Forget the Fear of Food: The Essential Guide (Need2Know Books Book 127)

---

Disappointingly there was only one paper that measured weight loss as a result of exercise Klam et al The study by Warren et al attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies. Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise Schwee et al Several qualitative studies found that people exercised in order to manage and control their weight.

Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind — namely second generation antipsychotics Hodgson et al Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al reported empirical information on this.

Klam et al described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by Cullen and McCann highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise.

However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording Warren et al ; Usher et al ; Scheewe et al The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff.

An important aspect of personal recovery highlighted, is personalised, individualised care.

Amazon Kindle Ebook Forget The Fear Of Food The Essential Guide Need2know Books Book 127 Pdf

The significance of peer support was a key finding, as was staff exercising with service users. The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women.

Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available. The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual.

The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise. The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness.

The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life. This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms.

Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope. The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals. The DH state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment.

Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves.

If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences.

Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs.

The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind Mental Health Foundation It appears to play a key role as one of the positive effects of exercise. NICE suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink c also recommend the use of peers to aid personal recovery.

In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place. For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed. The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship.

Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole Happell et al If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs. However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind.

The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research Rose et al Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses.

Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects Bental ; Moncreiff This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice.

There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise. The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice.

Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise.

Psychology of Sport and Exercise. Carless, D and K. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. International Journal of Mental Health Nursing. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland.

Journal of Psychiatric and Mental Health Nursing. No health without Mental Health. Atypical Second Generation Antipsychotics. Priorities for Essential Change in Mental Health. Moving More, Living More. Exploring the benefits of an exercise program for people with schizophrenia: Archives of General Psychiatry.

Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service. Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing.

Preventing type 2 diabetes: Psychosis and schizophrenia in adults: Psychosis and schizophrenia in adults.

Promoting healthy eating, physical activity and smoking cessation. Qualitative Research Methods Series. Metastudy of Qualitative Health Research. A report by the Schizophrenia Commission. Evidence-based practice in psychiatric and mental health nursing: Journal of the American Psychiatric Nurses Association.

Lifestyle and healthy outcome in physical education. Development of a lifestyle intervention program for people with severe mental illness. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry. Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems. Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Using exercise to treat patients with severe mental illness.

A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. Existential Counselling and Psychotherapy in Practice. Individual Therapy in Britain, edited by W. Exercise program adherence using a 5 kilometer 5K event as an achievable goal for people with schizophrenia. Biological Research for Nursing. There are currently unprecedented levels of demand on urgent and emergency care throughout the UK University of Sheffield Medical Care Research Unit ; Agarwal et al, ; NHS England , with ED attendances and ambulance call outs increasing consistently every year Nelson ; Newton et al, In doing so, this paper also aims to demonstrate the fundamental connection between ED and ambulance services, and how their performance is mutually dependant on one another.

Twenty-seven articles were included for review and four broad themes were identified; Definition of Terms, Patient Factors, Access to Healthcare and Healthcare Frameworks. A high number of diverse and complex contributors to inappropriate emergency department ED attendance and ambulance use were identified.

PL Magazine August by DCMedia - Issuu

Whilst some patient factors contributed towards this issue, problems with wider healthcare frameworks and organisational behaviours were significantly more abundant in reviewed literature. Fragmentation of services may be creating barriers to alternative care services to both patients and clinicians attempting to make referrals. Strategies to improve appropriate use of healthcare should focus on enhancing the way in which services work together.

A systematic search was performed using an adapted methodology from Moher et al Additional keywords derived from iterative searches were added to search terms until appropriate saturation of results had been achieved. Articles were critically analysed using a tabular matrix adapted from LoBiondo-Wood and Haber Research conducted outside of the UK was excluded due to the internationally unique framework of the National Health Service. The exception to this was material considered in systematic reviews, where articles were included as long as they were written in the UK.

Articles which focused solely on self-presentation at the ED, or which did not make any explicit differentiation between routes of attendance were also excluded. Material focusing upon paediatrics or specific medical complaints was excluded, with the exception of falls, and frequent users. Articles that did rigorously establish objectivity showed variation in their presented views. The University of Sheffield Medical Care Research Unit highlights significant inconsistency in defining appropriateness throughout healthcare research. Furthermore, Jones and Booker, Simmonds and Purdy argue that appropriateness is almost exclusively defined retrospectively by healthcare staff.

However, whilst there exists significant challenges in objectively defining inappropriate use, clarification on what this looks like is crucial in aiding clinicians to identify and reduce it in real terms. Further research in this area would be beneficial in providing clearer guidelines for prehospital clinicians when dealing with potentially inappropriate use. A significant proportion of extracted themes related to subjective factors influencing individual patient behaviour. However, this research was externally peer-reviewed, and several further articles provide consensus on this finding Agarwal et al, ; University of Sheffield Medical Care Research Unit ; Edwards et al, Conversely however, a literature review by Sheffield University University of Sheffield Medical Care Research Unit highlights that misconceptions of symptoms can potentially cause inappropriate delay or refrain from contacting emergency services.

Whilst the aforementioned makes no analysis of the ratio between inappropriate contact and non-contact, Kirkby and Roberts suggest that the majority of inappropriate classification occurs when no ambulance is required. Atenstaedt et al demonstrates the effectiveness of targeted campaigns in improving patient knowledge and reducing inappropriate attendance, however provides no cost-analysis of these strategies.

Perhaps a cost-effective opportunity exists for the ambulance service to deliver this type of patient education to inappropriate users. The ambulance service has previously demonstrated high levels of success in bringing health campaigns to public awareness Association of Ambulance Chief Executives Similarly three articles considered interpersonal factors such as relatives and carers in the decision-making process. They found that informal carers often experienced feelings of responsibility and helplessness, prompting them to take the least risky course of action.

In addition, risk-minimising behaviour was noted in patients themselves, who often felt pressured by what friends and family might think, regardless of their actual presence. The Association of Ambulance Chief Executives outlines similar risk-averse behaviour from staff in care homes, however primarily driven by misconceptions of organisational responsibility. In many cases this is dependant on patient and carer confidence managing minor ailments and long-term conditions. Interpersonal factors can significantly influence subsequent use of ambulance services, and therefore should be considered by the prehospital clinician when attending an incident.

In addition, clinicians should be aware interpersonal pressures when assessing patient wishes and when making best interest decisions. The Keogh Review NHS England identifies that the patient demographics most likely to benefit from alternative healthcare support are those least likely to be aware of it, prompting increased inappropriate dependence on urgent services. Several articles studied the effect of patient demographics on healthcare usage.

Whilst Kirby and Roberts found no statistically significant factors in their research, Dent, Hunt and Webster found that frequent ED attenders were more likely to be male, with a mean age of In a systematic review, Scott et al finds several concurring articles identifying frequent users as predominantly male. Despite some potential bias introduced from a single initial reviewer, established methodology and quality analysis is employed.

Edwards et al and Smith and McNally both agree that elderly demographics can make up a significant portion of inappropriate and frequent users. However, Scott et al found highly mixed evidence in regards to patient age, and only one limited study suggesting that frequent use increased with age. The majority of evidence suggests that inappropriate users are heterogeneous, presenting for a variety of health and social reasons Edwards et al, ; Scott et al, However, this research was limited by a small sample size at risk of self-selected participant bias Lavrakas Whilst there exists conflicting views regarding geographical influence on appropriate healthcare use, there is an overwhelming consensus of evidence suggesting social deprivation contributes towards inappropriate and frequent use of urgent services.

Healthcare campaigns have demonstrated success when socioeconomically targeted Atenstaedt et al, , and strategies by ambulance services to manage inappropriate use appear well advised to be initially targeted at economically deprived areas. Several articles discuss patient access to community services as an influencing factor of avoidable ED attendance and inappropriate ambulance use.

The Keogh Review NHS England highlights significant variation in GP service satisfaction levels nationally, with systemic fragmentation of community services causing further access issues. This is supported by Agarwal et al , which found GP access issues to be a consistently reoccurring theme in patients attending the ED inappropriately. This might explain why in highly rigorous, mixed-method action research, Endacott et al found that inappropriate ED attendances increased dramatically during OOH periods. If barriers to community care increase rates of inappropriate ambulance and ED usage, this has significant implications for ambulance services in analysing patterns of demand and managing response levels geographically and at different time periods NHS Office of Strategic Health Authorities Indeed, Turner et al outlines the potential for supplier-induced demand, particularly in the area of alternative community services such as NHS The Keogh Review NHS England supports this notion, and furthermore highlights that GP consultations have also been increasing, despite expansion of alternative services.

Therefore the issue may be more related to general demand rather than patient access. This is supported by Edwards et al , which found that frequent use of emergency services was linked to equivalent frequent use of other community services. However, as Patton and Thakore found GP referrals via the ED were associated with lower levels of inappropriateness, it is still reasonable to suggest that better access to GP services could improve avoidable ED admission rates. Paramedic Practitioners are now working more closely in supporting community GP services Association of Ambulance Chief Executives , and therefore perhaps this should be an important focus by ambulance trusts in managing overall demand.

Inversely, ease of access to ambulance and emergency department services was also a reoccurring contributor to inappropriate use of these channels. Patton and Thakore surmise that the convenience of an ED providing hour investigations without appointment must significantly influence patient behaviour, however this was not explicitly analysed in their research. Smith and McNally propose a similar rationale for frequent users of urgent and emergency care services, and furthermore speculate a similarity in the behaviour of ED and ambulance users; a view supported by Edwards et al Agarwal et al found confusion over alternative pathways to be a main contributor to patients accessing urgent services inappropriately.

Participants in this research cited familiarity of services, and perception of efficiency over GP services as important influencers on the decision to attend the ED. All articles appeared to demonstrate generally high levels of satisfaction amongst patients utilising ambulance and ED services, putting these services in the predicament of generating increased demand through positive performance. This represents a significant dilemma for the NHS, as these channels are by far the most expensive routes for patients to access health services NHS England In addition to improving the overall profile of the ambulance service within the NHS, the National Audit Office estimates that this would be a significantly more cost-effective response model if configured appropriately.

The Francis enquiry demonstrates how an organisational culture, and clinical behaviours within that culture, can have a significant impact on the quality of healthcare delivered to patients. A large majority of articles considered organisational and clinician factors in relation to inappropriate and frequent use of emergency care. Patton and Thakore demonstrate the potential impact of oversensitive triage from ambulance staff. Whilst a potential bias exists with the duty consultant subjectively assessing appropriateness, reviewers did rotate throughout the study, and rigorous assessment was made using both the ED notes and Patient Report Form PRF.

In addition, Newton et al demonstrates the moderate success of prehospital pathway finders adapted from the Manchester Triage System. However, whilst providing clinicians with support tools may improve confidence, it may be argued that such tools do not address the issue of clinician education, and furthermore may be inappropriate for clinically and socially complex situations. A proposed solution to this may be the implementation of secondary triage systems Eastwood et al, in order to decrease sensitivity whilst maintaining risk management.

However there exists little evidence on the most appropriate structure or benefits of this within a prehospital framework, and further research is warranted. The National Audit Office highlights the importance of multi-service collaboration in reducing overall demand, and the knock on effect when one service becomes congested. Indeed Edwards et al and Smith and McNally both concur that collaborative multi-level interventions are most effective in tackling frequent and inappropriate use, whilst Booker, Simmonds and Purdy call for closer collaboration between primary care and ambulance services.

Whilst this was a relatively small study, this theme reoccurred consistently throughout three individual trusts, suggesting a high level of reliability May However, the National Audit Office highlights a paucity of ambulance trusts adequately collating directories of alternative services, suggesting that the underlying issue may be prehospital awareness, rather than availability. This is furthermore supported by Mason et al , which found that ECPs increased admission avoidance rates, and were most effective in a mobile setting.

However Coates rightly questions the difference between avoided admission and avoided ED attendance, highlighting a paucity of studies differentiating between the two. Since a significant cost difference is applicable, further research in this area should be considered. Reviewed material demonstrates that specialised roles have a significant benefit on admission avoidance, concurring with established literature National Audit Office ; Association of Ambulance Chief Executives However, there is still variability in the deployment of these roles NHS England , and whilst there remains such a heavy prehospital focus on targeted response times over clinical outcomes National Audit Office , it may be argued that specialised prehospital roles cannot be utilised to their fullest potential.

These included availability of diagnostic equipment, availability of remote support and appropriate initial staff deployment. Clinicians also felt that lack of vehicles and resources increased the pressure to reduce on-scene times, prompting them to avoid time-consuming referral pathways. Endacott et al also identifies inconsistencies in ED management of inappropriate attenders. Despite having debatable direct impact on ambulance services, this demonstrates the difficulty of managing inappropriate use in a controlled environment, and suggests greater management complexities in the prehospital setting.

Indeed, Edwards et al outlines the challenges of individual case management for frequent users. In addition, the University of Sheffield Medical Care Research Unit outlines the difficulty of service management across boundaries, and how tensions between local and national policies can negatively affect management proficiency.

This tension is reflected by the National Audit Office , which highlights additional variation between trusts in resource deployment and performance measurement, and limited sharing of best practice. The Keogh Review NHS England demonstrates how variation in service management can lead to patient confusion, significantly reducing appropriate help-seeking behaviour.

It is apparent that national standardisation of service management across ambulance trusts may improve how patients access urgent services. In addition, improving training and resource support for responding clinicians may also significantly increase use of referral pathways. An unexpected finding of this review was the distinct lack of clear definitions outlining what constitutes avoidable attendance and inappropriate use of services. A significant number of articles did not establish how appropriateness was measured, and those that did relied almost exclusively on retrospective opinion.

Few articles subsequently highlighted rationales for concluding that patient behaviour was inappropriate, and those that did mostly presented their rationales narratively through interview extracts Agarwal et al, ; Booker, Simmonds and Purdy Booker, Simmonds and Purdy argue that appropriateness is almost always defined retrospectively by the healthcare professional, which would certainly explain why such a paucity of objective definitions exists.

Furthermore, as demonstrated in this review, a significant number of factors exclusive to individual patients can influence help-seeking behaviour. In this respect, appropriateness is also defined subjectively by the patient. Jones suggests that healthcare providers should seek to improve care options rather than attempt to influence patient help-seeking behaviour. Perhaps services should therefore aim to educate patients through targeted campaigns, whilst simultaneously seeking to better understand patient requirements, and align services accordingly.

Similarly, few articles outlined how admission avoidance was defined. Coates was the only study that explored this in detail, and outlined that non-conveyance of a patient might not necessarily result in an avoided hospital admission, either due to inadequate use of referral pathways or subsequent medical need.

This review has highlighted a universal lack of clarity regarding how successful admission avoidance is measured, and since this assessment is pivotal in evaluating adequate use of pathways, further clarity should be sought by ambulance services. Several factors influencing patient behaviour in the context of inappropriate use were identified. A number of articles highlighted risk-averse behaviours by both patients and carers when dealing with minor illnesses due to misconceptions of condition urgency. In relation to chronic illnesses, patients demonstrated a reluctance to temporise symptoms, and often sought out the most immediate form of assistance.

Material suggested that these behaviours were driven by misconceptions over the seriousness of conditions, in addition to a perceived lack of available alternatives. Sanctioning of help-seeking behaviours by carers and relatives was an additional reoccurring theme, and interpersonal influence was found to exacerbate inappropriate use in most circumstances. Reviewed material demonstrates that patient education, whilst an important consideration, only accounts for a partial driver of patient behaviour. Strategies to reduce inappropriate use should aim to improve patient access to alternative care, whilst also improving education and raising awareness of community services.

Whilst the individual clinician should take caution in stereotyping patients, the implications for wider healthcare services in response management and healthcare promotion appear to be evident.

In relation to healthcare access, two dichotomous issues provide equal contribution to inappropriate use of emergency services. It was furthermore suggested that barriers to non-urgent community care were not limited to patients. Whilst barriers to GP services were not explored in detail in this review, there is reasonable evidence suggesting that demand for these services is also increasing in line with other urgent and emergency care services NHS England A review of current community care paradigms in the UK could be beneficial in establishing whether or not reform is required to meet evolving patient needs.

There has been recent political suggestion that a solution may be found by bringing OOH care into the direct control of ambulance trusts Roberts The importance of multidisciplinary collaboration was emphasised universally across the majority of articles. Fragmentation of healthcare services was unanimously highlighted as a significant contributor to inappropriate ED attendance. The National Audit Office highlights that ambulance trusts are inconsistent in keeping directories of available referral pathways.

There is sufficient evidence to suggest a significant lack of collaboration, both between multidisciplinary services and between local trusts NHS England ; Edwards Since this fragmentation affects so many factors of appropriate use, including patient and clinician behaviour and organisational management, it is reasonable to consider this to be the most significant finding of this review. Further research into the causes of systemic healthcare fragmentation, and proposals for reform should be considered of the utmost importance in addressing increasing demand and appropriate use of NHS services.

Internal healthcare factors were not limited to issues accessing alternative pathways. Oversensitive triage was observed at multiple stages of assessment, due to a combination of organisational and educational factors. Oversensitive telephone triage was also highlighted as a potential contributor to inappropriate ambulance dispatch Turner et al, Studies showed that clinicians with greater experience, and specialised training, demonstrated greater levels of confidence in utilising referral pathways, and subsequently lower levels of over-triage.

If the ambulance service is to continue along its current trajectory establishing itself as a signposting service National Audit Office , further investment must be made in specialised clinical roles and education of staff at all hierarchal levels. Appropriate usage is a poorly defined concept in healthcare, and whilst it may be argued that appropriateness is a subjective term, rationales for defining users as inappropriate are consistently omitted. Healthcare services cannot expect to observe appropriate use of channels without clarification of what this looks like.

Further effort should be made to provide objective guidance to both patients and clinicians. Patient education and socioeconomic status contributed to patient help-seeking behaviour. However, healthcare access and framework issues influenced much of this behaviour. Perceived and tangible barriers to healthcare, combined with situations of perceived urgency, prompted the use of more immediate healthcare channels, contributing heavily to inappropriate use. This was reflected in prehospital clinicians making conveyance decisions. Articles suggested that lack of confidence and organisational support also prompted disproportionately risk-averse behaviour from ambulance staff.

Fragmentation of multidisciplinary services was a superordinate and reoccurring theme throughout this study. In this respect this review has demonstrated the fundamental link, not just between ambulance and ED services, but also between all multidisciplinary healthcare services. This review demonstrates that no single service can thrive in isolation, and that the collaboration of collective services is the most fundamental aspect of improving health services and the way patients access them. Whilst success is dependant upon the collective effort of wider multidisciplinary services, this review has shown the ambulance service to be in an ideal position to influence how patients access care, and how services interact with one another.

Potentially avoidable emergency department attendance: Association of Ambulance Chief Executives. Taking Healthcare to the Patient 2: British Journal of Healthcare Management 20 8: Patients who call emergency ambulances for primary care problems: Emergency Medicine Journal 0: An Introduction to Systematic Reviews, edited by D. Journal of Paramedic Practice 2 4: Ambulance service treat and refer guidelines: Emergency Medicine Journal 32 5: Hospitals struggle to keep up with festive demand. The Impact of frequent attenders on a UK emergency department.

European Journal of Emergency Medicine 17 6: Taking Healthcare to the Patient: Department of Health and Ageing. Commonwealth of Australia Department of Health and Ageing. Professional Issues Affecting Practice. Foundations For Paramedic Practice, edited by A. Secondary triage in prehospital emergency ambulance services: Frequent callers to the ambulance service: Improving emergency care pathways: Emergency Medicine Journal 28 3: Grading quality of evidence and strength of recommendations.

Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: Emergency Medicine Journal 28 1: Fifth Report of Session — Emergency Medicine Journal 29 2: Patients experiences and views of an emergency and urgent care system. Health Expectations 15 1: Avoiding inappropriate paediatric admission: BMC Family Practice 14 4: Immediate Handover — Standard Operating Procedure.

Healthcare and education content from the Mark Allen Group. Age and Ageing 43 2: Issues, Methods and Process. PLoS Med 6 7: Leading the way in clinical effectiveness. Journal of Paramedic Practice 1 7: National Institute for Health and Care Excellence. Methods for development of NICE public health guidance. Health inequalities and population health. Why patients visit emergency units rather than use primary care services. Emergency Nurse 19 1: Clinical navigation for beginners: High quality care for all, now and for future generations: Office of Strategic Health Authorities. A Comparison of Three Methodologies for Identification.

Academic Emergency Medicine 3 3: A system-wide approach to explaining variation in potentially avoidable emergency admissions: BMJ Quality and Safety 23 1: A qualitative study of systemic influences on paramedic decision making: Decision making and safety in ambulance service transitions. Identifying and Avoiding Bias in Research. Plastic and Reconstructive Surgery 2: Reducing inappropriate emergency department attendances: Emergency Medicine Journal 30 6: Improving GP services in England: GP out-of-hours could integrate with ambulances and under Labour.

Royal College of Nursing. Health inequalities and the social determinants of health. Frequent callers to and users of emergency medical systems: Emergency Medicine Journal 31 8: Delivering enhanced safety, productivity and experience: Journal of Paramedic Practice 6 Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: BMC Emergency Medicine 10 2: South East Coast Ambulance Service.

The Importance of External Validity. American Journal of Public Health 98 1: Combining results systematically and appropriately. Impact of the urgent care telephone service NHS pilot sites: BMJ Open 3 Building the evidence base in pre-hospital urgent and emergency care: All student nurses are allocated clinical placements throughout their three year course, in which to develop their practical skills.

In this context, mentor support is provided by practitioners, who have undertaken an approved mentor preparation programme, approved by the regulatory body, the Nursing and Midwifery Council NMC Nursing and Midwifery Council, The Code of Professional Conduct Nursing and Midwifery Council, outlines a responsibility for all registered nurses and midwives, known as registrants, to facilitate the education of learners in clinical practice. I am aware from discussions with students, and overhearing their conversations in the classroom setting that they perceive their placements to vary in quality, with some feeling they have benefitted from very strong, beneficial placements, through to others who do not feel so advantaged educationally.

Having been a student myself, I am fully conversant with the fact that students will compare one placement experience with another and will also discuss their experiences with peers Foster et al. A dedicated team within the university is responsible for the allocation of a broad range of placement experiences community and hospital to all students on a nursing course. Placement learning opportunities vary significantly in context, and it must be noted that no two placement settings are easily comparable. It is important to note the uniqueness of students and mentors, as all have a preferred way in which to teach and learn, and as such this factor must also be considered a significant variable.

In my mind, the key features of a work placement are to provide students with an experience similar to that of qualified status, as placements allow them to immerse themselves into the clinical setting. They are able to practice, under supervision, the skills they have been taught in the classroom setting and to develop their practice in readiness for qualification. Placements should also develop confidence and provide an opportunity to demonstrate competency to mentors.

A dual approach was taken to source literature to support the identification of a suitable research problem. Initially I undertook a systematic search of a number of recognised repositories, using specific search terms and a number of initial inclusion and exclusion criteria to ensure that the literature identified was relevant to my area of focus.

This process proved very fruitful in terms of the quality and quantity of literature identified. Alongside this process, I also undertook what can be classified as a serendipitous search. This involved using my own knowledge of the topic area to ensure that key policy and regulatory documentation was identified, along with material that I currently use within my teaching practice.

I also ensured that I followed up material found in the reference listings of articles I have read. On reflection, although this process goes against the traditional process for systematic literature searching that I am used to, it was extremely beneficial in giving assurance that I had reached saturation point as the majority of literature cited in the articles I was reading had already been covered. This provided confidence that I had not missed any key literature in the field I am focussing upon.

Literature was predominantly included if it originated in the UK, and was published within the last 15 years. Nursing is regulated differently across the globe and mentoring and placement requirements vary depending upon the country you are in. If relevant, literature from overseas was included after careful consideration was given, if it supported the identification of a research problem by offering a perspective that varied from the UK based material. Literature was only included if it originated from credible sources, which for the majority were peer reviewed journals.

The majority of the literature sourced has a firm focus around guidance to mentors, and how to make a placement learning experience as positive as possible. The makeup of the identified literature can also be categorised for significance.

The over-riding majority of identified literature was research based, having undertaken studies examining the experience of learners in practice. This was then published in credible journals. The literature acknowledges that although in placement settings the mentor has a lead responsibility for facilitating education, there are other factors that significantly impact on the overall educational quality of the experience.

For the purpose of this review, a total of 59 articles or sources were read, and a number of key themes were evident. I utilised a matrix as recommended by Oliver Oliver, to summarise each piece of literature and to conduct a mini thematic analysis. Upon saturation being reached, a review of the matrix enabled the identification of a number of themes that were consistent across numerous articles and sources.

The literature that was identified, as previously mentioned, all originated from credible sources — predominantly journals that are widely recognised in the field of healthcare and healthcare education. A critical approach was taken in reading each article, with a particular emphasis around critical analysis to understand what within the source was not being said. As an example, the majority of literature focussed on good examples of placements and an emphasis on positive experiences; there was a lack of literature that specifically examined the impact of negative placement experiences.

The overriding strand that ran throughout the majority of articles was the importance of the learning environment itself Beskine, ; Gopee, ; Stuart, ; Walsh, ; Papp et al. Other key foci of the literature sourced were concerned with examining relationships between mentors and mentee Foster et al.

On reflection, I was surprised that there was a minimal amount of literature with a focus around the support provided by universities to mentors supporting learners in practice Henderson and Eaton, ; Foster et al. Mentoring is recognised as an often challenging role, and for new mentors in particular, supporting students in practice placements can be difficult and could potentially impact upon the experience of the learner. It is only natural that they will perceive differences to exist between one area to the next, and likewise between the educational gain they have identified.

The literature states that students will emulate and role-model qualified staff who they perceive to be good examples of the nursing profession, and will compare staff in one area to the next Beskine, ; Brockbank and McGill, The literature does not highlight that practice varies in terms of standards and the evidence on which it is based, and as such role modelling can be problematic if the practice demonstrated is not current and credible.

Student nurses will naturally expect every placement to be a positive experience, through which they can develop their knowledge and gain a greater understanding of the role of the nurse. The literature covered would agree with this in the main, however an Australian article Green and Jackson, discusses the negative aspects of placements and associated mentoring.

This negative aspect of placements is a weakness in the literature and needs further exploration, as there is a need to explore how student can be prepared to deal with placements that they feel are not conducive to learning and to explore the benefits of being placed in a setting that is not supportive. Refreshingly, Green and Jackson acknowledge that poor mentoring and negative placements do occur regularly in practice, and for a number of reasons.

This paper led me to reflect and think about what was stated within it. Most of the literature reviewed outlines the importance of effective relationships between mentors and students Henderson et al. Theoretically, such an experience sounds very beneficial, and most students would be grateful to progress in such a manner. But is a poor placement also as beneficial to the education process? In my view, it is, as it introduces the student to the complexities of life as a healthcare professional. In reality, shifts as qualified practitioners will be challenging on a regular basis Wallace and Gravells, , and by gaining experience of challenging situations as a student, it assists in the development of building resilience and coping strategies Papp et al.

The university plays a significant part in supporting students in practice Foster et al. All students enter the course from a range of backgrounds many will have previous healthcare experience gained through previous employment in a support role, whilst others commence their nurse training with no previous experience at all. In some cases, this experience can be helpful, as an existing understanding of an area can assist the student to build upon their current knowledge base. The literature discusses in depth the importance of mentors and placement colleagues providing a positive, conducive setting in which all students can thrive and develop their knowledge and skills Beskine, ; Royal College of Nursing, ; Aston and Hallam, Elizabeth, a mobile therapist, said: The book also features illustrations from children at Goosewell Primary School whose parents are in the Armed Forces, as well as short quotes about how they feel.

Elizabeth has two children herself, Mathew, aged six, and Faye, aged three. Her husband cannot be named for safety reasons. I think while he was there we had a reality check and it was hard being pregnant and having him be away somewhere dangerous. It was a tough for us though. Warrior Wives is available from the Royal Marines shop at www. I took it to the Bologna Book Fair in [the largest childrens picture book publishing fair worldwide] as part of my MA. I had a number of interviews set up and one of them was Macmillan Publishers.

They loved it and it all went from there. I think that they were interested in the idea, rather than the story. That was really interesting because we kind of did it all backwards! A lot of my book ideas come from real life. Feature to think about what you liked when you were a child. I asked her to draw lions and families, I spoke to my publisher and they liked the idea of putting them in the book. She took the book into her teachers at school and they were really proud. My nieces are a fountain of inspiration. My first book took two. We were always read to, had trips to the library and were drawing.

There was always something creative to do. At Interseal we offer the very best in quality and price. We specialise in providing high quality products ranging from windows, doors, Bi-folding doors, composite doors and patio doors. We also undertake all design, build and installation for all our bespoke conservatories and porches. All with exceptional energy saving qualities. Provided you are clever in your choices, smaller spaces have the ability to function just as effectively as any other room in the home and look equally stylish, too.

When it comes to deciding on a colour scheme for a smaller space, it is always best to try to keep the backdrop as plain as possible. Steer clear of dark shades and bold, bright colours and instead, stick to paler, neutral tones to enhance the feeling of spaciousness. Pastel shades such as duck egg blue would work well, as would a soothing sage green. In fact, there is a neutral tone of just about every shade on the colour spectrum, so you can still inject your personality into the scheme by picking your favourite!

This, of course, also takes the attention away from the size of the room. One thing to always bear in mind when introducing pattern and colour into a scheme through the use of soft furnishings and accessories is to try not to get too carried away. The best thing about choosing accessories for a small space is that there are plenty of items available that can help to maximise the space in a small room. Take mirrors, for example; they be used as a decorating tool in a room but, when strategically placed, they have the ability to make a space feel larger than it is and also make the most of the natural light a room receives, making them a worthwhile addition to a smaller room.

Not only do they allow you to reflect your own personal tastes, Lesley Taylor is an interior designer, author and full they can also be used to make a small room feel member of the British Institute of Interior Design bigger. For further information, please In a small space, soft furnishings and visit the website at: Emily Smith met her in the studio. The year-old had always dreamed of moving to either the UK or America but never knew what she wanted to do.

Her life is a million miles from growing up in Romania and asking her friends to borrow their clothes. She admits that a Christmas present for her as a young girl was a bag of bananas or oranges - not designer clothes or bags. She died 12 years ago from breast cancer.

I was always amazed at what she could do. When her mother died she applied to become an au pair and was offered the position to move to the UK. Tavistock and fell in love with the style of Sue Radfield, the shop manager. I used to go in there with my little girl and always thought Sue really nice. I decided that I wanted to learn more about style. After leaving school she went on to sell car parts in Romania and had barely used a sewing machine until she enrolled at college. It was a big step for me but it was what I wanted to do.

From the drawing side of things - I had no idea. Romanian gypsies are quite different to the English in terms of what they wear. They wear scarves around their waist with lots of coins on. I worked in a factory in Romania but I was rubbish and only lasted two days then I gave up! She decided she would concentrate on her Romania roots and designed three outfits based on the clothes of Romanian gypsies. There are some things that are wrong but I wanted to bring something amazing from my country into my collection. I would bring that into my work. They have lots of patterns and prints on their skirts which is why I used the bright colours.

The stitching is all zigzagged like a wetsuit. Seaside style has sailed back in for summer. PL shows you how to get on board with coastal chic. But conjuring seaside style at home is easier than ever, no matter how far way from the. Perfect for summer this look is a perennial favourite, and taking the plunge may only mean a lick of fresh paint pick a brilliant white or a bright blue and a few appropriate accessories, such as a sailing boat ornament or a cushion with an anchor emblem. Before you know it, you will be decked out and shipshape. Louise Daniel meets the family behind DT Plastics.

Big-hearted Terry set up the well-loved guttering and fascia business 15 years ago with pal, Dave Beckwith after a long stint at the dockyard and running a pet store. It was no good, I had a young family and there was no money in it. We grew the trade counter side, took on a manager and Dave and I continued the fitting. He leaves that to his sons who he clearly trusts to continue the excellent work he and partner Dave started 15 years ago. I know my own sons do a better job than me! Every year I do something. We must have raised thousands.

I said we will sort the roof problem for you free of charge. Not bad for two lads who started with a van and a tenner! There are French marigolds, pots of wild flowers which attract wildlife, variegated fuchsia, begonia, salvia and petunia. Cornflower, cosmos, euphorbia, poppies, roses, can also be found, as can a miniature.

Margaret, and Pete aged 69, have owned Norwich Stores, just across from their Whitleigh home, for the past four years, and have been married for 47 years. They have three children, seven grandchildren and five great grandchildren with another on the way. The community-minded couple swap seeds with customers and neighbours, and have even encouraged youngsters in the area to plant bulbs. A decking area directly to the back of the house is home to a water feature, toadstool seats and table.

A gravelled section of the garden has a picnic table painted bright pink, complete with a matching parasol, providing shade in this south facing plot. Even the fencing has not escaped a splash of colour with some sections painted blue, providing a contrast against purple. From the patio a path leads to the rear of the garden featuring apple trees which are producing.

Open Mon — Sat 9am — 5. Compact roses with an upright habit are suitable for small gardens where beds are only 1m 40in wide, so choose compact floribundas,. How do we keep our roses blooming? When the flowers of floribundas and hybrid tea roses have faded, remove the whole truss, cutting the stem just above the second or third leaf down. Keep a look out for signs of fungal disease including black spot and mildew. They may need spraying regularly with a fungicide to keep diseases at bay and also look out for colonies of aphids on the stems, which will also require spraying as blackfly and greenfly populations can build up rapidly.

If you only have a small infestation, a sharp jet of water should dislodge the aphids, or you may be able rub them off the affected area. Otherwise, use an organic pesticide based on plant extracts, soft or insecticidal soap or plant oils. If you dead-head them now, repeat-flowering. Many hybrid teas produce more than one flower bud at the end of each shoot. Hopefully, a little TLC will lead to repeatflowering blooms and a delicious heady fragrance during those balmy summer evenings.

Good plant partners include clematis, which can climb through the roses and also enjoy the same conditions and similar feeds. The most important thing this month is to enjoy your garden; heady scents, glorious colours, an abundance of fruits and vegetables and hopefully more sunshine. What could be more enjoyable and satisfying than surveying the results of your hard work throughout the year? Remember to water and feed your plants regularly, especially those in hanging baskets, pots or containers as well as climbers and roses growing against a sunny wall.

Many a plant will not recover from a drought, so water regularly and do not resort to feast and famine. Water hydrangeas with hydrangea colourant for true blue hydrangeas next year. If possible, set up an automatic watering system for your vegetable plot, borders and even containers. They are worth their weight in gold and can work on a sensor system that detects how dry the soil is. Once you have one you will wonder why you did not install one years ago. Going on holiday will no longer involve wondering if your precious plants will survive a dry spell or paying someone else to hold a hose!

If it stays warm and dry, water saving strategies include using bathwater and washing up water, provided they are neither too dirty or oily. Keep your pond topped up, free of pond weed and clean - green algae can be toxic to pets. Keep on top of weeds in borders, the vegetable garden and all your pots and containers. Little and often will reduce what will become a Herculean task if left to spiral out of control.

Rob is the fourth generation of his family to take over Martin and Sons Monumental Masons and has taken its off-shoot Plymouth Stone from its embryonic beginnings to the thriving and productive company it is today employing timeserved craftsmen and a dynamic sales team. We guide our clients through the decision-making process, helping them choose both colour and type of stone to suit their individual needs.

We advise and offer reassurance every step of the way as it is of paramount importance to us to know that we have happy, satisfied clients who understand the product they are purchasing. Finishes range from polished - for the best light reflection — to honed for clients who prefer a softer matt look. There are also leathered and antiqued finishes available for those who like a textured look and feel to the stone.

As an alternative to granite and for those with specific colours in mind, Plymouth Stone offer an extensive range of quartzstones. Quartzstone is a manmade product manufactured using quartz, polymer resins and dyes. Quartz is becoming a popular choice for. Rob Martin and Rhianna Hatherley from plymouth stone. There are also a wealth of colours to suit all styles of cabinets.

Plymouth Stone are the approved fabricators for household names such as Silestone, Caesarstone and Compac. In addition to the many choices of granites and quartzstones there is a full range of natural stone and porcelain wall and floor tiles.

Social Effects

From a wet room to a kitchen floor to a patio they are sure to have something to suit everyone. With their quality and customer-focused business set in stone the future looks bright for Plymouth Stone. Looking to meet, relax, eat and drink? A new addition to the eating out scene is pitch perfect. Louise Daniel talks to Peter Castell and Tina Parker about piccolo dishes, coffee culture and relaxing the rules…. The summer sun sparkles on the Tamar, gulls hang on the warm breeze and high above stands the Royal Albert Bridge. In the on-display kitchen, a trio of chefs work diligently on what looks suspiciously like my lunch.

Just Be opened in June, Peter explains, after months of work to transform what was a traditional pub. The hard work clearly paid off — this is a wonderful place for a lunchtime treat. Pleasingly the menu is short and simple. Shorter menus tend to be good sign everything is freshly prepared. Tina tells me this is at the heart of the Just Be experience. They are perfect foils for each other — Tina cheeky and mischievous and Peter laid back and a little more contemplative.

The rapport is clear and their banter indicative of a good working relationship which translates to the staff and customers. Tina was the landlady of the Cherry Tree pub. She saw how cafes continued to be successful even in the recession and began to dream of a place of her own. They quickly found they shared an ambition — Peter wanted a sociable space where people could meet and try wine and Tina wanted to do the same with coffee. Changes in the college meant Peter faced redundancy but he saw it as a positive sign to take the plunge and fulfil his own ambitions to open his own place.

Our position is to encourage people to talk. Spanish tapas and Italian cichetti. Tina reckons putting smaller dishes on the menu was an obvious choice. You can just do what you want to do. People taking their time is important. We want you to come and stay for as long as you want to stay and take a food and wine journey. The area is a under serviced by decent eateries and cafes — true there are a few gems, but Just Be is unique in its offering. The Plymouth foodie landscape just gets better and better. Ours is a vibrant food scene which packs a flavoursome punch — you can find everything from Portuguese street food to African stews; Tex Mex classics to bespoke hot chocolate and authentic Sichuan classics among other cracking globe-spanning cuisines.

This is sociable eating with family-style food and cracking international flavours which are hassle-free and inexpensive. Experiment with flavour, embark on a world food journey and experience the best cafe culture the city has to offer. Why not take a trip out mid-week and get stuck in to these new food hotspots? Tex-Mex food to eat in or take away. Hand pulled pork, chicken and beef burritos bursting with flavour. Thick, made-to-order milkshakes with combinations of your choice.

Lunch on the go or sit and watch the word go by. They are licensed so you can grab a top-notch Mojito or Cuba Libre too. Specialising in proper Belgian hot chocolate, cookies, hand-made chocolate and home-made waffles. Chocolate of any description. Take a seat, they do table service.

Hard to choose but the curry goat rocks. A Portuguese cafe and mini mart which is no secret locally. Amazing Portuguese chicken and custard pastries which knock the socks off more famous eateries. Carne Porco Alentejana Pork with clams and chips for two. Fab coffee, scrubbed oak tables and a friendly relaxed atmosphere. Call up and order chicken in advance or you could sit and have a vinho , making it mouthwatering takes a little time.

Artisanal-style chain based in a Grade II listed building. Eclectic, stylish with a menu bursting with fresh flavours. Their Ultimate Burger is fab and the courgette fritters are amazing. Simple and delicious menu, good wines and beers, stunning setting. Baked mushrooms with Gorgonzola, spinach and walnuts is yummy and the oven roasted chicken is creamy and comforting. They have a delicatessen counter too. Soups, dumplings, fresh fish and braised dishes. If you prefer the usual British style Chinese dishes, they do them too!

Mediterranean food done well is fresh, zingy and full of flavour and you get that here in spades — great location and roomy dining area. The fresh flavour and great service. The wine list is worth a look. Traditional French classics, fresh seafood, awesome views over the harbour. Fruits de la Mer — oven baked seafood to share. Pop in for a Croque Monsieur. Forget about British versions of Chinese food, this is the real deal. Small but perfectly formed, the restaurant adds a genuine Sichuan flavour to cafe society. Each comes with a silky black wrist strap. A seriously good sparkler from Down Under, it is a rich, biscuity, food-friendly style that has similar flavours to an aged champagne.

A champagne for food and wine lovers, a new release from this highly regarded champagne house which is best known for its rose. A perfect partner with gourmet bites. Depending on which side of the fence you sit, Lidl has a cracking good cava which will make a ham sandwich and a pot of olives taste that more special with its lemony freshness. A Spanish gem that offers everything in the style stakes, is a rapturous raspberry pink with fresh summer fruit aromas.

But this super-versatile vegetable can be put to an array of delicious uses. Make a well in the centre, break in eggs, then gradually whisk together, adding milk, a little at a time, to make a smooth batter. Stir in courgette and season well. Heat oil in a non-stick frying pan. Add tablespoons of mixture to make fritters, and cook for mins on each side until lightly golden.

Serve with sweet chilli sauce. Why not enjoy your freshly prepared meal in the comfort of our restaurant or see our famous takeaway menu. Roll out the pastry on a lightly floured surface and line the tart tin. Leave untrimmed and chill for 30 minutes. Next make the tomato filling. Place the tomatoes, onion, sugar and garlic in a saucepan and cook for 20 minutes or until thick and well. Set aside to cool. Heat oven to C, C fan, F, gas 5. In a bowl toss the courgettes with the oil and thyme leaves until well coated.

Spread out on a baking tray. Line the pastry case with baking parchment and baking beans. Place in the oven with the courgettes on a lower shelf and bake for 15 minutes. Remove the paper and beans from the tart tin. Remove the courgettes and turn over. Place the tart and the courgettes back in the oven and cook for a further minutes until the pastry is golden.

Remove the tart and the courgettes. Reduce the oven temperature to C, C fan, F, gas 3. Carefully spread the tomato sauce over the base of the tart. Cover with the courgettes and the goats cheese. Beat the eggs, egg yolk and cream together. Season well with salt and pepper, then pour over the courgette and tomato filling. Sprinkle the parmesan over the top, return the tart to the oven and cook for 30 minutes or until the filling is just set. Remove from the oven, trim the top of the pastry and leave to cool for 10 minutes before serving.

Start off by cooking the courgettes gently in 2 oz 50 g of the butter until softened and beginning to colour. Remove them from the heat, season with salt and pepper and leave to cool. Now melt the remaining 2 oz 50 g butter in a saucepan, stir in the flour and cook for a minute or two before gradually adding the milk, stirring all the time.

Bring the mixture up to a simmer, still stirring, and let it cook for about 2 or 3 minutes. Take the sauce off the heat now and cool it by sitting the base of the pan in some cold water. Season with salt, pepper and freshly grated nutmeg. Now beat up the egg whites to the stiff peak stage and carefully fold them into the cheese mixture, using a metal spoon. Foster a young person. Not being able to live with your family can be a difficult and traumatic experience for a child. So what they need most when they come into foster care, is a strong family environment.

We are particularly good at placing brothers and sisters together in loving military families. To find out more: Granted, a serving of these fragrant fruits might seem a lot less glamorous than, say, a fresh green smoothie or a handful of chia seeds, but these wrinkly wonders have all sorts of health advantages — not least when it comes to your digestive system.

However, just three prunes which are simply plums with the water removed will amount to one of your five-a-day, ensuring you get that bit closer to your daily target and help keep everything ticking over nicely in the bathroom department. Very finely dice the duck then mix with the rest of the ingredients.

• Oops, I Did It Again!: God hates sin, but He loves you!
• La adolescencia, un puente para recorrer. historias de alummos (Spanish Edition)
• El país que nos habla (Spanish Edition)
• Crow 3: Tears of Blood (A Crow Western)
• Bilal (Écritures arabes) (French Edition)
• Le verdi dimore ancora sussurrano pace (Italian Edition)
• With A Village Church: Meditations on Life