Locker Gallery Essay - 929 Words

For extra credit, I visited the Locker Gallery on Friday, December 1st. This gallery appeared to have different artist’s work present, but their art was much more expansive, detailed, and followed individual themes compared to Gallery II. The exhibit mainly had paintings on display, but other media was also incorporated into some pieces. When entering the gallery, a large section of the left walls was taken up by sizable paintings which appeared to be created by the same artists based on the style and colour scheme. The five pieces consisted of earth tones and incorporated the illusions of light, movement, and flow into each painting. One work from the collection particularly captivating was the carousel piece. It had a haunting and†¦show more content†¦This piece was very symbolic and filled with so many aspects that you can notice and analyze new things each time you look at it. On the opposite side from where I examined the first paintings was another space filled with sizable works. I assume these works were also done by one artist since like the other large painting collection, it had a distinct colour scheme and style. Some of the paintings were large, quirky portraits of people and others were solely abstract paint on a canvas. In both the portraits and images, the painting’s similar styles and techniques were consistent throughout. The colour scheme worked with warm colours like oranges, reds, and purples with some browns. One of the standout techniques from this collection was the use of splatter that had physical weight (check). You could see the various layers on the canvas, which gave the pieces depth. The last piece I’ll talk about is one of my favourites. Across from the long, environmental piece was more of what would be considered an exhibit. â€Å"Fresh Meat† was written on the wall. On the ground was a hand-held shopping cart depicting the Fresh logo on its side. In the middle of the wall, 3 â€Å"meat† items were on display for sale- all of which looked real and ready to buy. There was a ready to bake pizza with mini human legs as a topping, a USDA Grade A human breast, and a USDA Grade A human liver. This collection spokeShow MoreRelatedLibrary Management204752 Words   |  820 PagesPatterns of Industrial Bureaucracy (New York: Free Press, 1954). 4. See, for instance, James D. Thompson, Organizations in Action: Social Science Bases of Administrative Theory (New York: McGraw-Hill, 1967). 5. Warren G. Bennis, Changing Organizations: Essays on the Development of Human Organization (New York: McGraw-Hill, 1966); Rensis Likert, The Human Organization: Its Management and Value (New York: McGraw-Hill, 1967). 6. Henry Mintzberg, The Structuring of Organizations: A Synthesis of the Research

Sophocles Tragic Demise Of Oedipus Rex - 2055 Words

A dispute that still storms today is whether we have free will, or if forces outside of human control, fate, decides our future. The same argument pertains to Oedipus Rex. The question raised is whether Oedipus caused his downfall due to his hamartia, his bad actions, or if it was simply fate, that the gods predetermined his life course. Sophocles expresses irony in his play to help the audience cognize the play and give them a better outlook on the reason Oedipus and his family brought about their tribulation and blamed fate for it. Due to Hubris, and the inadequate actions Oedipus makes in desperately preventing what was prophesied, the result led to his and his family’s tragic demise. It is understandable that many conclude Oedipus Rex is based on fate because of the perceived unavoidability of the prophecy. The prophecy of the child of Laius was that he was to kill his father and marry his mother. In the beginning of the play Laius was told of this prophecy and did not accept what was foretold of his future. From that day forward, he did everything in his power to prevent the prophecy from accomplishing. Laius and his wife Jocasta took extreme measures and pierced their child’s legs then ordering their shepherd to leave it on a mountain to die. As the Shephard leaves to the mountains, out of pity, he saves its life and hands it to another shepherd working across from him. After receiving the baby, the other shepherd offered him to his master and his wife which were theShow MoreRelatedDeconstructing Tragedy And The Definition Of The Protagonist’S1173 Words   |  5 PagesDefinition of the Protagonist’s Innocence In Sophocles’ Oedipus Rex, Oedipus meets the Aristotelian definition of a tragic hero as divine fate and tragic flaws lead to his downfall. Oedipus’s tragic flaws like hubris, curiosity, and anger, contribute to his unfortunate fate. The components of a perfect tragedy as defined in Aristotle’s Poetics are at the center of Oedipus Rex. The play contains the elements of a perfect tragedy such as â€Å"imitation †¦ purificationRead MoreOedipus Tragic Hero Analysis936 Words   |  4 Pagesdownfall. This concept could be correlated to the acclaimed work of Sophocles, Oedipus Rex, whereby the epitome of a tragic hero is created in the main character, Oedipus. Moreover, Sophocles has characterized Oedipus to be the embodiment of a respectable leader, possessing both extreme pride and relentless determination, which later proves to be the fatal flaw leading to his eventual, inescapable demise. This is due to how Sophocles codified this moral, or community sta ndard, in his Theban TrilogyRead MoreOedipus-a Tragic Hero706 Words   |  3 PagesRunning head: Oedipus-A Tragic Hero Research Paper ENGL 102: Literature and Composition) Fall 2015 Melinda Meeds L26683811 APA Outline Thesis: In Sophocles’ â€Å"Oedipus†, Oedipus is exemplified as a tragic hero according to Aristotle’s definition because his story appeals to the reader’s humanity in the way he maintains his strengths after inadvertently causing his own downfall. I. Oedipus A. The noble birth. B. Describe Oedipus’ character. II. Tragedy A. DescribeRead More Comparing A Dolls House and Oedipus Rex Essay1672 Words   |  7 PagesComparing A Dolls House and Oedipus Rex Ibsens drama A Dolls House, serves as an example of the kind of issue-based drama that distinguishes Ibsen from many of his contemporaries. The plays dialogue is not poetic, but very naturalistic, and the characters are recognizable people. Given the sense of modernity which the play possesses it seems unusual to compare it to a Greek tragedy produced more than two-thousand years previously. On closer examination however, thereRead MoreEssay The Tragic Fall Of Oedipus in Oedipus the King824 Words   |  4 PagesTragic Fall Of Oedipus Rex in Sophocles Oedipus Rex The tragic fall of Oedipus in Sophocles play â€Å"Oedipus Rex† is both self-inflicted and result of events drawn from his own destiny. First off early on in Oedipus’ life his first deadly mistake towards succeeding his self-inflicted downfall was the murder of his father the former king. In a blind rage without any motive, he kills Liaus and his men at a rode crossing. Fate may have had led him to that point but it was his own rage that resultedRead MoreMWD Oedipus Rex1701 Words   |  7 Pagesï » ¿Title: Oedipus Rex Author: Sophocles Date of Publication: around 430 B.C. Genre: Dramatic Tragedy Biographical information about the author: Born at Colonus, son of Sophilus. Sophocles was a playwright and served as a priest. He had a son with Nicartrata, who was also a playwright. And he also had a son with Theoris. Wrote 123plays but only 7 survived: Ajar, Antigone, Trachinian women, Oedipus Tyrannoss, Electras, Philocetes, and Oedipus at Colonus. Also increased the number of chorus fromRead MoreComparing Oedipus Rex And Death Of A Salesman By Arthur Miller1255 Words   |  6 Pagestwo works such as Oedipus Rex, which is a playwright written by the great Sophocles and another playwright named Death Of A Salesman written by Arthur Miller. c. Through out the years, there has been a lot of controversy on whether or not Death Of A Salesman is considered to be a tragedy, unlike Oedipus Rex which clearly is. d. I feel these two plays can compare in a multitude of ways despite being written in different historical times. II. Body Paragraphs a. In Oedipus Rex, Oedipus is the protagonistRead MoreCandide, Macbeth and Oedipus Rex1525 Words   |  6 PagesIn Candide, Macbeth and Oedipus Rex, fate and free will are always two opposing themes reflect on major characters. Fate is a belief that the future is predetermined, and it’s truly impossible to convert the consequence. No matter how people endeavor, the same thing will happen because that is what is supposed to occur. It’s also the philosophy that everything happens for a reason or relates to the God, things don’t happen â€Å"just because†. Free will is a constant concept that people act freely uponRead More Self-Damnation in Oedipus the King Essay1312 Words   |  6 PagesSelf-Damnation in Oedipus Rex (the King)   Ã‚  Ã‚  Ã‚   Sophocles play Oedipus Rex (the King) is a tragic tale of fate and hubris. At first glance, it seems that the terrible fates of the main characters are merely the doings of mischievous or cruel gods. That Laios should die at the hands of his unknowing son, that Jocaste should later marry that son to commit the crime of incest, and that Oedipus, the son, should be the actor in both crimes all seem to be deeds scripted unfairly by the gods for theirRead MoreCompare and Contrast Othello and Waiting for Godot Plays Essay1104 Words   |  5 Pages4/25/13 Oedipus the king is a representative of ancient Greek drama by Sophocles. The Latin title of the play is Oedipus Rex. Though produced as the second play in the three sequences of Theban plays by Sophocles, it finds its way at the top of the sequence as a result of internal chronology. The next play in the sequence is Oedipus at colonus and finally Antigone. The play is an excellent example of Greek tragic plays (Bloom, 51). Waiting for Godot is a play by Samuel Beckett, an Irish who won

Math Observations Free Essays

string(143) " few students in setting up their number in rows and would have liked to see her maybe show the students first how to put the numbers in rows\." Kindergarten Math Observations Mrs. Miller, Antelope Elementary, Kindergarten Observed: Wednesday (9:00am-10:30am) 3/27/13 Classroom rotation- children went from one room to the next for separate subjects, also each group of kids had been evaluated and put into advanced, moderate, and standard levels. This was also known as 3rd level, 2nd level, and 1st level kids. We will write a custom essay sample on Math Observations or any similar topic only for you Order Now Advanced Group- 3rd level kids Classroom was set up into three separate group tables. Kids would move from work table to work table to complete different math activities. Before starting their groups the teacher first went thru math skills they had learned the previous week (adding the dots on a two sided domino). Then the teacher went on to this week’s concept (adding objects). She then read a story about a girl and a boy that wanted to see how many magnets they had together. The girl had 3 black magnets and the boy had 2 hand magnets. She then had the children add up (count) the total amount of magnets on the board. She then asked what they thought the math problem would be. They repeated 3+2= 5. She then asked if all students had understood why it was that and all answered with either the sign language symbol for I understand or yes. Group #1- Played a version of math bingo. Used math problems to find what number to put there chip on. The answer to that answer was where there chip was then placed. This game continued until all squares were filled. This group was assisted by Mrs. Joyce (a. k. a teacher’s assistant). When kids began to struggle with problems for example like: 3+4, the assistant slowed down the game and made sure each student recognized that 3+4 was 7 and then to place their chip on seven. Group #2- This group was with the teacher. This group worked through a worksheet paper with their teacher. The first side of the worksheet was about counting coins. Mrs. Miller first asked them the name of the coin (ex. Nickel). The children answered nickel. She then asked what the value of the coin was (ex. Nickel= 5cents). The children answered 5. She then asked the children to count by fives for each coin. She then asked the children if the answer was 15 cents or $15. They answered 15 cents. Example problem : (three nickels) 5†¦10†¦15 = 15 cents The second side of the work sheet was drawing what the story was saying as first a picture, or a visual, and then as an equation. Mrs. Miller first read the story. Then the students went thru drawing the picture with the teacher. Example problem: Tanya has 2 red balloons and 1 yellow balloon draw the picture. Mrs. Miller then asked the students what the problem would look like. The students answered 2+1= 3. She then made sure that each student understood and had the correct answer before proceeding to the next problem. Example problem: Jamal has 3 blue squares and 2 green squares, draw the picture. Mrs. Miller then asked the students what the problem would look like. The students answered 3+2= 5. She then made sure once again that each student comprehended the problem and why it was 3+2= 5. After about 15-20 minutes the groups switched and rotated to the other table. At 10:30 the children lined up at the door and went back to their homerooms for snack. (end of observations) Summary/ Reactions – Mrs. Miller, Antelope Elementary, Kindergarten I enjoyed observing this classroom over all. I really liked the way her classroom had been set up with not just desks in a row but the students were assigned tables and then they also had an assigned seat on the carpet. I was pleasantly surprised at the level of math the students were able to complete and comprehend. I considered in the back of my head what I had originally thought kindergarten was and remembered only learning my alphabet and finger painting. I really liked that the students had been assessed into different levels of comprehension and was glad to see that most of them succeeded more in the segregated math environments. I also liked that their math time had been split into two subgroups. I noticed that this helped the students get a break from the monotony of doing the same math problems over and over by also allowing them to improve on some of their other math skills simultaneously. There were a few differences within each group level that I would like to consider also. First I would like to talk about my reactions to the level three students. My initial reaction to the students was that they were all very focused mildly behaved kids for kindergarteners. The students had no problem and truly looked like they enjoyed playing the Math Bingo. I noticed Mrs. Joyce did not have to help them as much with adding the numbers together and seemed to compute the answers quite quickly. When the students were in the second group with Mrs. Miller they were asked more difficult questions such as the three factor problem (mentioned in observations). I was surprised to see that most of the students had no problem drawing and writing out the problem even though an additional factor had been added. Then when they moved on to counting the coins I liked that majority of the students could recognize the coin, the value of the coin, and then by using its amount counting up to find how much money they had. Over all, this group definitely showed they were advanced. Next I would like to talk about my reactions to the level two students. My initial reaction to the students was that they were a little less focused but comprehension wise were still fairly up there. I liked that the group activity had changed for group number one from math bingo to a more practice oriented group. I did notice that Mrs. Joyce had to help a few students in setting up their number in rows and would have liked to see her maybe show the students first how to put the numbers in rows. You read "Math Observations" in category "Observation essays" In Mrs. Miller’s group, or group number two, I noticed she didn’t really focus on the writing of the problems to match the stories. I noticed that the kids didn’t understand as much as the previous level why they got there answer as much as what their picture looked like. And then when the students went thru the coin side of the work sheet I thought that a few students answered more frequently first and then the other students would copy there answer. Over all, this group was slightly less advanced but also above the average kindergartener. Finally I would like to talk about my reactions to the level one students. My initial reaction to the students was that they were definitely a lot more easily distracted by the set up of the room and each other. I did like that Mrs. Miller went through the numbers 1-30 on flashcards with this group and that when they began to struggle she slowed down and went thru them again before starting the groups. I will definitely consider this strategy in my classroom. I appreciated when Mrs. Joyce took the time to show the students what their numbers should look like when in order by writing them on the board. This was a great reference and I noticed majority of the students used it as such. I noticed though with this group, more than the last group, Mrs. Joyce helped he students find each number instead of letting them find them on their own. I assumed that maybe she was just trying to save time. In group number one with Mrs. Miller I noticed the students would lose focus much easier and found coming up the answer much more difficult. I especially noticed that at one point on the front of the work sheet students were mostly blurting out guesses not actual thoughts. I would have liked to have scene maybe a break at this time to go back and explain why the answers were what they were, but I understand at the same time that the groups were on a time schedule. On the back of the work sheet I noticed majority of the students struggled when asked what the coins were even though examples of the same coins had been placed on the board. I would have probably reminded them of the pictures on the board. Over all, this group was definitely willing to learn, but lost focus the most often. In conclusion, observing this kindergarten class has really changed my outlook on what I used to think kindergarten was. I am now more willing to consider this grade level as a possible career. I saw a few things I would have maybe done differently, but over all my observations of Mrs. Miller’s kindergarten class were mostly positive and rewarding experience wise as well. Third Grade Math Observations Mrs. Shaffer, Metteer Elementary, Third Grade Observed: Thursday ( 10:00am- 11:00am) 3/28/13 Classroom setup: The desks were set up in groups of two. Each group had been strategically placed there because of their willingness to volunteer or the lack there of. For instance a student that answered questions a lot would be placed with another student that didn’t volunteer so much so as to make that student more willing to raise their hand and participate in discussion. The classroom was covered in inspiring posters and excellent art work made from each student. There was also a wall dedicated to the highest scored English tests. There were a set of classroom Do’s and Don’ts on the wall. Examples: Make good choices, Make the teacher happy, and Fallow direction quickly. Each rule had a hand signal. For example make good choices is taking your pointer finger and pointing to the side of your head. After the teacher went through each rule she then had each student teach it to their neighbor. There was a wall with small pouches on it with each students desk number on each and in each pouch was a green, yellow, and red card. When a student talked out of turn or was not fallowing directions the student was then instructed by the teacher to go â€Å"turn their card† or switch their card from green to yellow or from yellow to red. On the board there was a tally system set for when the class as a group were not on task or not fallowing directions. If the students were too loud they got a tally mark on the frowny face side, and if they quieted down and got focused again they received a tally mark on the smiley side. At the end of the day the tally marks were added up and if they had more smileys then frownys they got extra recess that week. Math: The teacher began by going back over 8ths. She drew a square on the board and asked the class how many individual squares made a whole square. The students replied by saying â€Å"16 squares†. She then cut the whole square in half and asked the students how many squares made up one half of the whole square. The students answered by saying â€Å"8 squares†. The teacher then cut one half the whole square in half and asked the students how many squares equaled one fourth of a whole square. The students answered by saying â€Å"4 squares†. The teacher then cut one fourth of the whole square in half and asked the students how many squares make up one eighth of the whole square. The students answered by saying â€Å"2 squares†. Then the teacher asked how many eighths would fit in the whole square. The students replied by saying â€Å"8†. The students were then told to get out there small square eighth work sheets. The work sheets were about eight square grids on a piece of paper. On each grid the students were instructed to creatively shop up the grid into sections so that it had eight equal parts, or eight eighths. Then after they had finished their mini squares they were instructed to trade them with their neighbor and grade each other on if they completed the assignment correct as it had been assigned. Then when their squares had been approved, they were then supposed to choose one square they thought looked the best and make draw that mini square pattern onto a bigger square grid. The teacher then made sure that each student understood that the squares needed to all be colored a different color so they would over lap and that they wrote one eighth on their pages as well. Summaries/Reactions – Mrs. Shaffer, Metteer Elementary, third grade. When I first arrived at the classroom, the students were already starting the day out to a rough start. Mrs. Shaffer was apparently not content in the way they had walked to the classroom after recess and had the students walk all the way back to the line up on the play ground and walk back to the classroom again. Although the students slipped up a bit the first time when they had to actually go back and walk it again, I noticed a significant change in their attitudes and their level of focus. Once in the classroom, the students level of attentiveness went down again but it was mostly because they had a new distraction in the room, me. The teacher started going through the class rules and the hand signals with the students. I noticed that they really enjoyed sharing with their neighbors what they knew and I feel like this simple activity helped them to better know their class mates and grow as group partners. Then the teacher began asking the students their fractions for eighths and writing the answers on the board. I noticed that not every student was completely paying attention or answering the questions as much as other students. I would have liked to have seen the teacher maybe redirect the focus of the whole class as she had done previously in the day, just to continue with consistency. Then the teacher had the students break off into their groups and finish their mini grid papers. I noticed with some of the groups the students were really excited to show their neighbors their squares and had excellent creativity in their designs. The only thing that I noticed did happen with a few of the groups was that they started to act as though the appraisal of whose square was the best was more important than actually completing the assignment. But when the students reached too loud of a level of noise, the teacher put a tally on the board on the frowny side and the students refocused. Then the students that were finished with the mini squares were then instructed to redraw their favorite design on the larger grid square that would be shown at their open house. I really liked that the students made it a point to make their fractions very personal and neat. I then made it a point for myself to ask each student why they chose the colors they did. Most students replied that the colors they chose were their favorite colors. One boy said that he chose the colors brown, green, grey, and black because it made his fraction look like camo print. All in all I had a really great experience while observing in Mrs. Shaffer’s classroom. Her techniques and her instruction were very unique and different. I hope to visit and or observe her class again someday. Sixth Grade Math Observations Mr. Smith, Metteer Elementary, Sixth Grade. Observed: Tuesday (9:30am-10:30am) 3/26/13 Classroom setup: The classroom had its own computers, two wipe boards, and a job board. The Job Board included little pouches with each child’s name on them and included job such as Lunch Helpers, Paper Gatherer, Desk Straitener, Mad Minute Man, Computer Monitor, Clean up Foreman, and Phone Person. On the walls there were several posters. The first one was a poster titled â€Å"How to write a good paper. † It had four colored circles on it. There was one green forgo write your topic, one yellow for slow down and give reason, one red for stop and explain, and finally another green for go back and restate your topic. The next poster was a transition poster that had lots of helpful transitions sentences for the students to use as a reference. The next poster was an Editors Marks Poster. It had signs such as the paragraph sign,  ¶. The student’s desks were all together in a hollow box shape with two desk partners in the center. Math: That day Mr. Gappa was having the students build a mummy tomb out of Banana and Apple boxes. He first asked the students’ how they should start. They started by finding the area of the Banana Boxes (Banana: 10† ? 20† = 200 inches squared). Then he asked them what they should do next. They replied that they should find out how many boxes and fit in their tomb space. Mr. Gappa then measured each dimension of the corner of the room where the tomb would be placed. Wall one was 100in long and 110in tall. Wall two was 160in long and 110in tall. He then asked the students what they noticed about the dimensions of the banana and apple boxes compared to the dimensions of the walls. They replied that the banana boxes and the apple boxes dimensions were factors of the wall dimensions. Then he asked what they should consider next. They replied that they didn’t know how many columns they still needed. Mr. Gappa told them that they would need two columns, but then asked how many boxes it would take to make the columns using the apple boxes (Apple: 20† tall). The students then started to write down all the data on the board. Then Mr. Gappa went around the room making sure each student understood their data for the tomb building. For their final blue prints they were to use graph paper, making sure that there boxes were equal to at least two squares on the graph paper. Mr. Gappa then made it clear that he wants all the blue prints to be neat and colorful because they were going to be submitted to the Pharaoh contractor. For each wall the students then went about figuring out how many boxes they would need using the formula, area= length? width. When they had finished with their walls, they all gathered at the front of the classroom and went back over the data with Mr. Gappa. Mr. Gappa then went around the room making sure that each student was using lots of color on their blue prints and were making sure they were very neat. He then mentioned a real life situational fact to the kids that they were going to be like little construction workers when they begin building the tomb. Summaries/Reactions First of all I would like to begin by saying how much I really liked the set up of the room. The kids were close enough together for quiet discussion during tasks but also when out of their seats had plenty of room to move throughout the classroom. This class was also the quietest sixth grade class I’ve ever seen. Even Mr. Gappa spoke quietly when giving direction to make sure that each student had to listen very closely just to hear what he said, I almost didn’t even hear what he said. Next I would like to discuss the math. I really liked that Mr. Gappa had taken the time to create a math project for all the kids that used all the math skills they had learned during the year to help in the making of a mummy tomb which was also a part of their history lesson that week. I liked that when going over the data Mr. Gappa didn’t just give the students the answers but made them figure them out on their own. This to me showed the true attentiveness and memorization skills that the students had obtained that year. The last thing I liked was the student teacher relationship that Mr. Gappa had with all his students. He was serious when he needed to and the students switched modes as well and truly respected him as an authority. Yet at other times he could laugh and joke with the students about how the music that he played was really old. He also reminded me of the High School teacher Mr. Null in the sense that he called all the pretty girls fat and ugly, as to not let them get an ego in his class. All in all, I truly enjoyed observing this class. Their attentiveness to direction and the bond that they had with their teacher was to me very insightful. I will definitely consider using some of his teacher technics in my own classroom someday and hope to go back and observe his classroom someday as well. How to cite Math Observations, Essays

Professional Issues of Nursing Workload †MyAssignmenthelp.com

Question: Discuss about the Professional Issues of Nursing Workload. Answer: Introduction Burnout, medical errors and adverse events innursing practice are some of the major challenges that affect nurses performance and influence their motivation and satisfaction with the nursing job. All the above mentioned issues are mainly caused by the situation of high nursing working load which acts as the main mediator of escalating injuries, poor health outcomes and deterioration in quality of care in health care setting (Koy et al. 2015). This essay provides a detailed insight into the professional issue of nursing workload and explains the negative impact of the issue on the nursing practice. With special emphasis onimpact of the nursing workload issue on individual nurse and the nursing profession, it also explains about useful strategies that can be adapted to minimize the impact of the issue on nursing practice and patient safety. Professional issues of nursing workload: High workload is a critical professional issue in nursing practice. Heavy workload for the nurses is defined by the amount of nursing time, the amount of physical exertion in shift, complexity of care and level of nursing competency (Alghamdi 2016). Increase in any of these factors contributes to high workload and high burden for nurses. In short, nursing workload can be defined as the amount of time spend by nurses in direct or indirect care of patient, workplace and professional development (Alghamdi 2016). The overload experienced by nurses can be categorized into unit level, job level, patient level and situation level. The specialty of nurses and type of practice also determines the level of workload for nurses (Consiglio et al. 2014). The changing health care environment has mainly contributed to heavy workload for nurses. With the increase in ageing population, the demand of nurses in health care system has increased. In addition, inadequate supply of nurses and reduced staffing levels had made it necessary for nurses to work overtime. The above trend in health care practice has influenced nursing workload, quality of care as well as patient safety. Work environment factors and staffing level also determines nurses satisfaction with their job and commitment towards delivering high quality care (Carayon and Gurses 2008). However, many nurses have reported their due to high workload, they have lost motivation in work as it has contributed to high number of errors and patients safety related issues. The complex work environment and the demand to work outside shift have increased the mental workload of nurses too (Caruso 2014). As high nursing workload can have an impact on nurses productivity, satisfaction level, tu rnover rate, work stress and patient safety, it is necessary to find strategies to reduce the workload burden of nurse in care. Significance of the professional issue to nursing: The issue of nursing workload is of significant professional importance for nursing practice because it has direct impact both on the nurses individually as well as the nursing profession. High workload contributes to poor nursing performance, poor satisfaction with the job, burnout issues and high rate of nursing errors. The evidence by Hayes, Douglas and Bonner (2015) has shown that the performance of the nurse is highly affected by the work environment, stress level, work characteristics and job satisfaction. The study also pointed out that even when the work environment is favorable, then also nurses experience high level of burnout. This is mainly because of the complexity of the job and greater level of stress involved in delivering care. The nursing workload is also defined by nurses competency in the job and research has showed that younger nurse experience higher level of stress compared to experienced nurses. The lowest level of job satisfaction and highest level of burnout is mainly found in newly placed nurse as they are not accustomed to handling the complexities of the job (Flinkma and Salanter 2015). As nurses are the one who spend the maximum time in the care of patient, it is very important to respond to the workload issue for nurses. Implementing strategies in the direction of addressing workload and high level of burnout in nurses is likely to increase job satisfaction level and turnover rate of nurses. Association has also been found between nursing workload and the nursing profession. This can be said because the stress level or workload of nurses is also increased by decreased staffing ratio and increase in worse outcome for patients. Link has been found between nurse-staffs ratios and patient outcome. For example, the investigation about staffing level and mortality in patients has revealed that high workload/staffing ratios is associated with increased risk of death in critically ill patients (Shekelle 2013). Hence, the evidence mainly implies that maintaining the nurse staffing level is crucial to manage workload as well as improve patient outcome. Both competency to manage complex situation and promoting positive outcome of patient is an indication of quality nursing practice, however high workload has impact on these areas of the nursing profession. The nursing burnout is highly linked to nurse practice environment and nurse working characteristics. Van Bogaert et al. (2014) has shown that variation in perceived nurse practice work environment and burnout feelings results in adverse patient events and high rate of complains, medication errors and nosocomial infection. The nursing unit team particularly plays a role in quality of care and patient safety and treating sensitive issues of patients. However, there is plenty of evidence to prove the association between poor quality of care and feelings of burnout. For instance, Poghosyan et al. (2010) confirmed that dimension of practice environment determines practice outcome, quality of care variables and patient satisfaction with care. Nursing burnout is a direct consequence of high workload and nursing burning directly influences the quality of care. The explorative study regarding the relationship between the quality of care and nurse burnout among nurses in six countries has rev ealed that nurses experiencing burnout have lesser capability to deliver high quality care and increase in errors results in emotional distress and disengagement in nurses. Complex practice environment and longer shift time predispose nurses to burnout. This implies that nurse burnout and nursing shortage is a challenging issue in nursing practice as this mainly determines the patient safety level and quality of care. To improve the nurse related quality of care, addressing the nurse-patient ratio and work environment of nurse will be necessary (Humphries et al. 2017). Impact of the professional issue on patient safety: As the issue of nursing workload and nursing practice has direct impact on the engagement of nurse and motivation in nursing practice, it will directly affect patient safety too. The main goal of nursing practice is achieve optimal health outcome for patient and maintain patent safety. Patient safety is defined by the reduction in the risk of adverse events for patient starting from diagnosis to treatment in health care setting. To achieve the culture of patient safety, special emphasis is paid on preventing errors, learning from errors and complying with safety protocols throughout the health care delivery process (Weaver et al., 2013). The main role of nurse in patient safety is related to avoiding medication errors and preventing fall in patients. However, the opposite outcome has often been witnessed due to high workload and burnout experience in nurses. The study by MacPhee et al. (2017) gives an insight into the impact of heavy nursing workload on patient outcomes. The cross-sectional study with acute care nurses mainly investigated about the workload factors of staffing level, nurses perception of heavy workload, interruptions in work flow and compromise care standard. The patient outcomes that were evaluated included frequency of medication errors, patient falls and urinary tract infections. The study result gave the indication that heavy workload and task interruptions had a direct impact on patient and nurse outcomes. High patient-RN rations were weakly associated with adverse patient outcomes and heavy workload was independent predictor of adverse patient outcomes. This proves that different levels of nurs ing workload and workload demands have differential effects on patient and patient related outcomes. The chances of patient adverse events increase when the number of patients allocated to single nurse is high. In the situation of insufficient nursing workforce and high workload, the likelihood of medication errors, patients falls, nosocomial infections, death, cardiopulmonary resuscitation failures and pressure sores increases (Cho et al. 2016). The study regarding nurse perception of workload and adverse events showed that nosocomial infection (57.1%) was most frequently experienced by patients followed by pressure sores (45.2%) and medication errors (40%). The nursing workload variable of performance of non-nursing task was mainly associated with high rate of falls and nosocomial infections in patients. Bed to nurse ratio had an impact on incidence of pressure sores in patients (Kan et al. 2016). Parry et al. (2015) also gave the insight that environmental domain of clinical workload and work environment and personal domain of Registered Nurses characteristics and lived experienc e of work had an impact on medication administrative behavior of nurses. Environmental domain was found to increase medication rates in nurses. There is a need to establish the link between the environment and nurses behavior to prevent adverse events and promote patient safety. Strategies to minimize the impact of chosen professional issues on nursing practice and patient safety: As patient related adverse events such as falls and medication is directly caused by high nursing workload, there is a need to identify the strategies that can minimize the impact of the nursing workload on patient safety. Two effective strategies include the following: The first strategy is to enhance the positive practice environment in clinical setting to retain skilful nurse and improve the quality of care. This can be done by addressing the staffing levels and resource adequacy in nursing practice. The workload and work demands needs to be balanced to ensure that appropriate number of nursing staffs are there to handle patients in particular units. This will ensure that nurses work according to role expectation and deliver care in an effective manner without causing any injury or adverse events for patients. As low nurse-patient ration and high work demand often results in burnout in nurses, there is also a need to maintain adequate staffing levels so that all leave requirement for nurses can be fulfilled and they can get breaks or rest in between shift (Twigg and McCullough 2014). This is vital for improving the retention rate as well as improving the patient safety. Medication error is one of the common patient related adverse outcome that is observed in clinical setting due to poor staffing level and high nursing workload. Several distractions and interruptions during the medication administration mainly results in medication errors and poor outcome for patients. The frequency of such errors can be significantly reduced by the creation of safe environment during medication preparation and administration. One of the effective strategies is to put Do not disturb labels during drug administration to minimize disruptions and ensure full concentration of nurses during the procedures. There is also a need to support nurses in the implementation of five rights of medication administration to promote safety of patient (Kim and Bates 2013). Westbrook et al. (2017) proved the effectiveness of Do not interrupt intervention on reducing interruptions during medication administration. It led to the declined in the non-medication related interruptions faced b y nurses and promoted safety of patients. In addition, supportive environment to ensure compliance of nurses to five right of medication administration can reduce the error rates. Conclusion The essay summarized the professional issues of nursing workload on quality of nursing care and patient safety. The review of the impact of the professional issue on nursing practice gives the idea that high workload and poor nursing performance occurs due to low patient-staff ration, high work demand and lack of appropriate work environment to provide care. The strategy of maintain staffing levels and reinforcing the right to safe medication administration is crucial to minimize adverse events in nursing practice and reduce incidence of burnout in nurses. References Alghamdi, M.G., 2016. Nursing workload: a concept analysis.Journal of nursing management,24(4), pp.449-457. Caruso, C.C., 2014. Negative impacts of shiftwork and long work hours.Rehabilitation Nursing,39(1), pp.16-25. Cho, E., Chin, D. L., Kim, S., and Hong, O. 2016. The relationships of nurse staffing level and work environment with patient adverse events.Journal of Nursing Scholarship,48(1), 74-82. Consiglio, C., Borgogni, L., Vecchione, M., and Maslach, C. 2014. Self-efficacy, perceptions of context, and burnout: a multilevel study on nurses.La Medicina del lavoro,105(4), 255-268. Flinkman, M. and Salanter, S., 2015. Early career experiences and perceptionsa qualitative exploration of the turnover of young registered nurses and intention to leave the nursing profession in Finland.Journal of nursing management,23(8), pp.1050-1057. Hayes, B., Douglas, C. and Bonner, A., 2015. Work environment, job satisfaction, stress and burnout among haemodialysis nurses.Journal of nursing management,23(5), pp.588-598. Humphries, N., Morgan, K., Catherine Conry, M., McGowan, Y., Montgomery, A. and McGee, H., 2014. Quality of care and health professional burnout: narrative literature review.International journal of health care quality assurance,27(4), pp.293-307. Kang, J.H., Kim, C.W. and Lee, S.Y., 2016. Nurse-Perceived Patient Adverse Events depend on Nursing Workload.Osong public health and research perspectives,7(1), pp.56-62. Kim, J., and Bates, D. W. 2013. Medication administration errors by nurses: adherence to guidelines.Journal of Clinical Nursing,22(3-4), 590-598. Koy, V., Yunibhand, J., Angsuroch, Y. and Fisher, M.L., 2017. Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: literature review.International Journal of Research in Medical Sciences,3(8), pp.1825-1831. MacPhee, M., Dahinten, V.S. and Havaei, F., 2017. The impact of heavy perceived nurse workloads on patient and nurse outcomes.Administrative Sciences,7(1), p.7. Parry, A.M., Barriball, K.L. and While, A.E., 2015. Factors contributing to Registered Nurse medication administration error: A narrative review.International journal of nursing studies,52(1), pp.403-420. Poghosyan, L., Clarke, S. P., Finlayson, M., and Aiken, L. H. 2010. Nurse burnout and quality of care: Cross?national investigation in six countries.Research in nursing health,33(4), 288-298. Shekelle, P.G., 2013. NursePatient Ratios as a Patient Safety StrategyA Systematic Review.Annals of Internal Medicine,158(5_Part_2), pp.404-409. Twigg, D. and McCullough, K., 2014. Nurse retention: a review of strategies to create and enhance positive practice environments in clinical settings.International journal of nursing studies,51(1), pp.85-92. Van Bogaert, P., Timmermans, O., Weeks, S. M., van Heusden, D., Wouters, K., and Franck, E. 2014. Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse eventsA cross-sectional survey.International journal of nursing studies,51(8), 1123-1134. Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., and Dy, S. M. 2013. Promoting a Culture of Safety as a Patient Safety StrategyA Systematic Review.Annals of internal medicine,158(5_Part_2), 369-374. Westbrook, J.I., Li, L., Hooper, T.D., Raban, M.Z., Middleton, S. and Lehnbom, E.C., 2017. Effectiveness of a Do not interruptbundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.BMJ Qual Saf, Published Online First:23 February 2017.doi:10.1136/bmjqs-2016-006123

Rights of Immigrants and Immigration Policy

Introduction Each year, a great number of new immigrants arrive into the country from all over the world. Some of these immigrants enter the country legally while the others try to get in illegally. On the other hand, there are those who attempt to immigrate into the country illegally through various devious means. At the borders, they are apprehended and forcibly made to return to their country. Despite the challenges that the government faces with regard to the immigrant problem, there are cases when authorities are obligated to accept immigrants.Advertising We will write a custom essay sample on Rights of Immigrants and Immigration Policy specifically for you for only $16.05 $11/page Learn More The rising number of immigrants each year has become a serious debate issue. Some groups support policies that protect the rights of immigrants while others are strongly opposed to the laws that encourage immigrant entrance into the country. According to Sir Mi chael Dummet, the state has several duties towards immigrants. To begin with, the state has to recognize that its primary role is the welfare of its own citizens as well as protection of the others who are in need. Thus the notion that a state’s sole responsibility is only to ensure and care about its citizens’ wellbeing is faulty and misconceived. Dummet supports his supposition. He claims all the citizens have a personal a certain moral obligation to their country as well. The whole population is represented by their state in the world. Consequently, it follows that some country is also morally obliged to consider the welfare of other states and that of other individuals (Huemer, 2010). This paper will explore the obligations that the nation has towards the acceptance of immigrants. Furthermore, the paper will discuss what a morally justified immigration policy includes. The paper will uphold the position to support for the right of immigration. Statement of politici ans’ position The opposition directed towards immigrants and their rights stems from the sense of selfishness among the citizens and politicians of the host country. Both the electors and the politicians alike promote the idea that a nation is only responsible for its citizens without any regard for immigrants coming in from foreign countries. Consequently, the politicians will normally base their arguments on what they think about serving the interests of their country best. For instance, British politicians involved in the European Union deliberations always ground their decisions to support or veto motions on whether it is in the interest of Britain or not. This is contrary to the expectation that they should consider the interests of the European Union to make their decision whether to support the motion or denounce it. Politicians take this position with regard to one crucial reason, which is foreign citizens are of little or no value to their political ambitions. Since the foreign citizens hold no voting power in the country they immigrate into, the politicians deem them insignificant for their campaigns (Dummett, 2001).Advertising Looking for essay on constitutional law? Let's see if we can help you! Get your first paper with 15% OFF Learn More Critique of politicians’ position and my position The concept of ‘sovereignty’ promotes this state of affairs. This concept supports national independence and non-interference by other foreign nations, especially on matters of how it deals with its citizens. Additionally, another argument forwarded in opposition to immigrant rights and policies is that each country has an individual right to regulate the activities on its borders. Consequently, the government can exclude or admit foreigners who wish to pass through the country’s borders. However, those who support free immigration, suppose that countries should not impose any restrictions on immigration. A compariso n is drawn between free immigration and the free market concept. This proposition was strongly supported by Milton Fried Mans as well as Ernest Bevin, who envisioned the total abolition of passports. They argued that free immigration should have been allowed to ensure that basic human right which is the right for freedom – particularly freedom of movement would be enjoyed by all humans. Therefore, in the spirit of promoting human rights, no country would have the right to deny any individual entry into a country of his/her choice. Pope John XXIII also supported free immigration policies that excluded no individual from entering into any country. According to Pope John XXIII, all humans are members of a universal family and a greater world society. This existence, according to the Pope, is inherent and cannot be curtailed by any country. Additionally, Pope John XXIII endorsed the fact that immigrants deserved to have their rights recognized and respected. They should enjoy eco nomic rights and personal rights to ensure that they are able to comfortably adapt to a new society. Furthermore, it allows them to obtain a means of self sustenance. There are several reasons as to why the sanctions and restrictions are imposed on immigrants. However, these do not suffice as an excuse in denying those people their right. To begin with, some believe that restricting the number of immigrants entering into the country would protect the national heritage and culture. Additionally, it is claimed that accepting immigrants will increase the economic hardships he state faces as this would impose constrain on the scarce resources of the country. It is, therefore, argued that these restrictions are in the interests of the country’s native citizens (Dummett, 2001). From my perspective, the rights of immigrants should be upheld and protected. There are several reasons as to why immigration restriction is not a favorable option. To begin with, restricting immigrants from entering a country is a direct violation of their inherent rights. The most common reason for instituting these regulations is to protect and ensure the security of the native citizens.Advertising We will write a custom essay sample on Rights of Immigrants and Immigration Policy specifically for you for only $16.05 $11/page Learn More In most cases, terrorism has been cited as the main security concern that necessitates immigrant regulation. However, terrorist activities are perpetrated even by the citizens of the country. Additionally, not all immigrates are willing to enter the country to commit a terrorist act. Therefore, this cannot be used as a basis for such limitations. The other reason that has been widely cited is the effect of immigration on employment. Most native citizens feel that the higher the number of immigrants in a country the higher the competition on the existing jobs. This ultimately leads to a decrease in the quality of life of t he native citizens. Since the immigrants are normally desperate for finding jobs they tend to accept low salaries. Employees prefer such workers as the business would incur less operational costs. However this comes at the expense of the native citizens losing their jobs. However, this is not an acceptable reason since it is the duty of the government to regulate and state the base salary within its territory. Furthermore, the jobs are meant to be acquired based on merit and the individual’s qualification. A morally acceptable immigration policy is the one that meets both the interests of the citizens of the country and those of the immigrants. Such a policy is difficult to be developed and implemented as there are various challenges. The situation regarding the issue may be compared to a limited capacity lifeboat (Hardin 2001) since a country cannot take in all the immigrants. References Dummett, M. A. E. (2001). On Immigration and Refugees. New York: Routledge. Hardin, G. ( 2001). Living on a Lifeboat. The Social Contract. 36-47. Retrieved from http://www.garretthardinsociety.org/articles_pdf/living_on_a_lifeboat.pdf Huemer M (2010). Is there a Right to Immigrate? Social Theory and Practice. 36(3), 429-461. DOI: 10.5840/soctheorpract201036323.Advertising Looking for essay on constitutional law? Let's see if we can help you! Get your first paper with 15% OFF Learn More This essay on Rights of Immigrants and Immigration Policy was written and submitted by user Kingston I. to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Linguistics and Children Essay Example

Linguistics and Children Essay Example Linguistics and Children Essay Linguistics and Children Essay This assignment will foremost explicate the significance of the undermentioned footings. communicative competency and metalinguistic consciousness. Observations have shown that kids do copy older equals and grownups when speech production every bit good as marks of creativeness from an early age when developing linguistic communication. Then the 2nd subdivision will measure the functions of creativeness and imitation in respects to larning spoken English. This assignment will concentrate on the spoken English of immature kids. Part 1 Communicative competency – Is a term that refers to the manner in which a linguistic communication user communicates expeditiously and successfully depends upon their communicative competency. Linguist Noam Chomsky depicted a fluctuation within the term linguistic’ which he divided into to competence and public presentation. The term lingual public presentation is associated with falsely and/or repeated ill-formed delivered existent vocalizations of linguistic communication in usage. Linguistic competency refers to the cognition of the linguistic communication system which will enable the talker to separate the vocalizations that are grammatical in the linguistic communication from those that are non. ( Chomsky. 1965 cited in Book3. pg 48 ) However linguist Hymes believed talkers need to achieve typical accomplishments in public presentation such as what is the socially appropriate bend of phrase to carry through the coveted consequence every bit good as cognizing when to talk. With respects to kids every bit good as larning the building and sounds of peculiar linguistic communications they are really larning the discourse processs of their communities. The term besides incorporates word significance. grammar and pronunciations good as using linguistic communication competently. verbally. written and non- verbal cues such as organic structure linguistic communication. ( Book3. pg 201 ) Metalinguistic consciousness – Is a term used to specify an individual’s ability to reflect on the usage of linguistic communication in with respects to clear uping the transportation of lingual accomplishments and cognition across linguistic communications. When a linguistic communication user’s metalinguistic consciousness develops they start to make new and refined usage of metaphors such as the simile life is like a box of cocoas. you neer know what you’re traveling to get they besides begin to gain that statements can hold an implied significance every bit good as a factual significance. They may even get down to place irony along with perversity which connects with an individual’s capableness of stating and /or understanding gags. pull stringsing linguistic communication ( Kerper. 2009 ) Separate 2 Children can get linguistic communication as a consequence of imitation nevertheless it isn’t the initial method into linguistic communication acquisition due to kids showing originative pattern of linguistic communication. ( Book 3. pg 27 ) Infants produce a assortment of sounds during the initial twelvemonth of their life in add-on to experimenting with vocal drama. ( Book 3. pg 8 ) The rate of development differs between each kid. for illustration it is rare for a kid to jump the babble phase. which normally occurs at the mean age of 11months. and another factor that assists address development is physiological ripening. ( Book 3. pg9 ) Benedict. 1979 cited in Book 3. pg19 researched development of vocabulary of a little group of kids ( 8 ) during the class of six months. The findings demonstrated children’s ability to understand and make words between the ages of 10 months and on norm 1 twelvemonth 9 months. By the clip the kid is 11 months and 15 yearss they are normally attain a comprehension vocabulary of 20 words. The procedure of achieving words in production takes longer than it does in comprehension. comprehension can normally happen 4 months before production. With respects to imitation’ the function of the health professional ( a term used for those persons who spend the most clip interacting with and looking after the child. ) ( Book 3. pg 11 ) much research has been done in this country whereby the accent is on a brace in this instance it involves the kid and their chief health professional. this is besides known as a term called a couple. The findings from this research revealed that the individual the kid has most direct contact with impart the linguistic communication surroundings that the kid will pattern. Other lingual modeling that grownups provide is through caregiving agendas. for cases bathing and feeding. these modus operandis provide occasions for conventional interactions refering linguistic communication. Peek a boo’ A customary game that is normally played between baby and health professional and by and large in Western civilizations. ( Book 3. pg14 ) As a regulation the grownup efforts to hold on the infant’s involvement the hiding their eyes behind a manus or an object after which a type of discourse occurs. for illustration the grownup might state Are you ready? Then the infant’s voices or actions are indicated as a response. This sequence of inquiry –and – answer is continued until the apprehensiveness develops at this point the grownup takes their manus off or removes the object and says Boo! ’ ( Book 3. pg 15 ) Trevarthen and Aitken. 2001 cited in Book 3. pg 15 believed this sort of game could be termed protoconversations’ . because it is similar to a conversation. It requires turn – taking. each person’s bend relies on the old is input of the spouse. therefore it is contingent. the spouses understand the sequence unwrap the same purpose. Therefore this sort of interaction novices ceremonial characteristics of conversations before immature kids are able to talk but prompt transition to linguistic communication. A cosmopolitan observation made sing the type of duologue directed to kids by grownups is that the duologue differs to that addressed to other grownups. Consequently health professionals amend their duologue for case bringing slowed down. modulation is amplified and an elevated pitch may be used. Older kids besides adapt their duologue for younger kids comparable to adults. this is besides apparent that older kids are emulating grownups and implementing this technique to immature kids. ( Book 3. pg15 ) this duologue manner is referred to as kid directed address ( CDS ) . Clifton Pye. 1986 cited in Book 3. pg 16 observed a community in Central America called Quiche. they spoken one of the native Mayan linguistic communications. The consequences showed a difference in the manner in which Quiche health professionals and Western health professionals adapt their duologue for immature kids. Regardless of this cultural difference in health professional – kid interaction. the kids in the Quiche community were able to talk fluently in their native linguistic communication. Shirley Brice Heath’s research 1983 cited in Book 3. pg 16 of black propertyless English speech production community discovered that grownups in this community didn’t normally use baby talk’ when interacting with immature kids. The ways in which children’s grammar develop could besides be due to imitation every bit good. Descriptive grammar is a term mentioning to how kids organise and construction address. it doesn’t nexus to the right English’ people should utilize. Probes into children’s grammar showed that a changeless process is involved in the attainment of grammar. Crystal. 1995. cited in Book 3. pg 25 acknowledged seven phases runing from formative old ages to adolescent. In the early phases of grammatical development kids apply brief vocalizations of two to three words without any grammatical markers ; kids are normally aged between 18 months to 2 old ages. In the following phase of normally 3 old ages kids start to add markers to words such as tense ( I played ) . plural ( one cat. two cats ) . The 2nd phase within Crystal’s paradigm is a term called telegraphic address during this phase. kids do non utilize grammatical markers alternatively they use verbs. temporal adverbs. adjectives and nouns. The important information is evident because the inside informations and fixingss are removed ; this telegraphic quality is stated in children’s imitation of adult’s address. Besides during the 2nd phase it has been noted that children’s address will probably to be: a more H2O ; baby drink ; allgone sticky. However in this case it is improbable that kids will hold heard grownups make these types of vocalizations which means they can be depicted as alone vocalizations. and since the significance will be comprehendible. this vocalization can besides be viewed as a success. This all goes to exemplify that even at the first phases of linguistic communication development kids are showcasing their creativeness. Most grownups particularly parents have heard their child/ran emulate them utilizing big look and even modulation. With respects to creativeness and linguistic communication development. legion researches from the theories L. S. Vygotsky ( 1967 ) and Jean Piaget ( 1962 ) cited in Gillen. 2009 has found that there is a significant nexus between drama and linguistic communication acquisition. Play encourages children’s inventive idea procedure through playing with objects that will so finally lead to a better apprehension of their environment. As the child’s ability to make more meaningful representations develop so does the more complex their drama becomes. Bloom. 1993. p. 216 cited in Gillen. 2009. p 56. Observed that a spurt’ in first words was normally due to development in drama behaviors. From observations kids unconsciously obtain regulations about real-life behavior. and implement what they have observed into their drama with a mixture of their ain imaginativeness. When kids are involved in pretension games with other kids it is called sociodramatic drama. within this type of drama it is suggested that kids pattern different registries of talk that they observe to suit in with that function. To reason it seems as though the interactions typically viewed of health professionals and babies are non indispensable and general characteristic initial linguistic communication experience. There was a discrepancy in comprehension and creative activity of vocabulary. Evidence derived from research of linguistic communication acquisition is normally carried out from a limited aggregation of cultural and societal backgrounds so the findings of crude grammatical development in English are from linguistic communication users of the normal standard of the linguistic communication. The subdivision sing drama and linguistic communication development suggests that creativeness and imitation interlock. it appears that both coincide together it appears both weigh equally in footings of organizing spoken English. References Gillen. J. . ( 2009 ) Block C. Learning English. Unit 17 The relationship between drama and linguistic communication acquisition. The Open University Kerper. M. . J. Metalinguistic consciousness as defined through research’ San Diego State University 2009-08-10 Mayor. B. . Mercer. N. and Swann. J. ( explosive detection systems ) Learning English. London. Routledge/The Open University.

Unit 5 Discussion Board Essay Example | Topics and Well Written Essays - 500 words

Unit 5 Discussion Board - Essay Example : Public policy students have identified five dimensions of the policy process in U.S, healthcare: (1) the relationship of government to the Private sector; (2) the distribution of authority within the federal system; (3) pluralistic ideology as the basis of politics; (4) the relationship between policy formulation and administrative implementation; and (5) incrementalism as a strategy of reform. Answer: There are several components that comprise medical ethics of which three are considered cardinal: (1) autonomy (the concern with privacy; individual liberty, freedom of choice, and self-control); beneficence (for example, doing no harm, promoting the welfare of others, and doing good); and (3) justice (for example, equality of opportunity, equity, and access, as well as equity of benefits). Answer: The following attributes are desirable in clinical practice guidelines: (1) the purpose should be clearly expressed; (2) the content should be frequently reviewed and updated; (3) they should be flexible enough to account for the nuances of clinical medicine; (4) they should be easy to follow; (5) they should be applicable across geography and settings; and (6) they should be demonstrably linked to positive patient outcomes In a review of 585 hospitals in Great Britain in 1983, Donovon highlighting lack of pain assessments as healthcare professionals had not even enquired about patients’ pain. (Dr. Schofield. P., 2003). Pain relief today is viewed as a fundamental human right; in a landmark case in the United States, the court ruled $15 million in favour of the relatives of a man with prostrate cancer, who reportedly died in pain. The medical professional should understand these sensitivities while managing pain in a multi-ethnic populace. The definition and reactions to pain are often affected by cultural background of patients (Needham.J, 2004). While nurses may not be deliberately opting to providing lowered care to any group, understanding ethnic biological

FedEx corporation and Bowmans strategy clock Assignment

FedEx corporation and Bowmans strategy clock - Assignment Example (Bowman Strategy Clock, 2009) FedEx caters to global customers and business houses with a wide range of application, business packages as well as e-commerce services. It occupies the most trusted employer’s position in the world, supporting above 275000 human resources and contractors and maintaining immense professional benchmarks and customers’ requirements on regular basis (FedEx, 2011). Taking up the case of FedEx can serve as a case of analysis for the paper and the issues taken up for study cover the strategies of the company and an evaluation of the current and future position of the same. Bowman’s strategic clock and its success factors According to the Bowman’s strategic clock, there are six core strategic options (overall eight options) if properly represented, resemble the pattern of a clock hence named ‘the strategic clock’. According to Bowman, the first strategic option is low added value, which is likely to be specified by segme nts. The second strategic option is the low price of the products that helps in reducing the risks associated with price war and that with low margins. The third strategic option is hybrid that considers a base of low cost, availability of the options of reinvestment in low priced products and differentiation. The fourth strategic option is differentiation of products that can again be subdivided into two separate categories. The first category consists of those without a price premium that helps in yielding benefits from the market share through the process of value addition as perceived by the users. The second category is with the system of price premium that contains within itself sufficient added values as perceived so as to bear the price premium. The fifth strategy is called focused differentiation that... The FedEx, the biggest delivery company of the United States of America followed the strategy options prescribed by Bowman to gain sustainability through the achievement of competitive advantages over the other firms of the industry. The criterion of suitability is use to access the extent of the fitting of a proposed strategy and its contribution to the improvement of the competitive position of the firm and its sustainability. Feasibility of any strategy is the assessment of the successful implementation of a particular strategy. Acceptability on the other hand relates strongly to the people’s expectation about a particular strategy option taken by the firm. (Evaluation Criteria, n.d) The unique operating strategies undertaken by FedEx are the collective competition that enables each and every sub segment of the company to use the brand name for the marketing of their products. The second strategy is the independent operation of the firms under the company that focuses on me eting the distinct needs of the customers and handles them separately with proper individual care. The third strategy is the management of the firm collaboratively that is to work together under the loyalty of the workforce the customers and the investors of the company. All these strategies valued the people in promoting diversity, the service with full positive spirit, the innovation and the integrity of the organization increasing efficiency, reliability, and honesty.

'Common stock valuation' Essay Example | Topics and Well Written Essays - 500 words

'Common stock valuation' - Essay Example The dividend yielded from a particular common stock is not predetermined and is variable as compared to the fixed dividend offered in the case of preferred shares. The identification of the common stock’s value becomes quite difficult as the dividend rate is not already known and is always fluctuating. The basic principle applied while stock’s value is determined is that the current value of the stock is supposed to be its present value of all upcoming cash flows that is owed by the person who has invested in the stock. In simpler terms this means that an investor’s return depends on what price he is paying for a stock. The current price of a stock can be identified through discounted value of future cash flows by applying the principle of time value of money (Moyer, 2012). This value of the stock is recognized as the stocks intrinsic value as this value is obtained from different information available about the stock. This value is not the exact value of the sto ck, but this value is near to the stocks actual value and reflects the current position of the stock. The above formula states that Po is the current price of the share and D1 is the dividend for that particular stock which is offered for the first time and the same dividend will be offered throughout and r is used to represent the common stock’s required return rate (Mayo, 2007). If a particular stock’s dividend is not constant and keeps on changing then the current value of the stock is its present value of any growing cash flows. Formula: Do is used to indicate the dividend that is offered this time, if the dividend of that particular stock keeps on growing at a continuous rate, then the current common stock’s value is value that all future dividends will have (Chisholm, 2009). The constant rate of growth of stocks is represented by â€Å"g†. This model is referred as DVM or dividend

E-tailoring Online: Customer Views and Impacts on Services

E-tailoring Online: Customer Views and Impacts on Services Abstract An increasing number of customers are turning to the Internet to make their purchases, as a vast array of goods and services are now only a mouse click away. E-tailing clothes is even more challenging, with new e-tailers hoping to attract and retain satisfied online customers, are constantly creating new opportunities for them, and in order to do that they need to know what evaluative criteria customers use when selecting an e-tailer as well as what they will purchase online. Past research has provided some insight into what characteristics customers assess whilst making this choice. This report has not been without its limitations. Consequently, the present study utilizes a literature review, qualitative and quantitative research to identify the core customer behavior towards this channel, In addition, results of the analysis show that the type of product on offer and the web attributes (determinants) are predictors of customers attitude toward online shopping for clothing and their perception hence, providing an understanding of how they are responding to the new online buying opportunities. 1. Introduction This research report is divided into 5 Chapters. Chapter 1 is meant to introduce the background of the research area with aims and objectives and focus of the study providing guidelines into subsequent chapters. This then will be followed with Chapter 2 having literature review of the matter giving an insight of the research area that will be referred, compared with the data collection and analysis will be made in Chapter 4. However, Chapter 3 will be discussed prior to the actual data collection as it is necessary to identify Research Methodology to be used for the research. Finally, Chapter 5 will have conclusions and recommendations with any limitations faced and with the mention of area for further research if any. The expansion in electronic commerce (E-commerce) has been phenomenal, with most of todays business transactions being conducted through the Internet. The emergence of this electronic retail (E-tail) market has been extraordinary. E-tailing is also a gaining popularity and changing the retail landscape, it is pervasive in what we thought of it six months ago is probably different to what we think of it today and also what we will think of it in six months time. Customers decision making process has also altered greatly with the introduction of this medium and more so as an alternative channel for shopping. Online shopping concept has already caused a stir in the retail industry in the UK, as more people are opting to buy online due to various reasons, a vast array of goods and services are increasingly being made available now through a click of the mouse, creating a new experience and culture. Many retailers are already delivering high value, personalised products and services at a fraction of the cost thereby making it more low cost and also appealing to the consumers (Birch et al, 2000). The number of consumers shopping online has increased markedly, according to Jardine (1999) people have increasingly become price sensitive and often compare prices of goods both online and offline before making the final purchase, in turn increasing competition amongst the retailers. This is the general overview of the e-tailing concept, as understood b y most of us. However, the purpose of this study is to concentrate on the online clothing market in the UK specifically London, in order to determine predictors of customers purchase intentions for clothing products via this channel. E-tailing of clothing items online has always been debatable, especially since clothing are â€Å"feel-and-touch† products, and cannot be bought without engaging this sensory aspect, unlike other cognitive products like books, computer software, dvds and music which do not really require this. Nevertheless, customers tend to buy more clothing products when they perceive the features of the online store, such as a convenience and secure system of ordering and payment, returns policy, the focus on product display, and the offering of products that have a range of acceptable fits as opposed to a precise fit and most of all choice this are some of the most general attributes a customer considers whilst shopping online for clothes. The attributes that enhance the online experience can be particularly influential for products such as clothing, which generally require physical interaction and evaluation prior to purchase. Web experience attributes can affect early decision making stages (search and pre-purchase evaluation) and influence purchase intent of the customer. With the current fragmented nature of the subject area and to keep up with the rapidly developing technology as well the customer attitudes, the author aims to build on the current body of knowledge, investigating and drawing together the key aspects which influence online shopping for clothes, so as to understand how the customers are responding to the new buying opportunities presented to them by the e-tailers in UK then concentrating on London where the survey was conducted by collecting data from a sample of participants, which aided in exploring the capabilities and further to determine consumer behaviour and customer relationship management p atterns in relation to E-tailing, thus the research objectives being set as: 1. To explore the impact of e-tailing in London. 2. To determine customers attitude towards shopping online. 3. To investigate customers perception of shopping online for clothing in London. In order to achieve the results of the set objectives, the author has explored the determinants the customers consider most important when making a purchase online and to what extent they create an impact on their perceptions. The first hand elements collated from the survey has helped to gain rich insights into customers behaviour and attitudes towards this channel. The secondary data which is covered in the second chapter under the literature review the author here has studied and explained the general E-tailing concept and picked relevant data to help understand the subject matter and provide a better insight into the field of e-commerce, covering a wider area (UK), then narrowing it down to specific location (London) which in turn has helped to achieve the set objectives and later also support the resultant findings in terms of the primary data collected via the survey by the author. 2. Literature Review Xing (2001) stresses that â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business†. 2.1 The Commercialisation of the Internet The Internet, once a tax-sustained and a government-regulated endeavour, is no longer restricted to non-commercial traffic. The early commercialisation of the Internet, in the mid 1990s gave rise to the e-commerce phenomenon. The Internet population has since grown tremendously, as a result of its opening to the commercial traffic in 1991. Its utilisation has since become remarkably more wide and varied in businesses; the application of internet has grown rapidly over the last several years, due to its contribution of the ever evolving new information technology and its positive gains to the business organisations. Its use apart from being internal its also employed externally and its used more commonly referred to as E-business (electronic business) derived from such terms as e-mail and e-commerce, which is the conduct of business on the Internet, not only buying and selling but also servicing customers and collaborating with business partners. IBM was one of the first organisations to use the term E-business (electronic business) when, in October 1997, it launched a thematic campaign built around the term. Today, major corporations have reconsidered their businesses in terms of the Internet and its new culture and capabilities. Companies are utilising the Web to buy parts and supplies from other companies, to collaborate on sales promotions, and to do joint research, exploiting the convenience, availability, and world-wide reach of the Internet, using it successfully. 2.2 The E-tailing Concept â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business† says Xing (2001). It was seen as a new channel for sale of products and services along with the traditional channels as well as a market penetration strategy for others. E-tail or E-retail the term, came into discussions or rather its origins as early as 1995, its an addition in the computing subject such as, e-mail, e-business and e-commerce. The business of e-retail has been defined as the sale of goods and services via internet or other electronic channels, for personal or household use by consumers (Harris and Dennis, 2002). Its more efficiently used as a marketing tool, which is integrated into traditional business strategies, and also being viewed as a new marketplace by existing businesses as well as new business ventures as the market place becomes more competitive and unpredictable, due to this, the growth of the electronic retail market has been rapid, significantly expanding reach in terms of people, location and range being variety of information, the World Wide Web has created benefits for both the marketers as well the consumers. For consumers, the Web can provide access to a wide range of products and services with low cost (Bakos, 1997), extensive and tailored information, at home convenience for product comparisons, enhanced interactivity (Cross and Smith, 1995), hence facilitating the formation of virtual communities for users with common interests. E-tailing and E-trading operates in all four of the major market segments; business to business, business to consumer, consumer to consumer and consumer to business. Initially, much direct selling (or e-tailing) was taking place on the internet of computer-related equipment and software, one of the first to report successful sales in the millions of dollars directly from the Web was Dell Computer, there after other businesses started employing the concept in various fields from; Travel bookings, Holidays, Books, Clothing and other accessories, this has particularly grown in the Business to Consumer market segment directly or indirectly as a result of the wide usage of the internet. The Internets greatest commercial advantage is said to be the reduction in transaction cost that directly lowers the prices for consumer (Pavitt, 1997), and therefore E-tailing is said to be a low-cost, efficient way to display merchandise, attract customers, and handle purchase orders (Bellman, 2001). 2.3 Online shopping in the UK Home shopping in various forms has been available to the consumer market for more than 100 years in the UK, paper catalogue being the first and the oldest form illustrated with Victorian ladies and do-it-yourself house kits a lot has changed since, in terms of improvements and choice, then came the emergence of home shopping television, however none has had the influence or the expected impact of shopping, as much as the World Wide Web. E-commerce has grown steadily in the UK since the early 1990s. According to Exley (2006, cited in Haymarket, 2006) consumers have become comfortable shopping on the internet and e-tailing is clearly a part of retails future. He adds that e-tail does not have to replace traditional bricks and mortar stores, â€Å"all retailers need to do is to provide a good in-store experience† (Exley, 2006, cited in Haymarket, 2006). â€Å"Since 2000, Internet shopping has soared by over 5,000% with UK consumers spending an astounding  £200 billion during this period. Internet shopping is clearly the bright spot in the UK retail sector, but this industry is still young and has potential for further growth.† (Tina Spooner, director of information, Interactive Media in Retail Group (IMRG), cited in press release, May 2009). No doubt, online shopping is rising steadily in the UK (from a consumers perspective) as internet access has become cheaper, high street cyber cafà ©s are increasing and Internet service providers (ISPs) have already eliminated subscription fees (Daniel, 2000). Furthermore as technology is set to get even more advanced, hand-held devices have become internet-enabled and nowadays most mobile phones connect to the web (Daniel, 2000). With all the above possible ways of shopping more customers are getting accustomed to the online shopping experience and utilising the new channel. This exc eptional growth of Internet shopping is also driven by greater emphasis on customers efficient use of time, as well as the ever increasing number of computer trained customers, hence giving it a positive outlook and a further opportunity for growth to the existing and perspective e-tailers. A wide range of products and services are available for the customers in the UK to buy online from a variety of retailers, which also gives them a better choice, so why would they go buy anywhere else? Although one reason may be convenience, sadly another is fraud; fraud poses the biggest threat to online shopping (Economist, 2004) but according to Pavitt (1997) consumers fear of shopping online is already resolved by the use of encryption technology. Moreover, the security systems are rapidly improving by the day, further dispelling the notion which is perceived by a majority of people worldwide that online shopping is a risky business. For example, secure digital systems such as encryption tools, digital signatures and the guarantee about security or privacy concern provided by the e-tailers have reduced security inhibitors and thus have increased consumers willingness to visit or purchase from sites (Ah-Wong et al., 2001; Han and Maclaurin, 2002). UK is the second largest e-taling market in Europe like Germany, it combines a large consumer market with internet penetration above the European average (Datamonitor, 2002). There are six leading online shopping companies that dominate the UK e-tailing market. These are; streetsonline.co.uk, Jungle.com, Amazon.com, Lastminute.com, Thomascook.com and Egg.com, all these providing a variety of products and services. What is the future of high street stores when most analysts agree that in five years time, online shopping could be worth  £200billion? This does represent some form of concern to high street stores in the UK as a percentage or it could be of the sales they lose. Nevertheless according to Brewer (2006); cited in Haymarket (2007) the future is brightest for those high street stores that could adopt a multi-channel strategy. However, Murphy (2006); cited in Haymarket (2007) says that â€Å"we have the most vibrant, competitive high street in the world and high street shopping is one of our biggest leisure pursuits. Can high street shopping be our biggest leisure pursuits since they boast to sell a variety of diverse products in-store? It is the refore inconceivable that the future of retail would be solely online†, although the number of customers making purchases online is also on the rise in the UK as mentioned earlier in this report. 2.4 The extent to which e-tailing builds relationships The impact of e-tailing will be felt differently and at different times by various retailers. In the context of buyer behaviour preferences (Daniel, 2000) says that e-tail is a transactional-sales medium rather than a relationship-building medium which means that e-tail cannot substitute personal contact such as customer service advisors, that makes it the most critical differentiation aspect to high street stores today. This emphasises the need further research on the customers perception of e-tail, i.e. to what extent does e-tailing build relationships? If empirical research suggests that e-tailing is a transactional sales medium then ultimately there may be an opportunity for e-tail to focus building relationships with customers that will create the need for further research on how e-tail may be able to become a relationship-building medium. Personal contact with highly trained and motivated salespeople, the service factor is still the critical differentiator for such businesses, and on-line experiences have yet to match that or offer a suitable counter value (Quelch, 1999 cited in Maruca, 1999). As Pavitt (1997) states that the impact of e-tail on high street stores may result in changes on three key fronts; â€Å"change in the nature of product offerings, customer buying patterns and its place in the value chain†. The changes in product offering may alter as a result of advances in digital technology. For example media products delivered via the internet or newspapers being published electronically, that would be a direct impact on high street stores (Pavitt, 1997). There is lack of empirical evidence to show what customers perceive of digital medium against physical goods, as an simple example, would customers prefer buying a DVD from a high street store, so as to get a feel of the physical aspect of this product as well as more information from the back cover of the DVD case, or from the Internet where information on the product is limited in two dimensional form. â€Å"There will be a great deal of change in the value chain as well due to shrinkage in distribution channels†, (Bellman, 2001). E-tailing eliminates traditional chain of wholesalers, agents, and other intermediaries thus creating a new distribution model focusing on manufacturer to consumer direct that implies a great potential for savings (Bellman, 2001). Today, majority of the manufacturers do not want to take the responsibility of dealing with single customer queries, which is one reason why they sell their products through intermediaries even on the Internet. With lack of evidence it still remains to be investigated as to what extent is the internet an intermediary? Another common question which arises in this case is; do e-businesses have any storage for products they advertise or do they order them directly from the manufactures or other traders as required? However, this can also be different in the case of businesses which use internet as a secondary channel for sell or distribution of their products, which they also sell in their physical store. Another issue that arises is to investigate potential shoppers perception in relation to price. Smith et als (1999); cited in Lii and Lee (2005) indicated that online shoppers believe that online stores enjoy a cost advantage over traditional channels in terms of administrative cost, overheads and transaction cost. These features of the online retail channel add to the perception of online shoppers that prices generally tend to be much lower online than that of the high street stores. Considering this then, do customers shop online because they perceive it to be cheaper? If so then how and in what w ays is online shopping cheaper compared to the high street stores where lots of products are reduced at competitive prices even at times with offers such as buy one get on free or a second product at half price, are always there. Is price an issue of concern or is it about building relationships? Would customers be willing to pay that extra price in exchange for good service, remains to be investigated? Good service may be classed by online shoppers such as providing a tracking system for their ordered goods, free return policy and delivery of the goods or a full money back guarantee on items that customers return which is in place with most e-businesses today. With regards to customers online shopping behaviour, Brown (2000) states that a survey by BT found out that consumers choose well-known brands when shopping online and those consumers want to be served immediately, be remembered and treated as individuals. Therefore, in what ways can e-businesses build relationships? According to Kalyanarm and Winer, (1995); Chandrashekaran, (2001); cited in Lii and Lee (2005) prior studies have revealed that in the off line retail channels, customers may use the advertised original price as a frame for reference to assess the accompanying sale price. The resulting price comparison between the original price and the sale price makes the price promotion more appealing (Biswas and Blair, 1991; Grewal et al, 1996; cited in Lii and Lee, 2005). On the other hand on line retailing enables potential customers to have quick and easy access to price and other product attributes and information necessary for price evaluations. An example is amazon.co.uk websit e. The Internet has empowered on line shoppers to better detect price discrepancies and bargains (Balasubramanian, 1997; Bakos, 1997; Hoffman and Novak, 1997; cited in Lii and Lee, 2005). Today Majority of e-tailers attract customers through promotion codes normally available through advertisement and marketing media from which customers, can usually claim some money off or some percentage of discount on their online shopping. What remains to be assessed is whether the promotional codes attract new customers and also retain existing customers to shop online? If e-tailers start providing regular promotion codes to new customers as well as regular customers with this, then will it add up to building a relationship? 2.5 Customers general online shopping preferences in the UK On the basis of the objectives of this research, its crucial to investigate customers e-tail shopping preferences in the UK in general first, since ultimately perception leads to action. â€Å"When consumers are confronted by new forms of retail channels such as on line shopping, they may decide whether the difference between the on line shopping and off line shopping is significant to them. If the difference is perceived to be insignificant, customers may classify the two retail channels as the same. On the other hand, if the differences are perceived as significant, customers may classify the two shopping channels as different and make their purchase decision differently† (Lii and Lee, 2005). â€Å"Perception involves the process of categorization, and people tend to place new experiences into existing classifications of familiar experiences† (Monroe, 1990; cited in Lii and Lee, 2005). Late night shopping in the UK is fast becoming a way of life and a new culture, since for many people 24-hour high street shopping is invaluable as it allows them to fit it around their lifestyles, this is very common in the larger cities like London where this sort of service fits in well with the metropolitan lifestyle whereby time is crucial, however having said that, its also being almost equally favoured by people living in smaller towns or suburbs. The changes occurring in buyer behaviour patterns are alarming to high street retail stores as more and more people are beginning to work partly or wholly from home and they may prefer their goods bought online to be delivered at home, this is also rapidly picking up for supermarkets where the consumers prefer their grocery as well as other items shopped on line to be delivered at their doorstep (Haymarket, 2006). Whatever may be the case, Cottam (2006, cited in Haymarket, 2006) says that high street retailing is facing stiff competition with on line ‘anytime culture, meaning that customers are shopping 24/7 and therefore even high streets supermarkets such as Asda and Tesco have also launched 24-hour stores. Customers perceptions about 24/7 shopping remain to be investigated, since some high street supermarkets that tend to provide 24/7 services are closed on Sunday afternoons due to Sunday trading laws, but this has also changed in recent years. Once more it raises the question, what are customers perception of 24/7 culture in relation to the internet and high street stores, a fair example to portray, the 24/7 concept proved to be costly, in comparison to profitability against cost, for a superstore like Sainsburys as Sainsbury failed in its attempt, even though it believed it had the winning formula (Haymarket, 2006). The reason behind the failure was that Sainsburys could not attract enough customers as there is no guarantee that a fair percentage of existing or new customers will change their habits to take advantage of 24-hour shopping (Haymarket, 2006). Indeed this is a lesson for others (organisational learning) and thus most retailers are being cautious in their approach to 24/7 services. Bearing this in mind customers are constantly taking advantage of such facility and are trying or even getting used to shopping around the clock says Gladding (2006, cited in Haymarket, 2006). Analysts argue that 24-hour retailing is less likely to grow beyond its current levels as retailers have raised little awareness of the fact, hence stores such as Asda and IKEA are being cautious about this approach by advertising their long opening hours in the form of outside signage and flyers (Haymarket, 2006). The key question that arises from this scenario is the customers perception of the availability of 24/7 online shopping versus the high street 24/7 timings. Do customers really want go to shopping at high street stores and supermarkets at night (freely) compared to doing online shopping at night? Security is another issue that could be a vital sign of failure for high street stores or supermarkets to remain open 24/7 and be able to achieve their budget. Depending on the type of product, Andrew and Currim,(2004) have highlighted some key characteristics of customers shopping on line, despite the additional aspects. They say that consumers shopping online for products such as groceries differ from those who shop in high street stores claiming that on line grocery shoppers tend to be more frequent, heavy shoppers, less price sensitive, prefer larger sizes and do more screening on the basis of brand names. Alternatively, Morganosky and Cude ,(2000) suggest that convenience is the main motivation for on line shoppers, and according to Keh and Shieh,(2001) on line shopping is ideal for time-starved customers such as couples with two careers, children, and above-average income who want to spend time with their families instead. These suggestions are valid and can be applied to the reasons for consumers behaviour towards shopping online, however it also differs to the type of market and the products on offer. Hence, for those people, conven ience is more of a priority than price stresses, Keh and Shieh, (2001). Also Professionals, working women and single independent hard working individuals are just some of the people who do not have time on their hands and their perceptions of online shopping especially for items such as grocery remains to be determined. Keh Shieh, (2001) simply claim, with being deficient in practical evidence, that such customers dislike grocery shopping and only those with busy schedules will consider on line purchasing as a viable option. Online shopping may save time and money as the frustration of dealing with children at a store or supermarket that involves pushing carts up and down the aisles, waiting in long lines at checkout counters, and finding parking spaces, could be eliminated, Keh Shieh,(2001).Whilst on the other hand, as more people today having the opportunity to â€Å"surf† from their offices, they are more likely to shop during office hours and thus may prefer to collect their online shopping at ‘convenient stores on their way back home (Pavitt, 1997). Vaughan (1999); cited in Jardine (1999) head of consulting at Retail Intelligence says that â€Å"consumers might do their main shopping on the internet once a week but will still need to stock up on fresh foods locally† and this is the alternative method that supermarkets have taken by opening ‘convenience stores such as Tesco Express, Sainsburys Local, and MS Simply Food, (Jardine, 1999). According to Lii and Lee (2005), their study on examining customers perception of shopping on line suggests competitive pricing being the main reason. It allows them to compare prices of products more quickly and easily than when shopping in stores. (Korgaonkar and Wolin, 1999; Ernst Young, 2001; cited in Lii and Lee, 2005). According to the author, Mysupermarket.co.uk is a classic example; The website allows registered shoppers to compare their online shopping from high street supermarkets in the UK which are Tesco, Asda, Sainsbury and Ocado which is fully online based. Furthermore it allows users to switch at a click if they decide to change their preference to the cheapest supermarket. The problem associated with this is that it may be time consuming going through the tedious process of comparison because consumers may dislike switching from their preferred supermarket. In the authors view high street supermarkets also offer this service. A good example is that of Sainsburys supe rmarket where there is often a price comparison sheet placed next to their own shelf edge price tags showing their prices as compared to Tesco and Asda. If not then Sainsburys have opened small kiosks often located towards end of an isle where the customer advisor can compare their prices for customers with other competing supermarkets and if their prices are high then they do price match or sell the item even cheaper. This shows that the high street physical stores are also doing their best to match the benefits of on line shopping. Another factor that may drive away consumers from shopping on line is transportation cost. Bellman (2001), says that growing numbers of e-tailers are eliminating these costs as they find that customers often cancel orders after going through the entire ordering process and then considering the transportation cost being high, and this may be the key factor that drives potential customers away. The other fear of shopping online is privacy. Most web users refrain giving out their details, especially data in the form of credit card details as they fear exploitation of their privacy (Bellman, 2001). Insufficient product information on screen also contributes to decline of purchase. Apart from this, all secured websites do have a ‘time-out function where user sessions are based on time limits. If ‘time-out occurs, customers risk losing their entire shopping basket, which is quite frustrating from a customers point of view. These are some of the most common factors which may keep away customers from shopping online and reason their preference to shop in high street stores simply because they are well aware of the location, store layout, product selection and return policies as well as the stores reputation (Greenbury, 1999; cites in Maruca, 1999). Online e-tailing has a great and growing future, but the high street is still an important destination for customers. The limiting factor of e-businesses could be, a simple example, such as one cannot buy a piece of fruit via shopping online but can do so from a store. Furthermore, there is no empirical evidence to justify what drives customers to shop on line instead of high street stores, ultimately questioning what customers online shopping preferences are? 2.6 The E-tail clothing sector in UK Fashion is a sensitive and rapidly moving market which is growing at a faster pace in the UK, in comparison to its other European counter parts. Shopping on line for clothing products is also fast gaining popularity in the UK. Although buying over the Internet remains small in comparison with buying through the traditional channels, such as the brick-and-mortar physical stores, it is growing and clothing is a substantial portion of the e-tail sector in the UK. The online clothing sector caters for almost all segments of the UK market starting from the low cost value clothing to high end designer clothing including bespoke tailoring to couture clothing, the choice is unlimited and the options ever increasing. One can buy a single handkerchief to a full suit online, even clothing and accessories for all age ranges are available, whereby the customer can buy clothes for new born babies to clothes for senior citizens, therefore making this shopping Diabetes: Questions and Answers Diabetes: Questions and Answers DIABETES Diabetes Mellitus The medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey. Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the blood. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004) RELATED BIOLOGY Which organ is involved in the regulation of Blood Glucose Levels? The pancreas. Where is it located? Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen. What type of tissue is it made up of? Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions. Which area of this organ is responsible for producing the hormones involved in the regulation of blood sugar levels? The Islets of Langerhans What are the main functions of insulin? To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells. It increases the rate of glycogen synthesis in the liver It promotes the synthesis of fatty acids in the liver It inhibits the breakdown of fatty acids in adipose tissue It stimulates the uptake of amino acids It increases cell permeability to potassium (after Wills C et al 2003), What type of substance is insulin made of? Circle the correct answer. Carbohydrate Protein Fats Name the calls that produce the hormone glucagon. Alpha cells What are the main functions of glucagon? An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown. It activates hepatic glyconeogenesis It enhances lipolysis of triglycerides One of these hormones has a Catabolic action and the other an Anabolic action. State what these terms mean and identify which hormone falls into which category. CATABOLIC Catabolism is the breakdown of complex biological molecules into smaller component ones Glucagon ANABOLIC Anabolism is the synthesis of complex biological molecules from simpler components. Insulin What are considered normal limits of blood sugar readings? Fasting blood sugar 3.0 to 6.1 mmol/l (Client note: this is variable I have quoted WHO figures – check what your tutor recommends and add it here!) Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance (WHO 1985) CLASSIFICATION OF DIABETES MELLITUS State the 4 main categories. To the client: this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997 Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Secondary diabetes mellitus – includes: Genetic defects of beta-cell function Genetic defects in insulin action Diseases of the exocrine pancreas Pancreatitis Trauma/pancreatectomy Neoplasia Cystic fibrosis Hemochromatosis Endocrinopathies Acromegaly Cushings syndrome Glucagonoma Pheochromocytoma Hyperthyroidism Somatostatinoma Aldosteronoma Drug- or chemical-induced Vacor†  Pentamidine Nicotinic acid Glucocorticoids Thyroid hormone Diazoxide Beta-adrenergic agonists Thiazides Phenytoin Alfa-interferon Infections Congenital rubella Cytomegalovirus Uncommon forms of immune- mediated diabetes Other genetic syndromes sometimes associated with diabetes Down syndrome Klinefelters syndrome Turners syndrome Wolfram syndrome Friedreichs ataxia Huntingtons chorea Lawrence-Moon Beidel syndrome Myotonic dystrophy Porphyria Prader-Willi syndrome (RECD 1997) Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both. State 5 causes of Primary Diabetes Mellitus [aetiology]. Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varieties Aetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmental Environmental causes include exposure to Coxsackie B virus, Rubella virus and Cytomegalovirus and exposure to cows milk. Aetiology of Type 2 is also multifactorial. It includes genetic factors and environmental factors including: western diet, lack of exercise, obesity and hypertension (Todd W et al 2000) NB Causes are still unknown, the above are thought to be trigger factors. State 4 causes of Secondary Diabetes Mellitus. Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus including: gestational diabetes malnutrition-related diabetes pancreatic diseases causing diabetes endocrine diseases causing diabetes drugs and chemicals causing diabetes genetic conditions causing diabetes Causes depend on the variety but include pregnancy, pancreatitis and various drugs including: steroids thiazide diuretics phenytoin diazoxide streptozotocin Pancreatic diseases can cause Diabetes Mellitus including: acute and chronic pancreatitis pancreatic carcinoma cystic fibrosis haemochromatosis Disease processes can also cause secondary Diabetes Mellitus including: acromegaly Cushings syndrome glucagonoma phaeochromocytoma Complete the following chart by using the recommended textbooks to compare the two main types of Diabetes. TYPE 1 TYPE 2 Age at onset juvenile ( % of all cases about 10% about 90% Acute/insidious acute insidious Body build lean obese Genetic link high low Prone to ketoacidosis yes no Autoimmune Disease yes no Treatment insulin diet, oral hypog’s (Harris M 1995). What age group in the general population has the highest incidence of Type 2? Typically the 55-75 age range (Harris M 1995). Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign. Names these â€Å"At Risk† Groups 1. History of Heart Disease 2. History of Stroke 3. Obese (BMI>30) 4. Over 50s 5. Over 40s if from African Caribbean or Asian backgrounds PATHOPHYSIOLOGY / CLINICAL FEATURES DEFINITIONS Define the terms:– Gluconeogensis Biosynthesis of glucose from sources other than glycogen Glycogenolysis Oxidisation of hepatic glycogen into glucose Briefly describe how insulin deficiency / absence can cause the above processes to occur. Insulin deficiency and/or low glucose levels promote the secretion of glycogen Glucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kinease Clinical Presentation – Complete the following When blood glucose levels arise above a certain amount the renal threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body; this is called. Large amounts of urine are excreted. This is called polyuria. Excessive thirst is called polydipsia. Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to send a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are broken down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH. There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry mouth 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias. Numbness and tingling in the feet and cramps may result from peripheral neuropathy. Client Note (*)– this is debatable – your tutor may have a specific answer in mid for this one The recommendations of the W.H.O â€Å"Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications† were formally adopted in the UK on the 1st June â€Å"2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L. What is an OGTT? The Oral Glucose Tolerance Test In the oral glucose tolerance test the patient, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the drink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee. There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period, If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance. If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus OTHER TESTS / SCREENING PROCEDURES What is an HbA1c Test and why is it carried out? This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993) NICE target is 6.5 7.5 HbA1c When would Urea and Electrolyte levels and Blood Gases be tested? Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). U’s + E’s may be requested as part of a monitoring procedure. Blood gases may be useful if severe ketoacidosis is present. When would a Full blood count, specimen check and chest X-rays be carried out? This is more likely to be done as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anaemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client: this is contentious – as different clinicians have different rationales for these investigations.) When would and ECG and Lipid levels be checked? ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected. Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993) When would a neurological assessment and inspection of the lower limbs be carried out? Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993) Why are protein levels checked? Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993) When is urine checked for ketones? In the presence of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993) When would an eye inspection / photography be carried out and why is this done? Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993) Why would a diabetic require having their blood pressure regularly recorded and what value is recommended? Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident. A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who dont have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995) State the main complications Short-Term Hypoglycaemia, dizziness, lethargy, impaired conscious level – drowsiness. Hyperglycaemia, nausea, headache, malaise, ketosis. Coronary heart disease, Cardiovascular disease (macro- microvascular disease) Retinopathy which can lead to blindness Nephropathy, which can lead to kidney failure and the need for dialysis Neuropathy which can lead to, among other things, ulceration of the foot requiring amputation Microvascular Retinopathy, Nephropathy Neuropathy These are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12% Atherosclerosis Arteriosclerosis Both processes can lead to : heart disease stroke peripheral vascular disease (Stratton I et al 2000) What are the SIGN Guidelines and name those that relate to Diabetes. A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They include: visual impairment (SIGN 4) pregnancy (SIGN 9) children and young people (SIGN 10) renal disease (SIGN 11) foot disease (SIGN 12) cardiovascular disease (SIGN 19). Treatment- Give Principles   Type 1 Always insulin dependent. Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by manipulation of the insulin regime Constant monitoring by either patient or physician Constant vigilance for complications Type 2 Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction. If not successful then progression to oral hypoglycaemics and occasionally to insulin. Constant monitoring for the presence of complications Reduction of secondary causes of complication i.e. cessation of smoking. INSULIN Insulin was identified as a substance that prevented diabetes in the early 1890’s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client: see previous comments) Name 4 factors which influence control 1. Weight 2. Severity of disease process 3. Diet 4. Level of exercise (Wing RR, et al 2001) There are a variety of insulins available on the market. The two main sources are animal and human. How is human insulin produced? By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities. The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these. Why does insulin have to be given by injection? Being a protein it cannot be given by mouth as it would be denatured in the gastro-intestinal tract. What other route is being researched as an alternative? A great deal of research has been lavished on alternative modes of drug delivery. Transdermal routes do not give reproducible and consistent blood levels. Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut. Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period. Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect. Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001) SIDE EFFECTS Initially on the commencement of insulin people may experience sensitivity around the injection site. How would you recognise this? This is a form of allergy. It can be local, in which case the local skin becomes red and itchy at the injection site. It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis. Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food. Hard lumps under the skin may occur at injection sites if they are not rotated. What is the correct medical term for these? Lipodystrophy The number of units prescribed is calculated depending on time of day, age, weight and lifestyle. Typical dose is 0.7-1.0 units per Kg of body weight. WARNINGS Insulin should never be administered in cases of HYPO. The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly for up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin. Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement. During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential. During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester. The following drugs may increase blood glucose levels and therefore lead to a need for more insulin – Steroids Contraceptives Asthma Inhalers Some drugs lower blood glucose levels and therefore result in a reduction in insulin. These are:- Aspirin Beta blockers Mono-amine oxidase inhibitors. There are four categories of insulin. Give an example of each. Very short acting [ANALOGUE] – e.g. Humalog. Short acting [SOLUBLE, NEUTRAL] – e.g. Actrapid, Human Velosulin. Medium and long acting [ISOHANE, PROTAMINE ZINC] e.g. Human Insulotard. Combination of short and medium acting [MIXED, BIPHASIC] e.g. Human Mixtard. Who would most likely be prescribed very short acting insulins? The very unstable or out of control diabetic. Children more likely than adults. How long before a meal does short acting insulin require to be injected? Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours. The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it. How often daily would you require to take the following insulins:- Short acting – about 2-4 times a day( when stable) Medium acting – about twice a day Long acting – Once (or perhaps twice) a day These answers depend on the age and size of the patient, as well as the severity of the disease process. Why is short acting insulin sometimes given with medium acting insulin? To give a smoother blood glucose profile and also to â€Å"fill in the gap† before the medium acting insulin becomes biologically active. Where should insulin be stored? In the fridge, but not frozen. Briefly discuss the types of equipment that are used to administer insulin? Commonest is still the disposable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now. Other options include the pen devices (expensive but convenient and largely â€Å"fool proof†). Jet injectors are occasionally seen, but not very common. In hospital surroundings insulin pumps (drivers or infusers) can be used. Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control. (HSG 1997) What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin? Take plenty with you as your brand may not be available abroad. Make sure you can keep it refrigerated. Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home. Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences. ORAL HYPOGYCAEMICS Below are the main categories of drugs. Give an example of each, including daily dosage and side effects? Sulphonylureas Chlorpropamide 250 mg (100 mg in the elderly) This is a very long acting drug, usually taken once daily with breakfast. Alcohol may cause flushing to the face. Biguanides Metformin Start at 500 mg twice a day or 850 mg once daily. The maximum daily dose is 2550 mg given in three divided doses Gastrointestinal side effects are a common occurrence in people taking metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoea Occasionally a metallic taste in the mouth. Rare complication lactic acidosis (Knowler WC et al 2002) Prandial glucose regulator Repaglinide 0.5 to 4 mg with each meal Occasional gastro intestinal side effects (Bokvist K et al 1999) Alpha glucosidase inhibitor Acarbose 50 mg then titrated against clinical effect. Flatulence soft stools or diarrhoea. Glitazones [new drug] Rosiglitazone 4mg as starting dose increasing to 8mg if required Possible toxic effects on the liver (theoretical rather than practical) (Park JY et al 2004) ACUTE COMPLICATIONS The most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation. A decrease in the blood glucose level normally leads to stimulation of catecholamine secretion. Identify 5 causes. Insufficient carbohydrate intake Excessive carbohydrate utilisation (exercise) Intercurrent acute illness Overdose of insulin Other illnesses (viz glycogen storage diseases) Alcohol Name 8 clinical features that the patient experiences. Pallor Shaking Perspiration Fatigue A feeling of weakness Rapid heartbeat (Tachycardia) Hunger Agitation Difficulty concentrating Irritability Blurred vision Temporary loss of consciousness Confusion Convulsions Coma. What would be given in order to treat it? Depending on severity. If minor, warm sweet (glucose containing) drinks If major, IM Glucagon. Monitoring essential until fully recovered. What is ketoacidosis? A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentration is high enough. Identify 5 causes Fluctuations in insulin regime Intercurrent illness Trauma Reduction in carbohydrate intake Dehydration +- severe exercise State 10 clinical features of this clinical state High blood sugar levels Frequent urination (polyuria) and thirst Fatigue and lethargy Dry skin Facial flushing Nausea Vomiting Abdominal pain Fruity odour to breath Rapid, deep breathing (Air hunger) Muscle stiffness or aching Coma The principals of management are:- Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycaemia and ketonaemia Replacing fluid loss (from polyuria and vomiting) usually by intravenous fluids Restabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia. Treatment for any underlying cause such as infection. LONG TERM COMPLICATIONS There are 10 steps that the diabetic patient can take to reduce his chances of developing complications. Regular screening of BP and maintain at 140/80 or lower. Regular HbA1c testing. Maintain blood glucose levels between 4-7mmols/L before meals. A