Mind Is Not a Vessel to Be Filled, but a Fire to Be Kindled Essay Example for Free

Mind Is Not a Vessel to Be Filled, but a Fire to Be Kindled Essay â€Å"Education† may be an ordinary word to most people, but very few actually understand the deep meaning beneath it. In this dynamic world, we need to be equipped with the necessary skills and hard work to survive. Understanding the education system is integral to allow students to understand the purpose of studying, the purpose of going to school everyday. Is education in Singapore really â€Å"holistic†? Are there flaws? What is education? By definition, it would be something along the line of â€Å" transferring knowledge†. I beg to differ. In my opinion, education consists of more than just knowledge. From Kindergarden to University, students are put through the daily routine of waking up early in the morning, going to a place where teachers teach â€Å"the same old stuff†. By that, I am referring to knowledge. Knowledge is power, you might say. Indeed, being knowledgeable helps you stand out among the rest during the tests and examinations. But is that all about education ? Acing the tests and getting a degree? I’m afraid no. Years after years, Singapore universities and institutions are well-known on the global front for being able to produce students with top grades. These results just keep getting better and better. Foreigners come to Singapore for education. Most people might therefore think education in Singapore is perfect. I also acknowledge that these are true, but only to a certain extent. On the other spectrum ( which is usually not shown), there are students who are not performing as well as their peers, students who are doing well but facing a lot of unnecessary stress. This is prevalent as well. The obsessive reliance of tuition to produce grades, online forums to discuss ways to â€Å"headstart my child in education†. I find no meaning in these. This is passive learning. Similarly, there are exceptional cases which bring out the ugly truth about education in Singapore. Students faking degrees to earn scholarships, jobs , graduates saying vulgarities during graduation ceremony to ‘rejoice’ over the achievements, even local scholar prosecuted overseas for doing unethical things such as watching child pornography. If education in Singapore is so perfect, why would such disgraceful incidents occur? Let us look at some possible reasons. Memorizing dictionaries, memorizing textbooks, doing thousands of assessment books, attending endless tuitions and supplementary classes†¦ These are some things most pupils in Singapore are going through. They have my sympathy. Everything I have described until now is about passive learning, which revolves around results and lacking in true meaning of education. Now, let us zoom into another aspect. Imagine this : a child who does his work consistently, revises on daily basis, reads newspapers everyday. Everything without being told. Seems like a utopian child? No. It is possible. The only thing he has compared to other students is the passion. The burning passion inside him to learn, to absorb knowledge. This drive pushes him to do everything on his own. There is no tuition, no supplementary classes, reasonable number of assessment books. Yet, this child is scoring ‘A’s for his subjects. In Singapore schools, Ministry of Education is encouraging a whole new approach towards â€Å"holistic† education. Co-curricular activities, Community Involvement Program, Civics Morals Education†¦ these are programmes put in place after much effortful planning of the education ministries. There are even more recent policies such as not revealing top students for national examinations such as Primary School Leaving Examinations. I respect them for that. However, there are rooms for improvement. CCA, short for co-curricular activities, is a word that is often hung in the pupils’ mouth. Whether they say it out of pride in a good way or bad way, I do not know. This brings me to the point of CCA mismatch. Students who feel they are â€Å"not good enough† for a CCA only after a few years in that CCA, students who feel indignant as they feel they could have gotten into â€Å"better CCA†. What are the consequences of this? Students not attending CCAs regularly, students complaining about how ‘ sien ‘ ( boring and uninteresting) their CCA is. This leads to stereotyping about CCAs and split between different CCAs, especially Sports vs Non-Sports. While you might say it is good that CCAs are bonded together as a team, the purpose of bonding is wrong. They are making fun of other people and things they do. In the long run, this will not work. Another thing is when pupils do not attend CCAs, the school has no choice but to use deterrence methods such as demerit points. To tackle this whole situation, there is Direct- School- Admission put in place to reduce scenarios like this however the success is limited. After talking about limitations of the current education system put in place, I have some suggestions. What I will say is also something simple : passion. Again, a simple word yet deep meaning behind it. If a student is an active learner, problems such as late/no submission of work, lack of focus during lessons, loss of notes, game/social networking addiction etc will all be eliminated at once. Students will not complain ‘ Life is Tough’ or ‘ There is too much work yet too little time’ etc. Teachers no longer have to chase after the students for work, give students boring supplementary classes. Teachers no longer have to scold students, which deviates their focus on teaching that will result in drop in productivity. This will lead to more supplementary/remedial classes which make students get tired of learning. Ultimately, they lose passion in learning. This evil cycle of mad chase, forced homework, drilled practice will keep on going until the students change their attitude. If the students take charge of their own learning, they will automatically focus during lessons and give constructive feedback that can engage the whole class in a positive manner. This will accelerate learning so much that the teachers will be more willing to teach and even plan fun activities for pupils to play and learn at the same time. At the same time, the students will strive to do their best in everything including daily worksheet, assignments. Ultimately, success ( which is good grades people chase after) will follow them. Therefore, I strongly feel that passion is much more important than knowledge. To put this passion in them, I think teachers, parents and students themselves all play a crucial role to ‘kindle the fire’ within them. They can help create encouraging environment to allow pupils to share their opinions on certain topics and letting them think ‘out of the box’. They can reduce things such elitism stereotyping to encourage the pupils to exchange feedback healthily and letting them learn from one another. Occasionally, having useful motivation courses in schools by professionals also might help. Once this fire is lit, the action will follow. Students will start finding joy in learning and unknowingly, they will get good grades without even getting stressed or tired.

Nurse-led Clinics in Respiratory Care: a Literature Review

Nurse-led Clinics in Respiratory Care: a Literature Review INTRODUCTION 1. What is a nurse-led clinic? As the coined term suggests, a nurse-led clinic is a health care centre in which nurses are involved in high level specialist procedures and assessments. In such centres, nurses are the critical decision makers, being involved in patient care at the micro-, meso-, and macro-levels. While the role of the physician in the provision of health care is undisputable, the deity-like status that medical practitioners typically have in the mind of patients, coupled with the limited time available for individual patient consultations, make it hard for these group of health care professionals to tackle the ‘softer’ side of patient care. Nurses, on the other hand, defined by the Oxford Medical Dictionary as health care professionals that are trained and experienced in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines, are better placed to provide this essential follow-up, especially in the care of patients with chronic dise ases. According to Hatchett (2003), a nurse-led clinic is a clinic in which nurses have their own patient case loads of whom they take complete charge. Hatchett broadly describes the components of such a clinic. There would be an increase in autonomy associated with the nursing role in the nurse-led clinic, with the power to admit, discharge or refer patients, as appropriate. In Hatchett’s own words, the roles which nurses adopt in these revolutionary settings can be broadly classified as follows (Hatchett, 2003): Education Psychological support Patient monitoring The initiation of nurse-led initiatives probably owes its origins to the rise in nursing specialties in the United Kingdom. Throughout primary and secondary care, nurses are taking senior positions in health care institutions, such as nurse specialists, nurse practitioners, nurse consultants, nurse prescribers, etc, leading to a marked change in service delivery and the profile of the nursing profession. In addition to the usual registered nurse training, nurses working at higher levels of practice receive training to acquire a range of other medical skills such as physical examination and medical history taking in order to recognise abnormal clinical findings. In a two-phase exploratory study to evaluate the domains of structure, process and outcome of nurse-led clinics in supporting intermediate care after the acute phase of disease, Wong et al (2006) interviewed nurses from 34 clinics and 16 physicians and observed 162 nurse-led clinic sessions. Their findings demonstrated the high level of skill and experience of the nurses who ran the clinics. Their work involved skills such as adjusting medications and initiating therapies, and diagnostic tests according to protocols. Interventions included assessments and evaluations, and health counselling. All patients studied showed improvement after the nurse clinic consultation, with the best rates reported in wound and continence clinics; satisfaction scores for both nurses and clients were high. However, although physicians valued their partnership in care with the nurses, they were concerned about possible legal liability resulting from the advanced roles assumed by these nurses. Ultimately, nurse-led clinics provide an integral and invaluable patient-centred approach to the management of chronic disease which build upon skills such as counselling, teaching and health promotion which are key to contemporary nursing practice, as well as newly acquired medical skills. The advent if nurse-led clinics provides an opportunity for nurses to develop enhanced roles in which they can achieve more autonomy in their practice. This can be made a reality if adequate training and education, as well as effective leadership are in place (Wiles et al, 2001). 2. The general roles of nurses in chronic care management The chief nursing officer, Sarah Mullally has proposed ten key roles for nurses in autonomous patient care. These are outlined below as cited by Hatchett (2003): Order diagnostic interventions: just like a medical practitioner would, the present-day nurse is able to ask for laboratory or clinical diagnostic tests to aid the process of diagnosis. Furthermore, a well-trained nurse will also be able to read and interpret laboratory results effectively Make and receive referrals directly: while the all-important roles of nurses are recognised, the need for a multidisciplinary approach to patient care remains key in order to optimise patient outcomes. Accordingly, nurses should be able to recognise the patients’ needs and refer them to the appropriate health care service as required. Similarly, nurses should be ready to accept referrals from other health care disciplines as necessary. Admit and discharge patients for specified conditions, within agreed protocols: in order to make the best use of the often limited hospital resources, a nurse should have the power to recommend patients for hospital admission and subsequent discharge Manage patient case loads: in nurse-led clinics, nurses are also responsible for managing their individual case loads. It is important to delegate patient cases to other members of the team, when necessary to ensure that patients receive the best care possible. Run clinics: the autonomous role of the nurse in a nurse-led clinic includes all aspects of the management and day-to-day running of the clinic. Prescribe medications and treatments: nurse prescribers are able to advise patients on appropriate treatment, based on diagnosis of ailment and individual characteristics and laboratory findings. Carry out a wide range of resuscitation procedures, including defribillation Perform minor surgery and outpatient procedures: especially in injury clinics. While nurses are probably not equipped to carry out full-fledged surgical operations alone, they are trained to conduct emergency processes as appropriate. Triage patients, using the latest information technology, to the most appropriate health care professional Take a lead in the way local health services are organised and in the way they are run Nurses have always been considered as a supplement to the fundamental care provided by medical doctors. In fact, in some geographical regions, nursing roles are limited to menial tasks such as changing bedpans etc. In the new age, the nursing role as we know it is becoming increasingly important with nurses taking on infinitely more clinical roles. This has led to controversial debates with critics arguing that nurses cannot replace doctors in the provision of health care services. As Richard Hatchett very astutely pointed out (2003), the increased autonomy being acquired by nurses is not a bid to compete with medical doctors. Instead, â€Å"it is a case of considering who can provide the most appropriate service to the patient† (Hatchett, 2003). Thus, it is clear that the roles of nurses in chronic care management is very diverse and can be integrated into any nurse-led clinic intervention to the utmost benefit of the patient and all stakeholders. There have been numerous studies on the role of nurses in the care of patients with chronic diseases. In addition, and more specifically, the feasibility and benefits of implementing nurse-led clinics in practice have also been investigated to some extent. In the subsequent sections, we will review the evidence to support these innovative nursing interventions in an attempt to make the best use of health care resources. 3. Nurse-led clinics in the management of chronic care diseases: the evidence The World Health Organization (2002) defines chronic diseases as health care problems that require ongoing management over a period of years or decades. The nature of these disease conditions make it necessary to provide long term care and follow-up for the afflicted patients. Nurse-led interventions have been investigated a wide range of chronic diseases. It could be a logical, user-friendly, cost-effective and practical approach to improving long-term patient outcomes and should be explored fully to maximise the contributions of nurses to the chronic care management. Although this review aims to analyse the effectiveness of nurse-led clinics in the treatment of respiratory diseases, a prior look at the role of these interventions in the management of other chronic care diseases will provide an insight to the general contributory roles of nurses and will serve as a foundation for complete understanding of this state of the art intervention. 3.1 Nurse-led interventions in the management of diabetes Numerous studies have evaluated the benefits and practicalities of nurse-led clinics in the long-term management of diabetes. The renal diabetic nurse specialist is described as an â€Å"essential player† in organising the management of, and to meet, all aspects of need of this group of patients (Marchant, 2002). An unintended benefit of a nurse-led clinic to reduce cardiovascular risk is improved glycaemic control, HbA1c (Woodward et al, 2005). In particular, nurse-led diabetic clinics have been shown to benefit specific ethnic groups. Matthias et al (1998) identified the needs of diabetic patients from minority ethnic groups, such as blacks and Asians and postulated that nurse-led clinics were of particular benefit in this patient group. As epidemiological data show that diabetes is most common in minority ethnic groups (Carter et al, 1996), the importance of these innovative interventions is further emphasised. 3.2 Nurse-led interventions in the management of cardiovascular disease Care of patients with cardiovascular diseases is broad and involves many aspects, from risk factor management (non pharmacological interventions), primary and secondary prevention of clinical events, pharmacological therapy, surgical procedures, etc. Through a large well-designed randomised controlled trial in Scotland, Campbell et al (1998) showed that nurse-led clinics were practical to implement general practice and led to an significant increase in various aspects of the secondary prevention of coronary heart disease. Significant improvements were noted in aspirin management, blood pressure management, lipid profile management, diet and physical activity, regardless of the individual patient’s baseline cardio performance or status. However, surprisingly, there was no recorded improvement on smoking cessation, which would have been a beneficial intervention in most acute and chronic disease states, including respiratory diseases. In addition to the apparent effectiveness of the nurse-led clinics in the long-term primary and secondary prevention of coronary heart disease, the optimal use of nurses in the care of these patients has been shown to be cost-effective in terms of quality adjusted life years (QALYs) (Raftery et al, 2005). In this large cost-effectiveness analysis, although the cost of the nurse-led clinic intervention was  £136 higher per patient, the differences in other National Health Service (NHS) costs was not statistically significant. Furthermore, there were 28 more deaths in the non-intervention group leading to a gain, in the intervention group, in mean life-years per patient of 0.110 and of 0.124 QALYs. 3.3 Nurse-led interventions in rheumatology The role of clinical specialist medical doctors in the care of their patients is unquestionable; however, the role of nurses in the therapy area of rheumatology (i.e. in patients with rheumatoid arthritis) is also well documented. Hill and colleagues (1994) clearly demonstrated the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Although this was a small study with a sample size that only included 70 patients, the statistical significance of the findings of this randomised controlled trial cannot be ignored. In patients managed in the Rheumatology Nurse Practitioner clinic, pain, morning stiffness, psychological status, patient management and satisfaction all improved significantly (p = 0.001; p = 0.028; p = 0.0005; p In addition, patient satisfaction is frequently higher in patients who are allocated to nurse care than those allocated to standard medical care (Hill, 1997). In yet another study by Dr Jackie Hill, a registered nurse at the Academic and Clinical Unit for Musculoskeletal Nursing in the Chapel Allerton Hospital in Leeds, the researchers concluded that a nurse-led clinic is effective and safe and is associated with additional benefits, such as greater symptom control and enhanced patient self-care, compared with standard outpatient care. 3.4 Nurse-led interventions in cancer care The effectiveness of nurse-led care in different common cancer afflictions has been researched variously. An extensive review article by Loftus and Weston (2001) discussed the patient needs that could be met by nurses working in nurse-led clinics and highlighted the experience and skills of advanced nursing practice that make such innovative care a reality. The types of nurse-led interventions are as varied as the different types of cancers for which they are used. These range from nurse-led telephone clinics in patients with malignant glioma (Sardell et al, 2001); nurse-led follow up in patients receiving therapy for breast cancer (Koinberg et al, 2004); and nurse-led screening programmes in Hong Kong Chinese women with cervical cancer (Twinn and Cheung, 1999). In a randomised controlled trial in a specialist cancer hospital and three cancer units in southeastern England, Moore et al (2002) assessed the effectiveness of nurse-led follow-up in the management of patients with lung cancer. The findings of the study showed high levels (75%) of patient acceptability. This negates the possibility of patients’ reduced confidence in nurses’ ability and preference for standard medical doctor care. Clinical outcomes were also greatly improved as shown by less severe dyspnoea at three months (p=0.03), better scores for emotional functioning (p=0.03), and less peripheral neuropathy at 12 months (p=0.05). 3.5 Nurse-led interventions in the management of HIV infection Using a rigorous model of comprehensive care nurse-led clinic in genitourinary medicine to compare nurse-led and doctor-led clinics at a central London medicine clinic, Miles and colleagues (2003) reported reliable and valid results to support the use of the nurse-led variety as an acceptable alternative to the existing doctor-led clinics. More specifically, the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) advocate the benefits that can be accrued from a nurse-led educational intervention in the care of patients with HIV infection (Poppa et al, 2003). A small pilot study that investigated the effects of a 6-month nurse-led educational programme reported that improved virological responses were seen in treatment-experienced patients (Alexander et al, 2001). While a majority of the studies on nurse-led clinics in other chronic diseases can be broadly applied to nurse-led care in patients with respiratory diseases, differences in the nature of these diseases and the necessary care pathways mean that the extent to which these tested interventions can be applied to other therapy areas is, in actual fact, limited. Government policies that advocate the clinical and economic effectiveness of nurse-led interventions frequently pool together evidence from all therapeutic areas. Indeed, it can be hypothesised that, if nursing interventions are shown be practical alternatives for medical care in complex diseases with poor prognoses, such as cancer, HIV and coronary heart diseases, care of patients with respiratory diseases which generally have better prognoses should be easily, effectively and safely undertaken by qualified and well-trained nurses. Nevertheless, these findings of the effectiveness of nurse-led interventions in the numerous chronic diseases explored in previous sections, should be applied to the different patient population with respiratory diseases. As much as possible, research findings from similar patient groups should be applied in clinical practice in order to ensure that evidence-based practice in this case is relevant. 4. Government policies influencing the establishment of nurse-led clinics Government health policies in the United Kingdom actively support the extension of nurses’ skills into areas such as nurse prescribing and the development of nurse practitioner posts (NHS Plan 2000; Department of Health). Government initiatives that that strive to reduce consultation waiting times and optimise the use of medical practitioners indirectly support the establishment of nurse-led clinics. The Government has endorsed the implementation of nurse-led clinics as a means of increasing access to specialist health care and treatment more quickly and also as an effective way to manage chronic conditions (Hatchett, 2003). In the Department of Health (1999) document, ‘Making a difference’, government plans for strengthening nursing contribution to health care is presented. The Government has launched an ambitious programme of measures to improve the National Health Service and the health of the public, and the role of the nursing profession in this initiative cannot be overemphasised. The key nurse-related points of the document are outlined below: To extend the roles of nurses, midwives and health visitors to make better use of their knowledge an skills – including making it easier for them to prescribe To modernise the roles of school nurses and health visitors in supporting the new health strategy and other policies To see more nurse-led primary care services to improve accessibility and responsiveness The document highlights numerous nurse-led initiatives that have been effectively implemented all around the United Kingdom. A nurse-led minor injury service in rural Cornwall has provided patients with a number of benefits: easier accessibility, reduced waiting times, reduced need for on-site medical; attendance, increased patient satisfaction and reduced need for transfers to local Accident and Emergency departments. Similarly, a nurse-led rapid response team in Peterborough responds to acute crisis cases and allows patients to be nursed at home. Evaluation has shown that 71% of patients referred to this ‘hospital at home’ service would have been admitted to hospital if the service did not exist. Other effective live nurse-led services include a nurse-led rheumatology service in Merseyside and a nurse-led intermediate care unit in Liverpool. Furthermore, several nurse interventions are advocated in the document for contributing to the management of cardiovascular disease. Several of these are also applicable to respiratory diseases; these include: Smoking cessation clinics using national smoking cessation guidelines Healthy lifestyle clinics in collaboration with other health professionals to address factors such as diet, nutrition and exercise, thus improving overall health Care for patients with congestive cardiac failure under ‘home-based’ initiatives Nurse-led chest pain clinics or risk factor screening and reduction clinics Nurse-led blood pressure clinics to identify and help manage blood pressure disorders and medication adherence 5. Review objectives The objectives of this review are: To briefly summarise various studies on effectiveness and cost-effectiveness of nurse-led interventions in common respiratory diseases To critically appraise the methods employed by these studies To evaluate, interpret, and where possible, compare the findings of the various studies To explore the applicability and generalisability of the results to practice in the appropriate patient population To make suggestions for future studies in this area. METHODS Literature search A search of two major databases, MEDLINE and EMBASE, was conducted to identify articles published from 1990 through 2008. Search terms that were used include nurse, nurse-led clinic, nurse-led interventions, respiratory diseases, asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, cystic fibrosis, cost-effectiveness analysis, cost-benefit analysis, and economics. A secondary search of the reference lists was then conducted to identify relevant articles, editorials, and other unoriginal reports that may have been missed in the primary search. Some studies were excluded based on the following criteria: They were not conducted in patient populations with respiratory diseases Independent nurse-led interventions were not investigated The study populations being investigated were mixed in terms of diagnosis, which would affect the integrity of the study findings for respiratory diseases The methodology and/ or statistical analysis methods were not clearly elucidated 6. Nurse-led clinics in the management of respiratory diseases: a review of the evidence The role of the specialist respiratory nurse has evolved since the early 1980’s with the support of the Royal College of Physicians (RCP 1981). The possible complexity of respiratory patients’ regimens necessitates support with various aspects of their care plans, such as: Supervising nebuliser and inhaler techniques Monitoring progress, i.e. by periodical assessment of lung function and exercise capacity Education on the specific disorder, medications, potential adverse events, etc Counselling and education on positive lifestyle, or non-pharmacological, changes Adherence support and monitoring The role has developed further with nurses providing nurse-led clinics in chronic obstructive pulmonary disease (COPD) and asthma along with nurses providing early supportive discharge and ’hospital at home’ for patients with COPD (French et al, 2003). Some schools of thought argue that nurse-led clinics would culminate in the neglect of the more traditional nursing roles, as nurses focus on a more medical-focused aspect of patient care. However, research in other therapy areas, such as rheumatology (Hill et al, 1994) and mental health (Reynolds et al, 2000) shows that nurses can effectively combine the medical role with the traditional nursing approach. Nursing care strives to provide a holistic approach to care through practical management of disability, education and counselling and referral to other health care services as required (Rafferty and Elborn 2002). 6.1 Bronchiectasis Nurse-led clinics have been evaluated, compared with regular doctor-led clinics, in a single randomised controlled trial in patients with bronchiectasis, a respiratory condition in which there is widening of the bronchi or their branches (Sharples et al, 2002). The study was a randomised controlled crossover trial including 80 patients in a bronchiectasis outpatient clinic. Patients received 1 year of nurse led care and 1 year of doctor led care in random order, and were followed up for 2 years. Various outcome indicators were used in the comparison, including lung function and exercise capacity, infective exacerbations, hospital admissions, quality of life and cost-effectiveness of the intervention. The results of this study are illustrated in Table 1 below. Table 1: Nurse-led and doctor-led care in care of patients with bronchiectasis (Sharples et al, 2002) Measurement outcome Nurse-led Doctor-led Mean difference (95% CI) p-value Forced expiratory volume in one second (FEV1) (%) 1.87 1.86 0.01 (-0.04 to 0.06) Forced expiratory volume in one second (FEV1) (L) 69.7 69.5 0.2 (-1.6 to 2.0) Forced vital capacity (FVC) (%) 87.6 87.6 -0.02 (-1.5 to 1.4) 12 minute walk distance (m) 765 746 18 (-13 to 48) Infective exacerbations (patient years of follow up) 262 (79.4) 238 (77.8) 0.34 Hospital admissions attributable to patient’s bronchiectasis 43 23 0.22 As the table above clearly shows, there was no statistical difference in FEV1/FVC percent predicted or distance walked between nurse led and doctor led care in the two treatment periods. Furthermore, 262 episodes of infective exacerbations were recorded by patients in the nurse practitioner-led care group in 79.4 patient years of follow up, compared with 238 in 77.8 years in the doctor-led care group. Thus, nurse practitioner-led care is associated with a relative rate of exacerbations of 1.09 (95% CI 0.91 to 1.30), p=0.34. Using the St Georges Respiratory Disease questionnaire to assess differences in health-related quality of life between the two groups, there was no statistically significant differences in each of the scores for Symptoms, Control, Impact or total score. Also, the study showed that nurse-led care resulted in significantly higher costs per patient compared with doctor-led care; this was largely due to the difference in the number of hospital admissions and intravenous and nebulised antibiotic costs. The authors concluded that nurse practitioner-led care for stable patients within a chronic chest clinic is safe and is as effective as doctor led care, but may use more resources. This study has several potential limitations which could invalidate the findings. As the study relied on patient report to record the prescriptions issued by general practitioners, these may have been underestimated and could grossly affect the cost analysis. Conversely, the nurse practitioner was required to record prescriptions and tests issued at the clinic, and thus these records are probably more reliable and she would be more likely to have ensured that patients left with supplies of routine treatment. Another possible drawback of this study is the use of a crossover design in the methodology. Unless a wash-out period is incorporated in the study design, there is the possibility of a carryover effect with crossover study designs, with the danger that the effects of the earlier treatment is falsely attributed to the final experimental treatment. In this study, there was no allowance for a washout period and thus this could affect the reliability and validity of the study results. This order and time effect needs to be checked for within the analyses but it can rarely be excluded as potential biasing factors (Pocock 1983). However, as recruited patients received the interventions in random order, this may negate the carryover effect. Despite the possible limitations of the study that could potentially hinder its applicability in practice, the findings support the implementation of a nurse-led clinic in patients with chronic cases of bronchiectasis as an alternative to the standard rigid medical care. 6.2 Asthma Similar to the findings in the study by Sharples and colleagues (2002) in patients with bronchiectasis, Nathan et al (2006) more recently compared the effect of follow-up by a nurse specialist with follow-up by a respiratory doctor following an acute asthma admission. In a single centre prospective randomised controlled trial, 154 patients admitted with acute asthma were randomly assigned to receive an initial 30-min follow-up clinic appointment within 2 weeks of hospital discharge with either a specialist nurse or respiratory doctor. The intervention comprised a medical review, patient education, and a self-management asthma plan. Further follow-up was then arranged as was deemed appropriate by the corresponding doctor or nurse, and all patients were asked to attend a 6-month appointment. Despite hospital outpatient follow-up, there was a significant proportion of patients in both groups who had exacerbations. However, there was no statistically significant difference between the two groups (Table 2). In the same manner, there was no statistically significant difference in quality of life assessed with two different validated questionnaires, the Asthma Questionnaire and the St George Respiratory Questionnaire. Mean change in peak flow at 6 months was similar between the two groups, probably indicating equivalence of the two tested interventions. Nathan et al (2006) concluded that follow-up care by a nurse specialist for patients admitted with acute asthma can be delivered equivocally with comparable safety and effectiveness to that traditionally provided by a doctor practitioner. Table 2: Nurse-led and doctor-led care in follow-up care of patients admitted with acute asthma (Nathan et al, 2006) Measurement outcome Nurse-led Doctor-led Odds ratio (95% CI) Mean difference (95% CI) p-value Change in peak flow 1.39 (-3.84 to 6.63) 0.122 Infective exacerbations (%) 45.6 49.2 0.86 (0.44 to 1.71) 0.674 Quality of life 87.6 87.6 -0.02 (-1.5 to 1.4) Asthma Questionnaire 0.78 (-0.64 to 2.19) 0.285 St George Respiratory Questionnaire 1.08 (5.05 to 7.21) 0.891 The possible limitations associated with this study is the large amount of missing data for some outcomes, especially peak flow and quality of life

Quality Healthcare Includes Empathy Essay examples -- Healthcare

Quality Healthcare Includes Empathy A man walks into an emergency room with an intense pain in his abdomen. He is hoping to find a doctor who knows how to treat him. The doctor enters his room and begins robotically palpating his abdomen, showing no hint of recognition for the pain he is in. The man begins to ask himself, â€Å"Does this doctor care that I am in extreme pain?† He then wonders, â€Å"If he doesn’t care that I am in pain, how motivated can he be to ease my pain?† This might seem like a silly question. If the physician didn’t care about healing people, why would he become a doctor? Modern technology has caused doctors to become complacent and emotionally detached from their patients. Doctors must be empathetic towards their patients in order to deliver quality healthcare despite the lack of time they have for their patients. The patient’s perception of the doctor in this situation is that he lacks empathy. Empathy can be described as the ability for one person to understand another’s feelings and thoughts. The role of empathy in healthcare is very important; more specifically, it is crucial for doctors to be able to effectively express empathy without compromising their primary objective, which is to diagnose and treat patients. While the science of medicine is primarily based on the function of the human body, it cannot be ignored that emotional health plays a vital role in a patient’s quality of life. Improving physical health will inevitably improve emotional health. The appropriate way to approach healing is with an understanding of this concept. In the article â€Å"Empathy in Medicine—A Neurobiological Perspective,† Dr. Helen Rice states: Empathetic physicians can obtain critical information and ins... ...tag=contentMain;contentBody Rice, H. (2010). Empathy in medicine--a neurobiological perspective. JAMA, 304(14), 1605. Retrieved from http://drscottwright.wikispaces.com/file/view/Empathy and Medicine - A Neurobiological Perspective.pdf Switankowsky, I. (2005). From detached concern to empathy: Humanizing medical practice. Humane Medicine Health Care, 5(2), Retrieved from http://www.humanehealthcare.com/Article.asp?art_id=834 Hardee, J. (2010, February 16). The role of empathy in healthcare. Retrieved from http://realbalance.com/index.php?option=com_content&task=view&id=143&Itemid=999 Torrey, T. (2011, September 13). [Web log message]. Retrieved from http://patients.about.com/od/therightdoctorforyou/a/docpatientcomm.htm Wolfe, S., Carome, M., Barbehenn, E., & Sasich, L. [Web log message]. Retrieved from http://www.worstpills.org/public/page.cfm?op_id=3

Women Portrayed in Horror and Film Noir Films Essay -- Film Movie Noir

Women Portrayed in Horror and Film Noir Films Works Cited Not Included Horror films have always been more attractive to the male viewer than to the female viewer. Why is that? Usually horror films mainly present the audience with very graphic mutilation and the raping of females, more so than their male counterparts. Horror films have always depicted females as either objects or as the victim of a horrible act. In Linda William's essay 'When the Woman Looks,' she says that 'there is not that much difference between an object of desire and an object of horror as far as the male look is concerned' (Jancovich 63). That is just the way horror films are, and they will probably not change anytime, because the women in the films usually grab the attention of males. This is why horror films are usually more pointed at the male view. Some males like to see women depicted as the punisher because they like seeing evil women in these films precisely for their viewing pleasures, sexual and otherwise. An online essay defines horror as, 'its true subject matt er is that of the struggle for recognition of all that society represses? (Niver). Although horror films as well as film noir films are usually fictitious, the violence depicted among women is real and they show the dark side of the human experience especially in women. In some horror films, females are ?often asked to bear witness to [their] own powerlessness in the face of rape, mutilation and murder? (Jancovich 61). Women, who have been traumatized by violence in any way, have to live with their emotions and feelings regarding their situations everyday of their lives.... ...is very scary is that ?one-third of women report being physically or sexually abused by a boyfriend or husband at some time in their lives? (Boss 357-358). These statistics not only happen in real life, but are also depicted on the big screens. They have been for years because it brings people to the movies and they find it interesting to watch. The statistics that are mentioned here need to be changed before it is too late. People and today?s society need to be more cautious of their surroundings, know who they are getting involved with and to try and not make stupid mistakes. Society needs to take more responsibility for their actions and sexual attackers need to be put in prison for a long time. Horror films and film noir films, just like society, do depict a lot of violence among women and they also show the dark side of the human experience.

David St. John :: essays research papers fc

The Work of David St. John David St. John writes of love in a pessimistic way in his collection of poems, The Red Leaves of Night. His writings suggest love is unattainable and his relationships with people (especially with females) are portrayed as negative. St. John creates a fallen man in his text, especially when his poems focus on his dilemmas with women. Psychoanalysis plays a large role in the writings of St. John being that he shows the effects of his downfall and the negativity the downfall incorporates. Lacanian psychoanalysis suggests our language is structured like our subconscious and full of desires. Lacanian analysis also shows that the  ¡Ã‚ §signs ¡Ã‚ ¨ in language are split between the signifier and the signified and the barrier between the two lead to unfulfilled desires. St. John ¡Ã‚ ¦s poetry is swarming with lines alluding to unfulfilled desires or a longing for things that simply cannot be obtained. St. John establishes the breaking of a psyche and through Lacanian analysis we can s ee that the desires expressed in his poetry will never be met. Through Lacanian analysis, we are able to see that St. John is seeking more, and wanting more substance out of relationships and his life that cannot be obtained. St. John is longing for a sense completeness yet his completion is something that can never happen. Lacan shows the human psyche in three parts, similar to that of Sigmund Freud. Lacan calls the three parts  ¡Ã‚ §Orders ¡Ã‚ ¨ and they consist of the Imaginary, the Symbolic, and the Real. The Imaginary is  ¡Ã‚ §the part of the psyche that contains our wishes, fantasies, and, most importantly, images ¡Ã‚ ¨ (Bressler 156). Lacan ¡Ã‚ ¦s major focus is in his theory that our psyche is lack and fragmentation.  ¡Ã‚ §We have longings for love, for physical pleasure ¡Kbut nothing can fulfill our desire to return to the Imaginary Order and be at one with our mother ¡Ã‚ ¨ (Bressler 158). Many of the poems in The Red Leaves of Night withhold the sense that St. John is yearning for something and is never complete. For example, in his poem  ¡Ã‚ §The Unsayable, the Unknowable & You ¡Ã‚ ¨ St. John presents a situation where he is completely captivated by a woman and lusts for more activity with her.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚    ¡Ã‚ §My prize: A night alone (again) with you,tracing/This brocade of sweat along your amber shoulder./Let ¡Ã‚ ¦s weave together the dawn ¡Ã‚ ¦s superior light-/A script of bodies, inscribed by the summer ¡Ã‚ ¦s night ¡Ã‚ ¨ (St.

Ryanair Pestel

Complete a PEST(EL) analysis as preparation for a scenario planning exercise next week. POLITICAL: †¢Due to severe security measures, they had to cancel 279 flights and refunded 2. 7mâ‚ ¬. A loss of 1. 9mâ‚ ¬ in reduced bookings †¢Aer Lingus was fundamentally opposed to a merger with Ryanair, even if it raises its price †¢12. 6 % of the shareholding controlled by Aer Lingus, whose members rejected the offer by a 97% majority vote †¢Opposed to the BAA airport monopoly plans to build a 4bn gold plated Taj Mahal at Stansted SOCIAL: †¢Europe’s leading budget airline August 2006, Air Transport World magazine- most profitable airline in the world †¢72% negative response from a poll of readers of the Financial Times for one of its initiatives †¢In 2006, its employees count by more than 700, to 3. 500 people, comprising over 25 different nationalities †¢In 2006, it was voted the world’s least favourite airline because of the unfrien dly staff, delays and poor legroom †¢The airline formerly refused to provide accommodation or meal vouchers when flights were cancelled or delayed, until it became illegal to do so in 2005ENVIRONMENTAL: †¢Deploying more efficient aircraft that use less fuel and produce less pollution †¢Concerns about greenhouse gases from carbon emissions †¢Replace its fleet of old aircraft with new, more environmentally-friendly aircraft, reducing the average age of its fleet to 2. 4 years †¢New aircraft produced 50% less emissions, 45% less fuel burn and 45% lower noise emissions per sea ECONOMIC: Its average paid was 49612â‚ ¬, a higher figure than any other major European airline †¢August 2006, Air Transport World magazine- most profitable airline in the world †¢Cost-cutting/yield-enhancing measures for passenger check-in and luggage handling could save more than 1â‚ ¬ per passenger †¢Web based check-in and priority boarding, save costs on check-in s taff and airport facilities, as well as time †¢By tailoring rosters, they maximised productivity and time off for crew membersTECHNOLOGICAL: †¢Web based check-in and priority boarding †¢Fleet of over 100 new Boeing 737-800 aircraft and firm orders for a further 138 new aircraft to be delivered over the next six years †¢Stronger passenger safety: body searched, banned from carrying liquids and gels in their carry-on luggage LEGAL: †¢Complying with EU regulations which impose a ceiling on pilot flying hours to prevent dangerous fatigue †¢In litigation with various airport over landing charges Accused it of misleading passengers on its website by exaggerating the prices of its competitors in making comparisons †¢Following flight cancellations due to increase in security measures, they decided to file two legal cases against UK government †¢In 2005, new legislation that offered compensation cost to passengers affected by delays, cancellations or d enied boarding

Formative and Summative Assessment Essay

Assessment is a term that includes all of the various methods used to determine the extent of an individual’s achievement. In teaching and learning situation, assessment refers to the methods used to determine achievement of learning outcomes. Similarly in professional contexts, assessment is concerned with the achievement of professional standards or competence.(Aranda & Yates,2009). Assessment also provides a number of major benefits including: †¢ Grading: assessment may be used to define achievement and to measure the students’ preparedness for professional challenges. †¢ Motivation: assessment may focus on real learning by creating an opportunity that carries with it the rewards of completion or grades. †¢ learning process: assessment activities can guide individuals to learn and relearn subject content efficiently. †¢ Feedback: assessment provides opportunities for individuals to monitor the quality of their performance and identify areas for improvement. PURPOSE OF ASSESSMENT It is easy to become so immersed in the job of teaching that we lose sight the exact purpose of a assessment. There is then the possibility that we are overlooking another form of assessment which might be more appropriate. We actually assess students for quite a range of different reasons – motivation, creating learning opportunities, to give feedback (to both students and staff), to grade, and as a quality assurance mechanism (both for internal and external systems). Because all too often we do not disentangle these functions of assessment, without having really thought it through assessments are frequently trying to do all these things, to varying degrees.(Oxford Brookes University,2011). In fact it is arguable that while it is desirable for assessments meeting the first three of these functions to be conducted as often as possible, the final two do not need to be done anywhere near so frequently; it is simply important that they are done somewhere. The implications of this are that while an essay question, where all the answers are double marked and the marks count towards the students’ final grades, may fulfil all these functions, for all assessments to be this rigorous would be prohibitively expensive in staff time, while a peer-assessed seminar presentation, which does not count towards the students’ final grades but is simply a course requirement, could fulfil the first three functions and may not even require a tutor to be present. FORMATIVE ASSESSMENT Formative assessment is typically contrasted with summative assessment. The former supports teachers and students in decision-making during educational and learning processes, while the latter occurs at the end of a learning unit and determines if the content being taught was retained.(Wikipedia,2013). Formative assessment is not distinguished by the format of assessment, but by how the information is used. The same test may act as either formative or summative. However, some methods of assessment are better suited to one or the other purpose. CHARACTERISTICS OF FORMATIVE ASSESSMENT During formative assessment, learning is the shared goal of both teacher and student and alterations to the teaching and learning process take place as needed to further the goal. This allows both the teacher and the student the opportunity for assessment and improvement as an ongoing process instead of an end product. Formative assessments are assessments for learning, rather than assessments of learning, according to the Association for Supervision and Curriculum Development. Focused Formative assessments are focused on the learning process as well as the learning progress. While other assessments may only focus on the end result, formative assessments check the students progress consistently so that adjustments can be made to reach learning goals. Ongoing A formative assessment is consistent and ongoing throughout the learning process. It differs from assessments that focus on the end result. Ongoing assessments give both teachers and students the chance to make adjustments to teaching and learning strategies so learning ultimately takes place. Immediate While other forms of assessment focus on the end result, formative assessments provide immediate feedback to both teachers and students due to ongoing assessment practices. The immediate feedback teachers and students experience can be used to motivate and further learning. LIMITATIONS OF FORMATIVE ASSESSMENTS Although offering many benefits, effective formative assessment can be difficult to achieve at scale. It may be logistically impossible to provide detailed descriptive feedback for each student in a large class. Even with a smaller number of students to deal with, formative assessment is time-consuming as it requires significant, ongoing dedication and effort from the teacher to sustain. This is especially true when combined with the summative assessments teachers are required to complete. The layered accountability chain in education — student to teacher, teacher to school, school to district, etc. — creates systemic pressure for student performance to be objectively and comparatively measurable at each level. Formative assessment, by definition, doesn’t easily provide that kind of accountability. This explains why, although the advantages of formative assessment have been repeatedly articulated since the distinction between it and summative assessment was first made in 1967, empirical studies continue to show that very few teachers consistently make use of it in actual practice. SUMMATIVE ASSESSMENT Summative assessment measures attainment and allows for the recording of the learning progress. It usually takes the form of tests and examinations, though it is becoming increasingly common for summative assessment to include other tasks such as a project completed during the school year. This move away from assessments based on a single examination gives learners the opportunity to perform to the best of their ability. Not all learners perform well under examination pressure. Furthermore,examinations do not always lend themselves to eliciting the range of language structures and uses that have been the objective of teaching CHARACTERISTICS OF SUMMATIVE ASSESSMENT The results of summative assessment allow us to determine the degree to which learners have attained specific learning objectives. Such a decision may have an important consequence on learners’ future prospects. It is therefore crucial that not only is the assessment valid, but that the results obtained are reliable. Validity relates to whether the assessment tasks assess what they intend to assess. Reliability, on the other hand, refers to the results obtained and whether these would be the same if the same learners took the assessment on another occasion provided that no further learning had taken place and regardless of who marked the assessment if more than one person was involved in the process. (Summative assessment,2005). Whether summative assessment is norm-or criterion-referenced will be determined by the purpose of the assessment. If we need to select the best candidates to, for example, continue with their education, then norm-referencing would be appropriate. However, if we are interested in whether candidates have mastered certain skills, then we would not get the required information through norm-referencing.(Meason) For example, when assessing airline pilots we are interested in whether they can fly a plane safely to a very high level of proficiency. Knowing which trainees were the best would not suffice since it is possible that no trainee of a given group would have reached the required standard to safely fly a plane LIMITATIONS OF SUMMATIVE ASSESSMENT Students can face anxiety in preparation for a test, an anxiety that grows as the perception of the test’s significance grows. Summative tests advise schools to commit to prolonged pretesting procedures and preparation classes, which can increase student anxiety.(Spiral). In addition, some students simply do not test well, and the result is a testing procedure that fails to adequately assess the real talents of individual students, while a formative assessment would allow a teacher to evaluate these conditions and better assess a student’s ability Summative assessments fan have an overall negative impact on student self-esteem, resulting from the perception of inferiority that standardized tests can give test-takers. Students who perform poorly on standardized tests were found to suffer from lower self-esteem in situations where these same students had not previously exhibited signs of self-esteem problems.(Boggiano,1992). Even students who perform average or well on standardized tests can suffer from the failure to meet their own higher expectations. The result can be a reduction in educational motivation.(Hammond). EXAMPLES OF FORMATIVE AND SUMMATIVE ASSESSMENT FROM TEACHING AND LEARNING PERSPECTIVE CONCLUSION In my view,both types of assessments are better,that is a balanced assessment.A balanced assessment system in one in which a variety of assessments are used for a variety of purposes and communications about results facilitates student involvement and ownership of learning.Formative assessment can be vital importance in helping the teacher and students determine the quality of learning that is taking place and can allow them to forecast the results of summative tests some time in advance of the summative testing.Such results can be used as the basis for altering the teaching learning situation early enough to change the immediate as well as alter the forecast. Learning is a process which can be observed and evaluated as it is taking place.Formative evaluation can be used to make the process more effective long before the summative evaluation.Recognition of the interaction among formative evaluation teaching and learning and summative evaluation can do much to improve teaching and lea rning before it is too late. REFERENCES Aranda S,Yates P.An Overview of assessment.Canberra: (EdCaN),Australia;(2009).Retrieved from: www.edcan.org/pdf/edCanOverview.pdf Boggiano A,Pittman T. Achievement and Motivation: A Social-Developmental Perspective.(Eds).(1992).Cambridge Press.New York. Hammond,K.eHow.Education.Summative assessment weaknesses.Retrieved from: http://www.ehow.com/info_8568251_summative-assessment-weaknesses.html Meason C.eHow.Education.Characteristics of Formative assessment.Retrieved from http://www.ehow.com/list_6732311_characteristics-formative-assessment.html Oxford Brookes University.(2011).Purpose of Assessment.Retrieved from: www.brookes.ac.uk/services/ocsld/resources/assessment/purposes.htm Spira M.eHow.Education.Disadvantages of Formative Assessment.Retrieved from http://www.ehow.com/info_8502289_advantages-disadvantages-formative-assessment.html Stiggins,R.,Arter,J.,Chappuis,S.(2008).Classroom assessment for student learning.Educational Testing Service.Retrieved from: http://www.bcsd.org/district.cfm?subpage=55380 ‎Summative assessment.(2005).Retrieved from http://cd1.edb.hkedcity.net/cd/eng/tba_eng_sec/web/3_1w.htm Spira M.eHow.Education.Disadvantages of Formative Assessment.Retrieved from http://www.ehow.com/info_8502289_advantages-disadvantages-formative-assessmen