. unas cartas esta mañana?**
4. **¿Llegaron Uds. a las ocho en punto?**
5. **¿Salió Ud. a las nueve de la noche?**
6. **¿Pasó Ud. el verano pasado en el campo?**
7. **¿Oyeron Uds. el timbre?**
8. **¿Vendió Ud. su casa?**
9. **¿Dejaron Uds. el dinero en casa?**
10. **¿Trabajaron Uds. toda la noche?**
128D. Translate into Spanish, using the verbs indicated in the preterite tense.
1. **(salir)** I left
2. **(llegar)** we arrived
3. **(examinar)** they examined
4. **(oír)** he heard
5. **(responder)** you **(Ud.)** answered
6. **(preguntar)** I did not ask
7. **(llamar)** she called
8. **(desear)** you **(Uds.)** wanted
9. **(salir)** we went out
10. **(parar)** it stopped
11. **(olvidar)** I did not forget
12. **(gritar)** he shouted
13. **(creer)** they believed
14. **(vender)** we sold
15. **(volver)** did you **(Uds.)** return?
16. **(leer)** did he read?
### Exercise No. 129—Preguntas
1. **¿Quiénes revisaron el equipaje?**
2. **¿Quién se acercó al Sr. Adams en la sala de espera?**
3. **¿Qué dijo el señor?**
4. **¿Qué contestó el Sr. Adams?**
5. **¿Cómo pasó el libre por una gran avenida?**
6. **¿Qué deseó decide el Sr. Adams al chófer?**
7. **¿Qué olvidó?**
8. **¿Qué vió el Sr. Adams por la ventanilla?**
9. **¿Qué le gritó al chófer?**
10. **¿Qué le contestó el chófer?**
11. **¿Cómo llegaron al fin al hotel?**
12. **¿Qué le dijo el Sr. Adams al dependiente?**
# CHAPTER 39
CAPÍTULO 39 (TREINTAY NUEVE)
## PRIMERA PARTE
### Una visita a la familia Carrillo
#### Segunda carta de México
**Estimado amigo** : | Dear Friend:
---|---
1. **El lunes pasado el Sr. Carrillo me llamó por teléfono. Quiso invitarme a tomar la merienda en su casa el día siguiente. Así es que tuve la oportunidad de visitar a una familia mexicana.** | 1. Last Monday Mr. Carrillo called me on the telephone. He wanted to invite me to take "tea" (have refreshments) at his house the following day. So it is that I had the opportunity to visit a Mexican family.
2. **A las cinco de la tarde llegué a una casa grande de piedra roja en la colonia Roma. Me acerqué a la puerta enorme.** | 2. At five o'clock in the afternoon I arrived at a big house of red stone in the Roma district. I approached the enormous door.
3. **Toqué el timbre e inmediatamente oí pasos rápidos en el zaguán. Una criada me abrió la puerta y me invitó a entrar en la casa.** | 3. I rang the bell and immediately I heard rapid steps in the vestibule. A servant opened the door and asked me to enter the house.
4. **El Sr. Carrillo vino a saludarme.—Ud. está en su casa—me dijo, según la costumbre mexicana.** | 4. Mr. Carrillo came to greet me. "My house is yours," ( _Lit_ You are in your house.) he said to me, according to the Mexican custom.
5. **Le di las gracias.—Su casa tiene un aspecto verdaderamente romántico. Me parece una casa de un cuento antiguo.** | 5. I thanked him. "Your house has a truly romantic appearance. It seems to me a house out of an old story."
6. — **Hay muchas casas semejantes en México—me respondió—Esa casa fue construida en el siglo diecisiete.** | 6. "There are many similar houses in Mexico," he answered me. "This house was built in the 17th century."
7. **Miré las paredes gruesas, los balcones y las ventanas altas con sus rejas de hierro. Me encantó el patio lleno de árboles y flores. Gran parte del suelo estaba 1 cubierto de azulejos. Admiré la fuente de piedra en el centro del patio.** | 7. I looked at the thick walls, the balconies, and tall windows with their iron grilles. The courtyard full of trees and flowers enchanted me. Most of the ground was covered with tile. I admired the stone fountain in the center of the courtyard.
8. **Entramos en una sala grande, uno de los muchos cuartos que dan al patio. El Sr. Carrillo me presentó a su esposa y a sus dos hijos, jóvenes muy serios e inteligentes.** | 8. We entered a big living room, one of the many rooms that face the courtyard. Mr. Carrillo introduced me to his wife and to his two sons, very serious and intelligent young men.
9. **Los muchachos me dijeron que asisten a una escuela secundaria. El mayor quiere hacerse medico. El menor quiere ser abogado.** | 9. The boys told me that they go to a secondary school. The elder wants to become a doctor. The younger wants to be a lawyer.
10. **Dentro de poco tuvieron que volver a su cuarto para estudiar.** | 10. Within a short time they had to go back to their rooms to study.
11. **La señora de Carrillo me sirvió una taza de chocolate y algunas tortas muy sabrosas. Entretanto el señor Carrillo y yo platícamos de la vida en México, de las costumbres y del arte.** | 11. Mrs. Carrillo served me a cup of chocolate and some very tasty cakes. Meanwhile Mr. Carrillo and I chatted about life in Mexico, about its customs and art.
12. **Me dijo que vale la pena ir al mercado de Toluca tanto para ver un mercado típico como para buscar ejemplares del arte popular. Me dijo que el viernes es el mejor día para visitarlo.** | 12. He told me that it is worth the trouble to go to the Toluca market as much to see a typical market as to look for samples of folk art. He told me that Friday is the best day to visit it.
13. **Le respondí que tenía 1 la intención de ir allá dentro de unos pocos días.** | 13. I answered that I intended to go there within a few days.
14. **Sintió no poder acompañarme.** | 14. He regretted not to be able to accompany me.
15. **Después de una hora y media muy interesante y divertida nos despedimos y volví a casa, es decir, a mi hotel.** | 15. After a very interesting and pleasant hour and a half we took leave of one another and I returned home, that is to say, to my hotel.
**Su sincero amigo** , | Your sincere friend,
**Juan Adams** | John Adams
**NOTE:** 1. Imperfect tense. You will learn this tense later
### Pronunciation and Spelling Aids
1. Practice: | lle- **gué** | sin- **tió** | **hie** -rro | **se** -cun- **da** -rio
---|---|---|---|---
| a-cer- **qué** | re-pi- **tió** | se-me- **jan** -te | **ver** -da-de-ra- **men** -te
| sir- **vió** | ro- **mán** -ti-co | in-me-dia-ta- **men** -te |
2. **el joven, los jóvenes.** The plural must add an accent mark to hold the stress on the syllable **jo-.**
### Building Vocabulary
1. **¿De qué lo hace?** What is it made of? 1. **casa de piedra** | stone house
---|---
2. **reja de hierro** | iron grille
3. **silla de madera** | wooden chair
4. **falda de algodón** | cotton skirt
5. **guantes de lana** | woolen gloves
6. **vestido de seda** | silk dress
**NOTE** : In Spanish, what things are made of is indicated by **de** plus the material, not by using the material as an adjective. Thus **casa de piedra** (house of stone).
2. **la merienda** , a light afternoon meal, "tea." The Mexicans eat la **cena** , supper, rather late in the evening, about 8 or 9 o'clock or later.
### Expresiones Importantes
1. **al día siguiente** | on the following day
---|---
2. **es decir** | that is to say
3. **hacerse** | to become ( _Lit._ to make oneself)
**Se hace médico (abogado, ingeniero).** | He becomes a doctor (lawyer, engineer).
4. **llamar por teléfono** to call by phone | **Llamé por teléfono.** I telephoned.
5. **Tener la intención de** to intend to | **Tengo la intención de salir.** I intend to leave.
### Ejercicio No. 130—Completion of Text
1. **El Sr. Carrillo** (telephoned me).
2. **Quiso invitarme** (to have "tea") **en su casa.**
3. (The following day) **llegué a su casa.**
4. (I approached) **a la puerta.**
5. **Una criada** (invited me to enter) **en la casa.**
6. **El Sr. Carrillo** (came to greet me).
7. —(You are in your house)— **me dijo.**
8. **Me saludó** (according to the Mexican custom).
9. (It looks to me like) **una casa de un cuento antiguo.**
10. **Hay** (many similar houses) **en México.**
11. (I admired) **la fuente de piedra.**
12. (He presented me) **a la señora de Carrillo.**
13. **El hijo mayor quiere** (to become a doctor).
14. (He was sorry) **no poder acompañarme.**
15. (We took leave) **y volví** (home).
## SEGUNDA PARTE
### Grammar Notes
1. The Irregular Preterite with **-i** Stems. **hacer** to do (make) | **querer** to wish | **venir** to come | **decir** to say
---|---|---|---
I did (made), etc. | I wished, etc. | I came, etc. | I said, etc.
**hic-e** | **quis-e** | **vin-e** | **dij-e**
**hic-iste** | **quis-iste** | **vin-iste** | **dij-iste**
**hiz-o** | **quis-o** | **vin-o** | **dij-o**
**hic-imos** | **quis-imos** | **vin-imos** | **dij-imos**
**hic-isteis** | **quis-isteis** | **vin-isteis** | **dij-isteis**
**hic-ieron** | **quis-ieron** | **vin-ieron** | **dij-eron**
1. Irregular verbs of this group have an **-i** in the preterite stem.
2. The ending of the ( **yo** ) form is unaccented -e instead of **-i** ; the ending of the **(Ud., él, ella)** form is unaccented **-o** instead of **-ió.**
3. In the form **hizo, z** replaces **c**.
4. You know that the ( **yo** ) form of the present tense of these verbs ends in unaccented **-o.**
**hago** I do | **quiero** I wish | **vengo** I come | **digo** I say
---|---|---|---
2. The Preterite of Stem-Changing Verbs like **pedir (i).** **pedir (i)** to ask for | **servir (i)** to serve | **repetir (i)** to repeat | **vestir (i)** to dress
---|---|---|---
I asked for, etc. | I serve, etc. | I repeated, etc. | I dressed, etc.
**pedí** | **serví** | **repetí** | **vestí**
**pediste** | **serviste** | **repetiste** | **vestiste**
**pidió** | **sirvió** | **repitió** | **vistió**
**pedimos** | **servimos** | **repetimos** | **vestimos**
**pedisteis** | **servisteis** | **repetisteis** | **vestisteis**
**pidieron** | **sirvieron** | **repitieron** | **vistieron**
1. The preterite of verbs like **pedir (i)** is formed almost exactly like the regular preterite of **-ir** verbs. The only differences are in the stem of the **(Ud., él, ella)** form **(pidió)** and in the **(Uds., ellos, ellas)** form **(pidieron)** where **-i-** replaces **-e-** in the stem.
2. Note the same difference in the preterite of **sentir** to regret. **sentí** | **sentiste** | **sintió** | **sentimos** | **sentisteis** | **sintieron**
---|---|---|---|---|---
### Ejercicios No. 131A-131B-131C
131A. Translate:
1. **La criada nos sirvió la merienda.**
2. **¿Por qué no quiso Ud. invitarme?**
3. **Anoche volvimos tarde del teatro.**
4. **Quise llamarlo a Ud. por teléfono.**
5. **¿Qué hizo Ud. después de la comida?**
6. **Dijeron:—No tenemos prisa.**
7. **Repetí todas las respuestas.**
8. **Mi amigo no vino a tiempo. Lo sentí.**
9. **Pidieron información en la oficina de información.**
10. **Quisieron comprar boletos de avión.**
131B. Answer in complete sentences the following questions using the suggested words in the answer.
**Ejemplo: ¿Qué quiso Ud. comprar? (guantes de lana)**
**Quise comprar guantes de lana.**
1. **¿Qué le dijo al señor? (Pase Ud.)**
2. **¿Quién hizo un viaje al Peru? (mi hermano)**
3. **¿Cuándo vino Ud. a casa? (a las siete)**
4. **¿De qué se vistieron las mujeres? (de falda de algodón)**
5. **¿Qué quiso hacerse el hijo mayor? (médico)**
6. **¿Qué sirvió la criada? (una taza de chocolate)**
7. **¿Qué pidió el viajero? (información)**
8. **¿Qué quisieron ver Uds.? (la película nueva)**
9. **¿Cuándo hicieron Uds. un viaje a México? (el año pasado)**
10. **¿Qué dijeron Uds. cuando salieron de la casa? (hasta la vista)**
131C. Translate. Use the correct forms of **querer, decir, hacer, servir(i), repetir(i)** , and **sentir(ie).**
1. I wished
2. I did not say
3. he made
4. they came
5. she served
6. they wished
7. I repeated
8. we made
9. they said
10. they made
11. What did he say?
12. What did you (Uds.) say?
13. we did not wish
14. I did not come
15. they regretted
### Ejercicio No. 132—Preguntas
1. **¿Quién llamó al Sr. Adams por teléfono?**
2. **¿A qué hora llegó a la casa del señor Carrillo?**
3. **¿Quién le abrió al Sr. Adams la puerta?**
4. **¿Quién vino a saludar al Sr. Adams?**
5. **¿Qué le encantó al Sr. Adams?**
6. **¿Qué admiró él?**
7. **¿Cómo son los hijos del Sr. Carrillo?**
8. **¿A qué clase de escuela asisten los jóvenes?**
9. **¿Qué quiere hacerse el hijo mayor?**
10. **¿A dónde tuvieron que volver los jóvenes?**
11. **¿De qué conversaron entretanto los señores?**
12. **¿Vale la pena de ir al mercado de Toluca?**
13. **¿Quién quiso ir allá?**
14. **¿Después de una hora quiénes se despidieron?**
15. **¿Adónde volvió el Sr. Adams?**
# CHAPTER 40
CAPÍTULO 40 (CUARENTA)
## PRIMERA PARTE
### El Paseo de la Reforma
#### Tercera carta de México
**Estimado amigo** : | Dear Friend:
---|---
1. **¡Qué hermoso es el Paseo de la Reforma! Los árboles son tan grandes, los edificios tan imponentes, algunos de estilo español, algunos de estilo moderno, otros que combinan los dos estilos. La avenida es tan ancha, tan espaciosa que parece un no enorme.** | 1. How beautiful the Paseo de la Reforma is! The trees are so big, the buildings so impressive—some in Spanish style, some in modern style, others that combine the two styles. The avenue is so wide, so spacious that it seems like an enormous river.
2. **Naturalmente, tuve que pensar en nuestra conversación sobre las calles de México. Recordé que al norte del Paseo se puede cruzar algunos de los grandes ríos del mundo. Al sur del Paseo, como Ud. me dijo, se puede caminar por algunas de las ciudades más grandes de Europa.** | 2. Naturally, I had to think of our conversation about the streets of Mexico. I remembered that north of the Paseo one can cross some of the great "rivers" of the world. South of the Paseo, as you told me, one can walk along some of the largest "cities" of Europe.
3. **Ayer pude ver esto por mí mismo. Era 1 domingo. El Sr. Carrillo y yo nos encontramos cerca del «Caballito».** | 3. Yesterday I could see this for myself. It was Sunday. Mr. Carrillo and I met near the "Caballito."
4. **Le pregunté:—¿Qué es este «Caballito»? Mi profesor de español, Eugenio López, me dijo que las terminaciones -ito, -cito, e -illo quieren de-cir algo pequeño. También se usan estas terminaciones para expresar cariño. Pero—seguí yo—no veo más que una estatua enorme.** | 4. I asked him: "What is this 'Caballito'? My Spanish professor, Eugene Lopez, told me the endings -ito, -cito, and -illo mean something small. These endings are also used to express affection. But," I continued, "I only see an enormous statue."
5. **El Sr. Carrillo me respondió que precisamente por eso se llama el «Caballito». ¡Es un ejemplo del humor mexicano! Esta estatua, que representa al rey Carlos IV (cuarto) de España montado en su caballo chico, domina el Paseo.** | 5. Mr. Carrillo replied that just for that reason it is called the "Caballito." It is an example of Mexican humor. This statue (which represents King Charles IV) (Fourth) of Spain mounted on his "tiny" horse dominates the Paseo.
6. **A lo largo del Paseo de la Reforma, que se extiende desde el «Caballito» hasta el Parque de Chapultepec, vimos otros monumentos históricos. Ud. los conoce bien, el monumento de la Independencia, la estatua de Cristobal Colón y el monumento a Cuauhtémoc.** | 6. Along the Paseo de la Reforma, which stretches from the "Caballito" to Chapultepec Park, we saw other historical monuments. You know them well—the monument of Independence, the statue of Christopher Columbus, and the monument to Cuauhtemoc.
7. **He leído algo sobre este héroe de los aztecas, Cuauhtemoc, que tan valerosamente defendió a su nación contra los españoles.** | 7. I have read something about this hero of the Aztecs, Cuauhtemoc, who so bravely defended his nation against the Spaniards.
8. **Cuando vi todos aquellos monumentos comprendí el orgullo de los mexicanos en el pasado de la nación.** | 8. When I saw all those monuments I understood the pride of the Mexicans in the nation's past.
9. **No lejos del Parque de Chapultepec, el Sr. Carrillo me señaló un edificio casi enteramente de cristal, muy moderno en todos sus detalles.—Es el edificio del Seguro Social—-me dijo.—Aquí tiene Ud. la arquitectura del futuro, ¿verdad?** | 9. Not far from Chapultepec Park, Mr. Carrillo pointed out to me a building almost entirely of glass, very modern in all its details. "It is the Social Security Building," he told me. "Here is the architecture of the future, isn't it?"
10. **De veras, pude comprender el orgullo de los mexicanos, no solamente en su pasado, sino también en su porvenir.** | 10. Indeed I could understand the pride of the Mexicans not only in their past but also in their future.
**Saludos cordiales de su amigo** , | Best regards from your friend,
**Juan Adams** | John Adams
**NOTE** : 1. **Era** = Imperfect tense of **ser** to be
### Pronunciation and Spelling Aids
1. Practice: | im-po- **nen** -te | es- **ta** -tua | va-le-ro-sa- **men** -te | en-te-ra- **men** -te | Co- **lón**
---|---|---|---|---|---
| es-pa- **cio** -so | mo-nu- **men** -to | pre-ci-sa- **men** -te | Cuauh- **té** -moc | Cha-pul-te- **pec**
| ca-ba- **lli** -to | ter-mi-na- **ción** | | Cris- **tó** -bal |
### Building Vocabulary
A. **Related Words**
1. **pasar** | to pass | **el pase** | pass, permit
---|---|---|---
**el paso** | the step, passage | **pase de turista** | tourist's pass
**el pasillo** | corridor | |
2. **pasear** or **pasearse** | to stroll | **el paseante** | the stroller
**el paseo** | the walk, promenade | **dar un paseo** | to take a walk
3. **parecer** | to seem to appear | **Me parece bien.** | It seems all right to me.
**parecerse a** | to resemble | **La avenida se parece a un río.** | The avenue resembles a river.
### Ejercicio No. 133—Completion of Text
Complete these sentences based on the text.
1. ¡(How beautiful) **es el Paseo de la Reforma!**
2. **La avenida es** (wide and spacious).
3. (It seems like) **un río enorme.**
4. **Al norte** (one may cross) **algunos de los ríos más grandes** (in the **world).**
5. **Al sur** (one may walk) **por algunas** (of the largest cities).
6. (Yesterday) **fui al cine. Era domingo.**
7. **Juan y yo** (met) **cerca del «Caballito».**
8. **Las terminaciones -ito, -cito e -illo** (mean something small).
9. (I see only) **una estatua enorme.**
10. **Este «Caballito» representa** (King Charles IV of Spain).
11. 11. (You know well) **el monumento a Cuauhtémoc.**
12. (I have read something) **sobre este héroe.**
13. (I saw) **todos aquellos monumentos.**
14. **Aquel edificio es** (almost entirely of glass).
15. (I could understand) **el orgullo de los mexicanos.**
## SEGUNDA PARTE
### Grammar Notes
1. Irregular Preterites with **-u** Stems.
In the last chapter you learned the irregular preterite of some familiar verbs. Here are more familiar verbs with an irregular preterite. **poder** to be able | **poner** to put | **tener** to have | **estar** to be | **saber** to know
---|---|---|---|---
I was able etc. | I put (did put), etc. | I had, etc. | I was, etc. | I knew etc.
**pud-e** | **pus-e** | **tuv-e** | **estuv-e** | **sup-e**
**pud-iste** | **pus-iste** | **tuv-iste** | **estuv-iste** | **sup-iste**
**pud-o** | **pus-o** | **tuv-o** | **estuv-o** | **sup-o**
**pud-imos** | **pus-imos** | **tuv-imos** | **estuv-imos** | **sup-imos**
**pud-isteis** | **pus-isteis** | **tuv-isteis** | **estuv-isteis** | **sup-isteis**
**pud-ieron** | **pus-ieron** | **tuv-ieron** | **estuv-ieron** | **sup-ieron**
1. Irregular verbs of this group have a -u in the preterite stem.
2. The endings are the same as the irregular preterites (of **hacer** , etc.) you have already learned.
3. **saber** to know, in the preterite usually means _learned, found out._
**Supe el nombre del médico.** I learned the name of the doctor.
2. More Irregular Preterites **dar** to give | **ser** to be | **ir** to go
---|---|---
I gave, etc. | I was, etc. | I went, etc
**di** | **fui** | **fui**
**diste** | **fuiste** | **fuiste**
**dio** | **file** | **fue**
**dimos** | **fuimos** | **fuimos**
**disteis** | **fuisteis** | **fuisteis**
**dieron** | **fueron** | **fueron**
The verbs **ser** and **ir** have exactly the same forms in the preterite tense. The sense of the sentence will always tell you which verb is meant. Thus:
**Isabel file reina de España.** | Isabel was queen of Spain.
---|---
**Cristobal Colon file a ver a la reina.** | Christopher Columbus went to see the queen.
3. The personal **a** is always used before a specific person. It is often used before cities and animals that are important to a person. **La estatua representa al rey y a su caballo.** | The statue represents the king and his horse.
---|---
### Ejercicios No. 134A-134B-134C
134A. Translate:
1. **En Navidad di regalos a todos los niños.**
2. **No tuve oportunidad de conocerlo a Ud. personalmente.**
3. **No pudimos pagar toda la cuenta.**
4. **Esta casa fue construida en el siglo dieciséis**
5. **El domingo dimos un paseo por el Parque de Chapultepec.**
6. **Pude conversar con él en su idioma.**
7. **El no tuvo dificultad en entenderme.**
8. **Ella no quiso descansar mucho.**
9. **La familia del Sr. Adams no pudo acompañarlo.**
10. **Me puse el sombrero nuevo en la cabeza.**
134B. Change these sentences from the present to the preterite. Be sure to keep the same person.
#### Ejemplo: Pongo la mesa. Puse la mesa.
1. **Tengo que estudiar la lección.**
2. **El Sr. Adams está en el comedor.**
3. **Los árboles se ponen verdes.**
4. **El le da las gracias al Sr. Carrillo.**
5. **Soy un estudiante trabajador.**
6. **Vamos al mercado.**
7. **Vienen del cine a las once.**
8. **No digo nada.**
9. **Uds. no hacen nada.**
10. **¿Quieren Uds. comprarlo?**
134C. Translate, using the preterite of the given verbs.
1. **(tener)** I had
2. **(poder)** you **(Ud.)** were able
3. **(ir)** they went
4. **(decir)** she said
5. **(poner)** he put
6. **(querer)** we wished
7. **(dar)** they gave
8. **(ser)** I was
9. **(estar)** you **(Uds.)** were
10. **(encontrarse)** we met
### Ejercicio No. 135—Preguntas
1. **¿Cómo se titula esta lectura?**
2. **¿Es ancho o estrecho el Paseo de la Reforma?**
3. **¿En qué conversación tuvo que pensar el Sr. Adams?**
4. **¿Qué se puede cruzar al norte del Paseo?**
5. **¿Por dónde se puede caminar al sur del Paseo?**
6. **¿Qué día de la semana fue ayer?**
7. **¿Dónde se encontraron el Sr. Adams y el Sr. Carrillo?**
8. **¿Qué quieren decir las terminaciones -ito, -cito, e -illo?**
9. **¿A quién representa el «Caballito»?**
10. **¿Es grande o pequeño este «Caballito»?**
11. **¿Qué conoce bien el Sr. López?**
12. **¿Quién leyó algo sobre Cuauhtémoc?**
13. **¿Contra quiénes defendió a su nación?**
14. **¿Qué edificio en el Paseo es casi enteramente de cristal?**
15. **¿Dónde está este edificio?**
# CHAPTER 41
CAPÍTULO 41 (CUARENTA Y UNO)
## PRIMERA PARTE
### El meracado de Toluca
#### Cuarta carta de México
**Querido amigo** : | Dear Friend:
---|---
1. **La semana pasada fui al mercado de Toluca.** | 1. Last week I went to the Toluca market.
2. **La ciudad de Toluca está situada a unas cuarenta millas de México D.F.** | 2. The city of Toluca is located about forty miles from Mexico City.
3. **Mientras nuestro camión pasaba por las montañas vi mujeres y hombres caminando a lo largo de la ruta. Algunos llevaban cestas de caña.** | 3. While our bus passed through the mountains, I saw women and men walking alongside the road. Some were carrying baskets made of cane.
4. **Era viernes y el mercado estaba lleno de gente. Probablemente la mayoría vino del campo pero había también mucha gente de la ciudad y de otras partes del mundo.** | 4. It was Friday and the market was full of people. Probably most of them came from the country but there were also many people from the town and from other parts of the world.
5. **Uno puede fácilmente perderse en este mercado tan grande. Pero yo no tenía difícultad porque sabía pedir información en español.** | 5. One can easily get lost in this very big market. But I did not have difficulty because I knew how to ask for directions in Spanish.
6. **Mientras caminaba por una calle de puestos donde se vendían ropa, zapatos y sombreros, vi a un muchacho de siete u ocho años, de aspecto muy serio, cuidando un puesto.** | 6. While I was walking through a street of stalls where clothing, shoes, and hats were being sold, I saw a boy of seven or eight years with a very serious appearance watching a stall.
7. **Se parecía mucho a un viejecito con su sombrero de ala ancha y sus pantalones muy grandes. Como los demás vendedores arreglaba su mercancía con sumo cuidado. También vi que regateaba en serio.** | 7. He looked very much like a little old man with his broad-brimmed hat and his very large trousers. Like the rest of the sellers he was arranging his merchandise with extreme care. I also saw that he was bargaining seriously.
8. **En el mercado se vendía toda clase de mercancía, como fruta, flores, cerámica, cestas, ropa, sarapes. Había cosas corrientes y artículos de lujo.** | 8. All kinds of merchandise were being sold in the market—such as fruit, flowers, ceramics, baskets, clothing, blankets. There were ordinary things and luxury articles.
9. **Por todas partes veía el sentido estético de los vendedores. Hasta entre los puestos de comidas encontré color y arte.** | 9. Everywhere I saw the aesthetic sense of the sellers. Even among the food stalls I found color and art.
10. **Por ejemplo, una mujer estaba sentada en la acera. Delante de ella había unas pocas cebollas y chiles. Los arreglaba con mucho cuidado en montones pequeños.** | 10. For example, a woman was seated on the sidewalk. Before her there were a few onions and chiles. She was carefully arranging them in little piles.
11. **Junto a ella vi un puesto de frutas con algunas hojas verdes cerca de los mangos anaranjados y los plátanos amarillos.** | 11. Near her I saw a fruit stall with some green leaves near the orange-colored mangos and the yellow bananas.
12. **Cerca de esos puestos escuché la charla de las mujeres y pude aprender algo sobre la vida del campo.** | 12. Near those stalls I listened to the chatting of the women and I could learn something about life in the country.
13. **Supe que los campesinos vienen al mercado no solamente para vender y comprar sino también para divertirse, para charlar y para visitar a sus amigos.** | 13. I learned that the peasants come to the market not only to sell and to buy but also to enjoy themselves, to chat, and to visit their friends.
14. **La gente gritaba, charlaba, compraba, vendía, reía, todos con animación y humor.** | 14. The people were shouting, chatting, buying, selling, laughing, all with liveliness and humor.
15. **De veras pasé un día muy interesante y muy divertido en el mercado de Toluca.** | 15. Indeed I spent a very interesting and very enjoyable day in the Toluca market.
16. **Y mientras iba a casa, es decir, a la capital, recordaba nuestras conversaciones en que hablábamos de los mercados de México y de tantas otras cosas.** | 16. And while I was going home, that is to say to the capital, I kept remembering our conversations in which we used to speak of the markets of Mexico and of so many other things.
**Afectuosamente** , | Affectionately,
**Juan Adams** | John Adams
### Pronunciation and Spelling Aids
1. Practice: es- **té** -ti-ca | la- **va** -ba | a-rre- **gla** -ba
---|---|---
**plá** -ti-ca | cor- **ta** -ba | re-ga-te- **a** -ba
**fá** -cil- **men** -te | es- **ta** -ba | es-cu- **cha** -ba
pro-ba-ble- **men** -te | ca-mi- **na** -ba | gri- **ta** -ba
char- **la** -ba | **é** -ra-mos | re- **í** -a
com- **pra** -ba | í- **ba** -mos | ven- **dí** -a
ha- **blá** -ba-mos | ha- **bí** -a
com- **prá** -ba-mos | te- **ní** -a
### Building Vocabulary
1. **Palabras Relacionadas** 1. **el ánimo** | animation
---|---
**animado** | animated, lively
2. **campo** | country, field
**campesino** | farmer, peasant
3. **difícil** | difficult
**la difícultad** | difficulty
4. **divertirse** | to enjoy oneself
**divertido** | enjoyable
5. **la naranja** | orange
**anaranjado** | orange-colored
6. **platicar** | to chat
**la plática** | chatting, conversation
2. **La gente** people: requires a singular verb in Spanish.
**La gente del campo estaba allí.** The country people were there.
### Ejercicio No. 136—Completion of Text
1. (Last week) **fui al mercado.**
2. (I saw) **mujeres** (who) **lavaban ropa.**
3. **El mercado estaba** (full of people).
4. **Vinieron** (from the country).
5. **Se puede fácilmente** (lose one's way).
6. **Yo caminaba** (through a street of stalls).
7. (I saw) **a un muchacho** (of seven or eight years).
8. (Like the other sellers) **arreglaba su mercancía.**
9. **Se vendían en el mercado** (flowers, baskets, and clothing).
10. (Among the stands) **encontré color y arte.**
11. **Los campesinos vienen** (to enjoy themselves).
12. **Yo escuché** (the chatting of the women).
13. **Aprendí un poco** (about country life).
14. (I remembered) **nuestras conversaciones.**
15. **Pasé** (a very pleasant day).
## SEGUNDA PARTE
### Grammar Notes
1. The Imperfect Tense.
You have learned two tenses which indicate past time, the present perfect and the preterite. Of the two the preterite is more commonly used.
You will now learn a third tense that refers also to past time, the imperfect. We may call the imperfect the _"was, were, or used to"_ tense because it indicates actions that _were_ happening or _used to_ happen in past time. Thus:
1. _We were working_ when he entered.
2. _He used to do_ his lessons in the evening.
In sentence a., _were working_ is in the imperfect; _he entered_ , which interrupts the working at a definite moment, is in the preterite.
2. The Imperfect of Model Verbs— **hablar, aprender** , and **vivir.** SINGULAR | SINGULAR | SINGULAR
---|---|---
I was speaking, etc. | I was learning, etc. | I was living, etc.
**habl-aba** | **aprend-ía** | **viv-ía**
**habl-abas** | **aprend-ías** | **viv-ías**
**habl-aba** | **aprend-ía** | **viv-ía**
PLURAL | PLURAL | PLURAL
**habl-ábamos** | **aprend-íamos** | **viv-íamos**
**habl-abais** | **aprend-íais** | **viv-íais**
**habl-aban** | **aprend-ían** | **viv-ían**
1. To form the imperfect of all **-ar** verbs, without exception:
1. Drop **-ar** from the infinitive.
2. Add the endings **-aba, -abas, -aba; -ábamos, -abais** , and **-aban** to the remaining stem.
2. To form the imperfect of all **-er** and **-ir** verbs with the exception of **ver, ser** , and **ir** :
1. Drop **-er** or **-ir** from the infinitive.
2. Add the endings **-ía, -ías, -ía; -íamos, -íais** , and -ían, to the remaining stem.
3. The stress is on the first syllable ( **-a** ) in all the **-aba** endings.
To prevent it from shifting in the **-ábamos** ending the first -a must have an accent mark.
The stress in the **-ía** endings is always on the **i**.
4. The endings of the **yo** and the **(Ud., él, ella)** forms of the verb are alike in the imperfect.
The subject pronoun is used when the meaning is not clear
3. The Imperfect of **ver, ser** , and **ir.** I was seeing, etc. | I was, etc. | I was going, etc.
---|---|---
**veía** | **veíamos** | **era** | **éramos** | **iba** | **íbamos**
**veías** | **veíais** | **eras** | **erais** | **ibas** | **ibais**
**veía** | **veían** | **era** | **eran** | **iba** | **iban**
1. The endings of **veía** are regular. But the endings are added to **ve-** not to **v-.**
2. In all forms of **era** and **iba** the stress must be on the first syllable. To prevent it from shifting, an accent mark is added to the first syllable of **éramos** and **íbamos.**
### Ejercicios No. 137A-137B-137C
137A. Translate.
1. **Llovía a cántaros cuando nos despedimos de los jóvenes.**
2. **Yo pensaba en Ud. cuando me paseaba en coche por las calles cuyos nombres son fechas.**
3. **Los turistas y los vendedores regateaban y todos parecían divertirse mucho.**
4. **Me acercaba a la puerta cuando encontré a los hijos del Sr. Carrillo.**
5. **Mientras hablábamos sobre las artes populares, la señora de Carrillo leía un periódico.**
6. **Hacía mucho calor cuando volvimos a los Estados Unidos.**
7. **Cuando el coche se ponía en marcha se acercó un policía** (policeman).
8. **Los aviones llegaban y salían a todas horas.**
9. **Estábamos cansados pero no queríamos descansar.**
10. **Ya eran las cuatro y media de la tarde y teníamos prisa.**
137B. Each of these sentences indicates an action that was going on ( _imperfect_ ) and another action which interrupted it at a definite time ( _preterite_ ). Translate the verbs in parentheses, using the correct tense.
1. **Mientras** (I was eating), **me llamó por teléfono.**
2. **Cuando** (we were studying), **entraron en nuestro cuarto.**
3. **Cuando** (he was) **enfermo, lo visitamos.**
4. **Mientras** (you were taking leave), **empezó a llover.**
5. **Cuando** (they were taking a walk), **se perdieron.**
6. **Los vendedores** (were shouting) **cuando llegamos al mercado.**
7. **Cayó en la acera cuando** (he was getting out) **del auto.**
8. **No nos oyeron cuando** (we were speaking).
9. **Los encontramos cuando** (they were going) **al mercado.**
10. **Cuando** (we were passing) **por una avenida grande vimos a los vendedores.**
137C. Translate the following verbs in the correct tense, preterite or imperfect as necessary.
1. **(caminar)** I was walking
2. **(ir)** I was going
3. **(decir)** he said
4. **(jugar)** they were playing
5. **(cantar)** they sang
6. **(ver)** we were seeing
7. **(correr)** they were running
8. **(perder)** you **(Ud.)** lost
9. **(vivir)** they lived
10. **(leer)** she read
11. **(empezar)** it began
12. **(llamar)** they were calling
13. **(entrar)** you **(Uds.)** did not enter
14. **(estar)** were you ( **Ud.** )? (imperfect)
15. **(ser)** we were (imperfect)
16. **(oír)** they heard
### Ejercicio No. 138—Preguntas
1. **¿Por dónde pasaba el camión?**
2. **¿Qué día de la semana era?**
3. **¿De dónde vino la mayor parte de la gente?**
4. **¿Había 1 también gente de la ciudad?**
5. **¿Por qué no tenía dificultad el Sr. Adams?**
6. **¿A quién vio mientras caminaba?**
7. **¿A quién se parecía el muchacho?**
8. **¿Qué clase de sombrero llevaba?**
9. **¿Qué arreglaba el muchacho?**
10. **¿Qué veía por todas partes el Sr. Adams?**
11. **¿Quién estaba sentada en la acera?**
12. **¿Qué había delante de ella?**
13. **¿Cuándo recordaba el Sr. Adams sus conversaciones con el Sr. López?**
**NOTE** : 1. The imperfect of **hay** ( _there is_ or _there are_ ) is **había** ( _there was_ or _there were_ ).
The preterite is **hubo** ( _there was_ or _there were_ ).
# CHAPTER 42
CAPÍTULO 42 (CUARENTA Y DOS)
## PRIMERA PARTE
### Sobre el descanso
#### Quinta carta de México
**Querido amigo** : | Dear Friend:
---|---
1. **Ud. recordará, amigo mío, sus últimos consejos antes de mi salida para México. Me dijo: —No tenga prisa. Camine despado. Descanse varias horas por la tarde. De verda, no he olvidado sus consejos acerca del descanso, pero tengo que confesar, no descanso largo rato. Hay tanto que ver, tanto que oír, tanto que descubrir, tanto que hacer.** | 1. You will remember, my friend, your final advice before my departure for Mexico. You told me Don't be in a hurry. Walk slowly. Rest several hours in the afternoon. Indeed I have not forgotten your advice concerning resting, but I must confess—I don't rest very much. There is so much to see, so much to hear, so much to discover, so much to do.
2. **Ayer, por ejemplo, me paseaba al mediodía en la Alameda. Siempre hay allí una brisa y cuando hay mucho sol es muy agradable debajo de los grandes árboles cerca de una fuente de agua fresca.** | 2. Yesterday, for example, I was strolling at noon in the Alameda. There is always a breeze there and when it's very sunny it is very pleasant under the big trees near a fountain of fresh water.
3. **Pero no pude descansar por mucho tiempo. Al otro lado de la Avenida Juárez estaban las tiendas donde se venden artefactos, libros, artículos de cuero, de paja, de tela, de plata y de cristal. Muchas veces he visitado aquellas tiendas pero no pude resistir la tentación de volver a visitarlas.** | 3. But I was not able to rest very long. On the other side of Juarez Avenue there were shops that sell artifacts, books, and goods made of leather, straw, cloth, silver, and glass. I have often visited those shops but I was not able to resist the temptation to visit them again.
4. **También tuve que visitar otra vez el Museo de Artes e Industrias Populares. Nunca me canso de mirar las artes de los indios, ni de hacerles preguntas a los dependientes en la tienda del museo y al director.** | 4. I also had to visit once again the Museum of Folk Arts & Industries. I never tire of looking at the arts of the Indians, nor of asking questions of the sales people in the shop of the museum and of the director.
5. **Saliendo del museo, que está al sur del parque en la Avenida Juárez, volví a visitar el Palacio de Bellas Artes, que está al este del parque. Todavía no he asistido a ningún concierto en el palacio, pero me gusta mucho mirar los cuadros y las pinturas murales de los grandes artistas de México.** | 5. Leaving the museum, which is to the south of the park on Juarez Avenue, I again visited the Palace of Fine Arts, which is to the east of the park. I have not as yet attended any concert in the palace, but I enjoy very much looking at the pictures and murals of the great artists of Mexico.
6. **Pues, Sr. López, Ud. ve que voy aprendiendo más cada día, sobre todo porque soy muy hablador. Y sus consejos me han sido muy útiles, excepto (tengo que confesarlo otra vez) los que me dio sobre el descanso.** | 6. Well, Mr. Lopez, you see I am learning more every day, especially because I am very talkative. And your advice has been very useful to me, except (I must confess again) that which you gave me about resting.
**Reciba un apretón de manos de su amigo** , | Receive a handshake from your friend,
**Juan Adams** | John Adams
### Ejercicio No. 139—Completion of Text
1. (Before my departure) **para México, me dijo** :—(Don't be in a hurry).
2. (I have not forgotten) **sus consejos.**
3. (I do not rest) **por mucho tiempo.**
4. **Hay** (so much to discover).
5. (Yesterday) **descansaba yo** (at noon).
6. **En la avenida** (are sold) **artefactos.**
7. (I was not able) **resistir la tentación.**
8. (I visited again) **el Palacio de Bellas Artes.**
9. (Not yet) **he asistido a un concierto.**
10. (I like very much) **las pinturas de los** grandes (painters).
## SEGUNDA PARTE
### Grammar Notes
1. The Possessive Pronouns
In Spanish as in English there are possessive adjectives and possessive pronouns. The possessive adjectives **mi, tu, su** , etc. are important and useful words and you have learned and used them a great deal. Study the following examples: POSSESSIVE ADJECTIVES | POSSESSIVE PRONOUNS
---|---
(a) | (a)
**Mi** ( _my_ ) **libro es rojo.** | **El mío** ( _mine_ ) **es rojo.**
**Mi** ( _my_ ) **pluma es roja.** | **La mía** ( _mine_ ) **es roja.**
**Mis** ( _my_ ) **libros son rojos.** | **Los míos** ( _mine_ ) **son rojos.**
**Mis** ( _my_ ) **plumas son rojas.** | **Las mías** ( _mine_ ) **son rojas.**
(b) | (b)
**Es mi** ( _my_ ) **libro.** | **El libro es mío** ( _mine_ ).
**Es mi** ( _my_ ) **pluma.** | **La pluma es mía** ( _mine_ ).
**Son mis** ( _my_ ) **libros.** | **Los libros son míos** ( _mine_ ).
**Son mis** ( _my_ ) **plumas.** | **Las plumas son mías** ( _mine_ ).
1. The possessive pronoun agrees in number and gender with the noun for which it stands. Each form is preceded by **el, la, los** or **las.** (Group a)
2. When the possessive pronoun comes after the verb **ser** , the definite article is omitted. (Group b)
3. The complete table of possessive pronouns: SINGULAR | | PLURAL
---|---|---
**el mío** | **la mía** | **los míos** | **las mías** | mine
**el tuyo** | **la tuya** | **los tuyos** | **las tuyas** | yours (fam.)
**el suyo** | **la suya** | **los suyos** | **las suyas** | yours, his, hers, theirs
**el nuestro** | **la nuestra** | **los nuestros** | **las nuestras** | ours
**el vuestro** | **la vuestra** | **los vuestros** | **las vuestras** | yours (fam.)
4. Memorize the following common expressions in which the long form of the possessive follows the noun: **amigo mío** my friend (m.) | **un amigo mío** a friend of mine
---|---
**amiga mía** my friend (f.) | **unos amigos míos** some friends of mine
**amigos míos** my friends | **unos amigos nuestros** some friends of ours
**amigas mías** my friends (f.) | **unos amigos suyos** some friends of yours
2. The Definite Article as a Pronoun. a. **el libro de Pedro y el libro de Ana** | Peter's book and Anna's book
---|---
**la pluma de Pedro y la pluma de Ana** | Peter's pen and Anna's pen
**los libros de Pedro y los libros de Ana** | Peter's books and Anna's books
**las plumas de Pedro y las plumas de Ana** | Peter's pens and Anna's pens
b. **el libro de Pedro y _el_ de Ana** | Peter's book and _that_ of Anna
**la pluma de Pedro y _la_ de Ana** | Peter's pen and _that_ of Anna
**los libros de Pedro y _los_ de Ana** | Peter's books and _those_ of Anna
**las plumas de Pedro y _las_ de Ana** | Peter's pens and _those_ of Anna
In group a, the noun is repeated in each sentence. This, as you see, is monotonous. In group b, the noun is not repeated and the article that remains is translated _that_ (in the singular) and _those_ (in the plural).
## TERCERA PARTE
### Ejercicios No. 140A-140B
140A. Read each sentence on the left and complete the corresponding sentence on the right with the correct possessive pronoun.
**Ejemplo: ¿De quién es esta revista? Es** (mine) **mía.**
1. **¿De quién es este traje?** | 1. **Es** (mine).
---|---
2. **¿De quiénes son estos carteles?** | 2. **Son** (yours).
3. **Juan y yo tenemos corbatas.** | 3. **Éstas son** (mine), **ésa es** (his).
4. **Ana y yo hemos comprado sarapes.** | 4. **Éstos son (mine), ésos son** (hers).
5. **Ud. y yo hemos recibido cartas.** | 5. **Éstas son** (mine), **y ésas son** (yours).
6. **Pablo y yo compramos boletos ayer.** | 6. **Tengo los** (mine) **pero él perdió los** (his).
7. **Las revistas han llegado.** | 7. **Yo he leído las** (mine); **él ha leído las** (his).
8. **Fui al cine con mi madre.** | 8. **Ella fue con la** (hers).
9. **Fuimos al cine con nuestros amigos.** | 9. **Ellos fueron con los** (theirs).
10. **Ellos llevaron sus juguetes.** | 10. **Nosotros llevamos los** (ours).
140B. Change these sentences from the present to the imperfect and preterite. Translate each sentence.
**Ejemplo:** | **Respondo a su pregunta.** | I answer his question.
---|---|---
| **Respondía a su pregunta.** | I was answering his question.
| **Respondí a su pregunta.** | I answered his question.
1. **Salgo del cuarto.**
2. **Entramos en el museo.**
3. **Vemos las tiendas.**
4. **Uds. no olvidan mis consejos.**
5. **El chófer me responde.**
6. **Ellos no aprenden francés.**
7. **Estoy en casa.**
8. **Los jóvenes van a la corrida.**
### Ejercicio No. 141—Preguntas
1. **¿Qué no ha olvidado el Sr. Adams?**
2. **¿Por qué no descansa por mucho tiempo?**
3. **¿Dónde se paseaba al mediodía?**
4. **¿Qué había al otro lado de la avenida?**
5. **¿Ha visitado el Sr. Adams aquellas tiendas muchas veces o pocas veces?**
6. **¿Qué tentación no podía resistir?**
7. **¿Se cansa él de mirar las artes de los indios?**
8. **¿Qué palacio volvió a visitar el Sr. Adams?**
9. **¿Ha asistido a algún concierto en el Palacio de Bellas Artes?**
10. **¿Le gusta mucho al Sr. Adams mirar las pinturas de los grandes pintores?**
# CHAPTER 43
REVIEW, CHAPTERS 38–42
REPASO, CAPÍTULOS 38–42
## PRIMERA PARTE
### Repaso de palabras (Word Review)
#### NOUNS
1. **el abogado** | 1. lawyer
---|---
2. **el ascensor** | 2. elevator
3. **la brisa** | 3. breeze
4. **el caballo** | 4. horse
5. **el campesino** | 5. farmer
6. **la cebolla** | 6. onion
7. **el corazón** | 7. heart
8. **el concierto** | 8. concert
9. **el cristal** | 9. glass
10. **el chófer** | 10. driver
11. **el dependiente** | 11. employee
12. **el descanso** | 12. rest
13. **la dificultad** | 13. difficulty
14. **el este** | 14. east
15. **la fuente** | 15. fountain
16. **el joven** | 16. youth
17. **el médico** | 17. doctor
18. **el pase de turista** | 18. tourist pass
19. **el pintor** | 19. painter
20. **la pintura** | 20. painting
21. **la sala de espera** | 21. waiting room
22. **la seda** | 22. silk
23. **la tela** | 23. cloth
24. **el viejecito** | 24. little old man
#### VERBS
1. **acercarse a** | 1. to approach
---|---
2. **arreglar** | 2. to arrange
3. **asistir a** | 3. to attend
4. **cansarse** | 4. to get tired
5. **aconsejar** | 5. to advise
6. **cortar** | 6. to cut
7. **correr** | 7. to run
8. **descubrir** | 8. to discover
9. **descansar** | 9. to rest
10. **divertirse** | 10. to enjoy one self
11. **encantar** | 11. to charm
12. **expresar** | 12. to express
13. **gritar** | 13. to shout
14. **hallar** | 14. to find
15. **perder** | 15. to lose
16. **pintar** | 16. to paint
17. **regatear** | 17. to bargain
18. **señalar** | 18. to point out
19. **sonar** | 19. to sound
#### ADJECTIVES
1. **afortunado** | 1. lucky
---|---
2. **alegre** | 2. happy
3. **cansado** | 3. tired
4. **cuadrado** | 4. square
5. **demasiado** | 5. too much
6. **deseoso** | 6. eager
7. **divertido** | 7. enjoyable
8. **emocionante** | 8. exciting
9. **enorme** | 9. enormous
10. **guapo** | 10. handsome
11. **grueso** | 11. thick
12. **impaciente** | 12. impatient
13. **junto** | 13. together
14. **sabroso** | 14. tasty
15. **salvo** | 15. safe
16. **sano** | 16. sound (healthy)
17. **semejante** | 17. similar
18. **sumo** | 18. greatest
19. **vacío** | 19. empty
#### ADVERBS
1. **ayer** | 1. yesterday
---|---
2. **anteayer** | 2. day before yesterday
3. **anoche** | 3. last night
4. **en frente** | 4. in front
#### PREPOSITIONS
1. **dentro de** | 1. inside of
---|---
2. **excepto** | 2. except
3. **junto a** | 3. close to
4. **según** | 4. according to
#### CONJUNCTIONS
1. **mientras (que)** | 1. while
---|---
2. **antes de que** | 2. before
3. **puesto que** | 3. since
#### IMPORTANT EXPRESSIONS
1. **al día síguiente** | 1. on the following day
---|---
2. **de repente** | 2. suddenly
3. **dar un paseo** | 3. to take a walk
4. **es decir** | 4. that is to say
5. **por mucho tiempo** | 5. for a long time
6. **llamar por teléfono** | 6. to telephone
7. **pensar (+ infin.)** | 7. to intend to
8. **por entero** | 8. entirely
9. **sano y salvo** | 9. safe and sound
10. **darse la mano** | 10. to shake hands
11. **voy aprendiendo** | 11. I am learning
12. **apretón de manos** | 12. handshake
**NOTE: voy aprendiendo = estoy aprendiendo. ir** is often used like **estar** to form the present progressive.
## SEGUNDA PARTE
**Ejercicio 142.** For each Spanish word give the related Spanish word suggested by the English word in parentheses.
**Ejemplo: 1. comer** (the meal)— **la comida**
1. **comer** (the meal)
2. **difícil** (the difficulty)
3. **hablar** (talkative)
4. **platicar** (the chatting)
5. **divertirse** (enjoyable)
6. **el caballo** (the little horse)
7. **el viaje** (to travel)
8. **segundo** (secondary)
9. **la ventana** (the little window)
10. **caminar** (the road)
11. **pintar** (the painting)
12. **preguntar** (the question)
13. **responder** (the answer)
14. **llegar** (the arrival)
15. **fácil** (easily)
16. **el campo** (the farmer)
**Ejercicio 143.** Translate each verb form and give the infinitive of the verb.
**Ejemplo: dijeron** , they said, **decir** , to say
1. **pudo**
2. **quise**
3. **pusieron**
4. **vi**
5. **leyeron**
6. **Ud. dijo**
7. **tuvimos**
8. **di**
9. **fue**
10. **pidió**
11. **Uds. hicieron**
12. **vine**
13. **hizo**
14. **tuviste**
15. **supe**
**Ejercicio 144.** Select the group of words in the right-hand column which best completes each sentence begun in the left-hand column.
1. **Mientras nuestro camion pasaba por las montañas**
2. **Debajo de los árboles en la Alameda**
3. **Por todas partes había puestos**
4. **Vio a un muchacho**
5. **Cuando lo encontró** ,
6. **Escuchando la plática de las mujeres** ,
7. **¿Recuerda Ud. las conversaciones**
8. **Yo estaba sentado al mediodía en el parque**
9. **Mientras el Sr. Adams se divertía en México** , | 1. **el Sr. López sufría el calor de Nueva York.**
2. **donde se vendían cosas corrientes.**
3. **había una brisa firesca.**
4. **en que hablábamos de los mercados de México?**
5. **los hombres y las mujeres caminaban a lo largo de la ruta.**
6. **charlando con un estudiante.**
7. **que cuidaba un puesto.**
8. **el muchacho arreglaba su mercancía.**
9. **el Sr. Adams podía comprender todo lo que** (all that) **decían.**
---|---
**Ejercicio 145.** Complete each sentence by selecting the tense that makes sense. Translate each sentence.
**Ejemplo: 1. Ayer recibí un paquete.** Yesterday I received a package.
1. **Ayer___________________un paquete (recibí, recibiré, recibo).**
2. **Mañana___________________en casa (me quedé, me quedaré, me quedo).**
3. **Anoche no___________________al cine (vamos, iremos, fuimos).**
4. **Ahora___________________las maletas (hicieron, hacen, harán).**
5. **El maestro habla y los alumnos_______________(es-cuchan, escucharán, escucharon).**
6. **¿___________________Uds. de la ciudad pasado mañana? (salen, saldrán, salieron)**
7. **¿Lo___________________Ud. anteayer? (vio, ve, verá)**
8. **El año que viene___________________en Europa (viaja, viajé, viajaré).**
9. **¿Qué está diciendo él? No___________________oirlo (pu-dimos, podemos, podremos)**
10. **Yo___________________la semana pasada (llegué, llego, llegaré).**
**NOTE** : The present tense also can be used to express future. Example: **Mañana me quedo / me quedaré en casa.**
## TERCERA PARTE
### Diálogo
#### En la gasolinera
Practice the Spanish aloud.
**El Sr. Adams necesita gasolina y ha entrado en una de las gasolineras de la Pemex.** | Mr. Adams needs gasoline and has gone into one of the Pemex gasoline stations.
---|---
**En seguida se acerca al coche un joven para servirlo.** | Immediately a young man approaches the car to serve him.
— **Buenas tardes,—lo saluda el joven.** | "Good afternoon," the young man greets him.
— **Muy buenas,—le contesta Adams.—¿Me llena el tanque, por favor?** | "Good afternoon to you," Adams answers. "Will you please fill the tank?"
— **¿Regular o super?** | "Regular or super?"
— **Regular. ¿Y quiere chequear el aceite, el agua y el aire?** | "Regular. And do you want to check the oil, the water, and the air?"
— **Con todo gusto, señor,—le contesta el empleado.** | "With pleasure, sir," the employee replies.
**El joven llena el tanque, revisa el aceite, el agua y la presión de aire en las llantas. Entonces vuelve al Sr. Adams.** | The young man fills the tank, checks the oil, the water, and the air pressure in the tires. Then he returns to Mr. Adams.
— **Todo está bien,—le dice a nuestro turista.** | "Everything is all right," he says to our tourist.
— **Muchas gracias, ¿y cuánto le debo?** | "Many thanks, and how much do I owe you?"
— **Son dento treinta y dnco pesos cuarenta centavos.** | "It is one hundred thirty-five pesos forty centavos."
**El Sr. Adams le da dos billetes de cien pesos. El joven se lo cambia, entregándole sesenta y** | Mr. Adams gives him two bills of one hundred pesos. The young man changes it for him, returning
**cuatro pesos sesenta centavos. Adams cuenta el cambio y ve que todo está en orden.** | **to him sixty-four pesos and sixty centavos. Adams counts the change and sees that everything is in order.**
— **Está bien,—le 1 dice al empleado.** | **"All right," he says to the employee.**
— **Muchas gracias y muy buenas tardes.** | **"Many thanks and very good afternoon."**
— **Muy buenas y feliz viaje,—le contesta el joven.** | **"Very good afternoon and happy voyage," the young man answers.**
**NOTE** : 1. The indirect objects **le** ( _to_ or _for him, her, you_ ) and **les** ( _to_ or _for them, you_ ) become **se** before any other object pronoun that begins with the letter **I** (as in **lo** ). Complete treatment of two object pronouns will be found in **Capítulo 47.**
## LECTURA 1
### Ejercicio No. 146—Una visita a Xochimilco (Soh-chee- _meel_ -koh)
**En una ocasión el Sr. Adams llevó a los hijos del Sr. Carrillo en una excursión al pueblo de Xochimilco con sus canales interesantes, sus barquitos decorados y la música de los famosos mariachis.**
**El pueblo no está muy lejos de la capital y nuestro amigo llegó sin dificultad. Al llegar** (On arriving) **al pueblo, tuvo una idea muy luminosa. Propuso** (He proposed) **una merienda al aire fibre, al lado de uno de los canales. Los muchachos aceptaron el proyecto con entusiasmo.**
**Adams entró en una tienda de abarrotes** (grocery store), **compró unas tortillas y queso. Luego compró unas tortas y unos panes dulces en una panadería. Por último, compró unas naranjas y varios tomates en un puesto de verduras.**
**Quedó** (There remained) **el problema de los refrescos. Ahora uno de los chamacos** (boys) **tuvo una idea luminosa.—¿Por qué no comprar unas botellas de agua mineral? Por** (Along) **los canales siempre hay muchos vendedores de refrescos fríos.**
— **Estupenda idea,—comentó Adams.**
**Alquilaron** (They rented) **una canoa adornada de miles de claveles** (carnations). **Después de pasear** (riding) **dos horas explorando los canales, salieron de la canoa en un lugar muy tranquilo. El Sr. Adams repartió las tortillas y el queso, que comieron con los tomates. Por fin, de postre se comieron las sabrosas naranjas. Fue una merienda estupenda y los chicos quedaron** (were) **encantados. No olvidarán esta experiencia en muchos años.**
## LECTURA 2
### Ejercicio No. 147—En la Avenida Juáarez
**Al fin caminamos por la Avenida Juáarez. Es una avenida ancha en el centro del Distrito Federal. Está a un lado de la Alameda, un parque muy bonito con árboles altos, fuentes y monumentos.**
**Hay mucha gente en la Avenida Juáarez. Ahí vienen todos los turistas. En las tiendas se venden toda clase de artículos típicos de México—joyería, tejidos, artículos de cuero, alfarería** (pottery) **y ropa hecha a mano.**
**Naturalmente, vamos a visitar el Museo Nacional de Artes e Industrias Populares. Allí se pueden ver varios artículos de todas las regiones del país.**
**Caminamos por esta avenida hasta llegar al «Caballito», la estatua del rey Carlos IV en la Plaza de la Reforma. Allí termina la avenida.**
# CHAPTER 44
CAPÍTULO 44 (CUARENTA Y CUATRO)
## PRIMERA PARTE
### Forward
In Chapters 44– there will be no parallel translation of the texts. However, all new words and expressions that appear in the selections are given in the vocabulary sections which follow each text. There is also a Spanish-English dictionary in the Appendix to which you can refer for any words you may have forgotten. You should therefore have no difficulty in reading and understanding the texts. As a means of testing your understanding, a series of English questions to be answered in English are given under the heading "Test of Reading Comprehension," instead of the usual Spanish Preguntas. You can check your answers in the Answer Section of the Appendix.
### La Plaza
#### Sexta carta de México
**Querido amigo** :
**En nuestras conversaciones hemos hablado de muchas cosas pero no me acuerdo de ninguna conversación sobre las plazas mexicanas. Tengo ganas de escribirle mis impresiones de ellas.**
**He notado que cada pueblo en México tiene su «corazón». Es la plaza. Todo el mundo va a la plaza para el descanso, para los negocios, para el recreo, para todo.**
**En esto pensaba mientras estaba sentado en la plaza de Oaxaca.**
**Cada plaza es distinta. Algunas son circulares, otras son cuadradas. En algunas se ven árboles grandes, en otras no se ve nada más que algunas pocas hojas secas de quién sabe qué pobre arbolito.**
**En el centro de cada plaza hay un kiosco que puede ser cuadrado o redondo, elegante o sencillo, bien cuidado o mal cuidado.**
**Los músicos del pueblo tocan en el kiosco el domingo por la tarde, el jueves por la noche y a veces tocan otros días también.**
**Muchas veces hay arcadas a un lado o a dos lados de la plaza. En las arcadas se encuentran** (are found) **toda clase de tiendas, como papelerías, farmacias, mercerías, joyerías, librerías. Casi siempre hay un café. Allí se reúnen los hombres** (the men get together) **por la tarde para charlar o para leer el periódico mientras toman una taza de chocolate o café, una cerveza, o un refresco.**
**El hotel del pueblo puede estar en la plaza principal. También se ve allí una iglesia antigua.**
**El aspecto de la plaza cambia a cada hora. Por la mañana temprano se ve** (one sees) **solamente la gente que va al mercado. Más tarde vienen las madres con sus bebés y niños pequeños. Las madres se sientan en los bancos para charlar.**
**Durante las horas de la siesta, desde la una hasta las tres y media de la tarde, hay pocas personas en la plaza. Algunos descansan, otros hasta duermen en los bancos. Hace calor. A eso de las cuatro comienza otra vez la vida de la plaza.**
**El domingo por la tarde se reúne todo el mundo en la plaza para «el paseo». Los muchachos caminan de un rumbo** (in one direction), **las muchachas del contrario** (in the other). **Mientras tanto los músicos en el kiosco tocan una pieza alegre.**
**Al fin llega la noche. La plaza se pone tranquila. Se ven solamente algunos viajeros que vienen del mercado. La plaza duerme.**
**Reciba un cordial saludo de su amigo** ,
**Juan Adams**
#### Vocabulario
**el aspecto** | appearance
---|---
**la cerveza** | beer
**el contrario** | opposite
**el corazón** | heart
**la farmacia** | pharmacy
**la hoja** | leaf
**la joyería** | jewelry shop
**la iglesia** | church
**el kiosco** | bandstand
**la librería** | book shop
**la mercería** | notion shop
**la papelería** | stationery shop
**el músico** | musician
**la plaza** | square
**el paseo** | promenade
**la pieza** | piece (music)
**la arcada** | arcade
**el rumbo** | direction
**crecer** | to grow
**reunirse** | to get together
**alegre** | merry lively
**cansado** | tired
**cuadrado** | square-shaped
**cuidado** | kept, cared for
**circular** | round, circular
**seco** | dry
**mientras tanto** | in the meantime
#### Ejercicio No. 148—Test of Reading Comprehension
**Answer these questions in English. They will test your comprehension of the text.**
1. What does every town have?
2. Why does everybody go to the square?
3. What grows in some squares?
4. What does one see in other squares?
5. Where is the bandstand located?
6. When do the musicians play?
7. Name six kinds of shops which are found in the arcades.
8. For what purpose do the men get together in the cafe in the afternoons?
9. What do they drink?
10. What does one see in the main square?
11. What do some people do on the square during the siesta hour?
12. At what time does the life of the square begin again?
13. What happens on Sunday afternoons?
14. How do the boys and girls promenade?
15. Whom does one see in the plaza at night?
#### Ejercicio No. 149—Completion of Text
1. (The heart of each town) **es la plaza.**
2. **En esto pensaba** (while I was seated) **en la plaza.**
3. (One sees nothing more) **que algunas pocas hojas secas.**
4. **El kiosco** (may be) **cuadrado o circular.**
5. **Los músicos tocan** (on Sunday afternoon).
6. **Hay arcadas** (where one finds) **todas clases de tiendas.**
7. **Los hombres** (get together) **en el café** (in the afternoon).
8. **También se ve allí** (an old church).
9. (Later) **vienen las madres** (with their small children).
## SEGUNDA PARTE
### Grammar Notes
1. The Present **and** Preterite of **dormir (ue)** to sleep PRESENT | PRETERITE
---|---
I sleep, etc. | I slept, etc.
**duerme** | **dormimos** | **dormí** | **dormimos**
**duermes** | **dormís** | **dormiste** | **dormisteis**
**duerme** | **duermen** | **durmió** | **durmieron**
PRESENT PARTICIPLE: **durmiendo**
2. Relative Pronouns
1. **que** , who, whom, which, that
**que** is the most commonly used relative pronoun. Like the English _that_ , it can refer to persons or things, except with prepositions, when it may refer only to things. **El sombrero que compré me sienta mal.** | The hat which I bought fits me poorly.
---|---
**¿Dónde está el muchacho que perdió su libro?** | Where is the boy who lost his book?
**¿Dónde está la cesta de que Ud. habló?** | Where is the basket of which you spoke?
2. **quien, quienes** (plural), who, whom
**quien** and **quienes** refer only to persons. When they are used as a direct object the personal a is required **Los hombres de quienes hablé son abogados.** | The men of whom I spoke are lawyers.
---|---
**El niño a quien buscábamos está en casa.** | The child whom we were looking for is at home.
3. **lo que** what, that which; **todo lo que** all that **Sé** **lo que dijo.** | I know what he said.
---|---
**Le diré a Ud. todo lo que he aprendido.** | I will tell you all that I have learned.
4. **cuyo (o, os, as)** whose, must immediately precede the noun it modifies, and must agree with it in number and gender **Buscan las calles _cuyos_ nombres son fechas.** | They are looking for the streets whose names are dates.
---|---
**¿Dónde está el hombre _cuya_ casa hemos comprado?** | Where is the man whose house we have bought?
5. **donde, _en donde_ , a donde, de donde** may often take the place of a relative pronoun. **La casa _en donde_ vive es antigua.** | The house in which (where) he lives is old.
---|---
**No conozco la escuela _a donde_ van los niños.** | I do not know the school to which (where) the children go.
6. **el cual (la cual, los cuales, las cuales)** that, which, who, whom
These longer forms of the relative pronouns are used to make clear to which of two possible antecedents the relative clause refers. **Visité a la esposa del Sr. Adams, la cual toca bien el piano.** | I visited the wife of Mr. Adams, who plays the piano well.
---|---
## TERCERA PARTE
### Ejercicios No. 150A-150B
150A. Use the correct verb forms with these subjects:
1. **(Yo)** sleep
2. **(Yo)** am not sleeping
3. ¿ **(Quién)** sleeps?
4. **(Nosotros)** sleep
5. Do you sleep **(Ud.)?**
6. Sleep **(Ud.)** (Imperative)
7. Do not sleep **(Uds.)**
8. **(El niño)** sleeps
9. **(La niña)** is not sleeping
10. ¿ **(Quiénes)** sleep?
11. **(Ellos)** sleep
12. **(Nadie)** is sleeping
150B. Complete these sentences by using the correct relative pronoun.
**Ejemplo: Déme el lápiz que compré.**
1. **Déme el lápiz** (that) **compré.**
2. **¿Dónde está el alumno** (whose) **libro tengo?**
3. **Los muchachos** (who) **eran diligentes aprendieron mucho.**
4. **Aquí está la pintura** (of which) **hablábamos.**
5. **Las palabras** (that) **aprendemos son difíciles.**
6. (What, that which) **le dije a Ud. es verdad.**
7. **Me dio** (all that) **quise.**
8. **La casa** (that) **compré es de piedra.**
9. **Allí están las señoritas** (of whom) **hablábamos.**
10. **El Sr. Adams** , (who) **estaba sentado detrás de su escritorio, se levantó.**
**NOTE** : Use **que** for _who_ (sentence 3). If the relative clause can be omitted without changing the sense or clarity of the sentence, you can use both **que** and **quien** (sentence 10).
# CHAPTER 45
CAPÍTULO 45 (CUARENTA Y CINCO)
## PRIMERA PARTE
### Un paseo a Teotihuacán
#### Sétima carta de México
**Querido amigo** :
**Ayer llamé por teléfono a los hijos del Sr. Carrillo y les pregunté:—¿Quieren Uds. pasear en coche conmigo a Teotihuacán? Aceptaron con alegría.**
**Quería** (I wanted) **volver a tiempo para ir a un concierto por la noche. Así es que tempranito nos encontramos** (we met) **los tres delante de mi hotel. Saqué** (I took out) **el coche del garage donde lo había alquilado** (I had rented) **para el día. Charlando y riendo con animación nos pusimos en marcha** (we set out).
**Después de pasar los suburbios de la ciudad, atravesamos primero tierras laboradas y después tierras desiertas. Vimos de vez en cuando unas casas pequeñas de adobe o un indio con su burro. Más allá** (further on) **no vimos más que la llanura de la Mesa Central y las montañas a lo lejos.**
**Yo manejaba el coche y de repente oí un sonido que inmediatamente reconocí.—¿Qué pasó?—preguntaron los jóvenes.**
**Paré** (I stopped) **el auto y bajamos.—Tenemos un pinchazo—contesté yo.**
**Yo quería cambiar la llanta y los jóvenes tenían muchas ganas de ayudarme. Los dos, muy contentos, comenzaron a buscar el gato. ¡Ay! No había ningún gato** (there was no jack) **en la cajuela. ¿Qué hacer?**
**De vez en cuando pasaba un auto a toda veloci-dad. A pesar de nuestras señates nadie paró. Era casi mediodía y había mucho sol. Nos sentamos debajo de un pequeño árbol al lado del camino para esperar.**
**Pronto Carlos vio en el horizonte un camión grande. Se acercó** (It approached) **rápidamente y paró delante de nuestro árbol. El chófer bajó.**
— **¿Tienen un pinchazo?—dijo sonriendo.**
— **¿Me permiten ayudarles?**
— **¡Muchas gracias!—le respondí. —Tenemos un pinchazo y nos hace falta un gato.**
**El chófer nos presto su gato y nos ayudó a cambiar la llanta. Afortunadamente teníamos una llanta de repuesto** (a spare tire).
**Le di mil gracias al hombre y le ofrecí cien pesos, pero no quiso aceptarlos. Entonces nos dimos la mano y nos despedimos.**
**Seguimos nuestro camino hasta que llegamos a las Pirámides de Teotihuacán. De veras son muy imponentes. Subimos por aquella escalera ancha hasta la cima de la Pirámide del Sol, que tiene 216 pies de altura. Es más grande que cualquier pirámide de Egipto. Los jóvenes subieron corriendo. Yo subí muy despacio pero sin embargo llegué a la cima, algo jadeante** (somewhat out of breath). **Desde allí, como sabe, hay una vista maravillosa del valle entero. No es necesario describirle las otras ruinas imponentes de Teotihuacán, la Pirámide de la Luna y el Templo de Quetzalcóatl, dios de los aztecas. Ud. los conoce mejor que yo.**
**Después de tomar la comida que me habían preparado** (they had prepared for me) **en el hotel, subimos otra vez al auto y regresamos, cansados pero muy contentos.**
**Reciba un apretón de manos de su amigo** ,
**Juan Adams**
#### Vocabulario
**el camión** | truck, bus
---|---
**el gato** | car-jack, cat
**el dios** | god
**la cajuela** | trunk (of car)
**la escalera** | stairs
**la llanta (de repuesto)** | tire (spare)
**la llanura** | plain
**el paseo** | walk, stroll, ride
**el pinchazo** | puncture, flat
**la señal** | signal
**el sonido** | sound
**la tierra** | land
**correr** | to run
**ofrecer** | to offer
**manejar** | to drive
**Teotihuacán** |
( _tay-oh-tee-wah- **kahn**_ )
**regresar** | to return
**reír** | to laugh
**riendo** | laughing
**sonreír** | to smile
**ancho** | wide
**deseoso** | eager
**jadeante** | out of breath
**desierto** | deserted
**imponente** | imposing
**entero** | entire
**laborado** | cultivated
**tempranito** | very early
**a pesar de** | in spite of
**algo** | somewhat, something
**¡ay!** | oh!
**pirámide** | pyramid
( _pee- **rah** -mee-day_)
#### Expresiones Importantes
**a lo lejos** | in the distance
---|---
**a tiempo** | on time
**a toda velocidad** | at full speed
**dar mil gracias** | to thank a thousand times
**nada más que** | nothing but, only
**de vez en cuando** | from time to time
**hacer falta** | to be missing
**Nos hace falta un gato.** | We lack a jack.
**pasear en coche** | to go on an auto ride
**ponerse en marcha** | to set out
**sin embargo** | nevertheless
#### Ejercicio No. 151—Test of Reading Comprehension
Answer these questions in English.
1. Where did Mr. Adams want to go?
2. Whom did he invite to go with him?
3. Where did they meet at an early hour?
4. How had Mr. Adams obtained a car?
5. What did they see on the road from time to time?
6. What did they see in the distance?
7. What happened when Mr. Adams was driving?
8. Why weren't they able to change the tire?
9. What time of day was it?
10. How did they finally manage to put on the spare tire?
11. How did Mr. Adams try to show his appreciation of the truck driver's help?
12. How did Mr. Adams climb the Pyramid of the Sun, and how did he feel on reaching the top?
13. How did the boys go up?
14. Why isn't it necessary for Mr. Adams to describe the other ruins to Mr. Lopez?
15. How did they feel when they returned?
#### Ejercicio No. 152—Completion of Text
1. ¿lrá **Ud.** (with me by car) **a Teotihuacán**?
2. (The young men accepted) **la invitación** (with joy).
3. (We met) **delante de mi hotel.**
4. (I took the car) **del garage.**
5. (I have rented it) **para el día.**
6. (Chatting and laughing) **subimos en el coche.**
7. (From time to time) **vimos a un indio.**
8. (We saw nothing but) **la llanura.**
9. (Suddenly) **oí un sonido.**
10. ¿(What happened?)— **preguntaron.**
11. **Yo quería** (to change the tire) **pero** (there was no jack).
12. (In spite of) **nuestras señales nadie** (stopped).
13. **Dijimos al chófer** :—(We lack a jack).
14. **Nos presto un gato** (and helped us change the tire).
15. **Entonces** (we shook hands) **y** (took leave of one another).
## SEGUNDA PARTE
### Grammar Notes
1. The Past Perfect Tense. Model Verbs, **hablar, aprender** , and **vivir** SINGULAR
---
**había hablado (aprendido, vivido)** | I had spoken (learned, lived)
**habías hablado (aprendido, vivido)** | you had spoken (learned, lived)
**Ud. había hablado (aprendido, vivido)** | you had spoken (learned, lived)
**él había hablado (aprendido, vivido)** | he, it had spoken (learned, lived)
**ella había hablado (aprendido, vivido)** | she, it had spoken (learned, lived)
PLURAL
**habíamos hablado (aprendido, vivido)** | we had spoken (learned, lived)
**habías hablado (aprendido vivido)** | you had spoken (learned, lived)
**Uds. habían hablado (aprendido, vivido)** | you had spoken (learned, lived)
**ellos habían hablado (aprendido, vivido)** | they had spoken (learned, lived)
**ellas habían hablado (aprendido, vivido)** | they had spoken (learned, lived)
1. As in English, the past perfect tense in Spanish is formed by the auxiliary verb **había** ( _had_ ), plus the past participle of the verb. **Había** is the imperfect of **haber** _to have._
2. Verbs with Spelling Changes.
Note the Spelling Changes in these verbs. **sacar** to take out
---
PRESENT | PRETERITE
**saco** | **sacamos** | **saqué** | **sacamos**
**sacas** | **sacáis** | **sacaste** | **sacasteis**
**saca** | **sacan** | **sacó** | **sacaron**
IMPERATIVE
**_saciue Ud._** | **_saquen Uds._**
**llegar** to arrive
---
PRESENT | PRETERITE
**llego** | **llegamos** | **llegué** | **llegamos**
**llegas** | **llegáis** | **llegaste** | **llegasteis**
**llega** | **llegan** | **llegó** | **llegaron**
IMPERATIVE
**_llegue Ud._** | **_lleguen Uds._**
1. In verbs whose infinitives end in **-car** or **-gar, c** must become **qu** and **g** must become **gu** before the endings **e** and **en** , in order to keep the pronunciation of **c** and **g** , as found in the infinitive.
2. Other verbs ending in **-car** or **-gar** are: **buscar** to look for; **acercarse (a)** to approach; **pagar** to pay.
## TERCERA PARTE
### Ejercicios No. 153A-153B
153A. In the following sentences fill in the correct auxiliary verb in the past perfect tense.
Translate the sentence.
**Ejemplo: 1. (Nosotros) habíamos aprendido español en México.**
We had learned Spanish in Mexico.
1. **(Nosotros)__________visto la película.**
2. **¿__________leído Ud. muchos libros?**
3. **¿Quién__________abierto la ventana?**
4. **Los hijos no________dormido durante la noche.**
5. **Yo no_____________creído el cuento.**
6. **(Nosotros)______volado sobre las montañas.**
7. **Ellos__________ido al teatro.**
8. **¿__________tenido Ud. un buen viaje?**
9. **Uds. no__________dicho nada.**
10. **¿__________comido (tú) los dulces, Juanito?**
153B. Complete in Spanish.
1. (He had bought) **los boletos.**
2. (I had seen) **la película.**
3. (We had eaten) **la comida.**
4. ¿(Had they received) **la carta?**
5. ¿(Had you set) **la mesa?**
6. (You [ **Uds.** ] had not heard) **el cuento.**
7. (You [ **tú** ] had not slept) **bien.**
8. **El hombre** (had seated himself) **en el banco.**
9. (They had had) **un pinchazo.**
10. (We had said) **nada.**
11. **¿Qué** (had happened)?
12. (They had not found) **el gato.**
13. **¿Por qué** (had they not changed) **la llanta?**
14. **El chófer** (had approached) **a nosotros.**
# CHAPTER 46
CAPÍTULO 46 (CUARENTA Y SEIS)
## PRIMERA PARTE
### El Sr. Adams compra un billete de lotería
#### Octava carta de México
**Querido amigo** :
**Yo no soy jugador, Sr. López. Es decir, hasta la semana pasada nunca había sido** (I had never been) **jugador.**
**¿Qué pasó? Le diré todo.**
**Como Ud. sabe mejor que yo, en todas las esquinas en el centro de la capital hay un vendedor, y muchas veces dos vendedores de billetes de lotería. Cuando llegué a México noté inmediatamente que todo el mundo compraba billetes de lotería.** ¿ **Quién no quiere hacerse rico** (to get rich)? **Yo pensaba en la posibilidad de ganar uno de los muchos premios menores o tal vez, sacar el gordo. El año que viene, haría** (I would take) **viajes por todos los países de Sudamérica. Llevaría** (I would take) **conmigo a toda la familia. Los niños aprenderían** (would learn) **a hablar español. Podría** (I would be able) **volver a visitar a mis amigos en México. Pasaría** (I would spend) **mucho tiempo en las ciudades y pueblos de México que todavía no conozco.**
**Caminaría** (I would walk) **por todos los merca-dos para hablar con la gente del campo y para aprender más de la vida y de las costumbres de México. Compraría** (I would buy) **objetos de arte, pero no para venderlos, sino para mi casa.**
**Así soñaba yo.**
**El miércoles de la semana pasada paseaba por la Avenida Madero. Vi en la esquina, como siempre, a una señora que vendía billetes de lotería. Como siempre me dijo la señora —Compre Ud. este billete afortunado.**
— **Pero, señora,—le respondí—todos estos billetes son afortunados, ¿verdad?**
— **No, señor,—me dijo.—Le he guardado** (I have kept for you) **éste. Mire Ud. Tiene tres ceros.**
**Yo no sabía qué quería decir «tres ceros». Pero una voz dentro** (within) **de mí me dijo:—¡Compra!**
**Y me hice jugador.**
**Al día siguiente yo leía en el periódico los números que ganaron. Naturalmente no esperaba nada. De repente vi un número con tres ceros, el número 26,000. ¡Yo había ganado un premio de dos millones** (2,000,000) **de pesos!**
**Busqué** (I looked for) **mi billete. Y mientras buscaba, hacía** (I was making) **viajes por todos los países de Sudamérica con toda la familia...**
**Al fin encontré el billete en un bolsillo. Muy impaciente lo miré. Había tres ceros. Había un dos. Pero ¿qué lástima? Había también un «5». Yo tenía el número veinticinco mil (25,000).**
**¿Pero qué importa? Desde aquel momento, me hice jugador.**
**Lo saluda cordialmente su amigo** ,
**Juan Adams**
#### Vocabulario
**el billete de lotería** | lottery ticket | **ganar** | to win
---|---|---|---
**el bolsillo** | pocket | **guardar** | to keep
**la esquina** | corner | **hacerse** | to become
**el cero** | zero | **pasar** | to happen, to pass
**el jugador** | player, gambler | **pasear** | to stroll
**el premio** | prize | **soñar (ue)** | to dream
**el premio gordo** | first (grand) prize | **afortunado** | lucky
**la voz** | voice | **gordo** | fat
**buscar** | to look for | **impaciente** | impatiently
**busqué** | I looked for | **siguiente** | following
**Me hice jugador.** | I became a gambler. | **sacar el gordo** | to win the lottery
**NOTE** : the difference between **sonar (ue)** _to sound, ring_ , and **soñar (ue)** _to dreom._ **Tengo sueño** : _I am sleepy._
#### Ejercicio No. 154—Test of Reading Comprehension
Answer these questions in English.
1. What kind of man had Mr. Adams never been?
2. What had he noted when he came to Mexico?
3. What possibility was he thinking of?
4. After winning the first prize, to what countries would he take trips?
5. Whom would he visit again?
6. What would he buy for his house?
7. From whom did Mr. Adams buy a ticket with three zeros?
8. What was he reading in the newspaper next day?
9. What did he suddenly see?
10. What did he think when he saw the number with three zeros?
11. What was he dreaming of doing while he looked for his ticket?
12. What number did Mr. Adams have?
13. What number won the prize?
14. What expression does Mr. Adams use to show that he doesn't take the matter seriously?
15. Translate: **Desde aqel momento, fuí jugador.**
#### Ejercicio No. 155—Completion of Text
1. **Cuando** (I arrived) **en México** (everybody) **compraba boletos de lotería.**
2. **Había vendedores** (on all corners).
3. **Tal vez sacaré** (the first prize).
4. **Podría** (to visit again) **a mis amigos.**
5. **Llevaría conmigo** (the whole family).
6. **Así** (I was dreaming).
7. **Compré el boleto** (with three zeros).
8. **No sabía** (what the three zeros meant).
9. (The numbers which won) **estaban en el periódico.**
10. (I looked for) **mi boleto.**
11. (At last) **lo encontré** (in a pocket).
12. **Sí** (there were) **tres ceros, pero** (there was not) **un seis.**
## SEGUNDA PARTE
### Grammar Notes
1. The Present Conditional. Model Verbs— **hablar, aprender** , and **vivir**
The conditional may be called the would form of the verb. Its use in Spanish is much the same as in English. **hablar-ía** | I would speak | **hablar íamos** | we would speak
---|---|---|---
**hablar-ías** | you would speak | **hablar-íais** | you would speak
**Ud. hablar-ía** | you would speak | **Uds. hablar-ían** | you would speak
**el hablar-ía** | he, it would speak | **ellos hablar-ían** | they would speak
**ella hablar-ía** | she, it would speak | **ellas hablar-ían** | they would speak
1. The conditional endings of all verbs are: SINGULAR: | **-ía** | **-ías** | **-ía** | PLURAL: | **-íamos** | **-íais** | **-ían**
---|---|---|---|---|---|---|---
2. To form the regular conditional add these endings to the whole infinitive just as you do with the endings of the future. Thus: **hablar-ía, aprender-ía, vivir-ía, ser-ía, estar-ía.**
3. The endings of the conditional are the same as those of **-er** and **-ir** verbs in the imperfect. But remember: The endings of the conditional are added to the _whole infinitive._ The endings of the imperfect are added to the _stem of the verb_ after the infinitive ending has been removed. IMPERFECT
---
**aprendía** | I was learning
**vivía** | I was living
CONDITIONAL
---
**aprendería** | I would learn
**viviría** | I would live
2. The Irregular Conditional
Those verbs that have a change in the infinitive base for the future have the same changes in the conditional. INFINITIVE | FUTURE | CONDITIONAL
---|---|---
| _I shall etc._ | _I would, etc._
**saber** | **(yo) sabré** | **(yo) sabría**
**poder** | **podré** | **podría**
**querer** | **querré** | **querría**
**decir** | **diré** | **diría**
**hacer** | **haré** | **haría**
**haber** | **habré** | **habría**
INFINITIVE | FUTURE | CONDITIONAL
---|---|---
| _I shall etc._ | _I would, etc._
**venir** | **(yo) vendré** | **(yo) vendría**
**tener** | **tendré** | **tendría**
**salir** | **saldré** | **saldría**
**poner** | **pondré** | **pondría**
**valer** | **valdré** | **valdría**
### Ejercicios No. 156A-156B
156A. Change the following sentences from the future to the present conditional. Translate each sentence in the conditional.
**Ejemplo** : Future: **Haremos viajes.** We shall take trips.
Conditional: **Haríamos viajes.** We would take trips.
1. **Iremos a la plaza de Oaxaca.**
2. **Juan venderá sus boletos de sombra.**
3. **No sacarán el gordo.**
4. **Ud. encontrará a sus amigos.**
5. **Leeré muchas guías turísticas.**
6. **¿Llevará Ud. a su familia a México?**
7. **¿Les gustarán a Uds. los mercados?**
8. **Saldré de mi casa a las siete.**
9. **No podremos hacer los ejercicios.**
10. **No dirán nada.**
156B. Translate:
1. I would learn
2. he would write
3. they would go
4. we would eat
5. she would speak
6. would you ( **Ud.** ) work?
7. would John see?
8. who would visit?
9. I would not travel
10. would they study?
11. I would make
12. he would come
13. they would not want
14. would you ( **Ud.** ) go out?
15. you ( **Uds.** ) would put
# CHAPTER 47
CAPÍTULO 47 (CUARENTA Y SIETE)
## PRIMERA PARTE
### El Sr. Adams no es aficionado a los toros
#### Novena carta de México
**Querido amigo** :
**Era sábado. Yo había visitado al Sr. Carrillo en su oficina y estábamos para salir** (we were about to leave). **Me preguntó:—¿Quiere Ud. ir a una corrida de toros? Mañana sería** (would be) **el mejor día.**
**Al principio respondí sí. Pensé un rato y dije no. Pues, quizás.**
**Sonrió y dijo que tendría mucho gusto** (he would be very pleased) **en comprar los boletos.**
**Por supuesto acepté.**
**A las tres de la tarde, el Sr. Carrillo y yo llegamos a la plaza de toros. Faltaba una hora para el comienzo de la corrida. Ya había** (There were already) **mucha gente allí. Todo el mundo estaba de muy buen humor.**
**El Sr. Carrillo había comprado boletos a la sombra. Me explicó que los verdaderos aficionados a los toros no tienen que estar cómodos. Ellos se sientan en los asientos al sol.**
**Al principio teníamos dificultad en hallar nue-stros asientos. Todo el mundo ayudaba, señalando** (pointing out) **diferentes partes de la plaza. Al fin nos sentamos y esperamos el comienzo de la corrida.**
**La plaza de toros me hizo pensar en el estadio de futbol o béisbol en los EE.UU. Oí los gritos de los vendedores de refrescos, los gritos y las risas de los espectadores. Todos esperaban impacientes las cuatro de la tarde.**
**De repente oí la música muy animada que anunció el comienzo de la corrida. Pasó por el redondel un desfile** (a procession) **de hombres en trajes relucientes, matadores, banderilleros, picadores a caballo y monosabios. Se fueron** (they went away) **y salió el toro.**
**Hasta este momento yo estaba muy contento. Me gustaban la música, los trajes relucientes, los gritos y las risas, y el sol que brillaba tan alegremente.**
**Pero, allí estaba el toro.**
**No voy a tratar de describir la corrida. Ud. conoce bien este deporte y sé que le gusta mucho. Solamente quiero darle algunas de mis impresiones.**
**En breve, no me gusta la corrida. Sí, entiendo que la corrida de toros es un deporte muy emocionante. Pero, ¡los pobres caballos, el pobre toro, y muchas veces, el pobre matador!**
**He visto una corrida pero no pienso** (I do not intend) **asistir a otra. Tengo que confesarle, no soy aficionado a los toros y nunca lo seré.**
**El Sr. Carrillo me dijo:—En el futbol, no se puede decir** (one may not say) **«¡Pobres jugadores!» Sí, estoy de acuerdo** (I agree), **pero, por mi parte, prefiero un deporte más pacífico. Por ejemplo, el ajedrez.**
#### Vocabulario
**el aficionado** | amateur, fan | **la plaza de toros** | bullring
---|---|---|---
**el aficionado a los toros** | bullfight fan | **el redondel** | arena
**el ajedrez** | chess | **la sombra** | shade
**el asiento al sol** | seat in the sun | **refrescos** | refreshments
**el asiento a la sombra** | seat in the shade | **las risas** | laughter
**el banderillero** | thrower of darts (into bull) | **brillar** | shine
**la banderilla** | dart | **entender (ie)** | to understand
**la corrida de toros** | bullfight | **señalar** | to point out
**el deporte** | sport | **aficionado (adj.)** | fond of
**el desfile** | procession | **emocionante** | exciting
**el espectador** | spectator | **pacífico** | peaceful
**el matador** | bullfighter who kills bull | **reluciente** | brilliant
**el monosabio** | a general helper at bullfight | **alegremente** | joyously
**el picador** | man on horseback who jabs | **anunciar** | to announce
| bull with a pike | **quizás** | maybe
#### Expresiones Importantes
**a caballo** | on horseback | **estar para (+ _infin._ )** | to be about to
---|---|---|---
**en breve** | in short | **de buen humor** | in good humor
**estar de acuerdo** | to agree | **falta una hora para** | it is one hour before
#### Ejercicio No. 157—Test of Reading Comprehension
**Answer these questions in English**
1. What did Mr. Carrillo ask Mr. Adams when they were about to leave the office?
2. How much time before the beginning of the bullfight did they arrive?
3. What kind of tickets had Mr. Carrillo bought?
4. In what seats do the bullfight fans sit?
5. Of what did the bullring remind Mr. Adams?
6. What did Mr. Adams hear?
7. What sort of procession passed through the arena?
8. What happened when the men left?
9. What did Mr. Adams like about the bullfight?
10. Why does he not try to describe the bullfight?
11. In short, what does Mr. Adams think of the bullfight?
12. Whom does he pity?
13. What must he confess to Mr. Lopez?
14. In what does he agree with Mr. Carrillo?
15. What sport does Mr. Adams prefer?
#### Ejercicio No. 158—Completion of Text
1. (We were about to go).
2. **Pensé** (a while) **y dije** (well, maybe).
3. **Por supuesto** (I accepted).
4. (It was one hour) **para el comienzo de la corrida.**
5. **El Sr. Carrillo** (had bought) **boletos de sombra.**
6. (Finally) **hallamos nuestros asientos y** (sat down).
7. **La plaza de toros se parece a nuestro** (football or baseball stadium).
8. **Oímos** (the shouts and laughter) **de los espectadores.**
9. **Me gustó el desfile de** (men in brilliant costumes).
10. (They went away) **y el toro** (came out).
11. **Sí, entiendo que la corrida de toros es** (a very exciting sport).
12. **Sin embargo** (I must confess to you) **la verdad.**
13. (I do not intend) **asistir a otra corrida.**
14. (I agree) **si Ud. dice del fútbol** :—¡(the poor players)!
15. (I prefer) **el ajedrez.**
## SEGUNDA PARTE
### Grammar Notes
1. Two-Object Pronouns.
Note in the following Spanish and English sentences the position of the indirect object (a person or persons) and the direct object (a thing or things). 1. **Carlos _me lo_ da.** | 1. **Charles gives _it_ (m.) _to me._**
---|---
2. **Ana _me los_** **trae.** | 2. **Anna brings _them_ (m.) _to me._**
3. **Juan _nos_ _la_ manda.** | 3. **John sends _it_ (f.) _to us._**
4. **María no _nos las_ presta.** | 4. **Mary does not lend _them_ (f.) _to us._**
5. **_Te lo_ damos, hijito.** | 5. **We give _it to you_ , sonny.**
1. In Spanish, when there are two pronoun objects, the indirect object precedes the direct object.
2. In English, the opposite is true.
2. Two-Object Pronouns (continued)
Study the following examples and note what happens to the indirect object pronouns le (to you, to him, to her) and les (to you, pl., to them).
1. **Se lo digo (a Ud.)** | 1. I tell _it to you._
---|---
2. **Se la traigo (a él).** | 2. I bring _it_ (f.) _to him._
3. **Se las prestamos (a ella).** | 3. We lend _them to her._
4. **Se lo mando (a ellos).** | 4. I send _it_ (m.) _to them._
5. **Se los doy (a Uds).** | 5. I give _them_ (m.) _to you_ (pl.).
1. **Le** ( _to you, to him, to her_ ) and **les** ( _to you_ , pl., _to them_ ) may not be used before another object pronoun that begins with the letter **l.** In such cases **le** and **les** must become **se.**
2. Thus **se** may mean _to you_ (sing. and plural), _to him, to her, to them_ (masc. and fem.).
**a Ud., a él, a ella** , etc., after the verb, make the meaning clear.
3. Two-Object Pronouns After the Verb.
Like single-object pronouns, two-object pronouns follow the verb with the affirmative imperative, with the infinitive and with the present participle. Study the two-object pronouns in the following examples. 1. **Dígamelo.** | 1. Tell _it to me._
---|---
2. **Díganselo a él.** | 2. Tell _it to him._ (you pl.)
3. **Désela a ella.** | 3. Give _it_ (f.) _to her._
4. **Dénoslos.** | 4. Give _them to us._
5. **Mándeselos a ellos.** | 5. Send _them to them._
6. **Mándenselos a ellos.** | 6. Send _them to them_ (you pl.)
1. When two-object pronouns follow the verb they are attached to it and to each other.
2. An accent mark is added to the stressed syllable of the verb to keep the stress from shifting.
### Ejercicios No. 159A-159B-159C-159D
159A. Practice the Spanish questions and answers aloud many times. They will give you a "feeling" for the two-object pronouns construction.
1. **¿Le ha escrito el Sr. Adams la carta a su agente?** | 1. Has Mr. Adams written the letter to his agent?
---|---
**Sí, se la ha escrito.** | Yes, he has written it to him.
2. **¿Le ha dado (Ud.) el regalo a su madre?** | 2. Have you given the gift to your mother?
**Sí, se lo he dado.** | Yes, I have given it to her.
3. **¿Me prestará (Ud.) su pluma?** | 3. Will you lend me your pen?
**Sí, se la prestaré.** | Yes, I will lend it to you.
4. **¿Nos mandarán (Uds.) las flores?** | 4. Will you send us the flowers?
**Sí, se las mandaremos.** | Yes, we will send them to you.
5. **¿Les prestaron el dinero a Uds.?** | 5. Did they lend you the money?
**Sí, nos lo prestaron.** | Yes, they lent it to us.
6. **¿Les contó (Ud.) los cuentos a los niños?** | 6. Did you tell the stories to the children?
**Sí, se los conté.** | Yes, I told them to them.
159B. Before doing this exercise review Grammar Notes 1.
I. Translate into English: | II. Translate into Spanish:
---|---
1. **Los niños me los traen.** | 1. Charles gives it ( _m._ ) to me.
2. **Los alumnos nos las mandan.** | 2. Anna lends them ( _m._ ) to us.
3. **Ellos no nos los venden.** | 3. The teacher says it ( _m_.) to us.
4. **Te lo doy, hijito.** | 4. We give it ( _f._ ) to you, child.
159C. Before doing this exercise review Grammar Notes 2.
I. Translate into English: | II. Translate into Spanish:
---|---
1. **Se lo decimos a Ud.** | 1. John tells it ( _m._ ) to you ( _sing._ ).
2. **Se lo traemos a Uds.** | 2. Mary writes it ( _f._ ) to him.
3. **Se los damos a él.** | 3. The teacher gives them ( _m._ ) to you ( _pl._ ).
4. **Se las mandamos a ellos.** | 4. We send them ( _f._ ) to her.
159D. Before doing this exercise review Grammar Notes 3.
I. Translate into English: | II. Translate into Spanish:
---|---
1. **Dígamelo.** | 1. Lend them ( _m._ ) to me.
2. **Dénoslo.** | 2. Send it ( _m._ ) to us.
3. **Préstemelos.** | 3. Tell it ( _f._ ) to him.
4. **Mándeselos a él.** | 4. Give them ( _m._ ) to her.
# CHAPTER 48
CAPÍTULO 48 (CUARENTA Y OCHO)
## PRIMERA PARTE
### El señor Adams sale de México
#### Décima carta de México
**Muy amigo mío** :
**Cuando me fui** (I went away) **de Nueva York, como Ud. ya sabe, había aprendido algo acerca de México. Había leído varios libros muy intersantes sobre su** (its) **historia y sus costumbres. Ya sabía hablar español bastante bien.**
**Aquí en México he visitado muchos lugares. En nuestras conversaciones, que recuerdo bien, hemos hablado de algunos de ellos. En mis cartas le describí un poco de lo mucho que he visto. Lo demás** (the rest) **espero decírselo personalmente.**
**Como Ud. puede imaginar, me gustan mucho los lugares de interés histórico, el paisaje, el arte y las artes populares. Pero más me interesa el pueblo de México, con su cariño y su hospitalidad generosa. Me gustan su humor y su filosofía frente a las dificultades.**
**Me gusta mucho la vida de México. De veras es más tranquila que la de Nueva York a pesar de** (in spite of) **mis primeras impresiones en**
**el libre** (the taxi) **que me llevó con velocidad espantosa desde el aeropuerto hasta mi hotel.**
**Ud. sabe que vine a México en viaje de recreo y también de negocios. Afortunadamente pronto terminé los negocios y pude dedicarme enteramente al recreo.**
**Lamentablemente, no puedo ir ni a Colombia ni a Guatemala. ¡Qué lástima! Pero preferí llegar a conocer** (to get to know) **mejor México. Hay tanto que ver, tanto que hacer, tanto que aprender. Me encantó todo.**
**Tendré mucho que decirle de las personas muy simpáticas que he conocido, los lugares que he visitado y todo lo que he aprendido de las costumbres, de la vida, del idioma y de las artes de México.**
**Sin duda, pronto volveré a México. Quiero volver el año que viene. Pero entonces llevaré conmigo a la familia entera. Estoy seguro de que** (I am sure that) **no tendré ninguna dificultad. No he sacado el gordo en la lotería; pero, de todos modos, volveré.**
**Ésta es la última carta que le escribo antes de salir para Nueva York el primero de agosto. Tendré mucho gusto en telefonearle después de mi llegada, invitándolo a cenar con nosotros cuanto antes. Sin duda pasaremos gran parte de la noche hablando de nuestro querido México.**
**Hasta entonces y afectuosamente** ,
**Juan Adams**
### Vocabulario
**el cariño** | affection
---|---
**el paisaje** | landscape
**la filosofía** | philosophy
**la hospitalidad** | hospitality
**dedicar** | to dedicate
**encantar** | to charm
**enteramente** | entirely
**frente a** | in the face of
### Expresiones Importantes
**de todos modos** | anyway
---|---
**llegar a conocer** | to get to know
**cuanto antes** | as soon as possible
**lamentablemente** | unfortunately
**sin duda** | no doubt
### Ejercicio No. 160—Test of Reading Comprehension
Answer these questions in English
1. Before leaving for Mexico, how had Mr. Adams obtained some knowledge of the country?
2. How much was he able to describe in his letters?
3. What interests Mr. Adams most in Mexico?
4. Mention four qualities of the people that he likes.
5. How does Mr. Adams compare life in New York with that in Mexico?
6. When had he gotten a different impression?
7. Why didn't he go to Colombia or Guatemala?
8. Whom will he take with him on his next trip to Mexico?
9. What is he sure of?
10. When is he leaving for New York?
11. What will he be glad to do after his return to New York?
12. How does he think he and Mr. Lopez will spend much of the night?
## SEGUNDA PARTE
### Grammar Notes
1. **saber** and **poder**
1. **saber** plus an infinitive means _to know how to do something._ **Sabe escribir español.** | He can (knows how to) write Spanish.
---|---
2. **poder** plus an infinitive means _to have the physical ability or the opportunity to do something._ **Hoy no puede escribir, porque está enfermo.** | Today he cannot (is not able to) write, because he is ill.
---|---
2. Untranslated **que.**
1. You have learned that tener **que** means to have to. Thus: **Tengo que estudiar la lección.** | I must (have to) study the lesson.
---|---
2. **que** appears in a number of other expressions where it is not translated: **Tendré mucho que decide.** | I will have much to tell you.
---|---
**Tengo una carta que escribir.** | I have a letter to write.
**Hay tanto que ver.** | There is so much to see.
## TERCERA PARTE
### Ejercicios No. 161A-161B-161C
161A. Translate the following sentences accurately. Be sure the tense is correct.
**Ejemplo: Me fui de Nueva York. I left New York.**
**Me iré de Nueva York.** I shall leave New York.
1. **Leeré varios libros.**
2. **Había leído varios libros.**
3. **He leído varios libros.**
4. **Hemos visitado México.**
5. **Habíamos visitado México.**
6. **Visitaremos México.**
7. **Puedo describirlo.**
8. **Podía describirlo.**
9. **Podré describirlo.**
10. **Me gusta su carta.**
11. **Me gusto su carta.**
12. **Me gustará su carta.**
13. **Terminan los negocios.**
14. **Terminaron los negocios.**
15. **Han terminado los negocios.**
16. **Tienen mucho que decirme.**
17. **Tendrán mucho que decirme.**
18. **Tuvieron mucho que decirme.**
19. **Volveremos a casa.**
20. **Volvimos a casa.**
161B. Complete with the correct form of **saber, conocer** , or **poder** as needed:
1. **¿Quién** (knows) **todas las respuestas?**
2. (We know) **a ese hombre, pero** (we do not know) **dónde vive.**
3. (I cannot) **hacer el viaje con Ud.**
4. **El Sr. Adams quiere** (to know) **mejor a su agente.**
5. **Ahora** (they know each other) **mejor.**
6. (I know how) **jugar al fútbol.**
7. **Si** (you know) **el sistema monetario** , (you can) **regatear en el mercado.**
8. (You know) **aquellas ruinas mejor que yo.**
9. **Mucho gusto en** (know you).
10. (They are not able) **cambiar la llanta.**
161C. Translate.
1. Have you learned much about Mexico?
2. Yes, I have been ( **estado** ) there, and I have read many books.
3. Can you speak Spanish?
4. Yes, I speak it quite well.
5. Do you remember the places of which ( **de que)** we have spoken?
6. I remember them well.
7. Are you able to describe them in Spanish?
8. Yes, I can describe them.
9. What did you like most in Mexico?
10. I liked the people most.
11. Is the life of Mexico more tranquil than that of New York?
12. Indeed it is more tranquil.
13. Is there much to see in Mexico?
14. There is much to see, much to hear, much to do, much to learn.
15. My trip is finished.
# CHAPTER 49
REVIEW, CHAPTERS 44–48
REPASO, CAPÍTULOS 44–48
## PRIMERA PARTE
### Repaso de palabras (Word Review)
#### NOUNS
1. **la alegría**
2. **el aficionado**
3. **el banco**
4. **la biblioteca**
5. **el bolsillo**
6. **la carretera**
7. **los dulces**
8. **la esquina**
9. **el garage**
10. **la joya**
11. **la estación de gasolina**
12. **la librería**
13. **la lotería**
14. **la pieza**
15. **la posibilidad**
16. **el gordo**
17. **el paisaje**
18. **el recreo**
19. **el refresco**
20. **la risa**
21. **la señal**
22. **el sonido**
23. **la sombra**
24. **el sueño**
25. **la tela**
26. **el tabaco**
27. **el valle**
1. joy
2. amateur, fan
3. bench, bank
4. library
5. pocket
6. road, highway
7. sweets
8. corner
9. garage
10. jewel
11. gas station
12. bookstore
13. lottery
14. piece
15. possibility
16. first prize
17. landscape
18. recreation
19. refreshment
20. laughter
21. signal
22. sound
23. shade
24. sleep, dream
25. cloth
26. tobacco
27. valley
#### VERBS
1. **alquilar**
2. **anunciar**
3. **crecer**
4. **dormir (ue)**
5. **dormirse**
6. **ganar**
7. **manejar**
8. **matar**
9. **nombrar**
10. **ofrecer**
11. **parar**
12. **prestar**
13. **regresar**
14. **reunirse**
15. **sacar**
16. **señalar**
17. **sonar (ue)**
1. to rent
2. to announce
3. to grow
4. to sleep
5. to fall asleep
6. to win
7. to drive
8. to kill
9. to name
10. to offer
11. to stop
12. to lend
13. to return (go back)
14. to meet together
15. to take out
16. to point to
17. to dream
#### PREPOSITIONS
1. **durante**
2. **a pesar de**
3. **hacia**
1. during
2. in spite of
3. toward
#### IMPORTANT EXPRESSIONS
1. **a lo lejos**
2. **de todos modos**
3. **estar de acuerdo con**
4. **estar para (+ _infin._ )**
5. **en seguida**
6. **faltaba una hora para**
7. **No me falta nada.**
8. **más allá**
9. **no** (verb) **más que**
10. **¿Qué importa?**
11. **sin embargo**
12. **tener sueño**
1. in the distance
2. anyway
3. to be agreement with
4. to be about to
5. immediately
6. it was one hour before
7. I lack nothing.
8. further on
9. (verb) nothing but, only
10. What does it matter?
11. nevertheless
12. to be sleepy
## SEGUNDA PARTE
**Ejercicio 162.** Translate the following sentences accurately.
All the tenses you have learned and the imperative are practiced here.
1. **¿Quién pedirá información en la estación de ferrocarril?**
2. **Pablo ya había almorzado cuando lo vi.**
3. **¿Querrían Uds. hacer un viaje a todos los países de Europa?**
4. **Conozco a ese hombre pero no sé dónde vive.**
5. **Escribíamos nuestras cartas cuando el maestro entró en la sala.**
6. **Tomen (Uds.) estos papeles y pónganlos en mi escritorio.**
7. **Hemos comprado los diarios y los hemos leído.**
8. **Cuando llegué a México noté que todo el mundo compraba billetes de lotería.**
9. **Compre (Ud.) este billete y tendrá suerte.**
10. **No podía describirles todo lo que había visto.**
11. **Vine a México y me recibieron con cariño.**
12. **Guillermo hablaba toda la tarde mientras yo no decía nada.**
13. **No me gusto la corrida y por eso no asistiré a otra.**
14. **La tortilla se parece a nuestros panqueques.**
15. **Los padres trabajaban mientras los niños dormían.**
16. **Estábamos en el mercado cuando comenzó a llover.**
17. **Eran las ocho y media de la mañana y todavía dormían los niños.**
18. **No vendrán aquí porque no tendrán tiempo.**
19. **Niños, ¿no jugarán en el patio?**
20. **Mi tío viajó por todos los países de Sudamérica.**
21. **Al Sr. Adams le gustaba la comida picante, pero recordaba los consejos de su maestro y no la comía.**
22. **Yo quería los juguetes pero Carlos no me los daba.**
23. **Si encuentro platos con dibujos de animalitos, se los mandaré.**
24. **El pidió cambio por un billete de mil pesos y el cajero (cashier) se lo dio.**
25. **Ud. tiene el sombrero de María. Devuélvaselo.**
**Ejercicio 163.** Complete these sentences in Spanish.
1. **El Sr. Adams** (is a businessman of New York).
2. **Hizo** (a trip to Mexico in order to visit) **a su agente.**
3. **Quería** (to **know him better).**
4. **Antes de salir para México** (he learned to speak Spanish).
5. **También** (he had read many books) **sobre México.**
6. **Desde México escribió cartas** (to his friend and teacher, Mr. Lopez).
7. **Le gustaron mucho** (the places of historic interest).
8. **A pesar de sus primeras impresiones** (Mr. Adams found the life in Mexico more tranquil than that of New York).
9. **Pensó** (of the taxi which took him to his hotel).
10. **No le gusto** (the fearful speed of that taxi).
11. **Afortunadamente** (he finished his business matters quickly).
12. **Sin embargo** (he was not able to visit either Colombia or Guatemala).
13. **Había** (so much to see, so much to hear, so much to do, so much to learn).
14. **Pero el Sr. Adams** (will return to Mexico).
15. **Llevará consigo** (the whole family).
16. (He has not won the first prize) **en la lotería, pero tendrá** (enough money).
17. **Ésta es** (Mr. Adams's last letter) **desde México.**
18. (No doubt), **invitará al Sr. López** (to have dinner with his family) **después de su llegada a Nueva York.**
## LECTURA 1
### Ejercicio No. 164—Las Pirámides de Teotihuacán
**Se ven en los alrededores de México D.F. los restos** (remains) **de varias culturas muy desarrolladas (developed) y algo misteriosas: las culturas de las razas de indios que vivían en México hace diez siglos** (ten centuries ago).
**En el valle de Teotihuacán se encuentran unas pirámides enormes, monumentos de una cultura apenas** (scarcely) **conocida, la cultura de los toltecas. Vivían en el valle antes de los aztecas. Lo que** (what) **sabemos de ellos no existe ni en los libros de historia ni en las leyendas** (legends) **sino en pura piedra.**
**La Pirámide del Sol domina el valle. Tiene 216 pies de altura, y es más grande que cualquier pirámide de**
**Egipto. Se puede subir hasta la cima por una escalera ancha y muy escarpada** (steep).
**Más al norte, por la avenida de los Muertos** (dead), **está la Pirámide de la Luna y al sur se ve el templo de Quetzalcóatl, la Serpiente Plumada (plumed), dios de los aztecas. Esta pirámide está decorada con esculturas** (sculptures) **muy interesantes.**
**La gente que vive hoy día en el valle de Teotihuacán es descendiente de los aztecas. Los toltecas, arquitectos de las pirámides, desa-parecieron hace mucho tiempo. Sabemos solamente que era gente imaginativa con un sentido** (sense) **estético muy avanzado.**
## LECTURA 2
### Ejercicio No. 165—En el Zócalo
**Estamos en el Zócalo. Es la plaza principal de México, D.F. Caminamos al norte hacia** (toward) **la Catedral, que es del siglo dieciséis. A la derecha está el Palacio Nacional; también es antiguo, del siglo diecisiete. A la izquierda está el Portal de Mercaderes** (Merchants). **Allí vemos una cuadra de puestos y vendedores de mercancía barata. Más allá** (Beyond) **del Portal está el Monte de Piedad, y detrás de nosotros, al sur, están el Palacio Municipal y el Palacio de Justicia. Éste es un edificio nuevo. Aquél es del siglo dieciocho. Por todos lados, vemos edificios grandes y mucha gente.**
# CHAPTER 50
DICTIONARY
DICCIONÁRIO
## Spanish — English
### A
a | to, at
---|---
abajo | under, below
abierto, -a | open, opened
el abogado | lawyer
el abrigo | coat
abril (m.) | April
abrir | to open
acá | here (usually with a verb of motion)
acabar | to finish
acabar de ( _+infin_.) | to have just
aceptar | to accept
la acera | the sidewalk
acerca de | about, concerning
acercarse (a) | to approach
acompañar | to accompany
aconsejar | to advise
acordarse (ue) (de) | to remember
acostarse (ue) | to go to bed
acostumbrar | to accustom
el acuerdo | agreement
adelantar | to progress
adelante | straight ahead, forward
además | moreover, also
adiós | good-bye
admirar | to admire
el adobe | adobe, sun-dried brick
aéreo: por correo aéreo | by air mail
el aeropuerto | airport
el aficionado | sport fan
afortunado, -a | lucky
afuera | outside
agarrar | to pick up, to catch
el agente | agent
agosto (m.) | August
agradable | agreeable, pleasant
agradecido, -a | thankful, grateful
el agua (f.) | water
ahí | there
ahora | now
ahorita | just now, in just a minute
el aire | air
al aire libre | in the open air
alegrar | to make happy
alegrarse | to rejoice, to be glad
alegre | lively, merry
la alfarerbía | pottery
algo | something; somewhat
el algodón | cotton
alguien | someone, anyone
alguno (algún), -a | some, any
el alimento | food
el alma (f.) | soul
el almacén | department store
almorzar | to have lunch
el almuerzo | lunch
alquilar | to rent
alrededor de | around
los alrededores | surrounding areas
alto, -a | tall, high
la altura | altitude
alumno, -a | student
allá | there (usually with a verb of motion)
allí | there
amable | kind
amar | to love
amarillo, -a | yellow
el amigo, la amiga | friend
el amor | love
anaranjado, -a | orange-colored
ancho, -a | wide
andar | to go, to walk
animado, -a | lively, animated
el ánimo | soul, spirit; courage
anoche | last night
de antaño | ancient, of long ago
ante | before, in face of
anteayer | day before yesterday
antes de | before (refers to time)
cuanto antes | as soon as possible
antiguo, -a | old
anunciar | to announce
el año | year
el año que viene | next year
el aparador | sideboard
aparecer | to appear
apenas | scarcely
el apetito | appetite
apreciar | to appreciate
aprender (a) | to learn (to)
apresurarse | to hurry
aprisa | swiftly, quickly
apropiado | appropriate
aprovechar | make good use of someone
aprovecharse de | to take advantage of
aquel, aquella | that
aquél, aquélla | that (one); the former
aquí | here
aquí lo tiene Ud. | here you have it
el árbol | tree
arreglar | to arrange
arriba | above, upstairs
la arroba | @
el arroz | rice
el arte (m. and f.) | art
el artesano | craftsman
el artículo | article
el (la) artista | artist
artístico | artistic
el ascensor | elevator
así | thus, so
el asiento | seat
asistir (a) | to assist
el aspecto | appearance
atento | attentive
atrás | backwards, behind
atravesar (ie) | to cross
aún | yet, still
aunque | although
el autobús | bus
el automóvil | automobile
la avenida | avenue
averiguar | to find out
el avión | airplane
avisar | to inform
¡ay! | alas!
ayer | yesterday
la ayuda | aid
ayudar (a) | aid, help (to)
el azúcar | sugar
el azucarero | sugar bowl
azul | blue
el azulejo | tile
### B
bailar | to dance
---|---
el bailarín | dancer
el baile | the dance
bajar (de) | to get out (of); to climb (go) down
bajo, -a | low, short (person)
el balcón | balcony
el banco | bench
la bandeja | tray
bañar | to bathe
el baño | bath; bathtub; bathroom
barato, -a | cheap
¡basta! | enough!
bastante | quite, enough
la batalla | battle
el baúl | trunk
beber | to drink
la bebida | drink
el béisbol | baseball
bello, -a | beautiful
el beso | kiss
la biblioteca | library
bien | well
bienvenido, -a | welcome
el billete | ticket
bianco, -a | white
la blusa | blouse
la boca | mouth
la boletería | ticket-window
el boletero | ticket-seller
el boleto de ida y vuelta | round-trip ticket
el bolígrafo | pen
la bolsa | purse
el bolsillo | pocket
la bondad | kindness
bonito, -a | pretty, nice
la botella | bottle
el brazo | arm
brillar | to shine
la brisa | breeze
bueno (buen), -a | good
¡bueno! | hello! (on the telephone)
el bulto | bundle
el burro | donkey
buscar | to look for
el buzón | mailbox
echar en el buzón | to mail
### C
el caballo | horse
---|---
la cabeza | head
cada | each, every
caer | to fall
el café | coffee, café
la caja | box
la cajuela (Mex.) | trunk (of car)
el calcetín | sock
caliente | warm, hot
el calor | heat
Hace calor. | It's hot (weather).
tener calor | to be hot (for persons)
la calle | street
la cama | bed
cambiar | to change, exchange
el cambio | change
de cambio | in change
caminar | to go, to travel, to walk
el camino | road
el camión | truck; bus (Mex.)
la camisa | shirt
el campesino | peasant
el campo | country
la canasta | basket
la canción | song
cansado, -a | tired
cansarse | to grow weary, tired
cantar | to sing
la cantidad | quantity
la caña de azúcar | sugar cane
la cara | face
la carga | load
el cariño | affection
la carne | meat
la carnicería | butcher shop
caro, -a | expensive, dear
la carta | letter
el cartel | poster
el cartero | postman
la casa | house
en casa | at home
volver a casa | to return home
casarse con | to marry
casi | almost
la causa | cause
a causa de | because of
la cebolla | onion
celebrar | to celebrate
la cena | dinner, supper
cenar | to have supper, dinner
el centavo | cent
el centro | center
la cerámica | pottery
cerca de (prep.) | near
cercano | nearby
el cerillo | wax match
el cero | zero
cerrado, -a | closed, shut
cerrar (ie) | to close, shut
el certificado | certificate
la cerveza | beer
la cesta | basket
chequear | to check
el cielo | sky
el científico | scientist
ciento (cien) | one hundred
por ciento | percent
cierto | certain, true
por cierto | certainly
el cigarro | cigar
el cine | movie theatre
la cinta | film
el cinturón | belt
la cita | appointment
citar | to make an appointment with
la ciudad | city
claro, -a | clear, light
¡Claro que si! | Of course!
¡Claro que no! | Of course not!
la clase | class, kind
el clavel | carnation
el cliente | client
el clima | climate
el cobre | copper
cocido, -a | cooked, boiled
el coche | car, automobile
la cocina | kitchen
el color | color
¿de qué color es...? | what color is...?
el comedor | dining room
comentar | to comment
comenzar (ie) | to begin
comer | to eat
comerse | to "eat up"
el comerciante | businessman
la comida | meal, food, dinner
como | like, as, how
¿cómo? | how?
¿cómo no? | why not?
¿cómo se dice...? | how do you say...?
cómodo, -a | comfortable
el compañero | companion
el compatriota | countryman
completo, -a | complete
la compra | purchase
ir de compras | to go shopping
el comprador | purchaser, buyer
comprar | to buy
comprender | to understand
el compromiso | engagement
la computadora | computer
común | common
con | with
conmigo | with me
con tal que | provided that
el concierto | concert
condecorado, -a | decorated
conducir | to lead, to conduct
confesar(ie) | to confess
conocer | to know, meet, be acquainted with
conocido, -a | well-known
conseguir(i) | to get, obtain
los consejos | advice
consentir (ie) | to consent
consiguiente, por | consequently
consistir en | to consist of
contar (ue) | to count; to relate
contener | to contain
contento, -a | contented, happy
el contestador automático | answering machine
contestar(a) | to answer
continuar | to continue
contra | against
conveniente | convenient
conversar | to converse, chat
la copia | copy
el corazón | heart
la corbata | necktie
coronado | crowned
correcto, -a | correct
corregir (i) | to correct
el correo | the post office, mail
correo electrónico | e-mail
por correo aéreo | by air mail
correr | to run
la corrida de toros | bullfight
corriente | current, popular
cortar | to cut
la cortesía | courtesy
corto, -a | short
la cosa | thing
¡qué cosa! | the idea!
la costa | coast
costar (ue) | to cost
la costumbre | custom
es costumbre | it's customary
crecer | to grow
creer | to believe, "think"
Creo que no. | I think not.
Creo que sí. | I think so.
¡Ya lo creo! | Yes indeed; I should say so!
la criada | maid
el cristal | glass
cruzar | to cross
cuadrado, -a | square-shaped
el cuadro | block, square
¿cuál? ¿cuáles? | which (one, ones)? what?
cualquier | any
cuando | when
¿cuándo? | when?
¿cuánto, -a? | how much?
¿cuántos?, -as? | how many?
el cuarto | room, quarter, fourth
cubierto de | covered (with)
cubrir | to cover
la cuchara | spoon
la cucharita | teaspoon
el cuchillo | knife
la cuenta | bill
el cuento | story
el cuero | leather
el cuerpo | body
cuidar | to look after
cuidar de | to take care of
¡cuidado! | caution!
la culpa | guilt, fault, blame
la cultura | culture
el cumpleaños | birthday
cumplir | to fulfill
el cura | priest
cuyo, -a | whose
### CH
la chal | shawl
---|---
el chamaco (Mex.) | boy
charlar | to chat
chequear | to check
chico (a) | small
el chico, la chica | small boy (girl)
la chuleta | chop
### D
el bailarín | dancer
---|---
el daño | harm
dar | to give
dar a (una calle) | to face (a street)
dar las gracias a | to give thanks to
dar un paseo | to take a walk or drive
darse la mano | to shake hands
de | of, from, about
debajo de | under, beneath
deber | to ought to, to be obliged to, must
débil | weak
decidir | to decide
décimo, -a | tenth
decir | to tell, say
es decir | that is to say
defender | to defend
dejar | to let, to leave, allow
dejar de | to fail to (do something)
delante de | in front of
demandar | to demand
los demás | the rest
demasiado, -a | too much (sing.), too many (pl.)
dentro (de) | inside (of)
el dependiente | clerk
el deporte | sport
derecho,-a | right
a la derecha | to the right
derecho | straight ahead
desaparecer | to disappear
desayunarse | to breakfast
el desayuno | breakfast
descansar | to rest
el descanso | rest, leisure
el descendiente | descendant
describir | to describe
descubrir | to discover
desde | from, since
desde luego | of course
desear | to wish, want
desear un buen viaje | to wish a pleasant journey
deseoso | desirous
el desfile | parade, procession
desgraciadamente | unfortunately
el desierto | desert
desocupado | unoccupied
despacio | slowly
despedirse | to say good-bye
despertar (ie) | to wake (someone)
despertarse | to wake (oneself)
despierto, -a | awake
después | afterwards
después de | after
detrás de | behind
devolver (ue) | to give back, return
el día | day
al día siguiente | next day
hoy día | nowadays
diario, -a | daily
el dibujo | drawing
diciembre (m.) | December
el diente | tooth
diferente | different
difícil | difficult
el difunto | deceased
digno | worthy
diligente | diligent
el dinero | money
el dios | god
la dirección | address
la dirección electrónica | e-mail address
dirigirse a | to go to, to address (a person)
disculpar | to excuse
discúlpeme | excuse me
distinto, -a | different
la diversión | amusement
diverso, -a | varied
divertido, -a | amusing
divertirse (ie) | to have a good time, amuse oneself
dividir | to divide
el dólar | dollar
el dolor | pain
dolor (de cabeza), | (headache),
(de muelas), | (toothache),
(de estómago) | (stomachache)
dominar | to dominate
el domingo | Sunday
don (m.), doña (f.) | title used with first name
donde | where
¿dónde? | where?
¿por dónde se va a...? | how does one get to...?
dormir (ue) | to sleep
dormirse (ue) | to fall asleep
el dormitorio | bedroom
el drama | play
la duda | doubt
sin duda alguna | without a doubt
dulce | sweet
los dulces | candy
durante | during
durar | to last
### E
echar | to pour, to throw out
---|---
echar de menos | to miss
echarse | to stretch out
la edad | age
efecto; en efecto | in fact
elevar | to raise
elevarse | to rise
la embajada | embassy
embargo; sin embargo | nevertheless
la emoción | emotion
emocionante | touching, thrilling
empezar (ie) (a) | to begin (to)
el empleado | employee
emplear | to use
en | in, on, at
en seguida | at once
en vez de | instead of
encantar | to enchant, charm
la enchilada | a kind of pancake with chile and meat stuffing
encima (de) | on top (of)
encontrar (ue) | to find; meet
enero (m.) | January
enfermarse | to get sick
enfermo, -a | sick, ill
enfrente de | opposite, facing, in front of
enorme | enormous
enseñar | to teach
entenderse | to understand each other
entero | whole
entonces | then
la entrada | entrance
entrar (en) | to enter
entre | between
entretanto | meanwhile
enviar | to send
el envío | shipment
el equipaje | baggage
equivocado, -a | mistaken
la escalera | stairway
escoger | to choose
el escolar | student, scholar
escribir | to write
el escritor | writer
el escritorio | desk
escuchar | to listen (to)
la escuela | school
ese, -a | that
ése, -a | that (one)
eso | that (as an idea or statement)
a eso de | at about (time)
por eso | therefore
espacioso | spacious
español | Spanish (lang.)
el español | Spaniard
la española | Spanish woman
el espectador | spectator
esperar | to wait (for), hope, expect
Espero que no. | I hope not.
Espero que sí. | I hope so.
el esposo | husband
la esposa | wife
la esquina | corner
la estación de ferrocarril | railroad station
el estado | state
Estados Unidos (abbr.EE.UU.) | the United States
el estante | shelf, bookcase
estar | to be (location)
estar de prisa | to be in a hurry
estar en camino | to be on the way
estar para | to be about to
la estatua | statue
el este | east
este, -a | this
éste, -a | this (one)
el estilo | style
esto | this (as an idea or statement)
estrecho, -a | narrow
la estrella | star
el estudiante | student
el estudio | study
estudiar | to study
el examen | examination
examinar | to examine
excelente | excellent
excepto | except
exigir | to demand
explicar | to explain
expresar | to express
la expresión | expression
extender (ie) | to extend
### F
fácil | easy
---|---
facilitar | to facilitate
fácilmente | easily
facturar | to check (baggage)
la faja | sash
la falda | skirt
falso, -a | false
la falta | mistake, lack
faltar | to lack, to need
me falta | I need
la familia | family
famoso, -a | famous
la farmacia | pharmacy
favor | favor
el favor de | the favor of
Es favor que Ud. me hace. | You flatter me.
por favor | please
febrero (m.) | February
la fecha | date
¿Cuál es la fecha? | What is the date?
felicitar | to congratulate
feliz | happy
la fiesta | holiday
lafila | row
el fin | the end
al final | at the end
fino, -a | fine
firmar | to sign
el flan | custard
la flor | flower
la formalidad | formality
la fortuna | fortune
el fósforo | match
el francés | French (lang.), Frenchman
la francesa | Frenchwoman
la frase | sentence
la frente | front
en frente de | in front of
frente a | opposite, facing
fresco | cool
los frijoles | beans
frío | cold
hacer frío | to be cold (weather)
tener frío | to be cold (persons)
la fruta | fruit
la fuente | fountain
el fuego | fire
fuera de | outside of
fuerte | strong
la función | performance
### G
la gana | desire
---|---
de buena gana | willingly
ganar | to earn, to win
(tener) ganas de | to really like to, to feel like
el garaje | garage
gastar | to spend
generalmente | generally, usually
generoso, -a | generous
la gente | people
gordo, -a | fat
gozar (de) | to enjoy
gracias | thanks
gracioso, -a | graceful, amusing
grande | large, great
gris | gray
gritar | to shout
el grito | shout, cry
grueso, -a | thick
el grupo | group
el guajalote | turkey (Mex.)
el guante | glove
guapo, -a | neat, elegant, handsome
guardar | to keep, guard
la guía | guidebook
gustar | to be pleasing to
me gusta | I like
el gusto | pleasure
con mucho gusto | with much pleasure
El gusto es mío. | The pleasure is mine.
tanto gusto en conocerle | very pleased to meet you
### H
haber | to have ( _+infin_.)
---|---
el habitante | inhabitant
hablador, -a | talkative
hablar | to speak, to talk
hacer | to do, make
hace algún tiempo | some time ago
Hace calor, frío. | It is hot, cold (weather).
hacer daño a | to hurt (some one)
hacerse bien | to get along well
me hace falta | I need
Hace sol. | It is sunny.
hacer preguntas | to ask questions
hallar | to find
el hambre | hunger
tener hambre | to be hungry
hasta | until, to, as far as, even
hasta la vista | until I see you
hasta luego | until later
hasta mañana | until tomorrow
hay | there is, there are
hay que | it is necessary to, one must
Hay (viento), (polvo). | It is (windy), (dusty).
No hay de que. | You're wecome.
hecho | made
hecho a mano | handmade
el helado | ice cream
el hermano | brother
la hermana | sister
hermoso, -a | beautiful
el héroe | hero
el hierro | iron
el hijo | son
la hija | daughter
los hijos | children
la hoja | leaf, sheet (of paper)
la hojalata | tin plate
el hombre | man
la hora | hour, time
¿a qué hora? | at what time?
el horario | timetable
la hospitalidad | hospitality
hoy | today
hoy día | nowadays
el huevo | egg
huir | to flee
húmedo, -a | wet, humid
### I
el idioma | language
---|---
la iglesia | church
igual | equal
igualmente | equally; the same to you
imaginar | to imagine
imitar | to imitate
impaciente | impatient
el impermeable | raincoat
imponente | imposing
el importador | importer
importante | important
importar | to matter,
to be important;
to import
No importa. | It doesn't matter.
la impresión | impression
la impresora | printer
indicar | to point out, indicate
indígena | indigenous, native
el indio, -a | Indian
la industria | industry
la información | imformation
pedir información | to ask for information
informar | to inform
el inglés | English (lang.); Englishman
la inglesa | Englishwoman
el iniciador | founder
inmediatamente | immediately
inmenso, -a | immense
inteligente | intelligent
el interés | interest
interesar | to interest
interpretar | to act a role, translate, interpret
el invierno | winter
invitar | to invite
ir | to go
irse | to go away, leave
ir de compras | to go shopping
ir de paseo | to go for a walk or ride
izquierdo, -a | left
a la izquierda | to the left
### J
¡ja! ¡ja! | ha! ha!
---|---
el jabón | soap
jamás | never
el jamón | ham
el jardín | garden
el jarro, la jarra | jar
el jefe | chief
la joya | jewel
la joyería | jewelry shop, jewelry
joven | young
el joven | young man
el juego | game, set
el jueves | Thursday
el jugador | player, gambler
jugar | to play (a game)
el jugo | juice
el juguete | toy
julio (m.) | July
junio (m.) | June
juntar | to join, unite
junto a | near, close to
junto con | together with
### K
el kilo | kilogram
---|---
el kilómetro | kilometer
### L
el labio | lip
---|---
laborado | worked, tilled
la laca | lacquer
el lado | side
al lado de | beside
la lámpara | lamp
lamentablemente | unfortunately
la lana | wool
el lápiz | pencil
largo, -a | long
la lástima | shame, pity
¡Qué lástima! | What a pity!
la lata | can
lavar | to wash
lavarse | to wash oneself
la lección | lesson
la leche | milk
la lechuga | lettuce
leer | to read
la legumbre | vegetable
lejano, -a | far off
lejos de | far from
a lo lejos | in the distance
lentamente | slowly
levantar | to raise, lift
levantarse | to rise, get up
la libra | pound
libre | free
el libre | taxi (Mex.)
la librería | bookstore
el libro | book
el líder | leader
ligero, -a | light (not heavy)
la lima | lime
el limón | lemon
limpiar | to clean
la lista | menu
listo, -a | ready
lograr | to succeed
la lotería | lottery
la lucha | struggle
luego | then
desde luego | since then
hasta luego | until then
el lugar | place
el lujo | luxury
luminoso, -a | bright
la luna | moon
el lunes | Monday
la luz | light
### LL
llamar | to call
---|---
llamar por teléfono | to call on the phone
llamarse | to be called
Me llamo Pablo. | My name is Paul.
la llanura | plain
la llegada | arrival
llegar | to arrive
llenar | to fill
lleno, -a | full
llevar | to carry; to take, to wear;
llevarse | to carry (take) away
llevarse bien | to get along well
llover (ue) | to rain
la lluvia | rain
lluvioso, -a | rainy
### M
la madera | wood
---|---
la madre | mother
el madrugador | early riser
el maestro | teacher
magnífico | magnificent
el maíz | corn
el malestar | indisposition
la maleta | suitcase
hacer una maleta | to pack a suitcase
malo, -a | bad, sick
la mamá | mommy
el mandadero | office boy
mandar | to order, to send
manejar | to drive
la manera | manner
de manera que | so that
de (otra) (la misma) manera | in (another) (the same) way
la mano | hand
darse la(s) mano(s) | to shake hands
a la mano derecha | on the right
a la mano izquierda | on the left
la manta | blanket
mantener | to maintain
la manzana | apple
mañana | tomorrow
hasta mañana | until tomorrow
la mañana | morning
por la mañana | in the morning
la máquina de escribir | typewriter
el mar | sea
el martes | Tuesday
marzo (m.) | March
más | more, most, plus
más o menos | more or less
la máscara | mask
matar | to kill
las matemáticas | mathematics
mayo (m.) | May
mayor | older
la mayoría | majority
la media | stocking
el medico | doctor (physician)
la medida | measurement
medio, -a | half
medir (i) | to measure
mejor | better
el (la) mejor | best
el melocotón | peach
el melón | melon
la memoria | memory
de memoria | by heart
menor | younger
el (la) menor | youngest
menos | less, minus, except
por lo menos | at least
echar de menos | to miss
el mensaje | message
la mentira | lie
a menudo | often
el mercado | market
la mercancía | merchandise
la merienda | light supper, tea
la mesa | table
el mesero | waiter
el mexicanismo | Mexicanism
mexicano | Mexican
México | Mexico
mientras | while
mientras tanto | meanwhile
el miércoles | Wednesday
mil | thousand
la milla | mile
el millón | million
mirar | to look at, watch
mismo, -a | same
él mismo | he himself
lo mismo | the same thing
la mitad | half
moderno, -a | modern
el modismo | idiom
el modo | way
de este modo | in this way
de todos modos | anyway
mojado, -a | soaked, wet
la moneda | currency, money
la montaña | mountain
el montón | heap, pile
mostrar (ue) | to show
el movimiento | movement
el mozo | waiter
el muchacho | boy
la muchacha | girl
mucho, -a | much
muchos, -as | many
mudarse | to move (change house)
la muerte | death
el muerto | corpse, dead man
la mujer | woman
el mundo | world
todo el mundo | everybody
el museo | museum
muy | very
### N
nada | nothing
---|---
De nada. | You're welcome.
nadie | no one, nobody
la naranja | orange
la nariz | nose
la naturaleza | nature
la Navidad | Christmas
necesario, -a | necessary
la necesidad | necessity
necesitar | to need
el negociante | businessman
el negocio | business
negro, -a | black
nervioso | nervous
nevar | to snow
la nieve | snow
ninguno, -a | no one, nobody
el niño, la niña | child
no | no, not
la noche | night
por la noche | in the evening
esta noche | tonight
nombrar | to name
el nombre | name
el norte | north
el norteamericano | North American (usually means a person from the U.S.)
notable | worthy of note
las noticias | news
noviembre (m.) | November
nuevo, -a | new
el número | number
nunca | never
### O
o | or
---|---
obedecer | to obey
el objeto | object
observar | to observe
obtener | to obtain
occidental | western
octubre (m.) | October
ocupado, -a | busy
el oeste | west
la oficina | office
ofrecer | to offer
el oído | ear (hearing)
oír | to hear
el ojo | eye
la olla | pot
olvidar | to forget
omitir | to omit
la oportunidad | opportunity
la orden | order
a sus órdenes | at your service
ordinario, -a | ordinary
el orgullo | pride
orgulloso, -a | proud
el oro | gold
oscuro, -a | dark
el otoño | autumn
otro, -a | other, another
### P
pacífico | peaceful
---|---
el padre | father
pagar | to pay
el país | country
la paja | straw
el pájaro | bird
la palabra | word
el palo | stick
el pan | bread
el panadero | baker
el panecillo | roll
el panqueque | pancake
la pantalla | screen
el papá | papa
la papa | potato
el papel | paper, role
el paquete | package
paquete postal | parcel post
el par | pair
para | in order to, for
para que | in order that
el paraguas | umbrella
parar | to stop
parecer | to seem
Le parece bien. | It seems all right to him.
parecerse a | to resemble
la pared | wall
el pariente | relative
la parte | part
por todas partes | everywhere
la partida | departure
el partidario | partisan, supporter
partir | to leave
el pasaje | fare, passage
el pasaporte | passport
pasar | to pass, spend (time), happen
pasar sin | to get along without
pasarla bien/mal | to have a good/bad time
¿Qué pasa? | What's going on?
pase Ud. | come in; go ahead
el pasado | past
pasear | to take a walk, to walk about
pasearse | to go for a walk or
(en coche), | a ride (in a car),
(en barco), | (in a boat),
(a caballo) | (on horseback)
el paseo | promenade
el paso | step
el patio | courtyard
el pato | duck
el pavo | turkey
el pedazo | a piece
pedir (i) | to ask for
pedir informacíon | to ask for information
la película | motion picture
la película de acción | action movie
peligroso, -a | dangerous
el pelo | hair
pensar (ie) | to think, to intend
pensar en | to think about
peor | worse
pequeño, -a | small
la pera | pear
perder (ie) | to lose
perdonar | to pardon
perezoso, -a | lazy
perfectamente | perfectly
el periódico | newspaper
el permiso | permission
con su permiso | with your permission
permitir | to permit, to allow
pero | but
la persona | person
pesado, -a | heavy
pesar | to weigh
a pesar de | in spite of
el pescado | fish
pescar | to fish
pescarse un catarro, un resfriado | to catch a cold
el peso | weight; monetary unit of several Latin American countries
picante | spicy, hot (food)
el pico | peak
el pie | foot
estar de pie | to stand
la piedra | stone
la pierna | leg
la pieza | piece
pintar | to paint
el pintor | painter
pintoresco, -a | picturesque
la pintura | painting
la piña | pineapple
la piñata | pot full of candy and toys, broken by children at Christmas and birthday parties
la pirámide | pyramid
el piso | floor, story
el placer | pleasure
la plata | silver
el plátano | banana, plantain
el platero | silversmith
platicar | to chat
el platillo | saucer
el plato | dish
la plaza | square, park
la pluma | pen
pobre | poor
poco, -a | little
dentro de poco | in a short time
pocos, -as | few
poder (ue) | to be able, can, may
se puede | one can
el policía | policeman
el polio | chicken
poner | to put, to place
poner la mesa | to set the table
ponerse | to put on, to become
la naturaleza se pone verde | spring (Lit. nature turns green)
ponerse en marcha | to put in motion
por | for, in exchange for, by, through, along
por cierto | certainly
por eso | therefore
por lo tanto | therefore
por supuesto | of course
por todas partes | everywhere
¿por qué? | why?
porque | because
el portal | arcade
el porvenir | future
posible | possible
postal | post, mail
el paquete postal | parcel post
el postre | dessert
practicar | to practice
el precio | price
precioso, -a | exquisite, precious
precisamente | exactly
preferir (i) | to prefer
la pregunta | question
hacer una pregunta | to ask a question
el premio | prize
preocuparse (de) | to worry (about)
presentar | to introduce
prestar | to lend
la primavera | spring
primer, -o, -a | first
el principio | beginning
al principio | at first
prisa; de prisa | fast, quickly
tener prisa | to be in a hurry
probablemente | probably
probar (ue) | to prove; to explore; to taste
el problema | problem
producir | to produce
profesor, -a | professor, teacher
profundo, -a | profound
el programa | program
prometer | to promise
pronto | soon
la propina | tip
propio, -a | own
proponer | to propose
propósito; a propósito | by the way
proteger | to protect
próximo, -a | next (in time)
el pueblo | town; people
puertorriqueño, -a | Puerto Rican
la puerta | door
pues | well, then
el puesto | stand, booth
puesto que | since
el punto | point, period, dot
en punto | on the dot (time)
### Q
el queso | cheese
---|---
que | who, that, which, than
lo que | that which, what
¿qué? | what?, which?
¿Qué tal? | What's up?
quedar (se) | to remain, stay
querer (ie) | to wish, want
querer a | to love, to want
¿Qué quiere decir? | What does it mean?
querido, -a | dear, beloved
quien, -es | who
¿quién, -es? | who?
¿a quién -es | to whom?
¿de quién, -es? | whose?
¿Quién sabe? | Who knows?
quitar | to remove
quitarse | to take off (clothing)
quizás | maybe
### R
el radio | radio (set)
---|---
la radio | radio (broadcast)
la rapidez | speed
rápidamente | rapidly
rápido, -a | rapid, swift
raro, -a | strange, rare
el rascacielos | skyscraper
el rato, un rato | the while (a while)
largo rato | a long time
el ratón | mouse
razón; tener razón | to be right
no tener razón | to be wrong
el rebozo | shawl
la recámara | bedroom (Mex.)
recibir | to get, recieve
recibir a alguien | to greet someone; to have office hours
reconocer | to recognize
recordar (ue) | to remember
el recuerdo | souvenir, memento
el recreo | recreation
redondo | round
el refresco | soft drink
el regalo | gift
regatear | to bargain
regresar | to return
la reina | queen
reír (i) | to laugh
reírse de (i) | to laugh at
la reja | grate; grille
el reloj | watch, clock
reluciendo | shining, glittering
repente; de repente | suddenly
repetir (i) | to repeat
el representante | representative
requisito | necessary, requisite
el resfriado | cold (illness)
resistir | to resist
respecto a | in regard to
el respeto | respect
responder | to answer
la respuesta | answer
el restaurante | restaurant
los restos | remains
el retrato | portrait, photo
revisar | to examine
la revista | magazine
el rey | king
rico, -a | rich
el rincón | corner
el río | river
la risa | laugh
rodeado, -a | surrounded
rojo, -a | red
romper | to break
la ropa | clothing
rosado, -a | pink
el ruido | noise
### S
el sábado | Saturday
---|---
saber | to know, to know how
sabroso, -a | tasty, delicious
sacar | to elicit, to fetch
sacar el gordo | to win the lottery
la sala | living room, hall
la sala de espera | waiting room
salir (de) | to leave, to exit
salir para | to leave for
la salsa | sauce
la salud | health
saludar | to greet
el saludo | greeting
el santo | saint
santo | holy
el sarape | blanket
satisfecho, -a | satisfied
seco,-a | dry
sed | thirst
tener sed | to be thirsty
la seda | silk
seguida; en seguida | at once
seguir (i) | to continue, to follow
según | according to
segundo, -a | second
el boleto de segunda clase | second-class ticket
seguramente | surely
la seguridad | security
las medidas de seguridad | security measures
seguro | sure
de seguro | surely
la semana | week
semejante | similar
sencillo, -a | simple
sentado, -a | seated, sitting down
sentarse (ie) | to sit down
el sentido | meaning, sense, feeling
sentir (ie) | to feel, to regret
Lo siento mucho. | I'm very sorry.
sentirse (ie) | to feel (emotions)
Ie señal | signal
señalar | to point out
el señor | gentleman; Mr.
la señora | lady; Mrs.; Ms.
la señorita | young lady; Miss
septiembre (m.) | September
ser | to be
el servicio | service
el servidor | servant
servir (i) | to serve
servir para | to serve as
¿En qué puedo servirle? | How may I help you?
si | if; whether
sí | yes; certainly
siempre | always
la sierra | mountain range
la siesta | afternoon nap, rest
el siglo | century
significar | to mean
siguiente | following
al día siguiente | the following day
la silla | chair
el sillón | armchair
simpático, -a | pleasant, nice
sin | without (prep.)
sin que | without (conj.)
sino | but (on the contrary)
el sistema | system
el sitio | place
situado, -a | situated
sobre | upon, over
el sol | sun
solamente | only
no solamente... | not only...
sino también | but also
solo, -a | alone, only
sólo | only (adv.)
la sombra | shade
el sombrero | hat
sonar (ue) | to sound, ring
el sonido | sound
sonreír (i) | to smile
soñar (ue) | to dream
la sopa | soup
sorprendido | surprised
subir | to go up; to climb; to get into (bus, car, taxi, etc.)
el suburbio | suburb
sucio, -a | dirty
el suelo | floor, ground
el sueño | dream
tener sueño | to be sleepy
la suerte | fate, luck
buena suerte | good luck
el suéter | sweater
sumamente | extremely
supuesto; por supuesto | of course
el sur | south
el surtido | assortment
### T
el tabaco | tobacco
---|---
el taco | a tortilla sandwich
tal | such
tal vez | maybe
¿Qué tal? | What's up?
el tamaño | size
también | also
tampoco | neither, either
ni yo tampoco | nor I either
tan | as, so
tan... como | as... as
el tanque | tank
tanto, -a | so much (sing.), so many (pi.)
tanto... como | as much as (sing.), as many as (pl.)
el taquígrafo | stenographer
la taquilla | ticket window
la tarde | afternoon
tarde | late (adj.)
la tarjeta de turista (turismo) | tourist card
la taza | cup
el té | tea
el teatro | theater
el tejado | roof
el tejido | textile
la tela | cloth
el teléfono | telephone
llamar por teléfono | to call on the telephone
la televisión | television
el tema | theme, subject
temer | to fear
la temperatura | temperature
templado | temperate
temprano | early
el tenedor | fork
tener | to have
tener calor, frío | to be warm, cold (person)
tener cuidado | to be careful
tener dolor de (cabeza), (muelas) | to have a (head), (tooth) ache
tener ganas de | to have desire to
tener hambre | to be hungry
tener sed | to be thirsty
tener prisa | to be in a hurry
tener que | to have to
tener razón | to be right
tener sueño | to be sleepy
¿Qué tiene Ud.? | What's the matter with you
teñido, -a | dyed
tercero, -a | third
terminar | to end
la ternera | veal
el tiempo | weather; time
a tiempo | on time
la tienda | store
la tierra | land
el timbre | stamp, bell
la tinta | ink
el tío | uncle
la tía | aunt
típico, -a | typical
el título | title
titularse | to be called
tocar | to play (an instrument); to ring (a bell)
el tocino | bacon
todavía | still, yet
todavía no | not yet
todo, -a | all, every, whole, everything
ante todo | first of all
todo el mundo | everybody
todo el año | all year
todo lo posible | everything possible
sobre todo | especially, above all
tomar | to take, to eat, to drink
el tomate | tomato
el tópico | topic
el torero | bullfighter
el toro | bull
la toronja | grapefruit
la torta | cake
la tortilla | Mexican "pancake" of corn
trabajador, -a | hardworking
trabajar | to work
el trabajo | work
traducir | to translate
traer | to bring
el traje | suit
el tranvía | streetcar
tratar (de) | to try (to)
el trigo | wheat
triste | sad
truena | it is thundering
el trueno | thunder
el (la) turista | tourist
### U
u | or (before words beginning with o or ho)
---|---
último, -a | last
unir (se) | to unite, to join
la universidad | university
usar | to use
el uso | use
útil | useful
la uva | grape
### V
la vaca | cow
---|---
las vacaciones | vacation
vacío, -a | empty
la vacuna | vaccination
valer | to be worth
No vale nada. | It is not worth anything.
valer la pena | worthwhile
Más vale tarde que nunca. | Better late than never.
la valija | suitecase
el valle | valley
la variedad | variety
varios, -a | several
el vaso | glass (for drinking)
la velocidad | speed
a toda velocidad | at full speed
vendado, -a | bandaged
el vendedor | seller
vender | to sell
venir | to come
la ventana | window
ver | to see
¡a ver! | let's see
el verano | summer
veras: ¿de veras? | really
la verdad | truth
¿Verdad? | Is that true?
¿No es la verdad? | Isn't that true?
verdaderamente | truly
verde | green
el vestido | dress
vestir (i) | to dress
vestirse (de) | to dress in
la vez, veces (pl.) | time
a la vez | at the time
a veces | sometimes
de vez en cuando | once in a while
en vez de | instead of
otra vez | again
tal vez | perhaps
el viaje | trip
desear buen viaje | to wish one a pleasant trip
la vida | life
el viejito | little old man
viejo, -a | old
el viento | wind
hace viento | it is windy
el viernes | Friday
la visita | visit, visitor
la vista | view
hasta la vista | so long
vivir | to live
vivo, -a | lively
volver (ue) | to return
volver a casa | to return home
volver a ( _+infin_.) | to do something again
la voz | voice
el vuelo | flight
la vuelta | turn, return; change (money)
a la vuelta | around the corner
### Y
y | and
---|---
ya | already, now, yet
¡Ya lo creo! | I should say so!
### Z
el zapato | shoe
---|---
el zapatero | shoemaker
la zapatería | shoe shop
## English - Spanish
### A
@ | arroba
---|---
able, to be | poder (ue)
about | de, acerca de
about 2 o'clock | a eso de las dos
accept, to | aceptar
accompany, to | acompañar
according to | según
accustom, to | acostumbrar
ache | el dolor
headache | dolor de cabeza
stomachache | dolor de estómago
toothache | dolor de muelas
act (a role) | interpretar
address | la dirección
admire, to | admirar
advice | los consejos
advise, to | aconsejar
affection | el cariño
after | después, de (prep.) después que (conj.)
afternoon | la tarde
in the afternoon, P.M. | por la tarde; de la tarde
again | otra vez;
to do again | volver a ( _+infin_.)
against | contra
agent | el agente
ago; two years ago | hace dos años
agreeable | agradable
aid | la ayuda
aid, help, to | ayudar
air | el aire
in the open air | al aire libre
airmail: by airmail | por correo aéreo
airplane | el avión
airport | el aeropuerto
almost | casi
alone | solo
along | por
already | ya
also | también
although | aunque
always | siempre
amusement | a diversión
and | y, e (before i or hi)
announce | anunciar
another | otro, -a
answer | la respuesta
answer, to | contestar, responder
answering machine | el contestador automática
any | cualquier
anyone | alguien, alguno, -a
apple | la manzana
approach, to | acercarse a
arm | el brazo
around | alrededor de
arrange, to | arreglar
arrival | llegada
arrive, to | llegar
art | el arte
article | el artículo
artist | el (la) artista
as... as | tan... como
ask, to | preguntar
to ask for | pedir (i)
to ask questions | hacer preguntas
assortment | el surtido
at | a, en
attend, to | asistir a
attention | la atención
aunt | la tía
automobile | el automóvil
avenue | la avenida
awake, to be | estar despierto, -a
awaken, to (arouse) | despertar (ie)
### B
bacon | el tocino
---|---
bad | malo, -a
badly | mal
baggage | el equipaje
baker | el panadero
banana | el plátano
bargain, to | regatear
basket | la cesta, la canasta
bath | el baño
bathe, to | bañar, bañarse
bathroom | el baño
be, to | ser, estar
to be in a hurry | estar de prisa, tener prisa
to be on the way | estar en camino
to be about to | estar para
beans | los triples
beautiful | bello, -a; hermoso, -a
because | porque
become, to | ponerse, hacerse
becomes sick | se enferma
becomes rich | se hace rico
bed | la cama
bedroom | la alcoba: el dormitorio, la recámara (Mex.)
before (place) | delante de
before (time) | antes de
begin, to | comenzar (ie),
| empezar (ie)
beginning | el principio
at the beginning | al principio
behind | detrás de
believe, to | creer
belt | el cinturón
bench | el banco
better | mejor
between | entre
big | grande
bill | la cuenta
bird | el pájaro
birthday | el cumpleaños
black | negro, -a
blanket | la manta, el sarape
block | la cuadra
blouse | la blusa
blue | azul
boat | el barco
body | el cuerpo
boiled | cocido, -a
book | el libro
bookshelf | el estante
bookstore | la librería
bottle | la botella
box | la caja
boy | el muchacho
bread | el pan
break, to | romper
breakfast | el desayuno
breakfast, to have | desayunarse; tomar el desayuno
bring, to | traer, llevar
brother | el hermano
building | el edificio
bundle | el bulto
bus | el camión (Mex.), autobús
business | el negocio
businessman | el comerciante, el negociante
busy | ocupado, -a
but | pero
on the contrary | sino
buy, to | comprar
buyer | el comprador
### C
cake | la torta, el pastel
---|---
call, to | llamar
can (be able to) | poder (ue)
car | el coche, el automóvil
by car | en coche
care, be careful | cuidado
carry, to | llevar
carry away, to | llevarse
catch, to | agarrar
catch cold, to | pescarse un catarro, un resfriado
celebrate, to | celebrar
century | el siglo
certain | cierto, -a
certainly | por cierto
certificate | el certificado
chair | la silla
change | el cambio
in change | de cambio
change, to | cambiar
change clothes, to | cambiar de ropa
chat, to | platicar, charlar, conversar
cheap | barato, -a
check, to (baggage) | facturar
check, to | chequear
cheese | el queso
chicken | el polio
child | el niño, la niña
choose, to | escoger
chop | la chuleta
church | la iglesia
cigar | el cigarro, el puro (Mex.),
city | la ciudad
class | la clase
clean | limpio, -a
clean, to | limpiar
clear | claro, -a
clerk | el dependiente
climate | el clima
close, to | cerrar (ie)
closed | cerrado, -a
cloth | la tela
clothing | la ropa
coat | el abrigo
coffee | el café
cold | frío, -a
It is cold (weather) | Hace frío.
I am cold. | Tengo frío.
color | el color
what color is... | ¿de qué color es...?
come, to | venir
comfortable | cómodo, -a
comment, to | comentar
complete, to | completar
comprehend, to | comprender, entender (ie)
concert | el concierto
confess, to | confesar (ie)
congratulate, to | felicitar
consequently | por consiguiente
contain, to | contener
continue, to | continuar, seguir (i)
conversation | la conversación
converse, to | conversar
cooked | cocido, -a
cool | fresco, -a
It is cool (weather). | Hace fresco.
copper | el cobre
corn | el maíz
corner | el rincón, la esquina
correct | correcto, -a
cost, to | costar (ue)
costume | el traje
cotton | el algodón
count, to | contar (ue)
country | el campo, el país (nation)
course: of course | por supuesto;
desde luego;
creo que sí
of course not | creo que no
cousin | el primo, la prima
coven to | cubrir
craftsman | el artesano
cream | la crema
cross, to | cruzar
cry | el grito
cry, to (shout) | gritar
culture | la cultura
current (adj.) | corriente
custard | el flan
custom | la costumbre
cut, to | cortar
### D
daily | diario, -a
---|---
dance, to | bailar
dangerous | peligroso, -a
dark | oscuro, -a
date | la fecha
what is the date | ¿cuál es la fecha?
daughter | la hija
day | el día
nowadays | hoy día
the following day | al día siguiente
dear | caro, -a (expensive);
querido, -a (loved)
death | la muerte
decide, to | decidir
decoration | el adorno
defend, to | defender
demand, to | exigir
depart, to | partir
descend, to | bajar
describe, to | describir
desire, to | desear, tener ganas
desk | el escritorio
dessert | el postre
die, to | morir (ue)
different | diferente, distinto, -a
difficult | difícil
diligent | diligente
dine, to | cenar, comer
dining room | el comedor
dinner | la comida, la cena
dirty | sucio, -a
discover, to | descubrir
dish | el plato
distant | lejano, -a
divide, to | dividir
do, to | hacer
doctor | el médico, el doctor
dollar | el dólar
door | la puerta
dot | punto
doubt | la duda
without a doubt | sin duda alguna
doubt, to | dudar
drawing | el dibujo
dress | el vestido
dress, to | vestir (i)
dress in, to | vestirse de
drink | la bebida
drink, to | beber, tomar
drive | manejar
dry | seco, -a
dry clean | limpiar en seco
during | durante
### E
each | cada
---|---
each one | cada uno
ear | la oreja
early | temprano
earn, to | ganar
east | el este
eat, to | comer
educate, to | educar
egg | el huevo
elevator | el ascensor, el elevador
e-mail | el correo electrónico
e-mail address | la dirección electrónica
emotion | la emoción
employ, to | emplear
employee | el empleado
empty | vacío
end | el fin
finally | al fin
end, to | terminan acabar
engagement | el compromiso
English | inglés
Englishman | el inglés
Englishwoman | la inglesa
enjoy, to | gozar de
enough | basta, bastante
enter, to | entrar en
enthusiasm | el entusiasmo
entire | entero, -a
entrance | la entrada
equal | igual
especially | sobre todo
even | aun
everybody | todo el mundo
everywhere | por (en) todas partes
examination | el examen
examine, to | examinar, revisar (baggage)
excellent | excelente
except | excepto, menos
excuse, to | disculpar, perdonar, excusar
excuse me | discúlpeme
expect, to | esperar
explain, to | explicar
exporter | el exportador
express, to | expresar
eye | el ojo
### F
fable | la fábula
---|---
face | la cara
fall, to | caer
fall asleep, to | dormirse (ue)
false | falso, -a
family | la familia
famous | famoso, -a
far from | lejos de
fare | el pasaje
fast | rápido, -a
fat | gordo, -a
father | el padre
favor | el favor
fear, to | temer, tener miedo
feel like, to | tener ganas
feel, to (well, ill) | sentirse (ie)
few | pocos (as)
finally | al fin, al final
find, to | hallar, encontrar
find out, to | averiguar
fine | fino, -a
finish, to | terminan acabar
first | primero, -a
fish | el pescado
flight | el vuelo
floor | el suelo; el piso (story)
flower | la flor
follow, to | seguir (i)
following; on the following day | al día siguiente
food | la comida, los alimentos
foot | el pie
on foot | a pie
for | por, para
forget, to | olvidar
fork | el tenedor
form, to | formar
fountain | la fuente
French (lang.) | francés
Frenchman | el francés
Frenchwoman | la francesa
friend | el amigo, la amiga
from | de
from... to | desde... hasta
fruit | la fruta
full | lleno, -a
### G
game | el juego
---|---
garage | el garaje
garden | el jardín
generally | general mente, regularmente
gentleman (Mr) | el señor
get along (well) | hacerse (bien)
get, to | obtenen conseguir
get (become), to | ponerse
get on, to | subir a
get off, to | bajar de
get up, to | levantarse
gift | el regalo
give, to | dar
give back, to | devolver (ue)
glad | alegre
glass | el vaso (to drink from), el vidrio, el cristal
glove | el guante
go, to | ir
go away, to | irse
go shopping, to | ir de compras
gold | el oro
good | bueno, -a
grandfather | el abuelo
grandmother | la abuela
grape | la uva
grapefruit | la toronja
gray | gris
green | verde
greet, to | saludar
greeting | el saludo
grille | la reja
group | el grupo
guess, to | adivinar
### H
hair | el pelo
---|---
half | la mitad: medio, -a
ham | el jamón
hand | la mano
handmade | hecho a mano
to shake hands | darse la mano
happen, to | pasar
happy | contento, -a; feliz
hard | difícil (difficult), duro
hat | el sombrero
have, to | haber (auxiliary); tener que (+ _infin_.)
have a good time, to | pasarla bien
head | la cabeza
headache | dolor de cabeza
healthy | sano, -a
healthy, to be | tener salud
hear, to | oír
heart | el corazón
heavy | pesado, -a
help | la ayuda
help, to | ayudar
here | aquí, acá (usually after a verb of motion)
here you have it | aquí lo tiene Ud.
high | alto, -a
holiday | la fiesta
home | en casa
to go home | ir a casa
hope, to | esperar
I hope so. | Espero que si.
I hope not. | Espero que no.
horse | el caballo
hot | caliente
It is hot (weather) | Hace calor.
I am hot. | Tengo calor
hour | la hora
house | la casa
how | como, ¿cómo?
how much | ¿cuánto, -a?
how many | ¿cuántos, -as?
hungry, to be hungry | tener hambre
hurry, to be in a hurry | tener prisa
hurry, to | apresurarse
hurt, to | hacer daño a
husband | el esposo
### I
ice cream | el helado
---|---
if | si
ill | enfermo, -a: malo, -a
imagine | imaginar
immediately | inmediatamente, en seguida
in | en
Indian | el indio
industry | la industria
inform, to | informar, avisar
information, | la información
to ask for information | pedir información
inhabitant | el habitante
ink | la tinta
inside of | dentro de
instead of | en vez de
intelligent | inteligente
intend to, to | pensar ( _+infin_.)
interest | el interés
interest, to | interesar
introduce, to | presentar
invitation | la invitación
invite, to | invitar
iron | el hierro
### J
jar | el jarro, la jarra
---|---
jewel | la joya
jewelry shop | la joyería
juice | el jugo
### K
keep, to | guardar, quedar
---|---
kill, to | matar
kind | amable
king | el rey
kiss, to | besar
kitchen | la cocina
knife | el cuchillo
know (facts), to | saber
know (how), to | saber
know (persons), to | conocer
### L
lady (Mrs.) | la señora
---|---
lamp | la lámpara
land | la tierra
language | la lengua, el idioma
last | último, -a
last year | el año pasado
laugh | la risa
laugh, to | reír (i)
to laugh at | reírse de
lawyer | el abogado
lazy | perezoso, -a
leaf | la hoja
learn, to | aprender
least | el menos
at least | por lo menos
leather | el cuero
leave, to (go out of) | salir de
left | izquierdo, -a
on the left | por la izquierda
to the left | a la izquierda
lemon | el limón
lend, to | prestar
less | menos
let, to (permit) | permitir, dejar
letter | la carta
library | la biblioteca
lie, to (tell a) | mentir
lie down, to | acostarse (ue)
life | la vida
light | la luz
like, to | gustar
I like the game. | Me gusta el juego.
listen, to | escuchar
little | pequeño,-a;
a little | un poco
live, to | vivir
lively | vivo, -a
living room | la sala
load | la carga
long | largo, -a
look at, to | mirar
look for, to | buscar
lose, to | perder (ie)
loud | alto, -a
love | el amor
love, to | querer (ie) a, amar a
low | bajo, -a
luck | la suerte
lucky | afortunado, -a
lunch | el almuerzo
lunch, to have | almorzar
### M
magazine | la revista
---|---
magnificent | magnífico, -a
maid | la criada
mail, to | echar en el buzón, echar al correo
maintain, to | mantener
majority | la mayor parte, la mayoría
make, to | hacer
to make a trip | hacer un viaje
made by hand | hecho por mano
man | el hombre
manner | la manera
in the same manner | de la misma manera
many | muchos, -as
market | el mercado
marry, to | casarse con
match | el cerillo, el fósforo
matter, to | importar
it doesn't matter | no importa
What's the matter? | ¿Qué hay?
What's the matter with you | ¿Qué tiene Ud.?
maybe | quizás
meal | la comida
mean, to | significar; querer (ie) decir
meanwhile | entretanto
measure | la medida
measure, to | medir (i)
meat | la carne
meet, to (make the acquaintance of) | conocer a
glad to meet you | mucho gusto en conocerlo
meet, to (gather) | encontrar (ue)
meet someone, to (as at the aiport) | recibir a alguien
melon | el melón
memory | la memoria
menu | la lista, el menú
merchandise | la mercancía
merry | alegre, feliz
message | el mensaje
Mexican | mexicano, -a
Mexico | México
mile | la milla
milk | la leche
million | el millón
Miss (young lady) | la señorita
miss, to | echar de menos
mistake | la falta
mistaken (to be) | estar equivocado, -a
modern | moderno, -a
money (currency) | el dinero, la moneda
month | el mes
moon | la luna
more | más
morning | la mañana
in the morning, | por la mañana,
A.M. | de la mañana
most | el (la) más
mother | la madre
motion picture | la película
mountain | la montaña
mouse | el ratón
mouth | la boca
move, to | mover (ue)
to move (home) | mudarse
movie | la película
movie, action | película de acción
movie theater | el cine
much | mucho, -a
music | la música
must (ought to), | deber, tener que,
(to have to), (probably) | deber de
### N
name | el nombre
---|---
name, to | nombrar
nature | la naturaleza
near | cerca de (prep.)
necessary | necesario, -a
it is necessary | es necesario, hay que ( _+infin_.)
necessity | la necesidad
need, to | necesitar
neither | tampoco
neither... nor | ni... ni
never | nunca, jamás
nevertheless | sin embargo
new | nuevo, -a
news | las noticias
newspaper | el periódico, el diario
next | próximo, -a
nice | bonito, -a, simpático, -a
night | la noche
at night | por la noche
P.M. (after 8 P.M.) | de la noche
nobody | nadie
noise | el ruido
none, no | ninguno, -a
north | el norte
North American | norteamericano, -a
nose | la nariz
nothing | nada
now | ahora, ahorita
number | el número
### O
obey, to | obedecer
---|---
object | el objeto
observe, to | observar
obtain, to | obtener, conseguir (i)
occasion | la ocasión
of | de
offer, to | ofrecer
office | la oficina
office boy | el mandadero
often | a menudo, muchas veces
old | viejo, -a, antiguo, -a
older | mayor
oldest | el (la) mayor
on (top of) | encima de
only | sólo, solamente
not only... but also | no solamente... sino también
open | abierto, -a
open, to | abrir
opportunity | la oportunidad
opposite | frente a
or | u (before o or ho), o (all other instances)
orange | la naranja
orange-colored | anaranjado, -a
order, to | mandar, pedir (i)
in order to | para
other | otro, -a
ought to | deber
outside of | fuera de
over | sobre
owe, to | deber
own | propio, -a
### P
pack; to pack a suitcase | hacer una maleta
---|---
package | el paquete
paint, to | pintar
painter | el pintor
painting | la pintura
pancakes | los panqueques
paper | el papel
parcel post | el paquete postal
parents | los padres
park | el parque
pass (by), to | pasar
passport | el pasaporte
pay, to | pagar
peach | el melocotón
pear | la pera
pen | el bolígrafo
pencil | el lápiz
people | la gente, las personas
perfectly | perfectamente
permission | el permiso
permit, to | permitir, dejar
person | la persona
pharmacy | la farmacia
picture | pintura, dibujo, fóto
piece | la pieza, el pedazo
pineapple | la piña
pink | rosado, -a
pity | la lástima
What a pity! | ¡qué lástima!
place | el sitio, el lugar
place, to | poner
plane | el avión
play | el drama, la comedia
play, to | tocar (instrument); jugar (ue) (game)
pleasant | agradable
please | por favor; hágame el favor de; tenga la bondad de
pleasure | el placer, el gusto
with pleasure | con mucho gusto
pocket | el bolsillo
point out, to | señalar, indican mostrar (ue)
policeman | el policía
poor | pobre
portrait | el retrato
possible | posible
post office | el correo
poster | el cartel
pot | la olla
potato | la papa
pottery | la cerámica, la alfarería
pound | la libra
pour (a liquid), to | echar
practice, to | practicar
prefer, to | preferir (ie)
prepare, to | preparar
present, to | presentar
pretty | bonito, -a; lindo, -a
price | el precio
priest | el cura
printer | la impresora
prize | el premio
produce, to | producir
production | la producción
professor | el profesor, la profesora
program | el programa
progress, to | adelantar
promenade | el paseo
promise, to | prometer
proud | orgulloso, -a
purchase | la compra
purse | la bolsa
put, to | poner
put on (clothing), to | ponerse
### Q
quantity | la cantidad
---|---
queen | reina
question | la pregunta
quickly | de prisa, aprisa
### R
radio | el radio (set), la radio (broadcast)
---|---
rain | la lluvia
rain, to | Hover(ue)
raincoat | el impermeable
rainy | lluvioso, -a
raise, to | levantar
rapid | rápido, -a
rapidly | rápidamente
rare | raro, -a
read, to | leer
ready | listo, -a
really | ¡de veras!
receive, to | recibir
recognize, to | reconocer
recreation | el recreo
red | rojo, -a
regret, to | sentir (ie)
relate, to | contar (ue)
relative | el pariente
remain, to | quedar; quedarse
remember, to | recordar (ue), acordarse (ue) de
rent, to | alquilar
repeat, to | repetir (i)
reply to | responder, contestar
representative | el representante
request, to | pedir (i)
resemble, to | parecerse a
resist, to | resistir
respect | el respeto
rest, leisure | el descanso
restaurant | el restaurante
return, to | volver (ue)
(to go back, physically) | volver (ue)
(to go back in time) | regresar
(to give someting back) | devolver
rice | el arroz
rich | rico, -a
ride (in a can), to | ir (en coche)
to go for a ride | pasearse, dar un paseo
right; to be right | tener razón
right | derecho, -a
river | el río
road | el camino
roll | el panecillo
roof | el tejado
room | el cuarto
round | redondo, -a
round-trip ticket | boleto de ida y vuelta
row | la fila
run, to | correr
### S
salt | la sal
---|---
same | mismo, -a
the same thing | lo mismo
sash | la faja
sauce | la salsa
say | decir
how do you say | ¿cómo se dice?
say good-bye | despedirse
scarcely | apenas
school | la escuela
screen | la pantalla
season | la estación
seat | el asiento
seated | sentado, -a
security measures | las medidas de seguridad
see, to | ver
let's see | a ver
seek, to | buscar
seem, to | parecer
sell, to | vender
seller | el vendedor
send, to | mandar enviar
sense | el sentido
sentence | la frase
serve, to | servir (i)
set, to | poner
shade | la sombra
shawl | el rebozo, la chal
shine, to | brillar
shipment | el envío
shirt | la camisa
shoe | el zapato
short | corto, -a, breve, bajo (height)
shout, to | gritar
show, (point out), to show a film, to | mostrar (ue), enseñar poner una película
sick | enfermo, -a; malo, -a
to get sick | enfermarse
side | el lado
beside | al lado de
sidewalk | la acera
sight | la vista
silk | la seda
silver | la plata
silversmith | el platero
similar | semejante
simple | sencillo, -a
since | puesto que
sing, to | cantar
sister | la hermana
sit down, to | sentarse (ie)
seated, to be | estar sentado
size | el tamaño
skirt | la falda
sky | el cielo
skyscraper | el rascacielos
sleep, to | dormir (ue)
sleepy, to be | tener sueño
slowly | despacio,
| lentamente
small | pequeño, -a
smile, to | sonreír (i)
snow | la nieve
snow, to | nevar
it is snowing | nieva
so | así
so much | tanto, -a
so that | para que, de
| modo que
some | alguno, -a
someone | alguien
something | algo
somewhat | algo
son | el hijo
song | la canción
soon | pronto
sorry; to be sorry | sentir (ie);
I am very sorry | Lo siento mucho.
soup | la sopa
south | el sur
souvenir | el recuerdo
Spain | España
Spaniard | el español, la española
Spanish (lang.) | español
speak, to | hablar
spend, to (money) | gastar
spend, to (time) | pasar
spicy | picante
spite; in spite of | a pesar de
spoon (teaspoon) | la cuchara (la cucharita)
spring | la primavera
square | cuadrado, -a
stairway | la escalera
stamp | la estampilla, el timbre (Mex.)
stand | el puesto
stand up, to | ponerse de pie
standing, to be | estar de pie
star | la estrella
state | el estado
station (railroad) | la estación de ferrocarril
statue | la estatua
steak (beef) | el bistec, el filete (Mex.)
stenographer | el taquígrafo, la taquígrafa
step | el paso
still | todavía
stop, to | parar
store | la tienda
story | el cuento
story (of building) | el piso
straw | la paja
street | la calle
streetcar | el tranvía
strong | fuerte
student | el (la) estudiante
study, to | estudiar
style | el estilo
subject | el tema
suburb | el suburbia
succeed in, to | lograr
suit | el traje
suitcase | a maleta, la valija
pack a suitcase, to | hacer una maleta, una valija
summer | el verano
sun | el sol
It is sunny. | Hace sol.
supper | la cena
surely | de seguro, seguramente
surprised | sorprendido
surrounded | rodeado, -a
sweater | el suéter
sweet | dulce
sweets (candy) | los dulces
### T
table | la mesa
---|---
set the table, to | poner la mesa
tailor | el sastre
take, to | tomar
take away, to | llevarse
take out, to | sacar
tall | grande, alto, -a
tank | el tanque
taste, to | robar (ue), saber
tasty | sabroso, -a
tea | elté
teach, to | enseñar
teacher | el maestro, la maestra, el profesor, la profesora
telephone | el teléfono
telephone, to | llamar por teléfono, telefonear
tell, to | decir
temperate | templado
temperature | la temperatura
textile | el tejido
thankful | agradecido, -a
thanks | gracias
to give thanks | dar las gracias
that | ese, -a; aquel, aquella; que (conj.)
theater | el teatro
then | entonces
there | allí, ahí, allá (usually with a verb of motion)
there is (are) | hay
therefore | por eso, por lo tanto
these (adj.) | estos, -as
thick | grueso, -a
thing | la cosa
think, to (believe) | creer
think of, to | pensar en
thirsty; to be thirsty | tener sed
this (adj.) | este, -a
those (adj.) | aquellos,- as; esos, -as
through | por
thunder | el trueno
thundering, it is | truena
thus | así
ticket | el boleto (Mex.); el billete
round-trip ticket | el boleto de ida y vuelta
ticket window | la boletería
tile | el azulejo
time | tiempo
What time is it | ¿Qué hora es?
one time | una vez
two times | dos veces
on time | a tiempo
have a good | pasarla bien,
time, to | divertirse (ie)
timetable | el horario
tin plate | la hojalata
tip | la propina
tire, to | cansarse
tired | cansado, -a
title | el título
tobacco | el tabaco
today | hoy
tomato | el tomate
tomorrow | mañana
tomorrow morning | mañana por la mañana
too (also) | también
too many | emasiados, -as
too much | demasiado, -a
tooth | el diente
toothache | dolor de muela
topic | el tema
tourist | el (la) turista
tourist card | la tarjeta de turista
toward | hacia
town | el pueblo, la población
toy | el juguete
train | el tren
travel, to | viajar
traveler | el viajero
tray | la bandeja
tree | el árbol
trip | el viaje
take a trip, to | hacer un viaje
trousers | los pantalones
trunk | el baúl
trunk (of car) | la cajuela (Mex.)
truth | la verdad
try, to | tratar de
try on, to | probar (ue)
turkey | el guajalote (Mex.); el pavo
typewriter | la máquina de escribir
typical | típico, -a
### U
umbrella | el paraguas
---|---
uncle | el tío
under | debajo de
understand | comprender, entender (ie)
unfortunately | lamentablemente
United States | Los Estados Unidos abbr.: EE.UU.
university | la universidad
upon | sobre, encima de
upset | nervioso
use, to | usar, emplear
useful | útil
### V
vacation | las vacaciones
---|---
valise | la valija
valley | el valle
very | muy
view | la vista
visit | la visita
visit, to | visitar
voice | la voz
voyage | el viaje
### W
wait for, to | esperar
---|---
waiter | el mozo, el mesero
waiting room | la sala de espera
wake up, to
(someone), | despertar (ie)
(oneself) | despertarse
walk, to | andar, ir a pie, caminar
take a walk, to | dar un paseo, pasearse
wall | la pared
want | desear, querer (ie)
wash, to | lavar
watch | el reloj
watch, to | mirar
water | el agua (f)
way, by the | a propósito
weak | débil
wear | llevar, vestir (i) de
weather | tiempo
How's the weather? | ¿Qué tiempo hace?
week | la semana
weekend | el fin de semana
weigh, to | pesar
well | pues, bien
All is well | Todo está bien.
well-known | conocido, -a
when | cuando, ¿cuándo?
where | donde, ¿dónde?
where (to where) | ¿adónde?
whether | si
which | que, ¿qué?
which one (ones) | ¿cuál (cuáles)?
while | mientras
white | bianco, -a
who | que, quien, ¿quién?
whom | que, ¿a quién?
whose | cuyo, -a, ¿de quién?
why | ¿por qué? ¿para qué?
wide | ancho, -a
wife | la esposa
win, to | ganar
win, to (the lottery) | sacar (el gordo)
wind | el viento
It is windy. | Hace viento.
window | la ventana
winter | el inviemo
wise | sabio, -a
wish | el deseo
wish, to | querer (ie), desear
with | con
without | sin
woman | la mujer
wood | la madera
wool | la lana
word | la palabra
work | el trabajo
work, to | trabajar
world | el mundo
worry, to | preocu parse
worse | peor
worth, to be | valer
It's worthwhile. | Vale la pena.
worthy | digno, -a
write, to | escribir
writer | el escritor
wrong, to be | no tener razón
### Y
year | el año
---|---
last year | el año pasado
next year | el año que viene
yellow | amarillo, -a
yesterday | ayer
day before yesterday | anteayer
yet | todavía
not yet | todavía no
young | joven
younger | menor
youngest | el menor
youth | el joven
# CHAPTER 51
ANSWERS AND TRANSLATIONS
RESPUSTAS Y TRADUCCIONES
## CAPÍTULO 3
### Ejercicio No. 1
1. comerciante
2. quién
3. con
4. padre
5. madre
6. hay
7. su
8. se llaman
9. particular
10. todos los cuartos
11. piso
12. calle
13. grande
14. allí, todo el día
15. ciudad
### Ejercicio No. 2A
1. la
2. una
3. la, los
4. el, la
5. una, un
6. el
7. los, un
8. unos, la, unas, la
9. los, la
10. los, las, la
### Ejercicio No. 2B
1. las calles
2. los comedores
3. los cuartos
4. los señores
5. las recámaras
6. las cocinas
7. las madres
8. los padres
9. las salas
10. las hijas
11. las ciudades
12. los años
13. las mujeres
14. los hombres
15. los tíos
### Ejercicio No. 2C
1. El señor Adams es norteamericano.
2. Vive en Nueva York.
3. Hay seis personas en la familia.
4. La casa tiene seis cuartos.
5. Es una casa particular.
6. La señora Adams es la madre.
7. El señor Adams es el padre.
8. La oficina está en la calle Whitehall.
9. Va en tren a la ciudad.
10. Allí trabaja todo el día.
## CAPÍTULO 4
### Ejercicio No. 4
1. Quién
2. un comerciante de Nueva York
3. su oficina
4. otros
5. va
6. desea
7. además (también)
8. pero
9. Estudia
10. martes, jueves
11. rápidamente
12. muy inteligente
13. mexicano
14. un maestro bueno
15. en la primera conversación
### Ejercicio No. 5A
1. es
2. está
3. es
4. está
5. es
6. es
7. está
8. está
9. es
10. hay
### Ejercicio No. 5B
1. (d)
2. (f)
3. (a)
4. (b)
5. (c)
6. (e)
### Ejercicio No. 5C
1. y
2. en
3. con
4. también
5. a
6. tal vez
7. pero
8. por eso
9. alli
10. aquí
11. casi
12. siempre
13. ¿Cómo está Ud.?
14. muy bien
15. gracias
16. grande
17. pequeño
18. bueno
19. malo
20. rápidamente
## CAPÍTULO 5
### Ejercicio No. 7
1. está sentado
2. hay
3. saber
4. Dígame
5. mi esposa
6. sobre el estante
7. un lápiz, un bolígrafo y algunos papeles
8. Hay, en la mesita
9. basta
10. Hasta el jueves
### Ejercicio No. 8A
1. la calle, las calles, _street_
2. la oficina, las oficinas, _office_
3. la pared, las paredes, _wall_
4. la silla, las sillas, _chair_
5. el señor, los señores, _gentleman_
6. la mesa, las mesas, _table_
7. el papel, los papeles, _paper_
8. la puerta, las puertas, _door_
9. el estante, los estantes, _bookcase_
10. la ventana, las ventanas, _window_
### Ejercicio No. 8B
1. debajo de
2. cerca de
3. encima del
4. sobre
5. entre
6. delante del
7. alrededor de
8. detrás de
9. debajo de
10. cerca del
### Ejercicio No. 8C
1. de la
2. al
3. de las
4. del
5. a la
6. de los
7. a los
8. a la
9. al
10. a las
### Ejercicio No. 9
1. Está sentado en la sala de su casa.
2. El Sr. López está sentado cerca de él.
3. Sí, hay muchas cosas alrededor de nosotros.
4. Sí, hay muchas cosas en la calle.
5. La esposa del Sr. Adams escucha mucha música.
6. Está encima del piano.
7. Está sobre el piano.
8. El estante está delante de una ventana.
9. Está cerca de la puerta.
10. Cerca del escritorio hay una silla.
11. Están encima del escritorio.
12. Están en la mesita.
## CAPíTULO 6
**REPASO 1 CAPÍTULOS 1–5**
### Ejercicio No. 10
1. (g)
2. (e)
3. (i)
4. (h)
5. (i)
6. (l)
7. (k)
8. (a)
9. (d)
10. (c)
11. (b)
12. (f)
### Ejercicio No. 11
1. todo el día
2. por favor
3. tal vez
4. Buenas tardes
5. con mucho gusto
6. Por eso
7. Cómo
8. Dónde
9. Qué
10. Quién
### Ejercicio No. 12
1. (d)
2. (f)
3. (i)
4. (k)
5. (h)
6. (g)
7. (c)
8. (j)
9. (a)
10. (b)
11. (e)
### Ejercicio No. 13
1. delante de la casa
2. cerca de la puerta
3. alrededor de la ciudad
4. detrás del escritorio
5. encima del piano
6. Los libros del muchacho
7. La madre de las muchachas
8. El hermano de Felipe
9. El padre de Maréia
10. El maestro de los niños
### Ejercicio No. 14A-Reading Selection
Mr. Adams, New York Merchant
Mr. Adams is a North American businessman who imports art objects from Mexico. Therefore he wants to take a trip to Mexico in the spring. He wants to talk with his agent and to visit some places of interest in Mexico. But he does not know how to speak Spanish. Mr. Adams has a good teacher. He is a Mexican who lives in New York, and his name is Mr. Lopez. Tuesdays and Thursdays the teacher goes by train to the house of his student. There the two gentlemen speak a little in Spanish. Mr. Adams is very intelligent and learns rapidly.
For example, in the first conversation he learns by heart the salutations and farewells. He already knows how to say "Good day," "How are you?," "So long," "See you tomorrow." He already knows how to say in Spanish the names of many things that are in his living room and he knows how to answer well the questions: "What is this?" and "Where is...?"
Mr. Lopez is very pleased with the progress of his student and says: "Good. Enough for today. So long."
## CAPÍTULO 7
### Ejercicio No. 15
1. son importantes
2. unos verbos corrientes
3. ¿Porqué...?
4. Porque, mi
5. con él en español
6. a otros países
7. en tren o en avión
8. Cuanto
9. muy rápidamente
10. Basta por hoy
### Ejercicio No. 16A
1. to listen
2. to want
3. to visit
4. to form, make
5. to expect
6. to converse
7. to practice
8. to travel
9. to ask
10. to answer
11. to chat
12. to study
13. to import
14. to play
15. to enter
### Ejercicio No. 16B
1. Do you speak Spanish?
Yes, I speak Spanish.
What languages does your teacher speak?
He speaks English, Spanish, and French.
2. Who plays the piano?
Mary plays the piano.
Don't you play the piano, Rosie?
No, I do not play the piano.
3. Are the students studying the lesson?
No, they are not studying the lesson.
Are they chatting in Spanish?
Yes, they are chatting in Spanish.
4. Do you listen attentively when the teacher is speaking?
Yes, we listen attentively when the teacher is speaking.
### Ejercicio No. 16C
1. no habla
2. estudiamos
3. importa
4. desea
5. espero
6. platican
7. practican
8. viaja
9. esperamos
10. escuchan
### Ejercicio No. 16D
1. miro
2. escucha
3. formas
4. conversa
5. practican
6. ¿pregunta Ud.?
7. contestan
8. ¿estudiamos?
9. desean
10. visito
11. viajo
12. ¿espera Ud.?
### Ejercicio No. 17
1. Están sentados en la sala del Sr. Adams.
2. El Sr. López explica.
3. El Sr. Adams escucha con atención.
4. El Sr. López pregunta.
5. El Sr. Adams contesta.
6. Sí, son importantes.
7. Sí, es comerciante.
8. No, no habla español.
9. Porque desea hacer un viaje a México.
_or_ Porque desea hablar con su agente.
10. Espera visitar México, Guatemala y tal vez Colombia.
11. Viaja por avión.
12. Aprende rápidamente.
## CAPÍTULO 8
### Ejercicio No. 18
1. abre
2. Pase Ud.
3. Buenas noches, su
4. un resfriado
5. otros
6. Tengo
7. somos
8. años
9. la menor
10. el mayor
11. un rato más
12. al Sr. López
### Ejercicio No. 19A
1. es, Es
2. está, Estoy
3. están, Estamos
4. Es, soy
5. Está, está
6. están, estamos
7. están, Están
8. Son, somos
9. están, están
10. Son, somos
### Ejercicio No. 19B
1. al señor
2. la escuela
3. a su amigo
4. la lección
5. a la señora
6. el tren
7. a Isabel
8. a su agente
9. el parque
10. a José
### Ejercicio No. 19C
1. ¿Cómo está Ud.?
2. Regular, gracias. _or_ Así-así, gracias.
3. Mi hija está enferma.
4. Lo siento mucho.
5. Uds. son una familia de seis personas.
6. Van sus niños a la escuela?
7. ¿Habla Ud. español?
8. No, no hablo español.
9. Invito a Carlos a visitar mi casa.
10. Vamos a platicar un rato.
11. Vamos a comenzar (empezar).
12. Deseo (quiero) estudiar el español.
### Ejercicio No. 20
1. La esposa abre la puerta.
2. El Sr. López toca el timbre.
3. Espera al Sr. López en la sala.
4. Anita, la hija del Sr. Adams, está enferma.
5. Tiene un resfriado.
6. Tiene cuatro hijos.
7. Hay seis personas en su familia.
8. Sus hijos se llaman Felipe, Guillermo, Rosita y Anita.
9. Tiene diez años.
10. Sí, platican un rato más.
11. El Sr. Adams invita al Sr. López a visitar su oficina.
12. Sí, acepta la invitación.
## CAPÍTULO 9
### Ejercicio No. 21
1. dan a la calle
2. periódicos
3. detrás de su escritorio
4. entra en la oficina
5. Mucho gusto en verlo.
6. El gusto es mío.
7. Me gusta ese mapa.
8. A propósito
9. Veo
10. De qué color
11. De qué colores son
12. ¡Dios mío!
13. Tengo hambre.
14. No lejos de aquí
15. ¡Vámonos!
### Ejercicio No. 22A
1. vivos
2. cómoda
3. rojos
4. verdes
5. altos
6. muchos
7. blancas
8. Muchas
9. azul
10. simpática
### Ejercicio No. 22B
1. son
2. está
3. es
4. está
5. estoy
6. están
7. estamos
8. somos
9. son
10. son
### Ejercicio No. 22C
1. La oficina del Sr. Adams es muy bonita.
2. Las ventanas de la oficina son grandes.
3. Hay muchos papeles en la impresora.
4. Las paredes de la oficina son grises.
5. La mesa es verde.
6. El contestador es amarillo.
7. El edificio es muy alto.
8. ¿Cómo está Ud., Sr. Adams?
9. Estoy muy bien, gracias.
10. Los carteles son hermosos.
### Ejercicio No. 23
1. Está en el décimo piso de un edificio alto.
2. No, no es grande.
3. Sí, es cómoda.
4. En las paredes grises hay algunos carteles.
5. En la impresora hay muchos papeles.
6. Está al lado de la computadora.
7. Hay una mesa larga y verde entre las dos ventanas.
8. El Sr. Adams está sentado.
9. Es rojo.
10. Es amarillo.
11. Son blancos.
12. No, es negro.
13. Son grises.
14. Sí, es verde.
15. Es la oficina del Sr. Adams.
## CAPÍTULO 10
### Ejercicio No. 24
1. Sus padres
2. adelanta
3. ¿Qué tal, amigo?
4. A propósito, ¿verdad?
5. ¿Cómo no?
6. Aprendo
7. fácil, difícil
8. Estudio, deseo
9. comprendo
10. palabras, diaria
11. expresiones
12. Me gusta
### Ejercicio No. 25B
1. aprendo
2. toca
3. estudiamos
4. comprenden
5. Leen
6. beben
7. escribe
8. vive
9. bebes
10. deseas
11. viajan
12. abre
### Ejercicio No. 26
1. El Sr. Gómez es un habitante de Nueva York.
2. Sí, habla español bien.
3. No, son puertorriqueños.
4. Sabe que su amigo Adams aprende el español.
5. Entra en la oficina del Sr. Adams.
6. Saluda al Sr. Adams en español.
7. El Sr. Adams aprende a hablar, a leer y a escribir el español.
8. Estudia diligentemente.
9. El Sr. López es su maestro de español.
10. Sí, es un maestro bueno.
11. Sí, comprende.
12. Aprende las palabras de la vida diaria.
13. El Sr. Adams va a hacer un viaje a México.
14. Espera ir a México el verano que viene.
15. El Sr. Gómez dice—Buen viaje y buena suerte, _or_ Lo dice. (He says it.)
## CAPÍTULO 11
**REPASO 2 CAPÍTULOS 7–10**
### Ejercicio No. 27
1. civilización
2. reservación
3. instrucción
4. excepción
5. revolución
6. observación
7. aplicación
8. elección
9. invención
10. solución
### Ejercicio No. 28
1. Es azul.
2. Hablan español.
3. El Sr. Adams tiene hambre.
4. Es blanca y negra.
5. Vivo en los E.E.U.U.
6. Son blancos.
7. Beben leche.
8. Saluda a su amigo.
9. Tengo treinta años.
10. Me llamo...
### Ejercicio No. 29
1. (e)
2. (g)
3. (a)
4. (i)
5. (b)
6. (h)
7. (c)
8. (d)
9. (j)
10. (f)
### Ejercicio No. 30
1. vivimos
2. aprenden
3. trabaja
4. sabe
5. escriben
6. abres
7. permito
8. bebe
9. adelantamos
10. veo
### Ejercicio No. 31
1. Sí, aprendo...
2. Sí, estudio...
3. Sí, trabajo...
4. Sí, espero...
5. Sí, veo...
6. Sí, leo...
7. Sí, comprendo...
8. Sí, acepto...
9. Sí, visito...
### Ejercicio No. 32
1. es
2. está
3. Estoy
4. Estamos
5. es
6. Está
7. son
8. es
9. son
10. está
11. Son
12. eres
13. es
14. son
15. Estoy
### Ejercicio No. 33-Reading Selections 1
Two Friends of Mr. Adams
Mr. Adams already knows the names of all the objects in his house. Now he is beginning to study the verbs because he wants to learn to read, to write, and to converse in Spanish. He also wants to know the numbers in Spanish. Being a merchant who expects to visit his agent in Mexico he needs practice chatting with Spaniards or Spanish-Americans. Fortunately he has two friends who are from Mexico and who work near his office on Whitehall Street.
One day Mr. Adams goes to visit these Mexicans. The two gentlemen listen attentively to Mr. Adams while he speaks with them in Spanish. After ten minutes of conversation the Mexicans ask their friend many questions and are very pleased with his answers.
### Ejercicio No. 33-Reading Selections 2
Mr. Adams Gets Sick
On Thursday, April 22, at nine o'clock in the evening, Mr. Lopez arrives at the house of his student, Mr. Adams. The oldest child, a boy of ten, opens the door and greets Mr. Lopez. They enter the living room where Mr. Adams usually awaits his teacher.
But this evening he is not in the living room. Neither is Mrs. Adams there. Mr. Lopez is very surprised and asks the boy: "Where is your papa?" The boy answers sadly: "My papa is sick and cannot leave his bedroom. He is in bed because he has a severe cold. He also has a headache."
The teacher becomes very sad and says: "What a pity! We cannot have class today, but next week we are going to study two hours. Until next Tuesday."
## CAPÍTULO 12
### Ejercicio No. 35
1. Toman
2. dibujos
3. por todas partes
4. Cada, propio
5. para crema
6. para agua
7. despacio
8. Tiene que
9. de todos modos
10. Tengo
11. muy sencillo
12. Muchas veces
13. para el uso
14. Quiere Ud.
15. No quiere Ud.
### Ejercicio No. 36A
1. aquellas
2. Esta
3. Estos
4. Estas
5. Esas
6. Esos
7. Aquella
8. Este
9. aquellas
10. Esta
11. Eesa
12. estos
### Ejercicio No. 36C
1. Estos señores están sentados en el comedor.
2. Estas tazas son de Puebla.
3. Me gustan estos dibujos.
4. Esos platos son de Oaxaca.
5. ¿Trabajan despacio aquellos artistas?
6. ¿Tiene esta familia cinco niños?
7. ¿Tienes hambre, hijito?
8. No, no tengo hambre.
9. ¿Tiene Ud. que escribir una carta, Sr. Adams?
10. Sí, tengo que escribir una carta.
### Ejercicio No. 37
1. Están sentados en el comedor.
2. Toman café y pan dulce.
3. Dice—¿Le gustan estas tazas y estos platillos?
4. Es de Puebla.
5. Sí, cada distrito tiene su propio estilo.
6. Es de Oaxaca.
7. Es de Michoacán
8. Sí, son verdaderos artistas.
9. Trabajan despacio.
10. No tienen prisa.
11. Es difícil obtener un surtido adecuado para el mercado norteamericano.
12. El Sr. Adams ve mucha cerámica de interés artístico.
13. Están en el aparador.
14. Son amarillos y azules.
15. Sí, tiene ejemplares de cerámica corriente, _or_ Sí. _los_ tiene. (He has _them_.)
## CAPÍTULO 13
### Ejercicio No. 38
1. Sabe Ud.
2. tan importantes como
3. Nuestra civilización
4. Ud. tiene razón
5. Puede Ud.
6. no valen
7. Necesitamos, la fecha
8. pasar
9. Entretanto, que
10. ¿Qué quiere decir...?
### Ejercicio No. 39A
1. treinta
2. diez
3. cincuenta
4. cuarenta y nueve
5. dieciséis
6. setenta y ocho
7. diecisiete
8. quince
9. sesenta y dos
10. noventa y siete
11. ochenta y cuatro
12. trece
### Ejercicio No. 39B
* 5. cuatro más nueve son trece
* 6. siete por ocho son cincuenta y seis
* 7. ocho por tres son veinticuatro
* 8. ochenta dividido por veinte son cuatro
* 9. Diecinueve menos ocho son once
* 10. dieciséis menos tres son trece
* 11. ocho más siete son quince
* 12. cincuenta dividido por diez son cinco
### Ejercicio No. 39C
1. treinta
2. doce
3. siete
4. veinticuatro
5. sesenta
6. sesenta
7. setenta y cinco
8. treinta y seis
9. treinta y cinco
10. dieciséis
### Ejercicio No. 39D
1. quiero
2. puedo
3. pensamos
4. piensa Ud.
5. quiere
6. quiere
7. Quieren Uds.
8. pueden
9. Puedes tú
10. piensan
11. vale
12. cuento
13. tú cuentas
14. cuenta
### Ejercicio No. 40
1. Sí, son importantes.
2. Sí, son tan importantes como los nombres.
3. Necesitamos números.
4. Piensa en comprar y vender.
5. No valen mucho sin dinero.
6. No es posible comprar y vender sin dinero.
7. Sí, vende y compra.
8. Sí, es comprador y vendedor.
9. El Sr. Adams adelanta día por día.
10. diez, veinte, treinta, cuarenta, cincuenta, ciento.
## CAPÍTULO 14
### Ejercicio No. 41
1. es decir
2. ¿Cuántas veces...?
3. boletos y comidas
4. maletas, tamaños, distancias
5. El sistema monetario
6. Digamos que cada
7. centavos
8. Por supuesto, de cambio
9. noventa
10. próxima, este
### Ejercicio No. 41A
1. cuatrocientos
2. trescientos cincuenta
3. quinientos veinticinco
4. ochocientos sesenta
5. seiscientos veintisiete
6. cuatrocientos noventa
7. quinientos sesenta
8. setecientos ochenta
9. doscientos
10. novecientos setenta
### Ejercicio No. 41C
1. Sélos números.
2. ¿Sabe Ud. dónde vive?
3. Sabemos qué desea.
4. No damos el dinero.
5. ¿Dan los boletos?
6. ¿Qué da Juan?
7. Ella no sabe la respuesta.
8. No damos nuestros libros.
9. ¿Sabes las preguntas?
10. No saben quién vive aquí.
### Ejercicio No. 42
1. (40) cuarenta pesos
2. (750) setecientos cincuenta pesos
3. (50) cincuenta pesos
4. (40) cuarenta pesos
5. (270) doscientos setenta pesos
6. Sí, es millonario.
7. $2800 (dos mil ochocientos pesos)
8. No sé.
9. Sí, lo sé.
10. Vamos a continuar este tema en nuestra próxima conversación.
## CAPÍTULO 15
### Ejercicio No. 43A
1. nuestros
2. su
3. sus
4. mis
5. su
6. su
7. Nuestro
8. tu
9. Mis
10. Nuestra
### Ejercicio No. 43B
1. diez, veintidós
2. veinte, cuarenta y cuatro
3. treinta, sesenta y seis
4. cuarenta, ochenta y ocho
5. cincuenta, ciento diez
6. dieciséis, diez
7. treinta y dos, veinte
8. cuarenta y ocho, treinta
9. sesenta y cuatro, cuarenta
10. ochenta, cincuenta
### Ejercicio No. 43C
1. digo
2. hago
3. salgo
4. tengo
5. decimos
6. no ponemos
7. hacen
8. ponen
9. ¿hace Ud.?
10. ¿salen Uds.?
11. ¿dicen Uds.?
12. haces
13. ¿pone Ud.?
14. pongo
15. vale
### Ejercicio No. 43D
1. sino
2. sino
3. pero
4. sino
5. pero
### Ejercicio No. 44
1. Cenamos en el restaurante.
2. Damos al mesero diez por ciento.
3. La propina es un peso sesenta y cinco centavos.
4. Hago pesar mi maleta en la estación del ferrocarril.
5. Pesa treinta kilos. Sesenta y seis libras.
6. Se usan kilómetros.
7. El Sr. Adams sabe cambiar kilómetros en millas.
8. Compra un sarape, dos chales, tres cestas y cuatro cinturones.
9. El tema es "la hora".
10. Usa el refrán "Más vale tarde que nunca".
## CAPÍTULO 16
### Ejercicio No. 45
1. la película
2. la función
3. otras preguntas
4. la taquilla (boletería, _Mex_.)
5. la estación de ferrocarril
6. pide información
7. un boleto de ida y vuelta
8. sale el tren
9. a las nueve de la noche
10. Muchas gracias
11. Denada
12. hago el papel
### Ejercicio No. 46A
1. a las cinco y media de la tarde
2. a las ocho y cuarto de la noche
3. a las diez menos cinco de la mañana
4. a las once menos diez de la mañana
5. a las dos y veinte de la tarde
6. a las cinco menos veinte de la tarde
7. a las siete y diez de la tarde
8. a las siete menos diez de la tarde
9. a las ocho menos cuarto de la tarde
10. al mediodía
### Ejercicio No. 46B
1. pido
2. comenzamos
3. repiten
4. pide
5. comienzo
6. ¿Empieza Ud.?
7. pides
8. piden Uds.
9. repite
10. comienza
### Ejercicio No. 46C
1. Quiero un boleto de ida y vuelta.
2. Pide información.
3. ¿Cuándo sale el tren para Oaxaca?
4. ¿Sabe Ud. cuándo llega el tren de Puebla?
5. Llega a las cinco y media de la tarde.
6. ¿A qué hora comienza la primera función?
7. Comienza a las tres y veinte de la tarde.
8. ¿Repiten la función?
9. Sí, repiten la función dos veces.
10. Aquí tiene Ud. los boletos.
### Ejercicio No. 47
1. Todo el mundo quiere saber— ¿Qué hora es?
2. El Sr. Adams hace el papel de viajero.
3. El Sr. López hace el papel de boletero.
4. Quiere comprar un boleto de ida y vuelta.
5. Cuesta noventa y cinco pesos.
6. El Sr. López hace el papel de boletero de un cine.
7. El Sr. Adams pide información.
8. Tiene tres funciones.
9. Compra dos boletos para la tercera función.
10. Paga seis pesos.
## CAPÍTULO 17
**REPASO 3 CAPÍTULOS 12–16**
### Ejercicio No. 48
1. Sí, pienso...
2. Sí, quiero...
3. Sí, puedo...
4. Sí, pongo...
5. Sí, salgo...
6. Sí, cuento...
7. Sí, digo...
8. Sí, continúo...
9. Sí, le doy...
10. Sí, sé contar...
### Ejercicio No. 49
1. No, no repetimos...
2. No, no hacemos...
3. No, no pedimos...
4. No, no tenemos...
5. No, no venimos...
6. No, no creemos...
7. No, no traemos...
8. No, no tomamos...
9. No, no necesitamos...
10. No, no tenemos...
### Ejercicio No. 50
1. (b)
2. (d)
3. (h)
4. (a)
5. (i)
6. (c)
7. (e)
8. (j)
9. (f)
10. (g)
### Ejercicio No. 51
1. ¿Cuánto cuesta?, tiene que saber.
2. pide información. ¿A qué hora?, a las siete y media.
3. tiene hambre, una bebida, paga la cuenta, de cambio, una propina, es decir
### Ejercicio No. 52
1. esta
2. estos
3. ese
4. esos
5. este
6. esa
7. aquella
8. esos
9. estas
10. esas
11. aquel
12. aquellas
### Ejercicio No. 53
1. (e)
2. (f)
3. (a)
4. (g)
5. (b)
6. (h)
7. (d)
8. (j)
9. (c)
10. (i)
### Ejercicio No. 54-Reading Selection 1
The Family of Mr. Adams Comes to Visit His Office It is the first time that the Adams family comes to visit Mr. Adams's office. Mrs. Adams and her four children enter a very large building and go up to the tenth floor on the elevator. Annie, the younger daughter who is only five years old, is very curious and asks her mother many questions about the office.
When they arrive in the office the father gets up and says: "I am very happy to see you all here. What a pleasant surprise!"
The children admire the objects that they see in the office—the computer, the FAX machine, the Mexican magazines, the many colored posters. All are very happy.
Philip, the older boy, looks out of the high window. Below he sees the automobiles that pass through the street. From the tenth floor they seem very small.
After the visit the whole family goes to a restaurant that is not far from the office. They eat with gusto, especially the boys, because they are very hungry.
### Ejercicio No. 55-Reading Selection 2
A Modern Fable
Annie, the youngest of Mr. Adams's children, likes jokes very much. Mr. Lopez has written one for her. Its title is "The Fable of the Automobile and the Donkey":
An automobile is passing along the road and sees a donkey. The poor donkey is carrying a big, heavy load of wood.
The automobile stops and says to the donkey: "Good morning. You are walking very slowly. Do you not want to run fast like me?"
"Yes, yes sir! But tell me how is it possible?"
"It is not difficult," says the automobile. "In my tank there is much gasoline. You have to drink a little."
Then the donkey drinks the gasoline. Now he does not walk slowly. He does not run fast. He does not go to the market. He stretches out in the road. He has a stomachache.
Poor donkey! He is not very intelligent, is he? He does not know that gasoline is good for an automobile, but is not at all good for a donkey.
Annie doesn't like the modern fable and comments at the end: "What a silly joke, Mr. Lopez!"
## CAPÍTULO 18
### Ejercicio No. 56A
1. los
2. lo
3. lo
4. lo
5. le
6. las
7. la
8. los
9. las
10. le
### Ejercicio No. 56B
1. El camarero la trae.
2. Los niños lo comen.
3. Los pongo en la mesa.
4. Las digo al estudiante.
5. ¿Por qué no lo saluda Ud.?
6. ¿La visitas?
### Ejercicio No. 56C
1. Lo veo a Ud., Sr. Adams
2. ¿Meve Ud.?
3. ¿Quién nos ve?
4. El maestro los ve a Uds., muchachos.
5. Vemos la casa. La vemos.
6. Tomo el plato. Lo tomo.
7. Ella escribe los verbos. Los escribe.
8. Tenemos las sillas. Las tenemos.
9. Las espero a Uds., señoras.
10. Los esperamos a Uds., señores.
### Ejercicio No. 57
1. El Sr. Adams sabe pedir información.
2. Prefieren el teatro.
3. Prefieren las farsas detectivescas.
4. Claro está, las conocen.
5. Vive en los suburbios.
6. Está a unas ocho cuadras de su casa.
7. Prefieren las filas catorce o quince.
8. Sí, es posible ver y oír bien.
9. Piden ayuda al acomodador.
10. Vienen temprano.
## CAPÍTULO 19
### Ejercicio No. 58
1. No saben nada
2. pueden
3. en memoria de, patria
4. más importantes
5. desde, hasta
6. nombres, fechas
7. desde el punto de vista
8. significan
9. cura, iniciador
10. Estos sucesos
11. caminar, cuyos
12. recordar
### Ejercicio No. 59A
1. de Ud.
2. nosotros
3. ellas
4. mi
5. conmigo
6. contigo
7. ellos, ellos
8. usted
9. ella
10. él
### Ejercicio No. 59B
1. ¿Dónde está su libro (el libro de ella)?
2. ¿Dónde está su libro (el libro de él)?
3. ¿Dónde están sus libros (los libros de ella)?
4. ¿Dónde están sus libros (los libros de él)?
5. ¿Dónde están sus padres, muchachos (los padres de Uds.)?
6. ¿Dónde está su casa (la casa de Ud.), Sr. Adams?
7. ¿Dónde están sus sillas (las sillas de ellos, _or_ ellas)?
8. ¿Dónde está su cuarto (el cuarto de ellos, _or_ ellas)?
### Ejercicio No. 60
1. El 16 de septiembre es la fecha del Día de la Independencia de México.
2. El cura Hidalgo fue el inciador de la revolución de 1810.
3. El cura Hidalgo es el George Washington de México.
4. El cinco de mayo es el aniversario de la victoria contra los franceses.
5. Benito Juárez es el Abraham Lincoln de México.
6. Fue presidente de México desde 1857 hasta 1872.
7. El 20 de noviembre se celebra el comienzo de la revolución contra Díaz.
8. Francisco I. Madero fue uno de los líderes.
9. Las avenidas Juárez y Francisco I. Madero están nombradas en memoria de dos grandes héroes.
10. El 5 de febrero es la fecha del Día de la Constitución.
11. Sí, le interesan mucho.
12. Va a caminar por las calles cuyos nombres son fechas.
13. Va a recordar las palabras de su maestro y amigo.
14. El 4 de julio es la fecha del aniversario del Día de la Independencia de los Estados Unidos.
## CAPÍTULO 20
### Ejercicio No. 61
1. cuyos, recuerdan
2. los acontecimientos más notables
3. más conocidos
4. más famosos
5. más importantes del mundo
6. De veras, puede educarse bien y barato
7. A propósito, acerca de, Occidental
8. recibir
9. más grande
10. más pequeño
11. el más grande y el más largo
12. más alto
13. más altos
14. altos, no lejos de
15. Ud. tiene razón
### Ejercicio No. 62
1. tan alto como
2. mejor
3. más, que
4. mejor
5. tan, como
6. más
7. más, que
8. más, que
9. más alta
10. peor
11. mayor
12. más modernos
13. peor
14. tan, como
15. de
16. menor
### Ejercicio No. 63
1. El Amazonas es el río más largo de Sudamérica.
2. Londres es una de las ciudades más grandes del mundo.
3. El Aconcagua es el pico más alto de Sudamérica.
4. México, D.E es más grande que Nueva York.
5. Madrid no es tan grande como Nueva York.
6. Nueva York no es tan antigua como Madrid.
7. San Agustín es más antigua.
8. Chicago tiene uno de los edificios más altos del mundo.
9. El Salvador es el país más pequeño de Centroamérica.
10. 1. El Sr. Garcia es el menor.
2. El Sr. Torres es el mayor.
3. Sí, el Sr. Rivera es mayor que el Sr. García.
4. El Sr. Garcia es el más rico.
5. El Sr. Torres es el menos rico.
6. El Sr. Torres no es tan rico como el Sr. García.
## CAPÍTUL0 21
### Ejercicio No. 64
1. preguntarle a qué hora
2. a las seis y media
3. madrugador, madrugadora
4. temprano
5. estoy listo para salir
6. Leo, lo respondo
7. un sandwich con café y algún postre
8. Muchas veces, a visitarme
9. a las cinco en punto
10. Las costumbres
### Ejercicio No. 65A
1. At what time do you go to bed? I go to bed at 11 P.M.
2. At what time do you get up? I get up at 7 A.M.
3. Do you wash (yourself) before dressing (yourself)?
Yes, I wash (myself) before dressing (myself).
4. Where can you be found at noon?
I can be found in my office.
5. When do you go from here? I go from here tomorrow.
6. Do you get sick when you eat too many sweets?
Yes, I get sick.
7. In what row do you sit in the movies?
We sit in the fourteenth or fifteenth row.
8. Do you remember our conversations?
Yes, we remember them.
### Ejercicio No. 65B
1. se
2. se
3. se, se
4. se
5. me
6. se
7. se
8. se
9. nos
10. me
### Ejercicio No. 66
1. Se levanta a las seis y media.
2. Se lava y se viste.
3. Se viste en treinta minutos.
4. A eso de las siete se sienta a la mesa.
5. Se levanta temprano.
6. Se desayunan juntos.
7. Toma jugo de naranja, café, panecillos y huevos.
8. Toma panqueques en vez de huevos.
9. A las siete y media está listo para salir.
10. Va en coche a la estación.
11. A eso de las nueve llega a su oficina.
12. Lo toma casi siempre a la una.
13. Toma un sandwich con café y algún postre.
14. Muchas veces vienen clientes a visitarle.
15. Termina el trabajo a las cinco en punto.
## CAPÍTULO 22
**REPASO 4 CAPÍTJLOS 18–21**
### Ejercicio No. 67
1. (i)
2. (e)
3. (j)
4. (d)
5. (b)
6. (c)
7. (h)
8. (a)
9. (g)
10. (f)
### Ejercicio No. 68
1. Sí, los invito de vez en cuando.
2. No, no lo prefiero.
3. Sí, las conocen bien.
4. Sí, los esperamos a Uds.
5. Las pone en la mesa.
6. No, no lo busca a Ud. señor.
7. Me levanto a las ocho.
8. Sí, nos lavamos antes de comer.
9. Se sientan en la fila quince.
10. Mi padre se llama...
### Ejercicio No. 69
1. más grande del mundo
2. más grande que
3. mayor que
4. tan alto como
5. la menor de
6. el primer día
7. el 30 de enero de 2003
8. conmigo
9. sin mí
10. oigo, la recuerdo
### Ejercicio No. 70
1. se dan la mano
2. Tenemos que estudiar
3. Me acuesto
4. hace muchas preguntas
5. Por eso
6. de vez en cuando
7. dar un paseo
8. Ud. debe de estar
9. otra vez
10. a las siete y media de la mañana
### Ejercicio No. 71-Reading Selection
A Visit to the Puerto Rican District of New York
It is Saturday. Mr. Adams gets up at 8 o'clock and looks out of the window. The sky is blue. It is very sunny. He says to his wife: "Today we are going to visit the Puerto Rican district which is near Central Park."
"That's fine," says Mrs. Adams.
At nine o'clock they get into their auto and after one hour of riding they arrive at 116th Street. They get out of the auto and begin to walk through the street. In a little while they see a group of Puerto Rican boys who are standing near a shop and are talking very fast in Spanish.
Mr. Adams greets the boys and begins to chat with one of them. The conversation follows:
"Hello, young man! Are you a Puerto Rican?"
"No sir, I am a North American, but I know how to speak Spanish well. I have many Puerto Rican friends and they are my teachers. At home I have a Spanish book and every afternoon I study a little. By the way, are you Spanish?"
"No, young man, I am a North American and like you I am studying Spanish. I like the language very much. It seems that in New York there are many people who are studying Spanish. So long, friend."
"So long, sir," says the boy and in a few minutes he disappears among his group of friends who continue talking in Spanish.
—¡Qué muchacho tan simpático!—says Mr. Adams to his wife. And then he translates the sentence because his wife does not understand Spanish:
"What a nice boy!"
## CAPÍTULO 23
### Ejercicio No. 72
1. ¡Qué tiempo tan lluvioso!
2. Pase, pase, moj ado
3. Déme
4. Ponga
5. pescar un catarro (resfriado)
6. Venga conmigo
7. Tome
8. Permítame
9. Mientras toman
10. Sigue lloviendo
### Ejercicio No. 73A
1. Póngala
2. No la abra
3. Repítalas
4. No lo deje
5. Tráigalos
6. No lo tomen
7. Salúdenlos
8. Cómprenlos
9. Invítelo
10. Háganlo
### Ejercicio No. 73B
1. escribo, I write, escriba Ud., escriban Uds., Write, escríbe (tú)
2. leo, I read, lea Ud., lean Uds., Read, lee (tú)
3. tengo, I have, tenga Ud., tengan Uds., Have, ten (tú)
4. veo, I see, vea Ud., vean Uds., See, ve (tú)
5. pregunto, I ask, pregunte Ud., pregunten Uds., ask, pregunta (tú)
6. recibo, I receive, reciba Ud., reciban Uds., receive, recibe (tú)
7. repito, I repeat, repita Ud., repitan Uds., repeat, repite (tú)
8. voy, I go, vaya Ud., vayan Uds., go, ve (tú)
9. doy, I give, dé Ud., den Uds., give, da (tú)
10. soy, I am, sea Ud., sean Uds, be, sé (tú)
### Ejercicio No. 74
1. Hace mal tiempo.
2. La señora Adams abre la puerta.
3. Lo pone en el paragüero.
4. Llueve pero no hace frío.
5. Pasan al comedor.
6. Toman té con ron.
7. Pone en la mesa dos tazas y platillos, una tetera, un azucarero y unas cucharitas.
8. Sale del comedor.
9. El Sr. Adams le sirve al Sr. López.
10. Echa té con ron en las tazas.
## CAPÍTULO 24
### Ejercicio No. 75
1. Está lloviendo
2. están charlando y tomando
3. hace calor, hace frío
4. prefiere Ud.
5. Dígame
6. Acabamos de hablar
7. Al atravesar: se sube
8. se elevan
9. más alta de México
10. La mitad, tórrida
### Ejercicio No. 76A
1. Estamos estudiándolas.
2. Carlos está escribiéndola.
3. ¿Estás leyéndolo?
4. La señora Adams está poniéndola.
5. Los señores están tomándolo.
6. Juan y yo estamos contándolo.
7. ¿Están comprándolos Uds.?
8. No estoy leyéndolas.
9. ¿Quién está escribiéndolas?
10. Están vendiéndolos.
### Ejercicio No. 76B
1. No, no estoy leyéndola.
2. No, no estoy esperándola.
3. No, no estoy esperándolo.
4. No, no está mirándolas.
5. No, no está comiéndola.
6. No, no estamos aprendiéndolos.
### Ejercicio No. 76C
1. Estamos estudiando
2. Está poniendo
3. Estamos abriendo
4. ¿Está leyendo Ud.?
5. Está trayendo
6. ¿Quién está esperando?
7. ¿Está tomando Ud.?
8. Estás hablando
9. No estoy escribiendo
10. ¿Está trabajando Maria?
11. Estábuscando
12. Están enseñando
### Ejercicio No. 77
1. Están hablando del clima.
2. Hace buen tiempo.
3. No se pone verde en el invierno.
4. Ve el gran panorama de sierras y picos altos.
5. Está situada en la Mesa Central.
6. Su altura varía desde cuatro mil (4000) hasta ocho mil (8000) pies.
7. El Pico de Orizaba es la cima más alta de México.
8. Las montañas determinan en gran parte el clima.
9. La mitad de México está situada en la zona tórrida.
10. En la zona tórrida hace mucho calor.
## CAPÍTULO 25
### Ejercicio No. 78
1. seguimos charlando
2. en el mes de junio
3. a la misma hora
4. Por lo tanto
5. Vale la pena
6. Nunca, excepto
7. Tenga cuidado con
8. quedarse, sin
9. acordarme
10. Al hacer, a olvidar
### Ejercicio No. 79
1. nada
2. Nada
3. Nunca
4. Tampoco
5. Nadie
6. nadie
7. nunca
8. nunca
9. Tampoco
10. ni, ni
11. Nadie
12. ningún
13. nada
14. nada
### Ejercicio No. 80
1. Son la estación de lluvias y la estación seca.
2. La estación de lluvias comienza en el mes de junio.
3. Termina en el mes de septiembre.
4. Suele Hover a eso de las cuatro de la tarde.
5. Nunca hace frío en la ciudad.
6. Porque a veces hace fresco por la noche.
## CAPÍTULO 26
### Ejercicio No. 81
1. se siente un poco débil
2. un dolor de cabeza, dolor de muelas, dolor de estómago
3. Se dice
4. ¿Qué se puede hacer...?
5. Descanse, Camine despacio.
6. ¿Qué me aconseja Ud....?
7. Tiene cuidado
8. se venden
9. parecen
10. se parece
11. qué clase de carne
12. Les gusta
13. debe
14. Comemos, No vivimos
15. a olvidar
### Ejercicio No. 82A
1. Se puede
2. Cómo se dice
3. se venden
4. Se ven
5. Se dice
6. se habla español
7. Se comen
8. Conoce Ud.
9. No los conozco.
10. Sabe Ud.
11. me voy
12. Sabemos
13. se parece
### Ejercicio No. 82B
1. (i)
2. (m)
3. (f)
4. (k)
5. (a)
6. (c)
7. (b)
8. (e)
9. (d)
10. (n)
11. (g)
12. (h)
13. (j)
14. (p)
15. (l)
16. (o)
### Ejercicio No. 83
1. México DF está a una altura de 7500 pies.
2. Los mangos y las papayas.
3. Las naranjas, los plátanos, las peras y los melones.
4. Se venden en los mercados.
5. Es mejor tomar frutas ordinarias.
6. Es la tortilla.
7. Se hacen de maíz.
8. Se usa la tortilla para hacer tacos y enchiladas.
9. Comen un dulce, flan o frutas.
10. Porque el estómago norteamericano no se acostumbra rápidamente a la comida picante de México.
11. Porque el sol tropical es muy fuerte.
12. No se va a olvidar del impermeable.
13. Van a platicar de los efectos de la altura.
## CAPÍTULO 27
**REPASO 5 CAPÍTULOS 23–26**
### Ejercicio No. 84
1. (b)
2. (a)
3. (g)
4. (k)
5. (j)
6. (h)
7. (i)
8. (l)
9. (e)
10. (d)
11. (c)
### Ejercicio No. 85
1. tengo frío.
2. tengo calor.
3. hace buen tiempo.
4. llueve mucho.
5. hace fresco.
6. hace frío.
7. llevo impermeable.
8. llevo abrigo.
9. hay polvo.
10. todas las estaciones.
### Ejercicio No. 86
1. (d)
2. (f)
3. (a)
4. (b)
5. (c)
6. (h)
7. (e)
8. (j)
9. (g)
10. (i)
### Ejercicio No. 87
1. La abro.
2. Los cuento.
3. La como.
4. La pongo.
5. Las repito.
6. Los dejamos.
7. Las tomamos.
8. Las aprendemos.
9. Lo escribimos.
10. Lo leemos.
### Ejercicio No. 88
1. lloviendo
2. echando
3. pidiendo
4. leyendo
5. pensando
6. trayendo
7. escribiendo
8. contando
9. poniendo
10. haciendo
### Ejercicio No. 89-Reading Selection
Philip Does Not Like to Study Arithmetic
One day upon returning from school Philip says to his mother:
"I don't like to study arithmetic. It is so difficult. Why do we need so many excercises and problems nowadays. Isn't it true that we have calculators?"
Mrs. Adams looks at her son and says: "You are wrong, son. It is not possible to get along without numbers. For example, one must always change money, calculate distances, and..."
The mother stops speaking on seeing that Philip is not paying attention to what she is saying.
"By the way," continues the mother with a smile, "does not baseball interest you either, my son?"
"I should say so, mama."
"Well, if the Dodgers have won eighty games and have lost thirty, do you know what percentage of the games they have won?"
On hearing this, Philip opens his mouth and exclaims:
"You are right, mother. Numbers and mathematics are very important. I think I'm going to study much more."
## CAPÍTULO 28
### Ejercicio No. 90
1. hacerle
2. acerca del pueblo
3. Aquí tiene Ud., Continúe
4. Quiénes
5. hoy día
6. hermosa y cosmopolita
7. A causa de la variedad, una variedad
8. el producto más importante
9. artistas y artesanos
10. se ocupan
11. Se ocupan
12. cestas y artículos de cuero
13. Acabo de recibir
14. Volvemos a platicar
15. Que la pase bien.
### Ejercicio No. 91B
1. ¿Cuándo vuelven a casa?
2. Vuelven a casa a las diez de la noche.
3. Los alumnos vuelven a escribir los ejercicios.
4. Vuelvo a leer la guía de viajero.
5. Acabamos de recibir un envío de mercancía.
6. Acabo de hablar sobre el clima.
7. Ella acaba de volver de la joyería.
8. Acaban de comprar aretes de plata.
9. ¿Acaba de venir Ud. del cine?
10. Acabamos el trabajo.
### Ejercicio No. 92
1. El Sr. Adams va a hacer algunas preguntas.
2. La primera pregunta es—¿Quiénes son los mexicanos?
3. Son descendientes de los indios indígenas y de los españoles, conquistadores de México.
4. México tiene 100 millones de personas más o menos.
5. El Sr. Adams acaba de recibir un envío de mercancías.
6. Viven en el campo.
7. El maíz es el producto más importante.
8. Se ocupan de las artes populares.
9. Para hacer artículos artísticos se usa cuero, cobre, hojalata, plata, etc.
## CAPÍTULO 29
### Ejercicio No. 93
1. a ver
2. Entretanto, las artes populares
3. de uso diario
4. El vestido típico, pintoresco
5. faldas largas
6. un traje bianco
7. El sombrero de paja
8. un artículo de ropa
9. Me gustan
10. de lana o de algodón
11. sirve para todo
12. Por supuesto, cestas de varios tamaños
13. Tenemos que hablar
14. ¿Le parece bien el martes?
15. Me parece bien.
### Ejercicio No. 94A
1. Visto
2. Me visto
3. Visten de
4. Vestimos
5. se visten
6. lleva Ud.
7. Llevo
8. llevan
9. llevan
10. Llevamos
### Ejerdcio No. 94B
1. Este, ése
2. Estos, ésos
3. Esas, éstas
4. Esta, ésa
5. Aquella, ésta
6. éste
7. eso
8. esto, eso
9. Eso
### Ejerdcio No. 95
1. El Sr. Adams acaba de recibir una caja de mercancía de México.
2. Los hombres llevan sarape.
3. Son de Oaxaca.
4. Son de Toluca.
5. Llevan fajas.
6. Dibujos de pájaros y de animalitos adornan la bolsa.
7. El rebozo (la chal) sirve de manta y cuna del nene.
8. Llevan máscaras.
9. Sabe muy poco de las fiestas.
10. Dice—Que Ud. lo pase bien.
## CAPÍTULO 30
### Ejercicio No. 96
1. en algún pueblo u otro
2. se celebran
3. Por supuesto
4. cantando canciones y pidiendo «posada».
5. pasan un buen rato
6. cubierta de papel
7. trata de romperla
8. a romperla
9. Ud. debe ver
10. El Día de los Difuntos
11. Los panaderos venden
12. Se pueden comprar
13. mercados
14. Los compradores, hecha por
15. El 16 de septiembre, Grito de Dolores
### Ejercicio No. 97A
1. primer
2. tercer
3. bien
4. bueno
5. gran, grande
6. tercera
7. mal
8. primero
9. buenos
10. Algún
### Ejercicio No. 97B
1. Cantan
2. Celebramos
3. Visitan
4. dura
5. Estoy preparando
6. Usa Ud.
7. contiene
8. trata
9. cogen
10. llevan (traen)
### Ejercicio No. 98
1. Está titulada—Los días de fiesta.
2. Hay fiestas nacionales y fiestas dedicadas a varios santos.
3. Se celebran con bailes, cohetes, juegos y dramas.
4. Dura diez días.
5. Grupos de personas van de casa en casa.
6. Piden «posada».
7. La pasan bien, cantando, bailando y rompiendo la piñata.
8. Es una olla cubierto de papel de colores vivos.
9. Contiene dulces y juguetes.
10. Un niño con los ojos vendados trata de romperla.
11. Recogen los dulces.
12. Los reciben de los Reyes Magos.
13. Debe ver la fiesta de la Semana Santa en Tzintzuntzán.
14. Los habitantes del pueblo lo interpretan.
15. Es el 16 de septiembre, el Día de la Independencia.
## CAPÍTULO 31
### Ejercicio No. 99
1. Estoy leyendo
2. Viajaré
3. Visitaré
4. Veré
5. Pasaré
6. Estoy seguro
7. un clima de primavera
8. bonitos, llenos de flores
9. muchos árboles, hermosas vistas
10. el pueblo de los plateros
11. Iré
12. fuera de los grandes centros
13. No deje de ver, con callejones tortuosos
14. una cantidad de cosas interesantes
15. Tengo ganas
### Ejercicio No. 100A
1. We shall visit Taxco.
2. I shall spend a week there.
3. I shall be glad to see the murals.
4. Who will travel to Mexico?
5. They will not work hard.
6. Will you study the lesson?
7. Will you have coffee?
8. Philip will not write the letter.
9. I shall not be cold.
10. He will not come here.
11. We shall leave at 8 o'clock.
12. I shall play this role with enthusiasm.
13. They will want to eat.
14. She will put it on the table.
15. I shall not be able to go there.
### Ejercicio No. 100B
1. Compraré una corbata.
2. Costará cinco pesos.
3. Iré al campo.
4. Mi hermano irá conmigo.
5. Volveré a las nueve de la noche.
6. Veré a mi amigo Guillermo.
7. Saldré a las ocho de la mañana.
8. Cenaremos a las siete.
9. Visitaremos a nuestros amigos.
10. Estudiaremos nuestras lecciones de español.
### Ejercicio No. 100C
1. Aprenderé
2. Escribirá
3. Irán
4. Comeremos
5. Hablará
6. ¿Trabajará Ud.?
7. ¿Verá Juan?
8. ¿Quién visitará?
9. No viajaré
10. ¿Estudiarán?
11. Haré
12. Vendrá
13. Ud. pondrá
14. No querrán
15. ¿Saldrá Ud.?
16. Tendré
17. Estarán aquí.
18. Irán Uds.?
### Ejercicio No. 101
1. ¿Se titula—¿Qué lugares quiere Ud. visitar, Sr. Adams?
2. El Sr. Adams va a salir pronto.
3. Está leyendo guías de viajero.
4. Viajará por avión.
5. Usará el centro de la ciudad.
6. Está cerca de la Alameda.
7. Verá las pinturas murales.
8. Pasará un día en el parque de Chapultepec.
9. Verá la gran pirámide del Sol y la de la Luna.
10. Se dice que son tan imponentes como las de Egipto.
11. Tal vez irá a una corrida de toros.
12. Cuernavaca tiene un clima de primavera.
13. Taxco es el pueblo de los plateros.
14. Le interesa más la gente del campo.
15. El Sr. López tiene ganas de acompañar al Sr. Adams.
## CAPÍTULO 32
**REPASO 6 CAPÍTULOS 28–31**
### Ejercicio No. 102
1. (c)
2. (e)
3. (a)
4. (g)
5. (d)
6. (h)
7. (i)
8. (j)
9. (f)
10. (b)
11. (l)
12. (k)
### Ejercicio No. 103
1. los pantalones
2. el sombrero
3. el traje
4. la corbata
5. la faja
6. los zapatos
7. los guantes
8. las camisas
9. los vestidos
10. el abrigo
### Ejercicio No. 104
1. (c)
2. (e)
3. (b)
4. (f)
5. (d)
6. (a)
### Ejercicio No. 105
1. El panadero, la panadería
2. El platero, platería
3. El zapatero, zapatería
4. El sastre, sastrería
5. vendedor
6. comprador
7. boca
8. oídos
9. ojos
10. cara, la nariz, los labios
### Ejercicio No. 106-Reading Selection
Mrs. Adams' Birthday
It is March 22, the birthday of Mrs. Adams. Today she is 35 years old. In order to celebrate this day the Adams family is going to dine in a fine restaurant on 52nd Street in New York City.
When they enter the restaurant they see a beautiful basket full of red roses in the center of the table reserved for the Adamses. Naturally Mrs. Adams is very surprised and gives her dear husband a thousand thanks and kisses.
After a delicious meal, Annie, the younger daughter, says in a low voice to her brothers and sister: "Now!" And each one of the four children takes out from under the table a pretty little box. They are gifts for the mother.
Annie gives her a silk handkerchief; Rosie, a cotton blouse; William, a pair of gloves; and Philip, a woolen shawl.
## CAPÍTULO 33
### Ejercicio No. 107
1. a leerle
2. Me gustará mucho
3. de informarle
4. lo he apreciado
5. Tenga la bondad de, más conveniente
6. muy ocupado
7. Por eso, de antemano
8. de verlo a Ud.
9. le mostrará a Ud.
10. en entenderme
11. No hay ninguna
12. titulado, me ayuda
13. darle a Ud. mis agradecimientos más sinceros
14. Ud. es muy amable.
15. ¿Me hará Ud. el favor...?
### Ejercicio No. 108A
1. Will you give him the oranges?
2. Take my shoes to the shoe repairer's.
3. Kindly read us the letter.
4. As soon as possible I shall write her a letter.
5. Will you teach me the new words?
6. We are not able to send you the money.
7. Who will read the story to us?
8. Tell me: What is Mary doing in the kitchen?
9. I shall not like the bullfight.
10. Does that date seem all right to you?
11. It suits me.
12. These things don't matter to me.
### Ejercicio No. 108B
1. le
2. Nos
3. Le
4. Me
5. Les
6. Dígame
7. les
8. les
9. Me
10. comprándoles
11. Le
12. trayéndole
13. Tráiganos
14. Me
15. Nos
### Ejercicio No. 109
1. Están sentados en la sala del Sr. Adams.
2. Tiene en la mano una copia de la carta a su agente.
3. Va a leerle al Sr. Lopez la carta.
4. Le gustará mucho al Sr. López oírla.
5. La fecha es el 4 de mayo de 2004.
6. Escribe la carta al Sr. Rufino Carrillo.
7. Usa el saludo—Muy señor mío:
8. El Sr. Adams irá de viaje a México.
9. Saldrá de Nueva York el 31 de mayo.
10. Llegará al aeropuerto de México D.F. a las siete menos cuarto de la tarde.
11. Se quedará en la capital dos meses.
12. Hará viajes a lugares de interés en México.
13. Irá a Guatemala y tal vez a Colombia.
14. Ha apreciado los servicios del Sr. Carrillo.
15. Desea conocer al Sr. Carrillo personalmente.
## CAPÍTULO 34
### Ejercicio No. 110
1. una carta en la mano
2. Estoy muy agradecido
3. de informarme
4. Tendré el gran placer
5. platicaré
6. felicitarlos
7. Entiendo bien, ¿Cómo no?
8. sin duda alguna, simpático
9. Perdóneme, orgulloso
10. por sí mismo, muy simpáticos
11. Estoy seguro, podré
12. Lo mejor es
13. Lo peor es
14. Nos
15. algunos últimos consejos
### Ejercicio No. 111A
1. Cuánto tiempo
2. Hace seis meses
3. Hace diez años
4. Hace cuarenta y cinco minutos
5. Hace tres días
6. lo conozco
7. viven en esta casa
8. están en el cine
9. está en este país
10. estoy aquí
### Ejercicio No. 111B
1. No los pongan Uds...
2. No les escriba Ud...
3. No los traigan...
4. No me diga...
5. No le mande...
6. No me lleve...
7. No me dé...
8. No me compre...
9. No les lean...
10. No le venda...
### Ejercicio No. 111C
1. Sí, lo visitaré. No, no lo visitaré.
2. Sí, la escribiré. No, no la escribiré.
3. Sí, lo compraré. No, no lo compraré.
4. Sí, los traeré. No, no los traeré.
5. Sí, lo tomaré. No, no lo tomaré.
6. Sí, los pediremos. No, no los pediremos.
7. Sí, la venderemos. No, no la venderemos.
8. Sí, las querremos. No, no las querremos.
9. Sí, los seguiremos. No, no los seguiremos.
10. Sí, las repetiremos. No, no las repetiremos.
### Ejercicio No. 112
1. Acaba de recibir una carta de su agente en México.
2. Estará en la capital durante los meses de junio y julio.
3. Esperará al Sr. Adams en el aeropuerto.
4. Conversará con él en español.
5. Quiere felicitar al Sr. Adams y a su maestro.
6. Entiende bien que el Sr. Adams usará muchos modismos mexicanos.
7. El Sr. López está orgulloso de su pueblo.
8. Verá que el Sr. Carrillo está muy simpático como tantos mexicanos.
9. Será el martes que viene.
10. Se verán en la oficina del Sr. Adams.
## CAPÍTULO 35
### Ejercicio No. 113
1. Me alegro de
2. Tengo ganas
3. Por lo menos, darme
4. Eso de la cortesía
5. Quiere decir, es digno
6. Les gusta, acerca de
7. conocerse el uno al otro
8. Como le he dicho
9. Se dice, Espero que sí
10. de estar de prisa
11. Haleído Ud.
12. En cuanto a mí
13. He gozado
14. despedirnos
15. Se dan las manos.
### Ejercicio No. 114A
1. We have had a good trip.
2. The pitchers have fallen on the floor.
3. They have said nothing.
4. What has Paul done with the money?
5. No one has opened the doors.
6. We have not read those newspapers.
7. Have you been at the movies?
8. Has the child been sick?
9. I have never believed that story.
10. What have they said?
### Ejercicio No. 114B
1. He notado
2. Ha dicho
3. No han leído
4. Han sido
5. Hemos estado
6. No he trabajado
7. ¿Ha enseñado Ud.?
8. ¿Quién no ha escrito?
9. ¿Qué han hecho Uds.?
10. Has abierto
11. ¿Qué ha dicho Juan?
12. Ha tornado
13. No he creído
14. Hemos oído
15. ¿Han oído Uds.?
### Ejercicio No. 114C
1. El Sr. Garcia venderá... | El Sr. Garcia ha vendido...
---|---
2. Trabajaré... | He trabajado...
3. Escribiremos... | Hemos escrito
4. Leerán... | Han leído...
5. ¿Cenará Ud...? | ¿Ha cenado Ud.?
6. Tú no aprenderás... | Tú no has aprendido...
7. ¿Buscará el niño...? | ¿Ha buscado el niño...?
8. ¿Comprarán Uds...? | ¿Han comprado Uds...?
9. Saldré... | He salido...
10. Entrarán... | Han entrado...
### Ejercicio No. 115
1. Se encuentran en la oficina del Sr. Adams.
2. Hace calor.
3. Se oye el ruido de la calle.
4. El Sr. Adams se alegra de irse de la ciudad.
5. El Sr. López tiene ganas de acompañarlo.
6. Desgraciadamente, no es posible.
7. Sí, es más formal.
8. Quiere decir que cada hombre es digno de respeto.
9. Ha notado que entre los negociantes hay más formalidad en México que en los E.E.U.U.
10. El Sr. Adams está cansado de estar de prisa.
11. El Sr. Adams ha leído libros sobre México.
12. El Sr. López los ha recomendado.
13. Pasará el verano en Nueva York.
14. Pensará a menudo en su maestro.
15. Sí, le escribirá cartas.
## CAPÍTULO 36
### Ejercicio No. 116
1. Hace cinco meses
2. ha conseguido
3. Desde luego
4. Al fin
5. a acompañarlo
6. no es solamente, sino también
7. está lista
8. ha hecho dos maletas
9. suben al automóvil
10. Se pone en marcha, a eso de
11. de su equipaje, libras
12. tiene que
13. se despide de
14. A las once en punto
15. El Sr. Adams está en camino.
### Ejercicio No. 117A
1. We are beginning the lesson.
2. We have begun the exercise.
3. I do not remember him.
4. I have remembered her.
5. Are they sitting down?
6. Have they sat down?
7. Are you repeating the words?
8. Have you repeated the words?
9. The maid is setting the table
10. The maid has not set the table.
11. The table is set.
12. She is serving the coffee.
13. She has served the tea.
14. What fruits do you prefer?
15. What fruits have you preferred?
16. The children are going to bed.
### Ejercicio No. 117B
1. abierta
2. cerrada
3. despiertos
4. puesta
5. vendida
6. vestidos
7. sentados
8. escritas
9. terminado
10. hecho
### Ejercicio No. 117C
1. Duermo
2. Está durmiendo
3. Duermen
4. ¿Duerme Ud.?
5. Me despido
6. Se despiden
7. No nos despedimos
8. He dormido
9. ¿Ha dormido Ud.?
10. No hemos dormido
11. Me he despedido
12. No se han despedido
13. ¿Se han despedido Uds.?
14. Duerma Ud.
15. No duerman Uds.
### Ejercicio No. 118
1. Hace cinco meses que el Sr. Adams estudia español.
2. Han pasado muchas horas en conversación con su maestro.
3. Ha aprendido la gramática necesaria.
4. Ha trabajado mucho.
5. Ahora habla español bastante bien.
6. Ha conseguido los boletos para el vuelo.
7. Ha obtenido el certificado de vacuna.
8. Ha escrito a su agente.
9. Su agente le ha prometido recibirlo en el aeropuerto.
10. Están despiertos a las cinco de la mañana.
11. Sale a las ocho menos cuarto de la mañana.
12. Cada pasajero tiene que mostrar su boleto.
13. No, la familia no va a acompañarlo.
14. Tienen que terminar el año escolar.
15. La señora tiene que quedarse en casa para cuidar a los niños.
## CAPÍTULO 37
**REPASO 7 CAPÍTULOS 33–36**
### Ejercicio No. 119
1. (f)
2. (c)
3. (e)
4. (a)
5. (d)
6. (b)
7. (g)
8. (h)
9. (i)
10. (j)
### Ejercicio No. 120
1. Discúlpeme (c)
2. Hay que (f)
3. hace algún tiempo (i)
4. Tienen la intención de (a)
5. A menudo (b)
6. estoy de prisa (d)
7. se quedará en casa (g)
8. Por lo menos (e)
9. En cuanto a mí (j)
10. bastante bien (h)
### Ejercicio No. 121
1. (d)
2. (e)
3. (g)
4. (f)
5. (a)
6. (h)
7. (b)
8. (j)
9. (c)
10. (i)
### Ejercicio No. 122
1. Me gusta la carta.
2. Les gusta a ellos via jar
3. Nos gustan los aviones
4. ¿Le gustan a Ud. las pinturas?
5. A él no le gustan los tomates.
6. A ella no le gusta esta moda.
7. ¿Les gusta a Uds. bailar?
8. ¿No te gusta jugar?
9. Nos parece bien.
10. No me importa
### Ejercicio No. 123
1. cantado
2. vuelto
3. llegado
4. puesto
5. hecho
6. abierto
7. recibido
8. dicho
9. leído
10. despedido
### Ejercicio No. 124
1. sentadas
2. cubierta
3. abierta
4. cerrados
5. hechos
6. escritas
7. puesta
8. escrito
9. acabado
10. abierto
### Ejercicio No. 125
1. Sí, la he comprado
2. Sí, la he abierto
3. No, no lo he oído
4. No, no lo he conseguido.
5. Sí, los he ayudado
6. Sí, los hemos visto
7. Sí, los hemos vendido
8. No, no lo hemos completado
9. No, no las hemos escrito
10. Sí, la hemos leído
### Ejercicio No. 126-Reading Selection
An Extraordinary Program in the Movies
This afternoon Mr. Adams and his wife are going to the movies. Mr. Adams does not like most of the Hollywood films, especially those in which the American cowboys fire shots at each other. Neither do the detective pictures interest him.
But on this afternoon an extraordinary program is being shown in a theater which is about four blocks from his house. The film is called: "A Trip Through Mexico." It's a film about the country which our friend Adams is going to visit within a few months and which deals with its history, geography, rivers, mountains, cities, etc., that is to say a film which ought to interest tourists very much.
The Adamses enter the theater at 8:30. Almost all the seats are occupied and therefore they have to sit in the third row. Mr. Adams does not like this, because the movements on the screen hurt his eyes. Fortunately, they are able to change seats after fifteen minutes, and move to the thirteenth row.
The Adamses enjoy this picture very much and also learn a great deal about the customs of Mexico.
On leaving the theater Mr. Adams says to his wife: "Do you know, Charlotte, I believe that I shall get along very well in Mexico. I have understood almost all the words of the actors and actresses in this film."
## CAPÍTULO 38
### Ejercicio No. 127
1. la sala de espera
2. De repente
3. Discúlpeme
4. Mucho gusto en conocerlo.
5. El gusto es mío
6. un libre
7. López está muy equivocado
8. ¿Quién sabe qué más?
9. ¡No tengo prisa!
10. Ni yo tampoco
11. da a la plaza
12. Quinientos pesos al día.
### Ejercicio No. 128A
1. entré
entraste
entró
entramos
entrasteis
entraron
2. comí
comiste
comió
comimos
comisteis
comieron
3. salí
Saliste
Salió
Salimos
Salisteis
salieron
4. vi
viste
Vio
vimos
visteis
vieron
5. me senté
te sentaste
se sentó
nos sentamos
os sentasteis
se sentaron
### Ejercicio No. 128B
1. Who forgot the tickets?
2. Yesterday we received the letters.
3. The man bought a new suit.
4. Last night we did not hear the bell.
5. Did the train arrive on time?
6. They looked for the baggage.
7. The child fell in front of the house.
8. They left the airport in a taxi.
9. Where did Mr. Adams wait for his friend?
10. How much did the raincoat cost?
### Ejercicio No. 128C
1. No, no compré...
2. No, no volvimos...
3. No, no escribí...
4. No, no llegamos...
5. No, no salí...
6. No, no pasé...
7. No, no oímos...
8. No, no vendí...
9. No, no dejamos...
10. No, no trabajamos...
### Ejercicio No. 128D
1. salí
2. llegamos
3. examinaron
4. oyó
5. Ud. respondió
6. no pregunté
7. llamó
8. Uds. desearon
9. salimos
10. paró
11. no olvidé
12. gritó
13. creyeron
14. vendimos
15. volvieron Uds.
16. leyó
### Ejercicio No. 129
1. Los aduaneros mexicanos lo revisaron.
2. Un señor guapo se acercó á él.
3. Dijo—Discúlpeme ¿Es Ud. el Sr. Adams?
4. Contestó—a sus órdenes.
5. Pasó a una velocidad espantosa.
6. Deseó decir—¡Por favor, más despacio!
7. Olvidó el español.
8. Vio camiones, autos y tranvías.
9. Gritó—¡No tengo prisa!
10. Le contestó—Yo tampoco.
11. Llegaron al hotel sanos y salvos.
12. Buenas tardes. Tiene Ud. un cuarto con baño?
## CAPÍTULO 39
### Ejercicio No. 130
1. me llamó por teléfono
2. a tomar la merienda
3. El día siguiente
4. Me acerqué
5. me invitó a entrar
6. vino a saludarme
7. Ud. está en su casa
8. según la costumbre mexicana
9. Me parece
10. muchas casas semej antes
11. Admiré
12. Me presentó
13. hacerse médico
14. Sintió
15. Nos despedimos, a casa
### Ejercicio No. 131A
1. The maid served us "tea."
2. Why did you not wish to invite me?
3. Last night we returned late from the theater.
4. I wanted to telephone you.
5. What did you do after the meal?
6. They said—"We are not in a hurry."
7. I repeated all the answers.
8. My friend did not come on time. I was sorry.
9. They asked for information at the information office.
10. They wanted to buy airplane tickets.
### Ejercicio No. 131B
1. Le dije—Pase Ud.
2. Mi hermano hizo un viaje al Perú.
3. Vine a casa a las siete.
4. Se vistieron de falda de algodón.
5. Quiso hacerse médico.
6. Sirvió una taza de chocolate.
7. Pidió información.
8. Quisimos ver la nueva película.
9. El año pasado hicimos un viaje a México.
10. Dijimos—Hasta la vista.
### Ejercicio No. 131C
1. quise
2. no dije
3. hizo
4. vinieron
5. sirvió
6. quisieron
7. repetí
8. hicimos
9. dijeron
10. hicieron
11. ¿Qué dijo?
12. ¿Qué dijeron Uds.?
13. no quisimos
14. no vine
15. lo sintieron
### Ejercicio No. 132
1. El Sr. Carrillo lo llamó por teléfono.
2. Llegó a su casa a las cinco de la tarde.
3. Una criada le abrió la puerta.
4. El Sr. Carrillo vino a saludarlo.
5. El patio lleno de árboles y flores le encantó.
6. Admiró la fuente de piedra en el centro del patio.
7. Los dos hijos del Sr. Carrillo son serios e inteligentes.
8. Asisten a una escuela secundaria.
9. Quiere hacerse médico.
10. Tienen que volver a su cuarto.
11. Platicaron de la vida en México, de las costumbres y del arte.
12. Sí, vale la pena ir allá.
13. El Sr. Adams quiso ir allá.
14. El Sr. Adams y el Sr. Carrillo se despidieron.
15. Volvió a su hotel.
## CAPÍTULO 40
### Ejercicio No. 133
1. ¡Qué hermoso!
2. ancha y espaciosa
3. Parece
4. se puede cruzar, del mundo
5. se puede caminar, de las ciudades más grandes
6. Ayer
7. nos encontramos
8. quieren decir algo pequeño
9. No veo más que
10. al rey Carlos IV (Cuarto) de España
11. Ud. conoce bien
12. He leído algo
13. Vi
14. casi enteramente de cristal
15. Pude entender
### Ejercicio No. 134A
1. At Christmas I gave gifts to all the children.
2. I did not have the opportunity to know you personally.
3. We were not able to pay the whole bill.
4. This house was constructed in the 16th century.
5. On Sunday we took a walk in Chapultepec Park.
6. I was able to converse with him in his language.
7. He had no difficulty in understanding me.
8. She did not wish to rest much.
9. Mr. Adams's family could not accompany him.
10. I put my new hat on my head.
### Ejercicio No. 134B
1. Tuve que estudiar...
2. El Sr. Adams estuvo...
3. Los árboles se pusieron...
4. El dio...
5. Fui un estudiante...
6. Fuimos al...
7. Vinieron...
8. No dije nada.
9. Uds. no hicieron nada.
10. ¿Quisieron Uds...?
### Ejercicio No. 134C
1. tuve
2. Ud. pudo
3. fueron
4. dijo
5. puso
6. quisimos
7. dieron
8. fui
9. Uds. estuvieron
10. nos encontramos
### Ejercicio No. 135
1. Se titula "El Paseo de la Reforma."
2. Es muy ancho.
3. Tuvo que pensar en su conversación con el Sr. López sobre las calles de México.
4. Al norte del Paseo se puede cruzar algunos de los grandes «ríos» del mundo.
5. Al sur del Paseo se puede caminar por algunas de las «ciudades» más grandes de Europa.
6. Fue domingo.
7. Se encontraron cerca del «Caballito».
8. Quieren decir—algo pequeño.
9. Representa a Carlos IV (Cuarto).
10. Es muy grande.
11. Conoce bien los otros monumentos históricos de México.
12. El Sr. Adams leyó algo sobre él.
13. La defendió contra los españoles.
14. El edificio del Seguro Social es casi enteramente de cristal.
15. Está no lejos del Parque de Chapultepec.
## CAPÍTULO 41
### Ejercicio No. 136
1. La semana pasada
2. Vi, que
3. lleno de gente
4. del campo
5. perderse
6. por una calle de puestos
7. Vi, de siete u ocho años
8. Como los demás vendedores
9. flores, cestas y ropa
10. Entre los puestos
11. a divertirse
12. la plática de las mujeres
13. sobre la vida del campo
14. recordaba
15. un día muy divertido
### Ejercicio No. 137A
1. It was raining buckets when we took leave of the young men.
2. I was thinking of you when I was riding in an automobile through the streets whose names are dates.
3. The tourists and vendors were bargaining and all seemed to be enjoying themselves greatly.
4. I was approaching the door when I met Mr. Carrillo's sons.
5. While we were speaking about the folk arts, Mrs. Carrillo was reading a newspaper.
6. It was very hot when we returned to the United States.
7. When the car was starting, a policeman approached.
8. The airplanes were coming and going at all hours.
9. We were tired but we did not want to rest.
10. It was already 4:30 P.M., and we were in a hurry.
### Ejercicio No. 137B
1. yo comía
2. estudiábamos
3. estaba
4. Uds. se despedían
5. se paseaban
6. gritaban
7. bajaba
8. hablábamos
9. iban
10. pasábamos
### Ejercicio No. 137C
1. caminaba
2. iba
3. dijo
4. jugaban
5. cantaron
6. veíamos
7. corrían
8. Ud perdió
9. vivieron
10. leyó
11. empezó
12. llamaban
13. Uds. no entraron
14. ¿estaba Ud.?
15. eramos
16. oyeron
### Ejercicio No. 138
1. Pasaba por las montañas.
2. Era viernes.
3. La gente vino del campo.
4. Sí, había gente de la ciudad también.
5. Porque sabía pedir información en español.
6. Vio a un muchacho.
7. El muchacho se parecía a un viejecito.
8. Llevaba un sombrero de ala ancha.
9. Arreglaba su mercancía.
10. Veía el sentido estético de los vendedores.
11. Una mujer.
12. Cebollas y chiles.
13. Mientras iba a casa.
## CAPÍTULO 42
### Ejercicio No. 139
1. antes de mi salida, No tenga prisa.
2. No he olvidado
3. No descanso
4. tanto que descubrir
5. ayer, al mediodía
6. se venden
7. No pude
8. Volví a visitar
9. Todavía no
10. Me gustan mucho, pintores
### Ejercicio No. 140A
1. mío
2. suyos
3. mías, suya
4. míos, suyos
5. mías, suyas
6. míos, suyos
7. mías, suyas
8. suya
9. suyos
10. nuestros
### Ejercicio No. 140B
1. Salía... | I was leaving...
---|---
Salí... | I left...
2. Entrábamos... | We were entering...
Entramos... | We entered...
3. Veíamos... | We were seeing...
Vimos... | We saw...
4. Uds. no olvidaban... | You were not forgetting...
Uds. no olvidaron... | You did not forget...
5. El chófer me respondía... | The driver was answering me...
El chófer me respondió... | The driver answered me....
6. Ellos no aprendían... | They were not learning....
Ellos no aprendieron... | They did not learn....
7. Estaba... | I was...
Estuve... | I was...
8. Los jóvenes iban... | The young men were going...
Los jóvenes íueron... | The young men went...
### Ejercicio No. 141
1. No ha olvidado los consejos del Sr. López.
2. Hay tanto que ver, tanto que oír, etc.
3. Descansaba en la Alameda.
4. Veía las tiendas en la Avenida Juárez.
5. Las ha visitado muchas veces.
6. No podía resistir la tentación de volver a visitar las tiendas.
7. Nunca se cansa de mirarlas.
8. Volvió a visitar el Palacio de Bellas Artes.
9. No ha asistido a ningún concierto.
10. Le gusta mucho mirarlas.
## CAPÍTULO 43
**REPASO 8 CAPíTULOS 38–42**
### Ejercicio No. 142
1. la comida
2. la dificultad
3. hablador
4. la plática
5. divertido
6. el caballito
7. viajar
8. secundario
9. la ventanilla
10. el camino
11. la pintura
12. la pregunta
13. la respuesta
14. la llegada
15. fácilmente
16. el campesino
### Ejerdcio No. 143
1. he (she) was able, poder
2. I wanted, querer
3. they put, poner
4. I saw, ver
5. they read, leer
6. you said, decir
7. we had, tener
8. I gave, dar
9. he was (went), ser, ir
10. he (she) asked, pedir
11. You did (made) hacer
12. I came, venir
13. he, she made (did), hacer
14. you (fam. sing.) had tener
15. I found out, saber
### Ejerdcio No. 144
1. (e)
2. (c)
3. (b)
4. (g)
5. (h)
6. (i)
7. (d)
8. (f)
9. (a)
### Ejercicio No. 145
1. recibí, Yesterday I received a package.
2. quedaré, I shall remain at home.
3. fuimos, We did not go to the movies.
4. hacen, Now they are packing the suitcases.
5. escuchan, The teacher speaks and the students listen.
6. saldrán, Will you leave the city the day after tomorrow?
7. Vio, Did you see him the day before yesterday?
8. Viajaré, Next year I shall travel to Europe.
9. podemos, We are not able to hear him.
10. llegué, I arrived last week.
### Ejercicio No. 146-Reading Selection 1
A Visit to Xochimilco
On one occasion Mr. Adams took the sons of Mr. Carrillo on an excursion to the town of Xochimilco with its interesting canals. The town is not very far from the capital and our friend arrived without difficulty. On arriving at the town he had a very bright idea. He proposed a lunch in the open air. The boys accepted the project with enthusiasm.
Adams entered a grocery store, bought some tortillas and cheese. Then he bought some cakes and sweet rolls in the bakery. Finally he bought some oranges and some tomatoes at a vegetable stand.
There remained the problem of cold drinks. Now one of the two boys had a bright idea. "Why not buy some bottles of seltzer. Along the canal there are many vendors of cold drinks."
"Wonderful idea," Mr. Adams commented.
They rented a canoe adorned with thousands of carnations. After riding two hours exploring the canals they got out of the canoe in a very quiet spot. Mr. Adams distributed the tortillas and the cheese, which they ate with the tomatoes. They had as dessert the delicious oranges. It was a wonderful lunch and the boys were enchanted. They will not forget this experience for many years.
### Ejercicio No. 147-Reading Selection 2
On Juarez Avenue
Finally we walk through Juarez Avenue. It is a wide avenue in the center of the Federal District. It is on one side of the Alameda, a very beautiful park with high trees, fountains, and monuments.
There are many people on Juarez Avenue. All the tourists come there. In the shops are sold all kinds of things typical of Mexico—jewelry, textiles, leather goods, pottery, and various kinds of handmade clothing.
Naturally we are going to visit the National Museum of Folk Arts & Industries. There one can see various articles from all parts of the country.
We walk through this avenue until we arrive at the "Caballito," the statue of Charles IV, on the Plaza de la Reforma. There the avenue ends.
## CAPÍTULO 44
### Ejercicio No. 148
1. Every town has a plaza/square.
2. Everybody goes to the plaza/square for rest, business, recreation—for everything.
3. Big trees grow on some plazas/squares.
4. In others one sees nothing but dry leaves from some poor little tree.
5. The bandstand is in the center of the plaza.
6. The musicians play Sunday afternoon, Thursday night, or any hour, any day.
7. Six kinds of shops in the arcades are stationery shops, pharmacies, haberdashers, jewelry shops, and bookshops.
8. They get together in the cafe to chat or read the newspapers.
9. They drink a cup of coffee, chocolate, a beer, or soda.
10. One sees an old church in the main plaza and perhaps the hotel of the town.
11. During the siesta hours some people rest on the benches, others sleep.
12. The life of the plaza begins again about 4 o'clock.
13. On Sunday afternoons everybody gets together on the plaza for the "promenade."
14. The boys walk in one direction and the girls in the opposite direction.
15. At night one sees some travelers who come from the market.
### Ejercicio No. 149
1. El corazón de cada pueblo
2. mientras estaba sentado
3. Se ve nada más
4. puede ser
5. el domingo por la tarde
6. donde se encuentran
7. se reúnen, por la tarde
8. una iglesia antigua
9. Más tarde, con sus niños pequeños
### Ejercicio No. 150A
1. Duermo
2. No estoy durmiendo
3. ¿Quién duerme?
4. Dormimos
5. ¿Duerme Ud.?
6. Duerma Ud.
7. No duerman Uds.
8. Duerme
9. La niña no está durmiendo
10. ¿Quiénes duermen?
11. Duermen
12. está durmiendo
### Ejercicio No. 150B
1. que
2. cuyo
3. que
4. de que
5. que
6. lo que
7. todo lo que
8. que
9. de quienes
10. quien
## CAPÍTULO 45
### Ejercicio No. 151—Test of Reading Comprehension
1. He wanted to take an auto trip to Teotihuacan.
2. He invited the sons of Mr. Carrillo to go with him.
3. They met in front of Mr. Adams's hotel.
4. Mr. Adams had rented a car.
5. They saw nothing but some small adobe houses or an Indian with his donkey.
6. They saw in the distance the plain of the Central Plateau and the mountains.
7. They had a flat tire.
8. They could not find a jack in the trunk.
9. It was noon.
10. A truck driver stopped, loaned them a jack, and helped them change the tire.
11. He thanked him and offered him ten pesos.
12. He climbed up slowly, but was nevertheless out of breath.
13. The boys ran up.
14. Mr. López knows these ruins, the Pyramid of the Moon and the Temple of Quetzalcoatl, better than Mr. Adams.
15. They felt tired but happy.
### Ejercicio No. 152
1. conmigo en coche
2. Los jóvenes aceptaron, con alegría
3. Nos encontramos
4. Saqué
5. Lo había alquilado
6. charlando y riendo
7. de vez en cuando
8. No vimos más que
9. De repente
10. ¿Qué pasó?
11. cambiar la llanta, no había gato
12. a pesar de, paró
13. Nos hace falta un gato
14. y nos ayudó a cambiar la llanta
15. Nos dimos la mano y nos despedimos.
### Ejercicio No. 153A
1. habíamos, We had seen the movie.
2. había, Had you read many books?
3. había, Who had opened the window?
4. habían, The children had not slept during the night.
5. había, I had not believed the story.
6. habíamos, We had flown over the mountains.
7. habían, They had gone to the theater.
8. Había, Had you had a good trip?
9. habían, You had said nothing.
10. Habías, Had you eaten the sweets, Johnny?
### Ejercicio No. 153B
1. Él había comprado...
2. Yo había visto...
3. Habíamos comido...
4. ¿Habían recibido...?
5. ¿Había puesto Ud...?
6. Uds. no habían oído...
7. No habías dormido...
8. se había sentado...
9. Habían tenido...
10. No habíamos dicho...
11. ¿Qué había pasado?
12. No habían hallado...
13. no habían cambiado...
14. se había acercado...
## CAPÍTULO 46
### Ejercicio No. 154—Test of Reading Comprehension
1. He had never been a gambler.
2. He had noted that everybody was buying lottery tickets.
3. He was thinking of the possibility of winning one of the lesser prizes or perhaps the first prize.
4. He would take trips to all the countries of South America.
5. He would visit again his friends in Mexico.
6. He would buy art objects for his house.
7. He bought a ticket from the woman vendor on the corner of Madero Avenue.
8. Next day he was reading the winning numbers in the newspaper.
9. He saw a number with three zeros.
10. He thought he had won a prize of 200,000 pesos.
11. He was taking trips with his whole family through all the countries of South America.
12. Mr. Adams had the number 25000.
13. The number 26000 won the prize.
14. ¿Qué importa? What does it matter.
15. From that moment I was a gambler.
### Ejercicio No. 155
1. llegué, todo el mundo
2. en todas las esquinas
3. el gordo
4. volver a visitar
5. toda la familia
6. soñaba
7. con los tres ceros
8. qué querían decir los tres ceros
9. Los números que ganaron
10. Busqué
11. Al fin, en un bolsillo
12. había, no había
### Ejercicio No. 156A
1. Iríamos... | We would go...
---|---
2. Juan vendería... | John would sell...
3. No sacarían... | They would not win...
4. Ud. encontraría... | You would meet...
5. Leería... | I would read...
6. ¿Llevaría Ud.? | Would you take?
7. ¿Les gustarían? | Would you like?
8. Saldría.... | I would leave...
9. No podríamos... | We would not be able...
10. No dirían... | They would say nothing...
### Ejercicio No. 156B
1. yo aprendería
2. él escribiría
3. irían
4. comeríamos
5. ella hablaría
6. ¿trabajaría Ud.?
7. ¿vería Juan?
8. ¿Quién visitaría?
9. yo no viajaría
10. ¿estudiarían
11. yo haría
12. él vendría
13. no querrían
14. ¿saldría Ud.?
15. Uds. pondrían
## CAPÍTULO 47
### Ejercicio No. 157—Test of Reading Comprehension
1. Do you want to go to a bullfight?
2. They arrived one hour before the beginning of the bullfight.
3. Mr. Carrillo had bought tickets for seats in the shade.
4. The bullfight fans sit in the sun seats (bleachers).
5. The bullring reminded Mr. Adams of our football or baseball stadiums.
6. Mr. Adams heard the shouts of the refreshment vendors and the cries and laughter of the spectators.
7. A procession of men in brilliant costumes passed through the arena.
8. The bull came out.
9. Mr. Adams liked the music: the brilliant costumes, the shouts and the laughter, and the cheerful sunlight.
10. He does not try to describe the bullfight because Mr. Lopez knows this sport well.
11. He doesn't like it.
12. He pities the poor horses, the poor bull, and often the poor bullfighter.
13. He must confess that he is not and never will be a bullfight fan.
14. He agrees that one may say about football: "the poor players."
15. He prefers a more peaceful sport, chess.
### Ejercicio No. 158
1. Estábamos por salir
2. un rato, Pues, posiblemente
3. acepté
4. Faltaba una hora
5. había comprado
6. Al fin, nos sentamos
7. estadio de fútbol o béisbol
8. los gritos y las risas
9. hombres en trajes relucientes
10. Se fueron, salió
11. un deporte muy emocionante
12. tengo que confesarle
13. No pienso
14. Estoy de acuerdo, los pobres jugadores
15. Prefiero
### Ejercicio No. 159B
1. I
1. The children bring them to me.
2. The students send them to us.
3. They don't sell them to us.
4. I give it to you, son.
2.
1. Carlos me lo da.
2. Ana nos los presta.
3. El maestro nos lo dice.
4. Te la damos, niño.
### Ejercicio No. 159C
1.
1. We say it to you.
2. We bring it to you (pl.)
3. We give them to him.
4. We send them (f.) to them.
5. 1. Juan se lo dice a Ud.
2. María se la escribe a él.
3. El maestro se los da a Uds.
4. Se las mandamos a ella.
### Ejercicio No. 159D
1. 1. Tell it to me.
2. Give it to us.
3. Lend them to me.
4. Send them to him.
2. 1. Préstemelos.
2. Mándenoslo.
3. Dígasela a él.
4. Déselos a ella.
## CAPÍTULO 48
### Ejercicio No. 160—Test of Reading Comprehension
1. He had read various interesting books about its history and customs.
2. He was able to describe a little of what he had seen and learned.
3. The people interest him most.
4. Four qualities are affection, generous hospitality, humor, and their philosophy in face of difficulties.
5. He finds life in Mexico more tranquil.
6. He has gotten a different impression in the taxi which brought him to his hotel at fearful speed.
7. He preferred to get a better knowledge of Mexico.
8. He will take his whole family with him.
9. He is sure there will be no difficulties.
10. He leaves for New York August 1.
11. He will be glad to telephone Mr. Lopez and invite him to supper as soon as possible.
12. They will spend much of the night speaking of their beloved Mexico.
### Ejercicio No. 161A
1. I shall read.
2. I had read.
3. I have read.
4. We have visited.
5. We had visited.
6. We shall visit.
7. I can describe it.
8. I was able to describe it.
9. I shall be able.
10. I like your letter.
11. I liked your letter.
12. I shall like your letter.
13. They finish.
14. They finished.
15. They have finished.
16. They have much to tell me
17. They will have.
18. They had.
19. We shall return home.
20. We returned.
### Ejercicio No. 161
1. sabe
2. Conocemos, no sabemos
3. No puedo
4. conocer
5. se conocen
6. Sé
7. Ud. sabe, Ud. puede
8. Ud. conoce
9. conocerlo
10. no pueden
### Ejercicio No. 161C
1. ¿Ha aprendido Ud. mucho sobre México?
2. Sí, he estado allí y he leído muchos libros.
3. ¿Sabe Ud. hablar español?
4. Sí, lo hablo bastante bien.
5. ¿Recuerda Ud. los lugares de que hemos hablado?
6. Los recuerdo bien.
7. ¿Puede Ud. describirlos en español?
8. Sí, puedo describirlos.
9. ¿Qué le gustó más a Ud. en México
10. Me gustó más el pueblo.
11. ¿Es más tranquila la vida de México que la de Nueva York?
12. De veras, es más tranquila.
13. ¿Hay mucho que ver en México.
14. Hay mucho que ver, mucho que oír, mucho que hacer y mucho que aprender.
15. Mi viaje se acabó (se terminó).
## CAPÍTULO 49
**REPASO 9 CAPÍTULOS 44–48**
### Ejercicio No. 162
1. Who will ask for information in the railroad station?
2. Paul had already eaten lunch when I saw him.
3. Would you want to take a trip to all the countries of Europe?
4. I know that man, but I do not know where he lives.
5. We were writing our letters when the teacher entered the living room.
6. Take these papers and put them on my desk.
7. We have bought the newspapers and we have read them.
8. When I arrived in Mexico, I noted that everybody was buying lottery tickets.
9. Buy this ticket and you will have luck.
10. I was not able to describe to them everything I had seen.
11. I came to Mexico and they received me with affection.
12. William was speaking all afternoon while I was saying nothing.
13. I did not like the bullfight and therefore I shall not attend another one.
14. The tortilla resembles our pancakes.
15. The parents were working while the children were sleeping.
16. We were in the market when it began to rain.
17. It was 8:30 in the morning and still the children were sleeping.
18. They will not come here because they will not have time.
19. Children, won't you play in the yard?
20. My uncle traveled through all the countries of South America.
21. Mr. Adams liked _spicy_ foods, but he remembered the advice of his teacher and would not eat them.
22. I wanted the toys but Charles would not give them to me.
23. If I find plates with designs of little animals I shall send them to you.
24. He asked for change of a bill of 1000 pesos and the cashier gave it to him.
25. You have Mary's hat. Return it to her.
### Ejercicio No. 163
1. es un comerciante de Nueva York.
2. un viaje a México para visitar
3. conocerlo mejor.
4. aprendió a hablar español
5. habia leido muchos libros
6. a su amigo y maestro, el Sr. López
7. los lugares de interés histórico
8. el Sr. Adams encontró la vida de México más tranquila que la de Nueva York
9. en el libre (taxí) que lo llevó a su hotel
10. la velocidad espantosa del libre (taxi)
11. pronto terminó sus negocios
12. no pudo visitar ni Colombia ni Guatemala
13. tanto que ver, tanto que oír, tanto que hacer, tanto que aprender.
14. volverá a México
15. toda la familia
16. No ha sacado el gordo, bastante dinero
17. la última carta del Sr. Adams
18. Sin duda, cenar con su familia
### Ejerdcio No. 164—Reading Selection 1
The Pyramids of Teotihuacan
One sees in the outskirts of Mexico, D.F., the remains of various highly developed and somewhat mysterious cultures—the cultures of the Indian races who lived in Mexico ten centuries ago.
In the valley of Teotihuacan are found some enormous pyramids, monuments of a scarcely known culture, the culture of the Toltecs. They used to live in the valley before the Aztecs. What we know of them exists neither in the history books nor in the legends but in solid stone.
The Pyramid of the Sun dominates the valley. It is 216 feet high and is larger than any pyramid of Egypt. One can climb to the summit by a broad and very steep stairway.
Further to the north, through the Avenue of the Dead, is the Pyramid of the Moon and to the south one sees the Temple of Quetzalcoatl, the Plumed Serpent, God of the Aztecs. This pyramid is decorated with very interesting sculptures.
The people who live nowadays in the valley of Teotihuacan are descendants of the Aztecs. The Toltecs, architects of the pyramids, disappeared a long time ago. We only know that they were an imaginative people with a very advanced aesthetic sense.
### Ejerdcio No. 165—Reading Selection 2
In Zócalo
We are in Zócalo. It is the principal plaza of Mexico, D.F. We walk to the north toward the cathedral. It is from the 16th century. To the right is the National Palace; it is also old, from the 17th century. To the left is the Arcade of the Merchants. There we see a block of stands and vendors of cheap merchandise. Beyond the arcade is the pawnshop, and behind us to the south are the Municipal Palace and the Palace of Justice. The latter is a modern building. The former is from the 18th century. On all sides we see big buildings and a lot of people.
**SPANISH MADE SIMPLE.** Copyright © 1960, 2004 by Broadway Books,
a division of Random House, Inc.
A previous edition of this book was originally published in 1955 and 1984 by Doubleday,
a division of Random House, Inc. It is here reprinted by arrangement with Doubleday.
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**Library of Congress Cataloging-in-Publication Data**
Némethy, Judith
Spanish made simple/Judith Némethy
p. cm
Originally published: Garden City, NY: Doubleday, 1943.
I. Spanish language—Textbooks for foreign speakers—English. I. Title.
eISBN: 978-0-307-43459-3
2003041922
v3.0_r4
| {
"redpajama_set_name": "RedPajamaBook"
} | 9,363 |
\section{Introduction}
Let $M_n$ be the set of $n\times n$ matrices. The numerical range and numerical radius
of $A \in M_n$ are defined by
$$W(A) = \{x^*Ax: x \in {\mathbb C}^n, x^*x = 1\} \qquad \hbox{ and } \qquad
w(A) = \max\{|\mu|: \mu \in W(A)\},$$
respectively.
The numerical range and numerical radius are useful tools in studying matrices and
operators.
There are strong connection between the algebraic properties
of a matrix $A$ and the geometric properties of $W(A)$.
For example, $W(A) = \{\mu I\}$ if and only if $A = \mu I$;
$W(A) \subseteq {\mathbb R}$ if and only if $A = A^*$; $W(A) \subseteq [0, \infty)$
if and only if $A$ is positive semi-definite.
The numerical radius is a norm on $M_n$, and
has been used in the analysis of basic iterative solution
methods \cite{Ax}. Researchers have
obtained interesting inequalities related to the numerical radius;
for example, see
\cite{G,H,Hol,HolS,HJ1}. We mention a few of them in the following.
Let $\|A\|$
be the operator norm of $A$.
It is known that
$$w(A) \le \|A\| \le 2w(A).$$
While the spectral norm is submultiplicative,
i.e., $\|AB\| \le \|A\| \|B\|$ for all $A, B \in M_n$,
the numerical radius is not.
In general,
$$w(AB) \le \xi w(A)w(B) \quad \hbox{ for all } A, B \in M_n$$
if and only if $\xi \ge 4$; e.g., see \cite{GW}.
Despite the fact that the numerical radius is not submultiplicative,
$$w(A^m) \le w(A)^m \qquad \hbox{ for all positive integers } m.$$
For a normal matrix $A\in M_n$, we have $w(A) = \|A\|$. Thus,
for a normal matrix $A$ and any $B \in M_n$,
$$w(AB) \le \|AB\| \le \|A\| \|B\| = w(A) \|B\| \le 2 w(A)w(B),$$
and also
$$w(BA) \le \|BA\| \le \|B\|\|A\| = \|B\| w(A) \le 2w(B)w(A).$$
In case $A, B\in M_n$ are normal matrices,
$$w(AB) \le \|AB\| \le \|A\| \|B\| = w(A) w(B).$$
Also, for any pairs of commuting matrices $A, B \in M_n$,
$$w(AB) \le 2w(A)w(B).$$
To see this, we may assume $w(A) = w(B) = 1$, and observe that
\begin{eqnarray*}
4w(AB) &=& w((A+B)^2 - (A-B)^2) \le w((A+B)^2) + w((A-B)^2) \\
&\le& w(A+B)^2 + w(A-B)^2 \le 8.
\end{eqnarray*}
The constant 2 is best (smallest) possible for matrices of order at least 4
because $w(AB) = 2w(A)w(B)$ if $A = E_{12} + E_{34}$ and $B = E_{13} + E_{24}$, where $ E_{ij} \in M_n$ has $1$ at the $(i,j)$ position and $0$ elsewhere; see \cite[Theorem 3.1]{GW}.
In connection to the above discussion,
there has been interest in studying the best (smallest) constant
$\xi > 0$ such that
$$w(AB) \le \xi w(A)w(B)$$
for all commuting matrices $A, B \in M_n$ with $n \le 3$.
For $n = 2$, the best constant $\xi$ is one;
the existing proofs of the $2\times 2$ case depend on deep theory on analytic functions,
von Neumann inequality, and functional calculus
on operators with numerical radius equal to one, etc.; for example, see \cite{Hol,HolS}.
Researchers have been trying to find an elementary proof for this result in view of the fact
that the numerical range of $A \in M_2$ is well understood,
namely, $W(A)$is an elliptical disk with the eigenvalues
$\lambda_1, \lambda_2$ as
foci and the length of minor axis $\sqrt{({\mathrm tr}\, A^*A) - |\lambda_1|^2 - |\lambda_2|^2}$;
for example, see \cite{L,M} and \cite[Theorem 1.3.6]{HJ1}.
The purpose of this note is to provide such a proof.
Our analysis is based on elementary theory in convex analysis, co-ordinate
geometry, and inequalities.
Using our approach, we readily give a characterization of commuting pairs of matrices
$A, B \in M_2$ satisfying $w(AB) = w(A)w(B)$, which was done
in \cite[Theorem 4.1]{GW} using yet another deep result of Ando \cite{An} that a
matrix $ A$ has numerical radius bounded by one if and only if $A = (I-Z)^{1/2}C(A+Z)^{1/2}$
for some contractions $C$ and $Z$, where $Z = Z^*$.
Here is our main result.
\begin{theorem} Let $A, B \in M_2$ be nonzero matrices such that $AB = BA$.
Then $w(AB) \le w(A)w(B)$. The equality holds if and only if one of the following holds.
\begin{itemize}
\item[{\rm (a)}] $A$ or $B$ is a scalar matrix, i.e. of the form $ \mu I_2$ for some
$\mu \in{\mathbb C}$.
\item[
{\rm (b)}] There is a unitary $U$ such that $U^*AU = {\rm diag}\,(a_1,a_2)$
and $U^*BU = {\rm diag}\,(b_1, b_2)$ with $|a_1| \ge |a_2|$ and $|b_1| \ge |b_2|$.
\iffalse
\item[
{\rm (c)}] There is a unitary $U$ such that
$U^*AU = a R$ and $ U^*BU =b\overline R$ for some $a, b \in {\mathbb C}$ with $|a|= w(A)$, $|b| = w(B)$,
$R = ic^2 \gamma I_2 + \sqrt{1- (c\gamma )^2}
\begin{pmatrix} c & 2\sqrt{1-c^2} \cr 0
& -c \end{pmatrix}$ for some $\gamma, c \in (0,1]$.
\fi
\end{itemize}
\end{theorem}
One can associate the conditions (a) and (b) in the theorem with the geometry of the numerical
range of $A$ and $B$ as follows.
Condition (a) means that $W(A)$ or $W(B)$ is a single point; condition (b) means that
$W(A)$, $W(B)$, $W(AB)$ are line segments with three sets of
end points,
$\{a_1, a_2\}, \{b_1, b_2\}, \{a_1b_1, a_2b_2\}$, respectively, such that
$|a_1|\ge |a_2|$ and $|b_1| \ge |b_2|$.
\iffalse
condition (c) means that there are $a, b \in {\mathbb C}$ with $(|a|, |b|) = w(A), w(B))$ such that
$W(A/a) = {\mathcal E}$ is an elliptical disk symmetric about the imaginary axis insider the unit
circle at two points, and $W(B/b) = \overline{{\mathcal E}} =
\{\bar\mu \in {\mathbb C}: \mu \in {\mathcal E}\}.$
\fi
\section{Proof of Theorem 1}
Let $A, B \in M_2$ be commuting matrices. We may replace
$(A,B)$ by $(A/w(A),B/w(B))$ and assume that $w(A) = w(B) = 1$.
We need to show that $w(AB)\le 1$.
Since $AB = BA$, there is a unitary matrix $U \in M_2$ such that
both $U^*AU$ and$U^*BU$ are in triangular form; for example, see
\cite[Theorem 2.3.3]{HJ2}.
We may replace $(A,B)$ by $(U^*AU,U^*BU)$ and assume that
$A = \begin{pmatrix} a_1&a_3\cr 0 & a_2\cr \end{pmatrix}$,
$B = \begin{pmatrix} b_1&b_3\cr 0 & b_2\cr \end{pmatrix}$ and $w(A) = w(B) = 1$.
The result is clear if $A$ or $B$ is normal. So, we assume that $a_3, b_3 \ne 0$.
Furthermore, comparing the $(1,2)$ entries on both sides of $AB = BA$, we see that
$\displaystyle\frac{a_1-a_2}{a_3}= \displaystyle\frac{b_1-b_2}{b_3}$.
Applying a diagonal unitary similarity to both $A$ and $B$, we may further assume that $\gamma =\displaystyle\frac{a_1-a_2}{a_3}\ge 0$. Let
$r=\displaystyle\frac{1}{\sqrt{\gamma^2+1}}$. We have $0<r\le 1$. Then
$A = z_1 I + s_1C$ and $B = z_2 I + s_2 C$ with
\bigskip
\centerline{
$z_1 = \displaystyle\frac{a_1+a_2}{2}, \quad
z_2 =\displaystyle\frac{b_1+b_2}{2} , \quad s_1=\displaystyle\frac{a_3}{2r}, \quad s_2 =\displaystyle\frac{b_3}{2r}$,
\quad and \quad
$C = \begin{pmatrix} \sqrt{1-r^2} & 2r \cr 0 & -\sqrt{1-r^2}\end{pmatrix}$.}
\medskip\noindent
Note that $W(C)$ is the elliptical disk with boundary
$$\{\cos\theta + i r\sin\theta: \theta \in [0, 2\pi]\};$$
see \cite {L} and \cite[Theorem 1.3.6]{HJ1}.
Replacing $(A, B)$ with $(e^{it_1} A, e^{it_2 } B)$
for suitable $t_1, t_2\in [0,2\pi ]$, if necessary,
we may assume that
${\rm Re}\,z_1,\ {\rm Re}\,z_2 \ge 0 $ and $s_1,s_2$ are real.
Suppose $z_1 = \alpha_1 + i \alpha_2$ with $\alpha_1\ge 0$ and the boundary of $W(A)$ touches the unit
circle at the point $\cos\phi_1+i\sin\phi_1$ with $\phi_1 \in
[-\pi/2, \pi/2]$.
Then $W(A)$ has boundary
$$\{\alpha_1 +| s_1|\cos\theta + i (\alpha_2 + |s_1|r\sin\theta): \theta \in [0, 2\pi]\} .$$
\noindent
We {\bf claim} that the matrix $A$ is a convex combination of
$A_0 = e^{i\phi_1} I$ and another matrix $A_1$ of the form
$A_1 = i(1-r^2)\sin \phi_1I + \xi C$ for some $\xi \in {\mathbb R}$ such that $w(A_1) \le 1$.
To prove our claim,
we first determine $\theta_1 \in [-\pi/2, \pi/2]$ satisfying
$$\cos\phi_1+i\sin\phi_1=(\alpha_1 + |s_1| \cos\theta_1) + i (\alpha_2
+ |s_1| r\sin\theta_1).$$
Since the boundary of $W(A)$ touches the unit
circle at the point $\cos\phi_1+i\sin\phi_1$, using the parametric equation
\begin{equation}\label{para}
x+iy = (\alpha_1 + |s_1| \cos\theta) + i (\alpha_2 + |s_1| r\sin\theta),
\end{equation}
of the boundary of $W(A)$,
we see that the direction of the tangent
at the intersection point $\cos\phi_1+i\sin\phi_1$
is $- \sin \theta_1 + i r \cos \theta_1$, which agrees with $-\sin\phi_1+i \cos \phi_1 $, the
direction of the tangent line of the unit circle at the same point.
As a result, we have
$$(\cos \theta_1, \sin \theta_1)
= \displaystyle\frac{(\cos \phi_1, r\sin\phi_1)}{\sqrt{\cos^2\phi_1 + r^2\sin^2\phi_1}}.$$
Furthermore, since
$\cos\phi_1+i\sin\phi_1=(\alpha_1 + |s_1| \cos\theta_1)
+ i (\alpha_2 + |s_1| r\sin\theta_1)$,
we have
$$
\alpha_1=\cos\phi_1 - \displaystyle\frac{|s_1|\cos\phi_1}{\sqrt{\cos^2\phi_1 + r^2\sin^2\phi_1}}\ge 0 \quad
\hbox{ and } \quad
\alpha_2=\sin \phi_1-\displaystyle\frac{|s_1|r^2\sin\phi_1}{\sqrt{\cos^2\phi_1 + r^2\sin^2\phi_1}}.
$$
\noindent
\bf Assertion. \it If
$\hat s_1 = \sqrt{\cos^2\phi_1+r^2 \sin^2 \phi_1}$, then
$|s_1|\le \hat s_1$.
\rm
If $\cos \phi_1>0$, then
$\alpha_1=\(1 - \displaystyle\frac{|s_1| }{\hat s_1}\)\cos\phi_1\ge 0$, and hence
$|s_1|\le \hat s_1$.
If $\cos\phi_1=0$, then $\sin\phi_1=\pm 1$, $\hat s_1=r$ and
$(\alpha_1,\alpha_2) = (0,\sin\phi_1 (1-|s_1|r))$
so that the parametric equation of
the boundary of $W(A)$ in (\ref{para}) becomes
$$x+iy = |s_1| \cos\theta
+ i ( \sin\phi_1 (1-|s_1|r)\ + |s_1| r\sin\theta)\,.$$
Since $w(A)=1$ and $\sin\phi_1=\pm 1$, for all $\theta\in [0,2\pi)$ , we have
\begin{eqnarray*}
0 &\le& 1 - \[(|s_1| \cos\theta)^2+(\sin\phi_1 (1-|s_1|r)
+ |s_1| r\sin\theta)^2 \]\\
&= &1- \[ |s_1| (1-\sin^2\theta) +(\pm (1-|s_1|r)
+ |s_1| r\sin\theta)^2 \]\\
&= &1- \[ |s_1|^2 (1-(\pm 1\mp(1\mp\sin\theta))^2) +( 1-|s_1|r(1\mp
\sin\theta))^2 \]\\
&= &1- \[ |s_1|^2 ( 2(1\mp\sin\theta) - (1\mp\sin\theta)^2) + 1-2|s_1|r(1\mp
\sin\theta)+ |s_1|^2r^2(1\mp
\sin\theta)^2 \]\\
&= & 2|s_1|(r-|s_1|)(1\mp\sin\theta)+(1-r^2)|s_1|^2(1\mp
\sin\theta)^2 .
\end{eqnarray*}
Therefore, $(r-|s_1|)\ge 0$, which gives $|s_1|\le r=\hat s_1$.
\medskip
Now, we show that our {\bf claim} holds with
\begin{equation}\label{a0a1}
A_0=e^{i\phi_1}I \qquad \hbox{ and } \qquad A_1 = i(1-r^2)\sin\phi_1I+\nu_1 \hat s_1 C,
\end{equation}
where $\nu_1 =1$ if $s_1\ge 0$ and $\nu_1 =-1$ if $s_1< 0$.
Note that
$W(A_1)$ is the elliptical disk with boundary
$\{ \hat s_1 \cos \theta + i[(1-r^2) \sin\phi_1+ \hat s_1r\sin\theta): \theta \in [0, 2\pi)\}$,
and for every $\theta\in [0, 2\pi]$, we have
\begin{eqnarray*}
&&(\hat s_1\cos \theta)^2+((1-r^2)\sin\phi_1+\hat s_1r\sin \theta)^2\\
&=&\hat s_1^2(1-\sin^2 \theta)+(1-r^2)^2\sin^2\phi_1+\hat s_1^2r^2\sin^2 \theta+2\hat s_1r(1-r^2)\sin\phi_1\sin \theta\\
&=&\hat s_1^2 +(1-r^2)^2\sin^2\phi_1+(1-r^2)r^2\sin^2\phi_1 -(1-r^2)\(\hat s_1^2\sin^2 \theta-2\hat s_1r \sin\phi_1\sin \theta+r^2\sin^2\phi_1\)\\
&=&(\cos^2\phi_1+r^2 \sin^2 \phi_1) +(1-r^2)^2\sin^2\phi_1+(1-r^2)r^2\sin^2\phi_1-(1-r^2)(\hat s_1\sin \theta-r\sin\phi_1)^2
\\
&=&1-(1-r^2)(\hat s_1\sin \theta-r\sin\phi_1)^2\\
&\le& 1.
\end{eqnarray*}
Therefore, $w(A_1)\le 1$. By the Assertion, $|s_1| \le \hat s_1$.
Hence
$A=\(1-\displaystyle\frac{|s_1|}{\hat s_1}\)A_0+\displaystyle\frac{|s_1|}{\hat s_1} A_1$
is a convex combination of $ A_0$ and $A_1$.
\medskip
Similarly, if $W(B)$ touches the unit circle at $e^{i\phi_2}$
with $\phi_2\in[-\pi/2,\pi/2]$, then $B$ is a
convex combination of
\begin{equation}\label{b0b1}
B_0=e^{i\phi_2}I \qquad \hbox{ and } \qquad B_1 = i(1-r^2)\sin\phi_2I+\nu_2\hat s_2 C
\end{equation}
with $\hat s_2 = \sqrt{\cos^2\phi_2+r^2 \sin^2 \phi_2}$ and $\nu_2\in\{1,-1\}$.
Let $U = \begin{pmatrix}-r& \sqrt{1-r^2} \cr \sqrt{1-r^2}& r\end{pmatrix}$. Then
$U^*CU=-C$. If $\nu_2 = -1$, we may replace $(A,B)$ by $(U^*AU,U^*BU)$
so that $(\nu_1,\nu_2)$ will change to $(-\nu_1, -\nu_2)$. So, we may further
assume that $\nu_2=1$.
\medskip
By the above analysis,
$AB$ is a convex combination of $A_0B_0, A_0B_1, A_1B_0$ and $A_1B_1$. Since
$w(e^{it}T)=w(T)$ for all $t\in{\mathbb R}$ and $T\in M_n$,
the first three matrices have numerical radius 1.
We will prove that
\begin{equation}
\label{a1b1}
w(A_1 B_1) < 1.
\end{equation}
It will then follow that
$w(AB) \le 1$, where the equality holds only when $A=A_0$ or $B=B_0$.
\medskip
For simplicity of notation,
let $w_1=\sin\phi_1$ and $w_2=\sin\phi_2$. Then
\begin{equation}\label{hats}\hat s_i=\sqrt{1-(1-r^2)w_i^2}\ \mbox{ for }\ i=1,2.
\end{equation}
Recall from (\ref{a0a1}) and (\ref{b0b1}) that $A_1 = i(1-r^2)w_1 I +\nu_1 \hat s_1 C$ and
$B_1 = i(1-r^2)w_2 I + \hat s_2 C$ because $\nu_2=1$. Since $C^2 = (1-r^2)I_2$, we have
$$A_1B_1 = (1-r^2)(u I_2 + iv C),$$
where
$$
u = \nu_1 \hat s_1\hat s_2-w_1w_2(1-r^2)
\quad\hbox{ and } \quad v = w_1 \hat s_2
+\nu_1w_2\hat s_1.
$$
If $r=1$, then $A_1B_1 =0$. Assume that $0<r<1$.
We need to show that
$$
\frac{1}{1-r^2}w(A_1B_1) = w(uI+ivC) < \displaystyle\frac{1}{(1-r^2)}.
$$
Because $W(uI+ivC)$ is an elliptical disk with boundary
$\{u+iv(\cos\theta+ir\sin\theta): \theta \in [0, 2\pi]\}$,
it suffices to show that
$$f(\theta) = |u + iv(\cos\theta + i r\sin \theta)|^2
< \frac{1}{(1-r^2)^2}
\quad \hbox{ for all } \ \theta \in [0, 2\pi].$$
Note that
\begin{eqnarray*}
f(\theta) &=& (u-rv\sin\theta)^2 + (v\cos\theta)^2 \\
&=&u^2-2ruv\sin\theta+r^2v^2\sin^2\theta+v^2(1-\sin^2\theta) \\
&=&\displaystyle\frac{u^2}{1-r^2}+v^2-\(\sqrt{1-r^2}v\sin\theta+\displaystyle\frac{ru}{\sqrt{1-r^2}}\)^2\\
&\le&\displaystyle\frac{u^2}{1-r^2}+v^2\\
&=&\displaystyle\frac{1}{(1-r^2)}\[u^2+(1-r^2)v^2\]\\
&=&\displaystyle\frac{1}{(1-r^2)}\[ (\nu_1 \hat s_1\hat s_2-w_1w_2(1-r^2) )^2+(1-r^2)(w_1 \hat s_2+\nu_1w_2\hat s_1)^2 \]\\
&=&\displaystyle\frac{1}{(1-r^2)}\[ \hat s_1^2\hat s_2^2+w_1^2w_2^2(1-r^2)^2 +(1-r^2)
(w_1^2 \hat s_2^2+ w_2^2\hat s_1^2)\]\quad
\mbox{because }\nu_1=\pm 1 \\
&=&\displaystyle\frac{1}{(1-r^2)}\[ (\hat s_1^2+ (1-r^2) w_1^2)( \hat s_2^2 +(1-r^2) w_2^2)\]\\
&=&\displaystyle\frac{1}{(1-r^2)}\hskip 3.25in \ \mbox{ by (\ref{hats})} \\
&< &\displaystyle\frac{1}{(1-r^2)^2}\hskip 3.25in \ \mbox{because }0<r<1.
\end{eqnarray*}
Consequently, we have $w(A_1B_1)<1$ as asserted in (\ref{a1b1}).
Moreover, by the comment after (\ref{a1b1}), if
$w(AB) = w(A)w(B)$, then $A = A_0$ or $B = B_0$.
Conversely, if $A = A_0$ or $B_0$, then we clearly have $W(AB) = w(A)w(B)$.
The proof of the theorem is complete. \hfill $\Box$\medskip
\bigskip\noindent
{\bf Acknowledgment}
We would like to thank Professor Pei Yuan Wu, Professor
Hwa-Long Gau, and the referee for some helpful comments.
Li is an affiliate member of the Institute
for Quantum Computing, University of Waterloo, and is an
honorary professor of the
Shanghai University. His research was supported by USA
NSF grant DMS 1331021, Simons Foundation Grant 351047,
and NNSF of China Grant 11571220.
| {
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The Glendale Police Department is searching for a male wanted for assault on a police officer in the area of Foothill between Boston and Lowell. Male is described as wearing a blue flannel shirt and black pants with a torn or missing right pant leg.
Chamlian Armenian School located on Lowell is on lock down.
Lock your doors. A perimeter has been established. Call 911 if you see a male or any suspicious activity. Male is not believed to be armed. | {
"redpajama_set_name": "RedPajamaC4"
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<?xml version="1.0"?>
<ruleset name="geolid">
<config name="installed_paths" value="vendor/object-calisthenics/phpcs-calisthenics-rules/src/,vendor/wp-coding-standards/wpcs/,vendor/escapestudios/symfony2-coding-standard/Symfony/,vendor/slevomat/coding-standard/"/>
<description>geolid ruleset</description>
<!-- Private methods MUST not be prefixed with an underscore -->
<rule ref="PSR2.Methods.MethodDeclaration.Underscore">
<type>error</type>
</rule>
<!-- Private properties MUST not be prefixed with an underscore -->
<rule ref="PSR2.Classes.PropertyDeclaration.Underscore">
<type>error</type>
</rule>
<rule ref="PSR12.Operators.OperatorSpacing" />
<rule ref="PSR12.Keywords.ShortFormTypeKeywords" />
<rule ref="Symfony.NamingConventions.ValidClassName" />
<rule ref="Symfony.NamingConventions.ValidClassName.InvalidAbstractName">
<exclude-pattern>*TestCase.php</exclude-pattern>
</rule>
<rule ref="SlevomatCodingStandard.TypeHints.DeclareStrictTypes">
<properties>
<property name="newlinesCountBetweenOpenTagAndDeclare" value="2"/>
<property name="spacesCountAroundEqualsSign" value="0"/>
</properties>
</rule>
<!--TODO : remove when phpcs-psr12 is in master -->
<rule ref="SlevomatCodingStandard.Classes.ClassConstantVisibility"/>
<rule ref="SlevomatCodingStandard.Functions.RequireTrailingCommaInCall"/>
</ruleset>
| {
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} | 7,145 |
Styraconyx kristenseni är en djurart som tillhör fylumet trögkrypare, och som beskrevs av Jeanne Renaud-Mornant 1981. Styraconyx kristenseni ingår i släktet Styraconyx och familjen Halechiniscidae.
Underarter
Arten delas in i följande underarter:
S. k. kristenseni
S. k. neocaledonensis
Källor
Externa länkar
Trögkrypare
kristenseni | {
"redpajama_set_name": "RedPajamaWikipedia"
} | 9,127 |
Home Prince George of Cambridge James Middleton reveals why Christmases with Pippa and Kate are so special
James Middleton reveals why Christmases with Pippa and Kate are so special
It sounds like a big family get-together
James Middleton reveals why Christmases with Pippa and Kate are so special Photo C GETTY
Deciding where to spend Christmas is an ongoing dilemma for most families, including the Duke and Duchess of Cambridge, who usually split their time between Sandringham Palace with the royal family and Berkshire with Kate's family. In an interview on German TV channel, Leute Heute, the Duchess's brother James Middleton has revealed his excitement about spending Christmas with the whole family this year and welcoming others into their home, which suggests that Kate, William and their three children will spend the festive season at the Middleton home, along with Kate's sister Pippa, her husband James Matthews and their baby boy Arthur.
James explained: "I welcome people into our family home," before adding: "I want it to feel like it's their home." Describing what the Middleton Christmas is like, he said: "There'll be turkey, champagne and some wine.." then continued: "For me it's all about family… It's one where we can all regroup." To make things even more special, it will be the first Christmas for Kate's youngest son Prince Louis, and Pippa's newborn son Arthur.
The Middletons at Christmas Photo C GETTY
Traditionally, Kate and William spend 23 December at their own residence in the Queen's Sandringham Estate, Anmer Hall, just down the road from the 'big house'. Last year, they welcomed Prince Harry and Meghan Markle into their home for the festivities, which was Meghan's first Christmas spent with the royals. With Harry and Meghan recently married, along with the announcement of their first baby on its way, it looks like decisions about where to spend Christmas are set to become more complicated for the young royals!
Source: HELLO MAGAZINE
Previous articleThe Crown cast recreate extraordinary moment Charles became Prince of Wales – see photo Fans don't have too long to wait
Next articleYou might be surprised by the story behind one of Prince William and Kate's iconic engagement photos | {
"redpajama_set_name": "RedPajamaCommonCrawl"
} | 8,260 |
package org.apache.nifi.toolkit.cli.impl.result.writer;
import java.io.PrintStream;
/**
* A writer capable of printing a table to a stream.
*/
public interface TableWriter {
/**
* Writes the given table to the given PrintStream.
*
* @param table a table to write
* @param output the stream to write to
*/
void write(Table table, PrintStream output);
}
| {
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} | 8,137 |
Q: Delete rows from a table with not in ( another table ) I have two tables A and B, in the B there is a foreign key from A, what I want to do is to delete all the rows from A that they don't have an occurrence in B, I execute the following query but it's not working :
DELETE from A
WHERE id_A
not in (select DISTINCT(foreign_key_of_A_in_B) from B)
Any idea ?
A: My first recommendation is to try not exists rather than not in:
DELETE a FROM a
WHERE NOT EXISTS (SELECT 1 FROM b WHERE b.foreign_key_of_A_in_B = a.id_A);
NOT IN returns false or NULL if any value in the subquery is NULL. That is how the operator is defined. NOT EXISTS has more expected behavior. So, if you have any NULL values in the subquery, this will work (i.e. delete rows) but the NOT IN version will not.
I would recommend that you try the logic out using SELECT before doing a DELETE:
SELECT A.*
FROM A
WHERE NOT EXISTS (SELECT 1 FROM b WHERE b.foreign_key_of_A_in_B = A.id_A);
A: A standard for DELETE FROM table WHERE id NOT IN would look like this:
DELETE from Table_A
WHERE id -- ID of Table_A
not in (select ID FROM Table_B)
This should find the IDs not in Table A from Table B, as your question states
Try this in a SELECT statement first to see if it returns the correct rows:
SELECT * from Table_A
WHERE id -- ID of Table_A
not in (select ID FROM Table_B)
Don't forget to cross-reference some rows to double check.
| {
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{"url":"https:\/\/brilliant.org\/problems\/how-to-perfect-the-bottle-flip\/","text":"# How to perfect the bottle flip?\n\nA lot of skill goes into whether you can achieve a bottle flip. But with a bit of physics, you can maximize your chances by optimizing the volume of water in the bottle. Over- or under-filling the water bottle yields a high center of gravity, which can cause the bottle to tip over on landing, even if the throw is otherwise perfect. To stabilize the bottle's landing, the center of gravity should be as low as possible.\n\nTreat an empty water bottle as a cylinder with mass $$\\SI{12}{\\gram}$$ evenly distributed along its length. What is the water level $$h$$ in centimeters such that the bottle's center of gravity is lowest?\n\nNote: The density of water is about $$\\SI[per-mode=symbol]{1}{\\gram \\per \\centi \\meter \\cubed}.$$\n\n\u00d7","date":"2019-03-20 20:28:30","metadata":"{\"extraction_info\": {\"found_math\": true, \"script_math_tex\": 0, \"script_math_asciimath\": 0, \"math_annotations\": 0, \"math_alttext\": 0, \"mathml\": 0, \"mathjax_tag\": 0, \"mathjax_inline_tex\": 0, \"mathjax_display_tex\": 1, \"mathjax_asciimath\": 0, \"img_math\": 0, \"codecogs_latex\": 0, \"wp_latex\": 0, \"mimetex.cgi\": 0, \"\/images\/math\/codecogs\": 0, \"mathtex.cgi\": 0, \"katex\": 0, \"math-container\": 0, \"wp-katex-eq\": 0, \"align\": 0, \"equation\": 0, \"x-ck12\": 0, \"texerror\": 0, \"math_score\": 0.18054182827472687, \"perplexity\": 512.7059815112083}, \"config\": {\"markdown_headings\": true, \"markdown_code\": true, \"boilerplate_config\": {\"ratio_threshold\": 0.18, \"absolute_threshold\": 10, \"end_threshold\": 15, \"enable\": true}, \"remove_buttons\": true, \"remove_image_figures\": true, \"remove_link_clusters\": true, \"table_config\": {\"min_rows\": 2, \"min_cols\": 3, \"format\": \"plain\"}, \"remove_chinese\": true, \"remove_edit_buttons\": true, \"extract_latex\": true}, \"warc_path\": \"s3:\/\/commoncrawl\/crawl-data\/CC-MAIN-2019-13\/segments\/1552912202450.86\/warc\/CC-MAIN-20190320190324-20190320212324-00451.warc.gz\"}"} | null | null |
Q: c# JSON Serialization Use Value Instead of Property Name I am working on a JSON driven project and I would like to provide the SessionManager object with a dynamic list of permissionst. While I can work with an array of key value pairs for permissions, I was wondering if I could remove the property names so that the key is the Permission value and the value is the IsAllowed value.
public class SessionPermission
{
public string Permission { get; set; }
public bool IsAllowed { get; set; }
}
public class SessionManager
{
public string UserName { get; set; }
public string Password { get; set; }
public List<SessionPermission> Permissions { get; set; }
public void SetPermissions()
{
Permissions = new List<SessionPermission>
{
new SessionPermission {Permission = "CreateUsers", IsAllowed = false},
new SessionPermission {Permission = "EditUsers", IsAllowed = false},
new SessionPermission {Permission = "EditBlog", IsAllowed = true}
};
}
}
When I generate JSON it outputs an array of permissions:
{
"Permission": "CreateUsers",
"IsAllowed": false
},
I would like to know how to override the serialization so that it uses the values instead of the property names.
{
"CreateUsers": false
},
A: You could use the following custom converter:
public class SessionPermissionConverter : JsonConverter
{
public override object ReadJson(
JsonReader reader,
Type objectType,
object existingValue,
JsonSerializer serializer)
{
var obj = (JObject)JObject.ReadFrom(reader);
JProperty property = obj.Properties().FirstOrDefault();
return new SessionPermission
{
Permission = property.Name,
IsAllowed = property.Value.Value<bool>()
};
}
public override void WriteJson(
JsonWriter writer,
object value,
JsonSerializer serializer)
{
SessionPermission permission = (SessionPermission)value;
JObject obj = new JObject();
obj[permission.Permission] = permission.IsAllowed;
obj.WriteTo(writer);
}
public override bool CanConvert(Type t)
{
return typeof(SessionPermission).IsAssignableFrom(t);
}
public override bool CanRead
{
get { return true; }
}
}
Usage:
var manager = new SessionManager();
manager.SetPermissions();
string json = JsonConvert.SerializeObject(manager, new SessionPermissionConverter());
Sample JSON:
{
"UserName": null,
"Password": null,
"Permissions": [
{
"CreateUsers": false
},
{
"EditUsers": false
},
{
"EditBlog": true
}
]
}
It should work fine going the opposite way as well.
Example: https://dotnetfiddle.net/mfbnuk
| {
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Artashes Emin (, born January 4, 1961, in Yerevan) is an Armenian translator, essayist, member of Writers Union of Armenia, International Association of Conference Interpreters (2005), Armenian Conference Interpreters Association (ACIA), Armenian P.E.N. Centre, Oral History Association. Merited Artist of Armenia (2015), who served as Honorary Consul of Canada in Armenia from 1997 to 2019.
Biography
Born in the family of poet Gevorg Emin, he graduated from Yerevan State University's Faculty of Romance and Germanic Philology (cum laude) in 1982, completing post-graduate studies in 1986 as a doctoral candidate in comparative literature. At YSU he was the director of the William Saroyan Heritage Centre from 1986 to 1992. In 1992 he became the bureau manager of the Canadian Representation in Armenia. Lectured at the University of Michigan and Harvard University under the Fulbright Program from 1994 to 1995. Upon his return to Armenia he founded Babylon Interpretation Agency in 1996 which specializes in providing simultaneous interpreters. Appointed as honorary consul of Canada to Armenia in 1997, maintaining that role until 2019. Served as the general secretary of the Armenian P.E.N. Centre from 1990 to 1998. Graduated as a Master of Law from American University of Armenia, School of Law in 1999. He was one of the victors on the popular Russian-language intellectual game show What? Where? When? during the March 27, 2010 episode.
Work as interpreter
Since 1988 provided simultaneous interpretation between Armenian, English and Russian for numerous international institutions (sampling): Council of Europe, IMF, PACE, European Commission, European Parliament, OSCE, UNDP, UNHCR, UNICEF, UNFPA, FAO, WFP, WHO, OXFAM, OCHA, Fitch Ratings, Standard & Poor's, PricewaterhouseCoopers, Ernst and Young, Central Bank of Armenia, Federal Reserve System, Central Bank of Russia, Amnesty International, Transparency International, FBI, GIGN, NATO, DTRA, IAEA, ISTC, Deloitte and Touche, Armenian Academy of Sciences, Philip Morris, BMW, Pernod Ricard, Hublot, LVMH, US Department of State, USA Today, World Customs Organization, FIDE, Asian Development Bank, World Wildlife Fund, American Bar Association, Eurasia Foundation, EBRD, Catholic Relief Services, IREX, World Council of Churches, HALO Trust, Peace Corps, World Vision, HSBC, UNESCO, Basel Committee on Banking Supervision, Smithsonian etc.
During this period he interpreted a variety of interdisciplinary topics on Chemistry, Genetics, Ophthalmology, Neurology, Neurosurgery, Cardiology, Pediatrics, Urban Planning, Post-Modernism, Roman Baroque Art, Genocide Prevention, Criminal Justice, Renewable Energy, Innovation, Internal audit, Seismology, Ecumenism, Disaster Risk Reduction, etc.
List of published works
English to Armenian
Edgar Allan Poe, Nightmares and Slumbers (tales), Yerevan, Sov. Grogh. 1983;
George Orwell, Animal Farm, Yerevan, Apollon, 1991;
William Golding, Lord of the Flies, Pincher Martin, Yerevan, Sov. Grogh. 1990;
William Saroyan, Plays, short stories and memoirs in Selected works in IV vols. Yerevan, Sov. Grogh. 1987–91;
Arthur Miller, Death of a Salesman, in 20th century drama, vol. III, Yerevan University Press 1992;
Diana Der Hovanessian, Inside Green Eyes Black Eyes (poems), Yerevan, Sov. Grogh. 1986;
Harold Pinter's The Lover
To be published in 2020:
Thomas Pynchon, Gravity's Rainbow, Yerevan, Antares
Thornton Wilder, The Bridge of San Luis Rey, Yerevan, Antares
River of Names, A collection of 26 American Short Stories, Yerevan, Antares
English to Russian
Trevanian, Shibumi, Yerevan, Urartu #138-160, 1995–1996;
Trevanian, Hot Night in the City, Yerevan, Hairapet 2011
Jack Hashian, Mamigon, Moscow, Prestige Books 2018
Armenian to English
Nairi Zarian, Davit of Sassoun, Yerevan, Hairapet 2012
Russian to English
Platon Zubov, The Astrologer of Karabagh, ACF, Arlington 2012
References
Armenian translators
1961 births
Living people
Literary translators
Yerevan State University alumni
Writers from Yerevan | {
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} | 9,085 |
Glenn Drover's Empires: The Age of Discovery is the first of the Glenn Drover's Empires board games, created by Glenn Drover.
Age of Empires III: The Age of Discovery
The first game in the series is based on the video game Age of Empires III, and was originally titled Age of Empires III: The Age of Discovery before being renamed to Glenn Drover's Empires: The Age of Discovery in 2011 following the loss of the naming rights to the Age of Empires series. It was originally published in 2007 by Tropical Games, and is currently distributed by Drover's own publishing company, Eagle Games. The game may be played by up to five players, though pieces for a sixth player were available in limited supply, and are included in the Builders Expansion, released in 2011 along with the renaming of the series.
Gameplay
Like the video game, each player takes on the role of a major European power attempting to discover the Americas - according to the game's manual, the five player colors represent England, France, Spain, Portugal, and Holland (the identity of the sixth nation for the limited-release sixth player pieces were not stated, though the Builders Expansion, which also adds a sixth player, has Italy as the identity of the sixth player). Though the nations are otherwise undifferentiated in the base game, the Builders Expansion adds National Advantages for each nation, which allows players certain special privileges that apply over the course of the game.
The Americas are divided into nine regions, each of which being associated with a particular trade good (there are also two trade goods not associated with any region). At the start of the game, only one of the nine regions are discovered, and discovery tiles are placed face-down in each of the eight other regions.
Each player begins with a small supply of money as well as colonists. The game is played over eight turns, with the first three turns referred to as "Age I", the next three as "Age II", and the final two turns as "Age III". At the start of each turn, players must place their colonists in any number of event boxes, taking turns until every player has placed their colonists. Afterwards, each event box is resolved in a prescribed order. The turn ends with each player collecting resources.
Events are resolved in the following order:
Initiative, which alters the order in which players place their colonists in later turns as well as awarding a small amount of money.
Colonist Dock, which moves colonists played there to regions of the board that already have been discovered.
Trade Goods, which earn the player trade goods. Trade goods may also be earned if a player is the first to have three colonists in a region, or by the effects of capital buildings. Trade goods provide a fixed income for each player, awarded at the end of each turn, by arranging them in sets. Sets may be freely rearranged to optimize the amount of money earned.
Merchant Shipping, which allows players to earn merchant ships if they have the most colonists there. Merchant ships count as "wild cards" for the purposes of set arrangement with trade goods, though no set may use more than one merchant ship.
Capital Building, which allows players to purchase capital buildings. Five capital buildings are available for purchase each turn, and capital buildings are divided by age, with each capital building being only purchasable in their corresponding age. Capital buildings may either grant a one-time benefit or a lasting benefit.
Discovery, which allows players to discover new regions. When players attempt to discover new regions, players must commit a number of colonists to the discovery of an area. Should the number of colonists exceed the defense value of the region (represented by Native American symbols), the region is considered discovered, and the player may place one colonist in the newly discovered region. Should the discovery fail, however, any colonists committed to the discovery are lost. Discovery of regions award the player a certain amount of money. Once all nine regions of the board are discovered, players may continue to assign colonists to Discovery, except that a separate Discovery Card deck is used. Cards in the Discovery Card deck represent regions outside of the Americas that have been discovered, but no colonists are assigned there should a discovery attempt succeed. Players may only make one discovery attempt per turn.
Specialists, which allow a player to use a specialist for the following turn. Specialists are colonists which give extra benefits when assigned to specific tasks - for example, a captain, when assigned to Discovery, counts as two colonists, while a soldier may be deployed to defend colonies. There are four types of specialists, and only five specialists (one of each, plus one additional one) may be trained at any given turn (though the second specialist of a particular type requires an additional monetary cost). The Builders Expansion adds a fifth type of specialist to the game.
Warfare, which allows players to attack opposing colonists that have been placed on the board. Players may either declare small-scale battles against another player in any one region, which is free, or declare a full-scale war against another player, which costs money but applies for every region where both players have colonists. When battling in a region, each soldier in a colony eliminates one opposing colonist.
With the exception of colonists that are sent to the Colonist Dock or are on Discovery, colonists are returned to a player's supply at the end of the turn.
At the end of the each age, players earn victory points based on the number of colonists in each region. For each region, the player with the most colonists is awarded six points, while the player with the second most is awarded two points. If two players tie for the most, both players are awarded two points. If more players tie for the most, or players tie for the second most, all tied players do not receive any points. At the end of the game, points are also awarded for the player's final-turn income, discovery tiles and discovery cards earned by the player over the course of the game, as well as for certain capital buildings which award points. Players playing with the Builders Expansion may also choose to purchase victory points for money at the end of each age. The player with the most victory points wins.
Reception
The Age of Empires III board game won the Origins Award for Historical Board Game of the Year of 2007.
Glenn Drover's Empires: Builder Expansion
It is an Age of Empires III: The Age of Discovery expansion. Changes include the addition of Builder specialist type, 20 new capital buildings, a rules sheet with the new Builder Rules, Capital Buildings, and even special rules for a historical start (Each Nation has a special ability and one or two Capital Buildings to start the game); incorporation of Mint and Overpopulation, expand the game to support 6 players with complete set of purple colonists.
Glenn Drover's Empires: Age of Discovery
It is a redesign of Age of Empires III: The Age of Discovery, Empires: Builder Expansion following the loss of the naming rights to the Age of Empires series. The game included Empires: Builder Expansion along with its capital buildings.
Upgrade pack version also exists for owners of Age of Empires III: The Age of Discovery and Glenn Drover's Empires: Builder Expansion. Metal coins edition includes GDE:AOD, 100 metal replicas of gold and silver doubloons, free Ottoman Board, 4 Capital Buildings. Deluxe Edition BUNDLE includes GDE:AOD and 3 Player Expansions (Denmark, Prussia and Ottoman Boards & Pieces), World Map Variant Tiles (17 Trade Goods - 4 Types and 10 Capitals, 4 Bonus Capital Buildings, 3 Double-sided Player Reference Guides, 1 Additional 50 page (double-sided) Score Pad, 100 Metal Coins instead of Plastic Coins.
Deluxe editions of the game include Plague Promo Capital Buildings cards (Age 1 Plague Building, Age 2 Plague Building, Age 3 Plague Building).
Development
The game was started out as a Kickstarter funding campaign. The board game was published after receiving $207,936 from 1527 pledges, with lifetime funding reaching the 24 Stretch Goals (up to 210K Ottoman Empire player board) at $241,958. The $250K goal item (EAOD World Variant map), which fell short of the funding goal, is included with Deluxe Edition of the board game.
Glenn Drover's Empires: The Age of Discovery - Bonus Capital Buildings
It is an expansion of Glenn Drover's Empires: The Age of Discovery with four new Capital Buildings:
Conquest of the Aztec Empire - Age I
Spice Trade - Age II
Colony in India - Age III
Independence - Age III
References
External links
Eagle-Gryphon Games page: GDE:BE, GDE:AOD-DE, GDE:AOD-PEB
Age of Empires
Board games about history
Board games introduced in 2007
Eagle Games games
Origins Award winners | {
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