Gulf Coast Medical Center Essay Example | Topics and Well Written Essays - 1250 words

Gulf Coast Medical Center - Essay Example On the other hand, the presence of radiologists and the hospital administrators will ensure understanding of the issues with delay in scheduling procedures with the facility. Therefore, while physicians would be able to more easily identify the likely problems causing the unusually long time each procedure takes, the administrators and managed care companies might be better able to identify issues related with time it takes physicians to schedule a slot at the facility. The Shewhart Cycle proposes a four-step process of continuous quality improvement which includes: Act, Plan, Check and Do (Shewhart, 1980). Creating a work group to identify the relevant issues with the facility is obviously the first step, i.e. 'Acting'. The outcome of deliberations of the work group which will identify the relevant issues and propose steps towards resolving these issues is the Planning stage. The outcome of the work group will be critically appraised in the light of activities and practices of competitors and what is obtainable in evidence based practice, for viability; which is the 'check' process. Lastly, once the feasibility of these recommendations has been ascertained, implementation will follow. Reduction in the time and processes required for physicians to get a procedure slot in the facility by 40% after six months and keeping up with what is obtainable from competitors within th... Improving customer perception of the facility through better cleanliness, reduced charges and increased follow up screens. d: Measuring the Success of the Work Group The success of these measures would be measured by Reduction in the time per case from 1.5 hours per case to 55mins per case in the first six months and down to the national average of 50mins per case after 12months. Reduction in the time and processes required for physicians to get a procedure slot in the facility by 40% after six months and keeping up with what is obtainable from competitors within the next 18months. Better customer perception of the facility as measured by increased return rates for follow up screens and better customer satisfaction feedbacks. 2. Dealing with Physician Perforation Rates The medical profession being a human endeavor is prone to errors, miscalculations and other human errors, and the endoscopy services is not an exception. Several government documents have acknowledged the fact that medical error is a human fact (Linda, et al., 1999). Therefore, perforation after colonoscopy is no an unusual thing, however, the rates should not be too high. Thus to deal with the high physician perforation rates in the Gulf Coast Endoscopy Facility, the first step would be to get better commitment from physicians. The facility should be able to ensure that physicians get a procedure slot without having to go through so much time wasting processes and requirements. Furthermore, the facility should be placed in a better competitive position, through cleaner and tidier environment, better facilities, so that the improve customer levels will encourage the physicians to do better jobs (Wennberg, 2005, Kaiser Family Foundation, 2004). However, besides the

Interoffice Memorandum Essay Example for Free

Interoffice Memorandum Essay The Tarasoff case involved a murder victim, Tatiana Tarasoff, who was killed by an alleged acquaintance Prosejit Poddar. Poddar was a client of a psychologist employed by the University of California, and during a therapy session he revealed his intent to murder Tatiana Tarasoff. The psychologist assessed Poddar as a danger and informed the campus police, and was held briefly and released. Shortly after Poddar was released he indeed murdered Tatiana. The parents of Tatiana Tarasoff, plaintiffs, sued the school, campus police, therapists and anyone else who had contact. The argument was over whether the third party had the right to be warned and had the right to be protected. The defendants maintained they owed no duty of care to the victim, and were immune from suit. The court stated that when a client presents a serious danger of violence to another there is an obligation, both legal and ethical, to use reasonable care to protect the intended victim against such danger. The therapist must take steps to determine or within their standard of profession determines the danger. This may call for the therapist to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps reasonably necessary under the circumstances. This ruling imposes a liability on all human service professionals to protect a victim from violent acts. There is a duty to protect and a duty to warn the potential third party victims to violence. This may cause implications with the confidentiality of the client-helper relationship and may also cause violent clients to avoid treatment. This indeed will change the environment for human services and confidentiality; as now helpers may need to divulge confidential information to third parties in certain circumstances. The professional necessity of keeping a client’s information private is rooted in the ethical codes as well as in statutory law. As professionals in the human services realm we also have a right to withhold confidential information in a court of law. To stay within the law and the code of ethics that govern us it is necessary to consider the situation from all points of view, develop a list of issues that represent multiple viewpoints, generate the possible decisions on whether to break client confidentiality, and what would the consequences of each decision. Each case in which the outcome of this case may implicate the duty to protect and warn, we must make sure we are addressing every avenue within a small amount of time in case of imminent danger that exists. This will be an adjustment with our client-helper relationships, and must be shared not only with each other but also shared with our clients.

Improvement Is Better Than Delayed Perfection

Improvement Is Better Than Delayed Perfection Question-Continuous improvement is better than delayed perfection  Mark Twain (1835-1910). Analyse this statement critically and rigorously with reference to appropriate literature sources. Introduction This essay will be looking at the importance of quality and continuous improvement at a glance within an educational context. The writers interest in the topic is merely to explore and understand the essence to which every establishment for whatever purpose it was built upon should strive in continuous improvement to services rendered to its customers and the community at large while maintaining quality services. The focus is to highlight any flaws within the organisational practice with which quality could still be improved upon for the good of the whole community. The structure of the essay will take an explicit interpretation and description of quality and continuous improvement while portraying an interventionist stance at the conclusive statements made at the end of the essay. Literature review The concept of Quality Quality management is a systematic way of guaranteeing that organized activities happen the way they are planned. It is a management discipline concerned with preventing problems from occurring by creating the attitudes and controls that make prevention possibleà ¢ By Philip Crosby Writings in 2008, Winch and Gingell state that during the 1990s it became fashionable to talk about ËÅ"quality in education. Part of the reason for this is a renewed interest in accountability. Why should the concern for accountability be expressed in terms of quality? One major reason is that concerns about whether or not a particular form of education is worthwhile have been expressed in terms of a paradigm derived from manufacturing industry. ËÅ"Quality in a commercial context strongly connotes product usefulness and reliability. ËÅ"Quality assurance refers to systems that are robust enough to ensure that products that are defective or unreliable simply do not get made. The idea, as one quality guru has said, is to ËÅ"get it right first time. Of course, an artefact can be scrapped or reworked if it is defective, but a service cannot. If it is not ËÅ"right first time then it is not right. Some effective quality assurance systems ought to be particularly relevant to service are as of economic activity. Whether or not it is in the private or the public sector of the economy, it is sometimes maintained that education has the characteristics of a service industry. In particular, if education is poorly provided then there is no second chance for the recipient. A diner at a restaurant who has a badly cooked meal will feel disgruntled but will suffer no permanent damage. On the other hand, the pupil who receives a poor education may not even feel disgruntled but may suffer permanent damage in terms of future life prospects. It is, then, not surprising to hear that a key feature of educational accountability is the provision of quality assurance systems. Every aspect of leadership and management across all sectors of most organisations require a sustainable approach towards ensuring quality and sustainable measures are being utilised and developed within a global context. This includes measures which most leaders would adopt towards maintaining and sustaining the strategic aims of any organisation with due considerations of internal and external forces which influences the decisions made each day. An example of what entails leadership that is sustainable through quality measures can be found in a school management system. Where the Head teacher aspires to have very committed students who have good grades, a good school structure and a qualitative staff that would help the school achieve its strategic objectives successfully. But during the process of strategising for an academic year other factors comes into play i.e. customer service, effective acquisition and deployment of resources, school budget for the academic year etc. There may be a number of key factors that would help achieve such success Firstly, a well-devised system of service evaluation process of Search-Feedback-Act that could be put in place involving all employees, not just management or teachers, in developing plans for improvement. Secondly, all employees could be given considerable education and training to help them improve service quality and would actively and systematically encourage creativity and innovation. Thirdly, the organisation that may move away from measuring quality purely by the number of complaints it gets from customers and the impressions of the head of personnel department. Instead, organisations implement a multi-factor index which includes quantitative points such as the length of time customers have to spend being tested into the school, and qualitative points such as the friendliness/politeness experienced at reception. The concept of Continuous improvement Continuous improvement has been successfully used by the Japanese for a number of years, and the Japanese word kaizen is used to describe it. The idea of kaizen is not to sit back once improvements have been made to a product, but to be almost like bees working away at a hive. Each does a little at a time, but by adding on an incremental basis they can eventually produce something that is much larger and better. The issue of quality can be approached in the same way, so that very minor changes over time can result in a considerable improvement in performance. For example, the levels of fuel efficiency in the average saloon car have improved dramatically over recent years. This has been made possible due to the cumulative effects of continual minor changes in car body shape, fuel delivery systems and engine design (.Porter, K., Smith, P., Fagg, F. 2006). Foskett, N., Lumby, J. 2003 states that the third way of defining quality (in regards to continuous improvement) is to match the current state with an imagined future improved state. In other words, individuals or groups not necessarily take as their comparator an existing standard or expectation but, rather, work creatively to suggest ways to which a current aspect of education could be improved. This definition is realistically based on working form what exist to what could be achieved. It is a universally applicable in theory in that ideas for improvement will take into account resources and political realities. However, the emphasis on continuous improvement is predicated on a degree of autonomy and power that may not exist in all institutions or cultures. If governments impose a structure or curriculum on schools/colleges, or if the internal management structures are hierarchical and controlling, then the freedom of staff, parents and students to suggest ways forward is clearly constrained. This idea of continuous improvement can be linked to Demings(1986) idea of Plan, Do, Study and Act, where a problem is examined, information is gathered and a plan to improve it is suggested. The ËÅ"Do part is when the plan is tested on a small scale, followed by the ËÅ"Study stage, where evaluation of the trial takes place to see if any other issues have arisen. The ËÅ"Act stage is where the plan becomes standard and is carried out continuously. This leads back into the ËÅ"Plan stage for further analysis. The question then arises of how one assures the quality of education. There are two answers which are not necessarily incompatible with each other. The first focuses on processes, the second on outcomes. Process-based quality assurance relies on observation of teaching and learning and the activities that support it, as the key determinant of whether the education being offered is worthwhile. Inspection is the most common form of process quality assurance. Outcome-based quality assurance relies on the assessment of the outcomes against certain pre-agreed standards. Examination and testing are the most common forms. Leadership Approaches Qualitative leadership skills in educational management revolve around factors described below: Identifying the key issues Improving Customer satisfaction and ways of measuring it Customer care training employees and setting standards Employee involvement in overall goals of the organisation. Improving quality observation and benchmarking Reflection and conclusion Quality and organisational culture- Foskett, N., Lumby, J. (2003) stated that Quality can also be relative to cultural norms. What appears to be quality provision for pre-school children in China will look very different to western eyes and vice versa. They further noted that measures of Quality by definition are dependent on numeric values in relation to, e.g., examination passed or examinations met, but such values do not necessarily capture the variety of outcomes expected of education or the dynamic changes in expectations in the experiences of even the learner, let alone the all those of an institution. Quality will therefore remain a fluid and nebulous concept, interpreted variously in practice, an orthodox to which many feel indebted to follow. No single prescription will secure improvement in quality in a context as complex and animated as a school or college. The most that an educationist can do is to remain aware of the imprecision of the concept and be sensitive to both th e educational and micro-political forces which affect its achievements, choosing with care from the plethora of taxonomies, philosophies, good practice and recommended process they can offer. Methodology Qualitative researched literature review was adopted which typically includes positivist, interpretive, constructionist, critical, and participatory paradigms. The researchers perspective stems from the long documented history of naturalistic observation in real-world situations. Views of positivism range from conservative to progressive-activist, but all involve the belief that reality is external to self and can be observed using tools that produce information that can be understood and interpreted by others. The essay is linked historically to social activism through the idea that social situations can be studied, critiqued, and subsequently changed. The essay may have collected data through observations or various forms of instruments and often derive explanations for their results from pre-existing theory without concern for whether the study population understands or agrees with their views. a literature review is very much a plural rather than a singular one as there are many literatures a researcher must examine to produce a coherent literature review. For example, by doing qualitative research, the researcher is joining an ongoing debate in some shape or form. The originality of an idea, an approach, or a theoretical reinterpretation adds to existing literature. The objective of this entry is to describe the plurality of literature, to underline the difference between general and specific literatures, to highlight how to use theoretical literature as a tool to increase understanding of a subject area and test a research question or hypothesis, and to examine the methodology and data literatures that form important parts of the research process.( GIVEN, M. L. 2008) Data findings on quality and continuous improvement in educational context. Wherever an educational operation is based, whether it is public or private, it needs customers, and consumer choice has increased dramatically over the past twenty years because of three factors: globalisation, technology and competition. Technology Technology provides opportunities and threats. The development of computer technology in the form of online and blended learning, podcasts, webcasts and blogs can and increasingly will provide consumers with the option of new self-study methods and the choice to learn with an organisation in a foreign country while living at home or working in the office. At some point translation software may even negate the need for some people to learn a foreign language. These technologies, however, also provide organisations with opportunities to provide new methods of learning and new means of communication with customers. The rise of online learning and blended learning programmes, plus the expansion in state education of new technology [such as interactive whiteboards] means that students are increasingly more techno-literate. It also means that as technology develops and becomes more part of our everyday lives, students generally expect language classes, which in some cases take up a large p art of their disposable income, to be technologically well-equipped. The exponential growth of technology cannot be ignored as the speed of technological advancement is unlikely to slow down. Competition Competition may come from new organisations entering the market, as mentioned above, but it may also appear in other forms. As other countries gain economic power, their languages become more important and people begin to study them to enable them to enter that economy. This phenomenon has already been observed (Graddol, 1997) with Spanish, Arabic and Mandarin expected to gain importance over the next decades, eventually becoming a serious threat to English as a foreign language. As economies develop, education is becoming increasingly important as skill becomes essential to finding work. An increasing number of courses are becoming available, especially in the field of computers and information technology, which compete with ELT for customers, particularly within the training budget of major companies. Gaining an Edge over Competitors If an organisation has an element of its service which is different or more attractive than its competitors it is said to have achieved competitive advantage. Gaining competitive advantage requires a cross functional approach between an aspect of marketing which gathers data about customer needs and expectations and the day-to-day operational functions that translate those market needs into operational capabilities. The roles of marketing and managing the day to day operation are often taken by one person in small organisations, which can make it easier to translate customer needs into operational reality. In a small private language school of ten teachers, for example, the director may be the focal point for information about the local market, the local economy, the type of customers the school serves and how they feel about the service. In a school of this size the director may also be the person who decides what courses are offered and whether the market is best served by, for example, offering expensive one-to-one ESP tuition for business professionals or cheap general English courses for classes of 20 students. A not-for-profit organisation may also consider pursuing a particular strategy based on the kind of customers it serves. For example, a charitable or state ELT organisation may decide to provide cheap walk-in English classes for disadvantaged mothers to attend as and when they have time. In this case, flexibility is the key to satisfying the customer and gaining competitive advantage. The three factors of globalisation, technology and competition mean that educational organisations have to pay increased attention to the needs and expectations of existing and potential customers to retain them and to attract new ones. By gathering information on customers needs and through market analysis organisations can develop a service which is different or more attractive than that of competitors. (Walter. 2001) Conclusion If stakeholders allow ourselves to get caught by the short-term disease of modern management, non-thinking, market-driven practices then the idea of sustainable organization is out of the question. Also the chance of ever reaching the levels desired will be eliminated in all but the shortest of measures. It is necessary for every leader of the future to know enough about the moral side of business and how it could be approached with sacrificial aims through which sharing and upholding several values together among competitors would improve upon global problems. Or how the socio-economic profit of the organization could be able to express or aid the concerns required to reflect a longer-term view of the community at large. I would recommend that every leader in every spectrum or field of study to bring about ways through which the underlining influences bordering the choices we make in life (in regards to quality and continuous improvement) should reflect upon the healing societal issues rather than competing. Just as we know in the history of human relations over time that competition brings about a chaotic state while the harmony of shared values and sacrifices brings about societal cohesion and benefits all. References Crosby, P. (1980) Quality is Free. McGraw-Hill. Deming, W. (1986) Out of the Crisis. MIT. Foskett, N., Lumby, J.(2003) Leading and managing education-International dimensions.London. Paul Chapman Publishing Given, M. L. (2008)The SAGE Encyclopaedia of Qualitative research methods. California. Sage Publication series Graddol, D.(1997) The future of English. London. The British council Porter, K., Smith, P., Fagg, F. (2006) Leadership and Management for HR Professionals Oxford.Butterworth-Heinemann Walker, J. (2001). Clients Views of TESOL Expectations and Perceptions The International Journal of Educational Management 15/4. MCB University Press http://www.emeraldinsight.com/Insight/viewPDF.jsp?Filename=html/Output/Published/EmeraldFullTextArticle/Pdf/0600150404.pdf Walker, J. (2007)Service Climate in New Zealand Language Centres Journal of EducationalAdministration 2007 Volume: 45 Issue: 3 http://www.emeraldinsight.com/Insight/viewPDF.jsp?Filename=html/Output/Published/EmeraldFullTextArticle/Pdf/0740450305.pdf Winch, C., Gingell, J.(2008) Philosophy of education. Oxon. Routledge publishers

Within-Class Ability Grouping Essay -- Essays Papers

Within-Class Ability Grouping As a future educator ability grouping is more than likely going to be a part of my classroom. I think it can and will be a valuable tool in effectively teaching all students of varying abilities. Ability grouping is a greatly debated area in the field of education. Opponents to the practice believe ability grouping is detrimental to learning and student self-esteem, but ability grouping, specifically within-class ability grouping, can be very effective in teaching children. The students are able to learn at a pace that is suitable to their individual abilities and teachers are able to construct lessons that are specifically geared towards each level. Within-class ability grouping necessitates flexibility and frequent interactions between student and teacher to determine whether or not the child is in the proper group. In ability grouping the "high achievers benefit from having to compete with one another" (Hollifield, ERIC database). The low achievers in a group of children of simila r level feel more comfortable and are, therefore, more willing to participate. Children should not be put into groups in every subject area, but rather in a few areas where grouping has proven beneficial. "Low-achieving students seem to learn more in heterogeneous math classes, while high and average achieving students suffer achievement losses—and their combined losses outweigh the low achievers’ gains" (Loveless, internet). Regrouping for mathematics and reading has proven effective. The students are in heterogeneous groups for most of the day, but then are grouped according to level for those two subjects. "Results indicate that regrouping for reading or mathematics can improve student achievement. However, the l... ...teacher Mrs. Petrigala: November 17, 2000; Michael’s first grade teacher Joshua Hammond: November 22, 2000; 10 year old son Sara Hammond: November 22, 2000; 12 year old daughter Works Cited Goldberg, Miriam L., Joseph Justman, and A. Harry Passow. The Effects of Ability Grouping. New York: Teachers College Press, 1966. Hollifield, John. "Ability Grouping in Elementary Schools." [online]. Http://ericae.net/edo/ED290542.htm. Lou, Yiping, et al. "Within-Class Ability Grouping: A Meta-Analysis." Review of Education Journal 66 (1996): 423-458. Loveless, Tom. "The Tracking and Ability Grouping Debate." [online]. Http://www.edexcellence.net/library/track.html#anchor393575. Slavin, Robert. "Ability Grouping and Student Achievement in Elementary Schools: A Best Evidence Synthesis." Review of Educational Research 57 (1987): 293-336.

Morbid Obesity The Problem Health And Social Care Essay

Fleshiness is a medical status in which unnatural surplus fat has accumulated in our organic structure. Obesity has reached epidemic proportions in populations. Harmonizing to the Food and Agriculture Organization of the United state, 850 million people worldwide were undernourished in the old ages between 1999 and 2005. Genes and unhealthy life style do play a function in the development of fleshiness. Obesity besides associated with several comparatively common diseases such as diabetes, high blood pressure, bosom disease ( CVDs ) , and some malignant neoplastic diseases. So, I feel that is of import to hold an effectual intervention that can assist them lose weight for good. I am traveling to discourse the a possible solution for this job in this study.BMI = Weight in Kilograms / Square of tallness in metres.Obesity-image001 SoA A BMI = Kg / square MS. orA A A BMI = Weight ( pound ) * 703 / tallness ( inches ) 2 BMI is indexed as follows for mention: BMI A & lt ; 18.5 A = A Underweight BMIA 18.5 – 24.9 A =A Normal weight BMI A A 25 – 29.9 = A Overweight BMIA A 30 – 39.9 =A Corpulent BMIA A & gt ; 40 = A Severely corpulent Table 1: Body mass index ( BMI ) is the most simple and utile index to gauge organic structure fat. Overweight is the index people are being corpulent. hypertext transfer protocol: //www.obesity-cause-symptoms-treatment-cure.asp.htm ( 207 words ) bmiCompGraphSimple_-1661997252_Small Graph 1: Graph of BMI & gt ; 30kg/m2 by differents state for ages 15+ in 2005, harmonizing to the research made, the figure of people acquiring fleshiness is increase along the old ages in many state. hypertext transfer protocol: //www.who.com/obesity/BMI Based on the graph, the prevalence of fleshiness is increase dramatically in all Europes and United States. This observation is support in the book Obesity, Etiology Assesement Treatment and Prevention preface by Jack.H.Wilmore and edited by Ross E Andersen. ( 308 words )A possible solutionAfter making some research, I have found that bariatric surgery is the most effectual method in assisting those who are holding fleshiness. There are two types of bariatric surgery that are most common usage which are cut downing the volume of the tummy ( e.g. by adjustable stomachic stria and perpendicular banded gastroplasty ) , which produces an earlier sense of repletion, and cut downing the length of intestine that comes into contact with nutrient ( stomachic beltway surgery ) . Adjustable stomachic stria. MMPE_01NUT_06_01_eps Figure 1: Laparoscopic Adjustable Gastric Banding ( LAGB ) Restrictive processs [ 24 ] A silicone set is puting around the top of the tummy utilizing cardinal hole surgery. It so making a little pouch and a narrow transition into balance of tummy. No film editing or stapling of tummy involve. It will cut down the tummy gap where the gorge and tummy meet. The size of gap can be adjusted or controlled by increasing and diminishing the volume of saline solution inside it, through a port placed under the tegument. Patients usually can travel place after 1 or 2 after surgery [ 22 ] . ( 485 words ) Roux-en-Y stomachic beltway surgery. MMPE_01NUT_06_02_eps Figure 2: Laparoscopic Gastric Bypass Malabsorptive processs [ 25 ] The tummy is divided and a little pouch which limits Calories is formed silmutaneously as the bulk of the tummy is sealed of. A part of the little bowel is so divided and sewn to the freshly created little tummy pouch. It can be performed as the unfastened surgery or laparoscopic surgery [ 23 ] . †Forty per centum are utilizing the set and 30 per centum are utilizing are utilizing the marker † By Dr. Mal Fobi top bariatric sawbones Actually, it is based on the sawbones on taking the most appropriate type of bariatric surgery for the patient. ( 592 words )Effectiveness OF Bariatric SurgeryBariatric surgery is effectual in dainty fleshiness by lose their weight. It besides said have less complication therefore do it most suited as a intervention. †I do n't desire to be chesty, but I popularized the fleshiness surgery in America † By Dr Mal Fobi top bariatric sawbones Figure 3: Singer actress Jennifer Holliday, weighing 340 lbs is shown in this 1982 file exposure with the Tony award she won for her work in the Broadway knock Dreamgirls. In 1989 Dr. Fobi done beltway surgery on her and she lost 200 lbs until today she managed maintain her weight. [ 32 ] Graph 2: Shows decrease in organic structure mass index over clip ( B ) and percent surplus weight lost over clip ( degree Celsius ) after laparoscopic duodenal switch and concurrent processs [ 31 ] . ( 719 words ) I have found the effectivity of bariatric surgery based on the research done in the 1995 in Florida. The research included 34 patients who had undergone either a stomachic beltway ( RYGBP ) ( N=30 ) or a perpendicular banded gastroplasty ( VBG ) ( N=4 ) . The mean follow up period was 6 old ages. The per centum weight loss ( % EWL ) was 66 % . †When asked, most patients agreed that if they had to make it over once more they would ; merely two said they would non † based on research done in Florida in 1995 [ 32 ] . All the informations above are dependable beginnings since the informations are all in different beginnings but still shows about the same consequence in the effectivity of bariatric surgery. The writers of these beginnings are good known people that had done their research on bariatric surgery. Although, all the surveies showed the old ages that can be see out to day of the month comparison to now but this proven that the engineering in that clip is possible in overcome fleshiness by surgery. Therefore, now we have advanced in engineering which makes surgery go more effectual in dainty fleshiness. For illustration, now we have laparoscopic technique instead than open surgery which minimize the cut on the tegument and complication during carry out the surgery. ( 918 words )Social and economic deductionsSOCIAL EFFECTSWhen people are acquiring fleshiness it is really the beginning towards many fatal diseases particularly cardiovascular disease ( CVDs ) . This may take to the unhealty society in a large figure. Since people acquiring disease from the consequence of fleshiness that can likely do a patient bash non capable to execute their day-to-day activities particularly go to work and do a big load to their households and friends particularly their loved 1s. In the movie of play series †Manjalara † in TV3 which illustrates a teenage miss holding an fleshiness, it conveys the palpably existent hurting of household and loved 1s. Sometimes she besides being humilliated by others particularly by some of her relations and friends. The surgery done do work-albeit with side effects-and she are acquiring better after that [ 2 ] . Furthermore people with fleshiness tend to acquire emphasis when they are strive to cut down their weight. Some of them seek many medical specialties including pills, herb teas, and even utmost manner by non eating or others likes holding binge-eating syndrome and aneroxia nervosa syndrome of fearing acquiring weight addition that cause an inauspicious effects in their wellness. Some of Herbal weight loss pills are non regulated by the Food and Drug Administration. So there are no limitations to go around hazardous and unsafe herbal weight loss pills in the market [ 3 ] .Economic EffectsMedical costs associated with corpulence and fleshiness may affect direct and indirect costs ( Wolf and Colditz, 1998 ; Wolf, 1998 ) . Direct medical costs may include preventative, diagnostic, and intervention services related to fleshiness. Indirect costs relate to morbidity and mortality costs. Morbidity costs are defined as the value of income lost from decreased productiveness, restricted activit y, absenteeism, and bed yearss. Mortality costs are the value of future income lost by premature decease [ 4 ] . Corpulent air riders demand the offering of wider seatsA in the aircraft. A survey reveals that corpulent riders are bing air hoses and other clients an estimated $ 75,000,000 US dollars a twelvemonth [ 3 ] ( 1242 words )Benefits and hazardsSurgeryOne survey of bariatric surgery, found a weight loss of between 14 % and 25 % ( depending on the type of process performed ) at 10A old ages, and a 29 % decrease in all cause mortality when compared to standard weight loss steps. A pronounced lessening in the hazard of diabetes mellitus, cardiovascular disease and malignant neoplastic disease has besides been found after bariatric surgery. Marked weight loss occurs during the first few months after surgery, and the loss is sustained in the long term. The most common perioperative complication is wound infection ( in approximately 3 % ) ; the most common late complication is anastomotic tummy stricture ( in approximately 5 % ) . Patients should be monitored every 4 to 6 hebdomad while weight loss is rapid ( normally about the first 6 minute after surgery ) , so every 6 to 12 minute. Weight and BP are checked, and eating wonts are reviewed [ 8 ] . ( 1472 words ) Type of comparing Gastric Bypass Gastric Band Duration of processs 1 – 4 hours 0.5 – 2 hours Length of twenty-four hours 2-3 hours A 1 – 2 yearss Postoperative addendums MVI, Fe, Ca MVI, Ca Estimated weight loss 50-75 % EBW 40 – 60 % EBW Side effects Dumping syndrome Vomiting Short term complications DVT/PE, anastomotic escape, pouch escape, GI hemorrhage DVT / PE, port-site infection, esophageal perforation Long term complications Gasterojejunostomy stricture, Fe lack anemia, Ca lack, B12 lack, fringy ulcer, internal hernia set slippage, device escape, eroding into stomach/esophagus, pouch expansion, device infection Mortality rate 0-1 % 0-1 % Table 2: Comparison between Gastric beltway and Gastric set ( bariatric surgery ) hypertext transfer protocol: //www.jpma.org.pk/full_article_text.php? article_id=638Alternate solutions1.Anti-Obesity Drugs/MedicationBesides surgery drugs, medicine besides can be utile to handle fleshiness. Most weight-loss medicines are â€Å" appetite-suppressant † medicines. Appetite-suppressant medicines promote weight loss by diminishing appetency or increasing the feeling of being full. These medicines decrease appetite by increasing 5-hydroxytryptamine or catecholamine — two encephalon chemicals that affect temper and appetite [ 13 ] . There are two types of drug intervention which are individual drug intervention and combined drug intervention.GENERIC NameTrade NAME ( S )Phentermine Adipex-P, Fastin, Ionamin, Oby-trim Sibutramine Meridia Table 3 – Prescription Weight-Loss Medication, illustration of drug intervention approved by the U.SFoodAndDrugAdminstration ( FDA ) for short term and long term usage. hypertext transfer protocol: //www.athealth.com/prescription medical specialties.html Proactol is one of the new drug which is clinically proved and recommended by the professional. ( 1612 words ) †It is hence encouraging to see that a merchandise like Proactola„? offers a healthy manner of doing it easier to take charge of your weight and eating wonts. It besides turn toing issues beyond weight direction, such as take downing cholesterin and equilibrating blood glucose fluctuations. † † ( Dr. J GruenWald had to state about Proactola„? ) clinical_study Graph 3: The graph shows how the proactol works to adhere the fat. hypertext transfer protocol: //www.proactol.com Proactol drugs can adhere up to 28 % of our day-to-day fat consumption, lower blood cholestrol and act as of course supressing your appetency. Proactol drugs have been trial and passes all of the guidelines set by the EU Directive ( MDD/93/42/EEC ) . It is 100 % side effects free [ 14 ] .2.Screening procedureNowadays we have dedicated pysicians, dieticians, physical therapist to assist those who have obesity by talk to those who are expert.Initial testing procedure include: Individual audiences with our physicians Nutrition reding including anthropometric informations assemblage and organic structure fat appraisal Behavioral alteration therapy ( 1768 words ) Physical activity guidance and exercising prescription [ 5 ] In order to contend and get the better of fleshiness one should non contend and stand entirely since they need support and aid from others.3.Social theraphySocial therapy is the therapy that involved the action taken by household, authorities and society in overcome this job either among themselves or others. What are you making about the environment? The city manager has outlined a program to hold a park within a 10-minute walk of all New York City occupants. This is portion of an attempt to make an even more walkable and bicycle-friendly metropolis. ( New York City and the Public Health Interview with Thomas R. Frieden, M.D. , M.P.H. Commissioner of the New York City Department of Health and Mental Hygiene Interviewed by Xavier Pi-Sunyer, M.D. ) [ 6 ] . †Prof Anthony R. Leeds † †¦ For each kilogramme of weight lost, there is some metabolically active thin tissue lost with it. ( 1919 words )LocationStairss to Help Prevent and Decrease Overweight and ObesityHomeReduce clip spent watching telecasting and in other sedentary behaviours Build physical activity into regular modus operandisSchoolsEnsure that the school breakfast and tiffin plans meet nutrition criterions Supply nutrient options that are low in fat, Calories, and added sugarsWorkCreate more chances for physical activity at work sitesCommunityPromote healthier picks including at least 5 helpings of fruits and veggies a twenty-four hours, and sensible part sizes Create chances for physical activity in communities Table 4: Stairss to assist prevent and overcome fleshiness in different topographic points. [ 4,7 ]( 2026 words )3. Using Devicess: Palm runing system and PocketPC 2003 Treat overweight and fleshiness harmonizing to the Clinical Guidelines on Overweight and Obesity in Adults with this free synergistic plan for usage on Palm runing system and PocketPC 2003 devices of your manus that allows you to instantly bring forth individualised and evidence-based appraisal and intervention recommendations for each patient at the point-of-care that mention to the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report and the Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults [ 9 ] . Features include Body Mass Index computation, appraisal of cardiovascular disease hazard factors, and finding of demand for intervention. ( Palm OS devive and Pocket Personal computer 2003, National Heart Lung and Blood Institute ) .PDA imagesFigure 4: Palm OS devive and Pocket Personal computer 2003, National Heart Lung and Blood Institute ( 2174 words )EvaluationProactol have been found to cut down fleshiness efficaciously since it is clinically proved and 100 % side effects free based on the mention hypertext transfer protocol: //www.proactol.com/side effects or are at that place practol side effects.htm. It besides been recomended by many physician and dietitions therefore make it a dependable beginnings. It besides shows equal reviewed consequences and certified by many administration such as UK vegetarian society and France ECOcert SAS. I have besides found the other beginnings ( Win control information web ( WIN ) coaction with national institutes of wellness and U.S section of wellness and human services and besides information services of national institute of diabetes and digestive and kidney diseases ( NIDDK ) .prescription.htm ) . This web gives the information about the side effects of drugs taken. It explain about the usage of label and which drugs are aprroved by nutrient and drug adminstration. It is a dependable beginnings since the information are from national and many other administrations. ( 2331 words )BibiliographyWebsitehypertext transfer protocol: // hypertext transfer protocol: //www.obesitytherapy, /a turning job for United Kingdom populations.html, herbal weight loss pills.htm, not medical consequences.htm hypertext transfer protocol: //www.CDC.gov Centre for Disease Control and Prevention/economic consequences.htm Sime Darby Healthcare.com/Obesity_Clinic.aspx.htm The Expert Weighs In New York City and the Public Health/October 2007 Obesity Management DOI: 10.1089/obe.2007.0063 Obesity treatment.htm Fleshiness and metabolic syndrom: Merck Manual Home Edition.html NHLBI Health Information Network at NHLBIInfo @ nhlbi.nih.gov www.obesity-cause-symptoms-treatment-cure.asp.htm hypertext transfer protocol: //www.WHO/obesityandaverweight.index.html hypertext transfer protocol: //www.wikipedia.com/obesity.htm hypertext transfer protocol: //www.athealth.com/prescription medicines.html Proactol % 20Side % 20Effects.htm Fleshiness and corpulence for professional: informations and statistics: U.S fleshiness tendencies Genomicss, resources, diseases, fleshiness editorial.htm hypertext transfer protocol: //www.obesitypanacea.com obesity.htm hypertext transfer protocol: //www.obesitystockphotoimages.com free fleshiness pictures.html hypertext transfer protocol: //www.wikipedia.com/obesity.htm 10 Healthy Dieting Tips Obesity Therapy.htm Good primary attention is the fleshiness medicine.htm International diary of fleshiness: 10 Healthy Dieting Tips _ Obesity Therapy.htm A © 2009 Nature Publishing Group, a division of Macmillan Publishers Limited. All Rights Reserved. spouse of AGORA, HINARI, OARE, INASP, CrossRef and COUNTER hypertext transfer protocol: //patentdocs.com utilizations of egfr inhibitors to forestall or handle fleshiness hypertext transfer protocol: //www.weightlosssurgerymalaysia.com/weight-loss-surgery-laparoscopic-adjustable-gastric-banding-sleeve-gastrectomy-gastric-bypass-laparoscopic-bilio-pancreatic-d hypertext transfer protocol: //www.umm.edu/weightloss/roueny.htm Heisler, J 2009. What is The LapBand Weight Loss Surgery. Available from: hypertext transfer protocol: //www.surgery.about.com/od/proceduresaz/a/AdjGastrBanding.htm. Heisler, J 2009. Understanding Gastric Bypass Weight loss Surgery. Available from: hypertext transfer protocol: //www.surgery.about.com/od/proceduresaz/a/RouxEnYWLS.htm.TelevisionMedia Prima telecasting web in Malaysia ( TV3 play series MANJALARA ) , showed in 7 Mei 2007 with 75 episodes directed by Khabir Bhatia.BooksPearson instruction limited 2008, edexcel AS biological science. International edition, Campbell, reece, 6th edition publish by pearson instruction. Fleshiness, Etiology Assesement Treatment and Prevention preface by Jack.H.Wilmore and edited by Ross E Andersen, right of first publication by Human Kinetics Publishers in 2003 Surgery: A basic scientific discipline and clinical grounds, by Jeffrey A. Norton, A Philip S. Barie, A R. Randal Bollinger, publish by Springer in 2008 ( 2nd edition ) Fleshiness surgery: Principle and pattern by Cid Potombo 417 pages on page 385 article written by Robert A. Rabkin, MD, FACS, published by Mc Graw Hill Professional 2008. Laparoscopic bariatric surgery volume 1 by William B. Inabnet, Eric J. de Maria, Sayeed Ikramuddin,333 pages on page 300, published by Lippincot Williams and Wilkins 2004.Magazines33. JET,15 Dec 2003,64 pages vol 104 No 25, page 33-34, Surgeon Dr Mal Fobi †Revolutionizes Weight Loss Surgery with Fobi Pouch Operation for Obesity † , published by Johnson Publishing Company

Free Essays on Gilgamesh Vs. Ovid

Epic of Gilgamesh and Ovid’s Metamorphoses: Comparing the great floods In The Epic of Gilgamesh, the hero of the flood is not the protagonist, but a god who had once been mortal. Utnapishtim sees all, knows all, and carries the secrets of life Gilgamesh wishes to seek out. Once Gilgamesh does reach Utnapishtim, he’s surprised to find that he’s very human in nature. In fact, he had been deified for surviving the flood sent by Enlil. The gods warned Utnapishtim of the waters that were to come at the hand of Enlil, and for a week he built with all his resources a boat that could withstand the torrents. This is one major difference with Ovid: some people had forewarning from Ea and they had time to build an ark. In Ovid’s version, the gods conceived a plan that all men were wicked and deserved to perish at their hands. Zeus sought to conquer their wicked indignations, and many of the gods wondered who would bring them sacrifices, however they all agreed that it was wrong of men to be so tainted with evil. In the Epic, Enlil act ed on his own accord, without further approval of the other gods. This is a second major difference between the two. Enlil also meant for no man to survive, and for no race to be conceivably be born again on earth, but by Ea’s salvation and foreboding, Utnapishtim and his family were spared by her divine graces. Zeus, on the other hand, had in mind that by â€Å"miraculous origin† a new race of men shall spawn, and Deucalion and Pyrrha were spared, the first man and woman of the new race of man because they were pious in their ways. The new race of men spawned in Ovid’s version came not from Deucalion and Pyrrha coming together, but throwing stones over their shoulders, a symbolic meaning that man came from the earth. The gods were sympathetic to the couple who were very much afraid, yet honored the gods in the temple. In the Epic, man came directly from the survivors from the flood, a... Free Essays on Gilgamesh Vs. Ovid Free Essays on Gilgamesh Vs. Ovid Epic of Gilgamesh and Ovid’s Metamorphoses: Comparing the great floods In The Epic of Gilgamesh, the hero of the flood is not the protagonist, but a god who had once been mortal. Utnapishtim sees all, knows all, and carries the secrets of life Gilgamesh wishes to seek out. Once Gilgamesh does reach Utnapishtim, he’s surprised to find that he’s very human in nature. In fact, he had been deified for surviving the flood sent by Enlil. The gods warned Utnapishtim of the waters that were to come at the hand of Enlil, and for a week he built with all his resources a boat that could withstand the torrents. This is one major difference with Ovid: some people had forewarning from Ea and they had time to build an ark. In Ovid’s version, the gods conceived a plan that all men were wicked and deserved to perish at their hands. Zeus sought to conquer their wicked indignations, and many of the gods wondered who would bring them sacrifices, however they all agreed that it was wrong of men to be so tainted with evil. In the Epic, Enlil act ed on his own accord, without further approval of the other gods. This is a second major difference between the two. Enlil also meant for no man to survive, and for no race to be conceivably be born again on earth, but by Ea’s salvation and foreboding, Utnapishtim and his family were spared by her divine graces. Zeus, on the other hand, had in mind that by â€Å"miraculous origin† a new race of men shall spawn, and Deucalion and Pyrrha were spared, the first man and woman of the new race of man because they were pious in their ways. The new race of men spawned in Ovid’s version came not from Deucalion and Pyrrha coming together, but throwing stones over their shoulders, a symbolic meaning that man came from the earth. The gods were sympathetic to the couple who were very much afraid, yet honored the gods in the temple. In the Epic, man came directly from the survivors from the flood, a...

Strunk and Whites The Elements of Style

Strunk and Whites The Elements of Style Strunk and Whites The Elements of Style Strunk and Whites The Elements of Style By Maeve Maddox Strunk and Whites The Elements of Style receives frequent mention in articles about writing. Originating as a classroom study aid prepared by Cornell English Professor William Strunk in 1918, this widely-used desk reference of English usage, form, and style continues to influence writers after a hundred years. After Strunk died in 1946, essayist E.B. White was asked to augment and edit the guide for a wider audience. When White died in 1985, Elements was in its Third Edition. The current Fourth Edition has been, according to Whites stepson Roger Angell, modestly updated to include references to word processors and to acknowledge feminist concerns about pronoun usage. Elements has grown from Strunks original 43 pages to 105, but is still a compact, no-frills handbook for the writer in a hurry for answers to common questions. The guide is arranged in five sections: I. Elementary Rules of Usage II. Elementary Principles of Composition III. A Few Matters of Form IV. Words and Expressions Commonly Misused V. An Approach to Style The first four sections are easily skimmed, and the index will lead you quickly to the point of grammar you want. A 60-word glossary defines such basic terms as gerund and linking verb. The fifth section, An Approach to Style, provides a useful reminder that there is more to producing distinctive prose than just getting the grammar right: There is no satisfactory explanation of style, no infallible guide to good writing, no assurance that a person who thinks clearly will be able to write clearly, no key that unlocks the door, no inflexible rule by which writers may shape their course, According to White, style is a mystery, an entity that arises from the sum of an individuals writing: Style is an increment in writing. When we speak of Fitzgeralds style, we dont mean his command of the relative pronoun, we mean the sound his words make on paper. The Elements of Style deserves its long popularity as a concise guide to correct usage. It can equip a writer with the elements, but style must arise from the personality and mental furnishings of the writer. A searchable version of Elements (Third Edition) can be found at Bartleby.com. You can also find the book on Amazon.com Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Book Reviews category, check our popular posts, or choose a related post below:10 Rules for Writing Numbers and NumeralsList of Greek Words in the English LanguageComma After Introductory Phrases

Arthur Miller - The crucible

Arthur Miller - The crucible The CRUCIBLEHow does Arthur Miller prepare his audience for the conflict within the Salem community and the way they will come outA kettle with a broken pressure valve is the best metaphor to describe Salem's striving community. Arthur Miller effectively represents through act one all the characters of his play as a whole body moving towards a point of explosion, where " [...] suspicions and the envy of the miserable toward the happy could and did burst out in the general revenge."The first important thing we notice about Salem's society is their deep conviction in a strict theocracy, which has or wants control of the destiny of all citizens to maintain the community together : " [...] whose function was to keep the community together, and prevent any kind of disunity [...] " . The information Miller gives at the beginning of the play in his essays sets the correct situation, and describes the historical and cultural background of Salem's past.Legend (Abigail Williams EP)We understan d from these essays there are many hidden subtle "Long-held hatreds [...]" between neighbours and disputes for land "[...] which had been expressed before by constant bickering over boundaries and deeds[...] now could be openly resolved. The citizens saw the possibility of a witch-hunt as a way " [...] to express publicly his guilt and sins, under the cover of accusations against the victims."Act one develops from the solitary sorrow of a man in seeing his child mysteriously ill:Betty. Child. Dear child. Will you wake, will you open your eyes! Betty little one...To the serious matter of condemning nine human souls to witchcraft:Abigail: I saw Goody Hawkins with the Devil!Betty: I saw Goody bibber with the Devil!Abigail: I saw Goody Booth with the Devil!All this gets carried while...

Staging of Strategic Initiatives Assignment Example | Topics and Well Written Essays - 750 words

Staging of Strategic Initiatives - Assignment Example Consequently, strategic initiatives are bound by time, that is, time is specified for starting and completion of initiatives. The power of buyers dictates the number of sales that a firm makes. A firm has a large customer base if it uses giant retail outlets such as Wal-Mart. The store is a strategic distribution point since it is frequented by many buyers. However, this also implies that the buyers have immense power in dictating the success or failure of the firm. Thus, the buyers of Memorex flash drives have more power. Firms that are effective in reducing operational cost and also making products that look different from competitor’s products are better off than firms that implement cost leadership and differentiation separately. A differentiating firm is usually a step ahead in the market since customers tend to think theta the products are not close substitutes. This leads to more production at low costs, courtesy of economies of scale. Repeating the same task every time enhances the simplicity of the task. Consequently, an individual can understand various effects that can arise from a specific activity. This enhances the clarity and thus ability to be more productive. Repeatability enables a company to dedicate resources in new productive contexts, thus triggering more growth. A product loses value once new entrants impose substitutes on the market. The substitutes perform the same function as the original product, thus, purchase of one brand reduces sales of other substitutes. The market forces pull the prices down until an equilibrium price is achieved. This is the reason why the price of Laser teeth whitener fell from $500 to $100 upon introduction of other products that perform the same purpose. Espresso machines brew coffee and Starbucks roasts coffee beans and also makes a coffee beverage. However, the espresso process is automatic and involves pressurized  water mixing with coffee to produce the beverage.  

LAW2044 LAW OF TORT II Essay Example | Topics and Well Written Essays - 3000 words

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Why did China not Experience an Industrial Revolution Between c. 1700 Essay

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Phoenix one supersonic airplane Essay Example | Topics and Well Written Essays - 1250 words

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Problem Definition at Kudler Fine Foods Case Study

Problem Definition at Kudler Fine Foods - Case Study Example With the reasonable success of its first three stores, Kudler desires to expand into other locations in Southern California as well as in San Francisco. It is also planning to expand its products and services offerings with the addition of coffee & tea, a fish counter, and a deli, as well as more aggressively market its catering services. In order to target high-end areas in other cities, Kudler plans to launch an internet website that will eventually have e-commerce capabilities. Several issues have been identified in Kudler's current operations that need to be addressed before it can successfully achieve its future goals. Currently, it deals mainly in perishable goods which require extremely accurate forecasting of inventories so as not to incur losses. Kudler employs some relatively highly paid specialty personnel such as the butcher, the baker and the wine steward, and finding qualified people for a new store or to replace those who leave is difficult, especially so, since Kudler's pay is a bit below average. Kathy Kudler and her small management team may not be able to handle additional stores in farther locations, if their management approach is not adjusted to this situation, which limits their plans for expansion. The Del Mar location is not doing too well and needs to be addressed. Another gourmet shop opening within Kudler's current market areas would definitely pose a threat. And since, Kudler's gourmet products are pricey, an economic decline in i ts geographic area would definitely hurt Kudler. Problem/Opportunity Taking economic decline as the issue in question, this problem can only be solved by preparing for such an eventuality. According to Joseph Ellis (2005), a Goldman Sachs partner, economic cycles or periods of advancing and slowing are the rule and there are 4 stages of economic downturn: the peak, a modest slowing, intensifying worrying, and the advent of recession. Therefore, preparations to help minimize the threat of an economic decline are always worth undertaking so as not to be caught off-guard when it actually happens. Actions to hedge the disadvantageous effects of an economic decline can present opportunities. Kudler needs to carefully choose locations where it will set up additional stores, like identifying high-growth areas where profitable business operations could be better forecasted. These new locations may be in geographically dispersed areas, therefore the need to take a new management approach for managing more widely dispersed operations needs to be considered. Th e introduction and aggressive marketing of new products and services (such as online selling and catering) in its stores not only enhances Kudler's business viability but will also increase customers' patronage of Kudler as it expands into more stores. In the event of an economic decline in a certain geographic location, Kudler would be able to handle its negative effects because of the increased number of profitable stores operating, while actions are being undertaken to relocate a distressed store. End-State Goals The end vision for Kudler consists of several goals that would have

Why did China not Experience an Industrial Revolution Between c. 1700 Essay

Why did China not Experience an Industrial Revolution Between c. 1700 and 1949 - Essay Example As the paper highlights coal was at the time a better form of heat production. It gave constant, reliable amount of heat without giving out a lot of by products as a waste. The changeover was due to great innovation from individuals and group of people who skilfully devised ways to make work easier and create a better life for everyone. Most of the innovations were involuntary and automatic, but additionally, there were others that founded through a series of experiments and exploit of science. This revolution that is an industry based commenced in Britain and after a few years later it stretched to the United States of America, as well as Western Europe. It grades one of the most significant turning points in the account of the history of the whole world. Nearly all aspect of the everyday life of the inhabitants of the planet was greatly influenced in one way or another. The thing that was mostly experienced was the sharp growth of the human population. The society at this period was exceedingly rural in nature. The revolution changed this to a much modern and urban society for most of the nations at that time. Many countries experienced this mode of change that spread from the centre of origin in Britain. China has had a dynamic economy in terms of its economy in the recent years. But why did it delay in achieving better industrialization in the period that other states in Europe and other countries in the regions of the world were developing? This paper is going to assess the reasons why china did not experience ‘industrial revolution’ between c. 1700 and 1949.

Problem Definition at Kudler Fine Foods Case Study

Problem Definition at Kudler Fine Foods - Case Study Example With the reasonable success of its first three stores, Kudler desires to expand into other locations in Southern California as well as in San Francisco. It is also planning to expand its products and services offerings with the addition of coffee & tea, a fish counter, and a deli, as well as more aggressively market its catering services. In order to target high-end areas in other cities, Kudler plans to launch an internet website that will eventually have e-commerce capabilities. Several issues have been identified in Kudler's current operations that need to be addressed before it can successfully achieve its future goals. Currently, it deals mainly in perishable goods which require extremely accurate forecasting of inventories so as not to incur losses. Kudler employs some relatively highly paid specialty personnel such as the butcher, the baker and the wine steward, and finding qualified people for a new store or to replace those who leave is difficult, especially so, since Kudler's pay is a bit below average. Kathy Kudler and her small management team may not be able to handle additional stores in farther locations, if their management approach is not adjusted to this situation, which limits their plans for expansion. The Del Mar location is not doing too well and needs to be addressed. Another gourmet shop opening within Kudler's current market areas would definitely pose a threat. And since, Kudler's gourmet products are pricey, an economic decline in i ts geographic area would definitely hurt Kudler. Problem/Opportunity Taking economic decline as the issue in question, this problem can only be solved by preparing for such an eventuality. According to Joseph Ellis (2005), a Goldman Sachs partner, economic cycles or periods of advancing and slowing are the rule and there are 4 stages of economic downturn: the peak, a modest slowing, intensifying worrying, and the advent of recession. Therefore, preparations to help minimize the threat of an economic decline are always worth undertaking so as not to be caught off-guard when it actually happens. Actions to hedge the disadvantageous effects of an economic decline can present opportunities. Kudler needs to carefully choose locations where it will set up additional stores, like identifying high-growth areas where profitable business operations could be better forecasted. These new locations may be in geographically dispersed areas, therefore the need to take a new management approach for managing more widely dispersed operations needs to be considered. Th e introduction and aggressive marketing of new products and services (such as online selling and catering) in its stores not only enhances Kudler's business viability but will also increase customers' patronage of Kudler as it expands into more stores. In the event of an economic decline in a certain geographic location, Kudler would be able to handle its negative effects because of the increased number of profitable stores operating, while actions are being undertaken to relocate a distressed store. End-State Goals The end vision for Kudler consists of several goals that would have

Hardware reveiw Essay Example for Free

Hardware reveiw Essay Hardware is the physical part of the computer which you can actually touch. Software on the other hand is the part of the computer that you cannot touch. There are many different examples of hardware within a computer system including   Keyboards Printers   Scanners Monitors Disk drives   Computer towers When making my logo their where many different hardware that I used when making my logo. These include input, output and processing devises. The input device I used to make my logo was a keyboard. A keyboard is the main input devise attached to the computer. It allows you to enter text and numbers that will appear on the computer screen. A keyboard is made up of keys that are separate (as you can see in the picture below). These keys represent numbers and letter of the alphabet. An image of a keyboard There are many different advantages for using a keyboard when making my logo and my ID card including it will allow me to type the name of the Kingsbury health centre and it also allows me to type in the name of the workers on their ID card. It will also help my logo look more professional if I type the name of the health centre. Another advantage for using a keyboard is that it is simple and easy to use and I know how to use it. I could not find any disadvantages for using a keyboard when making my logo, Id card, database or user manual however if you are typing up a long piece of work it could damage you back if you use a keyboard for too long. Another advantage for using the keyboard when making my database and my user manual is that it allows me to type in the information I want to appear on the screen. Another input device I used when making my logo was a mouse. This is a hand operated devise that allows you to control the curser that appears on the screen. It also allows you to move things and to click on things on the computer screen. On the bottom of the mouse of most mousse is a ball that rolls when you move it. An image of two computer mouses The advantages for using a mouse when making my logo are that it allows me to easily move images around on my logo. This will ensure that that my logo is exactly as I want it to be. Another advantage for using a mouse to make the logo is that the mouse is simple and easy to use. The disadvantages for using this type of mouse when making my logo is that it easily break when it falls on the floor. This is because the ball in the back of the mouse falls out. It would probably be better if I use the newer mouse. The output devise that I could use to make my logo is a laser printer. A laser printer is a printer that produces high quality text and graphics. It does this by using a laser beam technology to produce an image on a photosensitive drum. An image of a laser The advantages for using a laser printer to print of my logo are that a laser printer prints of better quality images than the inkjet printer. Another advantage for using the laser printer is that it can print off colour images which I need because I want to print of my logo in colour. In addition, another advantage for using the laser printer to print of my logo is that it prints of quicker and quieter than the other printers. The disadvantages for using the laser printer o print of my logo are that it will be very expensive to buy a laser printer. Another output device I used when making my logo is the TFT monitor. TFT monitor is an output devise that displays signals on the computer screen. A TFT is a flat computer monitor, which gives high quality images on the screen and is modern. An image of a TFT monitor The advantages for using a TFT monitor is that it does not give of glare that CRT monitors do give off. This means that if I use this monitor for long periods of time it is less likely to hurt my eyes. Another advantage for using the TFT monitor when making my logo are that it will give off high quality images on the computer screen. This will make my logo look better. A disadvantage for using the TFT monitor when making my logo is that it is very expensive to buy a TFT monitor.

Impact of Aphasia on Health and Well-being

Impact of Aphasia on Health and Well-being Abstract This discussion paper considers the impact of aphasia on health and well-being, and following an in-depth exploration of relevant literature, provides suggestions for appropriate nursing interventions in respect of this relatively common condition following stroke. The introduction states that effective communication is essential to holistic care and positive outcomes for individuals affected by aphasia. However, when verbal communication is absent, nurses fail to adequately utilise alternative strategies so that the standard of nurse/patient communication is frequently poor. The discussion introduces the Theory of Human Scale Development. This theory emphasises that quality of life depends as much upon self-actualisation and relation-building as on physical health. The theory is used as a framework within the discussion in order to highlight the significance of communication to quality of life, and how its loss has profound psychological and social consequences. By utilising the theory, the discussion demonstrates that nursing care delivery must address loss of self-actualisation and relationship-building abilities, as well as physiological communication skills. The discussion reflects upon how aphasia results in loss of self, and how the situation is exacerbated by inadequate healthcare communication strategies such as nurse-controlled conversation, talking-over, and elderspeak. Suggestions are offered regarding more appropriate strategies. Efficacy of family input is considered; nursing competence regarding language practice therapies is discussed, and the quest approach is explored. Next, the discussion reflects upon the impact of aphasia on relationships. Aphasia denies access to support networks and results in isolation, stress, and loneliness. The individuals predicament is worsened by negative nursing responses such as communication filtering and avoidance tactics. The discussion reflects upon positive nursing strategies, which alleviate effects of aphasia on individuals social health. Concept analysis and self-awareness exercises as methods of enhancing compassion skills are explored. The social model of disability is discussed in order to highlight the benefits to individuals of environmental adaptations. Also, the social benefits of aphasia-group affiliation are discussed. The discussion concludes by emphasising that fundamental human needs involve social and psychological as well as physical aspects. Nursing interventions must therefore address all needs in order to provide holistic care in its fullest sense. Key Words Aphasia: nursing: relationships: self: Theory of Human Scale Development Summary Statements What is already known about this topic Good communication between nurses and patients is essential to the provision of quality healthcare that protects patients rights, autonomy and choice. Aphasia compromises nurse/patient communication leading to discrimination in health services, suboptimal care, poor long-term outcomes, and restricted rights. Communication difficulties faced by individuals with aphasia risks loss of self, and diminishes the beneficial impact of social integration on health. What this paper adds The multifarious impact of aphasia on the lives of individuals with the condition must be recognised and acknowledged by nurses. During their day-to-day nursing activities, nurses can facilitate the immediate communication needs of individuals with aphasia. Nurses can initiate aphasic individuals abilities to function independently and autonomously in the wider world via supporting the maintenance of personal identity and social integration. Introduction It has long been acknowledged and purported that good communication is essential to the provision of quality healthcare as it is integral to effective clinical assessment, health promotion, and patient choice and autonomy. Models of communication and research studies (Peplau, 1952; Fosbinder, 1994; Charlton et al, 2008) suggest that care delivery and health outcomes are improved when nurses use communication as a reciprocal interaction to express concern and commitment, and in return invite trust and human connection. These texts demonstrate that proficient interpersonal skills transform patients from objective clinical tasks to individuals meriting empathic, holistic care. However, because most communication strategies depend upon speech, the expediency of interpersonal relationships becomes severely compromised for individuals who experience aphasia as a consequence of stroke. Indeed, although the World Health Organisations (2001) definition of communication impairment encompasses verbal, non-verbal and graphic abilities, Finke et als (2008) systematic review finds that nurses continue to focus on stroke patients inadequate ability to verbally meet communication needs. Non-verbal messages are assigned a secondary, supporting role, and are therefore not adequately exploited as legitimate alternative strategies. The subsequent poor standard of professional/patient communication, described as appalling in the United Kingdoms National Sentinel Stroke Audit (Intercollegiate Stroke Working Party, 2009, p.12) has serious ramifications. O Halloran et als (2008) literature review suggests that health professionals inability or unwillingness to effectively enga ge with individuals affected by aphasia leads to discrimination in stroke services, suboptimal care, poor long-term outcomes, and restricted rights. Theory of Human Scale Development To avoid the suboptimal care of patients with aphasia, nurses must realise the necessity of effective communication to health and well-being. If nurses are to be motivated to explore, improve and exploit communication strategies as therapeutic tools, they must, in the first instance, understand the devastating impact of aphasia on quality of life. An analysis of aphasia in relation to the Theory of Human-Scale Development (Max-Neef et al, 1991) helps to illustrate its effect on the individual. According to the Theory of Human-Scale Development, quality of life depends upon the satisfaction of nine classes of interrelated ontological fundamental human needs (figure 1). Of these, only subsistence relates to physical health, the others being concerned with psychological and social issues associated with the sense of self and relationships. Because quality of life correlates with the number of satisfied needs, if a synergic satisfier (one satisfier that satisfies multiple needs) such as the ability to fluently verbally communicate, is removed, the impact on life quality is devastating (figure 2). Charmaz (1983; 1995; 1999) symbolic interactionist perspective reaches similar conclusions. These grounded theory studies of chronic illness demonstrate that the self is developed and maintained via self-actualisation and social relationships. Where illness reduces individuals participation in society, and prompts negative reactions from others, feelings of discreditation and loneline ss follow. Individuals beliefs that they are encumbrances on society rather than valuable contributors, lead to suffering and the loss of self. It is essential, therefore, that rehabilitative therapies should result in a synergic effect so that self, relationships, and thus quality of life are improved and maintained to the highest possible level (figure 2). However, many individuals with aphasia bemoan the fact that health professionals consistently focus on physical, biomedical definitions which view the condition as synonymous with physiological stroke events, rather than separate aphasia disability experiences (Liechty and Heinzekehr, 2007; Shadden et al, 2008; Wertheimer, 2008). This leads to the dismissal of psychological and social aspects of communication impairment and a thwarting of attempts to address them. Thus, the biomedical perspective, which defines aphasia as an inability to use or comprehend language as a consequence of injury to the cerebral cortex, results in the comment, I have aphasia, generating the response, You mean you had a stroke (Liechty and Heinzekehr, 2007, p.316). But, as Liechtys autobiographical account illustrates, aphasia is not an objective condition but a subjective reality, and focusing on the physiological brain damage both de-emphasises the pain that aphasia causes and denies the continual struggl es faced (p.316). Liechtys experience suggests that a psychosocial definition is more appropriate to describe the full extent of the consequences of aphasia to the individual. Sundin et als (2000) wider definition describes the condition as a defect in the use of language which causes extensive damage to psychological and social well-being resulting in isolation and depression. This study suggests that understanding the meaning of the illness for the individual rather than concentrating on the underlying physical causes, is the true initiator of holistic healing. O Halloran et al (2008) agree. This systematic review proposes that a biomedical perspective impoverishes care delivery because attributing communication breakdown to the disease process reduces nurses responsibility and motivation to develop ongoing communication strategies. The review suggests that a psychosocial perspective where nurses view communication impairment as an illness experience as well as a medical phenomenon, promotes the ide a that difficulties result from impaired interaction between nurse and patient. This increases nurses feelings of responsibility to overcome communication barriers and seek out the individual behind the disease. It is apparent, then, that reference to the Theory of Human-Scale Development helps to illustrate how a professional attitude which attempts to satisfy all fundamental human needs, not just the physical need of subsistence, subsequently leads to richer, more meaningful outcomes. Although fundamental human needs are to an extent, interrelated (figure 1), they are broadly split into three categories. The discussion paper will explore the impact of aphasia by focusing on self-actualisation and relationship needs. Self-Actualisation Needs Impact of Aphasia on the Self Rogers (1967) personality theory states that self-concept and self-perception are fundamental components of personal identity. He proposes that because life-meaning and behaviour are essentially purposeful, individuals require freedom to make choices, and create and develop their own personalities, in order to construct a valid presence in the world. Of course, language is the core of this process of self-construction. Without language, the ability to narrate lived experiences is lost. The individual cannot inform the world who and what he/she is, or understand who and what others are, hence is unable to find an appropriate place in the scheme of things. Shaddens (2005) literature review describes this predicament as identity theft, a state of affairs in which individuals with aphasia are ignored and invisible. However, Kagans (1995) masking of competence model refutes this, proposing that the individual is transformed rather than rendered invisible by aphasia. The model states that because communication impairment makes it difficult to perceive the individuals functional mind, it becomes difficult to envisage capacity. With capacity hidden, the individual is transformed from a person to a mere physical presence and is often viewed as a burden with little social value. According to Charmaz (1983), witnessing ones former self-image crumbling away is itself a fundamental form of suffering (p.168). Time and again, autobiographical narratives refer to the pain experienced when the self is reduced by an assumption that language loss is synonymous with the loss of intellectual and cognitive abilities (Neal, 1988; Bauby, 2008; Liechty and H einzekehr, 2007). Bauby (2008) summarises the feeling thus, [They] left no doubt that henceforth I belonged on a vegetable stall and not to the human race (p.90). Buber (1958) refers to this objectivising of people as an I-It relationship (as oppose to an I-Thou relationship defined by its reciprocal and mutually respectful nature). Aphasia renders the establishment of a nurse/patient I-Thou therapeutic relationship particularly challenging, because sharing and understanding become difficult to achieve. Unfortunately, this often results in I-It communication within the healthcare arena, which in nursing, is intrinsic to detached task-orientated care. According to Gordon et al (2008), this denies individuals with aphasia the freedom to control and direct their own lives. Gordon et als (2008) observational study concludes that staff control conversations and focus dialogue on their own nursing-task goals. The studys use of conversation analysis demonstrates that patients rarely initiate conversations and therefore have little influence over topics. In addition, due to heavy reliance on the sequential context of dialogue in order to maximise unde rstanding, individuals with aphasia find it difficult to alter the course of conversation to suit their requirements. Such asymmetrical, task-orientated communication is neither therapeutic or responsive to holistic needs. This results in a reduction of the self and a denial of individuals rights to participate in their own care or in the creation of their own future. According to Wertheimer (2008), curbing the freedom to express the self commonly leads to feelings of entrapment. Wertheimers (2008) detailed analysis of post-subarachnoid haemorrhage experiences suggests that language difficulties and loss of control during hospitalisation contribute to depression, and dreams and hallucinations, which frequently involve images of imprisonment and dictatorial authoritarianism. The negative impact of nurse-controlled conversation is exacerbated further by persistent occurrences of talking over patients. Flegels (2008) short article acts as a reminder that talking over is unethical because it contradicts health professionals codes of conduct that stipulate patient autonomy is paramount during care delivery. Quoting Kants (1785) argument that autonomy depends upon the hypothesis that all individuals have unconditional worth, Flegel (2008) believes that talking over signifies to patients that their presence is of no consequence and therefore they are not autonomous. Elderspeak also diminishes autonomy. This speech style is generally used as a means to communicate with elderly patients, but research confirms that it is commonly used by nurses when encountering individuals with physical, cognitive and communication disabilities (Kemper et al, 1998; Williams et al 2004; Melton and Shadden, 2005). Williams et al (2004) describe elderspeak as a demeaning mode of communication similar to baby talk that features exaggerated, simplified, repetitive language. Because elderspeak stereotypes elderly and disabled patients as incompetent and incapable, individual potential and progress may be ignored, thus reducing control and the sense of self even further. Reactions to Loss of Self Unsurprisingly, individuals with aphasia struggle to instigate the fight to rescue the self, and often surrender to discreditation. Charmaz (1983) explanation that self-concept depends upon reflected images of the self by others is confirmed by Simmons-Mackie and Damico (2008). This study of communication therapy sessions suggests that external negative responses to individuals with aphasia leads to internal negative perceptions of the self and a silencing of the voice. Poor nurse communication techniques based on task-orientated conversation, elderspeak and talking over compound this internalisation process. According to Ryan et als (1986) seminal literature review and subsequent theory of dependency over-accommodation, implications of incompetence and diminished capacity which arise from such condescending speech styles lower individuals confidence and self-esteem. This increases dependency and passive acceptance of care, and consequently promotes feelings of worthlessness and powe rlessness. Parr et al (2003) agree. This literature review reports that individuals faced with inadequate communication attempts of service providers, feel so diminished that they often apologise for their own existence. By reflecting on the impact of aphasia on self-actualisation needs, it seems that the nursing role in care delivery should involve supporting the individual to both recover the pre-aphasic self and connect this self to the new disabled identity. In order to achieve this, the nurse must firstly get to know the patient as a person, then secondly, empower that person to regain the creativity, confidence and freedom required to control his/her own life. Nursing Implications Use of Family Liaschenko and Fisher (1999) identify person knowledge as integral to the establishment of effective therapeutic communication and holistic care. The acquisition of this knowledge involves knowing the patients private biography with a view to revealing the unique individual. Where aphasia inhibits direct verbal interaction between nurse and patient, family and friends can relay information and re-construct much history, therefore contributing to the satisfaction of a range of fundamental human needs. According to Williams and Davis (2004), this indirect narrative is invaluable as it allows the nurse to participate in individualised communication when speaking directly to the patient. This deters any tendency for task-focused interaction or elderspeak, which in turn, reinforces the individuals sense of self. There are barriers to implementing such interaction however. Paradoxically, despite, for example, British Government calls for improved professional/patient/carer communication (Intercollegiate Stroke Working Party, 2009), some studies report that nurses efforts to personalise care by informal chat with patients and families are thwarted by sociopolitical systems that prioritise task completion over person knowledge. (McCabe, 2004; Speed and Luker, 2004). Also, Fairburns (1994) study of attitudes to visiting hours reports that nurses often feel patients and relatives resent staff presence as an intrusion upon their private time together. Perhaps the use of patient diaries can help overcome these barriers. Combes (2005) introduction of diaries in the intensive care setting demonstrates that by encouraging families to produce ongoing written narratives, which are left at the patients bedside, readily accessible relevant information concerning what is significant and individual to the patient is made available. This data can be utilised and built upon in later nurse/patient interactions. Research into the use of diaries in aphasia care should therefore be undertaken. Families are also useful when nurses are trying to ascertain the individual with aphasias immediate concerns and opinions. Goodwins (1995) well-cited case study illustrates that needs are more easily interpreted when relatives, familiar with the individuals gestures, facial expressions and idiosyncrasies, and who share common social contexts with him/her, are on hand to translate. Indeed, Finke et als (2008) systematic review finds that, where nurses are prepared to ask families for suggestions, or written directives, regarding the meanings of the individuals non-verbal strategies, communication is much more efficacious. In terms of advocacy, Hedberg et als (2008) study of multi-disciplinary care-planning meetings demonstrates that an in-depth knowledge of the individual with aphasias life and views, equips family members to act as advocates in the negotiation of care needs and future plans. The research therefore concludes that nurses require training in how best to involve relatives in the decision-making process in order to ensure individual needs remain salient. While the recommendation to involve families in the communication process is essentially sound, much of the proposing nursing literature quoted above nevertheless fails to fully explore the potential risks to patient autonomy of relying heavily on alliances with relatives. Translation literature (Englund-Dimitrova, 1997; Bradby, 2001; Leininger and McFarland, 2002) confirms that any form of interpretation via a third person amplifies the chances of misinterpretation. However, the risk is further heightened by relatives conscious or subconscious propensity to distort, omit or add to the patients messages and opinions in order to address their own concerns. Shadden et als (2008) review of autobiographical narratives reports that, while the well-being of patients is the central concern of most families, disability caused by stroke has a significant negative impact on the lives of all close family members. This may result in the interpretation of aphasic communication being influenced by the intermediarys own slanted perspectives. Thus, relatives feelings of guilt, fear, stress, and fatigue may filter out some of the true messages that the individual with aphasia is trying to express. Ryan et al (1986) offers a more cynical consequence to family advocacy by suggesting that it may undermine the individuals power to control situations, and can even disguise the sense of self by recreating and redefining elements of the individuals history, personality and wishes during the advocacy process. Hence, although it is helpful to use family knowledge to obtain patient information, nurses must recognise that individuals needs may not be adequately supplied by biased intermediaries. Nurses must therefore be able to use their own disinterested objective strategies to reach an understanding of the individual with aphasias meaning. Nursing Implications Competence Theory and research which explores the meaning of caring (Halldorsdottir and Hamrin, 1997; Brilowski and Wendler, 2005; Chang et al, 2005) states that a fundamental strategy when nursing any illness is the alleviation of the patients fear that nothing can be done to treat the condition. This literature reveals that while patients appreciate expressive caring behaviours, competence when performing instrumental therapies, is considered imperative to a secure caring base. As Halldorsdottir and Hamrin (1997) assert, caring without competence is meaningless (p.123). It is apparent that in aphasia, where preservation of the self is at stake, the nurse needs to convey competence and confidence in attitude and execution of language practice therapies, so that the individual with aphasia feels secure in the knowledge that recovery of identity is possible and in hand. Nystroms (2009) phenomenological study of interviews and biographies finds that such provision of security via nursing competence encourages patient hope, motivation, and fighting spirit (p.2509). Finke et al (2008) believes that nursing competence in language practice therapy requires training in basic speech therapy, familiarity with augmentative and alternative communication, and regular consultations with speech and language therapists. However, currently, none of these schemes are widely implemented. Hemsley et al (2001) suggests this is due to individual and organisational attitude barriers, which view specialised communication techniques as both too time-consuming and beyond the remit of nurses. Finke et al (2008), proposes that time and resources spent on enhancing nurses communication competence may prove more efficient than relying on minimal task-orientated interactions. This is because ineffective interactions are at high risk of misinterpretation, ineffective at meeting individual needs, result in frustration, fear and despondency, and may contribute to depression. Also, Nystrom (2009) finds that extended time periods required for personal care support, provide ideal opportunities for skilled practitioners to simultaneously offer language practice (thus reducing rehabilitation time and resources), while allaying patient fears. A participant in the research is quoted thus, One nurse talked to me while helping me to eat and get dressed†¦that made me feel calm and secure (pp.2507-8). Nursing Implications Quest Approach Aphasia traps individuals in the present. Struggling to express details of past achievements, individuals situations are worsened by an inability to shape the future. In effect, individuals have lost both identity, and the freedom and creativity to restore it. They have lost their place in the world. Nystrom (2009) believes that the optimal method of regaining place is to defer to individuals pre-stroke identities. An awareness of individuals previous competencies, allows the nurse to personalise language practice, communication strategies and conversation by basing subject matters on familiar contexts of family, work, interests, and achievements. This enables individuals with aphasia to grasp meanings more easily, but it also helps to maintain a sense of the old valued, accomplished self, thus providing a structure on which to base rehabilitation goals. This method, defined by Moss et al (2004) as a restitution approach, is fundamentally flawed because it overlooks the fact that for many individuals, aphasia remains a permanent disability. Preoccupation with the old self could therefore lead to a painful mourning for what is lost. It could even exacerbate feelings of worthlessness by highlighting comparisons between past abilities and present inabilities. Moss et als (2004) exploration of online illness narratives purports that a quest approach is more psychologically healthy. Here, individuals are encouraged to accept their changed circumstances, and envisage and create a different future. For the nurse, this involves using the individuals history, not as a source of goals, but a source of interests on which new modified goals can be built. This requires strong multi-disciplinary co-ordination skills to bring patient, nurse, speech therapist and occupational therapist together in order to fully explore interests, resources, potential and progress. Furthermore, according to Vickery et als (2009) quantitative analysis of self-esteem scales, the nurse must kindly but firmly guide individuals to a realisation of their limitations so that the risk of disappointment is reduced. However, simultaneously, the nurse should demonstrate motivating and commendatory attitudes that elicit a sense of pride from individuals in their gains and success es, which ultimately increases confidence, self-worth and a sense of freedom. Relationship Needs Impact of Aphasia on Relationships Berkman et als (2000) review of social integration theory demonstrates that relationships and affiliations are formidable influences on physical and psychological health. The study explains that relationships provide informational, instrumental (practical), appraisal (decision-making) and emotional support, as well as opportunities for social engagement. All these aspects are essential to the endorsement of meaningful roles, the reinforcement of participation and belonging, and the promotion of affection and pleasure. Charmaz (1983; 1999) reiterates that these factors add to the sense of self as a valuable entity. Any process or condition which leads to alienation, separation or disconnectedness from society, adversely impacts on mental well-being and mortality (figure 2). Generative studies by Durkheim (1952) and Bowlby (1991) suggest that relationships serve to buffer detrimental influences of stressful events. These texts illustrate that when consistent, reliable relationships are absent or damaged, psychological stability is weakened and the risk of depression increases. Berkmans (1988) hypothesis takes this concept further by suggesting that social isolation is itself a chronic stressor resulting in persistent heightened hypothalamic-pituitary-adrenal (HPA) axis responses which consequently accelerate physiologic aging and functional decline. Because conversation is pivotal to interaction and relationship building, aphasia inhibits individuals from exploiting the health benefits of social integration. Pound et al (2006) believe that conversation is primarily transactional, enabling individuals to participate within a supportive society consisting of mutually supportive relationships. Aphasia therefore, results in an inability to access support strategies resulting in isolation and stress. For example, appraisal support is compromised because individuals with aphasia are unable to talk problems over with friends. Likewise, informational and instrumental support may be inaccessible if individuals cannot express their opinions and needs, nor comprehend disseminated messages. While Laver (1975) acknowledges the transactional element of conversation, he also emphasises its interactional nature, which allows the development of social connections. He explains that it is a bonding ritual, which explores and categorises social position, conveys intimacy, conspiracy, affection and belonging, and as such, its loss can lead to a devastating sense of loneliness. For individuals with aphasia, whose health is already severely impaired by stroke, it is imperative that nurses are able to support the relationship-building process, and hence, diminish risks of further health problems associated with social isolation. Ramos (1992) research concludes that this is best achieved by establishing reciprocal or connected nurse-patient relationships which involve the development of emotional and cognitive bonds that persuade the individual to feel the nurse is taking on part of the burden (p.503). Reciprocation also encourages nurses to perceive coping with illness as a shared responsibility. Pound et al (2006) agree, stating that if professionals acknowledge patients are not solo performers, but part of a company of players (p.18), then this idea of joint responsibility is accentuated. However, poor therapeutic relationship development in aphasia remains a common problem. Perhaps this can be explained by Hindles (2003) suggestion that any phenomenon, which undermines nurses competence as communicators, leads to the implementation of communication filter barriers, such as rationalisation and projection. Sundin et al (2000) believe aphasia is a relationship leveller because both nurse and individual with aphasia have difficulty being understood by, and understanding, each other. This situation is uncomfortable for nurses working in a healthcare social construction that is founded upon competency achievement and proficient practice. Balandin et als research (2007) validates this idea. This small qualitative study finds that the undermining of competence and power results in rationalisation and projection in the form of defensive attitudes such as its not my job or the patient doesnt need to communicate (p.58). These avoidance tactics have been so widespread that Stock well (1972) included individuals with aphasia in her list of unpopular patients. Reactions to Diminished Relationships Charmaz (1983) research, confirmed by Davidson et als (2008) case study, reveals how unwillingness or inability of family, friends and professionals to establish effective relationships with individuals affected by aphasia leads to feelings of rejection. This in turn erodes patients perseverance to pursue support and comfort, often resulting in retreat and the seeking of solitude. Lyon (1998) refers to this behaviour as constructive because it provides a protective cocoon (p.12) in which individuals can rest and quietly contemplate their situation. Likewise, Shadden et al (2008) believe solitude-seeking is beneficial as it allows individuals to recapture the self which appears to bolster self-esteem. The authors quote from a patient interv