Public Health Reflection on Care

Public Health Reflection on Care Title: Reflect upon an incident which occurred during your clinical placement as a student Public Health Nurse. The chosen incident is one where you met an elderly client with a leg ulcer who was not complying with the treatment prescribed from hospital. This essay is a reflective consideration of a case that had been encountered in clinical practice. For the purposes of illustrative discussion, I shall use the Gibbs model of reflection as a guide. (Gibbs, G 1988) Description: describe in c.400 words the experience. Client fell at home and fractured lower ankle. He neglected this and developed ulcer. He attended GP and completed 2 courses of antibiotics: referred to leg ulcer clinic in local hospital; diagnosis was ulcer with mixed arterial / venous disease. The client concerned will be anonymised and referred to as Mr.S in accordance with the NMC guidelines (NMC 2004). Mr.S is a 68 yr old man who lives alone having been widowed for 12 years. He is normally self caring but has been getting progressively more frail as time goes by. He fell at home and fractured his lower tibia. There was a suspicion that he has been drinking rather more than might be considered good for him and it is possible that this fall was after a bout of drinking. (Nicol M et al. 2004). Being generally very stoical, he initially ignored this but was forced to seek medical advice when the pain got too great. The fracture was treated with a plaster cylinder after reduction of the fracture but he subsequently developed a leg ulcer from direct pressure and friction from the cylinder which eventually attained a size of about 10 15 cms across and, despite being referred to the leg ulcer clinic and having regular visits from the community nurse who applied Aquacell AG , it refused to heal. (Harding K G et al. 2002) It was subsequently discovered that after the nurses had been to clean and dress the leg, Mr.S would take the dressings off and put iodine onto the wound which produced a marked allergic reaction. When challenged about this he said that he â€Å"didn’t hold with these newfangled ideas† and that he wanted to use a remedy that his grandmother had used with great success when she had developed a leg ulcer. Initially there was an impasse with the nurses wanting to use the dressings that had been prescribed by the hospital and Mr.S, although allowing them to be out on, would promptly disturb them and put the iodine directly onto the wound. The community nurses were asked to persist with the dressing regime and after a few weeks it became clear that the leg ulcer was making no progress at all. It was not healing, it was permanently infected and persistently sore with inflamed and macerated wound edges. (Donnelly A et al. 2000). There was considerable discussion in the primary healthcare team relating to Mr.S’s right to autonomy (Seedhouse D 1998) and whether it was right or not to continue to commit large amounts of resources to a clinical situation that was not only not healing but was actually being actively undermined and made worse by the patient. (Thomas J E et al. 1990). To an extent, it is not ethical to insist on, or to impose a treatment which the patient is (by word or action) objecting to. It is difficult to justify a course of therapeutic action, which may have the strongest of evidence bases, if the patient does not want it. (Hunt T 1994) The situation was compounded by the fact that Mr.S was not an easy patient to deal with as, since his wife died, he had become progressively more reclusive and he was clearly uneasy with other people coming into his house. The current course of treatment was clearly not successful and therefore a completely different approach needed to be tried. Feelings: how did client/you/others feel in this situation? How did you know this? The student was annoyed that the client was not complying with treatment and she knew the treatment he was applying was outdated and potentially harmful. Student is accountable to An Bord Altranais for their practice and must refer to evidence based practice. Student observed how the treatment applied by client had its place in the past and PHN made family aware that new dressings have silver content which has greatly improved results. Empowerment and advocacy were adopted. I found my feelings ran through an evolution of emotions and that the initial set of feelings were of annoyance, frustration and irritation that Mr.S could not see that the healthcare professionals were trying to help him. I initially saw him as a rude and aggressive gentleman who clearly did not want â€Å"interference† from the nurses and was content to live in comparative squalor. His persistence of the use of the iodine seemed to me to be mainly due to sheer perversity rather than any rational reasoning. (Osterberg L et al. 2005) I know that my original exchanges with him were very terse and aggressive, as I could not understand why he was persisting in using something which had no substantive evidence base and was clearly making the situation worse. My feelings changed to being less overtly annoyed as I came to realise that Mr.S was actually trying to use something that he had seen his grandmother use to heal her own leg ulcer and that there was a degree of reason beneath his obstinacy. My mentor took a different view and explained that empowerment and education (Howe J et al. 2003) was the way to achieve success with Mr.S and I watched as she firstly gained his confidence and then explained the reasoning behind the new Aquacell AG, she also explained that the iodine, far from helping healing was, in his particular case, preventing the leg ulcer from healing and that his situation was quite different from the situation of his grandmother‘s ulcer. (Miller, A. 1995). After about three sessions, it was noted that Mr.S had stopped interfering with the dressings and that the iodine was no longer being applied. As a result, the wound started to heal. As soon as he saw this, Mr.S became much more content to allow the nurses to continue with their work and actually became almost welcoming. (Faden, R R et al. 1986). At this stage, I found that my feelings changed to actually liking Mr.S and looking forward to each meeting. I also developed a great deal of respect for m y mentor and the other important realisation was a feeling of annoyance towards myself at my own initial inability to realise the motivation behind Mr.S’s actions. (Schon, D. 1997) Evaluation: what was good and bad about the situation? Mentor was able to develop relationship of trust with client. The bad elements of the situation was that the concept of empowerment and education (Howe J et al. 2003), was not embraced earlier in the treatment programme and that each treatment application was simply met by the acceptance that Mr.S was interfering with the dressings. There was the additional possibility that Mr.S was drinking more than was good for him and this element of the situation was overlooked with the prime focus being on the leg ulcer rather than making a holistic assessment of the whole situation. Equally bad was my inexperience-based lack of insight into the situation. On the good side, the fact that the mentor was able to â€Å"stand back† from the situation and make a dispassionate and empathetic assessment of the situation, construct an appropriate managements plan and then persuade Mr.S to comply with it to achieve a good clinical outcome, was a very positive step and a testament to the clinical experience of the mentor. Analysis: what sense can you make of the situation? what knowledge did or should have informed you? how does this connect with previous experiences? Reflection is necessary to enlighten a clinical situation. Element of compromise needed. Client centred approach required. Student PHN had experience of working as Community General Nurse. She found observing how the mentor dealt with the situation very enlightening. Discussion with clients family was beneficial. Analysis of the situation shows the potential gulf between the pursuit of evidence based medicine and the practical difficulties in actually applying it. It is all very well knowing that Aquacell AG releases ionic silver into the wound in a delayed and controlled release manner as the wound exudate is absorbed, thereby releasing more silver in the most contaminated wounds. ( Bowler P G, 2003). The fact that the dressing formulation itself is thought to protect the periwound skin and thereby aid in granulation formation is of theoretical importance. In cases of leg ulceration, the fact that the dressing conforms easily to the surface of the wound helps with occlusion and thereby maintains a moist healing environment (Jude E B et al. 2007) is clearly a substantial contribution to the evidence base in this area. The fact that dressing exerts a demonstrable antimicrobial activity for up to 7 days reduces the need for frequent dressing changes and therefore frequent wound disturbance (Jude E B et al. 2007) is of practical and clinical importance, but none of these factors are of any use at all if the patient does not understand or is willing to comply with the clinical therapeutic regime. In essence, this case illustrates the gulf between the knowledge that is assimilated in an isolated academic situation and the knowledge that is derived from experience in clinical situations. (Van Manen, M. 2007). It was my reflection on the situation that allowed me to appreciate the true value of my mentor’s experience and handling of the situation which was the critical factor in persuading Mr.S to understand both his predicament and the rationale behind the treatment that was being offered and this was the key to his eventual understanding and compliance. (Marinker M. 1997). It was clear that simply persisting with the situation was not going to achieve the desired effect and that a degree of compromise was needed. That compromise was achieved by viewing the situation from the patient’s viewpoint and then tailoring the clinical approach to an empathetic understanding of that perspective. In other words a client centred approach. (Platt, F W et al. 1999). The point about Mr.S’s drinking was no longer overlooked and discussions with his extended family confirmed the clinical suspicion. Pressure was exerted by the family to reduce the opportunities for his drinking and they increased the degree of social interaction (reduced his social isolation) which also had a beneficial effect (Wilkerson, S. A et al. 1996) Conclusion: how do you now feel about this experience? what else could you have done? has this changed my ways of knowing? I can say with confidence that reflection on this whole episode was a major learning experience for me. Not only did I witness and important lesson in patient management, but I was able to reflect on the evolution of my emotional approach to the situation. It showed me how my initial aggression and annoyance was not only completely misplaced, but that it was also completely counterproductive. As a conclusion, I have seen just how important it is to stand back from a difficult or deteriorating situation and make a completely dispassionate and holistic assessment of the patient and his clinical situation before trying to construct an appropriate management plan. A further conclusion must be that there is very little merit in simply knowing the evidence base surrounding a particular course of treatment if one lacks the experience or humanity to actually effectively put it into action. (Fawcett J 2005) Action Plan: if this arose again, what would you do differently? As I have already mentioned in the conclusion, it is because this episode was a major learning experience for me that I can say with confidence that, if a similar situation arose again, I would deal with it in a completely different way to the way which I handled this episode. I would not initially approach Mr.S with a feeling of aggression and annoyance as it proved not only to be counterproductive but it was also a barrier to my standing back and reviewing the situation. If Mr.S was clearly not complying with the treatment I would ask myself (and the patient) what were the reasons why compliance was a problem. Having ascertained the reasons, I would then construct an appropriate treatment or management plan which directly addressed this reason and contained a mechanism for directly confronting it. Empowerment and education have been demonstrated to me as very powerful tools in the quest for patient compliance and concordance. I would actively use these concepts to try to maximise t he effectiveness of the treatment and also to enhance the overall patient experience. (Hewison, A. 2004) References Bowler P G, 2003. Progression towards Healing: wound infection and the role of an advanced silver-containing dressing. Ostomy Wound Management 49 : (8) Suppl. 2 5 Donnelly A, Alistair M Emslie-Smith, Iain D Gardner, and Andrew D Morris (2000) ABC of arterial and venous disease : Vascular complications of diabetes BMJ, Apr 2000; 320 : 1062 1066. Faden, R R, Beauchamp, T L. (1986) A History and Theory of Informed Consent Oxford University Press New York. 1986 Fawcett J (2005) Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories, 2nd Edition. Boston: Davis Co 2005 ISBN : 0-8036 1194 3 Gibbs, G (1988) Learning by doing: A guide to Teaching and Learning methods. EMU Oxford Brookes University, Oxford. 1988 Harding K G, Morris H L, Patel G K. (2002) Healing chronic wounds. BMJ 2002; 324 : 160 163 Hewison, A. (2004) Management for Nurses and Health Professionals : Theory into practice. Blackwell Science: Oxford. 2004 Howe J, Anderson M (2003) Involving patients in medical education. BMJ, Aug 2003 ; 327 : 326 328. Hunt T (1994) Ethical issues in Nursing. London : Routledge 1994 Jude E B, Apelqvist J, Spraul M, Martini J. (2007) Prospective randomised controlled study of Hydrofiber dressing containing ionic silver or calcium alginate dressings in non-ischaemic diabetic foot ulcers. Diabet Med. 2007; 24 : 280 288. Marinker M.(1997) From compliance to concordance: achieving shared goals in medicine taking. BMJ 1997; 314 : 747 – 8. Miller, A. (1995) The Relationship between Nursing Theory and Nursing Practice. Journal of Advanced Nursing 10, 417 424. Nicol M, Carol Bavin, Shelagh Bedford-Turner Patricia Cronin, Karen Rawlings-Anderson (2004) â€Å"Essential Nursing Skills† 2nd ed. Churchill Livingstone, Mosby 2004 NMC (2004) Nurse Midwifery Council: Code of professional conduct: Standards for conduct, performance and Ethics (2004) London : Chatto Windus 2004 Osterberg L, Blaschke T (2005): Adherence to medication. N Engl J Med353 : 487 – 497, 2005 Platt, F W Gordon G H (1999) Field Guide to the Difficult Patient Interview 1999 Lippincott Williams and Wilkins, pp 250 ISBN 0 7817 2044 3 London: Macmillian Press 1999 Schon, D. (1997) Educating the Reflective Practitioner. Jossey Bass, San Francisco. 1997 Seedhouse D (1998) Ethics; the heart of health care. London, John Wiley Sons 1998 Thomas J E Waulchow W J (1990) Well and Good : Case Studies in Biomedical ethics. Broadview Press 1990 Van Manen, M. (2007) Linking Ways of Knowing with Ways of being Practical. Curriculum Inquiry 6 (3), 205 228. Wilkerson, S. A., Loveland-Cherry, C. J. (1996). Johnson’s behavioral system model. In J. J. Fitzpatrick A.L. Whall (Eds.), Conceptual models of nursing: Analysis and application (3rd ed., pp. 89-109). Stamford, CT : Appleton Lange. 1996

Heights of Oppression

The hands maid tale is skillfully woven book that touches on plenty of issues. Though the book was written 1985, it has received present time praises that have increased its sales over the past few years. Serializing of the book on film also drew critics to it as it raised many touching issues; love, politics, religion, gender, language and sex among many other many other contemporary issues that still spark debates in the 21st century. We must acknowledge that the writer employed interesting writing styles to clearly depict the themes she wanted so as to achieve the rewards of a timeless masterpiece. Repetition to create emphasis was the main writing device. The recent buyers have had the motivation to acquire and read the book because each of them can at least find a sentimental issue to connect to from the book. My literature review will delve into on one theme from the book that will capture the attention of most of the readers because the society at large is by all means connected to it.I chose the theme of oppression because there a many people that will connect to this due to its diversity. In this theme are many other sub themes that can be expounded on; social oppression, religious oppression, economic oppression, gender oppression among many other forms. This paper is to make the audience aware of pressing issue and around them and motivate them to act to emancipate themselves. I will gauge the effect of my work according to how I will captivate my audience. The connection that my desired audience will feel towards my review will prove the sweat I put in it to. I will use online reviews to build my case and scholarly articles prove my point. Relevant examples with connection to the issues around us will be elaborated in the discussion part of the research. First I will elaborate and give a general meaning to the theme then state the specific types of oppression I will be touching on depending on how the book has presented it in its characters and stage setting. The scholarly references and online reviews will be stated and I will use my own arguments; that I will mainly draw from my culture to explain how my society perceives the matter and their notions or decisions they have on it. Where possible, I will be stating the origin of the notions and what they eventually lead to; either more oppression or redemption. My introduction will begin with the statement problem as depicted in the book. That will be followed by the research materials and research methods I used to expound on my themes. Finally, I will explain the main reason behind my writing and how it will help the readers connect to the real time issues. When looking for online reviews, ones made by literature professors would be most preferable. When selecting scholarly articles; I will stick to ones that expound to the theme of oppression to prevent myself from derailing the theme or my audience the chance of questioning my relevance. The links between the book, the theme in question, the reviews and scholarly articles capped with my earnest opinion about how the society perceives the matter will define the credibility of my essay. The main objective behind the essay is to show the audience that there exist unseen problems in the society; ones that happen as a norm and that there are solutions to them. This paper really matters to the society as it will give a guide on many other themes in the book and show the way to liberation from their miserable status quos. IntroductionOppression is the central theme in the book as it lays foundation to all other evils in the book. Sexism, gender discrimination, religious oppression and classism all lay allegiance to the theme. The major part of the book is a recollection of events from the protagonist; Offred. She is giving her take to her new audience after she luckily fled the dreaded city of Gilead. The language she uses; gives vivid picture to the grotesque status quo she was in. the authors base of emphasis also stresses on the key theme; oppression. Gilean is an imaginary authoritarian city that came into being when there was a significant drop in fertility scores and with them a drop of birthrates. The ruling class saw it relevant to come up with laws that would class people for the roles they were to do in that jurisdiction. Women were the main prey under the claws; they were to strictly bear children. No education or jobs were given to them as they would pose competition to men and divert them from their main role; reproduction. Margaret's description to them through the protagonist is; a set of ovaries encompassing a womb. They were barred from talking alcohol, caffeine or nicotine as it would reduce their fertility. The paradox is that it is women other female characters that take pleasure in oppressing other women either to please the regime or themselves. The society has also been oppressed as they have been classified and color coded. Different colors specified roles and authority to be used over the subject.Research methodQualitative literature analysis is the method I have employed in the whole research. The characters in the novel handmaid's tale are ones that I have used to extrapolate the theme of oppression. The settings in the book and the mood it presents made the book a choice as they all blended significantly to the theme in question. Carefully reading the novel was the first step. I had to be precise so as to note the stylistic devices used and their motive in either backing or refuting of the theme. My understanding of the book was enhanced by specific reviews of it that targeted the theme at hand. In order to relate the theme with the issues in the 21st century, I referenced the reviews and my own findings to scholarly articles that touch on the present issues. Watching the television series also clarified my view as it clearly depicted the situation as it was during the scripting of the book. The mood, setting and ambience set in the movie were a clear replica of the ones in the book. Apart from focusing on these only, I also touched on the other main theme to gauge if they are the ones that catalyzed the oppression or if oppression was the base that all other evils in the book were built on. That I did so as to cast away the shadow of biasness and portray issues as they were set to be by the author in a bid to convince my audience that the issues in the book were the exact semblance of the issues they faced.ResultsEven from the prologue of the book it was clear that oppression was the wind that sails of the evils in the book rode on. To be precise, it was gender oppression that lay founding to the utopian city and sexism that paved way for the ruling class. My own analysis revealed that oppression was so deep that the individuals and the society saw it as a norm and had no hope or motive to redeem them at all. The analysis put to record that there exist 2 measures of oppressions; systematic oppression and individual oppression. Systematic was one imposed by the regime; the formulated draconian laws and individual oppression was one that the individuals forced themselves to believe that what was being done to them was right and that they better contend with it or risk an immature end. From the commentary and remarks that the series got I noticed oppression was still the center stage in the present societies. In the book we saw the blacks and the Jews being treated differently from the rest of the ruling class; the whites. They even had names tags to refer to them; racial oppression. We see that the laws hugely disfavored them and they were given the crudest of all jobs and invoked the harshest form of punishments; death. Religion was seen as a catalyst to the broadening of them theme and not a savior to the situation; religious oppression. Color coding was done define authority, privileges and roles. Here I saw no form of rebellion to it and a society that was treated quite highly than the other always exploited the ones that were below it. This treatment and exploitation was toned down to individual level and done in the most sleek and dreadful ways; we notice that the characters mused at themselves for stamping their authorities over others. Depending on who was doing the oppression, why it was being done and where it was being done led to diversification and further classification of the evil; dictatorship, racism, sexism and sycophantism. Those were the exact settings that were portrayed in the televised series yet it spurred a lot of critics that it invoked bitter dissent in people. DiscussionIn this part I will be giving my evidence in support in the systematic then individual oppression format backed by speeches of the characters in the book and showing the page numbers. I will further give my own views about the cause and course of the speech and the motive behind it according to the setting and the situation the character was in. I will back my claim with a scholarly article then finalize this chapter with how the issues relate in our present society across the globe. Systematic oppression was prevalent to the book as it the law of gender classification and prescribed women to reproductive roles only. Women were raped and the whole thing enshrined in the law that formed ‘The ceremony'. This is the law that gave rise to handmaids (himberg-2018). Women are given no choice as the ‘Aunts' force them to commit themselves to the profaning doctrines or choose between that, death and the ‘unwomen'. We see the Offred justifying the act by saying â€Å"..nor does rape cover it; nothing is going o here that I haven't signed up for† (artwood-94). It is her justification and compliance that depicts individual oppression.The law that handmaids were only bear children with generals was another form of systematic oppression (haghi-2016). Twisted religious definitions also added weight on this saying that their God considered it a sin. The handmaids and ones that impregnated them would face automatic death penalties if found out. In this case we see Ofglen describe Janine's despondency she thinks its her fault..two in a row for being sinful† (artwood-215). This was after Janine had lost two of her babies. Janine is not happy with the situation but she justifies it. That statement reveals the height of individual oppression and that melted the people's willingness to stand for themselves.The laws Gilean were so ruthless to law breakers or even purported law breakers. We see a police force called ‘the Angels' that was basically an execution squad set to squash rebels; systematic oppression. A holy nun, aunt Lydia even works as spy in addition to being an administrator to the monastery that bred handmaids. A wall is even built to display the corpses of the rebels. In the heights of all we see the Offred justify the people hanged on the wall â€Å"have committed atrocities and must be made into examples, for the rest† (artwood-42).ConclusionThe above examples can be related to the scenarios prevalent in the present times. Back in 2014 we saw boko haram in Nigeria abduct 200 school girls and take them to militia camps so that they could sire a new generation of rebels. These are the same scenarios where gender discrimination breeds, we are aware of some primitive societies like the Maasai in Kenya that do not allow their girls to get education and they believe that their role is strictly to reproduce and take care of men (myers-2018). If we tone issues down we will see the need to dissect why Arab states dictate that women should never be their leaders leave alone drive cars. When names of heroin ladies like Rewiyya, Briska Bernard, Sayidat Zuhal get mentioned we see that women all over the world need saving as the vice has become a norm in the societies we live in (rea-2017). it his high time that people stop viewing these vices as norms and see the reasons behind the laws formulated or their adverse effects. ReferencesMargaret Artwood- 1985The Handmaid's TaleS Haghi-2016Suppressing Agency: transitive analysis of Margaret Artwood's The Handmaid's TaleJ Rea-2017Lessons from handmaid's taleJ Himberg-2018The lavender menace returns: reading gender and sexuality in the Handmaid's TaleN Myers-2018Hearing voices among the indigenous Maasai women in Tanzania: implications for global mental health

Chomsky s Theory On Transformational Generative Grammar

Stage 1 Noam Chomsky is an American linguist, philosopher, cognitive scientist, logician, and political commentator. He was born on December 7th, 1928 in Philadelphia. He is sometimes referred to as the father of modern linguistics. He earned a PhD in linguistics at the University of Pennsylvania. He has been a professor at the Massachusetts Institute of Technology (MIT) since 1955. Chomsky has written over one hundred books in his life. He is known for his theories regarding linguistics. Stage 2 Theory Chomsky is famous for his theory on transformational-generative grammar, also known as the universal grammar theory. He believed that language is innate, meaning that humans are born with a capacity for language. He based his theory on the fact that it unclear as to how humans acquired the ability to speak a language. The absence of environmental influences still allows the human brain to have a pre-determined set of rules for how language works when one is born. Chomsky stated, The most striking aspect of linguistic competence is what we may call the creativity of language, that is, the speaker s ability to produce new sentences; sentences that are immediately understood by other speakers although they bear no physical resemblance to sentences which are familiar. The basic foundation for language is provided to us, and is shaped by experience and learning, according to Chomsky. Children have an extraordinary ability to use languageShow MoreRelatedStructuralism in Linguistics3428 Words   |  14 Pagesviewed by Chomsky and other transformationalists. 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The Blue Hotel - 1797 Words

Within a letter written to a friend Stephen Crane once wrote â€Å" I always want to be unmistakeable†. (Greenfield 564) Crane wanted his short stories and poems to be read and understood by all men. Despite criticism Crane enjoyed writing, and later wrote to another friend â€Å" my chiefest desire was to write plainly and unmistakeably so that all men (and some women) might read and understand† (Greenfield 562) Crane was a modern writer â€Å"He rejected both the theism and humanism of the nineteenth century†. (Canfield 391) Although Crane was not concerned with style or literary art, he became well known for his use of imagery. Crane became a notable success and was befriended and admired by some of the most important literary figures of his time,†¦show more content†¦While covering the war in Cuba as a journalist, Crane was aboard a ship that sank. He was stranded and left adrift at sea for thirty hours with three other men. The men rowed back to sh ore in a small life raft, but unfortunately, one of the men did not survive. Crane later wrote about his experience in one of his greatest short stories, â€Å"The Open Boat†. â€Å"Crane highlights the beauty and terror of the sea in â€Å"The Open Boat† and memorializes the complex nature of the ordeal†. (Pierce 161) Crane was unable to return to New York because of his scandalous relationship. Never very healthy, Crane began to weaken in 1898 as a result of malaria. He lived well above his means, became debt ridden, and wrote letters to his friend about his money problems. After selling â€Å"The Blue Hotel† Crane wrote to his agent stating: â€Å" Your payment from Harper’s knocked a comfortable hole in them (debts) but I must have about $1200 more. . . . I have big matters to attend to this month†. (Pierce 161) Pierce also states that Crane did not die from malaria or tuberculosis but â€Å"of the cause most common among American middl e class males- anxiety about money†. (Pierce 161) Crane became exhausted and overworked and died before the age of twenty nine on June 5, 1900. Cranes uses the literary element of conflict to gain the interest of his readers. Within the short story â€Å"The Blue Hotel†, the conflict within the short story is continuousShow MoreRelatedQuestions On The Blue Garden Hotel Grand954 Words   |  4 PagesRequirements One of the deliverables for the Blue Garden Hotel Grand is the hiring of a Marketing/PR firm. The estimated cost is $45,000 for this contract. 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