The Effect of Hand Washing with Soap among Early Graders Assignment

The Effect of Hand Washing with Soap among Early Graders - Assignment Example The purpose of this qualitative study is to discover the effect of hand washing with soap among early graders by the use of school based campaign. The purpose of the study is to come out with an action based intervention that will reduce the occurrence of hand to mouth infections among children of school going age. This is a major social health concern that demands urgent professional attention. The reason behind this observation is that once children are plagued with some of these infections, they become so vulnerable that their chances of surviving the fatality become minimized. It is against this background that the proposed purpose of the study has been chosen as a means of campaigning in schools and among students on how they can use the basic practice of washing their hands with soap to reduce events of hand to mouth infections. Once research of these nature are completed, the researchers want to have a feeling of how relevant their works have been on existing practice and on general social change. The proposed research, once successfully completed would be no exception of such significance. The relevance of the proposed research to effecting social changes is numerous. In the first place, the intervention is action based and brings a new paradigm towards the approach commonly used in addressing some of these health issues in society. Indeed, the use of a school based campaign is highly social and can come with the added advantage of ensuring the easy involvement of otherwise reserved and shy participants into the research. What is more, by using a school based campaign as an intervention, there is the tendency that the habit of hand washing with soap that will be eventually cultivated among the students will become a permanent part of their social interactive lifestyle. Once this is achieved, it is going t o be possible that hand to mouth infections are going to be permanently prevented among the students. Finally, the research findings are going to form a part of a universal basis to qualitative study on the research study. This means that all future researches who wish to undertake evidence based research can fall on the findings.

The character of Scrooge Essay Example for Free

The character of Scrooge Essay He asks the ghost: Tell me if Tiny Tim will live if these shadows remain unaltered by the future, the child will die. This shows that Scrooge feels guilty for not giving his clerk more money as he witnesses their way of life. The ghost then takes Scrooge to visit his nephew Fred on Christmas day. Fred is having a splendid time and is celebrating a more modern Christmas with fun, laughter, drinking booze and playing games such as: similes and yes or no. It is less religious as they have more money and a bright, dry gleaming house However, they still have strong moral values like the Cratchits. Dickens suggests that Scrooge is missing out on the fun and games by saying, that the consequence of his taking a dislike to us and not making merry with us, is, as I think, that he loses some pleasant moments, which could do him no harm. This suggests that Scrooge starts to feel a bit of remorse, since he turned the invite down. Scrooge is forced to realise that he has missed a chance to be merry with the only family he has left in the world. Finally, the ghost shows Scrooge two personifications of the social situation in the form of two children: Ignorance (a boy) and Want (a girl), who symbolise mankinds downfall. Dickens uses this personification to emphasise the point of mankinds destruction, for instance the spirit says, Most of all beware this boy, for on his brow I see that written which Doom This signifies if people continue to ignore the poor, society will crumble. In this stave Scrooge feels new emotions such as regret for not paying his clerk Bob Cratchit enough money, since he lives in poverty with a huge family and a crippled son, and more regret for not attending the invite from Fred. Also, he feels a lot sadder and some happiness for Freds games and the laughter, Scrooges family had without him. The ghost of Christmas yet to come represents death and judgement, this ghost is also known as a phantom because it is wearing a black cloak which conceals its face and it doesnt say a word to add to the morbid atmosphere. They visited a house where there was one little knot of business men with a lady trying to sell some of Scrooges possessions, he sees nobody is upset by his death, but instead raiding his hose and selling off his property. I hope he didnt die of anything catching Eh? Dont you be afraid of that. This shows that people are joking over his death and no-one cares about his departure from the face of the earth. He is very upset that no-one cares about his death, all they can do is laugh and attempt to make a profit from his belongings. Scrooge asks the spirit If there is any person in the town, who feels emotion caused by this mans death Show that person to me, spirit They go to the Cratchits house, but The only emotion that the ghost could show him, caused by the event, was one of pleasure. This emphasises that no-one liked him and cared about him at all, so they were not sad to witness his death. After a while, they return to the Cratchits house where Bob has just returned from work. Dickens makes Scrooge feel miserable, regret and guilt that he did not offer his help to save Tiny Tim from dying, by making the Cratchit family more depressed, for instance, My little, little child! Cried Bob. My little child! He broke down all at once. This makes the reader feel sympathy for the Cratchits and anger towards Scrooge, as he did not help a poor family at need. Also, it makes Scrooge feel terrible and he realises that he must change his ways and become a better person, to stop these perceptions from happening. Stave four is a particularly religious section of the book, as it deals with Scrooges redemption and moral reformation. The language used by Dickens is similar to that used in a religious teaching, for example: Oh cold, cold, rigid, dreadful death, set up thine altar here. This biblical language is meant to make us aware that as readers we are being taught a moral lesson. All Christians believed strongly in heaven and hell; the thought of spending the rest of eternity in hell, frightened most Christians, so even the meanest of people would consider changing their ways to go to heaven. In stave five, Scrooge awakens on Christmas day as a changed man. He buys the largest turkey in town and donates it to the Cratchits. Ill send it to Bob Cratchits! This shows that Scrooge has finally reformed and he is now a better man, as he is being a lot more generous. Dickens shows that Scrooge has learnt his moral lessons and is not going back to his old ways, he does this by this continual joy, care and generosity, throughout the character of Scrooge in stave five, for example: Heres the turkey. Hallo! Whoop! How are you! Merry Christmas! This again emphasises that Scrooge has realised and acknowledged his faults and changed them; plus he donates lots of money to the poor, Scrooge says, not a farthing less This once more shows Scrooges generosity, the poor and the two gentlemen were very grateful. He also celebrates a lovely Christmas with his nephew; Dickens shows this by saying, Wonderful party, wonderful games, wonderful unanimity, won-der-ful happiness This stresses the changes Scrooge has made and that he is having a magnificent time with his family, at last. The next morning Scrooge was at his office ready to meet Bob Cratchit and give him a pay rise, he says Ill raise your salary, and endeavour to assist your struggling family And thats exactly what Scrooge did, he did not just raise Bobs salary, but he became like a second father to Tiny Tim, who did not die. There are many references to heaven in this stave such as: I am as happy as an angel, He went to church and God bless us, every one! in contrast to the references to hell when he was parsimonious, mean-spirited and had a cold heart, for instance, It is doomed to wander through the world , ages of incessant labour by immortal creatures, for this earth must pass eternity and dark master! This creates the impression that Scrooge was going to hell in stave one because he was stingy, cruel and uncharitable. Dickens teaches a social lesson to us, near the end of the book, so we remember it. He tells us not to worry if people laugh at the sudden change in you as long as you are doing good deeds that is all that matters, for instance, Some people laughed to see the alteration in him, but he let them laugh His own heart laughed: and that was quite enough for him. This puts emphasis on Scrooges reformation and confirms that Scrooge has changed for the better and for good. A Christmas Carol is an inverted tragedy, since it has five staves similar to the five acts of a Shakespeare play; but Scrooge begins a cold-hearted, cruel, spiteful and uncharitable and ends a loving, caring generous man with a stronger, warmer heart, especially to the poor and needy. Through the character of Scrooge, Dickens hoped to change the views of society by showing the rich people, who would have read the book that they were Scrooge (not sharing their wealth; being grumpy and cold-hearted). It reflects that money does not lead to happiness, but living a high-quality Christian, moral life does. As the book continues on, Scrooge becomes more and more enthusiastic to learn his moral lessons, for example: As I know your purpose is to do me good, and as I hope to live to be another man from what I was This shows his eagerness to gain knowledge of his moral and social lessons and his acceptance of his faults. Christianity was a vast issue in the 1840s, and the idea of burning in hell would have made a lot of people change their miserable, tight-fisted ways. This Christian theme is set throughout the book and if you repent your ways you will be saved (go to heaven). Dickens uses Christmas because it is an occasion when generosity, exuberance and affection should be in our hearts as a time to convey this message of charity.

The Tremendous Potential of Genetic Engineering Essay -- Argumentative

Genetic engineering, the process of using genetic information from the deoxyribonucleic acid (DNA) of cells to fix or improve genetic defects or maladies, has been developing for over twenty years. When Joseph Vacanti, a pediatric surgeon at Children’s Hospital, and Robert Langer, a chemical engineering professor at MIT, first met as researchers in the 1970’s, they had little knowledge of the movement they would help found. After they discovered a method of growing live tissue in the 1980’s, a new science was born, and it races daily towards new discoveries and medical breakthroughs (Arnst and Carey 60). â€Å"Tissue engineering offers the promise that failing organs and aging cells no longer be tolerated — they can be rejuvenated or replaced with healthy cells and tissues grown anew† (Arnst and Carey 58). The need for genetic engineering becomes quite evident in the promises it offers in various medical fields, as well to financial ones. Despite cr itics’ arguments about the morality or practicality of it, genetic engineering should continue to provide the essential benefits it has to offer without unnecessary legal impediment. Every year, the need for new organs in organ transplants becomes more apparent. â€Å"I recognized fairly early that the biggest problem facing me as a surgeon was the shortage of organs. I’ve devoted my professional life to solving that problem,† Vacanti said (Arnst and Carey 60). Approximately eight million people in the United States undergo surgery annually to correct organ failure (Arnst and Carey 61). While these patients wait for surgery and others wait on the transplant list, their medical expenses reach up to $400 billion. These expenses count for almost one-half of American heath-care bills. Nearly four... ..., Chrisitne. â€Å"An Attack on Aging.† Time. 26 January 1998: 60. Haney, Daniel Q. â€Å"Genes Help Heart Grown Own Bypass.† Columbus Dispatch. 10 Novemeber 1998. 3A. Johnson, B. Julie. â€Å"Genetic Engineering is Dangerous.† Genetic Engineering: Opposing Viewpoints. Ed. Carol Wekesser. San Diego: Greenhaven Press, Inc., 1996. 17-21. Kraemer, Duane C. â€Å"Genetically Altered Animals Will Benefit Humankind.† Genetic Engineering: Opposing Viewpoints. Ed. Carol Wekesser. San Diego: Greenhaven Press, Inc., 1996. 94-101. Lee, Thomas F. â€Å"Gene Therapy is Beneficial.† Genetic Engineering: Opposing Viewpoints. Ed. Carol Wekesser. San Diego: Greenhaven Press, Inc., 1996. 166-173. Mahoney, Richard J. â€Å"The U.S. Should Continue Investing in Biotechnology.† Genetic Engineering: Opposing Viewpoints. Ed. Carol Wekesser. San Diego: Greenhaven Press, Inc., 1996. 29-36.

Case Study Classic Watch Essay

1-2) After analyzing the structure of the Classic Watch Co, we have come to a conclusion, that the company is product oriented. The founder of the company Harry Brainch used to develop his product and then to find consumers. According to the case, he is quite a conservative person, who prefers old-fashioned business techniques. Twenty years ago, customers were less choosy and they were happy to have a product that is good value for money. In that case, Harry Brainch’s strategy fitted really well. However, times are changing and new market is much more complicated and severe. The competition is tough and product with simple design and good durability is not as attractive as it used to be in the past. According to this, product-oriented approach is not likely to succeed. A famous example of product-oriented company is the original Ford Motor Company. Henry Ford made one model in one color (black), no matter what the consumer might want. Although he followed this strategy for quite a long time, finally, Ford Motor Company had realized the need of customization and now we have Ford cars in various colors. The situation is the same with Classic Watch Co, the faster Mr. Brainch realizes that his old techniques are no longer useful – the better sales will improve. Probably, he should try to change his methods to become more market oriented. For instance, Apple has always been a great example of market-oriented company. Apple has achieved world fame by constantly monitoring market and then adjusting its marketing mix to response to the market needs. The Classic Watch Co should follow example of Apple and start developing new marketing strategy. To sum up, the old strategy is no longer successful because of following reasons: 1) same old-fashioned design 2) new needs and desires of consumers 3) change in consumer’s income (it became higher) 4) the old strategy did not take into account wants of modern consumers 5) reasons for buying watches have changed 3) In our opinion, Harry need to divide market into 3 segments. The first one – â€Å"Economical†, which include people, who are ready to pay the lowest price for any good-working watches. Even if they will be broken in the first year, person from this segment just substitute them by new one. They are mainly price-concerned. Brand and design of the watches is not the main point. The second segment – â€Å"Longevity and quality†. This group in search for watches with a good durability, quality and design. They ready to overpay for this features. This group is the biggest one. The third segment – â€Å"Symbolic† one. Watches should be prestigious, elegant, mainly maid from precious metals and gems. People from this segment buying not just watches, but unique qualities and emotional value. To be successful, The Classic Watch Company need to create watches suitable at least â€Å"Economic† and â€Å"Longevity and quality† segments. 4) Nowadays The Classic Watch Company is no longer succeeding company, but a policy of market segmentation could turnover situation. Segmenting market can help them increase sales and market share, protect brand and provide a variety of other benefits. By positioning themself with a specific benefit, they could create a unique selling proposition that sends a message to a target audience looking for that benefit. If The Classic Watch Company cater to a specific audience, they could lose sales among potential customers outside their target audience but increase overall sales by attracting more customers in your target audience. With specific market segments to reach, they can decrease distribution channels, targeting those outlets that have the highest amount of traffic from their desired customers. By limiting your audience, they can choose magazines, websites, radio and TV stations and events that their customers are more likely to hear, see, visit or attend. As we see, there are pl enty of benefits, which are necessary for modern company to survive.

Perspectives from Inner Windows Essay

Cheryl Albury in the book† Perspectives from Inner Windows,† reveals many of the social problems that we face in Bahamian society. In her stories â€Å"Waiting for Love† and â€Å"Pot of Gold† she uses them to reflect on some of the characteristics of Bahamian Men. From these two stories Albury portrays men as manipulative and selfish. In â€Å"Waiting for love† we are introduced to the relationship of Stafford and Phyllis a young couple from Exuma. Stafford, evil in his ways, preys on naà ¯ve Phyllis, coaxing her mind of dreams he had for them. He courted her around town and found an opportunity to rob her of her innocence. Although she loved him, she knew something wasn’t right about their relationship, because ever since he had asked her to elope she felt a â€Å"sense of foreboding and uneasiness† to the matter. He deceived her in believing they would elope and start a family, by him not doing this he betrayed her trust and left her waiting on love. In â€Å"Pot of Gold† best friends Cyril and Jacob are both family men with minimum paying jobs. They, influenced by the hard times, robbed the local hardware store of a large sum of cash and walked free. It was not until Cyril’s unknowingly told his girlfriend that they were found guilty. Because of their selfish ways it caused them to jeopardize their relationships with their family and to deceive the trust of their wives. After being imprisoned, Jacob tried to regain their treasure but a building was constructed on it, but in the end they learnt that true happiness does not come from being selfish. In conclusion, Albury in these stories uses the technique of dialect and imagery to help her readers understand her point more. Also I believe that Albury shows a true reflection of Bahamian men. She uses real life situations to bring her point across that most Bahamian men are selfish and manipulative.

Burmese Days by Gorge Orwell Essays

Burmese Days by Gorge Orwell Essays Burmese Days by Gorge Orwell Paper Burmese Days by Gorge Orwell Paper or Ko S’la, Flory’s servant is lazy and dirty, and his ex-wife as ‘a fat, lazy cat’ . U Po Kyin, more than anyone else stands for cunning, intrigue and flattery which were mentioned earlier. His brain though cunning was quite barbaric . For their distorted minds, Eliza mocks them for blocking up the roadway for spectacle, as Flory answered that ‘there are no traffic regulations here’ . Flory calls Ma Hla May a ‘liar’ when she said no brown hands touched me, however the readers know that she had an affair with a brown man. The Orientals have no nobility and grace except by accompanying and camaraderie with the occidentals. U Po Kyin and Veraswami’s efforts for admission to the Club are for this nobility and prestige, as Dr. Veraswami pointed it in his example of barometer. For mistreatment to animals, one can remember the scene that ‘a fat yellow woman with her longyi hitched under her armpits was chasing a dog round a hut, smacking at it with a bamboo and laughing. ’ Recurring images do not confine to the above mentioned and many other labels such as superstition, strangeness, polygamy are also attributed to the Orientals. The natives believe that the ‘strips of alligator hide’ has magical properties ; Ma Hla May sometimes puts love-philters in Flory’s food; â€Å"The Burmese bullock-cart drivers seldom grease their axles, probably because they believe that the screaming keeps away evil spirits† ; as the medicine, they eat and drink ‘herbs gathered under the new moon, tigers whiskers, rhinoceros horn, urine, menstrual blood! ’ And finally Weiksa or magician who distributes magic bullet-proof jackets. Edward Said points out that Oreint is always seen as mysterious and a muddle for the Occidents. Burma is an exotic place for Westerners and Orientals, strangeness and exoticism generate from that exotic locale. Elizabeth is terrified by this ‘strangeness’, as Adela in â€Å"A Passage to India† did. Accordingly, the bushes are foreign-looking, rhythms of the tropical seasons and hollow cries are strange ; Eliza among the natives’ spectacle wishes to escape from this strange place to familiar one, i. e. the Club and she always barked at strange Orientals Ko S’la is an ‘obscure martyrs of bigamy’ and Li Yeik, the Chinese shopkeeper had two girls as his concubines. In short, in Burmese Days like other colonial novels, a web of colonial images and cultural stereotypes are attributed to the Burmese which fix them in their inferior position. Elizabeth as a memsahib is also bigoted and she felt ‘the hatefulness of being kin to creatures with black faces’ . Eliza’s overt racism is also shown in two occasions: when Flory, assuming that ‘she was different from that herd of fools at the Club’ and she will appreciate native’s culture, took her to a pwe, a kind of Burmese play. Another occasion was when they paid a visit to bazaar. At first she is shocked when she sees how they have blocked the road for their performance, and Flory answers that â€Å"there are no traffic regulations here. The native music is a ‘fearful ‘pandemonium, a strident squeal of pipes, a rattle like castanets and the hoarse thump of drums’ . Elizabeth felt insecure to go among ‘that smelly native crowd’ and she watches ‘the hideous and savage spectacle’ with tediousness and horror: Its grotesque, its even ugly, with a sort of willful ugliness. And theres something sinister in it too. Theres a touch of the diabolical in all Mongols. And yet when you look closely, what art, what centuries of culture you can see behind it! †¦Whenever you look closely at the art of these Eastern peoples you can see thata civilization stretching back and back, practically the same, into times when we were dressed in woad. Eliza comes from the ‘civilized places, and her superiority is blatantly expressed when she calls them with a very offensive term even in that time, Mongols. She considers the White racially and civilizationally superior to the Burmese. The word woad signifies that the present-day Burma is less civilized than the ancient Briton (in that times, woad was used for painting their bodies). Furthermore, they are connected to devil and devil worship (as the term diabolical and sinister connote); besides, the dancer girl becomes a ‘demon’ figure for her. In the bazaar’s scene, Eliza once more humiliates the Orient and Orientals. The bazaar is described as ‘large cattle pen’ by ‘a cold putrid stench of dung or decay’, and ‘Everythings so horribly dirty’. Eliza becomes insecure and asked herself why Flory has brought her to ‘watch their filthy, disgusting habits’ (Ibid). The barbarity of the bazar and absolute savages was stifling her. The natives were ‘damnably dressed’. All the children are naked and one was ‘crawling like a large yellow frog’. The Chinese women practice deforming their insteps, a sign of being ‘behind the times’, an anachronism. She is too arrogant to say thank you to girls fanned them and poured out tea. It is a ‘sort of infra dig’ to sit in their houses. At length Eliza cannot tolerate the ‘absolutely disgusting people’ and ‘beastly Oriental things’ and went out. Flory tries to calm her down that one should not expect all the people behave at the same manner, suppose, for instance, you were back in the Middle Ages. Flory, the protagonist of the novel, at the first look, is against British Empire and he hates the devotion to Pukka Sahib code. He is ashamed of themselves and wonders how they oppose to Veraswami’s admission in the club only for his black skin. This seemingly animosity toward British Empire is revealed during a long conversation with Dr. Veraswami that he admits that we are here to â€Å"rub our dirt on them, and â€Å"wreck the whole Burmese national culture†. He goes further and prefers Thibaw, the last king of Burma to his white fellows. He believes that we do not have any â€Å"purpose except to steal†. What bothers Flory more than anything else is a lie,‘slimy white man’s burden humbug’, the pukka sahib pose. Flory knows that this lie corrupts not only the natives, but also the Whites themselves. The colonizers ‘build prison and call it progress’.

How to update your LinkedIn profile for 2019

How to update your LinkedIn profile for 2019 Whether you have a New Year’s resolution to boost your network or you are gearing up for a job search, sprucing up your LinkedIn profile is a great way to start the year. Let’s look at some strategies for starting your year off right, and setting yourself up for even better connections and opportunities in 2019. 6 ways you can refresh your LinkedIn profile for career successUpdate your profile photoThe human eye tends to gravitate toward images first, so when you’re making over your LinkedIn profile, thinking about your photo is a good place to start. How old is your current photo? If it’s several years old at this point, consider replacing with a newer photo. You may not have changed much, but it’s still important to keep things fresh.Remember, your LinkedIn profile picture should be a natural-looking headshot, or at least a photo of you solo. (No party pics, for so many reasons.) You don’t have to be doing a Zoolander-esque Blue Steel pose to show everyone you mean business, so a little smile and approachability can go a long way. It also doesn’t have to be an official production- a candid shot is fine as long as it’s a clear shot of you and is appropriate for any professional context.Upgrade your headline and summaryYour LinkedIn profile is the very definition of â€Å"first impression.† A hiring manager or recruiter might be browsing, or checking up on you to supplement a job application. You want the first thing they see to be attention-grabby, but informative.Here are some examples of strong headlines:Salesperson of the YearInnovative Project ManagerCreative Social Media MavenYour summary should be an updated snapshot of wh ere you are in your career right now. That means taking stock of the past year and thinking about what you’ve been working on, what you’ve achieved, and what you’ve learned about your industry. The summary isn’t a full-on resume, but it should be a brief paragraph or two for a reader to get a quick sense of who you are as a professional, at this moment.Check your settingsThis is a good idea with any social media account these days, but you should take this opportunity to do a yearly review of your LinkedIn account and privacy settings. Who’s able to see your profile? Who’s able to contact you? Are you officially open to opportunities from recruiters? All of this information is in your Account settings page on LinkedIn. The â€Å"open to opportunities† setting is most important if you’re about to kick off a job search. It’s not available to the world, but can bring opportunities your way that might not otherwise pop up.Update your keywordsMost industries move pretty fast these days, so the trends and buzzwords from the last time you updated might not be so relevant anymore. A little legwork can help you modernize your profile for 2019. Look at job descriptions in your field. What kinds of skills are they looking for? Are there new software programs or skills that are emerging? What kinds of qualities are they looking for? Even if you’re not actively looking for a job, browsing the current job openings can tell you what the landscape looks like and what language employers are using. Then you can apply that to your own profile, using keywords that can catch attention.Update your experience bullet pointsThis is especially true if you haven’t really touched your LinkedIn profile in the past year. Consider what projects you’ve done and whether you’ve picked up any new skills, certifications, or accolades. Part of LinkedIn’s appeal is tha t it can serve as a kind of living resume in addition to its social media aspects, so take advantage and make sure your professional bio is up to date.Review your connectionsIf you want to broaden your LinkedIn connections or maybe get rid of some that are no longer relevant, now is the time to do it. Look at your current connections and think about whether you want to keep them in your orbit. Browse connections-of-connections and see if there’s anyone new or interesting you’d like to have in your network. Search content or blog posts in your field and discover potential connections that way. If you want to maximize LinkedIn this year, make sure you’re getting the most out of the massive network of human connections.Your LinkedIn profile is one of the easiest targets for upgrading your professional life this year. It puts your most up-to-date information out in the world, so pay attention to it and keep it fresh! Some great new connection you make now could lead to awesome opportunities in 2019.

The Life of Lucius Annaeus Seneca (4 B.C. - A.D. 65)

The Life of Lucius Annaeus Seneca (4 B.C. - A.D. 65) The Life of Lucius Annaeus Seneca (4 B.C. - A.D. 65) Seneca was an important Latin writer for the Middle Ages, Renaissance, and beyond. His themes and philosophy should even appeal to us today, or so says Brian Arkins in Heavy Seneca: his Influence on Shakespeares Tragedies, Classics Ireland 2 (1995) 1-8. ISSN 0791-9417.   While James Romm, in Dying Every Day: Seneca at the Court of Nero, questions whether the man was as principled as his philosophy. Seneca the Elder was a rhetorician from an equestrian family in Cordoba, Spain, where his son, our thinker, Lucius Annaeus Seneca, was born in about 4 B.C. His aunt or someone took the young boy to be educated in Rome where he studied a philosophy that blended Stoicism with neo-Pythagoreanism. Seneca began his career in law and politics in about A.D. 31, serving as consul in 57. He fell afoul of the first of 3 emperors, Caligula. Caligulas sister suffered exile under Claudius on a charge of adultery with Seneca who was sent to Corsica for his punishment. Helped by Claudius last wife Agrippina the Younger, he overcame Corsican exile to serve as advisor of the last of the Julio-Claudians, from 54-62 A.D. whom he had earlier served as tutor. Seneca and the Julio-Claudian Emperors: The Suicide of Seneca Seneca wrote tragedies that have raised the question of whether they were intended for performance; they may have been meant strictly for recitation. They are not on original topics, but treat familiar themes, often with gruesome detail. Works of Seneca Works by Seneca Available at the Latin Library:Epistulae morales ad LuciliumQuaestiones naturalesde Consolatione ad Polybium, ad Marciam, and ad Helviamde IraDialogi: de Providentia, de Constantia, de Otio, de Brevitate Vitae, de Tranquillitate Animi, de Vita Beata, and de ClementiaFabulae: Medea, Phaedra, Hercules [Oetaeus], Agamemnon, Oedipus, Thyestes, and Octavia?Apocolocyntosis and Proverbs. Practical Philosophy Virtue, Reason, the Good Life Senecas philosophy is best known from his letters to Lucilius and his dialogues. In accordance with the philosophy of the Stoics, Virtue (virtus) and Reason are the basis of a good life, and a good life should be lived simply and in accordance with Nature, which, incidentally,  didnt mean you should eschew wealth. But whereas the philosophical treatises of an Epictetus might inspire you to lofty goals you know youll never meet, Senecas philosophy is more practical. [See Stoic-Based resolutions.] Senecas philosophy is not strictly Stoic, but contains ideas thrown in from other philosophies. He even coaxes and cajoles, as in the case of his advice to his mother to cease her grieving. You are beautiful, he says (paraphrased) with an age-defying appeal that needs no make-up, so stop acting like the worst kind of vain woman. You never polluted yourself with make-up, and you never wore a dress that covered about as much on as it did off. Your only ornament, the kind of beauty that time does not tarnish, is the great honour of modesty. So you cannot use your sex to justify your sorrow when with your virtue you have transcended it. Keep as far away from womens tears as from their faults.(www.uky.edu/ArtsSciences/Classics/wlgr/wlgr-privatelife261.html) 261. Seneca to his mother. Corsica, A.D. 41/9. Another famous example of his pragmatic philosophy comes from a line in Hercules Furens: Successful and fortunate crime is called virtue. He did receive criticism. He suffered exile for a supposed liaison with Livilla, mockery for his pursuit of wealth, and the scorn heaped on hypocrites for condemning tyranny,  yet being a tyrannodidaskalos - tyrant teacher, according to Romm. Parody and Burlesque in the Writing of SenecaMenippean Satire The Apocolocyntosis (The Pumpkinification of Claudius), a Menippean Satire, is a parody of the fashion of deifying emperors and a burlesque of the buffoonish emperor Claudius. Classical scholar Michael Coffey says the term apocolocyntosis is meant to suggest the conventional term apotheosis whereby a man, usually someone at the head of government, like a Roman emperor, was turned into a god (by order of the Roman Senate). Apocolocyntosis contains a word for some type of gourd probably not a pumpkin, but Pumpkinification caught on. The much ridiculed Emperor Claudius was not going to be made into a normal god, who would be expected to be better and brighter than mere mortals.   Senecas Social Consciousness On the serious side, because Seneca compared mans being enslaved by emotions and vices with physical slavery, many have thought he held a forward-looking view on the oppressive institution of slavery, even though his attitude towards women (see quotation above) was less enlightened. Legacy of Seneca and the Christian Church Seneca and the Christian Church Although currently doubted, it was thought that Seneca was in correspondence with St. Paul. Because of this correspondence, Seneca was acceptable to the leaders of the Christian Church. Dante placed him in Limbo in his Divine Comedy. During the Middle Ages much of the writing of Classical Antiquity was lost, but because of the correspondence with St. Paul, Seneca was considered important enough that monks preserved and copied his material. Seneca and the Renaissance Having survived the Middle Ages, a period that saw the loss of many classical writings, Seneca continued to fare well in the Renaissance. As Brian Arkins writes, in the article mentioned at the beginning of this article, on p.1: For the dramatists of the Renaissance in France, in Italy, and in England, Classical tragedy means the ten Latin plays of Seneca, not Aeschylus, Sophocles, and Euripides.... Not only was Seneca suited to Shakespeare and other Renaissance writers, but what we know of him he fits our mindset today. Arkins article predates 9/11, but that only means another incident can be added to the list of horrors: [T]he appeal of Senecas plays for the Elizabethan age and for the modern age is not far to seek: Seneca studies evil with great diligence and, in particular, evil in the prince, and both those ages are very well versed in evil.... In Seneca and in Shakespeare, we encounter first a Cloud of Evil, then the defeat of Reason by Evil, and, finally, the triumph of Evil.All this is caviar to the age of Dachau and Auschwitz, of Hiroshima and Nagasaki, of Kampuchea, Northern Ireland, Bosnia. Horror does not turn us off, as it turned off the Victorians, who could not handle Seneca. Nor did horror turn off the Elizabethans.... Main Ancient Sources on Seneca Dio CassiusTacitusOctavia, a play sometimes attributed to Seneca

Memoir Assignment Essay Example | Topics and Well Written Essays - 1250 words

Memoir Assignment - Essay Example untry to another- they don’t suffer from anxiety or added worry trying to conform to new surroundings or adjusting to a culturally oriented society, totally different from their own, but definitely, they are missing out on an exciting part of their lives. When speaking of myself though, I’ve had the good chance of this happening to me and that too, at such an opportune moment. I had to adapt myself to mass differences socially, culturally, economically, and even in a somewhat spiritual manner as well. These changes hadn’t been easy for me and needless to say, I don’t see how they’d be easy for anyone. It was a day like any other; a sunny April morning, the heat of which had been whetted the night before, due to the chill April showers. I had taken a shower and had spruced myself up with an expensive after – shave. I wore my brightest shirt with jeans and moved with an air of conquering the world. My life changed dramatically when I was just in my teens, the picture of which is clearly etched forever in my minds eye. I was drawing back the floral blinds, allowing the cool fresh air to engulf me and savoring every minute of it, when my dad’s rumbling tone was heard just within my bedroom door. Dad continued, â€Å"Never mind†¦don’t say anything, because parents know what’s best for their kid and I have better plans for you to make a success of your future, and yes, by the way, we are throwing a small send off party for you, so invite all your friends and we’ll have a great time before we see you off. My brother, your uncle Jim, in Alabama has generously consented to put you up for the next year since you are going to High School. I was confusion confounded as I heard the door slam shut! Oh, My God! I was almost terrified out of my wits. Confusion blocked my thinking and a lurking fear hit me in the pit of my stomach like a sledge hammer. Taiwan, my hometown was the be all and end all of my life. Everything in my environment seemed perfect

Brian Norris Essay Example | Topics and Well Written Essays - 2500 words

Brian Norris - Essay Example If an organization has to achieve its business objectives, its marketing manager has to look into the market demand, to determine the feasibility of marketing strategies. The marketing manager is responsible for attuning the level, timing and composition of customer demands to achieve business objectives. On the whole, marketing management all about determining and implementing effective marketing strategies. Marketing strategies are tactics by which an organization gains a competitive edge in the marketplace. Through these strategies an organization determines how to concentrate its resources to achieve, target business objectives. If a marketing strategy has to be effective, it must do research to find out if an organizational opportunity exists in the market in which they want to do business. The factors influencing organizational opportunity are environmental opportunity, distinctive competency and success requirements. Each of these factors is to be looked into during the process of market analysis. Marking analysis is a process which includes the process of ccustomer analysis, company analysis, collaborator analysis, competitor analysis, and analysis of the industry context. These five types of analysis constitute the four C's of marketing analysis and help to answer the following questions: In order to carry ou... What are the steps to be taken to gain a competitive edge in the market 2.1 Marketing Research In order to carry out marketing analysis, marketing research must be performed to collect the data required for analysis. Marketing research involved the employment of a variety of techniques. Some techniques of market research are: Qualitative marketing research, such as focus groups - Through Qualitative research, data can be collected from a relatively small group of respondents. This data will not be analyzed using statistical techniques, but its purpose is to help to determine the elements which drive the market on a product, generate a hypothesis on such elements and enable an organization to develop quantitative research designs for determine the feasibility of entry into a particular market. The methods used in this research include in-Depth Interviews, Focus Groups and Projective Techniques. Quantitative marketing research, such as statistical surveys - Quantitative marketing research applies quantitative research techniques, to understand the trends in the current market. The major steps involved in the research process include, definition of the problem of market to be studied, designing the search criteria, collecting data, analyzing the data collected and finally writing a report on what is understood from data gathered. The number of respondents from whom data is collected can range between something like a mere 10 in number to something like 10 million. This kind of marketing research may include a hypothesis on the trends found in the market. Random sampling methods can be used to draw inferences from people, who have provided information. Experimental techniques such as test markets - Experimental research

Hatton Gallery Essay Example | Topics and Well Written Essays - 2250 words

Hatton Gallery - Essay Example People from all walks of life, although learned and ingrained upon themselves the importance of "home" as well as its essence becoming a basic part of the human lifestyle rarely take a breather and view the "home" as an art. "Front Door, Back Gate" tries to encompass domesticity as theme on-going in Jeannie Finaley's exhibit at the Hatton Gallery. This exhibit is a yearly endeavour undertaken by the students from the University of Newcastle upon Tyne. The exhibit also reflects the limited space of domestic life as well as the varying themes underlying actions, choices, moods, and between-the-line emotions. The group have chosen "interior" and exterior" as the sub-theme showing Hatton;s historical collection along with contemporary works giving a wider variety and balance on domesticity as an art. The group also used complementary home and garden furniture to exude comfort and create an atmosphere that welcomes. The vivid "Red Table" by Patrick Heron reflects love and solitude as well as denoting lifestyle and exuberance. Heron have an affinity for the vivid, exotic and captivating red, and this abstract still life painting shows an interior space with a table, a selection of everyday objects. The table seems to be set for one, which addresses sustenance, yet also gives a sense of solitude. Perhaps the time and comfort of home allowed the artist to look at these ordinary objects differently. The composition is inspired by forms and patterns extracted from the domestic surrounding, which allows more artistic freedom and activates the space around the objects. Simplicity adds a flare of innocence to the painting and invites the mind to think of the story of the place. It is provocative in a sense that red is played in various hues, contrasting with the bright yellow and yet implying connectivity. It is mysterious in a way that shapes are obscured but with details that strike out like questions. Leon Maurine's "Net" photograph shows direction and sense of belonging. Likewise, the "Net" curtain photograph also reflects aspiration, privacy, territory and voyeurism. This photograph shows a glimpse through a net curtain looking out onto a blurred view. The image creates a visual link between interior and exterior. The sheer layer of the net curtain infuses the two spaces. The image conveys a "pulse" of life on both sides. It makes us think about the time spent behind and beyond the net curtain. We commonly think of interior spaces as private and reflective. Often exterior spaces are more public and engaging. The relationship between domestic public and private spaces has never been static- its boundaries are changing with time and new ways of life. The details of the net, or crocheted curtain also invokes domesticity as a pained detail of art form. It is not something to be lightly taken, but with meditation and composure. One slip of the hook, or an extra count makes an imbalanced design and finish which juts out like a sore finger. Same thing is pictured with domestic life. Everything must be in harmony and although with various patterns, a part of a whole. Front Door, Back Gate Reasons for

An Organizational Ethical Dilemma Coursework Example | Topics and Well Written Essays - 750 words

An Organizational Ethical Dilemma - Coursework Example A class action lawsuit was brought against Rite Aid by its employees because of the incurred losses in shareholdings and income due to the bookkeeping and accounting fraud ("Rite aid faces," 2003) The company’s reputation was severely hurt by this scandal and lost nearly a billion dollars in legal fees and in the shareholding settlement reached for the class action lawsuit. The company lost its good reputation and fell behind similar stores such as CVS and Walgreens ("Rite aid faces," 2003) The Ethical Issues There are several ethical issues that are illustrated in this particular incidence. The biggest issue is the breach of fairness. According to the book entitled â€Å"Managing Business Ethics,† a major aspect of ethics for most employees in an organization is the â€Å"climate of fairness† (Trevino, & Nelson, 2010). A climate of fairness involves all aspects of employee treatment such as â€Å"outcomes, processes, and interactions (Trevino, & Nelson, 2010). In order to be considered ethical, this climate of fairness cannot be breached. In this case, Rite Aid did not provide a fair work environment as employees were harmed in the all three of these key areas because of the fraudulent actions of several men. Instead, the company promoted a self-interest climate which is where â€Å"people protect their own interests above all and everyone is essentially out for themselves† (Trevino, & Nelson, 2010). Martin Grass and his accomplices placed their own greed above the good of the other employees and shareholders and ended up defrauding many of these people out of the money that they were entitled to ("Rite aid faces," 2003) Who is affected by the dilemma? The employees and shareholders were the individuals that were initially impacted by this ethical scandal due to the fact that they were the ones who lost out on the money they were owed. In order to rectify this situation, a class action lawsuit was filed and eventually the company h ad to pay out. The company was also affected by this dilemma as their reputation was ruined and they lost a lot of money because of the legal fees and profit loss. Finally, the customers are also affected because such a breach of ethics is going to change the perception of the organization. Customers likely felt that this was not a company they should trust. The fact that profit was impacted suggests that customers did not want to be associated with the store and its negative reputation. What are the possible consequences of specific and alternative actions (responses)? The company really did not have any other choice when it came to how they responded to this ethical dilemma. In order to save face in the long-term, they had to pay back the money to shareholders and employees. The only way to ensure that they were not ruined was to accept the short term consequences and respond appropriately. Had the company not responded appropriately, they might have been forced to go out of busin ess. Even with an appropriate reaction, Rite Aid lost billions and their stock plummeted to just a few dollars per stock in 2003("Company news; rite," 2003) What are the relevant obligations from your analysis of the dilemma? According to â€Å"Managing Business Ethics,† the obligations for a company â€Å"vary depending on the people involved and the roles they play (Trevino, & Nelson, 2010). For Rite Aid, the main obligation that they had was

Emerging market-The challenges and opportunities investing in China Essay

Emerging market-The challenges and opportunities investing in China - Essay Example In the thought of Beridze, emerging markets refer to the nations that have actively been involved in business activities that have seen their fast growth as well as a huge development in the industrialization process. Among these countries that are termed to be emerging range from Brazil to China. As seen in the research conducted by Palepu & Khanna, China has retained her position as the third in the list of the emerging markets. China has also been termed as one of the growing economies with largest imports and exports in the globe. Agtmael indicates that the economy has had a growth rate of about 10% over the years. With the country being termed as the world’s second-largest economy after the U.S.In the thought of Lorenzoni & Broner, emerging economies have been integral in the world economy. This may arguably be because the supposed emerging economies have already emerged and are taking the center stage of the global economy. A good example is China that is export-driven w ith strong capital inflows and investments from well-capitalized banking institutions. Additionally, the growth of the world’s economy is expected to emanate from the emerging markets, and 70% of the growth is anticipated according to the economists.  Despite the varying interpretations of the term, the fact about the entire aspect is that emerging markets have been instrumental in recording an increase in the capital share in the world economy and that their GDP is on the increase.

An Organizational Ethical Dilemma Coursework Example | Topics and Well Written Essays - 750 words

An Organizational Ethical Dilemma - Coursework Example A class action lawsuit was brought against Rite Aid by its employees because of the incurred losses in shareholdings and income due to the bookkeeping and accounting fraud ("Rite aid faces," 2003) The company’s reputation was severely hurt by this scandal and lost nearly a billion dollars in legal fees and in the shareholding settlement reached for the class action lawsuit. The company lost its good reputation and fell behind similar stores such as CVS and Walgreens ("Rite aid faces," 2003) The Ethical Issues There are several ethical issues that are illustrated in this particular incidence. The biggest issue is the breach of fairness. According to the book entitled â€Å"Managing Business Ethics,† a major aspect of ethics for most employees in an organization is the â€Å"climate of fairness† (Trevino, & Nelson, 2010). A climate of fairness involves all aspects of employee treatment such as â€Å"outcomes, processes, and interactions (Trevino, & Nelson, 2010). In order to be considered ethical, this climate of fairness cannot be breached. In this case, Rite Aid did not provide a fair work environment as employees were harmed in the all three of these key areas because of the fraudulent actions of several men. Instead, the company promoted a self-interest climate which is where â€Å"people protect their own interests above all and everyone is essentially out for themselves† (Trevino, & Nelson, 2010). Martin Grass and his accomplices placed their own greed above the good of the other employees and shareholders and ended up defrauding many of these people out of the money that they were entitled to ("Rite aid faces," 2003) Who is affected by the dilemma? The employees and shareholders were the individuals that were initially impacted by this ethical scandal due to the fact that they were the ones who lost out on the money they were owed. In order to rectify this situation, a class action lawsuit was filed and eventually the company h ad to pay out. The company was also affected by this dilemma as their reputation was ruined and they lost a lot of money because of the legal fees and profit loss. Finally, the customers are also affected because such a breach of ethics is going to change the perception of the organization. Customers likely felt that this was not a company they should trust. The fact that profit was impacted suggests that customers did not want to be associated with the store and its negative reputation. What are the possible consequences of specific and alternative actions (responses)? The company really did not have any other choice when it came to how they responded to this ethical dilemma. In order to save face in the long-term, they had to pay back the money to shareholders and employees. The only way to ensure that they were not ruined was to accept the short term consequences and respond appropriately. Had the company not responded appropriately, they might have been forced to go out of busin ess. Even with an appropriate reaction, Rite Aid lost billions and their stock plummeted to just a few dollars per stock in 2003("Company news; rite," 2003) What are the relevant obligations from your analysis of the dilemma? According to â€Å"Managing Business Ethics,† the obligations for a company â€Å"vary depending on the people involved and the roles they play (Trevino, & Nelson, 2010). For Rite Aid, the main obligation that they had was

Topics in film Studies Essay Example | Topics and Well Written Essays - 1000 words

Topics in film Studies - Essay Example The film focuses on the adventures of the crew of one ship, the Enterprise, as it is seeks to save Earth from destruction by what appears to be an omni powerful entity from outside their galaxy. The crew ultimately prevails through their pragmatic use of scientific study and technology, and the god-like aggressor turns out to be a returning, alien-upgraded Voyager space probe. In contrast, the people of Star Wars are ruled by the heavy handed Galactic Empire. The empire dedicates its resources to applying oppressive control over its population, destroying entire planets as it sees fit to further its goals. Rather than focusing on the crew of a single ship, the protagonist characters of Star Wars begin largely unaware of each other, living entirely separate lives and different worlds, only to come together near the end of the film to defeat the forces of the empire. Further, its the use of the mysterious, almost religious powers of "The Force", rather than science, that delivers the characters from defeat. Behind these on screen differences, though, the 1977 Star Wars film had inescapable, pervasive influences, both positive and challenging, on the production of the Star Trek film that followed. One of the most significant examples was Star Wars’ influence in convincing the Paramount film studio that the Star Trek movie should be made at all. In 1977, while there had been initial efforts to bring Star Trek to the big screen, Paramount had decided to develop a new Star Trek television series, instead. The success of Star Wars, however, changed their minds. â€Å"Box office receipts for Star Wars were making science fiction believers out of the most skeptical critics; even Charles Bluhdor, chairman of Gulf & Western, Paramount’s parent company, reportedly inquired why there was so much foot-dragging on Star Trek† (Stein) Gene

Political Aspects of Wireless Electricity Essay Example for Free

Political Aspects of Wireless Electricity Essay It is no secret that politics plays a big role when it comes to the introduction of the wireless electricity. Some parties are for it, as it can allow for slightly greener ways of powering devices, new jobs, and easier access. But others are against it, seeing the change as a threat to old ways of doing things, as well as a way for people to access electricity for free. Though wireless transmissions and the idea of wireless electricity have existed for quite some time, the actual possibility of creating usable, accessible wireless electricity is just now starting to become a reality. With wireless electricity looming on the horizon, more and more politicians, civilians, and companies are beginning to stand behind the idea; but that has not always been the case. Politics first began working their way into wireless electricity in 1905, when J. P. Morgan pulled all of his funding from Nikola Tesla’s Wardenclyffe Tower project when he erroneously began to believe that it could lead to free electricity for all (Haliburton, 2006). It is that same type of thinking that has helped to keep wireless electricity out of the mainstream for so long. However, information and general knowledge about wireless electricity has come far, and that type of thinking is quickly disappearing. With the recent surge of environmental and financial awareness, people are quickly beginning to gravitate towards the idea of wireless electricity. Even power companies are getting behind the idea, seeing a way to expand their business. Though the idea of wireless electricity has just begun to reemerge, it will quickly become a hot political topic, just as other forms of alternative energy have. The question is this: Will the general public and politicians continue to gravitate towards this new concept? And if they do, how long will it be until wireless electricity becomes the norm?

Role Expansion of Support Staff in the NHS

Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role Role Expansion of Support Staff in the NHS Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role