The Program Design and Evaluation Process

This article will address the data collection of aggressive behavior incidents at Pathway High School. We will address several different data collections and measurements to the following subjects: The occurrences of aggressive behavior incidents reported before and after a program implementation, the data and success rate on the behavior correction procedures in the classroom by teachers and the success rate to the implementation of the School-Wide Positive Behavioral Support (SWPBS) program, within Pathway High SchoolWe will use the already recorded data from our Spreadsheet (Kaplan University, 2013) in comparing the measurements and success rates of our implemented program.Figure 1: The purpose of this data requirement is to implement an affective program to decrease the student’s aggressive behavior incidents at Pathway High School. The quantitative data collection is used for this kind of measurement and data collection, because the distribution of variables can be genera lized to entire population (Dawson, C., 2002). In this case we will concentrate on the aggressive behavior of the students and the measurements of occurrences of the aggressive behavior of students, with the focus to decrease the number of aggressive behavior of the students.The occurrence of aggressive behavior incidents reported before the implemented program started was reported to the following: In September the  aggressive behavior incidents occurred 248 times. In October it went to 262 times and for November the behavior incidents occurred 275 times. This brings the aggressive behavior incidents, within the 3 month time scale, to the number of: 785 aggressive behavior incidents.After the program implementation began in December and was concluded in May. The behavior incident number indicates a decline of aggressive behavior in December with the number of 225, followed by decreasing numbers for January > 198, February > 144, March > 127, April > 99 and May > 83. The graph ind icates a significant decline in the aggressive behavior incidents, within the time of 5 month after the program was implemented in the number of 702 less incidents within 5 month. 785 > 3 month – 83 in May, after implementation of program for 5 month = 702 less incidents by May (Spreadsheet Kaplan University, 2013).This collected data will indicate that the program was successful because the aggressive behavior incidents of students declined, once the program implementation has started.Figure 2The purpose of this data requirement is to measure the impact of the program on behavior correction procedures in the classroom by teachers. In the collection of the impact of the program to behavior correction in the classroom by teachers, the quantitative data collection is used to measure and collect the results of the implicating program. This is measured to the following:Before implementation of program465 div. by 8 = 58.125 = meanTotal number of teachers A – H = 8 Total num ber before implementation of program = 465 Mean before program implementation is = 58.125 Mean is 58.125After implementation of program530 div. by 8 = 66.25 = meanTotal number of teachers A – H = 8 Total number after implementation of program = 530 Mean after program implementation of program = 66.25 Mean is 66.26 (Spreadsheet Kaplan University, 2013)Since the mean before implementation of the program is lower 58.125 then the mean after implementation of the program 66.25, then this would indicate the implementation of the program may have failed or provided little impact to the behavior correction procedures in the classroom, conducted by teachers.Figure 3The purpose of this data requirement is to rate the students satisfactory school experience before and after the SWPBS program was implemented. The data is recorded in the calculated measures of percentage and the quantitative data collection is used within this requirement.The data collection brings forth the following mea sures: Before the program started, the students satisfactory rate within their school experience provided the data of the highest level = 0 = 0% and the lowest level = 70 = 31%.After the program was implicated for three (3) month, the students satisfactory rate within their school experience provided the information of an increase, within the highest level = 15 = 6.6 = 7% and the lowest level = 25 = 11%.Six (6) months after program started, the student’s satisfactory rate within their school experience showed a significant increase in the highest level = 15 = 6.6 = 7% and significant decrease in the Lowest level = 10 = 4.4†¦ = 4% (Spreadsheet Kaplan University, 2013).These measures and data collection provides the information of the success to the implicated SWPBS program.The follow up on all of the collected data and the evaluation of the follow up, provides us with the feedback on results, accomplishments, or impacts on the students behavior by the program implementati on. In addition it will provide us information about the effectiveness and the appropriateness of the implemented program (Kettner, P. 2012).

The Return: Midnight Chapter 9

Damon dropped his hand. He simply couldn't make himself do it. Bonnie was weak, light-headed, a liability in combat, easy to confuse – That's it, he thought. I'l use that! She's so naive – â€Å"Let go for a second,†he coaxed. â€Å"So I can get the stave – â€Å" â€Å"No! You'l jump if I do! What's a stave?†Bonnie said, al in one breath. – and stubborn, and impractical – Was the bril iant light beginning to flicker? â€Å"Bonnie,†he said in a low voice, â€Å"I am deadly serious here. If you don't let go, I'l make you – and you won't like that, I promise.† â€Å"Do what he says,†Meredith pleaded from somewhere quite close. â€Å"Bonnie, he's going into the Dark Dimension! But you're going to end up going with him – and you'l both be human slaves this time! Take my hand!† â€Å"Take her hand!†Damon roared, as the light definitely flickered, for an instant becoming less blinding. He could feel Bonnie shifting and trying to see where Meredith was, and then he heard her say, â€Å"I can't – â€Å" And then they were fal ing. The last time they had traveled through a Gate they had been total y enclosed in an elevator-like box. This time they were simply flying. There was the light, and there were the two of them, and they were so blinded that somehow speaking didn't seem possible. There was only the bril iant, fluctuating, beautiful light – And then they were standing in an al ey, so narrow that it just barely al owed the two of them to face each other, and between buildings so high that there was almost no light down where they were. No – that wasn't the reason, Damon thought. He remembered that blood-red perpetual light. It wasn't coming directly from either side of the narrow slit of al ey, which meant that they were basical y in deep burgundy twilight. â€Å"Do you realize where we are?†Damon demanded in a furious whisper. Bonnie nodded, seeming happy about having figured that out already. â€Å"We're basical y in deep burgundy – â€Å" â€Å"Crap!† Bonnie looked around. â€Å"I don't smel anything,†she offered cautiously, and examined the soles of her feet. â€Å"We are,†Damon said slowly and quietly, as if he needed to calm himself between every word, â€Å"in a world where we can be flogged, flayed, and decapitated just for stepping on the ground.† Bonnie tried a little hop and then a jump in place, as if diminishing her ground-interaction time might help them in some manner. She looked at him for further instructions. Quite suddenly, Damon picked her up and stared at her hard, as revelation dawned. â€Å"You're drunk!†he final y whispered. â€Å"You're not even awake! Al this while I've been trying to get you to see sense, and you're a drunken sleepwalker!† â€Å"I am not!†Bonnie said. â€Å"And†¦just in case I am, you ought to be nicer to me. You made me this way.† Some distant part of Damon agreed that this was true. He was the one who'd gotten the girl drunk and then drugged her with truth serum and sleeping medicine. But that was simply a fact, and had nothing to do with how he felt about it. How he felt was that there was no possible way for him to proceed with this al -too-gentle creature along. Of course, the sensible thing would be to get away from her very quickly, and let the city, this huge metropolis of evil, swal ow her in its great, black-fanged maw, as it would most certainly do if she walked a dozen steps on its streets without him. But, as before, something inside him simply wouldn't let him do it. And, he realized, the sooner he admitted that, the sooner he could find a place to put her and begin taking care of his own affairs. â€Å"What's that?†he said, taking one of her hands. â€Å"My opal ring,†Bonnie said proudly. â€Å"See, it goes with everything, because it's al colors. I always wear it; it's casual or dress-up.†She happily let Damon take it off and examine it. â€Å"These are real diamonds on the sides?† â€Å"Flawless, pure white,†Bonnie said, stil proudly. â€Å"Lady Ulma's fianceLucen made it so that if we ever needed to take the stones out and sel them – â€Å"She came up short. â€Å"You're going to take the stones out and sel them! No! No no no no no!† â€Å"Yes! I have to, if you're going to have any chance of surviving,†Damon said. â€Å"And if you say one more word or fail to do exactly as I tel you, I am going to leave you alone here. And then you wil die. â€Å"He turned narrowed, menacing eyes on her. Bonnie abruptly turned into a frightened bird. â€Å"Al right,†she whispered, tears gathering on her eyelashes. â€Å"What's it for?† Thirty minutes later, she was in prison; or as good as. Damon had instal ed her in a second-story apartment with one window covered by rol er blinds, and strict instructions about keeping them down. He had pawned the opal and a diamond successful y, and paid a sour, humorless-looking landlady to bring Bonnie two meals a day, escort her to the toilet when necessary, and otherwise forget about her existence. â€Å"Listen,†he said to Bonnie, who was stil crying silently after the landlady had left them, â€Å"I'l try to get back to see you within three days. If I don't come within a week it'l mean I'm dead. Then you – don't cry! Listen! – then you need to use these jewels and this money to try to get al the way from here to here; where Lady Ulma wil stil be – we hope.† He gave her a map and a little moneybag ful of coins and gems left over from the cost of her bread and board. â€Å"If that happens – and I can pretty wel promise it won't, your best chance is to try walking in the daytime when things are busy; keep your eyes down, your aura smal , and don't talk to anyone. Wear this sacking smock, and carry this bag of food. Pray that nobody asks you anything, but try to look as if you're on an errand for your master. Oh, yes.†Damon reached into his jacket pocket and pul ed out two smal iron slave bracelets, bought when he had gotten the map. â€Å"Never take them off, not when you're sleeping, not when you're eating – never.† He looked at her darkly, but Bonnie was already on the threshold of a panic attack. She was trembling and crying, but too frightened to say a word. Ever since entering the Dark Dimension she'd been keeping her aura as smal as possible, her psychic defenses high; she didn't need to be told to do that. She was in danger. She knew it. Damon finished somewhat more leniently. â€Å"I know it sounds difficult, but I can tel you that I personal y have no intention whatsoever of dying. I'l try to visit you, but getting across the borders of the various sectors is dangerous, and that's what I may have to do to come here. Just be patient, and you'l be al right. Remember, time passes differently here than back on Earth. We can be here for weeks and we'l get back practical y the instant we set out. And, look† – Damon gestured around the room – â€Å"dozens of star bal s! You can watch al of them.† These were the more common kind of star bal , the kind that had, not Power in them, but memories, stories, or lessons. When you held one to your temple, you were immersed in whatever material had been imprinted on the bal . â€Å"Better than TV,†Damon said. â€Å"Much.† Bonnie nodded slightly. She was stil crushed, and she was so smal , so slight, her skin so pale and fine, her hair such a flame of bril iance in the dim crimson light that seeped through the blinds, that as always Damon found himself melting slightly. â€Å"Do you have any questions?†he asked her final y. Bonnie said slowly, â€Å"And – you're going to be†¦?† â€Å"Out getting the vampire versions of Who's Who and the Book of Peers,†Damon said. â€Å"I'm looking for a lady of quality.† After Damon had left, Bonnie looked around the room. It was horrible. Dark brown and just horrible! She had been trying to save Damon from going back into the Dark Dimension because she remembered the terrible way that slaves – who were mostly humans – were treated. But did he appreciate that? Did he? Not in the slightest! And then when she'd been fal ing through the light with him, she'd thought that at least they would be going to Lady Ulma's, the Cinderel a-story woman whom Elena had rescued and who had then regained her wealth and status and had designed beautiful dresses so that the girls could go to fancy parties. There would have been big beds with satin sheets and maids who brought strawberries and clotted cream for breakfast. There would have been sweet Lakshmi to talk to, and gruff Dr. Meggar, and†¦ Bonnie looked around the brown room and the plain rush-fil ed pal et with its single blanket. She picked up a star bal listlessly, and then let it drop from her fingers. Suddenly, a great sleepiness fil ed her, making her head swim. It was like a fog rol ing in. There was absolutely no question of fighting it. Bonnie stumbled toward the bed, fel onto it, and was asleep almost before she had settled under the blanket. â€Å"It's my fault far more than yours,†Stefan was saying to Meredith. â€Å"Elena and I were – deeply asleep – or he'd never have managed any part of it. I'd have noticed him talking with Bonnie. I'd have realized he was taking you hostage. Please don't blame yourself, Meredith.† â€Å"I should have tried to warn you. I just never expected Bonnie to come running out and grab him,†Meredith said. Her dark gray eyes shimmered with unshed tears. Elena squeezed her hand, sick in the pit of her stomach herself. â€Å"You certainly couldn't be expected to fight off Damon,†Stefan said flatly. â€Å"Human or vampire – he's trained; he knows moves that you could never counter. You can't blame yourself.† Elena was thinking the same thing. She was worried about Damon's disappearance – and terrified for Bonnie. Yet at another level of her mind she was wondering at the lacerations on Meredith's palm that she was trying to warm. The strangest thing was that the wounds appeared to have been treated – rubbed slick with lotion. But she wasn't going to bother Meredith about it at a time like this. Especial y when it was real y Elena's own fault. She was the one who had enticed Stefan the night before. Oh, they had been deep, al right – deep in each other's minds. â€Å"Anyway, it's Bonnie's fault if it's anyone's,†Stefan said regretful y. â€Å"But now I'm worried about her. Damon's not going to be inclined to watch out for her if he didn't want her to come.† Meredith bowed her head. â€Å"It's my fault if she gets hurt.† Elena chewed her lower lip. There was something wrong. Something about Meredith, that Meredith wasn't tel ing her. Her hands were real y damaged, and Elena couldn't figure out how they could have gotten that way. Almost as if she knew what Elena was thinking, Meredith slipped her hand out of Elena's and looked at it. Looked at both her palms, side by side. They were equal y scratched and torn. Meredith bent her dark head farther, almost doubling over where she sat. Then she straightened, throwing back her head like someone who had made a decision. She said, â€Å"There's something I have to tel you – â€Å" â€Å"Wait,†Stefan whispered, putting a hand on her shoulder. â€Å"Listen. There's a car coming.† Elena listened. In a moment she heard it too. â€Å"They're coming to the boardinghouse,†she said, puzzled. â€Å"It's so early,†Meredith said. â€Å"Which means – â€Å" â€Å"It has to be the police after Matt,†Stefan finished. â€Å"I'd better go in and wake him up. I'l put him in the root cel ar.† Elena quickly corked the star bal with its meager ounces of fluid. â€Å"He can take this with him,†she was beginning, when Meredith suddenly ran to the opposite side of the Gate. She picked up a long, slender object that Elena couldn't recognize, even with Power channeled to her eyes. She saw Stefan blink and stare at it. â€Å"This needs to go in the root cel ar too,†Meredith said. â€Å"And there are probably earth tracks coming out of the cel ar, and blood in the kitchen. Two places.† â€Å"Blood?†Elena began, furious with Damon, but then she shook her head and refocused. In the light of dawn, she could see a police car, cruising like some great white shark toward the house. â€Å"Let's go,†Elena said. â€Å"Go, go, go!† They al dashed back to the boardinghouse, crouching to stay low to the ground as they did it. As they went, Elena hissed, â€Å"Stefan, you've got to Influence them if you can. Meredith, you try to clean up the soil and blood. I'l get Matt; he's less likely to punch me when I tel him he has to hide.† They hastened to their appointed duties. In the middle of it al , Mrs. Flowers appeared, dressed in a flannel nightgown with a fuzzy pink robe over it, and slippers with bunny heads on them. As the first hammering knock on the door sounded, she had her hand on the door handle, and the police officer, who was beginning to shout, â€Å"POLICE! OPEN THE – â€Å"found himself bawling this directly over the head of a little old lady who could not have looked more frail or harmless. He ended almost in a whisper, † – door?† â€Å"It is open,†Mrs. Flowers said sweetly. She opened it to its widest, so that Elena could see two officers, and the officers could see Elena, Stefan, and Meredith, al of whom had just arrived from the kitchen area. â€Å"We want to speak to Matt Honeycutt,†the female officer said. Elena noted that the squad car was from the Ridgemont Sheriff's Department. â€Å"His mother informed us that he was here – after serious questioning.† They were coming inside, shouldering their way past Mrs. Flowers. Elena glanced at Stefan, who was pale, with tiny beads of sweat visible on his forehead. He was looking intently at the female officer, but she just kept talking. â€Å"His mother says he's been virtual y living at this boardinghouse recently,†she said, while the male officer held up some kind of paperwork. â€Å"We have a warrant to search the premises,†he said flatly. Mrs. Flowers seemed uncertain. She glanced back toward Stefan, but then let her gaze move on to the other teenagers. â€Å"Perhaps it would be best if I made everyone a nice cup of tea?† Stefan was stil looking at the woman, his face looking paler and more drawn than ever. Elena felt a sudden panic clutch at her stomach. Oh, God, even with the gift of her blood tonight, Stefan was weak – far too weak to even use Influence. â€Å"May I ask a question?†Meredith said in her low, calm voice. â€Å"Not about the warrant,†she added, waving the paper away. â€Å"How is it out there in Fel ‘s Church? Do you know what's going on?† She was buying time, Elena thought, and yet everyone stopped to hear the answer. â€Å"Mayhem,†the female sheriff replied after a moment's pause. â€Å"It's like a war zone out there. Worse than that because it's the kids who are – â€Å"She broke off and shook her head. â€Å"That's not our business. Our business is finding a fugitive from justice. But first, as we were driving toward your hotel we saw a very bright column of light. It wasn't from a helicopter. I don't suppose you know anything about what it was?† Just a door through space and time, Elena was thinking, as Meredith answered, stil calmly, â€Å"Maybe a power transmitter blowing up? Or a freak shaft of lightning? Or are you talking about†¦a UFO?†She lowered her already soft voice. â€Å"We don't have time for this,†the male sheriff said, looking disgusted. â€Å"We're here to find this Honeycutt man.† â€Å"You're welcome to look,†Mrs. Flowers said. They were already doing so. Elena felt shocked and nauseated on two fronts. â€Å"This Honeycutt man.†Man, not boy. Matt was over eighteen. Was he stil a juvenile? If not, what would they do to him when they eventual y caught up to him? And then there was Stefan. Stefan had been so certain, so†¦ convincing†¦in his announcements about being wel again. Al that talk about going back to hunting animals – but the truth was that he needed much more blood to recover. Now her mind spun into planning mode, faster and faster. Stefan obviously wasn't going to be able to Influence both of those officers without a very large donation of human blood. And if Elena gave it†¦the sick feeling in her stomach increased and she felt the smal hairs on her body stand up†¦if she gave it, what were the chances that she would become a vampire herself? High, a cool, rational voice in her mind answered. Very high, considering that less than a week ago, she had been exchanging blood with Damon. Frequently. Uninhibitedly. Which left her with the only plan she could think of. These sheriffs wouldn't find Matt, but Meredith and Bonnie had told her the whole story of how another Ridgemont sheriff had come, asking about Matt – and about Stefan's girlfriend. The problem was that she, Elena Gilbert, had â€Å"died†nine months ago. She shouldn't be here – and she had a feeling that these officers would be inquisitive. They needed Stefan's Power. Right now. There was no other way, no other choice. Stefan. Power. Human blood. She moved to Meredith, who had her dark head down and cocked to one side as if listening to the two sheriffs clomping above on the stairs. â€Å"Meredith – â€Å" Meredith turned toward her and Elena almost took a step back in shock. Meredith's normal y olive complexion was gray, and her breath was coming fast and shal owly. Meredith, calm and composed Meredith, already knew what Elena was going to ask of her. Enough blood to leave her out of control as it was being taken. And fast. That terrified her. More than terrified. She can't do it, Elena thought. We're lost.

Florence Nightingale Leadership in Nursing Essay

Nursing has never been simple profession and it is not an easy task to quantify the contributions nurses have made in shaping healthcare. Modern nursing is complex, ever changing and multi focused; requiring nurses to evolve personally and professionally as leaders in healthcare. What is leadership? Leadership is defined by what it is, as much as what it is not. Leadership has nothing to do with titles, age, seniority, education or status, but rather associated with the characteristics that define a leader. Per Forbes Magazine (April, 2013) â€Å"Leadership is a process of social influence, which maximizes the efforts of others, towards the achievement of a goal. An effective leader must inspire the group to follow in their lead, to guide them to accomplish a mutual goal.† Florence Nightingale, the innovative leader and pioneer of modern nursing, is the person I selected as the leader I most admire and one who continues to inspire me to continue to grow professionally. Read more:  The person you admire the most essay Nightingale, who lived from 1820-1910 was a visionary, healer, reformer, environmentalist, feminist, practitioner, scientist, politician and global citizen. Her achievements are astounding considering the Victorian era, and the submissive role of women in her time. Her contributions to nursing theory, research, statistics, public health, and health care reform are invaluable and inspirational. Florence Nightingale demonstrated the characteristics of leadership such as, mission conscious, tenacity, solution oriented and commitment by her ability to establish nursing as professional practice, separate from medicine, while practicing in a male dominated world. Secondly, she was intentional and focused in her efforts as an advocate for the advancement of nursing into leadership positions and not one of just servitude, by fostering an environment of continued education and training for nurses. She formalized an educational program and founded the first nursing school in England that helpe d to formulate standards of practice evident in nursing care today. Florence far reaching visionary concepts of nurses contribution to healthcare ,leadership and the transformational aspects of nursing has continued to propel nurses into the forefront of modern healthcare . According to, Selanders & Crane, (2012) â€Å"Today ANA states that high quality practice includes advocacy as an  integral component of patient safety. Advocacy is now identified both as a component of ethical nursing practice and as a philosophical principle underpinning the nursing profession and helping to assure the rights and safety of the patient.† If the true test of leadership is measured by the outcomes, Florence is a proven leader. It has been my experience that nursing is a transformational experience, it shapes you as much as your values and philosophies shape your practice. Florence Nightingale herself was a true visionary, who was also transformed into a leader by her courage, advocacy, focus and intentional pursuits, in advancing the practice of nursing. Her leadership style is aligned with that of a transformational leader, integrated with some democratic and authoritarian leadership styles of her time. Per Selander & Crane (2012) â€Å"Nightingale understood the value of and the methods for achieving visionary leadership. She repetitively utilized techniques which have been developed as the stair step leadership development model. This paradigm blends the ideas of Nightingale with the current leadership terminology of Burns (1978, 2003), who identified the relative merit of leadership outcomes, with the ‘novice-to-expert’ concept of Benner (2000) which focuses on the necessity of building leadership skills. â€Å"Her ability to empower and inspire others to follow in her path, is the ultimate pinnacle of success for a leader. Florence Nightingale embodies the true characteristics and spirit of leadership, one that has proven the test of time and continues to evolve with time, as nurses forge a path in the 21 century healthcare. Selanders. L, Crane.P, (2012), 17(1).The voice of Florence Nightingale on Advocacy. Online J.of Nursing Issues Kruse. (April, 2013).The Definition of Leadership in the 21 Century, Forbes Magazine.www.forbesmagazine.com

A painter's costs Research Paper Example | Topics and Well Written Essays - 500 words

A painter's costs - Research Paper Example 3) When a 1 percent rise in price evokes less than a 1 percent fall in quantity demanded, this is price inelastic. From the value that we have obtained, we then know that paint as a commodity is price elastic. How does this relate to revenue for companies? Total revenue is equal to price times quantity or PXQ. The three cases of elasticity correspond to three different relationships between total revenue and price changes: If a price decrease leads to a decrease in total revenue, it is a case of inelastic demand. If a price decrease leads to an increase in total revenue, it is the case of elastic demand. And if a price decrease leads to no change in total revenue, it may be the case of unit-elastic demand. Since our good is price elastic, it may be wise for firms to lower their prices if they are to expect an increase in total revenue or profits because slashing their prices down, they are hiking their sales up by a larger magnitude.

Advantage and Disadvantages of different modes of transport on a Essay

Advantage and Disadvantages of different modes of transport on a global scale - Essay Example He could always perch himself on an horse or an elephant or sledge himself using his dogs for his own personal transport. But when it came to moving material that belonged to him, he found himself in a tough spot. He had to invent wheels which started off as large logs to all those modes of transport today that we are going to discuss in this paper.In order to appreciate the way the freight transport industry is progressing and the methodologies that they have been adopting, it is important hat we understand their history and hence get a total perspective of the whole industry. The freight industry was and continues to be most important economic requirement that any of the countries would need. Many times in the history of the civilization of Man we find that the country that had better logistics won many battles and hence the war. Many times they also won wars that they never fought both economical superiority and logistic superiority. When a country could produce and sell their pro ducts across the world then they end up superior to the people who are yet to come to grips with the logistics of movement of goods and services.Let us trace the history of freight transportation from 1800 to the modern days. If we see today, there are five modes of transport that are very much in vogue. 1. The railways. 2. The waterways 3. The airways 4. The roadways 5. the pipelines. The ships had their major technology change when the steam engine was invented and they were mounted on the hitherto paddled or wind powered boats to make gigantic ships that could literally rush through the sea. The same invention also changed the way people and material traveled over the land as well in the form of railways. Steam engines altered the modes of transport on sea in 1807 and on land in 1829. Transportation now became cheap and fast over all the surfaces of the earth both land and water. This brought in a revolution that literally changed the way industry was looked at. The IC engines brought in another round of change with technological upgrade. The world became smaller and smaller with faster traveling and transport mechanisms, men could pack their material and send it over railroads that traveled over 5 times as fast an horse would. Soon there were the trucks and the vehicles that plied the roads. The roadways also changed the very approach to traveling by individuals. It also changed the way people started looking at manufacturing processes. With a reach that spanned every corner of the country, roads brought the neighborhoods as close as close can be. Central production with a distribution set up started forming across the country making cheaper products a reality. With IC engines another major development in technology was also ushered in. This was the aircraft. With the invention of the aircraft, we find the transport time getting reduced by more than 10 times across the world, leading time a world wide integration of manufacturing. This also was rising the scale of production and an economics of scale and the economics of logistics went together to make things possible in the country. Pipes and conveyors also formed another set of transporting mechanisms that helped in putting together an easy but effective way of transporting material over longer distances and huge volumes. 3. The Industry and how it works The logistics industry or transport industry has the following major constituents. 1. The supplier or the sender of the material 2. The buyer or the receiver of the material 3. Transportation in the mode of transport that is suited 4. In case of multimodal, arranging so that the time taken is

Response Essay Example | Topics and Well Written Essays - 500 words - 28

Response - Essay Example They were trained to embrace death without fear or panic. To ensure they faced their dreadful challenges, as society’s militants, they were prepared psychologically to be ready for death by accepting to die when presented with a dilemmatic situation of choosing either life or death. The philosophy that deemed essence of Bushido undoubtedly helped to instill gallantry amongst the Samurai warriors. It was like they were fighting a battle they had nothing to lose. Their only mission was to take down as many enemies as possible. This religion/ philosophy influenced the psych of the warriors making them protect Japan from its foes. However, this philosophical concept is distinctly dissimilar from that Judeo-Christian view of death. In Judeo-Christian, people are alive until they physically die. The unrelenting wars that were seen in Japan during the mid-20th Century can be attributed to these cultural teachings that the fighters had. The Japanese World War II was battled by the philosophical conceptions that significantly motivated the warriors to engage in an unrelenting battle. As a matter of fact, the challenge Japan gave America and other nations during the World War was as a result of its deep culture that had saliently spelt out ‘dos’ and ‘don’ts’. As Benedict recounts, it was virtually difficult to understand the real nature of the Japanese culture. It is like the Japanese had a ‘bipolar’ culture that constituted all the extreme features. Its inimitability and unpredictability would confound every rival that sought to challenge Japan. No one knew what to include in the propaganda meant to demoralize the Japanese soldiers. Japan was a mystery. They were invincible; they were a real puzzle to the international community. The secret to Japan’s tenacity was on their deep cultural philosophy known as ‘Essence of Bushido’. The Japanese soldiers’ mental status

International economics Essay Example | Topics and Well Written Essays - 6250 words

International economics - Essay Example UK economy has experienced greater growth in the current century as compared to the last few decades of the twentieth century. However, the international trade scenario of UK does not seem promising with a consistent trade deficit although there has been growth in both export and import values. This is because the real value of imports remains far below than the real value of exports. The growth of service exports in developing countries has also affected UK economy as the nation has lost market for service exports in those countries especially China. In the backdrop of globalization no country can survive within the boundary of economics at national level. A country’s economy including industry, service sectors, employment and standard of living is dependant on the association with its trading partners. This association is established with import and export of goods, services, labour, technologies and investments. It is not possible to create national economic policies without considering their effect on the economies of other countries. With a number of factors like the formation of the European Union in the 1950s, the growth of multinational companies in the 1960s, the growing market strength of the oil producing countries, and introduction of euro in the beginning of twenty first century have all paved the way for interdependence of countries worldwide and evolution of a global economy (Carbaugh, 2010, p.1). In the world of business in the current century, business is the key factor in the relationships between differe nt countries. Today any business enterprise even the small and emerging ones consider every nook of the world as market for its products and services, and no business confines its activities within the national boundaries. In many companies, the annual sales level exceeds the gross national product (GNP) of some

Management of the Non-Profit Organizations Research Proposal

Management of the Non-Profit Organizations - Research Proposal Example NPOs, on the other hand, do not usually provide for substantial monetary compensation, since most, if not all, of its work force are volunteers. As such, workers are motivated more by their love and dedication to the mission of the organization and the cause for which it stands. Because of this fundamental difference, workers in NPOs cannot be persuaded to remain with the organisation and contribute their best by the usual means of increasing pay and monetary incentives. Although volunteers are drawn to the job because of the psychic income, such may not be sufficient to sustain the commitment of these volunteers in the long term, without the necessary and appropriate support and action by the human resources manager. The threats posed by the social and physical environment on the continued commitment of an NPO’s volunteer staff will remain a source of challenge to its HR managers, which this dissertation shall aim to explore. Introduction Not too long ago, there was a clear d ichotomy of organizations according to their nature and purpose. The common taxonomy of organizations distinguished them according to whether they were business corporations, organizations supporting philanthropic causes or social development purposes, or public administrative organizations. Business organizations worked to maximize profit, public administrative organizations advanced the goals of the government, and the social cause-oriented organizations worked towards the development of marginalized sectors of society. Recently, there has emerged a changing trend in how organizations are expected to operate. Business organizations can no longer be motivated by the single goal of realizing profits; it must actively pursue a corporate social responsibility program and sustainability program integrally with its main operations, in order to return to society a portion of its profits for the benefits it enjoys as corporate citizen. Non-profit organizations, on the other hand, are comp elled to face the necessity of operating on a self-sustaining basis; it can no longer rely on its previous sponsors and donors who had so generously supported it during more prosperous times, because of the deep financial crisis that will continue to defy recovery efforts for some time to come. Even as many business organizations have been forced to close, NPOs, because of their less financially tenable position, are forced to face economic realities and find ways and means to become financially self-sustaining. There are implications to the obscuring delineations between the types of organizations. Business organizations are becoming increasingly socially oriented, while NPOs are assuming activities that are increasingly economic. These affect the manner in which human resources are expected to perform and how they are engaged. Conceptual framework The term employee engagement may immediately be considered a misnomer in the sense that NPO workers are mostly volunteers rather than e mployees. As such, they are normally not bound by an employment contract where they commit to discharge a particular set of duties in exchange for a predefined monetary compensation. NPO workers perform their duties of their own accord and volition, and correspondingly excel in these duties out of a sense of dedication to further the cause of the organization. Granted that there exists already a greater affinity and identity

International Business Environment Essay Example | Topics and Well Written Essays - 2000 words

International Business Environment - Essay Example Globalization has its benefits and challenges. However, it is almost inevitable and the global economy is expected to continue influencing operations of businesses. This paper â€Å"International Business Environment† addresses the question on whether globalization is good or not. The discussion will involve a brief explanation on how different schools of thoughts perceive globalization. Additionally the drivers of globalization, its implications on international business, the benefits, and challenges of globalization to the international society in general will be discussed.Globalization as Perceived by Various Schools of ThoughtInternational business entails any business activity conducted across national borders. The activities may involve sell of goods or services but must be done between two or more countries. Most multinational companies may have their management located in one country. However, they are international since they carry out business activities across more than one nation. International business has become a common phenomenon that influences decision in the political social as well as economic arena. International business operations are characterized by opportunities as well as challenges (Bray, 2003; Stefanovic, 2008).The term globalization means different things to different people. Some view globalization as increased worldwide interconnectedness in different aspects such as cultural as well as social ones. Hyperglobalists describe globalization as a phenomenon that exposes people.... International business operations are characterized by opportunities as well as challenges (Bray, 2003; Stefanovic, 2008). The term globalization means different things to different people. Some view globalization as increased worldwide interconnectedness in different aspects such as cultural as well as social ones. Hyperglobalists describe globalization as a phenomenon that exposes people to international market resulting in denationalization of economies. Skeptics consider globalization to be the economic interdependence resulting from economic integration. However, skeptics oppose hyperglobalist argument that globalization leads to denationalization. Conversely, skeptics claim that globalization leads to increased influence of national governments on the global economy (Bray, 2003). Transformationalists agree with the hyperglobalists’ argument that globalization reshapes social, political, and economic societies. However, transformationalist fail to agree with hyperglobalis ts’ argument that globalization leads to assimilation of the global societies into a single society. They argue that existence of a single business system does not mean that the global economic society is unionized (Bray, 2003). Drivers of Globalization Although the process of globalization has been going on for a long period, it has intensified in the recent past. There are several factors also referred to as drivers that are responsible for the increased pace of globalization. The main driver of globalization is technology. The economic world has made a great leap in technological advancement. Communication plays a major role in the business environment (Devemdra, 2009). This is because most business

Answer of 2 Question Essay Example | Topics and Well Written Essays - 500 words

Answer of 2 Question - Essay Example The thickness for this slice is given by ∆z = where Gz is the gradient strength, ∆z is the slice thickness, ÃŽ ³ is the young modulus, and ÃŽ ´f is the offset frequency. Therefore, making the offset frequency to be the subject of the formula we get ÃŽ ´f = where ÃŽ ´f is the offset frequency (Sheil, 44). Hence, From the figure, 7.9 showing out the signal of MRI obtained from fat and water there were two signals that were received. These signals include the signals from water which were at 4.8ppm and the signal from fat which was at 1.5ppm. The signal from water was displayed by a peak that was due to protons in water while that from fat was displayed by a peak due to protons within the fat. In the body of an organism, fat and water are the key components of protons. The molecules of fat and water contain a number of protons whose molecules is extremely beneficial in MR signal. From the figure, there were two peaks. One peak, which was 4.8ppm, was due to protons in water. Another peak, which was 1.5ppm, was due to protons in fat. These two peaks had different ppm because of a number of reasons. First, the relaxation time (T1) for water takes a longer duration of time compared to that of fat. This was evident in figure 7.10 where the weighted T1 image recorded reduced signals from water. In addition to this, transverse time of relaxation (T2) of water that was free had a short correlation time compared to that of fat. The decay of T2 is because of the interactions that are magnetic which occur in between the protons that are spinning. It is for this reason that the fat ppm had a shorter peak compared to that of water. Research has shown out that water has a longer time of relaxation since its natural motion frequency is higher compared to the clinically used larmor frequency (Sheil, 10). Relaxation time involves the time taken by protons to remain either coherent or have a phase rotation. This rotation normally

Strategic Management - Assignment for TNC Case Study

Strategic Management - Assignment for TNC - Case Study Example TNC is a diversified entertainment enterprise functioning in eight industry segments, including; Television; Filmed Entertainment; Direct Broadcast Satellite Television; Cable Network Programming; Magazines and Inserts; Newspapers; Book Publishing, and Other. The News Corporation functions mainly in the United States, the United Kingdom, Continental Europe, Australia, Asia and the Pacific Basin. It is engaged in the operation of broadcast television stations, and the development, production and distribution of network and television programming through its subsidiaries (Johnson, Scholes, & Whittington, 2008). The Company is involved in the direct broadcast satellite business through its subsidiary, SKY Italia. It also owns interests in BSkyB and DIRECTV, which are engaged in the direct broadcast satellite (DBS) business. It is also involved in the newspaper and magazine publishing business in the United Kingdom, Ireland, Australia and the United States through its various subsidiarie s. Through HarperCollins Publishers (HarperCollins), its wholly owned subsidiary, the Company is engaged in English language book publishing on a worldwide basis. TNC has shown consistent revenue and profit growth in recent years. ... They have a strong library content consisting of film achieves in the 1940s to present. Opportunities In the first instance many of its opportunities arise from the very nature of the competitive environment. Opportunities that are literally available to TNC in the television and print media market are many and varied. Especially its strategically important acquisitions have played a very big role in determining its success. TNC acquired Dow Jones & Company. This has helped place TNC on a firm footing. It allowed the company to expand its online presence and tap into the higher growth rates than many of its core traditional businesses. This will allow TNC to maintain their solid earnings growth without the downside of a pure growth company. TNC has benefited from the emerging markets in Asia, especially that of India and China. The combined population of the two countries equal approximately 2.5 billion. This is the economic reality and TNC has much to gain from its expansion into this region. Alternative media outlets such as the television, cable network programming, direct satellite broadcast and the print media such as magazines and newspapers. Therefore it can reach the market using any of these alternatives before or on par with their competitors. There has been a growth in High Definition Television (HDTV) in recent years and TNC has a sizable percentage in this technology. TNC is looking at new technologies that promise to improve spectrum efficiency or otherwise increase available capacity so that DIRECTV could expand the amount of HDTV content. Options such as the use of Ka-band capacity, higher order modulation schemes, such as the 8PSK technology FOX uses for its broadcast distribution

Discuss the dramatic impact of act 2 scene 2 Essay Example for Free

Discuss the dramatic impact of act 2 scene 2 Essay To achieve maximum impact in this scene, unconventional methods should be used to show how Macbeth is slowly beginning to slip into madness. Shakesphere has added an owl shrieking, this is to perhaps set up a dark atmosphere to link the scene with evil. The owls shriek should just begin as Macbeth kills Duncan to show that a evil deed has been committed. Shakephere has deliberately not shown you the actual murder-taking place to show guilt and also by not seeing it we are left to imagine the murder-taking place and may, perhaps, have more affect on the viewer. It can be imagined as being bloodier than it really is. As Macbeth enters on to the stage with bloody hand he should drop to his knees to show how he realizes that what he has done is so evil and it also shows how a psychological impact is starting to take place on him. As Lady Macbeth enters, she should enter slowly and silently to symbolize how the witches disappear and appear as if from nowhere. This shows how evil she is and cold hearted. She should remain calm as if to show no feelings towards what has happened. Lady Macbeth just wants to get back to bed and have the deed finished quickly. As Macbeth begins to tell his speech of how the guards were talking in there sleep, one cried, god bless us! And amen the other. Macbeth should say it slowly as if he is worried and as he comes to say the word amen he should stutter as if to show he still cannot say it. This shows the evil taking over Macbeth as anything related to good he has problems saying. Lady Macbeth would not commit the deed herself because as Duncan sleeps she resembles her father but she would be happy to kill her own baby as shown earlier on in the book. However she will make sure that the deed is complete without any problems by framing the two servants. A feint knocking should start in the background of the scene as Lady Macbeth departs to finish off the deed, the knocking should be in such away so that it resembles a heartbeat. Macbeth at this point should start scrubbing hands vigorously to show that there seems to be an everlasting amount of blood, like a sea of blood. This shows how evil the deed was and how bloody it was also. The knocking should get louder and faster to resemble Macbeths heart beat slowly getting faster as he gets more nervous and as he slowly begins to slip into madness. In this scene the stage should be mainly dark, there should be no lights focused upon Macbeth or Lady Macbeth to show that they are in darkness and evil. The lighting should be positioned in a way so that they are behind the two characters showing how they have left the light and goodness into the darkness and evil. Macbeth should enter the stage and collapse not starting to speak for several seconds to show how Macbeth it thinking of what he has done. Macbeth should breathe heavily to show his fear and anxiety. He should stare at the daggers and keep his eyes fixed on the daggers until he gives them to Lady Macbeth. This shows how he realizes that the deed is wrong but it is too late to late to go back and change what he has done. This shows that Macbeth is slowly beginning to slip into madness. Macbeth should shout most of his lines where as Lady Macbeth should whisper to show that Lady Macbeth is calm at this point where as Macbeth is scared and angry. The shriek that the owl makes should be loud and fast to show that the murder has been carried out quickly and smoothly. As Macbeth begins to clean the blood off his hands he should scrub it clean off but carry on to show that he is seeing his hands as being still covered in blood but are really clean. This shows that he is going mad.

Importance of Communication in Nursing

Importance of Communication in Nursing INTRODUCTION Communication is a process and has many aspects to it. Communication is a dynamic process by which information is shared between individuals (Sheldon 2005). This process requires three components (Linear model), the sender, the receiver and the message (Alder 2003). Communication would not be possible if any of these components are absent. While peate (2006) has suggested that communication is done every day through a linear process, Spouse (2008) argues that it is not so simple and does not follow such a linear process. He explains that due to messages being sent at the same time through verbal and non- verbal avenues, it is expected the receiver is able to understand the way this is communicated. Effective communication needs knowledge of good verbal and non-verbal communication techniques and the possible barriers that may affect good communication. The Nursing and Midwifery council (2008) states that a nurse has effective communication skills before they can register as it are seen as an essential part of a nurses delivery of care. (WAG 2003) Reflecting on communication in practice will also enforce the theory behind communication and allow a nurse to look at bad and good communication in different situations. This will then enforce the use of good communication techniques in a variety of situations allowing for a more interpersonal and therapeutic nurse patient relationship. This assignment discusses health care communication and why it is important in nursing by: Exploring verbal and non-verbal communication and possible barriers By exploring the fundamentals of care set out by the Welsh assembly and the nurse and midwifery councils code of conduct a better understanding of the importance of communication is gained. Reflecting in practice using a scenario from my community posting. VERBAL COMMUNICATION Verbal communication comes in the form of spoken language; it can be formal or informal in its delivery. Verbal Language is one of the primary ways in which we communicate and is a good way to gather information through a question (an integral part of communication) and answer process (Berry 2007; Hawkins and Power 1999). Therefore verbal communication in nursing should be seen as a primary process and a powerful tool in the assessment of a patient. There are two main types of questioning, open-ended questions or closed questions. Open-ended questions tend to warrant more than a one word response and generally start with what, who, where, when, why and how. It invites the patient to talk more around their condition and how they may be feeling and provoke a more detailed assessment to be obtained (Stevenson 2004). The use open-ended questions make the patient feel they have the attention of the nurse and they are being listened too (Grover 2005). It allows for a psychological focus to be given, this feeling of interest in all aspects of the patients care allows for a therapeutic relationship to develop (Dougherty 2008). Closed questions looks for very specific information about the patient (Dougherty 2008). They are very good at ascertaining factual information in a short space of time (Baillie 2005). There are two types of closed questions: the focused and the multiple choice questions. Focused questions tend to acquire information about a particular clinical situation (e.g. asking a patient who is been prescribed Ibuprofen, are you asthmatic?) whereas multiple choice questions tend to be more based on the nurses understanding of the condition being assessed. It can be used as a tool to help the patient describe for example the pain they feel e.g. is the pain dull, sharp, throbbing etc (Stevenson 2004). For verbal communication to be effective, good listening skills is essential. Difficulty in sharing information, concerns or feelings could arise if the person you are communicating with thinks you are not being attentive and interested in what they are saying (Andrews 2001). Good active listening can lead to a better understanding of the patients most recent health issues (Sheldon 2005). Poor listening could be as a result of message overload, physical noise, poor effort and psychological noise. Therefore being prepared to listen and putting the effort and time are essential in a nurses role (Grover 2005). NON-VERBAL COMMUNICATION This type of communication does not involve spoken language and can sometimes be more effective than words that are spoken. About 60 65 per cent of communication between people is through non verbal behaviours and that these behaviours can give clues to feelings and emotions the patient may be experiencing (Foley 2010, p. 38). Non-verbal communication functions as a replacement for speech; to re affirm verbal communication; to control the flow of communication; to convey emotions; to help define relationships and also a way of giving feedback. The integration between verbal language and paralanguage (vocal), can affect communication received (Spouse 2008) Berry (2007) highlights the depth of verbal language due to the use of paralinguistic language. The way we ask a question, the tone, and pitch, volume and speed all have an integral part to play in non verbal communication. In his opinion, personality is shown in the way that paralanguage is used as well as adding depth of meaning in the presentation of the message been communicated. Foley (2010) identifies studies where language has no real prevalence in getting across emotional feelings, in the majority of cases the person understands the emotion even if they dont understand what is being said. Paralanguage therefore is an important tool in identifying the emotional state of a patient. Non-verbal actions (kinesis) can communicate messages, such as body language, touch, gestures, facial expressions and eye contact. By using the universal facial expressions of emotion, our face can show many emotions without verbally saying how we feel (Foley 2010) refer to Appendix 2. For example, we raise our eye brows when surprised, or open our eyes wider when shocked. First impressions are vital for effective interaction; by remembering to smile with your eyes as well as your mouth can communicate an approachable person who is open. This can help to reassure a patient who is showing signs of anxiety (Mason 2010). BARRIERS TO COMMUNICATION The understanding of the barriers to communication is also very important for effective communication and taken into consideration could result in a failure in communication. The Welsh Assemblys fundamentals of care (2003) showed that many of the problems associated with health and social care was due to failures in communication. These barriers may be the messenger portraying a judgmental or power attitude. Dickson (1999) suggested that social class can be a barrier to communication by distorting the message being given and received as would be the case if the patients feel they occupy an inferior status thus making communication difficult and awkward. Environmental barriers such as a busy ward and a stressed nurse could influence effective communication. This can greatly reduce the level of empathy and communication given as suggested by Endacott (2009). People with learning disabilities come up against barriers in communicating their needs, due to their inability to communicate verbally, or unable to understand complex new information. This leads to a breakdown in communication and their health care needs being met (Turnbull 2010). Timby (2005) stresses that when effectively communicating with patients the law as well as the NMC (2008) guidelines for consent and confidentiality must be adhered to. This also takes into account handing over to other professionals. He suggests that a patients rights to autonomy should be upheld and respected without any influence or intimidation, regardless of age, religion, gender or race. The use of communication in practice is essential and reflecting on past experience helps for a better understanding of communication, good and bad. REFLECTION Reflecting on my experience while on placement in a G.P with a practice nurse in south Wales Valleys, has helped me understand and gain practical knowledge in communicating effectively in nursing practice. The duration was for one week and includes appointments in several clinics to do with C.O.P.D and diabetes. I will be reflecting upon one of such appointments using the Gibbss reflective cycle (1988). Description Due to confidentiality (NMC, 2008) the patient will be referred to as Mrs A.E. The Nurse called Mrs A.E to come to the appointment room. I could see she was anxious through her body language (palm trembling and sweaty, fidgety, calm and rapid speech). The nurse asked her to sit down. The nurse gained consent for me to sit in on her review (NMC, 2008). The review started with a basic questionnaire the nurse had pre generated on the computer. It was a fairly closed questionnaire around her breathing including how it was, when it was laboured. Questions were also asked around her medication and how she was taking her pumps. Reflecting on these questions, I feel that the way the questions did not leave much opportunity for Mrs A.E to say anything else apart from the answer to that question and the nurse controlled the communication flow. The Nurse did not have much eye contact with the patient and was facing the computer rather than her patient. I wondered if the nurse had notice the anxious non-verbal communication signs. The patient seemed almost on the verge of tears, I wasnt sure if this was anxiety or distress from being unwell, barrier of social class or if the lady was unhappy about something else. I felt quite sorry for her as all her body language communicated to me that she was not happy. She had her arms crossed across her body (an indication of timidity) and she did not smile, she also looked very tense and uncomfortable. The Nurse went on with the general assessment and did the lung test and I took the blood pressure and pulse, gaining consent first as required by the NMC. Once all the questions had been answered on the computer the Nurse turned to face Mrs A.E and I noticed she had eye contact with her and had her body slightly tilted toward the patient (non verbal communication). The Nurse gave her information on why her asthma may be a bit worse at the moment and gave her clear and appropriate information on how she can make herself more comfortable. The Nurse gave her lots of guidance on the use of her three different pumps, and got her to repeat back to her the instructions she had given to make sure she understood. I could feel the patient getting more at easy as the communication progressed and also on the confirmation that she understood the instruction. The Nurse knew this patient well and then set the rest of the time talking to the patient about any other concerns she had and how she was f eeling in herself, using a more open question technique. The nurse used her active listening skills and allowed the patient to talk about her problems and gave her empathy at her situation as well and some solutions to think about. She gave the patient information of a support group that helped build up confidence in people with chronic conditions and helped them deal with the emotional side of their condition. Feelings After the patient had gone, my mentor explained that the patient was a known regular patient to the clinic, that she had many anxiety issues which werent helped by her chronic asthma. Through-out the beginning of the review I felt very awkward. I thought because I was sitting in on the review may have been the reason the lady had not said why she seemed so anxious and upset. I also felt the nurse was not reacting to the sign of anxiety from Mrs A.E and this made me feel uncomfortable. I felt like I wanted to ask her if she was ok, but felt that I couldnt interrupt the review. However by the end of the review I felt a lot better about how it had gone. I did feel that by building up a relationship with the patients allowed the nurse to understand the communication needs of the patient and also allowed her to use the time she had effectively. She used empathy in her approach to the lady and actively listened to her. I understand that the start of the review was about getting the facts of the condition using a lot of closed questions, whereas the later part of the review was a more open questions and non verbal communication approach, allowing the patient to speak abo ut any concerns and feelings about those questions asked earlier. Evaluation Effectively using closed questions allow for a lot of information to be gathered in a short space of time, and can be specific to the patients review needs. These pre-generated questionnaires are good at acquiring the information needed by the G.P. and also for good record keeping which are essential in the continuity of care delivered to the patient. It can also protect the nurse from any litigation issues. The use of open and closed questions also allowed for the review to explore the thoughts and feelings of the patient, thus allowing for empathy from the nurse and is considered a vital part of the counselling relationship (Chowdhry, 2010 pg. 22). However the use of the computer screen facing away from the patient, did not allow for good non-verbal communication skills to be used. The lack of eye contact from the nurse may have exacerbated the anxiety felt by the patient. Hayward (1975, p. 50) in a summary of research into anxiety noted uncertainty about illness or future problems was linked to anxiety and therefore linked to pain. Nazarko (2009) points out, it is imperative that a person has the full attention of the nurse when they are communicating. He states that being aware of ones own non-verbal behaviours, such as posture and eye contact can have an effect on how communication is received by the patient. As evident in the reflection, the patient at the beginning of the review was anxious, upset and worried. By the end of the review her body language had significantly changed. The patient looked and felt a lot better in herself and had a better understanding of how her condition was affecting her and understood how to manage it. Whereas, bad communication would have caused more stress and aggression (Nursing standard 34 (30) 2010). This also links back to the need to understand medical conditions so that communication is channelled to the patients needs at the time. The fundamentals of care set out by the Welsh Assembly Government (2003), states that communication is of upmost importance in the effectiveness of care given by nurses. By looking at all the fundamentals of communication and the effect on patient care we can understand and recognise that the communication in this reflection was a good communication in practice. Analysis The closed questions were used at the beginning of the review, had their advantages. They allowed the nurse to focus the on the specific clinical facts needed to be recorded. The start of the review used mainly closed questions to get all the clinical facts needed to be recorded, such as Personal information, Spirometry results, blood pressure, drug management of COPD (Robinson, 2010). The structured approach allows the nurse to evaluate using measurable outcomes and thus interventions adjusted accordingly (Dougherty, 2008). The closed question approach allows the consultation to be shortened if time is an issue. However the disadvantage of this as identified by Berry (2007) is that important information may be missed. The use of closed questions on a computer screen hindered the use of non-verbal communication. Not allowing for eye contact, which is an important aspect of effective communication. The use of open questions in the review allowed the patient to express how they were feeling about their condition or any other worries. The nurse used active listening skills, communicated in her non-verbal behaviour. It gave the opportunity to the patient to ask for advice on any worries they might have. The use of open questions can provoke a long and sometimes not totally relevant response (Baillie, 2005), using up valuable time. The use of Egan (1990, p. 46) acronym SOLER allowed the nurse to focus on the skill of actively listening. Eye contact is another important part of communication in the reflective scenario. The eye contact at the start of the review was limited. The nurse made slight eye contact when asking the closed questions, but made none when given the answer. This may have contributed to the patients anxious state. However, the eye contact given during the open questions section. At this stage, there were several eye contacts between the nurse and patient and information was given and understood. The value of eye contact in communication is invaluable and has great effect at reducing symptoms of anxiety (Dougherty 2008). Reflection conclusion The use of communication in this COPD review was very structured. The use of closed questions helped to structure the consultation and acquire lots of information from the patient. The open questions allowed for the patient to express any feeling or concerns. The nurse used verbal and non-verbal communication methods, to obtain information about the patient; assess any needs and communicate back to the patient, within the time period. However in my opinion, if the computer screen was moved closer to the patient during the closed question section, better interaction could have been established from the beginning. It would also allow the nurse to look at the patient when asking the questions leading to a more therapeutic relationship, whilst still obtaining and recording a large amount of information. Therefore, the use of effective communication skills as seen in this review along with a person centred approach can significantly increase better treatment and care given to the patient (Spouse, 2008) and thus signifies good communication in practice. Action Plan The goal of the plan is to increasing patient participation in the use of the computer as an interactive tool. By allowing the patient to see what is on the screen and being written, allows the patient to feel more involved in the assessment and takes away any feeling of inferiority from social class difference. In attempt to achieving these goals, the following steps would be taken: Set up a team to investigate the issue which could involve nursing staffs or other hospital staffs. Drawing up a feedback questionnaire, to investigate how patients feel about the closed questions on the computer, including a section on how they would feel if they were allowed to look at the screen. Collation, analysis and review of the results of the feedback Identify barriers to the implementation of the plan (e.g. willingness of nurses to this change). Inform the NMC on the issues and the findings from the feedback questionnaire. Implementation of the plan. Set up a monitoring and evaluation team to see if the plan is being implemented appropriately. CONCLUSION This assignment has looked at communication and its importance in nursing practice. Communication is thus an iterative process involving the interaction between one or more persons using verbal and non-verbal methods. Understanding the barriers to communication contributes significantly to how effective a nurse communicates in practice. The use of questioning in nursing has been a valuable tool in assessing a patient and obtaining information. However the way this is done can have an effect on the development of empathy, trust, genuineness and respect, between the nurse and the patient. It is imperative for nurses to however reflect on their communication in practice to further improve the therapeutic relationship between them and the patient as has been identified as essential in the delivery of care (WAG 2003). REFERENCES Alder, RB. Rodman, G. 2003. Understanding human communication (8th edition). USA: Oxford university press Andrews C, Smith J (2001) Medical Nursing (11th edition) London: Harcourt Publishers limited Berry, D. 2007. Basic forms of communication. Cited in. Payne, S. Horn, S. ed. Health communication theory and practice. England: Open university press. Chowdhry, S. 2010. Exploring the concept of empathy in nursing: can lead to abuse of patient trust. Nursing times 160 (42) pg 22-25 Dickson, D. 1999. Barriers to communication. Cited In: Long, A. ed. Interaction for practice in community nursing. England: Macmillian press LTD, pp. 84-132 Dougherty, L. Lister,S. ed. 2008. The royal marsden hospital manual of clinical nursing procedures. Student edition. 7th edition. Italy: Wiley-Blackwell Egan, G. 1990. The skilled helper: A systematic approach to effective helping. (4th edition). California: Brooks /Cole Ekman, p. Friesen, WV. 1975. Unmasking the face. Englewood cliffs, NJ: prentice-hall INC Endacott R, Jevon P, Cooper S (2009) Clinical Nursing Skills Core and Advanced. Oxford : Oxford University Press. Foley, GN. 2010. Non-verbal communication in psychotherapy. Psychiatry (Edgemont) 7 (6) pg. 38-44 Gibbs, G. 1988. Learning by doing: a guide to teaching and learning methods. Oxford: Oxford futher education unit. Grover, SM. 2005. Shaping effective communication skills and therapeutic relationship at work. Aaohn journal 53 (4) pg. 177-182 Hawkins, K. Power, C. 1999. Gender differences in questions asked during small decision-making group discussions, small group research.(30) pg.235-256 Hayward, J. 1975. Information A prescription against pain. London: Royal college of nursing. Pg. 50 Marie- Claire Mason (2010) Effective interaction: Nursing Standard 24 (31) pp 25. Nazarko, L. 2009. Advanced communication skills. British journal of healthcare assistants. 3 (09) pg 449-452 Nursing and Midwifery Council (NMC) (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London. NMC Peate, I. 2006. Becoming a nursein the 21st century. England: Wiley and Son Robinson, T. 2010. Empowering people to self-manage COPD with management plans and hand held records. Nursing times. 106 (38) pg. 12-14 Sale, J. Neal, NM. 2005. The nurses approach: self-awareness and communication. Cited in Ballie, L. ed. Developing practical nursing skills (2nd edition). London: Oxford university press. Pg. 33-57 Sheldon, L. 2005. Communication for nurses: Talking with patients. London: Jones and Bartlett publishers. Spouse, J. Cook, M. Cox, C. 2008. Common foundation studies in nursing (4th edition). London: Churchill livingstone. Stevenson C, Grieves M, Stein Parbury J 2004 Patient and Person: Empowering Interpersonal relationships in Nursing London. Elsevier Limited. Timby BK (2005) Fundemental Nursing Skills and Concepts Philadelphia. Lippincott Williams and Wilkins Turnbull J, Chapman S (2010) Supporting Choice in Health Care for People with Learning Disabilities. Nursing Standard 24 (22) pg 50 55 Welsh Assembly Government (2003) Fundamentals of Care Guidance for Health and Social Care Staff Cardiff: WAG Importance of Communication in Nursing Importance of Communication in Nursing Communication in nursing Introduction Communication in nursing is vital to quality and safe nursing care (Judd, 2013). There is evidence that continues to show that breakdowns in communication can be responsible for many medication errors, unnecessary health care costs and inadequate care to the patient (Judd, 2013). Several reports exist from the Institute of Medicine that stress the importance of good communication and its link to providing safe and reliable care (Judd, 2013). (Smith Pressman, 2010). However, even nurses with the best communication skills can be challenged by difficult situations such as life threatening threatening illness or injury, complicated family relationships, and mental health issues, to symptoms such as unrelieved pain and nausea. How a nurse may respond during these situations depends on many factors. Each nurse brings their own history, culture, experience, and personality to a situation. Communication in the workplace can either be horizontal among workers at the same hierarchical level, vertical among workers in different hierarchical levels or diagonal amongst different workers in different hierarchical levels. All these kinds of communication are crucial in the work environment because work needs to be done and goals need to be met. A communication channel is made up of three components made up of the sender of the message (encoder), the channel of sending the message and the receiver of the message (decoder) (Anderson, 2013). For effective communication to be achieved, the encoder and the decoder must be able to understand one another. This paper will discuss some strategies which could be implemented to improve both written and verbal communication between nurses, health professionals and between patients and the health care team. Communication, a fundamental aspect of nursing, is a complex, continual transactional process that occurs between persons by which information, feelings, and meaning are conveyed through verbal and non verbal messages (Peereboom, 2012). It is crucial for nurses to identify communication strategies that should be put into consideration every time they are involved in conversations involving their line of practice. This is because clear and accurate communication strategies enable them to identify effective patterns in their interactions and in teaching themselves to improve their patient education techniques. Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation. Such communication breakups and challenges can lead to intense mishaps in the continuity of health care, incorrect treatment, and potential harm to the patient in general (Memoire, 2007). Simple strategies can easily impart critical information just by eye sight. For instance, nurses are able to communicate critical patient status issues like allergies and fall risk with color-coded patient identification wrist bands or stickers on their medical records, a seat belt or flag attached to a wheel chair, or any other objects which are easily identifiable by all medical practitioners (Joint contribution resources, 2005). The use of local jargon can also be avoided when making professional conversations because some words may portray a meaning that was not intended or is not readily understood by a large number of people. Assimilation of the ISBAR tool is a strategy that has been really helpful in enhancing communication in the healthcare sector when used. Identifying yourself (I), availability of the situation (S), background (B), assessment (A), and recommendations (R) facilitates communication allowing each health practitioner to receive and give important information in a format that satisfies numerous communication styles and needs (Dixon et al., 2006). This tool should be adopted by everyone to improve communication is because this technique utilizes the use of one common language for passing on critical information without leaving out anything. Another strategy that can be used to improve communication in healthcare centers is the Crew Resource Management technique which is both a communication and team building technique (ECRI, 2009). This strategy trains members of the healthcare sector to assert themselves respectively and be attentive when they are being spoken to and also encourages them to make use of briefings. Briefings are direct communications between physicians, nurses or other caregivers acting on patient status which includes sharing of important information at critical times, such as before the start of a procedure, at the change of shift and during normal patient rounds (ECRI, 2009). COMMUNICATION BETWEEN PATIENTS AND THE HEALTH CARE TEAM One stratergy that can be used to improve communication between patients and the health care team is the use of ‘The World Health Organization Surgical Safety Checklist’. This checklist is to be used in operating suites to ensure everyone involved with the patient including the patient understands what procedure they are having ad gives prompts to tick off so important information is not missed during handovers leading to reduced inpatient complications and death (Department of Health, 2010). In addition to the patient, their family members or next of kin can also be included in the rounds further increasing the opportunity for direct dialogue which reduces the development of complications which arise as a result of miscommunication in the form of home care. It is important to note that if personal care by the family of the patient is not provided as requested by the medical practitioner, cohesive care is not accomplished and the opportunity to achieve patient care goals will not be met (O’Leary et al., 2010). Joint commission reports also indicate that health practitioners should also encourage patients to actively participate in their own care as a strategy to enhance communicational barriers (Stein, 2006). Successful interactions are always co-constructed, involving a constant interplay among the two parties. When the patient and the healthcare provider are comfortable with one another communicating becomes easy and more effective in the sense that the healthcar e provider will be able to solve the needs of the patient. COMMUNICATION BETWEEN HEALTH CARE DISCIPLINES Communication between medical practitioners can greatly influence the general patients care outcomes. Medical practitioners are in the frontline to investigate and identify communication challenges and try to implement solutions that fit their line of duty. Some further research is also being carried out to evaluate potential solutions and more successful options (Rosenstein, 2005). Creating a collaborative relationship between nurses and other medical practitioners is also another strategy that can help reduce communicational barriers and thus improve the general treatment of patients (Arora, 2005). With regard to Schmalenberg and Kramer (2005), â€Å"MD/ RN collaboration is reflected in reduced patient mortality, fewer transfers back to the ICU, reduced costs, decreased length of stay in hospitals, higher nurse autonym, retention, nurse-perceived high quality care, and nurse job satisfaction†. Larabee (2006) also found out that positive relationships between medical practitioners were a major contributing factor to improved nursing job satisfaction and retention. Positive collegial relationships therefore result from good communication, mutual acceptance and understanding, use of persuasion rather than coercion, and a balance of reason and emotion when working with others (College of Nurses of Ontario, 2009, pg. 7). COMMUNICATION BETWEEN NURSES A number of strategies have been set up to address communication issues among nurses. For instance, the implementation of unit based care teams places nurses and people like physicians close to one another thus increasing the chances of communicating effectively (Gordon et al, 2011). The introduction of compulsory bed rounds is also another strategy that has enabled nurses to reduce communication barriers and promote effective communication thus creating patient health satisfaction and general health care providers satisfaction in their duties. The continuous flow of interruptions and multiple patient handoffs affect the ability of nurses and physicians to connect effectively, and establish a trusting and collegial relationship (Tschannen et al., 2011). The fact that the working environment of nurses and other medical practitioners is rather different also induces a number of communication barriers with regard to the intensity of activities on a normal working day (Burns, 2011).this could be improv4d by†¦ Communication challenges are recognized when set goals or achievements are not met or when there is great employee turnover. Technological advances have opened up communication across boundaries of different countries meaning that people with different languages, behaviors and culture interact with one another (Krizan, 2010).In the health care sector in particular, the most pertinent communication barrier is the inability for colleagues to interact physically as they are separated in different departments (Vignam, 2013). This lack of interaction minimizes the ability for team members to collaborate wholly in the sense that the ability to analyze body language and create a sense of energy among team members is null. This can be improved by†¦ Barriers Barriers to communication that exist are the use of machinery and equipment that might malfunction and deliver the message later than expected thus reducing the urgency of information. In addition to this, these machines are not able to express aspects of speech such as tone thus making them a true barrier to effective communication. Language is also a major communication barrier in the case where colleagues do not speak the same language or where they have difficulty in articulating clearly in one common language. The use of local idioms, jargon and acronyms further complicates language and kills communication among team members who find certain words ambiguous (Lingard, 2005). A patient in a hospital setting usually sees more than one health care practitioner and specialist during their stay (Memoire, 2007). Handover communication between practitioners may at times seclude crucial information and is even prone to misinterpretation. By improving communication among healthcare professionals the delivery of patient care improves and is saferStrong and effective nursing care is enriched and strengthened by good communication (2) In Victoria, the direct cost of medical errors in public hospitals is estimated at half a billion dollars annually [1]. Today, healthcare is evermore complex and diverse, and improving communication among healthcare professionals is likely to support the safe delivery of patient care. References Anderson, P., 2013. Technical communication, cengage learning, Canada Arora V, Johnson J, Lovinger D. (2005) Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care Burns, K. (2011). Nurse-physician rounds: A collaborative approach to improving communication, efficiencies, and perception of care. MEDSURG Nursing Dixon, J., Larison, K., Zabari, M. (2006). Skilled communication: Making it real. AACN Advanced Critical Care College of nurses of Ontario. (2009), conflict prevention and management, Toronto, ON ECRI. (2009), Healthcare risk control, 5200 butler pike, Plymouth meeting, PA 19462-1298, USA Fernandez, R., Tran, D., Johnson, M., Jones, S. (2010).Interdisciplinary communication in general medical and surgical wards using two different models of nursing care delivery. Journal Of Nursing Management Gordon, M., Melvin, P., Graham, D., Fifer, E., Chiang, V., Sectish, T., Landrigan, C. (2011). Unit-based care teams and the frequency and quality of physician-nurse communications. Archives of Pediatric Adolescent Medicine Joint commission resources. (2005), issues and strategies for nurse leaders: meeting hospital challenges today, joint commission resources, Inc, USA Krizan, A., Merrier, P., Logan, J., Williams, K., 2010. Business communication: Business communication series, Mason: USA: Cengage learning Larabee, L., Janney, M., Ostrow, C. Withrow, M. Hobbs, G. Burant, C. (2007), predicting registered nurse job satisfaction and intent to leave, journal of nursing Lingard L, Espin S, Rubin B. (2005) Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care Memoire, A. (2007), communicating during patient hand over, patient safety solutions, vol 1 O’Leary, K., Thompson, J., Landler, M., Kulkarni, N., Hawiley, C., Jeon, J.Williams, M. (2010). Patterns of nurse-physician communication and agreement on the plan of care. Quality and Safety in Healthcare Peereboom, K. (2012), facilitating goals of care discussions for patients with life limiting disease- communication strategies for nurses, journal of hospice and palliative care Rosenstein AH, ODaniel M. (2005). Disruptive behavior clinical outcomes: Perceptions of nurses and physicians.American Journal of Nursing Stein JS. (2006) Improving patient safety communication. Presented at: Philadelphia Area Society for Healthcare Risk Management; Mar 16; ECRI Institute, Plymouth Meeting (PA). Schmalenberg, C. Kramer, M., King, C. (2005), excellence through evidence: securing collegial nurse physician relationships, journal of nursing administration Schmalenberg, C., Kramer, M. (2009). Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Critical Care Nurse Vigman, S., 2013. Global challenges: communication and culture: people issues in a global environment, workforce solutions review Department of Health 2010 Promoting effective communication among healthcare professionals to improve patient safety 1-1-7 Retrieved from http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pdf http://www.health.vic.gov.au/qualitycoun http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paPromoting effective co Importance of Communication in Nursing Importance of Communication in Nursing Communication is a huge topic and can be considered on many different levels from a professional viewpoint. We can consider issues such as the relevance of various forms of communication between the healthcare professionals and the patient which, ultimately determines many of the parameters of treatment (and compliance).(Stewart M 1995) We can also consider the importance of communication between healthcare professionals themselves which can cause inordinate problems for the patient if they are less than optimal. (Hogard E et al. 2006) Firstly, communication requires a definition. There are many attempts at trying to define the essence of communication. They all differ in detail but, in essence, they all describe a complex process of both sending and receiving messages which can be either verbal or non-verbal or, more commonly, a mixture of both. This interchange allows for an exchange of information, feelings, needs, and preferences. Typically the two protagonists in a communication exchange will encode and decode messages in a cyclic pattern. Each making an analysis and response to the preceding gambit. (Wilkinson SA et al. 1999) In the context of professional nursing, its purpose is generally manifold but will include the means of establishing a nurse-patient relationship, to be a tool for expressing concerns or interest in the patient’s circumstances, to elicit information relevant to the patient’s condition and to provide healthcare information. (Bugge E et al. 2006) Implicit in the process of communication is the achievement of a shared understanding of meaning. This is validated by the process of feedback interpretation which indicates if the actual meaning of the message was interpreted as it was originally intended. Communication can be categorised into both type and level. In a nursing-specific context, the level of communication can be defined as â€Å"Social† which is considered to be safe and non-contentious, â€Å"Structuredâ€Å", which is typically utilised for situations of teaching and patient interviews and â€Å"Therapeutic† which has the characteristic of being specifically patient focussed, purposeful and generally time limited. If this is successful it develops further characteristics such as the nurse comes to regard the patient as a unique individual and begins to understand their motivations, and the patient develops a trust in the nurse. It is within this communication context that the nurse is generally able to try to provide care and, more importantly in some instances, help patient identify, resolve, or adapt to health problems. (DAngelica M et al. 1998) The types of communication are capable of endless subdivisions, but in broad terms, they are classified as verbal and non-verbal. The verbal communication requires, by definition, the conscious use of the spoken or written word. The nature, grammar and syntax of the words can reflect the patient’s mental age, their education, their culture and in some cases their mental state and feelings of the moment. Certain inferences can be made from the way the words are delivered such as their choice, their tone or pace of delivery. The characteristics most favourable for efficient and effective communication are that the words should be â€Å"simple, brief, clear, well timed, relevant, adaptable, credible†. (Philipp R et al. 2005) Non-verbal communication relies on the interpretation of facial expressions, hand gestures, and body language. This is an extremely subtle means of communication and can give credence (or otherwise) to the spoken word. In the nursing context, non-verbal communication can be manipulated to the nurse’s advantage to help to elicit information that may otherwise not have been forthcoming. It has been estimated that non-verbal communication accounts for up to 85% of information transfer between communicating adults. In the professional nursing context it requires both systematic observation and careful assessment and interpretation to derive the full meaning of what the patient wishes to convey. Most importantly, the nurse should be aware of incongruity between the verbal message and the non-verbal cues. The patient who smiles while describing a terrible pain is one such example. (Musselman C et al. 1999) Implicit in the understanding and correct interpretation of the non-verbal cues, (and to a lesser extent the verbal ones), is an appreciation of the various environmental and circumstantial factors which can affect the process of communication. There are a number of factors that are of relevance to the clinical situation, including the culture, developmental level, physical psychological barriers that pertain to the patient, their personal space (proxemics) and territoriality that they perceive, the roles and relationships of the people that they are speaking to, the local environment, and their personal attitudes and values and level of self esteem. (Derjung M et al. 2006) On a personal level, I find communication skills most important in the context of the nursing report. One can experience situations where a report is given and very little real information is passed between professionals. Other situations can occur where perhaps the same length of time is taken but enormous amounts of information can be derived from a good report. I recall one particular handover report which, despite being fairly long, left me with no clear information as to what was going on with the patients on the ward. I couldn’t recognise them as people and they were presented more as cattle. The report itself was completely task orientated and comprised little more than a list of jobs that the nurse herself had not been able to accomplish that day. If we consider the literature on the subject we can note that the nursing report predates the Nightingale era. (Carrick P 2000). The nursing profession has evolved as have the requirements, demands and procedures employed. The nursing report is no exception to this evolution. As with any process that involves humans, there is an intrinsic variability. It is seldom perfect and its standard can vary all the way from excellent to dreadful (RCN.2003) In consideration of comments made earlier in this essay we note that the issue of report giving is capable of considerable improvement with learning. This was demonstrated by two independent researchers who produced two seminal papers on the subject coincidentally at virtually the same time. (Ljukkonen A 1992) (Kihlgren et al 1992). In essence, their studies were a period of observation and analysis, a training period and then another period of reanalysis. There is no merit in considering the entire paper in detail here, but the significant findings (in terms of communication) were that before the training the reports were generally: Highly task oriented and (it was noted that) the staff often discussed the patients reaction in vague and general terms without imparting any specific or useful information. The authors were also able to comment that the nursing process was seldom adhered to during the structuring of the report. During the post training assessment the authors noted that the most significant areas of change were: More messages were given per report after the intervention compared to the control ward and the messages with psychosocial content had doubled. The relevance to communication issues is clear. These two studies show that communication is not necessarily innate, but is a skill that can be both learned and enhanced. Good communication equates with both efficiency and, in the case of these two studies, â€Å"less dissatisfaction and a greater team empathy between nursing colleagues which led to more collaboration between the various teams working on the ward.† There are a number of ways in which we can approach the discussion of such topics and we shall consider a few specific different types of communication as an illustrative vehicle for discussion. Much original and groundbreaking work in the area of communication in the healthcare setting was done by Orlando about two decades ago (Orlando I. J. 1987) who suggested that one of the core roles of the healthcare professionals (he was writing specifically about nurses at the time) was to: â€Å"ascertain and prioritise the patient’s needs and instigate and plan appropriate help.† Few would disagree with this comment, but it is clear that effective and precise communication between patient and nurse is essential if the patient’s needs are to be ascertained accurately in the first instance. Communication between healthcare professionals, the patient and other legitimately interested parties such as carers, is then vital if such a plan is then to be optimally implemented The importance of communication as a skill is clearly demonstrated by the fact that it is currently included as one of the six core skills required of the modern nurse manager. (ICN 1998). Another indicator of the importance of good communication is the fact that the majority of complaints currently made to UK Hospital Trusts can ultimately be traced back to poor communication (Richards T 1999). Communication is an attribute and skill that is rarely intuitive. (Davies et al. 2002). There are a great many papers which demonstrate the fact that communication skills can be improved at all levels of competence with both practice and learning. (Hulsman R L et al. 1999) A particularly comprehensive review has been recently published by Heinmann-Koch (2005) which gives an excellent analysis of the strengths and deficiencies in the communication skills of a number of healthcare professionals and the authors make a number of recommendations to address the shortcomings that they identified. The authors quantify the essential skills of communication as â€Å"Personal insight, sensitivity, and knowledge of communication strategies†. The latter being considered vital to maximise the efficiency and effectiveness of one’s communication abilities. If we consider the professional standing on issues of communication, we can note that the Royal College of Nursing has earmarked communication skill as a specific â€Å"competence goal† and the Royal College of Physicians have now included a specific element of assessment in communication skills in their Part II membership exam with elements of information gathering and information giving being specifically assessed. (RCP 2002) Dacre summarises the important elements of the healthcare professional / patient interaction thus: The importance of reflection before a consultation in order to form a clear agenda of the overall aims of the consultation and prepare questions. Checking the patient’s name as an appropriate opening gambit. Starting with an open question. Use a mixture of open and closed questions, structuring the questions carefully, and exploring each area in full before moving on. Make sure each question is effective. Take care not to interrogate patients. Avoid the use of overtly medical language and check at each stage that patients have understood what is being said. Ensure that the healthcare professional does not push his or her own agenda. Allow patients time to finish speaking, using verbal and non-verbal cues to makes it clear that the healthcare professional is listening. Respond to the information that the patient has given to show that this has been heard and understood. Use careful interjections to redirect the interview if necessary. Avoid premature closure (finishing very quickly). There should be a summary—for example, recapping decisions which have been made, and agreement of an immediate plan for the next step. (after Dacre J et al. 2004) In order to explore the area of communication more fully, we will consider a number of specific instances as illustrative examples. We shall begin with the study by Coiera (E et al. 1998). The study starts with the comment: The healthcare system seems to suffer enormous inefficiencies because of poor communication infrastructure and practices. It then cites the Smith paper (Smith A F et al. 2005) which points out the fact that communication problems were the most common cause of preventable disability or death, and were nearly twice as common as those due to inadequate medical skill This study took a cohort of 10 healthcare professionals working in a hospital setting and analysed all of their professionally based communications. For efficiency and content. The paper itself was both long and involved and some of the findings are only of peripheral relevance to our considerations here, so we shall confine our discussions to the parts that are relevant The first major finding was that there was a tremendous range of topics dealt with, ranging from the clinical to the administrative. The authors comment that efficiency of communication is inversely proportional to the diversity of topics. In other words, communication in a designated clinic setting, where all of the problems are likely to have a similar thrust, is more likely to be efficient than conversations encountered in a general ward on general topics. The second general finding was that efficiency of communication was significantly impaired by the frequency of interruptions. It follows that protected time in a consultation, free from interruptions, is more likely to be an efficient communication than one that is frequently interrupted. Interruptions were seen to be associated with a number of well recognised psychological responses including diversion of attention, forgetfulness, and errors. (Blum N J et al. 1992) Paradoxically, the authors found that the most junior staff, (I.e. the least likely to be experienced in communication skills), were the most likely to be interrupted, while the senior staff were the least likely to have their consultations interrupted. We have already considered a number of the factors that can influence communication and various communication strategies can be usefully employed to assist in eliciting appropriate information. Active listening is perhaps the most useful basic tool that the nurse can use. When interacting with the patient, the nurse should endeavour to utilise strategies that will facilitate both conversation and elaboration. Mechanisms such as use of broad opening statements, reflecting, open ended statements and directive questions can be strategically employed to elicit appropriate information. (Huizinga G A et al. 2005) Many patients will not be used to expressing themselves clearly and concisely, and can be helped by techniques such as acknowledging feelings, using silence as a prompt, reflection, and stating personal observations. All of these factors can be enhanced if used alongside strategies that communicate mutual understanding. (Yedidia M J et al. 2003) We have presented evidence that communication is the medium of mutual understanding. We should therefore not leave this area without making comment on some strategies that the professional nurse can employ to maximise the empathetic understanding of those that she is communicating with. These strategies are important not only in the nurse / patient interaction but also in the teaching environment. Ensuring that the message is thoroughly communicated and understood requires techniques such as clarifying, validating, verbalizing implied thoughts and feelings, focusing, using closed questions and summary statements. The converse of this argument is that the nurse should also be aware of issues that are potential barriers to communication. The absence of positive and attentive listening is a powerful disincentive to most forms of communication. The patient who perceives that they are not being listened to is not likely to produce any useful information. Other barrier behaviours include the use of reassuring clichà ©s, giving advice, expressing approval/disapproval, requesting an explanation (asking why?), defending, belittling feelings, stereotyped comments, changing the subject. (Arora V et al. 2005) We have devoted the majority of this examination to the spoken modes of communication, but we should not overlook that the written word is an equally important means of communicating ones thoughts to others, particularly on an interprofessional basis. In order to maximise the efficiency of communication a written report should ideally be brief, concise, comprehensive, factual, descriptive, objective, both relevant and appropriate and legally prudent. (Young B et al. 2003) In this assessment one should draw attention to the distinction between being both brief and concise. Brief equates with shortness as undue length will allow the reader’s attention to wander, whereas being concise implies an absence of irrelevant detail thereby allowing an emphasis on what is important. Conclusions. The preparation and literature review has allowed ample time for reflection on the issues raised. (Taylor, E. 2000). This has proved to be a valuable experience as some issues which I believed that I understood, became clearer and this gave me a much deeper insight into both the mechanisms and the possibilities of accurate and concise communication. Not only have the mechanisms of positive enhancement of communications become apparent but also the active removal of the barriers or impediments to communication clearly play an important role in the ability of the nurse to communication efficiently with both the patient and her healthcare colleagues. References Arora V, J Johnson, D Lovinger, H J Humphrey, and D O Meltzer 2005 Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual. Saf. Health Care, Dec 2005 ; 14 : 401 407. Blum N J, Lieu T A. 1992  Interrupted care: the effects of paging on paediatric resident activities. Am J Dis Child 1992 ; 146 : 806-808 Bugge E and I. 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