Family Project

The family that I chose for this assignment is the S family. This wonderful family consists of a father named Mr. S a 37 year old black male of African descent, a mother named Mrs. S a 33 year old Caucasian female of Anglophone descent; and their two children, Sabrina a 12 year old girl, and Venus a 7 year old girl. This family is considered a nuclear family. Mr. and Ms. S have been married for the last 14 years, and share a 3-bedroom apartment in Ontario. Both Mr. and Mrs. S have expressed their immense joy and sense of fulfillment, in having and raising their children. Mr. S, a native Nigerian is employed full-time as a security guard at Pearson International airport, and Mrs. S is a part-time customer service representative also working at the same airport where they had first met. According to Mrs. S, Due to her low hours at work she currently handles all of the cooking, cleaning, and other household duties (personal communication, September 13, 2013). This family comes from a Catholic background and both of the children attend catholic schools. They attend church almost every Sunday (personal communication September 13, 2013).

Family Developmental Stage and Tasks

I first met the S family over four years ago when I was employed with Mrs. S at the same position she currently holds. We worked the same shifts at the airport over three years ago, and we have been friends ever since. I called Mrs. S one day, and I informed her that I was in the midst of doing a project for a nursing theory class that I was taking. She seemed interested, so I explained that the class was a community health class, and that the assignment consisted of me interviewing a family and exploring what it would it be like to work with families in their homes, which is known as a community setting. Mrs. S seemed open to the idea, so I told her that the interview would consist mainly of me understanding each family members definition of health, and to explore any health related issues they may be having, and current or potential coping strategies they were currently using to deal with these issues.

Mrs. S was pleased she could be of help and mentioned that the family is ready to sit down for the purpose of this project any evening. I thanked her and stated that this interview would assist me in developing my therapeutic communication skills, and that I appreciated her willingness to help. I informed her that all aspects of this project would be kept confidential, and that I would only be using the initials of her families’ choice, to identify them. I explained that only my teacher who was grading my project would have access to it. Mrs. S seemed enthusiastic about being part of this assignment, so I asked her to confer with her husband and children, and to call me if they agreed.

The next week I called Mrs. S back and she asked me to come over to their apartment and begin the interview. I arrived at their home dressed in business casual attire and wore my GBC student I.D. I shook hands with everyone in the family, re-introduced myself and stated that I was a GBC practical nursing student, smiled as I was excited, and went over the components of the assignment, including confidentiality, and asked everyone in the family including the children if they consented to be a part of this assignment. They all eagerly agreed, and I informed Mr. and Mrs. S that they would need to sign a consent form before I could submit any part of this assignment to my GBC professor, and this was the beginning of my community nursing assignment. During my home visits with the S family, I was very mindful to show respect for their household, and I remained conscious of my body language. Useful non-verbal communication techniques are eye contact, body posture and use of facial expressions, gestures, voice and touch (Jarvis, 2009). I made sure to smile and listen attentively to all members of the family.

While communicating I would lean forward and maintain a comfortable level of eye contact to ensure that the speaker understood that I was interested in what they were saying, and mentally present. This helped set the tone for my assignment, and by remaining engaged I realized that all members of the family especially the children remained open, and very willing to share their thoughts with me. During the introduction of this assignment to the children of the S family, I found that the youngest child Venus was having a hard time understanding what an interview was, so I used verbal communication to provide examples which helped her understand what an interview is. “Effective communication depends on understanding the message, interpreting the message, and providing feedback that supports the correct interpretation” (Fortinash & Holoday Worret, 2008, p. 62 par. 3).

When Venus stated, “What does an interview really mean? Does it mean you want to tell me about your homework at school”, I stated, “ No Venus. An interview is when I ask you a question about something, and you give me an honest answer about what you think. Its kind of like this, I’ll ask you a question like, What do you like to do for fun? And you could say something like, ‘I like to play and dance. Or I could ask you, ‘How often do you watch television?’ And you could say, ‘I watch television all day long, and my favorite channel is tree house” (personal communication, September 13, 2013). After this explanation providing examples, I asked Venus if she understood and she nodded that she did.

The Definition of Health by Family

I then asked all members of the family to work together and provide a definition of what they felt the term ‘health’ meant to them. After a few minutes of conference, Mrs. S shared what health meant to her family. She stated, “ Health is not having any incurable issues with a persons physical, emotional, or mental state of being”. I then asked every member of the family if they agreed with this definition and they did. To seek clarification I asked Mrs. S what she meant by ‘Incurable issues’, and she replied, “ Well for instance, having an ear or throat infection can be fixed by taking antibiotics, and is therefore curable so it wouldn’t be considered unhealthy. Having HIV/AIDS or Cancer is not curable, so these types of things would make someone unhealthy (personal communication, September 24, 2013). To add to our definition, health also means doing things for your body and mind that help keep it fit and nourished like exercising and eating healthy”.

I acknowledged this addition, and then asked the family to compare themselves to their definition of health, and determine if they felt they were healthy. Both Mr. and Mrs. S quickly answered, “No”, and I asked them both to elaborate. Mr. S stated that he was unhealthy because he has had hypertension for the last 5 years, and still continues to eat unhealthy foods while at work. Mrs. S stated that she was unhealthy because she’s been a smoker for the last 10 years, and doesn’t have the time to work out like she used to before she had children. The eldest child Sabrina stated, that she was healthy because she ate lots of vegetables and played soccer, and the youngest child Venus, stated that she was healthy because she didn’t eat lots of junk food and candy (personal communication, September 24, 2013).

The Family’s Past Health Issues

I then asked the family to describe a past experience with any health issue that they had faced if they felt comfortable doing so. After a few minutes of thinking and looking at each other the eldest daughter Sabrina said, “Mom had a miscarriage”. Mrs. S agreed and continued to described how about 10 years ago she had 3 miscarriages, one of which were twins (personal communication, September 13, 2013). I could see the look of sadness in all of the family members’ faces, and I observed a period of silence before I asked them how they dealt with this devastating experience. Mr. S stated, “ It was the most painful thing him and his wife had to deal with”. Mrs. S nodded, and stated, “ If it wasn’t for the grace of God, and the support of our families and church, I don’t know how we could have made it through that” (personal communication, September 13, 2013).

Mrs. S elaborated that for a while she had her mother temporarily staying with them to help take care of the cooking, cleaning and childcare, while she grieved. Both her and her husband questioned God after three miscarried pregnancies, but their family was there to provide support and keep their faith strong. Mr. S shared that his wife cried for weeks, and even went through grief counseling. Mrs. S stated while hugging her youngest daughter, “ Nothing can ever replace the love we have for all 6 of our children, but the birth of Venus here really helped distract us from our grief, and gave the whole family a new life to celebrate, and a reason to smile again” Mr. S elaborated that, “Sometimes in life bad things happen, but people have to find a way to turn a negative situation into a positive one” (personal communication, September 13, 2013). Throughout this experience the family reported prayer and their faith in God as their major coping strategy.

The support of the family, communicating with each other and showing and receiving love and affection were also useful (personal communication, September 13, 2013). When the grief became unbearable the family acquired external help in the form of trained councilors, and even had another child to help fill the void they felt. These coping strategies are admirable, and the S family has proven to be strong.

The Family’s Current Health Issues

The S family identified their health issues/concerns as such: 1) Smoking. -Both Mr. and Mrs. S have smoked at least a half pack a day for the last 10 years. 2) Unhealthy eating (too much salt) / Hypertension. – Ms. S has reported using excessive seasoning salts in her cooking, and Mr. S has suffered from hypertension for the last 5 years. I measured his resting blood pressure as 130/85 mmHg, then again immediately after smoking as 142/94 mmHg. 3) Lack of exercise. – The parents of the family reported not exercising enough and feeling sluggish. 4) Gaining too much weight. 5) Lack of sleep – Mr. S works full-time, and has issues with insomnia. The children were adamant in adding: I was a little surprised when the children mentioned weight as an issue, however I then asked the family to identify a priority health issue, and all members agreed that it was the cigarette smoking (personal communication, September 24, 2013).

Although all of the S family’s identified health issues are important, on the basis of my assessment, the S family’s priority health issue is the fact that Mr. and Mrs. S are chronic cigarette smokers. Both Mr. and Mrs. S began smoking over 10 years ago, as they claimed that the smoking helped them deal with their stress. Mr. S smokes 15 cigarettes a day, and his wife smokes 10. Although Mr. S has been hypertensive for the last 3 years, and hypertension has been shown to run in his side of the family, I feel that there is a direct correlation between his high blood pressure and his smoking. I demonstrated to the family the effect that smoking had on Mr. S’s blood pressure. There is clinical proof that smoking causes many vascular, circulatory, and organ damage and therefore although these serious issues have not fully progressed as yet, I believe that smoking is definitely the greatest risk to the S’s family health. Mrs. S has even reported feeling fatigued, breathless, and ‘unhealthy’ as a result of her smoking (personal communication, September 24, 2013).

The S children have shown apprehension, and anxiety about their parents smoking, and have voiced concerns that their parents may get cancer. This emotional strain on the children is very unhealthy, and was a key factor in my choice of smoking as the families priority issue. My visual assessment of the S family shows that both Mr. and Mrs. S look a little older than they are in actuality; both are overweight with the majority of their excess weight concentrated in their abdominal areas. The children’s appearance revealed that their weight is within normal range, and showed no other indicators of unhealthiness. Of the entire S families identified health concerns, my assessment is congruent with theirs in identifying smoking as the most urgent and serious health issue.

Formulation

When I asked the S family to develop a goal in relation to their identified priority health issue, they initially stated that they wanted to quit smoking within the next 2 months, or before the New Year as Mrs. S put it. I then introduced them to the SMART goal criteria, and provided a little assistance to help them formulate their new goal. Their finished goal is as follows, “ By January 1st 2014, we will have successfully withdrawn from smoking cigarettes, by reducing our daily cigarette intake by 1 cigarette a week until 15 weeks have elapsed and we will have successfully quit”. As neither of the children are smokers, their parents helped them formulate this health goal, “ By January 1st, 2014 we will have successfully completed 15 hours of exercise, by playing our Just Dance 2, (A Nintendo Wii video-game which requires its participants to dance while playing) for 30 minutes a day for 30 days.” (Personal communication, September 24, 2013).

During the assessment stage of this assignment, I used a variety of verbal therapeutic communication skills, one of which was ‘Questioning’. (Fortinash & Holiday Worret, 2008). A verbatim example of this was when I asked Mr. S, “ I can see on your genogram that many of your family members are hypertensive and have other health issues involving their heart, how does this make you feel in regards to your health outcomes?” After asking Mr. S this question and observing his response (as he broke eye contact), I realized that through my direct questioning I was able to cause him to reflect on his health, and modifiable health behaviors. After asking the question however I felt that maybe I was a bit too personal in mentioning family members a few of whom have died from complications of cardiac disease. Next time I plan to assess, while using less invasive questions.

During the ‘Working’ phase of this assignment I was able to use the therapeutic verbal technique of ‘Assisting in goal setting’, by saying, “ I understand that this SMART goal technique is a bit tricky, but I will definitely help you guys formulate a goal, and give you some ideas to help you be successful” (Fortinash & Holoday Worret, 2008). After using this technique, I noticed that the S family was much more willing to utilize the SMART goal system, and seem encouraged in making a goal that would realistically work for them.

Implementation

To promote self efficacy within the S family I have shared information regarding the effects of smoking on the body and techniques many people have used to quit, which was retrieved from the ‘Smokers Helpline’ website which is a branch of the Canadian Cancer Society (Canadian Cancer Society, 2013). These techniques can assist during cravings and assist the S family to be more resilient in quitting. I also informed the S family of Nicotine Replacement therapy, which involves the usage of nicotine gums, transdermal patches, and lozenges to better control cravings, and avoid systemic damages (Mayo Foundation for Medical Education and Research, 2011). I have also assisted the S family’s capacity through the usage of a teaching plan, which outlines specific behaviors to foster, and avoid, to increase goal adherence.

Health Plan

While researching a teaching plan for the S family, I came across a program by the name of, ‘William Osler Health Centre “Kick It” program’, which is a free face-to-face resource for patients seeking basic cessation information in a group setting (Peel Public Health, 2013). This program is available to smokers in peel area and can be accessed by preregistering via intake phone line. I explored the website with the S family to provide them with a face-to-face community resource which would increase their chances for success. The S family had access to Internet on their computer; therefore I shared a website designed by the Mayo Foundation for Medical Education and Research to assist in developing a smoking cessation teaching plan for the S family.

The plan is as follows:
“1) Write it down- Consider what you don’t like about smoking and why you want to quit smoking. Write it all down and carry the list with you. Each time you pick up a cigarette or have the urge to, read your list and remind yourself why you want to quit smoking.
2) Enlist Support- Get others on your side. Tell your family, friends and co-workers that you want to quit smoking. You may even ask them to remind you why it’s important to quit smoking if they see you pick up a cigarette.
3) Contact the ‘Smokers Help-Line’, during periods of cravings to access support from Tobacco cessation specialists.
4) Increase fluid intake to assist the body in flushing nicotine from your system.
5) Avoid smoking triggers- Recognize places and situations that make you want to smoke and avoid them. Instead, visit places where smoking isn’t allowed, such as a museum or movie theater. Hang out with people who don’t smoke or who also want to quit smoking.
6) Try a stop smoking product- Do not use withdrawal symptoms or cravings as an excuse to not quit smoking. Plenty of stop-smoking products and medications with Food and Drug Administration approval are available to help you manage.
7) Manage your stress- Stress and anxiety can increase your urge to smoke and derail your effort to quit smoking. To keep stress and anxiety under control, prioritize your tasks. Consider what tasks you can eliminate or delegate to someone else.
8) Celebrate your successes-Reward yourself for not smoking by doing something you enjoy every day, such as spending extra time with your children or grandchildren, going to a ball game, taking a walk, soaking in the tub or watching a movie.” (Mayo Foundation for Medical Education and Research, 2011, pp. 1-2).

Communication Skills

During the working phase of this assignment I also used the therapeutic communication technique of ‘providing feedback’. (Fortinash & Holoday Worret, 2008). I was able to use this technique while helping the S family develop their SMART goal. I supported the family by saying, “ Why don’t you tell me what you are trying to say, and I will help you make it fit into the SMART criteria”. By offering the family feedback on what they were developing, I was able to assess their feelings and thoughts, while providing guidance through a process that they found complicated. During the termination phase of this assignment I was able to use the technique of, ‘Reinforcing healthy behaviors’, by saying, “ That is great that you have made a step towards achieving better health. I am really inspired by the way you have been able to plan and work together towards meeting your goals.” (Fortinash & Holoday Worret, 2008). Later on I reflected on the comment I had made, and I realized that I had empowered this family during their transition towards healthier behaviors. The family felt encouraged by my use of positive reinforcement and feedback in attempting to quit smoking.

Evaluation

I visited the S family 2 weeks after the implementation phase of this assignment, and I was very pleased to find that they were able to set their plan into motion and were on their way to achieving their priority goal. Instead of cutting down 1 cigarette per week, both Mr. and Mrs. S had effectively decreased their smoking intake by 3 cigarettes a week, for a total of 12 per day for Mr. S, and 7 per day for Mrs. S. They both stated that they were able to do so with little to no cravings for the smokes they had cut down on. Both Mr. and Mrs. S had registered with the Smokers Helpline, and had booked an appointment to attend a smoking cessation information session located at ‘Brampton Civic Hospital’ not far from where they lived (personal communication, October 8, 2013). The children were very proud of their parents and were hopeful that they would eventually be smoke-free. Mr. S reported that he was able to sleep better by not smoking 2 hours before he went to bed, and he looked visibly healthier, perhaps as a result of more sleep.

Mrs. S had joined in the workout with her children using the Nintendo Wii gaming system, and stated that they all looked forward to playing it on a daily basis. She also reported cutting down on her use of salts in her cooking. I took the opportunity to give her printable material from the Heart and Stroke Foundation outlining shopping tips for healthy food, including grocery list (Heart and Stroke Foundation, 2011). I was also able to direct their attention towards using the CFAM model, which can help to analyze their tobacco addiction, as well as any actions and feelings they may experience during nicotine withdrawal (Fortinash & Holoday Worret, 2008).

Relationship

By the time this assignment was near completion I felt that my relationship with the S family had grown and strengthened as a result of our partnership and high trust levels for each other. During the development of this relationship no issues arose, however there was one issue that was potentially harmful. During our first meeting I noticed that the family felt empowered and would some times interrupt to ask me a personal question about my current relationship status. “Boundary violations occur when the nurse goes beyond the established therapeutic relationship standards and enters into a social or personal relationship with the client” (Fortinash & Holoday Worret, 2008, p 75, par. 9). I believe that at times the fact that Mrs. S and I are friends inhibited the assignment as the lines between professionalism and friendship were sometimes blurred. However I also feel that at times our friendship was beneficial to the project, as her family trusted me enough to disclose personal information such as the miscarriages she had, which they usually wouldn’t share with a stranger.

Mr. S and I also share very similar cultural backgrounds, which I believed helped establish trust. We also all live in the same area which made our meetings much easier, and convenient. Throughout the assignment, I would always show each member of the family my undivided attention, and used professional language to conduct our meetings. I found that this helped me gain their trust and attention. I found that I was able to partner and empower the family while assisting them in developing their SMART goals, and use a wide variety of therapeutic communication techniques, such as providing information, questioning, providing feedback, and reinforcing positive behaviors. These techniques allowed me to clarify confusing information, gather important information and cause reflection, provide important feedback and pointers to assist with goals, and empower the family to stick to their set goals.

The family verbalized their appreciation of my help throughout the process, and stated that they were grateful for the opportunity to reflect on their health behaviors. I found working with a family in the community as a client much easier than I did working with individualized clients in institutionalized settings. The first reason for this difference was the setting and environment of my health promotion. During my pregrad experience I have not had enough time to really sit down and spend hours conferring with one patient. There are other patients who need assistance, which makes it a distracting environment and difficult to really spend one on one time with a patient. In the community however I have been able to prepare ahead, which has given me much more time to use the therapeutic techniques I have learned about from textbooks. With individualized clients I was unable to meet all family members and their natural working environment, which made it difficult to assess whether their basic needs were being met.

Another factor that has made a difference is that the family consists of more than one individual who are able to hold each other accountable. I have found in my pregrad setting that individualized clients are admitted and discharged without sufficient opportunity/time for me to really monitor any real life changes and adherence to set long term goals. Whereas the family lives in a fixed address, with a telephone number which makes it much easier to keep in
touch over the long-term and evaluate SMART goal progress.

Summary

Throughout my experience of working with the family as a client, I was able to utilize and apply the five principles of Primary Health Care efficiently as follows:

1) Accessibility: The family I chose are all OHIP recipients and live in a city where there are countless accessible resources which address all of the 5 types of healthcare. I was able to connect them with resources such as the ‘Smokers Helpline’ (Canadian Cancer Society, 2011), which they can access to contact specialized ‘Tobacco cessation specialists’ who can assist them in successfully attaining their health goals.

2) Public Participation: During this assignment I always respected the families diversity and regularly partnered with them and helped empower them to identify their priority health issues, and assisted them in making decisions regarding how they wanted to solve such issues.

3) Health Promotion: I was able to help the S family reflect on what health meant to them, and promote techniques such as setting SMART goals to help them gain control of health concerns. After they identified their list of health issues I was able to provide health education in various forms to assist them in attaining their definition of health.

4) Appropriate Technology: By directing the S family to various websites, I was able to demonstrate how the internet can be used as a tool for health education and promotion, with limitless potential for acquiring reputable health information.

5) Intersectoral Collaboration: By assisting the S family to register with the smokers helpline, I was able to facilitate their connection with a ‘Tobacco Cessation Specialist’, who will be able to assist this family during their journey to be smoke free. This ‘quit coach’, will have specialized training to ensure they are qualified healthcare counselors (Canadian Cancer Society, 2011).

SMART Goals for Professional Development

1) By December 1, 2013, along with reviewing the material on grief in my Fortinash Mental Health Textbook, I will research my community for mental health care resources, which can be used to assist families experiencing severe grief. (Ex. Pregnancy loss.)

2) By December 1, 2013 I will have reviewed Chapter 11 titled ‘Information Technology’ in my Community Health Nursing textbook, so as to fully understand the parameters involving quality
of health information on the Internet, which would result in only reputable websites being recommended to my clientele.

3) By December 1, 2013, I will have reviewed the CNO’s guidelines on effective therapeutic nurse-client relationships, (CNO, Therapeutic Nurse-Client Relationship, Revised 2006) so as to build on my foundational knowledge of how to better relate to clients, and to enhance future correspondences with all of my patients. All meetings (minimum 3 visits) with the family you have selected are to be documented in a reflective journal. Journal entries include the date, time and place of the meetings as well as your thoughts, feelings and actions. The Reflective Journal is placed in sequence at the end of the paper. The paper will also include a summary of your learning in relation to the objectives of the project.

Reflection Journal # 1

The first meeting with my selected family occurred on September 13, 2013 at 1900 hour. I went to the home of the family to begin the assignment and was greeted and welcomed by all members of the family. I was a little nervous about the whole process, as I had never previously had to interview a family. I remember thinking that Mr. S and Mrs. S would not take me seriously, however I quickly pushed those thoughts to the back of my mind and began the introduction of this assignment. I asked the family to tell me a little bit about themselves and they were more than happy to share their likes and dislikes. I remember the S. family was relaxed in their home environment. Observing how the children interacted playfully with one another helped calm my nerves, and made me feel comfortable. Before I came over to the family’s home I had reviewed the therapeutic communication section of my Fortinash textbook, and I was mindful of my body actions and demeanour, in order to portray interest and respect for the family. I looked around the room at pictures the couple had displayed of the family.

The family appeared flawless (smile and laughed, respect, attentiveness to one another) and I thought negatively about coming up with a teaching plan. Then I realized that this thought was somewhat of a preconceived notion, that the S. family would invite me for the purpose of the assignment and not be open to discuss any health issues they would like to learn. The interview was going smoothly, and I found that the family seemed to be enjoying the whole process, especially the two children involved. After asking the family about a health issue they had experienced in the past, I was almost moved to tears when I was told about the loss the S family experienced. I remember seeing pain in the eyes of Mr. and Mrs. S as they reflected on the painful experience of their pregnancy loss, and it was then that I got a sense of how devastating it must be to not be able to hold on to a pregnancy, both physical and psychological. After assessing the techniques the family used to cope, and identifying their health concerns, I decided that I would end the interview there, and return in a week. The family seemed touched that I had taken an interest in their health concerns, and welcomed me back anytime to continue with the assignment.

Reflection Journal # 2

My second meeting with the S family occurred on September 24, 2013 at 1900, the same time as previous appointment. Prior to the second meeting with the S family, I researched some community resources that I could share with the family to assist them with their health concern. As Mr. S stated that he had hypertension, I decided that now would be a good time to teach him the importance of monitoring blood pressure and going for regular physical check-ups. I was able to share the resources I had researched online, and I could see the appreciation the S family felt knowing that I was concerned about their health state and outcome. It was during this meeting that I measured Mr. S’s blood pressure and observed the change smoking a cigarette had on his blood pressure, and I knew that I had made on impact when I saw his eyes widen at his post cigarette pressure levels.

I worked with the family to develop their SMART goals during this visit, and I remember seeing pride in the eyes of the S children when their parents stated they were committed to kicking the smoking habit. I developed a teaching plan prior to my arrival, and I shared it with the family at this time. I ended the meeting shortly after sitting and discussing the techniques from the teaching plan, as they were about to have dinner.

Reflection Journal # 3

My third meeting with the S family occurred on October 8, 2013 at around 1745. It was during this meeting that I was able to assess the S family’s progress, and I was very happy with their results. I remember thinking how committed this family was in solving their priority health issues, and determined to achieve their goal. During this meeting Venus gave me a picture, which she drew up of me. I did not know why I felt so emotional at the time, but on later reflection I realized that it was because for the first time I sensed that I was making a real transition into the nursing role from the S family’s perspective. My final visit with the S family was a rewarding experience, as I felt that I was making a difference in someone’s life. The family expressed feeling more energetic and confident. As a result of this experience I was able to develop a therapeutic relationship and enhance my verbal and non-verbal communication skills. I will continue to utilize my community health nursing book to build my knowledge, as my future nursing career may lead me to an opportunity to work as a community health nurse.

Reference
Books:
Fortinash, Worret, H. (2008). Psychiatric Mental Health Nursing. (4th ed). Philadelphia: Mosby Elsevier.

Stamler, L. L., Yui, L. (2012). Community Health Nursing a Canadian Perspective. (3rded). Toronto, Ontario: Pearson Canada

Websites:
Canadian Cancer Society (2013). Smokers Helpline Version 6.0. Retrieved from http://quit.smokershelpline.ca/refer/

College of Nurses of Ontario. (2009). Therapeutic Nurse-Client Relationship, Revised 2006. Toronto, Canada: Author. Retrieved from: http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf

Heart and Stroke Foundation (2011). Heart and Stroke Shopping List. Retrieved from:
http://www.heartandstroke.com/atf/cf/{99452D8B-E7F1-4BD6-A57D- B136CE6C95BF}/GroceryList_FINAL.pdf

Mayo Foundation for Medical Education and Research (2011). Retrieved from: http://www.mayoclinic.com/health/quit-smoking/SK00056

Peel Public Health (2013). Smoking Cessation. Retrieved from: http://www.peelregion.ca/health/professionals/smoking-cessation.htm