British Arguments During the Revolutionary War Essay Example for Free

British Arguments During the Revolutionary War Essay The colonists are good for one thing: complaining. They cry like babies for what just a few cents on their sugar and stamps, when in reality we were HELPING THEM. We made these taxes to defray for the defense of the colonies and to supply the troops. All they do is whine, whine, whine. They go on all day like fools with that idiot saying†¦ â€Å"No taxation without Representation.† 1764-Sugar Act 1765- Stamp Act Little Brats Somehow these peasants have made us look like the villains in the tragic event they call the â€Å"Boston Massacre. † Hey that is one way to put it, but truly they are the ones to be blamed in this whole bloody mess. The idiots started it by harassing some of our own sovereign soldiers, they even through snowballs at our soldiers. How rude?!? Oh well, they simply don’t have class. Sure, a few of the peasants died but it was simply self-defense. 1770- Boston Massacre Cavemen The Peasants have yet again come up with some crazy antics that even top off their outrageous behavior so far. This time they burned down one of our schooners- The Gaspee to be specific. Yes, that is right they burned down a ship. How grotesque? Idiots! Better yet, cavemen! They have no taste act like villagers. They even accused one of our finest commanders who was the captain of the ship- Lt. William Dudingston of being unjust and corrupt. Lies, lies, lies! 1772- The Burning of The Gaspee A Truly Intolerable Act Wait for this one, it is truly mind-blowing. Believe it or not, the peasants dressed up as Mohawks Indians and dumped 342 chests of tea into the Boston Harbor. This is a new low even for them. They are real idiots, wasting all that tea. How extremely insensitive of them? There are many people in this world that could have made a use of that tea. On the bright side, we punished them thoroughly.

Independent Prescribing | Supplementary Prescribing

Independent Prescribing | Supplementary Prescribing Introduction This portfolio has been compiled in order to complete the non-medical prescribing qualification through the University of Central Lancashire. Throughout the portfolio, the author has analysed situations encountered whilst working along a designated medical practitioner (DMP). The author is a mental health nurse and is employed in a community mental health team, offering support to individuals who suffer with severe and enduring mental health problems. In the practice area, new ways of working (Department of Health (DH), 2007) is beginning to take effect which has enabled expansion of current roles, including non medical prescribing. The portfolio is organised into sections, with an index page for navigation. Two consultations are presented; the first involving an individual with a neurotic illness, where independent prescribing was deemed appropriate in the absence of co-morbid illness or significant risk. The second consultation pertains to an individual with severe and enduring mental health problems who has suffered adverse reactions to medication previously and for whom supplementary prescribing appeared to be the safest prescribing option. The consultations are followed by an evidence section and appendices. Completion of the portfolio has facilitated extensive development of knowledge in terms of pharmacology, including physiological variance (evidence 15). Knowledge of psychotropic medicines has also greatly improved and the importance of physical health monitoring for service users has since become a priority. The author believes that becoming a non-medical prescriber will provide an ideal opportunity to have a direct effect on public health targets such as reducing avoidable death from suicide and offering quicker, more appropriate treatment options to people with mental illness. The author also feels confident that non-medical prescribing in mental health will lead to increased concordance and better service user satisfaction. The required practice hours of the course have been achieved (evidence 1) through working with members of the prescribing team (evidence 2a, 2b, 2c, 2d, 2e). Throughout the portfolio, the author has ensured protection of confidential information, as directed by the Nursing and Midwifery Council (NMC) (2008) by referring to the service users by pseudonyms i.e. Alexander and by anonymising information related to the Trust for which the author works. Furthermore, consent forms have been obtained for named professionals and user perspectives Independent Prescribing Independent prescribing is defined as prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing (DH, 2006 p2). The author will critically analyse an independent prescribing situation, addressing learning outcomes 1,2,3,4 and 5 in doing so. Reference to the stages of the prescribing pyramid will be made as this is a useful model to ensure appropriate prescribing (National Prescribing Centre (NPC), 1999). The patient will be referred to as Anne Knowles. Anne was a 28-year-old woman with a history of depression, referred by her General Practitioner who suspected a relapse. In order to confirm this, a full assessment was undertaken. Fortunately in mental health, adequate time is allocated for practitioners to gather information. Prescribers are encouraged to approach consultations in a structured way (NPC, 2003) therefore the Calgary-Cambridge model (Silverman, Kurtz and Draper 1998) was used alongside a structured tool in support of this approach. Health authorities have formulated unique Care Programme Approach (CPA) assessment tools based on the original guidance in Caring for People (DH, 1990) to accomplish a holistic assessment and this is what is advocated by the NPC (1999), as the first element of good prescribing practice. The author used the tool designed by the local health authority in the assessment of Anne (evidence 3). While the CPA assessment is comprehensive, the author elected to enhance it with additional tools to better inform prescribing practice. Incorporating Mortons (1992) symptom analysis tool a thorough assessment of Annes presenting symptom was facilitated. Furthermore, an individualised report obtained using a solution-focused approach (de Shazer, 1988), gave the author an appreciation of what was currently happening and how improvement would be detected (evidence 3, page 13). The author also utilised Becks Depression Inventory-II (BDI-II) (Beck, Steer and Brown, 1996) (evidence 4). Although routinely used in the practice environment due to its ease and speed of completion, it has been criticised due to the gender and cultural bias (female, Caucasian), which it represents (Hagen, 2007). This is something with which the author would agree and plans to use the Montgomery-Asberg Depression rating scale (Montgomery and Asperg, 1979) in the future as this has a broader reflection than the BDI-II. The remainder of the assessment, including a full medical, social and medication history, allergy status and exploration of Annes beliefs about her illness and future treatment were also included in the assessment. It is commonplace in clinical practice for staff to present assessments to the medical team where discussion of differential diagnosis occurs. Such discussion facilitates accurate diagnosis and debate of treatment options; however it is reliant on a precise initial assessment and effective presentation of the case. Following this a diagnosis of moderate depression was agreed under section F32.1 of the International Classification of Disease (World Health Organization (WHO), 1992). Considering the prescribing pyramid, the second step requires deliberation of the appropriate strategy to use. As the diagnosis of moderate depression was established, the author knew that a prescription was needed. Guidance from the National Institute of Clinical Excellence (NICE) (2004) suggests that individuals diagnosed with moderate to severe depression should routinely be offered a pharmacological intervention before psychological interventions. When considering choice of products, the third step of the prescribing pyramid, prescribers have available various antidepressants from diverse groups, namely Monoamine-oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), and Selective Serotonin Reuptake Inhibitors (SSRIs). There are also listings in the British National Formulary (Royal Pharmaceutical Society (RPS) British Medical Association (BMA), 2007) for other antidepressant drugs that cannot be classified into specific groups due to their unique pharmacology i.e. Mirtazapine and Reboxetine. In choosing between the agents, the author consulted national guidelines (NICE, 2004) which examine the effectiveness, appropriateness, safety and cost-effectiveness of drugs. NICE (2004) favours use of SSRIs to other antidepressant groups. This is because they are as effective as TCAs but concordance is higher because of the better side effect profile (NICE, 2004). Barbui and Hotopf (2001) reported that Amitriptyline, a TCA was more effective than SSRIs however conceded that use of SSRIs was higher because of their enhanced tolerability. SSRIs are less likely to cause sedation and cause much fewer anti-muscarinic effects than TCAs (RPS BMA, 2007). The other major distinction is that should they be used in overdose, SSRIs are considered less toxic than TCAs. Use of an MAOI was not considered as first-line treatment for Anne. Although once viewed as less effective than other antidepressants, when used in adequate doses, MAOIs are as efficacious (Riederer, Lachenmayer and Laux, 2004). However MAOIs are generally better in treating atypical depression (Riederer et al, 2004) and are associated with dangerous dietary and drug interactions (Nash and Nutt, 2007). SSRIs are the agents of choice in the practice area (evidence 5), in line with national guidelines. The common pharmacology of SSRIs is the prevention of reuptake of the neurotransmitter serotonin into the pre-synaptic cell, leaving increased amounts of serotonin available to bind to post-synaptic receptors (Carrasco and Sandner, 2005). Although the central nervous system is the desired site of action, SSRIs also exert their effect throughout the body, which explains their side effects. Aside from the primary pharmacology of the SSRIs, each has diverse properties, knowledge of which assists prescribers to choose the most appropriate agent. NICE (2004) directs prescribers to opt for Fluoxetine or Citalopram due to their ease of discontinuation as with other SSRIs, users have reported distressing discontinuation symptoms. A review by Haddad (2001) found as many as fifty different discontinuation symptoms, ranging in severity from mild to severely disabling. These included dizziness, nausea, lethargy, headache, electric shock like sensations, insomnia and nightmares. An understanding of the physiological mechanisms underlying the syndrome has yet to be realised. Theorists such as Tamam and Ozpoyraz (2003) and Blier and Tremblay (2006) speculate that the readaptation of the neurotransmitter systems, which rapidly increase reuptake of serotonin and subsequently decrease the amount of serotonin able to bind to post-synaptic receptors, are the likely triggers. Drugs with shorter half lives i.e. Paroxetine are the most problematic and those with longer half-lives and active metabolites i.e. Citalopram and Fluoxetine appear to fair better (Taylor, Paton and Kerwin, 2007). In terms of appropriateness, all SSRIs share identical cautions and contraindications and research has shown that Citalopram is just as effective as Fluoxetine in treating depressive symptoms (Patris, Bouchard, Bougerol, Charbonnier, Chevalier, Clerc, Cyran, Van Amerongen, Lemming and Hopfner Petersen, 1996). Consideration of patient-specific factors during the history taking identified that Anne found previous success with Citalopram. The medical history had not highlighted any conditions where cautions apply such as epilepsy, cardiac disease, diabetes mellitus, allergies etc and the author was aware that use of all antidepressants was contra-indicated in mania (RPS BMA, 2007). The choice of product was made in discussion with Anne. She had a preference for Citalopram and after reviewing the available evidence, the author concurred with this choice and prescribed Citalopram (evidence 6). See evidence 7 for a profile of Citalopram. Next, it was necessary to negotiate a contract with Anne, stage four of the prescribing pyramid. Anne understood Citalopram from previous use, however education regarding what the prescription was for and how long it would take to work (evidence 7) was given. Anne did not have a preference in terms of formulation and therefore tablets were prescribed, as this was the cheapest option. The side effects and red flag concerns of the medication were then identified to Anne (evidence 1, section 6). All antidepressants have been linked with a possible increased risk of suicidality. Research into SSRIs and suicidality demonstrates conflicting findings in that Healey (2003) found increased risk in early treatment and Isacsson, Holmgren and Ahlner (2005) reported a reduction. The Medicines and Healthcare products Regulatory Agency maintain that prescribers of SSRIs should monitor and assess for this regularly. Due to the possibility of suicidality occurring as a red flag, a prescription for treatment to last seven days was given and the rationale explained to Anne and her partner. In the practice area, service users are given information from the United Kingdom Psychiatric Pharmacy Group (UKPPG), available via the Trust intranet; the data regarding Citalopram was given to Anne (Appendix 1). Furthermore, Anne was encouraged to refer to the patient information leaflet, dispensed with the product from the chemist. Annes partner expressed concerns about media reports questioning the efficacy of antidepressant medication; this was addressed by giving him a copy of the Trusts response to the information (Appendix 2). This information was successful in reassuring him (evidence 8), along with the arrangements for reviewing Anne on a regular basis. In terms of reviewing Anne, stage five of the prescribing pyramid, a further appointment was made for seven days, in line with NICE (2004) guidance due to her higher background risk of suicide as an individual under the age of thirty years. Based on the evidence that SSRIs can increase risk of suicide, planning to see any patient commenced on antidepressants within a week would better ensure safety and professional accountability, in addition to addressing the public health target to reducing suicide. Although increased energy and motivation is apparent a week into treatment, the antidepressant effect is not, therefore the individual may continue to experience depressive symptoms and have the impetus to act on suicidal thoughts (NICE, 2004). Frequent monitoring thereafter is recommended by NICE (2004) who suggest professionals look for signs of akathisia, suicidal ideas and increased anxiety and agitation, which can occur with all antidepressants, including Citalopram. The author elected to give Anne and her partner the contact details for the Crisis Team in the local area, should support be needed out of working hours, explaining that they could be contacted if her mental health further deteriorated or she began to suffer with suicidal thoughts. It was indicated to Anne that she would be unlikely to feel the full benefit from the treatment for approximately two weeks due to the pharmacology of the drug (evidence 7) and that once the depression had lifted; guidelines suggest treatment should continue for at least six months after this marker. Geddes, Carney, Davies, Furukawa, Kupfer, Frank and Goodwin (2003) found that treatment continued for this time frame reduces the risk of relapse. In terms of keeping records, stage six of the prescribing pyramid, Annes progress was recorded using the electronic Care Programme Approach (eCPA) system. Use of eCPA in the practice area is a new development, intended to replace the paper-record system, allowing immediate access to relevant mental health staff. It is currently inaccessible to other health professionals; therefore duplication of work is necessary in order to ensure effective communication. Currently, professionals involved in the care of an individual seen by psychiatric services are identified as part of the initial assessment (evidence 1, section 19) and are advised of their treatment plan and progress via separate letters (Appendix 3). Working in this manner ensures safe, ethical practice by good communication with members of the multi-disciplinary team (NMC, 2008). In line with the NMC standards for recordkeeping (NMC, 2005) the author recorded and disseminated the information in a timely manner, using the same format as her DMP. In the future, the author plans to work with the non-medical prescribing lead to develop an appropriate format for her practice, which should enhance professional accountability. The seventh and final principle of the prescribing pyramid encourages reflection on prescribing practice. The author was confident that a prescription was necessary and therefore did not feel pressured by the patient to issue treatment against better judgement as can be the case (Britten, Ukoumunne and Boulton, 2002). Neither did the advertising activities of the relevant drug company influence the choice of product. Reliance on independent research was used to inform prescribing practice. Supplementary Prescribing Supplementary prescribing is described as a voluntary partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patients agreement (DH, 2005a paragraph 8). A critical analysis of a supplementary prescribing scenario will follow, addressing learning outcomes 1, 2, 3, 4 and 5. As in the IP scenario, reference will be made to the prescribing pyramid (NPC, 1999). The patient will be referred to as Alexander Stewart. Alexanders General Practitioner (GP) had been managing his care; however he had been referred to the service following discontinuation of antipsychotic medication Risperidone, due to sexual dysfunction. Alexander was under the care of a consultant psychiatrist who had diagnosed Schizophrenia of the paranoid type, under Section F20.0 of the International Classification of Disease 10 (WHO, 1992). At the time of meeting Alexander, early warning signs of relapse were evident in that he believed others were against him and were sending messages via media sources. Alexander had sufficient insight to be able to recognise that his mental health was declining and had attended the appointment in the hope that an alternative treatment could be prescribed. The independent prescriber (IP), Dr Gater, felt that Alexander was a suitable candidate for a supplementary prescribing arrangement as there were no issues of substance misuse, no co-morbid illnesses and he had a good history of engagement. It is recommended that these factors be considered before contemplating supplementary prescribing in mental health care (DH, 2005b). New Ways of Working in Mental Health (DH, 2005c) dictate that individuals with highly complex needs, including those with dual diagnosis, history of poor engagement, co-morbid physical illness and assessed high risk of harm to self or others are seen by more advanced, highly trained professionals such as consultants. Dr Gater discussed with Alexander the possibility of supplementary prescribing and he agreed to work in this way, with the author as the supplementary prescriber (SP), who also took on the role of care co-ordinator. The IP set the parameters of the Clinical Management Plan (CMP) and this was then drawn up and signed, (evidence 9) indicating agreement by the IP, SP and Alexander as is mandatory for supplementary prescribing situations (DH, 2005a). The IP and SP had shared access to the patient record. The CMP in this instance was broad and permitted prescription of antipsychotic medication from a wide choice of agents, however CMPs can be specific, for example, only allowing the SP to make dose or frequency of dose changes to an identified medicine (DH 2005b). In such cases, if a patient were to develop adverse side-effects from the medicine, a new CMP would have to be developed, leading to increased workload and time delays for treatment. In this instance, because of the knowledge and experience of the SP, the close working relationship of the IP and SP and the accessibility of comprehensive guidance regarding the management of Schizophrenia (NICE, 2002b) a broad CMP was considered appropriate. The author used the prescribing pyramid to aid practice (NPC, 1999) and adhering to the first principle, considered a holistic assessment. The IP had already taken a thorough history and made a diagnosis, however the history taking was repeated by the SP to ensure that Alexanders presentation had not changed. Difficulties can arise if this occurs (evidence 2d). A CPA assessment was carried out (evidence 10), supplemented by a symptom analysis tool, namely Morton (1992). The assessment confirmed the original diagnosis. The National Service Framework for Mental Health (DH 1999a) reported that individuals suffering with this illness are nine times more likely than the general population to commit suicide and that the risk of death from other violent incidents is over twice as high. Government policy since this time has aimed to ensure that people with mental health problems are better able to access services and appropriate treatments in a timely manner, to prevent the aforementioned likelihoods. The author was keen to uphold these principles and treat accordingly. Theorists such as Wyatt (1991) and McGlashan and Hoffman (2000) have speculated that prolonged non-treatment of Schizophrenia can result in brain-damaging neurotoxicity and synaptic plasticity, respectively; however there is limited research into these theories (McGlashan, 2006). Findings from duration of untreated psychosis studies have lead to the recent development of Early Intervention Services which aim to ensure that people with mental illness receive timely treatment in order to prevent biological, psychological and social decline (Whitwell, 2001). Personal experience has further demonstrated that non-treatment of the illness results in further loss of insight, increased distortions of judgement and the possibility that the active phase will last indefinitely. This knowledge meant that the second principle of the prescribing pyramid was satisfied since the appropriate strategy was to issue a prescription. Alongside this, the author, working as care co-ordinator for Alexander highlighted interventions to address issues relevant to his quality of life and well-being including housing, finance and employment support etc as suggested by government policy (DH 1999a, DH 1999b). The third principle, consideration of product choice, was initially agreed via the CMP. This indicated use of antipsychotic medication; however the selection of agents was open for discussion between Alexander and myself. To aid the decision, referral was made to the NICE guidance for treatments in Schizophrenia (NICE 2002a). The guidance recommends use of atypical antipsychotics in the treatment of Schizophrenia. Evidence 12 explains typical versus atypical antipsychotics in further detail. Alexander previously had a good response to an atypical drug, namely Risperidone, however stopped it due to the adverse drug reaction (ADR) he suffered. Alexander developed retrograde ejaculation, a reasonably high reported adverse effect of this drug (Taylor et al, 2007). Alexanders G.P had been satisfied that the symptom was not caused by other conditions such as diabetes mellitus or multiple sclerosis; and as the symptom ceased following discontinuation of Risperidone, was satisfied that it was an ADR. Although evidence suggests that this effect is dose related (Raja 1999, Loh, Leckband, Meyer and Turner 2004), Alexander did not wish to recommence this treatment. In choosing the most appropriate treatment, the criteria was therefore further simplified to an atypical agent, where possible, with a low affinity for alpha1 adrenergic antagonism since this is thought to be the cause of retrograde ejaculation with Risperidone (Loh at al, 2004). From the atypical agents listed in the current British National Formulary (RPS BMA, 2007), the two with the lowest affinity for alpha1 adrenergic antagonism are Aripiprazole and Quetiapine (Loh et al, 2004). Alexander was also presented with information comparing antipsychotics in terms of other commonly experienced side effects (Appendix 4) and then given the opportunity to ask questions. Finally, Alexander and I agreed on Aripiprazole and a prescription was issued (evidence 11). In addition to the importance of the positive side effect profile, Aripiprazole also rated as less expensive than comparable treatment with Quetiapine (Taylor et al, 2007) and this is a factor which prescribers are directed to pay attention to (NPC 1999, NICE 2002). In terms of preparations, Aripiprazole is manufactured in tablet form, orodispersible tablets and as an oral solution. As Alexander was happy to take tablets, this was the preparation prescribed. Aripiprazole is described as having a uniquely robust pharmacology (Davies, Sheffler and Roth 2004), centred on it being a partial agonist at Dopamine D2 receptors. Evidence 12 provides a profile for Aripiprazole, which explains this in further detail. It is distinctive from the other atypical agents as it stabilises the spread of dopamine in two of the four major pathways (mesolimbic and mescortical) where the neurotransmitter Dopamine is found, as opposed to purely blocking dopamine receptors or working as an antagonist at D2 receptors. Despite this difference, a recent systematic review of Aripiprazole actually found that it did not have significant advantages over other atypical medicines, neither did it demonstrate increased efficacy over typical drugs (El-Sayeh and Morganti, 2004). Coupled with this, Aripiprazole was shown to instigate similar adverse effects as treatment with typical agents, with the exception of akathisia, which lead to improved compliance (El-Sayeh and Morganti, 2004). Aripiprazole has not been shown to cause elevation of prolactin levels, nor is it associated with the development of impaired glucose tolerance or weight gain, therefore in theory, monitoring of these factors is not required (Travis, Burns, Dursun, Fahy, Frangou, Gray, Haddad, Hunter, Taylor and Young, 2005). In fact, Travis et al (2005) purport that no specific monitoring is required outside of the basic screening advocated in NICE (2002b) i.e. monitoring for endocrine disorders and cardiovascular risk factors etc. Despite this, the NHS Trust for which the author works recommends extensive monitoring (Appendix 5). The author would therefore be compelled to work within the guidance of the employing authority. In negotiating a contract (stage four), because Alexander and I shared the decision to try Aripiprazole, it was hoped that concordance would be achieved. Evidence 14 highlights the implications of excluding service users from the decision making process. Delivering the choice agenda in mental health is considered key to an effective prescribing value base for nurses (Jones and Jones, 2007), however it must be identified that issues of capacity for individuals with mental health problems can jeopardise this. For individuals lacking capacity during an acute Schizophrenic episode, guidance recommends the use of oral atypical medications, prescribed after consultation with the individuals carer or advocate (NICE, 2002a). Government policy has stated that service users should be encouraged to compile an Advanced Directive (AD) as part of their care plan, highlighting their treatment choices (NICE 2002b), although in practice, the author has limited experience of this happening (evidence 13) and does not feel it is something that the Trust encourages. Concerns have been expressed that service users might draw up unrealistic and illogical plans, refusing all forms of treatment, however a recent study found evidence to the contrary of this (Papageorgiou, Mohamed, King, Davidson and Dawson, 2004). It is the opinion of the author that where possible ADs should be formulated, allowing the patient to be autonomous, however the author also acknowledges that there may come a point where decision-making is replaced by that of the prescriber. At present ADs can be over-ridden if the patient is subject to compulsory treatment under the Mental Health Act (1983). In Alexanders case, an AD was offered but refused. Alexander was considered capable of providing informed consent and therefore, following the principles of good practice (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996), the author communicated to Alexander, various details about the prescription. These included information on what the prescription was for, how long the drug would take to work, how long to take it for, what dose to take and the possible side effects. The UKPPG data regarding Aripiprazole was given to Alexander (Appendix 6). The fifth principle of the prescribing pyramid, review of the patient was dictated by the CMP. Weekly review was carried out in order to ensure that the treatment was effective, safe and acceptable. Had it not been, the broad CMP permitted use of alternative agents. The IP and SP reassessed Alexander as planned three months later. In this time however the IP and SP met frequently to discuss the progress of Alexander and record keeping was kept up-to-date using the eCPA system. At present, GPs are advised of supplementary prescribing arrangements and changes in these via Trust devised letters (see Appendices 7 and 8). In this instance the letters were compiled and sent within 24-48 hours in line with local policy. The author reflected on her prescribing decision as recommended by the final stage of the pyramid and is confident that neither patient pressure nor the action of pharmaceutical companies affected decision-making. In practice, the author has experience of nursing individuals on a range of antipsychotics and is aware that this may affect choice of drug in the future Conclusion The author has described and analysed an independent and supplementary prescribing experience and has attempted to meet the module learning outcomes in doing so. The author is confident that her rationale for prescribing decisions is based on sound comprehensive guidelines and practice experience. The author plans to base future decisions on the prescribing pyramid model, making a conscious effort to see outside of the prescriptive toolkit so as to remember the importance of other nursing interventions. It is the intention of the author to utilise the support and clinical supervision available in the practice area, including discussion about differential diagnosis and treatment options with the medical team following assessments. This will ensure safe practice, professional development and recognition of the contribution of non-medical prescribers within the team. Evidence 16 details the authors plans for continuing professional development in prescribing practice, both as an independent and a supplementary prescriber. These goals are important to ensure competency in prescribing practice is maintained. By ensuring that practice is updated, monitored and evaluated, service user experience is hopefully improved leading to increased concordance and better health outcomes

The New Immigration in American History :: American America History

The New Immigration in American History In 1886 the statue of "Liberty Enlightening the World," a gift from the people of France, was dedicated by President Grover Cleveland. Set at the entrance to New York, the statue was just in time to greet the biggest migration in global history. Between 1880 and World War I, about 22 million men, women, and children entered the United States. More than a million arrived in each of the years 1905, 1906, 1907, 1910, 1913, and 1914. Not everyone had to travel in steerage. Passengers who could afford the expense paid for first- or second-class quarters. Upon arrival these immigrants were examined by courteous officials who boarded the ships at anchor. But those in steerage were sent to a holding center for a full physical and mental examination. The facility at Ellis Island which opened in 1892 could process up to 5,000 people a day. On some days between 1905 and 1914 it had to process more than 10,000 immigrants a day. Many arrivals had left their homelands to escape mobs who attacked them because of their ethnicity, religion, or politics. The German, Russian, Austro-Hungarian, and Ottoman (Turkish) empires ruled over many different peoples and nationalities and often cruelly mistreated them. Until 1899, U.S. immigration officials asked arrivals which nation they had left, not their religion or ancestry. So oppressed people were listed under the countries from which they fled. Armenians who escaped from Turkey were recorded as Turks, and Jews who had been beaten by mobs in Russia were listed as Russians. This so called "new immigration" was different in many other ways from previous immigration. For the first time, Catholic an Jewish immigrants outnumbered Protestants, and still other arrivals were Muslims, Buddhists, or Greek or Russian Orthodox church members. Until 1897, 90 percent of all overseas immigrants had come from Protestant northern and western Europe. Many of these nations had democratic traditions and education systems. Even among the poor, many had spent a few years in school or had acquired some industrial skills on the job, and more than a few spoke English. Many of these men and women settled in agriculture regions of the Untied States.

Unfulfilled Dreams in Amy Tan’s Two Kinds Essay -- Two Kinds by Amy Ta

The short story â€Å"Two Kinds† written by Amy Tan is about conflict between a mother and daughter. A mother tries to live her life through her daughter and her daughter rebels. The prominent theme of this short story would seem to be "unfulfilled dreams†. After losing everything in China, the mother of Jing Mei comes to America with the dream that Jing Mei will have it all: fame, fortune, and most of all success unlike herself. Little does she know, her dream will be short-lived. All Parents have dreams for their children. A lot of parents want their children to succeed in life and push them to do so. Some parents want their children to be just like them, but most of the time parents push their children to do things that they were never capable of doing. There are some children who listen and do as their parents say but there are some who choose to be their own person and follow their own paths, not those of their parents, like Jing Mei. Young children want to follow dreams of their parents, it is not until they get older when some realize it is not for them and begin to make t...

Ralph Waldo Emersons Transcendentalist Philosophy and Its Influence on

Ralph Waldo Emerson's Transcendentalist Philosophy and Its Influence on Margaret Fuller's Feminist Philosophy Ralph Waldo Emerson was a leading thinker in the American Transcendentalist movement, who first proposed many of the movement’s most influential ideas regarding the relation between the human mind and the world. He believed each person to possess a â€Å"soul,† a power within the self to uniquely perceive and understand the world, and grasp the intricate relationships between all things; Emerson’s universe was infinitely knowable, and his ideal, independent soul should be in a state of constant consideration and reevaluation of the world around him. Emerson’s notion of the chief end of life was the growth and development of one’s soul, and the maintenance of a constant state of learning and changing, of always becoming rather than simply being. He viewed society as a fundamentally oppressive phenomenon, as it imprints itself upon one’s soul and possesses the dictatorial capacity to hinder the soul’s crucial independent thought; to E merson, society was a â€Å"conspiracy against the manhood of every one of its members†¦ The virtue in most request is conformity. Self-reliance is its aversion. It loves not realities and creators but names and customs. Whoso would be a man must be a nonconformist,† (Self-Reliance 1162). â€Å"Self-reliance,† the title of Emerson’s 1841 essay, advocates independent thought as a human ideal, above and beyond the confines of traditional, unquestioning society. Emersonian Transcendentalist thought influenced many other emerging figures, including the feminist thinker Margaret Fuller, who believed society, males and females alike, to be suffering from a lack of gender equality. Fuller took t... ...of minds, gains the capability of self-reliance. Emerson depicts his homeostatic society as governed by the tyranny of the fickle majority: â€Å"the sour faces of the multitude, like their sweet faces, have no deep cause,—disguise no god, but are put on and off as the wind blows, and a newspaper directs. Yet is the discontent of the multitude more formidable than that of the senate and the college,† (Self-Reliance 1164). This is paradoxical, in that the American people should ideally be free, but are instead manipulated by the tyrannical masses. If all Americans are governed by an oppressive majority, it seems that nobody is yet free. It would, therefore, follow, that some institutional or governmental reform should be necessary before anybody, man or woman, can be free enough to become self-reliant and, through Emersonian ideals, change society internally.

Hawthorne The Myth of the Docile Worker Essay

Review This journal begins with an introduction to the infamous Hawthorne experiments led by Elton Mayo and Fritiz J. Roethlisberger. These experiments were based on Mayo’s belief in the need to shift the focus of management from a scientific approach to one that valued human relations. The Hawthorne experiments surfaced as the pioneer studies of it’s time in human management psychology. The results developed a theory known as the â€Å"Hawthorne effect† in which many have incorporated to form the fundamentals of modern day human relations in commerce. Roethlisberger described the â€Å"Hawthorne effect† as an awareness from the working class when special attention is given by their managements thus bringing about a positive change in productivity. Today, the â€Å"Hawthorne effect† is even equated as simply treating employees well. Bramel is critical when pin-pointing the flaws of the theory. Being unconcerned over the methodology and accuracy of the experiments, he gives Mayo the benefit of the doubt and instead questions in particular two aspects of the theory. The first of which is the assumption that workers are easily manipulated by their higher managements to become constructive and cohesive with their fellow workers thus increasing productivity regardless of the working environment or economy. The second assumption being, conflict between management and it’s workers are due to external factors and downplays the fact that conflicts of interests between the two parties is inevitable. The truth remains that the firm is exploitive in it’s capitalist nature, managers will constantly seek to increase productivity whereas workers will always look out for their own economic interest. Bramel’s interpretation of the Hawthorne effect puts into play the fact that the capitalist recognizes that human relations is important. However, he puts it sharply that Mayo’s interpretation of the management- worker relationship is that of a myth, and is not relevant to all managements and cannot be used as a textbook answer towards dealing with workers. Bramel is not the only one who is critical when it comes to the Hawthorne effect theory. Richard Gillespie, 1991, presents us with the most balanced view he strongly disapproves with the Hawthorne effect theory that satisfied employees are productive employees. Instead, he believes the Hawthorne effect is subject to the interpretations by the various experts who manage the situations and apply the theory on their workers to achieve the results they require. I believe the question now lies, how can managements change their worker’s attitudes to achieve a trusting and productive worker? A review of : Bramel, D. (August 1981). Hawthorne, the Myth of the Docile Worker, and Class Bias in Psychology. American Psychologist, Volume 36(8) pp. 867-878. Oreg and Berson note that careful selection process when selecting personnel eliminates negativity in workers and helps bring together like minded people who are passionate about their jobs and look for work satisfaction. (Oreg and Berson, 2011) In this way, class biases and the conflict of interests between managers and workers is reduced. Managers can expect to achieve their desired results and produce a motivated workforce. Managers can expect to maximise the capacity and performance of their human resources by orientating their workers to familiarise them with the company’s goals, objectives and vision, help their workers understand the constant changes and demands of their job requirements and minimises misunderstanding and conflicts in the workplace. In other words, by setting performance expectations that correspond with the worker’s value systems help managers shape their employee’s attitudes. (Oreg and Berson, 2011) Armed with such valuable information, managers who relay their expectations and keep an open channel of communication between themselves and their workers, allow workers to achieve their targets using their best possible means in the the ways most comfortable to them. Integrating workers into the firm is crucial. By providing a flexible and comfortable work environment, managers are able to fully achieve productivity by allowing each worker to be individualistic and reach their full potential. (David Fairhurst, 2010) David woods agrees that complex management hierarchies should be removed and employees are looking for the freedom of speech and their opinions to be valued by managements. He illustrates that in order to retain the best talents, modern managements are to be less oppressive in their management styles and provide more engaging benefits. Employees appreciate the transparency help in management and no longer feel that the firm is looking to exploit them, rather to reward performance based or meritocracy. (David woods, 2010) Wayne Gwilym the HR director of insulation firm Rockwool is one such manager. â€Å"I am a change manager†, Gwilym states. A decade ago, the workers were negative and demotivated when Gwilym took over HR operations of the family based business. Today, Gwilym boasts of the transformation that the Rockwool workforce has gone through and has become a valuable asset to the company. The answer for Rockwool’s workforce transformation presented to us by Gwilym was simple. It was to get the HR team, managers and their workers to work together to develop employment policies as a collaborative effort and expedite it’s implementation. Today, Rockwell strongly believes that a motivated workforce who trusts and looks forward to the business’s future success is one of the forces driving the business forward. Gwilym is a change manager who sees the importance of giving his worker’s stretching targets and establishing a cost cutting project (Harrington, Sià ¢n, 2010) A survey based research conducted by Anne Delarue, Geert Van Hootegem, Stephen Procter and Mark Burridge on teamwork and organizational performance go hand in hand with the concepts as explained to us by Gyilym. The authors suggest that an A review of : Bramel, D. (August 1981). Hawthorne, the Myth of the Docile Worker, and Class Bias in Psychology. American Psychologist, Volume 36(8) pp. 867-878. inclusive human resource system which emphasizes on teamwork, will have a positive effect on employee’s job satisfaction, commitment and motivation. These factors in turn lead to an improvement in employee attitudes and organizational performance. The journal points out that it is important for managers to discover how and why employees behave and perform the way they do. (Anne Delarue, Geert Van Hootegem, Stephen Procter and Mark Burridge, 2008) Bramel’s speculations in the Hawthorne effect theory involving the myth of the docile workers and that class biases do exist is one that I believe holds substance even in our day and age. Further research into the factors as pointed out by Bramel drive the same point home, class biases will continue to exits due to the capitalist nature of the industries and that workers are also humans whose mental state cannot be controlled and is difficult to predict. In today’s context, management sees the importance of a changing and flexible management that places importance in the welfare of it’s workers in order to obtain maximum productivity. Our society’s demanding and constantly changing expectations requires mangers to step up to the challenge to become a change manager who can adapt and find a balance between the expectations of the employers and it’s employees. Management styles will continue to vary and change, however, one fact remains, it is the managers’ duty to employ management techniques to reduce and eliminate threats to the firm. By narrowing down the factors that causes negativity in the workplace, managers can prevent workers’ counteractive mentalities and detrimental company cultures from taking seed. As quoted from Leo Burnett, â€Å"When you reach for the stars you may not quite get one†¦ But you won’t come up with a handful of mud either†. And I believe this is the mindset managers should have when working with their workers bearing in mind that the workforce are the ones who make or break a firm. As quoted from Will Hutton, â€Å"Human resources play a crucial role in the transformation of an industry – but only if it embraces the challenges.† (Will Hutton, 2010) A review of : Bramel, D. (August 1981). Hawthorne, the Myth of the Docile Worker, and Class Bias in Psychology. American Psychologist, Volume 36(8) pp. 867-878. Resources: Richard Gillespie, (1991). Manufacturing Knowledge: A history of the Hawthorne experiments†. Cambridge University Press. Shaul Oreg & Yair Berson, (Autumn 2011 ). Leadership and employees’ reactions to change: The role of Leaders’ personal attributes and transformational leadership style. Personnel Psychology, Vol. 64 issue 3, pp. 627-659. Fairhurst, David, (Nov 2010). We’re in danger of losing sight of the fact employees are human beings rather than, well, human resources. Human Resources. Human Resources. pp. 15-15. David Woods, (Nov 2010). HR Lessons†¦ From history. Human Resources. pp. 62-62. Harrington, Sià ¢n, (Nov 2010). Order out of Chaos. Human Resources. pp. 29-31. Anne Delarue, Geert Van Hootegem, Stepjem Protec & Mark Burridge, (2008). Teamwork and organizational performance: A review of survey-based research. International Journal of management reviews, volume 10 issue 2, pp. 127-148 Will Hutton, (Nov 2010). We cannot wish back into existence factories and steel mills that have been closed over the past 40 years. Human Resources. Pp 22-22.

Mintzberg’s 10 Managerial Roles Essay

This chart summarizes a manager’s ten roles: | | |Mintzberg’s Managerial Roles | | | | | | |Category |Role |Activity |Examples | | | | | | |Informational |Monitor |Seek and acquire work-related |Scan/read trade press,   periodicals, | | | |information |reports; attend seminars and | | | | |training; maintain personal contacts | |   | | | | | |Disseminator |Communicate/ disseminate information |Send memos and reports; inform staffers and | | | |to others within the organization |subordinates of decisions | |   | | | | | |Spokesperson |Communicate/transmit information to |Pass on memos, reports and informational | | | |outsiders |materials; participate in | | | | |conferences/meetings and report progress | |   |   |   |   | | | | | | |Interpersonal |Figurehead |Perform social and legal duties, act |Greet visitors, sign legal documents, attend| | | |as symbolic leader |ribbon cutting ceremonies, | | | | |host receptions, etc. | |   | | | | | |Leader |Direct and motivate subordinates, |Includes almost all interactions with | | | |select and train employees |subordinates | |   | | | | | |Liaison |Establish and maintain contacts within|Business correspondence, participation in | | | |and outside the organization |meetings with representatives | | | | |of other divisions or organizations.   | |   |   |   |   | | | | | | |Decisional |Entrepreneur |Identify new ideas and initiate |Implement innovations; Plan for the future | | | |improvement projects | | |   | | | | | |Disturbance Handler |Deals with disputes or problems and |Settle conflicts between subordinates; | | | |takes corrective action |Choose strategic alternatives; | | | | |  Overcome crisis situations | |   | | | | | |Resource Allocator |Decide where to apply resources |Draft and approve of plans, schedules, | | | | |budgets; Set priorities | |   | | | | | |Negotiator |Defends business interests |Participates in and directs negotiations | | | | |within team, department, and organization | In the real world, these roles overlap and a manager must learn to balance them in order to manage effectively. While a manager’s work can be analyzed by these individual roles, in practice they are intermixed and interdependent. According to Mintzberg: â€Å"The manager who only communicates or only conceives never gets anything done, while the manager who only ‘does’ ends up doing it all alone.†