†REFLECTION Monitoring and Ensuring Quality Care

– REFLECTION Monitoring and Ensuring Quality Care Introduction The purpose of this paper is to reflect on a recent personal experience of patient care, which enabled me to achieve a module 9 competency, Actively seeks to extend own knowledge. I will be critically analyzing one nursing practice incident using Boud, et al (1985) model of reflection, (please see appendix 1) which will enable me to monitor and ensure quality patient care in future practice. The nursing incident happened when I was looking after a patient requiring enteral tube feeding (ETF). It is important to note that all confidential information relating to patients, wards, hospitals and professional colleagues has not been included in this paper to ensure ethical practice and adherence to the NMC code of professional conduct, section 5 which affirms that I must guard against breaches of confidentiality (NMC 2008). Reflection is a useful tool for the continuation of professional development among nurses (Somerville and Keeling 2004). The word reflection originates from the verb reflectere which means to bend or turn backwards (Hancock 1998). It is a tool, which unlike text books and videos, does not have a limited shelf-life, it is cost effective, is portable and can be used world wide. Patient Profile The aspect of nursing care I have chosen to reflect on is the care of a patient who required enteral tube feeding (ETF) due to dysphagia a condition in which the action of swallowing is difficult to perform (Unison Health Care 1998). This nursing intervention was essential for a patient in my care, who I shall call John. Please see appendix 2 for Johns past medical history. The Plan of Treatment for John John was admitted to my area of practice six days ago following his CVA. He is receiving ETF via an NG tube as an immediate intervention and is being assessed to see if he is a suitable candidate for a percutaneous endoscopic gastrostomy (PEG) tube which are used as a more permanent form of enteral tube feeding (Holmes 2004). The nasogastric tube is about 22 inches [55.9cm] in length (Holmes 2004) and was inserted into his left nostril down through the pharynx, through the oesophagus and through the cardiac sphincter muscle and into the stomach (Marieb 2001). Food can be administered through the tube directly into the stomach and the swallowing process does not need to take place. The food is administered by a pump that controls the amount of feed given in mls per hour. This description could sound as though ETF is always safe and effective and has no complications. Elia (2001) affirms that ETF is typically safe and easy to administer. However John did experience a number of difficul ties that could have been rectified sooner than they were. On reflection of Johns care it is clear to see (with the benefit of hindsight) that if Johns care was managed differently and if complications were noticed and acted on promptly, his hospital experience could have been very different. 1.) Returning to the experience Problems John faced. John experienced two main complications as a result of ETF. The first was regurgitation of the feed into his throat and mouth and the second was diarrhoea. The rate of the feed had been increased over a period of days to its optimal rate, following the ETF guidelines provided by the NHS trust that I was working in. The infusion was commenced during the night while he was sleeping to allow John greater freedom during the day as he could be disconnected from the pump. The regurgitation happened during the first night that the pump was running at the optimal flow rate. Davis and Shere (1994) report that regurgitation is a common complication of ETF. As a consequence, John had to swallow what had come up into his mouth. The rationale for John to undergo enteral tube feeding was to prevent further weight loss and aspiration which can be caused by dysphagia (DeLegge 1995, Gibbon 2002 and Davies 1999). Aspiration has various meanings, however in this context it refers to the movement of for eign material i.e. fluids or food, into the trachea and further down into the lungs (Unison Health Care 1998). This can occur when the swallowing mechanism is ineffective or impaired. Infection of the lobe of the lung, in which the foreign material has lodged, occurs. This is called aspiration pneumonia (Unison Health Care 1998). Patients suffering from dysphagia are at risk of developing aspiration pneumonia (DeLegge 1995 and Gibbon 2002). ETF was commenced to overcome this risk but now the very intervention that was intended to eliminate the risk has caused an even greater risk of aspiration pneumonia. According to Marieb (2001) there are two stages of deglutition (swallowing). The buccal phase, which is a voluntary action, occurs in the mouth and is the first phase of deglutition. The tongue progressively elevates anteriorly to posteriorly, propelling the bolus through the oral cavity. When the bolus has moved to the base of the tongue, the soft palate is raised, preventing food from being regurgitated via the nasal passage (Davies 1999). The second is the involuntary pharyngeal-oesophageal phase which Davies (1999) describes as a complex sequence of muscular movements. After a CVA the ability to initiate the secondary phase of deglutition can be disrupted resulting in ineffective or complete failure of this phase of deglutition. This short explanation of pathophysiology demonstrates how important it is to know nursing rationales for nursing interventions. Patients suffering from dysphagia can sometimes overcome the problem by eating a pureed diet and drinking thickened fluids, but this depends on the severity of the dysphagia (Stringer 1999). John needs ETF because his dysphagia is too advanced to be overcome by a change in diet. Arrowsmith (1993) recommends that patients who are receiving ETF via a NG tube that are lying in bed, should have their head and shoulders elevated 30-40 degrees during feeding and up to one hour afterwards to minimise gastric pooling and reflux of the feed. This example demonstrates how a simple action can make a substantial impact on the quality of care that they experience. It has the twofold purpose of Impact of the quality of care that they experience. It has twofold purpose of promoting the effectiveness of the intervention and minimises harm to the patient by reducing the risk of aspiration pneumonia. Assessing for signs of aspiration in a patient suffering from dysphagia should always be taken seriously by nursing staff. Stringer (1999) reports that if dysphagia is serious enough it can prevent the victim from swallowing their own saliva. The average person swallows approximately 590 times each day 146 when eating, 394 when awake and not eating and 50 times during sleep (Davies 1999). With the average person swallowing literally hundreds of times each day, patients are at risk of aspirating (on their own saliva) regardless of ETF. Barer (1989) found that over one third of conscious acute stroke patients admitted to hospital had unsafe swallowing. Davies (1999) citing Ellul and Barer (1994) affirms that dysphagia in the first three days after stroke is associated with a five to tenfold increased risk of chest infection during the first week. This is due to varying degrees of aspiration. Aspiration is a potentially fatal complication of ETF. John also experienced three episodes of diarrhoea since starting ETF. John was only provided with a commode which was only dealing with the symptoms rather than treating the cause. No contact was made with the senior house officer or dietician. Furthermore there did not appear to be much concern among the nursing team and there was no discussion or sharing of knowledge between colleagues accept what came from myself. I told my mentor what I had been reading during my reflection time and pointed out some reasons that have been identified as causing diarrhoea for patients receiving ETF. The attitude of my mentor was apathetic, and commented, Hes bound to pick up a bug, give it time, it will pass. This shocked me as Somerville and Keeling (2004) reports that the nursing profession depends on a culture of mutual support, and this was not what I received from my mentor. I wanted to discuss the temperature of the feed, his current medication and the cleanliness in which the feed was prepared and administered. If the feed is too cold when it is administered it can cause diarrhoea (Arrowsmith 2003). Howell (2002) reports that diarrhoea can be the result of ETF but it can also be due to the side effects of medications. Antibiotics can cause the common side affect of diarrhoea (BMA 2001) but John was not receiving any. Diarrhoea in ETF can also be caused through the introduction of bacteria through poor hygiene standards in the preparation and administration of the feed; however the preparation and administration does not need to be performed aspptically. This is only indicated if the patient is immunocompromised (Arrowsmith 1993). My professional knowledge reminded me that I could not dismiss the diarrhoea as a coincidence. If there were nursing interventions that could be used and I didnt use them, I would be failing to provide quality care for my patient. Nurses are responsible not only for their actions but also for their omissions (NMC 2008). I wanted to refer to each others professional knowledge through discussion, and to the ETF guidelines to see if there was a simple cause to the problem that could be rectified before consultation with the doctor or dietician became necessary. I was able to rule out most factors that can cause diarrhoea. This led me to believe that the infusion rate could be too fast. These are the factors that I wanted to discuss with my mentor so I could contact the dietician to seek help from the multidisciplinary team. Gibbon (2002) asserts that stroke care requires the services of a multi-professional te am, working towards an agreed therapeutic plan hence my reason to collaborate with the dietician. 2.) Attending to feelings What did I feel was Positive? During reflection time I was very interested and pleased to find this research to suggest that there could be something that I could do to put an end to the discomfort, distress and potentially disastrous complications of a patient in my care. Many times as a student I have felt that I personally, am not making a great difference to my patients health and wellbeing as I am not working independently, but under my mentor who in general decides on a course of action for our patients. This time I have found the answer from my own research. All that remains is for me to bring this research to my mentors attention and then put the intervention into practice. The patient will benefit, and I will have a great sense of achievement as I will have, in a small way, improved the quality of someones life, accomplishing one of the reasons why I decided to take a career in nursing. Attending to feelings What did I feel was Negative? In response to the apathy that I encountered, I felt disappointed and powerless and undervalued. My original mentor was off on temporary short term sickness due to a small operation and therefore I was allocated another Junior Ward Sister to take her place for the short period of time in her absence. I felt disappointed because my contribution to the care of my patient was not welcomed and that this mentor was not as patient or interested in my learning and on-going development. I also thought it was unfair because I had evidence to base my suggestions on. It was not a vague idea I had conceived but it was grounded in research. I felt powerless because as a junior and inexperienced member of the team I felt I had little influence over the overwhelming hierarchy. Morris (2004) states that student nurses possess little power because they are viewed as inexperienced. I wanted to make my mentor realise that the patient could be suffering (from diarrhoea and regurgitation) because of our negligence and not from inevitable causes. Why was Cognitive Learning Being Achieved? In this situation I was learning a number of things, mainly relating to communication, team work, assertiveness, accountability and responsibility. I learned that my priority is with the care of my patient and not with my popularity among colleagues, just as the NMC (2008) signifies when it states when facing professional dilemmas, your first consideration in all activities must be in the interests and safety of patients. When I met with my original mentor on her return back to work we discussed this incident of practice and she praised my efforts in extending my knowledge to improve patients care. I therefore achieved the competency, actively seeks to extend own knowledge. Do Any Barriers to Learning Exist? The barriers that existed to my learning were the apathy of the nurses and the limits of my own assertiveness. It was very hard on this ward to feel proud of the care that was being given. The ward was poorly staffed, the ward manager was unanimously unpopular, the ward relied heavily on agency staff that was not familiar with the ward and my temporary mentor wanted to leave nursing because of all of the above (and more). As a new and enthusiastic team member I found my self fighting against the low morale and low motivation of the current staff. Job satisfaction can impact on the care that nurses provide. Brown (1995) believes that when nurses enjoy good job satisfaction they provide a higher standard of care to their patients. Rohrlach (1998) and Govier (1999) cited by Kitson (2003) discovered that nurses who were happy with the care they were giving were more likely to stay within the clinical area which would in turn provide some stability and security within the workplace. Accor ding to this research, the inability to give quality care (due to the problems mentioned) was resulting in low morale. The dilemma I faced was as follows. I had already approached my mentor once regarding Johns problems and detected that there was little interest in what I had to offer and in the nurses willingness to correct any problems. If I addressed the issue again, I risked worsening the relationship between my mentor and myself. Morris (2004) identifies that student nurses often feel nervous about speaking out because they feel the need to conform or do not wish to be viewed in a negative way. Student nurses risk upsetting the status quo by speaking out. If I left the issue my patient may be suffering discomfort unnecessarily, but as a student I will never be held accountable in a way that registered nurses midwives or health visitors are (NMC 2008). Would this justify me leaving the issues and conforming to the apathy and bad practice of my mentor? Morris (2004) disagrees. She says that although students are not legally accountable for their actions and omissions, they are morally responsible for ensuring that patients are receiving good standards of care. The student nurse must be responsible. Semple and Cable (2003) affirm that responsibility is concerned with answering for what you do. Registered nurses, midwifes and health visitors are accountable which, Semple and Cable (2003) defines as being answerable for the consequences of what you do. 3.) Re-evaluating the Experience Drawing Conclusions Drawing conclusions is the most vital part of the process of reflection. It will shape future practice and quality of care. Conclusions that are drawn from reflection must agree with the Nursing and Midwifery Council code of professional conduct. It is with the NMC that all matters of conduct, practice and attitude are dictated to nurses. The NMC (2008) motto, protecting the public through professional standards can only be achieved if all those on the NMC register are willing to submit to the conditions and regulations that it upholds. Indeed Somerville and Keeling (2004) affirm that in order for nurses to meet the demands of the NMC, they must focus on their knowledge skills and behaviour which can be achieved through reflection. On reflection of the described incident, it was difficult to know what to do. My mentor was not up to date with the knowledge of this area of practice. I cannot, and do not expect her to know everything, however Glover (1999) points out the nurses should be reliant on others for information. The NMC (2008) states that nurses should work cooperatively within teams and respect the skills, expertise and contributions of colleagues, treating them fairly and without discrimination. Therefore I expected my temporary mentor to take more interest in what I had to offer. Indeed Morris (2004) argues that qualified nurses are obliged to listen to other staff regardless of their qualification status. Announcing that practice should be in accordance with the NMC is too simplistic an answer to such a diverse problem. It is correct to say this but how will this be achieved? The ward is in need of good clinical leadership, first of all from the sister in charge. Nadeem (2002) states that the call for good leadership in the NHS has reintroduced the matron figure and also the new role of nurse consultants. Specialist nurses do have a role in ensuring safe practice and quality care but this should be in addition to effective local leadership i.e. leadership from the ward sister. Leadership is perceived as being good if there is good team working and if managers have good relationships with staff (Lipley 2003) which is one area that needs consideration in this scenario. Meeting the staffs needs improves satisfaction, productivity and efficiency (Nadeem 2002) which in this instance principally means the provision of resources, i.e. human resources. Nurses who are happy with the care they give are more likely to stay within their clinical area (Rohrlach 1998 and Govier 1999 cited by Kitson 2003). This would provide some stability and security in the workplace. Clinical governance has also come to play a prominent role in ensuring quality care. The government has defined clinical governance as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding standards of care, by creating an environment in which excellence in clinical care will flourish (Department of Health 1998). It had been noted that unacceptable variations in clinical practice where becoming common in the NHS (Department of Health 2010). While some patients were receiving excellent health care, e.g. in stroke care, other patients in the country were receiving sub-optimal stroke care due to differences in facilities, funding, education and staff. Each clinical area can improve the quality of care by (1) using modern matrons and nu rse consultants as clinical leaders, (2) by having adequate staff to care effectively and to lift morale among existing staff and (3) by implementing clinical governance which will result in the flourishing of good practices across wards, departments and NHS trusts through the sharing of expertise, research and ideas. The wards problems could also be addressed through annual reviews or by encouraging staff to keep an up-to-date portfolio (Somerville and Keeling 2004). This will allow nurses to identify strengths and opportunities for development. Critically analysing using reflection on this incident has been valuable in maintaining the quality of care as set out in the NMC code of professional conduct. Gallacher (2004) says that she questions different peoples practices in order to provide her patients with first class quality care. Clinical practice will not improve if it remains unquestioned. Hindsight gives the practitioner the opportunity to discriminate between good and bad practices. Safe, legal and quality care can only be given if it is in keeping with the NMC code of professional conduct. Reference list Arrowsmith, H. (1993) Nursing Management of Patients Receiving a Nasogastric Feed. In: British Journal of Nursing. 2 (21) 1053-1058 Barer, D. (1989) The Natural History and Functional Consequences of Dysphagia after Hemispheric Stroke. In: Neurol Neurosurg Psychiatry. 52, 236-241 BMA (2008) New Guide to Medicines and Drugs. London: British Medical Association. Brown, R. (1995) Education for Specialist and Advanced Practice. In: British Journal of Nursing. 4 (5) 266-268 Department of Health (1998) First Class Service: Quality in the New NHS. London: The Stationery Office. Davies, S. (1999) Dysphagia in Acute Strokes. In: Nursing Standard. 13 (30) 49-55 Davis, J. Shere, K. (1994) Applied Nutrition and Diet Therapy for Nurses. 2nd Ed. Philadelphia: PA,WB Saunders. DeLegge, M. (1995) Percutaneous Endoscopic Gastrojejunostomy: A Dual Centre Safety and Efficacy Trial. In: Journal of Parenteral and Enteral Nutrition. 19 (3) 239-243 Gallacher, G. (2004) Gaining a Better Understanding of Reflection to Improve Practice. In: Nursing Times. 100 (23) 39 Gibbon, B. (2002) Rehabilitation Following Stroke. In: Nursing Standard. 16 (29) 47-52 Glover, D. (1999) Accountability. In: Nursing Times Clinical Monograph. 27, 1-11 Elia, M. (2001) Trends in Artificial Nutrition Support in the UK during 1996-2000. Maidenhead: BAPEN. Hancock, P. (1998) Reflective Practice using a Learning Journal. In: Nursing Standard. 13 (17) 36-39 Holmes, S. (2004) Enteral Feeding and Percutaneous Endoscopic Gastrostomy. In: Nursing Standard. 18 (20) 41-43 Howell, M. (2002) Do Nurses know enough about Percutaneous Endoscopic Gastrostomy? In: Nursing times. 98 (17) 40-42 Hutton C (2005) After a stroke: 300 tips for making life easier, London.UK Kitson, J. (2003) Education for High Dependency Nursing. In: Paediatric Nursing. 15 (1) 7-10 Lipley, N. (2003) Research Shows Benefits of Nurse Leadership Training. In: Nursing Management. 10 (2) 4-5 Marieb, E.N. (2001) Human Anatomy and Physiology. 5th Ed. United States of America: Benjamin Cummings. Morris, R. (2004) Speak out or Shut up? Accountability and the Student Nurse. In: Paediatric Nursing. 16 (6) 20-22 Nadeem, M. (2002) Evolution of Leadership in Nursing. In: Nursing Management. 9 (7) 20-5 Nursing and Midwifery Code of Professional Conduct. London: Nursing Council (2008) and Midwifery Council. Nursing and Midwifery An NMC Guide for Student of Nursing and Council (2008) Midwifery. London: Nursing and Midwifery Council. Semple, M. Cable, S. (2008) The new Code of Professional Conduct. In: Nursing Standard. 17 (23) 40-48 Somerville, D. Keeling, J. (2004) A Practical Approach to Promote Reflective Practice within Nursing. In: Nursing Times. 100 (12) 42-45 Stephanie K, Daniels, Maggie Lee Huckabee (2008) Dysphagia following stroke (clinical dysphagia) London. Stringer, S. (1999) Managing Dysphagia in Palliative Care. In: Professional Nurse. 14 (7) 489-492 Appendix 1 Three stages to the process of reflection. Boud, Keough and Walker (1985). a) Returning to experience Observations what happened? What was my reaction? Clarify personal perceptions b) Attending to feelings What did I feel at the time? What did I feel was positive? Why is cognitive learning being achieved? What did I feel was negative? Do any barriers to learning exist? Raise awareness and clarify feelings c) Re-evaluating the experience Draw conclusions and insights together with existing knowledge Identify gaps in knowledge Integrate existing and new knowledge

The Prince and the Pauper :: Essays Papers

The Prince and the Pauper The three main ideas of this book are (1) two boys' wishes become true but later they don't enjoy it (2) Be careful what you wish for(3) Always think about what you're doing first. The two major characters were Tom Canty and Edward, the Prince of Wales. The conflict was between John Canty, Tom's father, and the prince. The other conflict was between Tom and the lords, servants, the King, and all the royal people in the castle. John Canty, the lords, the servants, the King, and all the royal people in the castle opposed Tom and Edward. Tom and Edward opposed them also. The characters deal with the situation that they find themselves in by telling the truth. They never stopped telling everyone one who they really were. They insisted saying that there were not who everyone really thought they were. Everyone thought Tom and Edward were both mad. The reason why no one believed them is because they both looked alike and they both had exchanged outfits. They exchanged outfits because Edward wanted to feel how it was to be a pauper and how to live like one and Tom wanted to feel how it was to be a prince, the son of the King, and how to live like one. First Tom was enjoying it because he didn't have to beg anymore, he ate good food, and he slept in a nice, cozy bed in the King's palace, but later he didn't enjoy it because he wanted to go back home to his original family and live the way he used to live. The Prince of Wales, son of the King, Edward was then living like a Pauper. He was treated badly and never ate anything at all. He was beaten by John Canty, Tom's father and was always forced to beg. Tom's mom tried to stop John but John and Tom’s sisters watched in just slapped her horror. Edward didn't even enjoy being a pauper at least once. Everyone just thought that Tom and Edward were both mad. They solved the confusion, though. After the King had died and Tom was about to be crowned King of England Edward ran in and said that he was the true King.

Symbols and Symbolism in The Yellow Wallpaper and A Rose for Emily

Symbolism in The Yellow Wallpaper and A Rose for Emily      Ã‚   William Faulkner's "A Rose for Emily" and Charlotte Perkins Gilman's "The Yellow Wallpaper" hold numerous similarities. Both stories show the influences of society and the slow decay on a particular woman. The title of each piece becomes important to the plot and ultimate outcome. In several ways, each title takes shape to portray symbolism in one sense or another. The references to color identify contradictory messages to those who have not heard of these stories, while the title itself takes physical form and is "living" at some point in the piece.      Ã‚  Ã‚  Ã‚   When first assigned to read "The Yellow Wallpaper," a student may think of a bright, cheerful paper covered room. Little does he realize that, instead of a stereotypical yellow, the wallpaper's "color is...almost revolting; a smouldering unclean yellow" (Gilman15). It reminds the narrator of "all the yellow things [she] ever saw--not beautiful ones... but old foul, bad yellow things" (23). According to Carol Westcamp, "the author designed the wallpaper...to be yellow for a reason" ("Smouldering"). Even though "yellow is often viewed as a cheerful, joyful color...[it] can also cause unpleasant, exciting, and hostile moods due its symbolism" (Westcamp). The wallpaper takes on a distinctive odor that " 'creeps all over the house,' drenching every room in its subtle aroma of decay" (Gilbert 35). The only thing the narrator "can think of that [the smell] is like is the color of the paper! A yellow smell" (Kivo 23). The narrator feels herself being drawn closer to the brin k of insanity by the maddening color and begs her husband to do something about the paper, but he simply laughs at her.      Ã‚  Ã‚  Ã‚   As the... ...apy. New York: University Books, 1961.    Dillon, George L. "Styles of Reading." Polk 47-62.    Gilbert, Sandra M. and Susan Gumar. "The Madwoman in the Attic: The Woman Writer and the Nineteenth Century Literary Imagination." New Haven: Yale UP, 1979. Kivo 44-46.    Kivo, Carol, ed. The Harcourt Brace Casebook Series in Literature: "The Yellow Wallpaper." Fort Worth: Harcourt, 1997.    Polk, Noel, ed. William Faulkner's "A Rose for Emily." The Harcourt Casebook Series in Literature. Fort Worth: Harcourt, 2000.    Scherting, Jack. "Emily Grierson's Oedipus Complex: Motif, Motive, and Meaning in Faulkner's 'A Rose for Emily.'" Polk, 110-119.    Westcamp, Carol. "A Smouldering Unclean Yellow: An Analysis of 'The Yellow Wallpaper.'" Online. Ixquick. 4 Mar. 2002.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   <http://arapaho.nsuok.edu/~english/westcamp.html>

Western and Eastern Architecture

Culture and traditions have been an important component in influencing the development and creation of both Chinese and Roman architecture. It is through these norms that standards and perceptions of beauty are created. Each facet is deeply rooted in its ability to showcase the variety of actions from the structural foundations towards internal arrangements. These ideas then constitute the relevant ideas that have transformed the way construction and design is manifested within the boundaries of each culture. In the end, these differences created similarities and differences in approaches that harnessed each one’s individuality and contribution to the world today. On one aspect, we see the Roman architecture which bases its definition and construction of structures and buildings under a prescribed standard and format. These prevailing concepts have evolved through time under the pioneering Roman thinkers during the time. Under this process, a system for construction was introduced with by using important tenets such as geometry and mathematics that denote synchronization and order of things. Through this, the Romans advocate the relevance of proportion, both in exterior and interior design. It is through this that they are able to create their own distinct mark such as the formation of tablinum, atrium and peristyle courtyards. Comparing this with Chinese architecture, it can be argued that the overall design and architecture is considered to be free flowing. The plan captures the relevance of aesthetics by capturing the elements of nature and blending them accordingly with the both in the interior and exterior of the structure. It is through these actions that the idea of harmonization and being one with the overall surroundings becomes important. In addition, incorporation of natural elements such as trees and plants are also some distinct facets practiced by the Chinese. Moreover, adopting relative natural elements to these structures also necessitates generating freedom and ability to garner wholeness. Seeing these relevant differences, there are also similarities between these distinct approaches in viewing architecture and design. One relevant parallelism that can be seen in this process is that both approaches denote a system and standard of measurement and design. Though the Chinese may not be too strict about this and often tries to cover this up, the two ideas exhibit relevant attention to such facet and helps them apply significant ideas that contribute the creation of magnificent structures. Another significant similarity between these two styles is their ability to dig deep within their cultural backgrounds and affiliations to come up with standards and processes of how to construct and design structures. Take for example, the Chinese model for Buddhism and its relevance with being one with nature (Zen) has been the core concepts that generate such buildings. On the other hand, for the Romans, it is their constant passion for architecture and magnificent design that has enabled them to come up with ideas such as Coliseums, arched domes, and public baths. These similarities in turn foster their individuality as each approach makes their distinct mark in the overall application and design process. It may be true that each one possesses similar building foundations however; each one targets a different path in its application. With their ability to fabricate unique sets of designs, both the Chinese and Romans were able to create a framework that is encompassing and facilitative towards the growth of their relative inventiveness and capture the essence of their cultural heritage and practice.

Oceanview Marine Company Engagement Letter

LILTS BERGER & ASSOCIATES 4-1 Certified Public AccountantsCW 11/23/2012 Ocean City, Florida 33140 October 30, 2012 Mr. Donald Phillips, President Oceanvien Marine Company 36 Clearwater Lake Road Ocean City, Florida 33140 Dear Mr. Phillips: This letter is to confirm our understanding of the terms of our engagement as the auditors of Oceanview Marine Company for the year ended December 31, 2012. We will audit the company’s balance sheet for December 31, 2012, and the related statements of income, retained earnings, and cash flows for the year then ended.The purpose of our audit is to form an opinion as to whether these statements are fairly presented in accordance with accounting principles generally accepted in the United States of America. We will review the company’s federal and state income tax returns for the fiscal year ended December 31, 2012. In addition, we will be available to consult with you concerning the tax effects of any transactions or changes in company policies.Our audit opinion will be based on our examination, made on a test basis, of your records, documents, assets, and equities. We will not examine all transactions, assets, or equities in detail, and the examination should not be relied on to detect all errors, fraud, or illegal acts that may have taken place. Notwithstanding, should we discover material misstatements resulting from error, fraud, or illegal acts during our audit, they will be disclosed to you. Please note that management of the company has the primary 4-2CW 11/23/2012 responsibility for maintaining adequate accounting records, for the safeguarding of assets, and for the preparation of accurate financial statements. If, for any reason, we are unable to complete the audit or are unable to form or have not formed an opinion, we may decline to express an opinion or decline to issue a report as a result of the engagement. The timing of our services is scheduled for performance and completion as follows: Begin field workDecember 15, 2012 Completion of fieldworkMarch 15, 2013Delivery of management letterMarch 22, 2013 Delivery of audit reportMarch 29, 2013 Delivery of tax returnsMarch 29, 2013 It is agreed that your staff will provide assistance with the preparation of data and by providing documents and records as needed. Our fees will be based on our standard hourly rates. Invoices will be submitted periodically as the work progresses and are payable upon presentation. Should we find any conditions that could significantly affect our initial estimated total fees of $21,000, we will notify you immediately.If the above terms are acceptable, and the services outlined are in accordance with the company’s requirements, please sign the copy of this letter in the space provided and return it to us. 4-3 CW 11/23/2012 Yours very truly, Per: Charles Ward Charles Ward, CPA Partner The services set out in the foregoing letter are in accordance with our requirements. The terms set out are acceptable to us and are hereby agreed to. Per: Donald Phillips Donald Phillips, President Oceanview Marine Company November 10, 2012

Afterschool program Essay

The combined efforts of the Washington, DC School system and the Woodson Foundation in the development of an Afterschool program to help increase and improve student outcomes. They have identified amply room for improvement. Three of the primary problems in the Washington, DC School systems are truancy, low student performance, and crime. They have also identified new staff (teachers) are quickly burnet out due to their initial enthusiasm in to want to help the students. This has caused a high turnover rate in new teachers, causing the school system to lose some of the best and brightest teachers to other school system in the area. The first stage in building a coalition is to select a representative from each of the organizations which will be involved in the program. This will give equal representation across the team. It has been identified that an Executive Development team should be established. This team will span across a multifunctional area to establish an operating plan for improving school performance. Participation from the Woodson Foundation and Washington, DC School system is the key element of a successful Executive Development team. However, representation from the National Coalition for Parental Involvement in education (NCPIE) should be considered, because they represent for the parent on the behalf of the PTA. The Coalition is in the forming stage of group development. A representative from each of the organizations will need to be assigned to the group. Then the group will need to figure out the groups purpose, structure, and the leadership of the group. In order for the Woodson Foundation to create this cohesive group, the stages of group development will need to be followed. The next step in the group development is storming. The representatives of the different organizations accept that the Executive Development team is needed, however each organization has their own principles they feel is important to the development. The leader is also established in this stage and there is a clear hierarchy of leadership. The third phase is Norming: In this stage, the Executive Development team has a solid group structure and a set of common expectations. Roles are established within this cohesive group.  The fourth stage is Performing: The structure of the Executive Development team is functional and all members accept it. The team is performing the tasks at hand and successfully completing them. The fifth stage is Adjourning. Even though the team is adjourning, they will collect the detailed analysis and put together a presentation of the Operational plan for improving the student’s performance in the After School program. Their findings will give clear direction of how to get the ASP going. One of the primary problems the Woodson Foundation is facing is what organization will lead the Executive Development team. In order for the leaders to lead this primary team, strong leadership and management is needed for top effectiveness. Today’s leaders should challenge themselves to identify status quo, create visions for the future, and inspire organizational members to want to achieve organizational goals and visions. The representatives from each organization of the Executive Development team, has their own vision as to why their organization should take the lead in building the team. The secondary problem the Woodson Foundation is to identify goals and objectives. The Woodson Foundation primary objective is outsider involvement to get a bigger and clearer picture of the program. NCPIE primary objective is having parent imput. They feel the Woodson Foundation can come in and do all they want, however if the parents do not participate the program will not work. Washington, DC School system primary objective is to let the professionals get the job done. The administrators feel they have the background, education, and expertise to spear head the program. These various backgrounds will enable the Executive Development team members, to have an understanding of the needs of the children participating in the ASP. One solution to the problem is building trust between coalition members and parents. The leadership will need to create an environment of trust that is conducive to all. Trust facilitates information sharing, encourages taking risks. However, trust builds a more effect team and enhances productivity (Robbins, pg 315). My second solution would be to identify and define clear responsibilities within the group. Each individual must be responsible and successfully complete research, presentations, and analysis for their areas of focus. This can clearly be accomplished by soliciting input from other team members (Robbins, pg 316). Each member of the group should have some type of training in managing diversity, conflict resolution, team building, and team cohesiveness. All members should have a clear understanding of their roles within the group and promote a climate of trust. Having a clear understanding of the leadership and its structure would better serve the Executive Development team’s primary function. Work Cited Robbins, Judge, Stephen P., Timothy A. Organizational Behavior. 15th Edition. Pearson Learning Solutions, 2012. VitalBook file. Bookshelf.

Assessment Management Forensic Mental Health Health And Social Care Essay

Since the 1980s force per unit area is increasing on mental wellness professionals to better their ability toA predictA and better manage the degree of hazard associated with forensic mental wellness patients, and offendersA being dealtA with in the justness system ( Holloway, 2004 ) .A This increasedA pressureA has besides increased involvement within a wider scope of research workers and forensic clinicians, working in the justness system to better the truth, and dependability of their analysis of whether recidivism is a strong possibility.A The overallA valueA of rating of research is toA allowA theA improvementA in the appraisal, supervising, planning and direction of wrongdoers, in concurrence with a more dependable base line for follow up ratings ( Beech et al, 2003 ) . However, there continues to be an increasingA interestA andA expectationA on professionals from the populace and the condemnable justness system in respects to the potentialA dangerA posed byA seriousA offendersA being releasedA back into the community and the demand for the wrongdoers to be better managed, in orderA to adequately protectA the populace from unsafe persons ( Doyle et al, 2002 ) . As the appraisal of riskA is madeA at assorted phases in the direction procedure of the violent wrongdoer, it isA extremelyA important that mental wellness professionals have a structured and consistent attack to put on the line appraisal and rating of force. ( Doyle et Al, 2002 ) . This paper will compare and contrast three theoretical accounts of hazard appraisal thatA are usedA to cut down possible danger to others, when incorporating violent wrongdoers back into the community. These three attacks are unstructured clinical opinion, structured clinicalA judgementA and actuarialA appraisal. It is non intended, in this paper, to research the assorted instruments used in the appraisal procedure for theA respectiveA actuarial and structured clinical attacks. Unstructured Clinical Judgement Unstructured clinical opinion is a procedure affecting no specific guidelines, but relies on the single clinician'sA evaluationA holding respect to the clinicians experience and makings ( Douglas et al. , 2002 ) .A Doyle et Al ( 2002 ) , refers toA clinicalA opinion as â€Å" first coevals † ( p. 650 ) , and sees clinical opinion as leting the clinicianA completeA discretion in relation to what information the clinician will or will non take notice of in their concluding finding of hazard degree. The unstructured clinicalA interviewA has been widely criticised because itA is seenA as inconsistent and inherently lacks construction and aA uniformA approachA that does non let forA trial, retest dependability over clip and between clinician ‘s ( Lamont et al. , 2009 ) . ItA has been arguedA that this incompatibility inA assessmentA can take toA incorrectA appraisal of wrongdoers, as either high or low hazard due to the subjective sentiment inherent in the unstructured clinic al assessmentA approachA ( Prentky et al. , 2000 ) . Even with these restrictions discussed above the unstructured clinicalA interviewA is still likely to be the most widely usedA approachA in relation to the wrongdoer ‘s force hazard appraisal ( Kropp, 2008 ) . Kropp ( 2008 ) , postulates that the continued usage of the unstructured clinicalA interviewA allows for â€Å" idiographic analysis of the offendersA behavior † ( Kropp, 2008, p. 205 ) .A Doyle et Al ( 2002 ) posits, that clinical surveies have shown, that clinician ‘s utilizing the hazard analysisA methodA of unstructured interview, is non asA inaccurateA asA generallyA believed.A Possibly this is due, mostly to the degree of experience andA clinicalA makings of those carry oning the appraisal. The unstructured clinicalA assessmentA methodA relies to a great extent on verbal and non verbal cues and this has the potency of act uponing single clinician ‘s appraisal of hazard, and therefore in bend has a high chance of over trust in the appraisal on the exhibited cues ( Lamont et al. , 2009 ) .A A major defect with the unstructured clinical interview is the evident deficiency of structured standardised methodologyA being usedA toA enableA aA testA retest reliability A measureA antecedently mentioned.A However, the deficiency of consistence in the appraisal attack is aA substantialA disadvantage in the usage of the unstructured clinical interview.A The demand for a more structuredA processA leting forA predictableA trial retest dependability wouldA appearA to be aA necessaryA constituent of any hazard appraisal in relation to force. Actuarial Appraisal ActuarialA assessmentA was developedA toA assessA assorted hazard factors that would better on the chance of an wrongdoer ‘s recidivism. The actuarial attack relies to a great extent on standardised instruments to help the clinician in foretelling force, and the bulk of these instrumentsA have been developed, in an effort, A to foretell futureA probabilityA of force amongst wrongdoers who have a history of mental unwellness and or condemnable offending behaviors. ( Grant et Al, 2004 ) . However, Douglas et Al ( 2002 ) warns that usage of actuarial appraisal does non supply appraisal of any degree of forestalling the possibility of future force. The usage of actuarialA assessmentA has increased in recent old ages as more non cliniciansA are taskedA with the duty of direction of violent wrongdoers such as community corrections, correctional officers and probation officers. Actuarial hazard appraisal methods enable staff, that do non hold the experience, A backgroundA or necessaryA clinicalA makings toA conductA a standardized clinicalA assessmentA of wrongdoer hazard. This actuarial assessmentA methodA has been foundA to be extremelyA helpfulA when holding hazard measuring wrongdoers with mental wellness, substance maltreatment and violent wrongdoers. ( Byrne et al, 2006 ) . However, actuarial appraisals have restrictions in the inability of the instruments to supply any information in relation to the direction of the wrongdoer, and schemes to forestall force ( Lamont et al, 2009 ) .A Whilst such instruments may supply transferableA testA retest dependability, there is a demand for cautiousness when the instrumentsA are usedA within differing samples of theA testA populationA used as the validationA sampleA in developing theA testA ( Lamont et al, 2009 ) .A Inexperienced andA untrainedA staffA may non be cognizant that testsA are limitedA by a scope of variables that may restrict the dependability of the trial in usage. The bulk of actuarial toolsA were validatedA in North America ( Maden, 2003 ) . This hasA significantA deductions when actuarial instrumentsA are usedA in the Australian context, particularly when autochthonal cultural complexnesss are non taken into history. Doyle et Al ( 2002 ) postulates that the actuarialA approachA is focusedA on anticipation and that hazard appraisal in mental wellness has a much broaderA functionA † and has to beA linkA closely with direction and bar † ( p. 652 ) . Actuarial instruments rely on steps of inactive hazard factors e.g. history of force, gender, mental illness and recorded societal variables.A Therefore, inactive hazard factorsA are takenA as staying constant.A Hanson et Al ( 2000 ) argues that where the consequences of unstructuredA clinicalA opinionA areA openA to inquiries, the through empirical observation based hazard assessmentA methodA can significantly foretell the hazard of rhenium offending. To relyA totallyA onA staticA factors thatA are measuredA in Actuarial instruments, and non integrate dynamic hazard factors has led to what Doyle et Al ( 2002 ) has referred to as, â€Å" Third Generation † , or as more normally acknowledged as structured professional opinion. Structured Professional Judgement Progression toward a structured professionalA theoretical account, wouldA appearA to hold followed a procedure of development since the 1990s.A ThisA progressionA has developed throughA acceptanceA of the complexness of what hazard appraisal entails, and the force per unit areas of the tribunals andA publicA in developing an outlook of increased prognostic truth ( Borum, 1996 ) .A Harmonizing to Lamont et Al ( 2009 ) , structured professional opinion brings together â€Å" through empirical observation validated hazard factors, professional experience and modern-day cognition of the patient ( p27 ) .A Structured professional opinion attack requires aA broadA assessmentA standards covering both inactive and dynamic factors, and efforts to bridge the spread between the other attacks of unstructured clinical opinion, and actuarialA approachA ( Kropp, 2008 ) .A The incorporation of dynamic hazard factors that are takingA accountA of variable factors such as current emotionalA levelA ( choler, depression, emphasis ) , societal supports or deficiency of and willingness to take part in the intervention rehabilitation process.A The structured professional attack incorporatesA dynamicA factors, whichA have been found, to be besides important in analysingA riskA of force ( Mandeville-Nordon, 2006 ) .A Campbell et Al ( 2009 ) postulates that instruments thatA examineA d ynamic hazard factors are moreA sensitiveA toA recentA alterations that mayA influenceA an addition or lessening in hazard potency. Kropp ( 2008 ) , reports that research has found that Structured Professional Judgement measures alsoA correlateA substantiallyA with actuarial steps. Decision Kroop, ( 2008 ) postulates that either a structured professional opinion attack, or an actuarial attack presents the most feasible options for hazard appraisal of violence.A The unstructuredA clinicalA approachA has been widely criticised by research workers for missing dependability, cogency and answerability ( Douglas et al, 2002 ) . Kroop, ( 2008 ) besides cautions that hazard appraisal requires the assessor to hold an appropriate degree of specialised cognition and experience. This experience should be non merely of wrongdoers but besides with victims.A There wouldA appearA to be a valid statement that unless there is consistence inA trainingA of those carry oning hazard appraisals the cogency and dependability of any step, either actuarial or structured professional opinion, will neglect toA giveA theA levelA of predictability of force thatA is sought.A Risk analysis of force will ever be burdened by theA limitationA which â€Å" lies in the fact thatA exactA analyses are notA possible, andA riskA will ne'er be wholly eradicated † ( Lamont et al, 2009, p 31. ) . Doyle et Al ( 2002 ) postulates that a combination of structured clinical and actuarial approachesA is warrantedA to help in hazard appraisal of force. Further research appears to be warranted to better the rating andA overallA effectivity of hazard direction.