pico question: In adults diagnosed with schizotypal personality disorder, how does cognitive behavioral therapy compared to pharmacological treatment with Risperidone affect overall social functioning?
See instructions; Do not use adolescents using birthcontol and do not use anything that has to do with parent refusal of life saving measure such as Jehovah witness. The topic is chosen already located at the top.
Current Ethical Issues in My APN Track Presentation- My track is Family Nurse practitioner
Topic chosen
Chronic opioid management in primary care
Decision-Making Model
You already chose: ✅ Beauchamp and Childress’ Principlism Approach
· Focuses on autonomy, beneficence, nonmaleficence, justice
· Well-suited to FNP and aligns with ANA Code of Ethics
Chronic Opioid Therapy for Non-Cancer Pain
Ethical conflict: Beneficence vs. Nonmaleficence
· Risk of addiction vs. need for pain control
· Stakeholders: Patients, FNPs, DEA, insurers, families
· National crisis = lots of empirical data, EBP, policies ✅ CDC guidelines, ANA & AANP statements available
This assignment provides you with the opportunity to examine a healthcare or professional issue of interest in which ethical conflict is present.
Overview
Each of you will create a Kaltura Capture presentation in which you:
1. Identify a health-related topic that contains ethical conflict related to your APN track (AGACNP, CNM, FNP, NNP, PMHNP, or PNP) that is different than the topic you used in your Ethics Case Analysis (Assignment 7.1).
2. Select a decision-making model to use for your topic.
3. Provide background information, including relevant historical, social/cultural, policy, and political contextual factors from all viewpoints about the topic.
4. Supply empirical research that adds to the understanding of the topic.
5. Describe why the issue is significant to individuals, society, health care, and/or nursing.
6. Identify all alternative courses of action, identifying perspectives of relevant stakeholders.
7. Analyze different ways of thinking about the issue utilizing the ethical principles, moral theories, and codes of ethics encountered in the course.
8. Briefly summarize the ethical conflict and various courses of action open to stakeholders.
Important
You will not articulate the ethically correct course of action in the presentation or provide recommendations for APN practice, advocacy, or leadership. Your presentation should not convey what you think the ethically correct action should be for your topic.
Make sure you present both sides of the argument equally. The person watching your presentation should not have any idea of what you think the ethically correct action should be. Think of a courtroom, with both sides presenting a strong case before the judge. Be thorough, as your classmates should not have to do any additional research on the topic.
Remember to include strong supporting evidence and not just speak in generalizations, just like you would at a nursing conference. Be sure to include any position statements that our professional nursing or other organizations might have about supporting or opposing the issue. This topic should be well-researched.
Step 1: Choose Your Topic
You may choose a topic of your choice, but it must be related to your APN track (AGACNP, CNM, FNP, NNP, PMHNP, or PNP), and it must be a different topic than the one you used for the Ethics Case Analysis. A list of possible topics was listed in Week 7 and other possible topics were presented in your Week 11 readings.
Step 2: Choose a Decision-Making Model
Refer to Week 11’s readings and lesson for a list of decision-making models. Determine which model is best suited for your topic and presentation.
Step 3: Create Your Presentation
You must use this PPT templateLinks to an external site. when creating your video presentation. The template is to ensure a degree of uniformity across the presentations. You may add pictures or change the background color to personalize your presentation, but this is not required.
Tips to Create Uncluttered Slides
· Do not use complete sentences on slides. Use bullet points and concise language.
· Allow space around the text to enhance readability.
· Place APA citations in a smaller font than the main text.
· Group content under headings appropriate to your topic. For example, on background slides, you could use these headings (as appropriate to your topic): Federal & State Law; Cultural & Social Aspects
The presentation should be 18–20 minutes in length. The instructor will only grade the first 20 minutes of the video presentation. Please ensure that your appearance is professional and that your setting (which will be visible to the instructor and the student reviewing your presentation) is not distracting to the viewer. Also, make sure your audio hardware is working properly and your headset volume is set sufficiently loud.
Exemplar
Select the following button to review an exemplar. Since this topic is discussed at length, you cannot use it for this assignment. Also remember, you cannot choose abortion [includes termination of any pregnancy, at any point, for any reason] for this course, as exemplars were provided in Week 7.
Exemplar [PPT]Links to an external site.
Step 4: Record Your Presentation
You must use the Kaltura Capture Desktop Recorder to record your video presentation. Use a headset for the best quality audio, and test your recording for sound quality.
Note: You will not be able to upload a PPT or other files to this assignment. You must use Kaltura Capture.
Step 5: Submit Your Presentation
See the Video Assignments for Students tutorialLinks to an external site. for Kaltura video assignment submission instructions. Note: Do not publish your videos to the Media Gallery, your instructor will only grade the videos uploaded and submitted to this assignment page.
Note: You will not be able to upload a PPT or other files to this assignment. You must use Kaltura Capture.
Ethical Analysis Model
I will utilize Beauchamp and Childress' Principlism Approach in my Current Topics Presentation. Due to the fact that the four basic principles of autonomy, beneficence, nonmaleficence, and justice are highlighted, the model of this ethical analysis is widely applied in the field of health care. These guidelines provide an informative and balanced framework for the analysis of moral dilemmas in the field of advanced practice as well as nursing.
It is practical and flexible, thus my choice. It enables the APRN to be open to alternative views without being rigid in a given theory of ethics. Patient care by virtue of using the four principles can be compassionate yet ethically supportable in practical clinical practice even in controversial or complicated situations. For instance, this paradigm fosters reflective thinking that upholds patients' rights yet considers wider consequences in a given circumstance like in informed consent, in terminal care, or in the distribution of resources.
It fosters steady, intentional decision-making and is highly compatible with the nursing process as well as the ANA Code of Ethics. To determine the best moral and patient-centered solution, the model also fosters collaboration with interdisciplinary groups. It is also advantageous that the model places a strong focus on justice, as this works exceptionally well in addressing issues that are often the center of modern-day healthcare issues, including disparities in health, health determinants based on socioeconomic status, as well as the delivery of fair care. In my view, the Principlism Approach is well-tailored to my topic based on its flexibility and lucidity, and it will aid in directing a good ethical analysis.
References
American Nurses Association. (2021). Nursing: Scope and Standards of Practice (4th ed.).
Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press.
Rubric
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NUR6272: Current Ethical Issues in My APN Track Presentation Grading Rubric |
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Criteria |
Ratings |
Pts |
|
Identification of topic that contains ethical conflict (10 points) |
10 to >9.2 pts Noteworthy Describes clearly why topic meets the definition for a situation of ethical conflict. Identifies transgression of moral principles and undesirable outcomes for those who support and those who oppose the action. 9.2 to >8 pts Meets Expectations Adequately describes why topic meets definition. Transgression of relevant moral principles and undesirable outcomes not entirely clear. 8 to >0 pts Needs Improvement Description of topic does not meet the definition of a situation of ethical conflict. Moral principles and undesirable outcomes are omitted. |
/ 10 pts |
|
Background (10 points) |
10 to >9.2 pts Noteworthy Conveys the historical development and relevant legal, social, and cultural aspects of the topic so that listeners have an adequate understanding of the topic. Includes position statements and EBP guidelines, as applicable. 9.2 to >8 pts Meets Expectations Provides enough information so that listeners have a basic understanding of the topic, but some relevant background information is omitted. 8 to >0 pts Needs Improvement Background information is not adequate for understanding the topic. |
/ 10 pts |
|
Significance of ethical issue (10 points) |
10 to >9.2 pts Noteworthy Clearly demonstrates how the issue is significant to individuals, society, health care, and to nursing. Includes incidence, prevalence, and outcomes related to the topic. 9.2 to >8 pts Meets Expectations Significance of issue to individuals, society, health care, and to nursing is not entirely clear. 8 to >0 pts Needs Improvement Significance of issue to individuals, society, health care, or to nursing not addressed. |
/ 10 pts |
|
Decision-making model and stakeholders (10 points) |
10 to >9.2 pts Noteworthy Discusses decision-making model. Identifies stakeholders and briefly addresses how they may view the situation and factors that may influence their views. 9.2 to >8 pts Meets Expectations Identifies decision-making model. Stakeholders (1-2) missing. Analysis of stakeholders’ views is adequate but may omit a contextual factor. 8 to >0 pts Needs Improvement Decision-making model missing. Multiple stakeholders are missing and/or how they may view the situation is not adequately addressed. |
/ 10 pts |
|
Analysis 1 (15 points) |
15 to >13.94 pts Noteworthy Effectively utilizes all four moral theories, all four ethical principles, and the ANA Code of Ethics in a well-developed analysis of one perspective related to the situation of ethical conflict. 13.94 to >12.15 pts Meets Expectations Moral theories and ethical principles, provisions of the Code of Ethics adequately used, but a theory, principle, or relevant provision is missing from analysis. 12.15 to >0 pts Needs Improvement Moral theories, ethical principles, and relevant provisions of the Code of Ethics are missing from the analysis. |
/ 15 pts |
|
Analysis 2 (15 points) |
15 to >13.94 pts Noteworthy Effectively utilizes all four moral theories, all four ethical principles, and the ANA Code of Ethics in a well-developed analysis of the alternative perspective related to the situation of ethical conflict. 13.94 to >12.15 pts Meets Expectations Moral theories, ethical principles, provisions of the Code of Ethics adequately used, but a theory, principle, or relevant provision is missing from analysis. 12.15 to >0 pts Needs Improvement Moral theories, ethical principles, and relevant provisions of the Code of Ethics are missing from the analysis. |
/ 15 pts |
|
Summary (5 points) |
5 to >4.6 pts Noteworthy Briefly summarizes the ethical conflict and the various courses of action open to stakeholders. 4.6 to >4 pts Meets Expectations Summarizes the ethical conflict, but various courses of action open to stakeholders are omitted. 4 to >0 pts Needs Improvement Summary of the ethical conflict is inadequate, and various courses of action are not addressed. |
/ 5 pts |
|
Supporting Evidence (5 points) |
5 to >4.6 pts Noteworthy References 10 or more relevant, current, peer-reviewed journals and/or professional nursing/healthcare organizations. 4.6 to >4 pts Meets Expectations References 6-9 relevant, current, peer-reviewed journals and/or professional nursing/healthcare organizations. 4 to >0 pts Needs Improvement References 5 or fewer relevant, current, peer-review journals and/or professional nursing/ healthcare organizations. |
/ 5 pts |
|
Writing & APA format (10 points) |
10 to >9.2 pts Noteworthy No or minimal (1–2) errors in grammar, punctuation, spelling, or APA format for citations and references. 9.2 to >8 pts Meets Expectations Some (3–5) errors in grammar, punctuation, spelling, or APA format for citations and references. 8 to >0 pts Needs Improvement Numerous errors in grammar, punctuation, spelling, or APA format for citation and references. Reference slide is absent. |
/ 10 pts |
|
Communication (10 points) |
10 to >9.2 pts Noteworthy Presented within timeframe and in logical order. Presented in a manner that is articulate, confident, and well-rehearsed. Personal appearance and setting are professional. Sound quality is consistent, and video of the presenter is clear (e.g., not blurry or shaky). 9.2 to >8 pts Meets Expectations Meets Expectations Presented within timeframe. Disorganization hinders understanding. Some areas are not well-rehearsed. Some instances of “ums” and “ahs” or brief periods of silence. Personal appearance and setting are mostly professional. Brief sound quality or video issues. 8 to >0 pts Needs Improvement Needs Improvement Not presented in timeframe or in logical order. Communication skills unsatisfactory. Numerous instances of “ums” and “ahs” or periods of silence. Personal appearance and setting not professional. Consistent issues with sound or video quality, or video of the presenter is missing. |
/ 10 pts |
Scenario: A 13 year old boy is accompanied by his parents into the community mental health clinic for the evaluation of Attention Deficit Hyperactivity Disorder (ADHD). Both parents are impatient, demanding and requesting for you to start their child on a CNS stimulant medication.
Based on this scenario, respond to the following prompts:
Objectives:
Purpose:
Directions:
Video: https://youtu.be/W3hMmZQAdhw
MH708
COUNSELING INTERVIEW CRITIQUE
1. MSE – Perform a mental status exam on the patient. You should be able to complete most of the exam from the video, but if there is a section that you cannot complete, you may write “unable to assess.” If there is more than one patient in the video, you may choose one of the patients.
2. Communication skills – Use the handout from the Module 2 lecture to identify communication skills used by the therapist and give examples. Were these appropriate to the timing and issues being discussed?
3. Reaction to the session – Discuss your personal feelings about the session. This is not a commentary on whether the therapist did a good job, but rather, how did this session make you feel.
4. Therapy framework – Please list the principles of the framework of the applicable theory and which the counselor addressed and which he/she did not. Give examples.
5. What could the counselor have done differently and why – Within the currently used therapy, what are some different counseling skills, responses, and interventions that you might have used instead and why? If you cannot think of anything that should have been done differently, then what would be the next step in the therapeutic process?
6. Progression – Did the therapist and patient work on any goals? Did they make progress towards those goals? Please explain why you feel it did or did not progress how you anticipated.
7. Applicability – How might this psychotherapy approach relate to your future work as a PMHNP? In other words, how (cite examples) will you be able to use and apply the knowledge and/or skills of this psychotherapy in your further work?
,
Therapeutic Communication Techniques To encourage the expression of feelings and ideas
Active Listening– Being attentive to what the client is saying, verbally and non-verbally. Sit facing the client, open posture, lean toward the client, eye contact, and relax. Sharing Observations– Making observations by commenting on how the other person looks, sounds, or acts. Example:” you look tired” or “I haven’t seen you eating anything today”. Sharing Empathy– The ability to understand and accept another person’s reality, to accurately perceive feelings, and to communicate understanding. Example “It must be very frustrating to know what you want and not be able to do it”. Sharing Hope– Communicating a “sense of possibility” to others. Encouragement when appropriate and positive feedback. Example “I believe you will find a way to face your situation, because I have seen your courage in the past”. Sharing Humor– Contributes to feelings of togetherness, closeness and friendliness. Promotes positive communication in the following ways; prevention, perception, perspective. Sharing Feelings– Nurses can help clients express emotions by making observations, acknowledging feelings, and encouraging communication, giving permission to express “negative” feelings and modeling healthy anger. Using Touch– Most potent form of communication. Comfort touch such as holding a hand, is especially important for vulnerable clients who are experiencing severe illness. Silence– Time for the nurse and client to observe one another, sort out feelings, think of how to say things, and consider what has been verbally communicated. The nurse should allow the client to break the silence.
Providing Information– Relevant information is important to make decisions, experience less anxiety, and feel safe and secure. Example “Susie is getting an echocardiogram right now which is a test that uses painless sound waves to create a moving picture of her heart structures and valves and should tell us what is causing her murmur”. Clarifying– To check whether understanding is accurate, or to better understand, the nurse restates an unclear or ambiguous message to clarify the sender’s meaning. “I’m not sure I understand what you mean by ‘sicker than usual’, what is different now?” Focusing– Taking notice of a single idea expressed or even a single word. An example is “On a scale of 0 to 10 tell me the level of the pain you are experiencing in your great toe right now.” Paraphrasing– Restating another’s message more briefly using one’s own words. It consists of repeating in fewer and fresher words the essential ideas of the client. For example the client says “I can’t focus. My mind keeps wandering.” The student nurse says,” You’re having difficulty concentrating?” Asking Relevant Questions– To seek information needed for decision making. Asking only one question at a time and fully exploring one topic before moving to another area. Open-ended questions allows for taking the conversational lead and introducing pertinent information about a topic. For example “What is your biggest problem at the moment?” or “How has your pain affected your life at home?” Summarizing– Pulls together information for documentation. Gives a client a sense you understand. It is a concise review of key aspects of an interaction. Summarizing brings a sense of closure. Example “It is my understanding that your arm pain is a level 1 since you’ve taken a Vicodin one hour ago. Taking your pain medication before physical therapy seems to help you complete the activities the doctor wants you to do for your rehabilitation. Is this correct?” Client responds “Yes It really helps to take the medicine before I do my physical therapy because it helps reduce the pain in my arm.”
Self-Disclosure– Subjectively true personal experiences about the self, are intentionally revealed to another person for the purpose of emphasizing both the similarities and the differences of experiences. These exchanges are offered as an expression of genuineness and honestly by the nurse and disclosures should be relevant and appropriate. They are used sparingly so the client is the focus of the interaction: “That happened to me once, too. It was devastating, and I had to face some things about myself that I didn’t like. I went to counseling and it really helped…..what are your thoughts about seeing a counselor?” Confrontation– Helping the client become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors. Only to be used after trust has been established, & should be done gently, with sensitivity: “You say you’ve already decided what to do, yet you’re still talking a lot about your options.”
Non-therapeutic Communication Techniques
“Blocks” to communication of feelings and ideas Asking personal questions – Asking person questions that are not relevant to the situation, is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. “Why aren’t you married to Mary?” is not appropriate. What might be asked is “How would you describe your relationship to Mary. Giving personal opinions– Giving personal opinions, takes away decision-making for the client. Remember the problem and the solution belongs to the patient and not the nurse. “If I were you I’d put your father in a nursing home” can be reframed to say,” Let’s talk about what options are available to your father.” Changing the subject– “Let’s not talk about your insurance problems it’s time for your walk” Changing the subject when someone is trying to communicate with you is rude and shows a lack of empathy. It ends to block further communication, and seems to say that you don’t really care about what they are sharing. “After your walk let’s talk some more about what’s going on with your insurance company.” Automatic responses– “Administration doesn’t care about the staff,” or “Older adults are always confused.” These are generalizations and stereotypes that reflect poor nursing judgment and threaten nurse-client or team relationships. False Reassurance– “Don’t worry, everything will be all right.” When a client is seriously ill or distressed, the nurse may be tempted to offer hope to the client with statements such as “you’ll be fine.” Or “there’s nothing to worry about.” When a patient is reaching for understanding these phrases that are not based on fact or based on reality can do more harm than good. The nurse may be trying to be kind and think he/she is helping, but these comments tend to block conversation and discourage further expressions of feelings. A better
response would be “It must be difficult not to know what the surgeon will find. What can I do to help?” Sympathy– Sympathy focuses on the nurse’s feelings rather than the client’s. Saying “I’m so sorry about your amputation, it must be terrible to lose a leg.” This shows concern but more sorrow and pity than trying to understand how the client feels. Sympathy is a subjective look at another person’s world that prevents a clear perspective of the issues confronting that person. A more empathetic approach would be “The loss of your leg is a major change, how do you think this will affect your life?” Asking for Explanations– “Why are you so upset?” A nurse may be tempted to ask the other person to explain why the person believes, feels or is acting in a certain way. Clients frequently interpret why questions as accusations. “Why” questions can cause resentment, insecurity and mistrust. It’s best to phrase a question to avoid using the word “why”. “You seem upset. What’s on your mind?” Approval or Disapproval–“You shouldn’t even think about assisted suicide, it’s just not right.” Nurses must not impose their own attitudes, values, beliefs, and moral standards on others, while in the professional helping role. Judgmental responses by the nurse often contain terms such as should, ought, good, bad, right or wrong. Agreeing or disagreeing sends the subtle message that nurses have the right to make value judgments about the client’s decisions. Approving implies that the behavior being praised is the only acceptable one. Disapproving implies that the client must meet the nurse’s expectations or standards. Instead the nurse should help clients explore their own beliefs and decisions. The nursing response “I’m surprised you are considering assisted suicide. Tell me more about it…” gives the client a chance to express ideas or feelings without fear of being judged. Defensive Responses– “No one here would intentionally lie to you.” When clients express criticism, nurses should listen to what they are saying. Listening does not imply agreement. To discover reasons for the client’s anger or dissatisfaction, the nurse must listen uncritically. By avoiding defensiveness the nurse can defuse anger and uncover
deeper concerns: “You believe people have been dishonest with you. It must be hard to trust anyone.” Passive or Aggressive Responses– “Things are bad and there is nothing you can do about it.” Or “Being is sick is bad and it’s all your fault.” Passive responses serve to avoid conflict or sidestep issues. They reflect feelings of sadness, depression, anxiety, powerlessness, and hopelessness. Aggressive responses provoke confrontation at the other person’s expense. They reflect feelings of anger, frustration, resentment and stress. Assertive communication is a far more professional approach for the nurse to take. Arguing– “How can you say you didn’t sleep a wink when I heard you snoring all night long!!” Challenging or arguing again perceptions denies that they are real and valid to the other person. They imply that the other person is lying, misinformed, or uneducated. The skillful nurse can provide information or present reality in a way that avoids argument: “You feel like you didn’t get any rest at all last night, even though I thought you slept well since I heard you snoring.” –Author Unknown
What is the difference between qualitative and quantitative research methods? Give an example of each.
Submission Instructions:
Week 3 Project – Chi-Square
This assignment focuses on categorical data, and two of the statistics most often used to test hypotheses about categorical data are odds ratios (ORs) and the chi-square. A chi-square is calculated first to identify if two categorical variables are associated with each other, and if they are then an odds ratio is often calculated. The disease-OR refers to the odds in favor of disease in the exposed group divided by the odds in favor of the unexposed group. Chi-square statistics measure the difference between the observed counts and the corresponding expected counts. The expected counts are hypothetical counts that would occur if the null hypothesis were true.
Part 2: Chi-Square
Bain, Willett, Hennekens, Rosner, Belanger, and Speizer (1981) conducted a study of the association between current postmenopausal hormone use and risk of nonfatal myocardial infarction (MI), in which 88 women reporting a diagnosis of MI and 1,873 healthy control subjects were identified from a large population of married female registered nurses aged thirty to fifty-five years. There were 32 women who currently used hormones and had a diagnosis of MI and 56 women reporting a MI and never used hormones. Of the women controls (women who did not report a MI) 825 currently use hormones and 1,048 never used hormones. To test the hypothesis that there is no association between use of postmenopausal hormones and risk of MI, chi-square statistics need to be calculated in SPSS using a 0.05 level of significance. The SPSS data are provided in the link below. The SPSS dataset consists of two variables:
Click here to access the SPSS data.
Reference:
Bain, C., Willett, W., Hennekens, C. H., Rosner, B., Belanger, C., & Speizer,
F. E. (1981). Use of postmenopausal hormones and risk of myocardial infarction. Circulation, 64(1), 42–46.
Refer to following video on how perform a Chi-square analysis. https://www.youtube.com/watch?v=ysn-YL9bLdo
Using SPSS, download the data, perform appropriate procedures, and provide calculations.
In addition, in a Microsoft Word document, provide a written conclusion and interpretation of your results in APA format.
Week 3 Project – Chi-Square
This assignment focuses on categorical data, and two of the statistics most often used to test hypotheses about categorical data are odds ratios (ORs) and the chi-square. A chi-square is calculated first to identify if two categorical variables are associated with each other, and if they are then an odds ratio is often calculated. The disease-OR refers to the odds in favor of disease in the exposed group divided by the odds in favor of the unexposed group. Chi-square statistics measure the difference between the observed counts and the corresponding expected counts. The expected counts are hypothetical counts that would occur if the null hypothesis were true.
Part 2: Chi-Square
Bain, Willett, Hennekens, Rosner, Belanger, and Speizer (1981) conducted a study of the association between current postmenopausal hormone use and risk of nonfatal myocardial infarction (MI), in which 88 women reporting a diagnosis of MI and 1,873 healthy control subjects were identified from a large population of married female registered nurses aged thirty to fifty-five years. There were 32 women who currently used hormones and had a diagnosis of MI and 56 women reporting a MI and never used hormones. Of the women controls (women who did not report a MI) 825 currently use hormones and 1,048 never used hormones. To test the hypothesis that there is no association between use of postmenopausal hormones and risk of MI, chi-square statistics need to be calculated in SPSS using a 0.05 level of significance. The SPSS data are provided in the link below. The SPSS dataset consists of two variables:
Click here to access the SPSS data.
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SPSS Dataset Variables |
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Name |
Label of Variable |
Values |
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Group Association |
Group |
1. Control 2. Case |
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Use |
Hormone Use |
1. Currently Use 2. Never use |
Reference: Bain, C., Willett, W., Hennekens, C. H., Rosner, B., Belanger, C., & Speizer,
F. E. (1981). Use of postmenopausal hormones and risk of myocardial infarction. Circulation, 64(1), 42–46.
Refer to following video on how perform a Chi-square analysis.
Using SPSS, download the data, perform appropriate procedures, and provide calculations.
In addition, in a Microsoft Word document, provide a written conclusion and interpretation of your results in APA format.
Submission Details:
· Name your SPSS output file SU_PHE5020_W3_A2c_LastName_FirstInitial.mtw.
· Name your document SU_PHE5020_W3_A2d_LastName_FirstInitial.doc.
